HomeMy WebLinkAbout4700 COFFEE ROAD FMC 2013v
HOODS ALARMS SPRINKLER SYSTEMS SPRAY BOOTH AST UST
Permit No. Permit No. Permit No. Permit No. Permit No. Permit No.
dCM 3 b r
File Number: 113 0
Date Received: 7—y() 3
SYSTEM:
New Mod.
Commercial Hood System
Fire Alarm System
Fire Sprinkler System
Address: iC7 4-e --e_ Z
Bakersfield, CA 933
Business Name: S_,P_ (-
BUILDING SQUARE FEET: INSPECTION LOG
Building Sq. Feet:
Calculation Bldg. Sq. Ft:
2.
spvay Finish System 3.
Aboveground Storage Tank 4.
Underground Storage Tank
minor
modification Underground Storage Tank
removal Underground Storage Tank
her.
157/'1 1-1 /1 —1& 11aa) SPq'IGQ d,-4 /:ot
Date Time
vobg1aa%m.v
Signature
MONITORING SYSTEM CERTIFICATION
ktor Use By All Junisdictiomv Within llte State rlfCalifornia
Authatitt, Cited Chapter 6 7, health andSafety Code: Chapter Its, Dntision 3. Title 23, C'alf1bMia Code ofRegulations
This form must be used to document testing and servicing ofmonitoring equipment. A separate certification or report must tx
prepared for each monitoring system control panel by the technician who performs the work. A copy ofthis form must be provided
to the tank system owner /operator. The owner /operator must submit a copy of this form to the local agency regulating UST systems
within 30 days of this date.
A. General Information
Facility Name: Shell
Site Address: 4700 Coffee Road
Facility Contact Person: Matt Jeffries
City: Bakersfield
Bldg. No.:
Zip: 93308
Contact Phone No.: 661 - 496 -7006
Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 8/13/2013
B. Inventory of Equipment Tested /Certified
CheeL the appropriateboicstolndieatespecific equlpmem Iavertedher,lred:
Tank t D: 10000 gal. Regular (North) Tank 1 D: 10000 gal. Regular (South)
i] In -Tank Gauging Probe. Model: 847390.107 x] In -Tank Gauging Probe. Model: 847390 -107
x] Annular Space or Vault Probe. Model: 794390 -420 L] Annular Space or Vault Sensor. Model: 798390.420
x] Piping Sump / Trench Sen%or(s). Model: 794380 -208 Lx] Piping Sump / Trench Sensor(s). Model: 794380.208
x] Fill Sump Scnsor(s) Model: 794380.208 Ll Fill Sump Sensor(s). Model: 794380 -208
R1 Mechanical Line Leak Detector. Model: FX1V U Mechanical Line Leak Detector. Model: FX1V
Electronic Line Leak Detector. Model: Electronic Line Leak hector. Model:
x] Tank Overfill / High Level Sensor. Model: OPW -6I-SO L] Tank Overfill / High Leval Sensor. Model: OPW -61 -50
Other (specify equip. type and model in Sec. E- on Pg. 2) Other (specify equip. type and model in Sec. F on Pg. 2)
Tank ID. 10000 gal. Super rank ID: 10000 gal. Diesel
x3 In -Tank Gauging Probe. Mod6:847390 -107 Lx3 In= tank Gauging Probe. Model: 847390 -107
L] Annular Space or Vault Sensor. Model: 794390-420 x] Annular Space or Vault Sensor. Model: 794390.420
x] Piping Sump / Trench Sensor(s). Model-.7943W208 L] Piping Sump /Trench Sensor(s). Model: 794380 -208
L] Fill Sump Senors(s). Model: 794308 -208 xj Fill Sump Sensor(s). Model: 784380 -208
M Mechanical Line Leak Dec:ector. Model: FX1V L] Mechanical Line Leak Detector. Mode]: FX_ 1 D_ V
Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model:
L] Tank Overfill / High Level Sensor. Model: OPW -81-50 Lj Tank, Overfill / High Level Sensor. Model: OPW -6I -SO
Other (specify equip. type and model in Sec. E on Pg. 2) Other (specify equip. typs and model in Sec. E on Pg. 2)
Dispenser ID: 1 & 2 Dispenser 1D:_3 _8.4
i] Dispenser Containment Semsor(s). Model: 794390.420 L] Dispenser ontainment Sensor(s). Model: 794390 -420
z] Shear Valve(s). x] Shear Valve(s),
Dispenser Containment Floa(s) and Chain(s). Dispenser Containment Floa(s) and Chains)
Dispenser ID: _5 & 6 Dispenser ID: 7 & 8
Lx] Dispenser Containment Sensor(s). Model: 794390 -420 L] Dispenser Containment Sen%or(s). Model: 794390420
Z Shear Valve(s). E Shear Valve(s).
