HomeMy WebLinkAboutSB989 2010 Jun 231002:11p IIIIII�IIIIIIIIIIIII 39 f 2$$
IE p.2
SW'RCB,January 2002 Page of
Secondary Containment Testing Report Form
This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the
appropriate pages ofthis form to report results for all components tested. The completedform,written test procedures, and
printouts from tests(if applicable), should be provided to the facility ownerioperator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: "Jlffy C Date of Testing. 7-t
Facility Address: ' Nt i m G A ie F_.
Facility Contact; Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector(tfpresent wring testing):
2. TESTING CONTRACTOR INFORMATION
Company Name: Sunset Mechanical
Technician Conducting Test Scott Olinger
Credentials: D CSLB Licensed Contractor Q SWRCB Licensed Tank Tester
License Type: C-36 C-10 License Number: 589517
Manufacturer Training
Manufacturer Component(s) Date Trainin Ex fires
Incon TS-STS jpRection E ui tnent
Veeder Root Monitoring S stem `
ICC Cal UST Service Tech `
3. SUMMARY OF TEST RESULTS
Component Pass Fall Nat Repairs Component Pan Fait Not Repairs
Tested . Made ' Tested Made
iIDC 1 ❑ ❑ ❑ 5i P I ❑ ❑ ❑
D J 5 Ft 2 'sd ❑ ❑ ❑ S, ❑ i 0 ❑
Q I Sly 3 ® ❑ ❑ ❑ 5-7 P 3 ❑ F- ❑
0 15 q ® ❑ ❑ ❑ ❑ ❑ ❑ C
oiSP 5 ® ❑ ❑ ❑ V tp ❑ ❑ ❑
17 i S 1� R ❑ Ll C ❑ ❑ ❑ ❑
❑ ❑ ❑ C ❑ ❑ ❑ ❑
F,il % ti ❑ ❑ ❑ ❑ ❑ C ❑
"4 ft oz :9 ❑ ❑ ❑ ❑ ❑ ❑ ❑
; fl 3 N ❑ ❑ ❑ ❑ ❑ ❑ a
❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑
c C ❑ ❑ 1 ❑ ❑ ❑ ❑
1f hydrostatic testing was performed,describe what was done with the water after completion of tests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge,thefac a ed in this document are accurate and In full compliance with legal requirements
Technician's Signature- Date: 5 - -z'o
IIIII��IIIIIIIIIIIII 40
1 E
Jun 23 10 02:11 p F 3
SWRCB,January 2002 Page of
7. UNDER-DISPENSER CONTAINMENT C TESTING
Test Method Developed Bv: )(UDC Manufacturer O Industry Standard O Professional Engineer
0 Other(Specify)
Test Method Used: ❑Pressure ❑Vacuum X'Hydrostatic
C other(Sped)
Test Equipment Used; _ Equipment Resolution:
l Y fti _v UDC# U #
UDC# DC# UDC
UDC Manufacturer. ZAIR s t e--f7 L3 ram
UDC Material: v 3p'' li
UDC Depth:
Height from UDC Bottom to Top
of Highest Piping Penetration:
Height from UDC Bottom to
Lowest Electrical Penetration: /V A /VA
Condition of UDC prior to
testing-. NEW At -41
Portion of UDC Tested'
Does turbine shut down when
UDC sensor detects liquid(both X Yes DNo ❑NA %Yes ONo ❑NA W Yes C No D NA D Yes DNo ❑NA
product and water)?
Turbine shutdown response time so .SFG. 30 SKL'. 30-SEG.
