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Home My WebLink About2013 MINOR (2)HOODS Permit No. ALARMS SPRINKLER SYSTEMS SPRAY BOOTH Permit No. AST UST Permit No. Permit No. Permit No. Permit No. File Number: ,3G 614 'C Address: I zoc0 S Bakersfield, CA 933 Date Received: q --a-k - t3 Business Name: ,4- l rt=e ka- r-e.-• SYSTEM: BUILDING SQUARE FEET: INSPECTION LOG New Mod. ❑ ❑ Commercial Hood System ❑ ❑ Fire Alarm System ❑ ❑ Fire Sprinkler System ❑ ❑ Spvay Finish System ❑ ❑ Aboveground Storage Tank ❑ ❑ Underground Storage Tank minor modification Underground Storage Tank removal Underground Storage Tank ❑ ❑ Other. Comments: Building Sq. Feet: Calculation Bldg. Sq. Ft: Signature BAKERSFIELD CITY FIRE DEPARTMENT — INSPECTION RECORD Post this Card at the Job Site and DO NOT Remove: for Duration of Work Inspection Request Phone No. (661 ) 326 -3979 UST NEW INSTALL DESCRIPTION DATE SIGNATURE BACKFILL PRIMARY PIPE SECONDARY PIPE SECONDARY CONTAINMENT SENSORS AUTHORIZATION FOR FUEL ELECTRICAL SEAK -OFF TANK TESTING UST REMOVAL DESCRIPTION DATE. SIGNATURE AST NEW INSTALL DESCRIPTION DATE SIGNATURE 0 MODIFICATIONS MINOR/ A� mf2i'mme. *maw AST REMOVAL. DESCRIPTION DATE SIGNATURE EVR UPGRADE PRIOR TO OPERATION OF ANY SYSTEM; ALL UST AND /OR AST SYSTEMS SHALL BE ' INSTALL, COMPLETE AND ACCEPTED BY MISC. ACTIVITY THE BAKERSFIELD CITY FIRE DEPARTMENT. FIRE DEPARTMENT (FINAL) { BUILDING ADDRESS: JOB DESCRIPTION: OCCUPANCY TYPE: OWNER: 1 PERMIT NO. - / CONTRACTOR: PHONE # -- FD 1743 BILLING & PERMIT STATEMENT � -.4 BAKERSFIELD FIRE DEPARTMENT Prevention Services P,Ee,RMI` # �� Re ��' 2101 H Street PsPARlMINT Bakersfield, CA 93301 Phnne: 661 - 326 -3979 • Fax: 661 - 852 -2171 All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK. ❑ 1Alarm - New & Modification (minimum charge) $280 SITE INFORMATION LOCA ON OF PROIEg PROPERTY OWNER n $167 /site STARTING DATE COMPLETION DATE — 2 5 3 NAME 5.4.x" PRO] NAME ADDRESS PHONE # 84 ❑ PROJECT ADDRESS /� /� CITY gf� K Fi �S I E LD STATE CA ZIP CODE 7 ❑ Oil well (Installation, Inspection, or re- Inspection) X CONTRACTOR INFORMATION 82 CONTRACTOR NAME v rCi�4J C. LICENSE # TYPE OF LICENSE EXPIRATION DATE PHONE # 84 p ect- CONTRACTOR COMPANY NAME FAX # ADDRESS CITY ZIP CODE 84 • All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK. ❑ 1Alarm - New & Modification (minimum charge) $280 Underground Storage Tank (Minor Modification) MTM $167 /site 82 ❑ Underground Storage Tank (Removal) TR $573 /tank 84 ❑ Mandated UST Testing: Fuel Mont Cert/SB989 /Cath. Prot. NOTE: $96 /hr for each type of test/per site /per UST system even if scheduled at the same time $ 96 /hr (2 hrs minimum) _ $192 82 ❑ Oil well (Installation, Inspection, or re- Inspection) X $ 96 /hr 82 ❑ Tent # $ 96 /tent 84 ❑ After -hours Inspection fee $121 /hr (2 hrs minimum) = $242 • Pyrotechnic (1 permit per event, plus an inspection fee of $96 /hr during business hours) PY NOTE: After hours Pyrotechnic event Inspection is @ $121 /hr $ 96 /hr + (5 hrs min standby fee /insp) _ $576 5 hrs min standby fee ins = 605 84 • Re- inspection /Follow -up Inspection $ 96 /hr 84 • Portable LPG (Propane): # of Cages? _ $ 96 /hr 84 • Explosive Storage $266 84 • Copying & File Research (File Research fee $50 /hr) $0.25 /page 84 13 Miscellaneous 84 FD2021 (Rey 05/111 BILLING & PERMIT STATEMENT BAKERSFIELD FIRE DEPARTMENT lkll I BD Prevention Services PERMIT # iiRe 2101 H Street OfPAR rN"r Bakersfield, CA 93301 Phnna- F,F,1- '47F -'AQ7Q . Fay- F,F,1 -RS7 -7171 All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK. ❑ Alarm - New & Modification (minimum charge) $280 ❑ Over 10,000 sq ft $0 .028 x sq ft • Sprinkler - New & Modification (minimum charge) $280 ❑ Over 10,000 sq ft $0 .028 x sq ft • Sprinkler - Minor Modification ( <10 heads) $ 96 (inspection only) 84 ❑ Commercial Hood (New & UL 300 Upgrade Modification) $470 Additional Hood 58 hood ❑ Commercial Hood - Minor Modification (add /move nozzle) $ 96 (inspection only) 84 • Spray Booth (New & Modification) SITE INFORMATION LOCA ON OF PRO]E PROPERTY OWNER _ —� 20v $180 /tank STARTING DATE COMPLETION DATE NAME ❑ Additional Tank ATI PRO] NAME ADDRESS PHONE # PROJECT ADDRESS STATE CA ZIP CODE • •• .• • ❑ --�A CONTRACTOR NAME v �M_f 6 LICENSE # TYPE OF LICENSE EXPIRATION DATE PHONE # - ' 0 8 6/— Underground Storage Tank (Modification) MOD CONTRACTOR COMPANY NAME FAX # 82 ADDRESS CITY ZIP CODE n �' cG 30 All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK. ❑ Alarm - New & Modification (minimum charge) $280 ❑ Over 10,000 sq ft $0 .028 x sq ft • Sprinkler - New & Modification (minimum charge) $280 ❑ Over 10,000 sq ft $0 .028 x sq ft • Sprinkler - Minor Modification ( <10 heads) $ 96 (inspection only) 84 ❑ Commercial Hood (New & UL 300 Upgrade Modification) $470 Additional Hood 58 hood ❑ Commercial Hood - Minor Modification (add /move nozzle) $ 96 (inspection only) 84 • Spray Booth (New & Modification) $470 98 • Aboveground Storage Tank (1 inspection per installation) AST $180 /tank 82 ❑ Additional Tank ATI $ 96 /tank 82 • Aboveground Storage Tank (Removal, Mod,or Inspect'n) ATR $109 /tank 82 ❑ Underground Storage Tank (Installation /Inspection) NI $878 /tank 82 • Underground Storage Tank (Modification) MOD $878 /site 82 Underground Storage Tank (Minor Modification) MTM $167 /site 82 • Underground Storage Tank (Removal) TR $573 /tank 84 • Mandated UST Testing: Fuel Mont Cert/SB989 /Cath. Prot. NOTE: $96 /hr for each type of test/per site /per UST system ven if scheduled at the same time $ 96 /hr (2 hrs minimum) _ $192 82 • Oil well (Installation, Inspection, or re- inspection) X $ 96 /hr 82 • Tent # $ 96 /tent 84 • After -hours inspection fee $121 /hr (2 hrs minimum) = $242 • Pyrotechnic (1 permit per event, plus an inspection fee of $96 /hr during business hours) PY NOTE: After hours Pyrotechnic event inspection is @ $121 /hr $ 96 /hr + (5 hrs min standby fee /insp) _ $576 5 hrs min standby fee ins = 605 84 . • Re- inspection /Follow -up Inspection $ 96 /hr 84 • Portable LPG (Propane): # of Cages? _ $ 96 /hr 84 • Explosive Storage $266 84 ❑ Copying & File Research (File Research fee $50 /hr) $0.25 /page 84 ❑ Miscellaneous 1 84 BAKERSFIELD FIRE DEPARTMENT Prevention Services UNDERGROUND STORAGE TANKS 1501 Truxtun Avenue 1st Floor PERMIT APPLICATION 11 Bakersfield, CA 93301 • TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW FIRM Phone: 661- 326 -3979 Fax: 661- 852 -2171 A TANK INSTALL (E)ISTING FACILITY) /MOD -MINOR MOD i Page 1 of i ,Pe itrm # I TYPE OF APPLICATION: ❑ NEW TANK INSTAL.L,/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY (CHFCiC nNF ONI Y) n MODTFICATION OF FACILITY -' MINOR MODIFICATION OF FACILITY STARTING DATE/ PROPOSED COMPLETION DATE FACILITY NAME r` EXISTING FACILITY PERMIT S FACILITY ADDRESS y Mot:) a f` ` \ `�1 C `7APN ZIP CODE 30 TYPE OF BUSINESS G.Q -A'a 3 TANK OWNER PHONE 3 ADDRESS CITY ZIP CODE CA LICENSE t Itc ADDRESS sLt's \ c� ZIP CODE g�3o PHONE 3 BAKERSFIE n CITY BUSINESS LICENSE.