The URL can be used to link to this page

Home My WebLink About2014 RESULTSMONITORING 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 Lank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: California Chevron Bldg. No.: ----- Site Address: 4100 California Ave City: Bakersfield Zip: 93309 ------ Facility Contact Person: --=S:.:a:..:.m::..:.-=J-=o-=u-=d-=a _____________ Contact Phone No.: (661) 333-0000 Make/Model of Monitoring System: _V_e_e_d_e_r-_R_o_o_t_T_L_S_3_5_0 _________ Date ofTesting/Servicing: 2/20/2014 B. Inventory of Equipment Tested/Certified c heck the appropriate boxes to indicate specific eQuipment inspected/serviced: Tank ID: 10,000 Gal Regular North Tank JD: 10,000 Gal Regular South t8J In-Tank Gauging Probe. Model: 847390-107 t8J In-Tank Gauging Probe. Model: 847390-107 t8J Annular Space or Vault Sensor. Model: 749390-407 t8J Annular Space or Vault Sensor. Model: Ronan t8J Piping Sump I Trench Sensor(s). Model: 794380-420 t8J Piping Sump I Trench Sensor(s). Model: Ronan t8J Fill Sump Sensor(s). Model: Ronan t8J Fill Sump Sensor(s). Model: Ronan t8l Mechanical Line Leak Detector. Model: FX1V t8J Mechanical Line Leak Detector. Model: FX1V 0 Electronic Line Leak Detector. Model: N/A 0 Electronic Line Leak Detector. Model: N/A t8J Tank Overfill/ High-Level Sensor. Model: OPW-61-SO t8J Tank Overfill/ High-Level Sensor. Model: OPW-61-SO 0 Other (specify equipment type and model in Section Eon Page 2). 0 Other (specify equipment type and model in Section Eon Page 2). Tank ID: 10,000 Gal Regular-Si~hon Tank JD: 10,000 Gal Su~er t8J In-Tank Gauging Probe. Model: 847390-107 t8J In-Tank Gauging Probe. Model: 847390-107 t8J Annular Space or Vault Sensor. Model: 749390-407 t8J Annular Space or Vault Sensor. Model: 749390-407 t8J Piping Sump I Trench Sensor(s). Model: 794380-420 t8J Piping Sump I Trench Sensor(s). Model: Ronan t8J Fill Sump Scnsor(s). Model: 794380-208 t8J Fill Sump Sensor(s). Model: Ronan 0 Mechanical Line Leak Detector. Model: N/A t8J Mechanical Line Leak Detector. Model: FX1v 0 Electronic Line Leak Detector. Model: N/A 0 Electronic Line Leak Detector. Model: N/A t8J Tank Overfill I High-Level Sensor. Model: OPW-61-SO t8J Tank Overfill I High-Level Sensor. Model: OPW-61-SO 0 Other (specifY equipment type and model in Section Eon Page 2). 0 Other (specifY equipment type and model in Section Eon Page 2). Dispenser ID: 1&2 Dispenser ID: 3&4 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: t8J Shear Valve(s). t8J Shear Valve(s). t8J Dispenser Containment Float(s) and Chain(s). t8J Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Scnsor(s). Model: t8J Shear Valve(s). t8l Shear Valve(s). t8J Dispenser Containment Float(s) and Chain(s). t8J Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9 & 10 Dispenser ID: 11 & 12 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: t8J Shear Yalve(s). t8J Shear Valvc(s). t8J Dispenser Containment Float(s) and Chain(s). t8J Dispenser Containment Float(s) and Chain(s). . . . . •If the facility contams more tanks or d1spcnsers, copy th1s form. Include mformat1on for every tank and d1spenser at the facility . C. Certification -I ~ertify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelin es. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equiJ>ment. For any equi pment capable of generating such reports, I have also attached a copy of the report; (check all that apply): IZl System set-up IZl rm history report Technician Name (print): B ryan A Self Signature: ,h<;c,...~~'4F~:.._---+-\r--+--¥..:...l0~----- Certification No.: =B:.::3:..:.7-=5-=0..:.1 ______________ License. No.: Testing Company Name: Confidence UST Services, Inc. Site Address: 4100 California Avenue, Bakersfield CA 93309 Date ofTesting/Servicing: 2/20/2014 Page 1 of 3 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6. 