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HomeMy WebLinkAbout4013 H STREET MOD 2013 (2)HOODS ALARMS SPRINKLER SYSTEMS SPRAY BOOTH AST UST Permit No. Permit No. Permit No. Permit No. Permit No. Permit No. 3 i 10a4 File Number: ,36 zZ Address: 1-40(-S S . t 'E5C Bakersfield, CA 933 Date Received: Business Name: SYSTEM: BUILDING SQUARE FEET: New Mod. Commercial Hood System Fire Alarm System Fire Sprinkler System Spray Finish System Aboveground Storage Tank Underground Storage Tank modifica on nderground Storage Tank removal Underground Storage Tank Other. Comments: Building Sq. Feet: Calculation Bldg. Sq. Ft: 1. a. 3. 4. INSPECTION LOG Date Time Signature Signature ae T!svrr c i7Ji3 G R'y`s2Jty t'.` So2P s'T Signature Signature ae T!svrr UNDERGROUND STORAGE TANK PERMIT APPLICATION 04E A 0 P 1, P TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW /IR/ TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD ARII f IPermit # BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street Bakersfield, CA 93301 Phone: 661 - 326 -3979 . Fax: 661 - 852 -2171 Page 1 of 1 TYPE OF APPLICATION: NEW TANK INSTALL/NEW FACILITY NEW TANK INSTALL /EXISTING FACILITY CHECK ONE ONLY) M MODIFICATION OF FA(--TLTTY MTNr)R MODTFT(--ATTON C)F FACTLTTY STARTING DATE/ PROPOSED 5/28/2013 COMPLETION DATE 6/20/2013 FACILITY NAME Fastrip #22 EXISTING FACILITY PERMIT# FACILITY ADDRESS 4013 South H Street CITY Bakersfield ZIP CODE 93304 TYPE OF BUSINESS GDF APN # TANK OWNER Jamieson Hill PHONE# 661) 393 -7000 ADDRESS PQ BOX 82515 CITY Bakersfield ZIP CODE 93380 -2515 CONTRACTOR Confidence UST CA LICENSE # 970703 ICC # 8018524 -U1 ADDRESS 16250 Meacham Road cm Bakersfield Z 93ODE 93314 PHONE # 661) 631 -3870 BAKERSFIELD CITY BUSINESS LICENSE # 32864 WORKMANS COMP # 1308371 -2011 INSURER IState Fund BRIEFLY DESCRIBE THE WORK TO BE DONE: Removal of existing primary and secondary Smith Red Thread Product Line Piping and replace with same, like for like. WATER TO FACILITY PROVIDED BY DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE OF TANKS TO BE INSTALLED TAI'RE THEY FOR MOTOR FUEL? SPILL YES NO PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? YES NO THIS SECTION IS FOR STORAGE TANK IDENTIFICATION TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER 1 12000 gal., X i X 2 12000 gal.; X X 3 1 12000 gal. I X X Tank Testing Company NAME OF TESTING COMPANY Confidence UST PHqNE NUMBER661) 631 -3870 MAILING ADDRESS 16250 Meacham Road, Bakersfield, CA 93314 NAME OF TESTER Frank Landa ICC# I 8018524 -U1 THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS PERMIT AND ANY OTHER STATE, LOCAL, AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. NAME OF TESTER Frank Landa ICC# 8018524 -U1 THIS APPLICATION BECOMES A PERMIT WHEN APPROVED FOR OFFICIAL USE ONLY tDATEAPPROVED APPROVED BY ru4000 Inev Uo /U7) s -I ---> &Kj A-a4— ( o p, V . 3 ca CONFIDENCE M[ M 0 4 o UST Services, Inc. OR Lic. 804904 "Compliance With Confidence" www.ustservices.com Doug Young Testing of: President Underground Storage Tanks Ph: 800 - 339.9930 Vapor Recovery Systems Monitoring SystemsCell: 661 - 213 -6372 Product Lines Fax: 661 - 587 -9758 Secondary ContainmentEmail: doug@ustservices.com Designated UST Operators UNDERGROUND STORAGE TANK T3,:, 1: -"' 'r,-r. - ;•c, -- ,t ^..a -.t°T;: rte,,°;.. ij y PERMIT APPLICATION TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW 1 FIRE TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD A. r T ermit # BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street Bakersfield, CA 93301 Phone: 661 - 326 -3979 • Fax: 661.852 -2171 Page 1 of 1 TYPE OF APPLICATION: NEW TANK INSTALL/NEW FACILITY NEW TANK INSTALUEXISTING FACILITY ifHFrK nNF nNI Yl m mnr)tFTrATTr1N (1F FarTI TTV rl MIN(1D Mr)nTFTrATIOfJ f1F FAfTI T-IV PROPOSEDSTARTINGDATE/ 5/28/2013 COMPLETION DATE 6/20/2013 iFACILITYNAMEFastrip ## 22 EXISTING FACILITY PERMITI FACILITY ADDRESS 4013 South H Street CITY Bakersfield 2IPCODE 93304 TYPE OF BUSINESS GDF APH I TANK OWNER Jamieson Hill PHONE) 661) 393 -7000 ADDRESS PO Box 82515 CITY` ZIPZ193380 -2515 CONTRACTOR Confidence UST CA LICENSE J 1970703 ICC J 8018524 -U1 ADDRESS 16250 Meacham Road Cm Bakersfield 2 93393314 PHONE J 661) 631 -3870 BAKERSFIELD CITY BUSINESS LICENSE I 32864 WORKMANS COMP I 1308371 -2011 INSURER State Fund BRIEFLY DESCRIBE THE WORK TO BE DONE: Removal of existing primary and secondary Smith Red Thread Product Line Piping and replace with same, like for