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Home My WebLink AboutFMC 5-7-13HOODS ALARMS SPRINKLER SYSTEMS SPRAY BOOTH Permit No. Permit No. AST UST Permit No. Permit No. Permit No. Permit No. /3 :yOC7J0 zz7 File Number: 36- Address: Date Received: :;;- - 7-- i3 Bakersfield, CA 933 Business Name: _`� ��-- SYSTEM: BUILDING SQUARE FEET: INSPECTION LOG New Mod. ❑ ❑ Commercial Hood System ❑ ❑ Fire Aiarm System ❑ ❑ Fire Sprinkler System ❑ ❑ Spray FWsh Sys�ern ❑ ❑ Aboveground Storage Tank ❑ ❑ Underground Storage Tank minor modification Underground Storage Tank removal Underground Storage Tank ❑ C9' Other. "r-"4 L Building Sq. Feet: Calculation Bldg. Sq. Ft: 2. 3. 4. Date Time 1/ z -0 { gnature Signature Comments: DUALN5 r /'su2/ ;,v ot-c�;� «� ,�.U� 77)& LE2l� SrWSDA 4t�t� /CG.Zt fSl (., BYO ,2/244/ V'-1 UNDERGROUND STORAGE TANKS APPLICAUGN ID 5119r,9 SECONDARY CDN*1*A1A1lN'11-N*V It 11, II.S FIRE BAKERSHELD FIRE DEPARTKEA�y Pa-evention services :1.600 T111), Uill Ave., 13clkel-SNOW, (A 933011. Phone: 661-326-39790 F,-ly: Paw! I fir I n- ITAK DV•l4:1'I0N LD rei,rlw; 17-1 STTr INVOIIMATXON rA I 111 11 V nnnrte: 1'i% 0 SoW, b Ua I (► PUff•It'1 -117 •1TRATI: It ()I; TANKv TO HE TESTED: TANK V . ..... ..... .. .. - ..T. .. - JS PIPING NO V . 01 U M , 1. :0 .. N . I . EMYS .... . ..... ...... . . .. ......... TANIC 'HiSTING COMPANY ........ ... T(StIGG CnHPA• 1, PHONE 0 01; C01,1TACT 14:1UMN ImIkING mylmr;s Wt !',Pl:r.]Al. 111SPU-101t ID 75. ......... I C. C 11 101) DATE, THIS APPLICATION BECOMES Al PERMIT INDIEN APPROVED OATH 1:117.11T; (ltqv 011Jil7) W1LU,IN3 .& PERMIT STATEMENT BAKERSFIELD FIRE DEPARTMENT STARTING QM aWkei4ON -@ATE 11Mt 5 � 4. o�am All ' D Prevention. Services PERMIT # ill ' FIRE 1 �A R fM f 2101 H Street CITY 1$,AI_E _SF :1ELD STATE CA ZIP CODE a X30'1 Bakersfield, CA 93301 _.Phone: 661- 326- 3A7.9,..F;;y •• N LOCATIO OF PROJECT ' ' C + ` 6 �^ ( • PROPERTY OWNER STARTING QM aWkei4ON -@ATE 11Mt 5 � 4. o�am NAMIh K2� cu► PROJECT NAME ADDRESS 20 n P ON # 1 0 PROJECT ADDRESS 1'l U i � 3 �� CITY 1$,AI_E _SF :1ELD STATE CA ZIP CODE a X30'1 .• NiRACTOR'NAME' CA LICE SE S �- $ �6 .• TYPE OF LICENSE "EXPIRATION DATE z ' 0 1 PHONE - 3- _1 C OR COMPANY NAME 'o USY FAX # C 101 01 5 -1 -S-1 51 ADDRESS ti RaR CITY ZIP CODE 3 Please make checks payable to CM OF BAKERSFIEL D. Thank you. i FEE CALCULATION TOTAL DUE Alarm New & Modification (minimum charge) $280 TREASURY, ACCT'1�16- 7101 -0Sprinkler Over 10,000 sq ft $0 .028 x sq ft - 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) Additional Hood $470 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 ❑ Additionel'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 en 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 84 _FD2021_(Rev_05 /111 OAF IDF� V Ct� N F k*4VICES "COMPLIANCE WITH CONFIDENCE" May 7, 2013 CITY OF BAKERSFIELD Attn: David Weirather Office of Environmental Services Fire Department /UST Program 2101 H Street Bakersfield, CA 93301 To Whom It May Concern: Enclosed for your approval, please find Application to Perform Fuel Monitoring Certification and Billing and Permit Statement, along with our check in the amount of $1.92.00. Please fax the approved Applications and permit fee receipts to our office at 661- 587 - 9758. Should you have any questions, please feel free to contact me at 631 -3870. Thank you for your attention herein. Enclosures Yours truly, CONFIDENCE UST SERVICES, INC. {� Karli Karns, Dispatch Coordinator 16250 Meacham Road • Bakersfield, CA 93314 (661) 631 -3870 or (800) 339 -9930 FAX (661) 587 -9758 SYSTEM SETUP 20, 2013 '.=1:04 i4l - SYSTEM UNITS U.S. SYSTEM LANGUAGE ENGL I SH SYSTEM DHTE: 'T I t °IE FORMAT ["ION DD USA L I GUOR 1720 S UNIC:.