7, Health and Safety Code; Chapter I 6, 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 svstem control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: --------------------------------Bldg. No.: ___ _ Site Address: City: ---------------------------------Zip: Facility Contact Person: --------------------Contact Phone No.: -"---'---------- Make/Model of Monitoring System: -------------------Date of Testing/Servicing: _____ _ B. Inventory of Equipment Tested/Certified Ch k h ec t. e appropnate b oxes to indicate specific eQuipment inspected/serviced: Tank JD: 10,000 Gal Regular Diesel Tank ID: ~In-Tank Gauging Probe. Model: 847390-107 0 In-Tank Gauging Probe. Model: ~ Annular Space or Vault Sensor. Model: 794390-407 0 Annular Space or Vault Sensor. Model: 0 Piping Sump I Trench Sensor(s). Model: Ronan 0 Piping Sump I Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model: ~ Mechanical Line Leak Detector. Model: FX1 DV 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ~ Tank Overfill I High-Level Sensor. Model: OPW-61-SO 0 Tank Overfill I High-Level Sensor. Model: 0 Other (specifY equipment type and model in Section Eon Page 2). 0 Other (specifY equipment type and model in Section E on Page 2). Tank ID: Tank ID: 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump I Trench Sensor(s). Model: 0 Piping Sump I Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Scnsor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill I lligh-Level Sensor. Model: 0 Tank Overfill I High-Level Sensor. Model: 0 Other (specifY equipment type and model in Section Eon Page 2). 0 Other (specifY equipment type and model in Section Eon Page 2). Dispenser ID: Dispenser ID: 0 Dispenser Containment Se~sor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dis penser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Scnsor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). . . . . •If the facility contams more tanks or dispensers, copy th•s form. Include mformat•on for every tank and dispenser at the facility . C. Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): D System set-up D Alarm history report Technician Name (print): --------------Signature: __::....,..::~~~V!t..L-1--=---t-~-f=~>L..f---- -----------------License. No.: -=.=....:.=04...:...._~1----------+--Certification No.: Testing Company Name: Confidence UST Services, Inc. Phone No.: (800) 339-9930 Site Address: ---------------------------Date of Testing/Servicing: _____ _ Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: 327.04 ~~~--------------------------- c omp1ete th ~ II h kr e o owmg c ec rst: [83 Yes D No* Is the audible alarm operational? [83 Yes 0 No* Is the visual alarm operational? 181 Yes 0 No* Were all sensors visually inspected, functionally tested, and confirmed operational? [83 Yes 0 No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? DYes 0 No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) [83 N/A operational? [83 Yes D No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment 0 N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply) [83 Sump/Trench Sensors; C8l Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? C8l Yes; D No. DYes 0 No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no [83 N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill point(s) and operating properly? If so, at what percent oftank capacity does the alarm trigger? % C8] Yes* 0 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. 181 Yes* 0 No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) 181 Product; 181 Water. If yes, describe causes in Section E, below. 