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1830 FLOWER ST (2)
DATE KERN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT INVESTIGATION RECORD III�IIIIIIIIIIIIIIII 51 IE DBA e c-v% od P A.,t,,% I C e.v.% -r e OWNER a kc..` ADDRESS l Fr3d � /��e� cg4 ADDRESS Ills r�.,rlL.. A0e ASSESSORS' PARCEL CHRONOLOGICAL RECORD OF INVESTIGATION CT /;- I& L): a u/1+ 4 >r �• ro✓Ie �er •� : fib 12a M a /�� 1 /1m>►�� ✓�! �� e... � �`�� B ro''°��� y /fit �° /o =io«.� 719 -G sr� - 3 a -� scc : F -11� ,, c,.�.t. /.,r' �. /L id m I . I sA r e—A 4� @ Qf A, n. .ere- vow f 1 ��-i �.0�7 -i.Ln� r �. iiP /-'L' c, i•�. /i.. A[e_•f /...a , %�� 7a' C,— HU 1111111111 s= MC:ed F7 0- 0 KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT INVESTIGATION RECORD OWNER BEA ADDRESS ADDRESS OF VIOLATION: ASSESSORS' PARCEL # CT SPECIALIST /TECHNICIAN: CHRONOLOGICAL RECORD OF INVESTIGATION F? (3, MEN all r 'A ;Emu _ IN _ al m &WAAMPA"U" 9 mm IF Um II I Is- F? (3, 0 0 TIME HA) [= I �1 I Imi �I �I �I �I �I �1 �I �I �1 �1 �1 0 0 TIME (HR) I� I� COUNTY OF KERN 0 , .. ENVIRONMENTAL HEALTH SERVICES DEPARTMENT MEETING /CONFERENCE RECORD DATE: I' //o /fF TIME: CALL PLACED BY: TO /4A G44- PARTY REPRESENTED: TELEPHONE #: SUBJECT: h./ g e cg;r5 save94 A: \RECORD 11 I„ ILMORE AVE ( L F� 1p ':/FNU (:UFf 4 1Y[iUHN 103 4N 65 Ir ' FLOtYLINP!p[:k Cl /!ai R�IURI! tOti sar.,n 1 �' "[��++' BUILDING CORNIiR X., �" i }i,�+S,yF�V�y' P.N OWNEiC.1RQ F L 2 a 406.00 ATP C ONC PAO o ° x;OFU I4W 5 1 ;T ° °NI 14 CONCRETE I. EOIO MW X, .2 P'. TOP N RIM LI VOLU MW 'n PAD .az.or I OP C'1 F/ PVC CAP /OLD I.t W --- O BUILDIIW U +or , 't01? PAVkA � t� � • I. co tOP'NAVEMEN }(CONNF73 RUIII)ING ' it pg� r AP �. 4 ,'i.:':.. rNt State Water Resources Control Board Division of Water Quality Linda S. Adams 10011 Street; Sacramento, California 95814 (916) 341 -5866 Arnold Schwarzenegger Secretary for Mailing Address: P.O. Box 2231, Sacramento, California 95812 Governor Environmental Protection FAX (916) 341 -5808 Internet Address: http: / /www.wate� gov vLco JUN 2 0 2007 LfUN 2 2 E UU, v S FA0003356 KERN MEDICAL CENTER E�M��M'N IC�UN1y 15000 1830 FLOWER ST SEPVIcES . BAKERSFIELD CA 93305 SUBJECT: Withdrawal of Notification for Enhanced Leak Detection resting The State Water Resources Control Board's Underground Storage Tank (UST) Program is withdrawing the notification previously sent to your UST facility requiring Enhanced Leak Detection (ELD) testing. That notification required you to conduct ELD testing because our data indicated that your UST facility was within 1,000 feet of a public drinking water well. We have updated.our data and determined that your UST facility no longer meets the criteria that require ELD testing due to well proximity. No further action is required on your part regarding the earlier notification. If you have any questions, please contact the ELD information line at (916) 341 -5866 or email us at: eld@waterboards.ca.gov. Sincerely, Z�,Zt-� Kevin L. Graves, P.E. Undergound Storage Tank Program Manager CC: Kern County Env. Health ATTN: Joe Canas 2700 M Street, Suite 300 Bakersfield CA 93301 • r ENVIRONMENTAL HEALTH SERVE DEPARTMENT STEVE McCALLEY, R.E.H.S., DirecTor 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (661) 862 -8700 Fax: (661) 862 -8701 TTY Relay: (800) 735 -2929 ' e -mail: eh @co.kem.ca.us April 19, 2005 GILBERT MARTINEZ KERN COUNTY MEDICAL CENTER 1830 FLOWER ST BAKERSFIELD, CA 93305 - THIRD NOTICE - /0003 REJIWRCE MANAGEMENT AGENCY V1D PRICE Ill, RMA DIRECTOR Community and Economic Development Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department Underground Storage Tank, Designated Operator Requirement All Underground Storage Tank (UST) facilities were required to notify this Department of the person who will serve as their Designated Operator. The notification was required to be submitted by January 1, 2005. Your facility is currently in violation of the California Code of Regulations, Title 23, Chapter 16, Section 2715. Included with this notice is the form to notify this Department of each facility's Designated Operator. This form is to be completed and returned by May 13, 2005. Failure to comply may result in the assessment of administrative or civil penalties. Thank you for your cooperation in this matter. If you have any questions, please contact this Department at (661) 862 -8700. Sincerely, Steve McCalley, Director By: Joe Canas, REHS Hazardous Materials Specialist IV Unified Hazardous Materials /Waste Program Enclosure a s ENVIRONMENTAL HEALTH SEACES DEPARTMENT STEVE McCALLEY, R.E.H.S., Director 2700 W" STREET, SUITE 300 BAKERSFIELD, CA 93 301 -23 70 Voice: (661) 862 -8700' . Fax: (661) 862 -8701 TTY Relay: (800) 735 -2929 e -mail: eh@co.kern.ca.us October 15, 2004 120003 GILBERT MARTINEZ KERN COUNTY MEDICAL CENTER 1830 FLOWER ST BAKERSFIELD, CA 93305 R *URCE MANAGEMENT AGENCY DAVID PRICE III, RMA DIRECTOR Community and Economic Development Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department Subject: Underground Storage Tank Designated Operator Requirements SECOND NOTICE All Underground Storage Tank (UST) facilities must notify this Department of the person who will serve as their Designated Operator. This requirement may be found in the California Code of Regulations, Title 23, Chapter 16, Section 2715. The notification is required to be submitted by January 1, 2005. The State is offering an UST Owner /Operator Outreach Session to provide information and answer questions about this new requirement. This session date and location is: Tuesday, November 2, 2004 9:00 A.M. —12:00 P.M. City of Bakersfield, Council Chambers 1501 Truxtun Avenue Bakersfield, CA 93301 Included with this notice is the form to notify this Department of each facility's Designated Operator. This form is to be completed and returned by January 1, 2005. Thank you for your cooperation in this matter. If you have any questions, please contact this Department at (661) 862 -8700. Sincerely, Steve McCalley, Director By: Joe Canas, REHS Hazardous Materials Specialist IV Unified Hazardous Materials /Waste Program Encl. 0 s ENVIRONMENTAL HEALTH SERVICES DEPARTMENT STEVE McCALLEY, R.E.H.S., Director 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (661) 862 -8700 Fax: (661) 862-8701 TTY Relay: (800) 735 -2929 e -mail: eh@co.kern.ca.us August 26, 2004 GILBERT MARTINEZ KERN COUNTY MEDICAL CENTER 1830 FLOWER ST BAKERSFIELD, CA 93305 Subject: Underground Storage Tank Requirements R0OURCE MANAGEMENT AGENCY DAVID PRICE lll, RMA DIRECTOR Community and Economic Development Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department 0 1 �' 60 The State of California has established new regulations for Underground Storage Tanks (UST). UST facilities must meet the following requirements to maintain compliance with current regulations. 1. Designated Operator: All UST facilities must notify this Department of the person who will serve as their Designated Operator. This notification is required by January 1, 2005. Enclosed is a flyer explaining these requirements. The State is offering several UST Owner /Operator Outreach Sessions to provide information and answer questions about this new requirement. Also included is a notice about those sessions. 2. Double Walled Pressurized Piping Leak Detection: The State is requiring line leak detectors that detect a 3.0 gallon per hour release from the primary containment be installed by November 9, 2004. A mechanical or electronic line leak detector may be used to fulfill this requirement. This requirement is in addition to the continuous monitors (sensors) in the piping sumps and under dispenser containments. This requirement is only for double walled pressurized piping. A flow chart is included to further explain these requirements. Thank you for your cooperation in this matter. If you have any questions, please contact this Department at (661) 862 -8700. Sincerely, Steve McCalley, Director By: Joe Canas, REHS Hazardous Materials Specialist IV Unified Hazardous Materials/Waste Program a 0 STEVE McCALLEY, R.E.H.S., Director 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (661) 862 -8700 Fax: (661) 862 -8701 TTY Relay: (800) 735 -2929 e -mail: eh@co.kern.ca.us October 25, 2002 GILBERT MARTINEZ KERN COUNTY MEDICAL CENTER 1830 FLOWER ST BAKERSFIELD, CA 93305 &OURCE MANAGEMENT AGENCY DAVID PRICE III, RMA DIRECTOR Community Development Program Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department Subject: Secondary Containment Testing for Underground Storage Tank (UST) Systems Facility: KERN MEDICAL CENTER, 120003 1830 FLOWER ST BAKERSFIELD Dear Sir or Madam, This Department has determined that the above mentioned facility is subject to the Secondary Containment Testing Requirements. The deadline for completing the testing is January 1, 2003. . As of this date, the results have not been submitted to this Department. Enclosed is information from the State Water Resources Control Board reminding tank owners of this requirement. If for some reason you feel that this information is incorrect, please contact this Department. The Hazardous Materials staff is available at (661) 862 -8700 to answer any questions you may have. Thank you for your prompt attention to this matter. Sincerely, Steve McCalley, Director By: Joe Canas Hazardous Materials Specialist IV Unified Hazardous Materials /Waste Program Enclosures s s STEVE McCALLEY, R.E.H.S., Director 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (661) 862 -8700 Fax: (661) 862 -8701 TTY Relay: (800) 735 -2929 e -mail: eh @co.kern.caus GILBERT MARTINEZ KERN COUNTY MEDICAL CENTER 1830 FLOWER ST BAKERSFIELD, CA 93305 July 15, 2002 SOURCE MANAGEMENT AGENCY DAVID PRICE 111, RMA DIRECTOR Community Development Program Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department X03 Sao Subject: Updated Underground Storage Tank (UST) Monitoring and Response Plans Facility: KERN MEDICAL CENTER; FA0003356 1830 FLOWER ST BAKERSFIELD Dear Sir or Madam: The Kern County Environmental Health Services Department has recently reviewed the underground storage tank (UST) files. Many facilities do not have current and/or approved monitoring plans, response plans, and plot plans on file with this Department. These plans are to be submitted to and approved by this Department for each facility. Copies of the plans are to be kept at each facility site with the Unified Hazardous Materials/Waste Facility Permit. If you feel that you have already submitted these plans, please contact this Department to have your file reviewed. The submitted plans will be reviewed for completeness and you will be notified if updated plans are required. To assist you in completing these plans, the following forms have been enclosed: ' Monitoring Plan Cover Sheet': This form is to be completed for each facility and attached to the monitoring plan developed for the facility. Monitoring Requirement Options': This is a list of various options that facilities can use to monitor most UST systems. You may develop your monitoring plan(s) by picking and choosing the options that apply to the site. Specific site information is necessary to complete the monitoring plan. Samples of Log Forms: Most monitoring plans require the logging of inspections and test results. These forms may be used for that purpose. Emergency Response Plan Form': This form is to be completed for each facility. In addition to the above information, a plot plan for the facility is to be submitted which shows the location of the tanks, monitoring sensors, buildings, alarm panels, and rectifiers. The plot plan is to be on an 8 1/2 x 11 sheet of paper. 0 The forms noted with a * are available in Word and Word Perfect format. If you would like to receive the forms electronically, please e-mail your request to laurelf @co.kern.ca.us and the forms will be sent to you. Copies of the Monitoring, Response, and Plot Plans are to be submitted to this Department within 30 days of the date of this letter. If the facility owner is not contacted within 30 days of submittal, the plans are considered approved by this Department. The permit holder must notify this Department within 30 days of any changes to the monitoring, response, and plot plans. Thank you for your cooperation in this matter. If you have any questions, please contact the Hazardous Materials staff at (661) 862 -8700 Sincerely, Steve McCalley, Director By: Joe Canas, REHS Hazardous Material Specialist IV Unified Hazardous Materials /Waste Program JC:lf Enclosures a STEVE McCALLEY, R.E.H.S., Director 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (661) 862 -8700 Fax: (661) 862 -8701 TTY Relay: (800) 735 -2929 e -mail: eh&o.kern.ca.us November 30, 2001 GILBERT MARTINEZ KERN COUNTY MEDICAL CENTER 1830 FLOWER ST BAKERSFIELD, CA 93306 1,2000 3 SOURCE MANAGEMENT AGENCY DAVID PRICE 111, RMA DIRECTOR Community Development Program Department Engineering & Survey Services Department Environmental Health Services Department Subject: Underground Storage Tank (UST) Requirements and Deadlines Facility: KERN MEDICAL CENTER, FA0003356 1830 FLOWER ST BAKERSFIELD Planning Department Roads Department. The State of California has established new regulations for underground storage tanks. All UST files have been reviewed by this Department for compliance with both existing and these new regulations. The facility listed above must meet the following requirements to maintain compliance with current regulations. Enhanced Leak Detection Monitoring According to the State's Geographic Information System mapping database, this facility is located within 1000 feet of a public drinking water well. The following tanks have single walled components (i.e., single walled tanks, piping, or no dispenser containment). Therefore, this facility is required to initiate Enhanced Leak Detection (ELD) monitoring. The State will be mailing an official notification soon, and upon notification, the facility has six months to have an ELD program reviewed and approved by this Department. The program shall be implemented within 18 months of the notification and repeated every 36 months thereafter. The ELD requirements are enclosed. Tank # Tank Size Product Stored 3 10,000 DIESEL Secondary Containment Testing The following systems have at least one component which is secondarily contained (i.e., tank, piping, sump, or dispenser containment). Any tank using hydrostatic or vacuum monitoring is not required to be tested, however; piping, sumps, and dispenser containment still require testing. The secondary containment system is to be tested by the date listed below and every 36 months thereafter. If the date has already passed, the test must be completed within 60 days of this letter. If the system is untestable by an approved method, the system shall be tested by Enhanced Leak Detection (ELD). The facility shall have an ELD program reviewed and approved by this Department by July 1, 2002; implemented by December 31, 2002; and the secondary containment system replaced by July 1, 2005. The testing and ELD requirements are enclosed. Tank # Tank Size Product Stored Test Due Date 3 10,000 DIESEL 01/01/2003 0 . KERN COUNTY MEDICAL CENTER KERN MEDICAL CENTER, FA0003356 November 30, 2001 Page #: 2 In addition to the above - mentioned requirements, all monitoring equipment shall be calibrated, operated and maintained in accordance with the manufacturers' instructions. The equipment shall also be certified for proper operating condition and calibration every 12 months. All testing is to be completed by a licensed or approved tester. Permits may be required for some of the tests. This Department shall be notified at least 48 hours prior to conducting any tests or inspections. The results of the test are to be submitted to this Department within 30 days of completion. If for some reason the owner or operator of this facility believes that the above information is incorrect, please contact this Department. An inspection and file review can be completed to clarify and/or correct the information. California Air Resources Board (CARB) has implemented additional requirements for Enhanced Vapor Recovery. While the CARB requirements are separate from the UST requirements, modifications to comply with these requirements may activate the CARB requirements. Please contact the local Air District for assistance prior to making any modifications to this facility. Please contact the Hazardous Materials staff at (661) 862 -8700 if you need any assistance. Sincerely, Steve McCalley, Director ._ By: Joe Joe Canas, REHS Hazardous Material Specialist IV Unified Hazardous Materials/Waste Program 0 0 • CA Cert. No. 06527 Kern County Environmental Health Services Department Steve McCalley, R.E.H.S., Director 2700 M Street, Suite 300 Bakersfield, CA 93301 -2370 Voice (805) 862 -8700 FAX (805) 862 -8701 E -Mail: eh @co.kern.ca.us An upgrade compliance certificate has been issued In connection with the operating permit for the facility indicated below. The certificate number on this facsimile matches the number on the certificate displayed at the facility. Instructions to the issuing agency: Use the space below to enter the following information in the format of your choice: name of owner; name of operator; name of facility; street address, city, and zip code of facility; facility identification number (from Form A); name of issuing agency; and date of issue. Other identifying information may be added as deemed necessary by the local agency. Facility: KERN MEDICAL CENTER, 003356 Location: 1830 FLOWER STREET BAKERSFIELD, CA 93305 Owner: KERN COUNTY MEDICAL CENTER c/o GILBERT MARTINEZ 11830 FLOWER STREET BAKERSFIELD, CA 93305 UST Site ID: 120003 BP Site ID: 004453 Issue Date: March 2000 Kern County Environmental UNIFIED HAZARDOUS Phone: (805) 862 -8700 Health Services Department Certified Unified Program Agency MATERIALS / WASTE FAX: (805) 862 -8701 2700 "M" Street, Suite 300, Bakersfield, CA FACILITY PERMIT FACILITY NAME: KERN MEDICAL CENTER, 003356 OWNER'S NAME: COUNTY OF KERN 1830 FLOWER STREET LOCATION: 1830 FLOWER STREET BAKERSFIELD, CA BAKERSFIELD, CA 93305 Key Map No.: 103 -28B ISSUED FOR THE FOLLOWING ACTIVITIES: Underground Storage Tanks (Permitted) 120003C 7500 GAL., SINGLE WALLED, DIESEL, SUCTION 10000 GAL., SINGLE WALLED, DIESEL, SUCTION Haz Material Business Hazardous Waste Plan/RMPP (Authorized) Generator Site ID #: 004453 NOT AUTHORIZED THIS PERMIT IS GRANTED SUBJECT TO THE CONDITIONS LISTED ON THE BACK • Above - Ground Storage Tanks NOT AUTHORIZED -0 Issue Date: November 1, 1997 Expiration Date: November 1, 2000 — POST ON PREMISES — NONTRANSFERABLE HAZARDOUS MATERIALS / WASTE FACILITY PERMIT SUMMARY OF CONDITIONS CONDITIONS: 1. The facility owner and operator must comply with all conditions specified by this permit and must meet any additional requirements imposed by the permitting authority. 2. The facility owner and operator shall ensure that the facility has adequate financial responsibility insurance coverage, as mandated for all underground storage tanks containing petroleum, and supply proof of such coverage to the permitting authority. The facility will be considered in violation and operating without a permit if annual fees are not received within 30 days of the invoice date. 4. The monitoring/operational requirements shall be implemented within 30 days of the permit issue date. 5. Any inactive underground storage tank which is not being monitored, as approved by the permitting authority, is considered improperly closed. Proper closure is required and must be completed under a permit issued by the permitting authority. 6. The facility owner /operator must obtain a modification permit before: a. Uncovering any underground storage tank after failure of a tank integrity test. b. Replacement of piping. C. Lining the interior of the underground storage tank. 7. The facility owner must advise the Environmental Health Services 40 Department within 30 days of transfer of ownership. 8. The owner and/or operator shall keep a copy of all tank monitoring records at the facility for a minimum of three years, or as specified by the permitting authority. They may be kept off site if they can be obtained within 24 hours of a request made by the local authority. 9. The owner /operator must report any significant unauthorized release from permitted tanks within 24 hours of discovery. 10. The owner and operator must meet all applicable requirements of Chapters 6.5, 6.67, 6.7, 6.75, and 6.95 of the Health and Safety Code and applicable sections of the California Code of Regulations and the Kern County Ordinance Code. AEGirw hm 14swm.s 11. A hazardous materials inventory plan must be prepared and kept current by the owner or the operator of this facility. 12. An annual report shall be submitted to the Kern County Environmental Health Services Department each year after the monitoring has been initiated. The owner or operator shall use the form provided along with the permit or another approved by the Kern County Environmental Health Services Department. 13. All underground storage tanks designated as SINGLE WALLED on this permit shall be monitored utilizing Modified Inventory Control Monitoring (tank gauging two days per week). Kern County Environmental Health Department forms shall be utilized unless a facility form can provide the same information. And all tanks shall be tested annually utilizing a tank integrity test which has been certified as being capable of detecting a leak of 0.1 gallon per hour with a probability of detection of 95 percent and a probability of false alarm of 5 percent. The first test shall be completed before December 31, 1997, and subsequent tests completed each calendar year thereafter. All tank integrity tests shall be completed under a valid unexpired permit to test issued by the Environmental Health Services Department. 14. All underground storage tanks shall be retrofitted with an overfill prevention system and overspill containers by December 1998, or as specified by the Environmental Health Services Department. The overspill containers shall have a minimum capacity of 5 gallons, protected from galvanic corrosion, and equipped with a drain valve. 15. All equipment installed for leak detection shall be operated and maintained in accordance with manufacturer's instructions, including routine mainte- nance and service checks (at least once per year) for operability or running condition. 16. All suction piping shall be monitored for the presence of air in the pipeline by observing the suction pumping system for a rattling sound in the suction pump and erratic flow, indicating an air and liquid mixture. 17. By December 22, 1998, the SINGLE WALLED tank(s) shall be removed under a valid, unexpired permit for tank removal. 