-N h'vE BHKERSFIELD CAL. 93307 SHIFT TIME 1 : DISABLED SHIFT TIME 2 DI' :_HBLED SHIFT TIME 3 Ell ;D6DLED SHIFT TIME 4 D1�`1:7HBLED TANK PER T ST NEEDED WRN DISABLED TANK ANN TST NEEDED WRN DISABLED L1 NE PER TST NEEDED WRN DISABLED LINE ANN TST NEEDED WRN DISABLED PR NT TO VOLUMES ENABLED TEMP COMPENSATION VALUE ( DEG' F ) : 60.0 STICK HE I I3HT OFFSET DISABLED H- PROTOC, +1, DATE) F0RflHT HEIGHT DAYL I i_;HT SH'J 1 hJG 1' I ( "lE D I SABI.1 -: , RE -D I RI-c l ! .._ 'AI_ PRINTOUT DISAI.I11; S CODE : 0001JUIJ 'USTOM ALARM Lr,BELS ENABLED IIV- TAI'J} ALARi °1S LEAK ALr Rl l ANNULAR SPACE LIoUID SENSOR HLI "1S: SENSOR NORPAL STP ;SUMP FUEL ALARM STP SUMP EXTERNAL I1'•lPUTS EXTERN INPUT NORMAL STP SENSOR EXTERN INPUT ALr01 U U T S I DE ALARI°l IN -TANK SETUP T 1:UNLEAD PRODUCT CODE I THERMAL COEFF :.007000 TANK D I AI °IETER 97.00 TANK PROFILE 1 PT FULL !:OL 10310 FLOAT SIZE: 4.0 WATER WARNING 3.0 HIGH WATER LIMIT: 3.5 mAX OR LABEL VOL: 10310 OVERFILL LIMIT 90% 9279 HIGH PRODUCT 95% 9794 DELIVER; LIMIT 1 % 103 LOW PRODUCT 900 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 99 TANK TILT 2.50 PROBE OFFSET 0.00 S I PH011 MAN I FOLDED TANKS T#: NONE LINE MAN I FOLDED TANKS TO: NONE i DELIVERY DELAY 1 MIN PUMP THRESHOLD 10.00% PRODUCT CODE THERMAL -'OEFF :.007000 TANK DIAMETER 97.00 TANK PROFILE 1 PT FULL VOL 10310 FLOAT SIZE: WATER WARNING HIGH WATER LIMIT: MAX OR LABEL VOL: OVERFILL LIMIT HIGH PRODUCT DEL I VERY L 1111 T LOW PRODUCT LEAK ALARM LIMIT: SUDDE14 LOSE: LIMIT: TANK TILT PROBE OFFSET 4.0 II'•J. 3.0 3.5 103_10 q o% 92_79 95 i 9794 0% 0 900 99 99 3.20 0.00 SIPHON f °IANIFOLDED TANKS T #: NONE LINE MAN I FOLDED TANKS T #: NONE DELIVERY DELAY 1 I °l I N PUMP THRESHOLD 10.00% T 3:DIESEL PRODUCT CODE 3 THERMAL COEFF :.000450 TANI: DIAMETER 97.00 TANK PROFILE I PT FULL VOL 10310 FLOAT SIZE: 4.0 WATER WARNING 3. ID HIGH WATER LIMIT: 3.5 MAX OR LABEL VOL: 111310 OVERFILL LIMIT 90% 9279 HIGH PRODUCT 95 a 9794 DELIVERY LIMIT 0 0 LOId PR- '-lDU,:T 900 LEAK ALARM LIMIT: 99 I SUDDEN LOSS LIMIT: 99 TANK TILT 1.65 PROBE OFFSET 0.00 SIPHON MAN I Ft rLDED TANKS T#: NONE LINE MAN I FOLDED TAI -IK.S T #: NONE DELIVERY DELAY 1 f °1 I N PUMP THRESHOLD 10.00% I. I _,i.t 1 l , :- ;I_I'J::..,)•' :.I ..l i If. L 1 : UNLEAD TURK I PJ SUf °IP TRI -STATE (SINGLE FLl'-AT) CATEGORY STP SUMP L : PREf,'I I Uh,l STP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 3:DIESEL TRBIN SUMP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 4:UNLEADED INTERSTIAL TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR :=PACE L 5: PRE1,1 I utl I NTERST I AL TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 6: D I E 'EL. I NTERST I AL TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE EXTERNAL INPUT SETUP - -- - - - - - - NONE R 1:E STOP TYPE: STANDARD NORMALLY OPEN LIQUID SENSOR ALMS ALL:STP SUMP L 1 :SENSOR OUT ALARf -1 L 2:SENSOR OUT ALARf1 L 3:SENSOR OUT ALARM ALARM HISTORY REPORT -- -V N'I STE1�1 ALARl1 - -- -- PAPER OUT MAY 17. 2013 10:39 PH PRINTER ERROR MAY 17, 2013 10:39 P1'1 BATTER''` IS OFF OCT 24, 2003 8:00 AM ALARM H I STOR`,` REPORT - - -- I N —TANI; ALi4ll - - - -- T 3:DIESEL SETUP DATA WARNING NOV 24, 2003 4:19 PM NOV 24, 2003 4:17 P11 HIGH WATER ALARf;'1 JUL 19. 2008 6:48 PM ,JUL 10. 2008 9:33 All JUL 10. 2008 9:16 All LOW PRODUCT ALARM MAY 10, 2013 2:24 PH JUN 25, 2009 22:08 PM JUL 24, 2008 9:00 All HIGH PRODUCT ALARM .JUL 18. 2008 10:10 P11 INVALID FUEL LEVEL .JUN 25. 2009 2:07 P1 °1 .JUL 24. 2008 8:59 All JUL B. 2008 12 :42 Pll PROBE OUT JUL 24. 2008 8:57 All JUL 9, 201I0 9:38 All JUL 8, 2008 2:57 PM HIGH WATER WARNING JUL 19, 2008 6:48 PM JUL 10, 2008 9:33 AM JUL 10. 2008 9:16 All LOW TEMP WARNING JUL B. 2008 3:26 PM APR 7. 