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Home My WebLink About400 OLD RIVER ROAD MOD 2013HOODS ALARMS SPRINKLER SYSTEMS 1-51YR.OVV ° OC3`CUL1 Permit No. Permit No. AST UST Permit No. Permit No. Permit No. Permit No. 3- /aCx7a 3g7 File Number: 3- '7- cf Address: (n Cc -4,) - Bakersfield, CA 933 Date Received: _ - c 3 - t 3 Business Name: ,r -c_- - 405 j2 L L SYSTEM: BUILDING SQUARE FEET: New Mod. Commercial Hood System Fire Alarm System Fire Sprinkler System Aboveground Storage Tank Underground Storage Tank minor modfica ' Underground Storage Tank removal Underground Storage Tank Other: Building Sq. Feet: Calculation Bldg. Sq. Ft: zr 1. a. 3. 4. NSPECTMN L ®( Date Time Signature Signature Comments: 7-7, ; s ; ra_t z vE/ t+lrnv,' oe ewe -%c ./ rCA : F'ol/ Ca,ee.'lId ie r- -w- 5 5' f Eie. /rs/ VR -,Zr $.?l 7y1 6*a a UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELD /LINE TESTING / SB989 SECONDARY CONTAINMENT TESTING/TANK TIGHTNESS TEST AND FUEL MONITORING CERTIFICATION PERMIT # 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 E FUEL MONITORING CERTIFICATION SITE INFORMATION FACILITY C 50q-rH W ES'r NAME & PHONE * OF CONTACT PERSON KENT 661- - 1 7 - 3y \ 1ADDRESSWOOOLD1:b-J E. IZ RED PA ERS F I E LtD CA OWNER NAME ME1Z -f-1 H051?I T19 L OPERATOR NAME PERMIT TO OPERATE Y OF TANKS TO BE TESTED: IS PIPING GOING TO BE TESTED? YES NO TANK # VOLUME CONTENTS i SourN 000 t7- -t E S E L a N0JZTN g , 000 DtESE L TANK TESTING COMPANY TESTING COMPANY INC. NAME & PHONE S OF CONTACT PERSON MAILING ADDRESS 6630 osr --17A LE H W`! 4 'Z) NAME & PHONE # OF TESTER OR S ^ 3 PECIAL INSPECTOR CERTIFICATION f DATE & TIME TEST TO BE CONDUCTED TE ICC t TEST METHOD APPLICANT SIGNATURE C DATE g-13- 13 THIS APPLICATION BECOMES A PERMIT WHEN APPROVED APPROVE BY DATE 13 FD2095 (Rev 06/07) lY C'.VG &PERMIT STATEMENT „llil l l il BAKERSFIELD FIRE DEPARTMENT Prevention Services PERMIT # ' FiRs 2101 H StreetARrm1, uII U iiill;u. Bakersfield, CA 93301 979 • Fax: 661 -85 -2171 Please make checks payable to CITY OF BAKERSFIELD. Thank you. PERMITTYPE Alarm - New & Modification (minimum charge) LOCATI0 j OF PROJECT PROPERTY OWNER C QT c 1 AL STARTING DATE COMPLETION DATE NAME PR 3ECTNAME ADDRESS PHONE # 663-6 -3-4cI - PROJECT ADDRESS 1400 2 JER i2 CITY g/K Er -ISFI EL-D STATE CA ZIP CODC 311 Y. CONTRACTOR INFORMATION CONTRA; ,OR'N=AM` CA LICENSE # TYPE LICENSOE EXPIRATION DATE PHONE C 1 IOF Jd 88 _.766 CONTRACTOR COMPANY NAME FAX # u % - 588 -a X8 6 235 58 hood ADDRESS 6630 ,RC)SEL L'E H&3,4 -I'k a CITY K,EZsF IE Lb ZIP CODE Please make checks payable to CITY OF BAKERSFIELD. Thank you. PERMITTYPE Alarm - New & Modification (minimum charge) FEE CALCULATION TOTAL TREASURY DUE ACCT NO 280 Over 10,000 sq ft 0 .026 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) Additional Hood 235 58 hood Commercial Hood - Minor Modification add /move nozzle 96 (Inspection only) 84 Spray Booth (New & Modification) 235 98 boveground Storage Tank (1 Inspection per installation) AST 180 /tank 82 1 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 62 Underground Storage Tank (Modification) MOD 878 /site 82 V' underground-Storage Tank (Minor Modification) MTM 167 /site 82 Underground Storage Tank (Removal) TR 573 /tank 84 0 Mandated UST Testing: Fuel Mont Cert/SB989 /Cath, Prot. NOTE: $96 /hr for each type of test /per site /per UST system ven if scheduled at the same time 96 /hr (2 hrs minimum) _ $192 82 p Oil well (Installation, Inspection, or re- inspection) X 96 /hr 82 ID 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 0 Re- inspection /Follow -up Inspection 96 /hr 84 Portable LPG (Propane): # of Cages? _ 96 /hr 84 d Explosive Storage 266 84 Copying & File Research (File Research fee $50 /hr) 0.25 /page 84 0 Miscellaneous 84 64 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 PHONE # t37 = ?77 PRIMARY PIPE SECONDARY PIPE SECONDARY CONTAINMENT SENSORS AUTHORIZATION FOR FUEL ELECTRICAL SEAK -OFF TANK TESTING UST REMOVAL DESCRIPTION DATE SIGNATURE AST NEW INSTALL DESCRIPTION DATE SIGNATURE MAJOR AST REMOVAL DESCRIPTION DATE SIGNATURE EVR UPGRADE PRI6RTO.OP_ERATION_OF_ANY_SYSTEM,) ALL UST_ANRIOR AST-SYSTEMS- SHALL BED INSTALL, CQMP_LETE AND ACCEPTED BY-, MISC. ACTIVITY EfHE-BA-KERSFIELD-CITY-FIRE- DEPARTMENT. FIRE_DEP_ARTMENT (FINAL)"-? _ 3__ REMARKS: BUILDING ADDRESS: L ( L/ . JOB DESCRIPTION: OCCUPANCY TYPE: OWNER: ____ PERMIT NO. 13-1660C) CONTRACTOR: S PHONE # t37 = ?77 FD 1743 W10 Roaedale Hwy 0 B BakerskId, Cagtomla 83308 Phone: 661 588 2777 Fax: 681 588 2786 Fax Toe Bakersfield Fire — Emie Medina Fax 852 -2171 Phone: Re: Freme Kelly Tackett Data 8 -22 -13 Pagese Mercy Southwest _ .._. CCe __.. . 400 Old River Urgent For Review 0 Pkmse Comment C) Phase Reply 13 Please Recycle Cm nnent-m Hi Emie, Attached are monitor oen flcatlon results. Please call if you have any questions. Thanks, Kelly 11/1 d Aanaa5 xeJ << 9 171:171 EE- 80 -£IOE JJEaFl_ C .CIE ?A b11Z Appendix VI Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at ) MONITORING SYSTEM CERTIFICATION For Ute ByAll Jvrlsdkx/ons MINn the Stare o/ California Authority Cited; Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control parcel by the technician who performs the work. A Copy 01 the form must be 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 days of lest data. A. General Information Facility Name: Site Address: r-AVQ CA- 0...1'211J.ER_ Zip: 3O Facility Contact Person: — V. ES -- - .___— __..- -- Contest Phone No.: ( 661) 66 3 - 6 ( 7r' 1 .1i. MakgfMOdel of Mon4oring Stem: ,0_C,,,,, .>ED I_. = ,jt,d0 Date of Testinyservicinq: ! . / P?d J11 J g, InverAory of EqulpmentTested/CertlfiedChecktheapprolorlatoboystoIndicate spwfflc equipment Ins /servlced: ID: Tank ID:. 1 Taypk In•Tank Gauging Probe. Model: { _- -,.j.. I In -Tank Gauging Probe. Model ; VAnnular Space or Vault Sensor, Model: R$'""1Q t Annular Space or VaultSensor, Modal: w Plping Sump / Trench Senw(s)• i Piping Sump / Trench Sensor($)• Model:_. Fill Sump sensor($). Model: l Fill Sump Sensor(s). Model; Mechanical Line Leek Detector. Model: l Mechanical Line Leak Detector. Model: Electronic Una Leak Detector. Model: n electronic Line Leak Deteotur. Model: Tank C?rartlll/ hign•Level'Senior. Model: 1 Tank Overfill / HiylfLevel Sonsur. Mudei. _ 01110(opoeffy equipment and mode{ in Section E on Raw 21. 1 Qher s it i ent type and model In Section E o11 Page 2). Tank ID: Tank lip:_ In-Tank Gauging Probe. In-Tank Gauging Probe. Model: _....._. Annular Space or Vauft Sensor. Model:_.. ................ _ -- Annular Space or Vault Sensor, Model:.. Piping Sump /Trench Sonsor(s). Model:---- I Piping Sump / Trench Sonsor(s). Model: , rill Sump Sensor(s). Model: -- 1 FIII Sump Sensor(a). Madei:. _..._......_..........- _ MtWJ)drrlcal Line Leak Detector, Model;. I Mechanical Line Lusk Datuutor, Modcl: Eleotronlo Lino Leak Dote=. Model: 1 Electronic Una Leak Doteattx. Modal: , , , .. _ Tank Overfill I High.-Level Sensor. Model: - _ _ 1 Tank Overfill / High-Level Sensor. Modal: I Other (specify egulDment and model In Se tton E on PaW 2 1 Other (specify eguipment tvoe and model In Section E on Page 2). Dispenser ID: - -. -- Dispenser 10: Dispenser Containmem Sensor($)• Model t Dispenser Containment Sensor(a). Model'. „ Shear Vefve(s). i Shear Valve(s). 2l6 it er Containment Floe a and Chains). i n F ins . Dlapensw ID 01epansar10: — ..,.,.., Dispenser Containment Sensor($). Model: 1 Dispenser Containment Sensor(s). Modal: _ _ Shear Valve(s), 1 Shear Vafve(B), DisPonser Containment Float a and Chef e , 1 Dispenser Containment Fluat a and Chaln e , DlspenW 101. Dlspensot 10: DisPenserConlainmemSensor($). Model' I Dispenser Containment Sansor(a). Model:u_,_.. Shear Valve(s). l Smear Valve(s). Die nsor l,'',ontainmem Floats and Chain (s i Dis nser Containment Floats and Chain a . II the fdclllty contaWlB more tanks or dispensers, copy this form. Inclucie Irtlomiatlon rot every tanK ano Orsponser al the iaciiny. C. Car ifleatlon - I certlty that the equipment Identified in this document was Inspbeted/servieed In accordance with the manufacturers' guidelines, Attached to this Certtf cation Is Inlormatlon (e.g. manufacturers' checklists) necessary to vsrlly that this Inlormation Is Correct and s Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating suoh reports, I have also attached a copy of the report; (ahead etc that epplyr n System eel -up -1 Alarm history report Tetxuticiarl Narne (pliru): t DE L G A Z.! Ll. Signature: _.D4.,. .7`c+J- >'`ti•J .... - - -.- Certification No.: A C1111 -4 ui I License. No.: l L2iIsgi__Z. . 1 I\ _ .__.......— Phone No.:LiLd—1 _.. a% 'A-411TeatkiyCompanyNento: , Testing Company Address: L(:_ 1 .fi1EDALE 4 y ,. * 1_ Daur at TesflWSmvIcing: a Ii9 1 ao 1 Monitoring System Conitkatlon Page 1 of a 12107 2/21/07 II /Z d aaAaaS XPA << 8 411:01. ZZ- 80 -EIOZ D. Results of Tesltng/Servlcing Sollwwa Version Installed- Comotete the fodlowitia ohockllst; Yes ' No' Is the audible alarm operational? ae ; No' Is the visual alarm operaunrw . Yes No' Were a1 sensors visual inspected, unctionall tested, mid oonnrmad o rata es No' Were all sensors Installed at lowest point of Saco ary containment and position so Ihat uttlar egwprrtorll not interfere their 0 oporation? T os NO a alarmsare rersyeu to a remae murwuomig awuun, a an cvmmur wauu w nyulwim- tu.y. 11—.1 NIA Yes No' For pressurized piping aystama, does Iho alrbin0 aulomattcalfy shut down II Ilia plpbtg secondary containment monitoring syslatn X NIA detects a leak, fails to operate, or is electrically diseonrrtrded? If yes: Michsensors initiate positive shut•duwn? (Chad* ail that apply) Sump/Trenuh Sensors: 1 Dispenser Containment Sensors. Dill you Confirm positive shutdown dun to leaks ar cottsor f r n? ' Yea; No. I Yea No' ror tank systems that utilize the monitoring system as Ina primary tank overfIll warning device (I.e, no rnechauk;al overfill piovontiort 