18. An annual report shall be submitted to the Kern County Environmental Health Services Department (EHSD) each year after the monitoring has been initiated. The owner or operator shall use the form provided along with the permit or another approved by the Kern County EHSD. ENVIRONMENTAL HEALTH"ICES DEPARTMENT STEVE McCALLEY, R.E.H.S., Director 2700 "M "STREET, SUITE300 BAKERSFIELD, CA 93301 Phone: (805) 862 -8700 FAX: (805) 862-8701 4' '; (1A August 1996 —RESOURCE MANAGEMENT AGENCY DAVID PRICEIII, RMA DIRECTOR Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department TO: Owners /Operators of Permitted Underground Storage Tank Facilities SUBJECT:. UST OPERATIONAL PERMIT EXPIRATION Governor Wilson signed Senate Bill 1082 in September 1993, which mandated significant changes in the administration of six hazardous material and waste programs. These changes require the consolidation of inspection and compliance activities under one County Authority. Consistent with these regulations, in August 1995 the Kern County Board of Supervisors designated the Environmental Health Services Department as the Certified Unified Program Agency for the County. An important element of the unification process is the issuance of a single consolidated permit to facilities in compliance with underground storage tank, business plan, RMPP, and the generation of small quantities of hazardous waste requirements. The existing permit issued to your facility for the underground storage of Hazardous Substances may be expiring soon. The Environmental Health Services Department is currently preparing to re -issue facility permits for activities involving hazardous material and hazardous waste handling at your site. During this interim phase, adherence to permit conditions must continue. If you are delinquent in payment of permit fees, steps must be taken to ensure proper payment, or a payment plan must be arranged with the Department. Please continue to monitor, test, and to submit reports. Permits will not be issued to facilities which have not complied with the UST standards. If your facility has tanks which are required to be upgraded by December 22, 1998, you will have received a survey form along with this letter. Please complete the form 'summarizing your plans for compliance with the upgrading requirements. The forms can be faxed to the office at (805) 862 -8701 or mailed back. Please send them back by September 15, 1996. If you have any questions, please feel free to call me at (805) 862 -8717. Sincerely, Steve *y- 4 , Director Environmental Health Services Department SMc:AEG:jg /jrw (hm \green \letterus) M M UNDERGROUND STORAGE TANK UPGRADE STATUS REPORT (THIS FORM HAS BEEN COMPLETED FOR TANKS NUMBERED 1 FACILITY NAME KERN MEDICAL CENTER TANK OWNER KERN CO MEDICAL CENTER FACILITY ADDRESS 1830 FLOWER STREET, BAKERSFIELD, CA FACILITY PERMIT # 120003C TANK(S) 2 OPTIONS TO MEET THE 1998 DEADLINE Choose A, B, or C then enter the target or actual completion date(s) as appropriate COMPLETION DATES Target Actual A) Permanent closure or removal of the tank and piping. B) Replacement of the tank and piping with a double - walled tank, double - walled piping, and dispenser containment, (required for non -motor vehicle fuel tanks). C) Tank and piping upgrade as follows: 1) Installation of striker plate(s) in tank. 2) Installation of a spill container at the fill tube. 3) Installation of an overfill prevention device with one of the following: a) Automatic shutoff device b) Ball float valve c) Audible and visual overfill alarm 4) Corrosion protection for the tank provided by one of the following: a) Tank made of non - corrodible material (such as fiberglass) b) Steel tank clad with (or encased in) noncorrodible material c) Steel tank upgraded with interior lining and exterior cathodic protection d) Steel tank upgraded with interior lining, exterior cathodic cathodic protection, and a bladder system 5) Corrosion protection for the associated piping provided by one of the following: a) Piping made of non - corrodible material (such as fiberglass) b) Installation of new fiberglass or other non - corrodible double - walled piping and dispenser containment c) Steel piping with corrosion - resistant coating and cathodic protection d) Steel piping upgraded with cathodic protection 6) Installation of a line leak detector with an automatic shutoff system /device. Please complete this form and fax to (805) 862 -8701, or mail to Kern County Environmental Health Services Department, 2700 M Street, Suite 300, Bakersfield, CA 93301, by September 15, 1996. TANK OWNER/ OPERATOR /AGENT DATE HM96 ' (8i96) ENVIRONMEN`lkL HEALTH SERVICESOEPARTMENT STEVE WCALLEY, R.E.H.S. DIRECTOR County of Kern 1415 TriMun Avenue Bakersfield, CA 93301 SUBJECT: Permit No.. : Facility Name: Facility Address: Dear Tank Owner: 2700 "M" Street, Suite .300 Bakersfield, CA 93301 (805) 861 -3636 (805) 861 -3429 FAX September 4, 1993 120003 l Kern Medical Center 1830 Flower Street, Bakersfield, CA 93305 Kern County Environmental Health Services Department has changed its inspection frequency to once every other year for all underground storage tank facilities. To ensure that the program has received all information required within your permit to operate, the staff has reviewed your facility file and found the following information to be missing: 1. a Tank Facility Annual Report for 1992: Please submit the information lacking within 15 days of this letter. 'If the equipment has not been installed and you need information on equipment or companies certified by the state to meet your permit requirements, please feel free to call me at (805) 861 -3636. Sincerely, Steve McCalley, Director By: Carrie Georgi Hazardous Materials Specialist Hazardous Materials Management Program CG:cas \georgi \120003h.m49 • i ENVIRONMENTAL HEALTH SERVICES DEPARTMENT STEVE WCALLEY, R.E.H.S. DIRECTOR Don Aiken Sullivan's Petroleum May 2.0, 1993 2700 "M" Street, Suite 300 Bakersfield, CA 93301 (805) 861 -3636 (805) 861 -3429 FAX RE: Concerns .for overspillage of Motor -Fuel from Underground Storage Tanks. Dear Mr. Aiken: The Kern County Environmental Health Services Department has received information from. two County Departments which suggested that drivers from your company were associated with the overspillage of fuel from underground storage tanks. The Environmental Health Services Department has recently received a video which was developed by for EPA with the assistance of many Fuel Delivery companies including Sullivan's entitled "Keeping It Clean: Making Safe and Spill -Free Motor Fuel Deliveries ". The Department is providing you with this video on loan for one months period to review, and to go over with your drivers in order to assist you in making an effort to reduce the number of overspillages which occur, involving your staff. If you have any questions please feel free to contact Amy E. Green at (805)861 -3636. t,11 Sincerely S,tiO-it� McCallev_,-/Di eator smy -Tztreen _�•�J %' Ha rdous Materials Sp. Hazardous' aterials Management Program i ! RANDALL L. ABBOTT DIRECTOR DAVID PRICE III ASSISTANT DIRECTOR Permit No.: 120003C RF.ItURCE MANAGEMENT AAtNCY Environmental Health Services Department STEVE McCALLEY, REHS, DIRECTOR Air Pollution Control District WILLIAM J. RODDY, APCO Planning & Development Services Department TED JAMES, AICP, DIRECTOR ENVIRONMENTAL HEALTH SERVICES DEPARTMENT PERMIT TO OPERATE UNDERGROUND HAZARDOUS STORAGE FACILITY Issued to: KERN MEDICAL CENTER Location: 1830 FLOWER STREET Year BAKERSFIELD, CA Owner: COUNTY OF KERN Contents 1415 TRUXTUN AVENUE Installed BAKERSFIELD, CA 93301 Operator: KERN MEDICAL CENTER DIESEL 1830 FLOWER STREET 1954 BAKERSFIELD, CA 93305 Facility Profile: State ID No.: 45483 No. of Tanks: 3 This permit is granted subject to the conditions and prohibitions listed on the attached summary of conditions /prohibitions Issue Date: November 4, 1991 Expiration Date: November 4, 1996 2700 "M" STREET, SUITE 300 M Steve McCalley ,- Tf_. Title: Director, Environmental Health Services Department -- POST ON PREMISES -- NONTRANSFERABLE BAKERSFIELD, CALIFORNIA 93301 (805) 861 -3636 FAX: (805) 861 -3429 Substance Tank Tank Year Is piping Tank No. Code Contents Ca aci Installed Pressurized? 1 MVF 3 DIESEL 750 1954 NO- SUCTION 2 MVF 3 DIESEL 7,500 1964 NO- SUCTION 3 MVF 3 DIESEL 10,000 1982 NO- SUCTION This permit is granted subject to the conditions and prohibitions listed on the attached summary of conditions /prohibitions Issue Date: November 4, 1991 Expiration Date: November 4, 1996 2700 "M" STREET, SUITE 300 M Steve McCalley ,- Tf_. Title: Director, Environmental Health Services Department -- POST ON PREMISES -- NONTRANSFERABLE BAKERSFIELD, CALIFORNIA 93301 (805) 861 -3636 FAX: (805) 861 -3429 • s Ij HAZARDOUS UNDERGROUND STORAGE FACII.ITY PERMIT SUMMARY OF CONDITIONS/PROHIBITIONS 1. The facility owner and operator must be familiar with all conditions specified within this permit and must meet any additional requirements to monitor, upgrade, or close the tanks and associated piping imposed by the permitting authority. 2. If the operator of the underground storage tank is not the owner, then the owner shall enter into a written contract with the operator, requiring the operator to monitor the underground storage tank; maintain appropriate records; and implement reporting procedures as required by the Department. 3. The facility owner and operator shall ensure that the facility has adequate financial responsibility insurance coverage, as mandated for all underground storage tanks containing petroleum, and supply proof of such coverage when requested by the permitting authority. 4. The facility owner must ensure that the annual permit fee is paid within 30 days of the invoice date. 5. The facility will be considered in violation and operating without a permit if annual permit fees are not received within 60 days of the invoice date. 6. The facility owner and/or operator shall review the leak detection requirements provided within this permit. The monitoring alternative shall be implemented within 60 days of the permit issue date. 7. The facility underground storage tanks must be monitored, utilizing the option approved by the permitting authority, until the tank is closed under a valid, unexpired permit for closure. 8. Any inactive underground storage tank which is not being monitored, as approved by the permitting authority, is considered improperly closed. Proper closure is required and must be completed under a permit issued by the permitting authority. 9. The facility owner /operator must obtain a modification permit before: a. Uncovering any underground storage tank after failure of a tank integrity test. b. Replacement of piping. C. Lining the interior of the underground storage tank. 10. The tank owner must advise the Environmental Health Services Department within 10 days of transfer of ownership. 11. Any change in state law or local ordinance may necessitate a change in permit conditions. The owner /operator will be required to meet new conditions within 60 days of notification. 12. The owner and/or operator shall keep a copy of all monitoring records at the facility for a minimum of three years, or as specified by the permitting authority. They may be kept off site if they can be obtained within 24 hours of a request made by the local authority. 13. The owner /operator must report any unauthorized release which escapes from the secondary containment, or from the primary containment if no secondary containment exists, which increases the hazard of fire or explosion or causes any deterioration of the secondary containment within 24 hours of discovery. AEG.jrw (gmeMpermit.p2) MONITORING REQUIREMENTS:(MVF3s,M(750)su) 1. All underground storage tanks greater than 750 gallons, designated as MVF 3 within Page 1 of this permit shall be monitored utilizing the following method: a. Standard Inventory Control Monitoring (Tank gauging five to seven days per week). Kern County Environmental Health Services Department forms shall be utilized unless a facility form can provide the same information and has been reviewed and approved by the Environmental Health Services Department. (Monitoring shall be completed in accordance with requirements summarized in Handbook UT -10.) AND b. All tanks shall be tested annually utilizing a tank integrity test which has been certified as being capable of detecting a leak of 0.1 gallon per hour with a probability of detection of 95 percent and a probability of false alarm of 5 percent. The first test shall be completed before December 31, 1991, and subsequent tests completed each calendar year thereafter. All tank integrity tests completed after September 16, 1991, shall be completed under a valid, unexpired Permit to Test issued by the Environmental Health Services Department. 2. All 750 gallon underground storage tanks designated as MVF3 on the first page of this permit shall be monitored utilizing the following methods: a. Modified Inventory Control Monitoring (Tank gauging two days per week). Kern County Environmental Health Department forms shall be utilized unless a facility form can provide the same information and has been reviewed and approved by Environmental Health Services Department. (Monitoring shall be completed in accordance with requirements summarized in Handbook UT -15.) AND b. All tanks shall be tested annually utilizing a tank integrity test which has been certified as being capable of detecting a leak of 0.1 gallon per hour with a probability of detection of 95 percent and a probability of false alarm of 5 percent. The first test shall be completed before December 31, 1991, and subsequent tests completed each calendar year thereafter. All tank integrity tests completed after September 16, 1991, shall be completed under a valid, unexpired Permit to Test issued by the Environmental Health Services Department. 3. All underground storage tanks shall be retrofitted with overspill containers which have a minimum capacity of 5 gallons; be protected from galvanic corrosion, if made of metal; and be equipped with a drain valve to allow the drainage of liquid back into the tank by December 1998, or as specified by the Environmental Health Services Department. 4. All equipment installed for leak detection shall be operated and maintained in accordance with manufacturer's instructions, including routine maintenance and service checks (at least once per year) for operability or running condition. An annual report shall be submitted to the Kern County Environmental Health Services Department each year after monitoring has been initiated. The owner /operator shall use the forms provided within the Handbooks UT -10 and UT -15. 6. All suction piping shall be monitored for the presence of air in the pipeline by observing the suction pumping system for the following indicators: a. The cost /quantity display wheels on the meter suction pump skip or jump during operation; b. The suction pump is operating, but no motor vehicle fuel is being pumped; C. The suction pump seems to overspeed when first turned on and then slows down as it begins to pump liquid; and d. A rattling sound in the suction pump and erratic flow, indicating an air and liquid mixture. 0 1700 Flower Street Bakersfield, California 93305 Telephone (805) 861 -3636 OERN COUNTY HEALTH DEPARTME0 HEALTH OFFICER Leon M Hebertson, M.D. ENVIRONMENTAL HEALTH DIVISION = NTER= M PERM'= T T O O P E RAT E: UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY DIRECTOR OF ENVIRONMENTAL HEALTH Vernon S. Reichard PE1:;,M=T4#1200000 2 S S u E n: JULY 1, 1986 E X P Z R E S: JULY 1, 1989 NUMBER OF TANKS= 3 ---------------------------------------------------------------------- FACILITY: OWNER: KERN MEDICAL CENTER { COUNTY OF KERN 1830 FLOWER STREET { 1415 TRUXTUN AVENUE BAKERSFIELD, CA { BAKERSFIELD, CA 93301 ---------------------------------------------------------------------- TANK # AGE(IN YRS) SUBSTANCE CODE PRESSURIZED PIPING? 1 31 MVF 3 NO 2 21 MVF 3 NO 3 3 MVF 3 NO NOTE: ALL INTERIM REQUIREMENTS ESTABLISHED BY THE PERMITTING AUTHORITY MUST BE MET DURING THE TERM OF THIS PERMIT NO1V- TRANSFERABLE 'k 'k 'k POST ON Ell REM= SES DATE PERMIT MAILED: JUL 2 1 1986 DATE PERMIT CHECK LIST RETURNED: W"// , . (fi)- ' 7 . nDUD A TTvi -- DTi DI%XTT A DDT ird- A TTr%%T W A /"IrT TTt., a a, .,v ... •... _ ._ _ _ _ _ KERICCOUNT}Y'ENVIRONMENTAL HEALTH _ CES Unifie ogram Consolidated. Form (UPCF) DEPARTMENTDERGROUND STORAGE TANK 2760 M STREET, SUITE 300 BAKERSFIELD, CA 93301 (661) 862 -8700 Fax (661) 862 -8701 (one page per site) Page of Im Io400 : TYPE OF ACTION . ❑ 1. NEW PERMIT ❑. 5. CHANGE OF INFORMATION'. ❑ 7. PERMANENT FACILITY CPASURE I fit' a (Check one item only) ' ❑ 3. RENEWAL PERMIT , ❑ 6. TEMPORARY FACILITY CLOSURE . ❑ 9. TRANSFER PERMIT .: ..... � ..� .�.y .:..: �n2'...Tlr,..„- - - 'ir/:� e:4N r. F: �ru.::.h= -.YLL -• J1:: :M1d "IW[r ,,,1'w;. .. ,. ... ... :..... '�: ". ;':•'�:' "�.. ... y ..,. l �i�'li•: � ..�i� `...:111- ":L- (,'h':'i�..::..ry: :1'•Yr:rt'. �.. J.I.1;+�,.(' ^•a,., � ":':;'.I� A.�:; 1 !i • � M1;rQ..k n• w .,7...11. \�0:[�1�.1t'� 1 \- , 1 '� N ..F1 1.r. A:t�� TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID # (Agency Use Onfy) y • m% L -1 BUSINESS N E (Same u FACILITY NAME or DfiA - Doing Business As) EwIpO ilVENT/tL HEALTH SG V1 BUSINESS SI E ADDRESS 103. CITY 104. ei FACILITY TYPE ❑ 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403' Is the facility located on Ind.. Reservation or 40S' ❑ 3. FARM ❑ 4. PROCESSOR 6.OT14ER Trust lands? ❑ Yes o 4.,a, TRnP �t;�`QL''R7FOR1tiITIXi1!+T ..;s:`,. • .� .. �.. PROPERTY OWNER NAME, 407- PHONE aog. MAILING ADDRESS 1 409. CITY 410. STATE 411 ZIP CODE 412. �433� I s , 11 " ; esii ' r ' � 1 y I . .., ..i+, , •i ,::r..:'•; . , c� �� .t , > `L�ri:: "�',,"',..r"n'y �,�, r ,j `, r' . -. .... .. _i, a ... ... TANK OP!ATOR NAME, .428-1. PHONE 428 -2 MAILING ADDRESS 428-3 �j CITY 4284 STATE 4z8 s ZIP CODE . 42M Q33os � �. a...,:� TANK �O�V.NER INFORMATION 'i;9 ° 1 •.: r ,.. ?rn .'.: :e.' ",', �.. .'.: i j TANK OWNS NAME 414. PHONE 415. c (1 alto MAILING ADDRESS .416. CITY j 417. STATE 418. ZIP CODE 419. OWNER TYPE:. ❑ 4: LOCAL AGENCYIDISTRICT OUNTY AGENCY ❑ 6. STATE AGENCY 420. ❑ 7. FEDERAL AGENCY ❑ 8. NON- GOVERNMENT ... .: ._.: t.,: •:1 ,•:. !,.... .,., •: ,., _...�:.r.,4,1. .r_.. .:'?r...IR •. .I.nH k: ". .J= 'ih�iAhii'1'r 'C ,.:T;T:• .';!.2 OF EQUAL ATION 1'J;S GE`FEE'':ACCOTIN hSTQ TY (TK) HQ 44- p. 101 fo 1 a $ .1 : Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. ... • ...,: -'... .,., ^ ...a... . r ,,..., : - :'.'1: -.. '_ ��.:...,. 11 own• ry -r .., :.r•::�:rr:a;..',r.:�._,.:., �]�^. r��� .:•- .o-.•r(11..��y,"�•�'�C.';t; , ..::::. ?: •'I;...4.F$w�. r•'.�'+ �;:yr: r::iL: ti ". ftI iYY hll b, i it -I /�. 'Y 11G'4 •�. AI J'.R�:- ` • :�. �`. '�� J ''�,� j' �_:� ..:;�•:�.PERIM /QO 'f.7R: •O �.La•'IaT�V11 1 .1 Issue permit and send legal notifications and mailings to:. C, , FACILITY OWNER ❑ 4. TANK OPERATOR. 423 ❑ 3. TANK OWNER . ❑ 5. FACILITY OPERATOR 406. SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required.Far Public Ag licies Only) Ar- �...:..; sr;.., .s;._... �.... w:..,t. r'. ,._:!•�: :,� .r. � �.. r: !'. rv'.. e `:f.. '.I .'�"`.'. %x. 3.;a ���a;... AN'�SIG'NAE: -.� P�%C' _..... ;. _ r .:,. ,... • .:,r::. ,�•., �•y�I.,;�P ' r•rf':: h:_ •,�I�;.• r,!, a °':�" r. .. .. ._.. .,,,. .. .^ ' =' : '.�': ..; �;....: _' YYtlr.nv -.' •{^I•, .:IP•�'.ieR..,..1.i;7p -y_.:. .. Tvi?_. r ,.IJ .. %9f�w. CERTIFICATION: I certify that the information provided herein is true, accurate, and in full com' liance with leg ai requirements. A DATE 424. PHONE.' 425. Cam( 13� �'�q APPLICANT NAME (print) 426• APPLICANT TITLE 427 (5/2008 revised) KC Form A VICE! ;r � .. , s .�. .., OPERATING PERMIT APPLICA -TION KERN COUNTY ENVIRONMENTAL HEALTH ICES Unified Program Consolitlateu r Us a- DEPARTMENT UNDERGROUND STORAGE TANKS 2700 M STREET, SUITE 300 " BAKERSFIELD, CA 93301 (661)862-870 0 Fax (661) 862 -8701 (one page per tank) Page _ of TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, Il, 11I,-IV, and• IX:below) �•- 430 ❑ 1. NEW PERMIT." ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION°e ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: - 4300 I DATE EXISTING UST DISCOVERED: 430b L "`FA .TTY:INF 1 • FACILITY ID # (Agency Use Only) i1.�tt\ . "'- '(J!NI 3 BUSINESS N E (Same as FACILITY NAME or DBA -Doing Business As) �'• �- ENVIRO( (•il 11TF�L W1 AL'iN SERViC BUSINESSJLTE ADD 103 C 104 er' . lI TANK DESCRIPTION` r TANK ID # . 432 TANK MANUFACTURER 433 TAJjIK CONFIGURATION: THIS TANK IS ', 434 ASTAND -ALONE TANK -- 62. A COMPARTMENTED UNIT DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 434 NUMBER OF COMPARTMENTS IN THE UNIT 437 N(} T7SE AND 6N, E' . 4 r *;<:4 t v TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. AVIATION FUELING 43. 11 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used oil) WS. EMERGENCY GENERATOR FUEL (HSC §25281.5(c)I ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4399 CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 W3. DIESEL ' ❑ S. JET FUEL ❑ 6. AVIATION GAS 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440& NON- PETROLEUM: ❑ 7. USED OIL, ❑ 30. ETHANOL ❑ 1 I.OTHER NON - PETROLEUM (Specify): 440b COPSTRUCTTON .:.: TYPE OF TANK L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTARJMENT 1. STEEL X3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LD41NG ❑ 95. UNKNOWN ❑ 99. OTHER (S eci ): 444a SECONDARY CONTAINMENT ❑ 1. STEEL .. [13. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED .. 445 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a OVERFILL PREVENTION 1. AUDIBLE 8c VISUAL ALARMS 2. BALL FLOAT E3 3. FILL TUBE SHUT -OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS R EXEMPTIONFROM OVERFILL PREVENTION EQUIPMENT :v" PRODUCTJtR?ASTE PIPING CONSTRUCTIbN PIPING CONSTRUCTION ❑ 1. SINGLE - WALLED . DOUBLE- WALLED ❑ 99. OTHER 460 SYSTEM TYPE ❑ 1. PRESSURE 2. GRAVITY 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR .2636(x)(3) 4se PRIMARY CONTAINMENT ❑ 1. STEEL 4'. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE 95. UNKNOWN.. ❑ 99.OTHER(Spccify): 464a SECONDARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS" ❑ 8, FLEXIBLE ❑ 10. RIGID PLASTIC 464b [3 90. NONE ❑ 95. UNKNOWN' ❑ 99. OTHER (Specify): 464c PIP)NG/TURBINE CONTAINMENT SUMP TYPE LKI, SINGLE WALL 124. DOUBLE WALL ❑ 90. NONE 4644 h� VI 'SENT, VAPOR RE'C VERYI:(V12).' iD RISERr /.FQ�T, PIPE 'PIP -ING CONSTRUCTION . VENT PRIMARY CONTAINMENT 1. STEEL 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 464a • 464el VENT SECONDARY CONTAINMENT ❑ 1 • STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 0, NONE P 99.OTHER (Specify) 464 46af VR PRIMARY CONTAINMENT 1. STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC X90. NONE 0 99. OTHER (Specify) . - 464. 464 VR SECONDARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 464 464h VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL Q, 2. DOUBLE WALL Q 90. NONE 464 RISER PRIMARY CONTAINMENT 1. STEEL . 4. FIBERGLASS Lj 10. RIGID PLASTIC Lj 90. NONE ❑ 99. OTHER (Specify) 46 464 RISER SECONDARY CONTAINMENT ❑ 1• STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC' 90. NONE ❑ 99. OTHER (Specify) 4& 464 FILL COMPONENTS INSTALLED 1. SPT_L BUCKET 3. STRIKER PLATEMOTTOM PROTECTOR 4. CONTAINMENT SUMP 451s YIL UNDER DISPENSER'CO14TATNNIENT (UDC) j CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS X90. NONE Q CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469 STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODES) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION rLICANT�SIGN TURFi CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurl and II compliance with legal r uirements. APPLI I N DATE. APPLICANT NAME nt) 471. APPLICANT ITLE (05/2008 revised) v KC Form B ' - CERTIFICATI N OF INSTALLATION % MODIFI1:A-1 ivly (05/2008 revised) KC Form C KERN COUNTY ZNVIRONMENTAL HEALTH S CES Unifie ogram Consolidated Form (UPCF) DEPARTMENT MVERGROUND 2700 M.STREET, SUITE 300 STORAGE TANKS BAKERSFIELD, CA 93301 ' (661) 862 -8700 Fax.(661) 862 -8701 (one form per prof `ct)`CP0age�f_ I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ J A NJ 1 6,'009 BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Busines As) '3. COUNTY �� Gnnnnr,r i -1� H SERV(C4 BUSINESS SITE ADDRESS I03. CITY )a. II. INSTALLATION/ MODIFICATION PROJECT DESCRIPTION TYPE OF PROJECT (Check all that ann) vl ..: 4834 WORK AUTHORIZED UNDER PERMIT 483b. ❑ 1. TANK INSTALLATION OR REPLACEMENT: (Number or Date): ❑ 2. PIPING INSTALLATION OR REPLACEMENT ❑ 3. SUMP INSTALLATION OR REPLACEMENT ❑ 4. UNDER DISPENSER CONTAINMENT INSTALLATION OR REPLACEMENT ❑ S. OTHER DESCRIPTION OF WORK BEING CERTIFIED: 483c ". C III. CONTRACTOR INFORMATION NAME OF CONTRACTOR WHO PERFORMED INSTALLATION / MODIFICATION 4924 CONTRACTOR LICENSE # 4826 ICC CERTIFICATION # 482c. IV. CERTIFICATION I certify that the information provided herein is true, accurate, and that the following conditions have been satisfied: • The installer has met the requirements set forth in 23 CCR §2715, subdivisions (g) and (h). • The underground storage tank, any primary piping, and any secondary containment was installed according to applicable voluntary consensus standards and any manufacturer's written installation instructions. 0 All work listed in the manufacturer's installation checklist has been completed. 0 The installation has been inspected and approved by the local agency, or if required by the local agency, inspected and certified by a registered professional engineer havina education and ex erience with underground storage tank system installations. S[GN OF ER OR OWNER'S AGENT . DATE 484. PHONE 487. 