HomeMy WebLinkAboutFMC 2010 I IIIIIII 111111111111 71
MONITORING SYSTEM CERTIFICATION
I 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. AA§Qgge certification or report:must be nrenared for:each
monitoring.system corLtrol panel by the technician who performs.the.work. A copy of,tbh 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 VST;systems within 30 days,of test date. f
A. General Information
Facility Name:_ .RIO.BRAVO CHEVRON B1dg..No.;
Site Address: 6201 LAKE MING BLVD City: BAKERSFIELD Zip: 93306.
Facility Contact Person: DANNY Contact.Phone.No.: (: )
Make/Model of Monitoring System: GILBARCO Date of Testing/Servicing:71712010
B. Inventory of'Equipment Tested/Certified
.Check the appro2riate boxes to indicates citic a ul ment ins ed/servieed:
Tank ID: UNL87 1SPLIT TauklD: PREM_91/SPLIT
•In-Tank Gauging Probe. Model: MAG ®in-Tank Gauging Probe. Model: MAG
•Annular Space or Vault Sensor.. Model: 420 ®Annular Space or Vault Sensor. Model: 426
.®Piping Sump/Trench Sensor(s), Model: 208 ®Piping Sump/Trench Sensor(s). Model: 206
❑Fill Sump Sensor(s). Model; ❑Fill Sump Sensor(s). Model:
®Mechanical Line Leak Detector. Model; RED JACKET ®>Mechanical line teak Detector. Model: RED JACKET
❑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:Sectio.Et on Page 2). ❑Other(specify equipment type and model in;Section;E on Page 2).
Taak ID:: . . Tank;ID:
iln-Tank.GaugtngProbe. Model: ❑`.hi=Tank Gauging,Profit. Model:
19'!Aiimilar Space:&Vault Sensor. Model: ❑Annular Space orYault Sensor.. Model:
El Piping Snmp/Trench Sensor(s). Model: . ❑'Piping Sum /Trench S
..p. ensor(s):- Model`.
ftFi11 Sump Sensor(s). Model: ❑Fill Sump Sensor(s): Model:
❑`Mechanical Line Leak Detector. Model: ❑Mechanical line Leak Detector.
Model:
O Electronic Line Leak,Detector. Model: []Electronic.Line-Leak'Detectof., Model;
❑Tank Overfill/High-Level Sensor. Model-. 0 Tank:.Over l—n—igh-Level Sensor. 'Model;
❑Other(specify equipment type and.model in Section E on Page 2). []Other,(specify equipment type and m,ode)in:Section E on Page 2).
Dispenser ID: 1-2 Dispenser ID: 3=4
®.Dispenser Containment Sensor(s). Model: 208 ®Dispenser Contamritmt.S.ensor(s); Model: 208
®Shear Valve(s). ®Shear Valve(s)
❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and'Chair►(s).
Dispenser TD: Dispenser m::.
[],Dispenser Containment Sensor(s). Model: ❑'DispcnserCgntairimem Sensor(s). Model:
❑Shear Valve(s). ❑Shear Valde(s).
❑Dispenser Containment Float(s)and Chain(s), ❑Dispenser Containment Float(s)andChain(s)
Dispenser ID: Dispenser ID
❑.Di enser Containment Sensor(§): Model` ._
sp ❑:D> penser`ContAmmenf Se w4s), Model:
,❑Shear Valve(s). ❑ShearVatve(s).
❑Dispenser ContainmeutFloat(s)apdChain(s). ❑.Dispenser:Containment Floats)and Chains).
*lf the facility contains more tanks or dispensers;copy this form Include;information forevery tank and dispenser at ihe,facility.
Cr Certification-I certify-that the.equipment identified in this'document-was inspected/serviced.in accordance with>the,manufactnrers'
guidelines. Attached.to this.Certification,is;information. a m.anufacturers' checklists necessa, to°ver that.this information is
_correct and a Plot Plan showing the layout of monitoring equipment. For any equipmeat_capable7of generating such,reports,T have also
. attached a copy of the report;(check all thot"gppty): M System set-up [K.AJa1jm.hbt0ry report
Technician Name(print) RYAN MASON Signature;,
Certification No.: A273671. 8029371-UT License:No:; C 1/ 09850
Testing Company Name: RICH.ENVIRONMENTAL one No.: 661 392,8687
Testing Company Address: 5643 BROOKS CT.;BAKERSFIELD,:CA 83308 Date of Tesiing/Servicing: 7/7/2810
Page 1 of 5
IJN-036-1/4 WWw.uodnesorg IIIIIIIIIIIIIIIIIIII 72 Rev.01/17/08
IE
Monitoring System Certification
A Results of Testing/Servicing
Software Version Installed: 15.01
Complete the following 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 El No* Were all sensors installed at lowest point of secondary containment and positioned so.ihatiother equipment will
not interfere.with theirproper operation?
