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HomeMy WebLinkAboutUST-REPORT 3/28/2006(UNDERGROUND STORAGE TANKS) FILE # EAST HILLS MOBIL -- 2524 OSWELL STREET ~; --- --- ~- - --~-- ~----~ --- -- - - --. J(~1 MONITORING SYSTEM CERTIFICATION For Use By Aft Jwisd}ctions Wtthi» the State ojCalefornia Authority Cited.• Chapter 6.7, Health and Sajery Code,' Chapter 16, Divlslorr 3, 7YJle 13, California Code ojRegulations This fornt must be used to document testing and servicing of monitoring cquiprnenk .~se~arate rrti ion a~ rcnart must be nreoared for each monitoring system c t~l Hanel by the technician who performs the work. A copy of WLc form must bt provided to the teak system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systetas within 30 days of test date. A. General Information Facility Name: ~2(~f~I L Bldg. No.: Site Address: ~.;ttic./ l~IUJFG~ Sir City: ~-/L~',~S/C/.~, li .~._ Zip: ,~,~U__~__~ Facility Contact Person: Contact Phone No.: {!_~ Make/Model of Monitoring System: ~, 3 Date of TestingJServicing; ~/~/~ B. Inventory of Equipment Tested/Cerfifietl Check the auarnnriire hnxe~ to inAFuto enecinc eaninment iosaeeted/servlcedr TanklD: (J4J[.,~7 Tank ID: PLUS J~ In-Tank Gauging Probe, Model: s^'f~~ ~ to-Tank Qauging Probe. Model: -'v)~ls, / R4 Annulaz Space or Vault Sensor. Model r-1 ~ ~ Annular Space or Vault St~sar. Model: 'i ks J$ Piping Sump /Trench Sensor(s). Model: }f~~ ~$ Piping Sump/Trench SensoKs}. Model: a.0>'C O Fi115ump Sensot{s). Model: ^ Fill Sump Sensor(s). Model: J& Mechanical Line L.cak Detector. Model: i ~i ~ Mechanical Line Leak Detector. Model: ~~ ^ Electronic Line Leak Detector. Model: ^ Electron)c line Leak Detector. Model: ^ Tank Overfill /High-Level Senior. Model: ^ Tank Overfill /High-Level Sensor. Model: O Others i e ui men! and model in Section E on P e 2 . ^ Other ui ment and model in Section E on Pa e 2 Tauk iD: Tank 1D: ~ [mTank Cauging Probe. Model: Y`I~¢~ / _ O !n-Tank Gauging Probe. Model; 1~ Annulaz Space or Vault Sensor. , Model: y,}~ Q Annular Space o< Vartit Sensor. Model: fg1 Piping Sump 7 Trench Sensors}. ModeL• ~~_ ^ piping Sump / Tench Sensor(s). ModeE: Q Fill Sump Sensor(s). Model: Q Fill Sump Scissor(s). Model: .($ Mechanical line Leak Detector. Model: ,~ ~7Y9GtG61 ^ Mechanical Line Leak Detector. Misdel: 4 F,lccvoaic Line Leak Detester. Model: Q Elecdronie Line LealcAetcetor, Model; ^ Tank Uverfill /High-Level Sensor. Model: O Tank Overfill /High-Level Sensor. Model: ^ Other eci ui ant and model in Section E an Pa a 2). ^ Other s i ui enY and model in Batton E on P e2 . Dispenser ID: ~ „ ~ V Dispenser ID: 3 - ~/ l,Z pispenser Containment 5ensor(s). Model: lei Z ~L Dispenser Containment Sensors). ModeL• UPJ 1 1S SAeaz Valve(s). ,0 Shear Valve(s). ^ Dis enser Containment Floats and Chain s). ^ Df sec Contairunent Float s and Chains . Dispenser ID: tiS'~ ~A Dispenser Ip; )- ~ Dispenser Containment Sensor(s). Model: _ rJG I ~ Dispenser Contaitunent Sensor(s). Model: y'$, Shear Valve(s), ~D Shear Valve(s). O Dis nscr Containment Flo sand Chains , O Di enser Containmert Float s and Cbain s . Dispenser ID: -- /(} Dispenser ID: Dispenser Containment Sensors}. Model: ~t2/ D Dispenstr Containment Sensor(s). Model: ~ Shear Valve(s). O Shear Valve(s). QDis enser Containment Floats and Chains ^ Di scr Containment Flo sand Chains . •If the t8cility contains more tanks or dispertsers, copy this form. Jnclude information for every tank and dispenser at the facility. C. Certitlcation -1 certify that the equipment ldentiGed is this document was Inspeeted/servieed in accordanee with the maaafactartn' guidelines. Attached to this Certif[catlon b information (e.Y. manufacturers' checlrlitts) necessary to verity that this information )s correct and a Plot Pbn showing tFte layout of monitoring equipment For any egalpmant capable of generating tuck reports, I have also attached a copy of the report; (check al! char app(s); ~ System set-ap ~ rm Llstory r port Technician Name (print):~~1 ~ ~ Signature: Certification No.: CXJ(¢~- y,~ - Ia'~ S License. No: U ,Testing Company Name: d ts,tf j:..tJt~i t?