HomeMy WebLinkAboutMonitoring cert. 10/08
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MONITORING SYSTEM CERTIFICATION
For Use By AU Jurisdictions Within the State ofCalifomia
Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations
This fonn must be used to document testing and servicing of monitoring equipment A separate certification or report must be prepared
for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank
system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30
days of test date:
A. General Information
Facility Name: HP GO GO MINI MART
Site Address: 3301 WIBLE RD
Facility Contact Person: DILLON
MakelModel of Monitoring System: VEEDER ROOT TLS 350
B. Inventory of :Equipment Tested/Certified
Cleek the te boxes to indicate t.
Tank ID: T1-UNL
III In-Tank Gauging Probe. Model: MAG
a Annular Space or Vault Sensor. Model:
iii Piping Sump I Trench Sensor(s). Model: VIR fLOA I
a Fill Sump Sensor(s). Model:
iii Mechanical line Leak Detector. Model:
a Electronic Line Leak Detector. Model:
a Tank Overfill I High-Level Sensor. Model:
a Other . ui ment and model in Section E on P
Tank ID:
iii In-Tank Gauging Probe. Model: MAG
a Annular Space or Vault Sensor. Model:
iii Piping Sump I Trench Sensor(s). Model: V/RFLOAI
a Fill Sump Sensor(s). Model:
iii Mechanical line Leak Detector. Model: RED JACKE I
a Electronic Line Leak Detector. Model:
[J Tank Overfill I High-Level Sensor. Model:
[J Other ( . ui ment and model in Section E on Pa e 2 .
Dispenser ID: 1/2
III Dispenser Containment Sensor(s). Model: VIR FLOAT
iii Shear Valve(s).
[J . nser Containment Float s and Chain s .
DispeoserID:
III DispenserContainmentSensor(s). Model: VIR FLOAT
iii Shear Valve(s).
[J' Containment Fl
ID:
.JII..Bispenser
itShear Valve(s).
[J . Containment Flo s and Chain s . [J . user Containment F1oat{s and Chain s).
.If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility_
C. Certification - I certify that the equipment identified in this document was . serviced in ac:.oordaoce with the manufacturers'
guidelines. Attad1ed to this Certffkation is iDfonnation (e.g. manufacturers' iddists to verify that this iDformation is
correct and a Plot Plan showing the layout of monitoring equipment. For any eq pment f generating such reports, I have also
attached a copy of the ~ (check all that opply): is System set-up report
Technician Name (print): RON ROGERS Signature:
Certification No.: A29880
Bldg. No.:
City: BAK~RSFIELD Zip: 93309
Contact Phone No.: ( 661 ) 397-4553
Date of Testing/Servicing: ...!QJ 10 / 06
t Sensor(s). Model: ~.. . t.~T
Model: MAG
Model:
Model: V/K fLOAI
Model:
Model: FE PE fRO
2.
e2).
'.
ICC#5246218-UT
Phone NO.:{ 661 ) 387-6430
Date of Testing/Servicing: .Jl!J J!l..J. 06
Testing Company Name: ACE PETROLEUM SERVICES, INC.
Site Address: 15540 STREBOR DRIVE / BAKERSFIELD CA 93314
Monitoring System Certification
Page lof3
03101
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D. Results of Testing/Servicing
Software Version Installed: V14
us Yes
eheckJist:
Is the audible alarm 0
Is the visual alarm tiona1?
Were all sensors visuall ins red. functionall tested, and confirmed 0 rational?
Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will
not interfere with their r 0 ration?
If alarms are relayed to a remote monitoring station. is all communications equipment (e.g. modem)
operational?
For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
monitoring system detects a leak. fails to operate, or is electrically disconnected? If yes: which sensors initiate
positive shut-down? (Check all that apply) III Sumpffrench Sensors; II Dispenser Containment Sensors.
Did ou confirm sitive shut-down due to leaks and sensor failure/disconnection? II Yes; a No.
a Yes a No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no
III N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank
fill in s) and 0 rl ? If so, at what t of tank . does the alarm tri er? %
Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced
and list the manufacturer name and model for all lacement in Section E, below.
a Yes* .. No Was liquid found inside any secondary containment systems designed as dry systems'? (Check aU that apply) a
Product; a Water. If es, describe causes in Section E, below.
.. Yes a No* Was monitorin s stem set- reviewed to ensure ro settin? Attach set u
Q9 Yes a No* Is all monitorin ment 0 .onal manufacturer's ifications?
· In Section E below, describe bow and when these deficiencies were or wiD be corrected.
DYes
o No*
I!I N/A
a No.
a N/A
a Yes*
ll!I No
licable
E. Comments:
Page2of3
03101
F. In. Tank Gauging I SIR Equipment:
It Check this box if tank gauging is used only for inventory control.
a Check this box if no tank gauging or SIR equipment is installed.
