HomeMy WebLinkAboutBUSINESS PLAN (2)
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MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State of California
Authority Cited: Chapter 6.7, Heallh and Safety Code; Chapter 16, Division 3, Title 23. California Code of Regulations
This form must be used to documeml.estiog and servicing of monitoring equipment. A se.parate certlfi.!<!l-tion or Tenon must be Drqlared
for each monitoruw system control panel by the technician who pcrfonns the work. A copy of this fonn must be provided to the tank
~ystem owner/oper:~tor. The owner/operator must submit a copy of this fonn to the local agency regulating UST systems within 30
days of test date.
A. General In1ormation
Facility Name: J..M-t,l<...'-I -=t- Bldg. No.:
SiteAddress:3,GlG> N~S S'"'C. City: DA\C.f'.R..f.~ Zip: 9'S~
Facility Contact Person: HAI2JJ E:JL Contact Phone No.: ( J
Make/Model of Monitoring System: ertloo\..l ~ Sl:LcJ.,-1I" Date ofTestinslServicing: -Y.:J~/0Q
B. Inventory of Equipment Tested/Certified
CIl""k lh" a ro riUt boxts to indicate 5 eeinc e ui ment 1115 ectedlservlc~d:
TlInklD: ~.__.__ TJlnkID: p~ Cll
. 'SYn-Tanl; Gaugillg Probe. Model: I!l~~ ~ In-Tank Gauging Probe. Model: /flAG:::.
a Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model:
o Piping Sump / Trench Scnsor(s). Model: 0 Piping Sump / Treneh Sensor(s). Model:
::J Fill Sump Sensons). Model: 0 Fill Sump Sensor(s). Model:
o Mechanical Line ..eak Detector. Model: Q Mechanical Line Leak. Detector. Model:
o Electronic Line L ~ak Detector. Model: 0 ElectronieLine Lcak Detector. Model:
o Tank Overfill/ High-Level Sensor. Model: Q Tank Overfill / High-Level Sensor. Model:
o Other s ec'lfv ui ment' e and model in Section E on Pa e 2 . 0 Other s cci ui ment e and model in Section E on P e 2 .
Tank lD: Tank ID:
. 0 [n.Tnnk Gauging Probe. Model: 0 In-Tank Gauging Probe. Model:
o Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model:
o Piping Sump / Trc:nch Sensor(s). Model: Q Piping Sump /Trench Sensor(s). Mode!:
o Fill Sump Sensons}. Model: 0 FllI Sump Sensor(s). Model:
Q Mechanical Line :c.eak Detector. Model: 0 Mechanical Line Leak Detector. Model:
o Electronic Line L::ak Detector. \-lodel: 0 Electronic Line Leak Detector. Model:
o Tank Overfill f High-Level Sensor. Model: a Tank Overfill f High-Level Sensor. Model:
i 0 Other (s cci IIi mcnt e and model in Section E on pa e 2 . D Other eci ui ment e and model in SC(:tion E on P e 2 .
Dispenser In: -.L1!>.2. Dispenser JD: 31Jt..f
% Dispenser Contaillment Sensor(s). Model; ~.AV,{), -s:: Dispenscr COlltainment Sensor{s). Model: ~,
1 ~Shear Valve(~). Q-Shefl/'Valve{s).
Q Dis enser Containment Float s Q Dls enser Containment Floa s and Chain s .
Dispenser 10: ~.!J2.._, ,,__ Dispenser 10: 1-~
~Dispenser Conlailll'nenr Sensor(s). MOdel:/V'"A J.. n. ~ispenser Containment Sensor(s). Model: Bt=.Aill.
'la..Shcar Valve(s). 5itShear Valve(s).
o Dis enser ContaillJnent Floats and Chain s . 0 Dis eoseT Containment Flnat(s and Chaill s .
Dispenser In: DispenseT ID:
o Dispenser Containment Scnsor(s). Model: 0 Dispenser Containmelll Sensor(s). Model:
Cl Shear Valvl::(s).-oo Q Shear Valve(s).
