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Home My WebLink AboutSLOUNIFLOW_FS1 Admin iRC3926i Color_0176_001: ': MON{_. JqtNG SYS'I'BIVI CBRT'II?I lrI_QI\: : ,,, I;or L'se l).t' All tur,t,,,clions lllitltirt lht Stale ttf Calilornia 'llto oruicr'/opcrator tnust sttbnrit a copv of this lomr to thc local agenct' rcguiating LISI' systcnrs *ithin 30 drws of t*st date. A. General Infornration F'acilily Nanre:u sLo Bldg. No. zip:Sitc Aeltucss: 3601 Sacramento Dr Citl': San Luis Obaspo 93401 Facilitv Contact Person:Conlact Phone No.: (559) 978{5qa Ivlake/Model of Monitoring SYsten: TLS-350 Date of 'l'cslirrg/Sen,icing:10t112015 B. Inventory of Equillnlent Tested/Cer'tified (-hcch {hc bo:es to C. CertifiCntiOn - I certi$' lhat lhc cquipmcnt irlenlilied in this tlocunrcnt rr:rs ins;xclerUscn'iccd in accortlunce n'ith thc nranufncturers' guirlelines, All'achcd kr thi.r Certilication is informalion (c,g. nranufacturerr' chrcklists) nccessary to r-eri$ thal. lhis iufornration is capable of genenling such n>;xrris, I harc nlso Alnrm historT rcporl 'fcchnjcian Nnme (prirtt)James Welsch Signature : C.brrification No.: 8201843 UT Licemc, No.902034 Testing Conrpurl Narnc: B&T Service $tation Contractors Phone No.: (805) 929-8944 Addrcss; 630 S. Frontage Road Nipomo, CA. 93444 10t112015 corresl and a Plot Plnn shorving the layout of nronilorlng equipnrcnt. ['or an1' Itkrr:hr:d n copl'rrf ltrc reJrorti (check atlthat applfl: X Systcnt sel-up S ilrnular Spacc or Yault Scnsor. tr.lrrtlel: 302 E Ripl,,g Srunp /'lienclr Sensrr(s). \,Iodelt 205 I lrtechanical l,ine l,l:ak llctechl', trlodel: FXlDV I lJirctrcrlic ljne tcak Delsctor. Ilodel I f ann Qr'..rlill .' tligh-l-+vcl Serrsor. Ilodr'l Othcr (speili'cqrtipucnt tlpc urd ntodel in Stxtion Ii rrr Prrgo 2i, Tnnk lD: Diesel [! ftr-'l'orrk (ialgirg ltobc.lrlodel; Mag 1 fl Fill tiunrp scnsur(s),\lodel: I tr-'l'alk Gauging Plobc. \frrrJcl: [ ;\nmrlar Space or \iaull Scnsor. \'todr'l: I Piping Srurrgl i "lrench Seirsor{s}. llrrdr.l: E Hll Sunrp Sensor(s). l\lo,lcl: I Nlechanirnl Une L,:ak Detdch]r. Irlodel: I titectronic l.irro lcak Deluclor. ]r!odcl: [ 'l'ank Or";rlill I llighJ*vel Sensrr. ;\kxl*l: {)ther (sprr:ily etguipntrrrtl llpc alrl nrodel in Sgclion E orr Pag* ?)tr Ttnk II) fl Lr-'l'arrk Cirugine l\'obe, lr.lodel: F .&irrular Spaccor \rauh Sersur. l\'lodel: I Hping Sunrp /'I]rrrch Senvrrls). \{odel: I I'ill Sunrp Scnsor(s]. \todel: n \,lechanicat l-inc l.cak llclccltrr, \lodcl: I F,l,..ctr','rnic I jne l.cak Detcctor. Nlodel: [ 'Iank {)r'ellill ,'I lighJ.r:vcl Sursor. Ilodcl: I Olhvr (specill'xquipnrrrrl t1'pc ond nrodcl irr Tank ID: $icclion l, ou Pagc t). I ln-'l'alk tiauging l'robe. fl Alrulor Spacc or Yaull S\:n$or. I nping Sunrp r Trorch Senso{s). fl Fill Surnp Scxso(i). fl Ncch:urical Unc' Leak l)ulector. I Uectrryric l"ine Imk l).hol(,r. [ 'Izurk Ovsfill i lligh-l.eYBl Srrsor Irlodel; \lodel; Xodel: \lodel: \lcdel: l\lodel: i\fuxls.l: [ Oilrer {sprrifl'equipntcnl llpe ald model irr licclitrrr li on l'ag* 2). Tank lD: fi Dspns.r'Containnrr:rrt Selsor(s). lrtodel: 323 I shellr \"alr,cts). I Dispnscr Contairurcnl Float(s) and Chain(.r). Dispcnsc'r ID: 1-2 f] Dispefls$ Conlainnlqil S':rrs(x{s). \todel D Sh.ut \ralvc(s). I l)isparsu' Conlai,rnrcrrt tloat(s) ond Chain( s). Dispcnrcr lD: fl Disp:nsctConlainnterrlSensur!s). lrlodel: fl shcar \ ahc{s). I l)ispenscr Cbntainnrerrt fk:rt(s) and Chain(s). Dispnscr lD: f] DispeirselConlafulncnt Scnror{s). trtodcl fl Shcar Valvc(s). L] Dis}orso' Conlairrnrcnl l:'loat(s) and Chain(r). Dispcnscr ID: l] l)ispcns'r Ctrntainnrenl S!-nsorls). \lodcl: D sh*t \ialr,e(s). l] t)ispnser Conlainlrcnl Floirlis) eild C'train(s). Dispenser [D: I I)isporsr:r'Ourlainnrcill Scnsor(s). itloilcl: D Sh*ar \ruh'e(s), I I)ispearscr Contoirurrsrl l:loal(s; a:rd Chairr(s). Dispenser lD: 1'csti14 Con4tartl' Pagc 1 of 3 Datc of Tcs ting/Scn, icirrg : Ro'(2/0il) Ilonitoripg S1'stcm Certificittion ' \ F. In-Tanli Gauging / SIR Equipmenl:El Chcck this box iftank gauging is used only for inretttory conlrol. n Check this box if no tank gauging or SIR equipmcrlt is instnlled. This section tnust be cornpleted if in-tank gauging equipnrent is used to perforrn leak detection monitoring. Cornplctc the fol lowln g chccltlisl: fl Yes I-] No*Has all input wir-ing, bccn inspe cted for propcr entry and tcnninalion, including testing for ground faulls? D Yes f] No*Wcrc all tank gauging probcs virually irrspccted for dilttnge and residue truildrrp? fl Yes fl No*Was accuracy of s5,stcm product level readings tested? fl Yes I No*Was accuracl'of s1'slem n'ater lcvcl rcadings tested? I Yes fJ No*Were all probes reinslallcd propcrll'? E Yes D No*Wcre all itcms on thc cquipnrcnt ntanufaclurcr's rnainlcnflrlce chccklist contpletcd? * In lhe Scction H, bclow, dcscribc hon' and when tbe sc dcficicncies rycre or rvill lre corrcc tcrl. G. Line Leak Detectors (LLD): D Check this bos if LLDs are not installed. thc lbllorvin chcrklist: * ln thc Scclion H, bclorv, tlcscribc horr and rvltcn thcsc dcficicncics rvcrc or rvill bc corrcctcd. F'or cquipnrcr{ stnrt-up or arunAl cquiprneut certificrtiort, rlas a letk sirnulaled to verifl' LL,D pcrfontance? (C'heck all that a14rlyJ Simulated leak rate: [l 3 g.p,h.; E 0.1 g.p.h; tr 0.2 g.p,h. B Yes il No* tr N/A Werc all [,LDs coufirnrcd operntional and accurate rvithin regulatory rcquirenrcnts?El Yes fl No* D No*Was the tesling apparatus properly calibrated?El Ycs D No* fl N/A For nrechanical lIDs, does tlte LLD rcstrict producl flos il- il detccts a lcak?El Ycs For electrcnic l"LDs, does the turbinc autornaticnlll shut oll it thc LLD dctccts a leak?fl Yes D No* X N/A For clcctrorfc LLDs. dtrs the lurbinc autonmticnlll' slnrt off if any portion of tltc tttoltitorittg s1'stent is disablcd or disconnected'l E Ycs [] No* E N/A fl No* M N/A For elcclrorric LLDs. does tlle turbinc autonutically shut off if enl' portion of the ntonitoring svstcttt rnall'rurctions or fails n tcst'J ! Ycs For clecf onic LLDs. lntc all accessiblc rviring corurcctiot$ bccll listrallf inspecled'lf] No'r B N/A il Ycs fl No*Were all items on the cquipnrenl rrranufacturcr's n*linlenflItcc checklisl cornplcted?I Ycs I'I. Contnrcltts: Pugc 3 ol" 3 UST Monitoring Sitc I'lan Sitc Atklrgss: 3901 Sacranlgnto" San I.uis Obispo lllsP | /2 F]SO tSuilding . .Veeder ltoot Breakers l-lSO -|O S,i\CrttAlt4[N]"O AVE 1'r_\1 FUtutC Spill ll ! t t i lj SWRCB. January 200f) Spill llucket Testing Report Form I. FACILITYINFORMATION 2, TEST'ING CON'TRACTOR INFORMATION Conrpany Namc: B&.T Sen'ice Station Conuactor Technician Colducting Tesl: Janrcs Welsch Crcderttials 1: X CSLIJ Coruaclor X ICC Senicc Tcch l-ISWRCB'l'ankTesler i-lOtlrer (Spectrt') Licerue Nunfier(s): 902034 3. SPILL BUCKET TESTING TNtsORMATION TestMethod Used:l-l ll1'tlrostatic [-]Vacuum X Otlrcr Test Equipntcnt Used:Rcsolution: Identill Spill llucket (By'l'nnk I DicsclFill 2 3 ,t Stored Producl Bucket lnslallation Type:x Direct Bury -l Contained in Suntp i: Direct Bury i Contained in Sunrp i1 Dircct Burl' il Contained in Sump -l Dircct Bury fj Containcd in Surnp Buckct Diarneter:I l" Bueket Depth:l2* Wait tinrc betrtcen applying vacuurn/n'aler and slart of lest l5 nirr Test Start Time (Tr):See Initial Rea<ling (Rs): Test Eud Time (Tr)lncon Final Rcading (lld: Tesl Druation (Tr' - li)Rcsuhs Changc in Reading (Rr'- Rr) Passffail Tlueshold or Crite ria: Test Result:x Pnss LlFnil LJ Pas U tr'ail Ll Pasq Ll Fril lJ Pnss U Fail Contments - gtx:lnde inftnnatiort ott repairs nadc prior lo testing, and reconurcntled follot-up lbr feiled t$ts) Date of Tesline: t0- l-15UPS SI-OFacility Nanre: 3601 Sacramcnto Dr Mauricc Barksdale Facililv Addrcss: Facility Contact: Date Local Agcrtcv Was Notified of Tcsting : Nanre of Local Agency hupector /y'plasent during tesling):Kcr4, Boyle CERTII.'ICATION OF TECIINICIAN RESPONSIBLE FOIT CONDUC'I'TNG TITIS TESTING I herehy <:erlifl' thd illl the infurnailion contained in this report is tue, secilrille, and in lull corryiliance with legal requiremenls, Tcclurician's Sigtnturc Date: l0-l -l-i nrat bc rnorc stringcnt- ea TYPBS OF LEAK DETBCTORS TBSTBD TES'I" INIIORMATION etector Service Company: B&T Service Statiort Cotltractors Site Location: UPS SLO 3601 Sacramento f)r San Luis Obispo CA 9340i Date: l0lll20l5 'l'ech Number: 8201843 UTTechnician : James Welsch q&D (l l6-036-5) rt DLD (l l6-01?