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HomeMy WebLinkAboutBUSINESS PLAN 5/22/2007~~/ // p -~ \ e_liv~o~-~~ ~ ~~~ ~„ <~ ;, ~E; I ~~ ~~ LUCRY 7 STORE !2501 White Ln -- - - --- --- ---- -- - ------_ ~`i ~O~ ~ 3~5'~~ 1 ~a~~- Es~~s~s~y ~ ---= ~,~f _ _ DESIGNATED (UST) OPERATOR - MONTHLY VRSUAi. INSPECTIQN CHECKLIST UNDERGROUND STORAGE TANK Page 1 of 2 ~~, '~:, B A~F' B R S P ]',JI,+L D =n', FIRt . o~~w R relitnr Bakersfield Fire Dept. Envi ental Service n Ave.. Ste. 210 rsfleld, CA 93301 TeI: (661)326-3979 Fax.: (661) 852-2171 fTEM MONRORING PANEL l ALARM HISTORY Y N NA 1 Mor~r6rg system is pt>vrersd on and ht.ptoper aP9 3 Alarm liotayl reporfllOg tar the previous morrftr is a+ratabie, and has been reviewed by the 4 Each alarm for the previous month has been responded to apprapria~tely. List a8 tank-top Sumps whose elarrrrs otxtrned m the past maerth: , Nt#~ Sums rt9twla an alam- has occurred In dre perst mor+th meat be irrspaexed emte55 a tluaRred service tedrrrician responded to acrd pr>~eAy eked the cause ~ the abmL Ad~tr doamrore verrily&tg appropriette service do this repoR. lfstmrp!->specdorr is retpdred recavd rr in tern ~ bedrnv. UST SYSTEM INSPECTION Tank-top oruNaarerrettt swaps are flee of wafer. dads, and h2¢aMotrs sut-startce. Senses are bested properly. JVata: Irises! brslrec~Farr atsumps Is a~dy required Yr seenps where an alarm has occurred in the past monde for adraXr d-~e is no service raooral. Sump Locadean: Sum Location: ~ Locgdarr: Swrap Locadan: Sump Loe~an: SurrplocaVore ~ SpM catW~vntshuchws are free of watre, dsbzis, and hazardous sz~tarzrx. Y N NA Y N NA Tank 1- Cartettts: g'7 Tank 3 - Corrtertts: TaNr2-Lbrdow+~ ~~ ~ Tardr4-Carrtents: a U t:orztainnretzt~reas era free of water and tazardous substanew. Sensors are located Y N TiA ~ Y N NA Dfsporza9r if2 ... Dispenser 9H0 Dtspenser 3t4 Dispenser 1V12 Dispenser 518 Dispenser 13/14 Dispsrzaer Tl8 Dispenser 15116 __ 9 Monitoring system cert8ication has treen meted within past 12 months. `~ 10 _. Secondary oonta~nrnerrt tests have been meted within the reoerirett;#ntte~ralrle.. 11 Sgfll containment strucUue tbuckett tesfino was cgmgleted witl>ktH1a vear::..~ 12 Tank tightness testitw wascorngleted within required tirrretrame::. .:;~ 19 Line tiahtrtess testlno was completed within required timetrarne. - . 14 _ - Otteer regrur~ feslindmaintenanoe was camdeted within repulsed- ~ List tesNhiatldenarrCB Test/Ma/rtterrarrtaer Test/AtaiMenance: FACILITY EMPLOYEE TRAINING - Y N NA 15 A11 have reed the ~ witlmtifie 18 M faa7ity erriptoyees felted wdhin Ute bast 30 days'tiave receiired the +etttdt~ad girl-the-3ob trahpnft: i ,.;: Notoz Any saswor of ^N• shonid tba esxplainod in the eommont section on the fallowing pogo. and will rogniro follow-r action. DESIGNATED (UST) OPERATOR MONTHt-Y VISUAL INSPECT~pN CHECKLIST <' ,` , ~ . I~ --~=-~~' -~.. ...~:,: _ _ :._.v,_ .~r_~., .... ra ., .a,ri ..,..., v,- ~ a,~~`s a S F ~~A~~.n UNDERt3ROUND STORAGE TANKD, FlRt ARTAti1Yf ~',,~? Page 1 at 2 . BakersSeld Fire Dept. Environmental Services 900 TYttxtun Ave., Ste. 210 Bak+ersfield> CA 93301 Tel: (fi61~32fi-3979 Fax.: {661) 852-2171 REM MONfTORiNGPAN~.IALARMHISTORY Y N NA t~-MordtoArrg SYStern is Dowered on and kr.proper operating mode. ( s . ( Atanrn Hisiay oeportflog for une previous montH ~ a,raaable. and Has t>eern reviewed by rna I / I I ~ 4 { Earn alarm for the previous rtarMh has tnaen responded to appropriately. I `~i I I I flat of fardc-top ~ar~ where ads aa~irted in the past moMk Note: an alarm has oaawred in thepast rmorrth rmrst be irrspeded rade5s a 9uatrfled service techniaan rasportd~ed to, and properly add the treu~se of Hre atarrn. Attadt dncraner~Han verifying appropri~e service to tlua report lfarsnp atsper~iorr ~ regrared rsraordresuils in Item ~ trelow. UST SYSTEM INSPECTION Tank-top containment sumps are iree of water. debris, and Hazardoussubstance- Seniors are kx~ted properly. Nate: V1suaJbratrec0on ofsrar>psis arUyregedred in srrrrrps where an a~mr has oodured irr the past morrtlr for which there is no service record ~ I SpN ~ era true of water debris, and hasar+dous Tank 1- CoAter+Qa: g'7 I ~ ~' l I Tank 3 - CorKerrts: Tardc 2- Cow S rl TaMr a-Contents: -s- - _ - - - -- - Y N NA Y N NA t!2 Dispenser 9110 Dispenser su Dtspennser 1u12 Otspenaer 5fK Dispenser 18H4 . Dispenser 71tt D1spNraer 15t1ti .:. 9 Monitom+o system cer6fical;on ties been oomdeted wiltun-oast f2 moitlls. .- `- i 0 Secondary containment tests have been conroleted within the ieewaed~lile. / _ 11 sofa amtalnment saucture (budcati tesdrna was comolated wNhkl the bast v~ - . . i2 Tank tioMness testing was completed wdhin required timeftarrne. - .._ _... -... _ ~~ 13 Lme tiatttness testirta was comWeted with[n renuired timefrart 4a Oilier teauired testindmaint~anoe was cortmfeted within rearmed l&~iet~ri~:.: llsitesY/maltrteriaru~' Test/MaWenance: TesUMainterrarrce: FACILITY EMPLOYEE TRAININQ Y N. NA Note: Any answer of "N" should be explained ins the comment section on the following pager and will require follow: action. Jul 12 07 02:42p p,2 OE~GNATED (UST ~PERAT~R ~' .. ~ Ba~crsB.eYd. Flue D~ ~~ YOii~li'HLV MSI~AL IN.SPECI'~QN CAST ~ ~~ ~~:'``:_.:: .:-~ Eavironme at~ai e~+ S , _ ~ / ~'. a R 5 P 1..~~~ _ ~ r . tVx Ffltl , A G~ A 9~OU ~~ AV£., V 1.G. ~. U E TANK .. j:> d~P,~l~'rai~ils HakessHeid. CA 93301 . _ : ;' ~,:;::; ~. TeL• [fi61)326-39P9 ~e~az ,. F2uc: [~6L~ $52-Zi71 i T K M ~Y~1 y F , . ~ G~:~ " L! , f ~ ~ _, ~ ~ ~ ~ <~ ~.` - ~~ r~~~~ • .!~ .. yy {{ `` ~ ~ /~ y~ ~ ~ ~ ~ p ~ ~+~, y~ ~ ` p( ^ ~ ~ .-~ .: ~~/~ ~/y ~yi~~ly.~ ~j.}y~,, :~1~1c4Y~f}w~?~~{~!~aa~-1i~1/{Y~ ~,y~Tyy}~}]{~y~ ]y /jam ~M3~~/ia'LA\~G: ~ / 4, ~ it/~. _~~ ~ _ Y =Yes,; N s NoC NA n NotAppRwible 179J 110lYflOFtNi6PAflICL1ALJIRIAJgSTOliY Y N NA 1 .. .. .. .. ._ ilanNsA~tp fG poweredoo aMia mode. / 3 J11acQ+hb~y sapo~Nfop fore prewou6 aiorif-Isswn~6le, aed lies l~0en iesiewe0 by fis ~' 4 , f.