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HomeMy WebLinkAbout300 FAIRVIEW ROAD FMC SB-989 2013HOODS ALARMS SPRINKLER SYSTEMS 'WVV B000TH AST UST Permit No. Permit No. Permit No. Permit No. Permit No. Permit No. File Number. /00210gD Address: , oyoD f ,a , r,- -,/i,Pat - Bakersfield, CA 933 Date Received: /3 Business Name: SYSTEM: BUILDING SQUARE FE F INSPECTION LOG New Mod. Commercial Hood System Fire Alarm System Fire Sprinkler System Spvay FWsh System Aboveground Storage Tank Underground Storage Tank minor modification Underground Storage Tank removal Underground Storage Tank Building Sq. Feet: Calculation Bldg. Sq. Ft:_ 9. i r. • Comments: 9 3. 4. Date Time Signature BILLING &PERMIT STATEMENT BAKERSFIELD FIRE DEPARTMENT LL D Prevention Services PERMIT # 40' 1 FINE 11" r 2101 H Street Bakersfield / CA 93301 WWWWWW tt1 nti....... GG _']']G_']7 Gam..• 1 _RS7_7171 Please make checks payable to CITY OF BAKERSFIELD. Thank you. 1 Alarm - New & Modification (minimum charge) . 1$280 Over 10,000 sq ft $0 .028 x sq ft Sprinkler - New & Modification (minimum charge) $280 Over 10,000 sq ft $0 .028 x sq ft Sprinkler - Minor Modification ( <10 heads) $ 96 (inspection only) 84 Commercial Hood (New & UL 300 Upgrade Modification) $235 Additional Hood 58 hood Commercial Hood - Minor Modification (add /move nozzle) 1 $ 96 (inspection only) 84 Spray Booth (New & Modification) 235 98 SITE INFORMATION 180 /tank 82 LOCATION OF PROJECT A r, 2 1: TZ 'j c 4 5To p PROPERTY OWNER rn iZ k P A a L A 82 STARTING DATE 9-18-113 COMPLETION DATE NAME 82 PROJECT NAME r J'EL d TC VZ ADDRESS 878 /tank PHONE # PROJECT ADDRESS F A t 1Z-'j I TE (xi CITY FAA K ERSF I E LD STATE CA ZIP CODE 82 CONTRACTOR INFORMATION 167 /site 82 Underground Storage Tank (Removal) TR CONTRACTOR NAME CA LICENSE # 16798,1191 ZID:N0 OF LICENSE EXPIRATION DATE PHONE # v- 'T T 4FC 0- Oil well (Installation, Inspection, or re- inspection) X 30- I -5 CONTRACTOR COMPANY NAME 96 /tent FAX # After -hours inspection fee 121 /hr (2 hrs minimum) = $242 Pyrotechnic (1 permit per event, plus an inspection fee of 96 /hr during business hours) PY NOTE: After hours Pyrotechnic event inspection is @ $121 /hr ADDRESS D I O--b t LE NW * B CITY r ZIP CODE 4330$ Please make checks payable to CITY OF BAKERSFIELD. Thank you. 1 Alarm - New & Modification (minimum charge) . 1$280 Over 10,000 sq ft $0 .028 x sq ft Sprinkler - New & Modification (minimum charge) $280 Over 10,000 sq ft $0 .028 x sq ft Sprinkler - Minor Modification ( <10 heads) $ 96 (inspection only) 84 Commercial Hood (New & UL 300 Upgrade Modification) $235 Additional Hood 58 hood Commercial Hood - Minor Modification (add /move nozzle) 1 $ 96 (inspection only) 84 Spray Booth (New & Modification) 235 98 Aboveground Storage Tank (1 inspection per installation) AST 180 /tank 82 Additional Tank ATI 96 /tank 82 Aboveground Storage Tank (Removal, Mod,or Inspect'n) ATR 109 /tank 82 Underground Storage Tank (Installation /Inspection) NI 878 /tank 82 Underground Storage Tank (Modification) MOD 878 /site 82 Underground Storage Tank (Minor Modification) MTM 167 /site 82 Underground Storage Tank (Removal) TR 573 /tank 84 Mandated UST Testing: Fuel Mont Cert/SB989 /Cath. Prot. NOTE: $96 /hr for each type of test/per site /per UST system even if scheduled at the same time 96 /hr (2 hrs minimum) _ $192 82 0 Oil well (Installation, Inspection, or re- inspection) X 96 /hr 82 Tent # 96 /tent 84 After -hours inspection fee 121 /hr (2 hrs minimum) = $242 Pyrotechnic (1 permit per event, plus an inspection fee of 96 /hr during business hours) PY NOTE: After hours Pyrotechnic event inspection is @ $121 /hr 96 /hr + (5 hrs min standby fee /insp) _ $576 5 hrs min standby fee ins = 605 84 Re- inspection /Follow -up Inspection 96 /hr 84 Portable LPG (Propane): # of Cages? _ 96 /hr 84 