Dispenser Containment Float(s) and Chain%(s). Dispenser Containment Float(s) and Chain(s).
Dispenser ID: Dispenser ID:
Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model:
Shear Valve(%). Shear Valve(s).
Dispenser Containment Float(s) and Chain(s) Dispenser Containment Float(s) and Chain(s).
t , tactlity contains more tanks or dispensers, copy this form. Include infonnation ror every tank and dispenser at the facility.
C. Certification - t certify that the equipment identified in this document was inspected /services in accordance with the
manufacturers' guidlines. Attached to this Certification is information (e.g. manufacturers' checklist) necessary to varify that
this information is correct and a plot plan showing the layout of monitoring equipment. For equipment capable of generating
such reports, i have attached a copy of the report; (check all that apply) Q System Set -up x Alarm history report
Technician Name (print): Kristopher Kama Signature:1
Certification No: 834108 License No: 804904
Testing Company Name: Confidence UST Services, inc. Phone No: 800 - 339.9930
Site Address: 4700 Coffee Road, Bakersfield, CA 93308 Date of Testing/Servicing: 8113/2013
D. Results of Testing/Servicing
Software Version Installed: 329.00
Complete the following checklist:
x] Yes No* Is (tic audible alarm operational'?
x Y -s No* s to Visual alarm operational?
No* Were all sensors visually inspected, f inctiona y tested, and con inn operational? MXYes
Yes No* Were all selisors installed at the lowest point of sLconckiry containment and position so that other
equipment will not interfere with (heir proper operation?
Yes No* If arms are relayed to a remote monitoring station, is all communications equipment (e.g. nxdkmHxN/A operational?
x Yes No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary
NIA containment nxmitoring system detects a leak, fails to operate, or is elcc:tncally disconnected'? I f yes:
which sensors initate pasilive shut- dowri? [x] Sump/Trt nch Sensor..• [x] i ispentier Containment Sensors
Did you confirm positive shutdown due to leaks and sensor failure /discontiLeted? Lx] Yes; No;
Yes No* For tank systems that utilize the monitoring system as the primary tank overfill wanting evice (i.e. no
U N/A mechanical overfill prevention valve is installed), is the overfill wanting alarm visual and audible at
the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm
trigger? r Hl -SO %
x Yes* No Was any monitoring equipment replaced'? If Yes, identify specific sensors, probes, or other equipment
replaced and list the manufacturer name and model fir all replacement parts in Section E, below.
Yes* No Was liquid found inside any secondary containment systems designed as dry systems?
Product; [x] Water. Ifyes, describe causes in Section E. below.
x I Was monitoring system set -up reviewed to ensure proper settings? Attar sel -up reports, it ap cable.
x Yes No* I Is all monitoring equipment operational per manufacturer's specification~?
In Section E below, describe how and when these deficiencies were or will be corrected.
E. Comments: I had to replace both fate Regular North and Regular South FXl V Line Leak Detectors as both
originals failed to detect a leak of3 GPM a 10 PSI. After the repairs were made they were both re- tested and
confirmed operational. I also removed 1.5 Gal. of water from the Diesel STP Sump.
F. In -Tank Guaging /SIR Equipment: M Check this box iftank guaging is used only for inventory control.
Check this box if tank guaging or S1R equipment is installed.
