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HomeMy WebLinkAboutFMC 2008 IIIIIIIIIIIIIIIIIIII 23 O� 0 FROM :BSSR, INC FAX NO. :6615882786 Dec. 30 200e 03:24PM P2 ---�—_ BSSS,R, Inc, ¢630 Rasedalc Hwy,,#B,Bakersfield,CA 93308 Phone(661)588-2777-Fax(661)588-27$6 MONITORING SYSTEM CERTIFICATION This form must be used to document testing and servicing of monitoring equipment. e r 'earl or pr arcd each nitorin de �sY.53�oontrol;pane!by the teohnlalari,vhq performs the work. A Copy of thi 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, i A. General.Information Facility Name: g"CSoTH [ _T t'Yy 5 ti Et1 T11L ]bldg.No.: Site Address: 0Q DL.0 1.2tVl=R- Qb .� City: f(ZS t� Zip: — p: 933tt Facility Contact Person: Contact Phone No.: b GI 432 -5 912- Make/Model of Monitoring System: l5rr >EfL-1 o -t10'30 -022 Date ofTesting/Setvicing: 12, B. Inventory of Equipment Tested/Cerdfited Check th"ppropriate box to indicates ecldc equipment t ected/erviced: Tank ID: ' t om wL Tank W; G7-in=Tank Gauging Probe. Model: - ❑ fit-Tank Gauging Robe. Mod l: t7Annular Space or Vault Scup'or. Model:1cig-A D -5-0-2 ❑ Annular Space or Vault Sensor. Modei: _ tid'Piping Sump/Trench Sensor(*). Model: _19.8 Q Piping Sump/Trench Sensor(c). Qr,AW Sump Sensor's). pntstTOo11 Modol;dl� . K3AC�• • -Qg Q Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: Q Mechanical Llne Leak Detector. Modei; -- ❑ Electronic Line Leah Detector. Model: Q Electronic Line Leak Detector, Model: _ O Tank Overfill/High-Level Sensor, Model: ❑ Tank Overfill/High-Level Sensor. Moduli Q Other(s ifyequipnnent and model In Section B on Page 2). O Other(specify ui rrtent a and model n Section E on Ps e 2). Tank ID:• Tank ED: ❑ In-Tank Gauging Probe, Model: ❑ 'In=Tank Gauging Probe, Mode : ❑ Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s), Model: Q Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model." O Mechanical Line Leak Detector. ' Model: O Mechanical Line Leak Detector. Mvdej: ❑ Electronic Line Leak Detector. • Model: Q Electronic Line Leak Detector. Mode): O Tank Overfill/High-Level Sensor, Model: O Tank Overfill/High-bevel Sensor. Model: ❑ Other s eci meet type and model in Section E on Page 2 . Q Others of n:2quipmentum and model>n Sec on E on Pa c 2). DlspensertD: -�_ Dispenser XD; 0 Dispenser Conlair(Miht S Model: D Dispenser Containment Se r(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Q Dispenser Containment o in a. ❑ Dispenser Containment Float a an ain•s . Dispenser ID: I%S, Dispenser I D:_ 0 Dispenser Containment Model: ❑ Dispenser Containment Sen s). Model: ❑ Shear Valve(s), ❑ Shear•VaIve(s). rDispeni,er Dispenser Contain t Float i Chain s . D Di enser Containment Floats and s . ID: Dispenser ID: ser Cohtainmen�Float(s . Mo' pl: O Dispenser Containment San Modoh alve(s). D Shear Valve(s). er Contain t d Chain s. D Dispenser Containment Ploat s and s. •if the facility contains more tank: dispensers;copy this form. Include information'for every tank and dispenser at the flacility, C. Certification - I certify. that the equipment Identified In this document was Inspected/serviced In accordance with the manufacturers' guidelines. Attached,•to.this Certltleation Is information(e-g. manufacturers' ebecklists) dec6sary to verify that this Information is correct and.a Plot Plat'showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of too report;(check au that apply)' j t m set- p (Wkarm�lstory report Technician Name(print); D'GL CAj2W1 6 L Signature: T .f+�� gaw,s._lx= Certification No.: 19 7-S L Lice tise.No.: Testing Company Name: iz`z;s iz 61J Phone No.:( w ) l ni-4 Site Address: 6630 20S'r--DALE HIJ V 9 j3 ' Date of Testing/Servit