HomeMy WebLinkAboutFMC 2012MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State ofCcdifbrnia
Authority Cited: Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofRegulations
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: #3366 Chevron - Fastrip #640
Site Address: 8001 White Lane
Facility Contact Person: Omero Garcia
Make/Model of Monitoring System: Veeder -Root TLS 350
B. Inventory of Equipment Tested /CertifiedChecktheappropriateboxestoindicatespecificequipmentinspected /serviced:
Bldg. No.:
City: Bakersfield Zip: 93309
Contact Phone No.: 661 - 393 -7000
Date ofTesting/Servicing: 7/16/2012
Tank ID: _12000 gal. Regular 1 Tank ID: 12000 gal. Regular 2
x] In -Tank Gauging Probe. Model: 847390 - 107 x] in -Tank Gauging Probe. Model: 847390 -107
x] Annular Space or Vault Probe. Model: 794390- 420 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: 794380 -208
x] Fill Sump Sensor(s) Model: 794380 -208 U Fill Sump Sensor(s). Model: 794380 -208
x I Mechanical Line Leak Detector. Model: FX1V x] Mechanical Line Leak Detector. Model: Syphon
Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model:
x] Tank Overfill / High Level Sensor. Model: 847390 -107 U Tank Overfill / High Leval Sensor. Model: 847390 -107
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: 12000 gal. Super Tank iD: 12000 gal. Diesel
x] In -Tank Gauging Probe. Model: 847390 -107 x] in -Tank Gauging Probe. Model: 847390 -107
x] Annular Space or Vault Sensor. Model: 794390 -420 x] Annular Space or Vault Sensor. Model: 794390 -420
x] Piping Sump / Trench Sensor(s). Model: 794380-208 L] Piping Sump / Trench Sensor(s). Model: 794380 -208
Lx] Fill Sump Sensors(s). Model: 794380-208 X] Fill Sump Sensor(s). Model: 794380 -208
n Mechanical Line Leak Decector. Model: FX1 V x] Mechanical Line Leak Detector. Model: FX1DV
Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model:
x] Tank Overfill / High Level Sensor. Model: 847390 -107 x] Tank Overfill / High Level Sensor. Model: 847390 -107
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 8, 4
Dispenser Containment Sensor(s). Model: 794380 -208 x] Dispenser Containment Sensor(s). Model: 794380 -208
x-1 Shear Valve(s). x] Shear Valve(s).
Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s)
Dispenser ID: 5 8, 6 Dispenser ID: 7& 8
x] Dispenser Containment Sensor(s). Model: 794380 -208 X] Dispenser Containment Sensor(s). Model: 794380 -208
x] Shear Valve(s). X] Shear Valve(s).
Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chain(s).
Dispenser ID: 98,10 Dispenser ID: 11 & 12
x] Dispenser Containment Sensor(s). Model: 794380 -208 x] Dispenser Containment Sensor(s). Model: 794380 -208
x] Shear Valve(s). x] 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 infonnation for every tank and dispenser at the facility.
C. Certification - 1 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 varify 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 al[ that apply) X System Set- u X Ala history report
Technician Name (print): Bradley Seykora Signature:
Certification No: 840738 License No: 80444--=__ 04 4
Testing Company Name: Confidence UST Services, Inc. Phone No: -800- 339 -9930
Site Address: 8001 White Lane , Bakersfield, CA 93309 Date of Testing/Servicing: 7/16/2012
D. Results of Testing /Servicing
Software Version Installed: 327.04
Complete the following checklist:
x] Yes No* Is the audible alarm operational?
x Yes No* Is the Visual alarm operational?
x Yes I I No* Were all sensors visually inspected, functionally tested, and confirmed operational?
x Yes 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 ifthe 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? [] Sump /Trench Sensors Dispenser Containment Sensors
Did you confirm positive shut -down due to leaks and sensor failure /disconnected? [x] Yes; No;
x] 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 visual and audible at
the tank fill point(s) and operating properly? If so, at what percent of tank capasity does the alarm
trigger? 9p %
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?
Product; Water. Ifyes, describe causes in Section E, below.
x N * 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 420 annular sensor on the 87 tank was replaced and the 208 sump sensor was replaced durring
testing, after installation of new components they were all tested and confirmed operational.
A small amount of water was removed from the diesel annular durring testing.
F. In -Tank Guaging / SIR Equipment: [x] 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:
Fxj Yes No* Has all input wiring been inspected for proper enter and termination, including testing for ground faults?
x Yes No* Were all tank guaging 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?
xj Yes No* Were all probes reinstalled properly?
Lx] 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.
the following checklist:
Lx] 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. I g.p.h.; 0.2 g.p.h.;
Lx =fYes No* Were all LLD's confirmed operational and accurate within regulatory requirments?
x Yes r7 No* Was the testing apparatus properly calibrated?
Yes No* For machanical LLD's, does the LLD restrict product flow if it detects a leak?
N/A
Yes No* For electronic LLD's, does the turbine automatically shut off ifthe LLD detects a leak?
x] N/A
Yes 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
X] N/A malfunction or fails a test?
Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected?
X] N/A
x Yes 10 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.
H. Comments:
ARCHIVE UTILIT`,'
SAiVE SETUP D(=T;;: - - - -
START T I l -IE :
JUL 16. =012 12:,;F:.. P1i
HRCHIvE UTILIT`,'
H.:E SETUP DHTr;:
END TIME:
JUL 1r.. 12:.48:31 F'I °IBYTE:'. 1 651
P'STP I F' 36c.
01'1 l WMJ E L4.1
BHh;ERSF 1 El C
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1LLFtC;E 15111 i;hLS
InIHTE_ ,, ` 1
318 1"ALSTC' 'Ji:LUP'IE l Ut'67 i- - HE.fi;HT y7,yU IfJ' HEti :.IATEP. +.1t,L = 1 1 HLSWATER _ IJ , H I I NICHESTEP'IF' 99.'2 DE,:; F
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InIHTE_ ,, ` 1 GCI I NC'HES
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1. DU I lq, -.AEC: TEPIP = A"' l DFG F
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f I' VIL1•1TORY ToTAI..