Explosive Storage 266 84 Copying & File Research (File Research fee $50 /hr) 0.25 /page 84 Miscellaneous 84 4T bp A UNDERGROUND STORAGE TANKS `? APPLICATION TO PERFORM ELD /LINE TESTING/ rSB989SECONDARY. CONTAINMENT rTESTING/TANK TIGHTNESS TEST AND FUEL MONITORING CERTIFICATION PERMIT # VON RA' f/ARFAF F BAKERSFIELD FIRE DEPARTMENT Prevention Services 1600 Truxtun Ave., Suite 401 Bakersfield, CA 93301 Phone: 661-326-3979 • Fax: 661-852-2171 Page 1 of 1 ENHANCED LEAK DETECTION LINE TESTING &-'SB -989 SECONDARY CONTAINMENT TANK TIGHTNESS S -FUEL MONITORING CERTIFICATION SITE INFORMATION FACILITY c NAME & PHONE OF CONTACT PERSON PAS-CA - 0' - ADDRESS 1300 , CA OWNER NAME t L OPERATOR NAME PERMIT TO OPERATE i tt OF TANKS TO BE TESTED: IS PIPING GOING TO BE TESTED? Cjj/YES NO TANK # VOLUME CONTENTS 1 4 000 L t E FL TANK'TESTING COMPANY TESTING COMPANY asses t,c. NAME & PHONE OF CONTACT PERSON MAILING ADDRESS NAME & PHONE i OF TESTER OR SPECIAL INSPECTOR f O - CERTIFICATION s DATE `TIME TEST 0 BE CONDUCTED e -O ` ICC 5 a5 a TEST METHOD APPLICANT SIGNATURE DATE C) 3 THIS APPLICATION BECOMES A PERMIT WHEN APPROVED APPROVED BY 2", DATE F02095 (Rev 06/07) BILLING & PERMIT STATEMENT BAKERSFIELD FIRE DEPARTMENT Prevention Services PERMIT # x FIRE " 2101 H Street IIIu; 4 Bakersfield, CA 93301 Please snake checks payable to CITY OF BAKERSFIELD. WELLS FARGO BANK 9 9ISSRINCb r` 1 7 .2 6630 ROSEDALE HWY, ' #B s ti BAKERSFIELD, CA 93308 t x''16- 24/1220 661) 588-2777 4/10/2013L 1A11 _ 1 PAY TO THE BAKERSFIELD: FIRE DEPT.. } , f r '• * 192 00ORDEROF. One Hundred Ninety- Two'and 00/ 100********.:**'"'**`*** "**"**" ****` * **'*:.*..***" " *"*****'* DOLLARS BAKERSFIELD FIRE DEPT.,., MEMO ;ep „ .• 110017992il• i:"L ".:2 2000 2 4 71: 0.37.12S39,1510. 8 SECURITY FEATURES INCLUDED. DETAILS ON BACK. B Li I Ul luei yi UUl lu awi aye Tai iR krncn wvaiJ .— Pa' _ /l4nn Mandated UST Testing: Fuel Mont Cert/SB989 /Cath, Prot. NOTE: $96 /hr for each type of test/per site /per UST system even if scheduled at the same time 96 /hr (2 hrs minimum) = $192 SITE INF • RMATION Oil well (Installation, Inspection, or re- inspection) X LOCATION OF PROJECT I2\l'ituJ TINC4 ST ©ip PROPERTY OWNER fitoR K 1 9BLA 96 /tent STARTING DATE COMPLETION DATE NAME 121 /hr (2 hrs minimum) = $242 Pyrotechnic (1 permit per event, plus an inspection fee of 96 /hr during business hours) PY NOTE: After hours Pyrotechnic event Inspection is @ $121 /hr 96 /hr + (5 hrs min standby fee /insp) _ $576 5 hrs min standby fee ins = 605 84 PROJECT NAME Re- inspection /Follow -up Inspection 96 /hr ADDRESS 84 PHONE # Portable LPG (Propane): # of Cages? _ E O 'c 2 S 84 e - 3 PROJECT ADDRESS 1` J CITY F7/ICFiT S IFiL.D STATE Ci ZIP CODE 84 CONTRACTOR INFORMATION 84 CONTRACTOR NAME. L ^` CA LICENSE -S1IGV6CU TYPE OF UCENSaE EXPIRATION DATE MUM: eJ CONTRACTOR COMPANY NAME FAX # l C i- 97 ADDRESS P I O izo-SEbOt LE FkWi it 3 CITYI ZIP CODE q '33 0 3 Please snake checks payable to CITY OF BAKERSFIELD. WELLS FARGO BANK 9 9ISSRINCb r` 1 7 .2 6630 ROSEDALE HWY, ' #B s ti BAKERSFIELD, CA 93308 t x''16- 24/1220 661) 588-2777 4/10/2013L 1A11 _ 1 PAY TO THE BAKERSFIELD: FIRE DEPT.. } , f r '• * 192 00ORDEROF. One Hundred Ninety- Two'and 00/ 100********.:**'"'**`*** "**"**" ****` * **'*:.*..***" " *"*****'* DOLLARS BAKERSFIELD FIRE DEPT.,., MEMO ;ep „ .• 110017992il• i:"L ".:2 2000 2 4 71: 0.37.12S39,1510. 8 SECURITY FEATURES INCLUDED. DETAILS ON BACK. B Li I Ul luei yi UUl lu awi aye Tai iR krncn wvaiJ .