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Home My WebLink AboutBUSINESS PLAN 4/12/2006,/ ,~=,a r ~ ~.> ~ ~i -° L r~ .. / 1i ~~, ~ ~~ CIRCLE DELI 1416 GOLDEN STATE AVENUE I ~ CIRCLE DELI MART ___________________ _________________ SiteID: 015-021-001304 + Manager MERCEDES PENAREJO ~ BusPhone: (661) 327-0717 Location: 1416 GOLDEN STATE AVE Map 103 CommHaz Moderate City BAKERSFIELD Grid: 19C FacUnits: 1 AOV: CommCode: BFD STA 04 SIC Code:5541 EPA Numb: DunnBrad:77-0274431 Emergency Contact / Title Emergency Contact / Title MERCEDES PENAREJO / OWNER / Business Phone: (661) 327-0717x Business Phone: ( ) - x 24-Hour Phone (661) 832-3424x 24-Hour Phone ( ) - x Pager Phone (~G/) 3~2 - p~~x Pager Phone ( ) - x Hazmat Hazards: Fire DelHlth Contact MERCEDES PENAREJO Phone: (661) 832-3424x MailAddr: 910 S REAL RD State: CA City BAKERSFIELD Zip 93309 Owner MERCEDES PENAREJO Phone: (661) 832-3424x Address 910 S REAL RD State: CA City BAKERSFIELD Zip 93309 Period to Preparers Certif ' d: ParcelNo: TotalASTs: _ TotalUSTs: _ RSs: No Gal Gal Emergency Directives: YROG A - HAZMAT PROG C - COMM HOOD PROG U - UST ~N~'d p ~~ 2 ~ 2006 -_ Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true. urate, and complete. ,rtitrut ~f /~-G~ ignature Date -1- 04/03/2006 ,,.. ;. . _ - - .:, UNIFIED PROGRAM INSPECTION CHECKLIST ~: .SECTION i : Business Plan and Inventory Program BARERSFIELD FIRE DEPT p Prevention Services ~~Rrt 900 Truxtun Ave., Suite 210 sRir Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME NSPECTION DATE INSPECTION TIME ~ ~ / ~ _~ a~ Iv'3c~ ADDRES HONE NO. O OF EMPLOYEES S ~ AA d ~ HV FACILITY CONTACT USINESS ID NUMBER 15-021- ~~ _.~. -._ -1 _. Section 1: Business Plan and Inventory Program ^ ROUTINE OMBINED ^ JOINT AGENCY ^ MULTI-AGENCY i ^ COMPLAINT ^ RE-INSPECTION C V (c=cotnpliance) OPERATION V=Violation COMMENTS ,~_^ APPROPRIATE PERMIT ON HAND ~~] BUSIt1BSS PLAN CONTACT INFORMATION ACCURATE !~ ^ VISIBLE ADDRESS ~~) CORRECT OCCUPANCY ~^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITY ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~P' ^ EMERGENCY PROCEDURES ADEQUATE ~'' ^ CONTAINERS PROPERLY LABELED ' ~~ ^ HOUSEKEEPING ^ FIRE PROTECTION ~~` SITE DIAGRAM ADEQUATE & ON HAND ' ANY HAZARDOUS WASTE ON SITES ;YES ^ NO ExPLAw:~~,`feu-~'T£rZ~,`~~_d~tl~~~r~r~cT Sl~f1L<~'~_~r/`%Lv~~~z~ ~ _~E.~'~--_~-~~~ ~(~`l~~t ~-~f~~' o N S i7~{ 1C~'_ ~G*1.2~ ..._.~15®~ S~~f GC/ ~ /( _ ~~_~~ i ti jC~ ~~~ s , A~ So /I'by~`7;~~ Cr C 7 =Tcr1~J..~ ~yf ~~ rt .~/ t~.9 ~ ~r`~ S~e QUESTIONS REGA DING THIS INSPECTIONS PLEASE CALL US AT (881) 928-3979 ~~ ~~~~,~.~- P ~ - Inspector (Please Print) Fire Prevention / 1„ In / Shut of Sf1e/Station # mess Sit a Responsible Party (Please Pritt) ~+~5p ~~ i-Z3-6~ White -Prevention Services Yellow - Station Copy Pink - Busineae Copy FD2lN9 (Rw. OZ/OS) .. .- /! a.LD ~; 6 ~ f b1 ~W .1+1 ~ ~ ~ ~.