2005 2:41 PM PORT SETT I (4G2: OMf1 BOARD - (RS- 23'' BAUD RHTE 121-10 PAR I T'' ODD STOP B. i .i. 1 STOP:, DATA L1;P1C"TH: 7 DATA RS -232 LCLIFIT'�' CODE AUTO TRHI,i ,111'I' SETT I Nt- : AUTO LEAI ALAF:P1 l 1 rl l T DISABLED AUTO HIGH L.)ATER LIMIT DISABLED AUTO OVERFILL LIMIT DISABLED AUTO LO6J DISABLED AUTO THEFT L I H I'1' DISABLED AUTO DELIVER'',' Sl i-&."T DISABLED AUTO DEL I1!ERV E11D DISABLED AUTO EXTERNAL INPUT :II DISABLED AUTO EXTERNAL 1 IdPI i l' 1 i DISABLED AUTO SENSOR FUEL ALARfi DISABLED AUTO SENSOR WATER ALARM DISABLED AUTO SENSOR OUT ALARM DISABLED FNEi . ALARM HISTOR''; REPORT -- -- I N —TA11K HLARh1 T 2:SUPER SETUP DATA WARNING NOV 24. 2003 4:14 Phil NOV 24, 2:'003 4:14 Pfl HIGH WATER ALARM NOV 24, 2003 4:18 Pill HI GH PRODUCT HLHRtl NOV 24, 2003 4:15 PH INVALID FUEL LEVEL LIAR 25. 2013 5:51 PM JAN 26, '201'2 7:11 Ptl .JUN 25. 2009 '2:24 PIl PROBE OUT MAY 22. 2008 '2.29 PM APR 7. 2005 2:39 PM NOV 24, 2003 4:33 PM n x r - I.IdI - *� L 111 • - - i ALARM HISTORY REPORT - - -- I IV -T;-NY ALARM - T 1:UNLEAD SETUP DATA WhRN1 fdG tIOV 24. 2003 3:413 Pl OVERFILL HLARM APR 5, 2013 9:43 All AUG 8. 2011 12:09 PIl .J UL 5. 2011 G : 1 4 All LOW PRODUCT ALARM APR 16, 2013 3:40 PM MAR 26. 21-013 4:05 Pll SEP 27. 2010 9:30 All HIGH PRODI Ci T ALARM APR 5. 2013 9:45 All APR 3. 2012 9:39 AM AUG 24, 2011 7:49 PP11 I 14VAL I D FUEL LEVEL JUN 25. 2005 2 :47 Pll PROBE OUT MAY 22 2008 - :31 PM NOV 2'4. 2003 3:44 Pfl DELIVERY NEEDED SEP '27. 2010 9:30 All - - - -- SENSOR HLF kil L 2:PREMIUM STP STP SUMP SENSOR OUT ALARM MAY 21 - 2012 9:46 All STP SUMP MAY 21. 2012-' 1:33 All STP SUMP APR 15, 2011 5:12 All X END = n x ; ALARM HISTORY REPORT - - - -- SENSOR HLARI'1 - - - -- L 3 : D I ESEL TRB I f'.1 SUI °1P STP SUMP SENSOR OUT ALARM MAY 21, 2012 9:46 All STP SUMP MAY 21. 2012 9::32 At-,I STP SU11P MAY 21. 2012 9:26 All L 5: pREI-1 I 1-ii-1 I ANNULAR SL'r L-;L STP SUMP .3 MAY 21, 220122 11 :44 AM SENSOR OUT ALARM MAY 21, 2012 9:46 AM STP SUMP MAY 21. 2012 9:36 AM X x * X X END * x x x x ALARM HISTORY REPORT ----- SENSOR ALARM L 6:DIESELII,4TER.STIAL ANNULAR SPACE SENSOR OUT ALARM MAY 21, 2012 9:46 AM STP SUMP MAY 21, 20121' 9:37 All SENSOR OUT ALARt'll APR 15, 2011 9:47 AM * X 41 * k END t x X * OE . - - 1-11L, . , ALARM HISTORY REPORT ----- SENSOR ALARM - - - -- L 4:UNLEADED INTERSTIAL ANNULAR SPACE SENSOR OUT ALARM AUG 13.. 2012 8:19 AM STP SUMP AUG 9, 2012 7:20 PM STP SUMP MAY 21. 2012 10:02 k"I X * * * -A: END * * * * * ALARM HISTC +R'•,' REPORT ----- SENSOR ALARI'l - - - -- L I : U NLEAD TURB 11-4 S Ul"IP STP SUMP SENSOR OUT ALARM MAY 21, 2012 9:45 AM STP SUMP MAY 21, 20122 9:34 AM STP SUMP APR 15, 2011 9:14 AM * ;#E A A * E ['41, *- * )k * * BILLING & PERMIT STATEMENT IBAKERSFIELD FIRE DEPARTMENT _ s P Cn ,,L D Prevention Services PERMIT # i"' FLR6 "'ll Ai ANTH r 2101 H Street u Bakersfield CA 93301 L,w nl. cc, one I -,n ' - — LOCATION OF PROJECT STARTING DATE T PROJECT NAM} PROJECT ADDRESS C N FRACTOR NAME CONTRACTOR- ONT CTOR COMPANY NAME r. ��) cc� ADDRESS C9MPtiiYAlqfJkl 61 CA PROPERTY OWNER ,(SR. .L�uj' V4a,C_..... NAt�� ADDRESS CITY AICETZSFI6LD STATE CAIZIPC Iq TYPE OF LICENSE .1 EXPIRATION DATE Please make checks payabge to CITY OF BAKERSFIELD. Thank you. t1:: _A'1 FAX # ( 1, uS�5n ZIP CODE I n IAl nl.....o. I,fnnn I I P TO THE ��/ k 1 AY g", M .p iu r,m Q ORDER O F= SCI ,1f B_akgf� field 192 00 gb ' ❑ I Y. '.:• $573 /tank ..'_ ..:, �iL1B HU[lrlr Ninety Two and nQ /1 n0'«.*.....+...«:....,r; t. w....,...«. r�......«.......+.....,t.t+.*.. ...«..:....«......«.«...DOLLARS 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 s 82 ❑ z oClty of Bakersfield $ 96 /hr U 82 r e $ 96 /tent 84 s Q, MEMO After -hours inspection fee $121 /hr (2 hrs minimum) = $242 Permit ❑ 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 /insp) _ $605 84 — ❑ Re- inspection /Follow -up Inspection ' lie 109371I' 322271?24 i: 009S3L4898We 4 fi U urluCfyfuul lu JLol OYU It]I IN `Nall NA Vltjull R-CA U,f) r...