HomeMy WebLinkAboutUST-PLAN COVERSHEET 8/1/2012HOODS ALARMS SPRINKLER SYSTEMS SPRAY BOOTHOOTH
Permit No. Permit No. Permit No. Permit No.
File Number:
Date Received:
AST UST
Permit No. Permit No.
Address: d / ., •4'r`-P-,
Bakersfield, CA 933
Business Name:
SYSTEM: BUILDING SQUARE FEET:
New Mod.
Commercial Hood System
Fire Alarm System
Fire Sprinkler System
Spray Finish System
Aboveground Storage Tank
Underground Storage Tank
minor
modification Underground Storage Tank
removal Un rground Storage Tank
Other:
Comments:
Building Sq. Feet:
Calculation Bldg. Sq. Ft: 1.
2.
3.
4.
ORdSPECYION BOG
Date Time
Signature
Signature
BILLING & PERMIT STATEMENT `' "` u " „;!;;:` BAKERSFIEL® FIRE DEPARTMENT
B '4;4.bilL D Prevention Services
PERMIT # >fiRe I' 2101 H StreetAfrP1MYr
w,; Bakersfield CA 93301
Dhnno F, F,1 - 47F, -RQ7Q .Fax F,F,1 - RS7 -11 71
Please make checks payable to CITY OF BAKERSFIELD. Thank you.
1 Alarm - New & Modification (minimum charge) $280
Over 10,000 sq ft $0 .028 x sq ft
1 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) $235
Additional Hood 58 hood
Commercial Hood - Minor Modification add /move nozzle 8496 (inspection only)
Spray Booth (New & Modification) 235
LOCATION OF PROJECT
i C c,- .
PROPERTY OWNER
Y” r -2C-i& rr rl a" Za4A616q
STARTING DATE C?, - I i0 - ' Z r COMPLETION DATE
bI .- +
NAME
SvTraQ P GL17
PROJECT NAME
V L G 11-4 t% i4 P v 1-(_ ADDRESS L i o) Lt S A MsaYta 6
PHONE #
woI-
PROJECT ADDRESS LtG)D( L15 o rt 6 (LtE C,' cm g _ERS lELD STATE CA ZIP CODE 133 13
CO •• o• o
Aboveground Storage Tank (Removal, Mod,or Inspect'n) ATR
ONTRACTOR NAM CA LICENSE #
scow
r R NF `(M 2 t 6lgl N trfi b ,
TYPE OF CENSE EXPI TION D TE
10
PHONE #
ScIi1^
1p
CONTRACTOR COMPANY NAME
M V i Q.D03 r'i`m ' /a L
7Z
FAX # :k% - NGS
ADDRESS
D $
CrY
SI ri) \J '6u_6L1
ZIP CODE
3001 Lj
Please make checks payable to CITY OF BAKERSFIELD. Thank you.
1 Alarm - New & Modification (minimum charge) $280
Over 10,000 sq ft $0 .028 x sq ft
1 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) $235
Additional Hood 58 hood
Commercial Hood - Minor Modification add /move nozzle 8496 (inspection only)
Spray Booth (New & Modification) 235
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 7- ° 573• 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
Miscellaneous 84
3ILLING & PERMIT STATEMENT
B Pl;-iG EmmRSFS .n8'-L D
PERMIT # pFIRia'r
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Please make checks payable to CITY OF F>AKERSFIIELD. Thank you.
800860011• 1:1220002471: 3 2 L4 S S06 31311'
Underground Storage Tank (Minor Modification) MTM
SIT&INFORMATION
LOCATION OF PROJECT r.• %o/ L l {;r.J j it dZl c:. G_' Jf
PROPERTY OWNER
y ]ZC -(.'(Lc --- .?
STARTING DATE • COMPLETION DATE
Lt - i .- l".i .. i .- NAME qqf4W yt is L'-1 rn
PROJECT NAME ADDRESS PHONE #
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
PROJECT ADDRESS `^
1-'] % I.,.ij 11 /i r l %.'i• cITY Uf ICE1ZS lELD STATE G ZIP CODE `at 33 I
T tOWINFORMATION6'0'Nf
82
CONTRACTOR NAME, CA LICENSE #
S cdJ GL-,iF:j `)i2 (Ia 1S]t/r k >9'/;C
TYPE OF LICENSE EXPI TION D TE
Sail
1 3 j
PHONE #
jS'I -S 2 Sj7 C3
CONTRACTOR COMPANY NAME r t FAX # f-
SSE^" 1'
ADDRESS
c7 . 3Cl r5 eCITY ' 9 V i yy
ZIP CODE t'1'C3"_
Please make checks payable to CITY OF F>AKERSFIIELD. Thank you.