181 Yes 0 No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable DYes 181 No* Is all monitoring equipment operational per manufacturer's specifications? * In Section E below, describe how and when these defi ciencies were or will be corrected. E. Comments: I replaced the liquid sensor in the Diesel fill sump from a Ronan to a Veeder-Root 208 liquid sensor. There was a small mixture of fuel and water in the 87 South STP, i removed the liquid and put it in there Haz-Mat drum on site. The programing is not per manufacturer's specifications, all sensors are daisy chained together and not programed correctly. To fix this problem new wire will need to be pulled and programing will need to be changed. Page 2 of 3 Monitoring System Certification F. In-Tank Gauging I SIR Equipment: 1:83 Check this box if tank gauging is used only for inventory control. 0 Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the following checklist: 1:83 Yes 0 No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? 1:83 Yes 0 No* Were all tank gauging probes visually inspected for damage and residue buildup? 1:83 Yes 0 No* Was accuracy of system product level readings tested? 0 Yes 0 No* Was accuracy of system water level readings tested? 1:83 Yes 0 No* Were all probes reinstalled properly? 1:83 Yes 0 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): 0 Check this box ifLLDs are not installed. c I t th ~ II h kl' t ompte e e o owmg c ec IS : 1:83 Yes 0 No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? 0 N/A (Check all that apply) Simulated leak rate: 1:83 3 g.p.h.; 0 0.1 g.p.h ; 0 0.2 g.p.h. 1:83 Yes 0 No* Were all LLDs confirmed operational and accurate within regulatory requirements? 1:83 Yes 0 No* Was the testing apparatus properly calibrated? 1:83 Yes 0 No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? 0 N/A 0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? 1:83 N/A 0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled 1:83 N/A or disconnected? 0 Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions 1:83 N/A or fails a test? 0 Yes 0 No* For electronic LLDs, have all accessible wiring connections been visually inspected? 1:83 N/A 1:83 Yes 0 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: Page 3 of 3 CALIFOP.tiiA CHEVON 4100 CALIFORNIA AVE Bl:RSFLD CA 93309 661-336-0263 · FEB 20. 2014 9:41 AM SYSTEM STATUS REPORT ALL FUUCTIONS NORMAL I rNEUTOR'/ REPORT T 1 :UNLEADED NORTH VOlll1E .. 4017 GALS ULLAGE • 5667 GAts 90l! ULI.ACE• 4699 GALS TC VOLUME • 3996 GALS HEIGHT • 39.51 INCHES WATER VOL • 0 GALS WATER = 0.00 INCHES TEMP = 67.3 DEG F T 2:SUPRENE VOLUME • 3526 GALS ULLAGE .. 6159 GALS 90Y. ULLAGE• 5199 GALS TC VOLll1E • 3514 GALS HEIGHT a 34.99 I tK:HES WATER VOL a 0 GALS WATER • 0.00 INCHES TEMP • 64.8 DEG F T 3:UNLEADED SIPHON VOLUME • 3451 CAts ULLAGE • 6233 GALS 90% ULLAGE.. 5264 GALS TC VOLUME • 3433 GALS HEIGHT • 34.44 INCHES WATER VOL a 0 GALS WATER " 0. 00 INCHES TEMP • 67. I DEG F T 4: Uti LEADED SOUTH VOLll1E • 3458 GALS ULLAGE • 6226 GALS 90% ULLAGE• 5257 GALS TC VOLll-1E • 3439 GALS HEIGHT • 34.49 WCHES WATER VOL • 14 GALS WATER a 0.79 INCHES 7EHP • 67.6 DEG F T 5:DIESEL VOLUME • 1903 GALS ULLAGE .. 7781 CAts 90% ULLAGE• 6912 CAts TC VOLUME " 1894 GALS HEIGHT • 22.47 INCHES WATER VOL • O.CALS WATER • 0.00 INCHES TEMP = 74.0 DEG F MANIFOLDED TAN~S l tWENTORV TOTALS T t:UNLEADED NORTH 7 3:UNLEADEO SIPHON T 4:UNLEADED SOUTH VOLll'lE • I 0926 CAts &C VOLUME a 10968 GALS .·- -- SOFTWARE REVISION LEVEL VERSION 327.04 SOFTWARE~ 346327-100-E CREATED-07,02.06.10.28 S·MODULE~ 330160·004-a SYSTEM FEATURES: PERIODIC IN-TAtiK TESTS ANNUAL I N-TAtn: &ESTS lSD PHC SYSTEM SETUP FEB 20. 2014 8:42 AM SYSTEt1 UNITS u.s. SYSTEM LANGUAGE ENGLISH SYSTEM DATEIT li1E FORt1AT MOtl DD WW HH:tt1:SS >J-1 CALIFORtHA CHEVON 4100 CALIFORtiiA AVE BKRSFLO CA 93309 661-336-0263 SHIFT TIME I : 5:00 AM SHIFT TIME 2 : DISABLED SHIFT TIHE 3 : DISABLED SHIFT TIHE 4 : DISABLED &AUK PER TST NEEDED ~JRN DISABLED TAtfl: ANN TST tiEEDED WRtl DISABLED LitlE RE-ENABLE METHOD PASS LitlE TEST LitlE PER 7ST flEEDED WRfl DISABLED LitlE Atltl TST NEEDED WRII DISABLED PRINT TC VOLUMES ENABLED TEMP COMPEtiSATIOtl VALUE <DEG F >: 60.0 STICK HEIGHT OFFSET DISABLED ULLAGE: 90Yt H-PROTOCO'IL• DATA F0Rt1AT HEIGHT 