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Home My WebLink About1830 FLOWER ST (3) MONITORING SYSTEM CERTIFICATION IIIIIIIIIIIIIIIIIII 71 For Use By All Jurisdictions Within the State of California IE Authority Cited: Chapter 6 7,Health and Safety Code; Chapter 16,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 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 foim to the local agency regulating UST systems within 30 days of this date. A. General Information Facility Name: Kern Medical Center Bldg.No.: Site Address: 1830 Flower Street City: Bakersfield Zip: 93305 Facility Contact Person: Leann Victory Contact Phone No.: 661-326-2482 Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: 11/2/2010 B. Inventory of Equipment Tested/Certified Check the appropriate oxen to indicate specific equipment inspected/serviced: Tank ID: 1500 gallon Diesel AST Tank ID: 10000 gallon Diesel UST n In-Tank Gauging Probe. Model:847390-107 U In-Tank Gauging Probe. Model: 847390-107 Lx] Annular Space or Vault Probe. Model:794390-420 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: LX] Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s) Model: U Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: [x] Tank Overfill/High Level Sensor. Model:847390-107 L] Tank Overfill/High Leval Sensor. Model: 847390-107 ❑ Other(specify equip.type and model in Sec.E on Pg.2) ❑ Other(specify equip.type and model in Sec.E on Pg. 2) Tank ID: 2000 gallon Diesel AST Tank ID: [x] In-Tank Gauging Probe. Model:847390-107 ❑ In-Tank Gauging Probe. Model: Lx] Annular Space or Vault Sensor. Model:794390-420 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensors(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Decector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Lx] Tank Overfill/High Level Sensor. Model:847390-107 ❑ Tank Overfill/High Level Sensor. Model: ❑ Other(specify equip.type and model in Sec.E on Pg.2) ❑ Other(specify equip.typs and model in Sec.E on Pg.2) Dispenser ID: 10000 gallon End Sump Dispenser ID:_Day Tank 325 R] Dispenser Containment Sensor(s). Model: 794380-208 [x Dispenser Containment Sensor(s).Model: 794380-208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s) Dispenser ID: Day Tank 100 Dispenser ID: [x] Dispenser Containment Sensor(s).Model: 794380-208 ❑ Dispenser Containment Sensor(s).Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chains(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s).Model: ❑ Dispenser Containment Sensor(s).Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(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 inspected/services in accordance with the manufacturers'guidlines.Attached to this Certification is information(e.g.manufacturers'checklist)necessary to varify that this information is correct and a plot plan showing the layout of monitoring equipment.For equipment capable of generating such reports,I have attached a copy of the report;(check all that apply) ❑x System Set-up Ex j Alarm history report Technician Name(print): Kristopher Karns Signature: A Certification No: B34106 License No: 804904 Testing Company Name: Confidence UST Services,Inc. Phone No: 800-339-9930 Site Address: 1830 Flower Street,Bakersfield,CA 93305 72 _Date of Testing/Servicing: 111212010 I IIIIIII VIII III IIII IE D.Results of Testing/Servicing Software Version Installed: 324.03 Complete the