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HomeMy WebLinkAboutFMC 2008 . I IIIIIII VIII III IIII 49 o� IE Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htti7:l 1www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATiON For Use By All Judsd/ctfons Wlthln the State of Cefilom;e Authority Cited.Chapter 6.7, Health and Safety Code;Chapter 96, Division 3, Title 23, California Code of Regulations This form 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 technlclan who performs the work. A copy of this form must be provided to the tank system owner/operator. The ownerloperator 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 Clr Cu D���� _ _ Bldg.No.: Site Address:—LWJ B�Glri�. S`} 1 C C�. City: , l r / zip: Facility Contact Person: Contact Phone No.:( MakelModal of Monitoring System: J;16 Id Date of TestIVServicing:� 2 B, Inventory of Equipment TestedfCertified Check the a ro riate boxes to indicatespecific equipment insl ected/serviced: Tank ID! I Tank ID: V In-Tank Gauging Probe. Modal TSjV L12 U In-Tank Gauging Probe, Model, Cl Annular Space or Vault Sensor, Model: ❑ Annular Space or Vault Sensor. Model: _ F Piping Sump/Trench Senaor(a). Model (XX_ 0 Piping Sump I Trench Sensor(s). Model: 0 Fdl Sump Sensor(s). Model: ❑ FiII Sump Sensor(s). Model: yr Mechanical Line Leak Detector. Modek ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leek Detector. Moder: _ _ ❑ Electronic Line Leek Detector, Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill I Hlgh•Laval Sensor. Model: 0 Other(specify a ul meat type and model in Section E on Page 2). 0 Others equipment t e and model in Section E on Page 2). Tank 10: Tank ID; PP-In-Tank Gauging Probe. Model: 472 q In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor, Model; ❑ Annular Space Dr vault Sensor. Model: J15� Piping Sump/Trench Sensor(s). Model;______. C. ❑ Piping Sump 1 Trench Sensor(s). Model: 0 FIII Sump Sensor(s). Model: 0 FIII Sump Sensor(s). Model: 0 Mechanlcah Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: ❑ Electronic Llne Leak Detector, Model: 0 Electronic Line Leak Detector, Model: 0 Tank Overfill I High-Level Sensor_ Model: _.._ .J ❑ Tank Overfill 1 High-Level Sensor, Model: 0 Oth"pecify equ I ment twA and model in Section a on Page 2).- ❑ Other(spectfyaquiament=9 and model in Section E on Page 2), Dispenser 10, Dispenser ID: f�-Dispenser Containment Sensor(s). Model•110WEigaftak, 4V�l Vg ❑ Dispenser inment Sensor(s). Model: ,j4- Shear Volvo(&). ' D Shear Valve(s). ❑ Dis nser Containment Floats and Chains. is nser Containment Floats and Chal s. Dispenser 1D: Dispenser ID: _ 4r Dispenser Centainmant aor(s). el: ❑ Dispenser Contain man(Sensar(s), Model: p.' Shear Valve(s). U Shear Valve(s), Disvenser Containment FloaLsj and Chain(s). ft 0 Dispenser Containment Floats and Chains. DispenserlD: Dispenser ID; __ 40 Dispenser Containment Sensor(s). Model: D Dispenser Containment Sensor(s). Model: pl Shcar Valve(s). ❑ Shear Valve(s). Qii enser Containment Floats and Chain(s rl Die enser Containment Float(s) and Chains. 