1 DAYLIGHT SAVING TIME · ENABLED ; START DATE APR WEEK l SUr~ START TIME 2:00 AM END DATE OCT WEEY. 6 SUN END TIME 2:00 AM RE-DIRECT LoCAL PRI tiTOUT DISABLE~ f..;. _ EURO PROTOCOL PREFIX s SYSTEM SECUR I TV CODE : 000000 MAUITEtiAUCE HISTORY DISABLED TANK CHART SECURITY DISABLED CUSTOM ALARt1S DISABLED MASS/DENSITY DISABLED COHHUNICATIOt~ SETUP PORT SETTWGS: COHM BOARD : l <RS-232> BAUD RATE : 9600 PARITY : UONE STOP BIT : 1 STOP DATA LENGTH: 8 DATA RS-232 SECURITY CODE : DISABLED COMM BOARD : 2 <RS-232> BAUD RATE : 9600 PARITY : ODD STOP BIT : 1 STOP DATA LENGTH: 7 DATA RS-232 SECURITY CODE : DISABLED COMM BOARD : 3 <EDIH > RS-232 SECURITY CODE : DISABLED AUTO TRAflSMIT SETTWCS: AUTO LEA~ 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 EtlD DISABLED AUTO EXTERNAL I tlPUT OU DISABLED AUTO EXTERAAL I tlPUT OFF DISABlED AUTO SEtlSOR FUEL ALARM DISABLED AUTO SENSOR WATER ALARM DISABLED AtrrO SENSOR OUT ALARM DISABLED RS-232 EtiD OF MESSACE DISABLED IN-TAIIK SETUP T I :UNLEADED NORTH PRODUCT CODE : 1 THERMAL COEFF :.000700 TAtlK DIAMETER : 69.75 TAIIK PROFILE : 4 PTS FULL VOL : 9684 67.3 ltlCH VOL 7891 44.9 lflCH VOL 4918 22.4 INCH VOL 1900 FLOAT SIZE: 2.0 ltl. WATER WARtllt~ 2.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL! 9684 OVERFILL LIMIT 92Y. 8909 HIGH PRODUCT 98Y. 9490 DELIVERY LIMIT 5Y. 500 LOU PRODUCT : 500 LEA~ ALARM LIMIT! 99 SUDDEN LOSS LIMIT: 99 TAIIK TILT 0.49 PROBE OFFSET 0.00 SIPHON MArliFOLDED TAtlKS Til: 03.04 LitlE MANIFOLDED TANKS Til: 03.04 LEAK HIN PEP.IODIC: . LEA~ HI tl AtltiUAL 1% 100 1% 100 PERIODIC TEST TYPE STAIIDARD ANilUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANU TEST AVERAGING: OFF PEP. TEST AVERACJtlG: OFF TAll~ TEST IIOTIFV: OFF nn: TST SIPHON BREAK:OFF DELIVER'!(. DELA'I· : 1 Hltl . PUMP TH~e!HO£:D· : 10.0~· T 2!SUPR91E PRODUCT CODE 1 'fHERHAL COEFF TI\IIY. DIAMETER TANK PROFILE FULL VOL 67.3 INCH VOL 44.9 INCH VOL 22.4 IUCH VOL FLOAT SIZE: WATER WARtntiC : HIGH WATER LIMIT: MAX OR LABEL VOL: OVERFILL LIMIT : . HIGH PRODUCT DELIVERY LIHIT 2 .000700 89.75 4 PTS 9684 7991 4918 1900 4.0 ltl. 2.0 3.0 9684 92'/. 9909 9BY. 9490 5Y. 500 LOI~ PRODUCT : 500 LEA~ ALARM LIMIT! 99 SUDDEN LOSS LIHIT: 99 TAW\ TILT 3.40 PROBE OFFSET 0.00 SIPHOfl MAtHFOLDED TAIIKS Til: NONE LitlE HAtllFOLDED TANl:S Til: NONE LEAK MIN PERIODIC: . LEAK Ml N AWIUAL tr. 100 IY. 100 PEP.IODIC TEST TYPE STA!IDARD AN!IUAL T£!;)1 FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANti TEST AVERAGING: OFF PER TEST AVERACltlG: OFF TAtlK TEST NOTIFY: OFF Ttll\ TST SIPHON BREAY.:OFF DELIVERY DELAY : 1 Mltl PUMP THRESHOLD : 10 .OOY. T 3:UtiLEADED SIPHON I ~We~~-~~~F ~ .OOO?Og TAt!~ DIAMETER : 89.75 TAt!~ PROFILE : 4 PTS FULL VOL : 9684 67.3 INCH VOL : 7891 44.9 ltlCH VOL : -1918 22.4 ItiCH VOL : 1900 FLOAT SIZE: 2.0 IN. WATER WARtU tK> : HIGH WATER Llt'IIT: MAX OR LABEL VOL: OVERFILL LIMIT : HIGH PRODUCT DELIVERY LIMIT . . LOW PRODUCT : LEAK ALARM LIMIT: SUDDEN LOSS LIMIT! TAtiK TILT : PROBE OFFSET 2.0 3.0 9684 9~~ 8909 99:~ 9490 s:; SOD 500 99 99 0.26 0.00 SIPHON HAIHFOLOED TAIIKS TIS! 01.04 LWE HAtHFOLDED TAtii:S TIS: 01.04 L~ MIN PERIODIC: . L~ Hltl AtlllUAL IY. 100 1% 100 PERIODIC TEST T'IPE STAflDARD ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGIN(;: OFF TAflK TEST tlOTIFY! OFF Till: TST SIPHON BREA~!OFF DELIVERY DELAY : 1 HI tl PUMP THRESHOLD : 10.0Q); T ol :UtlLEADEO SOUTH PRODIJI.,"'T CODE : 4 THERMAL COEFF : • 000700 TAN!{ DIAMETER : 89.75 TAtlK PROFILE 4 PTS FULL VOL 9684 67,3 INCH VOL 7891 44.9 ltlCH VOL 4918 22.4 INCH VOL 1900 FLOAT SIZE: 2.0 lN. WATER WARtH fiG : HIGH WATER LIHIT: MAX OR LABEL VOL: OVERFILL LIMIT : . HIGH PRODUCT DELIVERY LIMIT LOW PRODUCT : L~ ALARM LIMIT: SUDDEN LOSS LIMIT: TANK TILT : PROBE OFFSET 2.0 3.0 9684 92:~ 8909 99:; 9490 ~: 500 500 99 99 0 .14 0.00 SIPHON MAtHFOI.DED TANKS TIS! 01,03 LINE MANIFOLDED TAfli:S Til! 01.03 LEAK MIN PERIODIC: LEAK Ml N AfltlUAL 1% 100 1% 100 PERIODIC TEST TYPE STANDARD ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED AtlN TEST AVERAGING: OFF PER TE::)"'T AVERAG IIIG: OFF TANK TEST flOTlF't: OFF TNJ\ TST SIPHON BREAK:OFF DELIVERY DELAY : I MIN PUMP THRESHOLD : 10.00:' T s:DIESEL PRODUCT CODE THERMAL COEFF TAtiK DIAMETER TAUK PROFILE FULL VOL 67.3 INCH VOL 44.9 IllCH VOL 22. 