HomeMy WebLinkAbout2010 RESULTS MONITORING SYSTEM CERTIFICATION 3wj�m
For Use By All Jurisdictions Within the State of California
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 seoarate certification or report must be prepared for each
monitoring 2EM 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. f
A. General Information 111111111111111111111111 05
Facility Name: MIKES FOOD 8t LIQUOR IE Bldg.No.:
Site Address: 2300 PANAMA LANE City: BAKERSFIELD Zip:
Facility Contact Person: MIKE Contact Phone No.:
Make/Model of Monitoring System: INCON TS1000 Date of Testing/Servicing: 11/812010
B. Inventory of Equipment Tested/Certified
Check the a ro ' to boxes to indicate s tic Equiement ins ivied:
Tank ID: UNLEADED Tank ID: PREM91
®In-Tank Gauging Probe. Model: MAG ®In-Tank Gauging Probe. Model: MAG.
®Annular Space or Vault Sensor. Model: LSD ®Annular Spas,or Vault.Sensor. Model: LS-3
®Piping Sump/Twich Saisor(s). Model: LS4 ®'Piping Sump I TT=ch Sensor(s). Model: LS4
❑Fill Sump Sensor(s). Model: ❑:Fill Sump Sensor(s). Model:
®Mechanical Linc Leak Detector. Model: RED JACKET . ®Mechanical Line Leak Detector. Model: RED JACKET
❑Electronic Line Leek Detectea, Model: ❑Electronic Line Leak Detector. Model:
®Tank Overfill/Higb-Level Sensor. Model: FLAPPER. O.Tank Overfill/.High-Level.Sensor. .Model: FLAPPER
❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and mode:in Section E on Page:2).
Tank ID: DIESEL Tank:ID:
®la Sank Gaugurg'Probe: Model: A1AG ❑In-Tank Gauging Probe. Model:
®Annular Space or Vault Sensor: Model: LS-3` ❑Annular Space or Vault Sensor. Model:
®Piping Sump/Trench Sensor(s). Model: LS4 ❑Piping Sump/Trench Sensor(s). Model:
❑Fill Sump Sensor(s). Model: ❑Fill:Sump Sensor(s). Model:
®Mechanical Line Leak Door.
Model: RED JACKET ❑Mechanical Line Leak Detector. Model`:
❑Electronic Litre Leak Detector. Model: ❑.Elec pnic Line Leak Detector. Model:.
®Tank Overfill/High-Level Sensor.. Model: BALL VALVE ❑.Tank Overfill/High-Level Sensor. Model-
El
Other(speetfy cquipment.type.and model in Section E on Page 2). ❑Other(specify equipment type and:model inSecdbn.E,on Page 2).
Dispenser ID: 112 Dispenser IDi 314
to Dispenser Containment Sensor(s). Model: 406 ®Dispenser Containment Sensor(s). Model: 406:
®Shemrvalvo(s). ®Shear Valve(s).
i
❑'Dispertser:Containmeat Float(s)and Chain(s). Dispense`Containment Float(s)and Chain(s):
Dispenser ID: 516 Dispeeser'ID: 718
®'DisPenser Cattairtatent Sensor(s). Model: 406 ®Dispenser Containment Sersor(s). Model: 406
®ShearValve(s). ®She-Valve(s).
❑Di cawContgamentFloat(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s).
Dispenser ID:
Dispenser ID-
❑DispgrwrCoutaitm=fSeosor(s). Model: 0.134enserContsimcmSersor(s). Model:
❑Shear Valve(s). ❑'Shear Yslve(s}.
