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HomeMy WebLinkAboutUNDERGROUND STORAGE TANK #1~'-r~ b57 `t b..~' ~~ ~ ~~ MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Aut{:ority Cite& 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 se arate certification or report mast be prepare for teach 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 test date. A. General Information Facilily Name: ~~~_fjZt~S l~~~~ StOz Bldg. No.: . Site Address: '~~4U ~a ~~~ ~ City: ~~~~~A Zip: ~d~ Facility Contact Person: Contact Phone No.: (____-_~} Make/Model of Monitoring System: ~LL {mss ~'iet,C' Date of Testing/Servicing: ~l r~l~ T3. Inventory of Ilquipment Tested/Certified INSPBCTQR ON-SITEQE NO NAME: Check the annronriate hnxes to indicate specific eouiomenl inspected/serviced: "hank ID: ~~ ~ Tank lD,:~~~=,~~C( In-Tank Gauging Prnbe. Model: "( In-Tank Gauging Probe. Model: ~,~~~~ Annular Space or Vault Sensor. Model: 2Ca Annular Space or Vault Sensor. Model: ~~~p Piping Sump /Trench Sensor(s). Model: ,~ $ Piping Sump /Trench Sensor(s). Model: ~~ 1 7~ Fill Sump Sensor(s). Model' ~o~ Fill Sump Sensor(s). Model: ~'~_ Mechanical Line Leak Detector. Modei: ~`F V) ~bMechanical Line Leak Detector. Modal: r}C U t __- L{ Electronic Line Leak' Detector. Model: (] Electronic Line Leak Detector, Model: ^ 'l'ank Overfill / 1-ligh-Levei Sensor. Model: ^ Tank Overfill/High-Level Sensor. Model: ^ Other (s ecif e ui ment t e and mode! in Section L on Pa e 2 . ^ Other (s ecify e ui ment pe and model in Section E on Pa e 2). Tank [D: ~ ,() ~ ~~ ~~ Tank [A: Q~~°~r' _ In-Tank Gauging Probe. Model: ~ ~ __._ QJ In-Tank Gauging Probe. Model: (~( ~r-~ Annular Space or Vault Sensor. Model: 20 Annular Space or Vault Sensor. Model: y7~ ~ P.iping Sump /Trench Sensor(s). Model: 2a~ ~ Piping Sump /Trench Sensor(s). Model: ~~ _ ,K~ Fill Sump Sensor(s). Model: _~z~ ~ Fill Sump Sensor(s). Model: ~.~ Mechanical Line Leak Detector. Model: _.__~~c V 1 Mechanical Line Leak Detector. Model: ~~ fJ~ ^ l;lec[ronic Line Leak Detector. Mudet; p Electronic Line Leak Detector, Model: ^ Tank Overfill /High-Level Sensor. Ntodel: ^ Tank Ovzrfill /High-Level Sensor. Model: O_thcr (specit'y equipment type and model in Section E on Page 2). ^ Other (spocify equipment type and model in Section E on Page 2). Uispenser ID: ~ ~ Z Dispenser ID; ~ ~ l~ Dispenser Containment Sensor(s). Model: _ ~~_ Dispenser Containment Sensor(s). Model: ~i'Zd Shear Valve(s). ~ Shear Valve(s). Dispenser Coni<ainmen[ Floats and Chain s). ^Dis eraser Containment Floats and Chains . ~ Uispenser Ill: 3 7~ U Dispenser ID: i ~ Dispenser Containment Sensor(s). Model: yip ^ Dispenser Containment Sensor(s). Model: ~ Shear Valve(s). ^ Shear Valve(s). D Dispenser Containment Float(s) and Chain(s). r ^Dis eraser Containment Float(s) and Chain(s}. Dispenser 1D: Dispenser ID: Dispenser Containment Sensor(s). ModcL• ^'Dispenser Containment Sensor(s). Model: Shear Valves}• ^ Shear Valve(s). )Dispenser Containment Float(s) and Chain(s). ^Dis enszr Containment Floats and Chain s). If the facrltry contains morn tanks or dispensers, copy this form. Include information for every tant< and dispenser at the facility C;. C:et-tlflCcgtlOri - I certify that the equipment identitied itt this document ryas inspected/serviced in accordance with the manufacturers' I;uidelines. Attached to this Certtficatiort is information (e.g. manufacturers' chec!<lists) necessary to verify that this Information !s correct and a Plot Plan sho+ving the layout of monitoring equipment: For any equlpment capable of generating such reports, I have also attached a copy of the report; (chec/c a!! that apply): System set-up f$At m histo port "I echnician Narne (print): ~,[~~~- ~` ~tG~~ Signature: Certification No.: _-_~~_~(p 3j°~'~ L,icensz. r~ ~ / '~ "t'esting Company Natne: RICH ENVIRONMENTAL Phone No.: ~ E" ~ ____~ 39~-86$7 Site,~ddress:~~bo C-o~~,fr",I,G't L~-,~~ l~(C~~i.