'lt the fadity 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 Inspoetedlserviced to accordance with the manufacturers' guidelines. Attached to this Cerliflcatton Is information(*.g.manufacturers'eheckltets)necessary to verity that this Information Is correct and a Plat Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): f2 System set-up C1�Xaarrrn history roport Technician Name(print): 1rLLC2 UX A}7C Signature:?:A•e&, It,-%k s& Cortificatlon No.:_'12G( .. _SI-/ � Lloonse.No.: 7RY17o/} Testing Company Name: B Phone Testing Company Address: t 1�� l �2t•Z.j&aj�rC Date of Testing/ServiclnD: r �/�� Monitoring System Cerdfleation Page 1 of 4 121D7 1 2/21/07 11111/1111 / 50 1 E t?. Results of TestingfSeMcing Software Version Installed; Com latathefollowin g checklist: es n No Is the audible alarm operational? Or Yes 17 No' is the visual alarm eparatrona Yas ❑ NW Were all sensors visual► Inspected,functional tested,and conflrrnod operational? �F Yes ❑ No` Were all sensors installed at lowest point of secondary oontainment and positioned so that other equipment will not interfere with their proper operation? n Yes D iro' If alarms are relayed to a remote monitoring station.Is all communications equipment(e.g.modem)operational? b N/A vl� Yes ❑ No' For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system ❑ WA detects a leak.fails to oparata,or is oladrieally diseonnaetad? If yes:which sensors initiate positive shut-down? (Check on that apply) Dr•Sump/Trench Sensors; ❑ Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failureldlsconnectlon? It Yes'. ❑No. i i Yes ❑ No' For tank systems that ublize the monitoring system as the primary tank overfill warning device(i.e.no mechanical overfill prevention J� NIA valve is installed),is the overfill warning alarm visible and audible at the tank PoI point(s)and operating properly? If so,at what percent of tank capacity does the alarm t er? % ❑ Yes` {! No Was any monitoring equipment replaced? If yes, Identify specl0c sensors, probes, or other equipment replaced and list t a manureoturer name and modal for all replacement parts in Section E below_ N Yes, n No Was liquid found Inside any secondary containment systems designed as dry systems? (Check all that apply)❑Product; 0 Water, If describe causes In Section E below, 0.� Yes ❑ No" Was monitoring System set-up reviewed to ensure proper dattings?Attach set up reports,if applicable X Yes ❑ W Is all monitoring equipment operational per manufacturer's specifications? In Section E below,describe how and when these deficiencies were or wgl be corrected. e. Comments: �,)SA?a�/ utmawhf Ode Inmhtj— &LO.0 fur !�h_7 +•__stp sw"P?5.xr i 4yl 6 e Y elMBVa. Monitoring System Certification Page 2 ota 12/07 2 2121/47 F. In-Tank Gauging/SIR Equipment; ❑ Check this box if tank gauging is used only for inventory control. 0 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. Complete the following ohecklist: 9 Yes 0 No' Has all input wiring been Inspected for proper entry and termination,including testing for ground faults? P Yes ❑ No' Were all tank gauging probes visually Inspactad for damage and residue buildup? at Yes ❑ No' Was accuracy of system product level readings tested? EX Yes ❑ No' Was accuracy of system water level readings tested PC Yes ❑ No' Were all probes reinstalled properly? X Yes 0 No' Were all Items on the equipment manufacturer's maintenance checklist completed? • In the Section H,below,describe how and when these deftctencies were or will be corrected. G. Line Leak Detectors(LLD): 0 Check this box if LLDs are not installed. CompAjet4followinac hecklist: Yes n No` For equipment start-up or annual equipment certlticatlon,was a leak simulated to verify LLD performance?