❑: CmWmnentFloat(s)and:amin(s),:. ❑.Dispenser Containment Fioat(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.. Certffi.Cation-I certifq that the equipment identified in this.document was inspected/serviced in accordlance;with the.manufacturers'
guldelines. Attached to this Certification.is`information je.g, manufacturers' checklists) necessary to verify'that°this information is
correct and a Plot`Pian showing the layout of monitoring aipment. For,any equipment capable of generating,such reports,;I have also
attached a copy of the report;(check all that any}; System set-up Alarm,,hhistory yreport
TechnicianName:(prirtt): RICHARD MASON Sigtiattite:
Certification No.:. 8 x2 I t�31402_
(AT-License.No.: C611 D40 809850
Testing Company Name: 'RICH ENVIRONMENTAL Phone No::(661):3264402`
Te 'C Address: 5643 BROOKS CT.BAKERSFIELD,CA 93308 Date of T
sting ompany esting/Servicing: 111812010.....
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IE
Monitoring System Certification
D. Results of Testing/Servicing..
Software Version.Installed:
Complete the:following checklist:
® Yes ❑ No* Is the audible alarm operational?
® Yes ❑ No* Is the visual alarm operational?
• Yes ❑ No* Were all sensors visually inspected,.functionally tested,and confirmed.operational?
• Yes p No* Were all sensors installed at 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 (erg:, modem)
® N/A operational?
Yes ® No* For pressurized piping._systems; does the turbine automatically shut down if the piping secondary'containment.
❑ N/A. monitoring system detects a leak,fails to operate,orris electricall y disconnected? If yes: which sensors initiate
positive shut-down? (Check all that.apply) ❑Sump/Trench.Sensors; ❑Dispenser Containment Sensors.
I Did you confirm positive shutdown due to leaks and sensor failure/disconnection? 0 Yes;.❑,No.
Yes Ip, No* For tank systems that utilize the.monitoring.system as. the primary tank overfill warning device (i.e., no
:Cg N/A mechanical.overfill prevention valve is installed),is the.overfill warning:alarm visible and audible at the tank `
fill point(s)and operating properly? If so,at what percent of tank capacity does the alarm.trigger? %
❑ Yes* ® No. Was any monitoring equipment replaced? if yes, identify specific sensors,probes,or other equip_ment replaced
and list the manufacturer name.and model for all replacement parts.in Section E,below.
,.❑Yes* ® No Was liquid found inside any secondary,containmentsystems designed as dry systems?'(Check all that apply)
❑Product; ❑Water. If yes,describe causes in Section E;below.
®.Yes ❑ No* Was.monitoring system set=up reviewed to ensure'proper:settings?Attach setup reports,.if applicable
® Yes ❑ No* Is all:monitoring equipment;operational:permarufacturer's specifications?
"In Section E below,describe how and when these'defciencies were or will`be corrected.:
K Comments; SITE HAS`NO POSITIVE SHUTDOWN OR FAIL SAFE'. MUST PERFORM ANNUAL LINE TESTING.
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Monitoring System Certification:
F. In-Tank Gauging[SIR Equipment: ® Check this box if tank gaugingis used only for inventory control.
❑ 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 checklist;
p Yes ❑.No* Has all input wiring been inspected for proper entry and termination,including:testing for ground faults?
❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup?
Yes ❑ No* Was accuracy of system product;level:readings tested?
Yes ❑ No* Was accuracy of system water level readings tested?
E3 Yes ❑ No* Were all probes reinstalled properly?
❑ Yes [j No* Were all items on the equipment manufacturer's maintenance checklist completed?
*]W"Section$below,describe hoW.and when these deficiencies were of will be corrected.
G. Line Leak Detectors(LLD): Q Check this box:if.LLDs:are not installed.
Com lete the follo checklist:
® Yes ❑ No* For equipment start-up or,annual equipment certification, was a leak simulated to verify ]LLD performance?
❑ 'NIA (Check aU dwi apply) Simulatedleak rate: E1.3 g.p h.; ❑0.1 g.p.h; ❑02&p:b.
0 Yes ❑ No* Were all LLDs:confamed operational and:accurate within regulatory requirements?
® Yes ❑ No' Was the testing'apparatus properly:calibrated?
