HomeMy WebLinkAboutSLOUNIFLOW_FS1 Admin iRC3926i Color_0171_001toilD/12Date of Testing:Facility Namc:UPS
Facility Address 3601 Sacramentc San Luis Obispo, CA
s59-978-3592
testing):Name of Local AgencY Inspector (ifpresent Kony Boyle
10109/12
Phone:Maurice BarksdaleContact:
Was NotifiedDate Local
Spill Bucket Tcsting RcPort Form
This form is intended for use by contractors performing annual tcsting ofUST spill containment strugtures. The completed form and printouts
from tests (ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agcncy.
I. FACILITY
2. TESTING CONTRACTOR INFORMAT]ON
INFORMATION
made l0
3.
Comments -
Cleaned
and
drain valvc.
t State laws and regulations do not cunently require testing to be performed by a qualified contractor. However, local requirements ma:
be more stingent.
s 2/il/A7
Company Name:B&T Service Station Contractor
Technician Test:Marcus Garcia
Credentialsr x CSLB Contractor x ICC Service Tech, tr SWRCB Tank'fester fl Other
License Number(s):902034 lcc##8074063
Test Method Used:X Hydrostatic : Otherf Vacirum
Equipment Resolution:'test Equipment Used: Incon
4231 DieselIdentiff Spill Bucket (By Tank
Nunber, Stored Product, etc')
J Direct Bury
! Contained in Sump
t-; Dircct Bury
ll Contained in Sump
tJ Direct Bury
l-l Contained in Sump
X Direct Bury
llContained in SumpBucket Installation Type:
I l"Bucket Diameter:
12"Bucket Depth:
l5 minutesWait time betwcen applYing
vacuum/water and start of test:
SEETest Start Time ('ll):
Initial Reading (Rr):
INCONTest End Time (Tr);
RESULTSFinal Reading (Re)
Test Duration (Tr -Tr):2 x 15 minutes
0Change in Reading (Rr - RJ:
0PasVFail Threshold or Crit€ria:
D Pass ! Feil tr Pess I X'ail I Pass tr tr'rilX Prss E FallTelt Rcsult:
UPS SLO
Diesel Spill Bucket
tDltOl12
UPS SLC
3601 SACRA}IENT(I
SAN LUIS (IBISPO CA
805-544-7184
1-E00-984-6266
10/10/2012 10: I7 Afl
SUI'IP LEAK TEST REPORT
DSLFILL
TEST STARIEO 10:02 A}I
TEST STARTED 10110/2012
BEGIN LEVEL 5.6600 IN
END TIIIE IO!1? AI.I
ENo DAIE 1011012012
END LEVEL 5,6656 IN
LEAK THRESHOLD O, OO2 IN
TEST RESULT PASSED
UPS SLO
3601 SACRAT'|ENT0
SAN LUIS OBISPO CA
E05-544-7184
-800-984-6256't
10110/2012 10:38 Ail
. SUI'IP LEAK TEST REPORT
I]SLFILL
TEST STARTED 10:23 AII
TESI 8TARTED 10/1012012
BEGIN LEVEL 5,6655 IN
ENI) TIl,lE 10:38 Al,l
ENo DATE lol1o/2012
ENO LEVEL 5.6656 IN
LEAK THRESHOLD O. OO2 IN
IEST RESULT PASSED
'\
MONITURING SYSTEM CERTIF.IC'TTION
For (Jse By'All Jurisdictions lltithin the State of CaliJbrnia
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. A separate c.ertifigation o
11gdleling_ty$gm c_ongqlpa4gl kry the technician who performs the work, A copy of this form must be provided to rhe tank system owner/oporator.
Thc owner/operator must submit a copy of this form to the local agency regulating US1'systems within 30 days of tcst date.
A. General Information
Facility Name: UPS Bldg. No.:_
Site Address: 3801 Sacramento City:San Luis Obispo zip 93454
Facilitv Contact Person: Maurice Barksdale Contact Phone No.: (559) 978-3392
Make/Model of Monitoring SYstem:TLS 350 Date of TestingiServicing:10t4t2012
B. Inventory of Equipment Tested/Certified
E tn-Tant Gauging Probe. Modsl;
E Annular Space or Vault Sensor. Model;
! riping Sump / Trench Sensor(s). Modcl:
I fitt Sump Sensor(s). Model;
E Mechanical Line Leak D€tector. Model:
! Electronic l.ine Leak Detector. Model:
! fant< Overfill / High-tovel Sensot, Model:
E Other (speci{ equipment type and model in Seotion E on Page 2).