T 1:UNLEADED
T 3:IUNLEADED 2VOLUME2u ?61 GALSTC .I•:itlll "1E 211;3;)5 !:;ALS
END t
S +.,FTIJ;I RE RE' I :J 1 41.1 LEVEL
EP, : = ] >1•a 330 , u {
S4FTWHREri 346330 -IDO -B
CREATED - 10.07.23.17.25
S - FK_;DULEp 3:.0 1 ,il -I }q:1 -a
SYSTEM FEATURE=;:
PEP I CiD 1 C I Pl- THIVk: TE: rS
ANNUAL Ild- Ti-=,PIk: TESTS
I C :D
TEI I SETUP - - - - - -
JUL 16. 2012 12:38 PM
ti`ISTEH UNITS
2TEP1 LANGI A- EEN, L I S H
S'l:STEM DATE; T 11 °IE FUPh9AT
MON DD Y,IY`! HH :1'111:55 ,11
FASTR I P 366
800 1, 61H I TE LN
FYWEPSF I F.LD C;H
HIFT TIP1E 1 DIJABLED
ULHiELUL
I IJLL»I.;E= I 62 GALS
6yr,,2 i_`AL:STi" 1;t1L.UP'IE _ GALSHEIGHTEC84II;,_ HESW. iTER V ?-qI _ 1 aALWATER _ I .:31 I Pk "'HE:_; TEI"IF` _ F DL'S,' F
hIr- ',f•11F;LC ED '1'HP91:5
f I' VIL1•1TORY ToTAI..
T 1:UNLEADED
T 3:IUNLEADED 2VOLUME2u ?61 GALSTC .I•:itlll "1E 211;3;)5 !:;ALS
END t
S +.,FTIJ;I RE RE' I :J 1 41.1 LEVEL
EP, : = ] >1•a 330 , u {
S4FTWHREri 346330 -IDO -B
CREATED - 10.07.23.17.25
S - FK_;DULEp 3:.0 1 ,il -I }q:1 -a
SYSTEM FEATURE=;:
PEP I CiD 1 C I Pl- THIVk: TE: rS
ANNUAL Ild- Ti-=,PIk: TESTS
I C :D
TEI I SETUP - - - - - -
JUL 16. 2012 12:38 PM
ti`ISTEH UNITS
2TEP1 LANGI A- EEN, L I S H
S'l:STEM DATE; T 11 °IE FUPh9AT
MON DD Y,IY`! HH :1'111:55 ,11
FASTR I P 366
800 1, 61H I TE LN
FYWEPSF I F.LD C;H
HIFT TIP1E 1 DIJABLED
SHIFT T 1 PIE 2 D Pr6ABLED
SHIFT TIME 3 D1t3Al LED
SHIFT TIME 4 DISrBLED
TANr PER TST NEEDED WRI•.1
L,1 s,Agi_EI)
TANS ANN T:3T NEEDED WRN
D 12"1': D
LINE RE -El* IBLE I "IETHOD
PASS L 114E TEST
L 1 14F.. PER TST NEEDED WRN
DISABLED
LINE ANN TST NEEDED WRN
Dl_I',BLED
PRINT TC VOLUPIES
ENABLED
TEMP 1- :OPIPENS'AT10N
of LIJIF (DEC; F ) : 60.0
STICK HEIGHT oUsET
DISABLED
ULLA, E : 91-1%
H- PPOTOCOL DATA FORMATHEIGHT
DAYL I GHT SA, I NG T I I °IE
ENABLED
START DATE
MAR WEED: 2 SUN
START TIME
2:00 AI °I
END DATE
NOV 6.1EEY 1 SUN
END TIME
2: 00 Al -i
RE -D 1 RE!-;T Lt:!':AL PRINTOUTDISABLED
EURO PROTOCOL F'REF I:>' S
a , STEI'1 SECTIR 1 T`.
ODE 0000Uu
P'!A 1 NTEt•IAf1C'E H 1 STjik1'
DISABLED
Tr411: is HART SECURITYDI "BLED
U 'Tt:iPl ALARI'1S
D I ,3A8LED
SERV I CE NU "I I CE
D IS iBLED
ISO 3166 COUNTRY
COLE:
DENS I T`,'
DISABLED
N -IMUNI ATIONS :_ETUP
IN-TANK :ETUF'
PORT SETT I NG:; T 1 :UNLEADED
C l %I "11.1 BOARD : I( ED I I.1 i PRODUCT ixODE I
1 THERI ,-IAL COEFF 0007U0
Cc L : DISABLEDEDD T( N): D I AI1ETER 1 20 . 00
TANI'; F'RCJF 1 LE 1 P1'
r:COHP1 - FI ILL vc)i.. 1 2000
BAUD RATE : 9600
PAF.' 1 TY NONE FLOAT SIZE: 14.13 11.1. STOP BIT I STOP
DATA LENGTH: h DATA L,IATER I BARN l PJG5 -23'2 SEi;URIT`,' L))r:;H WATER 1-11-IM