800860011• 1:1220002471: 3 2 L4 S S06 31311'
Underground Storage Tank (Minor Modification) MTM 167 /site 82
Underground Storage Tank (Removal) TR 573 /tank T- 1 -1 L " g?( 5 73, 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
Miscellaneous 84
FD202L(ReY- Q7L12) —
E, 1
t
YRC
Freight:
4901 Lisa Marie Ct.
Bakersfield, Ca
Scope:
Remove one 12,000
Gallon Diesel
Underground
Storage Tank.
Project Manager &
Contact:
Scott Covey
951 -522 -5110
Plot Plan & Excavation
Details, Copy of
Application
Tank Removal Work
Plan and Soil Sampling
Information
Copy of Pocket License,
General Liability
Insurance & Workers
Comp Policy
Health and Safety Plan
v
UNDERGROUND STORAGE TANK
PERMIT APPLICATION
FOR REMOVAL OF AN UNDERGROUND STORAGE TANK ..l
IPermit #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
B c1 11 1 11 ID 2101 H Street
PIRA Bakersfield, CA 93301
ARfN f Phone: 661 - 326 -3979 • Fax: 661 - 852 -2171
Page IofI
SITE INFORMATION
SITE YrzG 1%Q.%Ivu-r, I'4
G
ADDRESS —
Cg01 Llsp MAO _ C ZIP CODE 1
FACILITY NAME v 2 I CROSS STREET
TANKOWNER/OPERATOR Y tLL X281 vm•` SUIT tLF16 V /
PHONE # ,^u I qpN #
MAILING ADDRESS I-few 1 PIS,6 MAILI P CLl CITY 13AV-e -lmr -I ZIP CODE 93717,
CONTRACTOR INFORMATION
COMPANY TM r r-)4 J! rl,Ba lh) GrYTA L PHONE # y o s ^ t a r O3 Lp O LICENSE # IB203ZO
ADDRESS P.O. (10jr 4)1410) 'a 3 CITY Sim 1 ZIP CODE 93 Day1
INSURANCE CARRIER IZo(,KP11 1 NS u n.p aG6 GO . WORKMENS COMP # 00 Iy
PRELIMINARY ASSESSMENT INFORMATION
COMPANY OR.NSlM L DoN N E1.a. r;AzA fs 661u pAG IJi PHONE # I.DSO - $ -4' - 2-19Z LD LICENSE #
ADDRESS 3` 3 E • op > S) I s u r e 3 CITY Cov'ro S,s ri r- IZA)A U 5 (,O ZIP CODE
INSURANCE CARRIER WORKMENS COMP #
TANK CLEANING INFORMATION
COMPANY
N) r,„rO A4 a SOA S TQl%t,.iLl PHONE # ) SS1.
LICENSE #
ADDRESS p.O' &OX '+ 8 Cm VwLaA A&A ZIP CODE pZp r
1 V S
INSURANCE CARRIER W sfCGwt.t^1'A. SunP WS L1a GS WORKMENS COMP # GAGA - I H 1- 44
WASTE TRANSPORTER ID # FACILITY ID # NAME OF RINSATE DISPOSAL FAC `LITYCA1-- o$o - CI )Lp - I 1 Co Gq? 080 -o S - SZ pEJ"IeNrlo Ylrt ooN
ADDRESS ZOCb N .4L.4MF.)h CITY Comr140A ZIP CODE
1072
TANK - TRANSPORTER INFORMATION
COMPANY 14 1'rTo 4A t L So[3 S PHONE # -+ 1G(._ 99:110 . tYZ7 SS LICENSE *CA SS-'
ADDRESS i Z % I IS ZE .* CAt4_10 i M& CITY R 0-eQ _ ZIP CODE
TANK DESTINATION 64 ZO(+4 /3--34D tA 9j-mKuj ,4& 13 Q a 6 . I n r &rul I, ov r "—' A FE S9141465 GA
TANK INFORMATION
TANK # AGE VOLUME CHEMICAL STORED DATES STORED CHEMICAL PREVIOUSLY STORED
FOR OFFICIAL USE ONLY
APPLICATION DATE FACT LI TY # OF TANKS FEE S
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 PERJURY, AND TO THE BEST OF MY KNOWLEDGE ISTRUEANDCORRECT.
APPROVED BY APPLICANT NAME (PRINT) APPLICANT SIGNATURE
THIS APPLICATION WILL BECOME A PERMIT WHEN APPROVED
FD2088 (Rev 03 /08)
C
B
A
4
To Lisa Marie Ct
Existing Maintenance Bldg
N
4
9 Oa
Loading Dock
Island with Satellite Dispenser
Island with Master Dispenser —@
0
One (1) Existing 12,000 Gallon Diesel UST - To he Removed
O
O
I
Diesel Tank Location
3
COVEY ENGINEERING, INC
A Div of National Petroleum Inc
985 Kendall Dr, Ste A -151
San Bernardino, Ca 92407
951 -522 -5110 Phone
866 - 706 -8265 Digi Fax
Contractor:
TMR Environmental
PO Box 941983
Simi Valley, CA 93094
805- 218 -0360 Phone
CA Lic # 820320 A, Haz
2
Scope of Work: Remove I UST
1.) Upon approval from agencies, notify
Dig Alert, mark site.