• Yes ❑ No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem)
® NIA 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,failsito:operate,,or is:electrically disconnected? If yes:which sensors initiate
positive-shut-down? (Check all:that apply) 0'Sump/Tren&Sensors; ®Dispenser.Containment Sensors.
Did you confiim 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 warming: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.? %
❑ Yes* ® No Was any monitoring equipment replaced? Ifyes,identify specific sensors,probes,or other equipment replaced
and list the manufacturer name and model for all replacement:parts in Section.E,below.
p Yes* ® No Was li q uid found inside any secondary containments Y stems designed as drY-s stems?. (Check all•rhat.
aPP1Y)
❑Product; ❑.Water.; If yes,:describe causes in Section E,below.,
® Yes ❑ No* I Was monitoring:system set-up reviewed to ensure proper,settings?Attach:set up.reports,if applicable .
® Yes ❑ No* I Is all monitoring.equipment operational per manufacturer's-specifications?
*:In.Section E below,describe how and,when°Abese deficiencies were.or will be corrected..
K 'Cont,ments•
r.
Page 2 of 5
UN-0
36 2/4 wwwxuidomorg Rev.0In7/08.
Monitoring System Certification
F. In-Tank.Gauging/SIR Equipment: ®.Check ibis.box,iftank.gauging is:use&only for inventory control.
❑ Check this.box,if no tank gaugingor`SIR equipment:is installed..
This section must be completed if iir-tank gauging;equipnent is used to perform leak detection;monitoring.
Complete the following.checklist:
0 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* Were all probes reinstalled properly?
❑ Yes ❑ No* Were all items on the equipment-manufacturer's maintenance checklist'completed?
* In Section H,below,describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors(LLD): 0 Check this box if L-LDs are not installed.
l
-Complete the following checklist:
® Yes ❑ No* For equipment start-up or annual equipment certification, was a Teak simulated to verify LLD performance?
El N/A, (Check all that apply) `Simulate&leak rate: 01,g;p.h:; ❑ 0.'1 g:p.h ; ❑0.2.g,p.h.
® Yes ❑ .No* Were all LLDs confirmed_operational and accurate within regulato y:tequirements2
giNes' -❑ No* Was-the testing apparatus properly calibrated?
,® Yes ❑ No* For mechanical LLDs,.does the LLD restrict.prod`uct,flow if it detects.a leak?
❑ N/A
❑ Yes ❑ "No* For electronic LLDs,does'the turbine'.automaiically shut off if the LLD defects a leak?
® N/A
❑ Yes ❑ No* For electronic LL;ps; does the turbine automatically-shut_off if any portion of the monitoring system is disabled
® NA or disconnected?
❑ Yes C] 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 1 ❑ No* I Were all.items on the equipment manufacturer's maintenance checklist.completed?
IL
x In Section H, below,describe how, when these deficiencies Were or will be'corrected.
H. Comments:
Page 3 of 5
t'N-036—3/4 www:unidocs:org Rev,011.17/08
L6 l�
AA
Monitoring Srstem.Certitication
UST Monito.elfig-Site.Pla m..
We,AdQTrss: ��tl"l . l_A lf� m�►�.:L�::-�"�-T�-E� �':t��-`�-,..c 1'`.
. . . . . . .
Ili�trvetions;
I1 you alre2dv have a diagram that shows'.all tequired infoTmatiQn,.you may ,hiclude ii,.ruther than this page,with your 1ti'iun Loring
System C:ei2;rlcation. t7nyour s,itc plan; siiaw the genr7al layout of furies ziid.pipirig. tlearl�r identify locations of`Qhc tuflov ink,
.{uiprn�nt, if installed; mo�iiioring skstsrrr cot<trgl panels snsors"monitoring`€ttnlc ntinuiac spaces,sumps; o;spe3"iser pans, spill
containers,or other secondary contaulm m areas;rnccti�inicel or cl"ea tronic line leak dctctlors;an :m-tan,, liquid level probes(if used
for ICA det=tion), ir1 the space pruvid d,liotc the d"ate his Sitc Plairwas.nreparcd.
