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HomeMy WebLinkAboutBUSINESS PLAN (3)'~' ~' ~~XACU ~ ~ ~ (AKA TEXACO FOOD MART) 5609 STINE ROAD ~~ ~ • • 1 1 4r ~n I ~ ~`'J VU) I ;~'1 II `'- _ `' + STINE ROAD TEXACO ___________________________________ SiteID: 015-021-001916 + Manager BusPhone: (661) 665-2390. Location: 5609 STINE RD Map 123 CommHaz : Moderate City BAKERSFIELD Grid: 23A FacUnits: 1 AOV: CommCode: BFD STA 13 SIC Code:5541 EPA Numb: DunnBrad: +______________________________________________________________________________t _ Emergency Contact / Title Emergency Contact / Title LOUNG K CHAO / OWNER MELISSA CHAO / OWNER Business Phone: (661) 836-3766x Business Phone: (661) 836-3766x 24-Hour Phone (661) 393-8828x 24-Hour Phone (661) 393-8828x Pager Phone (661) 319-8828x Pager Phone (661) 319-8828x Hazmat Hazards ~ - . _ " - ~ ~- - -_-> - - - ~- _ .~ ~..: , ,_ _-__-:.- _ _-~~ ~_ _ _ ~: _ _ ~_ __ Contact Phone: (661) 665-2390x ~MailAddr: 5609 STINE RD State: CA City BAKERSFIELD ~ Zip 93313 Owner LOUNG K CHAD Phone: (661) 393-8828x Address 5609 STINE RD State: CA City BAKERSFIELD Zip 93313 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: ~ Emergency Directives: ~ PROG A - HAZMAT PROG U - UST x _ }~ ; 2 5 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, accurate, and complete. Si ~ - /.~"~SCj g Date -1- 04/04/2006 _* r~ _ UNIFIED PROGRAM INSPECTION CHECKLIST SECTION 1 Business Plan and Inventory Program Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NA E IN ECTI N DATE INSPECTION TIME ADDRESS ------~ S~t H~ ~ - __ ___ ________ _ ~ PH NE o. No. of Employees ~'3~ 3 >~_- --- -~ -- ------ -- FACILITYCONTACT i Business ID Number 15-021- Section 1: Business Plan and Inventory Program ^ Routine ombined ^ Joint Agency ^Mu1ti-Agency ^ Complaint ^ Re-inspection C V \ V=Vio ationnce } OPERATION i 1~^ APPROPRIATE PERMIT ON HAND COMMENTS -- ~--- ------------------------------------------ ---- B -------------_ L USINESS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY I ^ V ERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL >~ ^ VERIFICATION OF MSDS AVAILABILITYE ^ VERIFICATION OF HAT MAT TRAINING ~^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ~^ HOUSEKEEPING ^ FIRE PROTECTION ^ ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE: ^ YES ^ NO EXPLAIN: QUESTION GARDIN HI NSPECT ?PLEASE CALL US AT t66'I ~ 326-3979 -_ - - - -__--_------1------.--- _------ ----~-- ---- ---- Inspector Badge No., Business Site Responsible Party White -Environmental Services Yellow • Station Copy Pink • Business Copy -^. .,~~ O~~w4~' T~~\ CITY OF BAKERSFIELD FIRE DEPARTMENT `6 ~ ~ b OFFICE OF ENVIRONMENTAL SERVICES ~`~ '~~` UNIFIED PROGRAM INSPECTION CHECKLIST \~cY ~gti,,~'~~ 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 ~.~~~~ -- FACILITY NAME ~(~(L. ~'~C~.Q(~ INSPECTION DATE 3 X1.1 Section 2: Underground Storage Tanks Program ^ Routine ~mbined~, ^ Joint Agency ^Multf-Agency 3 ^ Complaint ^ Re-inspection Type of Tank ~Q(1}E- Number of Tanks _ Type of Monitoring ~LlY~ Type of Piping nU1 OPERATION C V COMMENTS Proper tank data on file Proper owner/operator data on file 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 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 overfill/overspill protection? C=Compliance =Violation Y=Yes N=NO Inspector: Oft7ce of Environmental Services (805) 326-3979 White- f-:nv. Svcs. Pink -Business Copy (,C[~' Business Site Responsible Party •{ UNIFIED PROGRAM INSPECTION CHECKLIST ~~' 3f,'ytl . ":..rt}~ -`7 :?354«.S':v°:3..< ..Y .:. i:, t c. .. ,-: ~;~ t. .'::::i"-~.. ~,. .'.:... .: -. ..-.;,::: ~ ~:...., ,.:• :.a:v: ': ~ -~~!'