The URL can be used to link to this page

Home My WebLink AboutMINOR MOD CONTRACTOR INFO 12-7-18�A$*II+CiJ�1i7�i9i�A� 9�Jr"Vl� @,fix 1!.tJ�+'r oill��e >. 9AAW.bE-16 h1rc-X -C M: October 11, 2016 To whom it may concern: a L� itr Sdu tiiri.ri� Era�.F� 1«rt aa�, lilt: This letter is to inform you that the following individuals are authorized agents for Belshire Environmental Services, Inc. This authorization provides them with permission to apply for permits or obtain information from your agency on our company's behalf. • Ted Stephenson • Mike Ellis • Jeff Badders • Zac Kavanaugh Feel free to contact me if you have any questions or require further information. Sincerely, Karen Cass President Belshire Environmental Services, Inc. bAff M 0 Aff ON, mah I MWAM Scope of Work wxzin w qIw ital services., inc. Page 1 of 1 Facility: Circle K Store #2708606 1030 OAK ST BAKERSFIELD, CA Date: 10/16/2018 Job Number: 0 Estimate No: 12694 Estimate Prepared by: TNS Location: Spill Bucket -Vapor Work to be performed: Type Description Qty Unit PARTS Pomeco 761 EVR Fill Bucket (New style) - Parts supplied by Circle K/Sour 1 EA Location: Permit Work to be performed: Type Description Qty Unit PERMIT Permit - Obtain Repair Permit 1 FF PERMIT Permit Fee* 1 EA Location: General Work to be performed: Type Description Qty Unit EQPT Service Truck 1 DAY LABOR UST Technician 11 - Straight Time 10, HR LABOR UST Technician I - Straight Time 10 HR MILES Mileage 360 MILES ACC> " CERTIFICATE OF LIABILITY INSURANCE �,,,.,►--'' DATE (MNYDDfYYY1) 1 3/29/2018 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 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the chi' cabe holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 c ertilficate holder in lieu of such endorsement(s). PRODUCER Garrett/Mosier /Griffith /Sistrunk CNAME, Marissa Romo Risk Management & Insurance Services 12 Truman Irvine, CA 92620 PHONE FAX 949 - 559 -6700 A/c No: 949- 559 -6703 ADDRESS: marissarP m s.com INSURER(S) AFFORDING COVERAGE NAIC # 4/1/2019 INSURER A. Great Divide Insurance Company 25224 www.gmgs.com OB84519 INSURED Belshire Environmental Services Inc. 25971 Towne Centre Drive INSURER B: Nautilus Insurance Company 17370 INSURER C: $ 5,000 INSURER D; Foothill Ranch CA 92610 INSURER E: GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 JECOT- 7 LOC OTHER: INSURER F; $ 1,000,000 COVERAGES CERTIFICATE NUMBER: 41115169 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. 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. MR LTR TYPE OF INSURANCE ADDL D SUBR WVD POLICY NUMBER POLICY EFF MWDD YYYY) POLICY EXP (WWDR= LffffM A ✓ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 7 OCCUR GLP01548949 -16 4/1/2018 4/1/2019 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 JECOT- 7 LOC OTHER: GENERAL AGGREGATE $ 1,000,000 PRODUCTS - COMP /OP AGG $1,000,000 $ A AUTOMOBILE ✓ LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY ✓ AUTOS ONLY BAP1547282 -16 MCS -90 Included Pollution Liab Included 4/1/2018 4/1/2019 Ea accidentSINGLELIMIT $1,000 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ ✓ PROPERTY DAMAGE Per accident $ $ B ✓ UMBRELLAUA13 EXCESS LIAR ✓ OCCUR CLAIMS -MADE I FFX1547284 -16 4/1/2018 4/1/2019 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED I RETENTION $ $ A WORIMRS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR /PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below WCA1547285 -16 4/1/2018 4/1/2019 �/ STATUTE ERH- E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1 000 D0.0._. E.L. DISEASE - POLICY LIMIT $1,000,000 B B Contractors' Professional Liability Contractors' Pollution Liability CCPC1547283 -16 CCPC1547283 -16 4/1/2018 4/1/2018 4/1/2019 4/1/2019 $1,000,000 Each Claim /Agg. $50,000 DED $1,000,000 Each Claim /Agg. $50,000 DED DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GEKTIFIGATE FIULDEK r nrr,% Evidence 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. AUTHORED REPRESENTATIVE Griff Griffith U 7UW4S-Zn* AGUKIJ cUKrWKra I /UFL w11 ngnLS rMHArvw. ACORD 25 (2D16103) The ACORD name and logo are registered nwzks of ACORD 41115169 1 18 -19 A /G /W /U /$1M E &O /POLL I Marissa Rom 1 3/29/2018 5:13:58 PM (PDT) I Page 1 of 1 Verity ICU Memberslup and Certiticatzon intormation (http://www.iccsafe.orq6 4TA# 5254$b1 My Professional Information: Last, First MI: Gonzalez,Saul Certified under this name: Saul Gonzalez City, State Zip: Foothill Ranch, CA 92610 Certification Type (s) : California UST Service Technician (expires 09/25120.17) RECEIVES MEMBER BENEFITS? NO Upload your image by pressing the 'Upload Your Photo' link on the left side menu. QUICK LINKS Wage I of -i Log in to myICC (https: /Iay. iccsafe .orgleweb /DynamlePage.aspx? WebCode= LoginRequired &Site= ICC &URL success= http: / /www. iccsafe .org /myicc / %3fusertoken %3d (token)) Renew my Membership (http: / /www. iccsafe. org /Membership/ Pages /RenewReinstateMembership.aspx) BackROFMW ffp9AQ1&ff fii f � %i�� ittB tc t ! iItefflageslnggng "bilto:webmastera@icrsafe.org) file: / / /C:/ Users / shawna/ AppData /Local/Temp/Low/PLQNHYFB.htm 10/21/2015 CIW OF BAKERSFIELD POST • BMi.ESS TAX GERTIFNCATE Business name.: BELSHIRE ENVIRONMENTAL SVCS IN Location address OUTSIDE CITY Lie Nbr /Class .: 19 00070170 HOME REPAIR Issue date ..: 6/04/18 Expiration date .: 6/30/19 License comment: REPAIR OF GAS STATIONS ILLEGAL BUSINESSES MAY BE SUBJECT TO $1,000 PER DAY CIVIL FINE BELSHIRE ENVIRONMENTAL SVCS IN 25971 TOWNE CENTRE DR FOOTHILL RANCH CA 92610 NOW TRANSFERABLE" �'� '7111,x,?; -^• Owner /Officer CASS, KAREN PRES MOOTHART, LARRY SEC /TREAS BUSINESS TAX CERTIFICATE IS HEREBY GRANTED, LICENSEE IS TO COMPLY WITH ALL LAWS AND ORDINANCES. ISSUANCE OF THIS LICENSE DOES NOT CONSTITUTE AUTHORIZATION TO CONDUCT BUSINESS IF LICENSEE HAS NOT COMPLIED WITH ALL APPLICABLE LAWS AND ORDINANCES, THIS LICENSE IS ISSUED WITHOUT VERIFICATION THAT THE LICENSEE IS SUBJEC'• TO OR EXEMPT FROM LICENSING BY THE STATE OF CALIFORNIA. ** Raintight cover is standard spill Co Of Ports Powder Capacity * ** .w: F 0 Coated 00 - No Containment vt o n t a -in1. m e- n t. „ Manhole 05 - 5- Gallon fl Covers 15 - 15- Gallon 5- Gallon bucket_ z; �� R- (1) Red is standard 3` (1) Orange W - (1) White (1) Orange Y - (1) Yellow 411 -5- gallon (Slip -On) Old Style Replacement Parts '31111.411 /5111521. Series Multi ;Ports Note 5 "1 1/521 parts,are for Multi Ports made prior o Nov.. 2003 Part # Description 1DK- 2100 -EVR 511/521 Series Drain Valve H13931 M Replacement Seal for SC Cover P110 -37G 34 " -37" Manhole Gasket P110 -42G 42” Manhole Gasket P110 -48G 48" Manhole Gasket 'i PROTO -LOCK (1) Roto -Lock P40- ROTOLID