~r~ Mir ?~ Phone No.:t Site Address: ~~ p~1~~ S T b/}~,Q~~/it.LO ~~~ Date of Testing/Serviciag: .3 J~fr /~ Page 1 of 3 03N1 Monitoring System Certification :, - - - ,~,~5 1~~ D. Results of Testing/Servieing Software Version Installed: ~ U~~ r,......le-n r1.. i..l{n,vina n6ar.lrlic-. 4fT Yes 0 No' is the audible alarm o tional? Yes Q No' Is the visual alarm o tional? Yes ^ No' Were all sensors visual ins cted funcdonall tested and consumed o rational? ~ Yes O No" Were aEl sensors installed at lowest point of secondary containment end positioned so that other equipment wiEl not interfere with their o er o ration? O Yes ^ No* If alarms are relayod to a remote monitoring station, is all communications equipment (e.g. modem) ~ N/A operational? Yes p No' For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment ^ N/A motitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply) ~ Sump/7'rench Sensors; ^ Dispenser Containment Sensors. Did ou confirm ositive shut-down due to leaks sensor failure/disconnectiaw? Yes; O No. 0 Yes ^ No' For tank systems that utilize the monitoring system as the printery tank overfill warniltg device (i.e, no 1~ NIA mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible ai ffie teak fill in s and o ratin r rl Ifso at what rcent of tank ca act does the alarm tri °~6 ^ Yes* Gli No Was any monitoring equipment replaced? If yes, identify sped&c sensors, probes, or other equipment replaced and list the manufacturer name and model for all r lacement arts in Section $ below. ^ Yes* 91, No Was liquid found inside aay secondary contaitunent systems des'igrted as dry systems? {Check a!! that apply) ^ Product' ^ Water. If es, describe causes in Station E below. Yes ^ Na' Was monitorin s stem set- reviewed to ensure ro r settin ? Attach ser u tr orts if Hcable Yes ^ No* Is all monitortin a u' ant o tionat manufacturer's s ifications? '~ Ia Section E below, describe haw and when these defleltocies were or will be corrected. E. Comments: Page Z of 3 03!01 12 •, F. In-Tank Gauging !SIR Equipment: ~ Check this box if tank gauging is used only for inventory control. ^ Check this box if no tank gauging or SIR equipmem is installed. This section must be completed if in-tank gauging equipment is used to perform teak detection monitoring. !'`r,mnlPtP the tnTlnwinv rher4liQf- 0 Yes ^ No' Has all input wiring been inspected for proper entry and termination, including testing for ground faults? O Yes ^ No* Were all tank gauging probes visually inspected for damage and residue buildup? ^ Yes ^ No* Was accuracy of system product level readings tested? ^ Yes ^ No* Was accuracy of system water lever readings tested? ^ Yes ^ No* Were all probes reinstalled properly? O Yes ^ No' Were all items on the equipment manufacturer's maintenance checklist completed? • In tde Section H, below, GescrtGe how a>tit wne6 [nese aencteactes were or wtu oe correc~ea. G. Line Leak Detectors (LLD): ^ Check this box if LLDs are not installed. !'.......1 e.e .Le f..ll..Wi.... nh....Ll1ai. Yes O No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ^ N/A (Check all that apply) Simulated leak rate: ®3 g.p.h.; ^ 4.1 g.p.h ; ^ (1.2 g.p.h. Yes O No' Were all LLDs confirmed operational and accurate within regulatory requirements? ($ Yes O No' Was the Costing apparatus praperly calibrated? 1>9 Yes O No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ^ N/A ^ Yes O No* For electronic LLDs, does the turbine sutomadcally shut off if the LLD detects a leak? 5if N/A O Yes O No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ¢! N/A or disconnected? O Yes ^ No* • For electronic LLDs, does the turbine automatically shut off if any portion of the monitotittg system tnalfunetions OA N/A or fails a test? A Yes ^ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ® N/A ~ Yes O No* Were all items on the equipment manufacturer's maintenance checklist completed? - 1n ule section H, below, describe bow and when these deficiencies were or wilE be corrected. H. Comutents: Page 3 of 3 03/x1 R j i1-Ionitoring System Certification 25 ~ UST Monitoring Site Plan site Address: ~~ C' S ~ E tr L S~' /ice-~t:£ILSFrE ~+. ~~ 4 3 ~~ ~ ... ~~ .. :::::: ~ ::::::::::::::::::: Q: : ~ .: ~ d~ ~c~~,~l: :: ~ :::::::::::::'~`s,-~so ~ :: ::::::::::::::::::::::: :::::.::::::::::::::~'.::::::::::::::::: .d: ::::: .: ................... ................. ~ v. ..... ...s........3........ ,.. ................~.... .... .. ~. .N .:.........:`~ ........................... ....: '1~.1 :::::::::::::O~c-~~~c:~ ::S ~~ :::::::::::::::::::::: ! :: Date map was drawn: 3 /~/cv~. Insr____ractions If you already have a diagram that shows all roquired infom~ation, 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. Page `f of `/ nsroe ~ a` 1 ~- 5 t~ -----~,. T? T f"Ta' l~'NVT k?~F'NTA T. 5643 BROOKS CT BAKBRSFIKLD,CA.93308 OFFTCE(661)392-8687 & FAX {661392-0621 MSCIi7~NIC'nT• j~K DETS{~TOA TAST W/0#: Facility Name: !'"jUt3! L Facility Address:~3~/ O~tcJtLL S% 13~t'.~~ZS~l~rl~ C~ Product Line Type (Pressure, Suctioa, Gravity? /f~~V~,~ PRC-DVCT LEAK DETECTOR TYPP TEST TRIP PASS sxR7nr. NIIaQBBR BELOW PST OR L/D TYPEr?EG1~'~//~ S$ A$S 38RIAL # ~ `~+~ .l~/~~.f"'r N J ~,v ~. ~ 7 L/D TYPE w-~GN~4~sJr{,~_ ~s ` _ Ass P~ ~ ~ r sRRTRL ~ R.~o .r,~~ l / B L/D TYPS WIEG1~9~i//~iYL 8 pg3 3SRTAL # FCEd T..rk~~i NO II NN L~~ L/A TYPB ]CBS PARS SRRTAL # NO BAIL I <:ertify the above tests were conducted on this date according to Red ~~acket Pumps field test apparatus testing procedure an limitations. They Mechanical Leak Detector Test pass /fail is determined by using a lour flow threshold trip rate of 3 gallon per hour or less at 10 PSI. Y ~:cknowledge that all data collected is true and gorract to the beat of m}~ knowledge . Tech : ~~~!~~ Sign2.ture : ~ Date :.~"~.~~~~. r.•. SG'FTWA1`'.I: REV I ~; I ON LEVEI. ' L+ER.~I~1N 13.05 SOFTt.~rAkEtt 349500-lZUti-F CREA'1'El:~ 55.07.Ob .08.33 NO : {?FT'WHR1; MODrJLE S`i'S'1~ENI FEATURES PER I i?D I C I N-TANK TESTS ANNUAL IfJ-TANK TESTS r1riR ~:tl,~:UOe• 1'x:44 AIN 5'iS'1'1:r1 UNI'1'ti~ U.S. SYSTEM LAIVL URGE ENuLISFI N1C?) I L ':?524 OtiWELL ST' BAY:EI2SF I ELD CA 9330Ei Sli I F`f 'T I f•1E I D I SA&LED SHIFT 'l' I h1E 2 D I SABLED SHIFT' T I h1E 3 D I SABLED SHIFT `fIr°tE a DTBABLED 1'ER l OD I C Tk~ST WARNINGS D 1 SAILED A1VIVLIAL TIaT' WAkNI NGS ri I SABLED 8`f 'TkiNl SECURITY i;C?DE 000000 PR i NT' T~ : VOL Uh1ES EIVABLED "1'I;h1P ~COf°IPENSHT'ION VALUIr {DEG F > : 60.0 COM!°IUNICATIONS SETUP - - PORT 3E'TT I NGS CONIr1 Bt~ARD i <RS-232) BAUD RATE : 1200 PAR I'1'Y ODD STOP BIT 1 STOP DATA LENGTH: 7 DATA HUTO 'I'RANS'M I T SETTINGS AUTO LEAK ALARhI LIMi'f nISABLED AUTO HIGH WATER LIMIT DISABLED AUTO OVERFILL LIMIT DISABLED HUTO LOW PRODUCT DISABLED AUTO 'THEFT LIMIT DiSHBLEri AUTO DELIVERY START DISABLED AUTO DELIVERY END DISABLED AUTO EXTERNAL INPUT ON DISABLED AUTO EXTERNAL INPUT OFF DISABLED AUTO SENSOR FUEL ALARM DISABLED AUTO SENSOR WATER ALARM DISABLED AUTO SENSOR OUT ALARhI DISABLED RS-~3,? SECURITY CODE 000000 RS-232 END OF MESSACaE n1sABL1;D ~-zsl~ i N TANK SETUP- - --~.~ T 1:UNLEADED ;1 PRODUCT CODE ;.0007170 THERMAL COEFF 113.75 TANK DIAMETER 1 PT TANK PROFILE FULL VOL 15023 FLOAT SIZE: 4.0 INCHES WATER WARNING : 2.0 HIGH WATER LIMIT: 3.0 ©VERFRLL~L I M 1 TOI~ ~ 150'03 13520 HIGH PRODUCT 9,5% 1471 DELIVERY LIMIT 1?0% 102 I I..OW PRODUCT : 500 LEAK ALARM LIMIT: °~y SUDDEN LOSS LIMIT: O~U TANK TILT MAPIIFOLDED TANKS Ttt: NONE LEAK MIN ANNUAL : 1502 PERIODIC TEST TYSTANDARD ANNUAL TESTALFA~ILDISABLED PERIODIC TALS,ARM DISABLED GROSS 'fEST~FA~IM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF • DELIVERY DELAY 15 M1N ,/ i ~- StS •r ~ : I'kEM I ur~l l~l.~::,i',u~:rr eL~t~E 2 T'HET;NIr'-aL. t:OEFF :.0007U^ T 3:DIESEL 'f~NK D I Af°IETER 90.00 PROD11i`T CODE 3 TANK PROFILE 1 PT THERMAL COEFF :. 