following checklist: U Yes ❑ No* Is the audible alarm operational? x Yes No* Is e Visual alarm operational? x Yes No* Were all sensors visually inspected,functionally tested,and confirmed operational? x I Yes ❑ No* Were all sensors installed at the lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? Yes No* If alarms are relayed to a remote monitoring station,is all communications equipment(e.g.modem) Hx N/A operational? Ll Yes ❑ No* For pressurized piping systems,does the turbine automatically shut down if the piping secondary L]N/A containment monitoring system detects a leak,fails to operate,or is electrically disconnected?If yes: which sensors initate positive shut-down? ❑Sump/Trench Sensors❑Dispenser Containment Sensors Did you confirm positive shut-down due to leaks and sensor failure/disconnected? E] Yes; ❑ No; [x] Yes ❑ No For tank systems that utilize the monitoring system as the primary tank overfill warning device(i.e.no [-1 N/A mechanical overfill prevention valve is installed),is the overfill warning alarm visual and audible at the tank fill point(s)and operating properly?If so,at what percent of tank capasity does the alarm trigger? 90 I % Yes* ❑ No Was any monitoring equipment replaced?If Yes,identify specific sensors,probes,or other equipment replaced and list the manufacturer name and model for all replacement parts in Section E,below. ❑ Yes* U No Was liquid found inside any secondary containment systems designed as dry systems? ❑Product; ❑ Water.If yes,describe causes in Section E,below. Tx] No* Was monitoring system set-up reviewed to ensure proper settings?Attach set-up reports,if applicable. x yes No* I Is all monitoring equipment operational per manufacturer's specifications? *In Section E below,discribe how and when these deficiencies were or will be corrected. E. Comments: I replaced the Overfill Light Bulb,and replaced the OPW spill bucket drain valve. After the repairs were made they were retested and confirmed operational. F. In-Tank Guaging/SIR Equipment: M Check this box if tank guaging is used only for inventory control. ❑ Check this box if tank guaging or SIR equipment is installed. This section must be completed if in-tank guaging equipment is used to perform leak detection monitoring. Complete the following checklist: Cx] Yes ❑ No* Has all input wiring been inspected for proper enter and termination including testing for ground faults? x Yes M No* Were all tank guaging probes visually inspected for damage and residue buildup? x Yes No* Was accuracy of system product level readings tested? x Yes No* Was accuracy of system water level readings tested? _Jxj Yes No* Were all probes reinstalled properly? Yes ❑ No*I Were all items on the equipment manufacturer's maintenance checklist completed? *In the Section H,below,describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): U Check this box if LLD's are not installed. Complete the following checklist: ❑ Yes ❑ No* For equip.start-up or annual equipment certification,was a leak simulated to varify LLD performance? (Check all that apply) Simulated leak rate: 03 g.p.h.: 00.1 g.p.h.; ❑0.2 g.p.h.; ❑ Yes No* Were all LLD's confirmed operational and accurate within regulatory requirments? Yes No* Was the testing apparatus properly calibrated? ❑ Yes No For machanical LLD's,does the LLD restrict product flow if it detects a leak? N/A ❑ Yes No* For electronic