Page 4 of 4
GN,UJG'-414 wwir.uniJucs urg. Ree.0 U17718
15
COMMON I .CATIONS SETUP. - -TAN)'. SETUP
T t UNLEADED 97
SOFTWARE REVISION' LEVEL PRODUCT CODE: 1
VERSION 15.01 PORT SETTINGS: THERMAL COEFF : .000700
SOFTWARE# 346015-100-B. ... TANK DIAMETER. : 128.10
CREATED - 97.10:23.08.56, COMM.BOARD 2 (.RS-232) TANK PROFILE : 4_ PTS
BAUD RATE ` 1210 FULL VOL : 12044
S-MODUL£1t 330161-001-A PARITY 'EVEN 96.1 INCH VOL 971
SYSTEM FEATURES: STOP ;BIT 1 STOP 64..1 I140H VOL 6050
PERIODIC IN-TANK TESTS DATA LENGTH: 7 DATA 32.0 INCH VOL 2380
ANNUAL IN-TANK TESTS
0.20 GAL/HR PLLD AUTO TRANSMIT SET.T1NGS:
PRECISION TEST SPECIAL FLOAT SIZE: 4.0 IN. 8496
AUTO LEAK ALARM LIMIT MATER WARNING 2:.0
DISABLED HIGH WATER LIMIT': 2 5
AUTO HIGH WATER LIMIT
DISABLED MAX OR LABEL VOL: 12044
AUTO OVERFILL. LIMIT OVERF3.LL LIMIT 95%
DISABLED LL
AUTO ,LOW PRODUCT HIGI PRODUCT 95%'
D I SAHLED' 11441.
AUTO THEFT' LIMIT D9L.IVtRY DISABLED LIMIT, 1(r!
SYSTEM SETUP 1204
AU
_ _ _ TO, DELUER
IY START .
DISABLED
JUL 7, 2010 2:04 PM LOW':PROD,UCT, 1000
AUTO DELIVERY END LEAK .ALARM L1P9IT' 99
DISABLED SUDDEN LOSE LIMIT: : 99
AUTO. EX,TEPNAL INPUT ON TANK TT`LT
SYSTEM UNITS DISABLED
u.s. AUTO ;EXTEkNAi:. INPUT OFF MAN I;FOLDED TANKS
SYSTEM .LANGUAGE DISABLED TO: -NONE.
•ENGLISH AUTO' SENSOR FUEL ALARM
SYSTEM DATEiTIME FORMAT DISABLED
TER ALARM
MON.,.DD ,YYYY HH:MM:SS xM AUTO SENSOR kfA D I SABLED, LEAK .MIN PERIODIC: 0°i
. �
AUTO SENSOR OUT.,ALARM D
DISABLED LEAK MIN ANNUAL. 0•.0
0
SHIFT TIME 1 DISABLED PERIODIC TEST TYPE.
SHIFT TIME 2 DISABLED STANDARD
SHIFT TIME 3 DISABLED R8-'232 SECURITY
SHIFT TIME 4 DISABLED CODE 000000 ANNUAL TEST FAIL.
ALARM DISABLED.
TANK PERIODIC WARNINGS
DISABLED PERIODIC TEST ;FAIL
TANK ANNUAL WARNINGS ALARM DISABLED
DISABLED RS-232 END. :OF.MESSAGE.
LINE PERIODIC WARNINGS GROSS TEST FAIL
DISABLED ENABLED ALARM .DISABLED
LINE .ANNUAL WARNINGS
DISABLED ANN TEST AVERAGING.: OFF .
PRi,NT TC VOLUMES :PER TEST' AVERAGING! , OFF
ENABLED TANK TEST NOTIFY: OFF
TEMP, COMPENSATION TNK TST SIPHON BREAK:OFF
VALUE_ (DEG .F 60:0.