This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring.
Co Ie the Ii Do' checldis
)mpJ te 0 )W1D2 I t:
QB Yes Cl No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
III Yes Cl No* Were all tank gauging probes visually inspected for damage and residue buildup?
III Yes a No* Was accuracy of system product level readings tested?
III Yes IJ No* Was accuracy of system water level readings tested?
III Yes a No* Were all probes reinstalled properly?
III Yes [J No* Were all items on the equipment manufacturer's maintenance checklist completed?
'" In the Section B, below, describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD):
a Check this box if LLDs are not installed.
Co Ie thliU
checldis
)IOP) te e 0 OW1D2 t:
. Yes a No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD perfonnance?
a NtA (Check all that apply) Simulated leak mte: .. 3 g.p.h.; (J 0.1 g.p.b; [J 0.2 g.p.h.
. Yes [J No* Were all LIDs confirmed operational and accurate within regulatory requirements?
III Yes a No* Was the testing apparatus properly calibrated?
. Yes It No* For mecbanical LIDs, does the LID restrict product flow if it detects a leak?
(J N/ A
a Yes a No* For electronic LIDs, does the turbine automatically shut off if the LLD detects a leak?
II N/A
IJ Yes a No* For electronic LIDs, does the turbine automatically sbut off if any portion of the monitoring system is disabled
It N/A or disconnected?
a Yes a No* For electronic LIDs, does the turbine automatically sbut off if any portion of the monitoring system malfunctions
II NtA or fails a test?
a Yes a No* For electronic lLDs, have all accessible wiring connections been visually inspected?
III Nt A
QB Yes a No* Were all items on the equipment manufacturer's maintenance checklist completed?
'" In the Section B, below. describe how and when these deficiencies were or wiD be corrected.
H. Comments:
UNL AND PREM LINE LEAK DETECTORS FAILED
Page 3 of3
03101
,,'
Monitoring System Certification
UST Monitoring Site Plan
Site Address: HP GO GO I 3301 WILBLE RD I BAKERSFIELD CA 93309
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Date map was drawn: JQj J!!.J 06 .
Instructions
If you already have a diagram that shows all required information, you may include it, rather than this page, with your
Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify
locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular
spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak
detectors; and in-tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan
was prepared.
Page _of_
05/00
"
SWRCB, January 2006
Spill Bueket Testing Report Form
This form is intended for use by contractors performing annual testing ofUST spill c;ontainment structures. The completedform and
printoutS from tests (if applicable), should be provided to thefacility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: HP GO GO MINI MART 1 Date of Testing: 10/10/06
Facility Address: 3301 WIBLE RD I BAKERSFIELD CA 93309
Facility Contact: DILLON T Photie: 661-397-4553
Date Local Agency Was Notified of Testing : 10/3/06
Name of Local Agency Inspector (ifpresent during testing):
z. TESTING CONTRACTOR INFORMATION
Co iJName: ACE PETROLEUM SERVICES INC
Technician Conducting Test: RON ROGERS
CJ:edenti~J: II CSLB Contractor II ICC Service Tech. 0 SWRCB Tank Tester
License Number(s): I b /? /#J z.. I a:.. tf:;- ~ Z
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: II Hydrostatic o Vacuum o Other
Test Equipment Used: Equipment Resolution:
IdentiiY Spill Bucket (By Tank 1 2 3 4
Number, Stored Product. etc.) 87 89 91
Bucket Installation Type: o Direct Bury o Direct Bury o Direct Bury o Direct Bury
il'Contained in Sumo ~ Contained in Sumo II Contained in Sumo o Contained in Sumo
Bucket Diameter: 12" 12" 12"
Bucket Depth: 12" 12" 14"
Wail time between applying
vacuumlwater and start of test:
Test Start Time (To: 9:00 AM 9:00 AM 9:00 AM
Initial Reading (RO: 10" 10 112ft ~4"
Test End Time (TF): 10:00 AM 10:00 AM 0:00 AM
Fmal Reading <RF): 10" 10 112" 4"
Test Duration (T F - To: 1 HR 1 HR HR
Change in Reading (Rp- R.): P k> 0
PassIFail 'Iln'eshold or
Criteria:
Test Result: II Pass o Fail !I Pass o Fail II Pass o Fail o Pass DFaU
Comments - (include Uiformation on repairs made prior to testing, imd recommended follow-up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONSmLE FOR CONDUCI1NG THIS TESTING
IIIereby certIh thflt tlll the bifo ell in this report is 1nIe. accurtIte. and in fuR complilmce with legal requirements.