~~N Date of Testing/Servicing. TJ j/~iO~ Page 1 of 3 03101 Nlonitoring System Certification D. Results of Testing/Servicing Software Version installed; ('nrnnlrtP the rnllnwina rherkli.ct: Yes D o Is the audible alarm o erational? Yes O o [s the visual alarm o erational? ~- Ycs ^ o Were all sensors visually inspected, functional) tested, and confin-ned o erational? ~' Yes O o Were all sensors instal led at lowest point of secondary containment and positioned so that other equipment wi I I not interfere with their proper operation? ^ Yes ^ o If alarms are relayed to a remote ttronitoring station, is all communications equipment (e.g. modem) ~' N/A operational? O Yes o For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment O N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? [f yes: which sensors initiate positive shut-down? (Check a!! that apply} ^ SumplTrench Sensors; ^ Dispenser Containment Sensors. Did you confirm positive shut-dog-vn due to leaks and sensor failure/disconnection? ^ Yes; ~fNo. C7 Ycs Oro For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm trigger? es' ^ No Was any monitoring equipment replaced? lfyes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all re lacement arts in Section E, below. ^ es ~[ No Was liquid found inside atay secondary containment systems designed as dry systems? (Check all that apply) O Product; ^ Water, If es, describe causes in Section E, below. - Yes O o Was monitoring s stem set-u reviewed to ensure ro er settin s? Attach set u re orts, if a licable Yes ^ o Is al( monitoring equipment operational per manufacturer's specifications? rn ~ccnon r: uerow, uescnue bow onq when these deficiencies were or will be corrected. E. Comments: ! r~s~G ~Ia,vrc- _~~tu.~t~ ~r~ic-~ ~ 71r2r3 su,w~,~ ~~~r,cjrr~ _ S~ ~ Sow d Lc._ tJ ~ n Po srr r v~ -S~!u-1" 1~v r_l r~_ ~~{~ d ,~, dl Gt Lr4~.~ SFa ~S'drl t~ / K .~N ~.t~ 57' SGt ~t r ~- ~ -qty" ~ ~ !S° ~_ a Sr~.v Sorg- ,_„~ ~ _I____- ~~5,2:- e~9~~'l ~A .u .S~',y so/~- /SL_CI~?~ Pa s~ v ~ SL`r ~ ~ _ __ _ ~,( f,J t~- ~ n ~~ o ~ ~ ~P2'~,~~ ~ C~~((~!~ ~~ L~ ~~ ---p' ~ r1 ~s ~,ti ~ r $~ r n Sri l ti ~~~ o S F7~s~ ~ S'r~ur- AO w,d ~,g r,t < g ~ ~Q ~~~~ r',y ~tt~ o,,V G_~_ - - T 9 SS Page 2 of 3 03101 F. In-Tank Gauging /SIR EquiplzzenY: '"Check this box if tank gauging is used only for inventory control. ^ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. VVIII /IGIG ^ Yes ll, {: IVIIV I ^ o Y III V1+~,. +~.+++• Has all input wiring been inspected for proper entry and termination, including testing for ground faults? O Yes O o Were all tank gauging probes visually inspected for damage and residue buildup? ^ Yes O o Was accuracy of system product level readings tested? ^ Ycs ^ o Was accuracy of system water level readings tested? ^ Yes ^ ~ o Were all probes reinstalled properly? ^ Yes ^ o Were all items on the equipment manufacturer's maintenance checklist completed? ~` In tl,e Section H, below, Qescrtue now ;uut wuen tnese aenclencles were ar wu, ue currec,eu. G. Line Leak DeteetorS (LLD): CI Check this box if LLDs are not installed ("nmr~lntn thn fnllnwino rhnnklict' Yes O Noy For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ^ N/A (Check all ghat up/ply) Simulated leak rate: ~; g.p.h., ^ 0. 1 g.p.h , O 0.2 g.p.h. ^ Yes o Were all LLDs col firmed operational and accurate within regulatory requirements? Yes ^ o Was the testing apparatus properly calibrated? Yes ^ o For mechanical LLDs, does the LLD restrict product flow if it detects a leak? O N/A ^ Yes ^ o For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ~N/A O Yes ^ o For electronic LLDs does the turbine automatically shut offif any portion of the monitoring system is disabled N/A , or disconnected? ^Ycs ^ o -For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions N/A or fails a test? ^Ycs ^ o For electronic LLDs, have all accessible wiring connections been visually inspected? N/A '~ Yes ^ o Were all items on the equipment manufacturer's maintenance checklist completed? ,u we JCCUU,I i'1, Ul',gN', UCSG'lUC ,IUW xuu when rnese aenc,enc,es were or wut oe corrected. H. Comments ; ~7J~' lit ,lj L - ~ ~ .t> n ,a-c~ M~ c ~ ,c f ,~-~ ,c ~,,r2~~~-~! ,~ ~-~~,~ Page 3 of 3 03101 Monitorltig System Certitcation R'orm: Addendum for VacuttnilPressure Interstitlal Sensors LG 163-1, Enc. F Y, Results of'Vacuwm/PressureMonitoring EgllipmentTesting ~ ' This page should be used to document testing and servicing of vacuum and plessure