1 l CERTIFI 'S NAME (print) 485 CERTIFIER'S TITLE: 486. NAME OF CER ER'S EMPLOYER (DBA) 488 CERTIFIER's RELA ONSHIP TO TANK OWNER 489. ❑ L TANK OWNER ❑ 2. TANK OPERATOR ❑ 3. CONTRACTOR ❑ 4. PROPERTY OWNER ❑ 5. OTHER AUTHORIZED AGENT OF TANK OWNER (05/2008 revised) KC Form C MONITORING PLAN TANKS SINGLE WALLED FIBERGLASS OR CLAD TANKS The tanks have an automatic tank gauging (ATasystem that is capable of conducting a 0.2 gph 5 3 leak test. The system is a '� "� ry K (make and model) and is located (panel location). The ATG is placed in the test mode at least monthly and after product delivery or when the tank is filled to within 10% of the previous month's highest operating level. The ATG generates a hard coy rant out) of the test data after each test. The copies are maintained on site or at i rL, V1 18 Ta-y ,roAyti (an approved location)- PIPING DOUBLE WALLED PIPING The double walled piping has a continuous leak monitoring system in the turbine sump. The system is a FL5 3 S—D 12 (make and model) and is located Im ci 1 ✓1 R&>i 1 e-v CO c9 ✓6Z (panel location). The system is connected to an audible and visual alarm. The alarm panel is inspected daily for power and alarm status and is documented on a daily log sheet. OVERFILL AND SPILL PREVENTION Each tank fill opening is equipped with an approved spill prevention container of minimum five gallon capacity. The container is equipped with a drain valve to permit spilled hazardous material to be drained into the tank primary containment. - AND - Each tank fill opening is equipped with an approved overfill prevention device which cannot allow manual override and alerts the transfer operator when the tank is 90% full by restricting the flow into the tank or by triggering an audible and visual alarm. MONITORING EQUIPMENT MAINTENANCE (All facilities) Equipment and devices used to monitor the UST system will be calibrated, operated, and maintained in accordance with the manufacturer's instructions, including routine maintenance and service checks at least once per calendar year for operability or running condition. The Kern County t M � ' f Environmental Health Services Desment will be notified at least two wAng days prior to the annual certification and the results submitted within 30 days. SECONDARY CONTAINMENT TESTING The secondary containment systems (i.e. tanks, piping, turbine (piping) sumps, fill sumps, and dispenser pans) will be tested every 36 months with the first test completed before January 1, 2003. ENHANCED LEAK DETECTION MONITORING This facility is located within 1000 feet of a public drinking water well and has at least one component that is single walled (i.e. tank, piping, or no dispenser pan). The tank system will be tested using an approved Enhanced Leak Detection program within 18 months of notification from the State and every 36 months thereafter. RECORD RETENTION Written monitoring records will be maintained on site or at ZO o m for the following periods of time: an approve anon Three years for monitoring and maintenance records Five years for written performance claims pertaining to release detection systems and calibration/maintenance records for such systems. • a a 0 EMERGENCY RESPONSE PLAN FORM UNDERGROUND STORAGE TANK MONITORING PROGRAM Facility Name: K E K nI M E D 1 cA L. C E LATE R Facility Address: /&30 FI- o W EQ -rT- , , bA KER.I Fl EL D�, CRT 1 330 9 1. If an unauthorized release occurs, how will the hazardous substance be cleaned up? Note: If released hazardous substances reach the environment, increase the fire or explosion hazard, are not cleaned up from the secondary containment within 8 hours, or deteriorate the secondary containment, the Kern County Environmental Health Services Department must be notified within 24 hours. NoR S PiUf by lcL E itltF2 jE T>?EfiTED w� A8 ro,2 A4.4-r6RI 1 L XWEPT of AND 'PlIPosED aF THRouGN AN ALA rHozizED VEND aR . TM,' 7T RKE IN PLRCf WITH AfU7-H021ZE1 HAZIV D ouJ 4419 1ALr HAS )PL6x To HANDLE LA2GE2 'T-ELEAfES' , 2. Describe the proposed methods and equipment to be used for removing and properly disposing of any hazardous substances. -CA/ 4 E A r A '9 ayE 3. Describe the location and availability of the required cleanup equipment in item 2 above. f9C,H E4uIPMEN7- JEadPn w/ -POT,(pT/fiL Far, A -gELE,+.rE HAJ A . F V - CALLa J -j RUM w/ 0- roRBAA/7 M,4r6Ah4(- .r IN I T, 4. Describe the maintenance schedule for the cleanup equipment. .S")TE.r AXE 1N1PEcTED TA/LY - PlAAWG- CQu1PME6)r 20(WDf 5. List the name(s) and title(s) of the person(s) responsible for authorizing any work necessary under the response plan: �� �03 klI .r6LL/9 , FA6)Ll7y MGR., 0-7- P6- f16N66 hm79 (5/02) 0 0 0 a Kern County Environmental Health Services Department 2700 M Street, Suite 300 Bakersfield, CA 93301 (661) 862 -8700 Fax (661) 862 -8701 Certified Unified Program Agency - Underground Storage Tank Program UST Owner Declaration of Compliance and Identification of Designated UST Operator Facility and Owner Intormation u:� J (_1 Date: Facility ID: 09/26/05 120003/004453 Tank Owner Name: Facility Name: KERN COUNTY MEDICAL CENTER KERN MEDICAL CENTER Tank Owner Address: Facility Address: 1830 FLOWER ST 1830 FLOWER ST BAKERSFIELD, C,^. 03305 BAK.ERSFIELD Tank Owner Phone: Facility Phone: 661/326 -2000 661/326 -2400 uesignatea operator Inrormation Name of Designated Operator: ANTHONY VETETO Facility Connection ❑Owner ❑ Operator ❑Employee aService Tech ❑ Other/Third Party Business Name / Phone # of ACE PETROLEUM SERVICES, INC. Designated Operator 661/387 -6522 (If Service Tech or Third Party ) California UST Operator ANTHONY VETETO Certificate Number, (issued by S246001 �.U(f 11/24/06 /CC): Declaration of Compliance Owner Declaration: I hereby designate the above -named individual as the "Designated UST Operator" for this facility. This operator has completed the required certified training and is in possession of the Operator Certificate noted above. This individual will conduct monthly visual inspections of the UST Facility, provide basic on-the-job- training to facility employees every twelve months, and keep records of these activities. It is understood that these tasks must be performed by the Designated Operator and cannot be delegated. Furthermore, As the owner of the underground storage tanks at the above -noted facility, I declare, under penalty of perjury, that 1 understand and am in compliance with all applicable Underground Storage Tank requirements pursuant to the California Health and Safety Code, Chapter 6.7. Signature of Tank Owner: � ��� r 9 KERN d0 WP SERVICE ARWENT 2 'M° STREE, UTE 300, BAKERSFIELD, CA 933U�' TELEPHONE (805) 861 -3636 'UNDERGROUND STORAGE. TANK FACILITY••INSPECTION ,:REPORT PERMIT NO.:' 120003C NO. OF TANKS: 2. • 1me,inr •Time: (hut: Inspection Date: Type of Inspection: Routine: Reinspection;, ❑ implaint: ❑ . FACILITY NAME: KERN MEDICAL CENTER OWNER -,NAME: KERN, CO MEDICAL CENTER FACILITY ADDRESS: 1830'FLOWER STREET OPERATOR NAME: KERN- MEDICAL CENTER BAKERSFIELD, CA COMMENTS: _.,Substance Tank Is Piping Violation ' MONITORING OPTIONS, Tank-4- Code, Contents- Pressurized Code Monitoring? 1. Primary Containment Monitoring: 2 MVF 3 DIESEL, NO- SUCTION !OS' a) 'Intercepting and Directing System 3 MVF 3 DIESEL NO /D b) Standard Inventory Control c) Statistical Inventory Rec. (SIR) d� Modified Inventory Control e) Automatic Tank Gauge f) Groundwater Monitoring g) Vadose Monitoring h) Other 0 ERVAT_IONS: (i.e. cond'tion f,overspill container, leaks /releases, monitoring concerns,e.tc , 2. Secondary Containment Monitoring YI YContinuous Monitor in Tank Annular Space /Secondary Containment b) Visual Monitoring c),Manual Monitoring.of Secondary Containment y d) Other yo vie n n &rMS U)NAt 3: Temporarily Abandoned, (under permit) ic ) •4. None 3o SC pan overspill Ix�X P VIOLATION RVED: 100 Operation, abandonment,.or modification of an underground storage tank system without obtaining a permit. KCOC, Section 8.48.030; HSC Ch. 6.7, Section 25284 or 25298. 105 Failure to monitor tank(s) using the method specified on the permit, or approved by the local agency; KCOC Section 8.48.140; HSC'Ch. 6.7 Section 25293. ❑ 110 Failure to report unauthorized release; KCOC, Section 8.48.220; HSC Section 25295. ❑ 115 Failure to close UST properly; KCOC, Section 8.48.270; HSC Section 25298. ❑ 120 Failure to install automatic line-leak detection system and keep it operational for all• pressurized piping; KCOC, Section 8.48.175; HSC Ch. 6.7, Section 25292. ❑ 125 Failure to maintain evidence of financial responsibility for taking corrective action and for compensating third parties for bodily injury and property damage caused by a release from the Underground Storage Tank system; KCOC, Section 8.48.117; HSC Ch. 6.7, Section 25292.2 If one of the numbered violations has been checked, Staff will -need to reinspect your _facility =: As.prescribed, by County Ordinance; a per -hour fee for extended services -will be charged for all reinspections._ To avoid or reduce reinspection costs: 1. Make the corrections.for the violations observed. 2. Submit documentation as described above. 3. Respond by reinspection date; or within 7 days if immediately is checked. NOTICE TO COMPLY: If violations have been identified, deficiencies must be corrected as specified. El I mmediately r�y -Reinspect ion on or after: ,���CAAS_ I ❑ NO•REINSPECTION REQUIRED Hazardous Materials Special f A//%" Received By: -' TDSSMT.qAg SOIVA32 HTJASH SATI?SMVIORIVT T14ITOb M57-3:4 :1 J .lU. ,l� �I i. •Y ' TAOgSA VIOIT33g2H1 - YTI1IOA3 NZAT SDA -ROT2 (INUORDRSCIMU _ .. a. -� `.. ;:,t" .r ♦•�_ r.a . _.r_ _. _ t :- - .- . sa sa v. _. ..e.. t -' _�. ...._r. �. ._:_c_.e• _ _ .. ,. .... . . ... . . . ... . ._. _�_.... AM IIM934, ;Y; :i• ?iFfUirO:J. 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' ArrAcam&&r A A& AL CY(07j FEM aripmd - tad Anna Copm - FadeWWW(t) State of Cali%mia t State Water Reaoumts Control Board CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. Ism required to demonstrate Financial Responsibility in the required amounts "specified in Section 2W7. Chapter t0. Div. 3. Title 23. CCR: Q500.000 dollars per occurrence a i Million daU m annual sUtopte of AND a OI million dollars per occurrence 2 million dollars annual &Utopia B County of Kern hereby certifies that it is in compliance with the requirements of Section 2807. (Name of Tank owner oo►ssaw) Article 3. Chapter to, Division 3, TWO 23, Cal fomla Coat of Regulations. The mechanisms used to abwnonsawe ffrancisl res as required by Section 2W7 am as follows. C. Mechanism Name and Address of Issuer Mech1knism Covemge Coverage Corrective Third Party Type Number Amount Period Action Coma. County of Kern 1 million Test 1115 Truxtun Avenue 5th Per 1 year yes yes Bakersfield, Bakersfield, CA 93301 N/A occurrenc 1 millicn to Note: If you are using the State Fund as any part of your demonstration of financial responsibility, ytour execution and submission of this cerdfAcabon also certifies that you are in compliance with all conditions for participation in the Fund. . Pa"tYName P&MIyAddran see attached list . FadligNams PaditrAddnm FwWrYName Fadtitymdraaa Fadliq Name PuWtyAddrer Fs"tyNsme FadWyAddraaa 1 ' E. Sipumn of o for Dwe Name and Tine o(Teak lases or apsata 5-31-94 Countv of Kern-Joseph E. Drew Sipaws or Notur Date Name o(VAa s er Noury 5 -31 -94 Sharon Pierce CY(07j FEM aripmd - tad Anna Copm - FadeWWW(t) 0 0 r1 U WORKSHEET FOR tii NICIPAL FL1ANCIAL TEST PART I: BASIC WFORIIZATION 1. Total Revenues a. Revenues (dollars) 726,259,315 Value of revenues excludes liquidation of investments and issuance of debt. Value includes all general fund operating and non - operating revenues, as well as all revenues from all other governmental funds including enterprise, debt service. capital projects. and special revenues, but excluding revenues to funds held in a trust or agency capacity. b. Subtract interfund transfers (dollars) 10,079,927 C. Total Revenues (dollars) 716,179,388 2. Total Expenditures 741,802,931 a. Expenditures (dollars) Value consists of the sum of general fund operating and non - operating expenditures including interest payments on debt, payments for retirement of debt principal. and total expenditures from all other governmental funds including enterprise. debt service, capital projects, and special revenues. 10,656,028 b. Subtract interfund transfers (dollars) C. Total Expenditures (dollars) 731,146,903 3. Local Revenues a. Total Revenues (from 1c) (dollars) 716,179, 388 b. Subtract total intergovernmental transfers (dollars) 375,524,602 C. Local Revenues (dollars) 340,654,786 4. Debt Service a. Interest and fiscal charges (dollars) 7,002,290 b. Add debt retirement (dollars) 4,296,700 C. Total Debt Service (dollars) 11,298,990 5. Total Funds (Dollars) 53,526,836 (Sum of amounts held as ash and investment securities from all funds. excluding amounts held for employee retirement funds. agency funds. and trust funds) 6. Population (Persons) 610,000 PART 11: APPLICATION OF TEST 7. Total Revenues to Population 716,179,388 a. Total Revenues (from 1c) b. Population (from 6) 610,000 C. Divide 7a by 7b 1174.065 d. Subtract 417 757.065 e. Divide by 5,212 0.1453 f. Multiply by 4.095 0.595 8. Total Expenses to Population a. Total Expenses (from 2c) 731,146,903 b. Population (from 6) 610,000 C. Divide 8a by 8b i 1198.601 d. Subtract 524 674.501 e. Divide by 5,401 6:1245 f. Multiply by 4.095 0.512 9. Local Revenues to Total Revenues a. Local Revenues (from 3c) 340,654,786 b. Total Revenues (from lc) 716,179, 388 c. Divide 9a by 9b 0.4757 d. Subtract .695 - 0.2193 e. Divide by .205 -1.070 f. Multiply by 2.840 -3.038 • 10. Debt Service to Population a. Debt Service (from 4d) b. Population (from 6) C. Divide 10a by 10b d. Subtract 51 e. Divide by 1,038 f. Multiply by - 1.866 11. Debt Service to Total Revenues a. Debt Service (from 4d) b. Total Revenues (from lc) C. Divide lla by llb d. Subtract .068 e. Divide by .259 f. Multiply by - 3.533 12. Total Revenues to Total Expenses a. Total Revenues (from lc) b. Total Expenses (from 2c) C. Divide 12a by 12b d. Subtract .910 e. Divide by .899 f. Multiply by 3.458 13. Funds Balance to Total Revenues a. Total Funds (from 5) b. Total Revenues (from lc) C. Divide 13a by 13b d. Subtract .891 e. Divide by 9.156 f. Multiply by 3.270 • 11 �9f� .990 610.000 18.523 - 32.477 - 0.0313 0.058 11,298,990 716,179,388 0.0158 - 0.0522 -0.202 0.712 716,179,388 731,146,903 0.980 0.070 0.0779 0.269 53,526,836 716,179,388 0.0747 - 0.8163 - 0.0892 -0.292 ." 4—. KERN COUNTY HEALTH DEPARTMENT • ENVIROMENTAL HEALTH REPORT • (805) 861-3636 2700 'M' STREET, BAKERSFIELD. CALIFORNIA 93301 RECOMMENDATIONS AND CORRECTIONS FORM_ Name (D.B.A.) ...... ....... t—aI7 ...................... Date .......... ............................................ Address .................. IfN2129 ...... .: .t............................. E.H. Specialist:......... .................... .............. ---------- �_ . -12211--- - - - - -- -------- -------------------------------------------------- - -------------------------------- - - - --------- ---- - ---------------- - ------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- & ------------n-Y - � -- --------- ---------------------------- ---------------- ....... .D-- - - - - -- l-ezz/m -------- I ----- - ----- ------------ - /4) -------- - - - - -- ------------------ &-o---- ---- ----------------------------------------------------------------------------------------------------------------------------------------- 0 -&'j ................. - -- ----------------------- ----------------------------------- ------------ ----- - ............. - -------------------------------------------------- ----------------------------------------------------------------- --------------------------------------------- ............................ Env. Health 580.2760 244 (Rev. 11/87) < NC a Ft N rG [J U T A 'T-'Y, Ft a C3 U R G E M A A +G E M e r%j T <_ ENVIRONMEN-S 'REALTH SERVICES DEPARTMER, ' 2700' "M" STREEl'; SUITE 300, BAKERSFIELD, CA.93301' (8.05)861 -3636 y "UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY i * INSPECTION REPORT AG ENC'N PERMIT# 120003C' TIME IN �'2�.. TIM : OUT._. /2* lb NUMBER -OF TANKS: PERMIT POSTED? YES_ N0. / ww, INSPECTION DATE- 74- r°m ",`� TYPE_ OF INSPECTION: ROUTINE ti% R.EINSPECTION www ww..w.w _.w..ww..,..w...,..,, r. , „_„ COMPLAINT :.� w.w� w:,.w..,.., FACILITY NAME:KE_RN MEDICAL_ CENTER . w w .w . , w w w ,.w . ww . ............ w......w............_,._..w . ........,.www..w..w.w...,.. ww,. ,.w..w.. ..w. ,....,. w. w..w............w.................. ww ,.w... ....ww,,,. F AC I LI T Y ADDRESS 18 3 0 FLOWER S T R E ET -BAKE.RSFIEL.D, CA .... . .w.,..., w,.., OWNERS NAME-COUNTY OPERATORS NAME- KERN OF KE�RN � MEDICAL... CENTER,w .w�l'n�ri►�V J�'�a► : "w...w..ww............... w.......... ; ITEM 1. PRIMARY CONJAINMENT MONITORING: Intercepting an directing system b Standar •Inventory Control _c Modified Inventory Control d. In- tank,Level- Sensing Device r e. Groi�n�, +dwater Monitoring f. Ved�bso Zone Monitoring 2.. SECONDARY CONTAINMENT MONITORING.: a. Liner b. Double- Walled tank c. Vault . 3. PIPING MONITORING: Pressurized Suction c. Gravity OVERFILL PROTECTION: TIGHTNESS--TESTING -6. NEW CONSTRUCTION /MODIFICATIONS 7. CLOSURE /ABANDONMENT 6. UNAUTHORIZED RELEASE MAINTENANCE, GENERAL SAFETY, AND OPERATING CONDITION OF FACILITY REINSPECTION INSPECTOR: 7 14+L P% I J. VIVJ/ V0JC r%V (, MWI /f10a/T/ra. NS �, Sucfid�,r �4ipiHy fore #Z �i�s a SU�iJ70 U. ea Ys /0 2 Se�oko%y =r'o tifa /,�`trPct �` fpe Yvtl �dPsht- o��P��-?a r” i� ,I STEVE,),,MCCALLEY Director RESOURCE DEPA JT 2700 'M Street, Suite 300 Bakersfield, CA 93301 Telephone (805) 861 -3636 Telecopler (805) '861 -3429 AGENCY ENTAL dye HAZARDOUS MATERIALS MANAGEMENT PROGRAM Date -2 F-12 Underground Tank Facility # Z7_000 Firm Name a F'' EPA I.D. # Address 1,41a Assessors Parcel Type Facility dr9 a G ge au Facility Address 51 - Person Interviewed Z NOTICE OF VIOLATION AND ORDER TO COMPLY The following conditions or practices observed this date are violations of one or more sections of the California Health.,_. and Safety Code, Div. 20, or the California Code of Regulations, Title 22, Div. 4,'Chap. 30,.relating to the "storage, handling, transportation, and disposal of hazardous waste" or the Ordinance Code of Kern County, Div. 8, "Underground Storage of Hazardous Substances." Conditions or practices must be corrected within the times-ordered below: Your signature acknowledges receipt of a copy of this report and collection of any samples described above, and is not an admission of guilt. Failure t fully omply wit is "Notice a Order" may result in furt r legal action County or State officials. Owner or Auth rized Representative Hazardous Materials Specialist White — Original Canary — Facility file Pink — Specialist Environmental Health 580 4113 120 (Rev. 2/90) STEVE MCCALLEY' Director . •y - RESOURCE r DEPART HAZARDOUS MATERI 2700 M Street, Suite 300 Bakersfield, CA 93301 Telephone (805) 861 -3636 Telecopler (805) 861 -3429 NT AGENCY RENTAL _y e 2... , T PROGRAM Date 2' Underground Tank. Facility #' 1266(0 3 Firm Name rYN, r �lG 1°N ff!'' EPA I.D. # Address u)? -e -T— Assessors Parcel' 1, V . P Type Facility �V e D btK Facility Address Person Interviewed Z Re 6 NOTICE OF VIOLATION-AND ORDER ,TO COMPLY The following conditions or practices observed this date are violations of one or more sections of the California Health and Safety Code, Div: 20, or the California Code of Regulations, Title 22, Div. 4, Chap. 30, relating to the. "storage, handling, transportation, and disposal of hazardous •waste" or the Ordinance Code of Kern County, Div. 8, "Underground Storage of Hazardous Substances." Conditions or practices must be corrected within the times ordered below: Your signature acknowledges receipt of a copy of this report and collection of any samples described above, and is not an admission of guilt. Failur tofu ly comply i this "Notice and Order" may result in further legal actin by County or State officials. Owner or A thorized Representative Hazardous Materials Specialist. White — Original .!:h- Canary — Facility file Pink — Specialist Environmental Health 580 4113 120 (Rev. 2/90) ts. . t. , � .' �• g� � �{ �+. }—� . 4s- ,,j �j �• �••�y �y p�,� /y, y� �•''�� p�� �• per, � �yq, �+ p� n ,�-•. +r,, IY \g`.�0V CS 'Vu N ��"J R e�CDPU FZ� �, YI"'t .1�"T AC=_ eU$A e1'411 -r �1�"'ti "Ta rY C-- 0 E:NVIRONMENI7' HEALTH SERVICES DEPARTME 27'00 "M" STREET, SUITE 300, BAKERSFIELD, CA.93301 (805)861 -3636 UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY * INSPECTION REPORT PERMIT 120003C TIME IN «t TIME OUT 2,`30 NUMBER OF TANKS - ;: 3 PERMIT 6_ _ YES NO _ _ INSPECTION DATE: y.... TYPE OF INSPECTION: ROUTINE « «REINSPECTIONe C0MPLAI "NT FACILITY NAME« «KERN MEDICAL CENTER «.. ........ «.........._ ,.......««... «. «.. «..... « «.:. «.,: « «,,..., «...« _. «... FACILITY A D D R E S S 1 8 3 0E L O W E•R STREET « . «.,.... «.... ...« ._, «,.,,.., «... «.... «. «.... «.. «.......:. «. «. «.« .... «.. « «...« « ...,..,, «.......,... BAKERSFIELD, CA OWNERS NAME: OF O P E R A T O R S N A WQE N K T P K � T E C F� I V CENTER ..,...,,. . ,« « ,,, .... .,,..«.. .. .«.,..., .«...,............« . .«.,.. , «.... . COMMENTS «............ «.. ,., «.,.. « «...., «. «, «...,,,,,, «.... «.,.., .., «,., ,, «,..,.., «, ,,,,,, ,,,,,,«,...,.,..,,.« ......, «_ „ « „«:,,,,,.«,,.,,.,.., «ITEM« VIOLATIONS /OBSERVATIONS 1 PRIMARY CONTAINMENT MONITORING: �/e ,� 'a. Intercepting an directing system` "`�-'`'y Standard Inventory Control 1 4 Modified Inventory Control d. In -tank Level Sensing Device e. Groundwater Monitoring f. Vadose Zone Monitoring 2� SECONDARY CONTAINMENT MONITORING: ll // a. Liner b. Dou�fe- Walled tank c. Vault �+ �f 3 PIPING MONITORING: a. Pressurized b. Suction C, Gravfity ff-`iOVERFILL PROTECTION: 4�2 TIGHTNESS TESING NEW CONSTRUCTION /MODIFICATIONS CLOSUREJABANDQNMENT S. MAUTHORIZED RELEASE 9. MAINTENANCE, GENERAL SAFETY, AND OPERATING CONDITION OF FACILITY COMMENTS /RECOMMENDATIONS,,,- __ - - -IV O rU o ` b «. «,« « . .................««,«.......,..,«,.,..., ..,..,_,...,,. «..,,,,..,. «...., .. �, «,,, « «,... ,_,_ ,.,« _....«.««. ... «..,.,.............. .... ............ «, «« .... REINSPE CTION SCHEDU ED? yes t/no APPROXIMATE” REINSPECT INSPECTOR ,.,.,.,..,« ` „ «, , «.._. « : «. «,,, ,, «, REPORT RECEIVED « «:"'..- -� LUVEU MONITORING .SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Stale of California D EC 1 2 2008 Authority Cited. • Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certificatio or, report must -be . �;I'L� � � ,�F:� TH 5ckViC�S prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must lie 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 this date. A. General Information Facility Name: Kern Medical Center A� 4453 Site Address: 1830 Flower Street City: Bakersfield Bldg. No.: Zip: 93305 Facility Contact Person: Ron Rogers Contact Phone No.: 661- 633 -9611 Make /Model of Monitoring System: Veeder -Root TLS 350 B. Inventory of Equipment Tested /Certified check the appropriate bona to att apednc equipment impectedltenimd. Date of Testing/Servicing: 12/05/2008 Tank iD: 1500 gallon Diesel AST Tank ID: 10000 gallon Diesel UST [x] In -Tank Gauging Probe. Model: 847390-107 Lx] in -Tank Gauging Probe. Model: 847390 -107 Lx] Annular Space or Vault Probe. Modcl:794390 -420 ' ' ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: Piping Sump /'french Sensor(s). Model: 794380 -208 ❑ Fill Sump Sensor(s) Model: U Fill Sump Sensor(s). Model: 794380 -208 0 Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ' Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High Level Sensor. Model-847390-107 1!1 Tank Overfill / High Leval Sensor. Model: 847390 -107 ❑ Other (specify equip, type and model in Sec. E on Pg. 2) ❑ Other (specify equip. type and model in Sec. E on Pg. 2) Tank ID: 2000 gallon Diesel AST Tank ID: [x] In -Tank Gauging Probe. Mode1:847390 -107 ❑ In -Tank Gauging Probe. Model: Lx] Annular Space or Vault Sensor. Model ?94390.420 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensors(s). Model: ❑ Fill Sump Sensor(s). Model: [] Mechanical Line Leak Decector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Lx] Tank Overfill / High Level Sensor. Model: 847390-107 ❑ Tank Overfill / High Level Sensor. Model: ❑ Other (specify equip. type and model in Sec. E on Pg. 2) ❑ Other (specify equip. typs and model in Sec. E on Pg. 2) Dispenser ID: Dispenser iD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser iD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains) ❑ Dispenser Containment Float(s) and Chain(s). *if the facility contains more tanks or dispensers, copy this form. include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected /services in accordance with the manufacturers' guidlines. Attached to this Certification is information (e.g. manufacturers' checklist) necessary to varify that this information is correct and a plot plan showing the layout of monitoring equipment. For equipment capable of generating such reports, l have attached a copy of the report; (check all that apply) o S t e up x Alarm history report Technician Name (print): Matt Turner Signature: Certification No: B36313 License No: 804904 Testing Company Name: Confidence UST Sorvicos, Inc. Phone No: 800 -339 -9930 Site Address 1830 Flower Street, Bakersfield, CA 93306 Date of Testing/Servicing: 12/06/2008 i f D. Results of Testing /Servicing Software Version Installed: 324.03 Complete the following checklist: U Yes ❑ No* Is the audible alarm operational? • Yes No* is the Visual alarm operational? • Yes No* Were all sensors visually inspected, ftmctionally tested, and confirmed operational? • Yes [--j No* Were all'sensors installed at the lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? LJ Yes No* if alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) Hx N/A operational? Yes M No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary UNIA containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initate positive shut - down? ❑ Sump/Trench Sensors❑ Dispenser Containment Sensors Did you confirm positive shut -down due to leaks and sensor failure /disconnected? ❑ Yes; ❑ No; U Yes ❑ No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no [� N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visual and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capasity does the alarm trigger? E9p % Yes* I ^.1 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 replacement parts in Section F_, below. ❑ Yes* U No Was liquid found inside any secondary containment systems designed as dry systems? ❑ Product; ❑ Water. if yes, describe causes in Section E, below. TX T * Was monitoring system set -up reviewed to ensure proper settings? Attach set -up reports, if applicable. x Yes No* is all monitoring equipment operational per manufacturer's specifications? * in Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: • • F. In -Tank Guaging / SIR Equipment: E Check this box if tank guaging is used only for inventory control. ❑ Check this box if tank guaging or SIR equipment is installed. This section must be completed if in -tank guaging equipment is used to perform leak detection monitoring. Complete the following checklist: * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): U Check this box if LLD's are not installed. Complete the following checklist: ❑ Yes x Yes El No* Has all input wiring been inspected for proper enter and tcrmination,including testing for ground faults? (Check all Mal app/v) Simulated leak rate: ❑3 g.p.h.: ❑0. I g.p.h.; ❑0.2 g.p.h.; x Yes No' Were all tank guaging probes visually inspected for damage and residue buildup? Yes x Yes No* Was accuracy of system product level readings tested? x Yes F1 No* Was accuracy of system water level readings tested? X 'Yes No* No* Were all probes reinstalled properly? ❑ U Yes ❑ No*j Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): U Check this box if LLD's are not installed. Complete the following checklist: ❑ Yes ❑ No* For equip. start-up or annual equipment certification, was a leak simulated to varify LLD performance? (Check all Mal app/v) Simulated leak rate: ❑3 g.p.h.: ❑0. I g.p.h.; ❑0.2 g.p.h.; Yes No* Were all LLD's confirmed operational and accurate within regulatory requirments? Yes No Was the testing apparatus properly calibrated? ❑ Yes No For mac amca LLD's, does the LLD restrict product flow if it detects a leak? N!A ❑ Yes No* For electronic LLD's, does the turbine automatically shut off if the LLD detects a leak? ❑ N/A ❑ Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is ❑ N/A disabled or disconnected? ❑ Yes No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system ❑ N/A malfunction or fails a test? Yes No* For electronic LLD's, have all accessible wiring connections been visually inspected? ❑ N/A Yes I Lj No I Were all items on the equipment manufacturer's maintenance checklist completed? * In the section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: KERN MEDICAL CENTER 1830 FLOWER ST. BAI'ERSFfELD-CA 93305 661 -026-2482 DEC 5. 