STICK HEIGHT,OF.FSET DELIVERY DELAY 5 MIN
DISABLED
H7PROTOCOL DATA FORMAT
HEIGHT
DAYLIGHT SAVING TIME
ENABLED
START DATE:
APR WEEK 1 SUN
START TIME
2:00 AM
END DATE
OCT WEEK 4 SUN .
END TIME
2:00 AM
RE-DIRECT LOCAL PRINTOUT
DISABLED
gvgrpm gpr*t iv f Tv
T 2:SUPREME 92
PRODUCT CODE 2 LIGUI;D4SENSOR SETUP- - - ALARM HI:'TORY REPORT Q�
THERMAL COEFF : .000700
TANK DIAMETER 128.10 ----- SYSTEM{ ALARM -_-
TANK PROFILE 4 PTS. L 1 :ANNULAR PAPER_OUT
FULL VOL 8029 TRI-STATE (SINGLE FLOAT) JUL: 29', 2009 1 :03 PM
96.1 INCH VOL 6475 CATEGORY : ANNULAR SPACE
64.1 INCH VOL 4034 PRINTER ERROR
32.0 INCH VOL 1587 JUL 29, 2010.9, 1 :03 PM
BATTERY IS ,OFF
JAN. 1, 1996 .8:00 AM
L 2:87 STP SUMP, CLOCK. IS INCORRECT
-FLOAT SI2E: 4.0 IN. 8496 TRI-STATE (SINGLE FLOAT.,)
OCT'. 18.: 1998 1 :'11 AM
CATEGORY : STP SUMP
WATER WARNING 2.0
.HIGH WATER LIMIT: 2.5
MAX OR LABEL VOL: 8029 L 3:92 STP SUMP
OVERFILL LIMIT g5% TRI.-STATE. (S[NGLE FLOAT)
7627 CATEGORY : 'STP SUMP
HIGH PRODUCT 95%
7627 L 4:.DI:SPENSER; PAN 1-2
DELIVERY LIMIT 10% TRI=STATE (SINGLE FLOAT)
802 CATEGORY DI.80ENSER PAN * END * *.
LOW PRODUCT 500
LEAK ALARM LIMIT: 99
.SUDDEN LOSS .LIMIT: . 99 L 5:DISP£NSER PAN 3-4
TANK TILT G.00 TR,-I;-+STATE.;tSINGLE,FLOAT),
MANIFOLDED TANKS CATEGORY : °:DISPENSER PAN
T#: NONE
LEAK MIN PERIODIC: 0%
0 ALARM 'HISTORY REPORT
LEAK MIN ANNUAL 0
0 --== I:N-TANK ALARM
T 1 :UNIEADED 87
PERIODIC TEST TYPE
STANDARD OUTPUT RELAY SETUP - �J2 -7:57 PH
ANNUAL TEST FAIL APR :29 :2010 2>:-10 PM
ALARM DISABLED R 1 :87 TURBIN CONTROL MAR 22 2010 b:;48 PM
TYPE:: L
FUEL LEVEVE
PERIODIC TEST, FA:I L STANDARD JUN INVALID 207;0 PM
ALARM DISABLED NORMALLY CLOSED
OCT 17:. `2009 8:48 .PM
GROSS. TEST FAIL
JUN' 19. 2009 2-:02 P.M
ALARM DISABLED LIQUID S£NSOR._:ALMS! PROBE OUT
L '2 FUEL .ALARM APR:. 4.. :2005 1:.2:49 .PM
ANN TEST AVERAGING.: 'OFF L 4.:FUEL ALARM
,PER TEST_AVERAGING:- OFF L 5:Fl1EL ALARM
L 2:51ENSOR OUT ALARM DEL[VERY .NEEDED
TANK TEST NOTIFY: OFF L 4:SENSOR OUT ALARM DELIVE. 2NEE 7:2.1 PM
L 5:SENSOR OUT ALARM MAY 29r 2010. 8;.08 PM
TNK TST SIPHON BREAK:OFF
R 2:92 TUPBIN CONTROL APR 27, 2010 . 6:02 PM
DELIVERY DELAY. 5 MIN TYPE:
STANDARD
NORMALLY CLOSED
L-IOU:ID' SENSOR ALMS
L.:3:FUEL ALARM
L 4-:FUEL. ALARM
L 5:FUEL ALARM
L 3:SENSOR OUT ALARM
L 4:SENSOR OUT ALARM X *: ' : x X END, x x * A w
L 5-SENIOR OUT, ALARM
LEAK TEST METHOD
TEST ON DATE ALL TANK
JAN. 1. 1.996
START TIME DISABLED' .
