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Home My WebLink AboutMAJOR MOD CONTRACTOR INFO 1.22.19vels.-nire �3i�9 /l�pifTa!�iil,`aB�!,��7A`V�a A1�3C'd 259 V, 3 1idi8' LfIlB �RYS t#►iII R9'nc :lam, =t0ZI'D :r�i?JE�1�.t3c"+151iItiE:C�K'1 October 11, 2016 To whom it may concern: F .r,J d'iu'y�nt I�y+�kl,�n��fre�i I�nti uass<1ti:i: 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. 1 2 3 4 5 6 7 8 9 10 11 12 13 BUSINESS NAME:Circle K #2701270 SITE ADDRESS:5634 Stine Rd. CITY: Bakersfield ZIP:93313 MAP DATE: 12/2/151 SURVEY BY: DRAWN BY:ZK 7 AGENCY FACILITY #. A B C D E F G H I I K L Scope of Work 1) Install Icon repair penetration on 87 product line and retest 2) Saw cut & breakout around 87 vapor spill bucket to replace like for like 3) Install new cord grip connectors on electical J-boxes & retest List of Material 1) 1 -Icon FIR L3.5LP 2)1- OPW 2100 Vapor Spill Bucket I Vacant I Lot l i i i �� G ; f i U A ry Z' 4 ( f II 1 AOL 7/8114! f I 51/61% 1 Enter /Exit Enter/Ekit N ( i Harris I ! RL Scope of Work 1) Install Icon repair penetration on 87 product line and retest 2) Saw cut & breakout around 87 vapor spill bucket to replace like for like 3) Install new cord grip connectors on electical J-boxes & retest List of Material 1) 1 -Icon FIR L3.5LP 2)1- OPW 2100 Vapor Spill Bucket . DIMMONMENTAL Scope of Work Facility: CIRCLE K 2701270 5634 STINE RD BAKERSFIELD, CA Date: 10/15/2018 Job Number: 0 Estimate No: 12691 Contact: Location: General ►Nork to be performed: concrete and old bucket will be placed in solid drum onsite Location: Dispenser 1/2 Nork to be performed: Install Icon penetration repair fitting on the 87 product line and re -test Location: Spill Bucket - Vapor Work to be performed: Break ground to install new OPW direct Bury spill bucket Location: Turbine Sump - 87 Master Work to be performed: Install cord grips on electrical wires, seal junction boxes /conduit and re- test ® � LIABILITY DATE (NN(DDIYYYY) 3/29/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOLDER. 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 certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the teens and conditions of the policy, cerWn policies may require an endorsement. A staternent on this c erlbificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Garrett/Mosier /Griffith /Sistrunk CNAM�E:' Marissa Romo Risk Management & Insurance Services 12 Truman Irvine, CA 92620 PHONE 949 - 559 -6700 a No): 949 - 559 -6703 E-MAIL ADDRESS: marissarg m s.com INSURERS AFFORDING COVERAGE NAIL # 4/1/2018 WSURERA: Great Divide Insurance Company 25224 www.gmgs.com OB84519 INSURED Belshire Environmental Services Inc. 25971 Towne Centre Drive INSURER 13: Nautilus Insurance Company 17370 INSURERC: INSURER D: Foothill Ranch CA 92610 INSURER E: I IMURER F: PERSONAL & ADV INJURY /%A\/CCPAf_CC GQT1GIr` ®TF NI WIRER- A 1 44 lli a0 KCVI`SKim IVLJML'31=11: 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 SUER POLIOYNUNIBER POLICY EFF NBWDD POLICY EXP MWDD LAS A ,� I COMMERCIAL GENERAL LMILITY CLAIMS -MADE F —./] OCCUR GLP01548949 -16 4/1/2018 4/1/2019 EACH OCCURRENCE $1,000000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 I PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I POLICY � PRO- F LOC JECT OTHER: GENERAL AGGREGATE $1,000,000 PRODUCTS - COMP /OP AGG $1,000,000 A AUrOMOBILELIABLITY ✓ 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 