2.) Tank is currently empty.
3.) Demolish concrete above Tanks and
piping.
4.) Excavate Tank & piping.
5.) Triple Rinse / Clean UST & piping.
6.) Remove & Destroy UST.
7.) Retreive soil samples per Bakersfield
Fire Dept..
8.) Submit Soils Report & Results to
Bakersfield Fire Dept.
9.) Backfill, Compact & Resurface.
Removal of 1 1 YRC Freight
12,000 Gal UST 901 Lisa Marie Ct
2
1 of 2
17
C
B
A
9
B
A
4
0
Existing Maintenance Bldg
3
Island with Satellite Dispenser
I I
I I
I I
I I
I O
I O
I I
Demolition Limits
2 a
Excavation Limits
No Persons shall enter this excavation for any reason
Remove existing tank backfill (gravel
or sand)
After tank removal, backfill with
existing material. Import additional
gravel /sand as needed.
Compaction to be performed during
backfilling operations. (No formal
compaction testing unless required by
City.
Repave the ecavation with 5" of
asphalt.
N COVEY ENGINEERING, INC Contractor: Removal of 1 YRC Freight
A Div of National Petroleum Inc TMR Environmental
985 Kendall Dr, Ste A -151 PO Box 941983 12,000 Gel UST 4901 Lisa Marie CtSanBernardino, Ca 92407 Simi Valley, CA 93094
951 -522 -5110 Phone 805- 218 -0360 Phone 9 0
866- 706 -8265 Digi Fax CA Lic # 820320 A, Haz C 2
4 1 3 41
2 1 1
soil
in
M
C
B
A
UNDERGROUND STORAGE TANK
REMOVAL WORK-PLAN
4901 LISA MARIE COURT
BAKERSFIELD, CALIFORNIA
Prepared for
YRC WORLDWIDE
July 13, 2012
Burns & McDonnell Engineering Company, Inc.
400 Oyster Point Boulevard, Ste. 533
South San Francisco, CA 94080
July 13, 2012
Bakersfield Fire Department
Office ofPrevention Services
2101 H. Street
Bakersfield, CA 93301
Subject: UST Removal Work Plan
YRC Worldwide Inc.
4901 Lisa Marie Court
On behalf of YRC Worldwide Inc. (YRCW), Burns & McDonnell Engineering Company,
Inc. (Burns & McDonnell) has prepared this work plan for the removal of one 12,000
gallon steel walled underground storage tank (UST), two fuel dispensers, and associated
piping at the subject site located at 4901 Lisa Marie Court, Bakersfield, CA 93313 (Site)
Figure 1).
1.0 SCOPE OF WORK
The scope of this project includes the removal of one 12,000 gallon UST, two fuel
dispensers, and associated piping (Figure 2).
2.0 TANK EXCAVATION AND REMOVAL ACTIVITIES
2.1 Contractors & Permitting
Covey Engineering (Covey) will perform the tank removal and associated soil excavation
and project related derived waste management. The removed UST will be hauled to the
disposal facility by Nieto & Sons, a CA 557 licensed waste hauler. Burns & McDonnell
will perform oversight and conduct the soil sampling program.
21.1 UST Removal Permitting
Prior to UST removal, appropriate permits will be obtained by Covey from the Bakersfield
Fire Department Office of Prevention Services (BFD). Covey will notify the BFD 48
hours prior to UST removal to arrange an inspection appointment.
2.1.2 Underground Service Alert
An Underground Service Alert (USA South) dig alert ticket will be attained by Covey, a
minimum 72 hours prior to Site activities commencing.
2.2 Tank Removal Excavation Activities and Project Schedule
Construction and sampling activities are tentatively scheduled to start on or about July 30,
2012. Contractor will erect 6' high safety fencing around work areas prior to construction
activities commencing.
Alameda County Environmental Health Services
UST Removal Work Plan
July 13, 2012
Page 2 of 4
2.2.1 Overburden Excavation
In the vicinity of the UST, the contractor will saw cut, demolish and remove a section of
concrete and or asphalt overlaying the UST, approximately 12 feet x 34 feet (actual
excavation area shall be determined during construction activities).
Once the overlying asphalt and/or concrete are removed, soil will be excavated to clear the
top and sides of the UST so that an evaluation can be performed on the UST condition, and to
prepare for interior cleaning and removal ofthe UST.
2.22 UST Rinsing & LEL (Inert)
Contractor shall triple rinse the interior of the UST prior to rendering the UST inert as
stipulated in BFD UST Removal Permitting requirements. Contractor will cut into the
existing UST's outer shells to provide excavation access. The use of non sparking /cold
chisel shall be allowed. The contents of the tank shall be monitored for Lower Explosive
Limit (LEL) before, during, and after all activity.
