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Home My WebLink About5201 WHITE LANEHOODS ALARMS SPRINKLER SYSTEMS SPRAY BOOT H AST Permit No. Permit No. Permit No. Permit No. Permit No. UST Permit No. P _ ,I evfw)n /' File Number: (_ r Address: Z. p / (jj (X. Bakersfield, CA 933 Date Received: Business Name: mad S AAA. v' cAo SYSTEM: BUILDING SQUARE FEET: INSPECTION LOG New Mod. Commercial Hood System Fire Alarm System Fire Sprinkler System apvay, f r sh System Aboveground Storage Tank Underground Storage Tank nor modification nderground Storage Tank removal Underground Storage Tank Other. Comments: Building Sq. Feet: Calculation Bldg. Sq. Ft: 1. a. 3. 4. Date Time Signature Signature Ng s RE in ,eE 3ESi T Signature Signature Ng s BILLING & PERMIT STATEMENT PERMIT NO BAKERSFIELD FIRE DEPT. B 8 R S F I D Prevention Serviceses ru rARr 1600 Truxtun Ave Ste 401 Bakersfield CA 93301 Tel.: (661) 326 -3979 • Fax: (661) 852 -2171 SITE INFORMATION LOCATION OFPROJECT 4 ' PROPERTY OWNER STARTING DATE OC`- COMPLETION DATE 1 NAME PROJECT NAME 1 V ADDREI V c V . PHONE NOS PROJECT ADDRESS CnY STATE ZIP CONTRAC TOR CONTRACTOR NAME CA LICENSE NO. J k!i'1'1 i-cS c tt d O INFORMATION TYPE OF LICENSE. EXPIRATION DATE q HA 30.2 0) PHONE NO. c 2 CONTRACTOR COMPANY N FAX MM qOO ADDRESS 5U y CRY ZIPwue All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK ON THAT PROJECT. Ft'.1 PERMIT TYPE FEE CALCULATION TOTAL DUE Alarms - New & Modifications - (Minimum Charge) $280.00 TREASURY 98 Over 10,000 Sq. Ft Sq. Ft. x.028 = Permit fee 98 Sprinklers - New & Modifications - (Minimum Charge) 280.00 84 98 Over 10,000 Sq. FL Sq. Ft. x.028 Permit fee Ba 98 Minor Sprinkler Modifications (< 10 heads) 96.00 (Inspection Only] 98 Commercial Hoods — New & Modifications 470.00 84 98 Additional Hoods 58.00 84 98 Spray Booths - New & Modifications 470.00 84 98 Aboveground Storage Tanks (Installationllnsp. -ts' Time) 180.00 82 Additional Tanks 96.00 82 Aboveground Storage Tanks (Removauinspecbon) 109.00 82 Underground Storage Tanks (Installatlonlinspection) 878.00 (per tank) 82 Underground Storage Tanks (Modification) 878.00 (persite) 82 Underground Storage Tanks (Minor Modification) 167.00 B2 Underground Storage Tanks (Removap 573.00 (per tank) 84 Oilwell (Installation) 96.00 84 Mandated Leak Detection (Testing) / Fuel Monit.Cert/SB989. Note: $96.00 foreach" of test 1per site (even ifscheduled at the same time) 9 3-@9- fpeFSiteL % , C* 82 Tents 96.00 (per tent) 84 Pyrotechnic - (Per event, Plus Insp. Fee @ $96 per hour) 96.00 + (5 hrs. min. standby feeAnspection)= $576..00 84 After hours inspection fee 121.00 84 RE401SPECTION(S) / FOLLOW -UP INSPECTION(S) 96.00 (per hour) 84 Portable LPG (Propane): NO. OF CAGES? _ 96.00 Explosive Storage 266.00 84 Copying & File Research (Fie Research Fee $50.00 per hr) 250 per page 84 Miscellaneous 1 84 FD 2021 (Rev. 06/07) 1 - ORIGINAL WHITE (to Treasury) 1- YELLOW (to Fite) 1 -PINK (to Customer) BILLING & PERMIT STATEMENT F_IPERMIIT NO.: 11 R S F 1 D 4 FIRE Herr r BAKERSFIELD FIRE DEPT. Prevention Services 1600 Tnuctun Ave Ste 401 Bakersfield CA 93301 Tel.: (6611326-3979 • Fax: (6611852-2171 All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK ON THAT PROJECT. 