Technician's Signature:
Date: /0-/0 -D~
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
SYSTEM SETUP
- - - - - - - - - -
OCT to. 2006 9:00 AM
SYSTEM UNITS
U.S.
SYSTEM LANGUAGE
ENGLISH
sYSTEM DATE/TIME FORMAT
NON DD YWYHH:MM:SS xM
HP GO GO 909 ""'>'.::;;\
3301 WIBLE RD
BAKERsFIELD CA 93309
661-397-4553
":"{~Nl~~v~II:1~i;~!?1f!f)~r~'tBM~jli\ ,....
SHIFT TIME 3 : DISABLED
SHIFT TIME 4 : DISABLED
TANK PER IODJC; WARNINGS
,'.:.fA~~k~~.;;~~'t~~w:r<,tu
DISABLED . '. ....
LINE PERIODIC WARNINGS
DISABLED
LI NE ANNUAL WARN I NGS
DISABLED
PRINT TC VOLUMEs
ENABLED
TEMP COMPENSATI ON
VALUE CDEG F ): 61:) ~O
STICK. HEIGfff OFFSET:>
D I SABl.ED
DAYL I GHT SAV I NG TI ME
ENABLED
START DATE
APR WEEK 1 SUN
START TIME
2: 00 AM
END DATE
OCT WEEK 6 SUN
END TIME
2:00 AM
SYSTEM SECURI TV
CODE : 000000
. -.--....-------
IN-TANK SETUP
- - - - - -
T 1: UNLEADED
PRODUCT CODE
THERMAL COEFF
TANK DIAMETER
TANK PROF I LE
FULL VOL
71.3~JNCH VOL.
47.$ INtH\lOL
23.8 INCH VOL
: 1
: .000700
: 95.00
4 PTS
1 0371
8227 .
. .0186<
2034
'.'FLC>A1',:SJ2E:"4.0 .IN,.8496
-.::":::_--,..,::--,::_,:;:-,-.....,.;,::,.,~:.:._.
. . -.-. -'-. .-..-.:....-.:...--: ,....:.::..:~:.:.:..:..,':::.<:::.;:>.. "'--".-. :---...._-....._-.
WATER WARNING : 2.0
HIQHi_~li~14F,;i~,Yi,
OVERFILL LIMIT 9004
9333
HIGH PRODUCT 9~
9852
--":;;~'.",~
:~~~~~2:.,
LOW PRoDUCT : 275
LEAK ALARM LIMIT: 99
SUDDEN LOSS LIMIT: 50
. .iJ.f{,f~ ';i'J2:;~5
Tit: NONE ... ...............-
LEAK MIN PERIODIC:
1~.
1037
LEAK HI N ANNUAL 10%
. 1 ()37
PER I OD I C TEsT TYPE
STANDARD
ANNUAL TEST FAIL
ALARM DISABLED
PER JODI C TEST FAIL
ALARM DISABLED
GROSS TEsT FAIL
ALARM DISABLED
ANN TEST AVERAGI NG: OFF
PER TEsT AVERAGI NG: OFF
TANK TEST NOTI FY : OFF
TNK TST SIPHON BREAK:OFF
DELIVERY DELAy : 15 MIN
'. ...--------
T 2:PREMIUM
PRODUCT CODE
THERMAL COEFF
TANK DIAMETER
TANK PROFILE
FULL VOL
71.3 INCH VOL
47.5 INCH VOL
23A3 I NCH VOL
: 2
; . 000700
95.00
4 PTS
10371
8227
5186
2034
FLOAT.~_I~:4~O IN. 8496
WAJE~{WARNI NG : 2.0
,.0;;HI'GH WATER Ll M IT; 3 . 0
MAX OR LABELV2f.;r 0371
OVERF Ill'1'hW;': 9O:~
9333
-!;;~jd.~~f.~i:fIt 95%
9852
10%
,1037
..{
,
DELIVERY LIMIT
-;j~;~;;j~~~~~~~[.~i-~r~i~;0.:,
;;. SUDDEN LOSS LIMIT:
f TANK TILT
'.275
99
50
5.45
I Of:-;
10%
1037
tl'!~~~~{fi1'l\i!_~
. - .. . ..
ANNUAL TEST FAlL
ALARM DISABLED
.,:-'~~
~U~~-~~tW'LED
GROSS TEST FAIL
ALARM DISABLED
ANN TEST AVERAGING: OFF
PER TEsT AVERAGING; OFF
TANK TEST NOTI FY : OFF
TN}{ TST SIPHON BREAK: OFF
DELIVERY DELAy : 15 MIN
'-<I.
co_______
T 3: PLl.JS
PRODUCT CODE
THERMAL COEFF
TANK DIAMETER
TANK PROF I LE
FULL VOL
71.3 INCH VOL
47.5 INCH VOL
23.8 INCH VOL
: 3
: .000700
95.00
4 PTS
10371
8227
5186
2034
fL.~TSlZE: 4.0 IN. 8496
",:,:;""".",::,,::,"::,,,,,,,--:..;...;...