0
CODE : DIS(iBLELi f
COMM BOARD 3 ! RS -2: 2 11A'-; OR LABEL VOL: 1 2000
BAUD RATE 9600 O1!ERFILL LIMIT 90%
PARITY NONE 10800
STOP BIT I STOF HIGH F'RODIh T
DATA LENGTH: is DATA DEL I VER`r` LIMIT
11400400
1 5 ":: RS -232 SECURITY 1800, CODL : DISABLED
LOW PR:iDUCT 500
AUTO TRANSMIT SETT I I'Ji LEAK ALARM L 1 I1 I I : 99
SUDDEN LOSS 1-11,11T: y9
AUT _i LEAK F;LAki °1 LIMIT TAI'iF; T I LT 0 . GO
D I2ABLEU PR.O> E OFFSET 0.1-.10
AUTO HIGH WATER LIMIT
DISABLED SIPHON W1AN 1 F0LDELi TA1, 1k:SAUTOOVERFILL1-11-11T T# : 02, L!ISABLED LINE 11I6I'41FOLDED TALCSmUTOLOWPRODUCTTO: Nl(hIEDI :c HBLFD
AUTO THEFT L I I °1 l T
D I SABLE!" LEA4Y 111N PER I C)D I i :: 1AUTODELIVER'! !TART 1 0D1SABLFfs
AUTO DELI VERY END LEAF' MIN I;NNUAL : IDI2tHRLFD 0AUTOEXTERNAL1NPUTC +N
D 1 2iARLED
AUTO EXTER1,01- 1 NPUT OFF F'ER' 1 iU l TE-T TYPEDISABLE[) STAI'IDAF.DAUTOSENSORFUELALARI °1
D I SABLED 101NUoL TEST FAILAUTOSENSORWATERALAPI1ALARMD122HBLEDDISABLED
F,,U "CO 13Efg2OR OUT t,LARI'1 PERIODIC' TEST FAILDISABLEDr= tiLARf1 DI 3r;BLED
Gk ;SS TENT FAIL
AL6R,fl CISABLED
ANN TEST AVERA, ; I Nk; OFF
PER TEST AVERAC." I NC; OFF
RS-232 ENE, OF P'1EF_S'AGE Ti UdY: TEST NOTIFY: OFF
DISABLE[' TNI' TtiT 51F'HON UREAY.:OFF
DEL]'WERY DELAY 1 1,1114
PI IMP THRESHOLD : 1 U . 00 %
PERIODIC: TEST T`(PE
STANDARD
ANNUi' l- TEST FA 1 L
ALAF.H DISABLED
PFKlI ? >Dli: TENT FAIL
ALARM DISABLED
ROSS TEST FAIL
ALARr1 D I `+µBLED
ANN TEST AVERAGING: NG: OFF
PER TEST ;;VERAG I NG : OFF
TANL: TEST 111T I FY : OFF
TNK TST SIPHON BREAI•::OFF
DELIVERY DELA''! I NI 1 1J
PU11P THRESHOLD I Cl. 00
PERIODIC TEST TYPE
STANDARD
ANNUAL TEST FAIL
ALARI °I D I SABLED
PERIODIC TEST FAIL
ALAR11 DISABLED
ROSS TENT FA 1 L
ALARI.1 DISABLED
Aldld TEST A'JERFtGlr1G: OFF
PER TEST AvERAG l ldc; : OFF
TANK TEST NOTIFY: OFF
TST SIPHON BRE0K. :OFF
DELI `,/ERY DELAY 1 1-111,1
PUMP THRESHOLD 10.00'15
PER 1 %1D l is TENT TYPE
STANDARD
ANNUAL TEST FAIL
ALHR.!'1 DIEW -BLED
F'F,RI.F IC TEST FAIL
ALARM DIE:aBLED
GROSS TEST FAIL
WAS r I SAEILED
Aldld TES: f : ;!EpHr;1 HG : OFF
PER TEST A',; ERAG 1 NG : OFF
TAId{:; TEST IWOT I FY : OFF
TAY: TST S'.IPHON BREA)::OFF
DEL I VERY DELAY I M 1 N
PUi °1F THRESHOLD 1 Cl . 00%
D I ESEL
T 2:UrJLEADEL L' PROCI_li.:T aODE a
PR.! >DUC:T ':'()CIE 2 T 3 : PREI"11 Ur'I THERMAL (.OEFF
THERMAL i ;OEFF : ,000700 PPOPU(:T C %)DE t TANY CjIF,METER 120.00
TAI'd}: D 1 =+METER 120. U0 THERMAL COEFF : , 000700 TANK PROFILE 1 PT
TAN}' PROFILE I PT TANK D 1 ANIF.TER 1 1110. 00 FULL VOL 12000
FULL Lr._ >I. 1 2001i TANK PROFILE 1 PT
FULL %11L 12000
FLOAT 212E:
FLOAT SI'E: 4.0 IN,
FLOAT S I ZE : 4.0 114. I•,JATEP M)PN I rU:: 2.0
WATER LIARNIN,; 2.0 m(,;H WATER LIMIT: 3.0
H1,;H WATER LIMIT: 3.0 13ATER WARNING 2.0
HIGH WATER LIMIT: 3.0 MAX OR LABEL 'Ji)L : 12000
t1m: i OR LriNEL tl %;L : 12000 ovFRF I Li. Lit-11T 90%
OVERF 1 LL L 1111 T 90% MAY OR LABEL VOL: 12000i 1 0800
10800 OVERF I LL L I M I T 90% HIGH PRODUCT 951.
HIGH PP ODUC'T 95 ". 10000 1 1400
1 1 4013 HIGH PRODUCT 95% DELIVERY LIMIT 15
DELI VERY LA M I T 15% 1 1 400 1 800
1 00ij DEL UO ERY L 1 NI I T 15%
1800 LOW PF)DLICT 500
L01,•I PRODUCT 500 LEAS. ALARM 1.1 PI I T : 99
LEAP. ALARM LIMIT: 99 LOld PRODUCT 500 ULiDE H LOSS LIMIT: 91i
SUDDFP LOS= LIMIT: 99 LEAs ALAR I1 M I T : 99 P U . 00
TANK TILT 0.00 SUDDEN LOSS LIMIT: 4 PROBE ; WFSET 0.00
PROBE OFFSET ii , 01j TANK T I LT 0.00
PROBE OFFSET 0.00
S:1PHON 11ANIFOLDED TA111 S
SIPHON MAN I FOLDED TANKS TO: NONE
TO: 01 1 PHOrI I"IAN I FOLDED TANK.; i LINE MAN I Fi >LDED TANKS
LINE VIANIFOLDED TANKS TV: WE Td: NONE
TO v NONE LINE NIAN I FoL LED TANKS:
TV: INNE
LEAK MIN PERMIT: I' %:
LEAK 1.11 N PER IOD W: It 120
120 LEAP: III N PER WD 1 C: 1 % <.•
120 LEol. 111I1 ANNUAL : I
LEAK MI H AI•JrdNAI. I % l =U
120 LEAF; MIN ANNUAL I
120
PERIODIC: TEST T`(PE
STANDARD
ANNUi' l- TEST FA 1 L
ALAF.H DISABLED
PFKlI ? >Dli: TENT FAIL
ALARM DISABLED
ROSS TEST FAIL
ALARr1 D I `+µBLED
ANN TEST AVERAGING: NG: OFF
PER TEST ;;VERAG I NG : OFF
TANL: TEST 111T I FY : OFF
TNK TST SIPHON BREAI•::OFF
DELIVERY DELA''! I NI 1 1J
PU11P THRESHOLD I Cl. 00
PERIODIC TEST TYPE
STANDARD
ANNUAL TEST FAIL
ALARI °I D I SABLED
PERIODIC TEST FAIL
ALAR11 DISABLED
ROSS TENT FA 1 L
ALARI.1 DISABLED
Aldld TEST A'JERFtGlr1G: OFF
PER TEST AvERAG l ldc; : OFF
TANK TEST NOTIFY: OFF
TST SIPHON BRE0K. :OFF
DELI `,/ERY DELAY 1 1-111,1
PUMP THRESHOLD 10.00'15
PER 1 %1D l is TENT TYPE
STANDARD
ANNUAL TEST FAIL
ALHR.!'1 DIEW -BLED
F'F,RI.F IC TEST FAIL
ALARM DIE:aBLED
GROSS TEST FAIL
WAS r I SAEILED
Aldld TES: f : ;!EpHr;1 HG : OFF
PER TEST A',; ERAG 1 NG : OFF
TAId{:; TEST IWOT I FY : OFF
TAY: TST S'.IPHON BREA)::OFF
DEL I VERY DELAY I M 1 N
PUi °1F THRESHOLD 1 Cl . 00%
I. I u : D:3L ANt•J
TP 1 r:'l'H "I'F c I NGLF FLOAT >
C:ATEGOR`" ANNULAR SPACE OUTPUT RELAY SETUP
LEAK. TEST HETHOD - - - - - - - - - - - -
TEST ON DATE : ALL TANS
Wl. 2:3. '2,010
START TIME : DISABLED
TEST RATE :0.20 GAL:HR
DURAT I I >N . _ HOURS
TST EAP.LY STOP:DISABLED
LEAK. TEST REPORT FORMAT
1'JORI ^IAL
Lit - W I D SEI,ISC;R SETUP
L i : UNL AKIN
TRI - STAATE (SINGLE FLOAT
r!ATE, R`r' : ANNULAR SPACE
L : UIdL F 1 LL
TR I -STATE i S [ IJ<:;LE FLOAT ;
CATEGORY : PIP 1 11C; SUI°IF'
L 3: UI,JL STP
TRI -STATE (SINGLE FLOAT)
C:ATEGORi . STP SUMP
L 4:UNL 2 ANN
TRI -STATE c. S I PN_:LE FLOAT 1
GNTEGOR'/ : ANNULAR 'PACE
L 5:UNL1, 2 FILL
TR I - .°_TATE (S [ I'J!.,LE FLOAT)
CATEGU ..1' : P I P I NC; SUMP
L 6:UNL 2 STP
TRI -STATE (SIPN'LE FLOAT;
STY' SUP1P
L 7 : PRENI ANN
TRI -STATE (S I NC;L.E FLOAT
t _'ATEGOR'•,' : ANNULAR SPACE
L S:PREM FILL
T' I - _:,'ATE (SINGLE FLOAT)
CPTEGC;RY : P I P l 1•JG SUMP
L 9 : PREI °I STP
TRI -STATE (S l PN". LE FLONT
i`.ATE,'OR`f . S "CF' SUP•IP
LI1 :DSL FILL.
TR 1 -STATE (S I NG11 FD. AT
i:ATEGOR`,' : P I P I Ni; :;UVIP
L I : DSL STP
TRI -- :;TATE {:11hJGLE FLOAT)
C'ATEC;OR'l : STP SUMP
Ll3:Dl:'P ! -2
TRI -STATE (SIhJC;1.[: FLOAT:')
r= :ATEGURI` : D I SPEN:_;FR PH' N
L.14:DISF 3 4
TRI -STATE (S14N1_E FLOAT,
i'ATEC :C;R ',' : DISPENSER PAN
L15:CifSF' S -6
TRI -STATE iS'INGLE FLi;AT)
i'iTEGUR`,' : DISPENSER PAN
1_16:DISP 7 -8
TRI -STATE (.SINGLE FLOAT;
C'F TEGC;R'r : DISPENSER PW%!