Groundwater, if encountered, will be pumped into baker style tanks during excavation and
will be disposed and or recycled at an appropriate facility. Groundwater in not anticipated
to be encountered during construction activities; nearby LUST sites report depth to
groundwater at 180 feet below ground surface (ft bgs).
2.3 Soil Management, Sampling and Analysis
2.3.1 Soil Sampling
Confirmatory soil samples will be collected, at a minimum, from the center of the 12,000
gallon UST and one -fourth of the way in the end of the tank. Soil samples will be collected
from depths 2 to 6 feet below the bottom of the UST and dispenser. A soil sample shall be
collected for every 20 feet of piping, and or at connections, joints, bends, etc.
Additional confirmatory soil samples will be collected based on visual observation and field
screening with a photo ionization detector (PID). If obviously impacted soil is screened or
visually observed, over - excavation will be undertaken and further confirmatory samples
shall be collected.
2.3.2 Soil Management/Stockpiling
Excavated soil will be stockpiled next to the excavation areas and placed on plastic sheeting;
stockpiles will also be covered with plastic sheeting. Composite samples of soil will be
collected from each stock pile, and submitted for analysis. Visually impacted soil will be
separated from the stockpiles and placed on plastic sheeting. A composite soil sample will be
additionally collected and submitted for a waste profile analysis. Based on waste profile
analysis, excavated soil will be transported to an approved facility for disposal or recycling.
23.3 Laboratory Analysis
All soil samples from the excavations and stockpiles will be submitted to Accutest
Laboratories, a California State Certified laboratory under Chain -of- Custody protocols. The
soil samples will be analyzed for the following constituents:
K: \YRC Enterprise Services Inc \YRC Bakersfield\Lisa Marie Ct \UST Removal workplan July 2012.docx
Alameda County Environmental Health Services
UST Removal Work Plan
July 13, 2012
Page 3 of 4
TPH as Gasoline and Light Hydrocarbons (C7 -C 12) — EPA Method 8260
TPH as Diesel (CIO-C24)— EPA Method 8015M
MTBE — EPA Method 8260
2.3.4 Quality Assurance/Quality Control
Field duplicates shall be collected and submitted as `blind' samples at a rate of 1 QA /QC
sample per 10 confirmation samples.
2.5 Backfill and Site Restoration
2.5.1 Backfd- l
Once the soil sample results are received, or the approval to backfill is given, the UST
excavation shall be backfilled as stipulated in BFD UST Removal Permitting.
2.5.2 Finish Grade
Finish grade shall be completed in accordance with YRC construction specifications.
3.0 REPORTING
3.1 Preliminary Soil Summary Report
Upon completion of the UST removal activities, a preliminary soil summary report will be
prepared and submitted to the BFD. The report will contain name and location of UST
disposal facility, name and location of reinstate disposal facility, signed copy of hazardous
waste manifest, UST disposal receipt, copies of certified analytical reports and chain -of-
custody documentation, and a plot plan indicating site features including buildings, tanks,
piping runs, dispensers, and sample locations.
3.2 USTRemoval Report
Upon completion of the UST removal activities, a UST Removal Report will be prepared
and submitted to the BFD documenting all construction activities, permitting, disposal
activities, certified analytical reports, analytical tables, and photographs.
KAYRC Enterprise Services Inc \YRC Bakersfield\1.isa Marie Ct \UST Removal workplan July 2012.docx
Alameda County Environmental Health Services
UST Removal Work Plan
July 13, 2012
Page 4 of 4
If you have any questions or comments regarding this UST Removal Work Plan for the
YRC Worldwide Inc facility located at 4901 Lisa Marie Court, please contact the
undersigned at 650- 871 -2661.
Sincerely,
Simon Barber P.G. 8607
Burns & McDonnell Environmental
Group
Attachments:
Figures
Figure 1 — Site Location Map
Figure 2 — Site Plan
Cc: Steve Shinners, YRCW
KAYRC Enterprise Services Inc \YRC Bakersfield\Lisa Marie Ct \UST Removal workplan July 2012.docx
FIGURES
rpe
L` .. —.
i 4. .L• `}.j..•y• 'iN `;:._i; a "`!T. .+ r.` j•XM.. . '?- C.::.."..:....:. .,. rl !
a
TAPProXl nate location and
limit of excavation for q
1 12;p00 gallon /UST
be Removetl , fir"` _3' f I
ic 1 U)
y
U I I fF„ — Aj '- • yam c r' r`'
t' „P•,J i .. t ..- .- ..
8
11, ' .' !ew3 ilSltr. Y' e-} ', rE. - - - xT" _' .. "•vn r o>. uk -c ,a. _ !•`p- .r.•s.,.Ls.r•r q, r.