* WORKMANS,CDMP S .Q . INSURER BRIEFLY DESCRIBE THE WORK TO BE DONE: WATER TO FACILITY PROVIDED BY :DEPTH TO GROUND WATER t ' SOIL TYPE EXPECTED AT SITE OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? O YES ❑ NO SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? ❑ YES ❑ NO !THIS;SECTION IS FOR STORAGE TANK IDENTIFICATION ik' `',:, ` .. ' <'' VOLIll1F UNLEADED REGULAR PREMIUM DtESEI. OTHER, Tank TwUng Company NAME OF TESTING CO \ PHONE NUMBER MAILING ADDRESS Fd` �� K NAME OF TESTER ICCa THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS PERMIT AND ANY OTHER STATE, LOCAL„ AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER.3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. NAME OF TESTER ICCR THIS APPLICATION BECOMES A PERMIT WHEN APPROVED FOR OFFICIAL USE ONLY ±DATE APPROVED::.. APPROVED.BY FD2086 (Rev 08/09) MONITORING SYSTEM CER'TIFICAT'ION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certificadon or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner /operator. The owner /operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: A -ONE FOOD STORE Bldg. No.: Site Address: 1200 H STREET City: BAKERSFIELD Zip: 93301 Facility Contact Person: BOBBY Contact Phone No.: (661) 324 -4138 Make /Model of Monitoring System: TLS -300 Date of Testing/Servicing: 411912013 B. Inventory of Equipment Tested/Certified Check the aaurooriate boxes to indicate soecirrc equipment inspected /serviced: Tank ID: UNL87 (SPLIT) Tank ID: PREM91 (SPLIT) ® In -Tank Gauging Probe. Model: MAG ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 420 (SPLIT) ® Annular Space or Vault Sensor. Model: 420 (SPLIT) ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: RED JACKET ® Mechanical Line Leak Detector. Model: RED JACKET ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: flapper ® Tank Overfill / High -Level Sensor. Model: flapper ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ in -Tank Gauging Probe. Model: ❑ in -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 314 ❑ Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ® Dispenser Containment Sensor(s). Model: 406 ® Dispenser Containment Sensor(s). Model: 406 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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 Technician Name (print): STEVEN OBERT Certification No.: A28531 18029980 -UT Testing Company Name: RICH ENVIRONMENTAL Signature: License. No.: C61/ D40 809850 Phone No.: (661) 392 -8687 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testing/Servicing: 411912013 Page 1 of 5 LIN -036— t/4 www.unidoes.org Rev. 01/17/08 Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 419.05 Cmmnlete the fnllnwina rhecklist- ® Yes ❑ No* Is the audible alarm operational? ® Yes ❑ No* Is the