— Pa' _ /l4nn Mandated UST Testing: Fuel Mont Cert/SB989 /Cath, Prot. NOTE: $96 /hr for each type of test/per site /per UST system even if scheduled at the same time 96 /hr (2 hrs minimum) = $192 82 Oil well (Installation, Inspection, or re- inspection) X 96 /hr 82 Tent # 96 /tent 84 After -hours inspection fee 121 /hr (2 hrs minimum) = $242 Pyrotechnic (1 permit per event, plus an inspection fee of 96 /hr during business hours) PY NOTE: After hours Pyrotechnic event Inspection is @ $121 /hr 96 /hr + (5 hrs min standby fee /insp) _ $576 5 hrs min standby fee ins = 605 84 Re- inspection /Follow -up Inspection 96 /hr 84 Portable LPG (Propane): # of Cages? _ 96 /hr 84 Explosive Storage 266 84 Copying & File Research (File Research fee $50 /hr) 0.25 /page 84 Miscellaneous 84 Fn2n21 (Rev m112)— 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 I AUTHORIZATION FOR FUEL ELECTRICAL SEAK -OFF TANK TESTING 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 USTAND /OR_AST SYSTEMS SHALL BE INSTALL, COMPLETE.AND ACCEPTED BY MISC. ACTIVITY THE - BAKERSFIELD CITY FIRE DEPARTMENT. fIRE DEPARTMENT (FINAL). REMARKS: BUILDING ADDRESS: o t j ( 7 JOB DESCRIPTION: -W C, OCCUPANCY TYPE: OWNER: ,-- r i L 1G `iQ PERMIT NO. CONTRACTOR: -BSS PHONE# a2% FD 1743 Of Appendix VI Copies of Monitoring System Certiricalion form and LIST Monitoring Plot Plan available at MONITORING SYSTEM CERTIFICATION For Use ByAll Jurlsdlctione Willim the Slato Or California Authority Cited: Chapter 8.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and semAOMO of monitoring equipment. A separate certification or report must be prepared lur each monitoring system control panel by the technician who performs the work. A copy of this form must De provided to the tank systern owner /operator. The owner /operator must submit a Copy Of this form to the local agency regulating UST systems within 30 tlay6 of Wet date. A. Generallnformatlon Facility Name: f [a1RJ l Et.1 „ TR.C IrL STC] - ...... Bldg, No,; 5ile Address:. ... _ _. Cty:.aij K. E 12 = t tr. . k ZIP: 3 Facikty Contact Person:. KQ % V. __Q (s 01AA._ Contact Phone No.: I. ( A ). 3d ;.L.i.8 u.._ . . Make/Mudel or Monitoring System; kt-s -Af- I .. .. Is - -L31-i. -._.. ... Dale of Testing/Servicing; `i, /n ;14 L .r . B. Inventory of Equipment Tested/Certlfled Check the appropriate boxes to Indicate specific equipment Ing000todib8rAWO: Tank ID, .., 1, ,_„ i 1 f- F. L -- I Tank ID: In -Tank Gauging Probe. Modal! _ _ I In -Tank gauging Probe. Model Annular Space or Vault Sensor. Model y ' •, I Annular Space or Vault Sensor. Model; ... _ ....... _ . _ . Piping Sump / Trench Sensor(s). Model; )„ I Piping Sump Trench Senaor(s). Model: — _,_- __— __- __,• „__ Fit Sump Sensor(!). Model: I Fill Sump Soneor(s). Model: V Mechanical Line Leak Detector. Modal: L C l J n Mechanical Line Leak Detector. Model:..__. Electronic Line Leak Detector. Model; I Electronic Lift Leak Detector. Model: Tank Overfill i High. Level Sensor. Model: I Tank Overfill I High -Level Sensor. Model: Other Lspecify equipment type and model In Section E on Pa 2). 1 Other (opoal mant type aril model in $action E an Pa 2). Tank 10: Tank ID: Irt•Tartk Gaup ng rthe. Model: -- -- — ._...— ...._. n In -Tank Gauging Probe. Model:.... ... Annular Space or Vault Sensor. Model: 1 Annular Space or Vauh Sensor, Model: Piping Sump/ TrenchSensor(a). Model: _ Piping Sump /TronohSammie)• Model:.,...,.,_,,,. •, I Fdi Sump Sensor(s). Model: _,•.- ,,,_ „_ -, - 1 Pill Sump Sensor(a), Model; Mechanical Line leak Delactor. Model: I Mechanical Line Leak Detectur. Model: —_-•— _ -• -• I Electronic Line Leak Detector. Model: I Electronic Une Leak Detector. Model: __— _,.,_,•„ Tank Overfill / High-Level Sensor, Model: i Tank Cvertlll I fth-Level Sensor. Model; Other (sDocify oQuipment iype and modal In SKVW Eon Page 2 1 Other (swity octuipmant type and model In Section It on Pa 2). Dispenser ID; .... _......