~ '-" .SECTION 1: Business Plan and Inventory Program BARERSFIELD FIRE DEPT a p Prevention Services rwlt~ 900 Tnixtun Ave., Suite 210 ~R>rr ~ Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY N ME ~--- NSP CTIO DATE INSPECTION TIME ~ ADDRESS H ONE NO. O OF PLOYEES `` ® ~ Y '~ ~j V FACILITY CONTACT USINESS ID NUMBER 15-021- (,~~~ Section 1: Business Plan and Inventory Program 5 ~ ` OV~ ROUTINE COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPFGTION C V (~=Compliances OPERATION V=Violation COMMENTS APPROPRIATE PERMIT ON HAND ^ BUSIfI@SS 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 D ~ ~~ ~ ~ ~~~ ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? ^ YES EXPLAIN: - _ _. THIS INSPECTION? PLEASE CALL U8 AT (881) 328-3979 Inspector (Please / 1" In /Shift of Site/Station # White -Prevention Services Yellow - Staton Copy i h ible Party (Please Print) Pink -Business Copy FD2048 (Rw.lMJ05) .~ ,- .a.Lll ~~ P~w~~' '~~ \ CdT1' OF fiAKERSFIELD FIRE DEPARTMENT d ~ ~ ro OFFfCE OF f1;NVfRON14'8EN'1'AL SERViC:ES `~~ yea UNIFIED PROGRAM INSPECTION CHECK~.[ST \ e„wE'~~~,~~'~~ f 7 i 5 Chester Ave.„ 3"' Floor, i~akiersfield, C'A 93301 ° _ ,,~. FACILITY NAME_~ It~f•O.t~Q _ (NSPFCTION DATE `g ~ © o Section 2: Underground Storage Tanks Program ^ Routine ~mbined ^ Joint Agency ^ Multi-Agenc ~ Complaint ^ Re-inspection Type of Tank l~f,(T~` ~ Number of Tanks Type of Monitoring ~-Ll/h Type of Piping OPERAATION C V COMMENTS Proper tank data on the Proper owner/operator data on the Permit fees 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 ti - -~ Section 3: Aboveground Storage Tanks Program TANK SIZE(S) Type of Tank AGGREGATE CAPACITY Number of Tanks OPERATION Y N COMMENTS SPCC available SPCC on the with OF.,S Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MVF? If yes, Does tank have overfill/overspill protection? C=Compliance =Violation Y=Yes N=NO Inspector• Office of Environmental Services (G61) 6-3979 ~~l'hitc - f-nv. Svcs. Business Site Responsi le Party Pink - F3usiness C~~Py STINE ROAD CHEVRON Manager LOUNG K CHAO Location: 5609 STINE RD City BAKERSFIELD SiteID: 015-021-001916 BusPhone: (661) 836-3766 Map 123 CommHaz Moderate Grid: 23A FacUnits: 1 AOV: CommCode: BFD STA 13 EPA Numb: SIC Code:5541 DunnBrad: Emergency Contact / Title Emergency Contact / Title LOUNG K CHAD / OWNER MELISSA CHAO / OWNER Business Phone: (661) 836-3766x Business Phone: (661) 836-3766x 24-Hour Phone (661) 393-8828x 24-Hour Phone (661) 393-8828x Pager Phone (661) 319-8828x Pager Phone (661) 319-8828x Hazmat Hazards: Contact LOUNG K CHAO Phone: (661) 836-3766x MailAddr: 5609 STINE RD State: CA City BAKERSFIELD Zip 93313 Owner LOUNG K CHAO Phone: (661) 393-8828x Address 5609 STINE RD State: CA City BAKERSFIELD Zip 93313 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD PROG U - UST a~ ~d ~~N~°~ i,J U L ~~ ~ ~ ~ ~ ~ , 7r o ~ dividuals res~nn~i ie `iL?r ocfa.irzin t a . d 9 h_, m.ormation, !certify unde r p..nalty of ;a~; t;,at I ha+ie personally examir°~; and am tarniiiar with th i e nformation subrn~tted ~1nd '~e;~eve the information is true , accurate, anti complete. Sig~~ature -- ~~ Date -1- 07/16/2007 ~_ . T,. F STINE ROAD CHEVRON SiteID: 015-021-001916 ~ STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: STINE ROAD CHEVRON Cross Street Business Type: Org Type: Total Tanks 3 IndnRes/Trust: No PA Contact: Dsg Own/Oper LOUNG K.CHAO ICC Nbr: 5246167-UC PROPERTY OWNER INFORMATION Name MELISSA CHAO Phone: (661) 836-3766x Address: City State: Zip: Type Name MELISSA CHAO Address: City Type BOE UST Fee# Firianc' 1 Resp Legal Notif Date: Name: State UST # TANK OWNER INFORMATION Phone: (661) 836-3766x State: Zip: Phone: ( ) - Ttl: 1998 Upg Cert#: x -2- 07/16/2007 ~ t ~ ~ l! F STINE ROAD CHEVRON SiteID: 015-021-001916 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP REGULAR UNLEADED L 12000.00 GAL Mod PREMIUM UNLEADED L 8000.00 GAL Mod DIESEL L 4000.00 GAL Low -3- 07/16/2007 -4- 07/16/2007 ,p _ ' 7 ~ F STINE ROAD CHEVRON SiteID: 015-021-001916 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME REGULAR UNLEADED Days On Site 365 Location within this Facility Unit Map: Grid: UST CAS# 8006-61-9 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TMixture ~mbient ~ Ambient --~ER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 