interstitial sensors. A copy of this form must be included with the Monitoring System Certification Form, which must be•~provided to the tank system owner/operator. The owi-er~operator must submit a copy of the Monitoring Systan Certification Form to the local agency regulating UST .systems within 30 days of test date. • Manufacturer: Model; System Type; Pressure; ~ Vacuum Sensor 1D Component(s) Monitored by this Sensor: j • Sensor Functionality Test Result; II Pass; ^ Fail Interstitial Communication Test Result: n Pass; II Fail Compoz;ent(c) Monitored by this Sensor:• Sensor Functionality Test Result: ^ Pass; ~ ^ Far] Interstitial Communication Test Result: ^ Pass; ^ Fail • Component(s)Monitored by this Sensor: Sensor Functionality Test Result: ^ Pass; ^ Fail IntczstitisI Communication Test Result: ^ Pass; ^ Fail Component(s) Monitored by this Sensor: SensorFtuicdonality Test Result: ^ Pass; ^ Fail Tntcrstitial Cpinmu1iication TestRcsult: ^ Pass; ^~ Fail 'Component{s) Monitored by this Sensor: Sensor Functionality Test Result: ^ Pass; ^ Fail Interstitial Communication Test Result: ^ Pass; j] Fail Component(s) Monitored by thIr.Senror: • Sensor Functionality Test Result: ^ Pass; ^ Fail Interstitial Communication Test Result: ^ Pass; ^ Fail Component(s) Monitored by•this Sensor: Sensor Functionality Vest Result: ^ Pass; ^ Fail Intersdtial Communication Test Result: ^ Pass; ^ Fail Component(s) Mo~iitored by this Sensor: Sensor Funcaonality Test Result; ,^ Pass; ^ .Fail .Interstitial Cornmunication'TestReault: ^ Pass; ^ Fail Component(s) Monitored by this Sensor: SS~nsot' Functionality Test Result: ^ Pass; ^ Fail Interstitial Commuaicatiori Test Result: ^ Pass; ,^ Fail Component(c) Monitored by this Sensor: ScnsorFuuctionaIity Test Result: ,^ Pass; j~ Fail Interstitial Communication Test Result. j] Pass; ^ Far] How was Interstitial communication verired? ^ Ltiak Introduced atFar End oflnterstitial Space; ^ Gauge; ^ Visual Inspection; .^ Othes (Describe !n Sec. J, below) Vacuum was restored to operating Levels in aII interstitial spacer: ^ Yes ^ No (~fno, describe fn Sec. /, belowf J. Conannents; Page of r ~ If rho sensor successfully detects a simulated. vacuum/pressure leak introduced in the interstitial space, aL the furthest point from the scissor, vacutun/prossure has been demonstrated to be communicating throughout the inttxstice. onitoring System Certification UST Monitoring Site Plan Site Address: >/' '" '"~ '^ ------- -------~---------- --- - ----5~~5-------- ~~ - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - -11 J ----------------- ~- .- - - -_---5'~~FoRs .--- - Date map was drawn: / / In~'~uctions If }you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in-tank liquid Level probes (if used for Leak detection). In the space provided, note the date this Site Plan was prepared. Aage of osioo 563 HRQR~S C~ ~~tSF~~~,D,~.A.983(18 a~'F2c_'~ (661) 32,8687 & ~'.F~C (661) 3A2~0621 ,I P~S'JL~.~?~~~~ i~~~ n~m~rmo~ m~~aT i~_~~; W/4#: Fae:l.2i~y Naame ~~~IZt~S ~~s /3/~1,~ Std ~'a,c;i.la,~y ~.ddx~~ss : y'lDO ~ e%1 ~} -- Prra(~ue~ ,T,i,z~e ~~a~ fPrsas'~ze~ suction, C3ravity) ~R~ssccoQs"' -. PR(:)DVCT LE.~K Iar.TFCTQ~ `.3;'i~,~D ^ TEST ~,'Rx~' P,~~asl S~.Rx.~.z, ~auz~za~~z a~'DC3W ~'&2 OR Nom ~/~ ~~.a~ ~X ~ U ~ x,~s ~ s ~~ g~ ST4~x,A,x~ #.~ bS-G _..~„ 1Q0 l'~~ FA .~ ~ B~2~AL #...~ ..,. G /2 Sr L. x,/n ~~P~ ,~11~.y p~ ~~~ s~~x.~,z. ~~~~ zoo ~3~s ~ FAZZ~ ; Z ;:ertify tl~.e ubo~;F~ tests were conducter.3 on this data aacaxd.irag ~o Rad ~:(ackeC trumps :Field i:est appa.xar_us testing px'ocedure axz limitatiana. xtir~ Mechanical. L,ealc I~Ptectaz 'Cast. pass / fail is determined by using a lo~fr flaw tkxx'esZ~o.ld trzp rate c.~~ 3 ga.l~oxi per hour or leas at. to psz. S .ac)c.n.owledg~ tl~.at t~.].1, da.ta eolleezed is true and porrec~ to the beat of rr4r knowle1d~ge,. szgrLe,tuze: ~ f!