COMBINED SINGLE LIMIT Ea accident $120002000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ B UN13RELLALIAB EXCESS LIAB ✓ occuR CLAIMS -MADE FFX1547284 -16 4/1/2018 4/1/2019 EACH OCCURRENCE $1,000000 AGGREGATE $1,000,000 _ DED E RETENTION $ $ A WORIMRS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANYPROPRIETOR /PARTNER/EXECUTIVE ❑ OFFICERIMEMBEREXCLUDED? (Mandatory in MIN) If yes, describe under DESCRIPTION OF OPERATIONS below N/ A WCA1547285 -16 4/1/2018 4/1/2019 �/ STATUTE OERH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $1_090�OQ0 $1,000,000 B B Contractors' Professional Liability Contractors' Pollution Liability I 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 I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GERTIFIGATE MULDEK 1 norm SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORMED REPRESENTATIVE Griff Griffith V 7M513.4ano ALOUKU 4unrur 4I LVIV. #all nynttv re=htxVt a. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 41115169 1 18 -19 A /G /W /U /$1M E &O /POLL I Marissa Romo 1 3/29/2018 5:13:58 PM (PDT) I Page 1 of 1 (http://www.iccsafe.o[g/) 5z5yeb) My Professional Information: Last, First MI: Gonzalez,.Saul Certified under this name: Saul Gonzalez City, State Zip: Foothill Ranch,, CA 92610 Certification Type(s): UST Installation/ Retrofitting(expires 06/02/2019) California UST Service Technician (expires 09/23/2019) RECEIVES MEMBER, BENEFITS? NO Upload your image by pressing the 'Upload Your Photo' link on the left side menu. LQL I UU lq 2/20/2017 Score Report: installer Certification Exam: Repair and MWay Pro Composite Covers If you have scored 80% or more you have passed! Congratulations! You are now a certified icon Installer I Please download and keep this Certificate with you as proof of your Certified Status If you have scored less than 80 % please re -take the Exam . If you are struggling and would like some free help please email us at sales @icontainment.com and we will arrange further training or to call you or answer any areas where you are having difficulty. If you would like to share your feedback with us on your Exam experience please Email any comments to training @icontainment.com Thank you for taking the Icon Containment Repair Certification Exam and we wish you future success with all Icon's products. Your Certificate I�(eS�1�ti Installer Certification: Exam: Repair and MWay Pro Composite G Covers Saul Gonzalez Mob 4FWjaY £ Con ainnient Solutions 891900 (89.13 %) belshlre environmental 2 Year Certification Start Hate: February 20, 2017 C:)) F30 V%f R E T A I IL F U E L t! N G A HOVER •COMPlWlr Dear Trained Contractor: Leud;<ng The Way to FuOin� Innovation Worldwide Congratulations on completing your OPW F1exWorks Contractor Training! OPW is proud to add you to our list of Factory Trained Installers. Your Training Wallet Card is below. Please cut it out and carer it with you as vefificatron of your trainingg. If you notice any errors on your card, or if you should lose it, please feel free to contact me by email at 1isa.1overing @opwglobaLcom or by phone at (919) 209 -2442 and I will promptly issue you a corrected version or a replacement. Your training remains in effect for 2 years, at which time you will require retraining. Please contact me or your local OPW District Manager to set up retraining. Again, Congratulations, We look forward to working with you. Regards, " Please cut along dotted line. Carry your card with you as verification of training. ' -I ------------------------------------ Lisa Covering 4C3 F30 VV. Marketing and Communications Coordinator ........ i OPW Retail Fueling acknowledges ; 919 -209 -2442 (phone) ' Saul Gonzalez of Belshire Environmental Svcs. 919 - 573 -9497 (fax) Lisa.lovering @opwglobal.com (email) has attended installation training for the FlexWorks System by Telephone: 1(919) 209 -2442 OPW Retail Fueling ' Fax:1 (919) 573 -9497 1 05/19/2017 05/1912019 ` Training Date Authorized OPW-FCS Expiration Date t Customer Service: 422 -2525 I Representative r _r i -wF WWW.oaWj�iobal.com onr>E connPp NY.. 014E hro.e ea.:;_iom,ivi'E �soitiif cE: DPW Retail Fueling ' -I OPW Retail Fueling DPW Fuel Management Systems` �__�' 9393 Princeton - Glendale Rd. 3250 US Highway 70 Business West 5900 Santa Fe Dr. =: €A ' Hamilton, Ohio USA 45011 Smithfield, NO USA 27577 -6954 Hodgkins, Illinois USA 60525 Tel: 1(800) 422 -2525 Telephone: 1(919) 209 -2442 Tel: 1(708) 485 -4200 Fax:1 (800) 421 -3297 Fax:1 (919) 573 -9497 Fax:1 (708) 485 -7137 ` Intl Tel: 1 (513) ( ) 870 -3315 Customer Service: 422 -2525 info @opwfm.com , .. •.;c t . F ; �. Intl Fax:1 (513) 870 -3157 Customer Service Fax:1 (800) 421 - 3297 domesticsales @opw- fc.com intisates @o w-fe.com - � i,co-.. � �� =MT SplitRepair fittings are designed to replace existing entry fittings that leak as the result of age, degradation, or other damage. These fittings are installed without the disconnecting of pipe, breaking concrete or replacement of the sump container. Encapsulation designed fittings completely seal over the existing fitting design and are ususally filled with a secondary fast-setting, fuel-compatable sealant. , SplitRepair requires no disconnecting ofpipe " More cost-effective than equipment replacement ^ Pernmanantly bonded in one hour • Testing can proceed immediately after installation • UL Listed and All-fuels compatible IRF L2.OLP Icon SplitRepair Encapsulation Fitting Kit for 2.0" OD Pipe, Flat Suftace, 8-Bolt, Low Profile |RF L2.2LP Icon SplltRepair Encapsulation Fitting Kit for �� Pipe, Flat Surface, 8-Bolt, Low Profile IRF L2.5LP Icon SplitRepair Encapsulation Fitting Kit for 2.5" OD Pipe, Flat Surface, 8-Bolt, Low Profile IRF L2.7LP Icon SplitRepair Encapsulation Fitting Kit for 2.7" OD Pipe, Flat Surface, 8-Bolt, Low Profile |RFUoLP Icon SpIuRnpar Encapsulation Fitting Kit for o.o^omPipe, Flat Surface, 8-Bolt, Low Profile |RFua.oLP Icon SplitRepair Encapsulation Fitting Kit for u,ruu Pipe, Flat Surface, u-uuu Luwrmn/e |npus.7Lp Icon SplitRepair Encapsulation Fitting Kit for 3.7" OD Pipe, Flat Surface, 8-Bolt, Low Profile |RF L4.5LP Icon SplitRepair Encapsulation Fitting Kit for 4.5" OD Pipe, Flat Surface, 8-Bolt, Low Profile IRF L4.6xl.9xl.4 Icon SplitRepair Encapsulation Fitting Kit for 4.6" x 1.9" x 1.4" & 1.0" OD Pipe, Flat Surface, 8-Bolt IAoMoun2m Manual Dispensing Gun for uuozCartridge Notes Volume for referenced material use with fittings on this page is as follows: FastFuse - 1 can per 4 fittings; Sikaflex - 1 tube per 4 fittings; and FastFill - 1.0-1.5 cartridges per fitting DEVR Models - Fill Port with Drain Valve Duratuff ®11 Base with Drain Valve Models Model # Gal. Liter Cover lbs. kg 1- 2100 -DEVR 5 119 Aluminum 40 18" 1 C- 2100 -DEVR 5 `19 Cast Iron 53 :24' 1 -2115 -DEVR 1557 :' Aluminum 47 21� " 1C- 2115 -DEVR 15 'S7 Cast Iron 60 .27 Cast Iron Base with Drain Valve Models Model # Gal. Liter Cover lbs. kg 1 -2100C -DEVR 5' 19, ".