Loading...
HomeMy WebLinkAboutFMC 2008 L . IIIIIIIIIIIIIIIIIIII 27 BSSR,Inca IE �o 6630 Rosedale Hwy.,# B,-Bakersleld,CA 93308 Phone(661) 588-2777 Fax(661) 588-2786 MONITORING.,SYSTEM'CERTIFICATION This form must be used to document testing, and servicing of monitoring equipment.. A separate certification or report must be arepared 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/operato inust,•submif a copy of this form to the local agency regulating UST systems within 30 days of test date. -''_'-; A. General Information Facility Name: Bldg. No.: Site Address: 3ci^�"F�.�iil�ld-4D city: Zip: ,' p Facility Contact Person: f11 Contact Phone No.: L ��0,� : ,'''Make/Model of Monitoring System: /V�"l Date of Testing/Servicing: 4; B. Inventory`of Equipment Tested/CertiIIed* ; Check the a2propriate boxes to Indicates ecitle equipment Inspected/serviced: Tank ID: 4= Tank ID: O In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: JQ' Annular Space or Vault Sensor.' Model: O Annular Space or Vault Sensor, Model: O Piping Sump/Trench Sensor(s). Model: O iping Sump/Trench.Sensor(s). Model: �j Fill Sump'Sen'sor(s): •. Model: Fill Sump Sensor(s): Model: FMechanical Line Leak Detector. Model: Mechanical Line Leak Detector, Model: Electronic Line Leak Detector. Model: O Electronic Line Leak.Detector. Model: Tank Overfill/High-Level Sensor. Model: . O Tank Overfill/High-Level Sensor. Model: O Other(specify equipment t and model in Section 9 on Page 2).' O'Other(specify a ui ment type and model in Section E on Page 2 . Tank ID:.. " :_ - = . - '"- - -- • Tank ID: - ❑ In-Tank Gauging Probe:- _ -Model: O`In-Tank�Gauging Probe. Model:` O•Annulai Space'o�:Vault Sensor; .:Model. D.Annular Space or.Vault;Sensor.' `Wdel:- , •.''...:�: O Piping Sump/Trench Sensor(s),_--Model: O,,Piping Sump/Trench_S_ensor(s). Model: -� OLFi11 Siirrip Sensor(s).',;` '•-Model: U Fill°Sump'Sensor(s): Model: O Mechanical Line Leak Detector:_ :Model:_ Or Mechanical_Line-Leak_Detector r LLModel: O'•Electronic Line Leak'Detector. :Model:- O Electronic Line Leak'Detector:-" Model:,' O Tank Overfill/High-Level Sensor."Model:" O.Tank Overfill/'High-Level Sensor:-Model:' ' O Other(spe&ry'equipment type and model in Section E on Page 2 O Other(specify equipment a and model in Section E on Pa e 2 . Dispenser ID: lspenser..ID Dispenser Containment Sensor(s). Model. Dispenser Containment Sensor(s). Model: hear Valve(s). ' O:Shear Valve(s). ❑ Dispenser Containment Floats and Chain si. O;Dis enser Containment Floats and Chain (s). Dispenser ID: ' Dispenser ID: • Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: O ShearValve(s)., . = O Shear,Valve(s)•'A` • Dispenser Containment Floats and Chains O Dispenser Containment Float(s)and Chain (s). Dispenser ID: Dispenser CD:" • Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: • Shear.Valve(s). O Shear Valve(s). ODis enser Containment Floats and Chains O:Dispenser Containment Ploat s and Chain(s). •if the faciiuy contains more tanks or dispensers,copy'this form. Include infotmationfor,every tank and dispenser at the facility. C. Cerdfication . I certify that :the equipment,Identified in' this document was ,inspected/sery iced. In accordance with the 1. manufacturers'.guidelines. 'Attach ed.to.41s Certlflcation'ls Iarormation'(e.g."manufacturers' checklists) necessary to verify that this information is correct and a P1ot;Pi.an.showing:tlie_layo'ut'of mogitoring a ipment. For an a meat.capable of generating s ch reports,I have also attach a'co y'orthp re ort• (c all that apply): ' O S m se p r AI Arm h story report/00 Technician Name(print): ( Signature: Certification No: �Q d -Tl a 1 License. Nor Tes[ing'Company Name: ,; •.i, .r n PhonelNo.a `JI Site Address: — / - -Date-ofTesting/Servicing: / © T", ' Page I`of ,, �r 03101 Monitoring System Certlflcaflon ,• ;'; ~.r IIIIIIIIIIIIIII III 28 D. Results of Testing/Servicing y Sofnvare Version Installed: Com lete the following checklist: Yes ❑ No* Is the audible alarm operational? Yes O No* Is the visual alarm operational? Y'es ❑ No*' Were all sensors visually inspected, functionally tested and confirmed operational? _ - Ves ❑ No* Were all sensors installed at lowest point of secondary containment and positioned so that other cquipmcw ,xiil i! II not interfere with their proper operation? ❑ Yes ❑ No* If alarms are relayed to a remote monitoring station, is all communications equipment (r h, mucl:!i!, N/A operational? Yes ❑ No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containrncn-I ❑ N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors midair �! positive shut-down? (Check all that apply) Pump/Trench Sensors; 2�bispenser C n ontaituent Sensos r �I Did you confirm positive shut-down due to kaks _ sensor failure/disconnection? e ; - N . O Yes O No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.c 110 ❑ N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the t ii4 Fill point(s) and operating ro erl ? If so at what percent-of tank capacity does the alarm trigger? ❑ Yes' X No Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipmew replaced and list the manufacturer name and model for all replacement parts in Section E below. _ ❑ Yes* o Was liquid found inside any secondary containment systems designed as dry systems? (Check all rhea applti/ l� ❑ Product; O Water. If yes, describe causes in Section E below. _ 'es ❑ No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicalb1c. I 1'es ❑ No* Is all monitoring a ui ment o erational 2er manufacturer's s ecifications? - In Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: Page 2 of l f o.vu t F. ✓In-Tank Gauging/SIR Equipment:`± . Q Check this box if tank,gauging is used only for inventory control. .