2008 9:56 AM 9VSTEM STATUS REPORT ALL FUNCTIONS NORMAL INVENTORY REPORT T I :DIESEL VOLUME 1218 GALS, ULLAGE 284 GALS 90% ULLAGE- 133 GALS TC VOLUME = 1220 GALS HEIGHT 27.21 . I NCHES WATER VOL 0 GALS .WATER m 0.00 INCHES TEMP = 56.3 DEG F T 2:DIESEL 2 VOLUME = 7016 GA ' LS ULLAGE = 2712-GALS 90% ULLAGE- 1739 GALS T(; VOLUME 6988 GAL'S, HEIGHT = .61.84 INCHES WATER VOL = 0 -GALS WATER = 0.'00 I'NGHEs TEMP '7U.1 DEGf F T 3:2000 DI'ESEL VOLUME = 13'79. GALS ULLAGE = 621 GALS 901% ULI-Ai,,'.E- 421-GALS ,TC * VOLL01E - t382-'Q LS 'HEIGHT .615 1 NCHES 'L4vrER VOL 0 GALS' ::WATER a 0.00 tilirl-lEs TEMP = 54.5 DEG F FND X SYSTEM SETUP COMMON I CAT J ONS. SETUP DEC 5, 2008 9:56 Atli SYSTEM UNITS u.s. SYSTEM LANGUAGE ENGLISH SYSTEM DATE ,-Tll-]E FOFJ1AT MON DD YTN 1-11-1:11111:S3 -fl KERN MEDICAL CENTER 1930 FLOWER-ST. SAYERS5181-0-CA 93305 661-326-2482 SHIFT TIME I DISABLED SHIFT TIME 2 DISABLED SHIFT TIME 3 DISABLED SHIFT TIME 4 DISABLED TANK PER TsT NEEDED WRN DISABLED TA14K ANN TST NEEDED WRN DISABLED LINE•RE- ENABLE METHOD ALARM ACKNOWLEDGE LIME PER TST NEEDED WRN DISABLED LINE•'ANN -,TST,-�;fj~ 8WAktD TEMP COMPENSATION VALUE (DEG F ): 60.0 ST I r,L' HE I.GHT OFFSET DISABLED DAYLIGHT SAVINC. TIME ENABLED START DATE APR WEEK I SUN START 'TIMIZ 0•:.00 AM EN6 DATE OCT WEEK 6 SUN END TIME 2'00 All SYSTEM SECURITY CODE : 000000 CUSTOM ALARM LABELS DISABLED PORT SETTINGS: NONE FOUp4r) k,':;--232 EPIC, OF l'IE13SAc;E DISABLED T 2:DIESEL 2 1 N- TAME. :SETUP PRODUG'T r_.ODE 2 - - - - - - -- - - - - - THERMAL COEFF :.000450 TAN}. DIAMETER 96.00 T f:DIESEL TANK PROFILE 4 PTS PRODUCT (,-,ODE 1 FULL VOL 72.0 INCH VOL : 9728 8246 T 3:2000 DIESEL THERMAL COEFF :.000450 48.0 1 NGH VOL 5149 PRODUCT CODE 3 TANK D 1 APIETER .36.00 24.0 I•PJ<�H VOL [935 _ T'HERr1FaL COEFF :.000e 1`�CI TANK PROFILE I PT TANK D I METER 60.00 FULL VOL. 1502 TANK PROFILE 4 PTs FLOAT SIZE: 4.0 1111. FULL VOL 45.0 INCH VOL 2000 1500 FLOAT SIZE: 4.0 I N. WATER WARNING : 2.5 30.0 114CH VOL 1000 WATER WARNING 2,5 HIGH WATER LiM1'T: 3.0 15.0 1i4CH VOL 500 HIGH WATER LiMTT: 3.0 MAX OR LABEL VOL: 9728 I1AX OR LABEL VOL: 1502 OVERFILL LIMIT 90 FLOAT SIZE: 4.0 I N. OVERFILL LIMIT 90:4 HIGH PRODUCT 8755 95% WATER WARNING .0 1351 9241 HIGH 41ATER LIMIT: :3.0 HIGH PRODUCT 9g14 . 14 ?1 DELIVERY LIMIT 25°0 2432 MAX LABEL VOL: '!000 DEL I VERY L I M IT 50 ", OVERFILL LIMIT 90f> 75.1 LOW PRODUCT 1000 HIGH PRODUCT 180.E 98% LOW PRODUCT 600 LEAK ALARM LIMIT: 99 t %0 LEAK ALARM LIMIT: 99 SUDDEN LOSS LIMIT: 99 DELIVERY LIMIT 250 SUDDEN LOSS LIMIT: 99 TANK TILT 0.00 500 TANK TILT 1.70 PROBE-OFFSET 0.00 PROSE OFFSET G . 00 LOW PPODU171" 500 S I PHON I IAN 1 FOLDED TA1,11•.S LEAK ALARM L.1 M I T : SUDDEN LOSS LIMIT: 99 99 SIPHON i9AN 1 FS:f1,DED T ArJKta TO. NONE TANK T 1 L.T 0.00 -TO: NONE LINE f°iA141 FOLDk "sl7 TANKS PROBE OFFSET 0.00 LINE MAN I FOLDED TANKS TO: NONE Td: NONE LEAK 111I N PERIODIC: Co. SIPHON MAN [ I"OLDED TANKS 0 TO: NONE LEAK MIN PERIODIC: 0:'a LINE MAN1FOLDED TANKS .0 LEAK MIN ANNUAL OQ TO* NONE LEAK M I !J ANNUAL 09p LEAX MIN PER1tbl":: U�. PERIODIC TEST TYPE 0 PERIODIC "TEST TYPE STAh7DARD LEAF'. II l N ANNUAL STANDARD, 0 ANNUAL TEST FAIL ANNUAL TEST FAIL ALARM DISABLED ALARil DISABLED PERIODIC TE2:T TYPE: PERIODIC TEST FAII. STANDARD PERIODIC TEST FAIL ALARM DISABLED ALARM DISABLED ANNUAL TEST FAIL GROSS TEST FAIL ALARM D 1 SABI GROSS TENT FAIL ALARM D I2SABLED -ED ALARM DISABLED AN14 TEST AVERAGING: OFF PERIODIC TEST FAIL ALARM DIPDAFLEG AN14 TEST AVERAGING: OFF PER TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST NOTIFY: OFF GROSS TEST FAIL ALARM DISABLED TANK TEST 140T f F4' : OFF TNK TST SIPHON BREAK:OFF • ANN TEST AVERAGING: OFF TNK TST S I PIi011 BREAK :OFF DELIVERY BELAY 1 MIN PER PEST AVERAG; I NC : OFF DELIVER`,` DELAY I. III N PUMP THRESHOLD : 1 0.00: TANK TEST NOTIFY: OFF PUMP THRESHOLD 10.00. _-•- rNX TST SIPHON 8REf:0, :OFF DELIVERY DELAY 1 MIN PUMP THRESHOLD 10.00% LEAh TEST METHOD TEST 1101frHLY . ALL TANK WEEK I MON START TIME . 2:00 Afl Tisi, RATE :0.20 GAL•R DURATION : 21 140UPS TST EARLY STOP:DISABLED LEAK TEST REPORT FORMAT NORMAL S, REVISION LEVEL VERSION 324.03 i`OFTWAREii 346324-100-D OREPiTED - 05,06.06.15.41 140 SOFTIJARE MODULE SVSTEM FEATURES: PERIODIC IN-TANK TESTS ANNUAL If'.1-TANIC TESTS LIQUID SENSOR SETUP - - - -- - - - - - - - - L I :'LANK I ANNULAR SPACE NORMALLY CLOSED CATEGORY : ANNULAR. SPACE L '?:FILL SUMP TRI-STATE 'SINGLE FLOAT) : OTHER SENSORS L 3:1,11D SUMP TRI,-STATE (S(NGLE FLOAT) CATEGORY : OTHER SENSORS L 4: END SUMP ,rR I -STATE (S I NGLE FLOAT) CATEGORY : OTHER SENSORS L $:2000 ANNULAR SPACE NORMALLY CLOSED CATEGORY : ANNULAR SPACE L 6:DT 325 TRI-2TATE (SINGLE FI.OmT) CATEGORY : 01-HER SENSORS - L 7: DT .1 CIO TRI'-STATE 09 ' 4440-LE FLOAl") CATEGO.Y : OTHER OUTPUT RELAY SETUP R I:T3 2000 DIESEL TYPE: STANDARD NORMALLY OPEN IN-TANK ALARMS ,ALL:OVERFILL ALARM "ALL:;L,Ow,-pR,orjUCf, ALARM ALL:HTOH PRODUCT ALARM LJ'QUID SENSOR ALI-IS L 5:FUEL AL.ARH R 2:10,000 HORN TYPE: STANDARD NORMALLY OPE-t4 1N -TANK ALARMS ALL:OVERFILL ALARM ALL:LOW PRODUCT ALARM ALL;HIGH PRODUCT ALARM R 3:Tl TYPE: STANDARD NORMALLY OPEN IN -TANKALARKS ALL:.OVERFILL ALARM ALL : LOW PRODUCT' ALARM ALL: H-I GH PRODUCt ALARM T I -(IhX PRODUCT ALARM 1.10 ' UID-SENSOR ALMS L I: FIJEL ALARM R. 4:.r)AY ' 'TANJ; IGO TYPE;*, ' STANDARD NORMALLY CLOSED - NO ALARM ASSIGNMENTS - ALARM HISTORY REPORT L I :TA,(), I ANNULAR SPACE ANNULAR SPACE FUEL ALARM DEC 5. 2008 9:50 AM FUEL ALARM NaV 20. 2013'? 1 '38 I"M FUEL ALARM 140v 1 -1 . 21007 j I : 09 hlll ALARM HISTORY REPORT SENSOR ALARM L '-':FILL SU11P OTHER SENSORS FUEL ALARM DEC 5. 2008 9:10 AN FUEL ALARM DEC 5. 2008 9:10 f= m FUEL ALARM 1,10\1 20. 12007 1:3',l PM A i. ;k END A. x �t, x END w " r ), � END ,« 'r' w R ALARM H!rA'ORY REPORT ALARM HISTORY REPORT c,ENSOR Al.,tiRil SENSOR ALARM L ?:VT 100 ALARM REPORT ANNULAR 5'2000 ANNULAk SPMCE ANNULAR SPACE OTHER FUEL ALARII SENSOR PALARII FUEL ALARM 140V 20, 2-1007 1 L 3:MID. SUM . P DEC 5, 2.008 9:50 AM SEN":,OR Our i�LARPI OTHER SENSORS SENSOR OUT ALARM NOV 14, 2CJ07 11:119 AM FUEL ALARM DEC 5. 2008 9: 19 AM NOV 19, 2008 5:59 AN FUEL ALARM FUEL ALARM DEC 5. 2008 9:15 pdl SENSOR SENSOR OUT ALARM NOV 14. 2007 9:58 Hpi FUEL ALARM 1 :32 P NOV 20 .. 2007 N 27. 2008 2:512. PI -I SENSOR OUT ALIAPIII 140V 14, 200? 9,:5B Am NOV 14, 2007 11:09 AM END w " r ), � END ,« 'r' w R w. w, x END ask ALARM Hf.,;TORY REPORT ALARM Hib-Topv PEPORT SENSOR ALAPIII SENSOR ALARN L 8: ALARM Hl-,TORY REPORT L. 6:DT 325 OTHER SENSORS OTHER SENSORS SETUP fiATA WApjqjNk� sENSOR ALARM FUEL ALARM NOV 14. 2007 10:32 AM NOV 20, 2007 1 :40 PI-I L 4 : EI ±ID SUMP OTHER SEN80PS SENSOR OUT ALARM FUEL ALARM DEC 5. 2008 9:15 pdl NOV 14, 2:007 11:09 Am FUEL ALARM FUEL ALARIII PH 140V 14, 200? 9,:5B Am NOV 20, 2007 1 2 SENSOR OUT Ai -ARM NOV 14. 2007 11:09 AM END w. w, x END ask 14.1:R14 MED 10AL CENTER 1 801:1 FLOWER ST. 83 8APSF l D A 93305 s1SO( ALARM - - - _ _ _ - SENSOR ALARM L 2: F I LL SCFE 661' 326-2402' 26 -2402 L I: TANk ' 1 ANNULAR SPACE OTHER SEI:1�ORS DEC 5. '2008 9:17 Ahry ANNULAR F�pACE FUEL ALARM � � � FUEL ALARM DEC b. 2008 9:10 AM DEC 5. 2008 9:50 Arj. SYSTEM sTATLIS REPORT L 4:FUEL ALARM SERSOR AL.r1F'M ------ ----- SENSOR ALARM L- 2:FILL 4UMP L 5:2000 ANNULAR SPAr:1 OTHER SE1,I23I7RS ANNULAR SPHCE FUEL ALARM FUEL �L(:IRM DEC 51 2008 9:10 A1I DEC 5. 2008 9:50 AM. :3ENSGR - ALARM L •3:MID_ SUMP OTHER .SENSORS FUEL ALARM' DEC 5. 2008 y;_!9 AM YERN IIED I CML CEN,rEp KERN ME[)! ,;:AL CENTER 1 830 FLOWER ST. ! 8,10 'FLOWER ST. BAKERSF I ELD . C'A %%305 BAKERSF 1 ELD - CA 93305 661 -326X249 6E1 -�t2b 2182 DEC 5. 2008 9:11 AM DEG 5. 2008 9 * -56 AM - -- IN -TANY ALARM - - -__ T.2:DIEBEL:2 SYSTEM STATUS REPORT H (,,H PRODUCT ALARM All DEC 5.. 200a 9 : 2 A SVST:Ei'1 STATIJ, `.RFPtIR'� _ _ _ •- _ _ _ _ L 2 : FUEL ALARM : -ry ry, = <.;. , : , _ _ _ � ALL FUNCT ! (448 NORMAL. -- 1N. -TANK ALARM ----- T 2 :,D I.t8EL , 2 SETUP DATA'WARNING SENSOR ALARM _.____ !)EC.. S. FL7G8 9:22 Art L 4:END SUMP OTHER SENSORS FUEL ALARM DEQ:1 5, 2000 9:15 AM IN-TANY ALARM T I :DIESEL SETUP DATA WARN! INC. DEC 5. 2006 9:58 AM IN -TANK ALARM T I :DIESEL HIGH PRODUCT ALARM DEC 5. 2,008 9:58 pim IN-TANK ALAPM T,3'.2bt3O D,I,ESr:*,I- HIGH PRODUCT ALARM DEC 5. 2008 9:5�-i Am ---- 114-TANK ALARM T 3:2000 DIESEL. SETUP DATA WARNING DEC 5. 2008 9:59 AM , SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structnray. The completed fora? and printouts.fronh tests (f applicable), should be provided to tre facility owner /operruor,for submittal to the local regidatory agenc)� 1. FAC11.1TV tNFORMATICIN Facility Name: Kern Medical Center I Date of Testing: 12/5/2008 Facility Address: 1830 Flower Street, Bakersfield, CA 93305 Facility Contact: Ron Rogers I Phone: 661- 633 -9611 Date Local Agency Was Notified of Testing: 11/13/2008 Name of Local Agency Inspector (if present during testing): Vicky Wun Kiu Cheung 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. Technician Conducting Test: Matt Turner Credentials': X CSLB Contractor X ICC Service Tech. 0 SWRCB Tank Tester D Other (Specif}) License Number(s): CSLB #804904 ICC #8004564 -UT 3. 1SP11,I. RUCKF.T TESTING INFORMATION Test Method Used: x Hydrostatic 0 Vacuum 0 Other Test Equipment Used: Lake Test Equipment Resolution: 0.0625" identify Spill Bucket (By Tank Number, Stored Product, etc. Diesel Bucket Installation Type: 0 Direct Bury X Contained in Sump 0 Direct Bury 0 Contained in Sump 0 Direct Bury 0 Contained in Sump 0 Direct Bury 0 Contained in Sum Bucket Diameter: 11.001, Bucket Depth: 11.5" Wait time between applying vacuum /water and start of test: 5 min. Test Start Time (T,): 9:05 am Initial Reading (Ri): 10.75" Test End Time (Tr): 10:05 am Final Reading (Rr): 10.75" Test Duration (Ti: — Tj): 1 hour Change in Reading (RF- Rj): 0.00" Pass /Fail Threshold or Criteria: 0.0625" 'i est:Result: �X:Pass =. 'O fail: :❑'Pass :- °❑,.Fait ❑;PassR ❑ F,ail r❑ Pass :,,❑ aili Comments — (include information on repairs made prior to testing, and recommended follow -iq) for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the injoJlnalion., rained in this report is true, accurate, and in full compliance with legal requirements. Technician's Signature: v ''VVI Date: 12/05/2008 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. CONFIDE CE UST SERVICE! ANC . 4171 Street , Bakersfield, CA 93309 800 -339 -9930 or 661 - 631-3870 :FINAL TEST RESULTS: C 1 2008 ALERT 1000 / ALERT 1050 / TEI LT -3 CUSTOMER ADDRESS: WORK ORDER: 17775 SITE ADDRESS Ace Petroleum Services Kern Medical Center 15540 Strebor Drive TEST DATE: 12/16/2008 1830 Flower Street Bakersfield, CA 93314 Bakersfield, CA 93305 SITE CONTACT:Ron Rogers PHONE NUMBER: 661-633-9611 TECHNICIAN: Doug Young PHONE NUMBER:800- 339 -9930 LICENSE:901076 WATER IN BACKFILL:n /a DATE 6 TIME OF LAST FUEL DELIVERY:n /a TANK INFORMATION: (WETTED) TANK 1 TANK 2 TANK 3 TANK 4 PRODUCT TYPE: Diesel UST TOTAL GALLONS: PRODUCT LEVEL: PERCENT FULL: TEST METHOD: WATER IN TANK: TANK MATERIAL: P.S.I.@ BOTTOM: TEST DURATION: FINAL LEAK RATE: TEST RESULT: TANK INFORMATION: (ULLAGE)U /F ONLY ALERT 1050X ALERT 1050X ALERT 1050X ALERT 1050X ULLAGE GALLONS: START PRESSURE: END PRESSURE: TEST RESULT: PRODUCT LINES: TEI LT -3 TEI LT -3 TEI LT -3 TEI LT -3 LINE TYPE: Suction START TIME: 10:25am END TIME: 10: 40am TEST PRESSURE: 15 psi FINAL LEAK RATE: -0.002 gph TEST RESULT: PASS MECHANICAL LEAK DETECTORS: MODEL: SERIAL NUMBER: CHECK VALVE PSI: BLEED OFF ml: LEAK RATE TESTED: TEST RESULT: A) These s stems and thods meet or exceed the criteria in USEPA 40CFR parts 280, NFPA 329 -87 and all applic state des. B) Any f 1 1'st 4' above may require further action, check with all regulatory agencies. Techni Manufacturer Cer�yfication No: an or Young zzz fZ -16 -D Alert: 2003040 TEI: LT -3,089 yy�3 S W RCB, January 2002 Page \ of n Secondary Containment Testing Report Form ._ _ This f orm is intended f or use by contractors performing P eriodic testing of UST secondary containment s Y stems.% US` d i/1jV ED appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner /operator for submittal to the local regulatory a ency. Z/ JHN 2 5 X1008 1. FACILITY INFORMATION 7 V 3 Facility Name: Kern Medical Center Date of Testing: January 15,_2008 Facility Address: Flower Street, Bakersfield, Ca. 93308 "�' � '" i Ei'v :�Vi: -,jT' .T Facility Contact: - - Phone: Date Local Agency Was Notified of Testing: January 10, 2008 Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION :CJ Company Name: Sunset Mechanical Fail Technician Conductin Test: Scott Olinger Component Credentials: RICSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester Fail License Type: C -36 C -10 License Number: 589517 Piping Sump #1 Manufacturer Manufacturer Training Component(s) Date Training Expires Incon TS -STS Inspection Equipment 1/12/08 Veeder Root Monitoring System 2/07/09 ICC Cal UST Service Tech 10/21/08 ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Piping Sump #1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 R' ❑ ❑ ❑ ❑ ❑ ❑ Lj Fill Sump pl ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel Product ❑'' ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel Return ©f ❑ 11 ❑ ❑ ❑ ❑ ❑ Vent S ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel Product ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Water for testing was removed in 800 gallon polly tank for reuse and /or disposal CERTIFICATION OF EC ICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the hest of my knowledge, t din this document are accurate and in full compliance with legal requirements Technician's Signatur Date:_01 /15/2008 SWWCB, January 2002 • 4. TANK ANNULAR TESTING . Page "Q of `1 Test Method Developed By: ❑ Tank Manufacturer ❑ Industry Standard ❑ Professional Engineer ❑ Other (Spec) Test Method Used: ❑ Pressure ❑ Vacuum ❑ Hydrostatic ❑ Other (Spec) Test Equipment Used: Equipment Resolution: Tank # Tank # Tank # Tank # Is Tank Exempt From Testing ?' es ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes C No Tank Capacity: 20,000 Tank Material: Fiberglass Tank Manufacturer: Unknown Product Stored: Diesel Wait time between applying pressure /vacuum /water and starting test: N/A Test Start Time: N/A Initial Reading (Rj): N/A Test End Time: N/A Final Reading (RF): N/A Test Duration: N/A Change in Reading (RF -RI): N/A Pass /Fail Threshold or Criteria: Test Result: s: .p Fail Pass ;Fail Pass ..❑ Fail ❑ Pass: ❑ Fail Was sensor removed for testing? F/A ❑ No C9 NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Was sensor properly replaced and verified functional after testing? ❑ No CKA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Comments — (include information on repairs made prior to testing, and recommended follow -up for failed tests) 20,000 Gallon fiberglass tank single wall 1 Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary containment, such as systems that are hydrostatically monitored or under constant vacuum, are exempt from periodic containment testing. {California Code of Regulations, Title 23, Section 2637(a)(6)) ' SWRCB, January 2002 • 5. SECONDARY PIPE TESTING iPage 3— of Test Method Developed By: APiping Manufacturer ❑ Industry Standard ❑ Professional Engineer ❑ Other (Spec) Test Method Used: ressure ❑ Vacuum ❑ Hydrostatic ❑ Other (Sped) Test Equipment Used: 4" Gel Filled Gauge W /Cert Equipment Resolution: 0-15--psi Piping Run #Product Piping Run #Return Piping Run #Vent Piping Run #Product Piping Material: Fiberglass Fiberglass Fiberglass Fiberglass Piping Manufacturer: Ameron Ameron Ameron Ameron Piping Diameter: 3" 3" 3" 3" Length of Piping Run: 100' 100' 80' 80' Product Stored: Diesel Diesel Diesel Diesel Method and location of piping-run isolation: Sump Sump Sump Sump Wait time between applying pressure /vacuum /water and starting test: 10 min 10 min 10 min 10 min Test Start Time: 1:28 1:44 1:46 2:04 Initial Reading (Ri): 5.1 5.6 5.5 5.1 Test End Time: 2:28 2:44 2:46 3:04 Final Reading (RF): 5.1 5.6 5.5 5.1 Test Duration: I hr 1 hr 1 hr 1 hr Change in Reading (RF -Rl): 0 0 0 0 Pass /Fail Threshold or Criteria: 0 0 0 0 Test Result: Pass q Fail :: , 94ass :0 Fail ",ass_, , ❑ Fail ` > > .. C- Pass".- 0 Fail Comments —(include information on repairs made prior to testing, and recommended follow -up for failed tests) SWRCB, January 2002 Page L-\ of 6. PIPING SUMP TESTING Test Method Developed By: Sump Manufacturer ❑ Industry Standard ❑ Professional Engineer ❑ Other (Spec) Test Method Used: ❑ Pressure ❑ Vacuum ydrostatic ❑ Other (Spec) Test Equipment Used: Incon TS -STS Equipment Resolution: 2:49 3:48 Sump #3 Fill Sump # 4.3203 Sump #1 Sump #2 Sump Diameter: 42" 42" 42" Sump Depth: 76' 78' 76' Sump Material: Fiberglass Fiberglass Fiberglass Height from Tank Top to Top of .0001 .0002 .0001 Highest Piping Penetration: 2899 29" 24" Height from Tank Top to Lowest OePass ; > [11 aill.- -.,C9''Pass OF il La! ass: , ❑ Fail. ❑ :Pass ❑ Fail Electrical Penetration: 38" 34" 38" ❑ Yes ❑ No ❑ NA Condition of sump prior to testing: Clean Clean Clean ❑ Yes ❑ No ❑ NA Portion of Sump Tested' 44 + or - 44 + or - 44 + or - Does turbine shut down when sump sensor detects liquid (both ❑ Yes ❑ No 9- A ❑ Yes ❑ No ETNA ❑ Yes ❑ No 91A ❑ Yes ❑ No ❑ NA product and water)?* Turbine shutdown response time Is system programmed for fail -safe shutdown ?` ❑ Yes ❑ No &I' A ❑ Yes ❑ No 91GA ❑ Yes ❑ No 9NA ❑ Yes ❑ No ❑ NA Was fail -safe verified to be ❑Yes ❑ No R C� Iii NA ❑Yes ❑ No 1A ❑Yes ❑ NoA ❑Yes ❑ No ❑ NA operational ?` Wait time between applying pressure /vacuum /water and starting test: 10 min 10 min 10 min Test Start Time: 3:48 2:49 3:48 Initial Reading (Ri): 1.6710 4.3203 3.3842 Test End Time: 4:03 3:04 4:03 Final Reading (RF): 1.6709 4.3205 3.3841 Test Duration: 15 min 15 min 15 min Change in Reading (RF -Ri): .0001 .0002 .0001 Pass /Fail Threshold or Criteria: .002 .002 .002 Test Result: :. „ OePass ; > [11 aill.- -.,C9''Pass OF il La! ass: , ❑ Fail. ❑ :Pass ❑ Fail Was sensor removed for testing? D'Yes ❑ No ❑ NA @Res ❑ No ❑ NA la'Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA [!yerifie:dZurictroparl as r pely replaced and after testing? C3'Yes ❑ No ❑ NA Comes ❑ No ❑ NA D es ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Comments — (include information on repairs made prior to testing, and recommended follow -up for failed tests) If the entire depth of the sump is not tested, specify how much was tested. If the answer to as of the questions indicated with an asterisk ( *) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160) SWRCB, January 2002 • • Page - of 7. UNDER- DISPENSER CONTAINMENT (UDC) TESTING Test Method Developed By: ❑ UDC Manufacturer ❑ Industry Standard ❑ Professional Engineer ❑ Other (Spec) Test Method Used: ❑ Pressure ❑ Vacuum ❑ Hydrostatic ❑ Other (Spec) Test Equipment Used: Incon TS -STS Equipment Resolution: .002" & ` UDC # UDC # UDC # UDC # UDC Manufacturer: UDC Material: UDC Depth: Height from UDC Bottom to Top of Highest Piping Penetration: Height from UDC Bottom to Lowest Electrical Penetration: Condition of UDC prior to testing: Portion of UDC Tested Does turbine shut down when UDC sensor detects liquid (both roduct and water) ?' PYes o ❑ NA ❑ Ye s ❑ o ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Turbine shutdown response time Is system programmed for fail- safe shutdown ?; o Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Was fail -safe verified to be operational?* ❑ yes ❑ No A ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No 1:1 NA Wait time between applying pressure /vacuum /water and starting test Test Start Time: Initial Reading (Rj): Test End Time: Final Reading (RF): Test Duration: Change in Readin (RF -K0: Pass/Fail Threshold or Crit ia: Test Result: D Pass ❑Fair � . Pass D Fail ;...t❑ , Pass . , D Fail : D Pass. ❑ Fail Was sensor removed f testing? ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Was sensor properly eplaced and verified functional fter testing? =Ycs o ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Comments on repairs made prior to testing, and recommended If the entire depth of the UDC is not tested, specify how much was tested. If the answer to an of the questions indicated with an asterisk ( *) is "NO" or "NA ", the entire UDC must be tested. (See SWRCB LG -160) SWRCB, January 2002 • Page Up of 8. FILL RISER CONTAINMENT SUMP TESTING Facility is Not Equipped With Fill Riser Containment Sums ❑ Fill Riser Containment Sumps are Present, but were Not Tested ❑ Test Method Developed By: ❑ Sump Manufacturer ❑ Industry Standard ❑ Professional En r ❑ Other (Spec) Test Method Used: ❑ Pressure ❑ Vacuum ❑ Hy static ❑ Other (Spec) Test Equipment Used: Equip nt Resolution: z Fill Sump # p.. Fill Sump # KI Sum p# Fill Sump # Sump Diameter: Sump Depth: Height from Tank Top to Top of Highest Pi pin Penetration: Height from Tank Top to Lowest Electrical Penetration: Condition of sump prior to testing: Portion of Sump Tested Sump Material: Wait time between applying pressure /vacuum /water and starting test: Test Start Time: Initial Reading (Rj): Test End Time: Final Reading (RF): Test Duration: Change in Reading (RF -Ri): Pass /Fail Threshold or Criteria: Test Result: .. ❑ Pass ❑ Fail ❑ .Pass ❑ Fail ❑ Pass O "-Fail 0 Pass..,. 11 Fail Is there a sensor in the sumps ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Does the sensor alarm whe either product or water is detected? ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Was sensor removed r testing? ❑Yes ❑ No ❑ NA ❑Yes ❑ No ❑ NA ❑Yes ❑ No ❑ NA ❑Yes ❑ No ❑ NA Was sensor properl replaced and verified functiona after testing? ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA Comments —linclude information on repairs made prior to testing, and recommended follow -up for failed tests) SWRCB, January 2002 0 • Page --\— of 9. SPILL /OVERFILL CONTAINMENT BOXES Facility is Not Equipped With Spill /Overfill Containment Boxes ❑ Spill /Overfill Containment Boxes are Present, but were Not Tested Test Method Developed By: ❑ Spill Bucket Manufacturer ❑ Industry Standard ❑ Professional Engineer ❑ Other (Spec) Test Method Used: ❑ Pressure ❑ Vacuum ❑ Hydrostatic ❑ Other (Spec) Test Equipment Used: Equipment Reso 'on: a� _ Spill Box # Spill Box # S Box # Spill Box # Bucket Diameter: Bucket Depth: Wait time between applying pressure /vacuum/water and starting test: Test Start Time: Initial Reading (Rj): Test End Time: Final Reading (RF): Test Duration: Change in Reading (RF -RI): Pass /Fail Threshold or Criteria: Test Result ❑Pass ail ❑: Pass:.: ❑Fail. ❑, Pass ❑Fail' ❑Pass ❑:Fail -1 f1l rTj --j _4 74) v) .1 m rq 6 ;u m r :P r-.3 r,,,, 0 cr, -1-i r-,'j r T f1 CQ cr, Ll I r- f ch CrJ, 7D P-1 cn j�l o7 1, 0 .11 CA a. (A cr! 0 0-1 5 M ri pj:z x -Z m ri H., f fo CC i1 Z C --i rq II, M, '-P, _0 71 F. r i ri .:=, X1 ;I] a, " , — t10 r- rl Cr, iij rvi I_z F1 C ZLI 7w" Cr, (C., • " C'.1 17, .0 .