HomeMy WebLinkAbout3001 SILLECT AVE IIIIIII VIII III IIII 33
IE
BSSR,, Inc.
6630 Rosodale Hwy,,# B,Bakersfield,CA 93348 Phone(661)588-2777 Fax(661)588-2786
Appendix VI
(Copies of Monitoring System Certification form and UST Wriltoring Plot Plan available at httD;ffwww.wateft jrds,ca-d.Q
MONITORING SYSTEM CERTIFICATION
For Use Sy All Jurredictmne Within the Slate of California
Authority Cl W:Chapter S.7,Mwfth and Sstety Code;Chspter if Dlvla)orl 3, TWO 23, Wtorn4P Code o!
Regulations
'rhie form must be used to document tasting and servicing of monitoring equipment.A separate camificatlon or report must be prepared for
each monitoring sysfarn control panel by the technician who performs the work. A copy of this form must he provided to the tank system
ownerloperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of teal date.
A. General Information
Fadllty Name BAK Bldg.No.:
�7
She Address: QQ I St e cnY:BAVEFUEl16 zip: 9330p$
Faeiiity Contact Person:�1[J4 AE L „- Conted Phone No.:( 66 1 ) 6 rJ P.`" 6 y C]-1
MakaWadd of Monitoring System:EMC Z Date of TesdnglSeMdng:.Z /;2 I
B. Inventory of Equipment Teated/Den(lled
k the appropriate boxes to Indicets macific alquilpitionli trial isiLloWw"Wo";
Tank 1D'
3elr-TSnk Gauging Probe. Model; Tattk lD
iv-Annular S 1GQ. ✓In nular Spoes Gauging Probe. Model: 1
Space or Vault sensor, Model: ✓Mnuler 6p�see or Veutt I;tgr{pr. Modal:0't�u 2�jfa- 4 jg
r Wptng Sump/Trench Senaor(a), Model: - ✓Piping Sump/Trench Senior{4), Model:b gy,�Rb- 7qk
C Flit Sump Sensor(!). Model: = Fat Sump Sensor(e). Model:
C Mechanical Una Leak Detector. Model: _ Mechanical Line Leak Dotoator. Model:
Electronic Una Leak Detector, Modek Electronic Uri@ Look Detector. Model: _
Tank Overfill 1 Hgh-Loyal Sensor. Model: Tank overfill/Hlgh-Levol Sensor, Model:
Other equipment type and model In Section E on page 2 Other(specify aW~type and model in Section E an Page 2).
Tank ID: Tom ID:
C Ins-Tank Gauging Probe, Model: C In-Tarts Gauging Model;
Annular Space or Vault Sensor, Model: = Annular Space or Vault Sensor. Model:
Piping Sump 1 Trench Senaor(s). Mader: = Piping Sump/Trench Sanaor(s). Modal:,
r Fill Sump Sensor(!), Model: - rill Sump Sensorial. Model;
Meohanical line Laek Detector. Model! - Mechanical Line Leak Detector. Model:
C Electronic Una Leak batactar. sAodai; = Electronle Une Leak Detector, Model:
C Tank overfill 1 High-Level Sensor. Model: = Tank Overfill/High-Level Sensor. Model
i. Other(specify m model In Section E an Pau@ 2). _ Other Ispecity agulament typs and modal In Section E on Pace%).
DtapahaarlD: - DIspMMrtD:_.__
Dilparleer GontZnMont Sonsor(e). Modal; = Dispenser Containment 8ensor(a). Model: _
L Shear Valva(S), _ shear Vatve(sk
I Di4pariset Containment Float is)and Chain 4, . sneer Cordalnment Float a and Uwln
Dispenser 10: Otepeheer10;
i. Dispenser Gonuunment Sensor(!). Model; = Dispenser Containment 8ensons). Model:
Shear Valve(s), Shear Vatve(s).
_()Jgpbftor ContNAMON Floats and Chain(s), Weer cwtafrlm nt Float 4 and Chain(s).
L d�
L ispeneer ContWnmard Sensorial. Model: : Dispenser Cordainmern Serreor(s), Model:
Shear Valva(a). 1--: Shear Verve(&).
l Pis ter Containment Floats and Chain(a DI! enoel Containment Float!) and Chain!,
'If the facility eontalns more tanks or dispensers,copy this term, include Information for every tank and dispenser at the facility.
C. CoMIcatlon - I car"owl the squlpment kfandtled in tlrla document was tnspectedissrvlosd In seoordance with the manufacturers'
guldellrim Attsohed to this Cwtillostlan 1s Ififo►rnatlon(a4 manufseturere'chatidlets)neft s ry to vertty that tilde Inrfarmatien is comet
and a Plot Plan showing the layout of monlloeing equlpm.rri For mrry-wipmoot sayable at genwating such report-,I have also attached a
copy or the report;(check all that apply): 1 syslern 4et-up ]Alarm history report It 1�
technician Name(print); ir tt D - CA IZtL 1 L l O Signature: e�tw�CQ �A...1 1L.t.