DDis enset Containment Floa s and Chain $). 0 Di enSer Containment Float s and Chain s).
-rf the facility cOlllwns more tanks or dispens<:rs, copy this form. Include information for every tank and dispenser at the faciJiIy.
C. Certificatio n .. I certifY that the equipment ideotified in tbis document wu Inspected/Jervlced 10 accordance with tile manufacturers'
guideJlllcs. Attached to this Certification is information (e.g. manufacturers' checklists) necessa.ry to verify that tbi.s information Is
correct and a Plot Plllll showing the layout of monitor in II equipment. For an,Y equipment capable of generating 8uth reportli, I bave a/so
attuhed a cop)' of the rJl>~: (check all thD1 apply): s..system set-up SAJarm history report
Technician Name (print): ~>JtN Olhf...er Sigoature: ~
Cenificatlon No.: ID4ID4 tt5'3L\' r (;~(pI';2l./h U'f'l tJ,c. License. No.:B
Testing Company !.Jame: {(::I;:{: ~ 'CA) ~~~~A.L- Phone NO.:(->
Site Address:'~,N:Cl ~f:> c;:"C ~\LCa.$~ I cA.q5'3a>b Date ofTesting.lServieing; J:L/~f/)(p
Monitoring System Certification
Page lof3
03/01
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D. Results of Testing/Servicing
Software Version !1stalled: NJA
DYes o No~
j!-NI A
o Yes o No~
'8- NI fl.
Q Yes Q No"
liil N/A.
0 Yes" ~No
0 Yes" ;B-No
Cl Yes SNo"
E. Comments:. tv'IDt0~\Q(.. -:1:'5lVd\~~-:r.~,M~ l~~ NLEDS
_-tb~f"~ pr~c.:.I2.A1v\.t::D -rD,J'I2.E.lbRfl\ ~~,.-eST: AI..~D fI'\.op.J"f1.H..,Y "'"TAN~
-r.F'~ S-r- ~ 3~:t:'I\JG PC? f PD!G1'€.D ~~ ~E1?f: ::z:-E, ....:r::sr F~G H
fu~I~-:CN'\\\-t.~I(,S Du~G ~E. -:m:~ 'IOJ.-. t--\u.S-r"~ t<\ ~~-r
ONE ~A~'S-:t.N~ 'l€.'Efl fu(2. 'OO'TI-ITl1rJ<'s,B(f{zc:UACI lXNt5 P€.~ toI\.ot0n4
D1L 'fou... 1.V--:p...L. ~1i=5..D iO CO AtoJllJU..fk. ~(...:t? L:L1'.Jf:. ~~S.
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PageZ 0(3
03101
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F. In-Tank G~liuging/ SIR Equipment:
o Check this box if tank gauging is used only for invCIltory control.
(J Check this box ifno tank gauging or SIR equipment is installed.
This section mmt be completed if in-tank gauging equipment is used to perform leak detection monitoring.
Complete the follllwinl! checklist:
r~Yes Cl No. Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
~ Yes Cl No. Were all tank gauging probes visually inspected for damage and residue buildup?
~ Yes Q No. Was accuracy of system product level readings tested?
'i:I Yes CJ No" Was accuracy of system water level readings tested?
~ Yes Q No. Were all probes reinstalled properly?
~ Yes 0 No" Were all items on the equipment manufacturer's maintenance checklist completed?
* In the Section H, below, describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD):
h kl'
O. Check this box if LLDs are nollnstalled.
Complete the folk,win2 c ec 1St:
'jiiI Yes )ii( No" For equipment start-up or annual equipment certification, was a leak simulated to verity LLD performance'!
Q N/A (Check all that apply) Simulated leak rate: }i!3 g.p.h.; (J 0.1 g.p.h;Q 0.2 g.p.h.
DYes DNa. Were all LLDs confinned operational and accurate within regulatory requirements?
DYes o No. Was the testing apparatus properly calibrated?
I CJ Yes o No. For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
o NJA
CJ Yes Q No" For electronic LLDs, does the Iurbine automatically shut off if the LLD detects a leak?
o N/A
0 Yes o No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
o N/A or disconnected?