Replacement 40 Style Gauge Port. Roto -Lock Lid ALL'> H15240M Replacement Gasket for 40 Style Gauge Port P511 -BK Steel Cover Bolt & Gasket Kit, (4 each) for complete cover P -30L Replacement 30 Style Bolt Down Gauge Port Lid P311 -G Bucket Top Flange Gasket P511 BUCKETBOLT Spill Bucket RT Ring Kit (4) Bolts, Washers & Gaskets H15238M Replacement Gasket, 30 Style (Bolt Down) 1- 2100 -DSH 5 Gallon Fill Bucket with Composite Base & Drain Valve 1- 2100 -PSH 5 Gallon Vapor Bucket with Composite Base & Plug See page 73 for additional cover options. Current Replacement Parts For N'e'w-'- 500.Seriies`EVR Multi -Ports 651116521, 6561!571 made post 11/2003 Part # Description P711 -EVRDV Replacement 5- Gallon Bucket, w/ Drain Valve P711 -EVRPL Replacement 5- Gallon Bucket, w /Plug (Vapor) P761 C -EVRDV Replacement 5- Gallon Bucket, C.I. Base w /Drain Valve P761 C -EVRPL Replacement 5- Gallon Bucket, C.I. P411 -EVRPL Replacement 5- Gallon Slip -On Bucket P511 -15- EVRDV Replacement 15- Gallon Bucket, Comp Base, W/ Drain Valve C05170M Gasket, Spill Bucket & Mounting Ring H15187M Replacement Seal for New Rain Tight Cover Note: New P711 & P761 EVR buckets will only work with New "EVR" Multi -Port covers. (made post 11/2003) See page 53 for replacement rings and covers part numbers. `Part # . Description 41.1,. ` P2105BUCKET 411 Replacement Bucket 5- Gallon Parts, 1 P -2105 H& Pump Kit for 411 /P2105 P111 -WT L Replacement Cover (RT) Pi 11 WTL -S Replacement Seal for RT Cover P311 -1 R Replacement RT Ring P311 -14 RT Ring for 14" Riser P511YBUCKET Replacement Waste Oil Bucket P511- DEVRBUCKET Replacement 5- Gallon Bucket with Drain Valve Bucket Top Flange Gasket for Notched Gasket P511 -G14 Set P51 1 -PEVRBUCKET Replacement 5- Gallon Bucket with Plug Replacement 5- Gallon Bucket With C.I. Base & P511 C- DEVRBUCKET Drain Valve Replacement 5- Gallon Bucket P511 C- PEVRBUCKET Parts With C.I. Base &Plug ; Replacement 5- Gallon Bucket with Drain Valve P51 1 -DEVRB-1 4 12" & 14" Risers Replacement 5- Gallon Bucket with Plug —12" P511- PEVRB -14 & 14 Risers ` Replacement 5- Gallon Bucket W/ C.I. Base, P511 C- DEVRB -14 Drain Valve for 12" & 14" Risers Replacement 5- Gallon Bucket W/ C.I. Base, P511 C- PEVRB -14 Plug, for 12" & 14" Risers P521 -GKIT 521 Multi -Port Complete Gasket Kit P511 -GKIT 511 Multi -Port Complete Gasket Kit .corn 71 LAM Loa ��g2211� LF DEM Le — I I m JOK M. co 69 LU :t log a� 0` OWN 6 loop= � .r . 40003 did J� .'tea Aft 0 40 co �qm co "a MOON coo As DEM Le — I I m JOK M. co 69 LU :t log a� 0` OWN 6 loop= � .r . 40003 did J� .'tea Aft 0 40 SWRCB, January 2002 Page of Secondary Containment Testing Report.Form 7'1 ?iS foYJll 1S ll?tel ?C %Cl foY use lJy CO) ?tYaCtOrs p2rfOY111117g peYlolliC testing of U,ST cecol ?ClaYy col ?fail ?lltel ?t .Systelrrs. Use the appropriate pages of this fords to report results for all components tested The completed form, ivritten test procedures, and prig ?toasts fivin tests (if applicable), should be provided to tl ?e facility otivner /operator for submittal to the local regatlatory agency. 