/ ~ Date;,/7~ R. d CH' ~2R 0~1TMENTAL ~ 5643 BROOKS CT BAKSRSFZSLD,CA.933Q8 ~ OFFICE(661}392-$687 & FAX (661)392-0621 ~('HAN7C_LL I~EJ~R• DETECTOR TEST W/0#: Facility Name:~~~12,I~S ~f~~7 ~~GC Sr(J~ Facility Address:•_,~~o~~ ~i~~ ,~_ R~~~~~,~SZ/,~~/~-~ Product Line Type (Pressure, Suction, Gravity) fSSGlO~rr~ PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS s~RIAL NvnassR BELOW PSI OR ~VC)RTl~ L/D TYPE ,~~C- ~ U YES PASS (,(~~-$~ ~ SERIAL # ~Ly2,n6c5L7G No l~ ~s~ IL L/D TYPF's YES PASS SERIAL # NO FAIL L/D TYPE YE3 PASS SERIAL # NO FAIL L/D TYPE YSS PASS SERIAL # NO FAIL I certify the above tests were conducted on this date according to Red Jacket Pumps field test apparatus testing procedure an limitations. The Mechanical Leak Detector Teat pass / fail is determined by using a low flow threshold trip rate of 3 gallon per haur or less at lO.PSI. I acknowledge that all data collected is true and correct to the best of my knowledge. ._.--, Tech:~~-=-~ ~ ~/~ Signature : -~'F' ' Date : ( `_ ~ ~'U t~~~ ~ '~~ • swlzc8, Jail Zo~ SpiIl Bucket Testing Report Form ' T'lsisform is tntended for use by contractors perforating annual testing of USTspill containment structures. •The completed form m printoutsfrom.tests (if applicable), should beprovided to thefacilily:otismer/operatorforsubmittal.to the local regulatory agency. • 1. FACILITY Il~ORMA~tON ~~ Facility Name: /~ _ fir` Date o~'Tcstang: - / f7--d Facility Address: C' ~- s'yi- ~-~ Facility Contact: Phone: Date Local Agency Was Notified of Testing : ~, Name of Local Agency Inspector (ifpresent. during testinpJ: 2. TESTING CONTRACTOR INFORMATION .. Company Name: . .Tecbnician Conducting Test: Credentials: CSLB Contractor„ ervice ec . S CB Tank T Other (Sped) License Number{s): /G 3. SPILL BUCKET TESTING INFORMATION T~.er Mnthrvi T 1su•A• v ostatic VSCnum OthCr _ Test Equipment Used: (J ~ ~ Equipmea~ Resolution: // ti Idartify Spill Bucket (ByTartk Number, Stored Product, etc. 1 U N~= $ }? 2 uN~~. 8" ~ 3 ~u - rfl 4 J~l~src- Bucket Installation Type: .Direct Bury Contained in S Direct Bury - Contained in Sum Direct. Bury Contained in Sum Direct Bury Contained in Sum Bucket Diameter: p_ ~ ° /d r' ,? `~ Bucket Depth: ~ ~ / wait time between applying vacuum/watcr and stag of test: ~~~ 1 a/ ~Si~G+- ~3.~ i ~ ~/t!-i Test Start Time (T~: .~: ov % /~ ~ f o o I.a~- Inidal Reading (R~: ~ ~~,~ ~~ o '~ ~ 'i . Test lrnd Tlme (Tp): (, : o.a ~ / ~ G /,r'~ tv ~ Fins! Reading (RP): 9//,z '~ r~ `- / z ~o y Test Duration (T'P - T~: / u Chango in Reading (RP - R~: l _g- ii .~ .r --~ A Pass/Fai1 Threshold or Criteria: ,4 Sf ~PQ 55 ~ sS ~,4 .~ Comments - (utclude information on repairs made prior to testing, and recommended follow-up forlailed tests CERTTF?CATxON OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate; and in fu11 eomplia~ee wlth legal requirements. Technician's Signature: DaxC: ~ --1 ~~.1~ • L I t State laws and regulatio • do not currently require testing to be performed by a qualified contractor. However, local requirements may be more saingent. SYS'I'EP9 SETUP - - - - - JUL 17. 20D7 1:3D PM SYSTEM UNITS u.s. SYSTEM LANGUAGE ENGLISH SYSTEM DATEi'T I N1E FORMA9 MON DD YYYY HH:MM:SS xf HR00};S 1 DI; MARKET 4700 COFFE RD HAKERBFIELD CA.93308 t;61-588-1338 3H [ FT 'T I NIE 1 1 : 00 AI• SHIFT TIME 2 DISABLEI `aHIFT TIh1E 3 DISABLE SHIFT TIME 4 DISABLE ?ERIOD[C TEST WARNINGS. )ISAaL~D ANNUAL TEST WARNINGS )ISABLED >RINT TC VOLUMES :NAHLED 'Ei"1P G`c~1°1P.ENSATION I VALUE (DEG F ?: 60.0 ~YSTEhI SECURITY 'ODE 000000 COh1MUN I GAT IOfVS SETTJP PORT SETTINGS: NONE FOUND RS-232 SECURITY CUDE OOOOUO RS-232 END OF NIESSHGE DISABLED T 2:UNLEADED SOUTH ~ T 3;UNLEADED NORTH 3 PRODUCT CODE THERMAL COEFF :. 000070 PRODUCT CODE THERMAL COEFF :. 000070 TANK DIAMETER 85.75 _ TANK DIAMETER 95.75 1 PT TANK PROFILE FULL VOL 1 pT 10152. TANK PROFILE FULL VOL 10152 ~ FLOAT SIZE: 4.0 IN. 849b I R A LIMIT: WATER IGH H 3.0 N1AX OR LABEL VOL: 10152 OVERFILL LIMIT 050 10 HIGH PRODUCT 99i 1U05U DELIVERY LIMIT p l l LOW PRODUCT : 500 L)~AK ALARM L I M I T: 99 SUDDEN LOSS L[MIT: BQ TANK TILT 0 FLOAT S[ZE: 4.0 IN. 8496 WA'fEk WARNING ~ 2.0 HIGH WATER LIMIT: 3.Q MAX OR LABEL VOL: 109 OVERFILL LIMIT 10050 HIGH PRODUCT 990 10050 DELIVERY LIMIT . 1% 101 LOW PRODUCT : 500 LEAK ALARM LIMIT: `~`~ SUDDEN LOSS LIMIT: 0 70 TANK TILT • MANIFOLDED TANKS T#: NONE I IN-TANK SETUP T 1:DIESEL PRODUCT CODE " MANIFOLDED TANKS THERMAL COEFF :.000041 T1}; NONE TANK DIAMETER 95.7. TANK FROFILE 1 P' FULL VOL 1015 LEAK MIN ANNUAL FLDAT SIZE: 4.0 IN. 849E WATER WARNING 2.G HIGH WATER LIMIT: 3.C' MAX OR LABEL VQL: 1D15i OVERFILL LIMIT 99i 10050 HIGH PRODUCT 99"~ . 