1 I Alarrrls - New & Modfications - (Minimum Charge) I $280.00 I ; 84 1 • 98 ytR m ... •` 7t'j,., V'r^ d' " h 4Q4 1 RICH ENVIRONMENTAL SERVICE STATION SERVICES 90- 716213222 4176 LIC. #809850 G5643BROOKSCT.. BAKERSFIELD, CA 93308- 3708. DATE 661) 392 -8687 PAYTOTHE ORRDER OF tJJV' irrrV tN Ji I/%— T— rt%FiIJ" C[rrAi' .- _ • DOLLARS CHASE JP Morgan Chase Bank, N.A. Bakersfield, CA 93308 FOR .. 2 / I. 7A .. p . t/'F[R- 11 JH/V1xYR ` I7MA A U"r7r4F1111SIONATURF u 004L7611' '1:32227L6271: 3083504 O7n ti!.. PETI' I•'r `11 'Ad' 'Y b' - " g'• ; VIIJGI .'VJ 14 1 tl I Q111V HI JVI QnI SITE INFORMATION LOCATION OF PROJECT PROPERTY OWNER San_b3 STARTING DATE t COMPLETION DATE 1 - NAME PROJECT NAME D W(A Ukd 1 ADDR ' \ 1 I PHONE NO I PROJECT ADDRESS ^ ^ r ^ 1 ^ CITY STATE ZIP CONTRACTOR CONTRACTOR NAME CA LICENSE NO. J E-S -R,c SO TYPE OF LICENSE. EXPIRATION DATE r 0A)I414 30 ,201 PHONE NO. g2 -8 87 CONTRACTOR COMPANY NAME 1 C v FAX NO. 521-71902ADDRESS CITY ZIP wut All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK ON THAT PROJECT. 1 I Alarrrls - New & Modfications - (Minimum Charge) I $280.00 I ; 84 1 • 98 ytR m ... •` 7t'j,., V'r^ d' " h 4Q41 RICH ENVIRONMENTAL SERVICE STATION SERVICES 90- 716213222 4176 LIC. #809850 G5643BROOKSCT.. BAKERSFIELD, CA 93308- 3708. DATE 661) 392 -8687 PAYTOTHE ORRDER OF tJJV' irrrV tN Ji I/%— T— rt%FiIJ" C[rrAi' .- _ • DOLLARS CHASE JP Morgan Chase Bank, N.A. Bakersfield, CA 93308 FOR .. 2 / I. 7A .. p . t/'F[R- 11 JH/V1xYR ` I7MA A U"r7r4F1111SIONATURF u 004L7611' '1:32227L6271: 3083504 O7n ti!.. PETI' I•'r `11 'Ad' 'Y b' - " g'• ; VIIJGI .'VJ 14 1 tl I Q111V HI JVI QnI b W (pe site) 82 Underground Storage Tanks (Minor Modification) 167.00 82 Underground Storage Tanks (Removal) 573.00 (per tank) 84 Oilwell (Installation) 96.00 84 Mandated Leak Detection (Testing) / Fuel Monit.Cert/SB989. Note... $96.00 for each type oftest / persite (even if scheduled at the same time) tJ8:66"(jBersite,L f q , 82 Tents 96.00 (per tenO 84 technic - (Per event, Plus Insp. Fee @ $96 per hour) 96.00 + (5 hrs. min. standby fee Anspection)=$576..00 84 After hours inspection fee 121.00 84 RE4NSPECTION(S) /FOLL0W- UP/NSPECTION(S) 96.00 (per hour) 84 Portable LPG (Propane): NO. OF CAGES? 96.00 84 Explosive Storage 266.00 84 Copying & File Research (File Research Fee $50.00 per hr) 250 per page 84 Miscellaneous 84 FD 2021 (Rev. 06/07) 1 - ORIGINAL WHITE (to Treasury) 1- YELLOW (to File) 1 -PINK (to Customer) BAKERSFIELD FIRE DEPARTMENT UNDERGROUND STORAGE TANK Prevention Services 1501 Truxtun Avenue 1s* Floor PERMIT APPLICATION Bakersfield, CA 93301 TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW a t r Phone: 661 - 326 -3979 • Fax: 661 - 852 -2171 TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD v Page 1 of 1 Permit # TYPE OF APPLICATION: 0 NEW TANK INSTALL/NEW FACILITY O NEW TANK INSTALL/EXISTING FACILITY CHECK ONE ONLY) 0 MODIFICATION OF FACILITY O MINOR MODIFICATION OF FACILITY STARTING DATE/ PROPOSED COMPLETION DATE` LA 2-A FACILITY NAME n J NG )CTI FAaLrI'Y:PERmrT t FACILITY ADDRESS O CITY 1 _ ' fS ZIP CODF,,[ 4q33 ( TYPE OF BUSINESS TANK OWNER PHONE S WATER-TO'FACILITY PROVIDED BY lJ i, , DEFT1i1T0 "GROUND WATER SOIL TYPE EXPECTED AT SITE FOtTANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? YES NO YES NO FHIS,SECTION IS FOR STORAGE TANK IDENTIFICATION ANK R VOLUME „'." UNLEADED `_" : REGULAR'. PREMIUM: DIESEL' OTHER Tank Testing Company INANE OFTESTING COMPANY ONE NUMBER C A111tt)r,- r. MAILINO.ADDRESS tF'- NAME OF TESTER Icc* 1_.