HWATER'fWARt.fi'NG.\: '. . 2.0
HIGH WATER LIMIT: 3.0
MAX. OR LABEL VOL: 10371
OVERF I LL 0 L 1t1!T.,:" 9OV4....
:~fl~~~Jt~8&lTI;~*,;;'!'\f,1,tttt=!~tl/C'"
DELIVE~ LIMIT' 10%
037
.
SUDDEN LOSS LIMIT:
TANK TILT . :
MANIFOLDED TANKS
T#: NONE
LEAK MIN PERIODIC: 10%
1037
LEAK HI N ANNUAL 1 0%
1037
PERIODIC TEST TYPE0'- . .... .....
STANDARD
ANNUAL TEST FAIL
ALARM DISABLED
PERIODI.;:0~ti~~I~I~;;r
G_=';~I~.
ALARM DISABLED
ANN TEST AVERAGI NG: OFF
PER TEST AVERAGI NG: OFF
TANK TEST NOT I FY: OFP.G"
TNK TST SIPHON BREAK : OFF
DELIVERY DELAY : 15 HI N
~-"-'''''-'''"''"'------'--
ALARM HISTORY REPORT
;/ ----- SENSOR ALARN
L I:DISP 1-2
DISPENSER PAN
FUEL ALARM
OCT 10. 2006 9:20 AM
FUEL ALARM
NOV 18. 2005 10:33 AM
FUEL ALARM
AUG 27. 2005' 9:35 AM
LEAK TEST METHOD
TEST WEEKLY
SUN
stART TIME
TEST RATE
DURATION
: ALL TANK
: 12: 00 AM
:0.20 GAL/HR
: 2 HOURS
LEAK TEST REPORT FORMAT
NORMAL
* * * * * END * * * * *
''l:'I'-2iiJIDSENsoR SETUP
. '. :~'::;:.~\
c.:.....'...'.........:......;.................~,.....,.......;'.....:rl........'...~..........',..........'.D...,. ..J...'.P1>"'................ ~2,..."..:.<>.::'..'::';..r:.. '.. .
".....""...~-"".ESJ;~10.E.:'FIWAT )
'cATEGORY ''blSPENsER PAN
. ....}i;hE.;{'~;;S:Bif&~J;S:XH.
TRJ-STATE(S
CATEGORY: DISPENSER PAN
ALARM HISTORY REPORT
, ",j;iQJ~~~.t~E
{'}\l5ISPEN5
FUEL ALARM
OCT 10. 2006
L 3:87 STP
TRI-STATE (SINGLE FLOAT>
C.
9:21 AM
FUEL ALARM
..N9\(J~~.~~~tfA..(:~5.A~7;..........
MAY 24~2004 3:13 PM
L 4:91 STP
TRJ79.Te.TE (SINGLE FLOAT)
.ii~Tfg<:>R'I:;STP SUMP
L 5:89 STP
TRI-STATE (SINGLE FLOAT)
CATEGORY: STP
'" '" '" '"
OUTPUT RELAY SETUP
R 1: POS I TI VE SHlJTDOWN
TYPE ~
STANDARD
NORMALL V CLOSED
.<"ch~RM HI STORY REPORT
L-:-'0:77':- SENSOR ALARM --___
3:av.STP
STP SuMP
FUEL ALARM
OCT 10~ 2006 9:16 AM
FUEL ALARM
NOV 18. 2005 10:29 AM
FUEL ALARM
f1AV 24. 2004 3:07 PM
LIQUID SENSOR ALMS
ALL : FUEL ALARM
ALL : SENSOR OUT ALARM
ALL : SHORT ALARM
~~~/'- {ic
ALARM HI STORY REPORT
----- SENSOR ALARM
L 4:91 STP
STP SUMP
FUEL ALARM
OCT 10. 2006 9:18 AM
FUEL ALARM
NOV 18. 2005 10:31 AM
FUEL ALARM
MAY 24. 2004 3:08 PM
* * * * * END * * * * *
ALARM HISTORY REPORT
----- SENSOR ALARM
L 5:89 STP
STP SUMP
FUEL ALARM
OCT 10. 2006 9:19 AM
FUEL ALARM
NOV 18. 2005 10:19 AM
FUEL ALARM
MAY 24. 2004 3:08 PM
/,U~
_~4:V.~.-
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* * * * * END * * * * *