7K N/A uatvo is installed), is the overfill weming alarm visible and audlbte at tho tank fill pnint(a) And operating properly? II so. at what peruertt of tank capacity does the alarm Ir' r? % es ?C Was any monitoring equipment replaced? II yes. Identity epeui ie sensors, pr000a, or other equipment replaced and list IhB mgnyfjgqjVnpr name and model for ad replacerriom pars In Section F below. I Yes' No Was liquid found Inside any secondary contalnmonl systems designed as dry systems? (C4wck all that a pty) i Produfl: i Water. If es, describe causoz In Section F., below Ytr• Nu' a8 mnnitonng system set-up reviewed to ensure proper setti Attach set u top", i a is e oa 1) No' Is all rnonitorkrg equipment operaliorwl per mates acturers specifications? In Section E below, describe how and when these deflclencles were Or wIH be corrected. E, cOmmenta; Monitoring System Conffloation II /E d Page 2 0114 2 AaAiaS xe4 « 12/tl7 2/21/07 9 G114 Er-BO -EIOE F, In -Tank Gauging / SIR Equipment; Check this box it tank gauging is used only for Inventory COrttrot. f.i Check this box It no tank gauging of SIR equipment is installed. This section must Ou completed it in -tank gauging equipment iv used to perform leak detection monitoring Yes D No' Has all input wiring been Inspected for proper entry and lermination, inoludloo testing for ground laullb 7 Yea D No' Were all tank gauoing probes visually Inspected for damage and resitlue bu loop? V Yes n o' Oas eccutaW of system pr3aucl leyot readings tested? Yes o Was accuracy of system water level re nos tested V yes l No' ere w probes reinstalled properly? Yes t NO' Were all rtema on the equipment manu acturer's maimenance checklist ctxnpleted In ins 3ecklon n, Derow, aeakinoe now aria wnun intrw aeimiu kame worm ur will — G. Line Leak Detaelors (LLD); Check this box if LLDs are not installed. Yes U No' For equipment start -up or annual equipment ford ication, was a leak simulated to verify LLD performance? (Check art J N/A that ogolyj Simulated leak rate; t1 3 g.p.h.; 0.1 g.p.h ; 0 0.2 g.p.h. Yea o ere all L s confirmed operational accurate within regulatory requirements? Yes 7 o' as t lasting apparatus properly calibrated? Yus 0 No' For me0hanleal LLDs, does the LLD restrict product flow it it detetl6 a leak? U WA Yus No' For electronic LLOs, does the turbine automatics ly shut off-if t LLD detects a leak? it WA Yus No' For electronic LLO&, does the turbine automatically shut Oft 0 any portion of the mo tOring system ib disabled or D NIA dipoonneCted? Yes No' For eleotr0 o L s, does the turbine automatically shut off it any portion of the monitoring system mallunctions or U WA lailaalost? Yes U No' For electronic LLDs, have all accessible wiring connections been visually inspected? U N/A I I C Yes No' I Were all Items on the equipment manu eOurer's maintenance crZZlIt Completed In {ne am ivn ", wmiew, VViHn4V nMw .11. wr rmrr ulamv VOIrGro1R+.V0 wo,v v, ..,,, vv ..w. w.w. H. Comments; Monitoring System Cent"Icatlon Page 9 of 4 3 12J07 2/21/07 11 /O d aaAaaS XPA << a sl :bl zz__9O_EIOZ System Certltientton too OL i UST Monitoring Site Plan L Aj r rf rte^ ............:: Data =p was drawn, you already have a diap= that.shows all required information, you may include it, rather than this page, with ;.)U onitoring System Certification. Cm your site plan, show the general layout of tanks and piping. Clearly idcrwi', cations of the following equipment, if installed; monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary eontai=ent areas; mechanical or electronic Itne leak tetcctors', and to.time liquid level probes (if used for leak detection), In the space provided, note the date this Sac 1'Iar as prepared Page -4— or j 9. 