1' S:;ra • { ! = S try. ,C Y `E""„q+,.Q. kt"yi t.
f
t+ '? + # '• +'?' : '
v I T,
o(jl - ^' _. 5 P ;". , '" i rr Z: 'u r,,,s aU F r.. .i
yM.' `° w , ...
r ' ...fi -x..,• 'f @'', ° •n5 t.." (r `s •
E ,t'.' v
Figure 2
SITE PLAN
N : YRC WORLDWIDE
4901 LISA MARIE COURT
BAKERSFIELD, CA
K:\ENV\YRC WORLDWIDE INC \SITE159448 \CAD\BAKERSFIELD\ FIGURES \59448BAKERFIELD VICINITY- FIGURE 2.DWG 7/13/2012 2:44 PM TDUCKER
c CONTRACTRSISTOATELIICmENSE BOARD
rtmn ACTIVE LICENSE
820320 INDIVTMRENVIRONMENTALTESTING
A HAz
0..06/30/2013 www.cslb.ca.gov
CERTHOLDER COPY
STATE
P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 05-29- 2012 GROUP: 000238
POLICY NUMBER: 0014854 -2011
CERTIFICATE ID: 5
CERTIFICATE EXPIRES: 03 -11 -2013
03-11- 2012/03 -11 -2013
NF
This is to certify that we have issued a valid Worker;' Compensation insurance policy in a form approved by theCaliforniaInsuranceCommissionertotheemployernamedbelowforthepolicyperiodindicated "
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
r t;l J- I:,; f ;,tlr. +U'f. ^i1.:a,01'1 l:i••t f;,.'1- This certificate of insurance is not an insurance policy and does not amend, extend or biter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other documentwithrespecttowhichthiscertificateofinsurancemaybeissuedortalwhichitmaypertain,'the- insurance
afforded by the policy described herein is subject to all the terms, exclusions; Nand'- conditions, of such policy.
Ctr•liFi' rt t• ,
Authorized Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW:
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 41,000,000 PER OCCURRENCE.
ENDORSEMENT 92570 ENTITLED 'WAIVER'OF'•SUBROGAT.ION IEFFECTIVE'2012-08 -29 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
LEIGHTON CONSULTING_ INC, INC r.,. •t ,. , Ht .,t.u, tti :ir, c + ;r...- N ,
f; . , , . , , .n , , .. , .
t;• 1 d: :l l - ;J —HN
i ... ,_ '1. . . a .._i.c -U ;i!' tt: /V1Y "IJ
1,
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p: =, .. ..lf'il,o- . -fc i. ... •'ii.. ., ,,,: a ,.'..
EMPLOYER
11 ,;,r! '' ' •. 1•s ;+N 7PrL'1 t., 1 ISU. =i £!nbt. i'1Y1 r.t
v
REX. TODD MICHAEL DBA: T M R ENVIRONMENTAL
TESTING :, c.n:t•1 t;1:r r;5i. G,,TE.: tt•C,t":,J.d:
PO BOX 941983
SIMI VALLEY CA 93094 ' 'r •-' %• n sa' :qli r.:::,a'ilcra f.FFIrC.1TYl i; t.
f•t11.!C.p. 1Fl:illl i I! °. r V,'P 1B1 B,NF1
REV.8.2010) PRINTED : 06-2972012
NF
OP ID: GC
CERTIFICATE OF LIABILITY INSURANCE A
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
06/1306/13/1122
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
MPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In Ileu of such endomeme s .
PRODUCER 7173 -7200MetroInsuranceServesic
Llc. #0695215 714-673-7202
17421 Irvine Blvd.
REACT
WL FAXAIC, No :
E-MAIL
Tustin„ CA 92780
GENERAL LIABILITY
PRODUCE
CUSTOM
Q2 ID s: COVEY -1
INSURER(S) AFFORDINGCOVERAGE NAIL I
INSURED Covey Engineering Inc INSURER A: Endurance American Specially
E 1,000,00
985 Kendall Drive
San Bernardino, CA 92407
ceMary Natkmal Lns Co. INSURER B ` 26905
INSURER C : Ie"I"aI Insurance Company
CCIOID07898 -03 08/08/12
INSuRERD:A Hartford Company
PREMISES Ea omcrence
OYSURER E
CLAIMS X OCCUR
INSURER F:
COVERAGES CERTIFICATE NUMRER- ocmaie%u urrsaoors.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRLTR TYPE INSURANCE POLICY NUMBER POLICY EFF
M
POUCY E PP
MM/DD LIMITS
GENERAL LIABILITY EACH OCCURRENCE E 1,000,00
COMMERCIAL GENERAL LIABILITY CCIOID07898 -03 08/08/12 08/08/13 PREMISES Ea omcrence i 50,0i)
CLAIMS X OCCURMADE MED EXP (Artyone person) 5,
X Pollution Liab. PERSONALSADV INJURY 1,000,
X Profeselortal Liab GENERALAGGREGATE 2,000,00
GENLAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 2,000,0
X POLICY PRO- LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB 1,000,00
ANY AUTO Ea acddent)
BODILY INJURY (Perperson) ALLOWNEDAUTOS
BODILY INJURY (Per accident) B X SCHEDULEDAUTOS BAP0167830 12131/11 12/31/12
PROPERTY DAMAGE
HIRED AUTOS Peraccident)
NON-OWNED AUTOS
UMBRELLA LWB HCLAIMS-MADE
OCCUR EACH OCCURRENCE
EXCESSLIAR
AGGREGATE
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS' LIABILITY YIN Y I T ERCANYPROPRIETOR/ PARTNER /EXECUTIVE 2WECEP4161 09/09/11 09/ 9/12 E.L EACH 1,000, OFFICER/MEMBEREXCLUDED? NIA ACCIDENT