Ceniticatlon No.: A A 1.-' LA I Ucanae,No,: -12 P.,1 A
Testing Company Name: Q=a I tN C. Phone Nc:1 "t 1 5 s- 4t't-4-4
Testing company Address: G6-A O Roo E(SALE NW I # R Date of TeadnVlSarvic ng:;L 11
Monitoring System ce""Watleh Page 1 014 14JO7
1 2/21/07
9/Z d 90) « IO:EI tlz-ZO-IIOZ
IIIIIII VIII III IIII 34
IE
r. In-Tank mautilitrry 13IR Equipment: Check this box If tank gauging Is used Dniy 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 getection monitoring.
Com let•the followlirme hackilst
r✓Yes No' Ras ell input wiring been inspected for proper entry and termination,including testing for ground faults?
;V—Yes NW Were all tan gauging probes visually Inspected for damage and residue buildup?
n✓Yes i No" Was accuracy of system produat level readings tested?
es i No' Was au>000y of system water level readings tested?
fY Yes n W Were all probes reinstalled property?
rr'Yes • No- Were ali horns on the equipment manufacturer's maintenance checklist completed?
`In the Section H,below,desedbe how and when ase deflclencfes were a will be corrected.
6. Line Leak Detector(LLD): l✓Check this;box if LLDs we not installed.
Gem plets the folllwmwinga checklist:
Yes o` For equipment start-up or annual equipment pert'roatlon,was a leak simulated to verify LLD performanos?(Check aN
VA that apply) Simulated teak rate: i,3 g,p.h.; i 1 0.1 g.p,h; ...0.2 g.p.h.
Yos No' Were all LLDs Confirmed operational and accurate within regulatory requirements?
I I Yes I No' Was TWIlestug apparatus property calibrated?
Yes No" For mechanical LLDs,dW the LLD restrict product flow if it detects a leek?
It NIA
Yes No' For electronic LLDs,does the turbine automatically shut off if the LLD detects a 1,06
WA
Yes No' For electronic LLDS, does line turbine automatically shut off if any portion of the monitoring system is disabled or
NIA disconnected?
ri Yes No" For electronic LLN, does the turbine automadcolly glut off if any portion of the monitoring system malfunctions or
NIA falls a test?
I I Yet; I I No' For ekwbonic LLDs,have all accessible wiring connections been vtswiy Inspected?
NlA
I I Yes I] No' Were all hems on the equipment manufacturers maintenance ist completed?
In the Section H.below,describe how and when these deficiencies were or will be corrected.
H. Comments:
Monkoring SWem cerllflaatlon Pape 3 of a 12107
3 2/2 l J07
s
9/E d 80D « z0 El tz-zo-lloz
Spill Bucket Testing Report Form
ThLr form is irnlended for we by contractors performing annual testing of UST spill containment structures. The complered form and
printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency.
I. >FACILM INFORMATION
Facili Name: �[ , L r— Deco of Testis : -
Facility Address: 00 t t L L EL E "
Facility Contact: %C H R E L phone: (, 4 ' `d 5 of 6 q -4
Date Local Agaacy Was Notified of Testing; l - 3 X - 11 �-
Name or Local Agency Inspector(J(present during testing): t=IZ+s VE rn•E fl i r-4 A
2. TESTING CONTRACTOR INFORMATION
Cam an Name: 5r 1tr3 -
Technician Conducting Test: "F 17.5 1=L C i3 i2 1Z I L.. L
Credentlnis1: 0 CSLB Contractor t3'ICC Service Tech, 0 SWRCB Taak Tester 13�66er(S ec )ALU&Rvo r
License Number(s): 1 cc # 52
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: SrH drostadc 0 Vacuum 0 Other
Test Equipment Used: Equipmont Resolution:
Identify Spill Bucket(By Tank I T t bt&SF L 2 T2 0 EE-.tF L 3 4
Number, Stored Product, etc) 4Grrl6 RA—� D R 801 Lin Il
Bucket Installation Type; SrDtrect Bury NMireot Bury D Direct Bury 0 Direct Bury
0 Contained in S=p 0 Contained in Sum 2 0 Contained in S 0 Contained in Sump
Bucket Diameter:
Bucket Depth: t p
Wait time betweea applying
vacuum/water and start of test: 15 MgtJ, TGS 15
Test Stan Time(TO: :U{, per. l ;0 6 ek-
Lr itial Reading(Ri7 9" !2 "
Test End Time(Tr): ,�: 3 O Prri Z 30 ?r^
Fuanl Reading(R.r): •' •f Z
"test Duration(TF-Tt): i Hoilz
Change in]reading(Rr-R�:
Pass/Fail Threshold or
Criteria:
Test Result: (amass ❑Fau ass 76 Fall ❑ Pass 0 pall 3 Pass 0 Fail
Comments-(include information on repairs made prior to tetting,and recommended.(ollow-up fen_fatled tests)
l
CERTIFICATION OF TECHNICIAN RSSPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the Information contained In this report Is true,accurate,and In fall compliance with legal requiremetw.