11 /S d aaMaS xeA << a S144 M-80-00Z D(CGEL 130 %LF_)Z Appendix VI Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at ) MONITORING SYSTEM CERTIFICATION For Use ByAllJurisdiction WUhin the Srate of Catb'orrim Authority Cited: Chapter 6. 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations rh a form must be used to document testing and servicing of monitoMq equipment. A separate certilication or repurl must be prepared for each monitoring system control panel by the technician who perform& the work. A copy of this form must be ptovlded to the lank system owne0operator. The owner /operator must submit a o0py of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: t(itizC`jJ S^Cy)l)YN+.t _..._........._ ... c-r BIdg.No•: - -.._._...... Site Address; 1d1. _ Q._. _S s1_ .1 . +t... City: , AYCEZSC. E t_ ZiP:: L-- 1 _6C) C7 Facility Contact Person;,,,__ Contact Pitons No.: L 1_.l__&0 2 ii Make/Model of Monitoring System: _ ,td5 `35.01 /C8H 10 9b -rJAGA Date of Tatting/Servicing; e) rly, ao 3 U Inventory of Equipment Tested/Centfied Check the arimmmafa hnium M lnAlvata enaMHe anulnmant frimmi aed/mrvioad: Tank ID: _. y.F-6 M t.3 R— . —_ Tank ID: _ V In-Tank Gauging Probe. Model: - -_i n Irl-Tar c pausing Probe. Modal: V-Annuiar Space or Vault Sensor. Model! 1 Annular Space or Vault Sensor. Model V Pfping Sump / TWoCh Sensorial. Model: e _ 1 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s), Model __ I FIN bump Seneor(a). Model' Mechanical tine Leak Detector. Model:.. _ _ I Mechanical Line Leak Detector. Model: _, ,, , Electronic Line Leak Detector. Model: 1 Electronic Line Leak Detector. Model: Tank Ovenal l Htgh•Level Sensor, Model 1 Tank Overfill / High -Level Senaor. Model . . Others cif equipment and model in Section E on Pane 21. i Others i m n and model In Section E at Pa 2 Tank ID, Tank ID: _ _....._..... In-Tank Gauging Probe. Modal: i In -Tank Gauging Probo. Model: Annular Space Dr Vauh Sensor. Model: _ __• . _... . _. ..... _._ • 1 Annular Space or Vault Sensor. Model: Piping Sump 1 Trench Sensor(s). Model: _ ........... .. t Plping Sump/ Trench Sensor(O. Model , 17111 Sump Sensor(s), Model: „ 1 Fill Sump Senwr(o)• Model:.. Mechanical Line Leak Detector. Model: .--- .... .._. i Mechanical Line Leak Detector. Model .._..--- ....... Electrunic tine Leak Dotector. Model: .. __— I Electronic Line Leak Detector. Model:._ ^.._._..... _ Tank Overfill I High•Loval Sensor. Modal: 1 Tank Overfill I High -L9vel Sensor. Model; Other (specrty egyZiont typy and model in 9WTon Er 'n 070 '04, 2 , 1 r ci a moot and m del in Sector Eon . Dispenser Containment Sensor($). Model: I Dispenser Containment Sonsor(s). Modal: Shear Valve(s). I Shear Valve(s). ng r Containment Floats and Chain a . I Dig r Containment F and Chain e . Dispenser ID: Dispenser Coltainment5emor(s)• Model:y n Dispenser Containment Sen$ O). Model: _.. . rehear