~~i FACILITY NAME ~~;~e~1~ /~ CITY ~DF BAKERSF'IELD FIRE ~EPAR'I'MENT OFFICE ()F ENVIRC)N>i'iENTAL SERVICES IINIFIEi~ PROC>iRAiVI lNSPECT'1()N CHECKLIST 1715 Chester Ave., 3r`' Floor, Bakersfield, CA 93301 INSPECTION DATE l -/l Section 2: underground Storage Tanks Program ^ Routine ~-C'ombined ^ Joint Agency ^ Mult1-Agency ^ C'omplaint ^ Re-inspection Type of Tank S~n~~.lf, mail Ly,~k .Ta.?N~Number of Tanks Type of Monitoring ~N ['~~ ~fype of Piping •~u ~l>: c.~Al OPERATION C V COMMENTS Proper tank data on the Proper ownerbperator data on the ~~ ~S Permit tees current Certification of Financial Responsibility Monitoring record adequate and current ~.~ ~ _~ ~ , Maintenance records adequate and current Failure to correct prior UST violations Has there been an unauthorized release? YeS NO Section 3: Aboveground Storage Tanks Program TANK SIZE(S) Type of Tank AGGREGATE CAPACITY Number of Tanks 7./oti/ OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MVF? If yes, Does tank have overtilUoverspill protection'? C=Compliance V=Violation Y=Yes N=NO Inspector: O/V f 7-/~~Z~ Office of Environmental Services (661) 326-3979 White - Pnv. Svcs. Busines ite Responsible Party fink -Business Conv _ _4- _ i a--` . . ~ o ~ , ~' 1P~i._ ~!=L_ . T i _. y . _ l~ir~ IjIIL I!Ef'ij `. i= ~~i~~y~ _ 1 j ~'I' ~_ T = i'1 i- i'~ i I ~ ~ T t,HFCE~:Sr TE_i?, IH 'a_;F_t~' rL_H i - _ j;TE ~ '1 F1FiL1], L ' 1 - _ ~~ _ ... ~ pt ;. -.~, -~iL 1~.t'. ~- I-LiEH i'~:. I H f'; ~+. '' I i •I li_Tr~j _ ~~.1 i FUiA- , . _ i i : _ _ ~ F_~ r, ~ • ( i q .~ .: ~ ri I I I 1'- -_ -- ~'i ~ ., ~ „ ., r _ FL. ,; I TH: ~ 1r; :_ I FLi!s'. ''..4 I Hi'~f:. T'i~f. .. .;'•i' ~'I Ern - , : ,. _ _'~~,-.T F LUi; T ti'r3 ~:; CIRCLE DELI MART SiteID: 015-021-001304 Manager MERCEDES PENAREJO BusPhone: (661) ~`v Location: 1416 GOLDEN STATE AVE Map 103 CommHaz Moderate City BAKERSFIELD Grid: 19C FacUnits: 1 AOV: CommCode: BFD STA 04 EPA Numb: SIC Code:5541 DunnBrad:77-0274431 Emergency Contact / Title Emergency Contact / Title MERCEDES PENAREJO / OWNER / Business Phone: (661) 327-0717x Business Phone: ( ) - x 24-Hour Phone (661) 832-3424x 24-Hour Phone ( ) - x Pager Phone (661) 342-0908x Pager Phone ( ) - x Hazmat Hazards: Fire DelHlth Contact MERCEDES PENAREJO Phone: (661) 832-3424x MailAddr: 910 S REAL RD State: CA City BAKERSFIELD Zip 93309 Owner MERCEDES PENAREJO Phone: (661) 832-3424x Address 910 S REAL RD State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD PROG U - UST ~NT'D .1 U ~ ~ ~ ~OQ~' k~a. ed on my inquiry of those individuals res~sonsib;e for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, ate, and complete. accu r ~~C.