Is system programmed for fail- gYes C'No DNA *es ONo DNA RYes ❑No =NA O Yes ❑No C NA
safe shutdown?*
Was fail-safe verified to be XVes C No ❑NA Yes D No DNA I9Yes ONo DNA C Yes ONo DNA
operational?*
Wait time between applying
pressure/vacuum.'water and
starting test AA1A0 / Nll
Test Start Time: 93 C. 8:36
Initial Reading(Rj): (40,6-13 3.1 5.73 17
Test End Time: 9 1151 B l3! 911S
Final Reading(RF): y 063o 3.19 5 i S.73 i it
Test Duration: /-5/Irt tN. 1 S M tN
Change in Reading(RF Rj: .OAa j .Odo oav
PassiFail Threshold or Criteria: _ Qoj- as
Test Result: t$ Pass 0 Fall IL Pass ❑Fail V Pass D Fail ❑ Pass 0 Fail
Was sensor removed for besting? %Yes DNo DNA :ZYes C No DNA XYes ONo ❑NA ❑Yes 0 No 0 NA
Was sensor properly replaced and IA Yes ❑No DNA 9Yes DNo ❑NA I$Yes ❑No D NA ❑Yes D No ❑NA
verified functional after testing?
Comments—(include information on repairs made prior to testing, and recommendedfollow-up for failed tests)
' If the entire depth of the UDC is not tested,specify how much was tested. If the answer to any of the questions indicated with an
asterisk(*)is"NO" or"_NA",the entire UDC must be tested. (See SWRCB LG-160)
Jun 23 10 02:11 p p.4
SWRCB,January 2D02 Page—of
7. UNDER-DISPENSER CONTALNIMNIMC)TESTIENG
Test Method Developed By: XUDC Manufacturer U Industry Standard 0 Professional Engineer
❑Other(Specify)
Test Method Used: ❑Pressure 0 Vacuum b<Ijydrostatic
0 Other(Specify)
Test Equipment Used: 111jZ eAl 1 5 Equipment Resolution: t 00 a
UDC#
UDC# UDC# UDC#
e
UDC Manufacturer: L110---5 A C-- 7 W
UDC Material: r.CT. F 9 FG rig
UDC the 30" '30
Height from UDC Bottom to Top
of Highest Piping Penetration: iaOl
Height from UDC Bottom to
Lowest Electrical Penetration: AM -11A MA NA
Condition of UDC prior to
testing, ill al Jve-al IV a(L,
Portion of UDC Tested' 151, /-511 )-S"
Does turbine shut down when
UDC sensor detects liquid(both 'Z Yes DNo CNA IXYes ❑No C]NA f4 Yes ❑No ❑NA XYcs; D-No ❑NA
product and water)r)*
Turbine shutdown response time 36 157--,, -30 5.ae-1 3050-4—
Is system programmed for fall- AYes n No DNA 9Yes 0 No DNA 5EYes 0 No DNA Yes 0 No DNA
safe shutdown?*
Was fail-safe veri fled to be VYes 3No DNA %Yes ❑No CNA XYes CNo DNA XYes C No DNA
0 rational?"
Wait time between applying
pressuWvacuum,lwater and
starting test IOAA W. 14) M Mr. 10 M iAf. A&AA JAJ
Test Start Time: 25 Cy".25 C1:2 5 S21 3&
Initial Reading R,): ',Q-47-3 .G 3 S.a J-3 q
Test End Time: 11,90 Cy"qC9
Final Readi ng(RF): 5.;N 74 tf,C1 J U — -5.a,133 9.7�L 1a2.