LLD's,does the turbine automatically shut off if the LLD detects a leak? ❑ N/A ❑ Yes No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system is ❑ N/A disabled or disconnected? ❑ Yes 0 No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system ❑ N/A malfunction or fails a test? ❑ Yes No* For electronic LLD's,have all accessible wiring connections been visually inspected? ❑ N/A Yes No Were all items on the equipment manufacturer's maintenance checklist completed? *In the section H,below,describe how and when these deficiencies were or will be corrected. H. Comments: SYSTEM 2ETUP - - - - - - - - - - - NOV 2. 20110 8:01 All - .-OMHU SETUP N I CAT 1 04-p - - KERN 111F.TliCAL QENTER SYSTEM UNITS - - - - - - - - - - 1830 FLOWER ST. U.S. BAKERSFIELD-CH 93305 iYSTEM LmNGUA1'E PORT SETT I N(3S: 661-3226-2 4 02 ENGL f SH SYSI'a'l DATE.,TICIE FORMAT ("IF FOUND F40V 2• '1,wIfj 8:01 vtl 111ON bit HHP'Il-I.SS Al YEPN MEDICAL CENTER 100 FLOWER ST. SYSTEM ST;iTlJ,_.', REPORT DAVEK3F I ELD.t'A 93305 -Ell[, OF - - - - -- - - - - - - - HLL FUNC.1*I ONS NORMAL SHIFT TIME I DISABLED 111VENTORY REPORT -,)ilF1' TIME c D I SABLEP SHJ FT TIME '3 DISABLED SHIFT TIME 4 DISABLED T I :D I ESEL VOLUME 1 0�41 UHLS TAN): PER TST NEEDED ORN LJLLAIaE 4 R CHLS 11 ISABLED 90% ULLAGE- 327 GALS TAN), fANN TST NEEDED WRN ,rc VOLUME - 1020 C-;ALS DISABLED HE I GHT - ''3.21 1 1110HES WATER VOL - 0 GALS. LINE RE-ENABLE METHOD WATER . 0.00 1 NcllrS ALARM AC-KNOWLEDCE TEMP = 66.1 DEC; F LINE PER TST NEEDED WRN D I SABLED T 2:DIESEL 2 LINE ANN TST NEEDED wRii VOLUME = 62.39 GALS DISABLED ULLAGE 3469 90W# lJI_1.A%;E- 2516 OAU*:� PRINT To VOLUMES TG VOLUME - 62'01 GALS ENABLED HEIGHT = gr 5 � .96 INCHES 14A,rER voL - 0 GALS TEMP t'_,'GNPE1-1:3iiT10N WATER = 0,00 1 NCHES VAUJE (DEC; F ) : 60.0 TEMP = 73.4 DEC F STlvY, HEIGHT OFFSET, 1)1 SABLE11 DAYLIGHT SAVING TIME T 3:2000 DIESEL ENABLED VOLUME - 733 GALS START DATE ULLAGE = 1267 GALS APR WFEY I SU14 904 ULLAGE- 1067 GH L S START TIME Tr, VOLUME = 730 GALS 2:00 AM HEIGHT = 21 .61 1 NCHES END DOTE WATER VOL cl (;ALS (1c.1, WEEI,' 6 SUN WATER = 0.00 1 N1**HES END T HIE TEMP = 65.2 DEG F co AM X � ok A ok ENCI W A A SYSTEM SECUR I TY CODE : Ociooriri CUSTOM ALHPM LABELS DISABLED IN-TANK SETUP - - - - - - - - - - - T 2:DIESEL 2 T 3:2000 DIESEL PRODUCT CODE 2 PRODUCT CODE 3 T I :D I ESEL THERMAL COEFF 000450 THERMAL COEFF : .0004SO PRODUCT CODE 1 TANK DIAMETER 91.00 TANK DIHMETER : 60.00 THERIb;L COEFF : .000450 TANK PROFILE 4 PTS TANK PROFILE . 4 PTS TANK G I AI-iETEP 16.00 FULL VOL 9726 FULL VOL : '-1000 TANK PROFILE I PT 72-.0 INCH VOL 8246 45.0 I NGH VOL : 1500 FULL VOL 1502 48.0 INCH VOL 5149 30.0 INCH VOL : 1000 24.0 INCH VOL : 1935 15.0 I N4,::11 VOL : 500 FL(:,Kr cF': 4.0 IN. FLOHT SIZE: 4.0 IN. FLOAT SIZE: 4.0 IN. WATER WHRN I rK: 2.5 H I H WATER LIMIT: :i.U WATER I4ARN I NC'. 2.5 WATER WARNING 2.U HIGH wHTER Llrll'f: 3.0 HIGH WATER LIMIT: 3.0 NW'}C OR LABEL VOL: 1502 OVERFILL LIMIT 90: MAX OR LABEL VOL: 9728 MF4N OR LABEL VOL: 2000 1351 OVERFILL LIMIT 9G. OVERFILL LIMIT 90% HIGH PRODUCT 95% 8755 1800 1426 H I C:H PRODUCT 95%, H I GH PRO10'.7' 95% DELIVERY LIMIT 50% 9241 1900 751 DELIVERY LIMIT 25`•e DELIVERY LIMIT 251' 2432 500 LOW I)kJDUC'f 500 LEAk: ALARM LIMIT: 99 LOW PPODL, ,'T 1000 LOW PP,ODUs:T 500 SUDDEN LOSS LIMIT: 99 LE14: ALARM LIMIT: 99 LEAK HLARM LIMIT: 99 TANK TILT 1 .70 SUDDEN LOSS LIMIT: 99 SUDDEN LOSS LIMIT. 