E.L. DISEASE - EA EMPLOYE 1,000,0MandatoryInNH)
if yes, describe under
E.L. DISEASE - POLICY LIMIT 1,000,00DESCRIPTIONOFOPERATIONSbelow
Professional Llab. CC101007RU43 06/08H2 06108/13 Ea. OCc. 1,000PollutionLlab. CC10100789843 06/08/12 06/08/13 Ea.Occ. 1,000,00
DESCRIPTION OFOPERATIONS ILOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, ifmore space Is requhed)
PROOF -1
Proof of Coverage Only"
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
W 1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
SITE SPECIFIC
HEALTH & SAFETY PLAN
YRC Freight, Inc
4901 Lisa Marie Ct
Bakersfield, CA
CEI Inc has prepared this report, for the use on:
Project # 12 -182
Located at:
Report prepared by:
Under the primary use of general safety:
Project Manager:
Site Contractor:
YRC Freight, Inc
4901 Lisa Marie Ct
Bakersfield, CA
Health and Safety Coordinator
Scott Covey — Covey Engineering Inc
Todd Rex — TMR Environmental
TABLE OF CONTENTS
2
SECTION 1.0
1.0 INTRODUCTION:
1.2 PURPOSES AND SCOPE:
SECTION 2.0
2.1 SENIOR SAFETY OFFICER:
2.2 ON -SITE PROJECT SAFETY:
SECTION 3.0
3.1 EMERGENCIES:
SECTION 4.0
4.1 SITE CONTROL:
4.2 EMERGENCY RESPONSE PLANS:
4.2.1 ON -SITE EMERGENCIES:
4.2.2 ACCESS FOR EMERGENCY PERSONNEL AND VEHICLES:
4.2.3 LOCATION AND DIRECTIONS TO EMERGENCY CARE:
4.3 EMERGENCY TELEPHONE NUMBERS:
4.4 EMERGENCY CONTACT LIST:
SECTION 5.0
5.1 COVEY ENGINEERING, INC HEALTH & SAFETY PLAN, FIELD PERSONNEL RELEASE
FORM:
APPENDIX A Driving directions to the nearest urgent care.
APPENDIX B Police, Fire, Hospital, Ambulance Phone #s
APPENDIX C
APPENDIX D
SECTION 1.0
1.1 INTRODUCTION:
This Health and Safety Plan, prepared by COVEY ENGINEERING, INC describes the basic safety requirements for
performing work at:
4901 Lisa Marie Ct
Bakersfield, Ca
The scope of work for this project includes the'following:
Removal of One (1) 12,000 gallon underground diesel tank. No building or structures are in the
immediate vicinity of the under ground task (25' away).
A chain link fence that is locked during non - business hours to prohibit access from the public surrounds the
facilities.
The provisions herein will apply to the employees of TMR Environmental, Covey Engineering, Nieto & Sons
Trucking and any sub - contractors working at this site. The Sub - Contractors may elect to modify these provisions,
only to upgrade or increase the safety requirements, and only then with the approval of COVEY ENGINEERING,
INC Project Manager.
The Health & Safety plan addresses the potential hazards that may arise from performing the work and from
interaction with CEI, Sub - Contractors employees at this site and the emergency response community. In response to
changing conditions at this site CEI will modify the Health & Safety plan to meet the new requirements.
1.2 PURPOSE AND SCOPE
The Health and Safety Plan is intended to describe the minimum procedural and equipment requirements for the
protection of Covey Engineering Inc, TMR Environmental, Bums/McDonnell Engineering Company Inc, their
employee's, their Sub Contractors, and the facility staff who may be affected by the work requirements. Operating
conditions may be expected to change as the work progresses, requiring some modification to the plan, as
appropriate addenda will be provided by the CEI, and the designated project manager.
The plan is designed & intended to comply with established Covey Engineering, Inc, & YRC Freight policies and
procedures, and applicable State, Federal, and Local regulations. Therefore no changes to the plan will be authorized
without prior approval of the Project Manager. All CEI, TMR Environmental, & Nieto & Sons Trucking personnel,
Bums/McDonnell site visitors, and Sub - Contractor personnel are subject to this directive.
SECTION 2.0
2.1 PROJECT MANAGER
The Project Manager reports to Covey Engineering, and is responsible for on -site safety. His major responsibilitiesinclude:
Health surveillance of all employees, and sub contractors;
4
Assuring that safety procedures in effect are in compliance with appropriate federal, state, and
Local regulations.