1. FACTT.TTV INFORMATION Facility Name: Circle K Store #2708606 Date of Testing: 9/2512018 Facility Address: 1030 OAK ST, BAKERSFIELD, CA 93304 -T-Phone: Facility Contact: Circle K Stores Inc. (661) 861 -1442 Date Local Agency Was Notified of Testing: 8/28/2018 Name of Local Agency Inspector f f present during testing): 7. TF.CTTNV- VnNTRACTOR INFORMATION Company Name: Belshire Environmental Services, Inc. Technician Conducting Test: Jeff Badders Credentials: ® CSLB Licensed Contractor 0 SWR.CB Licensed Tank Tester License Type: A. - General Engineering Contractor MILicense Number: 808313 M"ufheturer'Tr�ainine Manufacturer Component(s) Date. Training Expires � See Attached ❑ ❑ 3. SUMMARY OF TEST RESULTS Not Repairs Pass Fail Component Component ��E= Tested Made Tank Annulars 3 � ❑ ❑ ❑ == wmmm Secondary Pie 3 W ❑ ❑ ❑ 000m om__ Piping Sum 3 W ❑ ❑ ❑ wmmm UDC 2 0 ❑ ❑ ❑ mmm_ ■mm�v Fill Sump 3 ❑ ❑ ❑ Spill Bucket 6 ❑ � ❑ ❑ 87 Vapor Failed If hydrostatic testing was performed, describe what was done with the water after completion of tests: [� Placed in drums left on site for proper disposition. 0 Transported to next site for use in additional testing. zo ��E= mmm� WM == wmmm w-__ 000m om__ 00mm wmmm mmm� mmm_ ■mm�v CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my lrnoWedge, the facts stated in this document are accurate acid in full compliance with legal requirements Technician's Signature: �` �, <.(r.l� Date: 9/25/2018 A T A NU A NNr rr . A U TR4;.T1Nr Test Method Developed By: ❑ Tank Manufacturer ® Industry Standard. ❑ Professional Engineer ❑ Other (Specify) Test Method Used: ❑ Pressure ® Vacuum ❑ Hydrostatic ❑ Other (Specify) Test Equipment Used: Test plugs, venturi pump and gauges Equipment Resolution: 0.5% of span 87 Master 89 91 Is Tank Exempt From Testing?' No No No Tank Capacity: 10,000 10 000 10,000 Tank Material: Fiberglass Fiberglass Fiberglass Tank Manufacturer: Total Containment Total Containment Total Containment Product Stored: 87 89 91 Wait time between applying pressure /vacuum/Water and starting test: 10 minutes 10 minutes 10 minutes Test Start Time: 07 :50 AM 08:20 AM 08:45 AM Initial Reading (Rj): 10 In. Vac 10 In. Vac 10 In. Vac Test End Time: 08 :50 AM 08 :20 AM 09:45 AM Final Reading (Rr): 10 In. Vac 10 In. Vac 10 In. Vac Test Duration: 60 Min 0 Min 60 Min Change in Reading (RF -R,): 0 In. Vac 0 In. Vac 0 In. Vac Pass/Fail Threshold or Criteria: No Detectable Loss No Detectable Loss No Detectable Loss Test Result: Pass Pass Pass Was sensor removed for testing? Yes Yes Yes Was sensor properly replaced and verified functional after testing? Yes Yes Yes .Comments — (include illfor»ratio17 017 repairs made prior to testing, and recorniiiiei7dez`I follotii, -itp, for failed tests) i Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary containment, such as systems that are hydrostatically monitored or under constant vacuum, are exempt from periodic contairnent testing, {California Code of Regulations, Title 23, Section 2637(a)(6)} , C ONDARY PIPE TESTING Test Method Developed By: ❑ Piping Manufacturer ® Industry Standard ❑ Professional Engineer ❑ Other (Specify) Test Method Used: ® Pressure ❑ Vacuum ❑ Hydrostatic ❑ Other (Specify) Test Equipment Used: Test reducer boots, air compressor and gauges Equipment Resolution: 0.5% of span 11WIF 87M 89 91 Piping Material: Fiberglass Fiberglass Fiberglass Piping Manufacturer: AO Smith AO Smith AO Smith Piping Diameter: 3" 3" 31' Length of Piping Run: 70' 70' 70' Product Stored: 87 89 91 Method and location of piping -run isolation: Reducer Boots /Fittings Reducer Soots /Fittings Reducer Boots /Fittings Wait time between applying pressure /vacuum/water and starting test: 10 Minutes 10 Minutes 10 Minutes Test Start Time: 08:00 AM 08:00 AM 08 :00 AM Initial Reading (RI): 5 5 5 Test End Time: 09 :00 AM 09:00 AM 09:00 AM Final Reading (RF): S 5 5 Test Duration: 60 Min 60 Min 60 Min Change in Reading (RF -RI): 0 0 0 Pass/Fail Threshold or Criteria: No Detectable Loss No Detectable Loss No Detectable Loss Test Result: Pass Pass Pass Comments (include inforination on repairs made prior to testing, and reco»irrnet7clecl follo3t?- ttp,for failed tests) fi_ PTPTNC, ,S1TMP TESTING Test Method Developed By: ❑ Sump Manufacturer N Industry Standard ❑Professional Engineer ❑ Other (Specify) Test Method Used: ❑ Pressure ❑ Vacuum N Hydrostatic ❑ Other (Specify) Test Equipment Used: Incon TS -STS Sump Test System Equipment Resolution: +/- 0.002" 91 87 Master 89 Sump Diameter: 4811 48°i 48" Sump Depth: 69" 69" 69" Sump Material: Fiberglass Fiberglass Fiberglass Height from Tank Top to Top of Highest Piping Penetration: 2211 2211 22" Height from Tank Top to Lowest Electrical Penetration: 12" 12" 12" Condition of sump prior to testing: Good Good Good Portion of Sump Tested' 4" Above Pen. 4" Above Pen. 4" Above Pen. Does turbine shut down when sump sensor detects liquid (bath product and water) ?* ❑ Yes ❑ No ® NA ❑ Yes ❑ No ® NA ❑ Yes ❑ No M NA ❑ Yes ❑ No ® NA Turbine shutdown response time N/A N/A N/A Is system prograrnmed for fail -safe shutdown ?* ❑ Yes ❑ No ®NA ❑ Yes ❑ No M NA ❑ Yes ❑ No N NA ❑ Yes ❑ No ®NA Was fail -safe verified to be operational?� ❑ yes ❑ No M NA ❑ Yes ❑ No ®NA ❑ Yes ❑ No ®NA ❑ Yes ❑ No ®NA Wait time between applying pressure /vacuum/water and starting test: 30 minutes 30 minutes 30 minutes Test Start Time: 11:03 AM 10:15 AM 09:35 AM Initial Reading (Ri): 4.1303 6.0925 6.4634 Test End Tune: 11:19 AM 10:30 AM 09:50 AM Final Reading (RF): 4.1297 6.093 6.463 Test Duration: 15 min, 15 min. 15 min. Change in Reading (RF -Rj): - 0.0006 0.0005 - 0.0004 Pass/Fail Threshold or Criteria: +/-0.002" 0.002 +/-0.002 Test Result: Pass Pass Pass Was sensor removed for testing? Yes Yes Yes Was sensor properly replaced and verif ed functional after testing? Yes yes Yes Cominents (Inchide inforination on repairs made prior to testing, and recoiiiriieiided follow -tip foi- failed tests) Sensor functionality was not confirmed. This procedure is not part of the Secondary Containment Testing scope of work. ' If the entire depth of the sump is not tested, specify how much was tested. If the answer to M of the questions indicated IN"ith an asterisk (*) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160) ? TTV'n'P1?_nTCPIWXg1W.R MNTATNMF,NT (IJDQ TESTING Test Method Developed By: _ ❑ UDC Manufacturer ® Industry Standard D Professional Engineer ❑ Other (Specify) Test Method Used: ❑ Pressure ❑ Vacuum 0 Hydrostatic ❑ Other (Specify) Test Equipment Used: Incon TS -STS Sump Test System Equipment Resolution: + /- 0.002" UDC # UDC # UDC # 1/2 UDC # 3/4 UDC Manufacturer: Bravo Bravo UDC Material: Steel Steel UDC Depth: 10" 10" Height from UDC Bottom to Top of Highest Piping Penetration: Bottom Bottom Height from UDC Bottom to Lowest Electrical Penetration: Bottom Bottom Condition of UDC prior to testing: Fair Fair Portion of UDC Tested 4" Above Pen. 4" Above Pen=109NA