® Yes ❑ No* For mechanical LLDs,does the LLD restrict product flow'if it.detects a leak?
D N/A
;O Yes ❑ No* For electronic LJ Ds,does the turbine automatically shut off if the LLD detects a leak?
® N/A
p Yes D No' For electronic LL Ds does,the turbine autornaticatly shut'off if.any portion of the:monitoring system is disabled
® :N/A or disconnected?
l] Yes ❑ No* For elec ibnac LEDs,does the:bAine automatically shut.off if any portion of the monitoring system-malfimctions
or fails,a test?
❑ Yes [] No* ForeleatronicLLDs,.have all accessible wiringconnectlons been visually inspected?,
® N/A
0.Yes O No". Were all items on the equipment manufacturer's maintenance checklist completed?
in Section'H,below,describe how and when these;deficiencies were-or will be corrected.
H. Comments:
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Monitoring Systtm Certification
S UST onitoring Site Plan
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T -. r _ _ . - • - - - - - - - .• _ - • - r. r .r _ • r - _ _ _ _ _ r. • • _
Date u;ap was drawn:/4'
Ins'�ctions
If you alrem ly,have a diagram that shows all required information;you may.include it,rather than this pag-,'w ith your
System:CertificatimL On you-r site Plan,show the enmal
Mani y p $ layout oftanks and pip' :Clearly.identify
dentify
Locations o the following equipment, if installed:monitoring system control panels;sensors monitoring tank annular
spaces,SUMPS,dispe =pans,spill containers,or other secondary containment areas;mechanical or electronic line lcak
detectors;and in-tank liquid level probes(if used-for leak detection).In the space provided,note.the.date this:Site Plan
was prepared..
Y. , page of
o5,Co
RICH ENVIRONMENTAL
5643 BROOKS CT. BAKERSFIELD, CA. 93308
OFFICE (661)392-8687 FAX.(661)392-0621
PRODUCT LINE LEAK DETECTOR TEST
WORKSHEET
W/0#:
FACILITY NAME: NUKES FOOD& LIQUOR
FACILITY,ADDRESS: 2300 PANAMA LANE,BAKERSFIELD
PRODUCT LINE TYPE: PRESSURE
PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS
BELOW P.S.I. OR
SERIAL NUMBER 3 G.P.H. FAII.
87 LID TYPE: RJ DIAPHRAM YES i0 PASS
SERIAL#UNREADABLE
91 L/D TYPE: .RJ FX1V YES 10 PASS
SERIAL# UNREADABLE
.DIESEL IM TYPE: RJFXIDV YES 10 PASS
SERIAL# 3243
LID TYPE: YES PASS
SERIAL# NO FAIL
I CERTIFY THE ABOVE TESTS WERE CONDUCTED ON THIS DATE ACCORDING TO RED
JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND LIMnATIONS.
THE MECHANICAL LEAK DETECTOR TEST PASS/FAIL IS DETERMINED BY USING A
LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONS PER HOUR OR LESS AT 10 P.S.I.I
.ACKNOWLEDGE THAT ALL DATA COLLECTED IS TRUE AND.CORRECT TO THE BEST
OF MY KNOWLEDGE.
TECHNICIAN RICHARD MASON
SIGNATURE: DATE: I l/&l0
Spill Bucket Testing Report Form SWRCB,Jaauary2006
This form is intended for use by contractors performing annual testing,of UST spill containment structures. The.completed form and
printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory.agency:
1. FACILITY INFORMATION
Facility Name: MIKES FOOD&LIQUOR Date of Testing: .11/8/10
Facility Address: 2300.PANAMA LANE
Facility Contact: MIKE Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector(if present during:testing): ERNIE MEDINA
2. TESTING CONTRACTOR INFORMATION
Company Name: RICH ENVIRONMENTAL
Technician Conducting Test: RICHARD MASON,
Credentials': ❑.CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(specify).