TEST RATE; .0.20 GAL/HR.
DURATION :, 2 HOURS
LEAK TEST REPORT FORMAT
ALARM HISTORY REPORT
ALARM HI'STOR'Y.REPORT ALARM HISTORY REPORT
`= 1 N-TANK ALARM -----
---=- SENSOR ALARM -----
-- SENSOR. ALARM -----
T 2:SUPREME 92 L .2:0 STP SUMP L 4D'ISPENSER PAN 1-2
STP SUMP' DISPENSER: PAN
LOW PRODUCT ALARM SENSOR; OUT ALARM SENSOR OUT ALARM
MAY 23. 2010 6:,36 PM JUL 7. '201.0 1 :57 PM JUL 7. 2010 1 :5:7 PM
NOV 10, 2009 12:41 PM
SEP 13 2009 1'2:33 AM FUEL -ALARM`, FUEL ;ALARM
JUL 7. 2010 4 :38 PM JUL 7, 201.0 1 :39 PM
INVALID FUEL LEVEL
JUL 12. 1999 6:21 PM SENSOR OUT ALARM SENSOR OUT ALARM
JAN 31, 1999 2:01 PM AUG 25; 2009 2:.04 PM AUG 25, 2009 2:04 PM
PROBE OUT
APR 4. 2005 12:15 PM
DELIVERY NEEDED
JUN 28. 2010 1.:13 AM
MAY 17; 2010 3:32 PM
APR 24. 2010 10:53. PM
x * END xx * x9END * XXXX
.1.
X * * END X * * x �€
ALLARM' H I STORY REPORT ALARM' H I'STORY REPORT
------ SENSOR ALARM ----- ----- SENSOR .ALARM -----
L 3:92 STP-SUMP .L :5:1)I'SPENSER PAN 3-4
STP SUMP . DISPENSER PAN
SENSOR OUT.ALARM. SENSOR OUT ALARM
JUL 7, 2010 1 :57 PNI. JUL 7:: 2010 11:57 PM
FUEL ALARM FUEL, ALARM
JUL 7. 2010 1 :38: PM JUL. 7., 2010 1 :40 PM
ALARM HISTORY-REPORT .SENSOR OUT ALARM SENSOR OUT ALARM ,
----- SENSOR ALARM ----- AUG :25'. 2Q09 2:04 PM AUG 25: 2009 2:04 PM
L 1 :ANNULAR
OilNULAR SPACE
SENSOR OUT ALARM
JUL 7, 2010 1 :57 PM
FUEL ALARM
JUL 7, 2010 1 :39 PM
SENSOR OUT ALARM
AUG 25.. 2009 2:04 'PM
x :ENDXx * x X
* * x x X END
* *
. w x X END * x x x
ALARM HISTORY REPORT
- EXTERNAL INPUT ALARM -
I 1.:
u ati t-�
RICH ENVIRONMENTAL
5643 BROOKS CT. BA.KERSFIELD, CA. 9-308
OFFICE(661,)392=8687 FAX (661')392-062;1
PRODUCT LINE LEAK DETECTOR TEST.
WORK SHEET
W70#:
FACILITY NAME: RIO BRAVO CHEVRON
FACILITY ADDRESS: 6201 LAKE MING BLVD,BAKERSFIELD, CA
PRODUCT LINE TYPE:: PRESSURE.
PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS-
BELOW P;S.I. OR
SERIAL NUMBER: 3 G.P.H. FAIL
UNL87 L/D TYPE : RED JACKET PASS
YES 12
SERIAL:#.MECHANICAL
PREM91 L/D TYPE: RED JACKET PASS
SERIAL,## MECHANICAL YES 12
L/D TYPE:: PASS
YES
SERIAL.# FAIL
UP TYPE: PASS'
YES
SERIAL# FAIL
1 CERTIFY THE.ABOVE`TESTS.WERE CONDUCTED ON THIS DATE ACCORDING TO RED
JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND LIMITATIONS.