valve(s). I Shear Valve(e). Dispenser Containment Floats and Chain(s), Dispenser owWoment Flo a and Charm(s). DlsppeenswID; Dispenser Containment Sensorial. Model:._. I DI$penser Containment Sermar(s). Model: Shear Vafve(s).. Shear Vahe(s). Diaggnsar Containment Float (a) and Chem a 1 Dispenser QMonmW Floall andChain(s), if the Iacirly contains more tanks or dispensers. copy this form. Include intormation for every tank arc afapenser at me iacsfry. C. Certification • I oeAHy that the equipment Identified In this document was Inapacted/serviced In accordance with the manufacturers' guidelines. Attached to this Conilloatlon Is Inloirmatlon (e g. manufooturers' ohaokllsts) necessary to verily that this InlormaUon Is oorreot and a Plot Plan showing the layout of monlloring equipment. For any equipment capable al generating such reports, I have also attached a copy of the report; (ctrack an Uret apply)t -1 System set-up -1 Alarm history report Technician Nam (print): F1 a•.L_.A RI IL 1 Signawre: Certification Nu.: A a1 i _ . — License. No.: Tostrng Company Name .St — 1C:....._..._...... _ ... ... PhoneNc.:(__6&L)rp_g. .,7 .. Testing Company Address: G ...,} O$.l iii —llk ` J5_.... Date of TeetlnWServicN: &_/ ja / _aU 1 3 Monitoring System Certification Page 1 of a 12107 2/21/07 11 /9 d .faAaaS XPA « a Sari ZZ- 80 -00Z D, Hosults of Testing!Servletng Sultware vergion Installed' —_6U , W _... mmnlwn tho fnilraulnn --harleliN- You No' Is the audible alarm operational) Yes No' Is the visual alarm oporaliu ial? CIS No' Wara all sena0re visual ing IBd, 1UnCa0rlatl tested, and Conikmed 0 rational? es o' ere 98nsor8 Installed el lowest pointo secondary roMainment and positioned so that other oquiprrrom will nut urtwlme mUr ll rn o r o ation? Vag No' II alarms are relayed to a remote monitoring sW11on, iS all Commnications aquipmufit (a.g. modam) operational? Nr'A Yus No' For pressurized piping systems, does lho turbine eutOmulivalfy shul dumi it the piping secondary containment moirtomig oyolum x NIA detects a leak, fails to operato, or Is aleclrically diWonneuted? II yes: wtrich sensors initiate positive shul•down? (ChOClr all t1hI1at ,Wlyl 8umprTrench Sensors; ' Dispenser Containment Sensors. Did you corifirm positive shut -Jown due 10 teaks diJX serkuji failure/disconnection? , Yes i No. res No' For tank SyStems that utilize the monitoring system as the primary tank overfill warning devlue (i.e. no mechanical over i17r 11tiurr NIA valve Is installed), is the Overlitl warni Q alarm visible and audiblO at lho tank fill point(s) and operating property? It so. at what porconloftankcacflduesthestartlrir7 fo YBS' x No Was any rnarlilOring equipment replacedr, ifreplace yes, Identify 8096 iu BerWOra, probes, or other equipment rPWBGhI artd IiSI the manulacturer name mv& for allroplaco Ii5 In Section E below. You, No was Liquid round inside any secondary coma nrtnonl Syetarns designed as dry systems? (Chock all f 9f app I Piodi,U, Wutui. lr ri (n 0tion E, bulum Yus _ No' Was monitoring System set-up reviewed to 6rlSura proper seltings7 Attach set up reports, if applicable all inonrloring ayulpmenl operational per rnanufaclurer's specifications? es in 5action C oo4ow, oescrloe now an0 wrlen Inese a9mienew wom Pr will t)* pprrmeo. E. Comments: S?Tw R._. SUr \? 