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BSSR, Inc.
6630 Rosedale Hwy,# l3,Rakersf field,CA 93308 phone(661)588-2777 Fax(661)588.2786
MONITORING SYSTEM CERTIFICATION
This form must be used to document testing and servicing of monitoring equipment. A separate cell' tca ion or U=rt must be
plgped for each monitoring system control pa e]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 synems
within 30 days of teat date.
A. General Information �j{
Facility Name: _]�I S A&0 l jlel Bldg.No•:.
Site Address:`/ y City: Ae',✓ /EAZI Zip: O
Facility Contact Person: Contact Phone No.:( _) f -6153-7
Make/Model of Monitoring System: ---A 4120 4,0 Date of Testing/Serviciung: !_Zl_
B. Inventory of Equipment Tested/Certified
Check the appropri2te boxes to indicata spMfle• ui
Tank ID: Tank ID:
In-Tank Gauging Pro e. Model: 6 In-Tank Uauging Probe. Model;
Annular Space or Vault Sensor. Model: Q I Annular Space or Vault Sensor. Model:
❑ Piping Sump/'french Son (s). Model: C3 Piping Sump/Trench Sensor(s). Model.
�i gilt Sump Sensar(s).1T�' Model: - 11bF Sump Sensor(s). sj-� Model:
Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model:
0 Electronic Line Leak Detector. Model: M#O Electronic Line Leak Detector. Model:
Tank Overfill/High-Level Sensor. Model: f I -,. O Tank Overfill/Nigh-Level Sensor. Model:
O Other s eci tai t and model in Section E on Pe e 2 . O Other(specify ui ment and model In Section E on Pa 2).
Tank ID: U I Tank ID:
ln-Tank Gauging Probe, Model: S O In-Tank Gauging Probe. Model:
�L Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model:
O Piping Sump/Trench Sensor(s). .Model- ❑ Piping Sump/Trench Sensor(s). Model:
)Q 1*Sump Sensar(s). „p/75) ModeOW&FIC CI Fill Sump Sensor(s), Model:
Q Mechanical Line Leak Detector. Model: y f1 ❑ Mechanical Line Leak Cletector. Model:
Q Electronic Line Leak Detector. Model: ❑ Electronic Lint Leak Detector. Model:
❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor, Model:
❑ Other(pecify equipment type and model in Section E on Page Q, C1 Other(ocify equigment type and model in Section E on Page 2).
Dispenser IDs Dispenser ID:
Dispenser Containment Sensor(s). Model: Dispcnser Containment Sensor(s). Model:
Shear Valve(s). �Shear ValveM.
Dispenser Containment Float(s) and Chain (s). O ais cnser ntainment Floats and Chain (s).
Dispenser ID: 1&2 q Dispenser ID: r
Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor($). Model:
Shear Valve(s). Shear Valve{%).
❑ Dispenser Containment Float(s) and Chain(s). O Dispenser Containment Floats and Chain(s).
Dispenser TD, Lf-10 Dispenstr ID: '
Dispenser Containment Sensor(s), Model: U Dispenser Containment Sensor(s). Model: Mvigm&wo
PS Shear Valve(s). AWShear Valve(s),
0 p4penser Containment Floats and Chain ❑ Di cnser Containment Fio sand Chains .
'If the facility contains moro trunks or dispensers,copy this form. Inolude information fbr every tank and dispenser at the facility,
C. Cerdfieatioa - I certify that the equipment Identified in this document was laspected/aerviced in accordance with the
manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers'checklists) necessary to verify that ibis
Information is correct and a Plot Plan showing the layout of monitoring equipment. F any equ treat capable of generating such
reports,I have also attache eoQy o e ort;fc/teek all that apply): Syst �- m tory report
Technician Name(print): �� /� Signaturf
Certification No.: License.No.:
Testing Company Name: Phone No,:46 AS1 2717 1
Site Address: Date of Testing/Servicing:
Page t of 03rot
Monitoring System Certification
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11111111111111111111 28
1E
n; Results of Testing/Servicing
Software Version Installed:_ 32 C) , cc 1
Com fete the following checklist:
Z Yes 0 No* Is the audible alarm rational?
Yes ❑ No* Is the visual alarm o rational?
Yes ❑ No* Were all sensors visuall ins ected functionalIX tested,and confirmed operational? -�
Yes 4 No' Were all sensors installed at lowest point of secondary containment and positioned so that other equipment
not interfere with their proper operation?
es Q No' If 'Alarms are relayed to a remote monitoring station, is all communications equipment (e.g. rnodt
Q N/A operational?
CYYes 0 No; 1 For pressurized piping systems,does the turbine automatically shut dow4 if the piping secondary contairun
❑ N/A monitoring system detects a leak,fails to operate,or is electrically disconnected? If yes; which sensors loin
positive shut-down? (Check all that apply) 25umprl4ench Sensors; Gkl5upenser Containment Sensors.
Did you confirm posidye shut-down due to leaks And sensor failure/disconnection? rl m ❑No.
Yes 0 No* For tank systems that utilize the rxionitoriug system as the primary tank overfill warning devicc (i.c.
Q NIA mechanical overfill prevention valve is installed), is the overfill waroiug alarm visible and audible at the u
fill ins and operating r erl ? If so at what pffcent of tank capacity does the alarm trigger?
0 Yes* 9 No Was any monitoring equipment replaced? If yes,identify specific sensors,probes, or other equipment replac
and list the manufacturer name and model for all replacement parts in Section E below,
Q Yes* 51 No Was liquid found inside any secondary containment systeuts designed as dry systems? (Check all that app
❑Product, ❑Water. If ye3 describe causes in Section below.
