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HomeMy WebLinkAbout3699 WILSON ROAD (8)MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State ofCalifornia Authority Cited: Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofRegulations 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 panel by the technician who performs the work. A copy of this 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: HP Go Go Site Address: 3699 Wilson Road City: Bakersfield Facility Contact Person: Alondra Hernandez Make /Model of Monitoring System: Veeder -Root TLS -350 B. Inventory of Equipment Tested /CertifiedChecktheappropriateboxestoindicatespecincequipmenti®pectediterviced: Bldg. No.: Zip: 93309 Contact Phone No.: 661 - 835 -8044 Date of Testing/Servicing: 5/4/2011 Tank ID: 12000 gal. Regular Tank ID: 12000 gal. Regular 2 X] In -Tank Gauging Probe. Model: 847390-109 x] In -Tank Gauging Probe. Model: 847390 -109 x] Annular Space or Vault Probe. Model: 794390-303 x] Annular Space or Vault Sensor. Model: 794390 -303 x] Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: Veeder -Root X] Fill Sump Sensor(s) Model: Veeder -Root X] Fill Sump Sensor(s). Model: Veeder -Root J Mechanical Line Leak Detector. Model:FX1V X] Mechanical Line Leak Detector. Model: FX1V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: LxJ Tank Overfill / High Level Sensor. ModeI:OPW -6I -SO Tank Overfill / High Leval Sensor. Model: OPW -61-SO Other (specify equip. type and model in Sec. E on Pg. 2) Other (specify equip. type and model in Sec. E on Pg. 2) Tank ID: 12000 gal. Super Tank ID: Waste Oil x] In -Tank Gauging Probe. Model: 847390-109 In -Tank Gauging Probe. Model: x] Annular Space or Vault Sensor. Model:794390 -303 X Annular Space or Vault Sensor. Model: 794390 -420 X] Piping Sump / Trench Sensor(s). Model:Veeder -Root Piping Sump / Trench Sensor(s). Model: X] Fill Sump Sensors(s). Model: Veeder -Root X] Fill Sump Sensor(s). Model: Veeder -Root C1 Mechanical Line Leak Decector. Model:FX1V Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: rxl Tank Overfill / High Level Sensor. Model:OPW -6I-SO Tank Overfill / High Level Sensor. Model: 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 ID: 3 & 4 n Dispenser Containment Sensor(s). Model: Veeder -Root x] Dispenser Containment Sensor(s). Model: Veeder -Root X] Shear Valve(s). x] Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s) Dispenser ID: 5 & 6 Dispenser ID: 7 & 8 x] Dispenser Containment Sensor(s). Model: Veeder -Root x] Dispenser Containment Sensor(s). Model: Veeder -Root x] Shear Valve(s). x] Shear Valve(s). Dispenser Containment Float(s) and Chains(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s) Dispenser Containment Float(s) and Chain(s). If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I 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 S Set -up AI rm h!175 r ort Technician Name (print): Bryan A Self Signature: Certification No: B37501 License No: 804904 Testing Company Name: Confidence UST Services, Inc. Site Address: 3699 Wilson Road, Bakersfield, CA 93309 Phone No: 800 - 339 -9930 Date of Testing/Servicing: 514/2011 D. Results of Testing/Servicing Software Version Installed: Complete the following checklist: x] Yes No* Is the audible alarm operational? x Yes No* T-s—tFe-Visual alarm operational? x I Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational? x Yes No* Were all sensors installed at the lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? Lxj Yes No* Ifalarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) HN/A operational? x Yes No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary N/A containment monitoring system detects a leak, fails to operate, or is electrically disconnected? Ifyes: which sensors initate positive shut - down? Lx] Sumplfrench Sensors [x] Dispenser Containment Sensors Did you confirm positive shut -down due to leaks and sensor failure /disconnected? [X] Yes; No; X] Yes No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no L] N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visual and audible at the tank fill point(s) and operating properly? If so, at what percent oftank capasity does the alarm trigger? 90 % Yes* No Was any monitoring equipment rep ac ? IfYes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all replacement parts in Section E, below. x] Yes* No Was liquid found inside any secondary containment systems designed as dry systems? Product; U Water. If yes, describe causes in Section E, below. N * Was monitoring system set -up reviewed to ensure proper settings? Attach set -up reports, if app icable. Mes No* I Is all monitoring equipment operational per manufacturer's specifications? In Section E below, discribe how and when these deficiencies were or will be corrected. E. Comments: I replaced the Veeder -Root Sensor in the regular Fill Sump with a 794380 -208 sensor. I also pulled out about 35 gallons of water from the super fill sump. F. In -Tank Guaging / SIR Equipment: [X] Check this box if tank guaging is used only for inventory control. Check this box if tank guaging -or SIR equipment is installed. This section must be completed if in -tank guaging equipment is used to perform leak detection monitoring. Complete the following checklist: Lx] Yes No* Has all input wiring been inspected for proper enter and term ination,including testing for ground faults? Yes No* Were all tank guaging probes visually inspected for damage and residue buildup? Yes F71 No* Was accuracy of system product level readings tested? x Yes No* Was accuracy of system water level readings tested? For machamca LLD's, does the LLD restrict product ow i it detects a leak? Yes No* Were all probes reinstalled properly? xj U Yes No* Were all items on the equipment manufacturer'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] Yes No* For equip. start-up or annual equipment certification, was a leak simulated to varify LLD performance? Check all that apply) Simulated leak rate: E3 g.p.h.: 0.1 g.p.h.; 0.2 g.p.h.; x Yes No* Were all LLD's confirmed operational and accurate within regulatory requirments? x Yes 7 No Was the testing apparatus properly calibrated? Yes For machamca LLD's, does the LLD restrict product ow i it detects a leak? LN/A Yes No* For electronic LLD's, does the turbine automatically shut off if the LLD detects a leak? x] N/A Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is x] N/A disabled or disconnected? Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system Cx] N/A malfunction or fails a test? Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected? U N/A Lxj Yes No I Were all items on the equipment manufacturer's maintenance checklist completed? In the section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: There is a problem with the way the LLD's are wired. To insure that the LLD are working correctly, and catching the we had to disconnect the regular 2 tank. At this time we are trying to figure out a way to fix the wireing problem. HP GO GO 3369 WILSON RD 6AKERSFIE ,-D CA 93309 MAY 4. 