Test Duration: JSAAIM. —75— MlAk /,$/,-A I/U, /55 MIA/,
Chan;e in Reading(Ry:-R,): noci 1 0 1"420 t
Pass/Fail Threshold or Criteria: oz7*X .z7va .if>417 ZL
Test Result. FL Pass 0 Fail $L Pass ❑Fail 'AL Pass 0 Fail X Pass D Fall
Was sensor removed for testing? RYes D No DNA WYes C2No --NA KYes 0 No C NA KYes ❑No 0 NA
Was sensor properly replaced and
verified functional after testing? )I[Yes DNo DNA ( Yes DNo ❑14A U(Yes 0 No 0 NA AYes DNo -LjNA
1 1 1
Conmuents—(include information on repairs made prior to testing, and recommended follow-up for failed tests)
If the entire depth of the UDC is not tested,specify how much was tested. If the answer to any of the questions indicated with an
asterisk(")is"NO" or"NA",the entire UDC must be tested. (See SWRC13 LG-160)
Jun 23 1002:11p P.5
SWRCB,January 2002 Page_of
6. PIPING SUMEP TESTING
Test Method Developed By: 9 Sump Manufacturer 0 Industry Standard ❑Professional.Engineer
❑Other(Sped)
Test Method Used: ❑Pressure ❑Vacuum 53Hydrostatic
❑Other(Specify)
Test Equipment Used: rN60AO TS-s-' s Equipment Resolution: C C,2
Sump 4 S*r)o I Sump# rlo a Sump Sump
Sump Diameter: too q 87
Sump Depth:
Sump Material: F
Height from Tank Top to Top of
Hi hest Piping Penetration: _54)
Height from Tank Top to Lowest
Electdcal Penetration: 13 "
Condition of sump prior to testing: IV (41 iv IEW e1u.1
Portion of Sump Tested'
Does turbine shut down when
sump sensor detects liquid(both Yes DNo DNA )C Yes DNo DNA NYes DNo DNA OYes DNo DNA
.prpdu!qt and water)?
Turbine shutdown response time '30 See 3O SEC.
_5Ee-
Is system programmed for fail-safe Ycs DNo DNA ;K Yes ONo DNA l�Yes DNo 1:NA ❑Yes 0 No ❑NA
shutdown?'
Was fail-safe verified to be (�,Yes 0 No ❑NA t»Yes ONo DNA 1KYes ONo [I NA DYes 0No DNA
operational?*
Wait time between applying
pre,ssurelvacuum/water and starting
test: AA IN /jV/ ZQ 6A ik.
Test Start Time: 16,1_1 13
Initial Reading(Rj): -3.3 acs S.9 `i63
Test End Time: 0*0 r aq /p;;4 g!
Final Reading(Rr): 3.3 a C23 S.cY q 7 1 S.73)ci
Test Duration: IS /VAIN 5 4t%jV, ISM,Jv.
Change in Reading(RF-Rj)-. C)D a-
Pass/fail Thresbold or Criteria: nel a
Test Result: lR Pass C Fail ja Pass ❑Fall IX Pass 0 Fail ❑ Pass ❑Fail
Was sensor removed for testing? Yes DNo DNA 3(Yes C No DNA A Yes 0 No D NA 0 Yes ❑No ❑NA
Was sensor properly replaced and
verified functional after testing? ;KYes DNo DNA )(Yes CNo DNA, AYes E]No DNA ❑Yes ONo DNA
Comments—(include information on repairs made prior to testing, and recommended follow-rep for failed tests)
' If the entire depth of the sump is not tested,specify how much was tested. If the answer to any of the questions indicated with an
asterisk(*)is"NO"or"NA".the entire sump must be tested. (See SWRCB LG-160)
Jun 23 10 02:12p p,6
SWRCB,January 2002 Page of
6. PIPING SUMP TESTING
Test Method Developed By: )-(Sump Manufacturer ❑industry Standard D Professional Engineer
❑Other(Specify)
Test Method Used: ❑Pressure ❑Vacuum )<Hydrostatic
❑Other(Spec)
Test Equipment Used: '1`' r5 I Equipment Resolution: ,Upc,>p
Sump# Sump#1' f Sump# -11 Sump#
Sump Diameter. y Val,
Sump Depth: + ' ' " ' rr
Sump Material:
Height from Tank Top to Top of
Highest Piping Penetration: 13
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to testing: A1,5 V E sv
Portion of Sump Tested'
Does turbine shut down when
sump sensor detects liquid(both N:Yes D No DNA XYes C No DNA S Yes —.No DNA ❑Yes D No ❑NA
product and water
Turbine shutdown response time 70 .6f T FC,
Is system programmed for fail-safe
1
�
shutdown?� Yes ❑No DNA XYes DNo DNA XYes DNo DNA ❑Yes ❑No DNA
Was fail-safe verified to be 13 Yes 0 N 0 N XYes 0 N DNA Yes ❑No ❑NA ❑Yes ❑No L1 NA
o erational?'