Assuring appropriate personnel protective equipment is adequate for the actual hazards of on -site
conditions.
Coordination of health emergency plans with the local medical facilities;
Establishing and coordinating fit- testing for all respiratory protective devises to be used on -site;
Establishment of site - specific safety procedures for the problems that may be encountered on site.
2.2 ON -SITE PROJECT SAFETY
The Site Foreman, Todd Rex, is responsible for ensuring compliance with the safety procedures established for
the performance of the work. The Project Manager may modify work practices to meet safety requirements.
The Project Manager is responsible for the dissemination of the information contained in this plan to Nieto's,
TMR Environmental, Burns /McDonnell personnel assigned to the project, and to the responsible representative
of each Subcontractor firm working on the project. Site superintendant/Foreman shall be responsible for the
items listed below.
Safety Supplies and Equipment Inventory;
Personnel Protective Equipment;
Training programs/Hazard Communications;
Accident/Incident reporting procedures;
Decontamination and Contamination reduction procedures;
Monitoring air to ensure against over exposure to hazardous substances and to determine changes in
PPE and work practices;
Perform and document daily safety inspections and take corrective action(s).
The Project Manager has the authority to suspend work at any time he determines that provisions in the
plan or the application of the plan is not sufficient to ensure worker safety.
If the Project Manager is not on site, and in addition to the site responsibilities above, the job Foreman will
also be responsible for the following duties:
Monitoring the air against personnel overexposure to hazardous substances and to determine
changes in PPE and work practices:
Perform and document daily safety inspection and take corrective action(s).
SECTION 3.0
3.1 As appropriate, contacts will be established with emergency facilities and local agencies,.including local hospital
Facilities, Law enforcement agencies, local Fire Departments, and Ambulance services prior to starting work. Police
and Fire Department can be contacted by using the numbers in Appendix A
Directions to the nearest Hospital can be found in Appendix B.
SECTION 4.0
4.1 SITE CONTROL
Site control is necessary to protect the personnel of YRC Freight, TMR Environmental, Nieto & Sons Trucking and
Covey Engineering Inc., their subcontractors and the general public, and as a means ofreducing exposure to
contaminants and injuries.
The risk of exposure to hazards and injuries will be reduced or eliminated by the,use of the following methods
where appropriate:
Setting up security ofphysical barriers at the work -site; temp fencing will be utilized.
Minimizing the number of personnel and equipment on -site consistent with effective operations;
Establish work zones within the site;
Establish control points to regulate access to work zone;
Establish emergency evacuation routes and assembly area's;
The health and safety plan will be discussed at the beginning of each day, the job foreman will review it each day;
the Project Manager will review it each week. An emergency plan will be reviewed, along with routes to the nearest
emergency facilities. Tailgate meetings will be conducted on site at the beginning of each workday and will include
discussions of actions to be taken to minimize risks to on -site workers, visitors, and the public.
4.2.1 ON -SITE EMERGENCIES:
In the event of an accident resulting in physical injury, first aid will be administered and the worker will be
transported to the nearest hospital for emergency treatment. In the event of a chemical exposure or the potential of a
chemical exposure, site personnel should safely evacuate from the contaminated zone and meet at the designated
area. First aid should be administered as need at the assembly area and the exposed worker will be transported to the
nearest hospital for treatment.
In the event of an explosion, or property damage, all workers will evacuate to the assembly area, the client will benotified, and local authorities notified.
4.2.2 ACCESS OF EMERGENCY VEHICLES AND PERSONNEL:
Day -to -day operation will be conducted in a manner to allow access of emergency vehicles and personnel.
4.2.3 LOCATION AND DIRECTION OF EMERGENCY CARE:
SEE APPENDIX A
4.3 EMERGENCY TELEPHONE NUMBERS:
The following telephone numbers will be kept on site when work is in process.
Fire: SEE APPENDIX B
Police: SEE APPENDIX B
Hospital: SEE APPENDIX B
4.4 EMERGENCY CONTACT LIST
Key contact personnel: Steve Shinners (913)344 -3644
Client: YRC Freight
Site Project Manager: Scott Covey (951)522 -5110
Work -site Contractor: Todd Rex (805)218 -0360
5.0 SECTION: RELEASE
HEALTH AND SAFETY PLAN, FIELD PERSONNEL RELEASE FORM:
7
5.1 I have read and understand the health and safety plan for this Job @ YRC Freight, 4901 Lisa Marie Ct,
Bakersfield, CA
I do agree to follow this plan and to make every effort to keep this worksite safe. I will report any health or safety
hazards I observe to the site Superintendent. I do agree to defend, indemnify, and hold harmless TMR
Environmental, Covey Engineering, Nieto & Son's Trucking, Bums/McDonnell Inc, its owners, employee,
representatives, clients, and the property owner for any accidents, sickness, or injuries resulting from a violation of
the safe work practices included in this book.