2311 9:05 AM SYSTEM :3TATUS REPORT T I:DELIV3RY- NEEDED T 3; DEL IV, -R1' NEEDED INVENTORY REPORT T I: SUPREME VOLUME 706 GALS ULLAGE. 11143 GALS 90% ULLAG3m 9958 GALS TC VOLUME = 698 GALS HEIGHT 13.19 INCHES WATER VOL 9 GALS WATER 0.75 INCHES TEMP 75.7 DEG F T 2: UNLEADED 2 VOLUME = 1788 GALS ULLAGE a 10061 GALS 90% ULLAG'. =- 8876 GALS TC VOLUME a 1765 GALS HEIGHT = 25.03 INCHES WATER. VOL - 0 GALS WATER a 0.00 INCHES TEMP = 77.4 DEG F T 3: UNLEADED 1 VOLUME v 1713 GALS ULLAGE a 10136 GALS 90% ULLAG E!- 8951 GALS TC VOLLIME = 1694 GALS HEIGHT a 24.29 INCHES WATER VOL m 0 GALS WATER = 0.00 INCHES TEMP = 75.7 DEG F x x x* x END x x x w w SYSTEM SETUP - - - - - MAY 4.__,2 D.14 -,_9:05 AM SYSTEM UNITS U.S. SYSTEM LAVGUAGE ENGLISH HP GO GO 3369 WILSON PEI BAKERSFIE:J? CA 93309 SH 1 FT '1.1 M? i : D I.SABLED SHIFT TNT 2 : DISABLED SHIFT TIM= 3 : DISABLED PER (OD 1 +.: 'fEST WARN 1 NGS DISABLED ANNUAL TEST WARNINGS DISABLED SYST131 SE,_ UR I T' ' CODE : 001000 UUMMUN I CAT I ONS Sh:.i'IJP ^ l PORT SET"I' I NGS : NONE FOUND RS -232 SEl,URITY CODE : 003000 1149-232 EN') OF MESSAGE DISABLED ` IN-TANK S:jfUP T I : SUPREME PRODUCT CODE I THERMAL COEFF :.000700 000700 TANK DIAM3TER 120.00 TANK PROFILE 4 PTS FUEL VOL 11849 90;. 0 104'.H. VOL 9894 6,Q:10' 1'0,'H VOL 6143 30..01 ljN'3H VOL : 2313 FL'OAT' S Z-2: 4.0 INCHES WATER - WAR- g-I,NG -:.: 1:,0 3.0HIGHWATVLIMIT: MAX OR LA'3EL VOL: 11849 OVERFILL '_IM[T 90% 10664 HIGH PRODJCT 95% 11256 DELIVERY 15% 1777 LOW PRODUCT 600 LEAK ALARM LIMIT: 8 SUDDEN LOSS LIMIT: 25 TANK TILT - 0.50 MANIFOLDED TANKS Tit: NONE LEAK MIN ANNUAL 0 PERIODIC TEST TYPE STANDARD ANNUAL TE3T FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED CROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVERY DELAY 3 MIN T 2:UNLEA)ED 2 PRODUCT CODE 2 THERMAL CoEFF 000700 TANK DIAM :rTER 120.00 TANK PROFILE 4 PTS FULL VOL 11849 90.0 I Nt'H VOL 9894 60.0 1 ro`H VOL 61.43 30.0 IN,,H VOL 2313 FLOAT SIZ3: 4.0 INCHES WATER WARVING 1.0 HIGH WATER LIMIT: 3.0 MAX OR LA:3EL'VOL: 11849 OVERFILL LIMIT 9011 10664 HIGH PRODUCT 951.1 11256 DELIVERY LIMIT 15%4 1777 LOW PRODUCT 600 LEAK, ALARM LIMIT: 8 SUDDEN LOSS LIMIT: 25 TANK TILT 0.75 MAN I FO1.DE:) TANKS Tit: NONE LEAK. MIN ANNUAL 0 PERIODIC TEST TYPE QUICK ANNUAL TENT FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVERY ,)ELAY 3 M 1 N T 3: UNLEA;)ED l PRODUCT CODE 3 THERMAL COEFF :.000700 TANK D I AM:ETER 120.00 TANK PROFILE 4 F' CS FULL VOL 11849 50.0 INCH VOL 9894 E0.0 IN13H VOL 6143 30.0 IN,;H VOL 2313 FLOAT SIZE: 4.0 INCHES WAT9R WARNING 1.0 HIGH WATER LIMIT: 3.0 MAX OR LA3EL VOL k 11849 OVERFILL -IM1T 9on 10664 HIGH PRODJCT 95: 11256 DELIVERY :.IM1T 15yo 1777 LOW PRODL4:T 600 LEAK ALARIh LIMIT: 8 SUDDEN LOSS LIMIT: 25 TANK TILT 0.00 MANIEOLDED TANKS- " - -t, TO: NONE LEAK MIN ANNUAL 0 PERIODIC TEST TYPE QUICK ANNUAL TE:3-T FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TES'C FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVERY :BELAY . 3 MIN LEAK TEST ME'T'HOD TEST ON DENTE : ALL TANK NOV 24, 2308 START TIMT : 12:01 AM TEST RATE :0.20 GAL /HR DURATION : 2 HOURS LINE LEAK DETECTOR SETUP l' ry,E_LEAK TEST SETUP - - TES'f ON A TE ALL, L1 NE.S JAN 1. 2107 START 'TI Mz : DISABLED TEST PATE :0.20 GAL /HR LINE LEAK LOCKOUT SETUP LOCKOUT S, :HEDULE DAILY START TIM' =: DISABLED STOP TIME : DISABLED LIQUID SENSOR SETUP L 1: DUAL FLOAT HYDROSTATIC CATEGORY : DISPENSER PAN L 2:WASTE OIL ANNULAR TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 3:WASTE OIL SUMP TRI -STATE ( SINGLE FLOAT) CATEGORY : PIPING SUMP L 4:WASTE OIL HI LEVEL TRI -STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS L 5:DISP 1 -2 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 6:DISP 3 -4 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 7:DISP 3 -6 TRI -STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L 8:DISP 7 -8 TRI -STATE (SINGLE FLOAT) CATJEGORY : DISPENSER PAN L 9:91 ANNULAR TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE 1-10:91 Fl- TRI -STATE (SINGLE FLOAT) CATEGORY : PIPING SUMP Ll1:91 ST? TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L12:67 2 ANNULAR TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L13:87 2 . :ILL TRI -STATE (SINGLE FLOAT) CATEGORY : PIPING SUMP L14:07 2 2TP TRI -STATE (SINGLE FLOAT) CATEGORY : STP SUMP L15:87 ANNULAR TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L16:87 Fl.: L TRI -STATE (SINGLE FLOAT) CATEGORY : PIPING SUMP OUTPUT RE`_AY SETUP SENSOR'ALARIM 1.11:91 ST_ SENSOR ALARM - ---- 3369 WILSON RD TYPE: L 9:91 ANNULAR BAKERSFIE, --D CA 93309 STP SUMP FUEL ALARM ANNULAR VACE NORMALLY CLOSED FUEL ALARM FUEL ALARMMAY4, 2311 9:29 Ah! MAY 4. 2311 9:46 AM R.I:SUPREME T 3:HICH WATER ALARM TYPE: SYSTEI °I;'FATUS REPORT STANDAR') I• 1 : DEL I V. -RY NEEDED LIQUID SENSOR ALMS NORMALLY j "LOSED ALL:FUEL ALARM BEN30R ALARM - - - -- T 3:11ELIV3RY NEEDED IN-TANK N -ARMS L16-:87 F l " L L 10 : F UEL P3LARM T.I:HIGH WATER ALARM LINE DISA3LE SETUP FUEL ALARIN ° MAY 4, 2 )1 1 9:41 AM T I:LOW '?RODUCT ALARM 5-- SENSOR ALARM ----- SENSOR ALARM - -- -- 1'4 : 87 2 :STP L 10:91 F 1: L LIQUID SENSOR ALMS STP SUMP ' FUEL ALARM. PIPING SUMP ALL:FUEL ALARM ALL:SENS•)R OUT ALARM MAY '4, 2311 9:30 AM FUEL ALARM MAY 4, 2311 9:48 AM ALL:SHOR'P ALARM R 2:87 2 TYPE: STANDARD NORMALLY CLOSED SE0 OR ALARh1 SENSOR ALARM - - - -- L 1: 1.10:91 Fl"L IN-TANK "RMS DISPENSER PAN PIPING SUMP T.2 :HIGH WATER ALARM LOW LIQUID ALARM FUEL ALARM T 2:LOW ?RODUCT ALARM MAY 4. 2311 9:32 AM MAY 4. 2311 9:49 AM LIQUID SENSOR ALMS ALL:FUEL ALARM ALL:SENSOR OUT ALARM ALL:SHOR'C ALARM SENSOR ALARM - - - -- HP GO GO 1.12:87 2 ANNULAR 3369 WIL9)N RD ANNULAR S?ACE BA}.ERSF I E':D CA 93309 FUEL ALARM MAY 4, 2111 9:43 AM MAY 4, 2311 9:50 AM SYSTEM :STATUS REPORT T 1:DELIV:z-RY NEEDED T 3 :DEL1vz_RY NEEDED SENSOR ALARM - - --- L10:FUEL XARML13:87 2 !ILL PIPING SUI'IP FUEL ALARM MAY 4. 2311 9:45 AM SENSOR ALARM -- --- HP GO GO R 3:87 1 L15:87 ANVULAR 3369 WILSON RD TYPE: ANNULAR S?ACE BAKERSFIE, --D CA 93309 STANDARD FUEL ALARM NORMALLY CLOSED MAY 4, 2311 9:38 AM MAY 4 .. 23 1 1 9: 50 All I N -TANK 'A'.'ARMS T 3:HICH WATER ALARM T 3:LOW ?RODUCT ALARM SYSTEI °I;'FATUS REPORT I• 1 : DEL I V. -RY NEEDED LIQUID SENSOR ALMS ALL:FUEL ALARM BEN30R ALARM - - - -- T 3:11ELIV3RY NEEDED ALL:SENS-)R OUT ALARM AL.L : SHORT ALARM L16-:87 F l " L L 10 : F UEL P3LARMPIPINGSUMP LINE DISA3LE SETUP FUEL ALARIN ° MAY 4, 2 )1 1 9:41 AM SENSOR ALARM - - - -- HP GO GO 1.12:87 2 ANNULAR 3369 WIL9)N RD ANNULAR S?ACE BA}.ERSF I E':D CA 93309 FUEL ALARM MAY 4, 2111 9:43 AM MAY 4, 2311 9:50 AM SYSTEM :STATUS REPORT T 1:DELIV:z-RY NEEDED T 3 :DEL1vz_RY NEEDED SENSOR ALARM - - --- L10:FUEL XARML13:87 2 !ILL PIPING SUI'IP FUEL ALARM MAY 4. 2311 9:45 AM SENSOR ALARM - -- -- L 5:D1SP 1 -2 DISPENSER PAN FUEL ALARM MAY 4. 2711 9:54 AM ui SEN:30R ALAP41:= -- I- 6:DISP 3 -4 PISPENSER PAN FUEL- ALARM MAY 4, 2711 9:55 AM SEN30R ALARM L 8 :DISP 7 -8 DISPENSER PAN FUEL ALARM MAY 4, 2711 0:57 AM SENSOR ALARM - -- -- L 1: DISPENSER PAN SENSOR OUT ALARM MAY 4. 2311 9:57 AM SENSOP ALARM L 7 DISP 5 -6 DISPENSER PAN FUEL ALARM MAY 4. 2311 10:01 AM SEN:30R ALARM -- - -- i_ 1 DISPENSER PAN LOW LIQU1 :) ALARM MAY 4. 2711 10:03 AM HP 00 GO 3369 WILSON RD EAKENSFIE --D CA 93309 MAY 4, 2711 10:04 AP1 SYSTEM :STATUS REPORT T 1 : DEL I V.RY NEEDED T 3:DELIV -RY NEEDED L I:LOW LIQUID ALARM HP GO GO 3369 WILSON RD BAKERSF i E:.D CA 93119 MAY 4. 2)11 10:06 AM SYSTEM I.,,IATUS REPORT T I : DEL I V; RY NEEDED T 3:DELIV =RY NEEDED L I:LOIJ LIQUID ALARM 4 HP GO GO 3369 WILSON RD BAI:FRSF I E:_D CA 93309 MAY 4. 2311 10:14 AM S-M. CM :STATUS REPORT T I:DELIVL -RY NEEDED T 3:DELIV2RY NEEDED SEN:sOR ALARM - -_ L 9 :91 ANNULAR ANNULAR S?ACE SENSOR OUT ALARM MAY 4. 2311 10:'14 All SEN:30R ALARM - - - -- L 10:9.1 F.i :..I. PIPING SUMP SENSOR OUT ALARM MAY 4. 2711 10:14 AM ui? SER30R ALAI --- LI 1 :91 ST:? STP SUMP SEit"OR OUT ALARM MAY 4. 2311 10:14 AM SENSOR ALARM - - --- L12:07 2 ANNULAR ANNULAR WACE SENSOR OUT ALARM MAY 4. 2311 10:14 AM SENSOR ALARM - - - -- L13:87 2 =ILL PIPING,, SUMP SENSOR OUT ALARM MAY 4. 2311 10:14 AM SEN30R ALARM - - -- L14:87 2 :3TP STP SUMP SENSOR OUT ALARM MAY 4. 2)11 10:15 AM HP GO GO 3369 W I LS-)N RD BAKERSFIE: -D CA 93309 MAY 4, 2311 10:15 AM 3!STEM :STATUS REPORT T I:DELIV---RY NEEDED T 3:1)ELIVERY NEEDED 1.1 1 : SEWR OUT ALARM SENSOR ALARM - - - -- L 4:WASTE OIL HI LEVEL OTHER SENSORS FUEL ALARM MAY 4. 2311 10:22 AM SENSOR ALARM - ---- L 2:WASTE OIL ANNULAR ANNULAR &-ACE FUEL ALARM MAY 4, 2311 10:24 AM I SENSOR ALARM - - - -- 1-10:91 Fill. PIPING SUMP FUEL ALARM MAY 4. 2 31 1 12:21 PI-1 HP CO GO 3369 WILSON RD BAKERSFIEA CA 93309 MAY 4, 2311 12:51 PM SYSTEM STATUS REPORT T I:DELIV3RY NEEDED T 3:DEL1V'7-RY NEEDED L10:FUEL ALARM SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intendedfor use by contractors performing annual testing of UST spill containment .structures. The completedform and printoutsfrom tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: HP Go Go I Date of Testing: 5/4/2011 Facility Address: 3699 Wilson Road, Bakersfield, CA 93309 Facility Contact: Alondra Hernandez I Phone: 661 -835 -8044 Date Local Agency Was Notified of Testing : 4/28/2011 Name of Local Agency Inspector (ifpresent during testing): Ernie Medina 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. Technician Conducting Test: Bryan A Self Credentials: Z CSLB Contractor 0 ICC Service Tech. SWRCB Tank Tester Other (Spec) License Number(s): CSLB# 804904 ICC# 8022804 -UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: x Hydrostatic Vacuum Other Test Equipment Used: Lake Test Equipment Resolution: 0.0625" Identify Spill Bucket (By Tank Number, Stored Product, etc. 1 Regular 1 2 Regular 2 3 Super 4 Waste oil Bucket Installation Type: Direct Bury X Contained in Sump Direct Bury X Contained in Sump Direct Bury X Contained in Sump Direct Bury X Contained in Sum Bucket Diameter: 12.00" 12.00" 12.00" 12.00" Bucket Depth: 14.00" 14.00" 14.00" 16.00" Wait time between applying vacuum /water and start oftest: 5 min. 5 min. 5 min. 5 min. Test Start Time (Ti): 9:25am 9:25am 9:25am 10:30am Initial Reading (Rj): 10.00" 10.25" 10.00" 12.00" Test End Time (TF): 10:25am 10:25am 10:25am 11:30am Final Reading (RF): 10.00" 10.25" 10.00" 12.00" Test Duration (TF — Ti): 1 hour 1 hour 1 hour 1 hour Change in Reading (RF - 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 Fail X Pass Fail X Pass Fail X Pass Fail Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: Date: 5/4/2011 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.