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HomeMy WebLinkAbout3620 WILSON RD IIIIIII VIII III IIII 39 IE Appendix Vl (Copies of Monitoring System Certification form and UST Monitoring Plgt Plan available at htto://www,waterboar s.ca.aov,) MONITORING SYSTEM CERTIFICATION For Use By All JurisdiodonS W/thin the$fate of Califomia Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 96, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate ceitifioetion 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 Hot Pacllf Name: J Bldg.No,:_ Site Address: 26 Lofts j�Q � zip: Facility Contact Person: _ _ Contact Phone No.: Make/Model of Monitoring System: T-Z—S 350 Date of Testing/8ervtc{ng:�! / B. Inventory of Equipment Tested/Certified Check the ape=prlate boxes to indicate s ifie ui rent ins cted/eervicad; Tank ID; Tank IM In-Tank Gauging Probe. Model: V In-Tank(-auging Probe, Model ��T }Q Annular Space or Vault Sensor. Model; P Annular Space or Vault Sensor. Model: A Piping Sump/Trench Sensor(s). Model:E-ff ,fir Piping Sump/Trench Sensor(s), Model: Fill Sump Sensor(s). Model: pf FIII Sump Sertsor(s). Model, Mocharncel Line Leak Detector, Model: Mechanical Line Leak Detector. Mode. ❑ Electronic Line Leak Detector, Model: r1 Electronic Line Leak Detector. Model: ri Tank Overfill/High-Level Sensor. Model: ❑ Tank Ove n i High-Lwal Sensor. Model: ❑ Other s ul ment and model in Section E on Pa 2), rJ Other s d e ul merit tM and model In Section E on Page 2), Tank lb; TanklD: pf In-Tank Gouging Probe. Model: I'i In-'rank Gauging Probe. Model: Jf(Annular Space or Vault Sensor. Model: U Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: t7 Piping Sump/Trench Sensor(s). Model: FIJI Sump Sensor(s). Model: n Fill Sump!Sensor(s). Model: Machanical Line Leak Detector. Model: f ri Mechanical Line Leak Detector, Model: ❑ Electronic Line Leak Detector, Model, n Electronic Line Leak Detector. Model: U Tank Overfill I High-Level Sensor. Model ii Tank Ovglflll I High-Level Sensor, Model: riso. er s at a ul rent a and model in Section E on Page 2). n Other(spec ui menl type model in Section E an Pa 2), nser ID L-7— .. Dispenser itr spenser Containment Senso0s). Model; .!( Dispenser Containment Sensw(s), Model: ear Valve(s). X Shear Valve(s). Dispenser Containment Ploat s and n Dispenser Containment Floats and Chaln s. nggrlp DlsponserlD: spe nser Containment Sensor(s). Model: iD Dispenser Containment Sensor(s). Model: hear Valve(s). El Shear Valve(s). ❑ Dispenser Containment F sand Chains. 0 DIs eraser Containment Flogs)and Chain(s). DlsponsorlD; Xf& Dl6pertterID: Dispenser Containment Sansor(s), Model:A/W hG9W10A1F o Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Shear Vatve(s). 0 Dispenser Containment Floats and Chaln(s 1.) Dispenser Containment Float(s 2 and Chain(s), `If the facility contains more tams or dispensers,copy this ions, Include Information for every tank and dispenser at the faa'lity. C. Certification - I cortlfy that the equipment identified in this document was inspeotadlserviced in accordance with the manufacturors' guidelines. .4ttachod 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 equipmont capab generadng 6u ores, ova o attached a copy of the report;(check of that apply): ksystem soaup PW isbury ort Teohniclan Name(print): '1"E"Vt� Signature: certifioatlon No.: 4X2705, fir License,No.: Testing Company Name: CB Phone No.:(bbl )�? Testing Company Address: Date of Testing/Servicing: l l 2611 Monitoring System CortHlcatlon Page 1 of 4 12/07 1 IIIIIIIIIIIII IIIIIII 40 2/21/07 IiE 90/T0 3E)Vd NOI.Lona1SN00 Na3A EEZ6bE9T99 ET:80 TTOZ/9Z/170 ~ i D. Results of Testing►Senfioing Software Version Installed: Complete the follawl checklist: Yes f) No' Is the audible alarm operational? Yes. 0 No" Is the visual alarm operational? Yes I] No" Were all sensors visually inspected, functionally tested,and oonf renZoperation—atT- 1-1 No' Were all sensors Installed at lowest point of secondary containment and positioned so that other equ pmenT will not interfere wlth their proper 0 eration7 ❑ Yes 0 No" If alarms are relayed to a remote monitoring station,Is a communications equipment(e.g,modem)operational? 