`Aluminum 40 18 " "; 1 C -2100C -DEVR 5 19 :, Cast Iron 53 24: .1 -2-L14L -DEVR 15 ;—'57 Aluminum 47 2e1` 115C PEVR Models - Vapor Port with Plug Duratuff ®11 Base with Plug Models Model # Gal. Liter Cover lbs. kg 1- 2100 -PEVR 5 �19 'Aluminum 40 18 1 C- 2100 -PEVR 5 1�9, °- Cast Iron 53 2 Cast Iron Base with Plug Models Model # Gal. Liter Cover lbs. kg 1 -21000 -PEVR 5 Aluminum 40 18� 1 C -2100C -PEVR 5 19 ,., Cast Iron 53 Replacement Parts Part # Description 1 DK- 2100 -EVR Drain Valve Kit 1 -21AC Aluminum Cover w /Seal 1 -21 CC Cast Iron Cover wl Seal H12229M Cover Seal 1 PPK -2100 Hand Pump & Plug Kit for 1 -2100 1 DP -2100 Replacement Drain Plug Kit for 1 -2100 OPW 1 -2115, 15- Gallon 16" 1- 2100 -PEVR Series Vapor Recovery Spill Container 1e" :m i017/32" 52 cm 56 cm *Subtract 2" from height dimension for Cast Iron Base Models. NOTE: 2017/32" dimension is height from riser pipe to finish grade ( +1 " for slope) TC -400 Torque Cap Provides an easy means of threading a 4" NPT nipple into a spill container. The OPW TC -400 coupled with the OPW 61 SA -TOOL can provide the necessary torque requirements for installing adaptor nipples for spill containers. The TC -400 can easily be removed without disturbing the installed threaded nipple. The TC -400 also eliminates the need for a strap or chain wrench. 4" Threaded Pipe Nipple OPW pipe nipples are CNC machined, providing a smooth sealing surface where a gasket seal exists. Available in various lengths to custom fit the necessary height requirements for Fill and Vapor Adaptors. 61JSK Jack Screw Device See page 65 for detailed information. FSA -400 Face Seal Adaptor See page 65 for detailed information. The following products are in compliance with California Part # Description Water Resources Control Board (W.R.C.B.) for coating of SL -1100 Urethane Sealant (1.0.3 oz.) buried metal components, such as stainless steel clamps W.R.C.B, approved CCR Title 23, Div. 16, Sec. 1631 & 2636 or entire Spill Containment Bucket bottoms. POST r � BUSI�3EE'S •TAX �SE,RTI��ATE � � Jy f __'� .w;?4s4,...�n..��_..'_ ,LU,A. z.y ` .f ....� <r...,.. ars +ry , #>:.4rrs.�.,+cm �t .. ,k;»�''.✓x:�..., ;3_.��.v -t�rsYCi'- ,'s.wr= l..R..a ..'"a+r._x. e..,f, �; Business name.: BELSHIRE ENVIRONMENTAL SVCS IN Location address OUTSIDE CITY Lic Nhr /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 NON- TRANSFERABLE* E A,,� �l 1. v� • // Sri r c ^ 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 1.0 CONDUCT BUSINESS IF LICENSEE HAS NOT COMPLIED WITH ALL APPLICABLE LAWS AND ORDINANCES, THIS LICENSE IS ISSUED WITHOUT VERIFICATION THAT THE LICENSEE IS SUBJECT TO OR EXEMPT FROM LICENSING BY THE STATE OF CALIFORNIA. UffA J I, T -" A Date: 10/9/2018 To: Ernie Medina Bakersfield City CUPA 1500 Truxtun Ave Bakersfield, CA 93301 From: Zac Kavanaugh Sent Via: Email Re: Secondary Containment Test Circle K Store #2701270 5634 STINE RD BAKERSFIELD, CA 93313 The following test report(s) are included: SCT -3 yr Comments: Please do not hesitate to call me at (949) 460 -5200 if you have any questions or concerns regarding this work. - 0-c-, I Zac Kavanaugh Project Coordinator 1812041 SWRCB, January 2002 Secondary Containment Testing Report Form. Page of This form is intended for use by contractors perfofiiring periodic testing of UST secondat.y containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, ii�ritten test procedures, and printouts from tests (if applicable), should be provided to the, facility oianer /operator for stibniittal to the local regulatm,y agency. 