ing:111 I-/08 Page 1 or q. .03101 Monitoring System Certification IIIIIIIIIIIIIIIIIIII 24 I FROM :BSSR, INC FAX N0. :6615882786 Dec. 30 2008 03:25PM P3 -. r D, Results of Testifig/Servicing Software Version installed: Complete the folio win eheck.14tt ayes' ❑ NO* Is the audible ala o erational? Yes ❑ No* Is the visual alarm operational? Yes ❑ No} Were all sensors visuell ins Bete functionally tested,and confirmed operational? g''Yes ❑ No* Were all sensors installed at lowest point of secondary containrtientand positioned so that other equipment ,vill not interfere with their ro er operation? © Yes ❑' No* If alarms are relayed to a remote monitoring station, is all 'communications equipment (e.g. tnodcm) 12 N/A operational? • Yes 0 No* For pressurized piping systems,does the turbine automatically shut down if thc.piping secondary contnitimcni ® N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes'`which sensors inirime .positive shut=down? (Check all that apply) ❑ Sump/Trencb Sensors; O Dispenser Containment Sensors. Did you confirm positive shut-dawn due to leaks sensor failurt/disconnection? 0 Yes; ❑ No. ' • Yes ❑ No* For tank -systems that utilize the nrionitoring'system as the primary tank overfill wiaraiag device (i.e. no O N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible ind audible at.the inak, fill oint s .and operating ro erl ? If so at what Rercent of tank eapacity.does the alarm trigger! ❑ Yes* 0 No Was any monitoring equipment replaced? If yes,identify specific sensors, probes, or otl er equipment ieploced and list the manufacturer name and model for all re lacement parts in Section E,below. O Yes* ® No Was liquid'found inside,any secondary containment systems designed as dry systems? :(Check all that applv.! Q Product; ❑Water. If yes,descrbe causes in Section B below. ^_�- a,Yes ❑ No* Was monitorina system set-up reviewed to ensure proper settings?Attach set uR r.e orts,�if a licable­MN,.es 1 ❑ No Is all monitorin t ui ment operational per manufacturer's specifications? • In Section E below,describe how and when these deRclencles were or will be corrected. E. Comments: • j • i. t; Pago 2 of J FROM :BSSR, INC FAX NO. :66158827B6 Dec. 30 2ooe 03:26PM 44 F. In-Tank Gauging/SIR Equipment: *theck this box if'tatsSc gauging is used only(for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This suction must be eompletdd'if in-tank gauging equipment is used to perform leak detection monitoring. Com lets the folio win checklist: Yes ❑ No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults? Ycs ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? Ycs ❑ No* Was accuracy of system produt:t level readings tested? Ycs ❑ •N o* Was accuracy of system water level readings tested? Yes © No* Were all probes reinstalled properly? W Yes 10 No* Were all items on the equipment manufacturer's maintenance checklist completed? *In the Section D,below,describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): er(Nock this box if LLD&are not installed. Com lets the folio at checklist: ❑ Yes ❑ No* For equipm i start-up or annual equipment•certification, was a leak simulated to verity LLD performance? ❑ NIA (Check all that apply) Simulated leak irate: Cl 3 g.p.h.; ❑0.1 g.p.h; ❑0.2 g.p.h. ❑ Yes ❑ No* Were all LLX)s confirmed operational and accurate within regulatory requirements? O Yes O NO Was the tasting apparatus properly calibrated? • Yes ❑ No* For mechanical LLDs,does the LLD restrict product flow if it detects a'leak? O N/A • Yes 0 No* For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? Q N/A • Yes ❑ No* For electronic LLDs,does the turbine automatically shut off'if any portion of the monitot!ing system is disabled ❑ NIA or disconnected?. ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring.system 0 NIA malfunctions or fails a test? Cl Yes Cl No* For electronic LLDs,have all accessible wiring connections been visually inspected? ❑ N/A Q Yes ❑ No* Were all items.on the equipment manufacturer's maintenance checklist completed? *In the Section H,below,describe how and when these deficiencies�vwere or will be corrected. H. Comments- j:. i Page 3 of 03101 FROM :BSSR, INC FAX NO. :6615882786 Dec. 30 2008 03:26PM P5 I Monitoring System Certification USA' Monitoring Site Plan Site Address: 400 O Lb RAI f E 1z�- 9—D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . '.�' 'FIE L'. . . . . . . . . . Botcm -tVOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s . .. . . . . . . . . . . . . . . . . . . . . . . _ . . . . . 0 i1 .1 . . AiZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :: . . �_.. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . �tIFaJ.Papa�,t� . . . . . . . . . . . 4 Data map was drawn: �S�iCt10A� 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 Iayout of tanks and pipink.. 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 Y of osiuu i FROM :BSSR, INC FAX N0. :66158$2786 Dec. 30 2008 03:27PM P6 ISWRCB,January 2006 Spill Bueket Testing Report Form This form is Intended for.use by contractors performing annual tenting of UST spill containment structures. toe'completed form and printouts from tests(if applicq s),should be provided to the facility owner/operator for submittal to the local regulatory agency. I. FACILITY INFORMATION � Facility Name: SroyYrt WS"a-C M C1l 4aj'K-rgl_ Date of Testing: !Z„-JZ 3—O -Facility Address: LAOQ p� S2 Facility Contact: Pbone: ,Date Local Agency Was Notified of Testing. Name of Local Agency Inspector(lf present during t¢stinW: R�.{t,6 C'evE p%a A 2. TESTING CONTRACTOR INFORMATION Company Name: $S7r>'- tr,1C. Technician Conducting Test: V^%1b1F t_ CAT2Q-1t L t_O Credentials': 0 CSLB Contractor R ICC Service Tech. 0 SWRCS Tank-Tester'. ❑Other(Specify) l_.iceme Number(s): 52,6- 3. SPIT L BUCKET TESTING)<NFORMA'ITION Test Method Used: ❑Vacuum ❑Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket(By Tank 1 2 3 Jt. Number Stored Product, etc. Bucket'Installadon Type: lYDireet Bury 0 Direct Bury • 0 Direct Bury p Direct Bury ❑Contained in S2M ❑Contained in'Sum ' 0 Contained in Sump Q Contained in Sum Bucket Diameter: 1�{ • Bucket Depth: z w Wait time between applying vacuutn/wawr and start of test: 10 m`N- Test Start Time(TO. Cl ; 23 Initial Reading(Ri): Test End Time(TF): t o; 0!5 Final Readkng(RF): {'Z 1-1 Test Duration(Ty—TL): L{p k-mk 1- Change in heading(RP-Ri): �. Pass/Fail Threshold or 0.00�. Criteria: Test Result: ff"Pass ❑Fail ❑ Pass .0 Fall 0 Pass 0 Fail ❑ )bass O Fail Comments—(include Information on repairs made prior to testinX, and recommended follow-up farfailed fists) .. i i, CERTIF'ICATIONOF'TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING 1 hereby cer1W that all the information contalned In this report Is true,accurate,and in Rill compliance with.legal requirement.. Technician's Signature: L&&Q CC %U A_1T Date: 2 "a g ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements max,iv mnro Qrrinnnnr i FROM :BSSR, INC FAX NO. :6615BB27BG Dec. 30 2008 03:24PM P1 i i i i, I1 ®630 RoWdNe Hwy#B Bakersfield,Ca forrde Phone:869 688 2m Fax:861 588 2796 Fax Tog Bakerstk4d Fire Dept Froe s Kelly Tacked Faaa 882-2171 Daum 12-30-W fgmmm Pbgee: RM Merry Southwest HospW AUU 0 tuegentO For Revlew d Pisses Coaweet 0 Please Reply 0 Pleme Roayalrt Attached are monitor certification results. If you have any questions,please can. Thanks, Kedy i