Tank ID
E tn-Tank Cauging Probe.
El Annular Space or Vault Sensor.
[l Piping Sump / Trench Sensor(s).
! Fllt Surnp Senso(s).
i Mechanical Line Leak Detector- Model:
I Electronic Line Leak Detsctor, Model:
D fant Overfill / High-kvd Sensor' Model:
E Other (speciry equipment typc and m6dd in Section E on Page 2)'
Model:Maq 1
Model: 205
Model: 302
Modpl:
Tank ID: Dlasel
E tn-Tank Gauging Probe. Model:
! Annular Space or Vault Sensor, Model:
E Pipine, Sump / Trench Sensor(s). Model;
I Fitt sump Sensor(s). Model;
E Mechanical Line Leak Deteotor. Model;
E Electronic Line Lsak Delector. Model:
E fant Overfill / High-Level $ensor. Model:
I other (speoify equipmcnt type and model in Soction E on Page 2)'
Tank ID:
fy equipment type and model in Section E on Page 2).
Tank ID:
E In-Tank Cauging Probe.
E Annular Spac.e or Vault Sensor'
E Piping Sump / Trench Senso(s).
D nill sump Sensor(s),
E Mechanical Line l-eak Dctector.
I Electronic Line Leak Detector,
D tmk Overfrlt / High-Level Sensor.
Model:
Modcl:
Modcl:
Modol:
Modcl:
ModEI:
Model:
E Other (speci
D Dispenser Containment Sensor(s), Model:
E Shear Valve(s).
E Dispenser Containment Float(s) and Chain(s).
Dispenser ID:
I Snear Valve(s).
fl Dispenser Containmcnt Float(s) and Chain(s).
Dispenser lD: 1-2
I Dispenser Containment Sensor(s),Modell 00'l
I Dispenser Containment Scnsor(s). Model:
E Shear Valve(s).
fl Dispenser Containment Float(s) and Chain(s).
Dispenser IDDisoenser lD:
I Dispenser Containment $e nsor(s). Model
E Streat Valve(s).
! Dispenser Containment Float(s) and Chain(s).
fl Dispenser Containmsnt Sensor(s). Model
E sheff Valve(s).
fl Dispenssr Containment Float(s) and Chain(s).
Dispenser lD:Disnenser ID:
E Dispenser Containment Sensor(s). Model:
! Shear Valve(s).
E Dispensor Containment Float(s) and Chain(s).
*lf the facility contains more tanks or dispensers, copy this form. lnclude information for every tank and dispenser at the facility
C. CertifiCgtiOn - I certify thet the equipment identified in this document was inspected/serviced in accordance with the msnuficturers'
guidelines. Attached to this Certification is informstion (e.g. manufacturersr checklists)to vcri$ that this information is
reports, I have alsoof gencorrect rnd s Plot Plan showing the layout of monitoring eqqipment, For any
attached a copy of the report; (iheck ilt that upply)t M System set-up
Technician Name (print)
Cerrification No.:
MMc.\^< l+teetp Signature:
License, No.9020344a'z4ot3.
Testing Company Name: B&T $ervic€ Station Gontractots
630 S. Frontase Road Nipomo, CA. 93444
Phone No.: (805) 929-89,14
10t4t2012Testing Company Address
Page I of 3
Date of Testing/Servicing:
Rev (2/08)
Mon itoring System Certifi cation
D. Results of TestinglSenicing
Software Version Installed: 325.A2
the checklist:
* In Section E below, describe how and when these deficiencies were or will be corrected.
E. Comments:
Is the audible alarm oPerational?d ves D No*
M ves E No*
* Yes E No*and confirmed operational?
Is the visual alarm
Were all sensors vi
fl ves E No*Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will
not interfere with their
If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem)
operational?
fl ves fl No*
tr N/A
I No*
N N/A
For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate
positive shut-down? (Check all that apply) F Sump/Trench Sensors; [' Dispenser Containment Sensors.