like. WATERTO FACILITY PROVIDED BY DEPTH TO GROUND WATER SOILTYPE EXPECTED AT SITE J OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? YES NO SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILEI YES NO THIS SECTION IS FOR STORAGE TANK IDENTIFICATION TANK 0 VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER 1 12000 gal. X X 2 12000 gal. X X 3 12000 gal. X X Tank Testing Company NAME OF TESTING COMPANY Confidence UST PH N! NUt+BER16611631 -3870 MAILING ADDRESS 16250 Meacham Road, Bakersfield, CA 93314 NAME OFTESTER Frank Lands ICCtl 8018524 -U1 THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS PERMIT AND ANY OTHER STATE, LOCAL, AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. NAME OF TESTER Frank Lands ICCtl 8018524 -U1 THIS APPLICATION BECOMES A PERMIT WHEN APPROVED FOR OFFICIAL USE ONLY DATE APPROVED I APPROVED BY JACO OIL COMPANY, P.O. BOX 82515, BAKERSFIELD, CA 93380 -2515 661) 393 -7000 DATE CHECK NUMBER 06/04/2013 333512 Seven Hundred Eleven and 00 /100 Dollars PAY TO THE ORDER OF: I - CITY OF BAKERSFIELD I P.O. BOX 2057 i BAKERSFIELD, CA 93303 -2057 BANK OF AMERICA 1666 1220 GL NO. DISCOUNT AMOUNT 711.00 JACO OIL COMPANY 333512 1°33351211' 1:1 220006P. 1: 145 341 781011' California Environmental Reporting System (CERS) Underground Storage Tank - Facility Information Facility /Site r TWa9"+ " - - - -- = s _ 2a ., < _....-,,r ,.......».; 781 FASTRIP #22 (SOUTH SIDE) CERS ID 4013 SO. "H" STREET (11781) 10159163 BAKERSFIELD, CA 93304 d,. a• , v" Wes, Submittal=5tatus i Submitted on 12/4/2012 by Catherine Riccomini of Jamieson Hill Company (Bakersfield, CA) Submittal was Accepted; Processed on 12/6/2012 by Craig Perkins for Bakersfield City Fire Department T,Ype of$Acfion F ;" Confirmed /Updated Information 781 FASTRIP #22 (SOUTH SIDE) 4013 50. "H" STREET (#781) BAKERSFIELD, CA 93304 Facility Type Board of Equalization Account Number MotorVehicle Fueling 44003279 Is the facility located an Indian Reservatton/Trust lands? JAMIESON HILL 661) 393 -7000 PO BOX 82515 BAKERSFIELD, CA 93380 -2515 UNITED STATES JAMIESON HILL 661) 393 -7000 PO BOX 82515 BAKERSFIELD, CA 93380 -2515 UNITED STATES JAMIESON HILL 661) 393 -7000 PO BOX 82515 BAKERSFIELD, CA 93380 -2515 UNITED STATES Tank OwnerType s: t7%`, PIANO- tPermitHolder'Information.. 17 , Permit Holder Notification information Supervisor of Division, Section, or Office (Required for Public Agencies Only) Tank Owner Indicate which approved mechanism(s) are being usedto show financial responsibility either as contained In the federal regulations (40 CFR, Part280, Subpart H, Sections 280.93 through 280.107) or CCR, Title 23, Division 3, Chapter 18, Section 2808.1. Self - Insured Surety Bond State Fund and CFO Letter Other Mechanism Yes Guarantee Letter ofCredit State Fund and CD Insurance Exemption Local Government Mechanism 4 ye +" 'ter """`• •-, .tp,- , +" it }xya'+ - ft,Y -: `at'9 m5t sApplicant Applicant Name Applicant Title Applicant Phone Date Certffied R. CRAIG LINCOLN DIR CONST & MAINT (661) 633 -7555 3/1/2012 Printed on 6/3/2013 9:18 AM Facility "• al A 781 FASTRIP #22 (SOUTH SIDE) CERSID 4013 SO. "H" STREET ( #781) 10159163 BAKERSFIELD, CA 93304 t 7` e ' 1d%Attal- Sfatus " Submitted on 12/4/2012 by Catherine Riccomini of Jamieson Hill Company (Bakersfield, CA) Submittal was Accepted, Processed on 12/6/2012 by Craig Perkins for Bakersfield City Fire Department TypeofAction ' ejfflyL emu. Type ofAction (UST Tank) Confirmed/Updated Information 781 FASTRIP #22 (SOUTH SIDE) 4013 SO. "H" STREET ( #781) BAKERSFIELD, CA 93304 Tank ID# Date UST System Installed Tank Configuration 781:T1 S/1/2000 A Stand -alone Tank Tank Manufacturer Date Existing UST Discovered Number of Compartments In the Unit JOOR Sacrifidel Anode 1 Tank Capacity In Gallons Date UST Permanently Closed Additional Description 12000 Yes Spill Bucket Fiberglass Tank Use Motor Vehicle Fueling Tank Contents Regular Unleaded Other Petroleum Contents Other Non- Petroleum Contents Type ofTank Double Wall Primary Containment Fiberglass Overfill Protection Yes Audible/Visual Alarms Yes Bali Float Secondary Containment Fiberglass Fill Tube Shut -Off Valve Exempt Pr°dud /)Yigt pip ng Cbnst on 'p, Piping Construction Primary Containment Secondary Containment Piping/Turbine Containment Sump Double- walled ( Fiberglass I Fiberglass I Single- walled Piping System Type Pressure Primary Containment Vapor Recovery Primary Containment Riser Pipe Primary Containment Vent Piping Transition Sumps Fiberglass Fiberglass Steel None Sacrifidel Anode Fill Components Installed Secondary Containment Vapor Recovery Secondary Containment Riser Pipe Secondary Containment Yes Spill Bucket Fiberglass Fiberglass Fiberglass Yes Striker Plate /Bottom Protector Yes Containment Sump- UnderDf Cntainme `tUDC)k b 4 Corrosion Protections pf1' penr a Construction Type Construction Material Sacrifidel Anode Single - walled Fiberglass Impressed Current Isolation Applicant;Certification { ° MIMI Applicant Name Applicant Title Date Certified R. CRAIG LINCOLN DIR CONST & MAINT 3/1/2012 Printed on 6/3/2013 9:19 AM ecflity /Site-^ - ._. 