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HomeMy WebLinkAboutfmc result 2008 >\ . ............. .......__....- -._._............._ ......... .....-..._... I IIIIIIIIIIIIIIIII 13 1E MONITORING SYSTEM CERTIFICATION I� 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 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 form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: 9-U) Bldg,No.: Site Address: C.�t C��.1F.�N6 ZLV t City: �SiftQ SE Zip: - R33og Facility Contact Person: , 1o &a-Iq Contact Phone No.: L ) Make/Model of Monitoring System: 7 Llt>',3r50 Date of Testing/Servicing: P—'5�'� B. Inventory of Equipment Tested/Certified Check the agpro2riate boxes to indicatespecific a ul ment inspected/serviced: Tank ID: U+JL $7 Tank ID: Lj tJ L JS 7 bZ ;2�-to-Tank Gauging Probe. Model: 1W.4 67 ^-Tank Gauging Probe. Model: ,Annular Space or Vault Sensor. M OAnnular Space or Vault Sensor. Model: 0-Piping Sump/Trench Sensor(s). Model: C-X>g X'Piping Sump/Trench Sensor(s). Model: �O$ ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 'Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector Model: ❑Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill i High-Level Sensor. Model ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: 101ZEM Tank ID: ;64n-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: 12�Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 01 U ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 1d?(Mechanical Line Leak Detector. Model: /Z ! T ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. 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 E on Page 2). Dispenser ID: /7-p Dispenser ID: 3�y figr-Dispenser Containment Sensor(s). Model:2EA&aE 60 , Dispenser Containment Sensor(s). Model:, A0W-FAQ _ Shear Valve(s). ;prSbear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: —CO Dispenser ID: "7^2 8ispenser Containment Sensor(s). Model: -NZ E!�Dispenser Containment Sensor(s). Model: JA-Shear Valve(s). Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Flost(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 Flow(s)and Chain(s). *Ifthe 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/serviced in accordance with the manufacturers, guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this Information is correct and a Plot Plan showing the layout of monitoring eq pment. For any equipment capable of generating such reports,1 have also attached a copy of the report;(check all that apply): System set-up EZAlarm history report Technician Name(print): , },,c�vy,/ ��7 Signature: Certiftcation No.: Z 5 �L' _ License.No.: C- Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 392-8687 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD,CA. 93308 Date of Testing/Servicing: Page 1 of 4 UN-034-114 www.unIdocs.org Rev.01/17/08 1111111 VIII III IIII 14 IE Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: Complete the following checklist; Yes ❑ No* is the audible alarm operational? -0-.Yes ❑ No* Is the visual alarrri operational? Yes ❑ No* Were all sensors visually inspected,functionally tested,and confirmed operational?- .�I Yes ❑ 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 (e.g., modem) `NIA operational? 1®—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,or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply);ESumprFrench Sensors; dispenser Containment Sensors. Did you confirm positive shut-down due to leaks an sensor failure/disconnection? Yes; ❑No. ❑ Yes ❑ No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no -Ri—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* Eg-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* fR-No Was liquid found inside any secondary containment systems 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 set up reports, if applicable es ❑ No* Is all monitoring equipment operational per manufacturer's specifications? *In Section E below,describe how and when these deficiencies were or will be corrected. E. Comments: Page 2 of 4 UN-036—2!4 Ym mu n ido mo rg Rcv.01/17/08 1a-B3� Monitoring System Certification F. In-Tank Gauging/SIR Equipment: }-Check this box if tank gauging is 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: ❑ 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? • Yes ❑ No* Were all probes reinstalled properly? ❑ 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. G. Line Leak Detectors (LLD): ❑ Check this box if LLDs are not installed. Com lete the follo ing checklist: fiir-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: 53�3 g.p.h.; ❑ 0.1 g.p.h ; ❑ 0.2 g.p.h. -4r -Yes ❑ No* Were all LLDs confirmed 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? ❑ N/A ❑ Yes ❑ No* For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled T�r-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 LLDs, have all accessible wiring connections been visually inspected'? $—N/A 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. H. Comments: Page 3 of 4 UN-036—3/4 W W W.Unldocs.org Rev.01/17/08 Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors I. Results of Vacuum/Pressure 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 agency regulating UST systems within 30 days of test date. Manufacturer: Model: System Type: ❑ Pressure; ED vacuum Sensor ID 1lll 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 Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: Q 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 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 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 Component(s)Monitored by this Sensor: Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail How was interstitial communication verified? ❑ Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ❑ Other(Describe in Sec.J, below) Was vacuum/pressure restored to operating levels in all interstitial spaces? ❑ Yes ❑ No(/f no, describe in Sec.J, below) J. Comments: Page 4 of 4 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-1/1 www.unidoes.org Rev.01/26/06 Monitoring System Certification UST Monitoring Site Plan Site Address: C?W Z) '�yJt. -Dy,Jt,nf� ;��� , 11t->�.�-`�F'SF . . . . . . . . . . . . . . . d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : : : .T . �. . . . . . . . . . . . . . . . : : : . . . : : : : : . 1..._J : : : : . . : : : . : : : : : : : : . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..',. _:5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date map was drawn: 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 site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in-tank liquid level probes (if used for leak detection). In the space provided,note the date this Site Plan was prepared. Page 4 of 4 UN-036—4!4 www.unlducxmorg Rev.01!17108 aa83�} RICH ENVIRONMENTAL 5643 BROOKS CT. BAKERSFIELD, CA. 93308 OFFICE (661)392-8687 FAX (661)392-0621 PRODUCT LINE LEAK DETECTOR TEST WORK SHEET W/0#: FACILITY NAME:'S}pA404 = {R'(Z -o FACILITY ADDRESS: ��a -R�1c_kE7�,�F r1t $Wig �A�E-1�TCJ4 PRODUCT LINE TYPE: RE SS SUCTION GRAVITY (CIRCLE ONE) PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER 3 G.P.H. FAIL LID TYPE "")0AIL, - T SERIAL#9IECH88—rCAt- NO FAIL g 7 L/D TYPE/2E J Jy(J(,E T v SERIAL#rELM,,&�L a NO FAIL 4 LID TYPE 1 SERIAL# /4�L- NO FAIL 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 LIMITATIONS. 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: W-Q'o� /f7 j briN SIGNATURE : DATE:l1—,:;� 1 o '3 SWRCB, January 2006 Spill Bucket Testing Report Form Phis 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: N Ls Date of Tes7 U Facility Address: VLF ��l Facility Contact: ACM A kly Phone: Date Local Agency Was Notified of Testing: 0 Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test: rJ U,.l -'17W �>VIJ Credentials': CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other(Specify) License Number(s):&da'3 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic Vacuum Other Test Equipment Used: SU A L Equipment Resolution: Identify Spill Bucket(By Tank 1 'Ta� 2 L�-p�d� '3 q f 4 / Number, Stored Product, etc.) OO 7'J"-Trt Bucket Installation Type: ect u t Bury ct B Direct Bury Contained in Sump Contained in Sump Contained in Sump Contained in Sum Bucket Diameter: 47 1 4 0 4 Bucket Depth: /LIP Wait time between applying ? vacuum/water and start of test: 2b/77,� 36M Zn1 Test Start Time(T,): g• 6 Initial Reading(R,); '' 91, Test End Time(TF): !/2-'Aaam Final Reading(RF): 9114 •' 9" Test Duration(TF-Ti): [ 1*2 Change in Reading(RF-R,): G N oil 0 0 PasslFail Threshold or 0./ 10 011 Criteria: Test Result: Pass 0 Fail ass 0 Fail „Pass 0 Fail 0 Pass 0 Fail Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) 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: — Date: 11- 5- 0 0 ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements may be more stringent. MONITOR CERT. FAILURE REPORT SITE NAME: Jog nl"J .S IV-C-o DATE: / -S ADDRESS: (o)a VaE,)\JS Lw$'ECHNICIAN: ,-4 'J CITY: SIGNATURE- THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE TESTING. REPAIRS: LABOR: N PARTS INTALLED: N�'V NAME: TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING 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 CON VIENENCE.