Wait time between applying
pressureivacuum/water and starting
test:
"Pest Start Time: y I/ D r
Initial Reading(lj): 9,7/-55 9
'rest End Time: t);
Final Reading(RF): C
Test Duration: JAI. / AA im
Change in Reading(RF-R):
Pass/Fail Threshold or Criteria: 0p 2
Test Result: Pass D Fail Pc Pass ❑Fail PK Pass ❑Fail ❑ Pass ❑Fail
Was sensor removed for testing? KYes ❑No ❑NA KYes ❑No DNA KYes D No DNA D Yes ❑No ❑NA
Was sensor properly replaced and I
Yes ❑No ❑NA Yes ❑No ❑NA �dl'es ❑No ❑NA ❑Yes ❑No 0 N
verified functional after testing?
Comments—(include information cn repairs made prior to testing,and recommended follow-up for failed tests)
If the entire depth of the sump is not tested,specify how much was tested. If the answer to my of the questions indicated with an
asterisk(*)is"NO"or"NA",the entire sump must be tested (See SWRCB LG-160)
c
- SENSOR ALAP.M ----- rev
DISP 5 ANIV I -°--- SENSOR ALARM. ---- w
ILAR SPRrE __-- gE41SCv ALARM ----- L28:DISP 2 ANN
ALARM ANNULAR SPACE o
a7. 2010 2:33 PH FUEL! ANN FUEL ALARM ^�
ANNULAR SPACE ; MAY 27. 2010 2:47' PH FUEL. ALARM ^�
MHY 27. 2010 2:43 P11 i
--- S1 [1SUR ALARM ---
L22:UNL ! STP AIVIV
j' ANNULAR ACE
UEL ALARM
-.SENSOR ALARM ----- MAY 27. 201U 239 FM
DISP:6 ----- SENSOR ALARM -----
ENSER PAN 9FNSUR ALARM - L30:D1SP 3 ANN
ALARM --- ANNULAR SPACE
27. 2010. 2:34 PM L?7:DISY 2 FUEL ALARM
i DISPENSER PAN MAY 27, 2010 2:4B PM
FUEL ALARM
MAY 27, 2010 2143 PM
SENSOR ALARM
L23:UNL 2 STP
STP SUMP
FUEL ALARM 2 40 FM
- SENSOR ALARM -�---
MAY 27, 2010
DISPSPHCEN j ----- SENSOR ALARM - ---
-- SENSOR ALARI"4 L31:D1SP 4
ALARM[ --` DISPENSER PAIV
2 L29'DISP 3 FUEL ALARM
7. 2010 2:36 PH DISPENSER P AN
FUEL ALARM MAY 27. 2010 2:49 F19
IMAY 27. 2010 2:46 1'M
-. SENSOR ALARM
- -----
ANNUL SPACE
FUEL E ANN
FUEL ALARM
- SENSOR ALARM -----
MAY E7. 2010 2:40 PI'S
JNL 1 STP ----- SENSOR ALARM ----
iUMP -- SENSOR &AWl --- L32:DLSP 4 ANN
ALARM P 3 ANN ANNULAR SPACE
L3p:l7IS
7. 2010 2:39 PM ANNULAR SPACE
N FUEL ALARM
FUEL, ALARM MAY 27, 2010 2:49 fill
MAY 27, 2010 2:47 FM
i
----- SENSOR ALARM
L25:DISP 1
DISPENSER PAN
FUEL ALARM
tWl 27. 2o10 2:42 PM
zNSOR ALARM
r wx
311MP
gRM
2010 2:16 PM -- SENSOR ALARM — --- L14:UNLE2S FILL LANN y-
LIO:PNL STP ANN ANNULAR SPAC1:.