0 Yes (J No" For electronic LLDs, does the turoine automatically shut off if any portion of the monitoring system malfunctions
, CJ N/A or fails a test?
DYes o No. For electronic LLDs, have all accessible wiring connections been visually inspected?
Q N/A
DYes Q No" Were all items on the equipment manufacturer's maintenance checldist completed?
* In the Section H, below, describe how and when these deficiencies were or will be corrected.
H. Comments: '1\ T~-r.~E -k! x:.~L ~ PCW~ O't=-V C 8-N"'-X:'lT
-~2;t: L~\L D~l::tOR
n L. L. O. LJrlA... ,,-kY\' A:U.fY _) M.l'I....l-:r:T()R. "'ta
P~~12M A ~ {'.",.RH. \""'EAIL Pc~'S~ P\2.0~L'EAN 'J:"/'.J L...'h::RT~<':'
DR.. (\1-0 M":l=.: -rn(? ~ E.:r u.l~ ..
Page 3 of3
Q3101
'.
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Monitoring System Certification
\ ~'75l.e
UST Monitoring Site Plan
Site Address: :t-~ t-J-n:cs cr:, '~",AK.E..R.~F.:I:FillJ cA. G3"S('l)(o
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Date map was drawn: ..!:3j~fDI ~
Instructions
~
~
If you already h2,ve a diagram that shows all required infonnation, you may include it, rather than this page, with your
Monitoring Systl~m Certification. On your site plan, show the general layout of tanks and piping. Clearly iqentity
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..tanJ< liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan
was prepared.
Page _of_
USIIlI)
12{5~
--::.....: ,
MONITOR CERT. FAILURE REPORT
SITE NAME: L.UC\(:...~ =t- DATE: Lllga')lrzxo
ADDRESS: +fiT/) N'J:t..F)S GT: TECHNICk\N: ,Sn::.JJFJ.... \ ~[
Cl'IY: ~(~~~~ SIGNATURE: (~/ ~
TIm FOLLOWING COMPONENTS WERE REPLACEDIREP AlRED TO COMPLETE'
TE~TING.
REJ I AIRS: Nt:.FD "TO P<'Zo0RAM MQt-J'rjOR- -rO PR:t:FdQ1\ PRl'lPv-cr
LIf\J-c. -i12-Br (~€&09Q.oc::::ft=- OF ~ mC;;C:;-:z;Nb l>. Q('~~-n:.sr ~jC (V1O\l'iH")
Or-...) '"3OTH PRcOl.fL\ I :r:.~Ec;.
t-,)'tH? 1'0 ~B:l~ ~ "ID.JR.. TANtLS #Au's :0Jcu('..,H ~l..A&.
~ M.~~R~\2l1'\S 'mto....\t~ ~~ (tJ~D ONE ffi<:,c;" PaL r\t:N"'M ')
-rI\o~ v1:I:"L,- NO"T Pru-ow A f=OR..c...E.D '3(o)?!-/.7'ES-r
CL~ ~1- P eoD.A.er L:;:C'N'C.
:..... "fl.4-"ESE. 'P12.Oi6tZft1..'S NE,EJ:) 10 "6'f"_ 'P:r;.(.EO ~ -rt.."'S-rS
ll:t:-F()(2MV) A .& R. p,
~~ \ -T<..AiG~~vo..\....L NC5'\ ~~c:..R- Ot=t=. CM)~m-~tDRtf\
PAJ1:TSINTALLE.D: ~ TEc;T
NAJ!1E, JiARI/(i1< ~~ TITLE, /J.,/'feR.
SIGNATURE: .
THl~: ABOVE NAMED P RSON TAKES FULL RESPONSIDILITY OF NOTIFYING .
THJ~: APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR
THJ8: ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVlRONMANTAL FOR
ANY NEEDED RETESTL~G. THIS ALSO RELEASES RICH ENVIRONMENTAL OF
ANY FINES OR PENALTIES OCCURING FROM-NON-COMPLlANCE.