4 ItCH VOL FLOAT SIZE: WATER WARIH tiG : HIGH WATER LIMIT: MAX OR LABEL VOL: OVERFILL LIMIT : HIGH PRODUCT DELIVERY LIMIT LOU PRODUCT : LEAK ALARM LIMIT: 5 .000700 89.75 4 PTS 9684 7891 4918 1900 4.0 w. 2.0 3.0 9684 9~ 8909 9Er/o 9490 5% 500 500 99 SUDDEI~ LOSS LIMIT: 99 4.70 o.oo TAtlK TILT : PROBE OFFSET SIPHON MANIFOLDED TAfiKS TIS! tiONE LitlE MANIFOLDED TAfii\S 111: IIONE LEAK MIN PERIODIC: LEAY. MIll ANNUAL : IY. 100 1., " 100 PERIODIC TEST TYPE STAtlDARO AlltiUAL TEST FAIL ALARM DISABLED PEP.IODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ·." ALARM DISABLED ANtl TEST AVERA~lrK>: PER TEST AVERAGING: TAIIK TEST f~OTIFV: OFF OFF OFF TNK TST SIPHOfl BREAJ::OFF DELIVER'/ DELAY : 1 Mltl PUMP THRESHOLD : I O.OW. / LEA~: TEST METHOD I TEST Otl DATE : ALL TAtn~ FEB 6. 2007 ! START TIME : DISABLED . TEST RATE :0.20 CAL/HR DURATION : 2 HOURS TST EARLY STOP!DISABLED LEAK TEST REPORT FORMAT NORMAL LIQUID SENSOR SETUP ------------ L I :UNLEADED NORTH I NORMALLY CLOSED CATEGORY : OTHER SEtSORS L 2!SUPREHE tK>RHALLY CLOSED .CATEGORY : OTHER SENSORS ··'f. L· 3!UtllEADEf3iStPHOtl J :. NORHALLV:.CLi>Smrc=' '"' • · ~.-.. CATEGORY : OTHER SEtSORS L 4!UNLEADED SOUTH NORMALLY CLOSED CATEGORY : OTHER SENSORS L S!DIESEL tK>RMALLY CLOSED CATEGORY : OTHER SEtSORS L G!CASPER TRI-STATE <SINGLE FLOAT> CATEGORY : OTHER SEUSORS L 7:CHOST TRI-sTATE CSitlCLE FLOAT> CATEGORY : OTHER SENSORS L 8:CHOST TRI-STATE <SINGLE FLOAT> , CATEGORY : OTHER SEN$0RS Plt1P SEtiSOR SETUP S 4 :UtllEADED tiORTH TAtlK II! l DISPEtSE MODE: MAIIJFOLOED: ALTERIIATE OUTPUT REUW SETUP P. 1 !POSITIVE-SHUT OFF TYPE: STANDARD NORMALLY CLOSED TAUK II: tlONE I ti-TAtll: ALARMS ALL:LEA}: ALARM ALL!HIGH WATER ALARM LIQUID SEtlSOR ALMS ALL!FUEL ALARM ALL:SENSOR OUT ALARM ALL!SHORT ALARt1 lSD S ITE ALARMS lSD CR<>SS PRES FAIL lSD DECRD PRES FAIL lSD VAPOR LEAl: FAIL lSD VP PRES FAIL lSD VP STATIJ? FAIL lSD HOSE ALARMS -ALL!CROSS COLLECT FAIL ALL!DEGRD COLLECT FAIL ALL:FLOW COLLECT FAIL R 2: UtllEADED tK>RTH TYPE: PUMP CONTROL OUTPUT TANK II! I LIQUID SENSOR AI..MS ALL!FUEL ALARM ALL :SEtlSOR OUT ALARM Att:SHORT ALARM lSD SITE ALARMS lSD CROSS PRES FAIL lSD DEGRD PRES FAIL lSD VAPOR LEAK FAIL ISO VP PRES FAIL lSD VP STATUS FAIL lSD HOSE ALARMS ALL!GROSS COLLECT FAIL ALL!DEGRD COLLECT FAIL ALL!FLOW COLLECT FAIL R 3: UNLEADED SOUTH TYPE: PUMP CONTROL OUTPUT TAIIK II! 4 LIQUID SENSOR ALMS ALL!FUEL ALARI·I ALL!SENSOR OUT ALARM ALL:SHORT ALARM ISO SITE ALARMS lSD GROSS PRES FAIL lSD DECRD PRES FAIL lSD VAPOR LEAK FniL lSD VP PRES FAIL lSD VP STATUS FAIL ISO HOSE ALARMS ALL:CROSS COLLECT FAIL ALL!DEGRD COLLECT FAIL ALL:FLOW COLLECT FAIL SMARTSEtiSOR SETUP s I!PS 7-8 · CATEGORY VAPOR PRESSURE 5 2!FN 1-2 CATEGORY AIR FLOW METER s 3!FN 3-4 CATEGORY AIR FLOW METER s 4!FN 5-6 CATEGORY AIR FLOW HETER 5 s :ru 7-8 CATEGORY AIR FLOW METER s G!FN 9-10 CATEGORY AIR FLOW METER :s 7:FN 11-12 CATEGORY AIR FLOW METER EVR/ISD SETUP EVR TYPE: VACUlJ1 ASSIST VACUUM ASSIST TYPE HEALY VAC ~ NOZZLE A/L RANGE MAX: 1.15 HHI: 0.95 VAPOR PROCESSOR TYPE NO VAPOR PROCESSOR AllALVSIS TIMES TIME! 10:00 AM DELAY MlllUTES! ACCEPT HIGH ORVR: DISABLED lSD HOSE TABLE ID FP FL HL AA RR ------------------------01 33 01 02 01 uu 02 34 02 02 01 uu 03 35 03 02 02 uu 04 01 04 02 02 uu 05 03 05 02 03 uu 06 00 06 02 03 uu 07 07 07 02 04 uu 08 04 08 02 04 uu 09 OS 09 02 OS uu 10 08 10 02 05 uu 11 06 11 02 06 uu 12 02 12 02 06 uu lSD AIRFLOW METER NAP ID SERIAL NUM LABEL ------------------------I 18422 2 18424 3 19415 4 12370 5 19032 6 18433 FH 1-2 FM 3-4 FM 5-6 FH 7-8 FM 9-10 FH 11-12 ISO FUEL GRADE HOSE NAP I 2 3 4 FP HHH MHH MHH MHH AA 00 206 306 906 5 u 3 OJ 204 304 904 5 U 2 02 212 312 912 5 u 6 03 205 305 90S u u 3 04 208 308 908 u u 4 05 209 309 909 u u 5 06 211 311 911 u u 6 07 207 307 907 u u 4 08 210 310 910 u u 5 33 201 301 901 5 U I 34 202 302 902 5 U I 3S 203 303 903 5 u 2 LABEL TABLE I: UNASSIGNED 2: BLEtiD3 3: REGULAR 4: MID GRADE 5: PREHIUH 6: GOLD 7: BRONZE e: SILVER 9: BLEND2 10: BLEND4 PMC SETUP PROCESSOR CONTROL LEVEL: tlOtlE ALARM HISTORY REPORT -----SYSTEM ALARI1 -----PAPER our FEB 3. 