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Dec. 6. 2004 1:53PM lVl'West Star Environmenta1, Inc. \..;~Kl1.rl\.J1\lNo. 6599 P. 3
For Uae By Åll Jurisdictions Within the State of California
Authority Cite& Chapter 67, Health and Safety Code: Chapler 16. Division 3, Title 23, California Code of Regulal;l)1!.t
This form mnsr be used to document testing and servicing ofmonitorillg eq~i.pmenl A s_rate certification or reDOrt must be u.....-red
for eacb moni~ng system control panel by the tec1miçian who performs the worlt. A copy of this fonn mGSt be provided to tbe tank
system owner/operator. The owner/operator must submit a copy oftbis form to the local ageucy regulating UST systems within30
days of test date.
A. General Information
Facility Name: QUlK SHOP MINI MART
Site Address: 349 UNION A VB. BAKERSFIELD. CA 93307
Facility CœdzK:t Penon: BILLY
MakeIModel of Monitoring System: EBW AUTO STICK JR.
B. Inventory of EquiplØeøt Tested/Certified
Cbeek tbe approprbde MUll to IDdlate IpecUle eqalpmellt IDJ
iak ID- UNLEADED TapID- MID
In. Tan aU31ng Pro c. Model: [¡fJn- Tank Gauging Probe. ~~l:. +l./
Amiular. Space or Vault Sensor. Model. I:ÝftMular Space or Vault Sensor. IY.......__
Piping Sump I Trench Sensor(s). MQC;)eI; I7PipiDg Sump / Trem:b Seuor(s). Model:
[] Fill Sump 8ensor(s). Model: C Fill Sump Sensor(s). Model:
~echllniCll1 Line Leak DetectQr. Model: [] Mechanical Line Leak Detector. Model:
ectfonic Line Leak Deœçtor. Model: 00 [J Jñectronic Line Leak Dctcc:t.or. Model:
Tank Overfill/ Higb-Le\'el Sensor. Model: F/I!/IP(J/ [J'Tank Overfill I Hish-Level Sensor. Model: ~~......
[j Other . ui o.t and model in Sec;tj0J} E on 2 e Otbef . . em III1d model in Sedion E on
fSkID' Ta.k 1D:
T8DIë{¡augiDgl'iOhe. ModcJ: EBi;'; [J In-Tauk GaugiDg Probe. Model:
. Space or Vault Sensor. Modø~ / D Annular Space or Vault SCnsor. Model:
Piping Sump I Trench SeDsor(s). Modet; I 0 Piping Sump I Tnmeh Sensor(s). Moœl;
[J Pill Sump Seusor(s). Model: [] Fill S\II11P Sensor(s). Model:
o Mecbanical Line Leak Detector. Model: D Mechanical Line Leak Detector. Model:
[J,E1ectronic LiDc Leak Detector. Model: [] ElcctroDic LiDe Leak Detector. Model:
ø Tank Overtlll/High-Level Sensor. Model: ~A4'./ e Tank Ovccrflll/ High-Levcl Sensor. Model:
[] Other . . ment and model in Section E on Fa 2. e Other i . em t and model in SeCtÏórJ E on
D~euer 1»: 1&2 E ID- ~
lZfj>ìspenscr ContAinment Sensor(s). Model: .£dt./ ¡spenser ntamment Seosor(s). Model: l/
17 Shear Valve(s). Shear Valve(s). .
[]' ser Containment FJ s and Chain s . D Dis ser Containment PI II BDd Chain s .
Dlspeaier 10. Dispeasel' ID-
e Dispœ\SeT ContainmC!llt Sensor(s). Model: Dispcoser CoDtainmCDt Seo.sor(s). Model:
o Shear Valve(s). Sbear VaJve(s).
Di Containment FI II and Chain II . [] Di ser Contaimnent FI
ispeo.... IJ).. bpeDaer ß). .
Dispenser Containment Seosor(s). Model: Dispenser Containment SCftSOr(s). MOdel:
Shear Valvc(s). Sbear Valve(s).
nser Containmont Float $ and Cham 8 Di enser Containment FI 51 BJld Chain(s .
. Iftbe fadlhy coDtBfDs more tanks or dispensers. copy IhIs form. Include information for every tank and dispenser at the'fàcillty.
C. Certification - I certify that tbe equipmeat identificcJ in this documeotwu baspë'ètëdJñiviieït iD .Uõrdäãëi -';'ith'tbi m~inõiietõñiS"
guideliDes. Attached to thill CettifièatioD i$ informatioll (e.I. manafaetllren' cbeckliJtI) sary to verify tllat tllillaformatioD II
correct Ind a Plot Plan sbowbag the layout of mODltorillg equipmea" For ..7 equipme Ie of lcoeratilll such reports, I have also
attached a eop, oUhe report; (cbøllltl""'''',)l C System set-up L] is ry report
Tcclmician Name (print): JASON ESQUEDA Sianature: --
Certification No.: 39S9 License. No.: 142
Testing Company Name: WEST STAR ENVIRONMENTAL Phone No.: ( SS9 ) ?17...Q~~8
Site Address: 4688 W. JBNN F.RBSNO,CA 93722 Date of Testing/Servicing: .JlJ2!LJ. 04
Bldg. No.:
City: Zip:
CoJJálct Phone No.; ( 661 ) 322-8551
Date ofTestinglServiçiDg: .JlJ 30 I 04_
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2.
MODÎtoring System Certification
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Dec. 6. 2004u 1:54PMt;lðcWest Star Environmental, Inc.
Software Version lnstaJled:
No. 6599 P. 4
, if icable
B. Comments: 7Lrk/4/1(JJ h/llfrßÆeD .4// /Ãfxl..l
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03101
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Dec. 6. 2004 1 :55PM West Star Env i ronmental, Inc. No. 6599 p, 5
P: 11l-1'ønk Uauging / SIR hqUlpment: C1 Check this box if tank gauging IS USed. on]y tor mventory control.
o Check this box if no tank gauging 01' SIR. equipment is instaUed.
This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring.
faults?
G. Line Leak Detectors (LLD):
o Chec:k this box ifLLDs are not installed.
Com Jete the fol1owin checklist
o Yes 0 0 For equipment start-up or annual equipment certification, was a leak simulated to verify ILD per:fmmance?
o N/A (Check all that apply) Simulated leak rate: [] 3 g.p.h.; 0 O. 1 g.p.h. [] 0.2 g.p.h.
etects a leak?
s, does the turbine automatically shut off ü the LID detects a leak?
any portIon 0 e mOnItormg system IS
e turbine automatically shut off if any portion of the monitoring system malfunctions
H. Commeats:
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03101
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Dec. 6. 2004
1:55PM
West Star Environmental, Inc.
No. 6599
P. 6
Monitoring System CertificatioD
liST Monitoring Site Plan
Site Address: 349 UNION A VB. BAKERSFIELD, CA 93307
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Instruetio.
lfyou already have I diagram that sbows all required information, you may inelude it, rather d= this page, with your
Monitoring System Certification. On your site plan, show the generallayoat or tanks and pipiog. Clearly identify
locatioá$ of the foDowing equipmeBt, ü installed: monitoring system control paDela; HDBon ...oaitoring tank aRDular
spaees, sumps, dispenser paIlS, splu containers, or other seeoudary contammeøt anaSi mecbanieal or electroDic Jirae leak
detectors; and in-tank liquid level probes (ifused for leak detection). In the space provided, note the date this Site Plan
was prepared.
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