__..... S Lbl.pl 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 WATE4t "i7 , r:, .; ; PENALTY OF PERIURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. NAMEOFTESTER ICCa DEP1,, ,;, i bu l 14 Qto 11. QF TANKS t 0 f THIS APPLICATION BECOMES A PERMIT WHEN APPROVED r. - FOR OFFICIAL USE ONLY APPROVED; APPROVED BY FD2086 (Rev 08/09) SWRCB, January 2002 Secondary Containment Testing Report Form O`CaJ Page l of-3— Thisform is inlendedfor use by contractors performing periodic testing of USTsecondary containment systems. Use the appropriate pages ofthisform to report resultsfor all components tested The completedform, written testprocedures, and printoutsfrom tests (rfapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACTI.TTV INFORMATION Facility Name: GOOD SAMARITAN HOSPITAL Date of Testing: 12/20/12 Facility Address: 5201 WHITE LANE, BAKERSFIELD Facility Contact: SANTOS Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (fpresent during testing): ERIN 2. TESTING CONTRACTOR INFORMATION Company Name: Rich Environmental RESULTS Technician Conducting Test: CAMERON MASON Pass Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: C61/1340 A HAZ License Number: 809850 Manufacturer Manufacturer Training Component(s) Date Training Expires INCON TS -STS 10/12/2014 4/19/13 0 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made 4/19/13 0 0 0 SUPPLY SEC PIPE X 0 0 0 0 0 1 1 1 0 0 1 0 1 1 21 1 1 0 on= 1 1 0 000; 0 0 0 0 0 0 0, CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 12/20/12 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 12/20/12 SWRCB, January 2002 Page ?i of 3 5. SECONDARY PIPE TESTING Test Method Developed By: Piping Manufacturer X Industry Standard Professional Engineer Other (Specify) Test Method Used: X Pressure Vacuum Hydrostatic Other (Spec) Test Equipment Used: 4" DIAL GAUGE Equipment Resolution: .5% Piping Run # SUPPLY Piping Run # RETURN Piping Run # Piping Run # Piping Material: FIBERGLASS FIBERGLASS Piping Manufacturer: AO SMITH AO SMITH Piping Diameter: 2" 2" Length ofPiping Run: 30' 30' Product Stored: DIESEL DIESEL Method and location of piping-run isolation: TEST BOOT IN STP TEST BOOT IN STP Wait time between applying pressure/vacuum/water and starting test: 30 MIN 30 MIN Test Start Time: 10:00 10:30 Initial Reading (R,): 5.2 6.0 Test End Time: 11:00 11:30 Final Reading (RF): 5.0 5 Test Duration: 60 MIN 60 MIN Change in Reading (RF -R,): 2 5.5 Pass/Fail Threshold or Criteria: 0 0 Test Result: Pass X Fail Pass X Fail Pass Fail Pass Fail Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) SWRCB, January 2002 6. PIPING SUMP TESTING Page 3 of Test Method Developed By: Sump Manufacturer X Industry Standard 0 Professional Engineer Other (Specie) Test Method Used: Pressure Vacuum X Hydrostatic D Other (Spec) Test Equipment Used: INCON TS -STS Equipment Resolution: Sump # DIESEL Sump # Sump # Sump # Sump Diameter: 36" Sump Depth: 48" Sump Material: FIBERGLASS Height from Tank Top to Top of Highest Piping Penetration: 16" Height from Tank Top to Lowest Electrical Penetration: 30" Condition of sump prior to testing: CLEAN Portion of Sump Tested' 18" Does turbine shut down when sump sensor detects 1iquid (both product and water)?