-5 n ID I t 6-054-5 n FXz 016-046-5 FX2BFLD : FXIV (l l6-056-5) n BFLD (x11, Model I 16-{"}39-5 [] Irx2D (ll6-048-5)il FX2V (l l6-05 7-s) li BFLD (ll6-012-s)x FXIDV (l 16-055-5)LT FXIDV I l6-058-5 : xr,P (116,035-s , I FX2DV (l t6-053-5)n FXzDV (l l6-os9-s r_l PLD (t l6-030-5 - FXIBFLD r.D 2000 i,FXIV I t 6-051-.5 :1 FXI (ll6-047-5 FE Petro Prnducl Sclial Numbcr Opcning Time Mclcring PSI/lcPa Funclioml Dltrncnt Iloldlng PSkl'a r\ppmxinu{c TrS l,elk llnlt r\lt,/llln GPII }asVlrrtil Ttrl l.tnk Rate IlllJtIln GPII Puntp P$IlkPa l'tessure Diesel 3 sec l0 12 3gph Pass 30 -ji-'s iiru I :ln{lFAll[:iiLi SAI] LiJIS OEISPO tr-rii)l/?illi ll:Li1 Al'l g;1"1: ,FAK ifi;; FrEf Ulil lrst F ltL ir:Sl Sl-rlltlfl, 1''t:tiii AH IFST SlAFrlii 1rr/01/2015 BErilN L[Uir- ,1,6112 ll',l EUIJ Til1E 11100 AH ENt llATr l0/01/2015 Ehl ;-iVlL {, t-r I I I Il{ l.FA4 'hFESHCLiJ 0,002 Ifl TIST RESLILI FASSELI :L' \ rti ruill ii"1 i i ; L, 1!l'l - !_r jt. ir'i'ii ll I ,fili LIirill,' :i::i] I'ittIi-., iltr I ll !, FT!: I tfiu llHF , ii' ': '[FjT xi:::r;r, i , . 'ti'l 1r..., rrlr-i'l.' .i, ,i 1 1, I :ij lll . rr4 MONITORII\TG SYSTEM CERTIF'ICATIOI\ Frtr Use By All Jurisdictions llithin the State of California Authority Cired: Chapter 6.7, Heatth ani Safety Code; Chapter 16, Division 3, Title 23, Calfbrnia Code of Regulations This form must be used to docunrent testing and servicing ofrnonitoring cquipment, A separate certification Q.r report must be prepared for each monitorins. sysjem control panel by the technician who pcrforms the work, A copy ol'this form must be provided to the tank systcm owncr/operator' 'l'he owner/operator must submit a copy of this fbrm to the local agency regulating US'l' sy.stems within 30 days of tcst datc' A. General Information Facility Name: Uos SLO Bldg. No. City:San Luie O zip:Site Address: 3601 Sacramento Dr 93401 Facility Contact Person Contact Phone No,: (559) 978-3592 Make/Model of Monitoring System:TLS-350 Date of Testing/Servicing;I 0,t -14 B. Inventory of Equipment Tested/Certified boxes to indicstc +tfthe facility contains rnore lanks or dispensers, copy this forrn. Include information for every tank and dispcnscr at the facility C. Certification - I certify that the equipmen t ldentified in this documcnt was inspected/serviced in accordnnce with the manufacturers' guidelines. Attached to this Certification is information (e'g'manufacturers' checklists) neces$ary to verify thst this informetion is correct and a Plot Plan showing the layout of mon itoring equ 'El ipment. For any eq copable ofgenerrting such reports, I hrve also attached a copy ofthe report; (check sll thst applt)System set-up history report Technician Name (print)James Welsch Signature: Certification No.: 8201843 UT License. No,: 902034 Testing Company Name:B&T Service Station Contractors Phone No.: (805) 929€944 rontage Road NlPo mo, cA.93444 ot1t2014 Tank lD: Diesel [| ln.Tank Gauging Probc.Modcl: El Annular Space or Vault Scnsor Modol; 302 S riping Sump / Trench Sensor(s). Modeh 205 I fitt Sump Sensor(s). Modcl I Mechanical Line Leak Detector. Modcl f] Electronic Line Leak Detector. Modcl E talt Overfill / High-Level Sensor. Modct FX,IDV I E Other (speci$' equipment rype and rnodel in Seolion E on Page 2). Tank lD Model: Model: Model: Model: Model: Model: Model: E In-Tank Cauging Probe. n Annular Space or Vault Sensor. I Piping Sump / Trcnch Sensor(s)' fl Fitl sump Senso(s), E Mechanical Linc Leak Detector, E Electronic Linc Lcak Detector. E Tank Overfill / High-Level Sensor E Other (speciry cquipment tYPe and model in Section E on Page 2), I In-tank Cauging Probe, Model: I Annular Spaoe or Vault Sensor. Model: I niping Sump / Trenoh Sensor(s). Model: E fitt Sump Sensor(s). Model: E Mechanioal Line Leak Detector. Modcl: E Electronic Line Leak Detector, Modsl: E TankOverfill / High-Lsvel Sensor, Model: fl Othcr ispecily equipment tYPe ard model in Section E on Page 2). Tsnk lD: D Othcr (speciff equipment typo and model in Scotion E on Pagc 2)' ! In''l'ank Gauging Probe. ! Annular Spaoe or Vault Sensor. E Piping Sunp / Trench Sensor(s). E Pill sump Senso(s). ! Mccharrical Line [,eak Detector. I Electronio Line Leak Detector. E Tank Ovcrfill / High-Level Sensor Tank lD: Model: Model: Model: Model: Model: Modsl: Model: Dispenser lD 1-2 fi Dispenser Containment Sonsor(s)Model: 001 E St'tear Valve(s), fl Dispenser Containment Float(s) and Chain(s). Disoenser lD: I Dispenser Containment Senso(s). Modcl E Shear Valve(s). I Dispenser Containmcnt Float(s) and Chain(s). Dispenser ID ! Dispenser Containmcnl Scnso(s). Model fl shear Valve(s). ! Dispenser Containment Float{s) and Chain(s). Disoenser lD: D Dispenser Containment Senso(s), Model E Sheat Valve(s), I Dispenser Containment r*loat(s) and Chain(s), I Dispenser Containment Senso(s), Model n Shear Valve(s). ! Disponscr Containment Floa(s) and Chain(s). Disnenser ID: ! Dispenser Containment Sensor(s). Model E Shear Valve(s). ! Dispenser Conlainmcnt Floal(s) and Chain(s)' Disoenser lD: Testing Cornpany Address:630 S. F Page 1 of 3 Date ol Testing/Servicingl Rev (2/08) ) Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 325.02 the follow checklist: * ln Section E belowo describe how and when these deficiencies were 0r will be corrected. E. Comments: Small amount of water found in $TP sump and removed. Disposed of in DOT drum D No*Is the audible alarm operational?X Yes E Yes D No*Is the visual alarm al? Were all sensors visually inspected, functionall tested, and confinnedffi Yes E No* fi Yes E No*Were all sensors installed at lowest point of secondar) containment and positioned so that other not interfere with their ? equipment will ! No* tr NiA If alarms are relayed to a remote monitoring station, is all commun ications equipment (e,g,, modem) operational? ! Yes El Yes D No* D N/A containmenttheifutshdownthedoesautomaticalturbinesecondarypipinglyForpressurizedtngprpsystems, sensorswhich initiatetlsorlectricaledisconnected?a Ifai tos yesmondetectsleak,lyoperate,itoring system SContainment ensors.serSthatallSensors;Dispenump/Trenchshut-down?(Check applv)positive o.NesYfaisensorlure/d isconnection?leakstoduehut-downsitiveDidconfirm s) nodeviceoverfilltank(e,,theas warnrngthattheutilizeprimarytankForsystemmonitoringsystems b atle tankthevisibalarmanleauddoverfiwamIlsllinstatheISIlcailoverfivalveed)ing,echanm prevention %althe arTndoes trigger?tankofwhatatIfpercentandly?filt E No* 8 N/A ! Yes ! Yes*8No DNo Was liquid found inside any secondary containment systems if applicable otherorficIfidenti replacedequipmentsensors,probes,laced?YOS'fy speci,tsw mon repitoringequipmentany lowbeSectiontnformodelalufacturermanandnamelistandthe designed as dry systems'l (Check all that apply) onal manufacturer's fications? describe causes in Section E, below, ? Attach setreviewed to ensure I Water. If Was monitori Is all m uipment E Yes* E Yes D No* D NorEl Yes Page 2 of 3 Monitoring System Certification F. In-Tank Gauging / SIR EquiPment:El Check this box if tank gauging is used only for inventory control D 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 monitodng Complete the following checklist: * In the Section H, belowo describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD)! tr Check this box if LLDs are not installed' Com checkl * ln the Section H, below, describe how and when these deficiencies wer€ or will be corrected. fl Yes I No*Has all input wiring been inspected for proper entry and termination, including testing for ground faults? fl Yes E NoF were all tank gauging probes visually inspected for damage and residue buildup? E Yes I No+Was accuracy of system product level readings tested? I Yes E No*Was accuracy of system water level readings tested? I Yes D No*Were all probes reinstalled properly? E Yes [] Nof Were all items on the