HomeMy WebLinkAboutfmc result 2009. '~_~~,~s'
'~ a~~ 35 S~
MONiTORING SYSTEM CERTIFICATION
For Usc Bv All Jurisdictions Within the State of California
A~~thurrry CiJed: Chuptcr G.7, Hcctlth cind Sufery Code; Chapter 16, Divisinn 3, Tirle 23, Califi~rnia Cnde aJRegulutiurts
This form must be used to document testing and scrvicing of monitoring equipment. :~ seqara[e certification or repor~ musc be~repared for cach
~~ionitorin~ystem eonlrol t~anel by the technieian ~r~ho performs the worfc. A copy of this form must be pro~•~ded to the tank sysrem ownerioperator.
`fhe owner.-operator mus[ submit a copy of this form to the local agency rcgulating US"i' systems within 30 days of ecst date.
A. Generallnformation
f~acility Name: JOHNNY'S ARCO Bldg. No.:
Site Address: 2612 BUCK OWENS BLVD. City: BAKERSFIELD Zip: 93308
Facility Contact Person: HAING YAM Contact Phone No.: (661) 326-1309
Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 1121/20U9
B. lnventory of Equipment Tested/CertiCed
Chcck thc annrooriatc huzrs tu indicate ~nccifir rnuinmrnt incnrrird/srrvirrd~ ~I(..n)= ~ (~'F n'TA~~
Tunl: ID REGULAR 87 Tank ID: 87 SIPHON
~ In- I'ank C;auging Prnhe. 'vtodel: MAG ~ In-T~nk Gaugm~ Probe. Model: MAG
~.Annular tipace or ~'ault Sensnr. 'vlodel: 409 ~ Annular Space or Vxult Sensor Mudel: 409
~ Pipin~, Sump :"I rench tiensor(sl. Model: 208 ~ Niping Sump %Trench Sensor(s). Model: 208
^ Fill Sump Sensor(s). Model: ^ Fill Sump Sensor(s), Model:
~ Mc~hunical Line Leak Detrcwr. Mudel: FX DIAPHRAM ^ Mechanical Line Leak 1)etector. Mndel:
^ Glecironic Line Leak Uetecror. Model: ^ Electronic Line Leak Detectur. Model:
~'fank O~•er~ill / Hi~h-Lc~cl Scnwr. Model: FLAPPER ~ Tank Ovrrlill i Hi~h-Levcl Sensor. Model: FLAPPER
^ Othcr (ipcci~y ~yuipment type and model in Section E on Page 2). ^ Other (specify eyuipment n~e xnd model in Section F. on Page 2).
"1'ank ID: PREMIUM 91 Tank ID:
~ In-"Iank (lauging Prohz. Modcl: MAG ^!n-Tunk Gaugmg Prubc Model:
~ Annular Spuci ur Vauli tiensor. Mndel: 409 ^ Annuiar Space nr \'auli tien;nr. Model:
~ Pipiilg Swnp Trcnch Sensor(s). Model: 208 ^ Pipin~ Sump •' I rench Sznsorlsl. Modcl:
^ I ill Simip Scn~urls). Model Q Fill Sump tiensnr(s). Mudel:
~ Mechanical Linc Lcak Dcleciur. ;vludel. FX1V ^ Rlechanical I.ine Lr~k I)eieciur. Model:
^ I-:lec[ronic I.inc Lesk Dcicciur. Model. ^ F:lectronic Line Leak I)etector. Model
~ I'ank Qveiiill i Iligh-LrvCl Sensur. Mudcl: FLAPPER ^ Tank Overlill ! High-Level Seruur. Mudel:
^ bther (s~~e~i(y cyuipmrnt type ~nd muJel in Section ~ on f'age 2). ^ Uther (specify equipment type and mudrl in Sectiun L un Page 2).
Dispenser ID: 1/2 Dispenser ID: 3/4
~ Dispeiuer C'nntainment Se~isorls). Mudcl 406 ~ Uispenser Cnntainment Sensur(sj. Model; 406
~ Shcar Vahcysl ~ Shcar Val~•e(sl.
^ f~i,pciurr Containineni I~loat(s~ a~id ('ha~n(:) ^ Uispenser Cbitilainment I loati~/ and C'hain(sl.