shut-down due to leaks and sensor failure/disconnection?Yes; I No,Did you confirm
fl ves
device notheastankoverfillthattheutilizewamlng(i.e.,orF tank systemmonitoring primarysystems
at tanktheISoverflrlalarmandvisibleaudiblethevalveISoverfiwarnlngmechanicalinstalled),prevention
%thedoes alarmoftankftatwhatandsSo'fill
E Yes E No*
E NrA
otherorIf uipmenteq replacedsensors,asw identifY€So probes,specificmonitoringuipmenteqreplaced?any
tn Section belowE,namemanufacturer modeand for all lacementlistandthe
D Yes*Fno
! Yes*FNo Was liquid found inside any secondary containment systems designed as dry systems2 (Check all that apply)
describe causes in Section E, belowE Water. If
ff ves D No*? Attach set if icablereviewed to ensureWas
E No*manufacturer'sIs all ,|
f,, ves
Page 2 oI 3
Monitoring System Cerlification
F. In-Tank Gauging / SIR Equipment:E Check this box iftank gauging is used only for inventory control'
Check this box if no tank gauging or SIR equipment is installed'
This section must be completed if in{ank gauging equipment is used to perform leak detection monitoring.
Complete the following checklist:
E Yes E No*Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
fl Yes E No*Were all tank gauging probes visually inspected for damage and residue buildup?
! Yes E No*Was accuracy of system product level readings tested?
E Yes E No+Was accuracy of system water level readings tested?
E Yes E No*Were all probes reinstalled properly?
! Yes O No*Were all items on the equipment manufacturer's maintenance checklist completed?
* ln the Section H, below, descrlbe how and when these deficiencies were or will be corrected.
G. Line Leak l)etectors (LLD): E Check this box if LLDs are not installed.
Com the checklist:
* In the Section H, below, describe how and when these deficiencies were or will be corrected.
! Yes D No*
N N/A
For equipment start-up or annual equipment certification, was a leak simulated to verify LLD
(Check all that apply) Simulated leak tate: B 3 g.p'h.; f] 0.1 g.p.h ; il 0'2 g'p,h'
performance?
pv*fJ No*Were all LLDs confirmed operational and accurate within regulatory requirements?
p ves n No*Was the testing apparatus properly calibrated?
,Pd ves E No*
tr N/A
For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
p ves E No*
tr N/A
For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
D Yes ll No*
E nle
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
or disconnected?
! Yes I No*
E[, N/A
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions
or fails a test?
E Yes E No*
E lve
For electronic LLDs, have all accessible wiring connections been visually inspected?
frYes fJ No*Were all items on the equipment manufacturer's maintenance checklist completed?
fI. Comments:
Page 3 of 3
Spill Bucket Testing RePort Form
This form is intended for use by contractors performing annual testing of UST spill containment structures' The completed form and printouts
from tests (ifapplicable), shouid be provided to the facility owner/operator for submittal to the local rcgulatory agency.
I. FACILITY TION
2. TESTING CONTR.ACTOR INFORMATION
TESTING TION
to/Q4l't2DateFacility Name:UPS
3601 Sacramento San Luis Obispo,Address:
Phonc: 559-978-3592Maurice BarksdaleFacility Contact:
Date Local Agency Was Notificd of Testing I 09/13/12
Name of Local Agency lnspector (i!present durlng testing):Kerry Boyle
CompanyName:B&T Service Station Contractor
Technician Conducting Tost:s
Credentialsl: x CSLB Contractor x ICC Service Tech. tr SWRCB Tank Tester l,.r Other (Specify)
License Number(s):902034
fl VacuumTest Method Used:Other
Equipment Resolution:Test Equipment Used:
43tI DieselIdentify Spill Bucket (By Tank
Number, Storcd Product, etc.)I Direct Bury
fl Contained in Sump
! Direct Bury
n Contained in SumP
fl Direct Bury
n Contained in Surnp
X Direct Bury
IContained in SumpBucket lnstallation Type:
I l"Bucket Diameter:
l2nBucket Depth:
l5 minutestime botween apPlying
vacuum/water and start of test:
SEETest StartTime (T1):
lnitial Reading (Rr):
INCONTest End Time (Tp)
Final Reading (Rp):
RESULTSTest Duration (Tr - T1):
Change in Reading (Rr- Ril:
PasVFail Threshold or Crit€riat
E Prds tr Fail E Pass ! FailI Prss ffiril O Pass [ tr'eilTest'Result:
Comments - (inctude inlbrwation on repalrs made prior lo leslins, and recommended for failed tests)
t state laws and regulations do not currently require testing to be performed by a qualified conffactor. However, local requirements mal
5
be moro stringent.
2/2u0'l
-')
CERTIFICATION OF TECHNICIAN RESPONS]BLE FOR CONDUCTING THIS TESTING
I hereby certify tha
in fufl compliance w
Technician's
t all the
Tega
rmation contalned in Chls report is true, accurate, and
irements.