-. .p iu r,m Q ' ❑ I 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 /insp) _ $605 84 — ❑ Re- inspection /Follow -up Inspection $ 96 /hr 84 ❑ Portable LPG (Propane): fk of Cages? _ $ 96 /hr 84 • Explosive Storage $266 84 • Copying & File Research (File Research fee $50 /hr) $0.2S /page 84 • Miscellaneous � — ^^ 84 __.._..,.. FD2021 (Rev 05/11) 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 MODIFICATIONS MINOR / MAJOR AST REMOVAL DESCRIPTION DATE SIGNATURE EVRUPGRADE PRI, OR_TO OP-ERATI.ON- OF_ANY_SYSTEM� �U-PST AND /OR -AST SYSTEMS -SHALL BEj (INSTALL,,_COMPLEE.ANO ACCEPTED BY MISC. ACTIVITY THE BAKERSFIELD-CITY FIRE DEPARTMENT: � FIRE. D.EPARTMENT(FINAL) ?s7 77 32= REMARKS: BUILDING ADDRESS: / C3 5 . tiJfd� JOB DESCRIPTION: =kvl C--. OCCUPANCY TYPE: OWNER: A.. One— r cj-� PERMIT NO. --/ (!CQ A z % CONTRACTOR: PHONE # 17 — Q FD 1743 FJ.; r MONITORING SYSTEM CERTIFICATION 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 certification 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 this date. A. General Information Facility Name: USA Liquor Bldg. No.: _ Site Address: 1720 South Union Avenue City: Bakersfield Zip: 93307 Facility Contact Person: Refaat Make/Model of Monitoring System: Veeder Root TLS 300 B. Inventory of Equipment Tested /Certified (.beck the appropriate bow to indicate specific equipment Inspeeted/urvked: Contact Phone No.: 661- 917 -1790 Date of Testing/Servicing: 5/20/2013 Tank ID: 10000 gal. Regular Tank ID: 10000 gal. Super U In -Tank Gauging Probe. Model: 847390-107 [x] In -Tank Gauging Probe. Model: 847390 -107 [x] Annular Space or Vault Probe. Model :7943W426 [x] Annular Space or Vault Sensor. Model: 794390.420 [x] Piping Sump / Trench Sensor(s). Model. 794380 -208 [x] Piping Sump / Trench Sensor(s). Model: 784380 -208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s). Model: [x] Mechanical Line Leak Detector. Model: FX1V E Mechanical Line Leak Detector. Model: FX1V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: U Tank Overfill / High Level Sensor. Model: OPw -61-SO [x] Tank Overfill /: High Leval Sensor. Model: OPw -61-SO ❑ Other (specify equip. type and model in Sec. E on Pg. 2) ❑ Other (specify equip. type and model in Sec. E on Pg. 2) Tank ID: 10000 gal. Diesel Tank ID: U In -Tank Gauging Probe. Model•847390 -107 ❑ In -Tank Gauging Probe. Model: 847390 -107 [x] Annular Space or Vault Sensor. Model:79430420 ❑ Annular Space or Vault Sensor. Model: [x] Piping Sump / Trench Sensor(s). Model:794380 -208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensors(s). Model: ❑ Fill Sump Sensor(s). Model: [x1 Mechanical Line Leak Detector. Model:FX1DV ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: [x] Tank Overfill / High Level Sensor. Model:OPw-61-SO ❑ Tank Overfill / High Level Sensor. Model: ❑ Other (specify equip. type and model in Sec. E on Pg. 2) ❑ Other (specify equip. typs and model in Sec. E on Pg. 2) Dispenser ID: 1 & 2 Dispenser ID: 3 & 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: [7 Shear Valve(s). [X] Shear Valve(s). [x] Dispenser Containment Float(s) and Chain(s). E 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 Chains(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 an d dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/services in accordance with the manufacturers' guidlines. Attached to this Certification is information (e.g. manufacturers' checklist) necessary to verify that this information is correct and a plot plan showing the layout of monitoring equipment. For equipment capable of generating such reports, I have attached a copy of the report; (check all that apply) Qx System p ZAlarm history report Technician Name (print): Chris Bishop Signature: Certification No: 836744 License No: 804904 