A COpy OF THIS DOCUMENT HAS BEEN LEFT ON-SITE FOR YOUR
CONVIENENCE.
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:':.; :." ..'/)."m is imande.l 'ftr use by contractors pe>-:f'orming plltiodic /6snng of UST cecondf>>')J conta,Jnmtmr Systems. UStl /:bIZ 1 r
,;;:-;...,.,~~prii.![!= pages OJ.thisform to report res1Jlt.\'far all components tested.. The completedfarm, written tl19tprocedlJJ"it$, and
,,,' .;n i, .",sji'om rests (if applicable). should be p,.Qvided to theft;4:i1ity owner-Ioperatar for submittal to the local reguJo/or)' agency.
Secondary Containment Testing Report Form
1. I?ACILITY lNFORMATION
':~',:',~':;;~'~'Nan:e: u..A.C.\L"I ~ :.~ ~ _ . , - I Date of Testing: LU!)(Dl~~
::~2~~::';.~)~-:~ddl'e3s: ~ N~.5 S-~ -nA1~~ IC-A: q3~
j-'o,_:;lllV i...oma.cr: Phone. .
:'-:::;';t(~ Lo.:al Agency Was Notified afTesting.: '41 \~ I cp<.:::>
:''':;:.'~;~;~'~r' Local AglllCY Inspector (ifprcsel;f during restiT:
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2. TESTING CONl'MCTO~ INFORMATION
~. ~."'r . I>-
~,"~:',:,n':p:).j\v Narne: R.reR ENVIRON7:-fEN"DAL. .
!~;~;~:;~~:an Conducti~'g 'Test: S~ 0!:St:..f?;l 6tOG:;:> l.?y~.\.A.--r
.: '~.:''':~;~;~ll"l~: '~CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester
i~:~.:~~:,~~~~;.~~~~P~9_'~.r-~~~'~~.~~_"!I~:~;l'!~:~~ B~;~~50
',; -. ~1\~Ci~t\lr~l; 'tt;tiniru:!
1 t\:lanufacturer CO!ljPo~tJt(s)
L--.-- INCON INCON ~~-STS
-'-'''p..-
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Date ~ Expires ~
:1
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.-.--..---..----.
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,
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;::=~~I'~J Not .Repairs Component Pass Fail Not Repairs:
Tesbld Made TMi'M Made :
0 ,0 0 0 I
0 0
;
'''q..L-~aX:: I g.. 0 0 0 0 0 0 0 "
II
\
. J '] [J 0 0 0 0 0 0
:====fO 0 0 0 0 : f;
0 0 0
!J 0 0 O' 0 0 0 0 ~
, ;] 0 0 0 0 0 0 0 I
iJ 0 0 0 0 0 0 0 i.
\
il 0 0 0 0 0 0 0
rJ 0 0 0 0 0 0 0
!J I [] 0 0 0 0 0 0' .
. !
~ 0 0 0 0 0 D 0 J.
~
0 0 0 0 0 0 0 ~
0 I
.L-LI L "
3 SUMMARY OF TEST RESULTS
....._~.-.....:~... ':llU O;&;~_
I Compa
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ir-.------..-~-
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~~;yC:l~osraric testing ~vas per~onned, desc7ibe what was (fone. with the water afrer cattlpletioD aftests:
:RECYCLE A.r~D REUS~Q
CERTl151CATION OF TECHN11.CIAN '.lm.SPONSIBLE FOR. CONDUCTING THIS TESTING.
Tv ;,ili< iil~st ojmy kJWI>t'ledge, tbefl1cts stated ill this dl)l:J(.mll1.1 are i1.cC/!,raI.e IUId iltJu.O C8tnplJflnC4 with legal Nlf[Uul/1UMS
!'(:,:JlJlicia.fl 's Signatlll't::C::::-~ L51---
Date: t..f{{;)(1)( ~
"
It' . . 9. SP~UOVERFILL CON'{AINMEN'r BOXES
U&ci1tij' is Not Eq,u!pped With Spill/Overfill Containment B02(es 0
~ SpilJiOverfill Cont:cinment Boxes are Prese:il~but were Not 'tested 0
j: Test lviemod Developed By: 0 Spill Bucket Manufacturer
o Other (Specify)
1 Tesl Method Used:' 0 PressLUc~
~ _ 0 Other (Specify
~ Test :Equipment U!,ed:
1 . I
I
.,
SWRCB, January ;~002
1"2. "-ZC)k,
-
Pagc_.. 01'_..