_.. Dispeneer ID: _ Dispenser Containment Senaor(a). Model: 1 Dispenser Corimtnmem Senaor(s). Model: hoar Valve(s). I Sheer Velvets). I DirpAnser Contalnment Float (a) and Chalrt s . I Dispenser Contasment Ploa a and Chains . Dlspenesrl0: Dispenser ID: _ Dispenser Cordainmemt Serleur(a). Model: ,___,,,_—__,__-_ I Dispenser (anufrimant Si or(s). Model: ShearValve(e)• I Shearvelve(s)• Die nser i0cmi itowrtl Float 6 and Chat e . I Dispenser Corttactrnenl Floats and Chains , DiopenaerlD:_ DlapenserlD:.__— ___ -__ Dispenser Containment Sensor(a). Modal: Dispenser Corttairment Sensorial. Morlul I Shear volve(s). I Shear Velve(a). I D a nser Conlainrnant Flee a and Chains Dispenser (onldlnmam Fbel s and Chain e . If %no faciU(y contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the Iaoility. C. Certification • 1 oertify that the equipment Iderdifled In this document woe Inspected/serviced In a000rdanos with the manufacturers' guidelines. Attached to this Unification Is Informstlon (e.g. manufacturers' checklists) necessary to verity that this Information Is correct and a Plat Plan showing the layout of monitoring equipment. For any squlpmehl d pabte of ganomting ouch reports, I have also attached a copy of the report; (check aN thatapply): -1 System set-up l Alarm history report Technician Name (Plint): -QR11 LL .__"r(C' u! tb "C i Slgnaturo: ---- - - - -•_ -- .._._.... .. cerdllcadw No.: _ A -Ia A 1 "a _ License. No.: {]u_L¢__..__... _.._ —.- TeslirW Carnpany Name: R5:59- i is r- _ _ Phons No.:( 91 1 ) --sB_"71 Togling Company Address: - aQ__j Q$rt A ( ....._ -_ — Date of Testing /Servicing; t Monitoring System Certlfleatlon Page 1 of { 12107 trt/Z d 2/21/07 aaAaaS xej <a SWI OE- 00 -EIOZ i 0. Results of Teating/Servicing Suliwule Version Installed: 7-1at. th. wken611.4- Yes Nu' Is Ilia audible alarm openatuunal7 Yry No' Is the visual alarm operational? Yea Nu' Were all seluors visual inspected. functions tested, p confirmed o rallonar! Yes No' Wore all sensory installad at lowest point of secondary containment and positioned so that other equrprttanl will not interfere with their 0 r nrArAtinl ? Yes No' If alarms are rulayed to a remote monitonrtg elation. Is all communications oquornarll (e.g. modem) operational? X N: A reu No' For prtlssun7ed piping systems, dQoV the turbine oulomal;ually shut down it the piping secondary comanmunt monitodrV system A WA d0locta a foak, fads W operate, or is olaclrCally discoIinacted? II yes' which sensors inlliatu pusiiiva sturl•duvat? (Check all On(.rpylyl SumpiTrench Sensors, r Oispenser Conteinmont Senaons. DO you eonlirrn positive shut-down duu to luaks " sansot failurardiscol ion? 1 Y • 'r No. Yes No' Fur tank systems that Utilize the monitorurg system as the primary tank ovoftli waminy deviea (i.e. vo mechanical ovel'flll prevonit nt X Nr'A valve Is installed). is the overfill warning alarm visible and audible at the tank IN point(B) and operating properly? If so, at what percent of lank capacity does the alarm IrWar? % Yes' No Was any monitoring aqu'tpment rep ace yes, I ntl y dpaui k: sensors, probes, or a ter equipment roplauod and list the manulactlrrar name and model lot all replacement pmrtH In ac f n E. below. Yes' No Was liquid found Inside any secondary containmoni systems designed as dry systems (Check A r that Awly) *1 Pruduct: ' watei. 11 tld describe a in $eclion E. Wow Yes No' Was iftli[Oring system pat -up reviewed to ensure ra r settin Attach sat up reports, if appica e Yes No' Is all monitoring equipment operational pot manulaeturer s B OCillCalfOrta7 In section t oelow, eescnoe now ano wnon loose eeticlencies were or will oo eorrectea. E. Comments: Monitoring System Certlllcallon bl/E d Page 2 of 4 aanaa5 xej << t 2107 2/21/07 Sill OE -bO -EIOZ F, In -Tank Gauging / SIR Equipment: 1 Chuck this box it tank gauging is used ony, for inventory control. V' Check this boll it no tank gauging or SIR equipment Is Installeo. This section must be completed if in-tank gauging equipment is used to punoim leak detection monitoring. Cemnlata tha