12000.00 GAL 12000.00 GAL 12000.00 GAL t1AGHKLVU~ 1=V1~lYV1Vl;1V7J %Wt. RS CAS# 100.00 Gasoline No 8006619 t1F~iGH.tCL H~5~~~1~11;1V 1 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod ~ Inventory Item 0003 COMMON NAME / CHEMICAL NAME PREMIUM UNLEADED Location within this Facility Unit SPLIT TANK STATE TYPE -~~ PRESSURE Liquid TMixture ~ Ambient Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8006-61-9 TEMPERATURE CONTAINER TYPE Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 8000..00 GAL 8000.00 GAL I 8000.00 GAL ntiGlittLVUJ L.V1~1rVlvl;lvl7 %Wt. RS CAS# 100.00 Gasoline No 8006619 riH.Gti[CL H. 7.7~.7Jl~lJ~,1V l b TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod -5- 07/16/2007 r J ~L F STINE ROAD CHEVRON SiteID: 015-021-001916 ~ ~ Inventory Item 0004 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME DIESEL Days On Site 365 Location within this Facility Unit Map: Grid: SPLIT TANK CAS# STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid-TMixture f Ambient ~ Ambient ~ER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum 4000.00 GAL 4000.00 GAL Daily Average 4000.00 GAL ru-~c~titcLVU~ ~.vi~irvNENTS %Wt. RS CAS# 100.00 Fuel Oil No. 1 No 70892103 _ riE~Gf1.tCL L-~b ~~~51~1~1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Low -6- 07/16/2007 F STINE ROAD CHEVRON SiteID: 015-021-001916 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ r~yvu~:y 1VV1.1111:dl.lUil _ ~ i .... Lu~N.~.Vycc iVVl..lt . ~ rJVdl:Udl.1V11 ruLlllc: lvc~~lt . / rJVdCUaL1Oi1 ~:,uiciycllLy 1"1CUlC:dl Yldll -7- 07/16/2007 F STINE ROAD CHEVRON SitelD: 015-021-001916 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention Release Containment 1..1 CQ11 lJ~! v~.llc1 1CC.7vuLl.:C til:l.lVdl.lU11 -8- 07/16/2007 r. ~ - F STINE ROAD CHEVRON SiteID: 015-021-001916 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ JjJeC:ld1 ncLLcirus Utility Shut-Offs Fire Protec./Avail. Water Building Occupancy Level -9- 07/16/2007 IS „ i i F STINE ROAD CHEVRON SiteID: 015-021-001916 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training rayc a nciu iu.c r u~uL~ use nc.LU iv,L r u~u.~c v5C -10- 07/16/2007 i_-- -' Tank ID: U~~ g7 Tank ID,: f~l '~...In=Tank Gauging Probe. Modek !'I}d~~ ,f~ln-Tank Gauging Probe. Model; -Anni+lar Space or Vault Sensor. Model: t-i at? ~,4nnular Space or Vault Sensor. Model: (Sf~L=t~_ ~. Piping Sump /Trench Sensor(s). Model: ~O`~ ~-Riping Sump /Trench Sensor(s). Model: d$ ^ Fill Sump Sensor(s). Model: ^ Fill Sump Sensors}. Model: Mechanical Line Leak Detector. Model: ~t~,~T .l~Mechanical Line Leak Detector. Model:tt~ J/~~k.E.'i`' ^ Electronic Line Leak Detector. Model: ^ Electronic Line Leak Detector. Model: Q Tank Overfill !High-Level Sensor. Model: O Tank Overfill /High-Level Sensor. Model: ^ Other s ecif a ui meni t e and model in Section E on Pa e 2 . CD Other (s ecif a ui ment a and model in Section E on Pa e 2 . Tank [D: ~ lEcS t:l- Tank El): ,~In-Tank Gauging Probe. Model: L ^ In-Tank Gauging Probe. Model; ~Amnuiar Space or Vault Sensor. Model: ~l o ~T D Annular Space or Vault Sensor. Model: ,~~P.iping Sump /Trench Sensor(s). Model: ^ Piping Sump /Trench Sensor(s), Model: O Fill Sump Sensor(s}. Model: ^ Fill Sump Sensor(s). Model: ~-Mechanical Line Leak Detector. Model: J2E~ Jf~G1e~T Q Mechanical Line Leak Detector. Model: ^ Electronic Line Leak Detector. Model: ^ Electronic Line Leak Detector. Model: ^ Tank Overcll / Higft-Level Sensor. Moc1e1: ^ Tank Ove~ll !High-Level Sensor. Model: O Other (s ecify equipment type and model in Section 13 on Page 2). ^ Other (specify a uipment type and model in Section E on P e 2). Dispenser l4: 7- 1~Dispenser Con aintnent Sensor(s). Model: CInU ~ V Dispenser tD: 3l ~-{ .Dispenser Contatnment Sensor(s). Model: ~~A V '.Shear Vatvc(s). Shear Valves}. ' ^ Dis eraser Containment Floats and Chain s). ^Dis eraser Containment Floats and Chains . Dispenser ID: s~ Dispenser ID: 7 ,'~ ~ Dispenser Containment Sensor(s). Model: ~G ~J~. RE Ay _ Dispenser CoR~talnment Sensor(s). ModeL• ~ U r ~ Shear Valve(s). Shear Valve(s). O Di~pcnser Containment Floats} and Chain(s). ^Dis ehser Containment Floats and Chain s). Dispenser ID: /O i Dispenser Contai ment Sen Mod l ~ Dispenser ID: n sor(s). e : 0~7 ^ Dispenser Containment Sensor(s). Model: i f~"Shear Valves}. O Shear Valve(s). DDis eraser Containment .Float(s) and Chain(s). ^Dis ehser Containment Floats and Chains . ~ ~ °ZS MONITORING SYSTEM CERTIFICATION For Use By.411 Jurisdictions Within the State of California . Authority Cfte& Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code afRegulations This form must be used to document testing and servicing of monitoring equipment. A seBarate certification or report must be prepare for each monitoring system cont~o~anet by the technician who performs the work. A copy of this fot'm 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 Facility Name: ~ j-~Ey ~'`1 131dg. No.: Site Address: ~!v_U~1 .S Ti ^~ ~- IZS~ City: ~ fi K.C. S?r ~'~ t_~. Zip: Facility Contact Person: Long G-,~'~ NoAV Contact Pltone No.: (~) Make/Model. of Monitoring System: T~-S - 3 ~0 Date of Testing/Servicing: 3 /~/ t7 7 B. Inventory of Equipment Tested/Certified INSPECTOR ON-SITE: YES(NC NAME: ~c~N>`. Check the appropriate boxes to indicate specife equipment inspected/serviced; « +nc +acu+ry contains more tanks or atspensers, copy m+s totm. Include information for every tank and dispenser at the facility. C. CertlftCation - t certify that fire equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certlf'icatio~t is Information {e. g. manufacturers' checklists) necessary to verify thatthls informatiou is correct and a Plot Plan showt»g the layout of monitoring eq ipment: For any equipment capable of generating such reports, I have also attached a copy of file report; (check alt that appty~• System set-upAlarm history report Technician Name (-pripnt): ~Qfjvll ~~,~~ ~j/~Sp~ Signature: ~-~~ -s _ _ Certification No.: 8~~3 ~ ~ License. No.: _~~8~1~~$ a- U ~ ` Testing Company Name: RICH ENVIRONMENTAL Phone No.: ~ 661 ~ 392-8687 Site Address: ~~ Q ~ ~.r/U >= ~~ ~ ~f) ~~(~~ 1 EC-~V C~ Date of Testing/Servicing: ~/off ~, / e, 7 Monitoring System Certification Page I of 3 03101 i (o~2S D. Results of Testing/Servicing Software Version Installed: /(o • ~ S .,:_.. VV111 IGaG Yes ally a O o Is the audible alarrn o erational? ~ Yes ^ o Is the visual alarm o erational? Yes ^ o Were all sensors visual) ins ected, functional) tested, and confin-ned o erational? ~~Yes ^ ° -Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper o eration? ^ Yes ^ o If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) ~-~IlA operational? Yes O o For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment ^ N/A monitoring systein detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that app/y)~Sump/Trench Sensors; ,^ Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? Yes; ^ No. ~- Yes O o systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no For tank ^ N/A , mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill point(s) and operating pro erly? If so, at what percent of tank capacity does the alarm trigger? ~U ^ es ~, No Was any monitoring equipment replaced? If yes, 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 any secondary.containment systems designed as dry systems? (Check all that apply) ^ Product; ^ Water. If es describe causes in Section E below. --Yes ^ o Was monitorin s stem set-u reviewed to ensure ro er settin s? Attach set u re orts, if a licable Yes ^ o is all monitoring equipment operational per manufacture-'s specifications? * in Ject~on ~; netow, descnUe now and when tnese deticlenctes were or will de correctea. E. Comments: Page 2 of 3 031 o I z l fooaS F. In-Tank Gauging / SI1Z Equipment: ~ Check this box if tank gauging is used only for inventory control. 