Dispenser IU. 516 Dispenser ID 7/8
~ I>ispcnscr C'bnt~inment Sensor(s). ~1odel; 406 ~ pispenser C'antaminent Sensurlsl. MoJr{: 406
~ Shear \'alvc~;) ~ Shcar Vuhc(;)
^ l~ispzn;er C'ontainincnt f luat(s) ~nd Chain~s). ^ Dispcnscr Cuntainincnt Ploat(s) and Chain(sJ.
Uis3~enser ID: Dispenser ID:
^ Dispen>cr (: untuinmcnt Sensor(s). Model: ^ Dispenser Containment Sensor(s). A4odel:
^ S~II'~I' V~dI~'C(S~. ~ SFII'~i V;IIVI'~5~.
^ Dispenser Cuntainment I~luat(s) and C'hain(s). ^ Dispenser C'ontainmen[ Float(s) and C'hain(s).
~n mc taciuty contains morc tanks or dispensers, copy this form. Include information for every tank and dispenser al the facility.
~,. CCCtIfICal10^ - I certify that the equipment identitied in this document ~+~as inspected/ser~~iced iq accordance with the manufacturers'
Quidelines. Att~ched to this Certification is inf'ormation (e.g. manufacturers' checklists) necessary lo verif:v that this information is
correcl and a Plot Plan showing the la~•out of monitorin~ equipment. For an?• equipment capable of generating such reports, I have also
:ittached a cop~• of the report; (check all [hat npply): ~ System set-up ~ Alarm histor}• report
fechnician Name (print): STEVEN OBERT
Certification No.: A285311S1-603
Signature:
License. No.: 5261246-UT
Testing C:ompany Name: RICH ENVIRONMENTAL
Tcsting Company Address: 5643 BROOKS CT. BAKERSFIELD, CA. 93308
Page 1 of 4
Phone No.: (661 } 392-8687
_ Date of Testing/Servicing: 1l21/2009
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Monitoring S~~stem Certi6cation
D. Results of Testing/Servicing
Sottware Version Installed: 127.02
Complete ihe followinQ checklist:
~ Yes ^?~lo* is the audible alarm operational?
~ Yes ^ No* Is the visual alam~ operational'?
~ Yes ^ No* Were al] sensors visually inspected, fimctionally tested, and contirmed operational?
~ Yes 0 No* were all sensors installed at lowest point of secondary containmen[ and positioned so that other equipment will
nut interfere with their proper operation?
[J Yes ^ Nu* If alarms are relayed to a remote monitoring station, is all communications eyuipment (e.g., modem)
~ N%A uperational'?
~ Yes ^ No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment j
~ N;q rnoniloring system detects a leak, fails to operate, or is elecrrically disconnected? If yes: which sensors initiate I
positive shut-down? (Check all thar apply) ~ Sump/Trench Sensors; ~ Dispenser Containment Sensors.
Did you confirm positi~~e shut-down due to leaks and sensor failure/disconnection'? ~ Yes; ^ No.
^ Yes ~ l~o'~ For tank syste~ns [hat ucilize the monitoring system as the primary [ank overfill wa~ming device (i.e., no
~~;~;q mechanical overfill prevention valve is installed), is the overfiil warning alain~ visible and audible at the tank
till point(s) and ope:ratiii~ properly'? If so, at what percent of tanlc capacity does the alarm trigger`? %
^ Yes* ~\'o Was any monitorin~ equipment replaced? lf yes, identify specific se~isors, probes, or other equipment replaced
and list the manufacturer name and model for atl replacement parts in Section E, below.
^ Yes* 0~o ~'~'as liquid found inside any secondary containment systems designed as dry systems? (Chcck u!! ~ha~ «pply)
^ Product; ^ Vvater. If yes, describe causes in Section E, below.
~ Yes [J No* Was monitoring systero se~-up reviewed to ensure proper settings'? Attach set up reports, if applicable
~ Ycs p No* ls all moni~oring equipment operational per manufacturer's specifications?
* In Section L belo~+~, describe how~ and when these deficiencies were or will be corrected.