tnllnudnn eh"WId . Yes 0 No' Has all input wiring been Inspected for proper entry and termination, Including testing for ground faults? Yes 77 Were all tank gauging probes visually inspected for damage and roeldue buildup? Yes W. Was accuracy of system product level roadings tested? Yes C No' Was accuracy of system water level readings tested? Yes I No' Were all probes tolnatalled property? C: Ye8`1 No' Were all ems on the equipment manufacturer's maintenance ehedtlist completed? urn anuuun n, uinuw, oe6orlpp now ano wnen inese o9mien0ies were or will ou Correctm. G. Line Leak Detectors (LLD): 1: Check this box it LLDs are not installed. Comnist• the fellowlne chsrddlatr Ves C No' For equipment start -up or annual equipment Corti ical , was a leak simulated to verify LLD performance? (Check ufl 0 NIA C that aWy) Simulated leak rate: W3 g.ph.; tl 0.1 g,p,h ; O 0,2 g,p,h. Yes No' Were all LL09 CCnflrmod operational and accurate within regulatory requirements? Yes I No' Was the tea ng apparatus property cal ated? es J o or mechanical e, does the LLD restre product flow if II detects a leak. I NIA Yes 0 0' For electronic LLOs, does the turbine automatically shut off If the LLD detects a leak. V WA Yes I No' For electronic LLDs, dom ft lWrblng aiAornailoalty shut oil If any portion of the monitoring system Is disabled or qr NIA disconnected? Yes u o For electronic LL09, does the turbine automatically shut off it any portion of the monitoring system malfunctions or ti WA labsa lost ? Yes a No' For electronic LLDs, have all accessible wiring connections been visually inspected? WA Yes I u No' I Were all items on the equipment manufacturer's maintenance checklist completed um ae;awn n, uuiuw, eesurnm now *no wn9n inese oeTmen0ies were or win ou 9orregmg. H. Comments: Monitoring System Cori flcatlon Pepe 3 of 4 12107 3 2/21/07 bl /b d Aanaa5 XVA « 9111 OE- 00 -EIOZ 0 Monitoring System Certification UST Monitoring Site Plan site Address: 300 R l (,•J i2.N -, -- Date map was drawn:1J It 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 she plan, show the general layout of tanks and piping. Clearly Identify locations of the following equipment, if installed: monitoring system control panels; sensors montoring 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 iNs She Plan was prepared. Mardtoring System COr1r11caUon Page 4 of 4 12107 4 2/2 L /U7 17US d aaAaaS Xej << 91:11 OE- 00 -£IOZ SWRCR, January 2006 Spill,Rucket Testing Report Form Thisfn-m is intendedfor use by contractors perforating annual testing ofUST spill containment structures, The completedform and pruttuut.rfrom tests (ifapplicable), shouldbe provided to thefacility owner /operatorfor submittal to the local regularury ngertca'. rAC..ILt rY IlvruxmA rtuly _ tcilit Name: ql j7 t re - i>}{C. t 5-[-C jD Dote ofTestin 9-- Facility Address: I:ucilil\ Contact: fa\tn 9- 1IC 76 Ez'La Phone, j- 30`x- ;2 -.3.18 __ -... Date Local Agency Was Notified of Testing; y - q _ ( I Name of Local Agency Inspector (ifpresent during testing): '6 RN n G M Z L t j (:h 2. TF.STING CONTRACTOR INFORMATION l.'uutp:w.y Name: RZ55R Technickm Conducting Test: -F% C:r tl¢ntials': 0 CSLB Contractor Liccnsc Nuutber(S): 'a b C- RICO Service Tech, SWRCB Tank Tester 0 Other 3. SPILL RIICTKFT TF.gT1Nr. INPOP MATT ON I'c,a M_ctluxl Used; &H drostatic Vaetivin Other Test Equipment Used: t f_3c i j TS -STS I Equipment Resolution: _ } lcicntify Spill Bucket (A), Tank 1 wnber, Stured Product, etc. 1 Z 3 4 Buckct Installation Type: D Direct Bury Contained 1.11 Swup Direct Bury 0 Contained in Suitip Direct Bury 0 Contained in Suin U Direct Bury 1 -1 Contained in Sung Bucket Diluneler; Bucket Depth: 0 'r 1V;aii tinic between applying tcuum/waler and start of test: Tcsl Start Time (Tt): 11 'q Aar^ w..