Testing Company Name: Confidence UST Services, Inc. Phone No: 800 -339 -9930 Site Address: 1720 South Union Avenue, Bakersfield C.A. 93307 Date of Testing/Servicing: 6/2012013 D. Results of Testing /Servicing Software Version Installed: 424.00 Complete the following checklist: [x] Yes ❑ No* Is the audible alarm operational? x Yes No* Is the Visual alarm operational? x Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational? Yes [X] No* Were all sensors installed at the 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) Hx N/A operational? x Yes ❑ No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary ❑ N/A containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initate positive shut -down? U Sump/Trench Sensors El Dispenser Containment Sensors Did you confirm positive shut -down due to leaks and sensor failure /disconnected? [X] Yes; ❑ No; U Yes ❑ No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no C] N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visual and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capasity does the alarm trigger? 61-SO % Yes* [X] No Was any monitoring equipment replaced? If Yes, identify specific sensors, pro s, 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? x Product; Ej Water. If yes, describe causes in Section E, below. x * Was monitoring system set-up reviewed to ensure proper settings? Attach set-up reports, if applicable. x Yes No* Is all monitoring equipment operational per manufacturer's specifications? * In Section E below, discribe how and when these deficiencies were or will be corrected. E. Comments: The DSL STP sump sensor was hanging in the STP. Found small amount of DSL in STP. F. In -Tank Guaging / SIR Equipment: U Check this box if tank guaging is used only for inventory control. ❑ Check this box if tank guaging or SIR equipment is installed. This section must be completed if in -tank guaging equipment is used to perform leak detection monitoring. Complete the following checklist: * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): ❑ Check this box if LLD's are not installed. Complete the following checklist: [xj Yes • Yes No* Has all in ut wiring been inspected for proper enter and termination,including testing for ground faults? (Check all that apply) Simulated leak rate: E3 g.p.h.: ❑0.1 g.p.h.; ❑0.2 g.p.h.; • Yes No* Were all tank guaging probes visually inspected for damage and residue buildup? x Yes No* Was accuracy of system product level readings tested? x Yes No* Was accuracy of system water level readings tested? x Yes No* Were all probes reinstalled properly? (� Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): ❑ Check this box if LLD's are not installed. Complete the following checklist: [xj Yes ❑ No* For equip. start-up or annual equipment certification, was a leak simulated to varify LLD performance? (Check all that apply) Simulated leak rate: E3 g.p.h.: ❑0.1 g.p.h.; ❑0.2 g.p.h.; x Yes No* Were all LLD's confirmed operational and accurate within regulatory requirments? x Yes Was t e testing appar atus proper y ca rate ? Yes For mac anica LLD's, oes t e LLD restrict pro uct ow > it etects a e ? FNo* Yes For electronic LLD's, does the turbine automatically shut off if the LLD detects a leak? ❑ Yes r7 No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is x N/A disabled or disconnected? ❑ Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system U N/A malfunction or fails a test? Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected? rx] N/A Lxj Yes I Lj No I Were all items on the equipment manufacturer's maintenance checklist completed? * In the section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: • t r{ ". � r � r� ,,. i '' ' _ �i �. I ' i- - '' _' ' f.. .. ' ' .. - . • .;' r,� � _ USA L I i:)uiJR 1720 S UNI0'1 AVE Btil:Ef ?.