1DO~o DELIVERY LIMIT l~s . !01 LOW PRODUCT 5001 LEAK ALARM L I hl I T : 99: SUDDEN LOSS LIMIT: 99. TANK TILT 0.90' MANIFOLDED TANKS T#: NONE LEAK MIN ANNUAL : Io . 101 PERIODIC TEST TYPE CUICK ANNUAL TEST FA1L ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AV1rl2AG I NG : OFF TANK TEST NOTIFY: OFF TNK TST SIPHON FiREAK:OFF DELIVERY DELAY 15 MIN 101 LEAK III N ANNUAL 1 p PERIODIC TEST TYPE p)rRIOUIC TEST TYPE 9UICK BUICK ANNUAL TESALARhiLDISABLED PERIODIC TALARMADISABLED GROSS TESTAFLARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TES7' NOTIFY: DFF TNK TST SIPHON HREAK:OFF.. DELIVERY DELAY !5 MIN ANNUAL TESTALARMIDISABLED PERIOUIC Tp~A}2MADISAbLED GROSS TESTA~ARM D[SABLED ANN TEST AVERAGING: OFF PEk TEST AVERAGING: OFF TANK TEST NOTIFY: OFF T1VK TST S I pNON BREAK :OFF DELIVERY DELAY : 15 h1 I fV T 4:SUPRENIE PRODUCT CODE q THERMAL,COEFF :.000070 TANK D I ANIETER 95 , 75 TANK PROFILE 1 PT FULL VOL 10152 FLOAT SIZE: 4.0 IN. 8496 WATER WARNING 2,0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 10152 OVERFILL L[MIT g9o 10050 HIGH PRODUCT 99f 10080 DELIVERY LIMIT • 101 LOW PRODUCT 500 LEAK ALARM LIMIT: 9g SUDDEN LOSS LIMIT: 99 TANK TILT 2.3U MANIFOLDED TANKS T#: NONE LEAK N1IN ANNUAL li . lal PERIODIC TEST TYPE QUICK ANNUAL TEST FAIL ALARM D I SHELLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM D1SAD° ANN TEST AVERAGING: OFF PER TEST AVERAGING: .:., .. . . ~.. TANK TEaT F T (VK TST S I PHON BREAK :OFF DELIVERY DELAY 15 P1IN LEAK -TEST t~IETNOD `_'' _ . - - TEST ANNUALLY : ALL TAPIK JAN WEEK 1 MON START TIME : DISABLED DURATIONS :0220H0 RSHR LEAK 'LEST REFORTN~RMALT L I QU 1 D SENSOR SETUP ~- -`- L I:REGULAR SOUTH TRI-STATE (SINGLE FLOAT) CATEGORY ANNULAR SPACE L 2:REGULAR SOUTH TRI-STATE (SINGLE FLOAT) CATEGORY : PIPING SUMP L 3:REGULAR aOUTH TRT-STATE (SINGLE FLOAT} CATEGORY : STP SUMP L d:REGULAR NORTH TRI-STATE (SINGLE FLOAT} CATEGORY ANNULAR SPACE L S:REGULAR NORTH TRI-STATE fSIIVGLE FLOAT) CATEGORY( PIPING SUMP (: L 6:REGULAR NORTH TRT-STATE (SINGLE FLOAT) CATEGORY STP SUMP L ?:SUPREME TRI-STATE (SINGLE FLOAT) CATEGORY ANNULAR SPACE L 8 : SUPREME TRI-STATE (SINGLE FLOAT) CATEGORY.: PIPING SUMF L S:SUPREME TRI-STATE (SINGLE FLOAT) CATEGORY STP SUMP L10:DIESEL TRI-STATE (SINGLE FLOAT) CATEGORY ANNULAR SPACE L11:DIESEL TRI-STATE SINGLE FLOAT) CATEGORY PIPING SUMP L12:DIESEL ~~ TRI-STATE (SINGLE FLOAT) CATEGORY STP SUIHP L13:DISPENSER 1-2 TRI-STATE (SINGLE FLOAT) CATEGORY DISPENSER PAN L14:DISPENRER 3-4 TRI-STATE tSINGLE FLOAT? 'CATEGORY DISPENSER PAN L15:DISPENSER 5-6 TRI-STATE (SINGLE FLOAT} CATEGORY DISPENSER PAN L 1 6: D I SPEtVSER 7-8 TRI-STATE (SINGLE FLOAT} CATEGORY DISPEPJSEk PAN OUTPUT XtLHr .5~iur R 1:REGULAR-SOUTH TYPE: STANDARD NORMALLY GLUSED LIQUID SENSOR ALMS L S:FUEL ALARNI L 2:FUEL ALARM L 3: FUEL ALARP'1 R 2:REGULAR NORTH TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS L 4:FUEL ALARM L S:FUEL ALARNI L 6:FUEL ALARM R 3:SUPREI°fE TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOk ALr1S L ?:FUEL ALARM L B:FUEL ALARM L 9:FUEL ALARM R 4:DIESEL TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOK ALMS L 10 : FUEL ALARNI L11:FUEL ALARM L12:FUEL ALARM R S:DISPENSER 1-2 T'1PE STANDARD NQRMALLY CLOSED LIQUID SENSOR ALMS L13:FUEL ALARM R b:DISPENSER 3-4 TYPE: STANDARD NQRMALLY CLOSED LIQUID SENSOR ALMS Ll4:FUEL ALARM R 7:DISF'ENSER 5-6 TYPE: STANDARD cn NORMALLY CLOSED ~- 2~ a LIQUID SENSOR ALMS ¢ L 15 : F UEI. ALARNI v ~ ca ~ R B:DISPENSER 7-S ~~ ¢ ~ a ~' TYPE : • _ STANDARD "wF'2- mau~rx ~', m ~ NORMALLY CLOSED ?~ o ~ ~. z .~ LIQUID SENSOR ALNiS L16:FUEL ALARM yl_H KI'"I Ml:~IVKY Kk!-"VK1 ------- S'1STEN1 ALARM --- -- ?APER OUT JUL 17. 2007 2:26 PM ?RIN1'ER EkROk JUL 17. 2007 '':26 PM 3ATTERY .1S OFF JAN 1. 1996 8:00 At°I ALARM H I STOk'! RE!'ORT --- -- SEPJSOR ALARM ----- 1. b:REGULAR NORTH STP SUh1P FUEL ALARM JUL 17. 2007 1:56 Phl FUEL AI.ARh1 APR 30. 2003 2:08 PN1 FUEL ALARt'~ NOV 20. 2002 10:39 AM ALF~kM H I STORE` REISORT` --• •SENSOR ALARM ----- L ]:REGULAR SOUTH ANNULAR SPACE FUEL ALARM NOV 20, 2002 10:47 AM SENSO~Y2` OUT ALARM JUN 14, 2002 11:52 AM FUEL ALARM DEC 5, 2001 11:39 AM --- --~u~[!