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HomeMy WebLinkAbout1700 MT. VERNON AVENUE FMC 2013HOODS ALARMS SPRNKLER SYSTEMS - AST UST Permit No. Permit No. Permit No. Permit No. Permit No. Permit No. 3- /Dd©0Igi File Number: Address: 7 0 0 ?1-/ 7- 0 Bakersfield, CA 933 Date Received: .3-107-13 Business Name: /< 'IA4 C' SYSTEM: BUILDING SQUARE FEET: ENSPECTION LOG New Mod. Commercial Hood System Fire Alarm System Fire Sprinkler System Aboveground Storage Tank Underground Storage Tank minor modification Underground Storage Tank removal Underground Storage Tank M' Other. C-- Comments: Building Sq. Feet: Calculation Bldg. Sq. Ft: Ql 1. 2. 3. 4. Signature MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State ofCalifornia 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 segarate certification or repqrt must be prepared for each monitoring system control vaanel 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 oftest date. A. General Information Facility Name: KERN MEDICAL CENTER Site Address: 1700 MT VERNON AVENUE Facility Contact Person: Make /Model of Monitoring System: TLS -350 B. Inventory of Equipment Tested /Certified Check the appropriate boxes to indicate specific coulpment inspected /serviced: City: BAKERSFIELD Bldg. No.: Zip: Contact Phone No.: ( ) Date ofTesting/Servicing: 4/512013 Tank ID: TKA 1500 DIESEL AGT Tank ID: TK -2 10K DIESEL In -Tank Gauging Probe. Model: NIA In -Tank Gauging Probe. Model: MAGA Annular Space or Vault Sensor. Model: 208 Annular Space or Vault Sensor. Model: 208 Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (specify equipment type and model in Section E on Page 2). Other (specify equipment type and model in Section E on Page 2). Tank ID: TK-3 2K DIESEL AGT Tank 1D: TK-4 1 K DIESEL AGT In -Tank Gauging Probe. Model: MAG -1 In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 208 Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (specify equipment type and model in Section E on Page 2). Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Ifthe facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspectedlserviced 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 ofthe report; (check all that apply): ® System set -up ® Alarm history report Technician Name (print): RICHARD MASON Certification No.: 5297857 -UT l B36880 Testing Company Name: RICH ENVIRONMENTAL Signature: T C zwl License. No.: 1 D40 809850 Phone No.: (661) 392 -8687 Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testing/Servicing: 4/5/2013 Page 1 of 5 UN -036 —1/4 www.unidocs.org Rev. 01/17/08 5D'tl`1 Monitoring System Certification D. Results of Testing /Servicing Software Version Installed: 324.03 Complete the followine checklist: Yes No* Is the audible alarm operational? Yes No* Is the visual alarm operational? Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational? 21 Yes No* Were all sensors installed at lowest point ofsecondary 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) N/A operational? Yes No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment 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) Sump/Trench Sensors; Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure /disconnection? Yes; No. 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 visible and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm trigger? 