�:F I ELD i�AL . 93307 MAY 20, 2013 9:02 AM SYSTEM STATUS RE-PoR`I' ALL FUNCTIONS NORMAL I hJ- E11't•: >R%' REPORT T i : UNLEAV) VOLUME = 4994 GALS ULLA:;E = 5316 GALS 9Cr, ULLAGE- 4285 GALS TC VOLUME 4516 GALS HEIGHT = 47.11 I14CHES WATER VOL.= 0 GALS (.DATER = 0.00 INCHES TEMP 7 1,7 DEG F T = :SI IPER VOLUME = 1683 GALS ULLAGE = 8627 GALS 9O% ULLAGE= 7596 GALS TO VOLUME = 1436 GALS HEIGHT = '21.35 INCHES WATER VOL - U GALS WATER = 0.00 INCHES TEMP = 80.7 DEC, F T 3:DIESEL VOLUME - 1967 GALS ULLAC;E - 8343 GALS 90% ULLPG'E- 7'.12 GALE; TO VOLUME = 1953 GALS HEIGHT = 23.84 INCHES WATER VOL = 0 GALS WATER = 0.00 INCHES TEMP = 76.0 DEC; F n X * x LI.11 �. .•. �. !- 'oFTI,IARE RF. V I S I ON LEVEL VERSION 4_4.00 :'.OFTI:JAREtf 346424-100-A CR'EHTJ=L - 03.10.24.08.56 140 SOFTwARF. MODULE SY3TEI "1 SETUP MAY 20, 21313 y :OL AM >3YSTE•I UN I T U.S. SYSTEPI LANGUAGE ENGLISH SYSTEM DATE.TIME FORMAT MON DD YYYY HH : Mtl : S'S :41 USA LICIUOR 1720 S UNION AVE BAKERSFIELD CAL. 93307 SHIFT TIME 1 DISABLED SHIFT TIME 2 DISABLED SHIFT TIME 3 DISABLED SHIFT TIME 4 DISABLED TANK PEP TST NEEDED WRN DISABLED TANK ANN TST NEEDED WRN DISABLED LINE PER TST NEEDED WRN DISABLED LINE ANN TST NEEDED WRN DISABLED PRINT TO VOLUMES ENABLED TEMP •.01 "IF'Ef1:_ATION VALUE (DEG F ): 6O.0 STICK HEIGHT OFp::%l --•I' DISABLED H- PROTOCOL DATA FOR11AT HEIGHT DAYLIGHT SAVING TINE DISABLED RE- DIRECT LOCAL PRINTOUT DISABLED EURO PROTOc. L PREFIX S S YSTEMEC'URITY CODE : 000000 CUSTOfl ALARM LABELS E14ABLED IN -TANK ALARMS LEAP ALARM ANNULAR SPACE LIQUID SENSOR ALMS: SENSOR NOP.PIAL STP SUMP FUEL ALARM E:TP SUMP EXTERNAL INPUTS E�,'TERN I NPUT NORMAL STP SENSOR EXTERN INPUT ALAFS11 OUTSIDE ALARM COMMUNICATIONS SETUP - PORT SETT 11113'.3 : COMM BOARD : 2 (RS -232) BAUD RATE 1200 PAR I TY 01)D STOP BIT I STOP DATA LENGTH: 7 DATA RS -232 SECURITY CODE : * ** AUTO TRANSPIIT 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 -23:: END OF DISABLED IN —TANK SETUP T 1:UNLEAD PRODUCT CODE 1 THERI °IAL C_.OEFF :.007000 TANK DIAMETER 91 PT TANK PROFILE FULL VOL I C1310 FLOAT SIZE: 4.0 IN. WATER WARNINI- 3.0 HIGH WATER LIMIT: 3.5 MAX OR LABEL VOL: 10310 OVERFILL LIMIT 901 9274 HIGH PRODUCT 95% 9794 DELIVER'r LIMIT I °o 103 LOW PROD) ,':T 900 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 99 TANK TILT 2.50 PROBE OFFSET 0.00 SIPHON MANIFOLDED TANKS TO: NONE LINE HANIFOLDED TANKS Tit: NONE DELIVERY DELAY 1 1-1IN PU11P THRESHOLD 10.00,0 T 2:SUPER PRODUCT CODE 2 THERMAL COEFF :.007000 TANK DIAM^IETER 97.00 TANK PROFILE I PT FULL VOL 10310 FLOAT SIZE: 4.0 IN. WATER WARIJING 3.0 HIGH WATER LIMIT: 3.5 MA''X OR LABEL VOL: 10310 OVERFILL LIMIT 90% 9279 HIGH PRODUCT 95 %d 9794 DELIVERY LIMIT 0% 0 LOW PRODUCT 900 LEAK ALARM LIMIT: 59 SUDDEN LOSS LIMIT: 99 TANK TILT 3.20 PROBE OFFSET 0.00 SIPHON MANIFOLDED TANKS Td: NONE LINE MANIFOLDED TANKS TO: NONE DELIVERY DELAY t MIN PUMP THRESHOLD 10.00°% T 3:DIESEL PRODUCT CODE 3 THERMAL. C»EFF :.000450 TANI' D I -±METER 97.00 TANK PROF I LE 1 PT FULL VOL : 10310 FLOAT SIZE: 4.0 IN. WATER WARNING 3.0 HIGH WATER LIMIT: 3.5 MAX OR LABEL VOL: 10310 OVERFILL LIMIT 90% 9279 HIGH PRODUCT 95% 9794 DELIVERY LIMIT 0% 0 i RODUCT 900 K t;I.ARM L I M I T: 99 jDEN LOSS L1hIiT: 99 I -NK TILT 1.65 PROBE OFFSET 0.00 SIPHON MANIFOLDED TANKS Tit: NONE LINE MANIFOLDED TANKS Tit: NONE DELIVERY DELA`! 