equipment manufacturer's maintenance checklist completed? I Yes fl No* D N/A For equipment start-up or annual equ ipment certification,was a I eak simulated to veriff LL D performance? (Check all rhat apply) Simulated leak rate: El 3 g.p.h';tr 0.1 g,p,h; tr 0.2 g.P.h' El Yes El No*Were all LLDs confirmed operational and accurate within regulatory requiremenls? I Yes E No{'Was the testing apparatus properly calibrated? I Yes I No* N N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak? n Yes I Not I N/A For electronic LLDs, does the turbine automatically shut otTif the LLD detects a leak? D Yes D No* 8 N/A For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? I Yes E Nor tr N/A For electronic LLDs, does the turbin€ automatically shut off if any portion of the monitoring system malfunctions or fails a test? I Yes I No* 8 N/A For electronic LLDs, have all accessible wiring connections been visually i nspected? I Yes D No*Were all items on the equipment manufacturer's maintenance checklist completed? H. Comments: Page 3 of 3 SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intendedlor use by contractors performing annual lesting of UST spill cantainment slructures, The compleledform and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regalatory sgency. 1. FACILITY INT'ORMATION 2. TESTING CONTRACTORINT'ORMATION 3.BUCKET TESTING Comments - (include inhrmalion on repairs made prior lo tesling,qnd recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTINC I hereby certw thfit ttl the lnloftnatlon contained in this report ls true, uccutale, and in full compllance with legal reqalremenls, Technician's Signature:Date: 10-l-'14 ' State laws and regulations do not currently require testing to be performed by a qualified conffactor, However, local requirements may be more stringent. Facility Name:UPS SLO Date ofTesting: l0-l-14 Facility Address:3601 Sacramento Dr Facility Contact:Maurice Barksdals Date Local Agency Was Notified of Testing: Name of Local Inspector (ifpresent Kerry Boyle Company Name: B&T Service Station Contractor Technician Conducting Test: James Welsch Credentials X CSLB Contractor X ICC Service Tech. ! SWRCB Tank Tester D Other (Specrfu) License Number(:902034 Test Method Used ! Hydrostatic ! Vacuum X Other Equipment ResolutionTest Equipment Lised 4,3I DieselFillldentiff Spill Bucket (By Tank Number, Slored Product, etc.) ! Direct Bury E Contained in Sump ! Direct Bury E Contained in Sump I Direct Bury I Contained in Sump x Direct Bury tr Contained in SumpBucket lnstallation TYPe: Il"Bucket Diameter: 12"Bucket Depth: 15 minWait time between applying vacuum/water and start of test: SeeTest Start Time (T1) lnitial Reading (R1) lnconTest End Time (Tp) Final Reading (Rp): ResultsTest Duration (Tp - T1): Change in Reading (Rp'R1): Pass/Fail Threshold or Criteria: O Pess I FeilE Pass, I Fsilx Pas! E Fail I Pass E FsilTest Result: JiTARTEO 2:28 PI'I ' jTARTED 1o/01/?01{ .... LEVEL 4'695? IN t ;Jrr i il,lE 2143 Pl'l ;,,; i;ATE 10/01/2014 , trir : EVEL 4,698q IN ' : II-IRESHOLD O.OO2 IN I I :, I RESULT PA$$Eo SLri ufs i SACRAI1ENTO DR Luls Obispo, Ca 2014 2:40 Pll ' LEAK TESI REPORT tlSL FIL SLO UPS iOl SACRAI'IENTO DR r.r Luls 0bjspo, Ca ,/2Q1A 3lo0 Pl'l '., LEAK TEST REPORT DSt F]L STARTED 2145 PI,l sTARTc0 1o/01/2014 ,I LEVEL 4. 6964 IN r:r. tll'lE 3:00 Pt't ', ; JATE 10/01/2014 .,;, LEVEL 4.6959 IN THRE$HOLO O' OO2 IN '; r RESULT PASSED re}< Detectotr]FXT ]E\FA]I- Site Location: UPS SLO 3601 Sacramento Dr San Luis Obispo CA 93401 Service Company: B&T Service Station Contractors Date: lAlUZQl4 Technician: James Welsch Tech Number: 8201843 UT TYPES OF LEAK DETECTORS TESTEI) TEST INFORMATION r xLD (1i6-036-5): FXID(ll6-0s4-s IJ FXzBFLD I DLD (t l6-017-5 I FX2 (1 16-046-5 U FXIV (116-056-5) n BFLD (XL Model I l6'039-s ! FX2D (116-048-s)t_t FX2V (1i6-057-s) _ BFLD (t l6-012-5)x FXIDV (1 l6-055-5)tl FXI DV (116-058-5) i- xLP 0 t6,035-5 I I FXzDV (l l6-0s3-5)Ll FXzDV (il6-059-5 ! PLD fl l6-030-s t] FXIBFLD Lt FXIV 016-051-5 LJ FXI (1 16-047-5 LD 2000 X FE Petro Product Serial Number Opening Time Meterlng PSI/kPa Functlonrl Elcment Holdiug P$,/kPr Approximrtc Test Lcek Rrtc Mr,/Mln GPH PrsVFeil Test Lcrk RrtG ML/lVtIn GPH Pump PSl/hPr Prcssure Diesel 5 sec 10 l2 3gph Pass 28 ) :-;', r-i'l'EPl sETUP i.it"l l" ?014 I2:B4 PM ;':','i:;'fEM UNITSu.):, l:li'r::'fEl-l LANGUAGE ljl,{til I FH :','r'i-fEF1 DATE.zTII'lE FORI{ATtlll'l DD YVYV HH:Ml"l ISS xl''l :.ri1.,967 UPS :lr,r-t I SACRAIlENTO l-;rrll LUIS 0EIFPO Lil lri; 544 71 S4 C i.ll"ttlUl.l j r'A'l' |,:)[lt:i r:;L lI tl. POR SETTINGS: 'JOMI"I EOARD : BAUD RATE :PARITY : STOP BIT : DATA LENGTH: RS-?5? SECURITV,)ODE : DISABLEDDIAL TYPE : TQNE ANST.JERON : IRING T.,IODEH SETUP STRING : DIAL TONE INTEEVAL: 32 IiiECE I VER SETUP : II E:VEEDER EOOT (FMS) I *866-743-8S79 ).ICVR TYPE: COI"IPUTERIORT NO: G I.JETRV NO I 5 I;]ETRV DELAV: 5I-ONFIRMATION FEPORT I OFF i\UTO DIAL TIME SETUP: lili'il:J:' Hltll-i i)[r l'1F'::;!ir1L.;f: D I SABLLJD AUTO DIAL ALARI''I SETUP 3 (FXt'lOD 24Ct0 ODD 1 STOP7 DATA D S:VEEDER ROOT (FI'IS} I N-TANK ALAEI"IS ALL;LEAK ALARM ALL:HIGH I'JATER ALARI''I ALLIOVERFILL ALARM ALL:SUDDEN LOSS ALARI"I ALL:HIGH PRODUCT ALA}ij'I ALL I INVALID FUEL LE\iI'I. ALL:PROBE OUT ALL : HIGH I^JATER |aJARNI l'lr'r ALL:I"IAX PRODUCT ALARI,I ALLIGROSS TEST FAIL ALL:PERIODIC TEST FA]I ALL:ANNUAL TEST FAIL ALL:PER TST NEEDED lijlil'l ALL:ANN TST NEEDED liJtll"l ALL:PER TST NEEDED AI..I"I ALL : ANN TST NEEDED AI.,T1 ALL:NO CSLD IDLE TII'IE: ALL:CSLD INCR RATE I^IARN ALt :ACCU-CHART CAL t^lAI{N ALL i RECON I,'JARN I NG ALL:RECCIN ALARI"I ALL : LOhJ TEMP IA,ARN I NG ALL:GROSS FAIL LINE 1I'I1: I.IOUID $ENSOR ALI"IS ALL:FUEL ALARM ALL:SENSOR OUT ALARI"I ALL ISHORT ALARI'I ALL:I,IATER ALARI'I ALL:lilATER oUT ALARI-I ;rrtlFT TIl"lE 1 r,;lil FT T I t,lE ? l:ill IFT TIl"lE 3 li;il1FT TIl"lE 4 'l';i11K PER TST Ll,li"ELED'l iil'lH PER TgT I ti il'F = 30'l'r il'lK PER TBT t.lrl','S = 3n'lril'lK ANN TFT I r I r;IAELED I. I I,IE RE-ENAFLE I'rri::S LINE TEST 1 DI DI Di I D0 Al"1 SABLED SABLED SABLED I'IEEDED NEEDED NEEDED NEEDED I"IETHOD I,{RN t^JRN ALI"I t'lRN VEEDER ROOT (FI"IS) l^IEEKLV HECETVER ALARI'IS SERVICE REPORT I,'JAEN ALARM CLEAR I^JARNING 1 N_TANK SETUP .I' I :DIESEL I,RODUCT CODEl HERI'IAL COEFF I'ANX DIAI"IETER.I'ANK PROFILE FULL VOL 59.0 INCH VOL46.0 I NCH VOL 2B.O INCH VOL :HIGH LIGUID ALARM :LOI.J LIQUID ALARM :LIOUID I^IARNING 4,0 Il,l ALL ALL ALL 1.. t NE PER t r I:AELED LINE ANN N 1I]AELED TST NEEDED HRN TST NEEDED I.JRN Ul'I l.'R AL I B I'I'i I NT TC VOLUI.'IEF l'.ll;.rBLED 'I'I':I,IP COMPENSAT I ONI.JHLUE (DEG F ): 6CI.0 ;:i't'I CX HE I GHT OFFSET t. Ii|AELED II. I.RQTOCOL DATA FORI.IAT I'IIJ IGHT ['H'TTLIGHT SAV] NG TIHE Lil,lIBLED :i'l'nRT DATErlt+fi I^IEEK 2 SUN ::;'IHRT TINEi:00 AM HNlr DATE l.h r\J I^IEEX 1 SUN El'll1 TIt'!E ''. :rlu At'l F;F. DIRECT LOCAL PRINTOUT li l;:;AELED F;I.IF]O PROTOCOL PREFIX l:i r.'LI:;TOM ALARI"I LAEELS I rl,';AELED I'lAL TII'lE ; 4:47 Pl.1 RECEIVER REPORTS: 0r107qu t Llll L l[l l. r:r i,t.r 527 95% 950 4 P'ri1 I 1 5:"i 96Lr'l 60,.: r 236 r FLOAT SIZE: tiATER I'JARNING : HIGH I^IATER LIf"llT: I"IAX QR LAEEL VOL OVERFILL LITqIT HIGH PRfJDUCT l,i'l li.rt..l,l.,. L lnl'l 1t l0 90% i r:137'"1 I tj '': I I !'i:' I iI I IIL1N I"IAN i FOLDED TANXS I il: NONE I, I I'I[J I'IAN I FOLDED TANKS1'[: NONE l.t:.nll l"ll N PERI0DIC : l.Lrrli l'llN ANNUAL : r'Lr'rtoDIC TE,5T TVPE cutcK iil'lllI-JAL TEST FAIL ALARM DISAELED II:I.:IODIC TEST FAIL ALARM DISABLED UROSS TEST FAIL ALARI"I D I SAELED i'iI'II'I TE$T AVERAG I NG : OFF ilf:'Fr fEsf AveRRc I r'tc: oFF .t.;rt,lK TE$T NOTIFYI OFF I.hI}: TST FIPHOI.I BREAK:OFF | .(.rl"l f'l'lill.rl n."l' : l.[iil: '.'il..ii].jf'l l. itl t t' : SIJDUEN L{J';E LII'II'I i 'l nr.lli TILT : t-|.j,;.it.rE oFFSET : I'l.l,lVERV DELAY I'LII1P THRESHOLD l.t.;\K TEST |"IETHOD LIOUID SENSOR $ETUP L I:ANNULAR SPACE DUAL POINT HYDROSTATIC CATEGO)iY I ANNULAR SPAI'l. L 2:TURBINE SUI"IP TRI _STATE (SINGLE FLLIA.I.. CATEGORY : sTP SUI'IP OUTPUT RELAV SETUP R t :TURBINE SHUTDOI,'JN TYPE ] STANDARD NORMALLV CLOSED LIAUID SENSOR ALI'1S :FUEL ALARI"I :FUEL ALARI{ :SENSOR OUT ALARI'I :SENSOR OUT ALARI{ sHIGH LIAUID ALARI"I : HIGH LI6UID ALARI"I :LOl^l LISUID ALARM ;LQI^J LIOUID ALARI'I t tttl0 tr ru0 En BO 0u u% 0 o% 0 : 5 I'llN: I U.0n%L1L?LIL2LIL?L1I? 