51E&JS0iZ _._._..... - aODE L -k . 39 N 3 3n aC)9 _ Monitoring System Certification Page 2 of 4 12107 1) 21/07 11 1L d AaAAaS xej << 8 91:tr1 ZZ- 80 -EIOZ F. In-Tank Gauging 1 SIR Equipment: tl Check 111is box if lank gauging is used only for inventory ddntrul. Check this box it no lank gauging or SIR equipment is Installed I 1w; sect on must De Completed If In -tank gauging equipment is used to perform leak detection monitoring fl m—.i t. th. 4.11— 1.. k- 611.t- Yes U No' Hag ps input wiring own Inspected lot proper entry and termination, Including testing for ground au ts? V;—Yes U No' ere all tank gauging probes visually nspecl or amape and resJdue buildup? Yeg 0' as accuracy of system product level readings tested _ W Yes C1 No' Was accuracy of system water level readings testedl Yes u No ere all probes reinstalled propeny? Yes n o Waire all Items on the equipment manufacturer'; rnainlananoe checklist completed? in the uecUon n, oelow, oescrine now ana wnen inese asTlctencies were or win oe eorreclea. G. Line Leak Detectors (LLD)- t Check this box it LLDs are not installed. r'—.IM th. IAIIh,urAA .".LAI- Yes f, o' For equipment stan•uo or annual equipment certification, was a leak simulated to verity LLD pehormanceIr (Cheek ail NIA that ap#y) Simulated leak rate; U 3 g.p.h.; n 0.t g.p.h ; 0.2 g,p,h, es 77-7.7— Were all LL09 Conllrmed operational #nd accurate within regulatory requirements? Yes No' Was the testing apparatus properly calibrated? Yes J No' For mechanical LL s, does the LLD restre product flow it it detects a lea fJ N/A Yes No' For electronic LLDs, does the turbine automatically shut all II the LLD detects a leak? NIA os U o or eleclrOnlC LL 9, does the turbine automatically shut off it any ponlOn of the monhoring system 19 drsubled ur tl N/A als00nrtgpted? Yas No' For electronic LL09, does the turbine automatically shut oft if any portion Of the monitoring system mallunc.tions; ur U WA lails a lest? Yes o' I For electronic LLDs, have all amessiole wiring connections been visually Inspected? N/A Yes I —'—No' I Were all Remo on the 9quloment manufacturer's malmonance checkllst completed in ins aeciron n, oerow, oesonoe now ano wnen mesa aenerancrtis were or wm vii WrreOioo, H. Comments: Manitorinp System Caniflcatlon Page 3 014 3 US d AaAiaS XPA ec 12/07 2/21/07 9 91:01. M-80-EIOL f 1 I r sng 5yylem Certillcation 1 A01are$3 OLD RN E ji ti r 1 ...... i f Data map wan drawn; i ST Monitoring Site Plan cu already have a diagxam that. shows all required information, you may include it, rather than this page, with ,. yonitonng System Certification. an your site plan, show the general layout of tanks and piping, Clearly iden.iI, canons of the following equipment if installed; monitoring system oontml panels; sensors monitoring tank annular 2rts, sumps, dispenser papa, spill contailtey, or other secondary containment areas; mechanical or electronic !inc IC, .. xtors; and is -panic liquid level probes (if used for leak detection), in the spaoe provided, note the date this Sllc !' a.s prepartd. Page _a__, of 11/6 d aaMaS XPJ <t a 91:bI ZZ- 80 -£IN SWRCB, Januiul, 200(, Spill ,Bucket Testing Report Form 7%ns lbrm is intender! for use by contractorsperforating annual testing of UST spill conlainment structures•. The completedform mul