~ alarm far ffia proiaacss mo1Mh toes beets respocdBd So approprteMly. ~/ El~ta# Lrrtrriop aompacrrfrsealanaooarrad ialhepeslnbrrN[ IIIObC S~r~s wtreraan sAsmr dWSQOC7Aladhtllep6ef1110Yd7Ira/6t17sY6~C10d1t~teSS 7l gtQlli~YedGeN~as tedYi~f~t71~t6pOr101Bf~fa a11dp1~pOl~}' ad~98S9d.d~C8f1~9C~~1?Sl9mr. A~11~QJ[R91XAtlRIVfi~t.41-i!?94btl~SlerJOYi . Nsurpi~rppcKpvffin>~aYaQ, ra~ror~?.ttesrrtlsin~aar 8r briar. . TeNr•1ap OarNeirMrlBf# OfH11Yr6 safisR oFlwei9r. debris. and tt~d0us avbatarloa. Sepsats ere iarated praQe~ly. fYoio<' Y-la41f 4~epMCIiDROfrui7ptit arY~~ragiriredtn wr>ps nrler6 as a/Qiar hr:s aararedb fA9 pest matfh tDr rddclr f~ lB no service ~eoord. 7. spimnlarrw..t.sti.cl~.saq Tart ~ - QaniaNsc g'~ teak s _ r~orleelao $ 4 6 ~ leamraors sobsgnoe. t'ardc s- Qarrfurtt: Tanlc4- Codrrls~ Natra Aay aurstrr~r oI rN• should 6r rxplrWrd In thr aommeet saation oa ttr• tolla~ng paYrs wnd will rrgafra toll siet7oa. Jul 12 07 02:42p DEStCNATED ~USTj OPERATOR •~i - ~O~N_Y V~SUAE. A-13PEC'f~! CHBCK~JST ' . UNQERGROUNU STORAC'E T/rL1~EK - F+age t o[2 ' ' p.1 .~~ ~~ Ba~ers$eld Fire De; /^ ` ~ ~ ' Envim~neata~ Ser ~~ ~~. e a s R r ss;} n 900 TYtl2ttun AVe.. Ste. 2 t _,_, Fll~l ~,t~xsr~r B31aerSHeld. CA 93301 1~L: (661]326-379 1~: {66 Lj 852-2171 ~anr , ; `: = ~ - wa~_ X330 .. .i 4 .. .~_ .~, 1. ..f ,mot.. ..` . Y.~ ! ~~~~~: - - ;r w-naNnc.000~: . ~r~: ~~ iA,7IONUJ4'i~: j2 . !LT"l D~ -- - - ` ; : sNO: t~l' ~ . 397 ' 3 ? ~~ Y = Ys~ N a Nq NA = Nbt AppBcsble . Ra+l MDN[I~Otip1GFA[~i.IAtARWIHISTORY Y N NA 1 IAORiW~f1188y6bBlBiGp(NR19dOnendiit 4ri1d~ 8 /11mA tictgq iapOS[1bp t7IY18 pIBV[OUd rY0(r!s itt Srmiabim, ind tp16 been rer[e~u6d by flee / 4 EsrA1 HSann tx the pesnr[a~c tnaih teas trees responded W approp~ialely. Listartanic-1qp x~1111pe rv11B~e sienna oodlrred Ye1t~e pOStmondr • FIof6: Sis~stNiersanafarrnJwBt>D~a07r+a+epDStmor~musrbein~fe~du~fesssa4~~~servdceledr+kiar-r~ondedlGanrlpwpedy - aaf~e~ MlBafil~e8ha/ln. IICYChd7ptmgnfffiiOrl i~etr7ydr~epp-aprFatBSBIVd~B BD~IS tB,pOft lfsrnptgspecBonts figaGed, mcordlet~fMfs~den/Bi,CeIOW. ' l1STS1YS4L-iR Y~P'f~730N f~P oollfai~slfelst 8liefieb of vsaler, deLrfa, aM hemdorea srrbBlance. Setr8015 eselDGBtiBd ptC[redy. llio~6s: 1NQa[ LupprNag dsrrr~ l9 aYytaQuta9dhstnps sheraan inn lr®s ac~uoedii thspns[ mw~fi ~br wt+iph Yiere is noaarrice record Location LOratiprl' I,ocatlo~x LoCalkur 7 SyrN csrg0e41mestsksrsrawe iPe tiel~t`ereier, dsbris,and hasasdpue w6staoce: Y N NA Y NA • Tisrts i - ca~rc ~ Tanta- [~ ( ,~ aad s Y N NA Y N NA - Diepeoeer ilz Dgpesrser saND Aiepen~r alt plspeoeer ii/12 0[rpNSOC bIB Dfepsassr lEli4 _ t7lspesges•71C ~iepesAV15[1i ' 9~ ~ . . ~ b1011~OF1110lDVSE01¢~C~f~6oll lsBi6llaen CO[{~C[E~B~Md91in',oP~6t:~?r71~onMm.. •~ to semi~roa~i~imertt~ishavs+~eenmeio[eBedwu;ri-ur, _ , ,~ sofa ~ s~rueDa~a i~ertloe+D tvims ~omoietea..~nde.~sse',i~es~ _ 92 Tank;tidrines6les~na rras coarogated vr~ttr-.~eadred,fimet<aa~ia:.:: ~:::_ _: %.- :':.: ; :.. .. - 13 line ttclrf[lers lesEYYa was 6omoltfBd w8Mr1'teadted ~fleekeiwe: -• :: :.. 14 , .OU~er'asoufsad ~ wets coiialelell wiFin re0u4adyinrd6~artie::' 37tYJe6lVbraEYhgnce , . - Tesb7tQa3rterserroec : =: .. - - T _ .. ... ~. ,. fAOWIY'HiAP'Lt7Yl~'fRA4NINt3.•~.: 15. ABt~.it.et~llOVemdrsus~~ed:lln~enieid ~cak~nw9ditF~ia~Yf e~ ~ Notr: Any seswor of RIi• s[soss[d beT oxp[sirad in th• aoeroront soetioa as tp• fo[[arw[ag pogo, sad wf[I rogu[sw io[[~ arotioe. ~- ~ LUCKY 7 FOODSTORE 11 Manager : G~a`~~ ~T~" - ,` Location: 2501 WHITE LN A City BAKERSFIELD CommCode: BFD STA 05 EPA Numb: SiteID: 015-021-000083 BusPhone: (661) 397-3722 Map 123 CommHaz Moderate Grid: 13C FacUnits: 1 AOV: SIC Code:5541 DunnBrad:06-294-4160 Emergency Contact / Title Emergency Contact / Title GINA HAM / OWNER EDWARD HAM / C~6~~~;-~~,~-y Business Phone: (661) 397-3722x Business Phone: (_~"; °"" ~r-°'-~ 24-Hour Phone (661) 665-9370x 24-Hour Phone (b6t) h6S - `~37~ Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHlth _L~ _ _ _ _ _ __ __ - - Contact GINA HAM ~ ~~ ~ _ _ _ ~ 4 Phone: _ - -- -- (661) 397-3722x MailAddr: 2501 WHITE LN A State: CA City BAKERSFIELD Zip 93304 Owner GINA HAM Phone: (661) 397-3722x Address 2501 WHITE LN A State: CA City BAKERSFIELD Zip 93304 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif' d: RSs : No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG U - UST C/~~ IV F'~g 2 6 ZU o' 3ased"~on rriy inquir - - _ ,~ __ responsible for obtaini g n ~ ~ d - - - - ----- -~---= --- - _ .... - n the nformatio , I c ertify under penalty of law that I have perso e nally xamined and am familiar with the information submitted and belie ve the information is true, accurate, and compiete. r Si nat g ure Date -1- 02/02/2007 .~f F LUCKY 7 FOODSTORE 11 SiteID: 015-021-000083 ~ - STORAGE CONTAINER DATA (UST FORM A) ` Last Action Type: FACILITY/SITE INFORMATION Business Name: LUCKY 7 FOODSTORE 11 Cross Street Business Type: Org Type: Total Tanks 3 IndnRes/Trust: No PA Contact: Dsg Own/Oper AARON KOOP ICC Nbr: 5246167-UC PROPERTY OWNER INFORMATION Name Phone : ; .-' " ; " " ~ " r "' -~ Address: C-~rr~r~l~ ~~ev~s City ~' O ,~nx ~2~5 State: Zip: b61- q o4 ° `108 Type ~.~ ~.1'S~~ -e(c~ C~~ q 33$x9 TANK O4~TER INFORMATION Name ~ ro_ ~.,~ _o~~ ~~~,~„ Address : ~ q Y~ ~ G ~ D 1~~ City te: Zip: BOE UST Fee# : UNKNOWN Financ'1 Resp: STATE FUND Legal Notif Date: Phone: ( 2 ) - x Name: Ttl: State UST # 1998 Upg Cert#: -2- 02/02/2007 DESIGNATED (USTj OPERATOR MONTHLY VISUAL INSPECTION CHECKLIST UNDERGROUND STORAGE TANK Page 1 of 2 p,_ B_R_S P 7 D F-Rt swr,t r Bakersfield Fire Dept. Environmental Service 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel: (661)326-3979 ' Fax.: (661) 852-2171 FACILITY NAME: ~~ '~- DATE: FACILITY ADDRESS: `~ CITY: ~ ZJP CODE: '~ DESIGNATED UST OPERTOR CONDUCTING THE INSPECTION: ~ a ~' INTERNATIONAL CODE COUNCIL CE TIFICATION #. ~ 1.4 $ l)~~ PIRATION DAT E : ~ 2 l 13l SIGNATURE:' // II PHONE NO: ( ~7~ 3 ~ ~ 2 _ ~~ ~ ~' Y =Yes; N = No; NA =Not Applicable ITEM MONITORING PANEL /ALARM HISTORY Y N NA '- _ 1 - ---- - --- Monitoring system is