'It:llT I^IEEKLV : TANK 1 ::;Ul{ i-;'licnr rtPlE : l3:ol:l Al"l 'iiijt-nnrn :o' io GAL4HR i,DnArtot'l :6 HouRg .I':J'I EARLY STOP :DISAELED I I.,AK TEST REPORT FORI'IAT NORI"IAL UNDERGROUND STORAGE TANK SYSTEM DESIGNATED OPERATOR FACILITY SMPLOYEE TRAIMNG RECORI) For use by {Jnidocs Member Agencies or where apprwed by your ktcal Jurisdiction Authority Cited: Tiile 23, Div. 3, Ch. I6 Caldomia Code of Regulations (CCR) F acility Name: t'.*PS SLtl Facility Site Addres sz /oi { {a-a %-,tu**te- CiW: S -v- lyk AbDF O Scction 2715 of Tifle 23, Califomia Code of Regulations, requircs l}lat Dosignated Underground Storage Tank Operators provide trailing to facility cmployccs who hqve responsibilities associated with the opcration and/or maintenance of rudergrgwrd st6rago tant iUSfj systerns. this taining must be provirlcd by July 1, 2005, and every l2 months thereafter' tror tacitity employees hired after July 1,2005, the initial haining must bc provided within 30 days olthe date of hire' At lea$t one of tlJ facitity employees present during opcrating hours must have curt'ent training, This training must include, but is not limitcd to, the following iterns as specified in 23 CCR Sections 2715(D(1) and (2): fr Operation of the UST system in a manncr oonsistent with the facility's Best Managemcnt Praotioos; '.& 1't" ".ploycc's rote wiih rogard to UST monitoring equipment as spccihuJ in the written UST Monitoring Plan; l8 Th" u*ploy""'r role with regard to spills and overlills as specified in the written UST Response PIan; E Name(s) of contaot person(s) lbr cmcrgencies arrd monitoring equipment alarms; ,S fo. laciiities that aro ngt routincly staffed, facility enrployee responsibilities as speciliod in the training progmm approved by the local US'I'regulatory agency' 23 CCR $ Z?15(fX3) requires hat a list of employees wh<r have been trained by the Designated Underground Storage Tank Operato(s) be maintained on-site, or ofl.site at a rcadily-available location if approveSlylhcl-aaalggmgL and provided to the local agcrlcy upon request. Completion of this fonn will ratisff UST training rcoor<t kecping requireurents. The following etnployees have been trained as required by 23 CCR Scctions 271 s(fxl ) ond (2): Name Trainins Date Ifire Drter Trainer t{te/rorftq orlc*tlrr Qu-B-*'o/4--'*/ olt /t 4 otl'ru)s? \e*ot-tq 9 - :o-ft {7-,,-t<J /r/.rr/l.l (Contlnaed on retune) I lf hitcd ufter J$ly l, 2005. I 't'raher must bc a curant Dcrignated usT Qpmtor for the lacility al lhe time of lraining, UN-061 - lA www'unldos'org s7t13taJs UST System Designatcd Opcrator Facility Employee Training Record - Ptgc 2 ol 2 Facilitv Emolovc* Name Trainins Date Hirc Date Trainer Narne uN-061 - 2/2 www,unidoa,org 0?/13/o5 MONITORING SYSTEM CERTIFICATION For Use lly All Jurisdielions lyithin the State of California Authority Cited: Chapter 6,7, Health and Safety Code; Chapter 16, Division 3, Title 23, CaliJbrnia Code o/'Regulationo^ This form must be used to document testing and servicing of monitoring equipmcnt. A Fcpgr$to ccrtification or report muslbs:.preo4tell.fbr eacb monitorina qvsteln controLpanel by the technician who pcrforms thc work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this lbrm to th€ lr:cal agency regulating UST systcms within 30 days of test datc. A. General Information Faciliry Name: UPS Bldg, No,:_ Site Address: 3601 Sacramento _ City:San Luie Oblepo Zip:93454' Facility Contact Person: Jason Schoon Contact Phone No.: (559) 978-3592 Make/Model ol Monitoring System:TLS 350 Date of Testing/Servicing:1ot11r2n13 B. Inventory of Equipment Tested/Certified *llthe fhcility contains rnore tanks or dispenscrs, copy this fbrm. Include information for overy tank and at the lacility. C. CeftifiCAtiOn - I certifv that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' this infornation is rcports, I have also uidelines, Attachetl to this Certificstion is information (e.g. mtnufecturors' checklists) necassery to verify that b correct end a Plot Plan showing thc l*yout of monitoring attached a copy 0f the report; (check all that appl.ilt Technician Name (print) :Marcus Garcia eq uipment. E Systenr For any set-up Signature: capable of Certification No.: 8074063 UT Testing Cornpany Name B&T Station 530 S. Frontaqe Road NiPomo,cA.93444 Phone No.: (80{).9294944 .". . 10t1112013 License. No.; 902034 E tn-tarrk Cauging Probe. I Annular Space or Vault Sensor. I riping Sump / Trench Sensor(s). I rilt Sump Senso(s). ! Meohanical Line Leak Dcteotor. E Electronio Linc Lcak Dctcotor. Q Tank Overtill / High-Level Sensor E Othcr (speciF/ equipment type and model in Section E on Pagc 2). Model: Model: Model: Model: Model: Model: Modcl: Tank ID El In-Tank Cauging Probe. [l Annular Spacc or Vault Sensor. El Piping Sunrp / Trcnch Scnso(s). ! ritt Sump serrso(s). E Mcchunical Line Lrak De(ector. ! L,lectronio l,ine Leak Detector, n tank Overfill / High-l,evel Sensor I Other (specify equipmcnt typc and moclcl in Section E on Page 2) Tank ID: Diesel Model: 302 Model: 205 Model: Mag 1 __.. . _ Modcl: Model: Model: Model: I In-Tank Gauging Probe. ! Annular Spacc or Vault Sensor. I Piping Sump /'] rench Sensor(s). I nilt sump Senso(s). fl Meqhanicat Line Leak Detector. fl Eleotronic Lino Leak Detector. D Tank Ovcrfill / High-LcvEI Sensor Model: Model: Model: Model: Model: Model: Model: n Other (specify equipment type and model in Section E on Page 2). Tank ID D ln-Tank Cauging lrrobc. I Annular Space or Vault iiensor. F eiping Sump /'l'renuh Sensor(s). I Filt Sump Sensor(s). E Mer.:hanical Line Leak Detector. E Electronio Line Leak Detcotor, E 'l'ant< Overfill / High-Lcvel Sensor Model; Model: Model: Model: Modcl; Model: Model: i Otlrer (spccifu equipment type and model in Section E on Page 2). Tsnk ID: fl Dispenser Containment Senso(s). Model; E Shear Valve(s). E Dispcnser Containment Float(s) and Chain(s), Dispenscr lD: [t shear Valve(s). I DisperrserContainnrent Float(s) and Chain(s). Dispenser ID: 1-2 fil Dispenser Containment Senso(s)Model: 001 E Dispenser Containment Sensor(s). Model D.Sh"ar Valvc(.s). D Dispenser Containmont Float(s) and Chain(s). Daspenser lD:Disoenser ID: p Dispenser Containment S€nsor(s). Model: E Sh"rr Valve(s). E Dispcnser Containment Float(s) and Chuin(s). I Dispenser Containment Senso(s). Model: fl shca. Valve(s). ! Dispcnsor Containment Float(s) and Chain(s). Dispenser IDDispenser ID: U Dispen.ser Containment Senso(s). Model: ll shear valvc(s). I I)ispenser Containment Float(s) and Chain(s)- Testing ComPanY Address Page 1 of 3 Date ol Testing/Servicing: Rev (2/08) Monitoring System Certification D. Results of Testing/Servicing Software Version lnstalled: 325.02 the checklist: * ln Section E below, describe how snd when these deficiencies were or will be corrected. E. Comments: E No*ls the audible alarm operational?E Yes I Yes I No+Is the visual alarm I No{Were all sensor$ visually functionally tested, and confirmed ,)El Yes Were all sensors installed at lowest point of secondary containment and positioned so that other equipment wi il not interfere with their I Yes il No+ fi Yes E No+ N N/A lf alarms are relayed to a remote monitoring station, is all communications equipment (e,g',modem) operational? El Yes E No+ tr N/A For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment mon-itoring system detects a leak, fails to operate, or is electrically disconnected? lf yes: which sensors initiate positive shut-down? (check atl that appv 8 Sump/Trench Sensors; I Dispenser Containment sensors. ve shut-down due to leaks and sensor failure/disconnection? E Yes; E No'Did confitm E No* tr N/A For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no mechanical overfill prevention valve is installed), is the overfill warning alann visible and audible at the tank fill and If so, at what oftank does the alam % fl Yes 8No other ulorificbeseq pment replacedfIIdentisensors,?laced fy spec proASwmonyes,equipment repanvitoring lowbetnonSectiE,ist manufacturerthe andname formodel alland I Yes* 8No Was liquid found inside any secondary containment systems designed as dry systems?