-1 0 t,.) LN i In -, C4 Ln r-n -IJ CD .70 -A L, a, -p- C-4 ILI 0 CO yf :Y • III rri CD -4 r.:;, :z -z M, r I ',7.: w -A �2: 7- ill r"i r r-I 0) :—E, C2 lz�l rq V C., I 0 CO r !a, F ..V M :.-.j I -4 --4 -11 r•j r .-I-T r I P1 :r. -j-4 r " "I rq PI a, C. -A) Q) X-j r-1 M X Z., M P1 7.) n ri ri m :i, j> P1 C 0 Ln r 0" (.0 r --i .-A ZT: c cu r-F-, 0 r- N" :F:� O"i r rr.. rT, cr, vi -0 - 0 r-5 (0 C.4 L. -Q r-0 :fj CO ri — K , C-Z, I fr. " ;- — .� , r CO q Ll�� MONII&RING SYSTEM CERTIFIDATIDN For Use By All Jurisdictions Within the State of California R'-7 1C E I d E Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification orWybrt must lie biepared for each monitoring system control panel by the technician who performs the work. A copy of this form must -be provided to the tank system owner /operator. The owner /operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. CC?UNNITY ENVIRCi,!;v!ENW*1 HEALTH SERVICES A. General Information Facility Name: KERN MEDICAL CENTER Bldg. No.: Site Address: 1830 FLOWER ST. City: BAKERSFIELD Zip: 93305 Facility Contact Person: LeAnn Victory Contact Phone No.: (_§§ 1 ) 326 -2482 Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment Tested/Certified t'hnrk tha nnnrnnetinto h.— to indi f. ar-4n anninmant hra. pModla rvirM- Date of Testing/Servicing: 11 / 20 / 07 TanklD: T1 -DSL -ABOVE GROUND Tank ID: T3 -2000 DSL -ABOVE GROUND ® In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: IS Annular Space or Vault Sensor. Model: VR FLOAT ® Annular Space or Vault Sensor. Model: VR FLOAT ❑ Piping 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: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: O Other ui ment and model in Section E on P e 2). ❑ Other ui ment pTe and model in Section E on Page 2). Tank [D• I Z-UbL-Z- UtS I 6UU I ION Tank ID• i m In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: % O Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: f' ® Fill Sump Sensor(s). Model: VR FLOAT ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: i O Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: f ❑ Other ( ui ment Wn and model in Section E on Pa e 2). E3 Other,(specify cquipment!ae and modei.iri Section E on Page 2). Dispenser ED: Dispenser ID• Cl Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(sV Model: O Shear Valve(s). (3 Shear Valve(s). = O Dispenser Containment Floats and Chains . E3 Dispenser Containment Fioati s and Chain(s). Dispenser ID- Dispenser ID• ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valve(s). ❑ D" user Containment Floats and Chains . ❑ Dispenswerco ntarnment Floats and Chain(s). Dispenser ID- Dispenser II1 Cl Dispenser Containment Sensor(s). Model: 1 ❑ Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shea' Valve(s). " LIDispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain (s). =If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was ins se cordance with the manufacturers' guidelines. Attached to this Certification is information (e g. manufacturerVerk ecessary t verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any a e of g rating such reports, I have also attached a copy of the report; (check all that apply): W System set -up port Technician Name (print): RON ROGERS Signature Certification No.: A29880 License. No.. 813616 A HAZ Testing Company Name: ACE PETROLEUM SERVICES INC Phone No.:( 661 ) 387 -6522 Site Address: 15540 STREBOR DR. / BAKERSFIELD / CA 93314 Date of Testing/Servicing: 11 / 20 07 Page 1 of 3 03101 Monitoring System Certification D: Results of Testing/Servicing• Software Version Installed: 324.01 Complete the followina checklist: (l Yes ❑ No* Is the audible alarm operational? ® Yes ❑ No* Is the visual alarm operational? ® Yes ❑ No* Were all sensors visually inspected, functionally tested, and confirmed operational? ® Yes ❑ No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their pMRer operation? ❑ Yes ❑ No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) ® N/A operational? ❑ Yes ❑ No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment ® N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut -down? (Check all that apply) ❑ Sump/Trench Sensors; ❑ Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure/disconnection? ❑ Yes; ® No. ® Yes ❑ No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no ❑ N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill point(s) and operating ro 1 ? If so, at what 2ercent of tank capacity does the alarm trigger? 90 % ❑ Yes* ® 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 replacement parts in Section E, below. ❑ Yes* ® No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) ❑ Product; ❑ Water. If yes, describe causes in Section E, below. ® Yes ❑ No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable ® Yes ❑ No* Ing SSMment 2potional ger manufacturer's specifications? Is all moni!2n * In Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: SITE HAS ONE UNDERGROUND FIB R A TANK WITH SUCTION SYSTEM IN TA Fn- REST OF TANKS ARE ABOVE GROUND Page 2 of 3 03101 F In -Tank Gauging / SIR Egmment: • ® Check this box if tank gauging is used only for inventory control. ❑ 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 followin g checklist: ® Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ® 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 level readings tested? ® Yes ❑ No* Were all probes reinstalled properly? ® Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): Complete the following checklist: ® Check this box if LLDs are not installed. ❑ Yes ❑ 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.; ❑ 0.1 g.p.h ; ❑ 0.2 g.p.h. ❑ Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ❑ Yes ❑ No* Was the testing apparatus properly calibrated? ❑ Yes ❑ No* For mechanical LLDs, does the LID restrict product flow if it detects a leak? ® N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ® N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ® N/A or disconnected? ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ® N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ® N/A ITEd 0 No* I Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: 9LICTION SYSTEM- NO LINF LFAK DETECTORS Page 3 of 3 03/01 SYSTEM SETUP NOV 20. 2007 12:26 PI-1 �-SVSTF J - "I. UNI. -TS. SYSTEM LANGUAGE ENGLISH SYSTEM DATE/T'IE.1 M , ORAT-V, F MON DD Y-PIY HH: MM KERN MEDICAL CENTER 1830 FLOWER ST. BAKERSFIELD,CA 93305 661-326-2482 :SHIFT" T [ME, I DISABLED SHIFT TIME 2 SHIFT TIME 3 DISABLED SHIFT TIME 4 DISABLED TANK PER TST NEEDED WRN DISABLED -.._-TANK:_AllJN TST,NEEDED WRN DISABLED LINE RE-ENABLE METHOD:_. ALARM AC LINE PER TST NEEDED WRN- DISABLED ANN TST NEEDED WRN: DISABLED PRINT tC..;.,VOLUMES ENABLED TEMP COMPENSATION VALUE (DEG F 60.0. STICK HEIGHT OFFSET DISABLED DAYLIGHT SAVING TIME EtVAELEU START DATE APRI �. 1. -WEEK'l - :SUN _ START TIME 2'00 AM END DATE OCT WEEK 6 SUN!_. 'END TIME SYSTEM SECURITY CODE 000000 'CUSTOM :ALARM -L ABELS- DISABLED • _ • IN-TANK SETUP T 1*.DIESEL 2.5 ,...F'PODUr;T CODE I "THERMAL COEFF. :.000450 TANK lb I _A'HEtE_ R '315- * 00 TANK PROFILE I PT FULL VOL 1502 FLOAT -SIZE: 4.0 IN. WATER WARNING 2.5 HIGH WATER LIMIT: 3.0 M-AXOkLABEL VOL: 150" TANY DIAMETER 96.0 t THANY PROFILE 1351 HIGH PRODUCT 98n), 72.0 INCH VOL - 1471 DELIVERY LIMIT 50%-') 24.0 INCH VOL 751 500 LL: -T IE A K A LAPM;L IM i T: 99 SUDDEN i ]LOSS - tj il IT: 99 TANK `TI:LT 1.70 PROBE OFFSET 0.00 SIPHON MANIFOLDED TANKS TO: NONE ...LINE.MANIFOLDED-TANKS -, TW: N6111E LEAK MIN PERIODIC: ox 0 LEAK MIN ANNUAL 0% 0 PERTODJ_C:: Tqjt�_T YPE STANDARD ANNUAL.TEST.FAIL ALARM DISABLED PERIODIC TEST FAIL :ALARM DISABLED GROSS TEST FP11L ALARM DISABLED ANN TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANI' TEST NOTIFY: OFF TNK TST - "SIPHON BREAK:OFF DELIVERY DELAY I MIN PUMP THRESHOLD 10.00% T 2:LlIESEL 90"'. PRODUCT CODE 8755 THER11AL COEFF :.000450 9 an", TANY DIAMETER 96.0 t THANY PROFILE 4 PTS FULL VOL 9'; 28 72.0 INCH VOL - 81;_ 46 48.0 li,.I(--,H %1,.'-)L 5149 24.0 INCH VOL 1935 FLOAT "1'71E: I 4.0 111.1. t,.ATER WARt-111*73 HIGH wm rER 1_111IT: 3.0 OR LABEL VOL: 9728 OVERFILL 1_11-11T 90"'. 8755 HIGH PRODUCT 9 an", 9533 DEL I VERY L I rl IT 25%. 2432 LOW PRODUCT 1000 LET ALARM -6111IT: 99 SUDDEN LOSS LIMIT: qq TAN)," TILT 0.00 _PROBE OFFSET 0.00 SIPHON MAN! IpCLrjFj, Tf,111— TO: NONE LINE MANIFOLDED TANKS TO: NONE LEAK MIN PERIODD-1: 0 LEA)" 1111-4 AP-11•,IUAL PERIODIC; TEST TYPE STAI--JDr---PD 1111' -10AL TEST FAIL --E7 iSABLED PER I OD I TEST FA I L "r LARII DISABLED rl FAIL ALARM Ej I SABLED ANN TEST HVEPA,_-, I OFF PER TEST AVERAC-411*3: OFF TAN Y TEST NOTIFY: OFF TNY TST SIPHO1.14 BPEAY-:0FF DEL IVERY DELAY : I I'l I N PUNP THRESHOLD : 10.00 T 0:2000 DIESEL �'- PT ODUCT CODE .3 THERMAL COEFF :.00045+"1 TANK DIAMETER 60.00 TANK PROFILE 4 PTS FULL VOL : . 2000 45.0 INCH VOL : 1500 30.0 INCH VOL : 1000 15.0 INCH VOL : 500 FLOAT SIZE: 4.0 11%). WATER WARMING ,:,I.0 HIGH WATER LIMIT: 3.0 MAX OR LABEL VOL: 2000 OVERFILL LIMIT 901 1800 HIGH PRODUCT 98/. 1960 DELIVER`! LIMIT 25 500 LOW PRODUCT 500 LEAK: ALARM LIMIT: 99 SUDDEN! LOSS LIMIT: 99 TANK TILT 0.00 PROBE OFFSET 0.00 SIPHON MANIFOLDED TANK'S T#: NONE LINE MANIFOLDED TANKS TO: NONE LEAK: MIN PERIODIC: 0% 0 LEAK MIN ANNUAL 01/0 0 PERIODIC TEST TYPE STANDARD ANIVUAL TEST FAIL ALARM DISABLED PERIODIC TEST FAIL ALARM DISABLED GROSS' TEST FAIL ALARM DISABLED ANN TEST AVERAG F NC; :. -:OFF PER TEST AVERAGING: OFF _,.—TANK -�-TES-T-- NOT- I- FY-:-- — .OFF TNK TST SIPHON BREAK:OFF DELIVER;' DELAY I MIN PUMP THRESHOLD 10.00/. LEAK: TEST METHOD TEST MONTHLY : ALL TANK WEEK I MON START TIME : 2:00 AM TEST RATE :0.20 GAL /HR DURATION : 2 HOURS TST EARLY STOP:DISABLED LEAK TEST REPORT FORMAT NORMAL LIQUID- SEI4SOR SETUP L I:TANK I ANNULAR SPACE NORMALLY CLOSED CATEGORY : ANNULAR SPACE L 2:FILL SUMP TRI -STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS L 3:MID sump, TRI -STATE ' ( SI 14GLE FLOAT CATEGORY : OTHER SENSORS- L 4-END SUMP` TRI -STATE (S I HOLE FLOAT) CATEGORY : OTHER SENSOR: L 5:2000 ANNULAR SPACE NORMALLY CLOSED CATEGORY..:. ANNULAR SPACE L 6:DT 325 TRI -STATE (SINGLE'FLOAT) CATEGORY :..OTHER.. SENSORS L ?:DT 100 TR17STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS Ll OUTPUT RELAY SETUP R I:T3 2000 DIESEL TYPE : STANDARD NORMALLY OPEN I h! -TAN }: ALriRt °I� ALL:OVERFILL ALARM ALL:LOW PRODUCT ALARP9 ALL : HI ;H PRODUCT ALARM LIQUID SENSOR ALMS L 5:FUEL ALARM R 2:10.000 HORN TYPE: STANDARD NORMALLY OPEN IN -TANK ALARMS ALL:OVERFILL ALARM ALL:LOW PRODUCT ALARM ALL:HIGH PRODUCT ALARM R 3:TI TYPE: STANDARD NORMALLY OPEN IN -TANK ALARM ALL:OVERFILL ALARM ALL:LOW PRODUCT ALARM ALL:HIGH PRODUCT ALARM T 1 :MAX PRODUCT ALARM LIQUID SENSOR ALMS L I:FUEL ALARM R 4 : DAY TANK 100 TYPE: STANDARD NORMALLY CLOSED NO ALARM A SS I GNNEfITS 0 0 ALAR�1 HIS%TOR"' REPORT -RM HISTORY ALA REPORT -,L"Rl1 HI STOR`/ REPORT - - - -- SENSOR ALARM ----- -- SENSOR ALARit L 3 1. :M ID SUMP SENSOR ALr - IPI'l - ---- L I :Tm"NK I ANNULAR SPACE OTHER SENSORS -- ----- SENSOR ALARM ----- L 5:20CIO r"'SlINULAR SPA'1,E ANNULAR SPACE SENSOR OUT ALARM A1,111-JULAR SPACE FUEL ALARM NOV 14, 2007-11:09 Am FUEL ALARM NOV 14, 2007 11 :09 All NOV 14, 2007 11:09 All c-'Etic-' R OLIT A-L"'Rfl SO - NOV 14, 2007 I1 :09 mll SENSOR OUT ALARM:: FUEL ALARM NOV 14, 2007 9 .58 All iD "ENSOR OUT HD�iRH '�T OCT 24� 200� 13:4 5" '�PH FUEL ALARM NOV 14, 2007 9:58 AM 01- 24, 2007 3: 0'21 Pil SENSOR OUT ALARM ALARM FUEL OCT 24. 2007 2:57 Pm SENSOR OUT r= ,Lt 'L� R("! 2007 2:56. Pll FUEL ALARM OCT 214, 2007 '2:59 Pfl Et E14D 4D END -END E ND ALARM HISTORY REPORT ALARM HISTORY REPORT •LM-F.1") H1 PE•R'F - ----- SENSOR ALARM ----- -- ----- SENSOR ALARM ----- L 4:END SUMP ----- 20,12,.OR ALARm ----- L 2:FILL SUMP OTHER SENSORS L G:DT 325 OTHER SENSORS SENSOR OUT ALARM OTHER SENSORS SENSOR OUT ALARM NOV 14, 2007 11:09 All c-'Etic-' R OLIT A-L"'Rfl SO - NOV 14, 2007 1 1 : C19 All NOV 14, '2007 1 1 :0,; r-11-1 FUEL ALARM FUEL ALARM NOV 14, 2007 9:58 AM FUEL MLAR NOV 14, 2007 9519:.:AM NOV 1, 00'7 4 2m 1, 9: 5 ,, FUEL ALARM FUEL ALARM OCT 24, 2007 2:57 PM FUEL ALARM OCT 24, 2007 2:57 PM OCT 24. 2007 .;:5-; Pi-1 -END E ND ALARNt HISTORY REPORT - - - -- SENSOR ALARM - - - -- L 7:DT 100 OTHER SENSORS SENSOR OUT ALARM NOV 14, 2007 11:09 AM FUEL ALARM NOV 14, 2007 9:58 AM SENSOR OUT ALARM OCT 24. 2007 2:50 PM X x is x X EP'` 1� x x A x 12 -28 -05 14:08 RCVD MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited Chapter 6 7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Reguiations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be_preoared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownedoperator. 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 Facility Name: Site Address: Facility Contact Person: Make/Model of Monitoring System: B. Inventory of Equipment Teste&Certified Check the appropriate hoses to indicate specific eauioment ins » ected /serviced: Bldg. No.- City: �°P�,S"' ',P /� Zip: 9 ?_ _ Contact Phone No.: ( )_= Date of Testing/Servicing: /2 kW /gam It acC)C53 Tack ID o Tank ID ° Tank Gauging Probe. Model Tank Gauging Probe. Model ' An nular Space or Vault Sensor. Model: _ Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). J Model ping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model E3 Fill Sump Sensor(s). Model- 13 Mechanical Line Leak Detector. Model: ❑ Mechanical Line leak Lector. Model: ❑ Electronic lane Leak Detector. Model: ❑ Electronic Line Leak Detector. Model• ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s ui meat !M and model in Section E on Pa e 2). ❑ Others ui meat and model in Section E on ?a& 2). Tank ID: Tank Tank Gauging Probe. Model ❑ In -T ng Probe Model t"ping lar Space or Vault Sensor. Model- ❑ Annular S Vault Sensor. Model: Sump / Trench Sensor(s). Model- ❑ Piping Sump / Tren ensor(a . Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Lane Leak Detector. odeh ❑ Electronic Lane Leak Detector. Model• ❑ Electronic Line Leak Detector. M ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other ( eci ui meat t and model in Section E on a 2). ❑ Other s eci meat and model in Section n P e 2). Dispenser ID: Dispenser ID: ❑ Dispenser GQntainment Sensor(s). Model ❑ Spenser Containment Sensor(s). Model: • Shear Valve(s). ❑ Sh alve(s). • Dispenser Con Fl sand Chains . ❑Dis ntainmeat Fl s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Senso Model.- ❑ Dispenser Contain sor(s). Model.• ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and (s . ❑ Dispenser Containment Floats d Chain (s). Dispenser ID: Dispenser Mt Cl Dispenser Containment Sea a). Model- ❑ Dispenser Containment Sensor(s). Model*.**- ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Di enser Containment Flo s) and Chains . ❑ Dispenser Containment Fi s) and Chain(s). •Lf the facility contains more tanks or dispensers. copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment idea i6ed in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e g. manufacturers' mists) necessary to verify that ' information is correct and a Plot Plan showing the layout of monitoring equipment For any egtd capah b of generating rfs, I have also attached a Dopy of the rt; check aU tha a p "): ❑ System set-up ❑ ry report Technician Name (print): Signatum. Certification No.: s ��Z License. No.: r-- Testing Company Name: Phone NoAzaw • ��T 6. Site Address: % Date of Testing/Servicing. _ f J0 Page 1 of 3 03101 Monitoring System Certification • D. Results of TestinWSerrv�icin�g� Software Version Installed: C_amnlete the falinwina rherklict! Yes ❑ No* Is the audible alarm operational? O No* Is the visual alarm operational? VYes Yes O No* Were all sensors visually functionally tested, and ;confirmed operational? Yes ❑ No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? O'Yes O No* If alarms are relayed to a remote monitoring station,' is all communications equipment (e.g. modem) N/A operational? Yes O No* For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment O N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut -down? (Check all that apply)XSumpffrench Sensors; O Dispenser Containment Sensors. Did you confirm positive shut -down due to leaks and sensor failure/disconnection? es; ❑ No. Yes O No* For tank systems that utilize the monitoring system as: the primary tank overfill warning device (Le. no ❑ N/A th tank mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audibl31c% fill ins and tin If so, at what of tank does the alarm Yes* ❑ 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 replacement parts in Section E, below. Yes* ❑ No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) ❑ Product; water. If yes, describe causes in Section I, below. Yes ❑ No* Was monito ' stem set-up reviewed to ensure proper settings? Attach set reports, if applicable es O No* Is all monitorin 9quipment operational M manufacturer's. ecifications? * In Section E below, describe how and when these E. Comments: were or will be corrected. Page 2 of 3 0"1 F. In -Tank Gauging / SIR Equipment: Check this box' if tank gauging is used only for inventory control. E3 Check this box if no tank gauging or SIR equipment is installed This section must be completed if in-tank gauging equipment is used ito perform leak detection monitoring. Complete the following checklist: Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? Yes ❑ No* Was accuracy of system product level readings tested? i Yes ❑ No* Was accuracy of system water level readings tested? i Yes ❑ No* Were all probes reinstalled properly? Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section K below, describe how and when these deficiencies were or "i ' be corrected. G. Line Leak Detectors (LLD): X Check this box if LLDs are not installed. Complete the following checklist: ❑ Yes ❑ No* For equipment start-up or annual equipment certification, Iwas a leak simulated to verify LLD performance? AN /A (Check all that apply) Simulated leak rate: ❑ 3 g.p.h.; ❑ 0 it g.p.h ; ❑ 02 gp.h. ❑ Yes ❑ No* Were all LLDs confirmed operational and accurate within regulamry requirements? ❑ Yes ❑ No* Was the testing apparatus properly calibrated? ❑ Yes No* For mechanical LLDs, does the LLD restrict product flow if ft detects a leak? .q ak N/A i( ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut offlif the LLD detects a leak? N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled * N/A or disconnected? 1 ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off, if any portion of the monitoring system malfunctions j�N /A or fails a test? j ❑ Yes No* For electronic LLDs, have all accessible wiring connections`: been visually inspected? N/A ❑ Yes ❑ No* IWE all items on the equipment manufacturer's mainten checklist completed? * In the Section H, below, describe bow and when these deficiencies were or win be corrected. H. Comments: t i- Page 3 of 3 03101 Monitoring System Certification UST Monitoring SiN� Site Address: IX-30 -m-me T7-. ................................ ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................. ................... ....... ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . ................. ................... ............... . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... ..... ............... .... ....... ...... ... ............... . ..... ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I* ' * ' ' " ' * .. ..... .. . .. . ... .... ...I ...... ... . . ........ .. .... ... ..... .......... ...... ..... ......... XEP L .... .. ........ .. .... ..... ........ ... ..... ........ ........ .. ........ ........ .. . ...... ...... .. IV .. ..... ............. ....... ... . .... . . ... . .. . .... ........ . ................. .. .... .. . ........ ..... . .. ..... .............. — * – * . ........... ..10 ... ..... .................................. . ... ... ................... ..... .. ............. .............. ...... -.1 . ..... ...... .............. ...... ................................ ...... ............................... � :. : : : : : : : : : : : : : : : : : :: ................. I ... ........... ........................... ..................... ........................ ............... ............................... ................. . ............ ... ................................ ..................... ............................... 77 ---- ............... .............. Date map was drawn: Instructions 11 If you already have a diagram that shows all required information, YOUI may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the genei',al layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring systeni 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 of SYSTEM SETUP DEC 22. 2005 12:07 PM SYSTEM UNITS U.S. SYSTEM LANGUAGE ENGLISH SYSTEM DATE /TIME.FORMAT MON DD YYYY HH:MM:SS xM KERN MEDICAL CENTER 1830 FLOWER ST. BAKERSFIELD CA 93305 IN -TANK SETUP T 1:DIESEL PRODUCT CODE I ..THERMAL...COEFF :.000450 .TANk "blAMETER 36:00 TANK PROFILE 1 PT FULL VOL 1502 METER DATA NO FLOAT SIZE: 4'.0 IN. WATER_WARNING 2,5 HIGH WATER LIMIT: 3.0 I 661 - 326 -2482 MAX OR.LAHEL VOL: 1502 OVERFILL '` LIMI.T::.::.::_:i..::::::90 %: SHIFT TIME 1 . DI,SABLED 'T HIGH PRODUCT 1 SH I FT I ME 2 : `D I SABLED 98% .:........._ SHIFT TIME 3 : DISABLED`' "'` DELIVERY LIMIT 150% SHIFT TIME 4 : DISABLED TANK PER TST NEEDED WRN LOW DISABLED ? TANK TST NEEDED WRN 500 LEAK LEAK ALARM LIMIT: 99 .,ANN DISABLED 4,x „.n. '' SUDDEN LOSS LIMIT: 99 TANK TILT LINE RE- ENABLE METHOD PROBE OFFSET ALARM ACKNOWLEDGE LINE PER TST NEEDED WRN SIPHON:MANIFOLDED TANKS DISABLED T #`::NONE LINE ANN TST NEEDED WRN LINE MANIFOLDED TANKS DISABLED :: T #: NONE PRINT TC VOLUMES LEAK M:I N PER I ODwI C >, ENABLED ,;0% TEMP COMPENSATION LEAK MIN ANNUAL 0% VALUE (DEG F ): 60. 0 STICK HEIGHT. :OFFSET 0 DISABLED QPLD MONTHLY PRINTOUT .. . pERIODIC TEST TYPE DISABLED STANDARD DAYLIGHT SAVING TIME ENABLED ANNUAL TEST FAIL START DATE ALARM D,ISABLEDF3.... APR WEEK 1 SUN START TIME pERIOD`IC TEST FAIL 2:00 AM ALARM DISABLED END DATE OCT WEEK 6 SUN GROSS TEST FAIL., ... END TIME ALARM DISABLED 2:00 AM SYSTEM SECURITY CODE : 000000 CUSTOM ALARM LABELS DISABLED T 2:DIESEL 2 PRODUCT. CODE THERMAL COEFF TANK DIAMETER TANK PROFILE FULL VOL 72.0 INCH VOL 480 INCH VOL 24.0 INCH VOL METER DATA FLOAT SIZE: WATER WARNING HIGH WATER .LIMIT: MAX OR LABEL VOL: OVERFILL LIMIT HIGH PRODUCT , DELIVERY LIMIT LOW PRODUCT LEAK ALARM LIMIT' SUDDEN LOSS LIMIT: TANK TILT PROBE OFFSET . 2 .000450 • 96 "00 : 4 PTS • 9728 • 8246 • 5149 N01935 4,0 IN. 2.5 3.0 9728 90% 8755 98% 9533 25% 2432 1000 99 99 0.00 0.00 SIPHON MANIFOLDED TANKS T #: NONE LINE MANIFOLDED TANKS T #: NONE LEAK MIN PERIODIC: 0% 0 LEAK MIN ANNUAL 0 PERIODIC TEST TYPE STANDARD 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 RECON WARN LIMIT: 0 RECON ALM LIMIT: I DELIVERY DELAY : 1 MIN PUMP THRESHOLD : 10.00% T 3:2000..DIESEL 2.0 PRODUCT CODE 3 THERMAL COEFF :.000450 TANK DIAMETER 60.00 TANK PROFILE 4 PTS FULL VOL -2000 45.0 INCH VOL :.: 1500 30.0 INCH VOL 1000 15.0 INCH VOL 500:::.. METER DATA . ; NO FLOAT SIZE: 4.0''IN WATER WARN ING- ...... : 2.0 HIGH WATER U M I T MAX...OR LABEL VOL' 2000 OVERFILL L I M I T 90•� 1800.. HIGH PRODUCT' 125..... DELIVERY LIMIT • 500 LOW PRODUCT 500 SUDDEN LOSS I I M I T X99 TANK TILT p' 00 PROBE OFFSET 0.00 TNK TST SIPHON BREAK:OFF_,,. RECON WARN LIMIT. 0 RECON ALM LIMIT:. I DELIVERY DELAY I MIN PUMP THRESHOLD 10.00•% LEAK TEST METHOD TEST ANNUALLY: ALL TANK JAN WEEK 1 MON START TIME : DISABLED TEST RATE :0.20 GALiHR DURATION : 2. HOURS TST EARLY STOP:DISABLED LEAK TEST REPORT FORMAT NORMAL LIQUID SENSOR SETUP L 1:TANK 1 ANNULAR SPACE TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 2:FILL SUMP TRI -STATE (SINGLE FLOAT) CATEGORY OTHER SENSORS L 3:MID SUMP TRI -STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS L 4:END SUMP TRI -STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS L 5:2000 ANNULAR SPACE TRI -STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 6:DT 100 TRI. -STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS L:.7:DT 325- ':R:I: =STATE (SINGLE FLOAT) CATEGORY : OTHER SENSORS -. OUTPUT�RELAY SETUP R I:T3 2000 DIESEL TYPE: STANDARD NORMALLY OPEN IN -TANK ALARMS ALL:OVERFILL ALARM ALL:LOW PRODUCT ALARM ALL:HIGHPRODUCT ALARM LIQUID SENSOR ALMS L 5:FUEL ALARM R 2:10.000 HORN TYPE: STANDARD NORMALLY OPEN IN -TANK ALARMS ALL:OVERFILL ALARM ALL:LOW PRODUCT ALARM ALL:HIGH PRODUCT ALARM R 3:T1 TYPE: STANDARD NORMALLY OPEN IN -TANK ALARMS ALL:OVERFILL; . ALARM... AL'L :LOW- PRODUCT ALARM ` ALL:HIGH PRODUCT ALARM T 1:MAX PRODUCT ALARM LIQUID SENSOR ALMS L 1:FUEL ALARM R.:4:DAY TANK 100 TYPE :: STANDARD NORMALLY CLOSED - NO ALARM ASSIGNMENTS - SOF.TWARE-REVISION LEVEL VERSION 324.03 SOFTWARE# 346324 -100 -D CREATED - 05.06.06.15.41 NO SOFTWARE MODULE SYSTEM FEATURES: PERIODIC IN -TANK TESTS ANNUAL IN -TANK TESTS * * ** *END'„ is ALARM HISTORY REPORT - - - - -.. SENSOR;.,ALARM:;_ L 2 FILL SUMP° OTHER `SENSORS FUEL ALARM DEC 22. 2005 2:01 PM FUEL ALARM DEC 22. 2005 .1:54 PM SENSOR :OUT. ALARM DEC 22,::9005 1:51 PM E * END * * *:.* i-------- --- - ALARM HISTORY REPORT - - - -- SENSOR ALARM - - - -- L 3:MID:.SUMP OTHER SENSORS FUEL.ALARM DEC 22, 2005 11:09 AM * * * * * END * * * * * *`* END ** ALARM HISTORY REPORT SENSOR ALARM - - - -- L: 5 2000 ANNULAR SPACE ANNULAR SPACE SETUP DATA WARNING DEC 22, 2005 11:59 AM FUEL ALARM DEC 22. 