1781 FASTRIP #22 (SOUTH SIDE) CERS ID 013 50. "H" STREET ( #781) 10159163 AKERSFIELD, CA 93304 ah ' ; a .m' ' "R ... _ _' - 'Y'ig- ^v'sy- "a", -'x "+7`r -<r + +• v4k Sk 'o ri ati:; a inl ubmitted on 12/4/2012 by Catherine Riccomini ofJamieson Hill Company (Bakersfield, CA) ubmittal was Accepted, Processed on 12/6/2012 by Craig Perkins for Bakersfield City Fire Department ype of Action: , . ;,; err - - :` < ' .. <h, ipe of Action (UST Tank) onfirmed /Updated Information q "nfo } dv., a 'I mr •;u aality'lnformat om 781 FASTRIP #22 (SOUTH SIDE) 013 SO. "H" STREET ( #781) AKERSFIELD, CA 93304 Tank ID# Date UST System Installed Tank Configuration 781:T2 5/1/2012 A Stand -alone Tank Tank Manufacturer Date Existing UST Discovered Number of Compartments in the Unit JOOR 1 Tank Capacity In Gallons Date UST Permanently Closed Additional Description 12nnn Tank Use Motor Vehicle Fueling Tank Contents Regular Unleaded Other Petroleum Contents Other Non - Petroleum Contents Type ofTank Double Wall Primary Containment Fiberglass Overfill Protection Yes Audible/Visual Alarms Yes Ball Float Secondary Containment Fiberglass Fill Tube Shut -Off Valve P oduct.AMite Piping Ctinstnution ; . k 5 . Piping Construction Primary Containment Secondary Containment Piping/Turbine Containment Sump Double- walled I Fiberglass I Fiberglass I Single- walled Piping System Type Pressure Containment Containment Vapor Recovery Primary Containment Fiberglass Vapor Recovery Secondary Containment Fiberglass Riser Pipe Primary Containment Steel Riser Pipe Secondary Containment Fiberglass Vent Piping Transition Sumps None Fill Components Installed Yes Spill Bucket Yes Striker Plate /Bottom Protector Yes Containment Sump Under Dispenser Containment (UDCj Corrosion Protect,onvim- - - -- - . - • x < ... Construction Type Construction Material Sacrificial Anode Single- walled Fiberglass Impressed Current Isolation I"° 6pplitantiCerttfiraYtio s ata pplicant Name Applicant Title Date Certified CRAIG LINCOLN DIR CONST & MAINT 3/1/2012 Printed on 6/3/2013 9:19 AM California Environmental Reporting System (CERS) Underground Storage Tank - Tank Information Fa , Site ciIltY /, 781 FASTRIP #22 (SOUTH SIDE) CERS ID 4013 SO. "H" STREET ( #781) 10159163 BAKERSFIELD, CA 93304 Piping System Type Fill Components Installed Submittal Status Submitted on 12/4/2012 by Catherine Riccomini of Jamieson Hill Company (Bakersfield, CA) Riser Pipe Secondary Containment Submittal was Accepted, Processed on 12/6/2012 by Craig Perkins for Bakersfield City Fire Department Fiberglass Type ofAction (USTTank) n 781 FASTRIP #22 (SOUTH SIDE) 4013 SO. "H" STREET ( #781) BAKERSFIELD, CA 93304 TankID# 781:T3 Tank Manufacturer JOOR Tank Capacity In Gallons Tank Use Motor Vehicle Fueling Date UST System Installed 5/1/2000 Date Existing UST Discovered Date UST Permanently Closed Tank Contents Premium Unleaded Other Petroleum Contents Other Non - Petroleum Contents Tank Configuration A Stand -alone Tank Numberof Compartments in the Unit 1 Additional Description Type ofTank Double Wall Primary Containment Fiberglass Overfill Protection Yes Audible/Visual Alarms Yes Ball Float Secondary Containment Fiberglass Fill Tube Shut -Off Valve . Bd`<R'"«'3.;ar .'-; - rme a°s _ '0.'