-~lS~ ~Lr~ Sum y1 HLARM HISTORY REPORT .. -- SENSOR ALARNI ----- L 2:RECULAR SOUTH I-~'FPd6 SUMP F~ [.,L FUEL ALARM tJOV 20, 2002 10:33 AM FUEI. ALARM JUN 14, 2002 11:23 ANl FUEL ALARM JUN 14, 2002 10:46 AM ALARM HISTORY REPO - ----- SENSOR ALARM •----- L 3:REGULAR SOUTH STP SUMP FUEI. ALARM JUL 17. 2007 2:15 Pi°i FUEL ALARM N1A1' I . 2006 4:03 PM FUEL ALARM APR 30. 2003 3:08 PM ALARM HISTORY REPORT -- SENSOR ALARM ----- L 4:REGULAR NORTH ANNULAR SPACE FUEL ALARM JUL 17. 2007 2:00 PM FUEL ALARM PJOV 20. 2002 10:48 ANI SENSOR 4UT ALARM JUN I4, 2002 10:09 Ahl ALARM HISTORY REPORT ----- SENSOR ALARM ----- L 5:REGULAR NO TH SUMP L...(, FUEL ALARNI JUL 17. 2007 2:01 PM FUEL ALARM NOV 20, 2002 10:40 AM FUEL ALARM JUN 14. 2002 11:40 AM ALARNI HISTORY REPORT _____ SEIJSOR ALARM ----- L 7:SUPRI:ME ANNULAR SPACE FUEL ALARt°I JUL 17, 2007 2:04 PM FUEL ALARM NOV 20, 2002 10:48 AM SENSOR OUT ALARM JUN 14. 2002 9:03 AM LARhI HISTORY REPORT -- SENSOR ALARM ----- L B:SUPREME. ~}~tG SUMP ~'! ~ FUEL ALARM NOV 20. 2002 10:42 AM FUEI. ALARM - "~~-- JUN 14, 2002 11:41 AM FUEL ALARM DEC 5. 2001 11 :44 AI°1 ALARM H[STORY REPORT -- SENSOR ALARM -- L 9:SUPREME STF SUMP FUEL ALARNI JUL 17. 2007 1 :55 PIh FUEL ALARM tJOV 20, 2002 10:41 AM FUEL ALARM JUN 14, 2002 3:55 PM ALARM HISTORY REPORT ----- SENSOR ALARNI -•---=`'" L10:DIESEL ANNULAR SPACE FUEL ALARI°t JUL 17. 2007 1:59 PM FUEL ALARNI NOV 20. 2002 10:47 AM`J~~ FUEL ALARM 2002 4:1,5 PM AI.ARtH H I STORY REPORT -- SENSOR ALARh1 ----- L 1 1: D I ESirL PIPING SUMP FUEL ALARM JUL 17. 2007 l:58 PM FUEL ALARM NOV 20, 2002 10:30 AM FUEL ALARNI JUN 14. 2002 10:44 AM ALARNI H I STORY' Ri~PORT SENSOR ALARNI L12:DIESEL STP SUMP FUEL ALARM JUL 17. 2007 1:57 PM FUEL ALARM JAN 1. 2006 5:47 PM FUEL ALARM FEB 18, 20115 9:15 AM ALARM • H I STORY R~PGRT -- ---•-- SENSOR ALARM -----~ L13:DISFENSER 1-2 DISPENSER PAN FUEL ALARM JUL 17. 2007 2:i3 PM FUEL ALARM APR 30. 2003 ? : 52 PI°i FUEL ALARM DEC 5. 2001 11:55 AM ALARM HISTORY R1=PORT -- SENSOR ALARM ----•-- 1.14:DISPEIVRER 3-4 DISPENSER PAN FUEL ALARM JUL 17. 2007 2:11 Phl FUEL ALARM h1AY 1. 2003 1 :33 PM FUEL ALARM APR 30. 2003 5:47 PM ALARM HISTORY REPORT ------ SENSOR ALARM -----• - L15:DISPENSER 5-6 DISPENSER PAN FUEL ALARM JUL 17. 200? 2:09 PM FUEL ALARM NOU 20. 2002 10:35 AM FUEL ALARM DEC 5. 2001 11:47 ANI ALARM HISTORY REPORT -- SENSOR ALARM ----- L16:DISPENSER 7-8 DISPENSER PAN FUEL ALARM JUL I7. 2007 2:16 PM FUEL ALARM JUL 17. 2007 2:07 PM FUEI. ALARM DEC 5. 2001 11:50 ANI MONITOR CERT: FAILURE REPORT SITE NAME: ~ S Sr DATE: ADDRE S: ~' TECHNICIAN: , `--.. 11 I:. yr - - •• THE ROLLOWING COMPONENTS WERE REPLACED AIRS O COMPLETE 'TESTING. REPAIRS ~ l~ ~C Rf7 N~Rr7~l 1~4~n rtr~~1 ~'~ -- - ~ fa u L ~~ Syu'1~- ~~' u ~.~4c1 Y~>C .c~.)u //l,c~i` ~- br,~ a r LQ ~L/~.G .. ~ Qt a r,~~ ~ ~' R' S~.~sa~c. (~rQ ~as~~va S~ru ~ ~~u,.1-- o~J - DL~'~ t. LABOR•r~ ~ d ~.~1-c,~~ ~t~t ~.c.,n r~.u l~l~l~: &'~7 ,t~'a ~"~ - - --~a ~~ ~d1 Q ~ cLLr~t~ 5~',c~ s"o.~t. D !-C.c1 l..- k~J7 S6 r~'7~1 PARTSINTALLED: ~ R.,c'"D ~b4t~GCw~'T ~ ~~~~- J`~"~ /~,v<yUl~1~, 1 ~~~ ,r N ~r)/i NAME: TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NC-TITYING THE APPROPRIATE PARTY TO HAVE CORRECITVE ACTION TAKEN TO REPAIl2 THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVI~tOrfMAN'TAL FOR ANY NEEDED RETESTING. THiS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES OR PENALTIES OCCURING FROM NON-COMPLIANCE. A COPY OF TS[S DOCUMENT HAS BEEN LEFT ON-SITE FOR YOUR CONVIENENCE. UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM EI.D / UNE TESTING ! SB989 SECONDARY CONTAINMENT TESTING (TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION PERMff N0. BAKERSFIELD FIRE DEPT. f~Rr• Prevention Sexvices ART~II T 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93302 _ Tel.: (66I) 326-3979 Fax: (661) 852-2171 ) Page 1 of ] ~ ` ~. "~~-~~ a '- von r ^ ENHANCED LEAK DETECTION ^ LINE TESTING ^ SB-989 SECONDARY CONTAINMENT TESTING ^ 7ANK TIGHTNESS TEST ~ TO PERFORM FUEL MONITORING CERTIFICATION - .,_.._.._.