0 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. Complete the fnllowin>? checklist: O Yes O o Has all input wiring been inspected for proper entry and termination, including testing for ground faults? O Yes q o Were all tank gauging probes visually inspected for damage and residue buildup? D Yes O o Was accuracy of system product level readings tested? ^ Yes O o Was accuracy of system water level readings tested? D Yes D o Were all probes reinstalled properly? Q Yes ^ o Were al! items on the equipment manufacturer's maintenance checklist completed? * t.. •f.~ C....~:..., u L..tno. .loo.,ra,n 6•,.,. n„rl ,vha.. +F,ncn `Iaflnia'nrire warp nr will ha onrrPr•tert_ G. Line Leak Detectors (LLD}: ^ Check this box if LLDs are not installed. ('mm~tn+a +ha rn{Inwinn ohar4lict~ Yes O No' For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? O N/A (Check a!! [ha[ apply) Simulated leak rate; ~3 g.p.h., D 0. I g.p.h , ^ t}.2 g.p.h. .Td-Yes O o Were all LLDs confirmed operational and accurate within regulatory requirements? Yes O o Was the testing apparatus properly calibrated? Yes ^ o For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ^ N/A ^ Yes ^ o For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? _1 ~N/A ^ Yes D o For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ~N/A or disconnected? O Yes O o For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions N/A or fails a test? D Yes O 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? ••• .•.v.~,.~uvn •~, U~1VR, a/w~, ivc nvn nuu +YUCII 111C5C UCIICICIIC{eS Were Or Wlll ae COrreC:teQ. H. Comments: Page 3 of 3 03101 ~oaS Monitoring System Certification UST Monitoring Site Plan Site Address: rloo4 ~T~ NE ir-9 ~ ..3A~:-c2~F~ '~ LPS ------------- ----------{o-------.Icy-- ------ - - "-- ---------•-- ----------------- ---- -- ~/- -Y---- ------------- ----- ---------------- ~~ -- N c Date map was drawn: ~ !~,/~ Ins ructions 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. Page Ll of~ ostoo ~~~~ 563 ~~.00~3 C~ &'9xC~R,S~'x~LD,CA.93~08 OFk'TCE(&61}392-~G87 &`~`AX (661.}512^061. f W/0#: 8'ae:Lli~~r Naut®; C H ~V ~~J I k'aC:1.~3,t~ Addx~~ea: ~.12~~ bC~n)E'P~ ~~fj~1~~~~E~.~~ C~ prgc;~ue0 Line ~`Y1?e {pressure, suatiam, ex~avity) P~^' '~t1re-~--~- p$(:1DUCT LEAK DETECT07.2 T~'~~ Tk:ST '!~`RxF PAi38 s~txAL zatrraas~R BET~OW F6~ OR ~7 •s~~zAL # inEc.~~tA N~.c~tc_ gip. la ~~xLi i _ L/A 7CXPR„R-~~ JP~Ltc~r ~j 9' / S&RT.A.L #n'I~c.alPc~c~4L ~0 /~ b'A~L ~~SE~--- B~RTAL # !-~~~ft-n1SCf~.-- ~ ~O ~~ B.A.TL z.In ~x~~ ~s Pass? as~x~z. ~.._._ aro ~AZr. i ;:artify the above teats were ednductet3 on this data a,caoxding to Rsd ~:fackat Pumps faelra test appaxatua testl.ng pz~o.cecluxe azi lim3tat#,ane. Tki~~~ Mechanical Leak Detactar Test pas,9 / fa~.1. is' determined by u~iag a lour flow thz'eskaol~l trap rate o:~ 3 gallon-per hour ox' lees at 10 ~+SI. z s~aklaowledge tJriat all data collected ie true and oorxaae Co the besC of r~•}T knowledge . 5 igzLa t ure : ~----~--~ ~~---~" pate : 3 r"c~ C~ -~ k•. i ~ coo SWRCB, January 200b Spill~Bucket Testiing Report Form 1~'hisfonn is intended for use by contractors performing annual testing of iIS'T spi11 containment structures: 77te completed form and. printouts fromlests (applicable), should be provided to the facility'awner/operatorfor submittal.to the local regulatory agenry. Facility Name: C ~ E!J .J - -- -- -- Date of`TESting: -0'2 (o- O ' . Facility Addn~s: O ~ 5 ~~J t. K-E ~ - , . Facility Contactl ~ cw L-~ cv Phone: (o f - - ~ d ~ Date Local Agency Was Notif ed of Trsting : '. ~ ~ ' Nano of Local A,Yency Tnspectcr CffPresent during testing: • ~v a~ ~ ' . ' 2_ TF,CTiNC: C_t~NTR AC'TnR iNFnRMATION Company Name: N J ~~ L ~ .. .Toehnician Caanduccting Test. ~ iz A,v f~5ui..). Credtntis]a : CSLB Contractor., ICC Service Tech. SWRCB TatilcTester. Other eci ) License Numbers}: ~ v vv.++..