E. Comments:
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a3~35 ~
Monitoriug System Certitication
F. ln-Tank Gauging / S1R Equipment:
~ Check this box if tank gauging is used only for inven[ory control.
^ Check this box if no tank gauging or SlR equipment is installed.
This section must be completed if in-tank gauging equipment is used to perform lea3c detection monitoring.
Complete the following checkiist:
0 Yes ^ Nu" Has all input wiring been inspected for proper enh~y and tein~ination, including testing for ground CauUs'?
p Yes ^ No* ~b'ere all tank gauging probes visually inspected for damage and residue buildup'?
^ Y~;s ^ No* Was accuracy of system product level readings tested7
^ Yes ^ i~~o* Was accuracy of system water level readings tested'?
^ Ycs ~ I~o* Were all probes reinstalled properl'y'?
^ Yes ^ No* V1ere all itetns oti t}~e equipment mariufacturer's maintenance checklist completed'1
" ln 5ection H, belo~v, describe how and when these deticiencies were or will be corrected.
G. Line Leak Detectors (LLD):
Cumnlete the followin~ checklist:
p Check this box if LLDs are not installed.
~c Yes 0 No* ror equipment start-up or annua[ equipment certitication, was a leak simulated to verify LLD perfon~iance?
p~'~q (Check ull that opply~ Simulated leak rate: ~ 3 g.p.h.; ^ 0.1 g.p.h ;^ 0.2 g.p.h.
~ Yes ^ No* Were all LLDs conYu•med operational and accurate within regulatory requirements'?
~ Yes ^ No~` W~s the testing apparatus properly calibrated'?
~ Yes ^ No* ]=or mechanical LLDs. docs the LLD resaict product flow if it detects a leak?
^ N;A
^ Yes 0 No* For electronic LLDs, does the turbine automatically shut off if the LLU detects a leak'?
~ V%A
^ Yes p ~u" For elecu~onic LLDs, does thc aubine automatically shut off if any portion of d~e monitoring system is disabled
~ v;q or discomiectcd'?
^ Yes ^ No* For electronic I.LDs, does die turbine automatically shut off if any portion of the rnonitoring system malfunctions
~ N,q or fails a test?
^ 1'es 0 No* For electronic LLDs, have all accessible wiring connections been visually inspected'?
~ N~~
~ 1'es ~ No* Were all items on the equipment manufacturer's maintenance checklist completed?
" ln Ject[on H, below, describe how and wtien these deficiencies were or will be corrected.
H. Comments:
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Monitorink Systei-- Certification F'orm: Addendum 1'ur Vacuun~/Pressure Intcrstitial Sensors
1. Results uf Vacuum/Pressure 1~lonitoring Equipment Testing
'fhis pa~r shuuld be used ro docwnent testin~ and servicin~ of~ vacuum and pressure interstitial sensors. A copy of
thi~ lorm must be included wich the Monituring System Certificatiein Form, which must be providrd to the tank
~ystem owneriopcrator. The owner/operator must submit a copy of the Monitoring System Certitication F~orm to the
local agency re~ulating UST systems within 3U days of test date.
Manufacturer: N!A Vlodel: System Type: ^ Pressure; ~ Vacuum
Sensor lD + ~L ,~ ~ ~~ ~'` "~'
~ Component(s) Monitored by this Sensor:
Sensor }~unctionality Test Result: ^ Pass; ^ Fail Interstitial Communication Test Resuh: ^ Pass; ^ Fail
Cumpon~nt(s) ~louitored b~~ this Sensor:
I
I
Sensor Functionality Test Result: ^ Pass; ^ Fail Incerstitial C'ummunication Test Resulr. ^ Pass; ^ Fail
I Componcnt(s) ~1onirored by this Sensor:
Sensor Functionali[y Test ftesutt: ^ Pass; ^ Fail [nterstitial Communication Test Result: ^ Pass; ^ Fail
Componcnt(s) Monitored bJ~ this Sensor:
Sensor Functionality 1"esc [tesulr. ^ Pass; ^ Fail Inters~itial Communication Tesi Resulr. ^ Pass; ^ Fail
Component(s) Rlonitorcd b5' this Sensor:
~
~- Sensor Fiinccionality Tes~ Resul[: ^ Pass; ^ Fail Inters~itial Communica~ion Tesc Resulr. ^ Pass: ^ Fail
..