License Number(s): 5297857 UT.
3. SPILL BUCKET TESTING INFORMATION
Test Method;Used: X H drostatic ❑Vacuum. 0 Other
Test Equipment Used:VISUAL Equipment Resolution:0
Identify Spill Bucket(By Tank 1. 2 3. 4
Number,Stored Produck etc) ' 91.FILL DIESEY
Bucket Installation Type: X Direct Bury X Direct Bury X Direct Bury .0 Direct:Bury
❑Contained in Sum .0 Contained in S ❑Contained in Sump ❑Contained in Sump
Bucket Diameters 12" 12" 12"
Bucket Depth: 14" 44" 10"
Wait.time:'between applying 30 MIN 30 MN 30 MIN
vacuum/water and start of test
Test Start Time(T�: 9:00 9:00 9:00
Initial Reading(R.): 10" 10" 10"
Test End Time(Tr): 10:00 1.0:00 10:00,
Final Reading.(RF): 10" 10" 0
Test:Duration(TF-TO: 1-HOUR 1-HOUR 1-HOUR
Change inReading(RF- 0 0 10"
Pass/Fail Tlueshold..or +"/-0:00 +/=0:00 +/-0.00
Criteria:
CoIDmentS— include information on r airs made prior to testing;and recommended allow-u or ailed�tests
( �. eP P � .f Pf .� � )
r
DIESEL BUCKET FAILED TEST NEED NEW BUCKET
CERTIFICAT ION.OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
thereby certify that all the information contained in thb.report is true,accurate,and in full eampliance with
legal requirements.
Technician's Signature: Date: 11/8/10
'State laws and regulations do not currently require testing to be performed by;a qualified contractor.However'local:regnirenients
mIay be'more Stringent.
SCHD INUTRY im,LLY ll�ti/:'t.b1► s7>i�L� Ii NI
Ti ME INO T R t2: In rm SYSTEM SETUP ki ruUk'i
TIME2 1WR i,4;00 Hi9
TIME3 INvTR Irma Hri SOFTWARE QEk$iuN 0-vvlu
SLFiD IN:VRC UHlLY
TIME1 INORC 5;66 Hm LOCATION i �t1Kta
T IME2 INORC. t:to rig LOCATION 2 UNULHL
TIME3 INU12.C. 40:00. PI9 STREET 'I Lana
SCHD DLHST mint STREET 2 PANAMk LHKt
7IME1 DLHST 14:0U w14 CITY 1 SAKtic�ritw
iY;.00 Ht1 CITY 2
(IME2 DLHST
TIMES OLHS T 1:an Hii STATE Lw
SCHD ALNSi r+iint ZIP CODE. �Janr
TIME1 :A"h.ST r:e=n6 Am SITE � 6nan1
TITE2 ALHS:T iZ;ou :sir►
T1ME3 ALHST 12;iW Hm VOL UNITS 6MLLUMb
STD ALARM SCHD ACT AL Nurit LEVEL UNITS iniMta.
ALARM 1 UN TEMP UNITS FAMRENntlI
TI�IEI HtrT:AL 1[ an H('1
ALARM 2 uN T I ME2 AC T AL 12;t..b Am TIME STYLE 1[ Muut(
ALARM 3 UN TIME3 ACTHL i .�utl Am PATE STYLE 1411glriilYY
ALARM 4 UN SCHD ALST Nunt 60LIGHT SAO tlihdLtV
ALARMS UM T 1 ME1 AL671 12:k0b H11 SET T I:Mr zs:lG wrl
ALARM 6 urr TIi7Ei ALST ii;ar ►ii9 SET .DATE 210 110
ALARM 7 urr TIMES ALST 14'.00 mil
ALARM 8: urr NO. TANKS
CONFIDENCE y�,e, - LEAK LIrrI z•�b
STD RELAY THEFT LlMi- !10.mv
ALAkM I urr LEAK 1E,S;G �•.ia DELIV LIM1 tae.en
SCHD TEST
ALARM 2 urr TANK 1 Nvnt SNT.NL MODE Urr
ALARM 3 u.N i TANK 2 Nunt START SkTNL 1z:nn kl9
ALARM 4 Urr ;O
TANK 3: Nvnt END SNTHL iz ld kit
ALARM 5 urr TIME TEST GEL IV. DELAY 1?