(Check all thut apply) E Product; F Water. lf describe causes in Section below Attach set reports, if icableWas monitorin set-up reviewed to ensure I Yes* fi Yes fl No* E No*ts all monitoring onal ifications?manufacturer'sE Yes Page 2 of 3 Monitoring System Certification F. In-Tank Gauging / SIR Equipment: I Check this box if tank gauging is used only for inventory confrol, I 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: * ln the Section H, below, describe how and when these deficiencies were or will be correcled. G. Line Lesk Detectors (LLD): E Check this box if LLDs are not installed, * ln the Section H, below, describe how and when these deficiencies were or will be corrected. I Yes E No*Has all input wiring been inspected for proper entry and termination, including testing for ground faults? E Yes E No*Were all tank gauging probes visually inspected for damage and residue buildup? E Yes n No*Was accuracy of system product level readings tested? I Yes fl No*Was accuracy of system water level readings tested? E Yes E No*Were all probes reinstalled properly? ! Yes E No*Were all items on the equipment manufacturer's maintenance checklist completed? For equipment staft-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all that apply) Simulated leak rate: El 3 g,p.h.; ! 0.1 g-p.h ; tr 0'2 g.p.h. I Yes fl No* tr N/A E No*Were all LLDs confirmed operational and accurate within regulatory requirements?I Yes E No*Was the testing apparatus properly calibrated?ffi Yes E No* tr N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak?fi Yes fl Yes ! No+ tr N/A For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? I No* 8 N/A For elepfronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? I Yes 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* tr N/A fl Yes E No* tr N/A For electronic LLDs, have all accessible wiring connections been visually inspected? S Yes E No*Were all items on the equipment manufacturer's maintenance checklist completed? H. Comments: Page 3 of 3 SWRCB, January 2006 Spill Bucket Testing Report Form This form is intendedfor use by contractor.\ perforning annual testing of IJST spill conlainmen! slruclures. The canpleted form and priniousfrom tests (iJ'appticable), should be provided to thefacility owner/operatorfor,rubmittal to the local regulatory agency, I. FACILITYINT'ORMATION 2.CONTRACTOR INF'ORMATION 3. SPIL BUCKET Comments - ftnclude information on repairs made Df IOT tO and recommended follow-un for failed lesls) Facility Name:UPS Date of Testing: l0lll/13 Facility Address:3601 Sacramento Facility Contact:Jason Schoon Date Local Agency Was Notified of Test ta12/t3 Name of Local Keny Name: B&T Service Station Contractor Tesfi Marcus GarciaTechnician Credentials r: X CSLB Contractor X ICC Service Tech' ll SWRCB Tank Tester n Other (Specify) License 902034 Test Method Used:X OtherE VacuumXH Equipment Resolution:Test Equipment Used: INCON 432I DieselIdentify Spill Bucket (By Tank Number, Stored Product, etc.) E Direct Bury I Contained in Sump l-lDirect Bury ! Contained in SumP ! Direct Bury ! Contained in Sump XDirect Bury n Contained in SumpBucket Installation TyPe: I I'nBucket Diameter: 12"Bucket Depth: l5 minutesWait time between applying vacuum/water and start of test: SEETest Start Time (T) INCONlnitial Reading (R1): TESTTest End Time (Tp) RESULTSFinal Reading (Rr): 2 x 15 minutesTest Duration (Te - Tr) 0Change in Reading (Rr - Rr)l 0Pass/Fail Threshold or Criteria: O Pass O F''ail[1 Pass tr FailX Pass E Fail ! Pass I FailTest Result: Was cl ed ^nd A new drain vAlve wns insfnlled, CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certlfy thal all the report is lrue, sccurqte' und in full compllance wlth legal requlremenls' Technician's Signature:Date: l0/lll13 I State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. lL-eaI<Deteator IFX T IRVAIL-ILIA']TTON C]F]IART Site Location: UPS 3601 Sacramento San Luis Obispo Service Company: B&T Service Station Contractors Date: l0/l 1/13 Technician : Marcus Garcia Tech Number: #8074063 UT TYPES OF LEAK DETECTORS TESTED TEST TNFORMATION i i xLD (lr6-036-5): FXID (r r6-054-5 FX2BFLD I I DLD (r16-017-5 i FX2 (116-046-5 FXrV (1 r6-056-5) I i BFLD (XL Model I l6-039-5 i FX2D fl l6-048-5). . FX2V (r r6-057-5) il BFLD fi 16-012-s)iiFXlDV(l l6-0ss-s)x FXlDV (1r6-058-5) r : xLP (1r6-035-5 i FX2DV fl r6"053-5)- FX2DV fi l6-059-5 t-r PLD (r 16-030-5 iI FXIBFLD FX rV fl 16-051-5 L I FXI (l l6-047-5 _ FX2V (1r6-052-5) Product Serial Number Opening Time Metering PSI/kPa Fuilcllonol Element Holding PS/kPr Approximrte Test Lerk Rrte MUMin GPH PrsdFeil Test Lerk Rrte MUMIn GPH Pump PSI/kPr Prassure Diesel 1640 7 secs l0 psi 12 psi 3 gph Pass 28 psi UPS Sacramento Monitor Cert L0lrIl13 UPS 3OO1 SACRAITENTO $AN LUiS OBISPO 10/11/20i3 12r44 PH SUI1P LEAI( TEST REPORT DSL FL TEST STARTED 12:29 PI'I TEST STARTED iO/11/2013 BEGIN LEUEL 2.8259 IN ENo Til'lE 12:44 Pl'l EN0 oATE 10/11/2013 EM LEVEL 2,6240 IN LEAK THRESHOLO O' OO2 IN TEST RESULT PASSEO UP$ 3601 SACRAIIENIO SAN LUIS OBISPO 10/11/2013 12128 Pll SUI4P LEAK IEST REPORI DSL FL TEST STARTED 12Ii3 PI'I TEST slARTEo 10i11/2013 BEGIN LEVEL 2.8268 IN END TII'18 12128 PI|I ENU DATE 10/11/2013 ENO LEVEL 2,8258 IN IEAI( THRFSHOLD O, OO2 IN TEST RESULT PASSED County of San Luis Obispo Environmentsl Health Services (805) 781-s54.1 swpf srtr u,[s ryilE P.O. Box 12189 2156 Sierru Wry San Lulr Oblspo, CA 93406 cos N/A ilHpo Fire Departrnent (805) 781 -7380 ' 2160 Sani. Barberi Avonuo San Lul* Oblspo CA 934{ll-52t10 CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) HAZARDOUS MATERIALS INSPECTION FORM BPOl BPO2 BPOS TROI TRO2 EROI ERO2 ATOl ATll2 ..EFW data entry by: nate: Io/Irl2oL3 Time: ntrtrn nn nnftrnn TT NOntrn Dn YEFa [] 7 h F h F BUSINESS PLAN Business plcn is complete, curr€nt, & evellabledurlng lnapection (HSC 25503.5' Title l9 CCR2729l Ioventory of hazardous materirls il complete (HSC 25504' Title 19 CCR 2729) Site layouUfaciUty maps are rccurate (HSC 25504' Title 19 CCR 2729) TRAINING PLAN . Fecility has rpproprlatg treidng prognm (Titlc 19 CCR 2732 & 22 CCR 66265.16) Training documentation is malntained on site for current personnel (Title 19 CCR2732 & 22 CCR 66265.16) EMERGENCY RTSPONSE PLA}I Contingency plan is complete, updeted, end meintained on site (HSC 25504' Title 19 CCR273I &22 ccR $ 6626s.531s4) Facility is operated rnd msintalned to prevent/minimlzs/mitiggls fire, &xplorion, or release of hazardous materials/wrste constituenb to thi euvironmenL Maidtains rll requlred or rpproprlate equipment lncludlng an alarm md cimmqnicrtlonr ryrtem (Iltle 19 CCR 2731 & 22 CCI*6626SJI- .43) ABOYEGROUND PETROLEUM STORAGE TANK ACT SPCC Plan is revlewed snd cert[ied by r reSF&red eaglneer wlthln lrst 5 yrs- (40 CFR 1r2.5(b) SPCC Plan ls nialuteined on slte or nerrest fieH office. (IISC 25270)E ADDRESS: 3601 Sacramento Drive FACILITY NAME:S AGENCY D exs PHONE: AG DEPT CITY FIRE Reinepection Other _Certlflcatlon Result Code: 70 80 90 Action Gode: _3? ' 37 -33 -31 Gomplaint Monl ntor Routine I aer IcnlnnefilfttW Generator xRusrXR Buclnees PlanPROGRAMS INSPEGTED: Inspoctions may lnvolve obtainlng photographs, revlewlng and copying records, and ncnlAnpREINSPECTION REQUIRED:n rcrdno tr YEs ! usrE Butlness Plan I t{w ceneraior ERMISSION TO I codes, GRANTED BYwith ENTS GO tO ,slopublicheolth.org/environmurtalhealthlrazardous*to comply wilh BPO I -8P03 , TRo I and ERo I INSPECTORI ordinator iEAfTdTYREP:'l l"': ' ' mlnGPS Coordinates: Lrtitude; -deg D, Kerry Boy Hazardous Ma t MON "-"'ORING SYSTEM CERTII'-CATION For (Jse By'AIl Jurisdictions Within the State of CaliJbrnia AuthorityCited: Chapter6.7, HealthanilsafetyCode; Chatrtter 16, Division3,Tille23,CaliforniaCodeof Regulations This form must be used to documsnt testing and sorvicing of monitoring equipment, A separa(e certification