2005 11:58 AM FUEL ALARM DEC 22, 2005 11:47 AM X * * * * END * * * * * ALARM HISTORY REPORT -- SENSOR ALARM - - - -- L 6:DT 325 OTHER SENSORS FUEL ALARM DEC 22. 2005 2:03 PM SENSOR OUT ALARM . DEC 22. 2005 1:44 PM * * * * * END * * * * * ALARM HISTORY REPORT - - - -- SENSOR ALARM - - - -- L 7:DT 100 OTHER SENSORS FUEL ALARM DEC 22, 2005 1:27 PM * * * * * END * * * * * A1 7A XT 5 SWRCB, January 2002 \� Pa e / of Secondary Containment 'Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems Uje the, appropriate pager of this form to report results for all compurtents tested The complered form, written rest proud ires, and printouts from test.r (if applicable), should he provided to the facility owner /operaror for it.bmmal to the locul re,galalol;: ueenc., I. FACILITY INFORMA'T'ION Facility Name: Date of Testio �: — O Facility Address: . Facility Contact: fy,U Q ( ,� Phoru; Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during (esting): 2. TIFSTING CONTRACTOR INFORMATION a 774J 6 Co m any Namc: R 60 (,c1/ ti C I- U/L e- ! ru Technician Conducting Test, 41111 Not Tested Credentials: J1 CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: I License Number: L) — / � lytangfactuzcr Manufacturer 'I "sainin8 Com nent (s) Date Trainin Expires p -O 3. M IMMARY OF TEST RESULTS Component Pops Fail Not Tested Repair.s Made Compnnent Pa44 Pail Nol 'Tested , Rtpairi Made i c 4 r 4114 Y -, P S4 P14L IL If hydrostade testing was performed, dcscribt A-h4*, w:di the water aft:: cc,nl :c'.:J,! vt test.$ CERTIFICATION OF 'ITCFIN]CIAN f( SNONSI13LF FOR CONDUCTING TiIiS'I'ka'I'i N,(; To the best of my knowledge, the facts stated in thLi dnetimenr art, uccurute and in full compliance with legai requtrernents Technician's Signature: Datc: 0 SWRCB, January 2002 # 4. TANK ANNULAR 'r&,STING 0 Page of ? 'rest Method Developed By; 'Tank .Manufactw ej 13gridvs-try Standard PrVe4sional Eng1,Pv:,, Other (Specify) 'Pest Method Used: Pressure 0 Vacuum Hydrostau,., Other (Specify) Test Equipment Used: Equipment RespluUCrt Tank b Tank H I'K n Is Tank Exerept From Tcstingil tics No T Yes ^Nu I CS N, s No Tank Capacity: Tank Material; Tank Manufacturer: Product Stored: Wait time between applying pressure/Vacuum/water and starutg test: iNG I 4cc Test Start Time: Initial Reading (RO: Teat End Time: Final Reading (RP): Test Duration: Change in Reading (RF-Ri): Pass/Fail Threshold or Criteria: Bit '4, Was sensor removed for testing? YeR No NA yes No NA Yes No NA Yes No NA Was sensor properly replaced and verified functional after testing? Yes No NA I Yes No NA Yes No NA Ycs No NA Comments — (include information on repairs made prior to resting, and recommended fallow -up fo r Jailed tests) A40 A 41-94j () 4 R � 1 Secondary containment systems where the ConfinUOUS monitoring automatically monitors both the primary and .5eccnd&,) containment, such as systems that are hydrostatically awnitored or tjryJcr constart vacvvm. are e.kemp( fMfT1 c,;r.(ainmcn( testing. (California Code of Regulations, itle 23, Section 2637(a)(6)) SWRCB, )Imwdry 2002 • 1'(!st Method Developed U� Kest MV01od Used,. I•tyl Equil)mc!!; Uscc: D I A U -' E • Piping Ron 1011" T-1 4=7 Test Result-, A Puss 0 Fail i Ai P4 ss ' C Fail ' )0 Pass 0 Fail i --' 1*1,,s - Imi C,'ommtnts—(inclucte information oni-epairsmoeie prior totustitig, anci recommended follow-up for failed tevs-i—, SO/V0 30Vd NpIng Run A Piping MnnvI',cwfer� Piping Diameter. LQo,gth v(Piping Run: 1"t-oduct Stored: Method and locatim) of Wait time bciweeri 0 applyino 1 prtswre/vacuunl/wakcl and --7��O 'I't!$i Start Time: Initial Reading (RI): Test End Time: Filial Reading (R,•): Test Duration: Change in Kk:ading (RF-RI):; Pass/Fail Threshold or critcria: Piping Ron 1011" T-1 4=7 Test Result-, A Puss 0 Fail i Ai P4 ss ' C Fail ' )0 Pass 0 Fail i --' 1*1,,s - Imi C,'ommtnts—(inclucte information oni-epairsmoeie prior totustitig, anci recommended follow-up for failed tevs-i—, SO/V0 30Vd SWRCEi, Jiuiuuq 2002 C, swnp MUIIUfIcufof X lndtm , Sla;ldald, C profCssicnzi; 6. 11 1111 N G S C.,N'LJ:' TESTING I I Pest Method Used: C.) Pressure -i vacuwll Z Hydrostatic 'hest MethodDeveJopid By: C, swnp MUIIUfIcufof X lndtm , Sla;ldald, C profCssicnzi; :3 01h.'r (Specie ") I I Pest Method Used: C.) Pressure -i vacuwll Z Hydrostatic ( : C) d) e I Cost E�Juipn)(!M U5td• INCON TS-STS Sump 4 Ju llf P 'I S u fit SUMp Diameter: S_LIIIIP Depr1l: Sump M;itcrial: HciAh( from 'rank Top to Top of Highest Piping Pvtomition: lielo0 h( from Tank Top to Lowest Electrical Penetration: CotidlCionot sum p prior to tcZi119: Cl WrOun of Sump Tested t I Does turbine shut down wficn sump sensor detects liquid (both C Yes J No tNA :j 't, eS C! No A No �A 7, .j No A NA product and water Turbine shutdown response time is ,system programmed for fail-safe shutduml?, 0 Yes 0 No WNA D Yc s L i N, u) I9 A y ;0 A Cj Y,:s Was fail-safe verified to be 0 Yt:s U No No 'A C, Y's N Wait time between dpplViilg pre s sttre/vacu urn/wa(er and itaring Test Start Time: /0: Initial Rviding (K.): End Time i Fillid Reading (Pr): J Test Dur"111011: Change in Reading (RF-P\,): 4L- IX 3 Pass/Fail Threshold or C4f fla�s Fwl 1Q 1, L1.)) ha I) F XY No ;A A Vi A 1 01 f c- No D NA .,,A F;4, Test Result; VV S ser)sQl I,ClfluVccl k"I t�stinLj,,) 'Alas sensur properly r- aced and vcciticd functiona! after ivsUm"? CoMiller)(S — (include mforinuliai on rEP sIirlp It' Ole entire depth ot*d)c s;imp is nw tes(co, mQA 111"'tcli " "tS i,, i`C 4istcriA (4) I5 "NO" or N,� ', LhV MirU iU M P ;'.L;fl '01 iC,:','0. (S 1:1: 51\ P.CB L(j• i 6Q.) 80/G0 39Vd tZ90?6E t99 0z t e " ./Zd SWRC8, January 2003 hzgc oc �. IU:N'D 1 %-1) SPE SfR CON'I'..*tIN1•II::� "'I' iL'D(,:1 Tl'.S fL�'G "rest Method DevelvprJ H; _. i f;C `.I�n.:r::k:tt.rc, 00w (Spt.-I); _ -�. -- - ^— —._ ...� -- Tese MtUtud Used: U Nressure "•Vac,lulr� � hfy lresia�: C..0JIe; (S;: .I eel EltUip111I!111 USec!: 1 PJCUNI TJ- ST :•f ; ft.:5�;.:'J9C' .. , .U'. 7•.I,j�d' �: )'e �• :' -i '.'r: �' ,::..; L,S"�37►!(gwr9jR'f l'Ut. u ° ""� "V17 1,'OS7AvTr!r R. ": ^rR. ^G . ....�� 1. DC .. I. t)l. •• I T I. I)l. .. _ ^-{' UDC Material: _ bDC De th. 1 lieight from UDC Bo;tvnl to'foF 1 1 of Highest PipingPenetration: l•leighc fr0111 UDC Botwill tp i Lowest Electrical Penetration; Condition of UDC prior to - -- testing: Poilion of L DC Tested— l I Dots t }trbine shut down when '�^ 'T. —_� �.— .y� - - - -- • -� U DC Yensor detects Iiquid (both C Ycs U No C NA I -!Yes '_' Nc -• NA (r, F No DNA raduct and water)?, Turbine shutdown response time , Is system programmed for fail- Satz shutdown ?' VYes 3 N 'l NA LYes 7No ';!NA ]Y_s 1 _No CNA i., _ _ .;, ?�A • Was I'uil -sale verified to be ( C -; I p eracional • Yes No NA 0 Ycs F] No C-1 NA Yes —� C No CJNA I L'' YcsT' +o ?iA Wait time between applying pres sure/ vac uunVwater and starving lest J ; _. -._� - __.___ j...__..--- • - - -__ �_ ---- -- --•i -- Test Start 'Time: Initial Reading (RI); Test End Final 'Reading (R,- ): Test Duration: _ Change in Reeding (Rr -R1): [lass /Fail Threshold ut Criteria: "? Pnss C _ j Fail G Pass L Fail C' Pass 0 Fall T- -Test Result: Was sensor removud f'or testing'? C Yes C No 0 NA i "J Yes 'J No -.I NA U Yes C. No JJ NA Was sensor properly replaced and verified functional after testing? 0 Yes IT No u C NA I ^Yes No ;I NA I l.' Yes C NO DNA _Ycs i No Comments - (include informolion ore )•epuirs etude prior ' ; lesrrng, acrd %ece, ?rnr ?rrGrcd �!!ow up %yrLor!ea r2�l:i I if the entire depth of the UDC is not tested, specify how much was tested. If the answer to t of the questions til an asterisk (•) is "NO" or "NA ", the entire UDC must be tested. (See S WRCS LO. 160) 80/90 39Vd H 90Z6E199 0 Z t.1 <<2 ? /9Z /Z0 SWRCB. January 2002 0 Pap- ice.. of _7. x. hu.f ul�rr� (° Onlyt'. �I !�'v1EN'f'Si!�tP'1'l�'ti'I'1�'VC Facility is Not Equip ed With Fill Riser Containment Sumps Fill Miser Containment Sumps are Prescm, but were Not. Te.stcd Test Method Developed By: Sump Manufacturer X Industry Stanclald Yrvfess;:jnai f:r, racer Other (Specify) Test Method Used: Pressure Vacuum Hydrostatic Other (Specify) Test Equipment Used: A)CON — $ Equipment Resolution. Fill SurnR #gQf Sump Diameter: C '0.- Fill Sure k F'iU Sun, h fill 511111P q _ _ Sum2 Depth: 0 Height from Tank Top to Top of Highest Piping Penetration: / Height from Tank Top to L,oweat Electrical Penetration, O/ _ Condition of sump prior to testin : G "� Portion of Sump Tcsted Sump Material: ICi R 19Sj Wait time between applying prmvrelvacuum/watcr and Starting test: 36 m r /V Teat Start Time: Initial Reading Teat End Time: 0 '30 r`* Final Reading (R F); 1 Test Duration: s' Al iv •✓ Change in Reading -R : 60 I Pas&Tail Threshold or Criteria: 0 u iv III 11 illll ell i" 1 X11 1.1 !�!' ii11;I!� itIII' ,{': i. �� I lr. al! 'rn M1IMII'ti 1'lI ':�o.�o' :.t� J �` I'(. 1J 1Y� 1 A�'I:� � ! I:IF�11 �:�'!'1' '.r: %. `_ -- � Is there a sensor in the sump? Yes No Yes No Yes No �•'_•'__ Yes No Does the sensor alarm when either product or waw is detected? Yes No NA Yes No NA Yes No NA Yes No NA .Was sensor removed for toting? c�7 No NA Yes No NA Yea No NA Yes No NA Was sensor properly replaced and verified functional after testin ? _ es No NA Yes No NA Yes No SA �'as No NA Comments — (inetude information on repairs made prior to testin$, and recommended follow -up for failed tests) SIAIRCB, January 2002 9. q'1.L1_JOV) W,'1LL CON'TAL-01ENT BA FaCilio- is Not Equipped With SpiIVOverCill Containalem Soxes i SQill,'Ovcl t-111 cowaillillen( Bco�cs al-L prf-wnt, but -N� cj _ !",J! Tovr": Tes( Method Developed By. 0 Spill Bucket Nlanuraciuivr 1ndjsu,,,- L. Other (SpLuIfy) 1,cs( Method used: C) Pressure 0 VaCLIU1111 X Hydvos;ailc D Other (Spec Tes( Equipment Used: INCON TS -STS c0c. i n S 1) i I 1 8,,x 'I Spill H(ix Eton .a -Bucket Diameter: Bucket Depth: Wait time between applying pressure/vacuum/water and starting test: fr r' rj Test Start Time: /).'/)0 pol D S?O initial Reading (Ri): 3,17 Vv E, 171 ,fesL End Time: Final Reading (KF): � i r-i - 1'est Duration: i ; 15 N\ r-j- Chan're in Reading (RF-R,): 0, 1 1 Pass/Fail Thri.,shoid or -CTiceria'. CO "i Test Result: kPass -D Fail D Pass I i 17.1il Pass Fail COMM C13tS — (•nCluck information on reeoir$ made Pric),'10 tcslielg, and r c 'Cotll III up jot failvdievs) 80/80 39Vd I Z 'J'OZ G C 199 OZ • f I ;-' r�', i, ;_, / 4 6 / Z ki 2003 • 0 TIGHTNESS TESTING REPORTS EVALUATION FORM Specialist reviewing the tightness test report: �C�u` ✓(' l�Yt `C Date tightness test reports were submitted: _ I Date tightness tests were completed: 1 - -I (42 ,Facility Permit Number: Coo----�, Number of Tanks Tested at the site: O— (list the tanks by their tank numbers if provided) 4ZLy Was the method a test of the ntire tank`syst�; "piping alone, or just the facility tanks? (describe) — Did the facility pass all tests: Yes No (if no, provide the leak rate and a description of the tank(s) that failed the test) (failure is > 0.1 gal per hour) The facility will do the following to investigate the failed test: The test method certification that is submitted to the state specifies that each test method be completed in a certain manner. Is there anything within the results which ould suggest that the tank test was improperly completed? Yes No (describe) Information has been reviewed and placed within the database: ✓ YES NO Date entered within the database: .,3-✓12 HMZ Entered by (name RICH ENVIRONMENTAL 5643 BROOKS CT BAKERSFIELD,CA.93308 (805)392 -8687 ALERT 1000 UNDERFILL AND ALERT 1050 ULLAGE SYSTEM Precision Underground Storage Tank System Leak Test Job #RICH1034, Test Date: 1/19/96 Site: KERN MEDICAL CENTER 830 FLOWER ST. BAKERSFIELD, CA.93306 PRODUCT VOLUME %FULL WETTED NON - WETTED PRODUCT LEAK WATER IN (GAL) PORTION PORTION LINE DETECTOR TANK DIESEL 10000 90% +0.010 PASS SUCTION N/P 0" DIESEL 7500 83% +0.007 PASS SUCTION N/P 0" Measurements showed that water in the backfill area at the time of testing was below tank bottom, and therefore not a facterin test determination. A precision test was performed on tanks at the above location using the Alert 1000 underfill system and the Alert 1050 ullage system. I have reviewed the data produced in conjunction with this test for purpose of verifying the results and certifying the tank systems. The testing was performed in acorrdance with Alert protocol, and therefore satisfies all requirements for such testing as set forth by NFPA 329 -92 and USEPA 40 CFR part 280. The results of testing are shown on the following page, and indicate whether the wetted and non - wetted portion passed or failed. Included with the report are reproduction of data compiled during the test which formed the basis for these conclusion. This information is stored in a permanent file if future verification of test results is needed. AL \NC 040 Test Certified By: ames J. ich � State cert #90 -1072 J L E .- --N a I ICHEN IROI ER M D I D 0 FLOWER - -- - ALERT TECHNOLOGIES PLOT OF ULLAGE TEST DATA KERN MEDICAL CENTER 830 FLOWER ST. BAKERSFILD, CA. 10000 GALLON DIESEL TANK 12KHz AMPLITUDE RATIO 25KHz AMPLITUDE RATIO 12KHz DETECTION RATIO = 1.02 0+ 0. M I N U E 3 S 5 25KHz DETECTION RATIO = 1.08 TEST RESULT = PASS DATE AND TIME OF TEST: 1/23/96 5:16PM BEGINNING BOTTLE PRESSURE = 2100 ENDING BOTTLE PRESSURE = 2000 BEGINNING TANK PRESSURE = 1.5 PSIG ENDING TANK PRESSURE = 1.4 PSIG D+ WbUO gal ------------- .................. ............. .......... ........... ..................... ...................... ........... .. . ................... I .......... • 0. M I N U E 3 S 5 ALEli T TECHNOL OGLES PLOT OF ULLAC,E TEST DATA KERN MEDICAL CENTER 830 FLOWER ST. BAKERSFILD, CA. 7500 GALLON DIESEL TANK 12KHz AMPLITUDE RATIO 25KHz AMPLITUDE RATIO M I N U E 3 S 5 . 12KHz DETECTION RATIO = 1.04 25KHz DETECTION RATIO = 1.25 TEST RESULT = PASS DATE AND TIME OF TEST: 1/19/96 5:08PM BEGINNING BOTTLE PRESSURE = 2300 ENDING BOTTLE PRESSURE = 2200 BEGINNING TANK PRESSURE = 1.5 PSIG ENDING TANK PRESSURE = 1.4 PSIG )+ _ ENVIRONMEWAL HEALTH SERVICA STEVE WCALLEY, R.E.H.S. DIRECTOR DEPARTMENT TANK INTEGRITY TESTING INSPECTION FORM 2700 "M" Street, Suite 300 Bakersfield, CA 93301 (805) 861 -3636 (805) 861 -3429 FAX THIS FORM MUST BE COMPLETED AT TIME OF INTEGRITY TEST BY THE TECHNICIAN ON SITE AND SUBMITTED WITH THE TANK INTEGRITY TEST Facility Permit to Operate Number / a O ocos Facility Permit to Tightness Test Number %n gWo Facility Name Kern rA Q-A CC CQ>1i- � Facility Address / ff30 1 f- Facility Telephone Number V0 Have you complied with the following safety requirements stated in UT -20, Section 25? YES/ NQ ,)>c� The area within 25 feet of any underground storage tank opening is free of smoking, open flames, and any other source of ignition. Legible signs with the words "NO SMOKING" are posted in conspicuous Ir locations around the testing area. 115S The general public is restricted from the testing area by rope, flags, cones, and "if dark" a fluorescent barrier. Fire protection in the form of a 2AI20BC fire extinguisher is located within the restricted area. V65 Vehicles utilized during the testing period, or within 25 feet of the underground storage tank opening, have adequate ventilation, and the tester has equipment which can be utilized to monitor the concentration of flammable vapors within the vehicle. `f �5 Personal protective equipment, an eye wash and gloves, and a site safety plan are within the testing area. Equipment /materials is available to absorb and contain any small release of testing liquid which is discharged as a result of the test. (Examples include DOT - acceptable containers for storage of the absorbent and an adequate supply of absorbent). If the answer to any of the above questions is NO, stop the testing procedure IMMEDIATELY until compliance is obtained. COMPLETE REVERSE SIDE Kern County nal Use Only ° Environmental Heal►. rvices Dept. IPWNo.��[�# Tanks to Test 2700 M Street, Suite 300 Test to include: Tank only Bakersfield, CA 93301 Tank/Pipin (805) 861 -3636 PTO Nod 3 Appl. Date !- APPLICATION FOR PERMIT TO TEST UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK POST ON PREMISES A. Facility Information (If there is no permit number, an application for a permit to operate must be submitted and approved before the permit to test can be processed). Proposed Test Date: /--/ (o -9 Facility Name Address I ZZ KE9,A.) b IEL iV11-zd) i C kt, Cr tTTE117 aW F-0- 9 '1 cA - TANK # SIZE PRODUCT AGE OF TANK COMMENTS 1 ov V.; —2.— ©Oov h; 4,;5 4. Contact Person Day i3C2 h J6 N Phone ( ) 32 (n- ZYOO Night Sr,4,14 1�7 Phone (_ ) SA IM z B. Tank Owner Information Owner Name Mailing Address C. Testing Company Information FITO Phone (_� Zip Code Contact Person Day :A R1 C 1-z Phone (S2aj Night a Phone Worker's Compensation Insurance # Liability Insurance # Test Method Used Al, gg i ,/1) oa sqr /off State Licensed Tester -17S-A/OE;4 1 21 C G4 State Licensed Tester # 910 -/() t7 2 THIS APPLICATION BECOMES A PERMIT WHEN APPROVED PTT# �v' "4"'.• PTO ........................ POST ON PREMISES ......................... . CONDITIONS AS FOLLOWS: 1. It is the responsibility of the Permittee to obtain permits which may be required by other regulatory agencies prior to beginning work (i.e., City Fire and Building Departments). 2. Permittee must nM& the Hazardous Materials Management Program at (805) 861 -3636 twenty-four hours prior to tank integrity test to allow the Hazardous Material Specialist the option of performing an inspection. 3. Tank integrity test must be per Kern County Environmental Health and Fire Department approved methods as described in Handbook UT -20. 4. It is the state - licensed tester's responsibility to know and adhere to all applicable laws regarding the handling of hazardous materials. 5. The tank integrity testing company must have the state - licensed tester listed on the permit on site performing the test. 6. If any tester other than the one listed on the permit and permit application is to be utilized, prior consent must be granted by the approving specialist on the permit. Deviation from the submitted application is not allowed. 7. A modification permit must be obtained from the department prior to exposing the tank to retest or investigating a release or failed integrity test. 8. The following timetable lists pre - and post -tank integrity test requirements: D?RAD1.2 Complete permit application submitted to At least one week prior to tank the Hazardous Material Management Program integrity test Notify the approving specialist At least 24 hours before test of date and time of the tank integrity test Send written results of a test to the No later than 30 days after testing approving specialist is completed Notify the approving specialist No later than 24 hours after of the results of a failedAnconclusive test completion of analysis RECOMMENDATIONS/GUMELINES FOR THE PERFORMANCE OF A TANK INTEGRITY TEST ON UNDERGROUND STORAGE TANKS This department is responsible for enforcing the state laws pertaining to underground storage tanks Representatives from this department perform inspections to ensure that the job performance is consistent with permit requirements, applicable laws, and safety standards. The following guidelines are offered to clarify the interests and expectations of this department. 1. Job site safety is one of our primary concerns. Tank integrity tests are inherently dangerous. It is the tester's responsibility to know and abide by CAL -OSHA regulations. The state - licensed tester is responsible for any other testing company employees on the job site. Tools and equipment are to be used only for their designed function. 2. Property state - licensed testers are assumed to understand the requirements of the permit issued. The tester is responsible for knowing and abiding by the conditions of the permit. Deviation from the permit conditions may result in a stop -work order. 3. The testing company will be held responsible for the pout -test paperwork. Analyses documentation is necessary for each site in order to close a case file or move it into mitigation. When testers do not follow through on necessary paperwork, an unmanageable backlog of incomplete cases results. If this continues, processing time for completing new tank integrity tests will increase. THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITFI THE ABOVE CONDITIONS OF THIS PERMIT AND ANY OTHER STATE, LOCAL AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. Owner's Authorized Signature Date Representative Date/—/ 6 —q( INTERNAL USE ONLY f' Permit Approved Date g Permit Expiration Date HM44 / G Total Fee /00 Paid On Receipt # ash Check # Fee Received By THIS APPLICATION BECOMES A PERMIT WHEN APPROVED QUAAWmnI.Y MCDa F3 ED INVENTORY CONTROL SHEET 'AC T:LITY K•M.L' PERMYT Z .�o jESEL rv1&G TFf LANK 3 CAFACI'TY %f GA SUBSTANCE STORED OLBARTER /YEAR :OL. 11_ COL. 2 1 Cr l,. 3'COL. 41COL. 81 COL. 61COL. °TI COL. g31COL. 91 COL. 10 I COL. 11 TEST WEEK { WEEKLY { ISHUT -13OWN I WATER LEVEL { 2N13 (GAUGE _ 1ST C3AUGE INCH CHANGEIVOLUME I 2ND _ 1ST VOLUME CUMULATY v1 VOLUME 't- CHANGE _ 8 TINB PERIOD I CRES - IN MS C NCHES GALLONS GALLONS GALLONS GALLONS OALLONS 1 (DATE /M /!IS mood 1 1 e 1 --� { 193-5, { { 1 9 3, S" I -FY { 17 y 0 I { 0 7 Y3 0 1 { .; ' 1 O 1 I l� oarTO t PM ,3 (DATE /RR la rz fI'aM I ��: 1 IDArTO ) -� I 19�, s I 9 o 93, S 1 .�- { 0 7y3d B { 1 7 y3 o I I -g' 1 171 — ' I /S, IDATE /Im Jo Z)q g lei 3 IoaTHR `8- 1 93, S 193 , -� I -�-' 17 Y3o 17y3 o I -e� I'- 1 z/ owl 4 DAMER 10 2t I s 3 I I �Z.J y DATE /NR 10 8 I a DATE/RR IDar10 ►► I �- 19z s I ��' , s I -�- I y� Z I� V 6 z I G DAMER 1� TO I DarE /NR Z JP I 19 i- 7 DATE /RR IDATE/NR rf / zPn, ,S B 7. JUATE/HR 11 TO DATE /RR 9 (DATE /BR I) O 134AILIJ 'z z Noon I ��' (� L• S 1 9 L S I I I . I I I-- 1_ • oarNR 10 IDarE /DR z 2 AM I 1 ;,—/g 1 ?p °�,,, I �—' I q I / � I Q 1 I —ems DATE0 g IDATE/RR A#, I 1 TO , , ,. 6 - � I DATE /NRr — I q I /. 1 :.e�- 13 N 9 1 73 2 IDATE /HR z al uo I IOATEO/NR f 13 - I I q 1 ! I I I 90, -7 , r I I ?31F / 1 173 3 1 1 I /0 I IDATE /eR I&L21 qAm I I I I I I I 1 DATE / NR I �0 3 /l'. 1 `J C7. / I^ �A" GErJ STANr. 8Y - Z He - i��z3 A Z BK 7- 0 u17s. - rZISIYZ - y,f ((, -,K 1), MDM1M TABLE B MODIFIED INVENTORY CONTROL ACTION LIMITS TANK SIZE WEEKLY LIMIT MONTHLY LIMIT (GALLONS) (GALLONS) .(GALLONS) AVE. OF 4 TESTS 500 OR LESS 10 5 551 TO 1,000 13 7 1,000 TO 2,000 26 13 COLUMN E IESI WEER COlI1HN 9 VOLUME • CHANGE COLUMN It SUBTOTAL A pool" COLUMN 11 TOTAL FOR PONT" O O O 0 6 p 6 0 4 b d b / TOTAL AT THE END Of THE MONTH (rOLUMN IN). d B AVERAGE MONTHLY VOLUME CHANGE 6/4-9). O C MONTHLY LIMIT ORIAINED FROM TABLE B - 13 1` DOES IN[ AVERAGE VOLUME CHANCE (B) EXCEED THE ACTION LIMIT (C)1 YES IF YES CONTACT THE KERN COUNTY ENVIRONMENTAL HEALTH DEPT. AT (605) 861.7636 WITHIN 24 HOURS. 6 L WEEKLY LIMIT OBIAINEO FROM TABLE B DID THE VOLUME CHANGE IN COLUMN 9 EVER EXCEED THE WEEKLY LIMIT (E)1 NO YES If YES PROVIDE THE DATE AND TIME THAI 101 KERN COUNIV FNVIRONMENIAL HEALTH DEPT. WAS CONTACTED. • I COLUMN COLUMN I I TEST VEER OLUNE 1 • I SUB OTAL2 OTALNFOR 6 A. TOTAL AT IRE END OF THE MONTH (COLUMN IS)- 0 D. AVERAGE MONTHLY VOLUME CHANCE (A /I.B)• O C. MONTKL* LIMIT OBTAINED FROM INGLE B - 13 0. DOES THE AVERAGE VOLUUM CHANGE (B) EXCEED INE ACTION LIMIT (01 <N YES IF YES CONTACT THE BERN COUNTY ENVIRONMENTAL HEALTH DEPT. AT (805) 161.5616 WITHIN 14 HOURS. E. WEEKLY 1.11111 OBTAINED FROM TABLE B e Lc' F. DID THE VOLUME CHANCE IN COLUMN 9 EVER EXCEED THE WEEKLY LIMIT (E)I NO YES If YES PROVIDE THE DATE AND TIME THAT THE KERN COUNTY ENVIRONMENTAL HEALIN DEPT. WAS CONTACTED. THE CUMULATIVE VOLUME CHARGE (COLUMN 11. BOTTOM LINE) (GALLONS) FAIR CONTAINS WASTE all OB BON MOTOR VEHICLE FUEL JANSSEN QUESTION) IS THE CUMULATIVE VOLUME CHANCE 4/- 100 1111.1.0111 YES MO IF YES 11PORT 10 REIN COUNTY ENVIRONMENTAL HEALTH WITHIN 14 MRS. TANK CONTAINS MOTOR VEHICLE FUEL (ANSWER QUESFI01) IS THE CUMULATIVE VOLUME CHANCE 4/- 250 CRL10111 YES NO IF YES REPORT TO 9111 COUNTY ENVIRONMENTAL HEALTH WITHIN 24 HRS. BONIM 1173ii+Ii: • • • . � u 1 COLUMN 1. TEST WEEK COLUMN 9 VOLUME • CRAI COLUMN it SUBTOTAL FOR COLUMN 13 TOTAL FOR TN 0 6 a O o 0 12 G O A. TOTAL AT THE END OF THE ROSIN (COLUMN I3)• S. AVERAGE MONIHLY VOLUME CHANCE (A /4.9)- O C. MONTHLY LIMIT OBTAINED FROM TABLE B 3 D. DOES IRE AVERAGE VOLUME CHANCE (B) EXCEED IRE ACTION twill (I ,ND YES IF YES CONTACT THE KERN COUNTY ENVIRONMENTAL HEAl1H DEP1 Al (805) 861.3636 WITHIN 24 HOURS. E. WEEKLY IIMII OBTAINED FROM TABLE IT m 6 F. 010 THE VOLU10 CHANGE IN CDLUNVI 9 EVER EXCEED THE WEEKLY LIMI1 U' NO YES IF YES PROVIDE THE DATE AND TIME THAI THE KERN Cal ENVIRORMENIAI HEALIM DEPT. WAS CONTACTED. I HEREBY CERTIFY THAT THE ABOVE -NOTED RESULTS REPRESENT A TRUE AND ACCURATE REPORT. SIGNED_ /C. / '/� J� DATE 17 a1 TANK �1�CI LS TY ANNU °r_�EPORT Facility M Permit ;p 1Zb (,o3 Month /Yr. Iz 3° 7 3 1. I have not done any major modifications to this facility during the last 12 months. Signature Vote: All major modifications require a Permit to Construct from the Permitting Authority. 