* Yes No X NA Yes DNo DNA D Yes DNo NA Yes No 0 NA Turbine shutdown response time N/A Is system programmed for fail -safe Shutdown?* 0 Yes No X NA Yes DNo DNA D Yes DNo NA 0 Yes 0No 0NA Was fail -safe verified to be o eiational ?* Yes DNo XNA DYes DNo DNA Yes DNo DNA Yes 0N DNA Wait time between applying pressure /vacuum /water and starting test: 30 MIN Test Start Time: VISUAL Initial Reading (R,): FAIL Test End Time: Final Reading (RF): Test Duration: Change in Reading (RF -R,): Pass/Fail Threshold or Criteria: Test Result, Pass X Fail Pass Fail Pass Fail Pass Fail Was sensor removed for testing? 0 Yes No D NA 0 Yes No NA D Yes DNo DNA 0 Yes 0 No NA Was sensor properly replaced and verified functional after testing? 0 Yes 0 No 0 NA 0 Yes 0No NA 0 Yes 0 No 0NA 0 Yes 0 No 0 NA Comments — (include information on repairs madeprior to tesUng and recommendedfollow -upforfailed tests) If the entire depth ofthe sump is not tested, specify how much was tested. If the answer to any ofthe questions indicated with an asterisk(*) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LO -160) 500,5 ---) SB989 TESTING FAILURE REPORT SITE NAME: GOOD SAMARITAN HOSPITAL DATE: 12/20/12 ADDRESS: 5201 WHITE LANE TECHNICIAN: CAMERON MASON CITY: BAKERSFIELD SIGNATURE: THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE TESTING. REPAIRS: REPAIRED (2) CLAM SHELL FDUNG IN TRANS SUMP LABOR: BOTH SECONDARY LINES STILL FAIL TEST - PROBLEM UNDERGROUND AND STP STILL LEAKS - SEND ESTIMATE FOR REPAIRS. PARTS INSTALLED: NONE NAME: TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE. A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR CONVIENENCE. na-1w A SWRCB, January 2002 Page of 3 Secondary Containment Testing Report Form Thisform is intendedfor use by contractors performing periodic testing ofUST secondary containment systems. Use the appropriate pages ofthisform to report resultsfor all components tested The completedform, written test procedures, and printoutsfrom tests (ifapplicable), should beprovided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: GOOD SAMARITAN HOSPITAL I Date of Testing: 4/19/13 Facility Address: 5201 WHITE LANE, BAKERSFIELD Facility Contact: SANTOS Phone: Date Local Agency Was Notified ofTesting: 4/18/13 Name ofLocal Agency Inspector (fpresent during testing): ERIN 2. TESTING CONTRACTOR INFORMATION Company Name: Rich Environmental Technician Conducting Test: CAMERON MASON Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: C61/1340 A HAZ License Number: 809850 Manufacturer Manufacturer Training Component(s) Date Training Expires INCON TS -STS 10/12/2014 3. SUMMARY OF TEST RESULTS Component i SUPPLY .. DIESEL STP Mom If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best ofmy knowledge, thefacts stated in this document are accurate and infull compliance wilt legal requirements Technician's Signature: Date: 4/19113 SWRCB January 2002 Page Z of 5. SECONDARY PIPE TESTING Test Method Developed By: Piping Manufacturer X Industry Standard Professional Engineer Other (Spec) Test Method Used: X Pressure Vacuum Hydrostatic Other (Spec) Test Equipment Used: 4" DIAL GAUGE Equipment Resolution: .5% Piping Run # SUPPLV Piping Run # RETURN Piping Run # Piping Run # Piping Material: FIBERGLASS FIBERGLASS Piping Manufacturer: AO SMITH AO SMITH Piping Diameter: 2" 2" Length of Piping Run: 