or reoo$.f.nust be preoared for each ngffftpfllg-syslqLco.nlrcl_.pgn9l b1,the technician who perforrns 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: UPS Site Address: 3601 Sacramento City:San Luls Obispo 9s454 Facility Contact Person: Maurice Barkedale contacr Phone No.: (559) 978-3592 Make/Model of Monitoring $ystem TLS 350 Date of TestingiServicing:10t4t2012 B. Inventory of Equipment Tested/Certified ilf the facility contains more tanks or dispensers, copy this form. Include infornration for every tank and dispenser at the I'acility. C. CeftifiCatiOn - I certify that the equipment identified in this document was inspected/serviced in accordsnce with the mcnufacturers' guidelines. Attach0d to this Certilicstion is infornration (e.g. manufacturers'checklists)to verify that Bldg, No zip: the this informatlon is reports, I have also Technician Name (print): 1,4h4*!S 1&1"<t A- Signature: f,oz4o13 correct and a Plot Plan showing the layout of monitoring rttached r copy ofthe reporl; (check all lhat apply)t eqq EI ipment, For any equl of System set-up A istory License. No,; 902034Certification No. Testing Company Name:B&T Service Station 630 S. Frontage Road N cA.93444 Phone No.: (805) 929-8944 10t4t2012 f] ln-Tank Cauging Probc. E Arrnular Space or Vault Sensor. E Piping Sump / Trenoh Sensor(s). E Fill Sunrp Sensor(s). ! Mechanical Line Leak Deteotor. ! Electronic Line Leak Detector, E fant Overfill / High-Level Sensor Modelr Model: Model: Model: Model: Model: Model: E Other (spoci$, equipmcnt type and model in Section E on Page 2). Tank lD: @ liping Sump / Trench Sensor(s). Model: fl titt Surnp Sensor(s). Mo{el: fi! Mechanical Line Leak Deteutor. Model: E Electronio l-inc Leak Detector. Model: D l'ank Ovcrfill / High-Level Sensor. Model: D CXher (specity equipmcnt type and model in Section E on Page 2) Tank ID: Diegel 205 Model: ilao 1E ln-Tank Gauging Probc. @ Annular Space or Vault Sensor Model: 302 ! ln.Tank Oauging Probe. Model: E Annular Space or Vault Sonsor. Model: E Piping Sump / l'rench Sensor(s). Model: f] rilt Sump Sensor(s), Model; ! Mechanical Line Leak l)etector. Model: I Electronic Line Leak Detector. Model: E fanX Overfill / High-l-,evel Sensor. Model: F Other (specifu equipment typc and model in Tank ID Section E on Page 2), E In-Tank Cauging Probe, E Annular Spacc or Vault Sensor. D Piping Sunrp / Trenoh Sensor(s). E ritt Sump Sensor(s). E Mechanical Line l.eak Detector. fl Electronic t,ine Leak Detector. F fant Overfill / High-Level Sensor. E Orher (speci$ equipment type and model in Section E on Page 2), Model: Model: Model: Model: Model: Model: Model: Tank ID Dispenser lD, I DispenserContainmentSensor(s). Model E Snear Valve(s), I Dispenscr Containmont Float(s) and Chain(s). El She"t Valve(s). D Dispenser Containmeut Float(s) and Chain(s). Dispenser lD 1-2 fi Dispenser Containmenl Sensor(s).Model: 001 E Dispenser Containment Senso(s). Model: n snear Valve(s). ! Dispenser Containment Float(s) and Chain(s). Dispenser lD: I Dispenser Containment Sensor(s). ModEl E Shear Valve(s). E Dispenscr Containment Float(s) and Chain(s). Dispenser lD: ! Dispenser Containnrent Sensor(s). Model: E Strear Valve(s). E Dispenser Containment Float(s) and Chain(s). Dispenser lD D Dispenser Containment Sensor(s). Model: E Streu Valve(s). f] Dispenser Containment Float(s) and Chain(s). Dispenser ID Testing Company Address: Page 1 of 3 Date of Testing/Servicing: Rev (2108) Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 325.02 the followi checklist: * ln Section E below, describe how and when these deficiencies w€re or will be corrected. E. Comments: E ves E No*ls the audible alarm operational? M Yes fl No*ls the visual alarm ? flf ves D No*Were all sensors visuall tested, and confirmed operational? fi ves E Nox Were all sensors installed at lowest point of secondary containment and positioned so that olher equipment will not interfere with their fl Yes E No* tr N/A If alarms are relayed to a remote monitoring station, is all communications equipment (e.g,, modem) operational? fl ves D No* tr N/A For pressurized piping systems,do ES the turbine automaticallY shut down if the prprng secondary containm ent monitoring system detects a leak,fai ls to operate,or ts elechically disconnected ?I f ves:which sensors initiate positi ve shut-down?(Check all that qpplv)F Sump/Trench Sensors;E Dispenser Containment Sensors. Did confirm ve shut-down due to leaks and sensor failure/disconnection? E[Yes; ! No. I Yes El No*I nre For tank systems that utilize the monitoring system as the primary tank overfill waming device (i,e,, no mechan rca I overfill prevention va lve I s install ed )ls the overfi I warnlng al arm visible and audib le at the tank fi s and tf at what of tank does the a larm o/o fl Yes*FNn Was an v monitoring equipment replaced?rf Y€S'identiff specific sensors,probes,or other equl p ment replaced and ist the manufacturer name and model for al lacement ln Section be low. E Yes*FNo Was liquid found inside any secondary containment systems designed as dry systems?(Check all that apply) E Water. If describe causes in Section E, below 6 Yes E No*Was set reviewed t0 ensure Attach set if icable '8, Yes E No*Is all monitoring equ manufactuer's Page 2 oI 3 Monitoring System Certification 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-tank gauging equipment is used to perform leak detection monitoring. Complete the following checklist: * In the Section H, below, descrlbe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): E Check this box if LLDs are not installed. * In the Section H, below, describe how snd when these deficiencies we re or will be corrected. fl Yes fl No*Has all input wiring been inspected for proper entry and termination, including testing for ground faults? E Yes E No*Were all tank gauging probes visually inspected for damage and residue buildup? E Yes [f No*Was accuracy of system product level readings tested? D Yes I No*Was accuracy of system water level readings tested? E Yes E No*Were all probes reinstalled properly? E Yes D No*Were all items on the equipment manufacturer's maintenance checklist completed? E Yes E No* tr N/A For eq uipment start-up or annual eq uipment certificati ol'was a leak slmu lated to veil ry LLD performance? (Check all that apply) Simulated leak rate: [l 3 g.p.h'tr0,c,p,h tr 0.2 g.p.h. p'ves D No*Were all LLDs confirmed operational and accurate within regulatory req uirements? p ves D Nor Was the testing apparatus properly calibrated? / ve'E No* E N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak? P,ves E No* tr N/A For elechonic LLDs, does the turbine automatically shut off if the LLD detects a leak? E Yes E Nof E[ NIN For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? E Yes E Nor ET NIA For electronic LLDs, does the turbine automatically shut offif any portion of tle monitoring system malfu nctions or fails a test? E Yes E No+ EI N/A For elecffonic LLDs, have all accessible wiring connections been visually inspected? flYes I No*Were all items on the equipment manufacturer's maintenance checklist completed? H. Comments: Page 3 of 3 t0t04112Date ofFaciName:UPS 3601 Sacramento San Luis Obispo, CAAddress: Phono: 559-978-3592Maurice BarksdaleFacility Contact: 09il3il?Was Notified of TestinDate Local Name of Local Agency InsPector (if present during resting):Ketry SPill Bucket Testing RePort Form This form is intended for use by contractors performing annual testing ofUST spill containment structures' The completed form and printouts fiom tcsts (ifapplicable), shouid bc provided to the facility owner/operator for submittal to the local rcgulatory agency. Comments - I, FAC]LITY INFORMATION 2, TESTING CONTRACTOR INFORMATION lo and recommendedon ' State Iaws and regulations do not currgntly require testing to be performed by a qualified contraator. Howevet, local requirenrents mar be more stringent. 