°- ANNULAR SPACE — -- SENSOR ALARM FUEL ALARM
FUEL ALARM LIU:PNL STP ANN MAY 27, 2010 2:29 PM`
MAY 27. 2010 2:23 PM ANNULAR SPACE
FUEL ALARM !
MAY 27. 2010 2:26 PM !
SENSOR ALARM -----
JT BOX ANN
Z SPACE
—ARM ___-- -----
2010 2:16 PM SENSOR ALARM
—_ SENSOR ALARM ----- L15-:PREM FILL
L 4:UNL PREM TANK 2 PIPiE,10 SUMP .
ANNULAR SPACE ----- SENSOR ALARM ----- FUEL-ALARM
LOW LIQUID ALARM L11:UNL I. FILL MAY 27, 2010 2:?9 PM.
MAY 27. 2010 2:24 PM PIPING SUMP
FUEL ALARM
HAY 27, 2010 2:27 PM
i
SENSOR ALARM
VL 1 ANN
aR SPACE
:.19UID ALARM
7. 2010 2:16 To"' -----_-- SENSOR AALARM -- SENSOR ALARM -----
L16:PREM FILL ANN
L 4:UNL PREM TANK 2 ANNULAR SPACE
ANNULAR SPACE ----- SENSOR ALARM ----- FUEL ALARM i
HIGH LIQUID ALARM L12:UNL I FILL ANN MAY 27. 2010 2:30 PM �
MAY 27. 2010 2:25 PM ANNULAR SPACE
FUEL ALARM
MAY 27. 2010 2":27 PM . f
• I
SENSOR ALARM --..—_
)NL 5TP
3UM13 i
ALARM
?7, 2010 2:23 PM I ----- OrNSOP ALARM
-- SENSOR ALARM ----- L17:DISP 5
! L 9:PNL STP DISPENSER PAN
STP SUMP --- — SENSOR ALARM ----- FUEL t�LARt"I
FUEL ALARM L13:UNL 2 FILL MAY 27, 2010 2:33 PM
MAY 27, 2010 2:26 PM PIPING SUMP f
FUEL ALARM
N MAY 27, 2010 2:27 PM
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FROM :BSSR, INC FAX NO. :6615882786 Jun. 23 2010 03:12PN P1
6630 Ro"dela Hwy*B
Bak&relleld.Cearor.,la 93306
Phone:66115 2777'
Fax:961 S86 2786
Fmc
Tes Bakersfield Fire Dept IFrost19 Kelly TaCkett
Fain 852-2171 cats 6-23.10
Ph000s pagewe
Ras Mercy F ospltal--2215 Trtndun CCc
i
O 11agentO For Rriviaw 0 pswms 0onwnewt C3 Pfnaso Reply O Please Roayclo
.Conwmmnt.m
Attached are tank monitor oertffi mUon results. Please call If you have
any questions.
Thanks,
Kelly Tacked
FROM :BSSR, INC FAX NO. :6615892796 Jun. 23 2010 03:12PM P2
�i
I.
Appandf>4 VI
(Copies of Monitoring"am Certifioation form and UST Monitoring Plot Plan available athrtn'r8x ,MWt,grbaards„i A dov_)
MONITORING SYSTEM CERTIFICATION
lror We By.411 JurJsdk0ons IAMhIn Me SUMP W Ge1NOWa
Aathorrt�,Cited:ChapW 0,7,hV61th and Safety Code;Chapnw 16;Division 3, 7-We 23,Caffforn/a Code of
Reguiifst one
This form must be used to document tesdng and serAcfng of mori tGring equIpment.A separate oertlflostion or repbrt last be prepared for
saoh monftoring 8yetem oonlroi panel by the technlolan who performs the work. A copy of this form must be provid to the tank system
Owner/operator. Fhe owner/operator mtm vu"ft a oopy of this form to the looW agency regula itig UST systems within 8 cep's of tow Mrs.