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, 0 Industry Standard
o Professional ~gineer
.'
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o Vacuum
o Hydrostatic
....-:;
E~pment Resolution:
. ..,~
/,
~I
'-!
'-',1
f
,I
:,
-'-i!
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1: Buckl::t Diameter:
r '
r Bucket Depth:
.L .
1 V,railr.imc between applying
\ pr.:sst,rt\/vacuunllwater and
1 S'[a.l"lD.l~ test:
',--
II ". c:' T'
I est ...ta:r Ime:
J Iuitiai Reading (R[):
rr est End Time: .
I Fin~~eading (RF)~
~ Test Duration:
,1---- ...
~ Change i.i1 Reading (RrRj):
[r-pass/Fail Thresho!<i or
U:~!j~j~___
~ Test lResult:
'L r
Spill ~O:R #<2f+.
,~'t'
~t/____
Spill Box # '1
l~ tt'
'd -/
Spill Box #
Spill Box #
ZiJ;>fV\ -:c tJ
: l\P\q:99P
:Slp~ 3~
9: &,(J ~:yyP
'b.03'it Z-t:; ~Sl
I ~ N\ -:r::. ,...;)
-.(l)0 ~
5= .~0,;)
'3fZ; M ':t:1\..J
-..{
~
-1
~~
~.l
-.~--:
+:~?
fUIass 0 Fail
o Pass 0 Fail
o Pass 0 Fail
-9LPass
o Fail
ComlOCi.~nts - (ill!:lude tnformation on repairs made prior 10 testing. and reCGmmendedfolJow-up f()r failed tests)
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"'" 04/?"'/2'~'~':
-"-' "''''"''' 12: 26 PPl
SUMP LEAK TEST REPORT
87SPBOX
TEST STARTED 12:11 PM
TEST STARTED 34~e 2
BEGIN LEVEL .~ / ee6
END TIME 3.121384 IN
12:26 PM
END DATE 04/20/2Be6
EN~,LEUEl 3.0381 IN
LEAK THRESHOLD e e02 IN
TEST RESULT' PfiSSED
04/20/2006
12:44 PM
SUMP LEAK TEST REPORT
87SPBOX
TEST'STARTED 12:29 PM
TEST STARTED 84/20/2006
BEGIN LEVEL 3.0380 IN
END TIME 12:44 PM
END DATE 04/20/2006
END LEVEL 3.0381 IN
LEAK THRESHOLD @.002 IN
TEST RESULT PASSED
",
91SPBOX
TEST STARTED 12:11 PM
TEST STARTED 04/20/2096
BEGIN LEVEL 3.8211 IN
END TIME 12:26 PM
END DATE 04/20/2006
O~D LEVEL 3.8205 IN
lE~K THRESHOLD a.ee2 IN
TE~T RESULT PASSED
91SPBOX
TEST STARTED 12:29 PM
TEST STARTED 04/20/2eB~
BEGIN LEVEL 3.8204 IN
END TIME. 12:44 PM
END DATE 04/20/2306
END LEUEL. 3~8203 IN
LEAK THRESHOLD 0.002 IN
TEST ,RESULT' PASSED '-
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,
" I 27 80
SB989 TESTING FAILURE REPORT
SUE NAME: L.ULtLY ";f DATE: L\ \,QQ)llZ>l,."
ADDRESS: -:fan> to::t:'LE.<S. ST:' TECmfIClAN: S'nZ'l.JE00 C>~..4CI .
CITY: gAll-€:R..<;;;'..I::~ SIGNATURE: 6~
Till: FOLLOWThG COMPONENTS WERE REPIACEDJREPAlRED TO COMPLETE
TESTlNG.