5 2l2ll07 B&T Service Station ContractorName: Tcchnician Conducting Test:l44tlc4S b Credentialsr: x CSLB Contractor x ICC Service Tech. L SWRCB Tank Tester I Other License Number(s):902034 Tcst Method Used ll Vacuum l.l Other 'l'est Equipment Used;Equipment Resolution: Identifu Spill Bucket (By'fank Number, Stored Product, etc.) I Diesel 2 3 I Bucket Installation TyPe X Direct Bury lContnined in SumP l-1 Direct Bury n Contained in SumP I Direct Bury lf Contained in SumP I Direct Bury I Contained in Sump Bucket Diameter:11" Bucket Depth:l2 Wait time between aPPlYitlg vacuum/watcr and start oftest:l5 minutes Test Start Time (Tr):SEE lnitial Reading (R1) Test End Time (Tp):INCON Final Reading (Rs); Test Duration (Tr - Tr)RESULTS Change in Reading (Rn- Rr): Pass/Fail Threshold or Criteria: Tert Rcsultl I Prss {Fail renairs made orior lo testt E Pass E X'ail E Pasc D Fqtl tr Parr F Fail a CERTIFICAT]ON OF TECHNICTAN RESPONSIBLE FOR CONDUCS]NG THIS TESTTNG tion contained in this report i8 true, accvrate, andI hereby certify tha in full conpJiance w Technioian's t all the Iega iremen ts . .il 'f "/L 6 2l2UA7 '*) ) ll-.e Detect@:r IFX-TT ]EVA]LIUA"]TT() Site Location: UPS 3601 Sacramento San Luis Obispo Service Company: B&T Service Station Contractors Date: 10/04/12 Technician: M**t ttl q M44U Tech Number: # t'o"t yo 6 3 TYPES OF LEAK DETECTORS TESTED TEST INFORMATION n xLD fl 16-036-5)t] FXtD (r l6-054-5 N FX2BFLD ! DLD (116-017-5 I FX2 (116-046-5 ! FXIV (116-0s6-5) i-l BFLD (XL Model I l6-039-5 FX2D (l r6-048-5)n FX2V (r l6-057-5) l_t BFLD (r l6-012-5)_, FXIDV (l r6-055-5)KrxtDV (l t6-os8-s) ! xLP 0 r6-035-5 E FX2DV 016-0s3-s) -r FX2DV (l l6-059-s ! PLD(r16-030-5 D FX1BFLD ,: FXrV 016-051-s rl FXI (l r6-047-5 il Lt FX2V (116-052-5) Product Serial Number Opening Time Metering PSI/kPa Functionrl Elemcnt Holding PSVkPT Approximrtc Test Lcrk Rttc ML/lVtln GPH Prss/Fril Tcst Lcrlr Rrtc MUMin GPH Pump PSUkPT Pressurc Diesel r640 j evra {r's'1o p5t 7,oqp*P*<+Zt"fs.l UPS SLO Monitor Certification t0l04l12 UPS SLO 3601 SACRAI,IENIO SAN LUIS OEISPO CA E05-544-71E4 1-800-s80-6266 10/04/2012 1:11 Pil SUI'IP LEAK TESI REPORT DSLFILL TEST STARTEO 12!56 PIl TEST STARTEo 1olo4/2012 BEGIN LEVEL 2,48E0 IN ENI) TIIIE l: 11 Pl,l END DATE 10/04/2012 END LEVEL 2,4E40 IN LEAK THRESHOLD O, OO2 IN TEST RESULT FAILED UPS SLO 360I SACRAI.IENTO SAN LUIS I]EISPO CA 805-544-7184 l-800-9E4-8286 10104/2012 21 14 Pt'l SUI,IP LEAK TEST REPORT OSLFILL TEST STARTED 1:59 PI'I TEST STARIEO N/OA/2012 EEGIN LEVEL 2,4851 IN ENO TII,IE 2I 14 PII ENo DATE 10/04/2012 END LEVEL ?.4E44 IN LEAK THR€SHOLD O, OO2 IN TEST RESULT PASSEO UPS SLO 360't sAcRAtlENT0 SAN LUIS OBISP(] CA 805-544-?1E4 l-800-984-6266 1olo4/?01? 3;00 Pfl SUHP LEAK TEST REPORT OSLF I LL IEST STARTED 2:45 PI'I TEST STARTE0 10/0A12012 BEGIN LEVEL 2.4E45 tN ENt) TII{E 3:00 Ptl END DATE lolotlzo12 El\lD LEVEL 2.4624 IN LEAK THRESHOLD O, OO2 IN TEST RESULI FAILEO ' '{rl '1 ' SPill Bucket Testing RePort Form This form is intended for use by contractors perflorming 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 regulatory agency, I. FACILITYINFORMATION 2, TEST1N6 CONTRACTOR INFORMATTON 3. SHLL Co onts -on made and recommended Cleaned and worked the drain valve. , State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requiremenls ma: be more stringent. s 2l2ll07 t0/10/12Date of Testing:Facility Name:UPS Facility Address ispo, CA3601 Sacramento San Phone: 559-978-3592Maurice BarksdaleFaciliry Contact: Date Local Agency Was Notified of Testing t0l09lt2 lnspector (if present during lesting):BoyleName of Local Company Name :B&T Servico Station Contractor Technician Conducting Tost:Marcus Garcia Credentialsl: x CSLB Contractor x ICC Service Tech, il SWRCB 'lzurk Tester L Other License Number(s):902034 rCC# #8074063 n Otheril VacuumTest Method Used X Equipment Resolution:Test Equipment Used: Incon 432.l DieselIdenti$ Spill Bucket (ByTank Number, Stored Product, etc,) [i Dircct Bury fl Contained in Sump f] Direct Bury lJ Contained in SumP -J Direct Bury ll Contained in Sump X Direct Bury tlContained in SumpBucket Installation Typc: ll"Bucket Diameter; t2"Bucket Depth: l5 minutesWait time bstlveen applying and start oftest: SEETest Start Time (Tr): lnitial Reading (Rr); INCONTest End Time (Tr) RESULl'SFinal Reading (Rp) 2 x l5 minutesTest Duration (Tr - T') 0Change in Reading (Re - Rr): 0Pass/Fail Threshold or Criteria: I Pasg D FrilD Pass E Fail I Pass E FailTest Result:X Pass E Fril UPS SLO Diesel Spill Bucket r0n0lt2 UPS SLC 3601 SACRAI'IENTO SAN LUIS OBISPO CA 805-s44-71E4 1-600-9E4-6286 10/10/2012 10:17 Al'l SUI,IP LEAK TEST REPORT DSLFILL TEST STARTEO ]O:02 AI'I TEST STARTEO 10/10/2012 BEGIN LEVEL 5.6660 IN ENo TiHE 10!17 At1 END 0ATE 10/10/201? ENO LEVEL 5,6656 IN IEAI( THRESHOLD O, OO2 IN TEST RESULT PASSEO UPS SLO 3601 SACRAI'1ENT0 SAN LUIS OBISPO CA , 805-544-?164 "l-800-984-6266 10/10/2012 10:38 Atl . $UHP LEAK TEST REPORT OSLFILL TEST STARTED .IO:23 AII TEST STARTED 1O/1OI2A1P BEGIN LEVEL 5,6655 IN END TI}IE 10!38 AI'I ENo DATE 10/10/2012 ENO LEVEL 5,6656 IN LEAK IHRESHOLD O, OO2 IN TESI RESULT PASSED ,1. This form must be used to docurnent tcs'ting and scrvicing of monitoring equipment, nronljpJing svstem control p4nel by the The owner/operator must submit a copy A. General Information technician who pcrforms the work. A copy ol'this forrn must be provided to the tank systcm olvnsr/operalor of this forrn to the local agency regulating US'l'systclns within 30 days of tcst datc. Facility Name: UPS Bldg. No.:__- Site Address: 3601 Sacramento City; San_lltlq ObisPo ZiP:93454 Facility Contact Person:Maurice Contact Phone No.: (559) 978-3592 Make/Model of Monitoring System:TLS 350 Date of Testing/Servicing: 10121120'11 B. Inventory of Equipment Tested/Certified to +tfthe fncility contains more tanks or dispensers, copy this form. lnclude inlbrmation for every tank and dispenser at the facilitY C. Certification - I certiry that the equipment identified in this document was inspocted/serviced in sccordance with the manufacturers' guidelines.Attsched to this Certification is information (e'g.manufacturers' checklists) necessa ry to verify that this informalion is generating such reports' I have also MONITORING SYSTEM CERTIFICATION For IJse By All Jurisdictions Iyithin the State o[Cah{o1ryia- .. ^Aurhority Cited: Chapter 6.f , i"tiallh- and So|rty Coele; Chaptet' 16, Division 3, fiie 23, California Code of Regulations gquipment. EISystem equipment capable of 8[nlarm historycorrect and a Plot Plan showing the layout ofmonitoring attached a copy ofthe report; (check oll lhal apply): Technician Name (print):Aaron Shultz For any set-up Signature r€po rt Certification No.: 5266 795 Testing CompanY Name B&T Service Station Gontractore Nioomo. CA.93444 Phone No.(805) I License. No.902034 Tank lD: Diesel Model: Maq 1 Model: 302 Model: 205 E ln-Tanlt Gauging Probe . I Annular Space or Vautt Sensor. I Piping sump /'l'rench Sensor(s). E Other (spccify equipment type and nlodel in Seotion E on Pagc 2). E Fill Surnp Scnso(s). Modcl: ! Mechnnical Line Leak Detector. Modcl: E Electrortic Line Leak Detector. Modcl; I Tank Overfill / I'ligh-Level Scnsor. Modcl: Tank ID: I tn-'l'ank Oauging Probe, Model: fl Annular Space or Vaul! Sensor. Model: fl Piping Surnp /'l.rench Scnsor(s)' Model: El Filt Sunrp Scusor(s). Model: E Mechanical Line Leak Dctoctor. Model; E Electrooic Line Leak Detector, Model: I Tant< Overfill / Fligh-Lcvel Sensor. Modcl: I Other (specily equipment type and model in Scction E on Page 2)' Tnnk ID: ! ln-Tank Cauging Probe, Modcl: El Annuler Spacc or Vault Sensor. Model: ! Piping Sump / Trench Sensor(s). Model: ! fitt Sump Sensor(s). Model: I Mcchanioal Line Leak Deteotor. Model: E Electronic Line Lcak Dctcctor. Model: ['tank Overfill i Fligh-Level Sstlsor, Modcl; El Other (specify equiPment type and rnodel in Section E on Pagc 2). Tank ID: E In-Tunk Cauging Probe. ! Annular Spaoe or Vault Sensor. I Piping Sump / Trench Sensor(s). E Pitl sump Senso(s). E Mechanical Line Leak Detector. fl Electtonic Linc Lcak Detcotor' D Tank Overlill / High-Level Sensor E Other (speciff equipment type and modsl itt Section E on Page 2). Modcl: Model: Model: Model: Model: Model: Model: Dispenser