/, "l "lLl-\qta,
6 2/2U07
lL-ea Is Detect@lr
]F-X']T ]E\rA]LUA']T
Site Location: UPS
3601 Sacramento San Luis Obispo
Service Company: B&T Service Station
Contractors
Datet l0l04ll2
Technician: M&*c+tl qM.L(rY TechNumber: # tro'lYo6 s
TYPES OB'LEAK DETECTORS TESTED
TEST INFORMATION
n xLD (i 16-036-5)rr FX1D (l 16-054-5 L-] FX2BFLD
:J DLD (116-017-5
= FXz016-046-5 -, FXIV (116-056-5)
f BFLD (XL Model ll6-039-s . FXzD 0 l6-048-s)* FX2V (r r6-0s7-s)
i-t BFLD (1r6-012-s)t-t FXIDV fl16-055-s)i..l FXIDV (il6-058-s)
n xLP (116-035-5 t] FXzDV 016-053-5)u FX2DV (116-059-s
tr PLD (r l6-030-5 I] FXIBFLD ! FXIV (116-051-5
! FXI ft16-047-5 l_J ! FX2V fi 16-052-5)
Product Serial
Number
Opening
Time
Metering
PSI/kPa
F'unctlorrl
Elemcnt
Holdiog
PS/kPr
Approxlmste
Test Le*k
Rrtc
MUMin
GPH
PrsdFrll
Test Lcak
Rrtc
MUMin
GPH
Pump
PSI/kPr
Pressurc
Diesel r640 i eera tlrst 1r p9l ?'oq?*Pc46 Zt"f9l
UPS SLO
Monitor Certification
rut04lt2
UPS SLO
3601 SACRAI'IENTO
SAN LUIS OEISPO CA
805-s44-718{
1-800-984-6266
10/04/2012 1 :11 Pl'l
SUIIP LEAK TEST REPORT
OSLFILL
TEST STARTEO 12:5ts PI'I
TEST STARTEO 1OIO4/2012
BEGIN LEVEL 2.4886 IN
ENo TIt'lE 1;11 Pl'l
ENo DATE 10/04/2012
END LEVEL 2,4E4O IN
LEAK THRESHOLI} O, OO2 IN
TE$T RESULT FAILEO
UPS SLO
3601 SACRAI.IENIo
SAN LUIS OBISPII CA
805-544-7164
1-800-984-6266
10/0412012 2:',14 Pl'l
SUI.IP LEAI( TEST REPORT
IISLFILL
TEST STARTEO 1;59 PI.I
TEST STARTEo 10/04/2012
BEGIN LEVEL 2.485I IN
ENo Til'rE 2!14 Pl'l
END 0ATE fi10u2012
ENO LEVEL 2.48{4 IN
LEAK THRESHOLD O. OO2 IN
TEST RESULI PASSED
UPS SLO
3601 SACRAI'IENIO
SAN LUIS OBISPO CA
805-540-7184
1-800-984-6266
10/0412012 3i00 Pl1
SUI'IP LEAK TEST REPORT
OSLFILL
TEST STARIED 2:45 PI.I
TEST STARTED 1O/OT/2012
BECIN LEVET 2.4845 IN
END TII.IE 3:OO PII
ENo DATE lolo4/2012
END LEVEL 2.4824 IN
uAr runesHolD o, oo2 lN
TEST RESULT FAILED
B e. T Service Stauon Contractors woRKORDER 3S390
630 South Frontage Road
Nlpomo, CLUS4EM (805) 929-89U1 EAX (80il 9e9-894a License # 903034
To: ffre
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TOTAL
WORK ORDER
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Atlorney's Foes: Should tha ssNicos ol an attorney b€ roquired to snforca any part of th€ cradii
agrsBm€nt, or lor lh€ collgclion of a d€linqugnt account from the undar Signgd cuslomsr or
guarantor, ll le agread that the d€btor will pay reasonabl€ cosls ol coll€ction includlng a
reasonable attorney's fee,
TERMS: A SEHVICE CHARGE OF 1 1l2o/o PER MqNfH
cHAHcED oN pAsr ouE BALANcES oy6o onv\
(ANNUAL RATE OF .I8%) WILL BE
THIS IS TO CEFITIFY THAT
WORX WAS SATISFACTORILY
SIGNATUHE-DEALEF, JOBBER OR
COMPLETED IN INDI
TIMEul
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