1 MIN PUMP THRESHOLD 10.00 %b LIQUID SENSOR SETUP L I:UNLEAD TURBIN SUHP TRI —STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 2:PREMIUM STP TRI —STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 3:DIESEL TP.BIN SUMP TRI —STATE (S 1 I *':LE FLOAT) CATEGORY ORY : STP SUMP L 4:UNLEADED INTERSTIAL TRI —STATE (SINGLE FLOAT% CATEGORY : ANNULAR SPACE L 5:PREMIUM INTERSTIAL TR1—STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L t:DIESELINTERSTIAL TRI —STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE EXTERNAL INPUT SETUP ALARM HISTOR,' REPORT - - -- - - - - - - - - - AL ARI °1 HISTORY REPORT NONE - - -- IN-TANK Al...,i?Mi - - - -- - - -- IId -TANI; ALARh1 - T 1:UNLEAD T 2 :SUPER OUTPUT RELAY SETUP R 1:E STOP TYPE: STANDHRD NORMALLY 0PEN LIQUID SENSOR ALMS ALL.: STP S124P L I:SENSOR OUT ALARM L 2:SENSOR OUT ALARM L 3:SENSOR OUT ALARM ALARM HISTORY REPORT - - - -- SYSTEM ALARM - - --- PAPER OUT HA1t 17, 2013 10::39 PH PRINTER ERROR MAY 17, 2013 10:39 PH BATTERY IS OFF OCT 24, 2003 13:00 AM X w x x* END =: X x A SETUP DATA WARNING N0V 24. 2003 3:46 Pm OVERFILL ALARM APR 5. 2013 9:43 Am ALIG 6. '.:011 12:09 PH J UL. 5 , 201 1 6:14 AM LOW PRODUCT ALARM APR 16, 2013 3:40 PM MAR. 26, 2013 4:05 PH SEP 27. 2010 9:30 AM HIGH PRODUCT ALARM APR 5, 2013 9:45 AH APR 3, 2012 9:39 AM AUG 24. 2011 7:49 PH INVALID FUEL LEVEL JUN 25. 2009 2:47 PM PROBE OUT MAY 22. 2006 2:31 PM NOV 24. 2003 3:44 PM DELIVERY NEEDED . SEP 27. 2010 9:30 All A s A 4 END x► r X r SETUP DATA WARNING NOV 24, 2003 4:14 PH N0V 24, 2003 4 :14 PH HIGH WATER ALARM NOV 24, 2003 4:18 PM HIGH PRODUCT ALARM NOV 24, 2003 4:15 PM INVALID 1'UEL LEVEL MAR 25, 2013 5:51 PM .JAN 26, 2012 7:11 PM JUN 25, 2009 ^_:24 PM PROBE OUT MAY 22, 2008 2:29 PH APR 7, 2005 2:39 PH NOV 24, 2003 4:33 PH **z� x x END x X x X ALriG:M HISTORY RETIORT - - -- IN-TANK ALARM - T 3:DIESEL SETUP DATA WARNING NOV 24, 2003 4:19 PM NOV 24, 2003 4:17 PM HIGH WATER AL'iRth .JUL 19, 2008 6:48 PM JUL 10. 2008 9:33 Al-I JUL 10. '2008 9:16 All LOW PRODUCT ALHRI "l MAY 10, 2013 2:24 PM JUN 25. 21-.109 2:08 PM JUL 24, 2008 9:oO AM HIGH PRODUCT ALARM JUL 18. 2008 10:10 PM INVALID FUEL LEVEL .JUN 25, 2009 2:07 PM JUL 24, 2008 8:59 AM JUL 8, 2008 12:42 PM PROBE OUT JUL 24, 2008 8:57 AM JUL 9, 2008 9:38 AM JUL 8. 2008 2:57 PM HIGH WATER WARNING JUL 19, 2008 6:48 PM JUL 10, 2008 5:33 AM JUL 10. 2000 9:16 AM LOW TEMP WARNING JUL 8, 2008 3:26 PM APR 7. 2005 2:41 PM x x x; * END x +: x x ALARM HISTORY REPORT - - - -- SENSOR ALARM - - - -- L I:UNLEAD TURBIN SUMP STF' SUMP SENSOR OUT ALARM MAY 21, 2012 9:45 A11 STP SUMP MAY 21, 2012 9:34 AM STP SUMP APR 15. 2011 9:14 AM x iE x t x E14D s x X* ALARM HISTORY REPORT - - - -- SENSOR ALARM -- L 2:PREMIUM STP STF' SUMP SENSOR OUT ALARM MAY 21, 2012 9:46 All STP SUMP MAY 21. 2012 9:33 AM STP SUMP APR. 15, 2011 9:12 AM * * * * x END :_: x x * x ALARM HISTORY REPORT - - - -- SENSOR ALARM - - - -- L 3: D I a75EL TRB I N SUMP STP SUMP SENSOR OUT ALARM MAY 21, '201 9:46 AM STP SUMP MAY 21, 2012' 9:32 AM STP SUMP MAY ?-1, 2012 9 : ' 6 AM * x v x * END , x ALARM HISTORY REPORT - - - -- SENSOR ALARM - -- - L 4 :UNLEADED INTER'STIAL ANNULAR SPACE SENSOR OUT ALARM AUG 13. 2012 8:19 AM STP SUMP AUG 9. 2012 7:20 PM STP SUMP MAY 21, 2012 10:02 AM x x x i x END X* x> x ALARM HISTORY Fc'EPORT - - - -- SENSOR ALAR°1 - - - -- L 5 : PF::I 1I UM I NTERST I AL ANNULAR SPACE STP SUMP MAY 21. 2012 1 1 :44 All SENSOR OUT ALARM MAY 21, 2012 9 :46 AM STP SUMP MAY 21 • 2012 9:36 All X k x x x END x x x ALARM HISTORY REPORT - -- — SENSOR ALARM - - - -- L 6:DIESELINTERSTIAL ANNULAR SPACE ;_ENSOR OUT ALARM MAY 21. 2012 9:46 AM STP SUMP MAY 21. 2012 9:37 AM SENSOR OUT ALARM APR 15, 2011 9:47 All x x X. t x END x* x x x: ALARM HISTORY REPORT ALARM HISTOR'' REPORT - - - -- SENSOR ALARM - - - -- L I:UNLEAD TIJRB114 SUMP - - - -- SENSOR ALARM - - - -- STP SUMP L 7: SENSOR OUT ALARM OTHER SENSORS MAY 20. 2013 12:02 PM SENSOR OUT ALARM MAY 20, 2013 10:02 All STP SUMP MAY 20, 2013 9:54 fill x� x x END x x x x x x -. x* END v, * x� r ALARM HISTORY REPORT - - - -- SENSOR ALARM - - - -- L 2 : PREM I UP1 STP STP SUMP SENSOR OUT ALARM MAY 20. 