Yes ❑ No* 1 Was monitorin s stew set-u reviewed to ensure proper settings?Attach set up reports, if a livable
es ❑ NO Is all rnnnitoriniz equipment operational per manufacturer's specifications?
`In Section E below,describe hoer and when these deficiencies were or will be corrected.
E. Comments:
Page 2 of 3 03rD I
I
9/£d 90) « S041 [HO-HZ
F. In-Tank Gauging /SIR Equipment: 0 Check this box if tank gauging is used only for inventory control.
0 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,
Co ]ete the foUowln checklist: '
B ❑ No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults?
EF es Q No* Were all tank gauging probes visually inspected for damage and residue buildup?
X s O No* Was accuracy of system product level readings tested?
es 0 No* Was accuracy of system water level readings tested?
0 No* Were all probes reinstalled properly?
Yea 0 No* Were all items on the equipment manufhcturer's maintenance checklist completed?
'In the Section K below,describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD): C1 Check this box if LLDs are not installed.
Co lets the folio ins checklist:
tl Yes O NO For equipment stoup or aannal equ{pmeat cation, was a leak simulated m verify LLD performance?
Q N/A (Check all that apply) Simulated leak rate: Un g.p.h.; ❑4.1 g.p.h; 0 0.2 g.p.h.
Q No* Were all LLDs con&tned opermdotutl and accurate within regulatory regairements?
Va 0 No* Was the testing apparatus properly cah1rated?
Yes 0 No* For mechanical LLDa,does the LLD restrict product flow if it detects a leak?
0 N/A
Q Yes 0 No* For electronic LLDs,does the turbine automatically shut off if the LLD detacts a leak?
NIA
❑ Yes ❑ No' For electronic LLD9,does the turbine automatically shut off if any portiou of the monitoring system is disabled
N/A or disconnected?
O Yes Noy For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system
NIA malfunctions or fails a test?
O Yea 0 NO For electronic LLDs,have all accessible wiring connections been visually inspected?
NIA
bEL U No* Were all items.on the equipment manufacturer's maintenance checklist completed?
*In the Section R,below,describe how and when these deficiencies were or will be corrected,
H. Comments:
Page 3 of 3 03ro1
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Monitoring System Certification
UST Konitoring SWIM -
Site Address: 8S i RaS� I ALIIE- �1W�
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Date trap was drawn:,
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If you already have it diagram that shows all required informafloi'►, you may include it, rather than this page, with your
Monitoring System CartiRoadon,' an your $ite plan; 8hoW;thp ggaaral Joyout:ottanks and piping, Clearly idcntify
locations of the following equipment, If installed: monitoring system'control panels; sensors monitoring tank annular
spaces, sumps,dispenser Rana, spill contginers, or other secondary Containment areas; mechanical or electronic line leak
detectors, and in-tank liquid level probes(if used for leak detection). In the spaoe provided, note the date this Site Plan
was prepared.
Page —L of 05100
9/S d 80) « SO:11 11-10-Hz
S WRCB,Junuury'2000
Spill Bucket Testing Report Form
This furm is intended for use by contractors performing annual testing of UST spill containment structures. The completed form wid
printouts from tests(if applicable), should be provided to tha facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: Date of Testin
Facility Address: , '
F•'aciliry Contact; /C Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector((f present during testing): f if
2, TESTING CONTRACTOR INFORMATION
Company Name:
Technician Conducting Test: �-
Credentials: 0 CSLB Contractor CCC Service Tech. 0 SWRCB Tank Tester Cher(S eci ) f/l `
License Number(s):
3. SPILL BUCKET TESTBYG INI+'ORMATION
Test Method Used: 0 II drostatic 0 Vacuum 0 Other
Tcst Equipment Used: Equipment Resolution!
Identify Spill fr Bucket Product, Tank 1 r 000c) 2 p� �O Q� 3 �f a
Number, Stored Product, etc. i �/ �
Bucket Installation Type: 0 Direct Bury 0 Direct Bury Q Direct Bury 0 Direct Bury
ontained in Sum ontained in Sum ontained in Sum 0 Contained in Sump
� _
Bucket Diameter: it
Bucket Depth: r"
Wait time between applying
vacuuni/water and start of test' `
Test Stan Time(TO: _'� 4
Initial Reading(R!): }-
Test End The(Tf):
Final Reading(Rp):
Test Duration(TF W TO: �- -- —�
Change in Reading(Rp•RI):
Pa.ss/Fail Threshold or U
Criteria; U J
Test Result: r &P. 0 Fall Pass 0 Fa 11 Psse ❑Vall Q Pass 0 Fail
Comments—(include information on repairs made prior to testing, and recommended follow-up fbr/'ailed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
1 her"1Ma"raJ171Vhe1njfo:11on a nialned In this report is true,accurate,and In full compliance with legal requirements.
Ccchn Uatc:
' State laws and regulations do not currently require testing to be performed by a qualified contractor.however, local requirements
mw M mn?n errinnont
9/9 d 80) « 9011 11-10-110Z
oaw hoa+eaaie H"N tl
Bakersfield,CalltorNa 93308
Phone:681 588 2777 BSSR, Inc
Fax:661 588 2786
Fm
To: City Fire Dept. Frerre Kelly Tackett
Faye 852-2171 Data: 1-11-11
Phoeaa Pagan:
No: Rosedale Plaza Arco AM/PM Cc:
E3 UrgoetO For Review ❑Please Cwmuud 0 Please Ropfy ❑Plaasa R"le
-Commeet-M
Attached are monitor certification results. Please call if you have
any questions.
Thanks,
KeNy
9/I d 80] « b0:11 II-IO-IIOZ