1_17:DI2P
TRI -STATE c ]IJ_LE FLOAT>
ATEGUR`r' DI';3PENSER. PAN
LIS:DISP 11 -12
TRI -STATE t S I hJ;LE FLOAT)
ATEiv' RY : D [ SF'EIJSER PAID
R 1tSHUTDOWN
TYPE:
STANDARD
LJORNIALL`! C:LJ: ED
TANY' P: I
L I OU I D SEIJSOR HLI9S
L 3:FUEL F',LARI'1
L b:FUEL ALro-i
L 9:FUEL 6LARI1
L12:FUEL ALARM
L13:FUEL ALARM
L 1 ,I : FUEL riLARI °1
L 15 : FUEL ALARI°l
L 1 6 :FUEL F',LARt9
L 1 '7 : FUEL ALARM
L 1 8 : FUEL ALARI -1
L 3 :SENSOR OUT ALAP.I °I
L 6:SENS0R OUT HL.ARM
L 9:SENSOP OUT ALAPltl
1_12:SENSOR C;U'C ALARM
L13:SEP1S(;R C)U7 ALARll
L14:SENS, >R OiI'I HLAPH
L15:SENsOR OUT ALARII
L16:8ENSOR OUT ALARM
L 1 7 : S'Ed;3C >R OUT AI.ARI -I
L18:SENL3)P ULI'I ALARh9
L 3:SHC'RT ALARL•I
L 6:SH6RT ALARI'l
L 9:SHOPT ALARM
LI'2'SHORT ALARM
L 13: S HORT ALARM
L 1 4 : SHORT Al: ARI'I
L 1 5 :2HORT ALARI -I
L16:SHOW ALARM
L17:SHORT ALARI1
L18:SHORT ALARI-1
I SD S 1 TE ALARMS
I S'D GROS : PRES FAIL
1 SCi DEGRD PRES• FAIL
IS[) VAPOR LEAIC FAIL
ISD VP PRES FAIL
1 SD `• ?P STATUS FAIL
I SD HOSE AI .ARMS
ALL:GRO_S Ca011ECT FAIL
ALL:DEGR(i COLLECT FAIL
ALL : F•LObJ C'OLLEC T FAIL
R _' : U \1EkF I LI_ ALARM °1
T ;'PE :
STANDARD
NORI'IALL',' OPFN
I'AI'Jk: V: NONE
IN TANI{ ALARMS
ALL : i.'NFRF I LL ALARM
ALL : H I iH PRC;DU;:T ALAC.I °I
ALL. :I9A} PRCSDUC'T ALAF.'I "1
fl, J• I PI L rz 111HL HLiAhll
TYPE:
1-101"IE I-,JTAPY
Nt'-oRMHLLI, ,lPEI,I
11-4-TAI'4Y. HLmRI-I.S
ALL:LEAE ALARM
ALL:HIGH WATER Hl-t--,Rrl
ALL:ONiERFILL ALARI-I
ALL :LOW PPODIX;T
ALL :syDnEN LOSS N-AR11•1
ALL:HIGH PRODUCT ALARM
ALL:IM)ALID FUEL LEVEL
ALITROBE OUT
ALL:HIGH WATER WARNING
imIL:1ELIVERY NEEDED
ALLJ,lA:,--'. PRODIJ-',T AL(4.11,1
HLL:GROSS TEST FAIL
ALL TER IODIU TEST FAIL
ALL:ANNUAL TEST FAIL
KILTER TAT NEEDED WRN
ALW ANN TST NEEDED WRN
KILMER TST NEEDED ALM
ALL:hNll TST NEEDED FALf-I
ALL:Thhl: TE:;T ACTIVE
ALL :NO C:2LD IDLE TIME
ALL :Ts4IlJY 'SIPHON BRIEN:
ALL:LOW TEMP WARNING
LICJJID SENSOR ALMS
ALI..:FUEL ALARM
ALL :GENcD,GR OUT ALARM
ALL:SHORT ALARM
KIL:SETUP DATA WARNING
mLLNEWOR FAULT 4AWI
ALL;FUEL. WARNINC;
ALLTUEL ALAR-I
N..I.:I,If4TER WAR1•1 NG
ALL:WATER. ALARM
ALL:1-1113H LIQUID LImPHING
ALL:HIGH LIQUID mLARIl
ALL:L%l LIQUID WARNIM3
12D ID'I*I'E t)LARmS
I SD iTmGE I WARN
ISD GROSS PRES WARE)
ISD GROSS PRE2, FA I L
ISD DEGRD PRES I.-JARN
I SD DEGRD PRE Fti I L
I S@ %)AFIOKI LENT I,IARt--1
ISD VAPOR LENT FAIL
ISD VP PRES WARN
ISD VP PRES FAIL
ISE, VP STATUS WARN
ISD VP STATUS FAIL
MISSII*-I(; RELAY SETUP
11116SINt, HOSE SETUP
MISSING TANIT SETUP
MISS VAPOR FLOIJ I-ITR
1•15E'- VAPOR PRES REN
111S`61111.4 VP INPUT
ISE, SETUP W.Rtl
ISD SETUP FAIL
ISD SENSOR CCT WARN
ISD SENSOR OUT FAIT
c3111ARTSENSOR SETUP
CPS I I - 12
ATEGORY './APOR PRESSURE
2: Fil I -2
CATER AIR FLOW tlETEP
3:FI'I 3--4
AIR FLOW I-ETFR
4:FM 5-6
TEG-,)R`,` AIR FLOW METER
5:F11 7-9
CATE,jORY ;-ilR FLOW PIETER
5 6:Ftl 9-ill
CATEC,()R',,' AIR FLOLI METER
5 7: I'll I I - 12
CATEi OPV HIR FLOW I"IETER
EVR 122 SETUP
EVR TYPE : \)H(--:UUI"I
v;FA(-:UUM ASSIST TYPE
HEAL l kfAC;
NOZZLE A F.,At-•IC;E
mP(')R PRO(:;ES-SOR T',PE
NONE
HI-,IALvSIS TII,-IElD
TINE: 9'C16 At"I
DELAY PI I NUTES: I
ACCEPT HIGH OEM:
D I E;ABLED
ISD HOSE TABLE
2 9504
ID FP FL HL AA RR
ol ol ol 02 01 01
02 02 02 02 01 01
03 0:3 03 02 02 01