~t,~,Q. _ ~7 /~ ~ nature Date Si g -1- 07/10/2007 F CIRCLE DELI SiteID: 015-021-001304 ~ STORAGE CONTAINER DATA (UST FORM A) - Last Action Type: FACILITY/SITE INFORMATION Business Name: CIRCLE DELI Cross Street Business Type: Org Type: Total Tanks 2 IndnRes/Trust: No PA Contact: Dsg Own/Oper ICC Nbr: ARKO0062 PROPERTY OWNER INFORMATION Name Phone: ( ) - x Address: City State: Zip: Type INDIVIDUAL Name Address: City Type INDIVIDUAL BOE UST Fee# UNKNOWN Financ'1 Resp: SELF INSURED Legal Notif Date:05/03/2006 Name:MERCEDES PENAREJO State UST # . TANK OWNER INFORMATION Phone: State: Zip: - x Phone: (266) 134-24 x Ttl:OWNER 1998 Upg Cert#: 00837 -2- 07/10/2007 r '~ F CIRCLE DELI SiteID: 015-021-001304 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers on Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP UNLEADED GASOLINE PREMIUM UNLEADED GASOLINE F F DH DH L L 12000.00 12000.00 GAL GAL Mod Mod -3- 07/10/2007 -4- 07/10/2007 .i F CIRCLE DELI SiteID: 015-021-001304 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site ~ COMMON NAME / CHEMICAL NAME UNLEADED GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: S OF STORE ADJ PUMPS CAS# 8006-61-9 Liquid TMixture ~mbient~E ~ AmbientT~E ~ UNDER GROIUNDRTANKE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 12000.00 GAL 12000.00 GAL 2000.00 GAL ru~~HtcLVUa ~ul~ir~lvrJlvl~ °sWt . RS CAS# 100.00 Gasoline No 8006619 I1E~GF~KL A~ ~L' J a1~11;1V 1 A TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod ~ Inventory Item 0002 COMMON NAME / CHEMICAL NAME PREMIUM UNLEADED GASOLINE Location within this Facility Unit S OF STORE ADJ PUMPS STATE TYPE PRESSURE Liquid TMixture ~ Ambient Facility Unit: Fixed Containers on Site ~ Days On Site 365 Map: Grid: CAS# 8006619 TEMPERATURE CONTAINER TYPE Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATIONI Largest 12000100rGAL Dai112000100m GAL I Daily2000r00e GAL nr,t~rirxl~uu~ ~.v1nrJNElvta %Wt. RS CAS# 100.00 Gasoline No 8006619 Y1HGEitCL Lib JL" .7.'~1~1L' 1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod -5- 07/10/2007 F CIRCLE DELI SiteID: 015-021-001304 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 04/24/2006 ~ CALL 911. IN CASE OF NON-EMERGENCY RELEASE, CALL 326-3979 AND STATE OES. Employee Notif./Evacuation 03/13/1998 EVACUATE EMPLOYEES BY VERBAL NOTIFICATION. Public Notif./Evacuation EVACUATE PUBLIC BY VERBAL NOTIFICATION. 03/13/1998 Emergency Medical Plan 11/28/2000 MEMORIAL HOSPITAL, 420 34TH ST, 327-1792. -6- 07/10/2007 _ r. F CIRCLE DELI SitelD: 015-021-001304 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 04/03/2006 ~ EMERGENCY STOP PUMP INSIDE STORE, VAPOR RECOVERY NOZZLE IN PLACE, GASOLINE STORED UNDERGOUND, AUTOMATIC SHUT-OFF VALVE. Release Containment 04/24/2006 IN CASE OF LARGE SPILL, CALL OUTSIDE CONTRACTOR FOR CLEAN-UP. Clean Up 04/24/2006 IN CASE OF A LARGE SPILL, OUTSIDE CONTRACTOR WOULD BE CONTACTED FOR CLEAN-UP. V1.11C1 iCCAVl11. l:C titrLlVGl 1.1 V11 -7- 07/10/2007 F CIRCLE DELI SiteID: 015-021-001304 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ oNc~iai na~aiu~ Utility Shut-Offs 04/03/2006 A) GAS - NW CRNR OF BLDG B) ELECTRICAL - N SIDE OF BLDG OUTSIDE C) WATER - NW CRNR OF BLDG D) SPECIAL - NONE E) LOCK BOX - NO Fire ProteC./Avail. Water 01/29/2007 PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS. NEAREST FIRE HYDRANT - 1400 BLOCK 30TH ST S