^vu cw - urc~uae ur orinatton on re trs maare rior to testin and recommended Ilow~ or ailed tests' ' CERTIFICATION OF TECffir'ICLAN R~SPOI~ISIBLE FOR CONDUCTING T$iS TESTING I hereby eertlfy that all the information contained in this report is true, accurnty' and in fu11 co»iplianee with legal requirement Technician's Si~ature~ ~` f~----~ Date:,,~r"~- ~ 'O ~ Stato laws and ctgulations do mot currently require testing to ba performed by a qualified contracWr. Hoa~aver, local requiremcuta may be mon stringent, SOFTWARE REVISION LEVEL ~~r7MUNICATIONS SETUP ~ co o a S VERSION`16.05 - - - - - - - - IN-TANK SETUP SOFTWARE# 346016--100-F - - - - - - - - - ` CREATED - 98.08.21.18.55 PORT SETTINGS: T 1:UNLEADED NO SOFTWARE MODULE COMM BOARD SYSTEM FEATURES: 2 (S-SAT ? BAUD THERMAL COEFF :.000700 PERIODIC IN-TANK TESTS RATE 9600 PARITY TANK DIAMETER 95.00 ANNUAL IN-TANK TESTS STOP HIT O D TANK PR E : I STOP DATA LENGTH: 7 DATA VOL 12048 FULL RECEIVER SETUP: FLOAT SIZE: 4.0 1tU. 8496 -" I NONE •--• ~ WATER WARNING : 2.0 . HIGH WATER LIMIT: 3.0 MAX OR .LABEL VOL: 12048 OVERFILL LIMIT : 90i SYSTEM SETUP ~ 10843 _ _ _ _ _ _ _ _ _ _ _ _ H I GH PRODUCT 95% • MAR 26. 2007 2:46 PM ~ 11445 DELIVERY LIMIT 10: • 1204 SYSTEM UNITS LOW PRODUCT 500 U.S. SYSTEM LANGUAGE AUTO DIAL TIME SETUP: LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 50 ENGLISH NONE TANK TILT 0.00 SYSTEM DATEiTIME FORMAT MON DD YYYY HH:MM:SS xM MANIFOLDED TANKS • T#: NONE STINE RD TEXACO 5609 STINE RD HAKERSFIELD CA 93313 LEAK MIN PERIODIC: 10% 661-836-3766 1204 SHIFT TIME 1 5:00 AM LEAK MIN ANNUAL 109. SHIFT TIME 2 DISABLED 1204 .• SHIFT TIME 3 DISABLED SHIFT TIME 4 DISABLED RS-232 SECURITY CODE OOD000 PERIODIC TEST TYPE TANK PERIODIC WARNINGS ~ 9UICK DISABLED TANK ANNUAL WARNINGS ANNUAL TEST FAIL DISABLED ALARM DISABLED LINE PERIODIG WARNINGS DISABLED LINE ANNUAL 4dARNING$ ~ RS-232 END OF MESSAGE PERIODIC TALARMADISABLED DISABLED DISABLED PRINT TC VOLUMES AUTO DIAL ALARM SETUP _ - - GROSS TEST FAIL ALARM DISABLED ENABLED - - - - - - - ANN TEST AVERAGING: OFF TEMP COMPENSATION P>~R TEST AVERAGING:. OFF VALUE (DEG F >: 60.0 9T1CK HEIGHT OFFSET TANK TEST NOTIFY: OFF DISABLED TNK TST SIPHON BREAK:OFF H-PROTOCOL DATA FORMAT HEIGHT DELIVERY DELAY :`15 MIN DAYLIGHT SAVING TIME ~, ENABLED START DATE APR WEEK 1 SUN START TIME 2:00 AM END DATE OCT -WEEK 6 SUN END TIME 2:00 AM RE-DIRECT LOCAL PRINTOUT DISABLED SYSTEM SECURITY caner : aoaoao T 2:SUPER PRODUCT CODE 2 THERMAL COEFF :.000700 TANK DIAMETER 95,00 TANK PROFILE 1 -PT FULL VOL 8016 T 3:DIESEL PRODUCT CODE 3 THERMAL COEFF :.000450 TANK DIAMETER : 95.00 TANK PROFILE 1 PT FULL VOL 4008 FLOAT SIZE: 4.0 IN. 8496 FLOAT SIZE: 4.0 IN. 8496 WATER WARNING _ : WATER WARNING : 2.0 HIGH WATER LIMIT: 3.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 8016 MAX OR LABEL VOL: 4008 OVERFILL LIMIT gpi. OVERFILL LIMIT •90i HIGH PRODUCT 7214 95i HIGH PRODUCT 3607 95% • ?615 3807 DELIVERY LIMIT 10i DELIVERY LIMIT 15:c • 802 601 • LOW PRODUCT 500 LOW PRODUCT 300 LEAK ALARM LIMIT: 99 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 50 SUDDEN LOSS LIMIT: 50 TANK TILT 0,00 TANK TILT 0.00 MANIFOLDED TANKS MANIFOLDED TANKS T#: NONE T#: NONE LEAK MIN PERIODIC: 10% • 801 LEAK MIN ANNUAL l0i • 801 PERIODIC TEST TYPE eUICK ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVERY DELAY ; 15 .MIN LEAK MIN PERIODIC.: 10: • 400 LEAK MIN ANNUAL l0% 400 PERIODIC TEST TYPE QUICK ANNUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS TEST FAIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF TNK TST SIPHON BREAK:OFF DELIVERY .DELAY l5 MIN LEAK TEST METHOD TEST ANNUALLY: ALL TANK MAR WEEK 1 WED START TIME : 2:30 AM TEST RATE :0.20 GALiHR DURATION 2 HOURS LEAK TEST REPORT FORMAT ENHANCED LIQUID SENSOR SETUP O`~ L 1:87 ANNULAR TRI-STATE (SINGLE FLOAT? CATEGORY ANNULAR SPACE L 2:92-DIESEL ANNULAR TRI-STATE (SINGLE FLOAT) CATEGORY ANNULAR SPACE L 3:87 STP TRI-STATE (SINGLE FLOAT? CATEGORY STP SUMP L 4:92 STP TR1-STATE fSINGLE FLOAT) CATEGORY STP SUMP L 5:DIESEL STP TRI-STATE (SINGLE FLOAT) CATEGORY STP SUMP OUTPUT-RELAY SETUP - - - R 1:87 TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS - -- L . L~~ARP4 - _._.: L 3:FUEL ALARM R 2:92 TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS L 2:FUEL ALARM L 4:FUEL ALARM R 3:DIESEL TYPE: STANDARD NORMALLY CLOSED LIQUID SENSOR ALMS L 2:FUEL ALARM L 5:FUEL ALARM R 4:REMOTE ALARM TYPE: STANDARD NORMALLY OPEN 1N-TANK ALARMS ALL:OVERFILL ALARM ALL:HIGH PRODUCT ALARM ALL:MAX PRODUCT ALARM LIQUID SENSOR ALMS ALL:FUEL ALARM ALARM H]STORY REPORT ---- IN-TANK ALARM - T 1:UNLEADED HIGH WATER ALARM SEP 7. 