000450 FULL. VOL ]1550 R 50.00 TANK PROFILE FULL VOL : ]1550 FL{>A'!' i 1'~'E : 4 . U I NCHES l•JH'fEk W;RfVINc~ : 2.0 FLOAT SIZE: 4.D INCHES H 1 GH t~IATEF. L I hl I T: 3.0 WATER WHRNING :~,0 P9i-i?: ~+R LHBEL V~~L: 11550 HIGH WAT$R LIMIT: ;~,[J t?V)rIC'F I LI L I t°I i T 90% . 10395 F'lA'rC uR LABEL VOL : 1 ] 550 HIu`H F'RUDUi'f 95ia OVERFILL LIMIT 90 0 10972 1 Q 5 1:~IrL1l~ERY LIMIT' l0i HIGH PRODlh:T 6• g5 1200 DELIVERY LIMIT ; 10972 l0i LOW PkODUC'I' 500 1::110 LEA1 ALARM L I I°I I T: 99 SUUL!E(d LOSS LIMIT: 50 LOW PRODUCT 500 TANk; TILT 0.00 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 50 P'hNIF1+LDF.D TANKS TANK TILT ~~,00 •ru: NorvE MAN I FOLDED TANKS LEAK MIN HNNUAL 1200 T#: NONE P)rR I OT) I C 'PEST 'TYPE LEHK Ih I N ANNUAL 1200 STANDARD PERIODIC TEST TYFE ANNUAL 'PEST FAIL STANDARD ALARM JISABLED ANNUAL TEST FAIL PEk113DIC TEST FAIL ALARM DISABLED ALARM DISABLED pER10DIr. TEST FAIL (:BUSS "[ EaT' FAIL ALARM DISABLED ALARM DISABLED .ROSS 'PEST FHIL HNlV TF.'ST AL'ERHGIN13: OFF ALARM DISABLED PER TEST f;VERAGlNG: OFF ' HNN TEST AVERAGING; OFF 1 r`'+IVK TEa F NUT I FY : OFF PER TEST AVERAGING : OFF 'I'NK 1'ST SIPHUIV FREAK:OFF TANK TEST NOTIFSr: OFF DELIVERI' DELAY l 5 MIN TNK TST SIPHON BREAK :OFF DEL1VERY DELAY 15 MIN LEAK TEST METHOD TEST ANNUALLY: ALL TANK JHN WEEK 1 MON S"FART TIME 2.30 Aly DURAT ONE :022UHOAURSHR LIQUTA SENSOR SETUP L 1 :87 STP TRI-STATE (SINGLE FLOAT) CATEGORY STP SUMP L 2:87 ANNULAR TRI-STATE (SINGLE FI;OAT) CATEGORYi ANNULAR SPADE L 3:9] PROBE-SUMP TRI-STATE {SINGLE FLOAT) CATEGORY PIFING SUMP L 4:51 STP TRI -STATE (SINGLE FL(iAT' ) CATEGORY :STP SUMP L 5:91 ANNULAR TRI-STATE {SINGLE FLOAT? CATEGORY ANNULAR SPACE L 6:DIESEL PROBE-SUMP TRI-STATE (SINGLE FLOAT) CATEGORY PiFING SUMP . L 7:DIESEL STP TRI-STATE (SINGLE FLOAT) , CATEGORY STF SUMP L B:DIESEL ANNULAR TRI-STATE (SINu^LE FLOAT) CATEGORY :ANNULAR SPACE , ?U1'b`UT RE;L€a`f SETUP 1~ 1 : ~,' ~ ~~•1.1,, T`i F'L: S'I'€nNDAkL` N+iRr"IALI,Y' CLOSED LliilJll! ~?EIy;OR ALMS €aI..l..: F'UEI. ALARM ;LL.:aENk30R OUT ALARM ALL : SHfJRT AL€~RM R '_! : 91 ~1'P '!'4`F`E ~`I'AIVC~AIiD IVC~Rr'9AI.L1' CLOSED 1, l iVU I U ;,EPIS4R AIMS ALL :FUEL AIARM HLL:SENSOR OUT ALARNI F,LL : SHOR"I' ALARM R ;3 : T:i I E:SEL STF "tYF"f:' :i"1'ANllARU' rVORNIALI,Y CLOSED L I i;~l ~ 1 I~ SENSOR ALMS AL.T.:FUEL ALARNI ALI_:SENSOR OUT ALARM ALL:NHORT ALARM R ~~ : REP'iC+TE ALARNI TY'P)r ' TAIJI'fARD rVi?Rh'tALLY CLOSED LIQUID SENSOk ALMS nI.L:FUEL iiLARhI HLARhJ H I S'fORY REPORT ----- SYSTEM HLARM ----- PAPER OUT SEF 30, 2005 11:08 PM PR I N'TER ERROk SEF 30, 2DD5 11:08 PM BATTERY IS OFF JAN 1. 1994 8:00 AM ALARM HISTORY REPORT ----- IN-TANK ALARM ----- T 1:UNLEADED LEAK ALARNI JAN 2. 2006 3:30 AM JAM 3, 2005 3:30 AM OVERFILL ALARNI (°IAR 26, 2006 5:17 PM N1AR 24. 200b 8:28 FM h1AR 21, 2006 6:29 PM LOW PRODUCT ALARM AUG ]2, 2005 5:58 FYM DEC 17. 20D4 7:46 AM AL+G 22. 2004 9:18 PM SUDDEN LOSS ALARM JAN 2, 2006 2:37 AIM JHN 3. 2D05 2:38 AM HIGH PRODUCT ALARM MAR 14. 200b 5:50 FM rVOV 16.. 2005 5:54 FM NOU 5, 2005 8:00 PM INVALJD FUEL LEVEL AUG 12. 2005 6:00 AM DEC 17, 2004 7:50 AM AUG 22, 2004 9:23 PM DELIVERY NEEDED AUG 12, 2006 3:25 AM h1AR h, 2005 B:13 AM DEC 17, 2004 5:52 AM h1AY; PRODUCT ALARM MAY 1. 2005 11:39 AM 1- zs t~ ALARM HISTORY REPORT ---- IN-TANK ALARM ----•° T '2:PREMIUM OVERF T I.L ALARM MAR 1. 2004 b:34 PM SUDDEN LOSS AI"ARM JAN 2, 2006 3,07 Ahl JAN 3, 2005 3:55 AM UELIUERY NEEDED DEC 20. 2005 11:32 ANI DEC 18. 2004 12:09 AM ALARM HISTORY REPORT ---•- IN-TANK ALARM - T 3:DIESEL DELIVERY NEEDED OCT 20, 2005 5:39 PM SEP 15. 2005 4:16 FM SEF B. 2005 8:52 PM ~ K 1 AL.FikM rI1ST~?RY REPORT -- --- ~~ENSi)R ALARM ------ ALFIRM HISTORY REPORT, L 1 : £3'7 iT'P '1'P SUI°1P `---- SENSOR ALARM ----- F! i1;I.: HL,AkP9 L 4 : 51 STP h'1t-~R 27. '~OU6 11 :35 FM F~~ S~~ L RM FUEL HLH}2r•'I P9AR 27. 2006 11:38 Pht IyIFaR ''mot. 2U05 2::38 Ahl FUEL ALHRM FUEL HL.HRt°i MAR 28. 2005 2:25 AM FEH L. 2'004 10:56 AM FUEL ALARM FEB 2. 2004 10:56 HM HLA><.I°I ! I I STORY R>=PORT' -~--• - SEIV.