— _._._. iInttialReading (Ra): j t i'r T151 End Time (Tr): titan Reading (RF): I esa Duration (Ty - Tt): Changc in Rcudinb (RN - Rt): Pass/Fail Threshold or Criteria: O PC a Test Result: 0ass Fall Pass Full 0 Pays 0 Fail Q Pass l"l Fail Coin in ents (include information on repairs made prior to testing, and recommsende 1pflow-ueLbrfailed testsl 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. Teclwiciun's Sigmittre: k Q S. A t Date :, Sm(t: 1;iws and regulations do not currently require testing to be perfonried by a qualified contractor. However, local requirements nw.v be more stringent. N/9 d ]anaaS xej ac 91:11 OE- 00-EIOZ 1l'R('Fi. 1;nuuln' ?001 I'altc of G Secondary Containment Testing Report Form 7 hisJuan is intended Ji,r rr•vra h1' canrrucYnrs pa rfcumircx prriurlic restinK uJ'CIJ7'secarrctnry eorrluinmunl .rvsh'Irr.v. (se the appropriale pages uf*lhls fi)rnl to report resullsfor all components lested. 'lyre c'omplela'clform, %willen lesl prof- edlay.t. curd priiNUrusfiaJHr li'sl. (ifupplicable.J, shouhl be provielcd «) the frlcihrv, uwner;'operalrlr• for .flibmillol to [tar loe-ol rcgill'awl. l,Wljf.t 1. rALiLll Y UNtU1CI19A HUN r iLt N:Itli: FA l NJ k (= lj "T%Sj!' V, 5'ro J? .;jam. —"Ac) IS l ucilitl /lddnss: Facilite L:ontuct: li,Y 21 It RAM- A Phone: Dutc Local Aktency Was Notil'ied ui "I'cslin — ck - 1'3 Name of Local (if'pres(mu cluriny lexting): F 1z 2. TESTING CONTRACTOR INFORMATION L•ompuny Name: r'S lvOmiciun Conductinl('fast: 2E v j>F- >, 1ZI L LC) Credentials: I J CSL13 Licensod Con-actor I.icwtxc Tvjw: k cc, MIMUl'aCtUrer _ 11 SWRCB Lictm;a:d Tank 'feeler — License Number Munufucturcr Tralning Componcni(s) I'\ pig s V CIIMMARVAF'T17.CTRR.C111TC II' h drosttttie testing, aas Ixrlb111ted• describe what was dame mill) the wider ullcr cumplcliun uI lcsis: 1-1 CER'f IPICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING; Vv tire bust of nip knowledge, the facts stated in this dut•autent are accurate anti !n,(tU compliance Ivith legal reyuirraurnty l echnician'+ tii nsrlluC • ,.,1l QQ CCl 9..R . Dale: t A;?.— I. L d laAaaS xeJ << 91:11 OE- VO -EIOZ MMMM mom= Nom 00 moo MM II' h drosttttie testing, aas Ixrlb111ted• describe what was dame mill) the wider ullcr cumplcliun uI lcsis: 1-1 CER'f IPICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING; Vv tire bust of nip knowledge, the facts stated in this dut•autent are accurate anti !n,(tU compliance Ivith legal reyuirraurnty l echnician'+ tii nsrlluC • ,.,1l QQ CCl 9..R . Dale: t A;?.— I. L d laAaaS xeJ << 91:11 OE- VO -EIOZ SWRCR. himtnry 70117 1_ TANK ANNIII AD •rPQTfmr Pqo; 1, . %d' 4_ I'cst Method Nvelnho d By: O Tunk Manufacturer OVIndustry Stondttrd I'1 Professional E?nginecr U other (,SnrafY) Pest Mcthud Used: 1.1 I'resswv krVacutun dl I•lydrosuttie 1 I Other (Specify) Test Equipment Used: Tahk N 1 Tank N Rgtuputnnt Resolution: Tank N Tank M is Tank Exempt From Tcating ?t I I Yes WNo U Yes U No a Yes U No U Yes : 1 No Tank Capacity: 10,000 Ttutk Material: JCTG I.. Tank Manufacturer: Pruduct Stored: 15- t6 e L Wait time between applying pressure /vacuunt/water and slarun test: Text Stan Timc: Initial Reading (RI): t Ej. 4 e lest I,.ndl Time: a re% Final Reading (Rr): N C. Test Duration: l l Change in Reuding (Rr.Rt): 11axsl('ail ThrcHhotd or Criteria: Test Result: tt 4ass U Fall U pars U Pall U Past U Fail U Pass 1.1 Fall Was sensor removed ]'or testing'' Yes U No 11 NA U Yeas I J No t I NA I I Yes U No UNA i Yt I I No t i NA Was sensor properly replaced and voriftcd functional oiler testis 7 VOIYes I 1 No UNA U Yea U No UNA U Yes U No t I NA I I Yes U Nu UNA Comments — (incltule injbrmation on repairs made prier lu le,vting, and recommendedfollow -up for %ailed lest.,•) 1 Secondary amtaimnent systettts Where the continuous monitoring automatically molutors both the prunary and secondary containment, such as