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HomeMy WebLinkAbout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ame as Facility Name or DBA-Doing Business As) %XVLQHVV6LWH$GGUHVV &LW\ =,3&RGH ,, 81'(5*5281'6725$*(7$1.6(59,&(7(&+1,&,$1,1)250$7,21 1DPHRI&RPSDQ\3HUIRUPLQJWKH&HUWLILFDWLRQ 3KRQH 0DLOLQJ$GGUHVV 1DPHRI8676HUYLFH7HFKQLFLDQ3HUIRUPLQJWKH&HUWLILFDWLRQ(Print as shown on the ICC Certification) &RQWUDFWRU7DQN7HVWHU/LFHQVH ,&&&HUWLILFDWLRQ ,&&&HUWLILFDWLRQ([SLUDWLRQ'DWH 0RQLWRULQJ6\VWHP7UDLQLQJDQG&HUWLILFDWLRQV(List all applicable certifications.) ([SLUDWLRQ'DWH ,,, 5(68/762)7(67,1*6(59,&,1* Indicate and attach the following reports if the monitoring equipment is capable of generating either.<11$0RQLWRULQJ6\VWHP6HWXS$ODUP+LVWRU\5HSRUW :DVDQ\PRQLWRULQJHTXLSPHQWUHSODFHG" (If “Yes,” identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) :DVGDPDJHGHEULVRUOLTXLGIRXQGLQVLGHDQ\VHFRQGDU\FRQWDLQPHQWV\VWHPV" (If “Yes,” describe what was found in section IV below.) ,VDOOPRQLWRULQJHTXLSPHQWRSHUDWLRQDOSHUPDQXIDFWXUHU¶VVSHFLILFDWLRQV" (If “No,” describe why in section IV below.) ,9 &200(176 If directed to use this section, describe how and when the issues were or will be corrected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ill Wright Toyota 5100 Gasoline Alley Drive Bakersfield 93313 16250 Meacham Road, Bakersfield, CA 93314 Aaron Perrigo 804904 8485827 9/14/2020 INCON 1010993708 8/17/2020 Confidence UST Services, Inc. (800) 339-9930 ,' ,GHQWLILFDWLRQ6: 6LQJOH:DOOHG93+ 9DFXXP3UHVVXUH+\GURVWDWLF//' /LQH/HDN'HWHFWRU 81 ZZZXQLGRFVRUJ 5HY 81'(5*5281'6725$*(7$1. 021,725,1*6<67(0&(57,),&$7,21)250 3DJHRI  9, ,19(1725<2)(48,30(17&(57,),(' A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. 0DNHRI0RQLWRULQJ6\VWHP&RQWURO3DQHO  0RGHORI0RQLWRULQJ6\VWHP&RQWURO3DQHO  6RIWZDUH9HUVLRQ,QVWDOOHG  Check the appropriate boxes to indicate specific equipment inspected/serviced. 0RQLWRULQJ'HYLFH8VHG'HYLFH0RGHO0RQLWRULQJ'HYLFH8VHG'HYLFH0RGHO 7$1.,' (By tank number, stored product, etc.) 7$1.,' (By tank number, stored product, etc.) ,Q7DQN*DXJLQJ(SW Tank),Q7DQN*DXJLQJ(SW Tank) $QQXODU6SDFHRU9DXOW6HQVRU$QQXODU6SDFHRU9DXOW6HQVRU 93+6HQVRU93+6HQVRU 3URGXFW3LSLQJ3URGXFW3LSLQJ 0HFKDQLFDO//'0HFKDQLFDO//' (OHFWURQLF//'(OHFWURQLF//' 93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ  6XPS6HQVRU6XPS6HQVRU 93+6HQVRU 6XPS 93+6HQVRU 6XPS  )LOO3LSLQJ)LOO3LSLQJ 93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ  6XPS6HQVRU6XPS6HQVRU 93+6HQVRU 6XPS 93+6HQVRU 6XPS  9HQW3LSLQJ9HQW3LSLQJ 93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ  6XPS6HQVRU6XPS6HQVRU 93+6HQVRU 6XPS 93+6HQVRU 6XPS  9DSRU5HFRYHU\3LSLQJ9DSRU5HFRYHU\3LSLQJ 93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ  6XPS6HQVRU6XPS6HQVRU 93+6HQVRU 6XPS 93+6HQVRU 6XPS  0RQLWRULQJ'HYLFH8VHG 'HYLFH0RGHO0RQLWRULQJ'HYLFH8VHG 'HYLFH0RGHO 7$1.,' (By tank number, stored product, etc.) 7$1.,' (By tank number, stored product, etc.) ,Q7DQN*DXJLQJ(SW Tank),Q7DQN*DXJLQJ(SW Tank) $QQXODU6SDFHRU9DXOW6HQVRU$QQXODU6SDFHRU9DXOW6HQVRU 93+6HQVRU93+6HQVRU 3URGXFW3LSLQJ3URGXFW3LSLQJ 0HFKDQLFDO//'0HFKDQLFDO//' (OHFWURQLF//'(OHFWURQLF//' 93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ  6XPS6HQVRU6XPS6HQVRU 93+6HQVRU 6XPS 93+6HQVRU 6XPS  )LOO3LSLQJ)LOO3LSLQJ 93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ  6XPS6HQVRU6XPS6HQVRU 93+6HQVRU 6XPS 93+6HQVRU 6XPS  9HQW3LSLQJ9HQW3LSLQJ 93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ  6XPS6HQVRU6XPS6HQVRU 93+6HQVRU 6XPS 93+6HQVRU 6XPS  9DSRU5HFRYHU\3LSLQJ9DSRU5HFRYHU\3LSLQJ 93+6HQVRU 3LSLQJ 93+6HQVRU 3LSLQJ  6XPS6HQVRU6XPS6HQVRU 93+6HQVRU 6XPS 93+6HQVRU 6XPS  INCON TS-1000 6.600 Unleaded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pecify in section VII.)2WKHU(Specify in section VII.) 2WKHU0RQLWRUHG&RPSRQHQW,'2WKHU0RQLWRUHG&RPSRQHQW,' 2WKHU(Specify in section VII.)2WKHU(Specify in section VII.) 2WKHU0RQLWRUHG&RPSRQHQW,'2WKHU0RQLWRUHG&RPSRQHQW,' 2WKHU(Specify in section VII.)2WKHU(Specify in section VII.) Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring system control panel monitors more components than this form accommodates, additional copies of these pages may be attached. 9,, &200(176 Use this section to provide additional comments about the inventory of the equipment certified.  1 Boudreaux fiber optic < <HV1 1R1$ 1RW$SSOLFDEOH 81 ZZZXQLGRFVRUJ 5HY 81'(5*5281'6725$*(7$1. 021,725,1*6<67(0&(57,),&$7,21)250 3DJHRI  9,,, 021,725,1*6<67(0$1'352*5$00,1* This section must be completed if a monitoring panel is used to perform leak detection monitoring.<11$ $UHWKHYLVXDODQGDXGLEOHDODUPVRSHUDWLRQDO" :HUHDOOVHQVRUVYLVXDOO\LQVSHFWHGIRUNLQNVDQGEUHDNVLQWKHFDEOHVDQGIRUUHVLGXDOEXLOGXSWRHQVXUHWKDWIORDWVPRYHIUHHO\ IXQFWLRQDOO\WHVWHGDQGFRQILUPHGRSHUDWLRQDO" :HUHDOOVHQVRUVLQVWDOOHGDWORZHVWSRLQWRIVHFRQGDU\FRQWDLQPHQWDQGSRVLWLRQHGVRWKDWRWKHUHTXLSPHQWZLOOQRWLQWHUIHUHZLWK WKHLUSURSHURSHUDWLRQ" :DVPRQLWRULQJV\VWHPVHWXSUHYLHZHGWRHQVXUHSURSHUVHWWLQJV" :DVWKHPRQLWRULQJSDQHO¶VEDFNXSEDWWHU\YLVXDOO\LQVSHFWHGIXQFWLRQDOO\WHVWHGDQGFRQILUPHGRSHUDWLRQDO" 'RHVWKHIORZRIIXHOVWRSDWWKHGLVSHQVHULIDOHDNLVGHWHFWHGLQWKHXQGHUGLVSHQVHUFRQWDLQPHQW" 'RHVWKHWXUELQHDXWRPDWLFDOO\VKXWGRZQLIWKHSLSLQJVHFRQGDU\FRQWDLQPHQWPRQLWRULQJV\VWHPIDLOVWRRSHUDWHRULVHOHFWULFDOO\ GLVFRQQHFWHG" 'RHVWKHWXUELQHDXWRPDWLFDOO\VKXWGRZQLIWKHSLSLQJVHFRQGDU\FRQWDLQPHQWPRQLWRULQJV\VWHPGHWHFWVDOHDN" :KLFKVHQVRUVLQLWLDWHSRVLWLYHVKXWGRZQ"(Check all that apply.)6XPS8QGHU'LVSHQVHU&RQWDLQPHQW ,IDODUPVDUHUHOD\HGWRDUHPRWHPRQLWRULQJVWDWLRQLVDOOFRPPXQLFDWLRQVHTXLSPHQW HJPRGHP RSHUDWLRQDO" For any answer of “N” above, describe in Section IX how and when these deficiencies were or will be corrected. ,; &200(176 ; ,17$1.*$8*,1*7(67,1* &KHFNWKLVER[LIWDQNJDXJLQJLVXVHGRQO\IRULQYHQWRU\FRQWURO(Do not complete this section.) <11$&KHFNWKLVER[LI12WDQNJDXJLQJHTXLSPHQWLVLQVWDOOHG (Do not complete this section.) This section must be completed if in-tank gauging is used to perform leak detection monitoring. +DVDOOLQSXWZLULQJEHHQLQVSHFWHGIRUNLQNVDQGEUHDNVLQWKHFDEOHVDQGIRUSURSHUHQWU\DQGWHUPLQDWLRQLQFOXGLQJWHVWLQJIRU JURXQGIDXOWV" :HUHDOOLQWDQNJDXJLQJSUREHVYLVXDOO\LQVSHFWHGIRUGDPDJHDQGUHVLGXHEXLOGXSWRHQVXUHWKDWIORDWVPRYHIUHHO\IXQFWLRQDOO\ WHVWHGDQGFRQILUPHGRSHUDWLRQDO" :DVDFFXUDF\RIV\VWHP¶VSURGXFWOHYHOUHDGLQJVWHVWHG" :DVDFFXUDF\RIV\VWHP¶VZDWHUOHYHOUHDGLQJVWHVWHG" :HUHDOOSUREHVUHLQVWDOOHGSURSHUO\" :HUHDOOLWHPVRQWKHHTXLSPHQWPDQXIDFWXUHU¶VPDLQWHQDQFHFKHFNOLVWFRPSOHWHG" For any answer of “N” above, describe in Section XI how and when these deficiencies were or will be corrected. ;, &200(176 *3+ *DOORQV3HU+RXU< <HV1 1R1$ 1RW$SSOLFDEOH93+ 9DFXXP3UHVVXUH+\GURVWDWLF,' ,GHQWLILFDWLRQ 81 ZZZXQLGRFVRUJ5HY 81'(5*5281'6725$*(7$1. 021,725,1*6<67(0&(57,),&$7,21)250 3DJHRI  ;,, /,1(/($.'(7(&7257(67,1* &KHFNWKLVER[LIOLQHOHDNGHWHFWRUV //' DUH127LQVWDOOHG(Do not complete this section.)<11$This section must be completed if LLDs are installed. :DVDOHDNVLPXODWHGWRYHULI\//'SHUIRUPDQFH" (Check all that apply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¶VPDLQWHQDQFHFKHFNOLVWFRPSOHWHG" :HUHDOO//'VFRQILUPHGRSHUDWLRQDOZLWKLQUHJXODWRU\UHTXLUHPHQWV" For any answer of “N” above, describe in Section XIII how and when these issues were or will be corrected. ;,,, &200(176 ;,9 9$&88035(6685(+<'5267$7,&021,725,1*(48,30(177(67,1* &KHFNWKLVER[LI93+PRQLWRULQJLV127XVHG(Do not complete this section.) This section must be completed if VPH monitoring is used to perform leak detection monitoring. 6\VWHP7\SH 0DUNDOOWKDWDSSO\ 9DFXXP3UHVVXUH+\GURVWDWLF 6HQVRU,'&RPSRQHQW 6 0RQLWRUHG%\7KLV6HQVRU 6HQVRU)XQFWLRQDOLW\ 7HVW ,QWHUVWLWLDO&RPPXQLFDWLRQ 7HVW 3DVV )DLO 3DVV )DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO 3DVV)DLO3DVV)DLO +RZZDVLQWHUVWLWLDOFRPPXQLFDWLRQYHULILHG"6LPXODWHG/HDNDW)DU(QGVRIWKH,QWHUVWLWLDO6SDFH9LVXDO,QVSHFWLRQ 2WKHU(Describe the method in section XV below.)*DXJH :DVWKHYDFXXPRUSUHVVXUHUHVWRUHGWRRSHUDWLQJOHYHOVLQDOOLQWHUVWLWLDOVSDFHV"<HV1R(Describe the reason in section XV below.) For any answer of “Fail” above, describe in Section XV how and when these issues were or will be corrected. ;9 &200(176 &(56 &DOLIRUQLD(QYLURQPHQWDO5HSRUWLQJ6\VWHP,' ,GHQWLILFDWLRQ867 8QGHUJURXQG6WRUDJH7DQN,&& ,QWHUQDWLRQDO&RGH&RXQFLO 81 ZZZXQLGRFVRUJ5HY 81'(5*5281'6725$*(7$1. 63,//&217$,1(57(67,1*5(3257)250 3DJHRI  7\SHRI$FWLRQ,QVWDOODWLRQ7HVW5HSDLU7HVW0RQWK7HVW , )$&,/,7<,1)250$7,21 &(56,''DWHRI6SLOO&RQWDLQHU7HVW %XVLQHVV1DPH(Same as Facility Name or DBA-Doing Business As) %XVLQHVV6LWH$GGUHVV &LW\ =,3&RGH ,, 81'(5*5281'6725$*(7$1.6(59,&(7(&+1,&,$1,1)250$7,21 1DPHRI8676HUYLFH7HFKQLFLDQ3HUIRUPLQJWKH7HVW(Print as shown on the ICC Certification.) 3KRQH &RQWUDFWRU7DQN7HVWHU/LFHQVH ,&&&HUWLILFDWLRQ ,&&&HUWLILFDWLRQ([SLUDWLRQ'DWH 6SLOO&RQWDLQHU7HVWLQJ7UDLQLQJDQG&HUWLILFDWLRQV(List applicable certifications.) ,,, 63,//&217$,1(57(67,1*,1)250$7,21 7HVW0HWKRG8VHG0DQXIDFWXUHU*XLGHOLQHV(Specify) ,QGXVWU\&RGHRU(QJLQHHULQJ6WDQGDUG (Specify) (QJLQHHUHG0HWKRG(Specify) Attach the testing procedures and all documentation required to determine the results.RI$WWDFKHG3DJHV 7$1.,'(By tank number, stored product, etc.) 6SLOO&RQWDLQHU0DQXIDFWXUHU 0HWKRGRI&DWKRGLF3URWHFWLRQ1RQ0HWDOOLF1RQ0HWDOOLF1RQ0HWDOOLF1RQ0HWDOOLF ,VRODWLRQ,VRODWLRQ,VRODWLRQ,VRODWLRQ 2WKHU(Specify in V.)2WKHU(Specify in V.)2WKHU(Specify in V.)2WKHU(Specify in V.) ,QVLGH'LDPHWHURI6SLOO&RQWDLQHU(Inches) 'HSWKRI6SLOO&RQWDLQHU(Inches) 'RHVWKHVSLOOFRQWDLQHUKDYHDJDOORQFDSDFLW\"<HV1R<HV1R<HV1R<HV1R 0HWKRGWR.HHS6SLOO&RQWDLQHU(PSW\'UDLQ9DOYH'UDLQ9DOYH'UDLQ9DOYH'UDLQ9DOYH 2QVLWH3XPS2QVLWH3XPS2QVLWH3XPS2QVLWH3XPS 2WKHU(Specify in V.)2WKHU(Specify in V.)2WKHU(Specify in V.)2WKHU(Specify in V.) ,9 6800$5<2)7(67,1*5(68/76 6SLOO&RQWDLQHU7HVW5HVXOWV3DVV)DLO3DVV)DLO3DVV)DLO3DVV)DLO 9 &200(176 Any items marked “Fail” above must be explained in this section. Any additional comments may also be provided here. 9, &(57,),&$7,21%<8676(59,&(7(&+1,&,$1&21'8&7,1*7+,67(67,1* ,KHUHE\FHUWLI\WKDWWKHVSLOOFRQWDLQHUVZHUHWHVWHGLQDFFRUGDQFHZLWK&DOLIRUQLD&RGHRI5HJXODWLRQV7LWOH'LYLVLRQ &KDSWHU6HFWLRQDQGDOOWKHLQIRUPDWLRQFRQWDLQHGKHUHLQLVDFFXUDWH 8676HUYLFH7HFKQLFLDQ6LJQDWXUH If the facility has more components than this form accommodates, additional copies of this page may be attached. Bakersfield 93313 804904 8485827 9/14/2020 OPW 0148613 PEI 1200 1 T1 fill OPW 11.00” 13.00” T1 vapor OPW 11.00” 13.00” Aaron Perrigo (800) 339-9930 10172773 2/21/2019 Bill Wright Toyota 5100 Gasoline Alley Drive SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Date of Testing: Facility Address: Facility Contact: Phone: Date Local Agency Was Notified of Testing : Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Technician Conducting Test: Credentials1: CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) __________________ License Number(s): 3. SPILL BUCKET TESTING INFORMATION Test Method Used: Hydrostatic Vacuum Other Test Equipment Used: Equipment Resolution: Identify Spill Bucket (By Tank Number, Stored Product, etc.) 1234 Bucket Installation Type: Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Direct Bury Contained in Sump Bucket Diameter: Bucket Depth: Wait time between applying vacuum/water and start of test: Test Start Time (TI): Initial Reading (RI): Test End Time (TF): Final Reading (RF): Test Duration (TF –TI): Change in Reading (RF -RI): Pass/Fail Threshold or Criteria: Test Result: Pass Fail Pass Fail Pass Fail Pass Fail Comments –(include information on repairs made prior to testing, and recommended follow-up for failed 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:_________________________ 1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. Bill Wright Toyota 2/21/2019 5100 Gasoline Alley Drive Bakersfield 93313 Summer Hankins (661) 398-8697 1/31/2019 Kris Karns Confidence UST Services, Inc. Aaron Perrigo 804904 8485827 Lake Test 0.0625” T1 fill T1 vapor 11.00” 11.00” 13.00” 13.00” 5 min 5 min 9:00am 9:00am 12.25” 12.25” 10:00am 10:00am 12.25” 12.25” 1 hr 1 hr 0.00” 0.00” 0.0625” 0.0625” 2/21/2019 ✔✔ ✔ ✔✔ ✔✔