~OR ALARh9 ---•--- ALARM HISTORY REPORT L =' : 8'7 ANNULAR ANNU LAR SPACE --._•_- SENSOR ALHRM ----- FUEL HL.H1:M L 5:51 HNNIJLAR I.1AR 27. '006 11 :3b PM ANNIlLHR SPACE FUEI. ALARM FUEL ALHRM MAR 27. 2006 11:39 PM h9HR 28. '~G05~ : 35 Ahi FUEL ALARM FUEL ALFIRPI MAR 2B. 2005 2:25 AM FEB 2. '004 11:04 ANI FUEL ALARM FEH 2. 2004 11:01 AM HLARf°1 IiIi~TORY REPORT _- -- :~F:IVSOR AL,ARP1 --•-•-- HLHF.A'I HISTORY REPORT L 3:91 F'Ri>BE-SUMP P I F° I Nu SUhib' ----- SENSOR ALARM ----- FUEI. ALARM L 6:DIESEL PROBE-SUMP I1NR 21. 2006 11:38 PM PIPING SUMP FUEL ALARM FUEL F;LHRM t•'lAR 27. 200b 11 :40 PM fiRR 26. '?0L+5 2:26 AM FUEL ALARM FUEL HLARM MAR 28, 2005 2:30 AM APR 2. 2004 10:03 AM FUEL ALARM FEB 3, 2004 4:42 PM ( Z S(S ~~. ALHRM HISTORY REPORT -- SENSOR ALHRM --~--- I. 7:DIESEL STP ' STP SUMP FUEL ALARM N1AR 27, 2006 11:41 PM FUEL ALHRM MAR 28. 2005 2;29 AN1 FUEL ALHRM FEB 3. 2004 4:42 PM. ALARM HISTORY REPORT -- SENSOR ALARM ------ L B:DIESEL ANNULAR ANNULAR SPACE FUEL ALARM hIAR 27. 2006 11:42 PM FUEL ALARM MAR 28. 2005 2:29 AM FUEL ALARM FEB 2. 200x.11:18 AM ALARM HISTORY RBFGRT ----- SENSOR ALARM ----- 9 1 OTHER SENSORS ~. --- -- -- - r -zsi~ M4NIT4R. CERT. FA.IEURE REPURT SITE NAME: .l~~JiQf L- DATE:. ` ~-Ul.n ADDRESS: ~yLl d,~t.1~2.c_ ~T TECHMCIAN: ~ Y~~ w~ THL' FOLLOWING COMPONENTS WERE REPLACED~RE~Y~IRF.D~ COMPLETE TESTING. ~~ REPAIRS: LAEtOR• PAF.TS INTALLED: 7G~~ NA11ZE• TITLE• SIGi~IATURE• THF; ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING THF; APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THF; ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR AN1' NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANS' FINES OR PENALTIES OCCURING FROM NON-COMPLIANCE. A Ci~PY OF THIS DOCUMENT HAS BEEN LEFT ON-SITE FOR YOUR COrTVIENENCE. t' ~iluy Cont:acr- r -- •• ~ ,..._. ~ ...,.,~ n..~. !( 2~5~ Paga / of uny;3ny Name: R.TCH ENVIRONMENsI'AL '~i,c:i-uucian ConduckingTest: ~{.4-tJ ;; C:cd~.nlinls: of CSLB Licensed Contractor Q SWRCB Licensed Tank Tester ''-- License Nutxzber, 809850 ;; 1.cutse Typa. C611 D40 - - - _-- itiianuiacturer -o~gentG3) Date Train' ~ uzs INCON INCQN TS-STS ~' =07 3. 'SUIViMARY 01~' TEST RESYILTS +~~ Compo~~ent ;~_. Pass Fail Tested ~ de Component Pow 'Fail Not R®p des ~~ ~~ d ~ ^ ^ ^ a ^ ^ o ~i ~s~~- ~, ~~ ~ ^ a ^ ^ ^ A ^ y_____ ^ ^ ^ ^ [1 ^ D ^ ^ ^ Q ^ D 0 Q ^ ~~ -- D_ ^ D •^ ^ ^ [] ^ - --- ~ O D ^ ^ ^ ^ ^ •"" f:--_ _. ~ ^ ^ ^ ^ D Q ^' a ^ ^ a D D A o 1 [ !1-y~C~['OSI3IIC tC$Till$ ti'i+aS ])GT~QCII1CCi, describe what was dflne wi#h the water after eamp]etion of tests: _~_ Ri,.CYCLE AND REUSED ' CERTIFICATION OF TECHNICIAN R86PONSIBL7L FOR CONDUCTING THIS TESTING 1'v ~l:e tiest of my ]utot~vledge, tbee facts slated in tl:is dacroesitt ~tre acCttrate ttStd 1n,~ll co1>lpjiance sfv11JE~ Isga1 regw/rs~tts 1'ct:i~t~ci:~n's Signature:: Date• .~- a-'~"~/ ~,~„ Secondary Contaainment Testing Report Form - ...:: jam,-,r, is inrendec~jbr use by conlrQCrarspdrformingpertodtct6ectJng~'F!SPsecondpry canipf»yrJant,sysctp~ns. UsaShe ;:;:~~•:;Y•r~ure pages of thirform to report results for aI! cota~o~eet+t.4 tested The aompletedfor>~, written tPSSproeedw•es, and :.:.: ~~ ncus front tests (if appllenble), should be provided tp the fuGi111y owner/aperatorfar sxbmrttal to tlea laea! regrrlgte~y crgrney.. ~GVRCB, 3anuary2D02 9_ cpYr i rnvx:Rr~rr.r. enlvTan~Fr~rr soxEs z.s/ ~~ ~ of3_. Facility is Not Egtti ed With S iIUOverfil! Containment Boxes ^ SpilUOverftll Contfiinment Soxea ere Present, but were Not Tested ^ Test iti(i ethod beveloped By. ^ Spili Bucket Manufr3Cturer ^ Industry Standard ^ Professions! Engineer ~ Other (Specify) Test iVlethod Used: ^ Pressure ^ Vaeuttrn ^ Hydrostatic ~~ ^ Outer (specify) r Te Ets quipment Us:ad: Equipment Resolution: Spill Bos # {~ ~ Spill Hoz # ~ V Spill Boz #Qj l F SPIN Box # 1/ ~ Burke[ Diameter. tsucicct JDepth: I ~" i '~ 1 a l ~~ l •~ / ~ l a Wait rime between applying ~ prassure/vactuun/watersnd St~'ilit~ test: ~ (~ ,,,~ ~,LJ ~ ~ ~..,~ t,~ 3 ~ w, t,~ ,~C) •-L vL7 °1~~ststartTime: /=Y ~=~ I=~ .-, 1~O a~~7 r~ ~ ~:, ., ~ initial Reading (Rt}: 1• i 7 . ~~ v • 5 ...