systems that tin hydrostatically monitored or wider collstont vacuum, nre exeutpt from periodic containment testing. ,(:alifomia Code ofRegtdations, Title 23, Section 2637(nx6)) 01 /8 d aaAaaS xej « U It OE- 00 -EIOZ SW CH. Inminry 71107 5. SECONDARY PIPE TESTING Teat Method Developed By: U Piping Manufacturer WIndustry Standurd 1.1 Professional lingincer U Otb r (J eci ) Test Method Used: ea3tIre I I vacutun lJ Hydrostatic l I Othar (Specify) Test F..quipmrnt Used; Piping Materiel: PipingManufacturcr: i Y iLC91<Et-1 Piping Run # Piping Run N Equipment kesulutian; Piping Run M Piping Run q AEU r LE yC r"4 \j t 1-Z c, t-1 Piping Diumeter: Length of Piping Run: t `12 50 ' 1'rOdUCt Stored: t E t— Method and location of piiin - nutisolatiott; D,{- TO ST1' vMv Wait time butween applying pressure /vacuutn/water and stalling test: 115 M N . Test Start 'I"irttr; Initial Reudmg (Rr): us( Lind Tune: Nn in r-Y\ Ht-ml Reading (Rt ): 6 Rs t test Duration: Change in Reading (RR -Rt): er 11uss/Pail Threshold or Criteria; Test Result: s>t U Fail U Pass U Fair U Pass U Fall U Pass U Fail Comments — (inclh,de infurnration on repairs made prior to teaiin ,and recvnr »rendedfr,!lary -up jyrJniled tests) K/6 d aan,a5 xej « LIM OE- 00 -EIOZ tiWR(:R. Jnniinry V0 G. PIPING g11MP TAC'I'IN(: vage"I of —L I'e,l Method Developed Bv: U Stunp Manufticttuer Norndusuy Standard i 11'rnfessional l ttsinuer U Other (Specify) Tcst Method Used: U Presswe U Vacuum Wnydrostatic J Other (,j'peci.V.) Tudt hquiptuenl Used: t N CL r` T S - -;j T -3 Sump # t Sump # Sump Diameter: + Equipment Resolution: Sump # Sump 0 sump Depth: Swap Material: t319V 4 t.{5 I Icight from Tarik Top to Top of Highest Piping Penetration: y t i I leight from Tank Top to Lowest I:leclriunl Penetration: 1tS Condition of sump prior to testing; 0 yC Portion of Swnp Teslcd' 2` A00,4Li MC- Does turbine shut down when swap seltsor detects liquid (both ruducl and water)' ?* wY r es I 1 Nu U NA U Yes U No l I NA U Ycs U Nu 11 NA l J Yes LI Nu i I NA Turbine shutdown response tune ONE S C4+rb Is system pnidrumnied for fail -Afe shutdown ?* 11 Yes U No X NA U Yeq I I No U NA U Yes : I No I I NA U Yes ! ;No NA Wit, fail -safe verified to be uperatiowtl ?, I ; Yea U No XNA I 1 Yes U No J NA I i Yes I No U NA Yus . I No '. , NA Wuit time betwean applying pressure /vacuum /water and stdriing teal; rest Stan Time; lnitidl Reuding (RI); Test End Time: th Fimil Rending LRp): I *ust Duration: Change in Reading (RrR,): Pass/Fail Threshold or Criteria: O 0 Test Result: V; Pass U Fall U Pea U Fail U Pass U Fail 1.1 Pass U Fall Was sensor removed for tenting? kv7es U No U NA U Yes U No U NA I I Yes 1.1No U NA U Yes L. No !!NA Was sensor properly repla"d and vcritied 1lunctional a 7aftertesting'? es U NO U NA u Yes u No a NA 1.1 Yet u No u NA u Yt', I 1 Nu 1 . NA Comments— (!,,chide inJi),maliun on repairs made prior In Iestft!g, l,,st.91 If the entire depth ofthe sump is not tested, specify how much was tested. if the answer to dU of the questions indicated with urn asteiisk (11) is "NO" or "NA ", the entire swnp must be tested. (See SWRCB LG -160) 01/01 d aaAaaS XOJ « U:ll OE-00 -EIOZ SW1103. January 211112 7, UNDER- DISPENSER CONTAINMENT (UDC) TESTING l ngc of ._• test Method Developed Fay; I I UDC Manufacturer lAndustty Standard I I Prol''mional i_:nguieer U Other (S cijy) Pest Method Used: 1.1 Pressure U Vacutatt Ydrostativ I I Other (Specify) Test Equipment Used: 1 NCO rj Equipment Resolution; ()ppp a UDC M UDC # UDC # UDC 11 UDC Manufacturer: F_ lVV t 0 r-1 I.1DC Malarial: UDC Depth: 1 leighl from UDC Bottom to'1'op of Highest Piping Penetration: Height from U`X Bottom to Lowest Electrical Penetration; Condition of UDC prior to test I< Portion of UDC Tested ' t WE Does turbine shut down when UDC sensor detects. liquid (both naluct and