114 WA 2F Yes n No" For pressurized piping systems. does the turbine automatically shut down If the p p ng secondary containment monitoring system n NIA detects a leak,fails to operate,or is electrically disconnected? If yes:yuhlch sensors initiate positive shut-down? (Check all that apply) d-Sumplf7ench Sensors: X D4ansar Containment Sensors. Old you confirm poskive chin-down due to leaks bnd sensor failureldisconnection7 Yes; ❑No. Yes n No" For tank systems that utilize a monitoring system as the primary tank overfill warning devlce p,e.no mechanical overfill prevention n N/A valve is Installed),is the ove�ll warning a visible and audible at the tank fill point(s)and operating properly? If so,at what percent of tank capacity doft p1jotm ri r? % 0 Yes* X No Was any monitoring equipment replaced? If yes, Identify speclhr sensors, probes, *r other equipment replaced and list the manufgeturer name and model for all replacement parts in Section E.below, 0 e No as qur and inside any secondary containment systems designed as dry systems? (Check all that apply)I1 Product; 0 Water, If s,describe causes In Bectlon E,below. Yes n No" Was monitoring system set-up reviewed to ensure proper sett ngs.Atilgich set ifp reports,If applicable 0 Yos i1 Ne Is all monitoring equipment operational per marwfaCUrer 5 spedficatlo(is? "In Section 6 below,describe how and when these deficiencies were or will be correoted. E. Comments: O Monitoring System CanHlcatlon Pago 2 of 4 12107 2 2/271/07 90/Z0 39dd NOI1OMUSNOO NZ13>1 EEZ6t,E9199 ET:80 TIOZ/9Z/00 F. In-Tank Gauging/SIR Equipment: K Check this box if tank gauging is used only for inventory control. I7 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. Cam lets the follovWnI3 checklist: Yes Cl No' Has all input vrlring been Inspected for proper entry and termination,inoluding testing for ground faults? Yes Q No` Were all tank gauging probes vlau WWp_eated for damage and residue buildup? Yes u No' Was accuracy of system product level readings t"ted? Yes 13 No' Was accuracy of system water level readings tested? Y@S ri No' Were all probes reinstalled property? IL Yes n No' Wer®all items on the equipment manufacturer's maintenance checklist completed? In the Section H,below,describe how and when them efteienoies were or will be corrected. G. Line Leak Detectors(LLD): CI Check this box if LLDs are not installed, qojnpiete the followin checklist: Yes n No' For equipment start-up or annual equipment caA flCation,was a leak simulated to verify LLD performance?{Check all U NIA that apply) Simulated leak rate )3 g,p,h.; 1:10.1 g.p,h; 710.2 g.p.h. Yes 0 No Were all L,LI%confirmed operational and accurate within regulatory requlremonts? Yes u No` as the testing appsretus property calibrated? Yes I'I No" For mechanical LLDs,does t @ restrict product flow 9 it detects a leak? iJ N/A ❑ Yes it No" For electronic LLDs,does the turbine automaticaQy shut off If the LLD detects a leak? NIA ❑ Yes 0 No" For electronic LLDs, does the turbine automatically shut o r any portion of the monitoring system is disabled or fir' NIA disconneot@d? n Yes u No` For electronic LLOs, does the turbine automatically shut off if any portion of e monitoring system malfunctions or IC NIA fails a test? ❑ Yes ❑ No" For electronic LLDs,have sit accessible wiring connections been visually Inspect X WA 1� Yes ❑ No" Were all items on the equipment manufacturers maintenance checldist Completed? "In the Section H,below,describe how and when these defitlencies were or will be corrected. H. Comments: Monitoring System certification Page 3 of 4 12107 3 2/21/07 90/EO 30VcI NOI1011USNOO N83N EEZ6V69199 E1:80 TTOZ/9Z/00 Monitoring System Certification UST Monitoring Site Plan Site Address: . . . . . . . . . , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . , . . . . ; . , , . . . . , . . , . . . . . . . . . . . . . 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 foilowing 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 Certlfloatlon page 4 of 4 IV07 4 2/21/07 90/V0 39Vd N0Ii3ndlSN00 Nd3A ££Z6b£9I99 £1:80 ILOZ/9Z/b0 Monitoring System Certification UST Monitoring Site Flan Site Address; 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 of OSAO 90/90 39Vd NOIiOn i.LSNOO N635i 6CZ6VC9t99 61:BO ZZOZ/9Z/00 SWRCB,January 2002 Page of 9. SPILL/OVEIZFML CONTAWMCNT BOXES Facility is Not Equipped With Spill/Ovcrfill Colitainment Soxrs Spill/Overfill Containment Boxes are Present,but were Not Tested Test Wthod Developed BY: Spill Bucket Manufacturer industry Standard Professional Engineer Other(Specify) Tcat Method Used: Pressure Vacuum Hydrostatic Other(Specify) Test Equipment Used: Equipment Resolution; -�f+pill 800# Spill Sox#� ill Box# Spill Box# Buokat Diameter. r Z r e Bucket Depth: �4L�� 0� Wait time between applying pressure/vacuwn/water and 30^41 A/ starting test: Test Start Tima: AI Initial Reading(Rj): r r Ttst End Time: Final Reading(14): Test Duration: Change in Reading(R}•-Rj): d �� Fass/Fail Threshold or Criteria: ©.Q Teat Result: pass )Fail puss ail Puss Fail Comments— (include Information on repairs made prior to iestin ,and recommended folluw-up fur failed tests) 90/90 3E)Vd NOIlOnNiSNOO NNIIA EEZ6bE9T99 E1:80 TTOZ/9Z/00