1 _ FAC.TT.TTV TNFORMATTON Facility Name: Circle K Store #2701270 Date of Testing: 9/26/2018 Facility Address: 5634 STINE RD, BAKERSFIELD, CA 93313 Facility Contact: Circle K Stores Inc. Phone: (661) 834 -8625 Date Local Agency Was Notified of Testing: 8/28/2018 Name of Local Agency Inspector (ifpresent during testing): 2 TF.CTYNr- C nNTR ACTOR TOR TNFOUMA TION Company Nazne: Belshire Environmental Services, Inc. Technician Conducting Test: Jeff Badders Credentials: ® CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: A - General Engineering Contractor License Number: $08313 Manufacturer Training Manufacturer Component(s) Date Training Expires See Attached ❑ ❑ 3, SUMMARY OF TEST RESULTS Not Repairs Pass Fail Component Component Tested Made Tank A.nnulars 2 ❑ ❑ ❑ Secondary Pie 2 W ❑ ❑ ❑ Piping Sum 2 ❑ 0 ❑ ❑ LT DC 4 ❑ 'W ❑ ❑ Fill Sump ❑ ❑ ❑ ❑ Sp ill Bucket 4 ❑ 0 ❑ ❑ 87 Direct 91 Vapor Failed If hydrostatic testing was perfonned; describe what was done With thevater alter completion of tests: Placed in drums left on site for proper disposition. Transported to next site for use in additional testing. Pass Fail Not Repairs Tested Made El ❑ ❑ ❑ MODL' xnDOC wnDOM moos �DO� CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING . To the best of my knowledge, the f ets stated in this document. are accurate and in fall compliance with legal requirements Technician's Signature: ` �' "�'�� '`' Date: 9/26/2018 4. TANK ANNULAR TESTING 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 91 gM Is Tank Exempt From Testing?' No No Tank Capacity: 10,000 10,000 Tank Material: Fiberglass Fiberglass Tank Manufacturer: Xerxes Xerxes Product Stored: 87 91 Wait time between applying pressure /vacuum/water and starting test: 10 minutes 10 minutes Test Start Time: 08:00 AM 08:00 AM initial Reading (RI): 10 In. Vac 10 In. Vac Test End Time: 09:00 AM 09:00 AM Final Reading (RF): 10 In. Vac 10 In. Vac Test Duration: 60 Min 60 Min Change in Reading (RF -RI): 0 In. Vac 0 In. Vac Pass/Fail Threshold or Criteria: No Detectable Loss No Detectable Loss Test Result: Pass Pass Was sensor removed for lesting? No No Was sensor properly replaced and verified functional after testing? N/A N/A Comments — (include information on repairs made prior to testing, and i- ecoii1)71ei7deel folloii, -zip foi- failed tests) 1 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 containment testing. {California Code of Regulations, Title 23, Section 2637(a)(6)) 5. SECONDARY 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 87M =91 Piping Material: Fiberglass Fiberglass Piping Manufacturer: AO Smith AO Smith Piping Diameter: 3" 3" Length of Piping Run: 200' 200' Product Stored: 87 91 Method and Location of piping -run isolation: Reducer Boots /Fittings Reducer Boots /Fittings Wait time between applying pressure /vacuum/water and starting test: 10 minutes 10 minutes Test Start Time: 08 :45 AM 08:45 AM Initial Reading (Rj): 5 5 Test End Time: 09:45 AM 09:45 AM Final Reading (Rr): 5 S Test Duration: 60 Min 60 Min Change in Reading (Rr -RF): 0 0 Pass/Fail