°3'" =. oduct >/ .,Waste Piping ConstFuctiori Nlr Piping Construction Primary Containment Secondary Containment Piping/Turbine Containment Sump Double- walled I Fiberglass Fiberglass Single- walled Piping System Type Fill Components Installed Secondary Containment Pressure Riser Pipe Secondary Containment Yes Spill Bucket Fiberglass Primary Containment Vapor Recovery Primary Containment Riser Pipe Primary Containment Vent Piping Transition Sumps Fiberglass Fiberglass Steel None Fill Components Installed Secondary Containment Vapor Recovery Secondary Containment Riser Pipe SecondaryContainment Yes Spill Bucket Fiberglass Fiberglass Fiberglass Yes Striker Plate /Bottom Protector Yes Containment Sum g'' ` i Y" -''3s : awr ,srsm iA&R„74,4ro v >a z i 4° k § } b;` Under DispegContain Conosion3Profection _ Construction Type Construction Material Sacrificial Anode Single - walled Fiberglass Impressed Current Isolation I. - - ppNcantiCertification ° k } pplicant Name Applicant Title Date Certified CRAIG LINCOLN DIR CONST & MAINT 3/1/2012 Printed on 6/3/2013 9:20 AM California Environmental Reporting System (CERS) Underground Storage Tank - Tank Information Facility /Site:i. 781 FASTRIP #22 (SOUTH SIDE) CERS ID 4013 SO. "H" STREET ( #781) 10159163 BAKERSFIELD, CA 93304 ubmittal 5tatus ' r.r''.`j Submitted on 12/4/2012 by Catherine Riccomini of Jamieson Hill Company (Bakersfield, CA) Submittal was Accepted, Processed on 12/6/2012 by Craig Perkins for Bakersfield City Fire Department Ipe ofAction (UST Tank) Dnfirmed /Updated Information A' ,% ,.,, !out. } 'F.- ,'""y'?'6: ^x ?''t`ir.;:/ ; +.,?4j. `r ti 3 ^h Facilityinfo mation 781 FASTRIP #22 (SOUTH SIDE) 4013 SO. "H" STREET ( #781) BAKERSFIELD, CA 93304 Tank ID# Date UST System Installed Tank Configuration 781:T4 5/1/2012 A Stand -alone Tank Tank Manufacturer Date Existing UST Discovered Number of Compartments in the Unit JOOR 1 Tank Capacity In Gallons Date UST Permanently Closed Additional Description 12000 Fiberglass Fiberglass Tank Use Motor Vehicle Fueling Tank Contents Diesel Other Petroleum Contents Other Non - Petroleum Contents Type ofTank Double Wall Primary Containment Secondary Containment Fiberglass Fiberglass Overfill Protection Yes Audible/Visual Alarms Fill Tube Shut -OffValve Yes Ball Float Exempt Product * /Waste Pipingr On =; Al Piping Construction Primary Containment Secondary Containment Piping/Turbine Containment Sump Double - walled Fiberglass I Fiberglass I Single- walled Piping System Type Fill Components Installed Secondary Containment Pressure Riser Pipe Secondary Containment Yes Spill Bucket Fiberglass Primary Containment Vapor Recovery Primary Containment Riser Pipe Primary Containment Vent Piping Transition Sumps Fiberglass Fiberglass Steel None Fill Components Installed Secondary Containment Vapor RecoverySecondary Containment Riser Pipe Secondary Containment Yes Spill Bucket Fiberglass Fiberglass Fiberglass Yes Striker Plate /Bottom Protector Yes Containment Sump c `fit; - :, ? a'' . <- .,.,,, a;r rx - -- aer"°"r1.:z '` "E.€ -'`. .^a'i+a< ? r3<. Y . $km's y. <; w21", Under0ispenser Containment (UDC) Corrosion Protection - _ Construction Type Construction Material Sacrificial Anode Single- walled Fiberglass Impressed Current Isolation 3-,0 s APpji6iiint, Certification Applicant Name Applicant Title Date Certified R. CRAIG LINCOLN DIR CONST & MAINT 3/1/2012 Printed on 6/3/2013 9:20 AM uo#plDMcA U S T SITE HEALTH AND SAFETY PLAN for: CA INTRODUCTION A complete and approved Site Health and Safety Plan (SHSP) is required before operations commence at each worksite location. The intention of the SHSP is to direct the safety planning process well in advance of the onset of any project. This process ensures that any associated hazards and safety controls are properly identified by the contractor. In conjunction with scheduled and ad hoc Job Hazard Analysis /Job Briefings (JHA), the site specific safety plan outlines tactics utilized when identifying or evaluating potential safety risks, mitigation measures for such risks and safety event reporting procedures. The SHSP must be current and maintained on -site. All individuals involved in the project are required to review the SHSP and are mandated to comply with the requirements as defined. The Contractor shall conduct a Project Safety Orientation Meeting in order to communicate the requirements of the SHSP with any individual working within the project area. The Contractor shall maintain a record of personnel in attendance (e.g. sign -in sheet). The Contractor's safety management program and /or safety manual, or other safety related documentation, are included with this SHSP. Examples of such documentation may include, but are not limited to safe work practices, excavation /trenching, demolition, heavy and critical lift plans, etc. ACKNOWLEDGEMENT I certify on that I have read and understand the requirements of 29 CFR 1910 and 1926, completed a walk- through of the jobsite, competed applicable area hazard