04 04 04 02 n2 III
05 05 05 02 03 01
oe 06 06 02 03 01
iD7 07 07 1'12 0-1 01
00 08 08 02 04 01
rIq o-) o,,j 02 05 01
io 10 10 02 05 01
ii ii 11 02 06 01
12 12 12 02 06 1-11
ISD W RFLO14 PETER MAP
ID NI 11 °1 LnBEI-
1 9519 FM I-':'
2 9504 FM 3-1
3 8637 Fil 5-6
1 8593 FM 7-P
5 8613 FM 9-10
6 8594 FM 11.12
1p,D FUEL GRADE HOSE MAP
1 2 0 4
FP MHH I''IHH MHH MHH AA
Fj 1 2111 3111 901 5 U 1
02 202 302 902 5 U I
oa 203 303 903 It U
04 204 3C14 904 il U 2
05 205 305 905 U U 3
le, 206 306 qiDE U U 3
1-1? 207 307 907 U U 'I
Ci8 2110 311-D 906 U U 4
09 209 30? 9119 I J 0 5
10 210 310 91 Cl U 11 5
11 211 311 911 5 LJ
12 212 312 912 5 IJ
LABEL TABLE
1: UHASS I GNED
2: BLEf4D3
3; PEGMAR
4: MID GRADE
5: PREM I UPI
GOLD
BRONZF
a: OINER
9: BLEND_
1 o; BLD04
Flli. SETUP
Ftlf': VER.' "--L Rll HI'S7ORY REPORT
VAP-CA PR4(--:ESS0P TYPE -0,11,0R AbARl,l
NC) P-JE L 3;UPIL, STP
STP SUP-IF,
PFOCE'SSOR (-:0111TROL LEVEL: SENSOR OUT ALARil
JUL 21 - 20 1 1 12:58 F-P'I
SENSOR C)UT ALARM
JUL 21, 2011 1'2:51 F'I"I
FUEL ALARM
JUL 21. 201 1 122:26 Fl"I
Lt4Rf9 HIQTOR,' REPORT
SE Ill'iCiR tiLARI -1
L I :UPIL ANN
WINULAP SF Ai E
SENSOR OUT ALARH
JUL 21 2011 2:O0 PM END
FUEL. ALARri
JUL '21 '201 1 1 : 58 F'19
SEM:;CJR OUT ALNRt,l
JUL 21 2011 12:58 pP-I
HISTOPY REPORT
SEpjSOP ALARI'l - - - --
L 4: UNL 2 ;44111
END iAPjNUL(AR SF'A(-:E
SEPI'SQRc pCUT ;-il-6RIII
JUL 211 2011 2: 1 1 FT'I
SENSOR CUT AD)RIA
JUL 21 '2011 12 :58 F11"I
SENSOR CIUT ol-ARI'l
JUL 21 2011 12:51 PI-I
ALARM HIS-TOPY PEP,DRT
L 2:UNL FILL
P I P I PIG' sUriP
EHSOR OUT AliiRll
JUL '2011 12:58 F111
SENS70P UT AL; Rll
JUL 21 2011 p-I
FUEL ALH-RH
JUL 211 • *---,Gl 1 prf
END -. .. * ;k
L(431 HISTORI', REPCIRT
L 5 :UNLD 2 FILL
P I P I I.-K; Si i[liv,
FUEL ALHRH
111• '1-9- 2012 9:44 r'-'111
FUEL ALAPll
JLI N '29• :='01'2 9;40 011
OUT HLI-&-1
1111,4 '19. 2012 9:38 t'illI
x EPID : 'w
EITS(R o4.f4.111 - - - --
L h : 1,11AL 2 !;TF'
STP SUMP
SEPJSOP OUT o4l-HPH
JUL :'1 2f-I I I 12:58 I'M
OUT HLAPH
JUL 21 2011 12:51 PI-I
FUEL A'L,"Pll
JUI- '21 , 2-101 1 1'2:='7 PI-I
Li4RM H1STC)R'-,,' REP-CIRT (-iL(*,Rll H [.ST,,)P'" PEPOPT f4l_;;Pr9 111 'TORY
HI•MUDiR SF"CE
BEN'S( ')P OUT AL, iRM
JUL 21-Al i 12:16 f,f•l
FUEL ALAW,j
JUL [Dl 1 12;17 PH
SEN-SOP :)UT ALAR.1
JUL 22- 21-11 1 12: 12' PH
i 4 . • END - * - - .
ALAR'll HISTORY PEYoPT
L 6!PREI'l FILL
MAN sump
EN. OR OUT i-iLAW-1
JUL 21 . 2,ci j 1 12,:S8 Pm
SE1,60F., OUT ALAPrl
JUL 2 1
FUEL ALAFRi
JUL 211, 2011 12:46 P11
L PPEH .8TP
sn! SUPIP
FUEL ALARr-l
JUL 21 - 2011 12: 2 j Pl"!
FUEL ALmRM
JUL 21 , 2011 1.-';28 Pl'
END
i-iLARM HISTDPY REPORT
SEI-4:3,DR
Llu:D2L ANN
ANNULAR SPACE
FUEL ALARH
JUL 16. '2012 10:02 Afl
SERSOP OUT ALAR;")
JUL 22, 2M[ 1204 PH
FUEL Hi AM
JUL 21, 2011 12:42 PH
F I Ll
p I N M3 Saw
FUEL Lrikf,l
J IJI'l _9. '01 _ 8: 12
FUEL ALHRH
JUL 21 • 201 l 12:47 P11
FUEL HD4-.f'l
UD: le. 2010 1 129 pal
END * *
f4LHRN HISTOP'i PEPORT
LA 2 ON. Sn'
STP Slil•'IF*
FUEL f-il-AR'll
jtjj,j 3. 2012 9:57 Ml
FUEL iib k11
ItIC,'Al 17. '2101 1 1-2:31 PH
FlJF.L HD4JI
7:11 PH
t ENDEMC,
1-2,
Pl:;PEN :EP PAN
FLIEL
JUL :'1 - 20 1 1 1
END 4, * ;i - *
ALHPll HiSTORY REPiDIRT
SENSC.p ALARII
L 1 4 : D ',' 4
PAN
FUEL ALARI-I
JUL 21 • Gill I Pil
END i
AI-HFI,l H12'.T )RI; REPORT
FUEL.