/ , 'f rte!Shr � •� Bldg.No.:
rAw Address: cfty-Af* / 7* +�y�►
Facility Contact Person: =L / CorHaot Phone No,:(A
Makwuwal of Monitoring System: r / ��� Oats of TestlnWrWvk*v: �
B. Irneertto Of EqulptTient TsweOiCer'titied
baraq to Incrku"spectft aguiprnam ins Kpotowsarwiced:
Tank to-. Tank IQ
'r _Og Tw* au0lna I: -1.rd-Te np obo. :
arAnnUfar$Papa or V".tt Sensor.- 1tb�91: -1 Annukar or Vault Sensor. Model:z ~-
�^-Piping 8urrp J Trench Senrar(s), Modal:' 1 P" Trench SsnsOr(y). Modal:
n Fill Sum Sancor(a). model;--- -7 "ll Bummpp (s). Model:
"I Mechanical Una Leak Detector. Model: -1 MechrWcal Una Detector. Model:
I Electronic Line Leak Detector. Mod W: ^r. f?Wctronb Urne L Lectgr. Model:
'I Tw*Overirll J High-Leval Senior. Model: -i Tank Overfdf/Hvy - Sensor. Model'
'I Other u anti n t m in L no Y.
Tank 1D; Tankin:
I fn-rank Gnu nD P bo. rn-T eu g Probe,
'i Annular Space or V .Q$er'uor. Modal: -t Annular Spaoo or Vault 8ermor.
a..viphv Sump.i'Tren Monier: -1 pk3Ing BurnP J Tranat:$eneor(s). dal:
r Su ip Sanaor(s). "s Model: 'I FItt SUmmpp Sansor(a). Model:
►A'gphan"t4na Lpak Detest. 'r MeshwlloW Une L W4letector.
l Electronic Line leak Detector. -1 Electronic Lire Leak Deteow. I:
') Tank O,eiHtt!FItgh-level$ansd 'T Tank Overfm J'Hwh-Laval Sons 1:
1 "Eon -t Iln Eon 2.
tresp�nearlD: DIs
Gsperiaernmarn r aor(s), h max nine" ensor(a. , Modsh
SZWrvelve(s), -I SrreiiPV6lvs(s).
-� nt e. -i Dt@WM r and .
Drsgerraerto: sperraerto.
-I t�iePenaar nmemt 8). 7S0= nnl r(s), Me:
Ve(s)• ;°F.Mer V
rt
Flo s)and n
DlsppeenaM'IR i
7 Dispansar 'm rrsor(s)• err[8 a.
`t shearvalva(s' shear
'I r nm 8 and ChNa -1 DION r C-o"MInnow Floalf s n
`M The trlOY9 Or .CCpy form. omlatton tar every s riser t faC01n. ,
C. Certtfleatlon,- 1 cera}y Slum the equtpmeru Identflled in this doaurnoM was Inapm*udiservlced In wxmrdwrcr With Ih4�rnanutacwrafs,
ifutda Ines...Anaohed to this CertilicaUon Is Information(aq.ananuia pnerd a)uoklk")necessary to verity that Shia Inlorinatlon is oorreor
end a Prot Plan showing the layout of mordtorinp egWpment. For any egWprn t caps of ganeratinti ALmh reports.1 have also attached a
copy of the repo";(check all Niel apply): -1 System set-up -1 Alarm t bry rap
Taahniotan Name(griWM- �/ re:• •
Certification No.: ,lceriaq.No.:
Tearing Company Heme: Phone No.:
Testing Company Add,(sae: Drity cf Tesflnd8ervlcirq:.._�
Monitoring System QwdScallon page t of a 12W
1 2121107
FROM :BSSR, INC FAX NO. :6615882786 Jun. 23 2010 03:13PM P3
I '
D. Resorts of TestinglSo vbing
Soltwers Version Installed: aAK AWA)
t;om late this fol owi checklist:
V)iYes 't No' is the audible alarm operational,
I NO' Is the Vie a o
'1 No Were a sensors v u ne ed,functional tested,an son irme operational?