SIDE OF ST. Building Occupancy Level 04/03/2006 4 EMPLOYEES -8- 07/10/2007 r r ;c F CIRCLE DELI ~ SiteID: 015-021-001304 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 10/23/2006 ~ MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: EMPLOYEES WERE TOLD WHAT TO DO AS FAR AS CONTAINING A SMALL SPILL, LOCATION OF PUMP SHUT-OFF SWITCH, LOCATION AND OPERATION OF FIRE EXTINGUISHER, AND USE OF MATERIAL SAFETY DATA SHEETS. •f rayc c. nclu 1V.L PUI~ULC UDC 11C1u 1VI t'UI.ULC U.S'C -9- 07/10/2007 ~ L 6 ~~ ~s MON.~T~RYNG SYST~N.i Cl~R7'~FYCA-'~'TON Fur v.+c~ 11)•rur.rrrrisdirrinrr,~ tdrfl/tirt r(xNStute u(CuIiJU+~niu lurlxrr(n L'irrd; C7tcrpter 6, %. NetrltJi Urrc! Su(c+h• C irdr; CJtllpter 1fS, f~IPl.Yrl711 ,~, ?`i!!c 23, Cali%uri+rcr Codh [~l•R[',r,'+ilnrir,+tx This form must be used ttl dtlcumcnl testing t,nd servit:ing n1' n,anitorin~ Cgtripment. A scvarate c :rti!'icatiUtt or rcnarl tllu4t he nn:p:urd fc,r each n,onirorin~~ystcm c2ntrt>t vane) by the lecltnicisut wf,u perl'~rtns [Fte work, A copy (,I'this li,n,r nntsl L,c prtrvid,:d u, the lank ~ysecm owner/c~peratc>r. The gwncr/operat.or tntttit submit a <Opy of this form to fhC local agency regal;,tiny IlST syslcm> >~•ithin 3O clays UI'i25t dale. A. General Informatiojn /~ hucillll' va,nC' ~~~,~.~C~Y-~~~-~ • --- -^ Ffld^_. Ntt.:....----- . _. ~ ~ /~/ 5itr Add,r~.: ~~~ ~1l~GS~_~=.. Cily; .~C~S~~_ Zip: -- •---- i~;,Ciiily C~untaCl f'C,•cnn: ~ -.... ~, ConlaCt Phanc No,: ( •}--_,_._.__ -._..- ,MakelMvdci ~I' h•]onilnring System; .~j,~'p~j._ Datc nFTcslinglScrvicin~: _~.,1 f~ Id,~, ii. Invent()ry of equipment Tested/Certiltecl Check the NpprapriatC boxes to irrdit:ate specific egaipmEnt iaspet•terlJscn•ict:d; 'r:,,,k in: SSG ;L$7 T>znk «~: . ~-. _ , . .- {,ifi' ImTank Gauai,ts. Prnlh. _ i~kKlel' ...,~~^~~ _ _. ^ fn-Tank G:1u~ina ProUC. ..... . _ Medal' _„ _ ,1 r\nnuhri Sl.occ nr Vault Srnsor. MadCl: _ D Annular Spncc or Vault Sensor. Mndcl: _ _ _.. ,~! I'il)in~~ Sunth r french Sen.or(s). Mcxlcl: ~"U~ ^ Piping Sump !Trench Senso,{s). Mc,dcl: .....-_ i.l F,ll $uml> Sanwns,. Model: Q Fill Sump SCnsnr(s), Mcxlcl: -, , . . jai Mcc:6enic•al ~,nC. Leak DC,CCtor. Model: ~., ,,,- ^ Mechanical Linc Leak I?ctcctor. Mndcl; -. ~ .- ^ Flertronic t~inC Leak [)ctCCwr. Model: U F'icctronic Linc Leak f3ctccror. Model:. _. . Q Tank c i~•crfiN ! High-Leval Scnsar. Modci: _ _ Q 'Tank C)vcrfiIl !High-Level Sensor, Model: _ _, • Cl Other (s tcdf C. ui meet tv and model in Section G nn Pa~;r 2), ^ Ot.her (s ci C ui men[ [ entl mcldci in SCC11Pn L cm P;tic 2,. 'l'ank Ill: ~ f ~ +~ Tank ID: - , - ~ ht•'1';rn>< Gauging Probe. - Model: _ / ~`._ ^ In-Tank Gouging Probe. Mnt1Ci: _..-_-..._ ;] .'\irnul:n• tipace ctr V,u,k 5unxnr. Modci; Q 11t1,1ular SpaCC Or Vnr,)t Sensor. Madcl: "„_• _, _^__,- Piping: Sump I TrCgr:h Stator(s). M<xlel: Z-~, ^ fipin~ Sump I Trertt:h ScnSOt(s). M14odcl: _ - _- i;,] FI11 Sump Sr, nsvr(si. h1odcl; _ „_„ 0 Fill Sumt, Sensat(e). Mvdcl: -•_. ,_ , . ~--Mcchunle;,1 Linc i_enk 1]e,cCtoP. 