__ -_.._.. ._ - - J. . FACILITY ~ NAME PHONE NU 8ER ~C~ ACT PERSON / o a ADDRESS ~ ~1 V Ji ~ ~` /' (` OWNERS NAME OPERATt?RS NAME -PERMIT 70 OPERATE N0. NUMBER OF TANKS TO BE TESTED I P PfN 0 N T TE D? ^ N K# - rf TANK.TESTING COMPANY NAME OF TING OMP Y ~ l~ ^~ ~ V NAME PHONE NUMBER 0 ONT CT PERS N ~ / ~ HARING ADDRESS Y - .- - ~ ~~ C~~ ~ ~.,1 / V NAME d~ pHQptF~ NUMBER OFT R OR SPECIAL INSPECTOR ~/ CERTIFICATION #: DATE 8 TIME TE TO ~ CONDUCT ~ I ~ ICC #; ^ ~ TEST METHOD SIGNATURE OF APPLICANT ` ' DATE ~ ~ - DATE FD 2095 (Rev. 09105) BIL.LiNG & PERMIT STATEMENT PERMIT NO.: BAKERSFIELD FIRE DEPT. Prevention Services 'IRS 900 TrLtxtun Avenue, Suite 210 ~>Rlr~l T Bakersfield, CA 93301 _. .Tel.: tb611 326-3979 5 Fa : (66 1 852-21_~ • LOCATION OF PROJECT ~ • ~ • ~~~ STARTWG DATE COMPLETION DATE / i PROJECT NAME y"~ /~ I ADDRE S PHONE N0. ~ Q ~ ~ O O O ~~ ~O PROJECT ADDRESS CR'( STATE /'~~,- Z!P CODE CONTRACTOR NAME CA LICENSE NO. , ~~ ` TYPE OF LICENSE EXPIFiAT1ON DATE PHONE N0. ~ ~ ' CONTRACTOR COMPANY /' -r FAX NR ADDRESS OV CITY ZfP CODE G ~ ~ ~ i Ch $262 50 Mi difi ti ^ Al N & M & n arge) mum ca ons - ( arms - ew o . 9f FL Over 20 000 S 013125 = Pelmif fee FL x S 8` ^ , q. . q. 9F ^ rinkl rs -New & Modifications - (Minimum Char e) S $210 00 8` g p e . Sf n 000 S FL Over 5 042 =Permit fee FL x S ~ q. , . q. 9f ^ Minor Sprinkler Modifications {< 10 heads) 00 [Inspection Only) $ 93 ~ . 9F ^ Commerdal Hoods -New & Mod cations $ 398 26 ~ . 9E ^ Additional Haods $ 36.00 ~ 9E ^ Spray Booths -New & Modifications $458 00 ~ ~ . 9E ^ Aboveground Storage Tanks (tnsta/~ation/-nsp.-1° Time) $165.00 ^ Additional Tanks $ 26.00 82 ^ Aboveground Storage Tanks (RemovaUlnspection) $109.00 82 ^ Underground Siorage Tanks (tnstattationJlnspection) $878.00 (pertank) 82 ^ Underground Storage Tanks {Modification) $878.00 (persite) f32 ^ Underground Storage Tanks (Minor Modification) $155.00 ~ ~ ^ Underground Storage Tanks (RemovaQ $675.00 (pertank) f34 ^ Oilwell (Installation) $ 72.00 f34 Mandated Leak Detection (Testing) uel Monit. Cert. $ 81.00 {persffe) 82 ^ Terris $ t) 84 ^ After hours inspection tea $122.00 84 ^ Pyrotechnic - (Per event, Plus Insp. Fee ~ $90 per hour) $ 60.00 + (5 hrs. min. stand -may tee Anspaction) = $510.00 84 ^ RE-INSPECTION(S) /FOLLOW-UP INSPECTION(S) $ 93.00 (per hour) 84 ^ Portable LPG (Propane): NO. OF CAGES? $66.00 84 ^ Explosive Storage $249.00 f34 ^ Copying & File fesearch (Pita Research Fee 333.00 per hr) 25¢ per page ' f34 ^ Miscellaneous ~ ga FO 2021 (Rev, 09105) f - OR(GiNAJ. WHITE Ito Treasurvl f •YELLOw rto FIIs1 f-PtNK fto Customerl r,- r UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELD /LINE TESTING I SB989 SECONDARY CONTAINMENT TESTING /TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION BAKERSFIELD FIRE DEPT. ~~R~ Prevention Services ARfr f 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 PERMIT NO. /(/ ^ ENHANCED LEAK DETECTION ~^y LINE TESTING ^ SB-989 SECONDARY CONTAINMENT TESTING 11 TA AII! TI!_LJTAICCC TCCT YCI T(1 PFRF/1GM GI IFI ~A(1NITf1RINC: CFRTIFIf'CTI(1N FACILITY ~ NAME PHONE NUMBER ~C~ ACT PERSON / ~ ADDRESS o ~ - _- ~~ C OWNERS NAME ~ ' r 1 OPERATORS NAME PERMIT TO OPERATE NO. NUMBER OF TANKS TO BE TESTED IS PIPING GOING TO BE TESTED? ^ YES ^ NO TANK # VOLUME CONTENTS TANK TESTING COMPANY NAME OFT TING OMP Y ~ l~~ V,~`/~ 1 NAME PHONE NUMBER 0 ONT CT PERS N ~ ~ (~ ~ o MAILING ADDRESS ~ Y ~ ~ ~~ ~~ NAME 8 PH~ NUMBER OF TE T R OR SPECIAL INSPECTOR CERTIFICATION #: DATE JI< TIME TE TO E CONDUCT ,~^/ ICC #: TEST METHOD SIGNATURE OF APPL NT ` ~ DATE ~ APPROVED BY DATE ""'~ P( a FD 2095 (Rev. 09/05) ~f3ILLING & PERMIT STATEME~`~ PERMIT # TT-D~j B ~~E R S F [~~al. D ''¢¢~,.~ F/RE '~.~° d'e~PARTM~T BAKERSFIELD FIRE DEPARTMENT Prevention Services 1600 Truxtun Avenue, Suite 401 Bakersfield, CA 93301 Phone: 661-326-3979 • Fax: 661-852-2171 . LOCATION OF PROJECT '4 j'DD CD~~EI/ R.D - ~M Cl/RT D j /1~/D j 2{~M E TION DATE D~'/1~/O~ STARTING DATE D~/Z~/O~ COMPL PROPERTY OWNER NAME L I PROJECT NAME J 1/~~~1 ES P~T'ZOT~ I ~iR S ADDRESS PHONE # PROJECT ADDRESS '4'~DD CO~~I/E TZD CITY STATE ZIP CODE • • CONTACT NAME JL~M 1/S T2.