This section must be completed if in -tank guaging equipment is used to perform leak detection monitoring.
Complete the following checklist:
In the Section H. below, describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD): Check this box if LLD's are not installed.
Complete the following checklist:
x] Ycs
x Yes No* Has all input wiring been inspected for pr enter and termination,including testing for ground faults'?
x Yes No* Were all tank guaging probes visually iru;pec:ted for damage and residue buildup'?
x Yes No* Was accuracy of system product level readings tested?
x Yes No* Was accuracy of system water level readings tested'?
x Yes No* Were all probes reinstalled properly?
xj Yes No* Were all items on the equipment manufaclurer's maintenance checklist completed?
In the Section H. below, describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD): Check this box if LLD's are not installed.
Complete the following checklist:
x] Ycs No* For equip. start -up or annual equipment mrtificalion, was a leak simulated to varify LLD performance?
Check all that apph) Simulated leak rate: []3 g.p.h.: 0.1 g.p.h.. 00.2 g.p.h.:
IT-Yes No* Were all LLD's confirmed operational and accurate within regulatory requirments?
Rx Yes o* Was the testing apparatus proper y calibrated'?
x es o or mac nica s, does the restrict product ow i it detects a leak-? E N/A
Yes No* For electronic LI.D's, does the turbine automatically shut ol'f i f the LLD detects a leak?
x] N/A
Yes Ej No* For e1wronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is
x N/A disabled or disconnected?
Yes Fj No* For electronic .LLi7s, does the turbine automatically shut off i f any portion of the monitoring; sysleKn
x] N/A malfunction or fails a test?
Ycs M No* For electronic LLD's, have all accessible wiring; connections been visually inspected?
U N/A
x Yes I Lj No I Were all items on the equipment manuthcturers maintenance checklist completed?
In the section H, below, describe how and when these deficiencies were or will he corrected.
H. Comments: I replaced both the Rcgualr 87 North and Regular 87 South FX I V Leak Detectors as original
Leak Detectors were unable to detect a leak of3 GPH @ 10 PSI. After they were replaced they were re- tested and
confirmed operational.
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SWRCB, January 2006
Spill Bucket Testing Report Form
This. form is intendedfor use ht: contractors performing annual testing of UST spill corttcrtrune t1 st+uctuu ec. The completed_frrrm and
printoutsfrom tests (ifapplicable), should be provided to the facility o vner/operator•.frr submittal to the local regulaton, agency.
1. FACILITY INFORMATION
Facility Name: Shell I Date ofTesting: 9/13/2013
Facility Address: 4700 Coffee Road, Bakersfield, CA 93309
Facility Contact: Matt Jeliries I Phone: 661496 -7006
Date Local Agency Was Notified ofTesting: 7/29/2013
Name of Local Agency Inspector (ifpresent during testing): Ester Duran
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services, Inc.
Technician Conducting Test: Kristopher Karns
Credentials: X CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester 0 Other (Specify)
License Number(s): CSLB: 804904 [CC: 5264406 -UT SWRCB: 09 -1743
3. SPILL BUCKET TESTING INFORMATION
Test Method Used: X Hydrostatic 0 Vacuum 0 Other
Test Equipment Used: Lake Test Equipment Resolution: 0.0625"
Identify Spill Bucket (At, Tcmk
Number, Stored Product, etc.)
1 Regular (North) 2 Regular (South) 3 Super 4 Diesel
Bucket Installation Type: 0 Direct Bury
X Contained in Sump
0 Direct Bury
X Contained in Sump
0 Direct Bury
X Contained in Sump
0 Direct Bury
X Contained in Sum
Bucket Diameter: 12.00" 12.00" 12.W' 12.00"
Bucket Dcpth: 12.50" 13.00" 13.50" 13.00"
Wait time between applying
vacuum /water and start of text: 5 min. 5 min. 5 min. 5 min.