Name: Title:
Signature: Date:
Name: Title:
Signature: Date:
Name: Title:
Signature: Date:
Name: Title:
Signature: Date:
Name: , Title:
Signature: Date:
Name: Title:
Signature: Date:
Name: Title:
Signature: Date:
Name: Title:
Signature: Date:
Name: Title:
Signature: Date:
Name: Title:
Date
8
APPEND X-A
D RECTRONS TO THE
Info pending
APPEND X-B
EMERGENCY
1101110
Approx. ETA: 5 Minutes
Approx. ETA: 5 Minutes
Approx. ETA: 5 MINUTES TRAVEL
ISuggest ]Fire Dept. for Rife threatening nnnpauries.
10
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INTERNATIONAL'
CODE CWNCIL :.
Candidatedate ID: XX4341015271
K Name: SCOTT COVEY Date: 7/1212011:::.
Address: 985 KENDALL• DR Birth Date:,. 7/4/1968
s STE A 151 -
SAN BERNARDINO CA 92407
EXAMINATION RESULT: PASS .
Congratulations! You have passed the above ' named examination. Your wallet card will be forwarded d ' you by ICC within six weeks from the last day of the month in whicfortwoyears. h you tested. This certificate is;current
You may request a wall certificate from CC as well. Throughout 201.1 this cerlificatenocosttoyou, "rf you request it within 90 days of your exam. Only ohe wall certrficate exam
atfwillbeprovidedtoyouatnocharge. For more information on requesting a wall certificate passmtwwiccsafeornsoector. , go to>''
It is extremely important that you notify Pearson VUE and 1CC of any changes in name and/or address toavoidthepossibilityof `- Y your wallet card and/or certificate not being received. Please contact PearsonwVUEat800 - 275 -8301 and 1CC at certexam ®iccG fe.Jxa with changes toKchangesmayrequireadditionaldocumentation). There may be an ddit!onalfee 9 a certi cation
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namere- issued due to a misspelled name or Incorrect address.
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Candidate ID:
Name:
Address:
XX4341015271
VTIC DOCUMENT WILL CHANGE COLOR FF1CM ORANCC TO'EL'_0 /
EXAMINATION RESULT: PASS
Congratulations! You have passed the above named examination. Yourwallet card will be forwa . d toYoubyICCwithinsixweeksfromthelastdayofthemonthinwhichyoutested. This certificate intent :..: fbr two years.
You may request a wall certificate from ICC as well. Throughout 2011, this certificate will be provided atnocosttoyou, if you request it within 90 days ofyour exam. Only one wall cert&'ke per exam passed" will be provided to you at no charge. For more information on requesting a
wi
alf certificate, go towww. iccsafe.orgfins pector.
It is extremely important that you notify Pearson VUE and ICC of any changes in name and/or address toavoidthepossibilityofyourwalletcardand /or certificate not being received. Please contact Pearson: VUE at 800 - 275 -8301 and ICC at certexam@iccsafe.org with changes to your r eme and address namechangesmayrequireadditionaldocumentation) * There may bean additional fee iF a certification isreissuedduetoamisspellednameorincorrectaddress.
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f' in?-"a' :_ ,,.,.T• '° L^iw.- .tsil}'r `' :':.C. vfirL'SJ.- -'`Y -_ T4 Vtl ": ; ,'•': " :. I•:i, : "I4HL "1;IIW.7NT YOU MUST TURN OVER A p VI 1:, 7 {;ki I'F: :1: °.' ^;: VIIF LI:IH) ;JI'H
UST Installation / Retrofitting
INTERNATIONAL
CODE COUNCIL
Candidate ID: XX4341015271
Name: SCOTT COVEY
Address: 985 KENDALL DR
STE-A .15'1
SAN BERNARDINO CA
AUTHENTIC DOCUMENT CHANGE COLOR FROM ORANGE TO YELLO'.7
EXAMINATION RESULT: PASS
Congratulations! You have passed the above named examination. Your wallet card will be forwarded to ' you by ICC within six weeks from the last day of the month in which you tested. This certificate is curfier t: for two years.
You may request a wall certificate from ICC as well. Throughout 2011, this certificate will be provided_..,al, `i: . no cost to you, if you request it within 90 days of your exam. Only one wall_ certificate per exam passedwillbeprovidedtoyouatnocharge. For more information on requesting a walE certificate, go towww.iccsafe.org/inspector.
It is extremely important that you notify Pearson VUE avid ICC of any changes.in name and/or address toavoidthepossibilityofyourwallet.c i
rd and/or certificate not being received. Please contact Pearson:.....:;. VUE at 800 - 275 -8301 and ICC at certexam @iccsafe.org with changes to your r% i'e and address (namechangesmayrequireadditionaldocumentation). There may be an additional •fae if a certification isre- issued due to a misspelled name or incorrect address.