HomeMy WebLinkAbout3301 WIBLE RD O
MONITORING SYSTEM CERTIFICATION
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 IIIIIIIIIIIIIIIIII 1
Facility Name: Go Go Mini Mart IE Bldg.No.:
Site Address: 3301 Wible Road City: Bakersfield Zip: 93309
Facility Contact Person: Alondra Contact Phone No.: (661) 835.8044
Make/Model of Monitoring System: Veeder Root Tis 350 Date of Testing/Servicing: 10/1712008
B. Inventory of Equipment Tested/Certified
Check the a ro riate boats to indicates cific of ent inspected/serviced:
Tank 1D: 1 (87) Tank ID: 2,(91)
®In-Tank Gauging Probe. Model: 847390-107 ®In-Tank Gauging Probe. Model: 847390-107
❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model:
®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208
❑Fill Sump Sensor(s). Model: Ll Fill Sump Sensor(s). Model:
®Mechanical Line Leak Detector. Model: RJ-FXIV ®Mechanical Line Leak Detector. Model: RJ-FXIV
❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model:
❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/Higb-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: 3 (87) Tank m:
®In-Tank Gauging Probe. Model: 847390-107 ❑In-Tank Gauging Probe. Model:
❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model:
®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model:
❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model:
®Mechanical Line Leak Detector. Model: FE PetroSTP-MLD ❑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 andr model in Section E on Page 2).
Dispenser m: 1/2 Dispenser ID: 314
®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208
®Shear Valve(s). ®Shear Valve(s).
❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s).
Dispenser ID: Dispenser ED:
❑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 Float(s)and Chain(s).
Dispenser m: 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 Float(s)and Chain(s).
•If the 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 equipment. For any equipment capable of generating such reports,I have also
attached a copy of the report;(check all that apply): ®System set-up ®Alarm history re ° '7
Technician Name(print): Ruben Beeerra Signature: � � ''
Certification No.: V/R:A20642 ICC:5238591-UT License.No.: 532878 A-hair _
Testing Company Name: Redwine Testing Services, Inc. Phone No.:(661) 834-6993
Site Address: 3301 Wible Road, Bakersfield,CA.93309 Date of Testing/Servicing: 10117/2008
Page 1 of 3 y
UN-036—1/4 www.unidoes.org I IIIIIII IIIII III III 18 Rev.01/26/06
IE
Monitoring System Certification
D. Results of Testing/Servicing
Software Version Installed: 16.04
Complete the folio win checklist:
• Yes ❑ No* Is the audible alarm operational?
• Yes ❑ No* Is the visual alarm operational?
• Yes ❑ No* Were all sensors visually inspected,functionally tested,and confirmed operational?
• 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)
® N/A operational?
® 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) ® Sump/Trench Sensors; ®Dispenser Containment Sensors.
Did you confirm positive shut-down due to leaks and 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
® 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? 95%
❑ 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 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
® Yes ❑ 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 3
UN-036—2/4 www.unidomorg Rev.01/26/06
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* I 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.
Complete the follo ing 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 g.p.h.; ❑0.1 g.p.h; ❑0.2 g.p.h.
® 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
® 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 the Section H,below,describe how and when these deficiencies were or will be corrected.
M Comments:
Page 3 of 3
UN-036—1/4 www.unidocs.org Rev.01/26/06
Monitoring System Certification
I T
UST Monitoring Site Plan
Site Address:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
gQ. .
� . . . . . . . . . . . . . .
o. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
U
: : : . . ?l✓sa : : : : : : : : : : : : :
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . D
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . .
. . . . . . . . . ,. . . .
. . . . . . . . . : sv.r QS . . . . . . .
. . . . . . . . . . . :�
L_Q
. . . . . . . . . �. 8�6 9 lI . . . .
. . . . . . . . . . . . . . . �� . . . . . . . . . . . . . Z
. . . . . . . . . . . g�p.
SGt��c+ES. Rr
lT
. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .
. . . . . . . . . .
54pbo 125. .
. . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
. . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date map was drawn: Ifs/ 1710 g'
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.
Monitoring System Certification Page 4 of 4 12/117
1 2/21/07
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: GO-GO Mini Mart I Date of Testing: 10/17/08
Facility Address: 3301 Wible Road,Bakersfield,Ca.93309
Facility Contact: Alondra I Phone: 661.835.8044
Date Local Agency Was Notified of Testing: 10/03/08
Name of Local Agency Inspector(if present during testing): Bakersfield Fire dept.
2. TESTING CONTRACTOR INFORMATION
Company Name: Redwine Testing Services Inc.