visual alarm operational? ❑ Yes ® No* Were all sensors visually inspected, functionally tested, and confirmed operational? ® Yes ❑ No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? ❑ Yes ❑ No* if alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) ® N/A operational? ® Yes ❑ No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment ❑ N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut -down? (Check all that apply) ® Sump /Trench Sensors; ® Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure /disconnection? ® Yes; ❑ No. ❑ Yes ❑ No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no ® N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm trigger? % ❑ Yes* ® No Was any monitoring equipment replaced? 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. ® Yes* ❑ No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) ❑ Product; ® Water. If yes, describe causes in Section E, below. ® Yes ❑ No* Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, if applicable ❑ Yes ® 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: DISP #1/2 & #3/4 ARE POS. DISP #5/6 & #7/8 ARE STAND ALONE SENSORS 1) 87 STP SUMP SENSOR WILL NOT GO INTO ALARM NEEDS TO BE REPLACED. 2) WATER IN 87 STP WAS REMOVED DURING TEST. 3) 87 STP SUMP SENSOR WAS REPLACED AND RE- TESTED ON 5/10/13 BY RICHARD MASON Page 2 of 5 UN -036 — 2/4 w%munidoes.org Rev. 01/17/08 50'3 Monitoring System Certification F. In -Tank Gauging / SIR Equipment: ® Check this box if tank 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: ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? • Yes ❑ No* Was accuracy of system product level readings tested? • Yes ❑ No* Was accuracy of system water level readings tested? • Yes ❑ No* Were all probes reinstalled properly? • Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * in Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): ❑ Check this box if LLDs are not installed. C'mmnlete the fnllnwinv ehecklist_- • Yes ❑ No* For equipment start -up or annual equipment certification, was a leak simulated to verify LLD perfonnance? ❑ N/A (Check all that apply) Simulated leak rate: ® 3 g.p.h.; ❑ 0.1 g.p.h ; ❑ 0.2 g.p.h. • Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? • Yes ❑ No* Was the testing apparatus properly calibrated? • Yes ❑ No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ® N/A • Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ® N/A or disconnected? • Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ® N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ® N/A ® Yes I Cl No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: Page 3 of 5 UN- 036 -3/4 www.unidaes.o b Rev. 01 /17/08 Monitoring System Certification Form: Addendum for Vacuum/Pressure.Interstitial Sensors I. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of this form must be included with the Monitoring System Certification Form, which must be provided to the tank system owner /operator. The owner /operator must submit a copy of the Monitoring System Certification Form to the local agency regulating UST systems within 30 days of test date. Manufacturer: N/A Model: System Type: ❑ Pressure; ❑ Vacuum Sensor ID Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result. ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Pail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Components) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: j Sensor Functionality Test Result: ❑ Pass; ❑ Fail Inte:stitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail How was interstitial communication verified? ❑ Leak Introduced at Far End of Interstitial Space;` ❑ Gauge; ❑ Visual Inspection; ❑ Other (Describe in Sec. J, below) Was vacuum /pressure restored to operating levels in all interstitial spaces? ❑ Yes ❑ No (Ijno, describe in Sec. J, below) J. Comments: NIA Page 4 of 5 If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. UN -036A -1 /1 www.unidoes.org Rev. 01/26/06 Monitoring System Certification UST Monitoring Site Plan Site Address: 1200 "H" ST. BAKERSFIELD, CA. 93308 50VC6 I? Date map was drawn: 4_ / L Ct / 17�_. Instructions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in -tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan was prepared. Page 5 of 5 UN- 036 — 4/4 www.unidoes.org I Rev. 01 /17/08 RICH ENVIRONMENTAL 5643 BROOKS CT. BAKERSFIELD, CA. 93308 OFFICE (661)392 -8687 FAX (661)392 -0621 PRODUCT LINE LEAK DETECTOR TEST WORD SHEET W /0 #: FACILITY NAME: A -ONE FOOD STORE FACILITY ADDRESS: 1200 H STREET, BAKERSFIELD PRODUCT LINE TYPE: PRESSURE 5DIAd�-o ? PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS BELOW P.S.I. OR SERIAL NUMBER 3 G.P.H. FAIL 87 LID TYPE: RED JACKET YES 10 PASS SERIAL # 7921 91 L/D TYPE: RED JACKET YES 10 PASS SERIAL # 7915 LID TYPE: YES PASS SERIAL # NO FAIL LID TYPE: I YES PASS SERIAL # NO FAIL I CERTIFY THE ABOVE TESTS WERE CONDUCTED ON THIS DATE ACCORDING TO RED JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND LIMITATIONS. THE MECHANICAL LEAK DETECTOR TEST PASS / FAIL IS DETERMINED BY USING A LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONS PER HOUR OR LESS AT 10 P.S.I. I ACKNOWLEDGE THAT ALL DATA COLLECTED 1S TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. TECHNICIAN STEVEN OBERT SIGNATURE: DATE: 4 -19 -13 SWRCB, January 2006 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 (f applicable), should be provided to the facility owner /operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: A -ONE FOOD STORE Date of Testing: 4/19/13 Facility Address: 1200 H STREET, BAKERSFIELD Facility Contact: BOBBY Phone: 661 - 3244138 Date Local Agency Was Notified of Testing. Name of Local Agency Inspector (if present during testing): ESTHER DURAN 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician .Conducting Test: STEVEN OBERT Credentials: . ❑ CSLB Contractor X 1CC. Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): 8029980 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: VISUAL Equipment Resolution: 0 Identify Spill Bucket (By Tank Number, Stored Product, etc.2 1 87 FILL 2 91 FILL 3 4 Bucket Installation Type: X Direct Bury ❑ Contained in Sump X Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sum Bucket.Diameter: 12" 12" Bucket Depth: 14" 14" Wait time between applying vacuum/water and start of test: 30 MIN 30 MIN Test Start Time (Ti): 0900 0900 Initial Reading (Rj): 14" 14" Test End Time (Tr): 1000 1000 Final Reading (RF): 14" 14" Test Duration (TF — Tj): 1 -HOUR I -HOU R Change in Reading (RF - Ri): 0 0 Pass /Fail Threshold or Criteria: +/- 0.00 +/-0.00 Test Result: X Pass ❑ Fail X Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments — (include information on repairs made prior to testing, and recommended follow -up for failed tests) 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. Technician's Signature: ��` Date: 4/19/13 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. 