2005 2:58 PM 4VERFILL ALARM MAR 26, 2007 2:24 PM MAR 22. 2007 12:50 AM h1AR 14. 2007 1:44 PM LOW PRODUCT ALARM JUL 22. 2005 6:29 PM MAR 3. 2005 5:45 PM FEB 9. 2005 8:27 AM HIGH PRODllCT ALARM MAR 26, 2007 2:24 PM JAN 17. 2007 9:34 PM DEC 27. 2006 7:47 AM 1NVALID FUEL LEVEL JUL 22. 2005 6:20 PM MAR 3, 2005 5:35 PM MAR 2. 2005 9:08 AM PROBE OUT MAR 26, 2007 2:25 PM MAR 26. 2007 2:22 PM SEP 7. 2005 3:47 PM HIGH WATER WARNING SEF 7. 2005 2:58 PM SEP 7. 2005 9:42 AM Dirt 1 VERY NEEDED FEB 5. 2007 1:46 PM JAN 10. 2007 6:36 PM OGT 14. 2006 9:04 PM MAX PRODUCT ALARM SEP 7, 2005 3:31 PM SEP 7. 2005 3:05 pM SEP 7. 2005 2:53 PM LOW TEMP,WARNING SEP 7. 2005 10:48 AM DEC 9, 2002 12:25 PM ALARM HISTORY REPORT ---- IN-TANK ALARM ----- T 2:SUPER OVERFILL ALARM NOV 10, 2002 12:31 PM OCT 1. 2002 9:20 AM NOV 29, 1999 12:22 AM LOW PRODUCT ALARM JUL 5, 2002 7:50 PM DEC 6. 2001 9:20 AM SEP l5, 2001 6:39 PM NIGH PRODUCT ALARM MAR 26. 2007 2:1? PM AUG 10. 1999 6:57 FM INVALID FUEL LEVEL MAR 26: 2007 2:19 FM JUL 5. 2002 9:15 PM DEC 6. 2001 1:47 PM PROBE OUT MAR 26. 2007 2:19 PM MAR 26, 20D7 2:16 PM DEC 9. 2002 12:36 PM DELIVERY NEEDED AUG 24. 2004 12:06 PM JUI, 5. 2002 4:32 PM AEC 28. 2001 5:47 PM MAX PRODUCT ALARM MAR 26. 2007 2:17 PM ALARM HISTORY R~I~B~`~` ---- IN-TANK ALARM '-___ T 3:DIESEL OVERFILL ALARM MAR 26. 2007 2:08 PM FEE 17. 2007 4:42 FM LOW PRODUCT ALARM DEC 14. 2005 8:56 AM SEP 1, 2004 4:35 PM NOV S. 2003 4:04 PM HIGH PRODUCT ALARM MAR 26. 2007 2:10 PM F£B 21. 2007 3:42 PM INVALID FUEL-LEVEL SEP 1. 2004 7:30 PM JUL 3. 2002 8:24 AM MAR 3. 1999 6:57 AM PROBE OUT MAR 26, 2007 2:12 PM NOV 20, 2002 2:07 PM DELIVERY NEEDED JUL 19. 2006 8:19 PM OGT 29,.2005 10:58 AM MAX PRODUCT ALARM AUG 5. 2005 .1:41 AM AUG 22. 20D? 3:20 FM ~ ~ * * ~ END * * ~ x ALARM HISTORY REPORT SENSOR ALARM L 1:87 ANNULAR ` ANNULAR SPACE FUFL ALARM MAR 26. 2007 1:03 PM FUEL. ALARM MAR 30, 2006 11:08 AM FUEL ALARM MAR 28, 2005 9:27 AM ._ ____ __ .___ _ -- .-- l ~ oa 5 ALARM HISTORY REPORT ALARM HISTORY REPORT ----- SENSOR ALARM ----- L 2:92-DIESEL ANNULAR ANNULAR SPACE FUEL ALARM MAR 26. 2007 1:28 PM FUEL ALARM MAR 26. 2007 1:02 PM FUEL ALARM MAR 30. 2006 11:07 AM x ~ ~ ~ ~ END ~ ~ ~ * ~ ALARM HISTORY REPORT ----- SENSOR ALARM ----- L 3:87 STP '• STP SUMP FUEL ALARM MAR 26. 2007 1:01 PM FUEL ALARM MAR 30. 2006 11:06 AM FUEL ALARM SEP 7. 2005 1:34 PM ----- SENSOR ALARM ----- L 4:92 STP STP SUMP FUEL ALARM MAR 26. 2007 12:59 PM FUEL ALARM MAR 30. 2006 11:06 AM FUEL ALARM • MAR 28. 2005 9:25 AM x * ~ * * END * ~ * ~ ALARM HISTORY REPORT ----- SENSOR ALARM -- L 5:DIESEL STP STP SUMP FUEL ALARM MAR 26. 2007 1:27 PM FUEL ALARM MAR 3Q. 2006 11:07 AM FUEL ALARM MAR 26. 2005 9:26 AM ~ c~ oa S MQ1yITOR CERT. FAILURE REPORT SITE NAME• C N~.U ~~ DATE• ~-2~1v -U7 ADDT RESS• S(o~`~" ~,~~^-'E t/L~ TECHNICIAN: ~f~Anls~~,•~ rnfibo,v CITY::: ~ A 1~ ~S ~~~ !=~ SIGNATCiRF:~j'r~ ~-- TSE FOLLOWING COMPONENTS WERE REPLACED/REPAIItED TO COMPLETE TESTING. ~ .: . REPAIRS: /L~.~ E LABOR: ~o~ c- s- PARTSINTALLED: NU~~ i NAME:: 1TTLE: iV1~1A1~U1C1'~: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILTTy OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICE ENVIItONMANTAL FOR ANY NEEDED RETESTING. TH[S ALSO RFt.