2013 10:02 AM STP SUMP MAY 20, 2013 9:55 AN SENSOR OUT ALARM IIAY 21, 2012 5:46 AM x x< x x END x r x x* ALARM HIST(:I• REPORT --- — SENSOR ALARM - -- L 3:DIESEL TRBIN SUMP STP SUMP SENSOR OUT ALARM MAY 20. 2013 10:02 AM STP SUMP MAY 20, 2013 9:57 AM SENSOR OUT ALARM Htcr`,) 21. 2012 9:4i, AM x x x f x E14D x ;c x. x x ALARM H I STOP REPORT - - - -- SENSOR Al_,:kM - - - -- L 4:UNLEADED INTERSTIAL ANNULAR SPACE STP SUPIP MAY 20, 2013 11:59 AM SENSOR OUT ALARM MAY ''0. 2013 10:02 All STP SUMP MAY 20, 2013 9:50 All ALAFH HISTORY REPORT -- -- SENSOR ALARM -- -- L 5:PREMIUM 1NTERSTIAL ANNULAR SPACE S'Et•JSOR OUT ALARM i,iAY 20. 2013 10:02 All STF' SUMP MAY 20, 2013 9:49 AM STP SUMP MAY 21, 2012 11:44 AM 's, x X x +E END * x x X n ALARM HISTOR'r REPORT - ---- SENSOR ALARM - - - -- L 6 :1) I E2'.EL I NTERSTI AL ANNI_IL'R SPACE SENSOR OUT ALARM MAY 20, 2013 10:02 AM STP SUMP MAY 20. 2013 9:46 All SENSOR OUT ALARM MAY 21. 201'2 9:46 HM END f* x x fi E14D 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: USA Liquor Date of Testing: 5/20/2013 Facility Address: 1720 South Union Avenue, Bakersfield, C.A. 93307 Facility Contact: Refaat I Phone: 661- 917 -1790 Date Local Agency Was Notified of Testing: 5/6/2013 Name of Local Agency Inspector (f present during testing): Ernie Medina 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. Technician Conducting Test: Chris Bishop Credentials': X CSLB Contractor X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) License Number(s): CSLB #804904 ICC #8144916 3. SPILL BUCKET TESTING INFORMATION Test Method Used: x Hydrostatic ❑ Vacuum ❑ Other Test Equipment Used: Lake Test Equipment Resolution: 0.0625" Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 Regular 2 Super 3 Diesel 4 Bucket Installation Type: x Direct Bury ❑ Contained in Sump x Direct Bury ❑ Contained in Sump x Direct Bury ❑ Contained in Sump ❑ Direct Bury ❑ Contained in Sum Bucket Diameter: 12.00" 12.00" 12.00" Bucket Depth: 15.00" 16.00" 15.00" Wait time between applying vacuum/water and start of test: 5 min. 5 min. 5 min. Test Start Time (TI): 9:45 am 9:45 am 9:45 am Initial Reading (Rj): 10.75" 10.50" 10.75" Test End Time (TF): 10:45 am 10:45 am 10:45 am Final Reading (RF): 10.75" 10.50" 10.75" Test Duration (TF — Tj): 1 hour 1 hour I hour Change in Reading (RF - RI): 0.00" 0.00" 0.00" Pass/Fail Threshold or Criteria: 0.0625" 0.0625" 0.0625" Test Result: X Pass ❑ Fail I X Pass ❑ Fail X Pass ❑ Fail 1 ❑ 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 cent fy that all the Information contained in this report is true, accurate, and In full compliance with legal requirements. Technician's Signature: Date: 5/20/2013 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. f�, i ,. i. � ��,. � ` i 1. t� u 1 �,.� � i .� i ,. ., t � �. � � 1' ' t. i � � uO0FIDF%I� C0 OIDF4,� SL AST 't UCr0?0 '�hCES Y 013UIID WITH CONFIDENCE' 'COMPUANCE WITH CONFIDENCE' Lic.970703 Lic.804904 Toll Free #: 1-800- 339 -9930 Job Order / Invoice #: Date Called Time To Whom R Name: Confidence UST Site Name: Technician Print Name: Store Employee Signature: Date Street: 16250 Meacham Road Street: City: Bakersfield CA 93314 City: �•4 �' State: Zip: Terms: Store No: Description of work erformed: '✓Iff ��(i ra- TRAVEL and LABOR (0.5 Hour Minimum Labor Charge) OVERTIME (5:00 PM - 7:00 AM) Date Technician(s) Name a .e as.a: z, s �:�;;«y��, Start End Total OT Start OT End OT Total �Zp• I i O Travel Labor Travel Date Technician(s) Name "w 's = �x �i Start End Total OT Start OT End OT Total Travel Labor Travel Date Technician(s) Name Start End Total OT Start OT End OT Total Travel Labor Travel SUPPLIES - MATERIALS - RENTALS Check One Qty. UST Parts Site Parts ✓ .�l a L COMMENTS Store Employee Print Name: M Technician Print Name: Store Employee Signature: Date Technician Signature: Date INVOICE - WHITE SITE-CANARY