Test Start Time (T)): 12:00 PM 12:00 PM 12:00 PM 12:00 PM
Initial Reading (RI): 11.001, 11.50" 10.75" 11.75"
Test End Time (T,:): 1:00 PM 1:00 PM 1:00 PM 1:00 PM
Final Reading (Rr:): l 1.00" 11.50" 10.75" 11.75"
Test Duration (TI: — TI): I hour 1 hour 1 hour 1 /tour
Change in Reading (RI:- RI): 0.00" 0.00" 0.00" 0.00"
Pass/Fail Threshold or
Criteria: 0,0625" 0.0625" 0.0625" 0.0625"
Test Result: X Pass 0 Fail X Pass Fail X Pass 0 Fail X Pass 0 Fail
Comments — /include information on repaim made prior to fecting, and rt?contnrc +ndec fol/nt..- -tip forfoiled tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this report rr true, accurate, and infull compliance with legal requirements.
Technician's Signature: gc_1a't Date: 8/13 /2013
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
1= Veeder Root TLS 350
2= _mergency'Shut Off, Switch
3= Veeder,Roqt -ATG Probe
4= Veeder.Root'208 Sump Sensor
6= Veedor Root 420 Annular Sensor
6-- Veoder Root-420 Dispenser Son,
7= Red, Jackot,FXIV LLD
8= Red. .JaCk6t,FXI,DV LLD
9— 10000 -Gallon Regular North STP
10= 10000 Gallon ,Reg South
STPI I= 1000,0 -Gallon, Super STP
12= 1000P Gahm -Diesel STP
1-3= !Regular North 'Fill Sump
14= iRegular South Fill Sump
1,5-- Super Fill Sump
16= Diesel. ill. Sump
Shel
4700 Coffee Road
Bakersfield,CA 93308,
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10 S T
BUILDWH CONFIDENCE' T0M =W$TMCONR0ENCC
LIc.970703 Lic.804904
Toll Free ;a: 1- 800439 -9930
Job Order / Invoice #: < <29
Date Called
3/3
Time
21 ro f7'"
Towhom
Aa c -
Repair Date
ells] / /s'
Site Name: ' •lEd. e I
Te lean Signatu
Name: Conftdcncc UST
Store Employee PriT Name:
Site Name: ' •lEd. e I
Te lean Signatu
Street 16250 Meacham .Road Street: JU t F
City: Bakersfield, CA 93314 City: State: (../7 -. Zip:
Terms: N- Store No:
Description of work performed:
c l v Js k T r c gA
TRAVEL and LABOR 0.5 Flour Minimum Labor Charge) OVERTIME 5:00 PM - 7:00 AM)
Date Technician(s) Name Start End Total 67—SZr OT End OT Total
Travel
Labor i
Travel
Date Technician(s) Name Start End Total OT Start OT End 0717otal
Travel
Labor
Travel
Date Technician(s) Name Start End Total OT Start OT End OT Total
Travel
Labor
Travel
SUPPLIES - MATERIALS RENTALS Check One
City. UST Parts Site Parts;
COMMENTS
Store Employee PriT Name: To& i 'an Print Name: zU
Stom Empt yea nature: Data
n
Te lean Signatu Date
INVOICE -WHITE - SITE - CANARY
BAKERSFIELD CITY FIRE DEPARTMENT -- INSPECTION RECORD
Post this Card at the Job Site and DO. NOT Remove for Duration of Work
Inspection Request Phone No. (661 ) 326 -3979
UST NEW INSTALL
DESCRIPTION DATE SIGNATURE
BACKFILL
PRIMARY PIPE
SECONDARY PIPE
SECONDARY CONTAINMENT
SENSORS
AUTHORIZATION FOR FUEL
ELECTRICAL SEAK -OFF
REMARKS:
TANK TESTING =
UST REMOVAL
DESCRIPTION DATE SIGNATURE
AST NEW INSTALL
DESCRIPTION DATE SIGNATURE
MODIFICATIONS MINOR / MAJOR
AST REMOVAL
DESCRIPTION DATE SIGNATURE
EVRUPGRADE
PRIOR -TO OPERATION.OF ANY SYSTEM,
ALLUST AND /OR_AST SYSTEMS SHALL BE
INSTALL, COMPLETE
I
AND A_ CCEPTED BY,
MISC. ACTIVITY THE-BAKERSFIELD CITY FIRE DEPARTMENT:",
TIRE DEPARTMENT (FINAL)
n
BUILDING ADDRESS: -9200
JOB DESCRIPTION: OCCUPANCY TYPE:
OWNER: e C 6 PERMIT NO. /3-- /CQ6OO 36am
CONTRACTOR: ."J 2 c PHONE #
FD 1743
UNDERGROUND STORAGE TANKS
APPLICATION
TO PERFORM ELD /LINE TESTING/
SB989 SECONDARY CONTAINMENT
TESTING/TANK TIGHTNESS TEST AND
FUEL MONITORING CERTIFICATION
Please note that these are separate
individual tests and will be charged per
separate type test accordingly.)