90% 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? (Check all that apply) Product; Water. If yes, describe causes in Section E, below. Yes No* Was monitoring system set -up reviewed to ensure proper settings? Attach set up reports, ifapplicable Yes I No* I Is all monitoring equipment operational per manufacturer's specifications? In Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: SYSTEM IS SUCTION SYSTEM Page 2 of 5 UN -036 — 2/4 www.unidoes.org Rev. 01/17/08 Monitoring System Certification F. In -Tank Gauging / SIR Equipment: UL" Check this box iftank gauging is used only for inventory control. 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: Yes No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? Yes No* Were all tank gauging probes visually inspected for damage and residue buildup? Yes No* Was accuracy of system product level readings tested? Yes No* Was accuracy ofsystem water level readings tested? Yes No* Were all probes reinstalled properly? Yes No* Were all items on the equipment manufacturer's maintenance checklist completed? In Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): C'mmnlete the fnllnwina rherklietr Check this box if LLDs are not installed. Yes No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? N/A Check all that apply) Simulated leak rate: 3 g.p.h.; 0.1 g.p.h ; 0.2 g.p.h. Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements? Yes No* Was the testing apparatus properly calibrated? Yes No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? N/A Yes No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? N/A Yes No* For electronic LLDs, does the turbine automatically shut off ifany portion of the monitoring system is disabled N/A or disconnected? Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions N/A or fails a test? Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected? N/A Yes No* Were all items on the equipment manufacturer's maintenance checklist completed? In Section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: SUCTION SYSTEM - NO LEAK DETECTORS UN -036 — 314 Page 3 of 5 www.unidGes.org Rev. 01/17/08 Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors Y. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of this form must be included with the Monitoring System Certification Form, which must be provided to the tank system owner /operator. The owner /operator must submit a copy of the Monitoring System Certification Form to the local agency regulating UST systems within 30 days of test date. Manufacturer: NONE Model: System Type: Pressure; ® Vacuum Sensor ID Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fait Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Components) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail How was interstitial communication verified? Leak Introduced at Far End of Interstitial Space;' Gauge; Visual Inspection; Other (Describe in Sec. J, below) Was vacuum /pressure restored to operating levels in all interstitial spaces? Yes No (Ifno, describe in Sea J, below) J. Comments: NONE OF THESE SENSORS ARE PRESENT AT THIS SITE. Page 4 of 5 If the sensor successfully detects a simulated vacuum /pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. UN -036A -1 /1 www.unidoes.org Rev. 01/26/06 Monitoring System Certification UST Monitoring Site Plan Site