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Home My WebLink About2010 RESULTS MONITORING SYSTEM CERTIFICATION �� For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 67, 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 rn enared 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 IIIIIIIIIIIIIIIIIIII 19 Facility Name: LUCKY 7 FOOD STORE IE Bldg.No.: Site Address: 2501 WHITE LN. City: BAKERSFIELD Zip:. 83304 Facility Contact Person: MANJIT SINGH Contact Phone No.: ( ) Make/Model of Monitoring System: TLS-350 INSP.-ERNIE MADINA Date of Testing/Servicing: 11/23/2010 B. Inventory of Equipment Tested/certified Check the apg=rlste boxes to indicate sgmc egulginent ins ed/serviced Tank ID: REGULAR 87 Tank ID: MID GRADE 89 ®In Tank Gauging Probe. Model: NMAG' ®In-Tank Gauging Probe. Model: MAG ®:Annular Space or Vault Sensor. Model: 409 ®Annular Space or Vault Sensor. Model: 409 ®hping.Sump/Trench Sensor(s). Model• 208 Piping Sump/Trench Sensor(s). Model' 208 ❑Fill'Sump Sensor(s). Model [],Fill SumpSensot(s). ;Model: ®Mechanical Line Leak Detector: Model: FXIV 0 Mechanical Line Leak Detector. Model: FE431MO ❑Electronic Line Leak Detector. Model: [],Electronic Line Leak Deteaor. Model: ❑Tank Overfill/High-Level Sensor. Model: []Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type,and model in Section E on'Page 2). ❑Other(specify equipment type and model in Section Ton Page 2). Tank ID: PREMIUM 91 Tank'ID: •In-Tank Gauging'Probe. Model: MA.G' ❑In-Tank'Gauging.Probe. Model: •Annular Space or Vault Sensor: Modev.409 ❑Annular Space or Vault Sensor. Model: •Piping Sump/Ttench.Sensor(s). Modet 208 ❑Piping Sump/Trench Sensor(s). Model: �]Fill Sump Sensor(s), Model' ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: FX1 V ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electr6nic Line Leak Detector. Model ❑Tank,Ovcrm/High-level Sensor: Model: ❑Tank Overfill/High-Level Sensor. Model: ❑'Othei(specify equipment type and model in'Section E on Page;2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID, 112 Dispenser ID: 3/4' ®:Dispenser Containment Sensor(s). Model: 406 ®Dispenser Containment Sensor(s). Model 406 ®Shear Valve(s). ®Shear Valve(s). .❑:.Dispenser Coi►t8innxnt Floats)and.Chaiu(s). C]Dispense Containment Host(s)and Chain(s). Dispenser ID: Dispenser-ID: C]`:4coser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). .Model: [3 Shear'Valve(s). .0 Shear Valve(s). ::j ❑,Dispenser Containment Floats)and Chain(s).. 0 Dispense Containment Float(s)and:Cheiir(s). Dispenser'ID: Dispenser ID:. ❑ Dispenser Contawment Sensor(s):. Model:. ❑:Dispenser Conteinment'Sensor(s). Model: Q Shear Valve(s). ❑Shear Valve(s). C,].Dispensor'ConWnment Floats)and aWn(s). ❑Dispenser Containment Float(s).and C6ain(0, 'If the facility contains more tanks or dispensers,copy-this form. Include:information for every tank and dispense;•at the facility. C. Certification-I certify that the equipmment identified in'titis document was.inspected/servrced in accordance with the.maoufacturers' guidelines. Attached to this Gertification..is information (e:g. manufacturers' checkUsts) n rtor�y to verify that this information is correct and a'Vo Plan showing the layout of monitoring equipment For any equipment cap enerating sach reports,I have also attached a copy of the report;(check all that