ALARM! 6 ur.r REPORT .DEL i) tNHe�LCu
TANK. P l:t:i;a H19
ALARM 7 urr TANK 2 i2:ah Ail REPORT ALRRS ENHbLtu
ALARM, 8 urr TANK 3' i2:06 H11 REPORT TES.T6 EN AbLty
NO-OF ALARMS 1�
STD ALARM PRINT INTERVAL la.vv
ALARM I. UNL -14MULHK TIMEOUT n
ALARM 2 SPLi T HNULUZ HIGH LIM urr MODE CHAN i NH'i ivt
-ALARM 3 UNL :SuOr LOW Lim ur r SAUD CHAN i
ALARM 4 3uiJ£K Sul'+r HIGH H"GH urr DATA BITS t
ALARM 5 GiES.EL Sumr STOP BITS 1. 1
LO:bl`L:UIJ urr
ALARM 6 s'ic b WATER LM urr PARITY 1 Non.
'ALARM ? Siv r LEAK LIK urr SECURITY i
ALARM 8 -6 u t
SYSFAIL HccESS. i
Urr
PHONE. 1 b4FJbbtlitl[
SENSOR TYPE THEFT lJhr REDIAL 1 EMHtiLtU
SENSOR i Si u RELAY ACCESS 2
SENSOR 2 Siv TIMEOUT la PHONE 2
SENSOR. 3 Z�-Iv HIGH LIM vrr REOIAL 2 Ui�AtLtll
SENSOR 4 b4 LOW LIM urr ACCESS 3
SENSOR 5 : lfv HIGH HIGH u'rr PHONE 3
SENSOR 6 5"+u LOW Lulu urr REDIAL 3 ui H Ltu
SENSOR 7 5'+u EJATER L i iti' urr ACCESS .4
SENSOR 8 5iv PHONE 4
LEAK LIM urr
S1?SFAIL urr REDIAL 4 DiSHrsLtu
THEFT Lit t* DIAL DELI►i 1
DIAL ALARM
DIAL LEAD
X x s x x x x x 3: x
14 JD
IAJ t QL -i S:
Im Ix (m Im Mac
04 ine N --r N N f.14 N.-i C114 2 "r-n °.`J-=
\ -= im -i Ujw *\ 11 at 11 F— w \ <X 11 rn \-ro
co -j N. 3e (n w ID w Po W fo 'm Q's co m -30
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cn
OAKSRSFIELD, GH :9;�bulf
S 1-1 E IF U-0
0.4 1 MIKES UNUGAL
2300 P.AriHMA •AN�
11f8/2010 ui;au HN at BAKERSFIELD, L;H'
TANK SETUP R&�.vki TANK SEl-OF mt,tluK i SITE 4 6 601
TANK NO.