Threshold or Criteria: No Detectable Loss No Detectable Loss Test Result: Pass Pass Comments -- (include inforniation on repairs made prior to testing, and recornmiei7cled folloii, -up, for, failed tests) 6. PIPING SUMP TESTING Test Method Developed By: ❑ Sump Manufacturer N Industry Standard ❑ Professional Engineer ❑ Other (Specff Test Method Used: ❑ Pressure ❑ Vacuum N Hydrostatic ❑ Other (Specify) Test Equipment Used: lncon TS -STS Sump Test System Equipment Resolution: +/- 0.002" 87 Master 91 Sump Diameter: 52" 521' Sump Depth: 53" 53" Sump Material: Fiberglass Fiberglass Height from Tank Top to Top of Highest Piping Penetration: 13" 11 " Height from Tank Top to Lowest Electrical Penetration: 29" 21" Condition of sump prior to testing: Good Good Portion of Sump Tested' 4" Above Pen. 4" Above Pen. Does turbine shut down when sump sensor detects liquid (both product and water) ?* ❑ Yes ❑ No N NA ❑ Yes ❑ No N NA ❑ Yes ❑ No N NA ❑ Yes ❑ No N NA Turbine shutdown response time N/A NIA Is system programmed for fail -safe shutdown ?* ❑ Yes ❑ No N NA ❑ Yes ❑ No N NA ❑ Yes ❑ No N NA ' ❑ Yes ❑ No N NA Was fail -safe verified to be operational t ❑ yes ❑ No N NA ❑ Yes ❑ No N NA ❑ Yes ❑ No N NA ❑ Yes ❑ No N NA Wait time between applying pressure /vacuum/water and starting test: 30 minutes 30 minutes Test Start Time: 09:45 AM Initial Reading (RD: 4.3564 Test End Time: 10:00 AM Final Reading (RF): 4.3566 Test Duration: 15 min. 15 min. Change in Reading (RF -RI): 0.0002 Pass/Fail Threshold or Criteria: +/-0.002" +/-0.002 Test Result: Not Tested Pass Was sensor removed for testing? N/A Yes Was sensor properly replaced and verified functional after testing`? N/A Yes Comments — (include inforindlion on repairs made prior to testing, and reco)?in ►ei7declfolloli,- up,forfailed tests) Sensor functionality was not confirmed. This procedure is not part of the Secondary Containment Testing scope of work. 87 not tested missing cord grip and electrical box plugs. Sealed electrical box and all cord grips before testing the 91 turbine. ' If the entire depth of the sump is not tested, specify how much was tested. If the answer to any of the questions indicated with an asterisk ( *) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160) 7. UNDER - DISPENSER CONTAINMENT (UDC) TESTING Test Method Developed By: ❑ UDC Manufacturer ® Industry Standard ❑ Professional Engineer ❑ Other (Specify) Test Method Used: ❑ Pressure ❑ Vacuum. ® Hydrostatic ❑ Other (Specify) Test Equipment Used: fncon TS -STS Sump Test System Equipment Resolution: +/- 0.002" gili:lv 15g: IRWIN _ UDC # 1/2 UDC # 3/4 UDC # 5/6 UDC # 7/8 UDC Manufacturer: OPW /Pisses OPW/Picses OPW /Pisses OPW /Pisses UDC Material: Fiberglass Fiberglass Fiberglass Fiberglass UDC Depth: 30" 30" 30" 30" Height from UDC Bottom to Top of Highest Piping Penetration: 1211 12" 12" 12" Height from UDC Bottom to Lowest Electrical Penetration -, 6" 611 611 611 Condition of UDC prior to testing; Fair Fair Fair Fair Portion of UDC Tested 4" Above Pen. 4" Above Pen. 4" Above Pen. 4" Above Pen. ,Does turbine shut down when UDC sensor detects liquid (both product and water) ?* ❑ Yes ❑ No O NA ❑ Yes ❑ No ®NA ❑ Yes ❑ No ®NA ❑ Yes ❑ No ®NA Turbine shutdown response time N/A N/A N/A N/A Is system progranuned for fail- safe shutdown ?* ❑ yes ❑ No ® NA ❑ Yes ❑ No ® NA ❑ Yes ❑ No 0 NA ❑ Yes ❑ No ® NA Was fail -safe verified to be operational?