99 PROBE OFFSET 0.00 TANK TILT 0.00 TANK TILT 0:00 PROBE OFFSET 0.00 PROBE OFFSET 0.00 S I PHON M4141 FOLlIED TANKS Tit: NONE SIPHON MAN[FOLDED 'TANKS 9IPHO14 MAN1FOLOED TANKS LINE MANIFOLUEE, TANKS TO: NONE TO. NONE TV: NONE LINE 11HNiFOLDED TANKS LINE MANIFOLDED TANYS Tr<: 14014E Td: NONE LEAK MIN PER,101'',1 C': iar 0 LEHY M I N PERIODIC: W. LEAX MIN F'Lk I OED I C: 0%, O LEAs; N I N (1WI4UAL : on 0 LEAK P1114 ANNUAL 04 LEAF. MIN HNNUAI. O a , 0 0 PER 101)1C `f!yC TYPE yTHNC44RTi PERIODIC, TEs f TYPE PERIODIC: TeST TYPE i;,JANDAPEi STNND ikE- ANNUAL. TEST FAIL ALARM E,I:?•r;RLED ANNUiAL TEST PHIL ANNUAL TEST FA I L AI.APM DISABLED AUiM1 U 1 SiABLECI PERIODIC" TE:>T F1;1 L AI.NRM U I S ABLEU PERIODIC TEST FAIL PER 1 OC,PC TEST FAIL ALARV U I SkBLED ALARM El I rSiABLED GRO:S8 TrST FH 11_ HLHRI.1 DISABLED GROSS 'PEST FA 1 L 43RO jS TEST FAIL ALARM I')I i N8LFG ALAF•M V I:.ABLEU ANN TEST iVERHC I N{:: i)FF PER TEST AVERWj I W-;: OFF :;NN TEAT AVERkC:I Nu: OFF i;NN TEST AVERH::I NG: OFF PER TEST AVERAVING: OFF PER TEST HVERH�1NG.,: OFF TANY TAT NOT 1 F`d: OFF TANK TEST NOTIFY: OFF TANK TEST NOTIFY: OFF TNI: TST SIPHON BREAK:OFF TNK TST S 1 PHON BREI-N::OFF TNI: TST SIPHON BREAY.:OFF DEL I VE1tY UE1.HY - ! MIN PULP THRE2HOLD : 10.001: DELIVERY DELAY i MIN GEL I VERY DELAY ! MIN P'UMF' THRES;FHILC 10.00% PUMP THRESHOLD 10.00': LEHI: TEST METHOD AUARt1 H1S1'UR'1 REPORT OUTPUT RELAY SETUP "TEST PICINTRLY HLL TANK - - - - - - - - - - - - - SEPt3t)R Ht Rhi -~--- WEEK I NON - ' STATT 'C1Iv ; 2:01) AN L I :Tr1Nl': 1 ANNULAR SPACE R i :T3 2000 G I ESEE. ANNUI-AR SPACE TEST PATE :0-20 "hL. HR TYPE: DURATION . - HOUR'S STANDARD FUEL ALARM : HLHRI-i H I STORY NEPO SEIJSOR ALARM --- SEW;OR 1iLHRM ----- L 5:2000 ANNULAR SFhCE 1. 3:111U SUMP ANNULAR SPACE OTHEF SFNSORPj FUEL ALARM FUEL. ALAK1 JUL 30, 2010 8:19 AM AUG 1?. 2009 8:30 AM SE14SOR OUT ALARM FUEL ALARM APR 17, 2'010 10:li9 PM DEC 5. 2000 9:19 AM SENSOR OUT ALARM FUEL ALARM APR 17. 2010 10:''35 FM NOV 20. 2007 1 :02 PM END � x .• � � � E:ND . a , a ALARM H i s,rORY REPORT Ftit,rlRi1 Ht�-rrop,,, REr'GR•r -_°-- SENSOR wLfIRII - -- L 6:DT 32,5 L 4:E1D IJI'1F' OTHER SENSORS OTHER SE.NSOR:1 FUEL ALARM rUI L ALARM NOV 220, 21007 1 :40 Pill .JUL 30- 2010 10:01 HH SENSOR OUT ALARM FUEL ALARM 140V I q. 2007 1 1 :0:'► All JUL 30. 2010 10:00 All FUEL HLARM FUEL ALARM VVUV 14. 20117 9:$o H4'1 JUL 30. 2010 10;00 A1•1 A R n : END w 7a x k E ^ END ALARM HISTOPY REPORT SEtisop L~7 LET l 0 L 31:111r., SUMP 01•HEP SEWORS OTHFY.- 8FW-ORS: SENSOR OlfF ALABI FIJEL it-F;r,•m JUL 30. 2010 7:31 AM NOV 201U 6:50 (Al SENSOP OUT ALAKII JUL 30. 2010 7:301 N1 SENSOR OUT HLARM JUL 30• 2010 7:30 41 SXlT-,0P AtAkil L 2*FILI. WIP FoEl. AL�,Pil 2, 211 l'o. 17:51 rif°i X X w END L 6:91' 325 giick sEmDoF.:1 RIEL ALARM MOV 2. 2010 6:54 Al 1, 7:ril, I t10 OTHER FUEL hf.mFm NOV 2010 e:47 N-1 o-112'OR mLiARN L I :'I*rkl,)K* I ANNULAR FUEL. mlrKM IIIOV 2. '20 1(1 13:57 AM FUEI i-ibik-m NOV S ONNULAP SNit-M FLIL7L ALARM NOV 2'. 201 9:U2 tit? T 2:DlF-l'>EL 2 H1-3H I ROLII.V'T ALARM NOV 2. 