JUL 21. ",,Of! Pm
ALHRIVI HISTORY REP`;F'T
THSOF ALARII -----
L I El I P 7-8
Dl'SF'EIIJ;JE? P;-,01
FUEL ALAKTI -
JUL 21 - '201 1 FT,l
t ENII
iLA-Rll REPORT
SENSOR ALARIII
Ll ,:pisr, 4 -10
SE NS( KIT ALARH
JUL '21 2Ci 1 1 12, : SO, PH
El* ) GUT ALHRII
UL "1 • 2'0 ) 1 12;51 F-1.1
I"UEL " "L`Mln
JLIL "'.') . 201 I 112::_)h P11
A .. - I.: r END . .
r :-,LA'Rll H12,TOR' REPAT
cl'EviS;llR -
DISPENSER P""I'l
sENSOP OUT HLt4PH
JUL 21 • 21DI I 1,2:5R P1.1
L"EvISOR OuT iiL`Rl"
fit[-. 21, 201 1 12:52 PN
FUEL klARH
t - , • . END
JIJI II_.. !'I it I III
I I,tH I I L L.N
I N V L I L1:1=:: P
JI.Q.. 16- 2-01:!, Pr
I H -T- [!I): iLr;Pl I
T UNLEm"U,
S:+ FH
JUL. It;. CI I 1 .1.11 F1 'I
1-11 ` I 5:'i N-I
IN-T,i,H). AI -,;
T I :I-1r4LE-r.,FD
A-TRF ILL. ib-,E11
JUL 14•- --CI'2 12:r1 - 111
flit ica. T. K"TE ,,-(JT
j 1,11 I r. . ;'III- I
I vj r, , i,i) I , F-J -I
IA &.11
JUL 16-
T I : 11 1 U-1 F.I.
LI I I Ul
D-- rVP
ITHP ci::: Hj,
I EHD
I I IL I -'(I 12- 1 .--': `
17
iE 16 11' 1 1
T( -.
T PIE-LL
T I : L- I ESEL
11TAMM IWFI'T.A.: E
I A Rb
IMINGISE EVIL
HE I,'; HT
TIC'
L ;"'IT
STP SUI Ir-
FLILL
ji'll. ;r.. PI -I
1. h
FULL i;L-411
lr- 1 :1-10 Pill
L
Sul Sol,
FULL. r-,LAPI-I
1111 It.. *-.0 ?I:-, i :111 1'1' 1
LOWN. STY,
J1.11 k:- I
L 1 t:-4' I I - I
A DEEP 1"11)
FI. i-d.iApl'l
I 1 -2
prNEWR FAI•
FUR. r;LART1
AIL 16- 201'- 1 :O1 i F11
HNHIJL;R SINCE
FUEL ALARI-,i
1r'- --CII:; i :I-*[..'I
FILL.
FUEL ALARH
L 15 1 ;S'l- JOL. 16, 201'
bl-'-'FFHSER
FUEL ALAR1
J L' L I C - 2'0I :-,, 1 :0-4 111
L d : OHL W-N
7-F,
CHEI. AL;,Pi-i
J11L. It- '201:`,
SEME., -- -
L P; :,- P-4 - t Ci
F-11FIL
JUL th.
L KPAM MIHI
JUL IL•• -101,
IMINGISE EVIL
HE I,'; HT
TIC'
L ;"'IT
STP SUI Ir-
FLILL
ji'll. ;r.. PI -I
1. h
FULL i;L-411
lr- 1 :1-10 Pill
L
Sul Sol,
FULL. r-,LAPI-I
1111 It.. *-.0 ?I:-, i :111 1'1' 1
LOWN. STY,
J1.11 k:- I
L 1 t:-4' I I - I
A DEEP 1"11)
FI. i-d.iApl'l
I 1 -2
prNEWR FAI•
FUR. r;LART1
AIL 16- 201'- 1 :O1 i F11
HNHIJL;R SINCE
FUEL ALARI-,i
1r'- --CII:; i :I-*[..'I
FILL.
FUEL ALARH
L 15 1 ;S'l- JOL. 16, 201'
bl-'-'FFHSER
FUEL ALAR1
J L' L I C - 2'0I :-,, 1 :0-4 111
L d : OHL W-N
7-F,
CHEI. AL;,Pi-i
J11L. It- '201:`,
SEME., -- -
L P; :,- P-4 - t Ci
F-11FIL
JUL th.
L KPAM MIHI
JUL IL•• -101,
L. 9 Mal So-
M. Sul%-
FUM. Phaki
JUL. 16.
HOW !J1
JLI 1- 1 c. '-,( I I .' z : 1.10 PI-i
L
SEMP ALM
L ;`:PRFII Al-Irl
Suwon Q"RI*l
Ll',--J;C0BF 11-0
sysoy our mwyi
JUL 15, 2:11 fl-I
I I :11;-il FILL.
in IN no su if
Mil I _: +:,1'? z: I I I-m
In-
DWI WER syl-I
OUT r41.P;Rf1
JUL 16. 2101' I ] P[•I
ME& SUCH
Iji,2 2:11 PH
I,.-
1JUAGL Ml
PXIM LAW SHOE
FLJ• MIAMI spogy our ympi
J II )r:- 2t)I..., ::?: 04 Pq J 0L I b- :.':01 ' 2: 1 1
L I :LINI, i`,hN
IF. ()LIT
Ii PV,
F ` Jt---:'P.
L 2:mf. FIM
L 16 1 M 14 0
I]. I I-. • '2 0 '2: 1 1 v i. I
OEOmk OUT mK51-1
jiji, Z:11
L 0: MO. STP PAPI-or qu.
STP •U I 000i WITE U%;
SEWOR OUT A"•ll
JJI. 16. 200OR our RAO I
JUL 16. 201-' 2:'-,-r.- PI-I
At L H(J-31,1-
01 JT.I
L 5:1-11ILD FiLl.