(CI-t CA LICENSE # ~ 80- T • • TYPE OF LICENSE EXPIRATION DATE pHONE # 3~~-g(Og~ CONTRACTOR NAME 121C1-f- I/NV1120NM1/NT~L FAX# 3~~-D~21 ADDRESS ~~-4.3 URDOK~S CT CITY g/'CI~~i~S~~1-iLp STATE CilC ZIP CODE J°330g All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK ^ © ^ ^ Alarms -New & Modification (minimum charge) $280 ^ • 84 ^ 98 over 20 000 sq ft 028 x sq ft $0 ^ 84 ^ , . ^ 98 ^ Sprinklers -New & Modification (minimum charge) $280 ^ 84 ^ 98 ^ over 5 000 sq ft $0.028 x sq ft ' 84 , ^ 98 ^ Minor Sprinkler Modification (<10 heads) $96 (inspection only) ^ 84 ^ 98 ^ Commercial Hood (New & Modification) $470 ~ 84 ^ 98 ^ Additional hood $58 ^ 84 ^ 98 ^ Spray Booth (New & Modification) $470 ^ 84 ^ 98 ^ Aboveground Storage Tank (Installation/One Inspection) $180 ; 82 ^ Additional tank $96 ; 82 ^ Aboveground Storage Tank (Removal/Inspection) $109 ; 82 ^ Underground Storage Tank (Installation/Inspection) $878/tank ^ 82 ^ Underground Storage Tank (Modification) $878/site ^ 82 ^ Underground Storage Tank (Minor Modification) $167 ^ 82 ^ Underground Storage Tank (Removal) $573/tank ^ 84 ^ Oil well (Installation) $96 ^ ^ 84 px Mandated Leak Detection (test)/Fuel Monit Cert/SB989 NOTE: $96 for each type of test/site even if scheduled at the same time $g6/site Ci-tK. #1~8~ .~~^ ^ ^ 82 ^ Tent $96/tent ~ 84 ^ After hours inspection fee $121 ^ ^ 84 ^ Pyrotechnic (per event, plus inspection fee of $96/hr) $96 + (5 hrs min standby fee/insp)=$576 ~ 84 ^ Re-inspection/Follow-up Inspection $96/hour ^ 84 ^ Portable LPG (Propane): # Cages: $96 ; 84 ^ Explosive Storage $266 ; 84 ^ Copying & File Research (File Research fee $34/hr) $0.25/page ^ ^ 84 ^ Miscellaneous 84 FD2021(Rev 05/07) 1 -ORIGINAL (Treasury) 1 -YELLOW (File) 1 -PINK (Customer) A }. _.. .. I -__ .. Vii, ,} . nZ. ~~'~ , ' ~~``' ~ 5~~:~y~'=ffiYSTEM C~~tTII~i~ATIU1~ F'U~ ° .!•. ..,1 ~~~ ~ DATE / /9 65~ ." - ` :~~ tY... FACIY.ITY.ID_.~~~~~SLQ~~ip~c . ~.. . .~4 .. . ",+;, *..,~ ~~ . . '~. ~1t 1. x ~ ~~ .. ~ . ~ .-(V '~,: ` A '' ~ ' ~~ ~t t ~~ t~.:.::. : (~~~) ` ~,;- ~~,..: ~ fit,-. ~- . s' a ~ ..: '- ~ .. . ~~w ~ 1~.: ~ A yyw~y~~ VT~iWWWlAtill = O~IYl6 - 5{ . ,~.:~t_ : ~.#ne1. ~ ~ Line a - L#u 3 ~ . ~~°~ °> ~eucT~ - .•tx~ T.~ov ~;.~: ~4', ~~• ~~~~ ~ ~'7 ~~S ~. ! ~ ``~. . .~ ~s. h:p ~.• ~j .~;~• . .~. i. . ~ ~ n~: _ .. °t~ ~! . _ .:~ ~ ; ~,. Page ~ of _ . ,... `~,:. ;~ -: :; .. , :~s.. ..'.~~ .. y ' //^ /.~i ~~~U 3~7~ ,~ ~- . ~ 3~i,,, •I~ Ir?y :~ ~~t ~w~ °!y ~ ;,~ cos:., ~9f'.. ~v~ x~c ~/ ;~~ ;,~ ~ _9 ;,~ _ ~/y ,;~ Tune- ~: ~,q.~. -'SaA l-s~.~-r ~~o '~V~' ~i~ght ,',1,.' ' ~ ,,,~ • ~y~i.~ ~aArdflcat~an ~5~ ~ ~~~ o~-ai ~ ~_: ; : ~u x ~~ ~ j ~ ~~a a ~tarf Time :, r S : ,:.' 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" , FS' '~ ti'.iJ €:, 4.. -~ ~ E c~`(~ 3~,m k~~"L~?L; ~~~.~a~`~s~,.~ t~ °~~ a :R 5': +~-, .~~ ~k ~~,.~_*~ sue: , ~___ _._ ~J=' .i ,. _": - ~ ~ ~ R~F~I.I.~ FIRE DES. tJNDERGROl1ND Sl'ORAGE TANFC~ -~.:~~ „_ $ _ ; '~" ~ I~even~®n Seavices ~~ ~~ ~~~, + <.;~~ 900 Tn~~.un Ave., Ste. 210 ~~~'~~~® `~~ ~_` Bakersfield, CA 93301 To PERFORM Eta t LINE TESTING ' - Tel.: (661) 32G-3979 / SB989 SECONDARY CONTAINMENT TESTING Fax: (661) 852-2171 !TANK TIGHTNESS TEST AND TO PERFORM FI1EL MONITORING CERTIFICATION Page 1 of 1 i ~" Da PERMIT NO. ^ ENHANCED LEAK DETECTION ^ LINE TESTING ~ SB-989 SECONDARY CONTAINMENT TESTING ^ TANK TIGHTNESS TEST ^ TO PERFORtvt FUEL MONITORING CERTIFICATION _ _ ,~y~ _ 5 TF.INr.-~Rt~F.T.l0f~1 _ /~ _ _ _~1 FACILITY \/~1 h~M~L~1 ~ // I n~ ~p~ -- ANA ` & PHON`1t,D~/a spa ~ONTA/~/~P/ F~~ !~_ ~O7a Xa~C ~ II ~f+v vn coo y'? o o ~.R.e.e _ d. ~Q~I . ~ 9 33 0 ~ OWNERS NAME ~~~ ~~ L OPERATORS N E PER16'sIT TO OPERATE NO. i NUMBER OF TANKS TO BE TESTED __ TANK # ____ - _ ------- --- _ - ~- -- IS PIPING GOI> hG TO BE TESTED? V O L U tUl E - -- ---- --- -- ~- YES -_` ~__~___- ~ NO _ ~_~ _ CONTENTS ,__,___ ! Ir I ' I I I i ~ { i -- ---- ` ,__ I I --- ; i ~ I i ---- ------- -, I ~ TANK FESTIP~G COMPANY' --- _ _ IINAM OF TESTING CO PANY ~ - ----,NAME & PH(3NE NUMBER OI: CflNTAC~ PERSON --- - - 1 MAILING ADDRESS , ~ ~. a, i 5 I~ ~ ,tg c-~.,o1,~¢.Qal CA 433e~2 INANE & PHONE NU~~BERO~F TESTER OR SPECIA INSPE OR ~cERTIFICATION #: ,I,, 1.51.a,w~ (o(01- 39a - ~~~~ I d 5x351 ~- `~ - bSb3$ ~ 3~- ~ATE, IME TEST TO BE CONDUCTED PCC ~#: ES° METHOD ;SIGNATURE O PPLlCANT „~~ , _ _ _ (DATE / ~ ..• 7~J1'C'' s4PPROVED SY `~//Y/. l l/~./i..._L:1 (DATE /_1 / iv /.A i FD2i06