11'lodei: rJ Nlcchanical Linc Leak Dctcctoi. Mrxtcl: ,_, _--___ . it Elcclrnrtic Linc Lcak Deteefttr. Model: U Electronic Linc Leak Detector. lviodel: ,_• _ ?~ Tank (~t~crliil ! )iiCh•1,evCi Sensor. Mvticl: ^ Tallk t)vertill ! }1i~h-level 5cnsgr, Model: !_ i..a OlhCr (specif ~ ui illenl t c and mndcl ii, Section E Un I'n'C 2}. ^ Other (s eCif c UI meet t 3e and mntlCi in SecHnn E U,r Pa CC -1. Uispen.aer iU: I'^~ Aispcnscr 117: _ _ ~-- i,Ll I?i,peruar l:rmi,tinment Scnsor(x~. P9odel: ~a[ca+GYlPat~._~.~[ qg U f7ispcnscr Containment Sense~r(e1. tLtndcl: ~ ._. o~'Shcar Vah•cu1. Q 5hrar Valve{c}, .1 I?i.>emcr Cn+tutinu,cnt Flout(s) and Chaini5), ^ t7ts enrcr Go,tctinmcnt Float(s) and Chainl'<), IlisnrmcaY ID: _~~ _ _ Di5pe11SfC ID: ~-,,,~1 , „_ ~. Di5l,cnt:cr Cunt+nnmi.~lt Scnst,r(sl. Mgdekr,~Y~ebw ~bSr 4/p~ ^ ^ Uispcnser CuntainmCrlt 5ensor(s}. Mrxlri, _ _,_ (~-She;u' ~':tl++c(:,, ~ ^ Shear Valve(s), ^ Did enter Cc,mnimne,tt F~oat(s anti Chain(s). Q Dis reset Containment hlbal(s) and Chainlgl. Ai5l7t1tSUr fD: ~„~,_., - -_ I7islleftscr 1f); ~ _. _ .. ~ IJi>pcn.crCotu:,inmCmSens<tr(9). Moricl$te4ts~~y~i/ed ^ Disi+enscrContainment5cnigr(s). Mntlcl:_.._-___.. ..-__. '~'.`+'hcui volvrtai. ^ Shear Valve(s). JDiytcn4crt'c,ntainmrnt Float(s) and Chain(s). Q Dis nscrContainmCn[ Float(s)and Chain(s). 'i t im uu:uny cnm:wts ntt„'c Iitt1K%;7r tltShC,lRCrs. Copy tINF !N'rri. lnclUrtP fnlc)rmattnn rOf CVCry IAnK an0 OtSpt:flsCr al tnc I;,cuny C. Cer1:lflCtltiUt7 - 1 cattily that the equiptrteot idCntified in this docum~mt u;ts inspected/sficYiced in AccordancC with the mnnnt,rctorers` g,,idclines_ ,lttaehed to this CcrtiTicatinn Is information (e-g, ntsrmdacturers' check]isLe) necessary to verify that: tNiti intnrrt,.Uipn is Correct acct) Ft PIM 1'Ian showing the t;tyoul of mnnlloring equipment. Tor any equipment capAblc of ~GCnCYating such reports, 1 hsn•e :den attached:, cape of the repo t; (dreck allrltnJapply): A-Syslem SCt-up ~' )arm history report Tccltltiriaif ~Iantc (mint); .~`(~~~1,~r'.,~~(~~`J~-_ SI~R1fL1rC; ;r.+'+-. ~~~s ~~.- .-_,- _ ('.'CrUI'tu.ninn ~c,.. _Z23b~76J..~Sf~.B~,~`_-~-' f_i«,,.~t:. iv~.~ ~~r~-LTa_~~_----• -.....- T'c,,in~; Cr,n,i>:tny t~l.,n,c:: ~,~r• ..r<I.~f- - -- Phone No.;~~~ ~_.~~~"~~~ .._ ~itc ,\clJrCti.r; J~~'•[~p,~~~Z~E_,~.~~G,~"f~~_[~~Z- _, Dafrr UI'7'esting/$Gr~•iCin~?; ~ ~l~'/ D'~ 1'a~c 1 ol':D rt.vut ;Vit+nitttrim„ Sysietli C:crtilicatic-n U. RESults oF'~`estin~JServicing 5nftw.~rc Version L,Sta)Icd: ~~, , ~ Yes ^ No° Is the audible alarm n eratictnal? ~ 1M3+ Yc.ti ^ No" Is the visual alarm n stational? ~ Yes O No°° Were all scnsor5 vlsttali inspected, functionally tested, and confirmed operations!? U Ye< ~ No" Wcre all sensors installed at lowest poim of secondary containment and poei[ir-,ned sa that +tthcr cyuipmcru will not interfere with their ro er o er.,tion'? D Yes C] No" i! z-t)ar•ms are relayed u~ a remrne mnititorin~, static,,. is all communications equipment (c.