"i No' Were sensors installed at lowest point of secondary containment posboried so that other equipment win r t interfere with their
D atipn7
� o ar Mr.relayed to a r emote monitorkip on,is a commu a ons squipmem(e,g,modem)operator wA
JVP-i o' For preeeuftod piping systems.COBS 0%turtfufe automat shut own It the piping secondary W riMe monitoring system
WA detects a leak,falls to operate,or is electrically disoonnected7 yes:wtnlch sensors Initiate positive hl-dpwr,? Check all that apply)
'1 3ump/Trench Sensors; -1 Dispenser Containment Sensors. aid you confirm positive shut-down dug t leaks r1i sensor
failureldisconnedloi�? Y 7 No.
1 Yes -I No' For tan s ms monitoring system as the primary tank overfill warning d (i.e.no mechanical ovatfill prevention
�D N/A valve is inetaled),is the pverfill warning alarm vislble and audible at the tank fig point(s)and operating properly? If`so,at wrnat percent
of tank r?
i Yes' No any monyo tg equ rnent replaced? if yes, edam specific eer,evra, pro s, or Weer equipment replaced and list the
man r n model for al r acement its in Section tt,below.
Yes' n Was U ou re any eonta rnmerrt systems debipned as ry a erne that apply)-1 Product; 't Water, if
es ds=tr a causes in Section E.betow.
Yea ) No' Was MoNtodw systm set-up Tevi to ensure proper settin 7 Attach bet Lp repcM,it applicable
Yes Is all monito 0 =orwl per mane rers specifications?
•In Section 6 below,describe how and when these deficiencies were or will be Corrected.
E. rnenty
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i
monitoring System Ceri flcetion Page 2 of 4 467
2 2/21/07
FROM :BSSR, INC FAX N0. :6615882786 Jun. 23 2010 03:14PM P4
F. In-Tank Gauging!SIR Equipment: 0 Check this box N tanK gauging is used onry for Inventory oontrot,
3 Check this Wx it no tw*gauging or 61R eau%xnent is instelted.
This section must be completed M In-tank gauging equipment is used to perform ieek detection monitoring.
can fete the t0112=2 dteaicilot:
➢p Yes 0 NO` Has Rtl irW wiring been nspected for proper entry arw termination,including testing for Fund Runs
ya Yes 0 No` ere Wl tank gauging probes Visually inspected for damage and residue buildup?
Yea —T—N-7—
o"N Was accuracy of system product level readings test
Yes 0 NO` Was accuracy of sya nt water level reactrrtg8 tweed?
yes ❑ qv7-1 Were I home on equ pment manura=oes mai"enarx:o c iwT ccm e
In the S&ctlon M below,describe how and when these d=;=were or wIN be correoted.
G. Line Leak Detectors(LLD): XCheck this box it LLDs are not installed.
Coin lets the fdlowin ohe0ldist:
0 Yes 0 No' For equipment start-up or annual equipment certification,wW a Peak simulated to verify LLO pert ante?(Check all
o WA that aA*) Simulated leak rate; 0 9 g.p.h.; 0 0.1 g.p.h; 0 0.2 g.p:h.
El Yes t. NO. Were alf LLDs conthmetl operational and acourate whNn regulatory reWlrements
Q Yes ❑ No' a6 the testing apparatus properly calibrated?
p Yes 0 No" For mechanical a,does the LLD restrict product flow it it detects a leak?
0
0 Yes 0 NW For elet t. ruc s,does the turbine Rutornatoaly shut 0 it etects a leak?
0 W
p Yes 0 No` For electronic LLD%does the turbine automatically shut off It any O&Ton-of the monitoring sy m rs abred or
0 N/A disconnected?
-Na' , For elecvo s,does the tur 'ne autom uy shut off f1 any ppr i of ttte monitoring system mat uYCtipr,g or
0 NIA' fallsatest?
0 eb 0 or electronic LLD$,have all ac essible wiring c onnec om been visually inspected?