l,ri) In,uts Jro nr tests (ifapplicable), should be provided to thefacility owner /operatorfor subatiltol to the local regulatory aeenc.v- 1. FACILITY INFORMATION _ t acilit Milne: L' i 1-j4nk ^' LJE:5 - Date of Testing: — LA— Address: Facilit.v Contact: K-E tA I Phone: A6J — - Uatc Local Agency Was Notified of Testing me of Local Agency Inspector (ifpresent during testing): E RtJ I'E N) i~ D i r 3 A 2. TESTING; CONTRACTCIR INFORMATION N1 l'0111pany Name: p -sC? Technician Conducting Test: E t D-E L C A RR ,% L- LO Crcdcntialst: 17 CSLB Contrtetor PICC Service Tecli. 0 SWRCB Tank Tester it Other (Speci,&) License Nun,bcr(s): 5 11 n-4 a 8 ai 1 QPYY.r. nTIr 'P..T Tr..RTINt; INPOnMATICIN Method Used; WH drostatic n Vacuum 0 001erTest Test Equipnient Used: Equipment Resolution; Idendfv Spill Bucket (By Tank umber, Slorrd Product, etc.) 1 3o +LV R DI C,5S L 2 3 L3uckct InstallalionType: Bucket Diameter: Direct Bury Contained in Stun 1 Li $ I 0 Direct Bury Ll Contained in Sum U Direct Bury n Contained in_Sturt fl Direct 1301' ' J Cont<ti_ucd in Sump_ 8'L,,kT Depth Wiw lithe between applying acuunt /water and start of test: 15 ro itv. I r,, Q rest Slart'rime(TI): Initial Reading (Rt): l Test Fad Tit» e (TF): 13, + L 115 9r^ Fiiwl Reading (R,,): Test Duration (Tr - Ti); C'Itangc in Reading (R1'- -111): Pass/Fail Threshold or Critcri,,v O coo ;t., Test Result: Pays 0 Nall 11 Pass D Fall 0 Pays fl Fail 11 Pass IJ Fail Comments — (include information on t•epairs made priur to testing, and recorninendedfvliaw -trpforJatlec! tNSlsl CERTIFICATION OF TECHNICIAN I2.itiSPONSIBLE FOR CONDUCTING THIS TESTING l herebY certify that all the information contained in this report is true, accurate, and in fill compliance with legal requirements. 1'echniciutt's Signature: Date:` It State laws wid regulations do not currently require testing to be performed by a qualified contractor. However, local requircinents inay be more stringent. 11 /01 d aaAaaS xe « 9 z1:01 ZE- 90 -EIOZ 1 N-Tr1rJK hLhFrl i` 1 c J-z c `s 00 WE 's T T 1:BOILER DIESL HIGH PRODUCT ALARM AUC 19, 2013 2:13 PM CJ IN -TANK ALARM T I: BO I I.ER D I ESI. LOW TEMP WtiRNING AW 19, 2013 2:13 Pfl IN-TANK ALWR11 -- -- T I180ILLR LiESL MM: PRODUCT ALMRM pUG 19, 2bl'' 2:16 PM w IN -TANK ALARM - - - -- T 1:501LER DIESL PROBE OUT AUG 1'a, 2013 2:26 PM IN -TA14K ALARM - - - -- T 1 *0 I 1-ER D I ESI. INVALID FUEL LEVEL AUG 19, 2013 2:27 PI-1 MERCY SW HOSPITAL 400 OLD RIVER RD 5AKERSFIELD CA AUG 19, 2013 2:49 PNI S`C,9TEM STATUS REPORT ALL FUNCTIONS NORMAL L 31F(PING SUMP PIPING SUmp F IJEI. ALARM HUG' 19, 2013 1:25 PM SI~NSOR ALARM -- L 2:ANNULAR ANNULAR SPACE LOW LIQUID ALARM AU0 19, 2013 1.29 PM SENSOR ALARM L (:TRANSITION SUMP PIPING BUMP FUEL ALARM AUG 19. 2013 1:32 PM SENSOR ALARM L I:TRANS1T10N SUMP PIPING SUMP FUEL ALARM AUG 19, 2013 1 :34 PM IN -TANK ALARM -- -- T 1:801LER DIESL PROBE OUT AUG 19, 2013 2 :12 PM T 1 C'A-Tt 0 r` MERCY : *"bd 400 t:LG RIVEN RE' BAEEPR IELD CA AUG ; 9. ::'u I J 1: bu V -11 SYSTEM ALL FUNCTIONS NORMAL I NVEI'ITOR`f kLl"ORIT 11' 1:801LER LjlE:1 l. VOLUME 1039 GHL.r" ULLAGE = a9ta l Cxll ". ; 90% ULLAGE= 3461 GALS TC VOLUME = 1032 GALS HEIGHT a _4.UI INOHE8 WATER VOL = 0 GALS. WATER = 0. Oi I I NC. HES TEMP - 72.5 DEC; F X x x x x END x X x x . ItAl d aaAAaS XPA << 8 Llal ZE- 80 -EIOZ