apply): System set-up ®.Ala report Technician Name(print): RICH'PHILLIPS Signattuet. Certification No.: A290"I 1036169;UT License.No.; C611 D40 809850 Testing Company Name: .RICH ENVIRONMENTAL Phone No.:(661):3264402 Testing Company Address: 3305.BRITTAN RD ,BAKERSFIELD,CA.93308 _ Date of Testing/Servicing: 111231201.0 Page 1 of 5 [N4X—V4 Ti*W.uuidocaorg llllllllllllllllllll 20 Rev.01/17/09 IE Monitoring System Certification 3 D. Results of Testing/Servicing Software Version Installed: 323.03 Comp lete the`foltowin checklist: :® Yes _ ❑. No* Is.the audible alarm:operationaP ® Yes O 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 p No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) ® N/A operational? ® Yes C No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment p N/A monitoring system.detects a leak, fails tb operate,or is electrically disconnected? Ifyes:which sensors initiate positive shut-down? (Check all that apply) ®Sump/'Trench Sensors; ❑Dispenser Containment Sensors. Did you confirm positive.shut-down due,to:leaks pA sensor failure/disconnection7 ®Yes; ❑No. ❑ Yes i].No' For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no ® -NIA 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 percentof tank capacity'does the alarm.ttiggeO % 0 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* ® No Was liquid foetid inside any secondary containment systems designed asAry systems? (Check all that apply) ❑Product; p Water. If yes,describe causes':in Section E,below. ® Yes ❑ No* Was monitoring system set-up reviewed to ensure.proper settings?Attach.set up reports,if applicable ® Yes ❑ No' Is all monitoring equipment operational per manufactarer's.specifications? 4 InSection E:below,describe=how and:w6en these,deflciencies were or wi l be corrected. E. Comments: Page 2 of 5 UN-M-214 wrm,x0idomoi rg Rev.01/17/08 Monitoring System.Certitication F. In-Tank:Gauging[SIR Equipment: ® Check this box if tank gauging is used only for inventory control. D 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:. ❑ 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 p No* . Was accuracy of system water level readings tested? E Yes ❑ No* Were all probes reinstalled properly?. p Yes ❑ No* Were all items on the equipment manafacturer's maintenance checklist completed? *In'Seetion K below,describe how,and,when these de$clencies were or will be corrected. G. Line Leak Detectors(LLD): ❑ Check-this box if LEDs are not installed. Complete the following checklist:. ® Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? [] N/A (Check all that apply) Simulated leak rate: ®3 gsp.h:;.❑0.1 g:p.h; ❑0.2 g.p.h.: ® Yes ❑'No* Were al1LL.Ds confirmed operational and ac curate:within'regulatory requirements? C Yes ❑ No* Was the testing apparatus properly calibrated? ® Yes ❑ No* For mechanical LLDs;.does the LLD restrict product flow if it detects a leak? ❑ NIA ❑ Yes ❑ No* For electronic LEDs,does the turbine.automatically:shut off if the LLD detects a leak? ® N/A D Yes ❑ .No* For electronic LLDs,does,the turbine automatically shut off if any portion of the monitoring::system is disabled M N/A or disconnected? Yes. ❑ No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions ® N/A or fails a test? ❑ Yes ❑ No* For electronic L.LDs,haye:all accessible wiring connections been visually inspected? ® Yes ❑ 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. FL Comments: Page 3 of 5 vN4M-3/a www na .org .oin�ios 1 RICH ENVIRONMENTAL 3305 BRITTAN ST. B,AKERSFIELD, CA. 93308 OFFICE(661)326-8402 FAX(661)326-8934 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET W70#: FACILITY NAME: LUCKY 7 FOOD STORE FACILITY ADDRESS: 1501 WHLTE LANE,BAKERSFIELD PRODUCT LINE TYPE: PRESSURE PRODUCT LEAK-DETECTOR TYPE TEST TRIP PASS BELOW P.S.L OR SERIAL NUMBER 3 G.P.M . FAIL .UNL-87 L/D TYPE:, FXIV SERIAL# 6251 YES 11 P.S.I. PASS MID-89 L/D TYP1E FE-PETRO SERIAL# UNREADABLE YES 10 P.S.I. PASS PREM-91 L/DTYPE-: FXlV SERIAL# 9787 YES 10 P.S.I. PASS LID TYPE: PASS YES SERIAL# FAIL I CERTIFY THE_ABOVE TESTS WERE CONDUCTED ON THIS DA.TE ACCORDING TO RED JACKET PUMPS FIELD TEST APPARATUS TESTING-PROCEDURE AND LIMITATIONS. THE MECHANICAL LEAK DETECTOR TEST PASS/FAIL IS DETERMINED BY USING A :LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONS PERHOUR OR LESS AT 10 P.S.I.I .ACKNOWLEDGE THAT ALL DATA COLLECTED IS TRUE AND CORRECT TO THE BEST O.F MY KNOWLEDGE. TECHNICIAN: RI P SIGNATURE: DATE: 11/23/10 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%perator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name:. LUCKY 7 FOOD STORE. Date.of Testing: 11/23/10 Facility.Address: 2501 WHITE LN-BAKERSFIELD,CA.93304 Facility Contact: MANJIT SINGH Pbone: Date Local.Agency Was Notified of Testing: 11/12/09 Name of Local Agency Inspector(f present during testing): ERNE IvIADINA 2., TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test: RICH PHILLIPS Credentials`: ❑CSLB Contractor X ICC:Service Tech. ❑.SWRCB Tank Tester 0 Other(Specify) License Number(s): 1035169-UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic 0 Vacuum Q Other Test Equipment Used: VISUAL. Equipment Resolution:'0 Identify Spill Bucket(By Tank 1 2 PREMHUM 91- 3 4 Number,Stored Product etc) REGULAR 87-FILL FILL MID-89 FILL Bucket Installation.Type: X.Dired Bury X Direct Bury X'Direct Bury ❑Direct Bury 0 Contained in Sump C Contained in Sump 0 Contained in Sump O Contained in Sum Bucket Diameter: 12" 12" 12" Bucket Depth:14" 14� 14" Wait.time between applying 30 MIN 30 MIN 30 MIN vacuum/water and start of test: Test Start Time(Tj: 09:36 09:30: 09.30 Initial Reading W: 12" 12" 12" Test End Time(Tp): 10:30 10:30 1`0:30 Final Reading(RF): 12" 12" 12" Test Duration(To–Tb. 1:=HOUR 1-HOUR I-HOUR Change,in Reading(Rp-Ra: 0 0 0: Pass/Fail Threshold or +/-0:00 +/-0.00 +/-0.00 Criteria: Comments—(include in on repairs made prior to>testing and recommended fol low-up for;failed tests) CERTIFICATION OF - AN RESPONSIBLE FOR CONDUCTING THIS.TESTING I hereby certify drat all the Information,' d In this report is true,accurate,and in,full compliance with legal requirements. Technician's Signature: Date: 11/23110 `State.laws and regulations do not currently require testing to be.performed by a qualified contractor.However;local requirements may be more stringent_ Monitoring System Certification Form;;Addendum for Vacuum/Pressure Interstitial Sensors I. Results of VacuumMressure Monitoring Equipment Testing This page.should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of this form must be included with the Monitoring System Certification Form, which must be provided to the tank system owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the local agencyregulating UST systems within 30 days of test date. Manufacturer:NIA Model: System Type:❑Pressure;❑Vacuum SensorlD. Componen (s)Monitored by this Sensor: Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail Component(s)Monitored by this:Sensor: Sensor.Functionality,Test Result:❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; .