HomeMy WebLinkAboutFMC 2013MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State ofCal[fornia
Authority Cited: Chapter 6. 7, Health and Safety Code; Chapter /6, 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 perfonns 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
Facility Name: #7705 Fastrip #641 Bldg. No.: ____ _
Site Address: 1200 Coffee Road City: Bakersfield Zip: .=.9=-:33:..:0:..::8~--
Facility Contact Person: Omero Garcia Contact Phone No.: (661) 393-7000
Make/Model ofMonitoring System: Veeder-Root TLS 350 Date ofTesting/Servicing: 7/9/2013
B. Inventory of Equipment Tested/Certified
'-'""'"'"' ...... diJI-'• ~IJI • ._. ...... ~"'""""' ............ ·-···-.., ·--···--••. ··----· ---~ ~ ·---. d ~ ~ .
Tank 10: 12,000 gal. Regular Tank ID: 12,000 gal. Super
C8J In-Tank Gauging Probe. Model: 847390-107 C8J In-Tank Gauging Probe. Model: 847390-107
C8J Annular Space or Vault Sensor. Model: 794390-420 C8J Annular Space or Vault Sensor. Model: 794390-420
C8J Piping Sump I Trench Sensor(s). Model: 794380-208 C8J Piping Sump I Trench Sensor(s). Model: 794380-208
C8J Fill Sump Sensor(s). Model: 794380-208 C8J Fill Sump Sensor(s). Model: 794380-208
C8J Mechanical Line Leak Detector. Model: FX-1V C8J Mechanical Line Leak Detector. Model: FX-1V
0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:
C8J Tank Overfill I High-Level Sensor. Model: 847390-107 C8] Tank Overfill I High-Level Sensor. Model: 847390-107
0 Other (specifY equipment type and model in Section Eon Page 2). 0 Other (specifY equipment type and model in Section Eon Page 2).
Tank JD: 12,000 gal. Diesel Tank 10:
C8] In-Tank Gauging Probe. Model: 847390-107 0 In-Tank Gauging Probe. Model:
C8J Annular Space or Vault Sensor. Model: 794390-420 0 Annular Space or Vault Sensor. Model:
C8J Piping Sump I Trench Sensor(s). Model: 794380-208 0 Piping Sump I Trench Scnsor(s). Model:
C8J Fill Sump Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model:
C8J Mechanical Line Leak Detector. Model: FX-1 DV 0 Mechanical Line Leak Detector. Model:
0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model:
C8] Tank Overfill I High-Level Sensor. Model: 847390-107 0 Tank Overfill I High-Level Sensor. Model:
0 Other (specifY equipment type and model in Section E on Page 2). 0 Other (specil)' equipment type and model in Section Eon Page 2).
Dispenser ID: 1&2 Dispenser ID: 3&4
C8J Dispenser Containment Scnsor(s). Model: 794380-208 C8J Dispenser Containment Sensor(s). Model: 794380-208
C8J Shear Valve(s). C8J Shear Valvc(s).
0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s).
Dispenser ID: 5 & 6 Dispenser ID: 7&8
C8J Dispenser Containment Sensor(s). Model: 794380-208 C8J Dispenser Containment Sensor(s). Model: 794380-208
C8J Shear Valve(s). C8J Shear Valve(s).
0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s).
Dispenser ID: Dispenser ID:
0 Dispenser Containment Scnsor(s). Model: 0 Dispenser Containment Sensor(s). Model:
0 Shear Valve(s). 0 Shear Valve(s).
0 Dispenser Containment Float(s) and Chain(s) 0 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 report
Signature: -~~ ~ Technician Name (print): Bradley Seykora
Certification No.: B40738 ~~~---------------------------
Testing Company Name: Confidence UST Services
Site Address: 1200 Coffee Road, Bakersfield, CA 93308
Page 1
License. No.~ ~~~~---------------------------
Phone No.: (800) 339-9930
Date of Testing/Servicing: 7/9/2013
of 3
Monitoring System Certification
D. Results of Testing/Servicing
Software Version Installed: ___:::_32=-7:....:·..::.0..:.4 _____________ _
c ~ ~-----foil -heck!' I;) I..