Component{s) Nlunitored by this Sensar:
Seitsur Functionali[y l est ltesult: ^ Pass; ^ Fail Interstitial Conununication Test Resulr. ^ Pass; ^ Fail
Curnponen[(s) :~•Ionitured b~' this Sensor:
Sensor Functionality Test Result: ^ Pass; ^ Fail [nterstitial C:onununication Test Result: ^ Pass; ^ Fail
Component(s) Nlonitored b~• tt-is Sensor:
Sensor Functionaliry Test Resulr. ^ Pass; ^ Fail Interstitial Communication Test Result: ^ Pass; ^ Fail
Compooent(s) Monitored b;~~ this Sensor:
Sensor Functionality "I'est Result: ^ Pass; ^ Fail Interstitial Commwlication Test Result: ^ Pass; ^ Fail
I ~ Component(s) Monitc~red b~ this Sensor:
~ ~ Sensor Pwictionality ~I est Resulr. ^ Pass; ^ Fail Interstiiia] Conunwiicacion Test Resulr. ^ Pass; ^ Fail
Ffow was interstitiul communication verified?
^ Leak Introduced at ~ar End of Interstitial Spxce;~ ^ Gauge; ^ Visual Ins~ection; ^ Ocher (Describe in Sec. J, helow~
Was ~•acuun~/pressure restored to operating levels in all interstitial spaces? ^ Yes ^ I~o (If no. dcsa-ibe i,~ Sec. J, belowy
J. Comments: N/A
Page 4 of 4
' it the seusor successfully detects a simulated ~~acuwn`pressure ]eak introduced in the interstitial space at [he furthesc poim from the
sensur, ~~acuum%pressi~re has been demonsn•ated to be commun~catin~ t}u-oughoin the inters[icr.
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a3~3S
~9onitoring S}~stem Certification
UST Monitoring Site Plan
Siie P,ddress: 2612 BUCK OWENS BLVD. BAKERSFIELD, CA. 93308
5a
4 ~S
~ ~ a
Date map was drawn: 1!21 %2009.
instructions
lf you alrcady have a diagram that show•s all reyuired information. you may include it, rather than this paer. with your Monitoring
Systern Certitication. On ~~uur site plan, show the ~eneral layout of ~anks and pipin~. Clearly iden[ify locations of [he following
l't~ll1~111C11t, if installed: monitorittg system control panels; sensors monitori~ig tank annular spaces, sumps, dispeiisrr pans, sp~ll
containers, or odirr secondary containment areas; mechanical or electronic line leak drtectors; and in-Eank liquid le~el probes (it used
ti~r leak derection). In the space provided, notc the dare this Site Plan was preparcd.
I ~.~~-OtG - ara
Page 4 of 4
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RI CH EN [~IRONMENTAL
5643 BROOKS CT. BAKERSFIELD, CA. 93308
OFFICE (661)392-8687 FAX (661)392-0G21
PRODUCT LINE LEAK DETECTOR TEST
WORK SHEET
~~V/0#:
FACILII'Y NAN[E: JOHNNY'S ARCD
FACILITY ADDRESS: 2612 BUCK OWENS BLVD. BAKERSFIELD, CA. 93308
PRODUCT LINE TYPE: PRESSUR~
j PRODUCT I LEAK DETECTOR TYPE TEST TRIP PASS
BELOW P.S.I. OR
; j SERTAL NL'MKER 3 G.P,H. FAIL
~
REGULAR
g~ L/D TYYE : FX1 V I ~
YES ~
10 P.S.I. ~
pASS i
SERT.4L N 089U ,
~
NREMIUM '
y~ L/D TYPE : FX1 V ~
~
YES l0 P.S.1. I PASS
~ I
- SLRIAL # 3486
i
I
I ~~p ~~~YP~ ~ _
YES
PASS
SERIAL M ~;~ FA1L
I
I
i L/D `I'YPE YES ~
i PASS '
SER1~L #~ rJ0 I~ FAIL
I CEf27'IFY THE AE30VE TESTS WC1ZE CONDUCTED ON THIS DATL ACCORDING TO RED
J.4CKET PUMPS FIELD TEST APPAR,~-TUS TESTING PROCEllURE AND L[MITATIONS.