c~wvered,on and in Proper operating mode. - - _ ~/ _ _ -T _ 3 Alarm history teport/log for the previous month is available, and has been reviewed by the 4 Each alarm for the previous month has been responded to appropriatery. ~ List atl tank-top sumps where alarms oaxrmed in the past month: Note: Sumps where an alarm has aa+curred in the past month must be inspected unless a qualified service tect-nacian responded to, and P+oPeAY addressed, the cause of the alamt. Attact- documentarian verifying appropriate service to this report ff sump inspection is required, -ecord results in item 6, below. l1ST SYSTEM INSPECTION Tank-top containment sumps are free of water, debris, and trezardous substance. Sensors are located properly. Note: Yrsual inspection of sumps iS oMy required in sumps where an a/am- has occurred in the past month for which there fs no service nsrArd Stag Locati~: Sump LoCaBon: Sum Locati~: Sum Locatipr: Sump Lotretion: Sump Location: 7 SpfU coMainmeM structures are free of water, debris, and hazardous substance. Y N NA Y N NA Tank 1-Contents: uN t; $~ .Tank 3 -Contents: ~ ~ U'~- ~, - Tank 2 - Carrterrts: u N L- ~~ v Tank 4 - Contents: 9 Underdis near contaMment areas ar e free of water debris and hazardous-substance. Sensors are located ro rl . Y N NA Y N NA Dispenses 1/2 Dispenser 9110 Dispenser 3/4 Dispenser 11h2 Oispenser 5/ti Dispenser 13/14 Dispenser 7!B Dispenser 15/18 9 rvlpnitorireg system certiflption has been completed wittrin past 12 months. ~/ - 10 Secondary containmertt tests have been completed within the required tlmefreme: ~/ 11 Spill containment structure fbudcet) testing was completed wittun the psst veer. 12 Tank tiohiness testirw was completed within required timeframe. / 13 Line tightness testlrw was tbmoleted within required timeframe. 14 Other required testindmaintenance was cpmnteted wffhin feauired timeframe. List testlmai-llenerrce it Test/Maintenance: Test/Maintenance: FACILITY EMPLOYEE TRAINING Y -N NA ' 15: All. have received the red prl gb traintn within the' st ar: 18 Alt fall em _ tilted veitlun the 30 da 'have received the uiretl% . b trains Note: Any snswt•r of °N° should btt t.xplainrrd in the commrant srretlon on tbt• following pago~ end will rraquirs follow-ul sction. DESIGNATED (UST) OPERATOR MONTHLY VISUAL INSPECTION CHECKLIST UNDERGROUND STORAGE TANK Page 1 of 2 S_ _B_R_s_p.-~- ~ F/Rl were ~ Bakersfield Fire Dept. Environmental Service 9001Ytixtun Ave., Ste. 210 Bakersfield, CA 93301 Tel: (661)326-3979 Fax.: (661) 852-2171 FACILITY NAME: , f ~I ~ ;~j / ~ 1~ ' 1 l DATE: ~ O ~ ~ ' ~ {~ FACILITY ADDRESS: ~ ~ Q ( ~ ;'e (.. /mod ~J 1~f. I '~ P ~ V l (~ CITY: ` ~ ~ Y ~ {' ~ ~ C- I~ ZIP CODE ~ ~ ~ ~ DESIGNATED UST OPERTOR CONDUCTING THE INSPECTION: ~~ ~ A ~ ~~ vl~'\ INTERNATIONAL CODE COUNCIL CER CAT( #: ~~ g63r (RATION DATE: ~ ~ / ~,~ / Q 6 SIGNATURE PHONE NO: (~~) J ~ l -- ~ iT Z.Z ~~~ Y =Yes; N = No; NA =Not Applicable ITEM MONITORING PANEL !ALARM HISTORY Y N NA ., . _,._e~~. 1 _ - __ Monitoring system is powered on and in pnsper operating mode. __ 3 Alarm tdstory reportliog for the previous month >s available, and has been reviewed- by the . / V 4 Each alarm for the previous month has been responded to appropriatety. List all tank-top sumps where alarms occurred in the past montt: Note: Sumps where an alarm has oa:urred in the past month must be inspected unless a qualified service technklan responded to, and properly addressed, the cause of the alarm. Attach documentation verifying appr~riate service to this report. N sump inspection is raqulred, record resuNs in item 6, below. - UST SYSTEM INSPECTION Tank-top containment sumps are free of water, debris, and hazardous substance. Sensors are kxxted properly. Note: Visual inspecfron of sumps is onty required in sumps where an a/amr has occurred in tt-e past month for whict- there rs no service record. Sump location: Sump Location: sump Location: sump Location: Surrtp Location: Sunq~ Location: 7 Spill wMainmertt structures are free Of water, debAs, acrd hazardous substance. Y N NA Y N NA Tank 1-Contents: ~ ~ ~ ~ .Tank 3 -Contents: C~ u Q r U H L . ~ 1 ~ Tank 2 -Contents: ~ ~ Tank 4 -Contents: Under-dis oast contaloment areas a re free of water debri and hazardous substance. Sensors are located ro rl . 9 - _-. - - Y N NA -- ~ -- - Y N-~ NA Dispenser 112 Dispenser 9/10 Dispenser 314 Dispenser 11N2 Dispenser SIB Dispenser 13!14 D~penser 7/8 Dispenser 15118 9 Monitoring system certification has been completed within oast 12 months. 10 Secondary containment tests have teen completed wfthin'the reouired timeframe. - 11' Spin containment stnrcture fbudcetl tesHrm was opmoleted within the osst veer. 12 Tank tightness testing eras completed within required timeframe. 13' Line tightness testing was completed within required tlnieframe. /. 14 Other required testina/maintenanoe was'completed within required tlmeframe. Ust testlmairrterrance it resLMairrtenance: TestAWaintenance: FACILITY EMPLOYEE TRAINING' ,. r Y N NA 15 AlLfacili a ees have received the uir6d 'ob fralnt within the st r: 18 All ees hireA witttln:the. st 30 have reoeivedttte wired: ' b trains Noto: Any snswrar of •N* should bra •xpisinr:d in thra eommrant section on tbr: following page, and will require follow-ul action. DESIGNATED (UST} OPERATOR - MONTHLY VISUAL INSPECTION CHECiOJST UNDERGROUND STORAGE TANK Page 1 of 2 • s;:-~ „~~... F/itii ! >> ,~erlr~~vr Bakersfield Fire Dept. Environmental Service 9001Yuxtun Ave.. Ste. 210 Bakersfield, CA 93301 Tel: (661)326-3979 Fax.: (661 j852-2171 Y =Yes; N = No; NA =Not Appix~e 1713N MONfPORING PANEL! AIARlN HISTORY Y N NA 1 B system is powered on and In proper oP9 mode. . - 3 - Aleme histgy teportAog for the praviotn month ~ avaiWrbte, ark has Wean reviewed- by the -, J -- 4 Each alarm fa the preWats morrih etas bay responded to apprr. List ati tank-top sumps where alem>s ooaerred in the past month: J1foAec Strops rMeera ~ a(mm has oooumedh me past monm nwsf he /respected