PERMIT #
ENHANCED LEAK DETECTION
TANK TIGHTNESS
B B R 3 P I D
ARr/- r
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661-326-3979 • Fax: 661 - 852 -2171
Page 1 of 1
LINE TESTING SB -989 SECONDARY CONTAINMENT
FUEL MONITORING CERTIFICATION
SITE INFORMATION
FACILITY
Shell
NAME & PHONE # OF CONTACT PERSON
Matt Jeffries (661) 387 -0592
ADDRESS
4700 Coffee Road Bakersfield CA 93308
OWNER NAME
Jeffries Bros. , Inc.
OPERATOR NAME PERMIT TO OPERATE #
OF TANKS TO BE TESTED: IS PIPING GOING TO BE TESTED? YES NO
TANK # VOLUME CONTENTS
TANK TESTING COMPANY
TESTING COMPANY
Confidence UST Services Inc.
NAME & PHONE # OF CONTACT PERSON
Karli Karns (661) 631 -3870
MAILING ADDRESS
16250 Meacham Road Bakersfield CA 93314
NAME & PHONE # OF TESTER OR SPECIAL INSPECTOR CERTIFICATION #
B34106
DATE & TIME TEST TO BE CONDUCTED
8/13/13 m
ICc #
5264406 -UT
TEST METHOD
APPLICANT SIGNATURE
1
le"-
DATE
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
APPROVED BY DATE
FD2095 (Rev 03/08)
BILLING & PERMIT STATEMENT
PERMIT #
8 R
DRPARfYIMT
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Dhnno• F.F.1_Z7F._'2Q70 . Fav• AA1 -AE;)-7171
All
13
permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK.
PERMITTYPE FEE CALCULATION TOTAL
DUE
Alarm - New & Modification (minimum charge) $280
SITE INFORMATION
LOCATION OF PROJECT PROPERTY OWNER
Shell Jeffries Bros Inc.
STARTING DATE NAME
8/13/13 10:30am Matt Jeffries
PROJECT NAME ADDRESS PHONE #
Shell 145 Vultee Street 661- 387 -0592
PROJECT ADDRESS
4700 Coffee Rd. Bakersfield CA 93308 CITY a e.
STATE C ZIP CODE
93263
CONTRACTOR INFORMATION
CONTRACTOR NAME CA LICENSE # TYPE OF LICENSE EXPIRATION DATE PHONE #
Kristoipher Karns 804904 C61 D40 13/31/14 661- 631 -3870
CONTRACTOR COMPANY NAME FAX #
Confidence UST Services Inc. 661- 587 -9758
ADDRESS CITY ZIP CODE
16250 Meacham Road lBakersfield 93314
All
13
permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK.
PERMITTYPE FEE CALCULATION TOTAL
DUE
Alarm - New & Modification (minimum charge) $280
ONLY
TREASURY
ACCT NO
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)
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
Underground Storage Tank (Minor Modification) MTM 167 /site 82
Underground Storage Tank (Removal) TR 573 /tank 84
N 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
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 n5/ii)