2010 9:07 P11 SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual 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: Kern Medical Center I Date of Testing: 11/2/2010 Facility Address: 1830 Flower Street, Bakersfield,CA 93305 Facility Contact: Leann Victory Phone: 661-326-2482 Date Local Agency Was Notified of Testing: 10/13/2010 Name of Local Agency Inspector(ifpresent during testing): Ernie Medina 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. Technician Conducting Test: Kristopher Karns Credentials: X CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester ❑Other(Spec) License Number(s): CSLB#804904 ICC 45264406-UT SWRCB#09-1743 3. SPILL BUCKET TESTING INFORMATION Test Method Used: x Hydrostatic ❑Vacuum ❑Other Test Equipment Used: Lake Test Equipment Resolution: 0.0625" Identify Spill Bucket(By Tank Diesel Test#1 Diesel Test#2 Number, Stored Product, etc) Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury X Contained in Sump X Contained in Sump ❑Contained in Sump ❑Contained in Sum Bucket Diameter: 11.00" 11.00" Bucket Depth: 11.50" 11.50" Wait time between applying 5 min. 5 min. vacuum/water and start of test: Test Start Time(Tj): 9:00am 11:00am Initial Reading(R,): 10.00" 10.25" Test End Time(TF): 10:00am 12:00pm Final Reading(RF): 7.00" 10.25" Test Duration (TV—Tj): 1 hour 1 hour Change in Reading (RF-IQ: 3.00" 0.00" Pass/Fail Threshold or 0.0625" 0.0625" Criteria: TestResult ® ass XFail X Pass ®Fail ® asses ❑Fail P s ❑Fail z ,, Zvi--;,,. :. Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) The original spill bucket test failed. I replaced the OPW drain vave, then Retested the spill bucket and got passiny- results. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. Technician's Signature: LA k�6�� Date: 11/2/2010 State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. CONFIDENCE UST SERVICES, INC. 417 Montclair Street,Bakersfleld,CA 93309 800-339-9930 or 661-631-3870 : FINAL TEST RESULTS : ALERT 1000 / ALERT 1050 / TEI LT-3 CUSTOMER ADDRESS : WORK ORDER:24465 SITE ADDRESS: Kern Medical Center Kern Medical Center 1500 Mt. Vernon Avenue TEST DATE: 11/2/2010 1830 Flower Street Bakersfield, CA 93305 Bakersfield, CA 93305 SITE CONTACT:Leann Victory PHONE NUMBER:661-326-2482 TECHNICIAN: Kristopher Karns PHONE NUMBER;661-393-9330 LICENSE: WATER IN 13ACKFILL: NA DATE & TIME OF LAST FUEL DELIVERY:NA TANK INFORMATION: (WETTED) TANK 1 TANK 2 TANK 3 TANK 4 PRODUCT TYPE: Diesel TOTAL GALLONS: 10000 Gal. PRODUCT LEVEL: PERCENT FULL: TEST METHOD: WATER IN TANK: TANK MATERIAL: P.S.I.@ BOTTOM: TEST DURATION: FINAL LEAK RATE: TEST RESULT: TANK INFORMATION ALERT 1050X ALERT 1050X ALERT 1050X ALERT 1050X (ULLAGE)U/F ONLY ULLAGE GALLONS: START PRESSURE: END PRESSURE: TEST RESULT: PRODUCT LINES : TEI LT-3 TEI LT-3 TEI LT-3 TEI LT-3 LINE TYPE: Suction START TIME: 10:30am END TIME: 10:45am TEST PRESSURE: 20 psi FINAL LEAK RATE: -0.002 TEST RESULT: Pass MECHANICAL LEAK DETECTORS : MODEL: SERIAL NUMBER: CHECK VALVE PSI: BLEED OFF ml: LEAK RATE TESTED: TEST RESULT: A) These s stems and methods meet or exceed the criteria in USEPA 40CFR parts 280, NFPA 329-87 and all applicable state codes. B) Any failure listed above may require further action, check with all regulatory agencies. Technicians signature: Date: Manufacturer Cdgrti£ication No: an /or ` Kristopher Karns 1�'.0/op Alert:2008011 TEI : LT-098 GO�FID4 Ust TZY •�»�, M.,�,. Invoice No.: 24465 Site: Kern Medical Center 1830 Flower Street Bakersfield, CA 93305 Repairs Requested: Repairs completed: Replaced the OPW Drain Valve on the Diesel Spill Bucket. I also replaced the Overfill Light Bulb. Required Repairs, Still Pending: Technician Name: Kristopher Karns Signature:. Date: 11/2/2010