2. I have done major modifications for which I obtained Permit(s) to Construct from Permitting Authority Signature �F Permit to Construct * A 173/ -12- 11Z000JM Date o l 9X 7 �?1Z 3. Repair and Maintenance Summary Attach a summary of all: -- Routine and required maintenance done to this facility's tank, piping, and monitoring equipment. -- Repair of submerged pumps or suction pumps. -- Replacement of flow- restricting leak detectors with same. -- Repair /replacement of dispensers, meters, or nozzles. -- Repair of electronic leak detection components, or replacement with same. -- Installation of ball float valves. -- Installation or rehaii� ui vapur recovery /vent lines. Include the date of each repair or maintenance activity. MOTE: All repairs or replacements in response to a leak require a Permit to Construct from the Permitting Authority as do all other modifications to tanks, piping or monitoring equipment not listed here. 4. Fuel Changes - Allowed for Motor Vehicle Fuel Tanks Only. List all fuel storage changes in tanks, noting: Date(s), tank number(s), new fuel(s) stored. 5. Inventory control monitoring is required for this facility on the Permit to Operate, and I have not exceeded any reportable limits as listed in the appropriate inventory control monitoring handbook during the last twelve months (if not�a]nppllicable disregard). Signature lni LAfT QTR, aF /997- 6. Trend Analysis Summary and /or Quarterly Summary Please attach: Annual Trend Analysis Summary for the last 12 periods for all tanks required to do Standard Inventory Control Monitoring ( *UT -10) ; Quarterly Summaries for past year for tanks required to do ,Modified Inventory Control Monitoring (:UT -15). 7. Meter Calibration Check Form Please attach current, completed Meter Calibration Check Form if required in permit conditions. - ltd - ®K Ak 14C• ® MEDICAL CENTER AFFILIATED WITH UNIVERSITY OF CALIFORNIA SCHOOLS OF MEDICINE AT LOS ANGELES, SAN DIEGO AND IRVINE August 27, 1993 Carrie Georgi County of Kern Environmental Health Services 2700 "M" Street, Suite 300 Bakersfield, CA 93301 Re: Permit No.: 120003 Facility Name: Kern Medical Center Facility Address: 1830 Flower St., Bakersfield, CA 93305 Dear Ms. Georgi: Thank you for your letter of August 24 wherein you requested our Tank Facility Annual Report for 1992. Quite frankly, we thought we had sent in the report, but perhaps not. At any rate, the report is enclosed. If you have any questions or concerns, please feel free to call me at 326 -2400. Sincerely yours, Noel Burkley Assistant Facility Manager OWNED AND OPERATED BY THE COUNTY OF KERN 1830 FLOWER STREET, BAKERSFIELD, CALIFORNIA 93305 -4197, TELEPHONE: (805) 326 -2000 • G L >, - _q IDATE /HR zc !4,1 1 1 1 1 1 1 ( KI DA /HR Zs 0 y . 0 _ — I ``i 1 93 6 y I I ",& s IDATE /HR !; Z 9 AM I 0 wl 1 To ► ,► I -19- 1 8 � f , Z5 (8 . -�- DATE /HR B RITE /HR I TO i I g �. Zs z s 1 �- I 130 I Ml I -4)- DATE/Htt ,a DATE /eR ° IDATTO 11 /IR 2-P, q,2-( �q,zs �- 8 E /1 2 I DATHR 1 TG , 26 � I I gq. z S I y, Zs I 1931y 193eq DATE /HR �,/ IPM 9 DATE /HR o I TO � AINNI - 18q 7- i 91. z s I �- 143�� I y3�y I .-e- i DATE /HR J. ® (DATE/HR r2. b SA e-1 I I _O 31, �' , l I I I 37 IDATE/HR iz 18/. 7-S- S" 1 0 � I I 1�1 .�- , 1 (DATE /HR z kA,, I °DATEO/HR �Z c zPrw ° ° ��, z-S I A 1 . ZS 1137 T 2 (DATE /HR rZ z tAVJ I DATE/TO , `3 2 M 1 -Q I 'R 1. zS HR DATE /BR I DATE/ To RI QUAnTERL.Y MODS FI ED :t NVENT®RY C CONTROL SHEET aCILYT'Y )4�-! ... P . PERMYT 12-00 03 aNK* Z Z CAPAC$TY 10, G Q AL SUBSTANCE S STORED T T IES ,0L F F(AEL QUARTER /REAR r u-r :)L. 11 C COL_ 2 I C CrOL_ 31COL. 4 41COL_ — —51 6 6ICOL. 7 71 C COL_ 8 81COL_ 91 COL. IO 1 C COL. II 'EST ( ( WEEKLY ( W WATER I I 2ND _ _ 1ST - I INCH ( ( 2ND - 1ST VOLUME *SUBTOTAL- C CUMULATY VE LEEK I ISHUT -DOWN I L LEVEL_IGAUGE G GAUGE C CHANGE(VOLUME V VOLUME C CHANGE C CHANGE I TIME PERIOD I I INCHES _I I INCHES I I INCHES I I INCHES I I GALLONS I G GALLONS I I GALLONS I GALLONS I G GALLONS IDATE /He io .T 061*1 1 _49- 1 1 1 1 1 I I 1 1 939/ 1 1 O 2 I IDATE /HR c :z ,o I I 'f� 0 I I 1 8y. S g g 0 0 938 1 1 S Sag/ I I A ?6 /HR o Is z 3 D DATE /11H ZZ, I I 1 ` `�- I I �H . S 9 9 8�. S I - -e— I I g 3 91 I V Val I I - I ,� I { {� !4,1 1 1 1 1 1 1 ( KI DA /HR Zs 0 y . 0 _ — I ``i 1 93 6 y I I ",& s IDATE /HR !; Z 9 AM I 0 wl 1 To ► ,► I -19- 1 8 � f , Z5 (8 . -�- DATE /HR B RITE /HR I TO i I g �. Zs z s 1 �- I 130 I Ml I -4)- DATE/Htt ,a DATE /eR ° IDATTO 11 /IR 2-P, q,2-( �q,zs �- 8 E /1 2 I DATHR 1 TG , 26 � I I gq. z S I y, Zs I 1931y 193eq DATE /HR �,/ IPM 9 DATE /HR o I TO � AINNI - 18q 7- i 91. z s I �- 143�� I y3�y I .-e- i DATE /HR J. ® (DATE/HR r2. b SA e-1 I I _O 31, �' , l I I I 37 IDATE/HR iz 18/. 7-S- S" 1 0 � I I 1�1 .�- , 1 (DATE /HR z kA,, I °DATEO/HR �Z c zPrw ° ° ��, z-S I A 1 . ZS 1137 T 2 (DATE /HR rZ z tAVJ I DATE/TO , `3 2 M 1 -Q I 'R 1. zS HR DATE /BR I DATE/ To RI I DATE/ To RI 0 1110111111 1). TABLE B MODIFIED INVENTORY CONTROL ACTION LIMITS TANK SIZE WEEKLY LIMIT MONTHLY LIMIT (GALLONS) (GALLONS) .(GALLONS) AVE. OF 4 TESTS 500 OR LESS 10 5 551 TO 1,000 13 7 1,000 TO 2,000 26 13 COLUMN 1 COIURN 9 COLUMN 12 COLUMN 17 It WEEK VOLUME • SUBTOTAL TOTAL FOR CHANGE A MONTH PONT" 4> o d 6 o a o 0 4 6 6 A TONAL Al THE END or THE NORIN (rOIUNN 11)- 0 D AVERAGE MONTHLY VOLUME CHANCE 6/4 -9)- 6 c MORIHLY LIMIT OBTAINED FROM TABLE B - 13 1` DOES IHE AVERAGE VOLUME CHANCE (B) EXCEED THE ACTION 1.111111 (C)i NO YES If YES CONTACT THE KERN COUNTY ENVIRONMENTAL HEALTH DEPT. AT (805) 061.1616 WITHIN 24 HOURS. i WEEKIr tlMll OBTAINED FROM TABLE B - Z6 1 DID IMF VOLUME CHANGE IN COLUMN 9 EYER EXCEED THE WEEKLY LIMIT ([)i YES If YES PROVIDE THE DATE AND TIME THAT THE KERN COUNTY IF VIRONMENIAI HEALTH DEPT. WAS CONTACTED. Sulu COLUMN 1 TEST WEEK COLUMN 9 VOLUME • COLUMR it SUBTOTAL COLUMN 11 iOTAL FOR o tl O o d o J U O o o 1 0 A. TOTAL AT THE END Of THE MONTH (COLtTMR I9)- U B. AVINA91 MONTHLY VOLUME CHANCE (A /4 -9)- O C. MONTHLY LIMIT OBTAINED FROM TABLE B - 13 D. DOES THE AVERAGE VOLUME dW1GE (B) EXCEED THE ACTION LIMIT (C)l lam' YES IF YES CONTACT THE KENN COUNTY ENVIRONMENTAL HEALTH DEPT. AT (805) 161.1696 WITHIN 24 HOURS. E. WEEKLY LIMIT OBTAINED FROM iABLE B - 5 F. DID THE VOttXt CHARGE IN COIUMR 9 [TEN EXCEED THE WEEKLY LIMIT (E)1 YES If YES PROVIDE THE DATE AND Ilia THAI THE KENN COUNTY E�TfROWNIAL HEALTH DEPT. WAS CONTACTED. MONiN 117�ii�11: • • • ' � a top v IA' COLUMN E iEST WEEK COLORS 9 VOLUME + CHANGE COLUMN It SUBTOTAL R COLUMN 11 TOTAL FOR H o 0 O U O 6 0 o 12 1 /U O 1,) A. TOTAL AT THE 110 OF THE NORTH (COLUMN I1)- 1 U B. AVERAGE MONTHLY TOIUFE CHANGE (A/4 -0)- Z C. MONTHLY LIMIT OBTAINED FROM TABLE B 0. DOES THE AVERAGE VOIWE CHANCE (0) EXCEED THE ACTION UNIT NO YES IF YES CONTACT THE KERN COUNTY ENVIRONMENTAL HEALTH DEPT Al (GDS) 861.1616 WITHIN 24 HOURS. E. WEEKLY LIMIT OBTAINED FROM TABLE B - 4- F. DID THE VOLUME CHANGE IN COLUMN 9 IVIR EXCEED THE WEEKLY 111411 NO YES IF YES PROVIDE THE DATE A40 FINE THAT THE KFRN U, IROIYM[NTAt NEAtIH DEPT. WAS CONTACTED. THE CUMULATIVE VOLUME CHANGE (COLUMNS 11. BOTTOM LINE) _- (6AllONS) TANS CONiAIMS VAST[ OIL OR RON VOiDS VEHICLE FUEL (ANSWER QUESTION) IS THE CUMULATIVE VOLUME CHANGE +/- 100 611114,0111 YES go IF YES REPORT 10 KERN COUNTY ENVIRONMENTAL MERLIN WITHIN 24 HRS. TANK CONTAINS 90101 VEHICLE FUEL (ANSWER QUES1101) IS THE CUMULATIVE VOLUME CHANGE 4/- LSO 6AR0111 YES NO IF YES REPORT 10 KERN COUNTY ENVIRONMENTAL HEALTH WITHIN 24 HRS. I HEREBY CERTIFY THAT THE ABOVE -NOTED RESULTS REPRESENT A TRUE AND ACCURATE REPORT. SIGNED .� % ��(`' -4'v �" DATE Petroleum Hydrocarbons RLW EQUIPMENT Date Of 2080 3 640 640 F 4 BOX Report: 09/2S/92 BAKERSFIBLD, CA 93302 Lab #; 8573-1 Attn..- BM MC=B 834 -1100 Sample Description: #048461 KERN MEDICAL CENTER, 1834 PLOWER ST., SA)MRSFIELD, CA: WEST 1/2 TAIGK 9 2' 'SAMPLE (SOIL) 09 -23 -92 ® 11:42AM COLLECTED BY L01W S. TEST METHOD: 'TPH by D.O.H.S. / L X.P.T. Manual Method - Modified EPA 8o15 Sample Matrix: Soil Date Sample Collected-, 09/23/92 Benzene Total Petroleum Hydrocarbons (diesel) Date Sample Received a Lab; 09/23/92 Analysis _- Resu to 0.8 17000. Date Analysis C=*Ieted: 09/25/92 Reporting units mq/k9 mg /kg Note: High reported PQL's due to high concentration". 6f target analytes. California D.O.H.S. Cert. #1186 ti Department Supervis CC: KERN MEDICAL CEZMP Minimum Reporting x,GXQI 0.1 S000. w OWE i 410 0Atrss Cc. - Bnkersf ald. CA qaGoe . gaZm� 327_:91 1 • FAX (9CES) 327 -191 B l 90RA Cis ' Petroleum Hydrocarbons RLW EQUIPMENT Date Of 2080 3 640 640 F 4 BOX Report: 09/2S/92 BAKERSFIBLD, CA 93302 Lab #; 8573-1 Attn..- BM MC=B 834 -1100 Sample Description: #048461 KERN MEDICAL CENTER, 1834 PLOWER ST., SA)MRSFIELD, CA: WEST 1/2 TAIGK 9 2' 'SAMPLE (SOIL) 09 -23 -92 ® 11:42AM COLLECTED BY L01W S. TEST METHOD: 'TPH by D.O.H.S. / L X.P.T. Manual Method - Modified EPA 8o15 Sample Matrix: Soil Date Sample Collected-, 09/23/92 Benzene Total Petroleum Hydrocarbons (diesel) Date Sample Received a Lab; 09/23/92 Analysis _- Resu to 0.8 17000. Date Analysis C=*Ieted: 09/25/92 Reporting units mq/k9 mg /kg Note: High reported PQL's due to high concentration". 6f target analytes. California D.O.H.S. Cert. #1186 ti Department Supervis CC: KERN MEDICAL CEZMP Minimum Reporting x,GXQI 0.1 S000. w OWE i 410 0Atrss Cc. - Bnkersf ald. CA qaGoe . gaZm� 327_:91 1 • FAX (9CES) 327 -191 B l Petroleum Hydrocarbons RLW EQUIPMENT Date of 2090 8 UNION Report: 09/25/92 P 0 BOX 640 Saab #: 6573 -2 BAKERSFIELD, CA 93302 Attn.: BLM MCNABB 834 -1100 Sample Description: #C48461 KERN MEDICAL CENTER, 1830 FLOWER ST., B,AXERSFIELD, CA: WEST 1/2 TAW a 6' SAMPLE (SOIL) 09 -23.92 0 ll;SO.AX COLLECTED BY LOM S. TEST METHOD. `rPH by A.O.H.S. / L X.F.T. Manual Xethvd - Modified EPA 8015 Sample Matrix: Sail. Dates Sample Date Sample Date Analysis Collected: Received W Lab: Completed: 09/23/92 09/23/92 09/25/92 minim= Analysis Reporting Reporting rslj t 'e7el Benzene 3.1 Total Petroleum Hydrocarbons (diesel) 29000. mg /kg 5000. Nate: High reported PQL's due to high concentration of target analytes. California D.O.H.S. Cert. #1186 .-A Department Supervis cc: KERN MEDICAL CENTER 41 CX0.4 ss CC. - 6®ker nekd, CA 93306 • gq=5j 327 -4S1 1 • FAX 0 05) 327 -199 B 3�oRo,ES ' Petroleum Hydrocarbons RLW EQMPMENT Date of 2080 S MaON Report: 09/26/92 P Q BOX 640 Lab #: 8573 -3 BAKFRSFIELD, CA 63302 Attn.; BUD MCXABB 834 -1100 Sample Dencriptioni #C48461 KERN MEDICAL CENTER, 1830 FLOWER ST., S.AKERSPIELD, CA: 18' DEPTH 10' BENEATH T,=K (SOIL) 09 -23.92 0 12:05PU COLLECTED BY LONNY S. TEST METHOD: TPH by D.O.H.S. / L.U.P.T. Manual Method - Modified EPA 8015 Sample Matrix: Soil Date Sample Collected: 09/23/92 C is i.tueats Benzene Total Petroleum Hydrocarbons (diesel) Data Sample Received a Lab- 09/23/92 Analysis Results 0.3 21000. Date Analysis Ccopleted; 09/25/92 Minimum Reporting Reporting 13nits. Level m9' /kg 0.1 m9 /kg 5000. Mote: High reported PQL's due to high concentration of target analytes. California D.O.H.S. Cert, #1185 Department Supervisor cc: KRRN MEDICAL CENTER 4100 Arles Ct, - Sakers6eld, CA 933M • p=327'•4911 • PAX 0=_-;e7- -1919 - Petroleum Hydrocarbons RLW EQUIPMENT Date of 2080 S UNION Report: 09/25/92 P U BOX 640 Lab #: 8573 -4 BAKERSFIELD, CA 93302 .Attn. i BUD MCN7UaB 834. -1100 Sample Description: #C48461 KERN b2DICAL CENTER, 1830 FLOWER ST., BARERSFIELD, CA: 2' BENEATH PIPING (SOIL) 0923 -92 6 12:24PX COLLECTED BY LONNY S. TES's METHOD: TPH by D.O.H.S. / L X.F.T. Xanual Method - Modified EPA 8015 Sample Matrix: Soil Date Sample Collectedt 09/23/92 C. =etitu.ents Benzene Total Petroleum Hydrocarbons (diesel) Date SaMPle Received a Lab: 09/23/92 Analysis Res_ silts 0.06 8000. Date Analysis Completed: 09/25/92 Reporting trait* mg /kg mg /kg Minimum Reporting Level 0.01 2000. Note: High reported PQL's due to high concentration of target analytes. California D.O.H.S. Cert. #1186 Department Supervisor CC, XERN MEDICAL CENTER n`1•��'�. .1; :.1 1 r r • Petroleum Hydrocarbons 0 • - v o RLW EQUIPMENT bate of 2080 S MION Report: 09/25/92 P 0 BRx 640 Lab #: 8573 -5 BAKERSFIELD, CA 93302 Attn.: BVD MCNABB 834 -1100 Sample Description: #048461 KERN MEDICAL CENTER, 1830 FLOWER ST, BAXERSFIELD, CA: 6' BENEATH PIPING (SOI34) 09 -2a -92 Q 12:31PM COLLECTED BY LONNY S. TEST METHOD: TPH by D.O.H.S, / L,U.F.T. Manual Method - Modified EPA 8015 Sample MatriX: Soil Date Sample Date Sample Date Analysis Collected: Received 6 Lab: Completed: 09/23/92 09/23/92 09/25/92 Minimum Analysis Reporting Reporting anstituents Results Talits L vel Benzene 0.20 mg /kg 0.05 Total Petroleum Hydrocarbons (diesel) 4000. mg /kg 2000. Vote: High reported PQLIS due to high concentration of target analytes. Calif=ia D.O.H.S. Cart. #1186 Department Supervisor" cc-. KERN MEDICAL CBNTFp, v MEN VW 4' 1.5 .Ilk 1 *(a a 0 ffi r lt-Y` 0 klblij 04 9101109 At; 104 44 • 0 912U ` .1 � �c��o�� -�. Inl p� °� U Aug. 5, 1992 Ref.: Kern Medical Center 1830 Flower St., Bak. The 10,000 gallon Diesel tank serves the south boiler house and a stand -by generator. The stand -by generator uses a suction line coming from the north end of the diesel tank. This line was pressure tested at 7 PSI and no loss was seen. The Boilers are served by a Red Jacket turbine located on the diesel tank and the pressure is regulated to approximately 6 psi with a pressure regulator located in the building. This pressurized fuel line is a continuous loop line returning back to the UST. The installation of a Red Jacket PLT ( Piston Line Tester) on this line with it's return loop would not serve the necessary requirements since it would not be on a line that would hold pressure if the turbine was off. Thus the PLT would shut down the line when the turbine stopped and it is doubtful it would open properly again since the pressure regulator on the line would provide the same characteristics as a leak, with prod- uct returning to the tank through the return loop. The 7500 Gallon Diesel (North West) served the North Boiler house. The tank tested tight. The suction system had about 20 feet of pipe which was buried for both the suction and return lines. The suction line was not tested at this time since the lines had to be isolated at the tank since it was not apparent there was a foot valve ( old sys- tem). The line appeared to be wrapped steel with rust pitting on the exposed portion at the tank end. The 750 Gallon tank serving the stand -by generator (Northeast) failed the precision tank test. Test level was approximately 1 inch above tank top. The product was 12 inches below grade (2 ft. above tank top) when the tank was topped off the prior afternoon. 3 hours after this test the level was marked at tank top and checked 24 hrs. later with no difference noted. Fresh contamination was noted in soil at tank top in the pit around the foot valve. It is estimated the leak is along the tank top, but only a isolated precision test could confirm this, unless the level remains constant over the next few days. • 0 r • PLOT PLAN TEST NO. of 41 North NAME: Kef'N y'W CO— (See,-: CITY: LOCATION: • i3A� , V) Q T st �- t T3o1 F-Ivo5 P�'�y� � 0 � +,- 54 X50 �1Ai✓ z I af-1 I t)r 500 6Lr+L = 12 y 1 tA— - Z 1 tCO 00 6741 12 11 N TP11 -4-71 Drawn By ,�Qe��1yt Date: IF 7 a 5 Brockways 2014 S. Union Ave. No. 103 Bakersfield, CA., 93307 tok 1�IEsE Z PZ- t-' ® t 'r'j i T 13o Ie�s PY'e:�sv3i -� 1ti +,- 54 X50 �1Ai✓ z I af-1 I t)r 500 6Lr+L = 12 y 1 tA— - Z 1 tCO 00 6741 12 11 N TP11 -4-71 Drawn By ,�Qe��1yt Date: IF 7 a 5 Brockways 2014 S. Union Ave. No. 103 Bakersfield, CA., 93307 U E99MX 9:::' :L s=—i :L a=), —rm m —r (L-- 4—=5 -b ----------------------------------------------------------------------------- BROCKWAYPS 2014 S. UNION AVE. BAKERSFIELD9 CA. 93307 (805) 834-1146- ----------------------------------------------------------------------------- Performed for: Kern Medical Center Test Location: 1830 Flower St. Bakersfieldp CA Test Identification : 1241-1 Test Date R 08-04-1992 Start Data Collection 3 08 :43g20 Ending Test Period 11818 Time Filled for Test + IS Hrs. TANK ID. Vo I ume Depth Bury Groundwater Tank Type Test Fluid — — -T =--,% " B< n 4M -t-. � :No East -750 a36 - > 15 FT :I Wall Steel :Diesel -n- -X- -r a-- s -b F;t e--- In as v- -b CONTENTS Diameter Product level Pump Type Water in Tank Vapor Recovery Average Rate of Change is based on 235 Data Pointy Standard Deviation ....... * ..... .0053 Gallons - Volume change of Tank Contents - Net Volume # ( 60 min/Test Time) -0173 Sal. C 60/ 61032 min.) = -61692 Sphb, Diesel -48 -49 :Suction 0 No - Volume change due to Temperature - Avg. Temp. * Volume * Coef. of Expn..* (60 min./ Test Time) -.0145 Deg.F * 750 Gal. * 0.00044 SO/ 61.32 =,-.0047 Sph. Net change = Level Volume - Temperature Volume v i Based on the Information pr ded and the D to Collected This Tank Test has...... IF=^ x I Certified Tester es Robert Brockman # 92-1251 - ------------- This Test meets all U.S.EPA and NFPA requirements. �i �, •. ,. li :� .. . •i ��, � f.. r( c, , .. � .. � i i , ,, I„ ;� 3 G ' . � �. •'z 9A � .. ��.�� y �� � ,: b •. .. 1 �lj i• Id ' }, .�w , !' ,.. It, 6, „ ,. �._ . , , , 1' � • . g }\ \. ~ ©� 6 � ^� ` \ \)� } \ \}� . <, \ 0 ,§-0-1-U-- §$97,e - - - Its >yp.� \ > .._ }\ \ \J \, !2\ a7� )§ w } (7' /9 `qdq 369 ;`- ■ ,qd5 j@@,- ■ " ... Cleo Coll n d i At _ 11 !' rot I" (J tr 1 i c �C�.._ �r �G:r. � �__ L, �� -r '� `-3�� �. it _' ;f��� • n i .' 1 � + Z EEs a X FF ' r- c=:9 r-a T- a► m k 'Ei — ss -� ----------------------------------------------------------------------- - - - - -- BROCKWAY °S 2014 So UNION AVE. BAKERSFIELD9 CA. 93307 (805) 834 -1146 _________________________________________________ ___ ____ ____________ ___ ______ Performed fora Kern (Medical Center Test Locations 1830 Flower Bakersfield, CA Test Identification : 1241 -2 Test Date s 08 -04 -1992 Start Data Collection - 08s43s20 Ending Test Period s 11 :18a16 Time Filled for Test - + 18 Hrs. TANK ID. Vol ume Depth Bury Broundwater Tank Type Test Fluid -- T=-%MR n am, •�<M sN.West x7456 x36 s > 15 FT sl Wall Steel :Diesel CONTENTS Diameter Product level Pump Type Water in Tank Vapor Recovery Average Rate of Change is based on 235 Data Points Standard Deviation ............. .0108 Gallons - Volume change of Tank Contents - Net Volume # ( 60 min /Test Time) -40098 Gale # ( SO/ 61032 min.) _ -00095 Gpho - Diesel s95 -125 aSuction -0 shone - Volume change due to Temperature - Avg. Temp. * Volume * Coefo of Expne (60 min. / Test Time) -00160 Deg.F * 7456 Gale * 0°00044 # 60/ 61°32 = -00519 Gph Net change = Level Volume - Temperature Volume 14RE -T- (-- "ANd3E; o - C> a C"-'D �- Based on the Information provided and Data Collected This Tank & System Lines Test has...... Certified Tester s Robert Brockman # 92 -1251 _ This Test meets all U.SaEPA and NFPA requirement . +a ..� �,) �' � I { r9d is yid IBA61 Isai 0 ° = 39NN 136 i 1 0 argil 0 cot Loy }.. " a "oil "Al 1. C RAM'' ..� n I I ^7 1= }I t It II 1 1 r L . 1 I 4 � _ �l I I_ ( I` jc I� l � _ will .y t 11 'I cot Loy }.. " a "oil "Al 1. C RAM'' _n l I, LIB • 1� 1 4i ,nll �Q. �4 r'¢ I I ^7 II f ) 1I 4 � _ �l I I_ jc I� .y 'I C ii �I I i c ; _n l I, LIB • 1� 1 4i ,nll �Q. �4 r'¢ I n 1= XOR r• di co, M "r'�' ----------------------------------------------------------------------- - - - - -- BROCKWAY °S 2014 So UNION AVE. BAKERSFIELD9 CA. 93307 (805) B34 -1146 ----------------------------------------------------------------------------- Performed fora Kern Medical Center Test Locations 1830 Flower St. Bakersfield, CA Test Identification s 1241a -1 Test Date s OB -04 -1992 Start Data Collection s 12:00:43 Ending Test Period s 14s07:1B Time Filled for Test s + 20 hrs. TANK ID. Volume Depth Bury Groundwater Tank Type Test Fluid :0 3 South :10000 :6 Ft s ? 15 FT :I Wall F. G :Diesel CONTENTS Diameter Product level Pump Type Water in Tank Vapor Recovery M Average Rate of Change is based on 235 Data Points Standard Deviation ............. 00023. Gallons - Volume change of Tank Contents - Net Volume ( 60 min /Test Time) -.0069 Gale ( 60/ 61.32 mine) = -00067 Gpho s Diesel s92 : 149" :Turbine :0 shone - Volume change due to Temperature - Avge Tempo * Volume * Coefo of Expno # (60 min./ Test Time) -.0019 Deg.F * 10000 Gala * 0000044 # 60/ 61032 = - °0082 Gpho Net change = Level Volume - Temperature Volume N M -r c1b o CD C1 1 TS (a F=" Based on the Information provided and the Data Collected This TANK & SYSTEM LINES Test has. o n e o o F"^c-3E33E X3 -i Certified Tester s Robert Brockman ## 92 -1251 -- -- `�'` -°= --------------- - -- This Test meets all UeSeEPA and NFPA requirements. 6 R, � . �� V e �. . .. t• : �a .1 yR�: ". '7 � �? • � . bir � • . ' C'A't 6 •�I ' C � 'v'f ' � ;r �... c. � ..i'' . "'� bror ii 1,�, _�. n o r . ,y � � ' � )�1 IFS . .. .. ,� �I, ! 1 .i� �,�' .. t ;y.. 6� � {' 9 on , ..G6 � C !�b t� T' L -1 U'l 7 0 m 9 1. `il W� 0 L 1_: Go Q 0 _ D G O e® � e fl ', t{ . .� _ . .'1 �I � • `'' � it � � h �r toy " - G r j. 11 111 �l Since 1937 2014 S. Union Avenue, Suite 103 Bakersfield, CA 93307 805-834-1146 L I N E T E S T R E S U L T S Date: PRODUCT: Location: ��N V�e� , CeJeAe- NUMBER OF DISPENSERS: i?m %t 1 5 TANK: Soc3�-In �o ------------------------------------------------------------------------ OPERATING PRESSURE: TEST PRESSURE: � 1 Ps; (1 -1/2 * operating pressure) ------------------------------------------------------------------------ INITIAL PRESSURIZATION LIQUID LEVEL = STARTING POINT. TIME PRESSURE LEVEL READING Starting Point: (0: 30 `( rl ( , I- a5- } VOLUME CHANGE -------------------------------------------------------- Ist check: 10 35q ---t c) 217 2nd check: 10 0 Lf 9— R f o Z'Y 3rd check: 10! 50 4 4th check: ( (: 00 lobo n 00Vg o, , 5th ------------------------------------------------------------------------ check: TOTAL TIME: TOTAL VOLUME CHANGE: ov GioS CALCULATIONS: 60 MIN /TEST TIME * OVERALL LIQUID LOSS = GPH RATE N(OTES:r_ lJw�ue. G(�5�,�eSSure��4�t�v I « �arleo� -- Y l Ou? cj.,, d .4 -ia i 4l ej , las— LINE IS TIGHT IF NET GPH CHANGE IS LESS THAN .05 GALLONS PER HOUR P A Ss F A I L Signed State License * 92 -1251 Robert Brock-m—ali- Test witnessed by This test is performed to comply with Federal EPA UST regulations (40 CFR Part 280, Subpart D), using a threshold of .05 gallons per hour as the determination of the integrity of the pipeline at 1 -1/2 times operating pressure. d' • Since V 937 2014 S. Union Avenue, Suite 103 Bakersfield, CA 93307 805-834-1146 LINE TEST RESULT -S -� Date: _ 5 2 PRODUCT:- ,I Location: V�G. NUMBER OF DISPENSERS:- TANK: --------------------------------------------------------- - - - - -- ,1 OPERATING PRESSURE: �'L..) io t-� TEST PRESSURE: P° (1 -1/2 * operating pressure) ------------------------------------------------------------------------ INITIAL PRESSURIZATION LIQUID LEVEL = STARTING POINT. TIME. PRESSURE LEVEL READING Starting Point: G?; 3'0 7 Q5 ,, ---------------------------------- - - - - -- 1st check: Gl ; ua 2nd check:-C/" 5-0 3rd check: /0.'00 .i 4th check: 5th check: --------------------------------- - - - - -- ( , U 8 y ) VOLUME CHANGE ---------------- '090 1 fl -------------------------- - - - - -- TOTAL TIME: u-b4.� TOTAL VOLUME CHANGE: CALCULATIONS: 60 MIN /TEST TIME * OVERALL LIQUID LOSS = GPH RATE NOTES: �� �'t i o &j U — �a /r�. 2�� } ��tA - J3/ LINE IS TIGHT IF NET GPH CHANGE IS LESS THAN .05 GALLONS PER HOUR A S F A I L Signed State License # 92 -1251 Robert Broc man Test witnessed by This test is performed to comply with Federal EPA UST regulations (40 CFR Part 280, Subpart D), using a threshold of .05 gallons per hour as the determination of the integrity of the pipeline at 1 -1/2 times operating pressure. r s' RANDALL L. ABBOTT DIRECTOR DAVID PRICE III ASSISTANT DIRECTOR RESOURCE MANAGEMENT AGENCY CY Environmental Health Services Department STEVE MCCAIIEY, REHS, DIRECTOR Air Pollution Control District WILLIAM J. RODDY, APCO Planning & Development Services Department TED JAMES, AICP, DIRECTOR ENVIRONMENTAL HEALTH SERVICES DEPARTMENT TANK INTEGRITY TESTING INSPECTION FORM Date 3- 4- - 92_ Facility Permit to Operate Number 120003 Facility Permit to Tightness Test Number TD 34— Facility Name 1< Yro mP�-d -1;Cu l C e tit r r Facility Address N -00 1' l oweJ y- 5t Facility Telephone Number 32_lo - Z 4 g Il Has the tester complied with the following safety requirements stated in UT -20, Section 25? YES/NO The area within 25 feet of any underground storage tank opening is free of smoking, open flames, and any other source of ignition. 1165 Legible signs with the words "NO SMOKING" are posted in conspicuous locations around the testing area. r� The general public is restricted from the testing area by rope, flags, cones, and "if dark" a fluorescent barrier. Fire protection in the form of a 2A/20BC fire extinguisher is located within the restricted area. S Vehicles utilized during the testing period, or within 25 feet of the underground storage tank opening, have adequate ventilation, and the tester has equipment which can be utilized to monitor the concentration of flammable vapors within the vehicle. Personal protective equipment, an eye wash and gloves, and a site safety plan are within the testing area. I �5 Equipment /materials is available to absorb and contain any small release of testing liquid which is discharged as a result of the test. (Examples include DOT - acceptable containers for storage of the absorbent and an adequate supply of absorbent). If the answer to any of the above questions is NO, stop the testing procedure IMMEDIATELY until compliance is obtained. HM -35 2700 "M" STREET, SUITE 300 BAKERSFIELD, CALIFORNIA 93301 (805) 861 -3636 FAX: (805) 861 -3429 • 0 TANK INTEGRITY TESTING INSPECTION FORM continued Is the following data consistent with the information submitted on the application for Permit To Perform Integrity Testing (PTT)? YES/NO .S The number of tanks being tested Testing company Test method used --r66)< State Licensed Technician on site State Licensed Technician's # _yf - !