>(Cheek this box if no tank gauging or SIR equipment is installed. This sk ction`must be completed if in-tank gauging equipment is•used to perform leak detection monitoring. Com lete the folio win checklist: ❑ Yes O 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 .O No* Was accuracy of system product level readings tested? ❑ Yes O 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 the 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 fete the follo In&checklist: Yes, ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? El N/A (Check all that apply) Simulated leak rate: 3 g.p,h.; O 0,1 g.p.h; O 0.2 g.p.h. Yes O No*, Were.all LLDs confirmed operational and accurate within regulatory requirements? Y es O No' Was the testing apparatus praWly cal rated? 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 C2 No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled N/A or disconnected? ❑ Yes 0 No* For'electronic LLDs, does the turbine automatically shut off if.any portion of the monitoring system N/A •malfunctions or fails a test? ❑ Yes O No* For electronic LLDs;have all accessible wiring connections been visually inspected? N/A Yes 110 No* Were all iiems:on the equipment manufacturer's maintenance checklist completed? * In the Section fl,below„describe how and when these deficiencies were or will be corrected. H. Comments: Page 3 of q. 03/0 Monitoring System Certification Form:Addendum for Vacuum/Pressm Interstitial Sensors LC 163-1, Enc. 11 r I. Results cif--Vacuum/Prewurc 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 Monitoririg System Certification Form, which must be provided w the gull, 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: Modal: System Type: ❑ Pressure; ❑ viteuum Sensor ID Component(s)Monitored by this Sensor: Sensor Functionality Test Result; ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass` ❑ I.._u I Component(s)Monitored by this Sensor: Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ F;iii y Component(s)Monitored by this Sensor: - Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑ pass; ❑ F;11-11 Component(s)Monitored by this Sansor: Sensor Futtccio.Wity Test Result:❑Prig.; ❑ Fail Interstitial Communica[ion Test Result:❑Pas_s; ❑ Fai I Component(s)Monitored by this Sensor: _ Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass: ❑ t u1 Components)Monitored by this Sensor: _ 9 Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass, ❑ F:ul 1 Components)Monitored by this Sensor: ---- -j 1 YYa Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass: ❑ I ;ul 7 Component(s)Monitored by this Sensor: _ Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑ Puss; ❑ Pail j Component(s)Monitored by this Sensor: _ Sensor Funcdoadhy,Test Result❑Pass; ❑ Fail latatstitial Communication Test Result: ❑ Pass; ❑ Component(s)Monitored by this Sensor: _ Sensor Functionality Test Result: ❑Pass; ❑ Fall Interstitial Communication Test Result: ❑ Pass; ❑ f-ui How was intersdtial communication verifled? ❑ Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ❑ Other(Describe in .Sec. 1, hrirnj Vacuum was restored to operating levels in all interstitial spaces: ❑Yes ❑No(If-no, describe in Sec. 1, belmt') J. Comments: 1107Ar��� ------ - Page of If the sensor successfully detects a simulated vacuum/pressure leak introduced in tho interstitial space at the furthest point Iron, tt,c sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice, 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(f 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: SCV A / Facility Contact: �j Phone: Date Local Agency Was Not feed of Testing: Name of Local Agency Inspector(fpresent during testing): TESTING CONTRACTOR INFORMATION Company Name: Technician Conducting Test: Credentials': 0 CSLB Contractor XICC Service Tech. D SWRCB Tank Tester 0 Other(Specify) License Number(s): 3. SPILL BUCKET TESTING INFORMATION Test Method Used: JVHydrostatic 0 Vacuum 0 Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket(By Tank 1 2 3 4 Number, Stored Product, etc. i Bucket Installation'Type: 0 Direct Bury 0 Direct Bury ❑Direct Bury 0 Direct Bury Contained in Sump 0 Contained in Sump ❑Contained in Sump 0 Contained in Sum Bucket Diameter: Bucket Depth: Wait time between-applying vacuum/water and start of test: v" Test Start Time(TO: ,'00 Initial Reading(Ri): 0 Test End Time(TF): ` Final Reading(Rf): ' Test Duration(TF—Ti): Change in Reading(RF-Ri): Pass/Fail Threshold or �` Criteria: J Test Result: Pass ❑Fail ❑ Pass 0 Fail 0 Pass 0 Fail 0 Pass ❑ Fail Comments—(include informati n on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING 1 hereby certj&that all the Information contained In this report is true, accurate, and In full compliance with legal requirements. Technician's Si ture: Date: ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements maxi}xa mnrp etrinnPnt g System Certification'.. 000f�11` UST M0. nitoririg Site Tian r Site Address: . 5S�1S�o�. .. . . . . . . U , . . . . . . Aso . . . . . . . . . . . . . . . . . . . . . . . . . . � S4, +<;►+ . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . C4-V-Aj!5=IL . . . . . . . . . . . . . . . . . ... .. . .. • Date map was drawn: x �: instructions you already have a diagram.that,shows all required information, you may include it, rather than this, age, with our Monitoring.System Certification. On your site plan, show the general layout of tanks and piping."-Clearly len�Y locations of the following a i ment,:if installed: monitoring s Y stem control anel�; sensors monitoring ink annular spaces,.sumps; dispenser pans,spill containers; or other secondary containment areas; mechanical or ectronic line leak detectors; and in-tank liquid level probes (if used for leak detection). In the space provided, )te the date this Site Plan was prepared.