21:11,.;, F UEL KMA-1
I) , -,: -1 -* 11-11 1", , .J- -, - PII
L FILL
PIr-IIj,:4 '21-11-IF
FUM. ALAT-I
SENSOR ALYNI
L C-:IJHL 'STF,
s P smll-,- 8001 IMITR W
t VW ;OP
JUL 16. I PH
I - I I ; 1,r; L Y I L L
FAA 40 SMIP
FUH, ALARM
jLIL It. ;III •' <': i,--j F-1.1
1. 8 3101 F H,.L
PHIND swir,
J1.1 16. 2nj_ 2 : I '' PH
L V:PP-F.II
N( Hh-I1.i-1P
3LN2 F: (,UT F-,LAP H
11A 1 t-- -.012 z: I_,
JUL 16. .3 : Oli P1°1
1 2 FILL
P, I P I H,-, SI-li-)P
FUEL
I 1 1-* 1 N6,
U'r
JUI. 1c - P1. I SERAT OUT HIARI-1
J11L. If- : GI2 2:4iu 1-1
L FILL
PIr-IIj,:4 '21-11-IF
FUM. ALAT-I
SENSOR ALYNI
L C-:IJHL 'STF,
s P smll-,- 8001 IMITR W
t VW ;OP
JUL 16. I PH
I - I I ; 1,r; L Y I L L
FAA 40 SMIP
FUH, ALARM
jLIL It. ;III •' <': i,--j F-1.1
1. 8 3101 F H,.L
PHIND swir,
J1.1 16. 2nj_ 2 : I '' PH
L V:PP-F.II
N( Hh-I1.i-1P
3LN2 F: (,UT F-,LAP H
11A 1 t-- -.012 z: I_,
JUL 16. .3 : Oli P1°1
SWRCB, January 2006
Spill Bucket Testing Report Form
Thisform is intendedfor use by contractors performing annual testing of UST spill containment structures. The completed, form and
printoutsfrom tests (ifapplicable), should be provided to the facility owner /operator.for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: #3366 Chevron I Date of Testing: 7/16/2012
Facility Address: 8001 White Lane, Bakersfield, CA 93309
Facility Contact: Omero Garcia I Phone: 661 - 393 -7000
Date Local Agency Was Notified ofTesting: 6/19/2012
Name of Local Agency Inspector (Jpresent during testing): Ernie Medina
2.' TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Bradley Seykora
Credentials: X CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Specify)
License Number(s): CSLB #804904 ICC #811123 1 -UT
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.)
l Regular #1 2 Regular #2 3 Super 4 Diesel
Bucket Installation Type: Direct Bury
x Contained in Sump
Direct Bury
x Contained in Sump
Direct Bury
x Contained in Sump
Direct Bury
x Contained in Sum
Bucket Diameter: 12.00" 12.00" 12.00" 12.00"
Bucket Depth: 14.00" 15.25" 15.00" 13.75"
Wait time between applying
vacuum /water and start of test:
5 min. 5 min. 5 min. 5 min.
Test Start Time (Ti): 12:15pm 12:15pm 12:15pm 12:15pm
Initial Reading (Rj): 10.50" 11.25" 11.25" 10.75"
Test End Time (TF): 1:15pm 1:15pm 1:15pm 1:15pm
Final Reading (RF): 10.50" 11.25" 11.25" 10.75"
Test Duration (TI: — Ti): 1 hour 1 hour 1 hour 1 hour
Change in Reading (RF- R1): 0.00" 0.00" 0.00" 0.00"
Pass /Fail Threshold or
Criteria:
0.0625" 0.0625" 0.0625" 0.0625"
TestResultt X Pass Fail X Pass Fail X Pass Fail X Pass Fail
Comments — (include information on repairs made prior to testing, and recommendedfollo", -up forfailed 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: 7/16/2012
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
3366 Chevron (West)
8001 White Lane
Bakersfield, CA 93309
3
1= Veeder Root TLS 350
2= External Overfill Alarm
3= Emergency Shut Off Switch
4= Veeder Root 208 Sump Sensor
5= Veeder Root 420 Annular Sensor
6= Red Jacket FX1 V LLD
7= Red Jacket FX1 DV LLD
8= Veeder Root ATG Probe
9= Regular 1 Siphon STP Sump
10= Regular 2 Master STP Sump
11= Super STP Sump
12= Diesel STP Sump
13= Regular 1 Fill Sump
14= Regular.2 Fill Sump
15= Super Fill Sump
16= Diesel Fill Sump
2 1
12 11
4,7,8,12 '
4 4,16
10 9 4,6,8,15 `5` 000415
4 3
4 4
4,6,10 5 0 004,8,14
8 7 6 5
4,6,9 00
4 4,8,13 4
tOpF
Ijjl'jjI s ir( N V j Job Order / Invoice # z 7 3 7
Toll Free q: 1 -800- 339 -9930 Date Call Made Time To Whom Station Control Number Repair Date Invoice Date
U
Name Confidence UST Services, Inc.
F
M
Site Name: 33 ®j
Street 16250 Meacham Road Street L N
City Bakersfield,Ca 93314 City i StatEV Zip _7_7
Terms Store Number: 3
Description of work performed:
k s - J
f 0
Total Amount
Invoice A + B + C
Labor
Date Name /Number Class Hours y
Rate AmountArrivedDepartedLaborTravelTotal/
Rate
a.
Sub Total
AM
PM
A
PM r P Z!9-
Tax ( If applicable)
AM
PM
AM
PM
Total B
May we please have your comments regarding service / equipment provided by the above named contractor:
Store Elp y rinte
AM
PM
AM
PM
t ate Approved By Date
c 7 l
Contractor Supplied - Materials - Rentals Amount Sub -Total
Quantity
Total A Labor
Yeelk — A- Total B Material
Total C Mileage
Total Amount
Invoice A + B + C
Accounting Breakdown
Mileage
Miles Rate Total Sub Total
Handling %
Tax ( If applicable)
Total C Total B
May we please have your comments regarding service / equipment provided by the above named contractor:
Store Elp y rinte
Store Emplo ' Si re I t ate Approved By Date
ITS isas'c{,M"