unless a 9uaf~ed service teduei'ciare responded to, and prcpeAy aQftsssed the tie ~ me aierm. At18Ch dopman appropef~e setvioe to this tepoii. Nswrp besper~n k ragtirao, raoad results m dem 6y below. UST SYSTEM INSPECTION TaNc-top oae~epnerd surt~ps are free of water, debris, and t>azerdous substance. Sensors ate kx~atad property. Notsr Yt~ inspecUOre tbswryes Is artiy ragtdiad /n straps whets an steno has otx~rred Ire the past nrorem ~ rrha~lee mere is no sergkae recarri ~ I Spill nmsn! strreeUtrsa are flee d water, debrb, and Insardous sut>atarwe. Tank i - Contertta: ~ h ~ g "/ Tank S - Contents: ~ t.4 ~ U Lt !. q Tank 2 - Cpttertte: L v Ttttdt 4-Contents: B eontakunent aro free of waler and hewn substance. Sensors are located - -- - - Y N NA - - Y N NA Dhpwtser 1fZ Dispenser 9V10 Dispenser 3I4 Dispenser 11h2 SIB Disperser 19H4 Dlsperssr 7/8 Dispenser 15H8 8 Monitgrtrep system oertiticatigr- has been cotrwleted vvithGi oast 12 nwnths. 10 Secondary cor-tainmertt tests i-avao teen meted within the resulted tirt~eframe. --- 11 Snili cot>leinment strtnxure !bucket) testing was oomnieted wittart the asst year. 12 Tank tightness testis was comateted vvit)tirt recurred timeframe. 13 t.ltle tighhtess testtrm was rbrrtoteted within required tlmeframe. ,.. . 14 Other reouired testinglmaintenance was completed wiUiin required timeframe. lest ~istiFrrainterear-oe Test/Maintenance: TesUMainter-arrca: FACILITY t=MPLOYF~ TRAINMG ,. _: ... Y N..-. NA ~R :ens nn...e....d..,.~ r.e..s .,s..e~..sa a~,., .......t.,sw ..., a+...:..4, a~.:..:.......sas..ar.~:,..s.::a-.~:..~> . ~ :.: ~ ... , i Noto: Any answer of 'N" sbouid bo •xplaint.d in the: txomnront section on tbta following psge, and will regnire• foilow- setion. ;~ a C UNIFIE® 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 NAME T i INS CTIO DATE INSPECTION TIME ~ ~~ ~ . ADDRESS ~~~~----!~-~--------____.---.__ ----- PH NE No. No. of Employees 341'3?~~. ~_------- - FACILITYCONTACT ~ Business IO Number 15-021- • Section 1: Business Plan and Inventory Program ^ Routine ombined ^ Joint Agency ^Mnlti-Agency ^ Complaint ^ Re-inspection ,~C/V \V=Voationnce} OPERATION LY ® APPROPRIATE PERMIT ON HAND qy ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE --,,~-T -----------------------......-- -- - ----- _ _ W ^ VISIBLE ADDRESS lSV ^ CORRECT OCCUPANCY I -L-/------------------------- -----------....._._._. --- l~' ^ VERIFICATION OF INVENTORY MATERIALS ~^ VERIFICATION OF QUANTITIES ~^ VERIFICATION OF LOCATION K ^ PROPER SEGREGATION OF MATERIAL ~^ VERIFICATION OF MSDS AVAILABILITYE LW ^ VERIFICATION OF FIAT MAT TRAINING (~^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~^ EMERGENCY PROCEDURES ADEQUATE ~^ CONTAINERS PROPERLY iJ~BELED --y ----------- - ------_. __-------------------- -_---._~...-- L7 ^ HOUSEKEEPING ~ ^ FIRE PROTECTION LY' ^ SITE DIAGRAM ADEQUATE $c ON HAND i COMMENTS ANY HAZARDOUS WASTE ON SITE: ^ YES ^ NO EXPLAIN: )..~ QUESTION EGARDI TH INSPECTIONS PLEASE CALL US AT (66'I ~ 326-3979 ~~,~. -~ , . _. .~ ~ I ~~ Inspector Badge No., Business Site Responsible Party ' White • Environmental Services Vellow - Sletbn Copy pink • Business Copy 4~ I .. -' ,~~+w~~` '~~~\` CITY OF BAKERSFIE[~U FIRE DEPARTMENT ~~ ~ ~ r=+~ OFFICE OF ENVIRONI<'[ENTAL. SL:RVIC:ES a~ y~J iJNIFIED PROGRAM INSPEC'T'ION CHF,CKL,IST \~w ~gti,0'~~ 1715 Chester Ave., 3r`' Floor, Bakiersfield, CA 93301 ..~,~ FACILITY NAME~~ INSPECTION UATE~c~ ~ Section 2: Underground Storage Tanks Program ^ Routine ~ombined ^ Joint Agency Type of Tank 1~')tIJ~S Type of Monitoring tL~~ ^ Multi-Agency ~ ^ Complaint ^ Re-inspection Number of Tanks Type of Piping ~(~__ OPERATION C V COMMENTS Proper tank data on file Proper owner/operator data on file 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 NU ~~ 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 OES Adequate secondary protection Propcr tank placarding/labeling Is tank used to dispense MVF? If yes, Does tank have overfill/overspill protection'? C=Compliance ~ V=Violation Y=Yes N=NO Inspector: ' `~~ ~~i~J Office of Environmental Services (661) 326-3979 \b'hitc - Fnv. Svcs. fink -nosiness Ci~ry ~rJ r~~1~~-- Business Site Responsible Party s - ~° ~v + LUCKY 7 FOODSTORE 11 ________________________________ SiteID: 015-021-000083 + Manager Location: 2501 WHITE LN A City- BAKERSFIELD BusPhone: (661) 397-3722 Map 123 CommHaz Moderate Grid: 13C FacUnits: 1 AOV: CommCode: BFD STA 05 SIC Code:5541 EPA Numb: DunnBrad:06-294-4160 Emergency Contact / Title Emergency Contact / Title GINA HAM / OWNER EDWARD HAM / Business Phone: (661) 397-3722x Business Phone: (510) 847-4581x 24-Hour Phone (661) 665-9370x 24-Hour Phone ( ) - x Pager Phone :_( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact GINA HAM Phone: (661) 397-3722x MailAddr: 2501 WHITE LN A State: CA City BAKERSFIELD Zip 93304 Owner GINA HAM Phone: (661) 397-3722x Address 2501 WHITE LN A State: CA City BAKERSFIELD Zip 93304 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: R5s: No ParcelNo: Emergency Directives: PROG A - HAZMP,T PROG U - UST Based on m EWT'D ~~ I J ~ 006 responsible for obtarnin y °f those lndivi~tUe1g under penalty of iawghat ~~ h Vetion, I certify examined an a familiar with the ,ngpr~nally submit ed a d b sieve t . ation acc d co information is true, piete. >i9n ure ~ !~ D~ -1- 03/29/2006 ' x :~ ~ ;; Prevention Services UNIFIED PROGRAM INSPECTION CHECKLIST;; B E R s F, 0 9ooTruxtunAve., Suite2lo ~______ _~~__.._~-_____ _ _.______----.-----__- FRE..... -- Bakersfield, CA 93301 SECTION 1: Business Plan and Inventory Program ' "R'M T Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME G~.~~ ~ god ~d~ ~ ~~ INSPECTI N D a ~~ E a6 INSPECTIONrIME p -~/ ADDRESS PHONE NO. NO OF EMPLOYEES 25 a ~ k~~`~ L FACILITY CONTACT BUSINESS ID N UMBER . 