REI'AffiS: N 010 E-
LAlli OR: Na-..Je...
P AJi~TS INTALLED: ~o-JP--
NA~i1E:
TITI..E:
SIGNATURE:
THiG ABOVE NAMED PERSON TmsiFULt RESPONSIBILITY OF NOTIFYING , :
THJ~ APPROPRJA. TE PARTY 1'0 HAVE CORRECTIVE ACTION TAKEN TO REPAIR :
TH]~ ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR I
ANY NEEDED RETESTING. TIDS ALSO RELEASES RICH ENVIRONMENTAL OF
ANY FINES OR PENAL'TIES OCClJRING FROM NON~COMPLlANCE.
A COpy OF THIS DOCUMENT HAS BEEN LEFT ON-SITE FOR YOUR
CONVIENENCE.
;.
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)2.750
-
RICH ENVIRONMENTAL
5643 BROOKS CT.
BAKERSFIELD, CA 93308
OFFICE (66J)392-8687 FAX (66J)392--0621
i am es.res(a)l!mail.com
DATE: tJ -/:;'-o(p TIME: /0; 3D ,4{1Y)
AGENCY: '- \Ty oF' ~,4..J(EltSFl€L1J
ATTENTION: S TEu~ UvfD r:..-Jt Uo-t;> D
F'AX#: t....L:./- '3~to- 05?lP PHONFfi cPvl- 3.:?CP - 3'1'79
NO. PAGES
I
CELL#
PERM IT#
VERBAL COMF NAME
JOB LOCATION:
L vc-~
'1
BILLING ADDRESS:
SA-VYl E-
'100 N'L~~ ?I
E~e..~FIE(..,1:> I CA 9S5~
DATE & TIME REQUESTED: t.t.;:2~-ol, (!) ~;o&f,..,
TECHNJCIAN: . 51ElJCA) o;g;~~
ICC CERT#
ALT. DATE & TIME
5~l.oJ~4~ -UI'
VAPOR TESTING ENVIRONMENTAL HEALTH TESTING
TP201.3 LEAK DECAY MONITOR CERTIFICATION X
TP201.3B LEAK DECA Y ON AGT LINE LEAK DETECTOR TEST ~
TP201.4 BLOCKAGE TEST SB989 ANNUAL SPILL BOX TEST S<
TP201.5 AIL RATIO TEST 3- YEAR SB989 TEST
. TP201.6 LIQUID REMOVAL TEST LINE TEST
TP201.1B TORQUE TEST T ANI( INTEGRITY TEST
TP201.1 C/D DROP TUBE TEST DESIGNATED OPERATOR INSPECTION
TP201.1E PN VENT TEST FACILITY INSPECTION
LEAK DECAY OF CLEAN AIR SEPERA TOR CA THOme PROTECTION
VOLUME TO LIQUID RATIO TEST HELIUM TEST
DATE & TIME CONFIRMED q -I?-ot., ,\ '. 3 4 A-rn
SITE CONFIRMATION NAME ~ A'i<..;V'E K
TESTING ESTIMATE
LABOR ESTIMATE
NOTES:
t." L t.
/"JI FE TbO~ /N).tI~Aue: I4ND
LET l+4'i2. ~Ll }LV) en.J
- -;+-
PARTS ESTIMATE
MISC. ESTIMATE
TOTAL ESTIMATE
~..'
:. .~DD;:;'2S8
I 2. '7 50
BAKERSFIELD FIRE DEPT.
Prevention Services
900 1'ruxtun Avenue, Suite 210
Bakersfield, CA 93301
BiLlJNG & PERMIT STATEMENT
l' ?E.Riwirr NO.:
~ ~
LOC."'TION OF' PROJECT
!
!~rAA:':;I~GD;:r~
; PI~O.J'"C'\ NAI"'"
PHONE NO.
l
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!.f'f<OJf.c'r AOOflt:SS
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: 0 I Sprinklers - New & Modifications. (Minimum Charge)
I I.
o
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o
Over 20,000 Sq. Ft.