Address: 1 100 M--. V&—,ly pV\ pAtE-, f o- erS'CAe -ka CA W Date map was drawn: \-/ I S I ! Instructions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in -tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan was prepared. Page 5 of 5 UN -036 — 414 www.unidomorg Rev. 01/17/08 SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and printouts from tests (tfapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: KERN MEDICAL CENTER I Date ofTesting: 4/5/13 Facility Address: 1700 MT VERNON AVENUE, BAKERSFIELD Facility Contact: Phone: Date Local Agency Was Notified ofTesting: Name of Local Agency Inspector (fpresent during testing): ESTHER 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Technician Conducting Test: RICHARD MASON Credentials: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Spec) License Number(s): 5297857 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: X Hydrostatic Vacuum Other Test Equipment Used: VISUAL Equipment Resolution: 0 Identify Spill Bucket (By Tank Number, Stored Product, etc. I DIESEL IOK 2 3 4 Bucket Installation Type: Direct Bury X Contained in Sump Direct Bury Contained in Smp Direct Bury Contained in Sump Direct Bury Contained in Sum Bucket Diameter. 12" Bucket Depth: 14" Wait time between applying vacuum/water and start of test: 30 MIN Test Start Time (Ti): 2:00 Initial Reading (Rj): 14" Test End Time (TF): 3:00 Final Reading (RF): 14" Test Duration (TF — Tj): I -HOUR Change in Reading (RF - Rj): 0 Pass/Fail Threshold or Criteria: 0.00 Test Result: X Pass Fail Pass Fail Pass Fail Pass Faii Comments — (include information on repairs made prior to testing and recommendedfollow -upforfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and infull compliance with legal requirements. Technician's Signature: r Date: 4/5/13 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. R I:T3 2000 DIESEL TYPE: STANDARD LEAK TEST METHOD ;- T' 3:2000 DIESEL NORMALLY OPEN TEST WEEKLY ALL TAW PRODUCT CODE 3 THERMAL COEFF :.000450 MON TANK DIAMETER 60.00 IN -TANK ALARMS START TIME 2:00 AM •: TY'ST RATE :0.20 GAL/HR j.; TANK PROFILE 4 PTS FULL VOL 2000ALL:OVERFILL ALARM DURATION 2 HOURS 45.0 INCH VOL 1500ALL :LOW PRODUCT ALARM 30.0 INCH VOL 1000ALL:HIGH PRODUCT ALARM TST EARLY STOP: DISABLED 15.0 INCH VOL 500, LIQUID SENSOR ALMS LEAK TEST REPORT FORMATLS:FUEL ALARM ? L 5:SENSOR NORMAL FLOAT SIZE: 4.0 IN':, OUT ALAR11 d R 2:10000 HORN WATER WARNING 2.0 TYPE, k HIGH WATER LIMIT: 3.0 STANDARD NORMALLY OPEN MAX OR LABEL VOL: •'-2000' ; OVERFILL LIMIT 90% sj 1600 IN -TANK ALARMS HIGH PRODUCT 95 %, ALL:OVERFILL ALARM 1900 DELIVERY LIMIT 25% ALL :LOW PRODUCT ALARM 500ALL :HITCH PRODUCT ALARM LIQUID SENSOR SETUP R 3:T1 LOW PRODUCT : 500 TYPE: L 1:TANK 1 ANNULAR LEAK ALARM LIMIT: 99' SUDDEN LOSS LIMIT: 99 -; STANDARD NORMALLY OPEN NORMALLY CLOSED CATEGORY TANK TILT 0.00 ANNULAR SPACE PROBE OFFSET 0.00 IN -TANK ALARMS `~ i ALL:OVERFILL ALARM L 2 :FILL SIPHON MANIFOLDED TANKS ALL:LOW PRODUCT ALAI;A SUMP TRI- STATE (SINGLE FLOAT) T#: NONE LINE MANIFOLDED TANKSALL:HI6H PRODU" A i CATEGORY OTHER SENSORS T#: NONET1:MAX PRODUCT AL I LIQUID SENSOR ALMS 6r. , L 1: F UEL `: LEAK MIN PERIODIC: 090ALARM -;; L 3: M I D SUMP 0y%F R 4:DAY TRI -STATE : `(Stf`1GL FLOAT ) TANK 1 TYPE: } CATEGORY : OTHER-SENSORS LEAK MIN ANNUAL 0i STANDARD 0 NORMALLY CLOSED 1 NO ALARM L 4 : END SUMP PERIODIC TEST TYPE ASSIGNMENTS - y TRI -STATE (SINGLE FLOAT) STANDARD CATEGORY OTHER SENSORS ANNUAL TEST FAIL ALARM DISABLED SPACE PERIODIC TEST FAIL r CATEGORY C: ANNULAR SPACE ALARM DISABLED GROSS TESL' FAIL rn yo . . • ALARM DISABLED L -7 : DT 100 ANN 'OFF SOFTWARE REVISION LEVEL TRI —STATE (SINGLE FLOAT)'- k CATEGORY OTHER PER :TEST •AVERAG I NG *: OFF VERSION 324.03 SENSORS TANK TEST NOTIFY: OFFSOFTWARE #.346324- 100 -B- CREATED 05.06.06. A1,,,^ TNK TST SIPHON BREAK:OFF NO SOFTWARE MODULE'-` j DELIVERY DELAY 1 MINSYSTEMFEATURES: PUMP THRESHOLD 10.00X. PERIODIC IN —TANK TESTS'° ANNUAL IN —TANK TESTS IN-TANK SETUP 2' D 1 ESEL 2 SYSTEM SETUP iODUCT CODE 2 SRMAL COEFF :.000450 T 1 : D I ESEL PRODUCT CODE APR 5. 2013 12:'04 PhlANKDIAMETER ANK PROFILE 96.00 4 PTS iTHERMALCOEFF :.000850TANKDIAMETER FULL VOL : 9728 36. 00TANKPROFILE 72.0 1NCH VOL : 8246 I PTFULLVOL1502 SYSTEM UNITS 48.0 INCH VOL : 5149 U.S. 24.0 INCH VOL 1935 FLOAT SIZE: SYSTEM LANGUAGEENGLISH4.0 IN. SYSTEM DATE /TIME FORMATFLOATSIZE: 4.0 IN. WATER WARNING 2.5WATER MON DD YYYY HH:MM:SS xM WATER WARNING HIGH WATER LIMIT: 2.5 4.0 LIMIT: 3•D MAX OR LABEL VOL: i KERN MEDICAL CENTER 1502OVERFILLLIMIT BAKERFOIED,CA.93305MAXORLABELVOL: 9726 911i, HIGH PRO 1351DUCT 661- 326 -2482 z OVERFILL LIMIT 890% 95% SHIFT TIME 1 HIGH PRODUCT 941 DELIVERY LIMIT 142E 50% SHIFT TIME 2 : DISABLED DELIVERY LIMIT : 9241 25% 2432 751 LOW PRODUCT SHIFT TIME 3 DISABLEDSHIFTTIME4DISABI -ED LEAK ALARM LIMIT: 500 TANK PEP, TST NEEDED WRNLOWPRODUCT LEAK ALARM LIM1T: 1000 99 SUDDEN LOSS LIMIT: 99 TANK TILT 99 DISABLED TANK ANN TST NEEDEDSUDDENLOSSLIMIT: 99 PROBE OFFSET 1.70 0.00' DISABLED WRN TANK TILT 0.00 PROBE OFFSET 0.00 SIPHON MANIFOLDED LINE RE- ENABLE - METHODALARMACKNOWLEDGET #: NONE TANKS SIPHON MANIFOLDED TANKS LINE IFOLDED TANKST #' L TST NEEDED;WRNDISABLEDT#: NONE LINE MANIFOLDED TANKS LINE ANN TST NEEDED WRNT #: NONE LEAK MIN PERIOD!,': DISABLED PRINT TC VOLUMESLEAKMINPERIODIC: m o 0 LEAK MIN ANNUAL ENABLED 0%. TEMP COMPENSATIONLEAKMINANNUAL00% 0 D VALUE (DEG F ): 60.0STICKHEIGHTOFFSETPERIODICTESTTYPEDISABLED STANDARD DAYLIGHT SAVING TIMEPERIODICTESTTYPE STANDARD ANNUAL TEST FAIL ENABLED START DATE ALARM DISABLED APR WEEK I SUNANNUALTESTFAIL ALARM DISABLED PERIODICDIC TEST FAIL START ATIIME ALARM DISABLED END DATEEND PERIODIC. TEST FAIL ALARM DISABLED GROSS TEST F' AIL WEEK 6 END TIME SUNME ALARM DISABLED 2: u0 Am GROSS TEST FAIL ALARM DISABLED ANN TEST APERTEST ER GAGAING: OFF ANNTESTAVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: r SYSTEM SECURITY TANK TEST NOTIFY: OFF OFF TNK TST SIPHON.BREAK:OFF CODE : LABELS TNK TST SIPHON BREAK:OFF DELIVERY PUMP THRESHOLD 1 MIN. DISABLED DELIVERY DELAY 1 MIN t0.D0i PUMP THRESHOLD 10.00'% T ALARM HISTORY REPORT SE14SOR ALARM - - - -- L 4:END SUMP OTHER SENSORS SENSOR OUT ALARM - APR 5. 2013 1:07 PM FUEL ALARM ' APR 5. 2013 12:31 P(°! x x k ** END ii x x* x ALARM HISTORY REPORT SENSOR ALARM - - - -- L 5:2000 ANNULAR SPACE ANNULAR SPACE FUEL ALARM APR 5. 2013 1:07 PM FUEL ALARM APR 5, 2013 1:05 PM ALARM HISTORY REPORT SENSOR ALARM - -- -- L 7:DT 100 OTHER SENSORS SENSOR OUT ALARM APR 5, 2013 1 :07 PM F'LIEL ALARM APR 5. 2013 1:06 PM x ri x END * : ALARM HISTORY REPORT SENSOR ALARM L I:TANK 1 €iNNULAR ANNULAR SPACE FUEL. ALARM APR 5, 2013 1:07 PM FUEL ALARM APR- 5. 