Technician's Signatwe: nth [ L(L.b� Date!
State laws and regulations do not currently require testing to be performed by a qualified contractor,However, local requircmcnts
mom}�+rnrw OMitln wnt
9/ir d 80) << W£I 4Z-ZO-II0Z
Ix lR"Utts of Te lowservkkQ
Software Varslon lnalaW:
pIM the lollarrd chaOM W
Yas I I I ko' Is 1110 autWo alarm opendfonel
es u o elarrn gwatlonat.
I.: No• w nertsora ftsvourAwy 1eoeo,and aon11rn10G Z
u.,Yes C tVo' Ware sertapR ins ai wsm point t�et Wxmy corwro ril am poattbned so that gnrer equlpment will not erfere With their
re wern Psicw?Yes No' h MOM are to a erts noilpp sn h ell pDrtMpp♦Catn ag t(s p.nd
iA
WA
U se 1 1 No" For pregsurizid pipVrp systems Cole tf19 M down N th@ pon0 seoondary ronOAinnlMp nG gystsm
9 WA Ovlects a leek tRilB to opsreta,or W eleotrlosJly duK*rwotad7 II yes:wt>bft sw+sorR iniROfe positive shut drrWn9 (Crieak ag bW dp*j
'I Sum Wrench Sensors: :1 Dispvnsar Conladrstlerd Senaws• Did you confkm posW@ shut-down due to leaks bpd sensor
Ialhueyd 7 l]Yes; ❑No.
ae u No, systama that utlllm the mordtodM spi m as IM PfNnary p wen>�g devlca(I•@.no mechanical overfill preverrlbn
n WA vulva Is Vratpsad),is the o 4kM uwrkq,harm vWI A end auabla at to tarp Nf point(s)and opsrstNp prnperiy9 t!so.at wtu g pomm
Of tardt %
1 Yes' PAD Was wq montorinp equipment rcpt wW? N yea sensors, probes. or ww equipment raptaped and Net the
malwlactu name and model for ell nt its in Swbn E bat)w.
I p6 Sf
Was found Inside any aft nme syaoams 8b dry systems. ( aN rirsr Aoply) .i roau t: f:WaW. n
aaatI lb Crireea in Ocofttlrt E.
M I ae rovWtrad m art6ul+a sat 4P rppoAe,iF
Iu-IYes u NO Is a equipment oparaliq"par rnarKdaof m s=Riom ns
In Socftft E bMow,tlascrtba how and when MOOD dgftWnCM wOrs or
E CoRrM11af1b:
O ri E 1Q 5 U S2 At,) "Tan n)'S 1-C Q 1t:l S ur y)i>is
Mork► + ftpa p ai 4
2 2/21/07
9/S d 90) MCI trz-zo-iloz
Monitoring myetan,cwtincaftin
UST Monitoring Site Man
Site Ad&&.m:.
U)R . . . . . . . . . . . . . . . . . .N.
. . . . . . . . . . . .
t4T ft R t-A C E. . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
. . . . . . .. . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
, 0
440,Gpt TA L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
s'�i,np. a . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
. . . . . . . . . .
. . . . . . . . . . . . . . .
. . . . . . . . . . a . . . . . . . .
. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . soo 2 . . . . . .
. . . . . . . . . . . . • . . 0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oa(e rn a 11 vp a drawn,.
linstruo—Qns
If you already have a d*wn that shows all required Intwmallon,you may linctude it, rather than this page, vAth your Monhorwg System
Certification. On your site plan,Show the general layout of tarks and plping. Clearly identify locations of the following equipment,if Installed;
monitoring system control panels; sensors monitoring tank annular spaos, . sumps, dispenser pans, spill contalners, or other seowdary
oontainmont areas; mechanical or slectronk: llne leak detectors; and In-tank IlquId i probes (If used for Is&datectIon). In the space
provided,note U*date this Site Plan was prepared.
fAmItoring System Cort1flestion Page 4 of 4
4 2/21/07
9/9 d GOD « E0:E1 17Z-Z:O-lIO7-
0030 FkLmoddl a Hwy#B
Bakersfield,California 93308
Phone:661 588 2777 BSSR, Inc
Fax;661 588 2786
Fm
To: Bakersfield Fire Dept—Emle From Kelly Tackett
Fam 852-2171 Dates 2-2411
Phone: P"*e
Re: Bakersfield Heart Hospital CD:
❑urgent❑For Review ❑Pismo Canwmwt ❑Pismo Rely ❑Please Roe"
•Cennnent-e:
Attached are tank monitor oertifiraGon results for Bakersfield Heart Hospital.
Please call if you have any questions.
Thanks,
Kelly
9/1 d 90D « to Er bZ-Zo-L1oL