Sq. Ft X .013125 = Permit fee
$210.00
Over 5,000 Sq. Ft.
Sq. Ft X .042 = Permit fee
$ 93.00 [Inspection Only}
Minor Sprinkler MOdifications (< 10 heads)
'-------,
o \ Commercial Hoods - New & Modifications
;--0'--1
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: 0 i Spray Booths - New & Modifications
I .
[,~'_~'--I Aboveground Storage Tanks (Installalion/lnsp.-1'" Time)
~. 0 I Additional Tanks
I U ! Aboveground Storage Tanks (Removalllnspection)
: 0 Underground Storage Tanks (lnstal/stionJlnspectlon)
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LJ I Underground Storage Tanks (Modification)
o Underground Storage Tanks (Minor Modification)
o . Underground Storage Tanks (Removal)
. ell (Installation)
Man ated Leak Detection (Testin
ents
Additional Hoods
$ 398.26
$ 36.00
$458.00
$165.00
$ 26.00
$109.00
$878.00 (per tank)
$878.00 (per site)
$155.00
$675.00 (per tank)
7
$ 81.00 (per site)
$ 93.00 (perten!)
$122.00
$ 60.00 + (5 hrs. mln. stand-byfee/lnspedlon) = $510.00
$ 93.00 (per hour)
$ 66.00
$249.00
25~ per page
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FO 2021 (Rev. OQ/05)
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After hours inspection fee
I Pyrotechnic. (Per event, Plus Insp. Fee @ $90 per hour)
RE-INSPECTlON(S) / FOLLOW-UP INSPECT/ON(S)
Portable LPG (Propane): NO. OF CAGES?
Explosive Storage
Copying & File Research (File Rese.lfCh Fee $33.00 per hr)
Miscellaneous
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APPLiCATION
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/ S8989 SECONDARY CONTAINMENT TESTING
IT ANK TIGHTNESS TEST AND TO PERFORM
rUEL 1\t10NITORING CERTIFICATION
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BAKERSFIELD FIRE DEPT.
Prevention Services
900 Truxtun Ave., Ste. 210
Bakersfield, CA 93301
Tel.: (661) 326-3979
Fax: (661l8~2.2171
Page 1 or 1
ui.JOERGROUND STORAGE TANKS
Pf.R"u'i' 1,0. l
CJ, :::NHANCED LEAK DETECTION
C TJ\I~K TIGHTNESS TEST
o SB-Ila9 SECONDARY CONTAINMENT. TESTING
~ TO PERFORM FUEL MONITORING CERTIFICATION
NUMBER OF TANKS TO BE TESTED
T
NAME & PHONE NUMBER OF CONTACT PERSON
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OWNERS NAME ,
I OPiiRATORS NAME
PERMIT TO OPERATE NO.
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TEST METHOD
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APPROVED BY
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FD 2095 (Rev. 09/05)
APPLlCA liON
TO PERFORM ELD I LINE TESTING
I S8989 SECONDARY CONTAINMENT TESTING
/TANK TIGHTNESS TEST AND TO PERFORM
FUEL MONITORING CERTIFICATION
BAKERSFIELD FIRE DEPT.
J) Prevention Services
900 Truxtun Ave., Ste. 210
Bakersfield, CA 93301
Tel.: (661) 326-3979
Fax: (661) 852-2171
UNDERGROUND STORAGE TANKS
Page 1 of 1
PERMIT NO. I \\ -I.\- t ~
o ENHANCED LEAK DETECTION
o TANK TIGHTNESS TEST
o LINE TESTING 0 S8-989 SECONDARY CONTAINMENT TESTING
o TO PERFORM FUEL MONITORING CERTIFICATION 621 Cathodic Protection Testing
SITE INFORMATION
FACILITY Lucky 7 Mini Mart I NAME & PHONE NUMBER OF CONTACT PERSON
ADDRESS 700 Niles St.
OWNERS NAME Same
OPERATORS NAME Same I PERMIT TO OPERATE NO.