15-021- ~3 ~~~ ~ ~ Section 1. Business Plan andfnrrentory Progfam~ ~~ ~ o~ ^ ROUTINE COMBINED ^ JOINT AGENCY ^ . MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION J c.nm1 C V ~ C=Compliance OPERATION V=Violation - COMMENTS ^ APPROPRIATE PERMIT ON HAND ~ ~ ~ `C~ ^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE O ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES I f~ ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITY ^ VERIFICATION OF HAZ MAT TRAINING ^ ~ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~2 t ~ ~ ~ y~~~ ~~ ~A R 1 ' (~ a~ _ L "'l 'lG S"L ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ ~ FIRE PROTECTION ~ ~~~ r~ ~x't'~ns K ts~ ~ 1 ~~ ~'"~ L'9 ~ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? EXPLAIN: QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 Inspector (Please Print) Fire Prevention / 1~~ In /Shift of Site/Station # ^ YES ~ NO nnr-Hula Print) White -Prevention Services Yellow -Station Copy Pink -Business Copy ~ FD 2155 (Rev. 09/05 INSPECTIONS - B D E R S F I L D BUSINESS PLAN & ~RrM r INVENTORY PROGRAM UNIFIED PROGRAM INSPECTION CHECKLIST .7 FACILITY NAME: ~~LK-~ ~ ~oo9.s"t"df.~ ~-/ Section 2: Underground Storage Tanks Program INSPECTION DATE: t~ 3! 6 ^ Routine ~ Combined ^ Joint Agency ^ Multi-Agency C mplaint ^ Re-Inspection Type of Tank D ~ ~ ~ bo ~ I its Number of Tanks -3 Type of Monitoring e.~ Type of Piping ~ 2a ~~- OPERATION C V COMMENTS Proper tank data on file Proper owner /operator data on file 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 ~SNO Section 3: Aboveground Storage Tanks Program Tank Size(s) Type of Tank • 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 V =Violation Y =Yes N = No Inspector: ~ 7 ~~~^~ Questions regarding this inspection? Please call us at (661) 326-3979 White -Prevention Services Pink -Business Copy Aggregate Capacity Number of Tanks 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 KBF-7335 FD 2156 (Rev. 09/05) .~ , , FI~;C'.t; Ek F' 1 E1_.L~ , i ='ri _n.;"1' _; 1 ~'i iClt. 1 1 : F.l ~(:.~ :. - ALL FUhJC`TI~:~~Pd;_, ti::,ra't~;l `~ I fd'~,+f=PC1 ~_: t~,`I 1•tLp~:_?};`I' ~:~ T I : F'1:EP9 '~.i'_+LLIf°lE _ :"_~~~- ;ail := I II_i_tii ~E _ ~,i]' ~ ~-A ~ , iJ ~- 9~i'::r i ILl_H~ F::> rl'~r`~i ~ rl, .~ ' II.III 1 L~ ~~ -•~L - I I i_~i Y'1I..~J Tip, ,. _:'I_IIf1F: _ -`1i`i. ~_riL:= HEIGHT = ~_.~_.-:'_' IIJi_HF.:=. I;,I;;TEFi = CI . Cu_1 11`Ji=:HE:~ '1 EP'1F' _ 'F . 1 IIE~:~ F • • C~ -T' _ NiONXTOR~NG SYSTEM CERTIFICATION 1(Q ~ For Use By.lll Jurisdictions YYirhin the State of California .-iutha•in• Cirzd,• Chapter 6.7, Nealth and Safety Code; Chapter 16, Dlvisia» 3, Tine 23, Cal forma Code of Regulirtions '111i•:> iurm must be uszd to document testing and servicing of monitoring equipment, g s~l2srato certification ar repo+T muse b~ preu~re~i Cdr each rnonitoring,s~ttm control panzl by the technician who performs the work. A copy of this form mast be provided to the ratil: s~:5t~u} rnvuer/upzrator. The owner/operator must submit a copy of this form to the local agency regulating 01ST systems within ~U Mews i+f rest dart. ~. 1_brY1~rJ1 )<IItOt•7;lYt;t10II Facility iVunz: ~~iC.~/ ~'" Bldg. No.: ____--.. _.._ ~irr :~cldress: ?~fL1l L~4-lZT'~ L.1~ • City: )~1C F ~~,~=E~f1 Zip: ~----• -- 1'z~ciiit} CotnacrPerson: Contact PhoneNo.:(_______~ _-___ n•1:i!•_r:: i\~1ud~1 of Monitoring System: 'rl.S~'3~ra Date of Testing/Setvicing: ~/o~/~CQ t;. .i~tvr.~itor}~ of Equipment Tested/Certified c:u~, r rLc :,t,nrupriate bogies t~ iodieate speetrie equipment iusnectedlsrrvieed: t ~, If I:tuk.tU:. ~Iv~~~- TanklD: ~~ _ -__-- " '"~-1.:-Paul. Gauging Prubz. t~ Model: ~J-In-Tank Gauging Probe. V l S d Model ~ ~ _.._ _ .. d ( ~ m M _ j ~.~unuLu• Space or Vault Sensor. Model: au t znsor. i .Annular Space or ~ o e : g _ _ _ !j~l'i,~iu~~5ump!'TrenchSznsor(s). Model: ~mg' ~PipingSump/Trench Sensor(s). Model: am~ _..___._. .•_ ,~ ~~ i.7 i ill Sump 5cnsor(s}. [vladel: ^ Fill Sump Sensor(s). __ Model: , t~ q3.+\t:~lt,utir•alLinzl.zakDerzctor. Model:~~~~e..~- lam-Mechanical Line Leak Detector. Model: Q~p~4~ET'____ _. ~'' ^ 1. l:.r~uvnic l.inc. Lzak Azteewr. ModeL• ^ Blectronie Linz Leal: Detector. tvlodel: _ _ __ il', ~~ l::uk O~•~rtitl t High-Level Sensor. Model: ^ Tank Overfill 1 High-Leve! Sensor. Model: _ _ __ si '1_J cJtlter s zr:ifv z ui mtnt r ~ z artd model in Section E on Pa e 2 . ^ Other s ci a ui meat a sad model in Section E on I>a ~ 2)~ r . Cauk Ill: ~ Tan1tID; _ . . d I ~.1~,-t;u:t: Gauging Probz. 'fi _ _ Model: (lf1 A (~ ^ In-Tatil: Gauging Probe. Model: ---- --.. . ~.UUUitar Spatz or Vnulr Sznsor. Model: ,~~ ^ Annular Space or Vault Sznsor. NCodel. ~_.___ _ _ ~' ;I }~..1't ping Jun•:p / "french Sensor(s). Morsel: aZt~~ ^ Piping Sump /Trench Sensor(s). Model: ____ _ ii r ~l Fi_l pump Sznsur(~). Ivlodzi; ^ Fill Sump Sensor(s). Model: ____ .__.. __ ~; ;~, aq !~1~~h:uliCtll Linz Lzak Detector. Model: ~' ~~~ ^ Mechanical Line Leal: Detector. _ Model: _____.-._ d' Nj ~J t:f_crrr+nie Linz Leak Dzrzcror. Ivladel; _~ ^ Electronic Line Leak Detector. _ Model: ______.__. _ ., ~. " :.i 1':utl.- O~ zr~ill / Hi;h-Level Sznsor. Model: ^ Tank Overfill l High-Levi! Sensor. Modet: __ ,_ _ _, '' .J ~+ri+" ~specih• c.. ui mznt tv a and model in Section T on Pa e 3 . ^ Other (s zcify e ui meat ~ e and motifs in Section L' on l'a c '?}, ~ uisprnscr [!); _, ~__ __ Dispenser YD: •~$ ~$ y ` ~i?i;pzu,;;r Containment Sensor(s). Model: ~A•02~•lfC. ~`•Dispenser Containment Sensor(s). Model: ~iDQt~l,~ °' .~S-~h,::,r \~ al~•zts}• QFtShear Valve(s). _. _. _ p 'J l!:> >,:nser Containment Float(s) and Chain(s). ^Dis enser Containment Float s) and Chain s). _ _.. ~ Llisptus~r lll: Dispenser ID: .__ _.. ~~ .:] i)tspzn;~r Containment Sensors}. Model: ^ Dispenser Containment Sensor(s). ModeL• J $!uar\'alvz(s). 1 ^ ShearValve(s). ''' ,J Uis ~~nstr Contain,ncnr Ploar s and Chain s). ^Dis enser Containment Floats attd Chains . II ~I L)ist~cuser ill: Dispenser YD; ~~ ;.: ir7 1?iaxnsar Conwinmenr Sensor(s). l~tocsel: ^ Dispenser Containment Sensor(s). ModeL• ^ ___ .. '~ C1 til:i;:u~ V,l~'zlsl. ^ Shear Valve(s). _,._,. __, ~ f~ ? JDis ~•nsr~- Conr:unmtnr }~loar s and Chain(s). O Dis enser Containment Float(s) and Chains . ~~ 1i d+~• rz,~iliry contains more tanks or dispensers, copy this form. Include information fist every tank turd dispenser at the facility. Z.. ~eL'tl)flCatlOri - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers" ~uideiiues. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verily that this inlorn+atiuu i> ~un•ecr and a Ytot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, t hate also :+tru~hed a copy of the report; (check a!1 tftrrt rpply): system set-up $'Alarm history report ('c~lt,ticiattNamz(print): ~'Clzt~rC,1~) [Z3E,~~ Signature: C' ~ __..._.-__.- ~eniiicarion No.: trD~(p-pa~ l~~ ,[,S~~I'~ytrsi.~T License. No.: C6 i/D40- # 809850 ____. _,. C~srin~ContpanyName: RICH ENVIRONMENTAL phaneNo.:~661 ~ 392-8667 _ "•-_" ~11c• aildl"d55: ~~~~ ~~1~~ (, -1~] . ~L~ 7~-~-~~i ,~ , Date of `I'~sting/Servicing: ! ~~ ;'Q~(~ Page l of3 tlz:o~ ~li+~niturinb System Certification -(F ~. .i~:csuits i;i"ll'estiuglServicing j j~ tiuir~~:uc V~r,iun lnstalled: J,d c~L~,~ -- L'on,a;~rtr rLe ibllowin~ checlaist: ~'~C~-l ~;T ^ No* is the audible alarm o eratiunal? ~~~ I ~. ~ : s~ ^ No* Is ~e visual alarm o erational? ~ !i _4!-`:: ~ ^ No* ~ Were all sensors visual] iris ected, functionall tested and confirmed o erational? __ ;; ~' `~ y :~~ ~, ^ No* _ Were all sensors installed at lowest Dint of secon containment and ositioned so that other e ut n,ent wil! P ~rY P tl ~P ~~ ~_ _ ___ not interfere with thzir ro er o eration? !I ~ 1,., L7 No* If alarms are rela ed to a remote monitoriz station, is all conununications a ui ment y g Q P Ce.g. moacm) II II ~3`-NiA operational? ~' i~~ 1,:; ^ No" Fur pressurized piping syst,;ms, dues t11e ntrbine automatically shut down if the piping secondary containmenr ~! ^ N!A moniroring system detects a leak, fails to operate, or is electrically disconnected? if yes: which sensors uZiti.ur . ~~ positive shut-down? (Check all Char apply}~ump/Trench Sensots; ^ Dispenser Contai~unent Sansors. I' _ Did rou confirn~ ositive shut-down due to leaks a sensor failure/disconnection? ~'~les; Cl No. i. _ u ~ ^ ND* For rant: systems that utilize the monitoring system as the prunary tanh overfill warning devicz (i.~. no j; I~N!~ mechanical overTTl! prevention valve is installed), is the overfill warning alarm visible and audible ar the mnl; ;'; ! l till Dint(s) and o eratinff pro erl ? If so, at what ercent of tank ca aci does dte alarm u-i per? "~~ _i: ;' ,`j 1'. `: 4 AND Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment repiac.t:cl !~; ~ ~ and list the manufacturer name and model far all re lacement arts in Section E, below. _ i. it J 1~~~`~ ~.No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that ap~~h~! U ~; Product; D Water. Tf es, describe causes in Section E, below. ~~ __ __ _ i ?~ ~_ ~.~ O Nu* Was monitoring s stem set-u reviewed to ensure ro er settin s? Attach set u re oils, if a licable `__~ ~~2:cs ^ ND* is alI monitoring a ui ment o erational er manufacturer's s ecifications? ___ •` 1n ~~ coon E below, describe how and when these deficiencies were or will be corrected. 1 ~C'i;ilinlelli~: P,~ge 2 of 3 ii;;n, i .l, ;1;. iv-_i curl. Gauging / SI12 Equipment: ~~~ ~-Check this box if tank gaugung is used only £or invontery cantr~.l. ^ Check this box if no tank gauging or SIR equipmznt is installed.. -Chas ~~rtion must be completed if in-tank gt~uging equipment is used to perform leak detection monitorinE;. i'n,r.rJ.~i~ the f,;llowin~ checkl[S[: ----- ^- j ^ `~ ~ s D No* ~=~I Has all input wiring been inspected for proper entry and termination, including testing for ground faults? _~ ~' ~~ Gl 1'.: l7 No* ~ __.. Were all tank gauging probes visually inspected for damage and residue buildup? _ ;~ -_---- u i a ~ t=] No* Was accuracy of system product level readings tested? ^_ ~ -' ~ ^ No* ~ h ~ ~~ ~ Was accuracy of system water level readings tLsted? '~~ u 1 ~~^ No* ij t3 ~ ~s_ ~ ^ No* Were alt probes reinstalled properly? Were all items on the equipnlznt manufacture,'s maintenance checklist completed? __J ~~ t„ [I;r ~cctiun H, below, describe now and wuen tl[ese detlclencies were or wilt be corrected. iy. ~_itir Leal: Detectors (LLD): ^ Check this box if LLDs sre not installed. i ",,,,, r,IrT.~ rhN 1'nllnwina checklist: it ~-~ es O No* For equipment start-up or asutual equipment certification, was a leak simulated to verify LLD performsn~.~'.' ~:' ~ O N!A (Check n11 that apply) Simulated teal: rate: ft'7=3 b.p.h.; Cl 0.1 g.p.h ; ^ 0.2 g.p.h. -~ ?~ .1,~ ~ ^ No* Were all LLDs conf-rnred operational and accurate within regulatory requirements? ji1 ~. ~s ^ Nu* Was the testing apparatus property calibrated? 1',;s D No* For mechanical LLDs, does the LLD restrictproductflnw if it detects a leak? ,~ ^ NIA __ _ _ i lr ~'cs ^ No* ) For electronic LLDs, does the turbine autoratically shut off if the LLD detects a leak? ~ NIA _ ~~ -, ^ ~.~5 D No* For electronic LLDs, does tha turbine automatically shut off if any portion of the monitoring system is' dis.~bl~d ~ ~NlA or discowiecrod? +? !; :.~ ~s ~~ ~`~ ' D No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system ma Itunction~ jJ ~ NIA or fails a test? __!~ i"; '~'~~ I D No* For electronic LLDs, have all accessible wiring connections been visually inspected? ~~ ~ ~,/ PJ~N!A ~, -- Il~ 1 zs ^ No* ,; Were all items on the equipment manufacturer's maintenance checklist completed? ~- i~; il;~. Sectiot; H. below. describe how and when these deficiencies were or will be corrected_ f. t:'ot~~tnettts; !'age 3 of 3 l9(~ly l•loaitoring System Certification US's[' N~onitoring Site Plan Site _~~t~ir~ss: ~S_Q~ ~~~1~ i ~_ ~...ay. -..__..._ L ~ ~ . ~ . ~ I ~ . . i ~ ... . , i ~ . .A. . (.~` .,~ :~~. . Q :::::::::::::. :Q~~ea~:::. ~::::::::::::::::~ .~~~ a,~ .... ................... ~: ::::~: ~~~Q~ ~ ate ................... I. ................ ~?.. ..4 JP~ ..................... . r: :::::::::::::::::::~,?