183 Yes 0 No* Is the audible alarm operational?
183 Yes 0 No* Is the visual alarm operational?
183 Yes 0 No* Were all sensors visually inspected, functionally tested, and confirmed operational?
183 Yes 0 No* Were all sensors installed at lowest point of secondaty containment and positioned so that other equipment will
not interfere with their proper operation?
0 Yes 0 No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem)
183 N/A operational?
183 Yes 0 No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
0 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) 183 Sump/Trench Sensors; 183 Dispenser Containment Sensors.
Did you confirm positive shut-down due to leaks and sensor failure/disconnection? 183 Yes; 0 No.
183 Yes 0 No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no
D N/A mechanical overfill prevention valve is installed), is the overfill warning alarm vbible and audible at the tank
fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm trigger? 90%
DYes* 183 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.
183 Yes* D No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
0 Product; 183 Water. If yes, describe causes in Section E, below.
183 Yes D No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
183 Yes 0 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: Small amounts of water were removed from all STP sumps witch appear to be a result of washing the
tank location.
Page 2 of 3
Monitoring System Certification
F. In-Tank Gauging I SIR Equipment: 181 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.
Complete the following checklist:
181 Yes 0 No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
181 Yes 0 No* Were all tank gauging probes visually inspected for damage and residue buildup?
181 Yes 0 No* Was accuracy of system product level readings tested?
1:8:1 Yes 0 No* Was accuracy of system water level readings tested?
1:8:1 Yes 0 No* Were all probes reinstalled properly?
1:8:1 Yes 0 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): 0 Check this box if LLDs are not installed.
c he foil heck I' . .;, ...
181 Yes 0 No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance?
0 N/A (Check all that apply) Simulated leak rate: 181 3 g.p.h.; 0 0.1 g.p.h ; 0 0.2 g.p.h.
181 Yes 0 No* Were all LLDs confirmed operational and accurate within regulatory requirements?
181 Yes 0 No* Was the testing apparatus properly calibrated?
181 Yes 0 No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
0 N/A
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
181 N/A
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
1:8:1 N/ A or disconnected?
0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions
181 N/A or fails a test?
0 Yes 0 No* For electronic LLDs, have all accessible wiring connections been visually inspected?
181 N/A
181 Yes 0 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.
H. Comments:
Page 3 of 3
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SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors pe1jorming annual testing q( UST spill containment structures. The completed form and
printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: #7705 Fastrip #641 I Date of Testing: 07/9/2013
Facility Address: 1200 Coffee Road , Bakersfield, CA 93308
Facility Contact: Omero Garcia -~ Phone: 661-393-7000
Date Local Agency Was Notified of Testing: 6/17/2013
Name of Local Agency Inspector (if present during testing): Ernie Medina
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Bradley Seykora
Credentials 1: !g) CSLB Contractor !g) ICC Service Tech. 0 SWRCB Tank Tester 0 Other (Specify)
License Number(s): CSLB #804904 ICC #8111231-UT
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: !g) Hydrostatic 0 Vacuum 0 Other
Test Equipment Used: Lake Test Equipment Resolution: 0.0625"
Identify Spill Bucket (By Tank 1 Regular 2 Super 3 Diesel 4
Number, Stored Product, etc.)
Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury
!g) Contained in Sump !g) Contained in Sump !g) Contained in Sump 0 Contained in Sump
Bucket Diameter: 12.00" 12.00" 12.00"
Bucket Depth: 13.50" 14.00" 14.25"
Wait time between applying 5 min. 5 min. 5 min. vacuum/water and start oftest:
Test Start Time (T1): 1:10PM 1:10PM 1:10PM
Initial Reading (R1): 11.00" 11.50" 11.00"
Test End Time (TF): 2:10PM 2:10PM 2:10PM
Final Reading (RF): 11.25" 11.00"
Test Duration (TF-TJ): I hour I hour
Change in Reading (RF-R1): 0.25" 0.00"
Pass/Fail Threshold or 0.0625" 0.0625" 0.0625" Criteria:
Test Result: 0 Pass !g) Fail !g) Pass 0 Fail !g) Pass 0 Fail 0 Pass OFail
Comments-(include information on repairs made prior to testing, and recommendedfo//ow-ugfor failed tests)
The 87 grade Phil-Tite fill spill bucket was a visual fail as it had a bad drain valve
and would not stop draining hack into the tank. A new bucket needs to be
installed and retested.