~ . ~ ~ti /. gai5~v ~¢H~v ,,~ TestEndTime: /:tit 1: /•' :<rv ~-7 ~%.~~ a~I? a'3 Fi TldlRea~ing(RF). ~~ ~ ,,~ .~-~ .v a.3 ,v .,~ . g ~ti /. a7 3~ 7&ya 3.7 ,,~ ~ 'Test Duration: ,.~ 1.J i r~rJ i ~a i .zip t .,~*a M,~ Change in Reading (Rx-Rt}: , Od/, - UGU -.~ . U ~ . . GYJI,.i a4~ Pass/Fail Threshold or i Criteria: .DUd•+J .J •~..J .fl~/d~ ./ .O!/d,v rd .D~1 Teri ll3esult: ~.Q Pass Q Fail .R Pass ^ Fail ~l Pass ^ Fail .>a Pass Q Fail ~i (~kcix~eIIts -- {ins lode u~orntatian on r_ pairs nsade prior to testlli~, and ~+ecommenaled follow~rtp~orr failed tests) 3 w hi.B, J-atiuary 2 QQ2 ` _ 9. SPXLL/OYERFII.)~, CU1~I~'A Facility is Not Egtu~~ed WiRI- SgillfOvez'fill Cot>tiainmattE Bolas ^ -SpilUi~verfiIl Contstvometu Boxes are Present, but were~Not T.osGGd ^ ~~ 'T~ e t iviethod Developed By: Q Spill Bucket Meuu~hu~er 1 Q Other (~.P~ifY~ `~'~sr ~zethod Usrd: - O Pressure ^ Other fSnecifvJ ^ Industry Stated C7 Vacuwn Z Sl Pagie .~ of ___-- O Ptofesslo~! Engineer ^ Hydrostatic ~i--------- ~~. Tear :quipment l3s~d: FquipmcntResohttian: ~ ~ • Spill Box # L y, ~ SpID Hos # Spill Box # SpAi Box # !~_B_~u~c_k~et Diameter, ~ ti ~~ uci~zr Depth: ;i d / __ l~~%ait ume between applying p cssur/vacuum/water and ~a t"l +~ ~tiai city rest: _ i',sr Stan Time: Y 3:iU 1r~tri~tl Reading (Rt); 7 ,v 3• ~&'0i ~ Tc~L end Tune: ~ ; /O .~-, .~: a5` i~ final Reading (RF): 3. 7 fig, v 3. 7 S3',,, r'Pasr Duration: ' Chsnae in Reading (RF-R~, I~ - ~ ~ . CXXJ~N 1'ass/Fail Threshold or U~iteria: ~ •DOd~~ •OOJ~ "~ i ~~i He~uTt: ~ Pass 0 Fall ^ Pear D Fail 0 Par>o D Fain D Pais CI Fail s uY[iiCtlreYtYS -- (in,:lude ia~ormation on repairs made prior in isstu:~a+id reaoarrae~rdedfaJla-v-yp~orfailed tests r r.IGCtN INTELLIGEk~IT CONTROLS ING P. 0. BOX 63v =:ACC1 ME En4072 1-800-984-6266 a rH r2~+G~E. 1:41 PM SUMP LEAK TEST REPORT $7F TEST STARTED 1:26 PM TEST STARTED 03/06/2F~6b F;Er,IN LEVEL 2.8176 IN END TIME 1:41 PM END DHTE 03x06x2086 ENC~ LEVEL 2 8166 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED 87V TEST STfiRTED 1:26 Phi TEST STARTED 83x86/2006 BEC+IN L EUEL 2.9542 IN END TIME 1:41 PM END DATE 03/0b/2086 END LEt1EL 2.9535 IN ' LEAK THRESHOLD 0.002 Ih! TEST RESULT PflSSED INGON INTELLIGENT CONTROLS INC P ~~. BOX 638 SAGO ME 04072 1-809-984-6266 Ei;xaG/200r. 2:33 PM 'SUMP LEAK TEST REPORT 91F TEST STARTED 2:17 PM TEST STARTED 03/86f2i~06 BEGIN LEVEL 1.9082 IN END TIME 2:33 PM =ND DnTE 03/06/2006 END LEVEL 1.9@79 IN LEAK THRESHOLD 0.062 IN j TEST RESULT PASSED 91U TEST STARTED 2:17 PM TEST STARTED 03x06/2006 BEGIN LEVEL 3.7847 IN END TIME 2:33 PM END DATE 03/06/2806 EfJD LEVEL 3.7846 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED ..~ ;: TNGON ~' INTELLIGENT CONTROLS INC ~'. 0. BUX 638 '. SAGO ME 04072 1-800-984-6~6b 03xb6/200b 2:00 PM SUMP LEAK TEST REPORT B7F TEST STARTED 1:45 PM TEST STARTED 03/Bbx2006 ';!3EGIN LEVEL 2.8166 IN 3 END TIME 2:00 PM .~ END DATE 83x06/'1066 ~'. END LEVEL 2.8166 IN ~,.i LEAK THRESHOLD 0.002 IN ~ TEST RESULT PASSED 87U ~:: TEST STARTED 2:45 PM TEST STARTED 03x06/2006 BEGIN LEVEL 2.9536 IN END TIME 2:06 PM END DATE 63x6ax2006 END LEVEL 2.9535 IN LEAK THRESHOLD 0.602 IN TEST RESULT PASSED INCON INTELLIGENT CONTROLS IMG P. 0. BOX 638 SACO ME 04072 1-800-984-6266 03x06x2806 3:i8 PM SUMP LEAK TEST REPORT DSt TEST STARTED 2:55 PM TEST STARTED 03x06r2666 BEGIN LEVEL 3.78$9 IN END TIME 3:10 PM EMD DATE 63x6,6/2606 END LEVEL 3.7$90 IN LEAK THRESHOLD 0.062 IN TEST RESULT PASSED INCON INTELLIGENT CONTROLS INC P. 0, BOX 63~, SAGO ME 04072 1-B06-984-6266 03/06/2606 x:17 PM SUMP LEAK TEST REPORT 91F TEST STARTED 2:02 PM TEST STARTED O's/06/200b BEGIN LEVEL 1.9081 IN END TIME 2:17 PM END DATE 03x062866 END LEVEL 1.9080 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED 91U TEST STARTED 2:02 PM TEST STARTED 03/06x'2606 BEGIN LEVEL 3.7847 IN END TIME 2:17 PM END DATE 03/66/2606 END LEVEL 3.7847 IN LEAK THRESHOLD b.602 IN TEST RESULT PASSED INTEI.L IGENTCON P• 0. BOX~~LS ING SAGO ME 04072 1-800-984-6266 03/86/2086 3:25 PM SUMP LEAK