2014 11!19 AM PRlrlTER ERROR FEB 3. 2014 11!19 AM ALARM HISTORY REPORT ----IN-TANK ALARM ----- T I :UNLEADED NORTH INVALID FUEL LEVEL FEB 6. 2014 7:31 ~1 FEB 5. 2014 8:23 PM JAN 31. 2014 1!43 PM PROBE our FEB 3. 2014 11:00 AM j ALARM HISTORY REPORT ----IN-TANK ALARM ----- T 2!SUPREME )( )( 11 l< l< END l< M l< )( )( ALARM HISTORY REPORT ----IN-TANK ALARM ----- T 3:UtiLEADED SIPHON PROBE our FEB 3. 2014 11:07 AM ALARM HISTORY REPORT ----IN-TANK ALARM ----- T 4:UtlLEADED SOUTH OVERFILL ALARM AUG 23. 2013 2:44 AM PROBE OUT FEB 3. 2014 11:09 AH M M )i * * EtlD l< l< M M M , ALARt1 HISTORY REPORT ----I ti-TANK ALARM ----- T 5:DIESEL ~ ~ M M * END * M * ~ ~ ALARM HISTORY REPORT -----SENSOR ALARM -----L I :UNLEADED NORTH OTHER SENSORS FUEL ALARM FEB 7. 2014 11:16 AM ALARM HISTORY REPORT -----SENSOR ALARM -----L 2:SUPREHE OTHER SENSORS SENSOR OUT ALARM HAY 9. 2013 5:22 AH SENSOR OUT ALARM HAY 9. 2013 5:17 AM SEtSOR Our ALARM HAY 9. 2013 5:07 AM ALARM HISTORY REPORT -----SENSOR ALARM ----- L 3:UNLEADED SIPHON OTHER SENSORS SENSOR OUT ALARM DEC a. 2013 5:42 AM SEtlSOR OUT ALARM ~-r 5. 2013 12:21 AM 1 SEtlSOR our ALARM OCT 5. 2013 12:20 AM )( )( ;. )( )( EtiD ;( ;( * * )( ALARM HISTORY REPORT -----SENSOR AlARt1 -----L 4:UNLEADED SOurH OTHER SENSORS SETUP DATA WARtH NG FEB 6. 2007 1:47PM SETUP DATA WARtH NG FEB 6. 2007 8:11AM FUEL ALARM FEB 6. 2007 8:05 AM )( * )( )( )( END )( * j( j( * ALARM tllSTORY REPORT -----SEtSOR ALARH -----L 5:DIESEL OTHER SENSORS )( M l< )( ,_ END M K )( l< M ALARM HISTORY REPORT -----SENSOR ALARM -----L 6:CASPER OTHER SENSORS ,,.. ....... ALARM HISTORY REPORT -----SENSOR ALARM -----1. ?:GHOST OTHER SENSORS ALARM HISTOR\' REPORT -----SENSOR ALARM -----1. e:GHOST OTHER SENSORS (!. I -----SENSOR ALARM -----. L 3:UNLEADED SIPHON I OTHEP. SENSORS FUEL ALARM FEB 20. 2014 9:49 AM I I -----SENSOR AlARM -----L 4: UNLEADED SOUTH OTHER SENSORS FUEL ALARM FEB 20. 2014 9:49 AM -----SENSOR ALARM -----1. 5:DJESEI. OTHER SENSORS FUEL ALARM FEB 20. 2014 9:49 AM ~----SENSOR ALARM -----1. 6:CASPER OTHER SENSORS SENSOR OUT ALARM FEB 2Q. 2014 9:49 AM -----SENSOR ALARH ----- L..?:GHOST . OTHER SENSORS SENSOR OUT ALARM FEB 20. 2014 9:49 AM ~ ... , 'I• ;----SENSOR AtAR~\----L 1 !UNLEADED NORTH OTHER SENSORS FUEL ALARM FEB 20. 2014 9:49 AM .... ~ -----SENSOR ALARM -----L a:GHOST . OTHER SENSORS . SENSOR ·our ALAAN·-·:- 1 FEB 20. 2014 9 :.t9 Pi-1- ~ -----SEtiSOR ALARM -----1. 2:SUPRENE OTHER SENSORS FUEL ALARM ~EB 20. 2014 9:49 AM -----SENSOR ALARM -----1. I :UilLEADED NORTH OTHER SENSORS FUEL ALARM FEB 20. 2014 10:10 AM .. ~ ,• -----SEtSOR A!_~RM -----L I !UtiLEAOED NORTH OTHER SENSORS F.UEL ALARM FEB 20. 2014 10!14 AM -----SEtSOR ALARt1 -----L I :UNLEI~DED NORTH • OTHER SENSORS FUEL ALARM FEB 20. 2014 10:17 AM ~----SEtSOR ALARM ----- I.~· I :UtiLEADE& t~RTH OTHER SENSORS FUEL ALARM FEB 20. 2014 10:19 AM -----SENSOR ALARM -----1. 1 :Utll.EADED NORTH OTHER SENSORS FUEL ALARM FEB 20. 2014 10:19 AM i\· -----SENSOR ALARN -----L 1 : Ut{!.EADED NORTH OTHER SENSORS FUEL ALARM FEB 20. 2014 10:26 AM ----SEtSOR ALARM -----1. 1 :UttLEADED NORTH OTHER SEtSORS FUEL ALARM .f-EB 20. 2014 10:26 AM . i ;· of).:· --~--SENSOR ALARN -----t 1 :UNLEADED NORTH OTHER SENSORS F.UEL ALARM FER 20. 2014 10:28 AM -----SENSOR ALARM ----- L·2:SUPRENE QTHEP. SENSORS FUEL ALARM .;FEB 20. 2014 10:33 AM ,,•~:•., . ·:;~~ ' . '!f '· .. -----SENSOR ALARM -----L~ 2:SUPREHE OTHER SENSORS FOEL ALARM FEB 20. 