TANK NO. 2 qOUO UHL I.vlaud UHL 11✓8/2016 H,"
Ev
UNLEAD
DiE$EL TANk SETUP K"t'r'U-K''I
TANK TYPE TYPE. TANK Dlm TANK NO. .3 auou UHL
TANK DIMS NK Scl.ZE- d Ae r
bk4 UNLEADED bQ
TANK SJ2E TANK ShApi juvou
TANK SHAPE C"e Ll.fqUtl( 1,YLINUrk TANK T-08
DIAMETER b.aa LP46TH TANK DIMS 1 t)
LENGTH let.a,W PRODUCT U U TANK SIZE boue
PRODUCT VltbtL OFFSET P UNLE41tv KLU TANK SHAPE %YLLNLjtK
OFFSET P i.tly 3FFSET w •zo DIAMETER J6.laid
OFFSET W 0-i via MANIFOLD ky.ve LENGTH:
MANIFOLD NUNt P j?OrS E 14UNt PRODUCT UNLEAI)EV bUe'
PROBE ;bAv Jul FLOATS biv .10, OFFSET P 'i.Ufa
FLOATS FL OAT TYPE z OFFSET W
FLOAT TYPE UIL MANIFOLD NUNt
SPADIEtIT
.GRADIENT J.0 6 SEN$OR `L'fl6-j'jjx b. PROBE 5iu !UL al SENSOR-LENG-1 11 i to I HIGH Llhia FLOATS
HIGH Ll M 1-1 do'.IOU LOW LIMIT` do..bid.
T� FLOAT TYPE 6AbVLiRt
LOW LIMIT
L1100U.i ov HIGH HIGH iat.an GRADIENT S..aar
HIGH HIGH
�0.too LOW LOW yn,ba SENSOR LEH6T. ill. 101
LOOT LOW Y.aa WATER. L.IMIT IOU HIGH LIMIT tsa.nq
WATER Li:ri!T ).an TEMP Comp 4 a rl LOW: LIMIT Ujo
d/ ? I bo/a4v IGHr
TEMP COMP' AP I b a4b API GRkViTy H HIGH '�U,blj
UITY ;i1.OU ALPHA LOWtOW ou
AOI GRA
ALPHA 4D. OU NO. �RTDS vo
WATER LIM-l.T
NO. RTDS a KTD LOG I a TEMP COMP., Api blj 640
RTD LOG I 11.4y RTD LO.0 2 API -GRAU'I'TY a1. v
RTD :LGC 2
LUC 3 3.a. a ALPHA s20.Ufa
.RTD LOG a 40.di 1 3
:RTD LOG, 4 NO. RIDS r
RTD LOC 4 6U.4( ; . . TO L
:RTO. LOC, 5 R OC i i.. .
:RTD LOC.5 RTD LOC 2 su.to..)
:RTD LOC 3 1+0.U I
STRAPPING vAiH INCHES RTD LGC 4 616.4e
It3CHES :UHLLUr4b . . , UALLQNb RTD LOC: 5
10.000 :44a.a 20.000 *bl. i STRAPPING UAIH
20.000 Z)JZ.b
INCHES bHLLUnS
Js 00.D
40. 06 : 0 0 00'... O.0
zoux—) 10.000 26kgr.Z)
1 20.60b 766. s
60.:006 0, 70.000 .bb eb.1. 36.886 2303.0
70.000 J bb.r6 .
40.
80.000 46-20.is 90.06i)
90.00e is
60.089
S906.z'
9&00
MONITOR CERT. FAILURE REPORT
SITE NAME : M MS FOOD&LIQUOR DATE : 11/8/10
ADDRESS : 2300 PANAMA LANE TECHNICIAN RICHARD MASON.
CITY: BAKERSFIELD SIG A
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE
TESTING.
REPAIRSz N.9-0 ff0l'.lTW f �' }•1 wi+moo n.� c /c:;'-r iLYA f9,
N(---t�> - -o �ko-tjt- to t- t
KD\.0 I Cad y lVt C Ci 4 4 ,rte r urC e
LABOR: C
.PARTS INSTALLED : Njc kj
NAB.
TITLE :
SIGNATURE
THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOT]FYING
THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR
THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR .
ANY NEEDED RETESTING..THIS ALSO RELEASES RICH ENVIRONMENTAL OF
ANY FINES OR PENALTIES OCCURING FROM NON-COMPLIANCE.
A COPY.OF THIS DOCUMENT HAS BEEN LEFT ON-SITE FOR YOUR
CONVIENENCE.