12 :1:xhm I UM 2 (RS -232) PRODUCT CODE 2 THERMAL COEFF :.000700 TANK DIAMETER 128.00 TANK PROFILE 1 PT FULL VOL 7026 FLOAT SIZE: 4.0 IN. 8496 WATER WARNING 2.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 7026 OVERFILL LIMIT 90% 6323 HIGH PRODUCT 95% DELIVERY LIMIT 6694 700 LOW PRODUCT 500 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 50 TANK TILT 0.00 MANIFOLDED TANKS T#: NONE LEAK MIN PERIODIC: 9% 700 LEAK MIN ANNUAL 9% 700 PERIODIC TEST TYPE STANDARD ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVERY DELAY : 15 MIN SOFTWARE REVISION LEVEL VERSION 419.05 SOFTWARE# 346419 -100 -F CREATED - 00,02,25.12.40 S- MODULE# 330161 -001 -a SYSTEM FEATURES: PERIODIC IN -TANK TESTS ANNUAL .rN -TANK TESTS EXTERNAL INPUT SETUP -- - - - - - - NONE IN -TANK, SETUP T 1:REG UNL PRODUCT CODE 1 THERMAL COEFF :.000700 TANK DIAMETER : 128.00 TANK PROFILE 1 PT FULL VOL 15055 FLOAT SIZE: 4.0 IN. 8496 WATER WARNING 2.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 15055 OVERFILL LIMIT 90•% 13549 HIGH PRODUCT 95% 14302 DELIVERY LIllIT 9% 1500 LOW PRODUCT 500 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 50 TANK TILT 0.00 MANIFOLDED TANKS TO: NONE LEAK MIN PERIODIC: 9% 1500 LEAK MIN ANNUAL 9% 1500 PERIODIC TEST TYPE STANDARD ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVERY DELAY : 15 MIN OUTPUT RELAY SETUP R 1:87 TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS ALL:FUEL ALARM ALL:SENSOR OUT ALARM R 2:92 TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS ALL:FUEL ALARM ALL :SENSOR OUT ALARM 14V19illutl1l.- (i11UIVb 5t1UF - - PORT SETTINGS: COMM BOARD : 2 (RS -232) BAUD RATE : 1200 PARITY : ODD STOP BIT : 1 STOP DATA LENGTH: 7 DATA AUTO TRANSMIT SETTINGS: AUTO LEAK ALARM LIMIT DISABLED AUTO HIGH WATER LIMIT DISABLED AUTO OVERFILL LIMIT DISABLED AUTO LOW PRODUCT DISABLED AUTO THEFT LIMIT DISABLED AUTO DELIVERY START DISABLED AUTO DELIVERY END DISABLED AUTO EXTERNAL INPUT ON DISABLED AUTO EXTERNAL INPUT OFF DISABLED AUTO SENSOR FUEL ALARM DISABLED AUTO SENSOR WATER ALARM DISABLED AUTO SENSOR OUT ALARM DISABLED RS -232 SECURITY CODE : x* -x*xx RS -232 END OF MESSAGE LIQUID SENSOR SETUP L 1:DISP 1 -2 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 2:DISP 3 -4 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 3:87 STP NORMALLY CLOSED CATEGORY : STP SUMP L 4:92 STP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 5:ANNULAR NORMALLY CLOSED CATEGORY : ANNULAR SPACE SYSTEM SETUP APR 19, 2013 91 s SYSTEM UNITS U.S. SYSTEM LANGUAGE ENGLISH SYSTEM DATE/TIME FC MON DD YYYY HH:MM:£ A -ONE STORE 1200 H ST BAKERSFIELD CA 933[ 661 - 324 -41313 SHIFT TIME 1 5:, SHIFT TIME 2 DISC SHIFT TIME 3 DISF SHIFT TIME 4 DISF TANK PER TST NEEDEI DISABLED TANK ANN TST NEEDEI DISABLED LINE PER TST NEEDEI DISABLED LINE ANN TST NEEDEI DISABLED PRINT TO VOLUMES ENABLED TEMP