2014 10:36 AM ' ,, 7i,·---SEtSOR ALARM ----- 1.(}2 :SUPREME , OTHER SENSORS ~FUEL ALARM FEB 20. 2014 10:38 AM . ':----SENSOR ALARM -----1. 2:SUPREME OTHER SENSORS FUEL ALARM FEB 20. 2014 10:45 AM ,., /'I • -----SEtSOR ALARM ----- 1. 2:SUPRENE OTHER SENSORS FUEL ALARM F.EB 20. 2014 10:47 AM r:f: ~ .r:· ~----SEtSOR ALARN -----1: 2:SUPREME O:THER SEtSORS FUEL ALARM FEB 20. 2014 10:48 AH CALIFORIHA CHEVON 4100 CALIFORtHA AVE BKRSFLO CA 93309 .. §61-336-0263 .. ,..tll .FJiB ~o. 2014 1 o: 52 AM .. , . . ~ : .. i !::sysTEM STATU3 REPORT ~ ~---------i!''I('2:FUt-:L ALARN \'~~' .... ~ ·.' .. ,,,. . .;r ·'• -. ·.; ' . '-~: ':' __ !/_ SEtSOR ALARM ----- 1. '2~SUPREHE OTHER SEtiSORS FUEL ALARM FEB 20. 2014 10:59 AM ~ ~~· :-,·'f: ~·~ .... '.ift ·· .. ' .. '!;~~-: SEtlSOR ALARM -----. I,. <!jSUPRENE OTHER SEtSORS ,:FUEL' ALARM : ~~·~0· 2014 1l :04 AM J ::, :J -~1\ ·:~u. ·. .:r.. \ : ~ . , . . _l• ,('I ,. ~ .. .. ---:::-;SElSOR ALARN ----- . L 3:UtlLEADED SIPHON OTHER SEtiSORS FUEL ALARl1 FEB 20. 2014 11:05 AH .0:. ,·:, . ! ;f: ~-~--SEtSOR ALARM -----L 3:Uti!.EADED S1PHOH OTHER SEtSORS FUEL ALAR11 FEB 20. 2014 11:07 AM -----SEtSOR ALARH -----1. 3:UtlLEADED SIPHOtl OTHER SENSORS FUEL ALARM FEB 20. 201~ 11:09 Ah ,·, ~~-' . • . . ----~ SENSOR ALARt1 ----- 1. 3:UNLEADE[I SI PHON OTHER SENSORS FUEL ALARN FEB 20. 201~ 11:15 AH .... ----SENSOR ALARM ----- 1. 3:UNLEADED SIPHON OTHER SEtlSORS FUEL ALAP.M FEB 20. 2014 11:17 AM , .. ..... ~~·-SEIISOR AUIRH ----- : ~:LNLEADED SOliTH 10"{tiER SEtiSORS FUEL ALARM .FEB~O. 2014 II :20 AM ~~;~: .. ~~~j ~~ ~·it. r·---SEtiSOP. ALARM -----L 4'!i.lflLEADED SOliTH OTHER SEUSORS FUEL ALAPJ1 FEB 20. 2014 11:22 AM .. of}/:~' $1 ~-~1 ·1';!.1-&,-: SEtlSOR ALARM -----a(.'(A".U{lLEADED SOliTH O!P_ER SENSORS .FUEC. ALARM "FEB 20. 2014 11:30 AM -----SENSOR ALARM ----- 1. S:DIESEL OTHER SENSORS FUEL ALARM FEB 20. 201~ 11:32 AM ----:. SENSOR ALARM -----L S:DlESEL ,OTHER SENSORS FUEL ALARM FEB 20. 2014 11 :32 AM ~t~~: ~,..s . :"''i· \..:; . .. -'"'..:;.. SElSOR ALARt1 ----'t ~:DIESEL . OTHER SEt-ISORS 1FUEI!' ALARM •FEB.~O. 2014 11 :34 AM v 11:. .CAP.IFOP.NIA CHEVON f11 00 CALIFORNIA AVE ~~~LD CA 93309 r.-e_6~36-0263 .fEB 20. 2014 11:<11 lil1 -----SENSOR ALARt1 -----L 4 :UtlLEADED SO liTH OTHER SEtlSORS SETUP DATA WARNING FEB 20. 2014 11:44 AM -----SENSOR ALARI1 -----L 4 :UNLEADED SOliTH OTHER SENSORS SETUP DATA WARNitlG FEB 20. 2014 11:45 AH -----SENSOR ALARM -----L 4:UNLEADED SOUTH OTHER SEtiSORS SETUP DATA WARtntlG FEB 20. 2014 11 :53 AM -----SEt-ISOR ALARM ----- 1. 4: UNLEADED SO liTH OTHER SENSORS SETUP DATA WAIWI NG FEB 20. 2014 11:53 AM SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors pe1jorming annual testing ofUSTspi/1 containment structures. The completed form and printoutsji·om tests (if applicable), should be provided to the facility owner/operator for submit/a/to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: California Chevron I Date of Testing: 2/20/2014 Facility Address: 4100 California A venue, Bakersfield, CA 93309 Facility Contact: Sam Jouda I Phone: 661-333-0000 Date Local Agency Was Notified ofTesting: 1/24/2014 Name of Local Agency Inspector (if present during testing): Ernie Medina 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. Technician Conducting Test: Bryan A Self Credentials1: X CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester 0 Other (Specify) License Number(s): 804904 ICC# 8022804-UT TT# 11-1756 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic D Vacuum 0 Other Test Equipment Used: Lake Test Equipment Resolution:0.0625" Identify Spill Bucket (By Tank I Regular (North) Number, Stored Product, etc.) 2 Regular (South) 3 Regular (Siphon) 4 Super Bucket Installation Type: Direct Bury Direct Bury 0 Direct Bury L Direct Bury X Contained in Sump X Contained in Sump X Contained in Su.np X Contained in Sump Bucket Diameter: 12.00" 12.00" 