~::.::::::::::::::::::::::.: Date map was drawn: t /0~3 / ~ Instructions if ~ uu already Dave a diagram that shows all required information, you may include it, rather than this page, ~~~iih ) ~un~ tilonilori~lg SySKein Certification. On yoa~r site plan, show the general layout of tanks and piping. Clearly ~dcniiJ~~ locari~~u~ of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annuL•u~ :paces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line !~~al, dziccror~; and in-rank liquid level probes (if used for leak detection). In the space provided, note the date dlis Site. ~?la~~ ~~,,: i,r~pared. Page cf n~:at~ ! ! 9Co lP 5643 BROOKS CT BAKRRSFISLD,CA.93308 OFFICTib61)392-8687 & FAX (661)392-0621 MRCHANICAL LR~ D~$ TBST W~ W/()#: Facility Name : ~~`C.~t-Y ~' Facility Address : 0'1 ~ t c~ H ~ _ L,~1. Product Line Type (Pressure Suction, Gravity) PRODUCT LEAK DETECTOR TYp$ TLST TRIk PA3$ ssa=AL 1JVl~Sr-R BELOW PSI OR L/D TYBF, Q~(}c'~ULE'l'" YSs 58RIAL # rO a ~ ~ NO (S FAIL L/D TYPE_R•~•OJRUCF:a" S sSRIAL # ~"+ ~ a rto ~ ~- s L/D TXB& ~'E PETR~ YSS AS SSRIAL # 1[ A) Q~-A(~A~IQ- NO 1 ~ FATL L/D TYP$ YRS PASS SBRTAL # NO HAIL i certify the above tests were conducted on this date according to Red Jacket Bumps field test apparatus testing procedure an limitations. The Mechanical Leak Detector Tact past / fail is determined by using a low flow threshold. trip rate of 3 gallon per hour or less at 10, PSI. 2 acknowledge that all data collected is. true and correct to the bent of my knowl®dge. Tech • S~l1rC(J ~ l~~f?~ Signature : Date ~ 1 +a3 ~ fp ~ . h'• a ;~'•. I f ~l~ MONITOR CERT. FAILURE REPORT S T TE NAME : 1~y~L. ~,`"'~ ~- DATE : ~ ~ a ~7 I ~ ADDRESS: a s~1 ,~1-E~'-~. u.1. TECHNICIAN: ~~ 7F~o~~ CITY: A'Y ~ 2~~~~1,~ SIGNATIIfiE:~ SITE CONTACT: THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE THE MONITOR CERTIk'ICATION TESTIN[3. LIST OF PARTS REPLACED/REPAIRED: REPAIRS: ~ Q h LABOR: ~3 oN ~ PARTS INSTALLED: wji~)C .1`1~rVl`I IhiTELLTGEh1T CONTROLS ING . P. D. EOk 633 SRCO h1E X34672 1-'0'@8-984-626(1 2T/~J 1.'2Jj1"?6 15:11 SIJt9P LEAF: TEST REPORT ~~ (/ SUMP 1 ~i~- TEST STARTED 14:56 TEST STAP,TED 23/@1i'2@@Ca BEGIN LEVEL 2.4210 IN END TIME 15:11 END DATE 23/@1/2Ei@6 END LEVEL 2 4211 IN LEAK THRESHOLD @.@82 IN TEST RE:'aLJLT PASSED .......... . ~J2~1n suMP 2 mil' TEST STARTED 15:44 TEST STARTED 23~8if28Jab BEGIN LEUF1 1.6195 IN END TIME 15 59 END DATE 23/81/2886 END LEVEL 1.6ze4 IN LEAK THRESHOLD @.002 IN TEST RESULT PASSED COMMUNICATIONS SETUP Pc?RT SETT I 1Vi3S NONE FOUND NILE SUMP 2 ~( TEST STARTED 13:56 RS-'2:ii END OF NIES:~AGE D I SAI3LED TEST STARTED 23~~01i2@66 BEGIN LEVEL 1.4S5.S IN LEAK TEST hIETHOD END TIME 15:11 _ _ END DATE 23~31~29@6 TEST-ON DATE : ALL TANK END LEVEL 1.4558 IN JAN 1. 1996 LEAK THRESHOLD 0.@02 IN START TIME DISABLED TEST RESULT PASSED TEST RATE :0.'~0 GAL~HR ItdCON IIURATIOIV 2 HOURS INTELLIGENT CONTROLS ING ~. O. BOX 638 SACO ME @4Jd72 1-86@-9846266 23if~if2EE~E. 15:26 SUMP LEAK TEST REPORT ~~ ~SUNP 1 TEST STARTED 15:11 TEST STARTED 23~@12@@6 BEGIN LEVEL 2.4212 IN END TIME 15:26 END DATE 23fF91f2@Jb6 END LEVEL 2.4214 IN LEAK THRESHOLD 0.@02 IN TEST RESULT PASSED SUMP 2 ~Qj TE^T .STARTED 15:11 TEST STARTED 23~81~2A86 L'EGIN LEVEL 1.4555 IN - END TIME 15:26 END DATE 23!01/28@6 END LEVEL 1.4555 IN LEAK THRESHOLD 0.@02 IN TEST RESULT PASSED Q(ZE,If'a'~ SUMP 2 CJ~ TEST STRRTEfl 15:2ts TEST :STARTED 23~@2~086 SErIN LEVEL 1.619© IN END TIt9E 15:43 END DATE 23rE1~2@06 END LEVEL 1.6195 IN LEAK THRESHOLD JJ.1~2 itil TEST RESULT PRSSEI) ,DUI ! 1,.~rik'k I~IrV 1 ti 1 cs IV Lt,\../tL SOFT6JAF•:'Eti ti46~+3-100-D ~^REAT'ED - iJ3. U6 . U6 . u8. 1 0 NU k_~VFTI.1HkL MC;Li1JI..E PER 1 t~3D I i:' [ N-TNIVI? TESTS ~=,raruu;~L 1 r~~-T~,r~~: Ti;srs TST EARLY STOP:DISABLED LEAK TEST REPORT FORMAT NORt°lAL . iLt~RM H I STORY kEPukT ----- i N-TAPJK ~LAR1W --- - -- T 3:SPECIAL DELIVERY IVEEDETi AUG 22. 'F005 8:03 AM ALr~Rt"1 H I ST'Jk4" REPURT ---- I td-TAPJK ALARIW ----- T 2:SUPER PROBE OUT QCT 1 E.. 200:1 8:36 ~;M DELIVERY NEEDED OCT 18. 2005 8: 5:? Ph•1 ~~JrJi; I L I AT I ON SETUP AUTOMATIC DAILY CLO111ING TIME: ':':00 AM PERitiDIC RECONCILIATION MODE : PiONTHLY TEMP CciMp]~IVSATION STANDARD bUS SLOT FUEL METEk TAN! TAPK MAP EMPTY ALARM HISTORY Rt.l'Uk1 _~~1ulll-SENSOR SE'TU$J ---- IN-TANK ALARt°1 --•--, l • L 1:87-STP T !:UNLEADED TRI-STATE rSINCLE J=L1 CATEGORY STP SUM1? OVERFILL ALARf"1 SEP 9. 2005 ll:l3 AM JUPJ 28. 2005 1:29 PM L 2:85-STP APR 28, 2005 10:42 Ahl TRI-STATE (SINGLE FLi CATEGORY STP SUh1P INVALID FUEL LEVEL OGT 3. 2005 7 : 21' PM JUL 22. '005 1:50 PIW MAY 29. '2005 5:03 PM PROBE OUT Or•T 16. 2003 8:44 AM DELIVERY NEEDED OCT 14. 2005 5:15 PM OCT 3. 2005 5:16 PM JUL 22. 2005 12:U9 PNi OUTPUT RELAY SETUP R 1:87 SHUTOFF TYPE: STANDARD NORMALLY CLOSED LIGIUID SENSOk ALMS ALL:FUEL ALARM R 2:91 SHUTOFF TYPE: STANDARD NORMALLY CLOSED L '3:91-STP TRI -STATE r S I JUGLE F CATEGORY STF SUMP L 4:87-ANNULAR TRI-STATE SINGLE CATEGORY ANNULAR L 5:91-AJVNULAR TRi-STATE (SINGLE CATEGORY AtVNULAR 1[O J i i L b:89-ANNULAR TRI-STATE (SINGLE FLOA"~i CATEGORY HNNULAR SPA~E ------ SENSOR ALARh1 --- + -- L 5:91-ANNULAR ~ ANNULAR SPACE FUEL ALARM JAN 23. 2006 10:15 HM LI4~UID SENSOR ALMS ALL:FUEL ALARM R 3:89 SHUTOFF TYPE: STANDARD N4RNIALLY CLOSED LIQUID SENSOR ALMS ALL:FUEL ALARhI --- SEPJSUR ALARM --- ~ - L sJ:89-ANNULAR ANNULAR SPACE FUEL ALARM JHN 23. 2006 9:59 AI"1 ----- SEiVS4R ALARM -- --- L 1:87-STP STP SUMP FUEL ALARM JAN 2Li • 2U06 10:1,1 AM -- --- SENSOP, ALARM ----- L 2:89-STF STP SUMP FUEL ALARIW JAN 23. 20u6 1D:09 AM ----- SENSOR ALARM -= L 3:91-STP STP SUMF FUEL ALARM JAN 23. '006 10:10 AM ----- SENSOR ALARM ----- L 4:87-ANNULAR HNNULAR SPACE FUEL ALF',R{~! JAN 23. 200b 10:02 Aht 'f :3 : FaP1:C I r=11. FRC>DUC'1 r~sTDE 3 THERt°IriL +_:CiEFF :.000070 TAM' D l ~METEk 96.On Tr~1fJ!•; F'R~_'F I LF. 1 FT .FULL VvL : 10000 FLt~r~iT f~ I ZE Wr1'I=k I.~I~RIV 11Vu . HIiaH Wr~iTER. LI('1IT: f°lA%; c":~R LrtI3El. V~aL CiUERF I LL L I P9 I'T . HIGH I='R~JLiUI:T . DEL I 'v'ER`f L I Wt I'f 1.04J >;'RiiIiUCT' LEr;K HLHRM LIMIT SUDDIrIV LG;3S L I f°1 I T: TAIVk: 'f I LT . PROBI~ OFFSET A,0 I•N. 2.U 3.0 1G000 9 Usy y0U0 55r;, 5500 10.