COMPENSATION VALUE (DEG F ): I STICK HEIGHT OFFSE' DISABLED H- PROTOCOL DATA FO! HEIGHT DAYLIGHT SAVING TII ENABLED START DATE APR WEEK 1 SUN START TIME 2:00 AM END DATE OCT WEEK 6 SUN END TIME 2:00 AM RE- DIRECT LOCAL PR DISABLED EURO PROTOCOL PREF S SYSTEM SECURITY CODE : 000000 LEAK TEST METHOD TEST ON DATE : ALI APR 25, 2001 START TIME : 2:3( TEST RATE :0.20 ( DURATION : 2 H( LEAK TEST REPORT F ENHF 0 INVALID FUEL LEVEL MAR 29, MAR 19, NOV 15, PROBE 0 MAR 21, * * * x END MAR 10, SEP 4, 2013 2013 2012 UT 2005 2005 2003 5:59 PM 9:52 AM 3:58 PM * END 11:06 AM 11:43 AM 3:16 PM rwn�v i n a a � vic Y nLrvrt i •,,•r ��• •• ALARM HISTORY REPORT - - -- IN-TANK ALARM - - - -- AM APR 4, 2013 7:04 ----- SENSOR ALA ALARM HISTORY REPORT T 1:REG UNL MAR 29. 2013 L 1:DISP 1 -2 DISPENSER PAN AM OVERFILL ALARM SENSOR OUT ALARM _ - SENSOR ALARM - - - -- L 4:92 STP SEP 2, 2010 3:14 PM APR 19, 2013 9:58 F STP SUMP OCT 24. 2008 9:19 AM SENSOR OUT ALARM SEP 30. 2008 1:35 PM FUEL ALARM APR 19, 2013 9:58 AM LOW PRODUCT ALARM APR 19. 2013 9:53r FUEL ALARM APR 10, 2013 7:48 PM FUEL ALARM APR 19. 2013 APR 4. 2013 3:45 PM MAY 9. 2012 1:21 1 -9:49 AM MAR 29, 2013 5:31 PM FUEL ALARM HIGH PRODUCT ALARM FEB 11, 2013 3:12 MAY 9, 2012 1 :15 PIW DEC 27. 2006 1:13 PM 3:07 12:43 PM PM DEC 15, 2006 2:16 PM DEC B. 2006 4:25 PM LEVEL INVALID FUEL LEVEL MAR 29, MAR 19, NOV 15, PROBE 0 MAR 21, * * * x END MAR 10, SEP 4, 2013 2013 2012 UT 2005 2005 2003 5:59 PM 9:52 AM 3:58 PM * END 11:06 AM 11:43 AM 3:16 PM DELIVERY NEEDED * * * END APR 15, 2013 8:42 PM MAR 19. 2013 10:57 AM FEB 18, 2013 9:15 PM ALARM HISTORY REPO - - - -- SENSOR ALARM L 3:87 STP STP SUMP FUEL ALARM APR 19, 2013 9:5E FUEL ALARM MAY 9. 2012. 1 : 1 E DELIVERY NEEDED APR 10, 2013 8:23 AM APR 4, 2013 7:04 AM MAR 29. 2013 10:01 AM ALARM HISTORY REPOF - - - -- SENSOR ALARM ALARM HISTORY ALARM HISTORY REPORT L 2:DISP 3 -4 REPORT DISPENSER PAN - - -- IN -TANK ALARM - - - -- SENSOR OUT ALARM - - --- SENSOR ALARM - - - -- L 5:ANNULAR T 2:PREMIUM APR 19, 2013 9:58 ANNULAR SPACE FUEL ALARM FUEL ALARM LOW PRODUCT ALARM APR 19, 2013 9:52 APR 19, 2013 9:58 AM FEB 11, 2013 3:12 PM FUEL ALARM FEB 1, 2013 APR 21, 2011 3:07 12:43 PM PM FUEL ALARM MAY 9. 2012 1:20 APR 19, 2013 9:46 AM INVALID FUEL LEVEL FUEL ALARM FEB 4. 2013 2:36 PM MAY 9, 2012 1 :23 PM PROBE OUT FEB 28, 2011 6:29 PM MAR 21. 2005 11:06 AM MAR 10. 2005 11:22 AM DELIVERY NEEDED * * * END APR 15, 2013 8:42 PM MAR 19. 2013 10:57 AM FEB 18, 2013 9:15 PM ALARM HISTORY REPO - - - -- SENSOR ALARM L 3:87 STP STP SUMP FUEL ALARM APR 19, 2013 9:5E FUEL ALARM MAY 9. 2012. 1 : 1 E 3. MONITOR CERT. FAILURE REPORT SITE NAME: A -ONE FOOD STORE DATE: 4/19/13 ADDRESS : 1200 H STREET TECHNICIAN: STEVEN OBERT THE ]FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO TESTING. REPAIRS: 1) 87 STP SENSOR (208) DID NOT ALARM, NEEDS TO BE REPLACED AND RE- TESTED. 2) 87 STP HAD WATER IN IT I REMOVED WATER AT TIME OF TESTING. 3) I REPLACED 87 STP SUMP SENSOR AND TESTED ON 5110113 LABOR: NONE PARTS INSTALLED: NONE NAME: TITLE : SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYIN`'G RICH ENVIRONINIANTAL FOR ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE. A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR CONVIENENCE. rjp'Llo 3