2013 1:04 PM XxkxXENDWxxx) ALARM HISTORY REPORT SENSOR ALARM - - - -- L 2:FILL SUMP OTHER SENSORS SENSOR OUT ALARM APR 5, 2013 1:07 PM FUEL ALARM APR 5, 2013 12:29 PM FUEL ALARM APR 5. 2013 12:28 PM r k END * x ALARM HISTORY REPORT SENSOR ALARM - - -- L 3:MID SUMP OTHER SENSORS SENSOR OUT ALARM APR 5, 2013 1:07 PM FUEL ALARM APR S. 2013 12:30 prwmw. . 5o'il9 MONITOR CERT. FAILURE REPORT SITE NAME: KERN MEDICAL CENTER DATE : 4/5/13 ADDRESS: 1700 MT VERNON AVE TECHNICIAN: RICHARD MASON THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE TESTING. REPAIRS: NONE LABOR: NONE PARTS INSTALLED: NONE NAME: TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE. A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR CONVIENENCE. BILLUN_r & PERMIT STATEMENT n DEFT- FIRS 1600 Truxtun Ave Ste 401FP; ERMR NO.: ARTM Bakersfield CA 93301 Tel_- (6611 R2R..RA79 Faur (6611852-2171 r - Atamrs - Now & ModtficsMons - (Minimum Charge) SITE INFORMATION all 84 11 1A 141 wmam, 1 i ' t lip !b OVW 10,1900 Sq. Ft INI.M 96.00 (per tend CONTRACTOR INFORNIATION 9 8 FEUVAN O I / / ti s 280.00 84 ANpermits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK ON THAT PROJECT. Atamrs - Now & ModtficsMons - (Minimum Charge) 280.00 • 84 98 . OVW 10,1900 Sq. Ft Sq. FL it.== Permit fee : Ants 96.00 (per tend 84 9 8 Spdnlders - New & Moditations - (MlNmum Charge) 280.00 84 After hours inspection fee 98 84 RICH ENVIRONMENTAL 96.00 (per hour) SERVICE STATION SERVICES 90- 7162/3222 4151 Portable LPG (Propane): NO. OF CAGES? 96.00 LIC. #809850 84 ExPloshm Storage 5643 BROOKS CT. 84 BAKERSFIELD, CA 93308 -3708 DATE 3 661) 392 -8687 Miscellaneous Po nE°RO 84 Zs ..( x 0 0 DOLLARS s 0 CHASE U JP Morgan Chase Bank, N.A. sFrGBakersfield, CA 93308 9 FOR G AUTHORIZED 316NATUR ry, co ,`0 , p4 II2004 L S lit' 1: 3 2 2 2 7 l6 2 7t: 308 3 50400 W2 Q W911 (Installation) 96.00 84 Mandated Leak Detection (TestingQ1Fu,(e,11 Monft WSB989. Note: $9aOOfor each My of test/pe scheduled at ft same Wne) b& fps % q O b B2 Ants 96.00 (per tend 84 Pyrotechnic - (Per event, Plus Insp. Fee 0 $96 per hour) 86.00 + (5 Ms. mh standby fee Anspection)4576 -00 84 After hours inspection fee 121.00 84 RE-INSPECT10N(S) /FOLLOW- UPINSPECTION(S) 96.00 (per hour) 84 Portable LPG (Propane): NO. OF CAGES? 96.00 84 ExPloshm Storage 266.00 84 Copying & File Research (Flee Research Fee $50.00 per hr) 25d per page Miscellaneous 84 FD 2021 (Rev. 01 07) 1 - ORIGINAL WHrTE (to Treasury) 1- YELLOW (to File) 1-PINK (to Customer) BIWUNQ & PERMIT STATEMENT PERMIT NO.: AR i/ T IRA MRSFIELD FIRE DEPT. Prevention Services 1600 Truxtun Ave Ste 401 Bakersfield CA 93301 Tel.: (661) 326 -3979 • Fax 661) 852 -2171 FD 2021 (Rev. 06ro7) 1 - ORKiNAL WH(rE (to Treasury) 1- YELLOW (to File) 1-PINK (to customer) INFORMATIONSITE LOCATION aFPROJECT ` PROPERTY ewNM STARTING DATE COMPLETION DATE NAME PROJECT NAME - o ADOWI-1. PHON O. PROJECT ADDRE89 I CITY STATE ZIP CODE CONTRACTOR INFORMATION CONTRACTOR NAME CALICENSE NO. 1'1 TYPE OF LICENSE. EXP DATE PHONE NO. CONTRACTOR COMPANY FAX 5S OS ZIPS 9 ?8n ADDRESS 5U 1-1 GTM All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK ON THAT PROJECT. • Alarms - New & Modifications - (Minimum Charge) $280.00 • 84 98 Over 10,000 Sq. Ft Sq. Ft x.020 = Permit fee i 98 Sprinlders - New & Modifications - (Minimum Charge) 280.00 84 98 13 Over 10,000 Sq. Ft S¢ Ft x.020 = Aennitfee 84 98 Minor Sprinkler Modifications (< 10 heads) 96.00 [Inspection Only] 84 98 Commercial Hoods — New & Modifications 470.00 84 98 Additional Hoods 5&00 84 98 Spray Booths - New & Modifications 470.00 84 98 Aboveground Storage Tanks (tnsmllauwnsp: to Time) 180.00 82 Additional Tanks 96.00 82 Aboveground Storage Tanks (Removedinspecuon) 109.00 82 Underground Storage Tanks (tnstaast(onJinspection) 878.00 (per tank) 82 Underground Storage Tanks (Modification) 878.00 (persite) 82 Underground Storage Tanks (Minor Modification) 167.00 82 Underground Storage Tanks (Removal) 573.00 (per tank) 84 011well (Installation) 96.00 84 Mandated Leak Detection (Testing / Fue! Mon rVSB989. Note: $9600 foreach type of test /pe eve scheduled at thesame Ohre) 98 09 (pe f 9 ,O n 82 rents 96.00 (per tend 84 Pyrotechnic - (Per event. Plus insp. Fee 0 $96 per hour) 86.00 + (5 hrs. min. dWX4 feeAnVection)W&.00 84 After hours inspection tine 121.00 84 RE- WSPECTION(S) / FOLLOW-UP INSPECTION(S) 96.00 (per hour) 84 Portable LPG (Propane): NO. OF CAGES? _ 96.00 84 Explosive Storage 266.00 84 Copying & File Research (File Research Fee $50.00 per hr) 250 per page 84 Miscellaneous 84 FD 2021 (Rev. 06ro7) 1 - ORKiNAL WH(rE (to Treasury) 1- YELLOW (to File) 1-PINK (to customer) 0 UNDERGROUND STORAGE TANKS f qT^•• °^-- ^•^•^••' f4",. 7ri{ 759P^ 4rYd: l9yii` CuYLL'< Yk F.! 3lsc' ')! iL :fi6CTi'If.`'i!'GriiGt— Yi:SI+;. APPLICATION TO PERFORM ELD /LINE TESTING /; SB989 SECONDARY CONTAINMENT TESTING/TANK TIGHTNESS TEST AND FUEL MONITORING CERTIFICATION Please note that these are separate Individual tests and will be charged per separate type test accordingly.) PERMIT # I I 11- Rex a _ Fw i Atfl f BAKERSFIELD FIRE DEPARTMENT Prevention Services Q101 He SZR,EET Bakersfield, CA 93301 Phone: 661-326-3979 • Fax: 661-852-2171 Page 1 of 1 ENHANCED LEAK DETECTION S13-989 SECONDARY CONTAINMENT TANK TIGHTNESS FUEL MONITORING CERTIFI ON SITE `INF'ORMATI FACILITY NAME & PHONE # OF CONTACT PERSON ADDRESS OWNER NAME OPERATOR NAME PERMIT TO OPERATE OF TANKS TO BE TESTED: IS PIPING GOING TO BE TESTED? O YES 13 NO TANK # VOLUM`E\ CONTENTS V V 2 C7 u3Cs TANK TESTING COMPANY TESTING COMPANY NAME $ PHONE # OF CONTACT PERSON MAILING ADDRESS Jln -13 t C.00 c5 cT. - FSA K RSF1E.c -'O C/ °13308 NAME & PHONE t OF TESTER OR SPECIAL INSPECTOR CERTIFICATION # S09 GsU DATE & TIME TEST YO BE CONDUCTED ICC # TEST METHOD APPLICANT ATURE Wu DATE THIS APPLICATION BECOMES A PERMIT WHEN APPROVED APPROVED BY DATE FD2095 (Rev 03/08) BAKERSFIELD CITY FIRE DEPARTMENT -- INSPECTION RECORD Post this Card at the Job Site and DO NOT Remove for Duration of Work Inspection Request Phone No. (661) 326 -3979 UST NEW INSTALL DESCRIPTION DATE SIGNATURE BACKFILL PRIMARY PIPE SECONDARY PIPE SECONDARY CONTAINMENT SENSORS AUTHORIZATION FOR FUEL ELECTRICAL SEAK -OFF TANK TESTING 1 UST REMOVAL DESCRIPTION DATE SIGNATURE AST NEW INSTALL DESCRIPTION DATE SIGNATURE MODIFICATIONS MINOR / MAJOR AST REMOVAL DESCRIPTION DATE SIGNATURE EVR UPGRADE PRIOR TO OPERATION OF ANY SYSTEM, ALL UST AND /OR -AST SYSTEMS-SHALL BE% INSTALL, COMPLETE AND ACCEPTED BY,, MISC. ACTIVITY THE "BAKERSFIELD, CITY-FIRE, DEPARTMENT. FIRE DEPARTMENT (FINAL) _ REMARKS: BUILDING ADDRESS: T n%b JOB DESCRIPTION: 'cam C_ OCCUPANCY TYPE: OWNER: K PERMIT NO. 13,- /Q ® / CONTRACTOR: fL PHONE #,39Z — 6$% FD 1743