(Check all ❑ NIA that apply) Simulated leak rate: g 3 g.p.h.; ❑0.1 g.p,h; u 0.2 g.p.h. f� Yes 0 No' Were all LLDs confirmed operational and accurate within regulatory requirements? j&- Yes ❑ No' Was the testing apparatus properly callbratad? Yes ❑ No' For mechanical LLDs,does the LLD restrict product flow if it detects a teak? n N/A 0 Yes 0 o` For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? It NIA 0 Yes 0 No' For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or W NIA discwnnected7 n Yes 0 No' For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system mathmetlons or p.. NIA fails a test? ❑ Yes ❑ No' For electronic LLDs,have all accessible wiring connections been visually Inspected? k NIA jr Yes 0 No• Were all items on the squlpment manufacturers maintenance checidiat completed? ♦In the Section H,below,describe how and when these deficlencles were or will be corrected. H. Comments: Monitoring System Certification Paga 3 of d 12ro7 3 2121107 i 40 Monitoring System Certification UST Monitoring Site Plan Site Address; �ZII Q/4441 shsl[ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . I . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $fit/. . . . . . . . . . . . . . . . . . . . . . . . I . I . . . . . . I Vie : : : : : : : : : : : : : : : : : : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date map was drawn:_17_l_z1_/z_Wx. 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 sita plan,show the general layout of tanks and piping. Geary identify locations of the following equipment,if installed: moniWring system control panels; sensors monitoring lank annular spaces, sumps, dispenser pans, split containers, or other secondary conta;timment areas; mechanical or electrordc line leak detectors; and in-tank liquid level probes (if used for leak detection). In the space provided,note the date thla Site Plan was prepared. Monftoring Systerh Certification Page 4 of 4 12107 4 2/21/07 CVE Cal-Valley Equipment 3500 Gilmore Ave. Bakers}?eld, CA 93308 661-327-9341 F'AX#661-325-2529 V.A,FORLESS MANUFACTURING,INC. LDT-890 Leak Detector est Rec d Contra custom Q'1/—y%'/�eLy sv_ui�merrt CirCJe Del' Date Lacaaon Pict jj�G_ 129/ ✓;1 S*fC ,¢I/2. I Kr s <°L4>r '(yL. �/I& Te-4hnician Submtersible)Pump Identification Manufacturer Model No. Serial Number Rekc�k& Leak Detector Identification Manufacturer Desafatiott Other_Style Leak Detector p, C&e f_ Diaphragm-type Piston-type d.— Tamper-proof seal installed? Yes No Leak Detector in Submersible laamp Test at Dispenser 1. Operating Pump pressure 26' psi (para. 15) 2. Gallons per hour rate 3.D (Para.22) 3. Line pressure with pump shut off I V psi (pare.23) 4. Ble-edback Test with pump oft' S D ml (pars.26) 5. Step-through time to fitll flow seconds(para.30) 6. Leak detector stays in leak search position.(para.42) Yes 6� No LEAK DETECTOR TEST Note: Pane-beak deteow tits test protocol Fail =Leak detector faits test protocol Pam L Fail Form 89OC(9-1-96) *ConV]ft thermal expansion test before failing leak detector. 1996 Vaporless Manufacturing,Inc.,Prescott Valley,AZ CVE Cal-Valley,Equipment 3300 Gilmore Ave. Bakersfield, CA 93305 661-327-9341 FAX#661-325-2529 VAPORLESS MANUFAC'T'URING, [NC. LDT-890 Leak Detector Test Record Contractor Custo[rter 0f-yaillt'r Ffu4jot"Cot Cljlf PC/i Date ocatxora P,roduc 9-29 wog NJ6' Golden Star due. t3aKeecyc,&4 L'a. $7(14 Technician `- �3ru.ce Submersible ftmp IdentiBeatto q Manufacturer do el No. Serial Number /�¢�!jctClk'ET Leak Detector Identiffeatl.oln Manufacturer Aesc1129 Other Style Leak Detector 964ia Gk-e t Diaphragm-type _ Piston-type ! Tampm-proof seal installed? Yes No Leak Detector in Submersible Pump Test at Dispenser 1. Operating Pump Pressure— psi (para, 15) 2. Gallons per hour rate 3.o (Para.22) 3. Line pressure with pump shut off_ psi (para.23) 4. Bleedback Test with pump off 5.S nil (para.26) 5. Step-through time to full flow 3 seconds(part.30) 6. Leak detector stays in leak search position.