assessment(s) and applicable Job Hazard Analysis (JHA) related to the scope of this project and attest that my firm and its subcontractors will comply with the requirements of the contract and referenced OSHA standards as applicable to the scope of work and any applicable on -site company policies. f-MPff. MEMBER EMERGENCY TELEPHONE NUMBERS FIRE DEPARTMENT 9 -1 -1 from landline) FIRE DEPARTMENT (661) 326 -3911 from cell) POLICE DEPARMENT 9 -1 -1 from landline) POLICE DEPARTMENT (661) 327 -7111 from cell) MERCY SOUTHWEST (661) 663 -6000 CONTRACTOR (661) 978 -8847 Keith Hooten) UST: SITE HEALTH AND SAFETY PLAN PROJECT INFORMATION Project Number: 7781 Project Name: 4013 H Street Fastrip 7781 Project Description: Re -pipe of product lines at 4013 H Street, Bakersfield Remove and replace existing primary and secondary product line piping system Project Location: 4013 H Street, Bakersfield, CA Project Start Date: JTBD Project End Date: JTBD PROJECT CONTACTS Customer Name: Jameison Hill TITLE NAME PHONE /EMAIL Project Manager Keith Hooten 661) 978 -8847 Contractor Name: I CONFIDENCE UST CONSTRUCTION, INC. TITLE NAME PHONE /EMAIL Project Manager Frank Landa 661) 205 -5944 Subcontractor Name Badger TITLE NAME PHONE/EMAIL Vacuum Extraction Anthony Phillips 661) 325 -2101 Subcontractor Name Advanced Environmental Inc. TITLE NAME PHONE/EMAIL Geologist John Buck 661) 979 -1828 Subcontractor Name TITLE NAME PHONE/EMAIL Subcontractor Narnel Global Environmental Network, Inc. TITLE NAME PHONE /EMAIL Subcontractor Name Penhall Company TITLE NAME PHONE/EMAIL OMB MEMBER yUSTi SITE HEALTH AND SAFETY PLAN PROJECT INFORMATION Project Number: 1 7781 Project Name: 14013 H Street, Fastrip 7781 Project Description: Remove and replace existing primary and secondary product line piping system Project Location: 4013 H Street Bakersfield, CA Project Start Date: 6/5/2013 Project End Date: 6/20/2013 PROJECT CONTACTS Customer Name: jJameison Hill TITLE NAME PHONE /EMAIL Jameison Hill Keith Hooten 661 - 978 -8847 UST Construction Doug Young 661 - 213 -6372 Contractor Name: ICONFIDENCEUSTCONSTRUCTION TITLE NAME PHONE /EMAIL Owner Doug Young 661- 213 -6372 Foreman Joe Landa 661) 205 -5944 Craftsman Henry Meraz Subcontractor Name TITLE NAME PHONEIEMAIL Subcontractor Name TITLE NAME PHONE /EMAIL AMPH MEMBER PAGE of uo # 01D USLduct+° SITE HEALTH AND SAFETY PLAN Training Documentation By signing the acknowledgement statement of this plan, the Contractor certifies that employees have been trained in the following safety procedures and in accordance with their company safety management system & manual. Evidence of training with employee's names shall be submitted with this SHSP. Qualification Yes or N/A List Employees If yes for heavy equipment, list equipment and operators authorized) Aerial Lift Operator Confined Space Entry YES Joe Landa Crane Operator Excavation Competent Person YES Joe Landa Fall Protection Competent Person Fire Extinguishers YES Joe Landa First Aid/CPR/Blood borne Pathogen Training Forklift Operator Certification Heavy Equipment Operator Certifications Scaffold User /Erector Competent Person Asbestos & Lead OSHA Construction 30 hr. Other 40 hr HAZWOPER YES Joe Landa Bravo F- series certified YES Joe Landa Contractor Review and Approval Name: Position: Signature: PAGE 0 F Date: eg)j MEMBER 001D40 USTs SITE HEALTH AND SAFETY PLAN PROJECT SAFETY CONTROLS OW MEMBER PAGE 1 OF 2 Applicable or Controls N/A Action if Applicable Demolition Attach demolition plan and procedures to be used while demolition takes place in occupied buildings to include NA protection of workers and facility employees. Traffic Control Attach traffic control plan, including diagram, identifying Flaggers /lane closure or access NA how flaggers will be used and specifying signage, restricted clothing, and illumination as appropriate. Environmental Describe what releases might be anticipated and how Protection /Stormwater prevention and mitigation will occur. Describe: Potential for spills, protection of NA storm drains and building drains Site Control /Barricades / Signage Describe what controls will be implemented to assure Construction Site, danger tape, control of construction zones and areas construction caution tape, fencing, open trenches, zone may encompass. Describe any additional signage etc. Applicable that will be used other than what is stipulated within the contract and where it will be located. Describe:Barricades will be