THE ntECHANICAL LEAK DET~CTOR TEST PASS / rAIL IS DETERMINED BY USING A
LOW F1;OW THRESHOLD TRIP RATE OF 3 GALLONS PER HOUR OR LESS AT 20 P.S.I. I
ACKNO~VLEDCE THAT ALL DATA COI,LECTED IS TRUE AND CORRECT TO THE BEST
OF ~1Y KNOWI.EDGE.
TECI-INICIAN: S1'EVEN ORERT
S[C:VATL~RE: ~ DAT~: O1/21/09
a3~3 S sa
SWRCB, January 2006
Spill Bucket Testing Report Form
This' %ornr rs intc.~2ded J~r u.se by contrac•tors pc~Jnrming an~iuaJ lesting of UST spil! contninrnent s!~-uclure.+. The contpleeetl forn~ und
prr,itouts~ fi•nrn te.rt.s (if ctpplicable~, shoc~/d he provided to rhe facilit}~ owner/operruor fur scr6mir~a/ ro rhe locul,-egulntay ciKency
l. Fr1CILITY INFORMATTON
Pacility Name: 30HNNY'S ARCO Date of'Testing: U1'2U09
Facility Address: 2612 BUCK QWENS BLVD. BAKERSFIELD, CA. 93308
Facility Contact: HA1NG YANI Phone: (661) 326-1309
Date Local Agency Was Notified ofTesting : 12/11/O8
Name of Local Agency lnspector (if present dan~rng lestingJ: ERNIE MEDWA
2. TESTING CONTRACTOR INFORMATiON
Company Name: R1CH ENVIROI~MENTAL
Technician Conductin~ "1'est: STEVE;~ UBERT
Ca•edentials~: CSLB Con[ractor X 1CC Service Tech. SWRCB Tanl: Tester ~Uther (Spcc~Jy)
Licensr Nurnber(s): 52612~36-1~T
3. SPILL BI;CKET TESTING INFORMATIO~I
Test Method Used: X Hydrostatic Vacuum Other
Test Fquipment Used: VISUAL Equipment Resolu~ion: 0.00
__.
Identify Spill Bucket (By Tank
Niuribu~, Sturer! Producr, ecc.J 1
REGULAR 87-FII.L 2 PIiEM1IiJM 9]-
FILL 3
87-SIYHUN-FILL 4
Bucket Installation "fype: X Direct 13ury
Contained in Sump X Direct Bury
Contained in Sump ~ X Direct Bury
Contained in Sum Direct Bury
Contamed in Sum
Qucket Diameter: 12" 12" 12"
Bucket llepth: 12" I 12" 12"
Wail time between applying
vacuuilv~vater and s~art of test:
30 MfN ~
30 MIN
30 MI?~J
Test Star[ Time (Ti): 090U 0900 0900
lnirial Reading (Ri)~ 10" 10" ]0" I
Test End Time (TF): 1000 1000 1000
Final Readin~(RF): !0" 10" 10"
Test Duration (TF ~~ Tij: 1-HOUR 1-HOI:R ~ 1-}IOI;R
Change in Reading (RF- Ki): 0 0 U
Pass; Fail "I'hreshold or
Criteria: +I_ p.UU -~!- O.OU -~-: - 0.00
I
~
`1'est ltesult: X Pass LJ Fail X Pass ^ Fail X Pass 0 Fail G~ Pass C Fail
COI111t1CtttS -(inclc~de infoimcuron on r•epairs rncrde prior to testing, unrl recommended follow-iip forJuiled tests)
CERTIFICATION OF TECN~IIC[AN RESPONSIBLE FOR CONDUC7'INC `I'H1S TESTING
I hereby certlJj~ tha- nl! the i~rformutio~i co~rlained in this report is true, accurate, und in.~ul! co~nplin~rce voitl~ lega/ requirements.
~l'ecluucian's Sienature:_~~ ~ ~--} Date: OU21i09
~ State la~vs and regulations do not currendy rrquire testing to be performed by a qualified contractor. f lo~.ever, local requiremen~s
rnay bc rnorr spin~ent.