(para.42) Yea .�- No LEAK DETECTOR TEST Note., Pau-Leak der fits test protocol Pail -i,cak detector tails roar pr ot )Pass t/ Fail Form 890C(9-1-96) 'Complete thermal expansion test before failing leak detector. 1996 Vaporless Manufacturing,Toe.,Prescott Valley,A7 $WRCB'January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing anneal testing of UST spill containment structures. The completed form and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Date of Testing: Facility Address: C Facility Contact: Phone: Date Local Agency Was Notified ofTesting; Name of Local Agency Inspector(fpresenI during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: /k/e Technician Conducting Test: t lr/. p CredcntialsT: J�CSLB Contractor 0 ICC Scrvicc Tcch. 0 SWRCB Tank Tester 0 Other(Sped) License Number(s): 7C W70,# 3. SPILL BUCKET TESTING INFORMATION Test Method Used: 04iydrostatic 0 Vacuum 0 Other Teat Equipment Used: Equipment Resolution; Identify Spill Bucket(By Tank I 2 3 4 Number,Stored Produce,etc.) PZ CIL (!L Bucket Installation Type: it Direct Bury TVirect Bury 0 Direct Bury IJ Direct Bury 0 Contained in SuMe 0 Contained in Sump 0 Contained in Sump 0 Contained in Sum Bucket Diameter: 4 Bucket Depth; Wait time between applying vacuum/water and start of test: Test Start Time(Ti): ;t Initial Reading(AT): ts" y Test End Time(TA Final Reading(RF): Test Duration(I'T:—TT): Change in Reading(RF-R;): Pass/Fail Threshold or Criteria: .25 • (�. Test Result: a Pass []Fail ®-Pass 0 Fail 0 Pass 0 Jail 0 Pass 0 Fail Comments—(i);clude information on repairs madeprior to testing,and recommendedfollmw�-up for ailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTJNC THIS TESTING I hereby Bert&that all fhe information contained in this report&true,accurate,and in full compliance poith legal requirements. Technician's Signature: �. ­4- „✓ Date: z9-2gPK T State laws and regulations do not currently requite testing to be performed by a qualified contractor.However,local requirements may be more stringent CAL-VALLEY E12UIPMNT 3500 Gi3.m=e kvems �3- Bab%refield, CA 93305 x.61-327-9341 'FaL661-325-23-59 NAME: _Ci rc k Deli � 1m1E#1: qI VL XCHWOM: Q% .►��, - A=e%: Qlaleh 4ve. UNE#2: 0-7 tfL. uCZ � 9L•1.10 CRY,g: .Gct. UNE ft w DA*: Mite the +e dwwjww uwus rime(-i 5 1,wgcn wo omw ro rQhffft lla 4M%maw=vt rye ro p0t M Pw ha=. ltd COr3+l�n OOR6f�'A Ls�li9ei�t�0 i1'IflI�Ii 17:70�9f�t Ott. , PRCDUO WE PS! swva(iJ ) (tNUNVL vr�[�, (anL Gf4 moss PM FAX UIL .os s4 :Z30 �.� 1 — 1 J( :20 Sv 226 2� 2 y r! c�aaes: _7-4 I PRODUCT MUE PO 9M VCL w IpgLl �&t VOL E�9f r. GPH QW&OSS PM FAL C/� :34 J_0 Q 6 i t SD 13 ,o c:o�tna�l�s: - J vwwx IFRCDJ= WE PSI swMXIMU (MLI GM GAMM P�6 f§�1L I declare under pulalty of PO4u y that I am a I10e869d tank tester In the State of CaIllon la and that the informatlon contained In this report is true ond correct to the best of my knowledge. -�- Vii•. CAL-VALLEY EQUIPMENT 3500 GILMORE AVE. BAKERSFIELD, CA 93308 CAL-VALLE (661)327-9341 FAX: (661)325--2529 EQUIPMENT CONTRACTOR'S LIC.#784170 A HAZ Fax _ &Z� k4t. From. Fax; C�' o�/ � Pages: INCLUDING COVER Aft Date: ❑ Urgent ❑ For Review 0 Please Commant ©Ple"o Reply Q Phase Recyda Comments: