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HomeMy WebLinkAboutFMC 8-24-2020Testing and Inspection Certificate Tanknology Inc. 11000 North MoPac Expressway, Suite 500, Austin, TX 78759 800-800-4633 www.tanknology.com Page 1 of 1 Test Date 8/24/2020 Tanknology WO#SC1-3447817 Test Purpose COMPLIANCE Customer PO# Customer Location WALMART/SAM'S CLUB DEPT. 9641 2101 SE Simple Savings Dr. BENTONVILLE, AR 72716 SAM'S CLUB # 4819 (SC4819) 5625 GOSFORD ROAD BAKERSFIELD, CA 93313 Attn: TARA STEGALL Attn: Asset Protection Manager (479) 277-8205 (661) 654-8565 Test / Inspection Description Item Tested Date Tested Result Line Leak Detector (3 GPH) Tank 87 NORTH Line 1 UNLEADED 8/24/2020 Pass Line Leak Detector (3 GPH) Tank 87 SOUTH Line 1 UNLEADED 8/24/2020 Pass Line Leak Detector (3 GPH) Tank T3: 91 Line 1 PREMIUM 8/24/2020 Pass Line Leak Detector (3 GPH) Tank DIESEL Line 1 DIESEL2 8/24/2020 Pass Impact Valve Inspection See test report for details 8/24/2020 Pass Leak Detection Monitoring System Inspection See test report for details 8/24/2020 Pass California Spill Container Report UNLEADED SB 1 - Fill - Direct 8/24/2020 Pass California Spill Container Report UNLEADED SB 1 - Fill - Direct 8/24/2020 Pass California Spill Container Report PREMIUM SB 1 - Fill - Direct 8/24/2020 Pass California Spill Container Report DIESEL2 SB 1 - Fill - Direct 8/24/2020 Pass Spill Containment / Bucket 87 NORTH SB 1 - Fill - Direct 8/24/2020 Pass Spill Containment / Bucket 87 SOUTH SB 1 - Fill - Direct 8/24/2020 Pass Spill Containment / Bucket T3: 91 SB 1 - Fill - Direct 8/24/2020 Pass Spill Containment / Bucket DIESEL SB 1 - Fill - Direct 8/24/2020 Pass Stage 1 Vapor Recovery Survey See test report for details 8/24/2020 Complete Emergency Shut Off Switch Inspection See test report for details 8/24/2020 Pass Tanknology Representative: Mark Lindsey Technician: Jeffrey Crisostomo Telephone: (800) 666-2176 Technician Certification: (See forms) LDT 5000 Field Test Apparatus Line Leak Detector Test Page 1 of 1 Work Order:3447817 Date:8/24/2020 Site Name / ID:SAM'S CLUB # 4819 / SC4819 Address:5625 GOSFORD ROAD City:BAKERSFIELD State:CA Zip:93313 Tank ID Product Product Line Tested From Existing/New Mechanical/Electronic Manufacturer/Model Serial No. Pump Operating Pressure (psi) Calibrated Leak (ml/min) Calibrated Leak (gph) Holding PSI *N/A for Electronic LD's Resiliency (ml) *N/A for Electronic LD's Metering PSI *N/A for Electronic LD's Opening Time (sec) *N/A for Electronic LD's Test Results 87 NORTH UNLEADED 1 2 Existing Mechanical Red Jacket FX1V 307098751 32.00 189.0 3.00 26.00 180.00 12 4 Pass 87 SOUTH UNLEADED 1 8 Existing Mechanical Red Jacket FX1V 307098752 32.00 189.0 3.00 26.00 150.00 12 5 Pass T3: 91 PREMIUM 1 8 Existing Mechanical Vaporless LD-2000 17021315 34.00 189.0 3.00 28.00 145.00 18 4 Pass DIESEL DIESEL2 1 5 Existing Mechanical Red Jacket FX1DV 111136174 34.00 189.0 3.00 30.00 160.00 12 3 Pass Technician Comments: Technician Name:Jeffrey Crisostomo Certification #:91137 Technician Signature:Expire Date:4/2/2022 Environmental Compliance for Petroleum Systems © 2021 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com Impact Valve Inspection Impact Valve Operational Inspection Work Order:3447817 Date:8/24/2020 Site Name/ID:SAM'S CLUB # 4819 Address:5625 GOSFORD ROAD City:BAKERSFIELD State:CA Zip:93313 How Inspected: Line Test NFPA 30A PEI RP1200 Other Dispenser Number Grade Secure Mount? Valve Lock?Pass/ Fail Comments 1/2 87 Pass Fail Not Tested 1/2 91 Pass Fail Not Tested 3/4 87 Pass Fail Not Tested 3/4 91 Pass Fail Not Tested 5/6 40 Pass Fail Not Tested 5/6 87 Pass Fail Not Tested 5/6 91 Pass Fail Not Tested 7/8 87 Pass Fail Not Tested 7/8 91 Pass Fail Not Tested 9/10 87 Pass Fail Not Tested 9/10 91 Pass Fail Not Tested 11/12 40 Pass Fail Not Tested 11/12 87 Pass Fail Not Tested 11/12 91 Pass Fail Not Tested Technician Comments: Technician Name:Jeffrey Crisostomo Signature: Environmental Compliance for Petroleum Systems ©2021 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the USTs within 30 days of the date of the monitoring system certification. I. FACILITY INFORMATION CERS ID 10027021 Date of Monitoring System Certification 8/24/2020 Business Name (Same as Facility Name or DBA-Doing Business As.) SAM'S CLUB # 4819 Building # Business Site Address 5625 GOSFORD ROAD City: BAKERSFIELD Zip: 93313 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification TANKNOLOGY INC. Phone # (800) 800-4633 Ext. Mailing Address 11000 N. Mopac Expressway #500, Austin, TX 78759 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) Jeffrey Crisostomo Contractor/Tank Tester License # Class A General Engineering 743160 ICC Certification # 8199847 ICC Certification Expiration Date 4/22/2021 Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date Tanknology Certification Level III ATG Operability Training Certification Exam 91135 07/11/2022 ICC CA UST Service Technician 8199847 04/22/2021 III. RESULTS OF TESTING/SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Monitoring System Set-up Alarm History Report Y N NA Was any monitoring equipment replaced? (If "Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Was damage, debris, or liquid found inside any secondary containment systems? (If "Yes," describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? (If "No," describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. Programmed s9: no vac alarm and high liquid to positive shutdown. Pump out H20 on diesel stp and 87 t2 fill sump, total of half gallon. V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2638 and all information contained herein is true and accurate. Attached to this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature CERS=California Environmental Reporting System, ID=Identification, UST=Underground storage tank, ICC=International Code Council UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI. INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel Veeder Root Model of Monitoring System Control Panel TLS-350 Software Version Installed 333.05 Check the appropriate boxes to indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Tank ID: 87 NORTH Gasoline - Regular (By tank number, stored product, etc.) In-tank Gauging (SW Tank) Annular Space or Vault Sensor 794380-303 VPH Sensor Product Piping Mechanical LLD FX1V Electronic LLD VPH Sensor (Piping) Sump Sensor 794380-208 VPH Sensor (Sump)857280-304 Fill Piping VPH Sensor (Piping) Sump Sensor 794380-208 VPH Sensor (Sump)857280-304 Vent Piping VPH Sensor (Piping) Sump Sensor VPH Sensor (Sump) Vapor Recovery Piping VPH Sensor (Piping) Sump Sensor VPH Sensor (Sump) Monitoring Device Used Device Model # Tank ID: T3: 91 Gasoline - Premium (By tank number, stored product, etc.) In-tank Gauging (SW Tank) Annular Space or Vault Sensor 794380-303 VPH Sensor Product Piping Mechanical LLD LD2000 Electronic LLD VPH Sensor (Piping) Sump Sensor 794380-208 VPH Sensor (Sump)857280-304 Fill Piping VPH Sensor (Piping) Sump Sensor 794380-208 VPH Sensor (Sump)857280-304 Vent Piping VPH Sensor (Piping) Sump Sensor VPH Sensor (Sump) Vapor Recovery Piping VPH Sensor (Piping) Sump Sensor VPH Sensor (Sump) Monitoring Device Used Device Model # Tank ID: 87 SOUTH Gasoline - Regular (By tank number, stored product, etc.) In-tank Gauging (SW Tank) Annular Space or Vault Sensor 794380-303 VPH Sensor Product Piping Mechanical LLD FX1V Electronic LLD VPH Sensor (Piping) Sump Sensor 794380-208 VPH Sensor (Sump)857280-304 Fill Piping VPH Sensor (Piping) Sump Sensor 794380-208 VPH Sensor (Sump)857280-304 Vent Piping VPH Sensor (Piping) Sump Sensor VPH Sensor (Sump) Vapor Recovery Piping VPH Sensor (Piping) Sump Sensor VPH Sensor (Sump) Monitoring Device Used Device Model # Tank ID: DIESEL Diesel (By tank number, stored product, etc.) In-tank Gauging (SW Tank) Annular Space or Vault Sensor 794380-303 VPH Sensor Product Piping Mechanical LLD FX1V Electronic LLD VPH Sensor (Piping) Sump Sensor 794380-208 VPH Sensor (Sump)857280-304 Fill Piping VPH Sensor (Piping) Sump Sensor 794380-208 VPH Sensor (Sump)857280-304 Vent Piping VPH Sensor (Piping) Sump Sensor VPH Sensor (Sump) Vapor Recovery Piping VPH Sensor (Piping) Sump Sensor VPH Sensor (Sump) CERS=California Environmental Reporting System, ID=Identification, UST=Underground storage tank, ICC=International Code Council UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 3 of 6) Monitoring Device Used Device Model #Monitoring Device Used Device Model # Vent/Transition Sump ID: vent Vent/Transition Sump ID: Sump Sensor 794380-208 Sump Sensor VPH Sensor 857280-304 VPH Sensor UDC ID: 1/2 Electronic Sensor 794380-208 Mechanical Device VPH Sensor 846391-304 UDC ID: 5/6 Electronic Sensor 794380-208 Mechanical Device VPH Sensor 846391-304 UDC ID: 9/10 Electronic Sensor 794380-208 Mechanical Device VPH Sensor 846391-304 UDC ID: 3/4 Electronic Sensor 794380-208 Mechanical Device VPH Sensor 846391-304 UDC ID: 7/8 Electronic Sensor 794380-208 Mechanical Device VPH Sensor 846391-304 UDC ID: 11/12 Electronic Sensor 794380-208 Mechanical Device VPH Sensor 846391-304 UDC ID: Electronic Sensor Mechanical Device VPH Sensor UDC ID: Electronic Sensor Mechanical Device VPH Sensor Other Monitored Component ID: Other Monitored Component ID: Other(Specify in section VII) Other(Specify in section VII) Other Monitored Component ID: Other Monitored Component ID: Other(Specify in section VII) Other(Specify in section VII) Other Monitored Component ID: Other Monitored Component ID: Other(Specify in section VII) Other(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, additoinal copies of these pages may be attached. VII. COMMENTS Use this section to provide any additional comments about the inventory of the equipment certified. CERS=California Environmental Reporting System, ID=Identification, UST=Underground storage tank, ICC=International Code Council UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 4 of 6) VIII. MONITORING SYSTEM AND PROGRAMMING This section must be completed if a monitoring panel is used to perform leak detection monitoring.Y N NA Are the visual and audible alarms operational? Were all sensors visually inspected for kinks and breaks in the cables and for residual buildup to ensure that floats move freely, functionally tested, and confirmed operational? Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? Was monitoring system set-up reviewed to ensure proper settings? Was the monitoring panel's backup battery visually inspected, functionally tested, and confirmed operational? Does the flow of fuel stop at the dispenser if a leak is detected in the under-dispenser containment? Does the turbine automatically shut down if the piping secondary containment monitoring system fails to operate or is electrically disconnected? Does the turbine automatically shut down if the piping secondary containment monitoring system detects a leak? Which sensors initiate positive shut down? (Check all that apply.) Sump Under-dispenser containment If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational? For any answer of "N" above, describe in section IX how and when these deficiencies were or will be corrected. IX. COMMENTS Use this section to provide any additional comments about the inventory of the equipment certified. X. IN-TANK GAUGING TESTING Check this box if tank gauging is used only for inventory control. (Do not complete this section.) Check this box if NO tank gauging equipment is installed. (Do not complete this section.) This section must be completed if in-tank gauging is used to perform leak detection monitoring. Y N NA Has all input wiring been inspected for kinks and breaks in the cables and for proper entry and termination, including testing for ground faults? Were all in-tank gauging probes visually inspected for damage and residue buildup to ensure that floats move freely, functionally tested, and confirmed operational? Was accuracy of system's product level readings tested? Was accuracy of system's water level readings tested? Were all probes reinstalled properly? Were all items on the equipment manufacturer's maintenance checklist completed? For any answer of "N" above, describe in section XI how and when these deficiencies were or will be corrected. XI. COMMENTS Use this section to provide any additional comments about the inventory of the equipment certified. Y = Yes, N = No, NA = Not Applicable UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) XVI. LINE LEAK DETECTOR TESTING Check this box if line leak detectors (LLD) are NOT installed. (Do not complete this section.) This section must be completed if LLDs are installed.Y N NA Was a leak simulated to verify LLD performance? (Check all that apply.) Simulated leak rate verified: 3 GPH 1.1 GPH 0.2 GPH Was the testing apparatus properly calibrated? For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? For electronic LLDs, does the turbine automatically shut off when a leak is detected? For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? Were all items on the equipment manufacturer's maintenance checklist completed? Were all LLDs confirmed operational within regulatory requirements? For any answer of "N" above, describe in section XIII how and when these issues were or will be corrected. XIII. COMMENTS XIV. VACUUM / PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING Check this box if VPH monitoring is NOT used. (Do not complete this section.) This section must be completed if VPH monitoring is used to perform leak detection monitoring. System Type (Mark all that apply.) Vacuum Pressure Hydrostatic Sensor ID Component(s) Monitored by this Sensor Sensor Functionality Test Interstitial Communication Test s1 87n prod Pass Fail Pass Fail s2 87 n vent Pass Fail Pass Fail s3 87 s prod Pass Fail Pass Fail s4 87 s vent Pass Fail Pass Fail s5 87 s vapor return Pass Fail Pass Fail s6 91 prod s Pass Fail Pass Fail s7 91 prod n Pass Fail Pass Fail s8 91 vent Pass Fail Pass Fail s9 91 vent box Pass Fail Pass Fail s10 diesel prod Pass Fail Pass Fail s11 diesel vent Pass Fail Pass Fail Pass Fail Pass Fail How was interstitial communication verified? Simulated leak at far ends of the interstitial space. Other (Describe the method in section XV below.) Visual Inspection Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? Yes No (Describe the reason in section XV below.) For any answer of "N" above, describe in section XIII how and when these issues were or will be corrected. XV. COMMENTS GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 6 of 6) XVI. MONITORING SITE PLAN Date site map was prepared: If you already have a site plan that shows all required information, you may include it, rather than this page, with your Monitoring System Certification Form. The site plan must show the general layout of tanks and piping and clearly identify locations of the following equipment, if installed: 1) monitoring system control panels; 2) in-tank liquid level probes (if used for leak detection); 3) devices monitoring tank annular spaces or vault; 4) devices monitoring product piping; 5) devices monitoring fill piping; 6) devices monitoring vent piping; 7) devices monitoring vapor recovery piping; 8) devices monitoring vent/transition sumps; 9) devices monitoring under-dispenser containment; 10) line leak detectors; and 11) devices monitoring any other secondary containment areas. UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) Type of Action Installation Test Repair Test 12 Month Test I. FACILITY INFORMATION CERS ID 10027021 Date of Spill Container Test: 8/24/2020 Business Name (Same as Facility Name or DBA-Doing Business As.) SAM'S CLUB # 4819 Business Site Address 5625 GOSFORD ROAD City: BAKERSFIELD Zip: 93313 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Jeffrey Crisostomo Phone # (800) 800-4633 Contractor/Tank Tester License # Class A General Engineering 743160 ICC Certification # 8199847 ICC Certification Expiration Date 4/22/2021 Spill Container Testing Training and Certifications (List applicable certifications.) ICC - CA UST Service Technician 8199847 04/22/2021 III. SPILL CONTAINER TESTING INFORMATION Test Method Used: Manufacturer Guidelines: (Specify) Industry Code or Engineering Standard: (Specify) PEI RP 1200 Engineered Method: (Specify) Attach the testing procedures and all documentation required to determine the results. # of Attached Pages Tank ID: (By tank number, stored product, etc.) Spill Container Manufacturer: Method of Cathodic Protection Inside Diameter of Spill Container: (Inches) Depth of Spill Container: (Inches) Does the spill container have a 5 gallon capacity? Method to Keep Spill Container Empty IV. Spill Container Test Results Fill 87 NORTH UNLEADED OPW Non-Metallic Isolation Other (Specify in section V) 12 16 Yes No Drain Valve Onsite Pump Other (Specify in section V) Fill 87 SOUTH UNLEADED OPW Non-Metallic Isolation Other (Specify in section V) 12 16 Yes No Drain Valve Onsite Pump Other (Specify in section V) Fill T3: 91 PREMIUM OPW Non-Metallic Isolation Other (Specify in section V) 12 16 Yes No Drain Valve Onsite Pump Other (Specify in section V) Fill DIESEL DIESEL2 OPW Non-Metallic Isolation Other (Specify in section V) 12 16 Yes No Drain Valve Onsite Pump Other (Specify in section V) SUMMARY OF TESTING RESULTS Pass Fail Pass Fail Pass Fail Pass Fail V. COMMENTS All items marked failed above must be explained in this section. Any additional comments may also be provided here. Per inspector Peter Armogost 5gal of water is okay. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.1 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS=California Environmental Reporting System, ID=Identification, UST=Underground storage tank, ICC=International Code Council 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: SAM'S CLUB # 4819 Date of Testing: 8/24/2020 Facility Address: 5625 GOSFORD ROAD , BAKERSFIELD, CA 93313 Facility Contact: Asset Protection Manager Phone: 661-654-8565 Date Local Agency Was Notified of Testing: 2/4/2020 Name of Local Agency Inspector (if present during testing): Bakerfield Fire inspector 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY INC. Technician Conducting Test: Jeffrey Crisostomo Credentials1: CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify) License Number(s): 743160-8199847 3. SPILL BUCKET TESTING INFORMATION Test Method Used By: Hydrostatic Vacuum Other Test Equipment Used: LAKE TEST Equipment Resolution: 0.0625 in. Identify Spill Bucket (By Tank Number, Stored Product, etc.) Bucket Installation Type: 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: Spill Box # Tank 87 NORTH UNLEADED - Fill 1 - Direct - Grade level in containment sump Direct Bury Contained in Sump 12.00 16.00 15 min 10:05:00 10.37 in. H20 11:05:00 10.37 in. H20 1 hr 0.00 in. H20 +/- 0.00 Pass Spill Box # Tank 87 SOUTH UNLEADED - Fill 1 - Direct - Grade level in containment sump Direct Bury Contained in Sump 12.00 16.00 15 min 10:05:00 10.77 in. H20 11:05:00 10.77 in. H20 1 hr 0.00 in. H20 +/- 0.00 Pass Spill Box # Tank T3: 91 PREMIUM - Fill 1 - Direct - Grade level in containment sump Direct Bury Contained in Sump 12.00 16.00 15 min 10:05:00 10.12 in. H20 11:05:00 10.12 in. H20 1 hr 0.00 in. H20 +/- 0.00 Pass Spill Box # Tank DIESEL DIESEL2 - Fill 1 - Direct - Grade level in containment sump Direct Bury Contained in Sump 12.00 16.00 15 min 10:05:00 10.77 in. H20 11:05:00 10.77 in. H20 1 hr 0.00 in. H20 +/- 0.00 Pass 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:8/24/2020 1State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. WO: 3447817 Per inspector peter Armogost 5gal of water is okay. Stage I Vapor System Survey Survey to determine compliance with Requirements of Title 40 Part 63 National Emission Standards for Hazardous Air Pollutants for Source Categories Survey Date 8/24/2020 Work Order 3447817 Cust Name / Location Number SC4819 Street Address 5625 GOSFORD ROAD City, State, ZipCode BAKERSFIELD CA 93313 Product Stage I Type Drop Tubes Type Drop Tubes Max inches from tank Bottom Fill Adapters Type Vapor Adapters Type NESHAP Work Required? Vent Caps Type Labeled Positive Cracking Pressure Labeled Negative Cracking Pressure 87 NORTH UNLEADED Dual Point Straight 5.00 Swivel Swivel (poppet) No 87 NORTH 1 Pressure Vacuum cap 2.5 - 6.0 6-10 87 SOUTH UNLEADED Dual Point Straight 5.00 Swivel Swivel (poppet) No 87 SOUTH 2 T3: 91 PREMIUM Dual Point Straight 5.00 Swivel Swivel (poppet) No 91 DIESEL DIESEL2 Dual Point Straight 5.00 Swivel No Describe Work Required Vents are manifolded. Surveyed by Signature Sam's Club Emergency Stop (E-Stop / ESO) Periodic Inspection Facility Information Technician Information Site #: SC4819 Date: 8/24/2020 Address: 5625 GOSFORD ROAD Name: Jeffrey Crisostomo City / State: BAKERSFIELD CA Technician Signature: SITE DATA 1 Number of E-Stop switches INSIDE the building: 0 2 Number of E-Stop switches OUTSIDE the building: 2 3 Call Alarm Central at 479-273-4600 a.Press 1 for Alarm Central b.Then press 4 for Technician c.Tell the operator you want the Sam's Club / Wal-Mart Gas Station account for club membership SC4819 put on test. d.They will ask for a password which is: 9350. e.Record the Alarm Central persons name and the time that you spoke to them(Pre Alarm) 09:00:00 PERFORMANCE DATA Yes No NA 4 You have added or confirmed that all E-Stop locations are on the Site Diagram 5 Do all E-Stops shutdown power to ALL DISPENSERS 6 Do all E-Stops shutdown power to ALL STP's 7 Are ALL E-Stops clearly Labeled 8 Are the TURBINE BREAKERS clearly identified / labeled POST TEST 9 All equipment secured and any access ports, lids, enclosures are closed. 10 All safety barricades and test equipment has been properly removed 11 E-Stop was reset and all dispensing functions are normal 12 Call Alarm Central at 479-273-4600 a.Ask if Alarm was Received and if Yes, advise that testing is complete b.Record the Alarm Central persons name and the time that you spoke to them(Post Alarm) E-Stop Inspection Results PASS FAIL INCONCLUSIVE Comments WO: 3447817 Site Diagram (This site diagram is for reference only and is not drawn to scale) Work Order:3447817 Site ID / Name:SC4819 / SAM'S CLUB # 4819 Address:5625 GOSFORD ROAD City:BAKERSFIELD State:CA Zip:93313 W.O.# SC1-3447817 Ovf W.O.# SC1-3447817 Vr Test Duration Test Pressure P/F Threshold Tank Annular - Vacuum 1 hr, 20k or less tank 10" hg 0 loss, int dry before and after test Tank Annular - Vacuum 2 hr, >20k tank 10" hg 0 loss, int dry before and after test Line Annular - Pressure 1 hr 5 psi 0 loss STP Sump - Hydro 1 hr 4" above highest penetration or sidewall seam less than 1/8" over hour, settle time of 15 minutes minimum prior to starting the test UDC Sump - Hydro 1 hr 4" above highest penetration or sidewall seam less than 1/8" over hour, settle time of 15 minutes minimum prior to starting the test Spill Bucket - SW Vac 1 min 30" wc no greater than 4" wc vaccum decay - bucket must be dry Spill Bucket - SW Hydro 1 hr within 1.5" of top of the bucket less than 1/8" over hour, settle time of 5 minutest minimum prior to starting the test Spill Bucket - DW Vac 1 min 15" wc no greater than 3" wc vaccum decay - int must be dry