❑ N/A
U Yes 0 1,40` Were all items at the equiprherd man ulaou or's maintehanob aiiadW canpleted?
In tha•Saatlan H.below,describe and when them delfickwdes were or win be Corrected.
H. Comments:
i
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1
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Monitoring System Certification Page 3 of 4 1?Jy7
3
2/21/0?
FROM :HSSR, INC FAX NO. :6615882786 Jun. 23 2010 03:14PM P5
__ ... .......... �--
Monitoring Syatft Cd-dflCatiott
UST Monitoring Site Plan
Site Address: 2 Z t 5 T tZ�1 X T Q tQ . AV e
: . • . . . .
. . . . . . . . . : : : : : :psil : : : : : : : : : : :
• : : � : �.../ pip„�: .
• cv p
. . . . . . . : : : : : : : : : : : : : : : : i.' . . . . . . . .
�.. . . . . . . .
. . . . . .. . . . . . . . . . .
pin►n►:vt Al1z: : : .
. . . . . . . . .
: : : : : : : : .. . . . .. . . . . . : : • : : : : : rt : : : : :
. . . . . . . . .
Date map was drawn'
Instructions
If you already have a diagram that shows all required„inforrimtign, you'rnay include it, rather than!this page, with your
Monitoring System Certification. Qn your site plan,, show the.general:layout of tanks and piping. Clearly identify
locations of the following equipment, if installed: 'monitoring systeal control pancls; sensors monitoring tank annular
SPA ces,sumps,dispenser pans, spill.oontainers,.or,of*seaoudary eontainmp!ii areas;mechanical of electronic'line leak
-detectors; and ix-tank liquid lowl,probes(if used for Ieak detcotion). Ih tha space provided;note the date this Site Plan
was prepared. ',
Page of 4 os/oo
j.
FROM :BSSR, INC FAX NO. :6615882786 Jun. 23 2010 03:15PM P6
SWICB,January 2006
. Spill Bucket Testing Report Form
This form is intended for use by contractors performing annual resting of UST spill containment structures. The completed form and
prhuouufrom tests({f applicable),should beprovided to thafacility ownerloperatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: / Date of Testis'.
Facility Address:
Facility Contact:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector(fpresent during testtn : /
2. TESTING CONTRACTOR INFORMATION
Compau Name:
Technician Conducting Test: / /
Credcatials 0 CSLB Contractor MCC Service Tech. 0 SWRCR Tank Tester VOther(Specj
LicenseNumber(s): Zpa!l �-
3. SPILL BUCIMT TESTING MORMATION
Test Method Used: V&droatatic 0 Vacuum 0 Other
Test Equipment Used: Equipment Rosolution:
identify Spill Bucket—*Tank 1' � -� 2 3 4
Number,Stored Product, etc.
Bucket installation lWe: treat Bury' 0 Direct Bury 0 Direct Bury 0 Dkreet Bury
t.Oltifiine in S Contained in S192 0 Contained in Sump 0 Contained In Sum
Bucket Diameter: /
Bucket Depth:
Watt time between applying
vacuum/water and start of test:
Test Start Time(T):
Initial Reading(R j).
Test End Time(T,,): f
Fine!Readin (lit);
Test Duration(Tr—TO:
Change in'R (14-Rr):
Pass/Fail Threshold or
Criteria.:
Teat Result: Pass O FaU ° :':i3 Pasco C71Rail=;"„' ''.Cl pass a Fats 11 Pass 0 Fail
Col] ments—Cnclude ijrormailon on repairs made prior to testing and recommeg*!t chow-up for d test)
t '
CERTIFICATION OF TECBMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this rVort u true,accurate,and In Jill compliance with�egal requirements.
Technician's Signature: D !5 � /
y,.ca ogulaKO�3 CS , T
m0W FW mnro a1ri nOt 1,
nn�nt currently�TIn'e tE$tjne to be
vv P'formed by a qualified contractor,HoWeVer, loc$I rcouirp�„ ._