~. nx+dcn+) 1~'N1A opcrationa!? J~h Yc.v O Nc,"• For pressurized piping systems, does the turbine automatically shut down if the piping sccor,dary cctniainn,er,t U NIA monitoring; system deterrs a leak, fails to orrcrate, nr is electrically discpnnccted? If yes: which scnsorv initiate prsitive shut-down? (C:hf•cR all nc~+l applti~) ~Sumprl'rench Sensors: ^ fJisp~nscr Containment 5ensnr~. pid ou confirm . osilivc shut-dawn due to Icaks and sensor failtrrddisGOnRectipn'? J~`ti'cw: ^ Nu. D Yes Ll Nct" _ Ftv tank Systems that nulizc the monitoring system as the primary tank overfill ,tiarnins; dcvic~ (i.c. rtv ~Nlf1 n~echanir:al overfitl prr:ventinn valve is installed), is the ovcr~ll wam;ng alarm vi~ihlc: eutd audible ;u thr i,mk lill ointt~}and p. cralin ~ rp. Crl '? if sn, at what crcent of tank ca acit does the alarm tri ~gcr'' __ _ +% ^ Yes" ~ Nn wars any ,nonitctring equipment replaced? ],f yes, identify specific sensors, probes, nr other ecluipn,c~u replacc,d and list the manuFactorer n;tme and model 1'or• all rc, lacemtnt arts in Section E, hcla„r. jd'Yc~" O Nt, Was liquid foernd inside anv secondary containment systems designed as rlry systems? 1Check rall,ha+ rrl,p/r) ^ Prnciuct; ^ Wata~. 11'vcs- clcscritic cau.ees in 5rsction E, below. Yes ^ No'" _Was monitoring_sysrenicet-up reviewed to ensure pro~,er settings? Attach set up reports. il• applic:ihlc; f~- `y'es C~ Nit" is ;ill mnnitorinC c ui tmcnt o a•atipnal cr msnufacttrrer's s eciflcatiores? In Section E belr,t7~, descrihC hm'•~ and whian these deF7cienries tirere or will be cprrected. [~;. Comments: ~, c+~, P,~ ~ S"i~~l~?~~1._t/_~.,~~U~-~~ G!~- bl~~-- 1'rtr;e 2 of 3 n3la t i )H, In-Tank Ga[a~;in~; !SIR Equipment: CJ Ghsck this bvX if tank g;,t+gln~, is u~ctl 4,nly for invcntor5',:onlr4,1, ^ Check lhiti box if no tank gauging of 5{R CquiPm~nt is inctsllc(I, -this scctit:)n mull be completed if in-tank caugir,g equiptncnt is used to perf~rrrt leak detection fnonit~rin~~. C:om Icte the fnllowin^ checklist: 1 ~' Ycc ^ Nn" Has atl input wiring hCCn inspected For proper entry and lCrminatidn, including testing for groun[i fatdts? ~" Yes ^ vv" Wcrc all tank ~taeiging {)robes visually inspected frn' damage and residue bui](lup? _ ~'YCS ^ Nn~° Wa.ti BCCtII'Bt:V O1 SyRlCnl ~lPe)({left 1CVCl feaLiin~S ICSICd? ~Yce ^ No"' Vdas accuracy +)f cy'sicrn ev;ttrr level rcadn)gs tested'? c. ^ Not Were :,I1 probos trios[>tllcd pt•c)perly' _ - Yc> ^ N(,*' Wcrc all items rnt [hc equipment rr,a+nul'acturcr'a maintenance checklist cvmplered? "' fn the Se(•linn I-1, belm4', descrifte hmv ftnd ~rhen These deficiencies were ar wi11 I,e Corrected, (.',. Lin e Leak DeteCi.urs (]G.LU): ^ Check this box if i..l.f~s are qot inst~}kd. C'otn lets for f~lln-vin checklist: 4~- Yes ^ No"' For cquipn,rnt srarl-up or annual cc}uiprncnt certifcativn, was a leak sin,ula[r(i to vcril'4 [_i.p pcrfc+re„artcC! ^ NIA rrlrrck ulI ,l,crr upp(t'1 Simtrlated