NUMBER OF TANKS TO BE TESTED IS PIPING GOING TO BE TESTED? DYES o NO
TANK # VOLUME CONTENTS
1 87 UL
2 91 UL
TANK TESTING COMPANY
NAME OF TESTING COMPANY Cal-Valley Equipment I Bruce W. Hinsley 661-327-9341
MAILING ADDRESS 3500 Gilmore Ave. Bakersfield, Ca. 93308
Bruce W. Hinsley 661-327-9341 CERTIFICATION #: 006-05-1178
DATE & TIME TEST TO BE CONDUCTED August 1,2006 15:00 ICC#: I
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SIGNATURE OF APPLlCANT~~ --tV- 1'( /J DATE July 26, 2006
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APPROVED BY ~ tV f / . lJ DATE '71 J-'l/8 ~
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FD 2095 (Rev. 09105)
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APPLICATION
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FUEL MONITORING CERTIFICATION
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BAKERSFIELD FIRE DEPT.
Prevention Services
900 Truxtun Ave., Ste. 210
Bakersfield, CA 93301
Tel.: (661) 326-3979
Fax: (661)852-2171
f; UNDERGROUND STORAGE TANKS
Page 1 of 1
PERMIT NO. I r(, "'-- O~lo V
o ENHANCED LEAK DETECTION
o TANK TIGHTNESS TEST
o 58-989 SECONDARY CONTAINMENT TESTING
~ TO PERFORM FUEL MONITORING CERTIFICATION
FACILITY
NAME & PHONE NUMBER OF CONTACT PERSON
ADDRESS
OWNERS NAME
OPERATORS NAME
PERMIT TO OPERATE NO.
1
d.
DYES
o NO
CONTENTS
NUMBER OF TANKS TO BE TESTED
TANK #
TEST METHOD
APPROVED BY
FD 2095 (Rev. 09/05)
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~~:ING & PERMIT STATEMENT
BAKERSFIELD FIRE DEn.
Prevention Services
900 Truxtun Avenue, Suite 210
Bakersfield, CA 93301
STARTING DATE
PROJECT NAME
PHONE NO.
PROJECT ADDRESS
ADDRESS
Alarms - New & Modifications - (Minimum Charge) 84
98
Over 20,000 Sq. Ft. Sq. Ft. x .013125 = Permit fee 84
0 98
0 Sprinklers - New & Modifications - (Minimum Charge) $210.00 84
98
0 Over 5,000 Sq. Ft. Sq. Ft. x .042 = Permit fee 84
98
0 Minor Sprinkler Modifications (< 10 heads) $ 93.00 [Inspection Only] 84
98
0 Commercial Hoods - New & Modifications $ 398.26 84
98
0 Additional Hoods $ 36.00 84
98
0 Spray Booths - New & Modifications $458.00 84
98
0 Aboveground Storage Tanks (Installation/Insp.-1st Time) $165.00 82
0 Additional Tanks $ 26.00 82
0 Aboveground Storage Tanks (Removalllnspection) $109.00 82
0 Underground Storage Tanks (/nstallation.llnspection) $878.00 (per tank) 82
0 Underground Storage Tanks (Modification) $878.00 (per site) 82
0 Underground Storage Tanks (Minor Modification) $155.00 82
0 Underground Storage Tanks (Removal) $675.00 (per tank) 84
ell (Installation) 72.0 84
Man ated Leak Detection (festin $81.00 (per site) 82
ents $ 93.00 (per tent) 84
0 After hours inspection fee $122.00 84
0 Pyrotechnic - (Per event, Plus Insp. Fee @ $90 per hour) $ 60.00 + (5 hrs. min. stand -.by fee /Inspection) = $510.00 84
0 RE-INSPECT/ON(S) / FOLLOW-UP INSPECTION(S) $ 93.00 (per hour) 84
0 Portable LPG (Propane): NO. OF CAGES? $ 66.00 84
0 Explosive Storage $249.00 84
0 Copying & File Research (File Research Fee $33.00 per hr) 25ft per page . 84
'..
0 Miscellaneous :. 84
:.
FD 2021 (Rev. 09/05)
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