❑ Fail .Component(s)Monitored.by this Sensor: Sensor FunctionalIity'TeA Result:❑Pass; ❑ Fail Interstitial Communication Test Result ❑Pass; -❑. Fail Component(s)Monitored by this Sensor:. Sensor Functionality Test Result;❑Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result F-1 Pass; ❑ Fail Interstitial Communication Test Result:[]Pass; ❑ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail Component(s)Monitored by-this Sensor: Sensor Functionality Test Result: ❑Pass; ❑ ,Fail Interstitial Communication Test Result:❑.Pass; ❑ Fail Compooent(s}Monitored by this Sensor. Sensor Functionality:.Test Resulr_O❑Paw;.. ❑ Fail Interstitial.CommunicationTest,,Result:,❑.Pass; ❑ Fail Components)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass, ❑ Fail Interstitial Communication Test Result:El Pass; ❑ Fail Components)Monitored by this Sensor: Sensor Functionality.Test Result: ❑.Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; 0 Fail How was interstitial communication;verified? ❑ Leak Introduced at Far End.of Interstitial Space;' ❑. Gauge; ❑ Visual Inspection;. ❑ Other(Describe in Sec.J, below) Was vacnum/pressure restored to operating levels in.-alt interstitial spaces? ❑Yes ❑No(If no, describe in Sec.J, below) I Comments: NONE OF THESE SENSORS ARE PRESENT AT THIS SITE. Page 4 of 5 1 If the sensor successfully detects,a.simulated vacuum/pressure leak introduced in the interstitial,space at the furthest point from the sensor,vacuum/pressure has been demonstrated to be communicating throughout the interstice. UN-036A-i/1 www;nn1dom6rQ Rev.0126/06 LEAK TEST METHOD 7�LVvU t�FTWARE'-REV 15 f,O.N LEVEL COMMUNICATIONS' SETUP - - - - -- - - - - - - - /k OFTWA E'RE 03 - - - - - - - TEST ON DATE : ALL TANK OFTWAREii 346823-100-D JAN.. , 1 , 1996 START TIME : DISABLED REATED - 03.08.06.08.10 PORT SgTTINGS: TEST RATE :0.20 GAL/HR 0 SOFTWARE :MODULE NONE FOUND DURATION HOURS YST.EM FEATURES: T PERIODIC IN=TANK.TEST: ST EARLY STOP:DISABLED ANNUAL IN-TANK TESTS LEAK TEST RETORT FORMAT RS-.232 END OF MESSAGE NORMAL DISABLED I N--TANK. SETUP T 1 :UNLEADED 87 STEM SETUP PRODUCT .CODE 1 Y THERMAL COEFF : .000070 IOU 23, 2010 8:40 AM - TANK DIAMETER 96:00 TANI" PROFILE 1. PT LIQUID SENSOR SETUP FULL VOL 1.0000 - - - - - - - - - - - - L I :87 STP SYSTEM UNITS FLOAT SIZE: 4.0 IN. TRI-STATE (SINGLE FLOAT) U.S., 3YSTEH .LANGUAGE CATEGORY STP SUMP WATER WARNING 2.0 ENGLISH HIGH WATER LIMIT: 3.0 7YSTEM DATE/TIME, FORMAT L 2:89-STP ION DD YYYY HH:MM:SS xM MAX OR :LABEL VOL 10000 TRI-STATE (SINGLE FLOAT) OVERFILL LIMIT 90% CATEGORY : STP SUMP .UCKY 7 9000 2501. WHITE LN HIGH PRODUCT 95% 3AKERSFIELD .CA 93304 9500 L 3:91-STP 561-397-3722 DELIVERY LIMIT 10Y TRI-STATE (SINGLE FLOAT) SHIFT TIME 1 DISABLED 1000 CATEGORY : STP SUMP SHIFT TIME .2 DISABLED LOW PRODUCT 500 3H I FT TIME 3 DI,SABL.ED LEAK ALARM L I M1 T: 99 L 4:87-ANNULAR SHIFT TIME 4 DISABLED SUDDEN :LOSS LIMIT: 99 TRI-STATE (SINGLE FLOAT.) TANK PER TST NEEDED WRN TILT 4.00 CATEGORY : ANNULAR SPACE D.1 SABL:ED PROBE OFFSET -111.00 TANK .ANN TS"T NEEDED WRN DISABLED SIPHON 1"IANIFOLDED TANKS L 5:91-ANNULAR LINE RE-ENABLE METHOD T#,' NONE TRI-STATE (SINGLE FLOAT) PASS :LINE TEST LINE MANIFOL:DED TANKS CATEGORY : ANNULAR SPACE Tit; NONE LINE PER TST NEEDED WRN DISABLED LEAK MIN PEEIODIC: 0% LINE ANN TST NEEDED WRN L 6:89-ANNULAR 0 TRI-STATE (SINGLE FLOAT) DISABLED CATEGORY ANNULAR SPACE PRINT TC VOLUMES LEAK MIN N .FtNNUA'L 0% ENABLED 0 TEMP 'COMPENSATION PERIODIC TEST TYPE VALUE (.DEG F $ : 60.0 STANDARD STICK HEIGHT OFFSET DISABLED ANNUAL TEST FAIL DAYLIGHT SAVING TIME ALARM DISABLED DISABLED PERIODL:G 'TEST FAIL. ALARM DISABLED SYSTEM SECURITY GROSS_ TEST FAIL CODE : 000000 ALARM DISABLED CUSTOM ALARM- LABELS ANN TEST AVERAGING: OFF DISABLED PER TEST AVERAGING,: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVERY DELAY : 15 MIN PUMP THRESHOLD : 10.00% a GUTPUT RELAY SETUP r ALARM HISTORY REPORT — ALARM HISTORY REPORT — — - - — — Y — _ -- SENSOR ALARM ----- ----- SENSOR ALARM ----_ k 5:87 SHUTOFF L 1 :87 STP L 3.91-STP TYPE:: , STP SUMP ST A' SUMP STANDARD SENSOR OUT ALARM SENSOR OUT ALARM NORMALLY CLOSED NOV 23. 2010 9:41 AM .NOV 23, 2010 9:41 AM FUEL ALARM FUEL ALARM LIQUID SENSOR ALMS NOV 23, 2010 9.:29 AM NOV 23. 2010 9:30 Atli ALL:FUEL ALARM ALL:SENSOR OUT ALARM SE;ISOR OUT ALARM ALL:SHORT ALARM SENSOR OAll T ALARM NOV 25, 2009 1.0`:20 AM NOV 25. X009 10:20. At R 2:91 SHUTOFF TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS ALL:FUEL ALARM ALL:SENSOR OUT .ALARM ALL:SHORT ALARM * *i X X * END END * R 3:89 SHUTOFF TYPE: STANDARD NORMALLY CLOSED L10UID SENSOR ALMS ALL FUEL ALARM ALL: SEN80R.OUT ALARM ALL:SH4RT ALARM • ALARM. HISTORY REPORT ALARM HISTORY REPORT — SEfVSOR ALARM ----- ----- SENSOR ALARM ----- L~2:89—STP L. 4:8.7 ANNULAR NN STP SUMP AULAR SPACE SENSOR OUT ALARM SENSOR OUT ALARM NOV 23, 2010 9:,41 AM NOV 23, 2010 9:4:1 .AM FUEL. ALARM FUEL ALARM NOV 23 201.0 9:30 AM NOV 23, 2010 9:36 AM RECONC.LLI'ATION SETUP ' SETUP DATA WARNINt.- SENSOR, OUT ALARM — — — — — — — — — - — — FED 16, 2010 1 :05 PM NOV" 25, 2009 10:20 AM AUTOMATIC DAILY CLOSING TIME`: 2:00 AM PERIODIC RECONCILIATION MODE: MONTHLY TEMP COMPENSATION STANDARD BUS SLOT FUEL METER TANK. -j( X END X * X * r TANK MAP EMPTY ALARM HISTORY REPORT ---=— SENSOR ALARM. ----- L 2:89=STP STP SUMP SENSOR OUT ALARM NOV 23, 201.0. 9:41 AM FUEL ALARM NOV 23, 2010 9:30 AM SETUP DATA WARNING FEB 16.. 2010 1 :05 PM ALARM HISTORY REPORT -- SENSOR ALARM ----- L 5:91-ANNULAR ANNULAR SPACE SENSOR OUT ALARM NOV 23, 2010 9:41 AM FUEL ALARM NOV 23, 2D10 9,:33 AM SENSOR OUT ALARM NOV 25.• 2009 10:20 AM * END ALARM HISTORY REPORT --- SENSOR ALARM ----- L 6:89-ANNULAR ANNULAR SPACE SENSOR OUT ALARM NOV "23. 201,0 9:41 Ahl FUEL ALARM NOV 23, 2010. 9:31 AM SENSOR OUT ALARM NOV 25; 2009, 10:2b AM MONITOR CERT.. FAILURE REPORT SITE NAME : LUCKY 7 FOOD STORE DATE : 11/25/09 ADDRESS : 2501.WHITE LN. TECHNICIAN:. STEVWOBE RT CITY : BAKERSFIELD. SIGNATURE : THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE TESTING. REPAIRS : NONE LABOR: NONE PARTS INTALLED : NONE. NAME . TITLE : SIGNATURE THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILIW OF.NOTTFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICA ENVIRONMENTAL FOR ANY NEEDED RETESTING.TEUS.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.