30' 30' Product Stored: DIESEL DIESEL Method and location of piping-run isolation: TEST BOOT IN STP TEST BOOT IN STP Wait time between applying pressure /vacuum /water and starting test: 30 MIN 30 MTN Test Start Time: 2:00 2:00 Initial Reading (R1): 5.5 5.5 Test End Time: 3:00 3:00 Final Reading (RF): 5.5 5.5 Test Duration: 60 MIN 60 MIN Change in Reading (RF -RO: 0 0 Pass/Fail Threshold or Criteria: 0 0 Test Result: X Pass Fail X Pass Fail Pass []Fail Pass Fail Comments — (include information on repairs madeprior to testing, and recommendedfollow -upforfailed tests) SWRCB, January 2002 6. PIPING SUMP TESTING aowOT Page -.;5 of3 Test Method Developed By: 0 Sump Manufacturer X Industry Standard Professional Engineer D Other (Spec) Test Method Used: 0 Pressure 0 Vacuum X Hydrostatic D Other (Spec) Test Equipment Used: INCON TS -STS Equipment Resolution: Sump # DIESEL Sump # Sump # Sump # Sump Diameter: 36" Sump Depth: 48" Sump Material: FIBERGLASS Height from Tank Top to Top of Highest Piping Penetration: 16" Height from Tank Top to Lowest Electrical Penetration: 30" Condition ofsump prior to testing: CLEAN Portion of Sump Tested' 18" Does turbine shut down when sump sensor detects liquid (both product and water) ?* 0 Yes D No X NA Yes 0 No NA D Yes No 0 NA 0 Yes 0No NA Turbine shutdown response time N/A Is system programmed for fail -safe shutdown ?* 0 Yes No X NA Yes No NA Yes No 0 NA 0 Yes 0No 0NA Was fail -safe verified to be o erational ?* Yes No X NA Yes No DNA Yes DNo DNA Yes 0N DNA Wait time between applying pressure /vacuum /water and starting test: 30 MIN Test Start Time: 11:44 12:03 Initial Reading (R,): 5.271 5.271 Test End Time: 11:59 12:18 Final Reading (RF): 5.271 5.271 Test Duration: 15MIN 15MIN Change in Reading (RF -R,): 000 000 Pass/Fail Threshold or Criteria: 002 002 Test Result: X Pass Fail D Pass Fail Pass D Fail 0 Pass Fail Was sensor removed for testing? X Yes No 0 NA 0 Yes No 0 NA 0 Yes No NA D Yes D No DNA Was sensor properly replaced and verified functional after testin ? X Yes No NA 0 Yes 0 No 0 NA 0 Yes No NA 0 Yes 0 No D NA Comments — (include information on repairs made prior to testing, and recommendedfollow -upfor failed tests) If the entire depth ofthe sump is not tested, specify how much was tested. If the answer to any of the questions indicated with an asterisk(*) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160) Cot" Cry tr,l l(TIrl 31 X12 1._ i CP IQ c KI 11 911, Lk rVI T.T :' , 1, ' Iirl 2 2 r'l P i C. G. c: Cl I,- G' C., tf-: v 1 it1 3:"s- W u Ci Gr ip ul C: I- coi,rvlr C. Y C. fOrA Z Ar coil !t ri 1-1PIF, P; 2 C' X M. I U l — I ty x A: g MK3 7 OC- IV ai r rip' uu - - — I VI tTl -21 2 rtl f, 1 rtI Iirl 2 2 r'l Pi C. G. c: Cl I,- G' C., tf-: Ci Gr ip ul C: rl C. Y 1 r coil !t ri 1-1PIF, P; 2 C' X M. I Ul — I ty x A: 7 ai C's 4 CD (A C." fj. f'j cp 4' cr, kr. 2 C4 1 SB989 TESTING FAILURE REPORT SITE NAME: GOOD SAMARITAN HOSPITAL DATE: 4/19/13 ADDRESS: 5201 WHITE LANE TECHNICIAN: CAMERON MASON CITY: BAKERSFIELD SIGNATURE: r'T= THE FOLLOWING COMPONENTS WERE REPLACEDIREPAIRED TO COMPLETE TESTING. REPAIRS: FIX LEAK IN SECONDARY PIPING AND FIX LEAKS IN SIP LABOR: NONE PARTS INSTALLED: NONE NAME: TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE. A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR CONVIENENCE. 7u 'Ccj —1