°••. 1000 50U 9y 99 A.00 0.00 :SUPER PRODUCT CODE THERMAL CQEFF :.0000?0 TANK DIAMETER 96.OG TAIVK PRGFILE 1 PT FULL V;iL 10000 FLOAT SIZE: •3.0 IN. WATER waRra I r~G ~ . o HIGH WATEk LIr1IT: 3.0 MAn OR LABEL VL,L: 10000 OVERFILL LIM1T 90 9000 HIGH PRODUCT 95%a 950G DELIVERY LIMIT 10°.~ loco LOW PRODUCT 500 LEAI; ALARM! L I P1 I T :. 99 SUIi[lEN LOSS LIMIT: 99 THIVF; TILT 3.10 PRUNE OFF:.ET 0.00 S I F'H.O('J P9ritV I FGLDEU TAIV}•;S SIPHON N1AN I F'bLDED TANKS Tu : IVC;IVE T# : NONE L i NE MHIV I FCiLDED TANKS L i NE MAIV 1 FOLDER TANKS T#: NONE T#: NONE LEAK f°I I N F'ER I OD I ~' : U:~ LEAK MIN PER I OD I i° : 0 u ° LEr}.: I°I I N APJIVUNL 0`t~ LEHK h'll tV AIVIVUAL 0~ 0 0 ':'ER 1 Ul.i 1 ~:f TEST TYPE FER I OD 1 C TEST' 'i''fPE STA NDi~RD STf~NDARD HlViVUAL TEUT FA I L HLARNI DISABLEG PEP' I Oli I C TEST F:~ I L ALARI°1 Ii I E~;bLED GROSS TENT Fii i L ALARI°1 Dl;i.f;BLED AIVN TEST AL+ERAG i NG : OFF F'ER TE:"::T AVERAGING : OFF TAhU '1'E ~T IVOT 1 FY : OFF TNK TST SIPHON EREAI::UFF DEL I I.IER'f DELAY I ~ N1I PJ FUhl1=' THRESHOLD 10.00 ANIVUAL TEST FA I L ALARM DISABLED PERIOD 1 C TE:,T FA I L ALARM DISABLED GROSS TEST FAIL ALAF.M D I iaBLED AVIV TEST AVERAG ! tJG : OFF PEk TEST AVERAGING: OFF TANk: TEST NOTIFY: OFF TNl; TST SIPHON BREAK :OFF DEL ! VER :' DELAY 15 t`1I N PUMP THRESHOLD 10.00% IIY-LI".f11- .JLL l1L'v - - _ T 1:UNLEAPED F'RGDUCT CODE 1 THERMAL COEFF :.UUOU7U TANK DIAMETER - 96.00 TANK PROFILE 1 FT FULL VGL 10000 FLOAT SIZE: 4.0 IN. WATER WARNING '~.U HIGH WATER L1PIiT: 3.0 MAn OR LABEL VUL: 10000 bVERFILL LIMIT 90°~ 9000 HIGH PRODUCT 950 ' 9500 DEL 1 VER`r' LIMIT 10~ 1000 LOW PRGGUCT 500 LEAK ALARIM L [ M I'P : 95 SUDDEN LOSS LIMIT: 99 TAPJK. TILT 5.00 PRGBE OFFSET 0.00 SIPHON f1ANIFOLUED TAIVKS T#: NONE LINE MANIFOLDED TAtVKS T#: NGNE LEAK hl I N PERIODIC : 0~~ U LEAK N1I N ANNUAL Of 0 PERIODIC TEST TYPE STANDARD I ANNUAL TES~LARMLDISABLED PERIODIC TEST FAIL ALARM AISABLED GRGSS TE5T PHIL ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAG I IVG : OFF TANK TEST NOTIFY: OFF TNK TST SiPHUN BREAK:OFF DELIVERY DELA`1 15 MIN PUMP THRESHOLD ID.00`~ i s L ~ i=+ F=7 4H i-=t w w W w z Z ac oc ~ ~ ` - x ar o ~ ,;r CkU] '`~ ~ ~ '~ w~~W 3 3 ~ 3 3 ~ i c~ ,~, u-s ~ in~r~r~i w tAU ~. A t7 w w ~n E-~ f ' -' `~~ W~ W s auaa w r~ ~ ai w cn w ~ ~ E" ~z ~-_ ~ <~~ .. .. .. .. ~ w. ~ ~ au] z z ~ l:o z - - ~ 'i J [-' ~ LU ?• '-] CI ~ '" Cu ~"~ V ~ ~ [~ FW- O b _ 'n G.. F 7 ~ , Fi• W..IC WWWW F F-•.,., • C Q i!2 ~ '~- i 4 ~ az~.L>. u?' ~ ~~~.~ HHFH Ixcazq wwzw ~ ~ w•. GCA~A Ci ~AWAF»A `' ~ `~ ~ r In ~ ,(-. a a wwzw ,~..a ~ a Ho r~ o•..=wow u .~ c~ .~ ' ~• ~ w3• 3117 ~ il 2 ~iQ?~ ~ ~fllFill ^Q _ ,a.--. y.~ ~r' ' ~ _' ~ ~ v~ ~ . a ~~.i ~ zSZ u] rr c H c ~ `K . ~ _ n cn , f. c~ ~ . u. .J ~ .a a o , to t=- ~ 1 ra n'ca rn a ,. F O a O ££ 0.~ (jI O Q Q ~ •• ~~ ~w °~ ~~•Q a~-- inr, uA ~~~~~~ SWRCB, January 2002 1~ 9(e~o Page / of„~„ Secondary Containment Testing Report Form This form !s iraended for use by contractors performing peri'odlC testing of UST secondary contairrmant systems. Use the appropriate pages of this form to report results for all components tested The completed form, x~ritten test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for .submittal to the local regulatory agency. 1. FACILITY Il~TFURMATION Facility Name: L. Date of Tes - Facility Address: Facility Contact: Phone: Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during testi ~ ~ ~rFC~r-ivr rnx•ru a [°~Yltz Ilvrnutvr a ~r'Tnx Company Name:R,ZCH ENVIRONMENTAL Technician Conducting Test: ..- vr' O 1~ C,f~T~ fm 1 ~-l ^ 1.1~~ Credentials: ~ CSLB Licensed Contractor ^SWRCB Licensed Tank Tester License Type. C 611 D4 0 ~ License Number: 8 0 9 8 5 4 M~,~,er Training Manufacturer m' ovens Date Trainin Ex fires INCON INCQN T$-STS 8/04 3. SUPVIMARY OF TEST RESULTS Component Pass Fail Not Tested $ep~rs Made Component pass Fall Not Tested Repairs Made N ~- x ~ ^ ^ ^ 0 0 0 ^ ~ ^ ^ ^ ^ a ^ ^ ^ a o ^ a a ^ ^ ^ ^ a ^ ^ ^ ^ o ^ ^ a ^ o ^ ^ ^ ^ ^ ^ ^ ^ ^ a ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ a ^ ^ ^ ^ ^ ^ ^ If hydrostatic testing was performed, describe what was done with the water after comptetion of tests: RECYCLE AND REUS$B„~ CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, tke facts stated In tlrls docueunt are accurate and to full compliance with legal requiremtnts feclmician's Signature: '~(~ Date: ~ ~a3 ~m~ S W RCB, 7anuary 2002 i/9(v6 Page -~ o~~Q'~ 9 CPTT.T JffVT.T2FTT.T. C'nN7•ATNMFIVT R~XTi'C Facilit is Not ui With S illlOverfill Containment Boxes ^ SpilUOverFll Containment Bowes are Present, but were Nat Tested ^ Test Method Developed By: ^ Spill Bucket Manufacturer ®Industry Standard ^ Professional Engineer ^ Other (Spec) Test Method Used: ^ Pressure ^ Vacuum >~ Hydrostatic ^ Other (Specify) Test Equipment Used: INCO N TS--ST5 Equipment Resolution:. oooin . ~'-~ ' ~'z`~'r` : t1~1J l~pili Box # pill Box # Splll Box # Spill ~ x # Bucket Diameter: Bucket Depth: Wait time between applying pressw-elvacuumlwater and startiti test: ~ mT ~ ~ M~.[~ `~ 1't1=t~.? Test Start Tune: a ; ~(o ( 07 ; (o l initial Reading (R~: a •y al o?• ~1'a 1 ~• N . ~ ' Test End Time: ~ ; (~ ?J'. ti 3: ' Final Reading (RF): I 1 07• l ('~ .~-I o~ Test Duration: ~ ~ tn~N ~ i ~ I MZtJ Change in Reading (R~-R~: ~t l '~ ~ma '~" + Pass/Fail Threshold or Criteria: ,1.. -- • ~ ~ o`~ + • ~~ -~ • ®~a Test Result; •9ePass ^ Fail mass !]Fail 1~Pass ^ Fat7 ^ Pass ^ Faii Comments - (include information on repairs made prior to testing and recommended~olla-y-up~for failed tests) ~• /~ ~~(v SB989 TESTING FAILURE REPORT SITE NAIKE: t_~['~C~Y_ ~ DATE:~I a34~ ~.D~~ss :.~~~Z ~ l~~'~1 ~ c ~. ~ T~cHrtic=AN : S'~4 ~ e. )~r.~C t" CITY : 1Yi ~~~~1~ S I GIIATURE SI'PE CONTACT: `PHE FOLLOWING COMPONENTS WERE REFLACB:D/REPAIRED TO COMPLETE THE SB989 TE S'TING . LIST OF PARTS REPLACED/REPAIRED; FEPAIRS: x('1/`1 LABOR : N ~ N PARTS INSTAL7.~ED : /~~~ ~,