TEST REPORT DSL TEST STARTED 3:16 Piq TEST STARTED 03/66s2006 BEGIN LEVEL 3.7890 IN END TIME END DATE ®3x8~60b END LEVEL 3.7$88 IN t LEAK THRESHOLD, 0, TEST RESULT ~Z IN PASSED rzS15 -----,.. t ~zsi SB989 .TESTING FAILURE REPORT SITE NAME: ~~~ ~ L DATE: ~ ' ~~- ~~ ADIIRESS: ~C~~-1 , ~4~pi[-C- S % TF~CHNICIAN: ~L Y~'y h~~G2~ THIS FOLLOWING COMPONENTS TESTING. REF'AIRS• LAE-OR• ~~~ ~ PAF.TS INTALLED: ~~~~ NAP~IE: TITLE: SIG:KATURE: TIiI ABOVE NAMED PER50N TAKES FULL RESPONSIBIII7'Y OF NOTIFYING THT APPROPRIATE PARTY TO HAVES CORRECTIVE ACTION TAKEN TO REPAIR TH3~: ABOVE LISTED PI20BLEMS AMID NOTIFYING RICH ENVIItONMANTAL FOR ANI! NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF AN7r FINES OR PENALTIES OCCURING FROM NON-COMPLIANCE. A C~DPY OF THIS DOCUMENT HAS BEEN LEFT' ON-SITE FOR YOUR ~ COPd'VIENENCE. ~ 5(~ ~~L~IiV~ & PERMlT STATEMENT { PEt~tlnli" NO.: ;` BAK~RBFIELD B'IIZE D~I'T. Prev~nt3on ServHces ~~ 900 Truxatn Avenue, Suite 210 Bakersfield, CA 93301 it 40CATlON Of PROJE T ~ ~ - r',RMFJ(rT pWNtl( 1 fARTWu DATE COAAPLETION PATE NAA4ff A~~l..`~/J'A` PP.O~cCT~ V ~R~ESS _- - - - ~ PHONE NO. ~ PRO.~EC7ADORESS ~5: ~ . ~ ~ CRY STA~E IJPCADE o co CONTRACT NAME CA LICENSE NO• T1'P OF LICENSE EXPIRATION QATE PH041E N0. CONTRACTOR MPANY NAME ,. ~ Less ~ ~ cRr ~ ~ ~ FAX NQ ' !~ ~ ~ 34 ~ -o ~ ~ 1 z>P of ~~ ._ v 5p un Char 2t32 ^ Alar s -New & Modificati ns - (Minurl e) $ ~ g t m o . ~ 9 Ft+ O r 20 000 S 013125 = Permit fee FZ x S ^ q. ve , . q, ^ kl w & Modific tion Minim m Char N i S $210 00 9 ge) ers - s - ( u pr n e a . ~ ^ 000 S FL Over 5 042 = Pernrlt fee Ft x S , i q. . q. ~ ^ Miner S rinkler Modifications {c 10 heads) 00 [lnspeckori Ontyj $ 93 ~ L. r ^ p Commercial Hoods -New & Modifications . $ 398 $6 ~ . ^ AddltYonat Hoods 336 04 ~ i . ^ Booths -New & Modifications Spra $458 00 y I . 9 _ ^ Above round Storage Tanks (Installattion/lnsp: 1'r Tlme) $165.00 ^ Additlona! Tanks 326.00 ^ Aboveground Storage Tanks (RemovaNtnspectWOn) $109.t~1 h ^ Underground Storage Tanks (Ir~staNa~oan.Anspection) $878.Op (pertank) ^ Underground Storage Tanks (Modification) $878.OQ (persite) ^ Underground Storage Tanks (Minor Modification) $155.Op ^ Underground Storage Tanks (Removan $675.0() (p'ertanl~ ^ Sitwell gnstallaGon) $72,00 Mandated Leak Detection (festi I Fuel Montt $ 81.OQ (persite) ^ Tents $ 93.00 (per tent) ~ ^ After hours inspection fee $122.00 ~ t3p ^ Pyrotechnic - (Aer event, Plus Insp. Fee ~ S90 per hour $ 60.00 + (5 hrs. min. sta*W -by tee pr>spegion) = $510.00 8{t ^ RE INSPECTION(S) /FOLLOW-UP INSPECTIONS $ 93.00 {per hour? 8}t ^ Portable LPG (Propane): NO.OF CAGES? $ 66,OQ 8A ^ Explosive Storage ~ $'149.00 ^ Copying & File Research (a=ils Research Fee 533.00 Per hrj 25¢ PEr Page ^ Misceilaneous ; FD 2021 (Rev. 09105 !1, i ~~' 1iiVt31:RGROUND STORAGE TANKS ~~~~icaTioN TO PERFORM ELD 1 UNE TESTING ;~~ 58988 SECONDARY CONTAINMENT TESTING ~~ (TANK TIGHTNESS TEST AND TO PERFORM 1=UEL MONITORING CERTIFICATION f ~ / BAKERSFIELD FIRR DEPT. ` Prevention Services IRrr 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: {661) 326-3979 Fax: {661) 852-2171 Pape 10(1 ' PERh,IIf NO. ^ ENHANCED LEAK DETECTION ~^-y LIN E ^ 38.988 SECONDARY CONTAINMENT TESTING ~~ r,. ~r Tv~~Tw~rcc TCCT fZl TA OGOCl1CI1A GI IG1 •~A1J17/lOtl12 f`FRTIFI/`1TIAIU iI FACtL1TY ~~ \ 1 i `~-~~ I ADDRESS ~~ ~ I ~ _ NAlMIE 8 PHONE NUMBER OF CONTACT PERSON t~S 0., q3 0 ~ OWNERS NAME OI~kRATORS NAME I PEhtaIIT TO OPERATE NO. ' I NUMBER OF TANKS TO BE TESTED PI !N Y ~ l} 1 ~ ~~ ~- 3 - ~_ TANK~'E8TlNG CQMPANY 1VAME OF TE NG CO PANY NAME 3 PHONE NUMBER pF CONTRACT PERSOeN~ p /~ iNAiLiNG ADDRESS _ ~ ~ ~' r~c~lc C~ -- ~ -ltd Cot- 9 3'3 0 $ NAME 8 P ONE NUMBER OF TESTER OR SPECIAL INSPECTOR t~ m t - Coro ~- GERTIfICATtON ii: UA]'E & TIME TEST TO BE CONDUCTED ~--~ - ~ i 51GNATURE OF APPLICANT 11 _ 1 0 d 1'"t r C ~~ ICC f: DATE ~ ~' Cj . TEST METHOD ANPROVED BY DATE FD 2095 (Rev. 08/05) UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELD /LINE TESTING SB989 SECONDARY CONTAINMENT