Icak rate: ~''i g,p.h.; ^ O, l ;.p,h : ^ 0.2 g.p.h. Yes [1 No°~° Wen; :dl LI.F)s crn,l'irerCCl ni)cr;itional and accurate within regulatory requirUnc~nts'? Yes O Nay Was the testing apparauts properly calibrated? $~ Yep C7 v4,"' l~qr n,ecft:~nical L.I„[7c. df,r±s the [_C.D restrict product Plow if' it detects a leak? • ^ N!A ^ Yes C] N4;~' Ft)r cicctrnnic L[_Ds, doe's the turhinc autt)rnatically shut oFf if the LLD detects a Ic,.tk? 6~-. N/,1 ^ Yc~ Gl No" For eicctroni,: LLUs, does the [urbitte aatnm:,tticaiiy shut of"I" if any portion Uf the t,x~nitofin~. ~y,t.cm i. disr,hled ~^ Nl~1 or disconnec[c.(I? © Yes ^ Nrt~' For c}ccu•onic Ll,i~s, dflca the turbine auuamatical}y shut pfF iFany portion of the monitoring cycr('.m nla{funCUOn~ i~ NIA rtr Ixi1s a lest? ^ Yes U lvn~` For cacctrrnvc LLhs. hove ull accessible wiring connections been visuaily inspected? ~- NIA ~ Yes D N4t~` Wen; ,tl! items on the: cquilnt+cnt ntanufacun~cr's maintena.ntc checklist corrtpletec3? ~' '" In the Section fi, l,elu44'• tfesct•ihr how and when these deficiencies were or wiT} he aprrected_ r 1~. Gvmrnents: Pale :e n('3 n1l11t Monitoring Sysrem Certifcation US"C Monitoring Site Plan llate map was drawn: ,~.~/„~,., Instructions If you already have a diagrzm that shows all required infor.IT3ation, you may include it, ratl3cr than tltis pale, whit your iLToniroring System Certification. On your site plan, show the general layout of tanks and piping. Caearly identify locations of the (otlowin~: equipmciit, if installcci; monitoring syste3n control panels; sensors monitarinl; ta3zk annUla3' spaces, sumps, dispenser pans, stain containers, or athar secondary eontaittrnent areas; rneci,anical nr elecu'o~,ic line Ie~tk deteCfOr5; and it1-tank liquic! level probes (if uscil for leak detection). In the sp~cc provided, Wort the crate rl~is Sile Plan was t~repared. Pale of nsrao ~~~ Cal-Palley Equipment 3500 Gilmore Ave. Bakersfrerd, CA 93308 661-3z7-9341 FAX# 661-3.25-2529 YAFORLESS MANLTFACTURrNG, INC. Ll]T-890 Lead Detector Test Record Contractor -- - - Customer , Techtuctan Manufacturer Mode No. Serial Number ~~o~Jack"e ~ _ . Leak Detector Identification Manufacturer ` tiptt other Stvle Leak betector ~~ifl r Diaphxa~n-tYP~ Piston-type _ f~ Tamper-pr~vol'seal installed? Yes, Leak Test at Dfspea~ser t. Operatiuas Pumpl~ressttne ~6 psi (para. ls) Z- Gallons per boor rate ~,. L~ (para. 22) 3. Line pressure with pump strut off ~_$'~ asi (para. 23) 4. 13leedback Tcst with pump oil rnl (para. 26} 5. Step-through time to full flaw ~ -,seconds (para. 30) G. Leak detector stays in leak search position. (para.42} Yes ~ No LEAS DETECTQlt~ 'SST Note: Pass ~ Leak dehecLpr fro test ptafooot Fill - Leak detector fkils tit prottxol Pass 6r-' Fail Form 840C(9-1-96) +Comp~ete tltertttal expansion test before failing Icak detector. ]996 Vaporless Manufacturing, [ne., Prescott Valley, AZ -~~ ~~~ Cal-Palley Equipment 3500 Gilmore ~4ve. Bakersfield, CA 93305 661-327-9341 ,~,4X# 6b,~-3~5-2529 VAl'QRLESS MANU~'ACTU~2YNG, ANC. DT-89a ,Leak Detector Test Record Contractor Customer Tecltaician - - .