placed around excavations along with caution tape Material /Equipment Staging Location for materials, location for contractor vehicles. Attach diagram identifying locations where materials orApplicableequipmentthatisdeliveredorstagedonsitewillbe located. See attached Waste Disposal List wastes that will be generated while working at the General debris, recycled materials, project site and determine location and sizes of debris contaminated and hazardous wastes. Applicable boxes/recycling containers, or how waste material is to be managed. List:All concrete spoils will be removed and recycled Control fo Hazardous Energy Describe how hazardous energy is controlled throughout Lock out/tag out (LOTO): electrical, the project. Describe and include LOTO procedures: chemical, pneumatic, pressure, NA thermal, mechanical, etc. OW MEMBER PAGE 1 OF 2 uo F,ce 0 WS uc^n° SITE HEALTH AND SAFETY PLAN PROJECT SAFETY CONTROLS 4JOWT MEMBER PAGE 4OF4 Applicable or Controls N/A Action if Applicable Emergency Response Specify who can issue evacuation notice or how Accidents /injury Response evacuation will occur. List where assemby areas are located and who will be responsible for ensuring head Applicable count (provide explanation or diagram). List: See attached Fire Protection /Prevention List any fire system impairment needed for this project. Fire System Coordination, hot work, Identify if hot work permits are needed and for what type general construction, storage of NA of operation. List any combustible/flammable materials flammable materials used and how they will be managed. List: Evacuation Identify under what conditions evacuation of the immediate work site would occur. List.-Fire or tsunami Applicable Dust, Fume and Odor Control Describe how dust, fume and odor control is managed Sheet rock, soil, asbestos, sanded throughout project and identify what type of dusts will be paintes, grinding welding, VOCs, generated, associated exposure limits and any special paint thinners, etc. Applicaple control /monitoring /equipment that will occur. The goal is 100% control of dust, fumes and odors. Describe:Dust generated when cutting concrete will-be controled with the use of water. . Confined Space All confined spaces, whether Permit Required or Non Permit Required will be identified. All individuals in and around the job site will be made aware of the location of Applicable all confined spaces. All monitoring and reporting requirements, such as the use of air monitoring and ventilation equipment, will be met per 29 CFR 1910 and 29 CFR 1926 Excavation Excavated soil will be placed on and covered with plastic. Applicable Excavations over 4'6" will be shored. Air in trench will be continuously monitored. Personal Protective Equipment All employees working with fiberglass will use respirators. PPE) Applicable All employees working on the project site will be required to wear OSHA approved safety footwear. 4JOWT MEMBER PAGE 4OF4 SITE PLOT PLAN for: 015 -021 -03022 721/ #'781 FASTRIP #22 4013 SO. "H" STREET BAKERSFIELD, CA 93304 03/01/2012 0 3 - 12,000 GALLON Q ES51UNq JrZTIz ts So. 12-31eAq. OF v SCOPE OF WORK-, L AT CLOUDED AREA REPIPE EXISTING UNDERGROUND FUEL LINES, 2. SAW CUT AND REMOVE AC PAVING AND CONCRETE AS REQUIRED, OFA 3, BACKFILL AS REQIRED WITH PEA GRAVELDoo CIRCUIT REPLACE PAVING AND BREAKER C,NCRETE AS REQUIRED CIRCUIT BREAKER P%V TLS350 VENTS 1#781 #721 13 "v `.a a r ., I ] L5, 11 L7 I L3 I 81 187 -1 87 -2 91 DSL I2jll 6il LIi 4i 14 111 I,'II 1I Il I WHIlm LANE USTs mil 1 ESO EMERGENCY SHUT -OFF OFA OVERFILL ALARM 0 PRODUCT SPILL CONTAINER M VAPOR SPILL CONTAINER 4 ANNULAR FIRE EXTINGUISHER GAS METER SHUT -OFF WATER METER SHUTOFF HEALY CAS EVACUATION MEETING POINY 721 "L" SENSOR SETUP: 781 "L" SENSOR SETUP: L1 L1 87 STP L2 L2 87 ANNULAR FIRE L3 91 STP ESO L3 L4 91 ANNULAR L4 L5 DSL STP L5 L6 DSL ANNULAR Z L6 L9 U DC 9/10 L7 L10 UDC 11/12 L8 L11 UDC 13/14 L9 L12 U DC 15/16 L10 L13 U DC 17/18 L11 L14 U DC 19/20 781 "L" SENSOR SETUP: NORTH SCALE 1" =201 I DATE I RImI ©N5 SITE PLAN I FASTRIP - 7 -721 CONVENIENCE MARKET FOR; JAMIESON HILL COMPANY 4013 S. H STREET BAKERSFIELD, CALIFORNIA umsm L1 87 -1 STP L2 87 -1 ANNULARFIRE HYDRANT L3 DSL STP L4 DSL ANNULAR L5 87 -2 STP Z L6 87 -2 ANNULAR L7 91 STP L8 91 ANNULAR L9 UDC 1/2 L10 U DC 7/8 L11 UDC 5/6 L12 UDC 3/4 L13 NO. TRANS L14 SO. TRANS NORTH SCALE 1" =201 I DATE I RImI ©N5 SITE PLAN I FASTRIP - 7 -721 CONVENIENCE MARKET FOR; JAMIESON HILL COMPANY 4013 S. H STREET BAKERSFIELD, CALIFORNIA umsm SITE PLOT PLAN for: 015- 021 -03022 721 / 4781 FASTRIP #22 4013 SO. "H" STREET BAKERSFIELD, CA 93304 03/01/2012 D] 3 - 12,000 GALLON USTs r _ _ (STP- L6 `' SL L5 r- -- - - - -P- L4 A 91 TT - r STPL2 ® 87 — L1- L` - - - -_ j CIRCUIT BREAKER P/V VENTS B c TLS350 781 x#721 113 781 m sslo 4z 140. c113A9p Exp• 19 12i-):L1 III #721 18j" 17 16 SCOPE OF WORKi 1, AT CLOUDED AREA REPIPE EXISTING UNDERGROUND FUEL LINES, 2, SAW CUT AND REMOVE AC PAVING AND CONCRETE AS REQUIRED, 3, BACKFILL AS REQIRED WITH PEA GRAVEL PLACE PAVING AND CONCRETE AS REQUIRED WHrR LANE L1 L5 I L7 L3 II 87 -1 87 -2 ; 91 DSL Z6ll Lii j USTs_..