TESTING !TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION P/l~l A/~rr T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 PERMIT NO. ~~ '- ~~~ ^1 ENHANCED LEAK DETECTION - ^ LINE TESTING SB-989 SECONDARY CONTAINMENT TESTING 1 1 T4Al1C TI/_LITAICCC TFCT n Tn PFRFnRM FI IFI MnNITnRwr rFRT1FIraTInN SITE INFO RMATION ' ., FACILITY ^\ ~,n NAME 8 PHONE NUMBE OF CONTACT PERSON `~_ ADDRESS ~ ~ (~ O~ 1..T~~ V ~ ., ~ ~ ~ V~~ OWNERS NAME OPERATORS NAME PERMIT TO OPERATE NO. NUMBER OF TANKS TO BE TESTED I PIPING GOIN TO BE TESTED? YES ^ NO T # VOL ME CONTENT 1 y Z TANK TESTING COMPANY NAME OFT TING MP Y U ~ NAME PHONE NUMBE OF CONTACT PERSON e^~ ~nf pC ..- MAILING ADDRESS ~~ ~1~~ r _ ~ I ~~ G NAME HONE NUMBER OF TESTER OR SPECIAL INSPECTOR CERTIFICATIO #: DATE & TIME EST OBE CONDUCTED ~ N ~ V c U ICC #: ~~ ~ ^ ,, ~[,~ ~~ TEST METHOD SIGNATURE OF APPLIC NT DATE ~~. APPROVED BY ~ -' DATE ~ FD 2095 (Rev. 09/05) F/RE ARTM RONALD J. FRAZE FIRE CHIEF Gary Hutton, Senior Deputy Chief Administration 326-3650 Deputy Chief Dean Clason Operations/Training 326-3652 Deputy Chief Kirk Blair Fire Safety/Prevention Services 326-3653 0 2101 "H" Street Bakersfield, CA 93301 OFFICE: (661) 326-3941 FAX: (661) 852-2170 RALPH E. HUEY, DIRECTOR PREVENTION SERVICES FIRE SAFETY SERVICES • ENVIRONMENTAL SERVICES 900 Truxtun Avenue, Suite 210 Bakersfield, CA 93301 OFFICE: (661) 326-3979 FAX: (661) 852-2171 David Weirather Fire Plans Examiner 326-3706 Howard H. Wines, III Hazardous Materials Specialist 326-3649 December 1, 2005 Oswell Mobil 2524 Oswell Street Bakersfield, CA 93306 FINAL REMINDER NOTICE RE: Necessary Secondary Containment Testing Requirements by December 31, 2005 of Underground Storage Tank (s) Located at the Above Stated Address Dear Valued Customer, Over the last six months this office has continued to send reminder notices regarding secondary containment testing. Code requires that all secondary containment systems must be tested 6 months post construction and every 36 months there after. Senate Bill 989 became effective January 1, 2002, section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and every 36 months, thereafter, to insure that the systems are capable of containing releases from the primary containment until they are detected and removed. Our records indicate that your facility is due prior to December 31, 2005. Those sites that have not been tested and have not pulled a permit prior to December 31, 2005, will have their permit to operate revoked. This office does not wish to take such action, which is why we will continue to send monthly reminders. Contractors are already booked several weeks in advance. I urge you to schedule your testing date as soon as possible to avoid possible revocation of your permit to operate. Should you have any questions, please feel free to call meat (661) 326-3190. Sincerely, RALPH HUEY, Director of Prevention Services n _n ~^ r-. Steve Underwood Fire Prevention Officer SU:db UNDERGROUND STORAGE TANKS AIPPLICATION TO PERFORM ELD /LINE TESTING / S8989 SECONDARY CONTAINMENT TESTING /TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION , !-/R/ AIlTM T '~ BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Pi~ge 1 of 1 PERMIT N0. t ~"'~ ^ ENHANCED LEAK DETECTION ^ LINE TE ^ SB-989 SECONDARY CONTAINMENT TESTING ^ TANK TIGHTNESS TEST ~ TO PERFORM FUEL MONITORING CERTIFICATION i FACILITY ~(~ 1 1 ~C~~I~ d NAME S PHONE NUMBER OF CONTACT PERSON ADDRESS ~ i - l^~ ` ~ ~~~~` ~ i, V OWNERS NAME OPERATORS NAME PERMIT TO OPERATE NO. NUMBER OF TANKS TO BE TESTED IS PIPING GOING TO B TE TED? YE ^ NO i TANK # VO E CONTEN S I ._ g '"~ I 2 ~ -~~-~ 3 TANK TESTING COMPANY ! NAME OF TES NG CO PANY ~ ~ NAME & PHONE NUMBER OF CONTACT PERSON c~~ - a -s~ ~ MAILING ADDRESS NAME r;< P ONE NUMBER OF TESTER OR SPECIAL INSPECTOR o~ YYl 0 (- ~ a ~ -- CERTIFICATION #: DATE & TIME TEST TO BE CONDUCTED _ ICC #: TEST METHOD SIGNATURE OF APPLICANT ~ C C~ DATE ~ j Cj . (0 APPROVED BY DATE ~ ~~ / % ~~--.1~ FD 2095 (Rev. 09/05)