12.00" 12.00" Bucket Depth: 13.75" 14.25" 14.00" 13.75" Wait time between applying 5 min. 5 min. 5 min. 5 min. vacuum/water and start of test: Test Start Time (T1): 9:43AM 9:30AM 9:43AM 9:43AM Initial Reading (RI): 9.00" 9.00" 9.00" 9.00" Test End Time (TF): 10:43 AM 10:30 AM 10:43 AM 10:43 AM Final Reading (RF): 9.00" 9.00" 9.00" 9.00" Test Duration (T F-T1): I hour I hour I hour I hour Change in Reading (RF-R1): 0.0" 0.0" 0.0" 0.0" Pass/Fail Threshold or 0.0625" Criteria: 0.0625" 0.0625" 0.0625" Test Result: X Pass DFail X Pass 0 Fail X Pass OFail X Pass OFail Comments-{include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the i11jormatio11 co11tai11ed ill this report is true, acqurate, a11d ill full compliance with legal requireme11ts. Technician's Signature: f Lf "'iL~ ~~I I Date: 2/20/2014 1 State laws and regulations do not currently require testing to be performed bjt a qualified contractor. However, local requirements may be more stringent. SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors pe1jorming annual testing ofUSTspi/1 containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Califomia Chevron 1 Date ofTesting: 2/20/2014 Facility Address: 4100 California Avenue, Bakersfield, CA 93309 Facility Contact: Sam Jouda I Phone: 661-333-0000 Date Local Agency Was Notified of Testing: 1/24/2014 Name of Local Agency Inspector (if present during testing}: Ernie Medina 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. Technician Conducting Test: Bryan A Self Credentials': X CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester 0 Other (Specify) License Number(s): 804904 ICC # 8022804-UT TT# ll-1756 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic 0 Vacuum 0 Other Test Equipment Used: Lake Test Equipment Resolution:0.0625" Identify Spill Bucket (By Tank 1 Diesel 2 3 4 Number, Stored Product, etc.) Bucket Installation Type: Direct Bury Direct Bury 0 Direct Bury 0 Direct Bury X Contained in Sump Contained in Sump Contained in Sump Contained in Sump Bucket Diameter: 12.00" Bucket Depth: 15.75" Wait time between applying 5 min. vacuum/water and start oftest: Test Start Time (T1): 9:43AM Initial Reading (R1): 6.50" Test End Time (TF): 10:43 AM Final Reading (RF): 6.50" Test Duration (T F-T1): I hour Change in Reading (RF-R1): 0.00" Pass/Fail Threshold or 0.0625 Criteria: Test Result: X Pass o Fail 0 Pass 0 Fail 0 Pass 0 Fail 0 Pass OFail --------- Comments-(include information on repairs made prior to testing, and recommended[ollow-up[or failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information co11tained in this report is tr~, accJtrate, and in full compliance with legal requirements. Technician's Signature: '=-..... , ., , O../ 1 '--" T' q,; v v 1 t r . <J • 1 State laws and regulati.ons do not currently re may be more stringent. Date: 2/20/2014 qualified contractor. llowever, local requirements z ...J 0:::: w .... tJ) w :I: (.) * NT 5 • 10,000 GAL USTs ® CA L I F O R N I A AV E . 2 8 6 ~r : : :r -- - -- . ·u 10 12 TL S ST O R E LJ O P A N E SI T E PL O T PL A N fo r : SA M C O CA L I F O R N I A CH E V R O N 41 0 0 CA L I F O R N I A AV E . BA K E R S F I E L D , CA 93 3 0 9 02 / 1 5 / 2 0 1 3 LE G E N D L 1 87 - N ST P L2 91 ST P L3 87 -S I PH O N ST P L4 87 - S ST P L5 DS L ST P ES O EM E R G E N C Y SH U T - O F F OF A OV E R F I L L AL A R M f PR O D UCT SP ILL CO N T A I N E R 0 VA P O R SP I L L CO N T A INE R rA, AN N U L A R * FIR E EX T I N G U I S H E R G GA S ME T E R SH U T - O F F • WA T E R ME T E R SH U T - O F F ® HE A L Y C A S * EV A C U A T I O N ME E T I N G PO I N T ~flDE"+, ()0 ~ \UST; • +' }'lfuc1\0 ~flDE"+. ()0 (\ '(C\ ~UST(,. + ~ ~CES•~ 'SUlLO WITH C0Hflll€NCE" "'CQ~W!TM COHAOENCE" Lie. 970703 ( _;v· ~04904 Toll Free #: 1-800-339-9930 Store Employee Print Name Store Employee Signature· )ICE-WHITE Job Order /Invoice#: )ZO'f 1 Date Called lime To Whom COMMENTS Date