?UGUCT COliE . 3
~EkMAL COEFF :.UUt770u
ahJ}; U 1 AMETEk . 92 . UO
at~K PkUF 1 LF . 4 PTS
FULL VOL : 11b27
69.U INCH VOL : 9438
46.0 INCH VOL : 5814
~;i . 0 I Nc,H vGL : 1 I 70
~~JAT S I ZE :
~TER WARNINr '
] GH WATER L 1 f~l I T:
4X OR LABEL VOL:
JERF I l.L L I Nl I T .
IGfi ~F'iQI~UCT .
ELIVERY L[MIT :
PRODUCTyCOUE ~ . 2
THERMHL CGEFF :.uOU?Uu
THNK DIHhIETER . 92.Ou
TANK F~R~F I LE , 4 FTS
FULL VOI. : 1 1 E27
b9.u [NCH VOL : 9438
46.p INCH ~'OL : 5814
23.U INCH VOL : 2190
I
~
3.0 IN. ~ FLUAT SI?E: ,s.0 IN,
~~ •~ I l~l~;TER WARN 1 NG : 2. U
3.0 ' NIGH WATER LIP~IIT: 3.0
1 1 b27 MAx. OR LHE+EL ~/OL : l 1 E,27
~~~ C~VERFILL L1MIT . 90%
1U464 ~ . t0464
HIGH PRQliU+;T .
~ 95~~
11445
~ 1104.,
1~~ C~EL 1 VERY L l i°I [ T . ] 0%~
1200 . 1200
~W F'RODUI;T . 5d0
EAK ALARNI L I f°l 1 T: 95
UUUE IV LOSS L I fh I T: 50
~;NK TILT . 3.5U
RUBE UFFSET . 0.00 `
~'
1PHON IhANIFOLDED ?ANKa ';
u: NONE
1 IVE MAN 1 FOLDED TANA:S
q: NUNE ~~ ~
~
+LU~J PkUUUC:7' . 500
~ LEH}; ALr;Rh1 L[ hl I T: 99
~'UDUEfV LU ~'S L 1 I°1 I T: 50 i
TAhIF; T I LT • 4. 50
PRUBE OFFSET . 0.00 r
I
S I FHOPd f°lAN I FGLDED TANKS
T#: NUNE
I.1 fVE P'IAfJ 1 FOLUEL' TANKS
T#: NONE
_ ~G, ~i
1200 ~'
l0i
1200
1 fJ_THh~iK SETUP_ _ _ _ _ _
T I:UNLEADEU l ,
pF,t:~pUCT i npE • 1
THEkMA1. UUEFF : . UiJ07U0
TAP~lK D 1~IhETEk . 92 . 00
TANK PkGFILE . 4 PTS
FULL VUL : 11G27
69 . U I PJCH 'JflL : 9438
45.0 It~CH V~~L : 5814
2:i . U I tVi:;FI UdL : "1 9U
FLOAT' ~ 1 ZF. :
6JATER ldAkM I PJ~ :
HIGH wr~TER. LIrIIT:
IhHX Uk LABEL '~'UL
OUERF I LL L I f1 f T
H1GH F~k~?DUCT
UEL [ VEkY L 1 I°I I T
_ a3~ 36- - - - -~~° -
J~N ~l. '?u~79 ti:21
,~`r'aTEf°I UN I TS
U.S.
SYSTEM LANGUAGE
FNGLISH
SYSTEM PATE.: ~T 1 hIE FUkf°1r
C'IOfV UD YY',~Y HH:h1h1:S5
HkCV FHC 1 L I TY ~tt 1 36G
2t12 6UCK OW£ IVS BLVD
3.0 IN. BkKERSFIELD ~ H 933G8
tb1-326-1309
2.0
3.U SHIFT Tlf°lE l : t:UU ~
SH1FT TIME 2 : DI~~iBLE
11627 SH1FT T[ME 3 : DISHBLE
90o UHIFT T[ME 4 : BI~BLE
1 U4E;4
y5i THfdY F'Ek TST N£EliEU WF
11045 DISAFiLED
~pi THNK ANN TST N~EL~ED WF
1 ~pp iiIS~BLED
LOW F'kuUUCT : 5U0 .