- — `( BAS, N LEGEND ESO EMERGENCY SHUT -OFF OFA OVERFILL ALARM PRODUCT SPILL CONTAINER VAPOR SPILL CONTAINER ANNULAR FW FIRE EXTINGUISHER GAS METER SHUT -OFF WATER METER SHUT -DOFF HEALY CAS EVACUATION MEETING POIN -r 721 "L" SENSOR SETUP: 781 "L" SENSOR SETUP: L1 L1 87 STP FIRE L2 L2 87 ANNULAR HYDRANT L3 L3 91 STP ESO L4 L4 91 ANNULAR L5 L5 DSL STP Z L6 L6 DSL ANNULAR L7 L9 U DC 9/10 L8 L10 U DC 11/12 L9 L11 U DC 13/14 L10 L12 U DC 15/16 L11 L13 U DC 17/18 L12 L14 U DC 19/20 781 "L" SENSOR SETUP: NORTH SCALE 1 " =20' e A.P.N.: 405-330-13-00-5 I DATE RIEMI4NS I r a ro sm SITE PLAN FASTRIP - 7 -721 vim n CONVENIENCE MARKET FOR; SHEET NO. JAMIESON HILL COMPANY Amo4013S. H STREET BAKERSFIELD, CALIFORNIA OF 1 I7 L1 87 -1 STP FIRE L2 87-1 ANNULAR HYDRANT L3 DSL STP L4 DSL ANNULAR L5 87 -2 STP Z L6 87 -2 ANNULAR L7 91 STP L8 91 ANNULAR L9 UDC 1/2 L10 UDC 7/8 L11 UDC 5/6 L12 UDC 3/4 L13 NO. TRANS L14 SO. TRANS NORTH SCALE 1 " =20' e A.P.N.: 405-330-13-00-5 I DATE RIEMI4NS I r a ro sm SITE PLAN FASTRIP - 7 -721 vim n CONVENIENCE MARKET FOR; SHEET NO. JAMIESON HILL COMPANY Amo4013S. H STREET BAKERSFIELD, CALIFORNIA OF 1 I7 o- ACc`,: LIABILITY INSURANCECERT'IFICA TE ®F DATE 9/12/2012 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Walter Mortensen Insurance / INSURICA CA License #OD44424 8500 Stockdale Hwy., #200 Bakersfield CA 93311 CONTACT gNAME: Me Rasmussen, CISR PHONE , (661) 834 -6222 ac No: (661)281 -4992 E -MAILADDRESS: mrasmussen@INSURICA.com INSURERS AFFORDING COVERAGE NAIC# INSURER A -,Endurance American Specialty INSURED Confidence UST Services, Inc. 16250 Meacham Road Bakersfield CA 93314 INSURER B :Allstate Insurance Company 9232 INSURER C: INSURER D: INSURER E 1,000,000 INSURER F: 50 , 000 COVERAGES CERTIFICATE NUMBER:12 /13 General REVISION NUMBER: THIS 1S 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. INSRLTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER DD/YYYMMDD/YYYY MMYLIMITS GENERAL LIABILITY EACH OCCURRENCE 1,000,000 DAMAGE RENTED PREMI ES Ea occurrence 50 , 000XCOMMERCIALGENERALLIABILITY A CLAIMS MADE OCCUR CC10100269304 9/2012 9/2013 MED EXP ( one person) 5,000 PERSONAL 8 ADV INJURY 1,000,0001 GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG S 2,000,000 FX1 POLICY M PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) 11000,000 BODILY INJURY (Per person) B X ANY AUTO ALL OWNED SCHEDULED AUTOS - AUTOS 48799895 9/2012 9/2013 BODILY INJURY (Per accident) PROPERTY DAMAGE Per identHIREDAUTOS NON -OWNED AUTOS Uninsured motorist combined 1,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATEEXCESSLU18CLAIMS -MADE v DED RETENTION $ WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A Mandatory in NH) E.L. DISEASE - EA EMPLOYE It yes, describe under DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Jaco Oil Company is added as additional insured on the general liability policy per the attached form FE1319ECCO708 subject to the terms, conditions and exclusions of the policy. A written contract is required for the additional insured to be valid. Form to follow. CERTIFICATE HOLDER CANCELLATION Jaco Oil Company P.O. Box 82515 Bakersfield, CA 93308 ACORD 25 (2010105) INS025 (201005).01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Burcham /MRASMU - 1!5 7 - /- 1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Endurance Confidence UST Services, Inc. Endorsement Number: 5 Automatic Additional Insured -- Owners, Lessees or Contractors This endorsement, effective 9/9/2012 attaches to and forms a part of Policy Number ECC101002643 -04. This endorsement changes the Policy. Please read it carefully. FEI- 319 -ECC -0708 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person(s) or organization(s) whom the Named Insured agrees, in a written contract, to name as an additional insured. However, this status exists only for the project specified in that contract. The person or organization shown in this Schedule is included as an insured, but only Nvith respect to that person's or organization's vicarious liability arising out ofyour ongoing operations performed for that insured. POLICYHOLDER COPY NT P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08 -04 -2013 JACO OIL COMPANY NT PO BOX 82515 BAKERSFIELD CA 93380 -2515 GROUP: POLICY NUMBER: 1308371 -2012 CERTIFICATE ID: 129 CERTIFICATE EXPIRES: 11 -01 -2013 11 -01- 2012/11 -01 -2013 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1800 - DOUGLAS YOUNG PRESIDENT THE - EXCLUDED. ENDORSEMENT #1800 - CHERYL A. YOUNG SECRETARY VICE PRESIDENT - EXCLUDED. ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 11 -01 -1995 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER CONFIDENCE UST SERVICES INC. NT 18250 MEACHAM RD BAKERSFIELD CA 93314 P15,NT] IREV.1 -20121 PRINTED : 06-04 -2013 BALING &ERMIT STATEMENT BAKERSFIELD FIRE DEPARTMENT Prevention Services PERM TIT # B I PIRG * 2101 H StreetARfMt Jiro. Bakersfield, CA 93301 Please make checks payable to CITY OF BAKERSFIELD. Thank you. Alarm - New & Modification (minimum charge) 280 R r SITE INFORMATION Over 10,000 sq ft 0 .028 x sq ft 84 LOCATION OF PROJECT 22 013 wk4 S-IrQ PROPERTY OWNER Sprinkler - New & Modification (minimum charge) 280 e 2 1 Over 10,000 sq ft STARTING DA E COMPLETION DATE NAt1E 5 5 p 84 PR ]ECiNAME Z Commercial Hood (New & UL 300 Upgrade Modification) Additional Hood ADDRESS Usk PHONE #' Q3_ 1 dJ PROJECT ADDRbu11'• IIYY,. 1- CITY gAKERS I6LD STATE CA ZIPCO 84 f Spray Booth (New & Modification) 5 5 R INFORMATION 98 Aboveground Storage Tank (1 Inspection per Installation) AST CO CTOR`NAME CA =N5E # TYPE OF EXPIRATION DATE PHONE a 9' 0 103 0 Aboveground Storage Tank (Removal, Mod,or Inspect'n) ATR CONTRACTOR COMPANY NAME 82 FAX # Underground Storage Tank (Installation /Inspection) NI 878 /tank 82 JCILAD115 ZIP CODE 1 —"151 ADDRESS CITY 01130 AQL Ur Underground Storage Tank (Minor Modification) MTM 3 Please make checks payable to CITY OF BAKERSFIELD. Thank you. Alarm - New & Modification (minimum charge) 280 R r Over 10,000 sq ft 0 .028 x sq ft 84 Explosive Storage Sprinkler - New & Modification (minimum charge) 280 Copying & File Research (File Research fee $50/hr). 0.25 /page Over 10,000 sq ft 0 .028 x sq ft Miscellaneous Sprinkler — Minor Modification ( <10 heads). 96 (inspection only) 84 Commercial Hood (New & UL 300 Upgrade Modification) Additional Hood 470 58 /hood Commercial Hood - Minor Modification (add /move nozzle) 96 (inspection only) 84 Spray Booth (New & Modification) 470 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 Ur Underground Storage Tank (Minor Modification) MTM 167 /site 82 Underground Storage Tank (Removal) TR 573 /tank 84 m 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 Pvrotechnic event inspection is @ $121 /hr 96 /hr + (5 hrs min standby fee /insp) 5 hrs min standhv feehnsn) = t605 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 l BALLING & PERMIT STATEMENT ully;;; BAKERSFIELD FIRE DEPARTMENT A A1100* P R 3 F I 1bhL D Prevention Services PERMIT # 1i FIB6 2101 H Street Bakersfield, CA 93301 Phone: 661 - 326 -3979 • Fax- 661 -R52 -2171 Please make checks payable to CITY OF BAKERSFIELD. Thank your. lie 00 1 2 7 40 1:3 2 2 2 7 L T 2 41: 0 20 4 4 40 9 78u' TE INFORMATION 167 /site 82 Underground Storage Tank (Removal) TR 573 /tank LOCATION OF PROJECT 22 L1013 &VkMti S IrQe PROPERTY OWNER Sam s a Fri 11 96 /hr (2 hrs minimum) = $192 STARTING DA E COMPLETION DATE NAt1E 96 /hr 82 Tent # 96 /tent 84 PR JECT NAME i. 'l 2 121 /hr (2 hrs minimum) = $242 ADDRESS w , fox g PHONE # b 313- X000 PRO]ECTADDRESS d l a u CITY $AI—'GZSFIELD STATE C4 ZP CODE Re- inspection /Follow -up Inspection 84 Portable LPG (Propane): # of Cages? 96 /hr 84 CONTRACTOR INFORMATION Explosive Storage 266 84 CO TRACTOR NAME Copying & File Research (File Research fee $50 /hr) CA LICENSE # TYPE OF LICENSE EXPIRATION DATE PHONE # Miscellaneous a 9' 103 0 C 1 3 -" -7 CONTRACTOR COMPANY NAME FAX # ADDRESS crlY ZIP CODE M a 3 Please make checks payable to CITY OF BAKERSFIELD. Thank your. lie 00 1 2 7 40 1:3 2 2 2 7 L T 2 41: 0 20 4 4 40 9 78u' underground Storage Tank (Minor Modification) MTM 167 /site 82 Underground Storage Tank (Removal) TR 573 /tank 84 ID 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 FD2021 (Rev 05/11)