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.
Tcchn;dan's s;g"'tucec ~-----Date: 07/9/20 13
1 State Jaws and regulations do not currently require testing to be performed by a qualified contractor. Ho.vever, local requirements
may be more stringent.
I
LEGEND SITE PLOT PLAN for:
I FIRE HYDRANT L1 87STP
I FIRE EXTINGUISHER L2 87 ANNULAR #705 FASTRIP #641
L3 87 FILL 1200 COFFEE RD.
G. GAS METERISHUT·OFF L4 91 STP BAKERSFIELD, CA 93308
w+ WATER SHUT .OFF L5 91 ANNULAR (661) 615-6033
• OVERFILL ALARM L6 91 FILL
L7 DSLSTP • Eso LB DSL.ANNULAR
A ANNULAR l.9 DSL.FIL.L
PN PNVENTS L10 UDC 1·2
TLS VEEDER-ROOT Tl.S 350R L.11 UDC3·4
L12 UDC 5 ·6
H HEALY l.13 UDC7·8
~
CIRCUIT
BRErKE~XTINGUISH
f ~ d-~ z ,.,
~ I -----' ,.
11~~111 I r-n I J'l • 1111111 I =
AT~IIi
II i,~ ~r·1~
n ...
0 ~ ,..,
i'9 ""Tl II G) ID ~ ... -i ;;l 0 n
:::0 ~ :l: ,. ~ -u~ F w,.. ,., ~ nom I BRIMHALL RD. ~ 0 ~ :!~•• '!::! ~ ~ 0~ -< (") Oo:: 1!: S:::?:;
"Tl "'Oi:j !il )> ~ -~~ ~ I I I I I ~
r-~ -u I I I I I
=""!l!l I I I 1i 0·.
~flDE'+,
CJo <'~ ~flDf'+, CJo <' "' iPSl~ ~UST(J. Job Order /Invoice #: '36'88 ~
~'~tuc't\0
"SUlLO WTTll CONFIDENCE"
Lic.970703
~,CES•~
"COMPUANCE WITH CONAOENCE"
lic.804904
Toll Free #: 1-800-339·9930
Date Called Tome To Whom
Name: Confidence UST Site Name: F-7 7 ~ c;-J:.c; ~·n #6'1'/
Street: 16250 Meacham Road Street: 1 2.0r" ~ {',-,~.p Q()~ .I
City: Bakersfield CA 93314 City: ~ /r.:> &Ji '+:> { r j/ State: ~ .,4-Zip: 73 :>o6
Terms: Store No: dl770 s-
Descriotion of work oerformed:
~L.t y-~,..; "T ~ .P M,,,..J tl:vV't'N~ c ~ v--.L '.£... 'r---"ih tr-.J vr;_ B7 ,l;'/1
$'p/l( ~~ c !r:f{:;{ ~--k~ / e:~ _,..ty A.r.J>O /s ~ • /., ~0 kt'.o /a'
fP -~-~--/
'(
TRAVEL and LABOR (0.5 Hour Minimum Labor Charge) OVERTIME (5:00 PM -7:00AM)
Date I Technician(s) Name Start End Total OT Start OTEnd OTTotal
7~7.-tj 'Bf'~ !ley ~YI/;_1G? Travel
7 Labor :1. "'~-Travel
Date I Technician(s) Name Start End Total OT Start OTEnd OTTotal
I Travel
Labor -
Travel
Date I Technician(s) Name Start End Total OTStart OTEnd OTTotal
I Travel
Labor
Travel
SUPPLIES -MATERIALS -RENTALS Check One
oty. I UST Parts Site Parts
COMMENTS
Store Employee Print Name:
SITF -CANAii