LEAK hLhRM L! I°I [ T: 99
SUD~EN LOSS LIh11T; 50
TAPJK T i LT-y` • Q. 5U
PROBE OFFSET . 0.00 ~
~ .
S I PHOIV I~IHN I FULDEL~ 'tHPd}'~
T#: NuNE
L I NE IhA(d 1 FULDED T~NK~
Tp: NGIVE
EAh Ih I N FEk 1 UD I C: I Oi LEF~};._I"11 N. FEk I OD I C
. 1200 ~-
EAK. 1~11 N HNNUAL : 1 Oi i LEF1K I'11 N ANNIJAL :
. 1200
ERIUDIC: TE9T TYPE
STANDARD
IvIVUAL TEST FH 1 L. _
~~ ALARM UISABLED
Ek 1 GD ( C TEST Fr~ 1 L
ALAR11 D t SABi.ED
kUSS TEST FAIL
ALARM UISABLED
NN TEST AVERAGlIVG: OFF ~
ER TEST AVERAGING: OEF !
AhIK TEST hIGT I FY : OFF
hIK TST SIPHON BREAK:OFF ;
ELIUEkY UELAY : l5 MIN
UMP THkESHOLU : IQ.QO~
I
I--~
E-'
F-
~ O ~
O
~
'~ '
'~ '~
u
. a t
i. a u
. a
~ ~
41 ~ W 4.1 ~
~ .a Cn .~ u~ ~ ~n
~ ~ ?
~
a a a
-- F- -- F- - t-
-• i1~ U]
i -. N(f? U2 Ul if~
~ .
~ ~ .
~ ..
~ ~w ~w mw
E-~ ~ H .`~ F ~
~ a ¢a a~zac a¢a
~
!~
u ~
~
n ~
7
~
C
f.~
~ U
2 ~]~
7
C
• i W •• i.~il -• i W
I -" F~
~ ~~1 -- ~"7 -~ F-
tx2 ~YQ ~Y~L
~ .._7 f-~ C~ J E-~ U .-] F^ <>
LEryK f1I I•J FEk I OL~ I~~
IO". ~
12Uu
PER ] UD I C TEST T1'PE •" ~ L:EHk; I'9 [ W~NNUHL :
STtiNDARLi ~ "''~ ~ •
alVt~tUAL TEST FA 1 L
QLAkM DItihBLED
PERIOI>I•C TEST FAIL
~ ALAkf°l D i SAbLED
GROSS TE4~' FA I L
~,ALF~kht . D I SABLE'L
HIVN TEST F1VEF.AGIIV~: UFF
F~ER 7'E~ST AIIERHG I fVG : OFF
THP~K TEST NOTIFY: OFF
TI~~fK TST S 1 PHON BREAK :OFF
DELIVERY DELAY : 15 MIPJ
PUMP
-- THRE~ ~iOLU : 1-~J0%.- ,
---
-
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MONIT~R CERT. FAILURE REPORT
S17'E VAi'V1E : JOH~TNY'S ARCO DATE : 01/21/09
ADDRESS : 2612 BUC'K O~VE'.~TS BLVD. TECHNICIAN : STEVEN OBERT
CI7'Y : BAKERSFIELll SIGNATURE : C~~ '~~
THE FOLLOVVI?vG COMPONEI~`TS WERE REPLACED/REPAIRED TO CONIPLETE
TESTING.
ItEPA1RS : NONE
LAt30R : NONE
PAKTS INTAI_LED : NONE
NAME : T1TLE :
S1G\A`I~CRE :
THE ABOVE NAMEU YEItSUN TAKES FULL RESPONSIBILITY OF NOTIFYING
"fHE APPROYRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR
7'HE ABOVE LISTED PROBI,EMS AND NOTIFYING RICH ~1VVIRONMANTAL FOR
A'VY :VEEDED RETESTTnG. TEI1S ALSO RELEASES RICH ENVIRONMENTAL OF
AVY FINES OR PENALTIES OCCL;RING FROIVI NON-COMPLIANCE.
A COYY UF TH1S DOCUMEI~'T HAS BEEN LEFT ON-SITE FOR YOUR
COVV[ENENCE.