THE MECHANICAL LEAK DETECTOR,TEST PASS:/FAIL.IS DETERMINED BY USING A
LOW FLOW THRESHOLD.T.RIVRATE OF 3;GALLONS PER HOUR OR'LESS AT l0 P.S:1. i
ACKNOWLEDGE THATALL DATA COLLECTED IS:TRU.E AND CORRECT TO THE BEST
OF MY KNOWLEDGE.
TECHNICIAN: RVAX MASON .
SIGNATURE:. DATE: 7-7-2010
SWRCB,January 206
Spill Bucket Testing Report Form
This form is intended for use by contractors.performing annual.testing.of UST spill containment structures. The compl eted f)rm.and
printouts frvm.te is(#applicable), should:be pro"vided to he facility owner/operator;for submittal it)the local regulatory agency.
I.: FACILITY INFORMATION
Facility Name: RIO BRAVO CHEVRON: Date of Testing:, 7=7-10
Facility Address: 6201 LAKE MINO BLVD,BAKERSFIELD;,CA
Facility Contact: Phone:
Date Local Agency Was Notified of Testing
Name of Local Agency Inspector(if present during testing): ERNIE
2. TESTING CONTRACTOR INFORMATION
Company Name: RICH ENVIRONMENTAL
Technician Conducting Test: RYAN MASON
Credentials': F CSLB Contractor X ICC Service`Tech. G,SWRCB Tank Tester D Other(Specify}
License Number(s): 8029371-UT
3. SPILL BUCKET TESTING'INFORMATION
Test Method Used: X Hydrostatic . C Vacuum D.Other
Test Equipment Use&'VISU'AL EquipmenfResolution:z;0
Identify Spill Bucket(By Tank I 2 PREMI1UM 91 3 4
Number,Stored Product, etc.) REGULAR 87-FILL FILL
Bucket Installation Type: X Direct Bury X Direct Bury '.I.Direct Bury. I 'Direct,Bury
J Contained in Sum L.Contained in Sump D Contained in Sump: (I Contained in Sum
Bucket Diameter: 12" 12"
Bucket Depth: 14" 14"
Wait time between applying 30 MIN 30 MIN
vacuum/water and start of test:
Test Start Time(T,): 9.:00 AM 9.:00..A'M
Initial Reading(R,): 91' 9"''
Test End Time(TF): 10:00'A1VI 1.0:0U>;Alvl
Final Reading.(Rr): 91, 9
Test Duration(TF—Ti): 1=HOUR 1':=HOU R
Change in Reading.(RF-Rj): 0" . 0
Pass/Fail Threshold or -4-/-0.00 +1-0.00.
Criteria:
COmmentS— (include information on repairs made prior to testing,'and recommended folloia-up for failed tests)
I
CERTIFICATION OFTECHNICIAN RESPONSIBLE FOR CONDUCTING.THISTESTING
I hereby certify that aU th..e informat nn_.contained Yn this report is true;aceurate,-and in full compliance with legal requiremenlc.
Technician's Signature: Dater 7-7=10
VI A
' State laws and regulations,hoot cu ent "require testing to be performe&by a qualified contractor: However, local requirements
may be more stringent.
MONITOR CERT. FAILURE: REPORT
SITE NAME : RIO'BRAVO CHEVRON DATE : 7-7-20.10.
ADDRESS 6201 LAKE MINE.BLVD TECHNICIAN : RYAN MASON
CITY : BAKERSFIELD SIGNATURE :
THE FOLLOWING COMPONENTS:,
OMPONENTS WERE REPLACED/REP D COMPLETE
TESTING.
REPAIRS : NONE
LABOR : NONE,
PARTS INTALLED : NONE
NAME : TITLE :
SIGNATURE :
THE..ABOVE NAMED'PERSON TA.KES.FULLRESPONSIBILITY OF,NOT.IFY1N.G
THE APPROPRIATE PARTY TO HAVE CORRECTIVE:ACTION TAKEN TO REPAIR
THE ABOVE LISTED PROBLEMS AND NOTIFYING.RICH-ENVIRONMANTAL FOR
ANY NEEDED RETESTING.THIS ALSO RELEASES RICH ENVIRONMENTAL OF
ANY FINES OR PENALTIES.00CURING FROM NON-COMPLIANCE.
A COPY OF THIS DOCUMENT BEEN LEFT ON-SITE FOR YOUR
C.ONVIENENCE.