* ❑ yes ❑ No ® NA ❑ Yes ❑ No ® NA ❑ Yes ❑ No ® NA ❑ Yes ❑ No ® NA Wait time between applying pressure /vacuunm/water and starting, test 30 minutes 30 minutes 30 minutes 30 minutes Test Start Time: 11 :11 AM 11:11 AM 11:11 AM 11:11 AM Initial Reading (Rm): 3.6953 4.816 5.4614 4.8856 Test End Time: 11 :27 AM 11:27 AM 11:27 AM 11:27 AM Final Reading (RF): 3.5235 4.8163 5.4605 4.8861 Test Duration: 15 min. 15 min. 15 min. 15 min. Change in Reading (RF -R�: - 0.1718 0.0003 - 0.0009 0.0005 'Pass/Fail Threshold or Criteria: +/-0.002 +/-0.002 +/-0.002 +/-0.002" Test Result: Fail Pass Pass Pass Was sensor removed for testing? Yes Yes Yes Yes Was sensor properly replaced and verified functional after testing? Yes Yes Yes Yes Comments — (inchide information on repairs ntade prior to testing, and reconnnended follola -up for failed tests) Sensor- functionality was not confirmed. This procedure is not part of the Secondary Containment Testing scope of work. 1/2 failed at 87 penetrations. ' If time entire depth of the UDC is not tested, specify how much was tested. If the answer to g1ly of the questions indicated with an asterisk M is "NO" or "NA ", the entire UDC must be tested. (See SWRCB LG -160) 9. SPILL/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 ® Hydrostatic ❑ Other (Specify) Test Equipment Used: Incon TS -STS Sump Test System Equipment Resolution: +/- 0.002" Spill Box # 87 Master F Spill Box # 87 Master Spill Box # 91 FB SpiII Box # 91 VB Bucket Diameter: 12" 12" 12" 12" Bucket Depth: 12" 12" 12" 12" Wait time between applying pressure /vacuunVwater and starting test: 30 minutes 30 minutes 30 minutes 30 minutes Test Start Time: 08:31 AM 08:31 AM 09:11 AM 09:31 AM Initial Reading (RI): 4.2802 4.3524 3.8445 3,2567 Test End Time: 08:46 AM 08:46 AM 09:26 AM 08:46 AM Final Reading (Rr): 4.2797 4.3517 3.8438 3.0607 Test Duration: 15 min. 15 min. 15 min. 15 min. Change in Reading (Rr -RI): - 0.0005 - 0.0007 - 0.0007 - 0.1960 Pass/Fail Threshold or Criteria: +/-0.002" +/-0.002" +/-0.002" +/-0.002" Test Result: Pass Pass Pass Fail Comments — (in chide infortuation on repairs made prior to testing, ai7d i ecorrrmei7cled folloli? -alp for failed tests) 91 vapor bucket tested below cap and still failing. Manufacturer Training Name Training Completed Expires Badders, Jeff Containment Solutions Tank Installation 2/17/2017 2/17/2019 Badders, Jeff INCON Level 4 - Franklin Sump Test System 10/28/2016 10/28/2018 Badders, Jeff NOV FiberGlass Systems Piping (Formerly AO S 6/22/2017 6/22/2020 Badders, Jeff Xerxes UST Installation Training Seminar 9/14/2018 9/14/2021 Badders, Jeff OPW EVR Phase I - UST 5/19/2017 5/19/2019 Badders, Jeff OPW Fueling Containment Systems - FiexWorks 5/19/2017 5/19/2019 Badders, Jeff Phil Tite Spill Collectors & Associated Hardware 6/19/2017 6/19/2019 1 2 3 4 5 6 7 8 9 10 11 12 13 BUSINESS NAME:Circle K #2701270 SITE ADDRESS:5634 Stine Rd. CITY: Bakersfield ZIP-,93313 MAP DATE: 12/2/151 SURVEY BY: DRAWN BY:ZK AGENCY FACILITY #: A B C D E F G H 1 ] K L M ' ! ; LEG END Vaca , t Lot I 1 F-1 DISPENSER SHUTOFF CASHIER �A ABSORBENT FL FLAMMABLE LIQUID MSDS & MSDS EMERGENCY PLAN gR BATHROOM GAS PUMP EMERGENCY FIRE HYDRANT S MONITORING WELL c COMBUSTIBLE LIQUID I I ®SEWER /FLOOR DRAIN SHUT OFF pi E� ELECTRICAL PANEL TANK MONITOR O WATER me MOTOR COOLANT - .. 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