°-~~~ M---der Manufacttu~er ~oo€seal installed? YE odel No. Sezi~l Number JrCAK Ue#@CtOr I~eSCrl pII Diaphragm-type` Piston-type [~- 'I'es# at Dispeuselr !- apcratiitg Pump Pressac+e_..~j, ns; {para. ts) 2. Gallons pcr bony robe ~. O _{para. 22) 3. Line pressure vnith punnp slut ofF ~ f ~ asi (para. 23) 4. Ble~dback Tort with pump off' ~p rlal (pars. 26) 5. Step-througkt time ro full flow~,~ seconds (para. 3D) Other S le Leak Detector 6. Leak detector stays in leak search position. (pata.42) Yes tr No LEAIC DETECTO#t TEST iYote: Psaa m t~earc ae[eeeor Fda tes~ praeecroi tF1-ir ' rock deDectvr fae`la teat prvrornl Fass~~ Tail -.-.~_ 1;'omt 840C(4-1-96) *Con7plctr thernsal c7tp~~sion test bCforc failing l~alc dMCCtor. 1994 Vnporlcss Manufachaing, Inc., Prescott Valley, Ax swr~cs, ranuary zaa6 Spill Suck~et 'Testling Ra~gorit Fvrtl~ l<'ftis farm is intended for use by ooraractors performing amruvt testing of UST spill comainme»t str~cltrres. Tfie coraplel~ed form and printoars from tests rf applicable), should be provided to the facility owmer/operator fat submftral to the !Deal rega~Jc~ory agency. I. FACILIT4t INFORMATION Facility Nxme: C'i~r-~/~ _~~ ~~ _ ~ Date ofTesting: $'y6-0 7 Facility Address: ,~' ~ Facility Contact: Phone- Date Loca[ Agency Was Notified al'Testitag Name aflocal ,A.¢encv Insnoctar (ifnresent durirt~ tesli~l: ~7~~?1i~ ~ 1~..~6,~r.~.y.P 2. TES'T'ING CONTRAGTOIi ]INP'URMATIQIy Company Namc: ~ ~,, Technician Conducting Test: Q kj, Cred~asls'= f~-CSL:g ContracGar Q ICC Setvicc ech. ^ SWRCB Tank Tester ^ Uther Licensc Numborfs): ~Qyl7a 1~ CEIRTIFICATION OF TECHNICIAN RESPONSIRI.E l~(7R COr+TUUGTit`1C„ Tlit$ TESTING I hereBy cerilfy tAat all the infor~tlon cnnialned i,e this rgpoft is true, a~rrate, and In Jydt compliance with legal r+equirement~ '~ Tecl-nician's Signature c .~w~~~ Date: ~~~ ~~ 'State laws and regutaticros do not currently require testing to be perFormoa by a qualified contractoor. However, local requirements may be more stringent. Gom~onents - (include irr~oTmoxian on repairs made prior to testir~ anrd recanunendedfallow~-up~or fafl¢d iesrr} ~~~ CAS.--V~L~,>ri~ ~I~`t' 354fl Gilsaoace Aar ~sfi~ld, ~A ~3~iflg P~~~1-33?-~3+~t -r~'Cj.~ G1ri 1~~1: ~ Fa~!5~1-32~-Z~S~ f6 Go gyp, ~ ~ ~~ G ~+` .w "! _____--.-_. e me ~ _ X11 ~Ip ~ ~°^~ t~°"'''Dir0.o91~st.v~tao~reelt~~~drrrrnaettsSD~~tRerridr. +r~~i3:7~pgr txa TYNE ~ 1POL ~'~ (N6L) ~L o : ~ 2A2- j S7 rf a9`:~S ~ ~ rem ~~ .. V~ (~F. ~1 CPw C.,rdI~11C73S P,a~S FlUO. >~ ~ ~~ ~~ _ 10;~r~ So ~~~ fE~ 5K11 [JIFF. ~~ <:. ~,, >~ MH.1 t~.i r~ CAN C+AII+111GSS RgSS Fp1L _'• ~ Y . e J~_ KPH ~ ~ ~ FAQ ~~~^~ unaer penalty of pe~arY that I a111 a Ilceps$d tarEk tester In file State of Cailfarnia and that the Inforrttatfon conta[ned in this rgaort is true a~~ ~„ra..t.~. ati_ ,,,,_. _, ._,- ~_-- . . --~ -