water)'?' tJ''rs U No U NA U Yes 1 J No l I NA I I Yes t 1 No U NA U Yvs L1 No I I NA Turbine sliutdo%vn rtWnse time 1 6rcot-JTJ Is system programmed for fail- sti Cc shutdown ?' L Yes U No KNA U Ym U No U NA lJ Yes 1 I No t 1 NA Yea I 1 No t i NA Was fail,Qfe verilied to by O >erational'1' 11 Yes U No SLNA U Yes I I No U NA I 1 Yeti U Nu U NA t Yes U No U NA wait time between applying pres.sure/vacuum/watvr and starting test rest Start Time: io. ( A rn Initial Reading ): Pest E:nd'fime: 419160 IC. l Am Vinal Reading (RF): 1 eat Duration: LOS rn t ra , C'lwn a in Reading 'R R : D, 00 0 a Pan/Fail Threshold or Criteria; 0 •Op bZ Test Result: Paff •.EJ Fail U Pats U Fall U Pass IJ Fall U Pnrs U Fail Was sensor removed for testing? 19'Ves A No U NA U Yea U No U NA U Yes U No U NA U Yom+ L' Nu LJ NA Was sensor properly replaced and verified functional after tcsting9 Yes U No U NA 1 1 es I I No l l NA I l Yas 1 1 Ne I I NA I I Ycr1 i; Nu :!NA Conlntents — (include ikyb mation on repairs mode prior Ia lesdrig, and ree•ummrndedfulluw-up urjililrel test.!) _ I f the entire depth of the UDC is not tested, spray how much was tosted. If the answer to i of the questions indicated with tin asterisk (') is "NO" or "NA ", the entire UDC must be tested. (See 18WRCf1 1,0 -1 60) KAl d AaAAaS XQJ << UTll OE- VO -EIM SWKC13, January 2007 , I'ags 6_, of Sprt.r.lnvFRrrrr.r. rntv'rett\ttusrtv'r an.r' Facility is Not F.'quippod With 5 UI /Overfill Containment Roxes U Spill/Overfill Containment Roxes are Present, but wort: Not'f'ested U Test Methml Developed Hy: U Spill Bucket Manut'aclurer t&?fndustry Standard I ' Professional lingmeci U Other {Speed ) Pest Method Used: ti Pressure U Vucuutu 11Vi=tydrostulic I.1 other b' ecrif Test Equipment Used: C0 i.1 T S - S T 5 Spill Box N Spill 'Box q LAM I t Rexolulion: Spill Box # Shill Box by 13ucket Diatnetcr, 13ucket Depth: i t Wait time between applying prensun/vacuum/wnter trod stnt'tiri lt.t: 15 m , N Fes( Slart'tinle: Ar.n Initial Rending, (RI): 5 1l Test Frii Timc: Final Reading (RF): j1 O Text Duration: I rrt I ra . t.`.han a in Rtmding (Rp -Kt): O , op 0 3 l'nss/i: ail Threshold or Criteria: Test Result: ass U hall tl Par! U Fall U Pass U FaU U Pass 1.1 Fail CO"1111e1111S — (include irJiam nion on repuirx mule prltu- to test! &, and revammmijeelJvllraw• tip /br jailed iests) VI /V d aanJaS xeA << 8111 OE- tO -EIOZ WEI d AaAaaS XPJ « 81:11 OE- bO -EIOZ 300 FA I Fl END LFVE' ' ! , 9964 'k, a. L f o "SHr'LDDSLF'i TES- ': -, -: • •;,; , 5•' ,AkeD END 'T.r{'1: I AM4 i 1133- i /7.3/413 TEST >TARTEQ,.: •. ! ?!.39 oM j END 'LEVEL ' AK .. 3.95x8 .IN ' a:• TFQ. 66,1N "..: 2.7568. Ir, { rh .HOLD LEVELr'esT ..'Al,4A2. RESULT+ iENiwDATE' 04!22.29:' i :.•; .•. v.,. L;, 7,,:;.•,4;, LEAK THRESHOLD 4).'kO7 r• ta1T9 KDIN 22/2611LEk1 :r' END 13 ,3 •. AMD9T' , IlAi22/2013UE1t;.;`' °''.8:Fr8000 ILEAKTHRESHOLD: 0.002' IN '' IEgT,:.tZESUL7'.•.;.:; ' AILFD'• L,` •.r'')dr'.;5'v I:y:'1s''`a "I` y'•I .., •,L,, .• ^,, I1:. 3 10 J I Lj i v c {/ Y d } FFMK iE;;T b 1 j .. — r,r -.s;Tl -ED TEST, STARTED ' 04r22-,101*?. F..h1p TIME <•,t; Io-x FI1(? EVF;I.. k';4495 9 rtN i \ surf 1 BEGIN LEVEL 2.7%5 TAI END DATA LEAK THRESHOLD 0.0HI7 10, i WEI d AaAaaS XPJ « 81:11 OE- bO -EIOZ 2013 -04 -30 11:18 » Fax Server P 14/14 I f I, f •. {•,G /.r7;' ! ,• +Iti.YC :.tip? ylt4 ,C; 717 "f! : I ',i:': :.:» 'i` - Y C . r`lfi F { ,311 Id Si r''+, 1t, I OoW RuMyualy Ylwy 0 D Bakersfield, California 933M Phone; 661 588 2777 Fax: 661 588 2786 Fax To: Fan: Pbonee Bakersfield Fire — Emie Medina 852 -2171 From Kelly Tackett Date 430-13 Pages: Ras Fairview Truk Stop CCs 300 Fairview Rd. 17 Urgent For Review Please Conmmmt O Please Reply please Recycle CanmoMat Hi Emie, Attached are test results. Please call 9you have any questions. Thanks, Kelly W1 d aanaa5 xe j << SGU OE- 00 -EIOZ