IDr 1-2 El Dispenscr Cou(ainment Sensor(s)Model: 00'l El Shear Valvc(s), E Dispcnscr Containnrent Float(s) and Chain(s). Dispenser ID: ._ .,, . , I Dispenscr Cotttainmcnt Scnsor(s). Morlsl: E Shear Valvc(s), E Dispcnscr Containment Float(s) and Chain(s). I Dispcnser Containment Sensor(s). Model: E Shcar Valve(s). Dispenser ID: I Dispenser Corttainment Float(s) and Chain(s). Dispenser ID ! Dispcnscr Cotttainnrent Sensor(s). Model: n Shear Valve(s). E Dispenser Conlainment Floa(s) and Chain(s), E Dispenser Contoinment Sensor(s). Model: E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). Dispenser lD: ,- D DispcnscrContainmentSensor(s)' Model E $hear valve(s). ! Dispenser Conltinmen! Float(s) and Chain(s). Dispender lD: .. - --.. Testing Company Address:630 S.Frontage Page I of 3 Date of Testing/Servicing:10t21 Rev (2/08) Monitoring System Cerlification D. Results of TestingiServiding Softivare version lnstalled: 325.02 the * [n section E below, describe how and when these deficiencies were or will be corrected. E. Comments: Is the audible alarmd ves E No* EI No*dY"s Eil Yes E No* ! No*Were all sensors installed at lowest point of secondary containment not interfere with their functional tested,and confirmed and positioned so that other equipment will Is the visual alarm Were all sensors Bl Yes If alarms are relayed to a remote monitoring station, is all communications equipment (e'g', modem) operational? EI Yes I No* tr N/A D No* n N/A initiate containmentfthedownsecondaryshutautomaticalturbineprplngthelydoesForurizedsystems,press p iping sensorswhichItdisconnected?tofails or yes:adetects electricallymonleak,operate,itoring system Sensors.ContainmentthatSensors;Dispenserallheckshut-down?tive aPPIY)Ef Sump/Trench(cposl N 0.Y nes;tsfaisensorlure/disconnection?leakstodueshut-downitiveconfirmDid device nooverfil.9,,theas tank warning (iutilizethattheprrmarytankFormonitoringsystemsystemstheat tankleaudibvtalarmandsiblethewarnoverfillvalisvelsrngoverfillcalinstalled),mechani prevention o/othedoesalarmoftankwhatatIflfilland ffYes E No* EI N/A E Yes lacedotherorrepIfequipment$ensors,probes,identifyyes'specificWasreplacedanyequipmentmonitoring lowbetnSectionallandnameformodelistmanufacturertheand E Yes+Ef No ElWater. lf icableifAttach set designed as dry systems? (Check all that apply)Was liquid found inside any secondary containment systems describe causes in Section E, below settireviewed to ensure manufacturer'sIs all Was tr I Yes*Es tlo E No*E[ Yes !( ves E No+ Page 2 of 3 Monitoring Sysl.em Ccrtifi cation F. In-Tank Gauging / SIR EquiPment:E Check this box if tank gauging is used only for inventory control' E Check this box if no tank gauging or SIR equipment is installed. This section must be complet€d if in-tank gauging equipment is used to perform leak detection monitoring. Complete the fotlowing checklist: * In the Section H, below, describe how and when these d eficiencies were or will be corrected G. Line Leak Detectors (LLD): D Check this box if LLDs are nor installed' checklist; * In the Section [I, below, describe how and when these deficiencies were or will be corrected. E Yes EI No*Has all input wlnng been tn spected for proper entry and termination,includ ing testing for ground faults? E Yes E No*Were all tank gauging probes visually inspected for damage and residue buildup? fl Yes E No*Was accuracy of system product level readings tested? E Yes I No*Was accuracy ol'system water level readings tested? E Yes E No*Were all probes reinstalled properly? fl Yes E No*Were all items on the equipment manufacturer's maintenance cheCklist comp leted? E No+ tr NiA For equipment start-up or annual equiprnent certification,was a leak simulated to verifu LLD performance? (Check all that applv)Sim ulated leak rate:a J c.p ,h,n 0 l os'p ,h tr 0.2 t6'p.hff Yes S Yes E No*were all LLDs confirmed operational and accurate within regulatory req uirements? $ Yes fl No*Was the testing apparatus properly calibratcd? El Yes E No* tr N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak? E Yes I No* trf N/A For electronic LLDs, does the turbine autornatically shut offif the LLD detects a leak? I Yes E No* E N/A For electronic LLDs, does the turbine automatically shut off if any portion of the monitorirrg systern is disabled or disconnected? il Yes E No* * N/A For electronic LLDs, does the turbine automatically shut offif any portion of the monitoring sy$tem malfunctions or fails a test? D Yes E No+ E NIA For elecfronic LLDs, have all accessible wiring connections been visually inspected? $ Yes E No*Were all items on the equipment manufacturer's maintenance checklist comp leted? H. Comments: Page .3 of 3 t-) ftnrbt\4(: UST SitP Plof :G o*Fgp ,r#(tu"' E.s iffi: : I t. I I I -i Vq.b&a AilnlM "l CERf,IFICATION OF TECHNICIAIO RESPONSIBIJE FOR CONDUCTTNG flITS TESTING I hereby cer1ify that a77 the infarmation eontained in thjs repor: js Erue, accuraEe, and jn fuJJ. compl iance Eh legal te s. Technician's Signature Date:-Ll* | 6 2121107 ) SPill Bucket Testing RePort Form This torm is intended lor use by contraqtors performing annual testing of uS't spill containment s$uclures. The completed form and printouts f-* tcsts (if applicable), shouid bc provicled to the l?rcility owncr/operator for submittal to thc local regulatory ogency' ILITY 2. TESTING CONTRACTOR INFORMATION INFONMA l0l?.t/11Date of TUPSName:Facil Facility Address:360 I San CA Phone: 559-9'18-3592Facility Contact:Maurice Barksdale 09129/t1Was Notified of TestingDate Locat Inspector (if presenl during testing):Kerry BoyleName of Local B&T Service Station ContractorName: Aaron ShultzTechnician Conducting Test: Credentialsl: x CSLB Contractor x ICC Service Tech. . ; SWRCB Tank'l'ester : . Othcr Licensc Number(s):902034 Test Method Used OtherVacuum Resolution:EquTest Equipment Used: 43t1 DieselIdcntify Spill Bucket (BYTank Num .. i Direct Bury , Contained in Sump ; Direct Bury , Containcd in SurnP , i Direct Bury : . Contained in SumP X Direct BurY ,Containcd in SumpBucket lnstallation TYPc: ll"Bucket Diameter: t2"Bucket Depthl l5 minutesWait time between aPPlYing vacuum/water and stafl oi'test: SEETest Start Time (Tr): Initial Reading (R1): INCONTest End Time (Ts): Final Reading (Rp): RESULTSTest Duration (Tp - Tr): Change in Reading (Rr - Rr): Pass/Fail Threshold or Criteria: D Pass tr FailI Prss E Failtr Pess tr Fail{'Pass DFeilrTestRgsulll and recommendedloon , State laws and regulations do not currently require testing to be performed by a qualitied contractor However, local requirements may 5 be more stringent, 2/2r107 j) et@ctorea Service Company: B&T Service Stntion Contractors Site Location: UPS 3601 Sacramento San Luis Date:10/21111 Tech Number: #5266795 UTTechnician: Aaron Shultz TYPES OF LEAK DETECTORS TESTED TEST INFORMATION Owner/Operator lo *Lt-) \ ) :l xLD fl 16-036-5)ir FXID fl l6-054-s -I FX2BFLD r DLD (116-017-5 -1FXz (116-046-5 I FXIV (116-056-s) :l BFLD (XL Model I l6-039-5 I FXzD (r l6-048-s)I FX2V I 16-057 _t BFLD (l l6-012-s):1 FXlDV (116-055-5)I FXIDV r 15-0s8-5 -t xLP (1r6-035-5 I FXzDV (I r 6-0s3-s)-t FX2DV (116-059-5 ;t PLD ( il6-030-s :l FX1BFLD :l FXIV 0l6-051-s :t FXt /116-047-5 .l FX2V (1 16-052-s) Product Serial Number Opening Time Metering PSI/kPa Functional Element Holdlng PS/kPa Approximrte Test Lerk Rrtc ML/Mln CP}I PrsVFril Test Lerk Rrte ML/Min GPH Pump PSI/kPr Presgurc Diesel r640 ?.eec.lo 7sr ljytr lfr,tr.7t{.fAss uftl (Date) I UPS SLO #9340 Monitor Certilication l0l2llll UPS 3ri01 sAtjRAliEr{Tri cH, SAN LUIS I]BISPO CA, fi/21/?.011 I :C8 Pl'l SUI1P LEAK IEST REPORI IJSLF I LL itsl SIARIEIJ '12t53 t'l'l IESI $TARTED fi121/2011 BEt;IN LEVEL. . ?,58{7 IN END TIl'lE .IIO8 PII [N[ DATE fi/u/?411 F.Nl] LEVEL 2.5859 tN LEAK THRESHOLD O. OO2 IN IESI RE$ULT PASSET) UPS 3Ij|]1 $ACRAIIHHTI] I]Fi. SAN L.UIS OBISPO CA. 10121/201f irffi fH :iIJflI, L[AI( ITSi R[I.'|JR.I TJSLF ILI. IIST SIA|ITEU 'I: IU PI1 TtflT STARTEU 10/21/2011 SEffIN LEVEL 2,5896 IN HND llf'lE 1;33 Pl'l END DATE 10/21/2011 END LEVEL 2.5S07 IN i.EAI( IHRESHOLU t). OO2 IN TEST RESULT PASSEI]