Does turbine shut down when UDC sensor detects liquid (both product and water)? ❑ Yes ❑ No ® NA ❑`Yes Yes ❑ No IZ NA ❑ Yes ❑ No ®NA Turbine 'shutdown response time N/A N/A Is system programmed far fail - safe shutdown. ❑ Yes ❑ No ® NA ❑ Yes ❑ No ® NA ❑ Yes ❑ No ® NA ❑ Yes ❑ No ® NA Was fail -safe verified to be operational?' ❑ Yes ❑ No ®NA ❑ Yes ❑ No U NA . ❑ Yes ❑ No ®NA ❑ Yes ❑ No U NA Wait time between applying pressure /vacuum/water and starting test 30 minutes 30 minutes Test Start Time: 12:48 PM 12:48 PM initial Reading (RI): 2.6507 3.8305 Test End Time: 01:03 PM 01:03 PM Final Reading (Rr): 2.6501 3.831 Test Duration: 15 min. 1 S min. Change in Reading (RF -R): - 0.0006 0.0005 'Pass/Fail Threshold or Criteria: +/-0.002 +/-0.002 Test Result: Pass Pass Was sensor removed for testing? Yes Yes Was sensor properly replaced and verified functional after testing? Yes Yes Comments — (Inchede information on repairs inacle prior to testing, and recomiiiended folloii -tip for failed tests) xvac nn+ ennfirmed. This procedure is not part of the Secondary Containment Testing scone of work. ' If the entire depth of the UDC is not tested, specify how much was tested. If the answer to and of the questions indicated with an asterisk ( *) is "NO" or "NA ", the entire UDC must be tested. (See SWRCB LG -160) R_ FTT.T, RTIqFR CONTAINMENT SUMP TESTING Facility is Not Equipped With Fill Riser Containment Sumps ❑ Fill Riser Containment Sumps are Present, but were Not Tested ❑ Test Method Developed By: ❑ Sump Manufacturer 9 Industry Standard ❑ Professional Engineer ❑ Other (Spec ) Test Method Used: ❑ Pressure ❑ Vacuum 0 Hydrostatic ❑ Other (,Specify) Test Equipment Used: tncon TS -STS sump Test system Equipment Resolution: +/- 0.002" 89 91 INESOMM 87M Sump Diameter: 48" 48" 48" Sump 13epth: 65" 65" 65" Height from Tank Top to Top of Highest Piping Penetration: N/A N/A N/A Height frdm Tank Top to Lowest Electrical Penetration: 22" 26" 19" Condition of sump prior to testing: Good Good Good Portion of Sump Tested 4" Above Pen. 4" Above Pen. 4" Above Pen. Sump Material: Fiberglass Fiberglass Fiberglass Wait time between applying pressure /vacuum/water and starting test: 30 minutes 30 minutes 30 minutes Test Start Time: 08:50 AM 08:50 AM 10:15 AM Initial Reading (Rj); 5.5685 3.8927 5.0967 Test End Time: 09:05 AM 09:05 AM 10:30 AM Final Reading (Rr): 5.5678 3.8918 5.0969 Test Duration: 15 min. 15 min. 15 min. Change in Reading (Rr. -RD: - 0.0007 - 0.0009 0.0002 Pass/Fail Threshold or Criteria: +/-0.002 +/-0.002 +/-0.002 Test Result: Pass Pass Pass is there a sensor in the sump? Yes Yes Yes Does the sensor alarm when either product or water is detected? ❑ Yes ❑ No ® NA ❑ Yes ❑ No ® NA ❑ Yes ❑ No ® NA ❑ Yes ❑ No N NA Was sensor removed for testing? Yes Yes Yes Was sensor properly replaced and verified functional after testing? Yes Yes Yes Comments — (include information on repairs made prior to testing, and reco»tnlencled follow -up foi•,failed lests) () .1RPTT,T.1OVFRFTT.1. CONTAINMENT BOXES Facility is Not Equipped With Spill/Overfill Containment Boxes ❑ Spill/Overfill Containment Boxes are Present but Nvere Not Tested ❑ Test Method Developed By: ❑ Spill Bucket Manufacturer N Industry Standard ❑ Professional Engineer ❑ Other (,Specify) Test Method Used: ❑ Pressure ❑ Vacuum 9 Hydrostatic ❑ Other (Specify) Test Equipment Used: Incon TS-STS Sump Test System Equipment Resolution: +/-0.002" �UW Spill 87 FB Spill Box # 87 VB Spill Box # 89 FB Spill Box # 89 VB Bucket Diameter: 1211 1211 1211 1211 Bucket Depth: 12" 12't 1211 1211 Wait time behveen applying pressure/vacuum/water and starting test: 30 minutes 30 minutes 30 minutes 30 minutes Test Start Time: 11:03 AM 11:03 AM 11:37 AM 11:37 AM Initial Reading (RI): 3.7782 5.7571 2.2085 5.0362 Test End Time: 11 :19 AM 11:19 AM 11:52 AM 11:52 AM Final Reading (Rr,): 3.7779 5.5709 2.2083 5.0358 Test Duration: 15 min. 15 min. 15 min. 15 min. Change in Reading (RF-R,): -0.0003 -0.1862 -0.0002 -0.0004 Pass/Fail Threshold or Criteria: +/-0.002" +/-0.002" +/-0.002" 0.002ft - Test Result: Pass_ Fail Pass Pass -Comments —(iiiclitcleii?foniiation oil repairs made prior to testing, and recoi?ii)iej7c7edfolloii,-iipfoi-.failed tests) 9. SPTLL /OVERFILL CONTAINMENT BOXES Facility is. Not Equipped With Spill /Overfill Containment Boxes ❑ Spill/Overfill Containment Boxes are Present, but were Not Tested ❑ Test Method Developed By: ❑ Spill Bucket Manufacturer ® Industry Standard ❑ Professional Engineer ❑ Other (Specify) Test Method Used: ❑ Pressure ❑ Vacuum N Hydrostatic ❑ Other (Specify) Test Equipment Used: !neon TS -STS Sump Test System Equipment Resolution: + /-0.002" Spill BOX # 91 ` B Spill Box # Spill Box # 91 FB Spill Box- # Bucket Diameter: 12►f 1211 Bucket-Depth: 12" 12" Wait time between applying pressure /vacuum/water and starting test: 30 minutes 30 minutes Test Start Time: 11:37 AM 11:37 AM Initial Reading (RI): 2.0376 7.0138 Test End Time: 11:52 AM 11:52 AM Final Reading (RI,): 2.037 7.0139 Test Duration: 15 min. 15 min. Change in Reading (RF -RI): - 0.0006 0.0001 Pass/Fail Tlueshold or Criteria: +/-0.00211 +/-0.002" Test Result: Pass Pass Comments — (include in formation on repairs made prior to testing, and recorntmejided folloii,- itp.for failed tests) Name Badders, Jeff Badders, Jeff Badders, Jeff Badders, Jeff Badders, Jeff Badders, Jeff Badders, Jeff Manufacturer Training Training Containment Solutions Tank Installation INCON Level 4 - Franklin Sump Test System NOV FiberGlass Systems Piping (Formeriv AO S Xerxes UST Installation Training Seminar OPW EVR Phase I - UST OPW Fueling Containment Svstems - FlexWorks Phil Tite Spill Collectors & Associated Hardware Completed 2/17/2017 10/28/2016 6/22/2017 9/14/2018 5/19/2017 5/19/2017 6/19/2017 Expires 2/17/2019 10/28/2018 6/22/2020 9/14/2021 5/1.9/2019 5/19/2019 6/19/2019 1 z 3 4 S 6 7 8 9 10 ix iz xs BUSINESS NAME:Circle K Store #2708606 SITE ADDRESS: 1030 OAK St. I CITY: Bakersfield ZIP: 93304 MAP DATE: 12/3/15 SURVEY BY: DRAWN BY:ZK AGENCY FACILITY #: LEGEND DISPENSER SHUTOFF CASHIER /� { A) ABSORBENT F[ FLAMMABLE LIQUID MSDS & MSDS EMERGENCY PIAM �R BATH ROOM O EMERGENCY FIRE HYDRANT WELL MONITORING V�EU„ CL COMBUSTIBLE LIQUID 78 TRASH BIN ❑ SEWER /FLOOR DRAIN SHUT OFF pi OELECTRICAL PANEL TANK MONITOR WATER MC MOTOR COOLANT . - • FENCE + FIRST AID SOLID WASTE DRUM EVACUATION PPE M() MOTOR OIL •�• VENT RISERS 1 FIRE EXTINGUISHER O LIQUID WASTE DRUM / ® AREA OVERFILL ALARM TELEPHONE EM EMERGENCY EXIT CO2 CO2 CYLINDER ® STORM DRAIN S or CLEAN AIR \ UST SENSOR ® OISPENSER a TRANSFORMER VENT RISERS with VENT SUMP/ SEPARATOR HCAS �•� 1 NITROGEN (� J NATURAL GAS SHUTOFF VENT BOX