~'A c~r.S glCg E~rgtONMEN•TAL OF ANY FINES OR PENALTIES OCCURING FROM NON-COMPLIANCE, A COPY OF TffiS DOCLTNIENT HAS BEEN LEFT ON-SITE FOR YOUR CONVIENENCE. l ~e oa5 UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELD !LINE TESTING ! SB988 SECONDARY CONTAINIIRENT TESTING !TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION BAKERSFIELD FIRE DEPT... ~~t~ Prevention Services A~l~I r 900 TTwctTan Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (6b1} 326-3979 Fax: (661) $52-2171 Page 1 of 1 Vv~ f C~ PERMIT N0. ~-T~ ^ ENHANCED LEAK DETECTION ^ LINE TESTING-------~_ ~ ~~~ 0 J~.ov~Om ^ 5688 SECONDARY CONTAINMENT' TESTING l.J IA1'IR 10.a1111'ICJJ ~ W ~ ._ L~ .. .. .. v r ~... v ..... ......, .... ) .,c ~ ~_ - . FACILITY ,. NAME 8 PHONE U E ON T P N ADDRESS -. 3 OWNERS NAME ' OPERATORS NAME PERMIT Tp OPERATE N0. N MBER OF TANKS TO BE TESTED P N 1 T ®~ ~ r 2 ~, d o Q - j "~ DO C7 iAN1C;7EST! G COMTPANY.. NAME OF TESTING MP Y NAME & P MB R ACT PE N MAILING ADDRE NAME d. PHONE N BER OF TER OR PATE 3 TIME TES TO B COND ED P CULL INSPECTOR ~rn~ `~ !~ ^~RTIfICATION >st: ~~ ICC #: ' TEST MEtHOD SIGNATURE OF APPLICANT ~ ~ DATE a APPROVED BY DATE Fp 2095 (Rev. 09/05) .. ~~0~5 Bfl~LING & PERMIT STATEMENT ~~Rr rPERMIT NO.:, r BAKERSFIELD FIRE DEPT. Prevention Services 900 'Truxtun Avenue, Suite 210 Bakersfield, CA 93301 w r-___ IGLt 1 OC•] h171 ^ ~ r.~~• • LOCJ1110N OF PROJECT. - ~ ~ PROPFATY OWNER STARTNIG DATE N DATE • CU O NAfrE PROJECT Nh1.E ADDR PNOt~E NO i pRQlECTADORESS CITY STATE ~ • ~• CONiTtACTOR F14AE CA LICFTISE N0. , •• • TYPE OF LICENSE EXPSiAT10N DATE PHONE N0. r CONTRACTOR OOAa+ANY NAriAE FAX N0. ADDRESS Crn' ZJP CODE ~ ~ ~ 262 $ 50 ^ h • • ~ arge) Alarms • New & Modifications -(Minimum C . . 8t3 000 S FL 013125 = Permit fse FL x S ~ ~ q. Over 20, . q. 98 ^ r s - Mi i Ch difi ti S kl s & M ri N $210 00 ~ ge) ( mum a n ca on n p er - ew o . 98 O 000 S Over 5 FL 042 =Penult fee S Ft x ~ q. , q. . 98 ^ rinkler Modifications (< 10 heads) Minor S 00 [fnspecction Only) $ 93 ~ p . 98 ^ Commercial Hoods -New & Modifications $39826 ~ 98 O Addttlona/ Hoods Z 36 00 ~ . 38 ^ Spray Booths -New & Modifications $458 00 ~ . 98 ^ Aboveground Store a Tanks.{lnstapatioMnsp -1' Tme} $165:00 ~ ^ Additions! Tanks S 26.00 ~ ~ a Aboveground Storage Tanks (RemovaYinspectan) $109:00 82 C7 Underground St a Tanks (lnstal/atanJirlspedion) $878.00 (pertank) 82 ^ UndergrTwnd Storage Tanks (Modircation) $878.00 {persite), 82 ^ UndergrntrrTd Storage Tanks (Minor Modification) $155.00 82 ^ Underground Ston~ge Tanks (R+9mova~ $675.00 (pertankJ 84 ^ oitwell {Irrstaflation) $ 72.00 ~ 8a Mandated teak Detection (1'esti Fuel Moniu Ctir2~~ $ 81.00 (perslteJ tit 0 Tents $ 93.00 (pertenQ 84 ^ ARer hours lnspecdon fee 5122.00 84 ^ PyrotechrTic - (Per event, Plus Insp. Fee ®590 per hour) S 60.00 + (5 tva min. stand -by bee nnspecUOn) _ $510.00 84 ^ RC~INSPECT70N(S) /FOLLOW-UP INSPECTION(S) $ 93.00 (per hour) 84 ^ Portab{e LPG (Propane): NO.OF CAGES? „_ $66.00 84 ^ Expbsive Storage $249.00 84 ^ Copyir-g ~ File Research (File Research Fee $33.00 per hr) 25¢ per page 84 O Miscellaneous ~ ~ 84 FD 2021(RSV: 09V0~ 1- ORiGtMltt. WHITE tto T4easurvl 1-YELt.OW tto Flle) 1?rNK coo Gustomorl (: . ~1:CH: S~F3i~`1~1 `w Tir14 :~ ~. I$ 3798 n S'CE' a L~ ... ~ _ At.I~1~i4~~~ 3~MATpRE ;",~,os`~' a UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELD /LINE TESTING / SB989 SECONDARY CONTAINMENT TESTING /TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION PERMIT N0. ~ OJ BAKERSFIELD FIRE DEPT. f~R~ Prevention Services ART/I r 900 Truxtun Ave., Ste. 210 ~. Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 1^ ENHANCED LEAK DETECTION ~ ^ LINE TES _~~~ ^ SB-989 SECONDARY CONTAINMENT TESTING 1 1 TA HIV Tlr!uT-ILCC TCCT Tn DCDCAD~A CI IFI \An N1TnDIAIr (`CRT'IFIhATInAI .. _.:. :.: !:SCTEINFO RMA FACILITY NAME 8 PHONE U E 0 ON T P N ADDRESS .-- OWNERS NAME OPERATORS NAME PERMIT TO OPERATE N0. NUMBER OF TANKS TO BE TESTED I PIPIN OIN TO BE TESTED? YES ^ NO T V LUME CONTENTS 8~~ J 2 ~~oo ~ ~ o0 0 TANK TESTI G COMPANY NAME OF TESTING MP Y NAME 8 P UMB R N ACT PE ON MAILING ADDRE ~ _ NAME 8 PHONE N BER OFT STER OR DATE & TIME TEST TO B COND ED -O PECIAL INSPECTOR ~~RTIFICATION #: ~~~~~~ ICC #: ' DO TEST METHOD SIGNATURE OF APPLICAN~ ~ DATE a ~.O APPROVED BY ` ~ ~~ ~ J DATE ~ FD 2095 (Rev. 09/05)