Technician Conducting Test: Ruben Becerra
Credentials': X CSLB Contractor XICC Service Tech. ❑SWRCB Tank Tester ❑Other(Spec)
License Number(s): 532878 A-Haz, 5238591-UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic ❑Vacuum ❑Other
Test Equipment Used: Visual/Marker Equipment Resolution:
Identify Spill Bucket(By Tank (1)87 fill (1)87 vapor (2)87 fill (2)87 vapor
Number, Stored Product, etc.
Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury
X Contained in Sump X Contained in Sump X Contained in Sump X Contained in Sum
Bucket Diameter: 111, 11"
Bucket Depth: 15" 15" 15" 15"
Wait time between applying 30 minutes 30 minutes 30 minutes 30 minutes
vacuum/water and start of test:
Test Start Time(Ti): 9:00 am 9:00 am 9:00 am 9:00 am
Initial Reading(RI): 9" 9" 8.5" 8"
Test End Time(TF): 10:00 am 10:00 am 10:00 am 10:00 am
Final Reading(RF): 9" 9" 8.5" 8"
Test Duration(TF—Tj): 1 hour 1 hour 1 hour I hour
Change in Reading(RF-RI): None None None None
Pass/Fail Threshold or Pass Pass Pass Pass
Criteria:
TestResult r r X Pass ❑Fail X Pass Fad _ X�Pass ❑Fail; :X Pass, ❑Fail
. .. ,.,...� . .., . ... _. .__ ..t . _ ...._, ..
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.
dovo
Technician's Signature: Date: 10/17/08
' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements
may be more stringent.
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: GO-GO Mini Mart I Date of Testing: 10/17/08
Facility Address: 3301 Wible Road,Bakersfield,Ca.93309
I' Facility Contact: Alondra I Phone: 661.835.8044
Date Local Agency Was Notified of Testing: 10/03/08
Name of Local Agency Inspector(ifpresent during testing): Bakersfield Fire Dept.
2. TESTING CONTRACTOR INFORMATION
Company Name: Redwine Testing Services Inc.
Technician Conducting Test: Ruben Becerra
Credentials': X CSLB Contractor X ICC Service Tech. ❑SWRCB Tank Tester ❑Other(Specify)
License Number(s): 532878 A-Haz, 5238591-UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic ❑Vacuum ❑Other
Test Equipment Used: Visual/Marker Equipment Resolution:
eIX�.Daw chi."r�T rn��m—
Identify Spill Bucket(By Tanki 91 fill 91 Vapor
Number, Stored Product, etc.
Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury
X Contained in Sump X Contained in Sump ❑Contained in Sump ❑Contained in Sum
Bucket Diameter:
Bucket Depth: 14" 15"
Wait time between applying 30 minutes 30 minutes
vacuum/water and start of test:
Test Start Time(Ti): 9:00 am 9:00 am
Initial Reading(Ri): 8" 7"
Test End Time(TF): 10:00 am 10:00 am
Final Reading(RF): 8" 7"
Test Duration(TF—Tj): 1 hour 1 hour
Change in Reading(RF-RI): None None
Pass/Fail Threshold or pass Pass
Criteria:
Test Result : _ ` Pass Y (]Fail X�Pass Fad t C3Pass, `❑Fail; ❑Pass ❑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 fult compliance with legal requirements.
Technician's Signature: ��' Date: 10/17/08
' State laws and regulations do not currently require t-h- o be performed by a qualified contractor.However,local requirements
may be more stringent.
MECHANICAL LEAK DETECTOR TEST
WORK SHEET
W/O# :
Facility Name: GO GO Mini Mart
Facility Address: 3301 Wible Road
Product Line Type • (Pressure, Suction, Gravity) Pressure
PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS
SERIAL# BELOW PSI OR
3 GPM FAIL
L/D TYPE RJ-FXIV YES 13 psi PASS
87 (l) SERIAL# 116-056
L/D TYPE FE Petro-STP-MLD YES 12 psi PASS
87 (2) SERIAL#
L/D TYPE RJ-FXIV YES 12 psi PASS
91 SERIAL#
L/D TYPE
SERIAL#
I certify the above tests were conducted on this date according to Red Jacket Pumps
field test apparatus testing procedure an limitations
The Mechanical Leak Detector Test pass / fail is determined by using a low flow
threshold trip rate of 3 gallon per hour or les at 10 PSI
I acknowledge that all data collected is true and correct to the best of my knowledge.
Tech: Ruben Becerra
Signature: p _ f Date: 10/17/2008