�i/S� dl.rre 1 jrLoc� Is the site layout consistent with the application plot plan? Al 1141�� / , State exceptions for any NO answers to the above questions: State Licensed Tec ician on site Hazardous Materials Specialist Inspection Date HM35 HM44 If plot plan info ion is available before the test, provid lot plan of the facility showing all important polff (including but not limited to): * tank location and number /designation, pump location, all buildings and roads, vapor, vent and product lines, fill boxes, etc. * Proposed tanks to be tested designated by this symbol " O ". * Nearest street or intersection • Any water wells or surface waters within 100' radius of facility * North Arrow If plot plan information is not available before the test, it must be submitted with the test results. I R • Kara County Environmental Health Setvica DepL 2700 M Street, Suite 300 Bakersfield, CA 93301 (805) 861 -3636 Internal Use Only PTT No.T6% ^; # Tanks to Teat Test to include: Tank only Tank/Piping Ye - / A!, ✓Pe s is. PTO No. Uad ppL Date 2- APPf -ICAnON FOR PERMIT TO TEST UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK POST'ON PREMISES- A. &W ill Information Kern Cdunty Environmental Health Services Dot. Permit to Ooerate # 12 0 0 n 3 - (If there is no permit number, an application for a permit to operate must be submitted and approved before the permit to test can be processed Proposed Test Dater a a n Facility Name Kern Medical Center Address 1830 Flower Street, Bakersfield, CA 93305 TANK # SIZE PRODUCT AGE OF TANK COMMENTS 1 750 Diesel 10 yrs. + - 10„00. Di PsP1 10 Yrg _++ 3 7nnn nlPQP1 1n + Contact Person Day u e n 2; r h a r.i c Phone (an -19 F- a A 1 Night Same Phone( if MI WA."JITWIT .•�n? •r Owner Name Kern Medical Center Phone ( 8 0 5 326 -2481 Mailing Address 1830 Flower Street Bakersfield, CA Zip Code 93305 � �Llri� r •�n. t�. Company Name Brockway I s Address 2014 S. Union Ave., Suite 103, Bakersfield. CA 93307 Contact Person Day Deborah Brockman Phone (805 )Q34-1146 Night Deborah Brockman Phone (805_J834 -1100 Worker's Compensation Insurance # Signed waiver on file (owner - operator) Liability Insurance # CGL- 25900179 (Wm. K.. Lyons Agency, Inc. ) Test Method Used Ibex Precision Test Method �AC� - /'LT - /bole UuU -YV(- � State Licensed Tester Robert Brockman State Licensed Tester # 9 2 -12 51 THIS APPLICATION BECOMES A PERMIT WHEN APPROVED Z n n 0 n E CO) M z m v m � � R � C� H O Cyi� or A m �v 0- Q 10 P ac Q w 7d 10 R g° ID VVII.O -1 °° a o G 'R R g� D A 0 0 _c F. •, F 0w 04 g D' Q o ao ct E rn .v �$S ro op3 is rn �z� by R in G1 � tt � Cb 5 n ° $ w� w 00 .,r:r c ff og- Pr D .o � �93- tf all 10 0 O Cy 0 cr A C 6> gwc..�s•e ^�A a93. �•�I6 �e�o� : g 00 w `7 is Er o s � 47 s R IRIS � _s CL . co $ Or s a " CO'+jNTY OF KERN ENVIRONMENTAL HEALTH SERVICES ?700 "M" STREET, SUITE 300 BAKERSFIELD, CALIFORNIA 93301 (805) 862 -8700 INVOICE NUMBER: CUSTOMER NO: 01 *9 -I1\1 20 -KERN2 CUSTOMERS COPY PAGE: 1 DUE DATE 01/14 / DUE kERN MEDICAL CENTER AMOUNT 75.00 LEE WILLEFORD 1830 FLOWER STREET BAKERSFIELD CA 93305 AMOUNT ENCLOSED L J DESCRIPTION: EMT1070: 12/01/98 - 12/04/98 PLEASE MAKE CHECK PAYABLE TO THE COUNTY OF KERN AND NOTE ANY CHANGES ON ORIGINAL INVOICE PLEASE RETURN ORIGINAL INVOICE WITH YOUR PAYMENT FEE CODE DESCRIPTION AMOUNT Mt^1001C 4751 TEMP ABANDONMENT PERMIT 75.00 ' TEMPORARY CLOSURE /ABANDONMENT PERMIT FOR + UNDERGROUND STORAGE TANKS WORK ORDER ENT1070 LABOR FOR THE PERIOD: 12/01/98 - 12/04/98. SEE ATTACHED FOR DETAIL TAP NUMBER: TAP0070 -12 PTO NUMBER: 120003 REF: JANE WARREN DELINQUENT CHARGES ARE SUBJECT TO 50% PENALTY PER KERN COUNTY ORDINANCE CODE 8.04.990. -,3f 75.00 TOTAL AMOUNT DUE ACCOUNTS THAT ARE 120 DAYS PAST DUE MAY BE SENT TO COLLECTIONS. TH STEVE McCALLEY, R.E.H.S., Di 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (661) 862 -8700 Fax: (661) 862 -8701 TTY Relay: (800) 735 -2929 e -mail: eh&o.kern.caus May 6, 1999 Mr. Jim Colt County Administrative Office General Services /Construction Services Division 1115 Truxtun Avenue Bakersfield, California 93301 ;_SOURCE MANAGEMENT AGENCY DAVID PRICE Ill, RMA DIRECTOR Community Development Program Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department SUBJECT: CLOSURE OF ONE HAZARDOUS SUBSTANCE STORAGE TANK LOCATED AT 1830 FLOWER STREET, BAKERSFIELD, CA PERMIT NO. 120003 Dear Mr. Colt: This is to _advise you that this Department has reviewed the project results for the preliminary assessment associated with the closure of the tank noted above. Based on the sample results submitted, this Department is satisfied that the assessment is complete, and that no further action is indicated at this time. It is important to note that this letter does not relieve you of further responsibilities mandated under the California Health and Safety Code and California Water Code if additional or previously unidentified contamination at the subject site causes or threatens to cause pollution or nuisance or is found to pose a significant threat to public health. Thank you for your cooperation in this matter. Sincerely, Steve McCalley, Director By: Michael Driggs, R.E.H. A. Hazardous Materials Specialist III Unified Hazardous Materials/Waste Program MD:dt Driggs \HazMatslclncls.120003.ltr IT N ENVIRONMENTAL HEALTH SERVICES DEPARTMENT P4 411 ►t9111 I " Office Memorandum TO: Steve McCalley, Director Date: April 26, 1999 Attn: Mike Driggs FROM: Steve McCalley, Director Environmental Health Serv' es Department By: Marty Brownfield SUBJECT: UST Removal at Kern Medical Center, 1830 Flower Street, Bakersfield, California, UST File # 120003. I was present on 4/2/99 when a single 7,500 gallon Diesel tank was removed from the area of the maintenance shop and boiler room on the north side of Kern Medical Center, (KMC). There was no soil staining or odors present in either the tank hole or in the two soil samples that were obtained from the area below the tank. There were only two soils samples taken from under the tank. These samples were from a depth of approximately eight inches, (8 "). The reason for this is because there was a large "monolithic" slab that the tank was "strapped" to. This slab extended beyond the side walls of the tank hole for an unknown distance. The thickness of the slab has not been determined either. Due to the "unique" situation at the site I waived the requirements for attaining samples at depth with the caveat that if the preliminary samples returned with indications of contamination then additional subsurface characterization would be required. On 4/ 26/99 I reviewed the analytical report submitted by Advanced Geo Environmental, Inc. The report indicates that there were no detectable target analyte present in any of the samples. Based on the foregoing information I would recommend that we close this case with no further action required. W, r r • WORK ORDER 0 WORK ORDER ------ - - - - -- DESCRIPTION EMTOOOOOOOCI07C PROJECT 8996 -8435 FUND 35030 E N D O F R E P O R T ..« Cl� COUNTY OF KERN ENVIRONMENTAL HEALTH DEPARTMENT HAZ MAT PROGRAM TAP WORK ORDER BILLINGS NOTES FOR SERVICE THROUGH 12/15/98 ADDITIONAL WORK ORDER INFORMATION --------------- -- 1830 FLOWER ST, REMOVE TANK FILE: WOIN TAP N DATE: 12/14/98 TIME: 14:19:36 PAGE: 1 ADDITIONAL WORK ORDER INFORMATION ----------------- 11/98 • • 1] FILE: WOIN_TAP_S COUNTY OF KERN ENVIRONMENTAL HEALTH DEPARTMENT DATE: 12/14/98 HAZ MATS TEMPORARY ABANDONMENT PERMIT WORK ORDER BILLING DETAIL TIME: 14:17:40 FOR THE PERIOD 12/01/98 - 12/15/98 PAGE: 1 WORK ORDER # WORK ORDER TASK HOURS BALANCE DESCRIPTION DESCRIPTION DUE EMTOOOOO0001070 PROJECT 8996 -8435 FUND 35030 PLAN CHECKING TOTAL 1.00 75.00 EMTOOOOO0001070 PROJECT 8996 -8435 FUND 35030 BALANCE DUE FOR THIS PERIOD TOTAL 1.00 75.00 1] FILE: WOIN_TAP_S S 4 Sequence = 1336 COUNTY OF KERN DEPT: 2730 INTERFUND TRANSFER JV — FORM' 115 n Jl t. t t 9.' TOTAL: $150.00 , DESCRIPTION: TEMP ABANDONMENT EMT1070 From: FUND NAME ' FUND ..AMOUNT ' PY , DEPT'-, ' RE_ V -/EXP;; DI•V?, • , GENERAL SERVICES -TRANS. 1602 35030' ,t f FUND NAME .',TRANS FUND AQUNT ,,E DFPT REV' /EXP.: ENVIRONMENTAL HEALTH 3601 00001.. 00' i EXPLANATION OF PURPOSE AND AUTHORITY THEREFOR: TEMPORARY ABANDONMENT UNDERGROUND STORAGE TANK EMT1070 PERMIT NUMBER 120003 KERN MEDICAL CENTER PREPARED BY: BEVERLY BRIANO APPROVED BY: 12/14/98 s DEPUTY AUDITOR- CONTRCILLER • KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT TEMPORARY ABANDONMENT TANK INSPECTION FORM Permit To Operate #: 120003 Temporary Abandonment Permit #: TAP0070 -12 Name: KhKN MUXUAL UhN 1 tK First Inspection Date: Person Inspecting Tanks: Are all fills, access locations and piping sealed ?, After removal of at least one locking cap has any liquid or sub- stances been added to the tank? Has there been any change in the abandonment status? Second Inspection Date: Person Inspecting Tanks: Are all fills, access locations and piping sealed? After removal of at least one locking cap has any liquid or sub- stances been added to the tank? Has there been any change in the abandonment status ?. Third Inspection Date: Person Inspecting Tanks: Are all fills, access locations and piping sealed? After removal of at least one locking cap has any liquid or sub- stances been added to the tank? Has there been any change in the abandonment status ?, Fourth Inspection Date: Person Inspecting Tanks: Are all fills, access locations and piping sealed? After removal of at least one locking cap has any liquid or sub- stances been added to the tank? Has there been QUIT m48 in the abandonment status? ENVIRONMENTAL HEALTH ES DEPARTMENT STEVE McCALLEY, R.E.H.S., Director 2700 -M- STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (805) 882 -8700 FAX: (805) 882 -8701 TTY Relay: (800) 735 -2929 e-mail: eh@akerncounly.corn Kern Medical Center Attn: Randy Hoffman 1830 Flower Street Bakersfield, CA 93305 January 6, 1999 OURCE MANAGEMENT AGENCY DAVID PRICE /11, RMA DIRECTOR Community Development Program Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department SUBJECT: Application for temporary abandonment of one underground storage tank located at 1830 Flower Street Dear Mr. Hoffman: The Kern County Environmental Health Services Department has received an application for a permit to temporarily close the underground storage tank located at the site referenced above. The permit is being processed. Before the permit can be issued, you must arrange to have all tank contents removed from the tank in question, using the methods specified within the permit application. Except for required venting, all fill and access locations and piping are to be secured with a locked cap. The enclosed certificate of compliance is to be completed and returned after the tank has been secured. Upon receipt of the certificate, the program staff will issue the permit and provide any additional monitoring forms required for this site. If we may be of any further assistance to you, please contact this Department at (805) 862 -8700. Sincerely, Steve McCalley, Director By: ane M. Warren Hazardous Materials Inspector Unified Hazardous Materials /Waste Program 120003 Enclosure mss ENVIRONMENTAL HEALTH 9WICES DEPARTMENT STEVE McCALLEY, R.E.H.S., Director 2700 •M' STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (805) 882 -8700 FAX: (805) 882 -8701 TTY Relay: (800) 735 -2929 e -mail: eh @kerncounty.com FOURCE. MANAGEMENT AGENCY DA V/D PR /CE ///, RMA DIRECTOR Community Development Program Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department CERTIFICATE FOR TEMPORARY CLOSURE OFUNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANKS This form must be completed and submitted to the Kern County Environmental Health Services Department along with payment for the enclosed invoice before a permit for temporary abandonment will be issued to the facility owner. Site Information: Facility Name: Kern Medical Center PTO# 120003 Facility Address: 1830 Flower Street, Bakersfield, CA 93305 Owner's Name: Kern Medical Center Operator's Name: Kern Medical Center 2. The Kern County Environmental Health Services Department has received an application to temporarily abandon the tanks described below: Tank No. Tank Contents Tank Capacity Is Piping Pressurized? KMC 2 Diesel 10,000 No Sworn Statement of Evidence I, , certify that I have no knowledge of any unauthorized release from the tank systems described above; I have removed all tank contents which can be pumped from the tank systems listed, and I have placed a locked cap on each tank access opening. I CERTIFY THAT THE AFOREMENTIONED FACTS ARE TRUE AND CORRECT UNDER PENALTY OF PERJURY. (Not valid if not signed and dated.) Signed this day of , 19 , at date month city and state THIS IS NOT A PERMIT JMW:jrw (hm \warren \kmc -m80) Signature Date. WORK 0RDXR LOG SHEZT APN : - - - -_ Worm Order * : EMT /070 WO Category: Hazmats WO Type: TAP Reimb.: Y ✓ N RP Code: WORK ORDER NAME: ?( -0 0 �?'�1 �o •__ '���� (location) RESPONSIBLE PARTY (RP) NAME: G-ene-nr -d services RP CONTACT: RP ADDRESS: I I 1 I r Ate RP CITY: rKGf5i2�tt STATE: ZIP: &336 ¢ RP PHONE NOS.: ( ) to - 3 o a 7 ( 1 INSPECTOR: JANE WARREN EXT. x8736 PROGRAM: DESCRIPTION: HMMP- Permitting (PTO #) /a aoo 3 (TAP #) ��r�OD7D-�oZ LOCATION: FACILITY NAME: COMMENTS: i � KERN COUNTY ENVIRONMEi HEALTH SERVICES DEPARTME NTERNAL USE TAP# 2700 'M" STREET, SUITE 300 - BAKERSFIELD, ( 1 CALIFORNIA 93301 � _ _ .; APPLE A� ON DATE: PTO#�� ( 805) 862 -8700 �t U- (FILL OUT ONE APPLICATION PER CILn ` APPLICATION FOR PERMIT FO.RZEWFO�F7SIIRE/ABANDONMENT OF UNDERGROUND �ARDOUS.SUI1 TANCE STORAGE FACILITY THIS APPLICATION IS FOR TEMPORARY CLOSURE OF FROMMU TO: /S� /Sn .�_ TANKS. MAXIMUM PERIOD = 1 YEAR A. Emergency 24 -Hour Contact: Name M77= Phone # Days g _ 707® Name Af g:' Phone # Nights d 700 Facility Name ZAE� ee.,& No. Of Tanks 1' Type Of Business (check): ( )Gasoline Station (Other (Describe)'i,,�� Is Tank(s) Located On An Agricultural Farm? ( )Yes MNo Is Tank(s) Used Primarily For ricultural Pur oses? ( )Yes ()4No Facility Address' ® �� �F7: City T R SEC (Rural Locations Only) Nearest Cross Street Tank Owner Phone #: Address City /State Zip°? Operator Phone Address City /State =060192 ZIP 5is� BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739 -2582 If questions arise. TY (TK) HO J 4T. - I I l{! l I B. INFORMATION ON UNDERGROUND STORAGE TANKS: (Utilize the same descriptions provided on the operational permit. Limit to those that will be tempgrgrily abandoned) * Test lVpe Chemical Composition Of Materials Stored: Tank # Tank Capacity Tank Contents * Date of Last Integrity Test Completed * Did all tanks /piping pass or fail the tests? -X—Sassed failed If they failed, was a followup test completed? S = System P = Piping T = Tank 7- If the test results have not been sent to the Kern County Environmental Health Services Department - submit a copy of the most recent test along with the application. Have the tank(s) had an unauthorized release or had monitoring records which have exceeded any reportable values? _yes ),C no. If yes discuss: LIP �h Or t Yip flu IIf V o ,FP s. O C3 • 'VI t Yip flu IIf V o ,FP s. O C3 • C. -DISPOSAL INFORMATION Tank contents will be removed from the underground storage tank using the following method: If a contractor /vacuum truck or fuel distributor are to be used complete the following: Company Name: n i =- =&im,&V M2 0 aaP-.a zZ Mla a2m=25Z Company Address: Contact Name /Phone Number: Final Destination for the Tank Contents: T D. SW ORN_ STATEMENT: 1, understand that in applying for a permit to temporarily close the underground storage tanks (LISTS) cited within this application, I have not been given pe mission to discontinue monitoring. I will meet new monitoring specifications provided on the temporary abandonment permit when received, and maintain the permit to operate by paying any invoices generated. I understand that the Department will invoice me for time spent in reviewing /or processing. permit applications, and in issuing the permit. I certify that Information provided on the permit application Is true and correct, under penalty of perjury. (Not Valid If not signed and dated). Signed this day of ALV& a= _ month, 195A at — Q - . . city state Signature CG:ch HM47 Aa • • Qi 1p .01 ek. ER dj 1101 -.9 9. VII LL w • Drawing E. All of the following information MUST a included in order for the application to be processed: C CG:ch HM47 Tank(s), piping and dispenser(s), including lengths and dimensions Nearest street or intersection Any water wells or surface waters within 100' radius of facility North arrow 9 Memorandum KERN COUNTY ADMINISTRATIVE OFFICE General Services Division to: Amy Green, Environmental Health Specialist cc: Share Foon Ko Environmental Health Services Department project no: 8996.8435 from: James D. Colt date: November 30, 1998 subject: Kern Medical Center Emergency Fuel System Improvements As the December deadline approaches we thought it would be best to inform you of our plans for the underground tanks of the emergency fuel system at Kern Medical Center. That facility has two underground tanks that we have a project to upgrade or remove. One is a 10,000 gallon tank that supplies diesel fuel for the emergency generator, boilers and other mechanical equipment of "D" Wing, the Emergency Facility and Surgical Services. The other is a 7500 gallon tank that supplies diesel fuel to the boilers for the older parts of the hospital, and an emergency generator. I have sent a copy of the current plans with this letter. They show the locations of the tanks. The 10,000 gallon tank is single - walled fiberglass. We intend to upgrade the fill to include spill containment. We will install a Veeder -Root Mag 1 magnetostrictive probe into the tank to provide in -tank leak detection. This will be connected to an existing Veeder -Root monitoring .panel in the mechanical control room. The existing steel piping will be replaced with underground, double - walled fiberglass pipe, which will have leak detection in the piping sumps. While this tank is being retrofitted, it will be out of service, and an above ground temporary tank will set up and plumbed to take its place. The 7500 gallon tank is a steel tank. We will be replacing it with a 2,000 gallon above ground tank. The piping for that tank will be underground, double - walled fiberglass. We will have a tank removal permit in effect before December 22, 1998. The tank will probably not be removed before that date. We will remove the fuel from the 7500 gallon tank as soon as possible after December 22, 1998. If the above ground tank is not in service before the fuel is removed from the existing underground tank, we will may set up a temporary above ground tank for this location also. I hope this synopsis of our proposed project is helpful. If you have any questions or comments about the plans or the project, give me a call at extension,3027. from the desk of... James D. Colt, Engineer III General Services Division of the County Administrative Office 1115 Truxtun Avenue Bakersfield, California 93301 (805) 868 -3027 PTA # • PTO # POST ON PREMISES 8. Sample locations to be specified either within a plot plan attac . hed or on provided -on this permit application. 9. Soil Sampling (piping area): Jv `u• Samples are to be retrieved at depths of approximately two feet and six feet for every 20 linear feet of pipe run and under the dispenser area. 10. Soil Samples shall be analyzed for key constituents representative of the materials stored. The following are local recommendations for sample analysis: a. For gasoline, samples should be analyzed for benzene, toluene, xylene, total petroleum hydrocarbons (gasoline), and MTBE. b. For diesel, samples should be analyzed for benzene, and total petroleum hydrocarbons (diesel). C. For waste oil, samples should be analyzed for oil and grease, and total lead. d. If unknown, the samples should be analyzed for a full range of substances which may have been stored within the tank. 11. To ensure that the permit processing is cost - effective, the following time line is recommended: o- DE , ^° , f,, e . . A �D A 8'► 3,A t.°. .3 Drj; inn bfPti•vsiathiir fFacilii� Notification to inspector listed on perm of date Two working days , a dty�pg of,;,�1o, g gg ��nd,sK oll ��rp7 Itt� �-• ., 4 rW yeti 6�'orr'2b�r.a�.F!„o ,'N\ Transportation and tracking forms sent to Hazardous No later th#rr 5 working days f9r ' 'o Materials Management Program. All hazardous waste transportatibn�titf•1 Jo&Wo; es k `� ��t.. �• C'.°n� a :�A:p `-°A e�`"zi °1� manifests must be signed by the receiver of the for thF. tr*�kgorm after removal t o•. `t °. , hazardous waste i"„i', .� •, . .. �• . . Sample analysis to Hazardous Materials Management No later than 3 working days aMr. Program completion of analysis program k'� �' ' " r t - »•�' � r 12. Purginganerting Conditions: aq;. L�qui$soajl be � ped tank prior to purging such that less than 8 gallons,of liquid rfomain4n&n?. H� f{�om 1700) `�.a °'a. i e ;, °a4�tr0. . 9+ t.s o•�. a T °: b. Tank shall be purged through vent pipe discharging at least 10 feet above ground level. ^i (CSH &SC 41700) . ' . ' c. No emission shall result in odors detectable at or beyond property line. (Rule 419) d. No emission shall endanger the health, safety, comfort or repose of any person. (CSH &SC 41700) e. Vent lines shall remain attached to tank until the inspector arrives to authorize removal. Provide a drawing in the space above of tanks, piping, lengths, d' ensions, proposed sampling locations desig- nated by Q9, and north arrow (use additional page if needed). RECOMMENDATIONS /GUIDELINES FOR REMOVAL OF UNDERGROUND STORAGE TANKS This department is responsible for ensuring that the standards contained in the Kern County Ordinance Code, Division 8 and State regulations pertaining to underground storage tanks are met. The guidelines and conditions provided within this permit are to assist this Department in meeting that goal. I. It is the contractor's /applicants responsibility to know and abide by CAL -OSHA regulations. 2. Tracking forms, hazardous waste manifests and analyses documentation are necessary for each site in order to close a case file or move it into mitigation. When contractors do not follow through on necessary paperwork, an unmanageable backlog of incomplete cases results, resulting in prolonged processing time for completing site closures. THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ABOVE CONDITIONS OF THIS PERMIT AND ANY OTHER STATE, LOCAL AND FEDERAL REGULATIONS PERTAINING TO WORK COMPLETED ON SITE. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. a Owner's Signature INTERN XL USE ONLY Approved By: Issue Date: Permit Expiration Date: HM899 lI / ®` Authorized Date Representati Total Fee Paid On Receipt # Fee Received By Date // 136 Cash Check # THIS APPLICATION BECOMES A PERMIT WHEN APPROVED s, Kern County ! .,,�, ! ternal Use Only: Environmental Health Services Dept. --"'�� Application DateV 3 kPTA:IU397 42 2700 M Street, Suite 300 I # of Tanks to Abandon: Bakersfield, CA 93301 II Piping Ft. to Abandon: PTO.&JaW (805) 862 -8700 APPLICATION P ENT CLOSURE UNDERGROUND HAZARD bLT- S S BS -ANCES STORAGE TANK SYSTEMS This Application is for Removal or ❑ Abandonment in Place Facility Information Owner's Information Contractor's Information Proposed Start DateftgWaft Project Contacts ,i�� 17® e!!�;ee V Phone Number: Sampler 9911 i -f Laboratory ' ' " Disposal Name Name Decontamination Contractor Address Address Rinsate Disposal Location City City Disposal Location for Tank & Piping Phone Phone TANK INFORMATION Tank Number Volume Chemical Stored Previous Chemical e Da¢e ....... ............................... POST ON PREMISES ...... ............................... CONDITIONS AS FOLLOWS: 1. It is the responsibility of the Permittee to obtain permits which may be required by other regulatory agencies prior to beginning work (i.e., City Fire and Building Departments). 2. Permittee should notifx the Hazardous Materials Management Program at (805) 862 -8700 two working days prior to tank removal or abandonment in place to arrange for required inspections(s). , v 3. Tank closure activities should be per Kern County Environmental Health and:Wiie Depa ,Menf,agproved rpethods as described in Handbook UT -30. 4. ice, it ise ,tlke' contractors responsiklity �o know annd ohere to all applicable laws regarding .the ..handling, transpo Ration or treatment of hazardous maienals. " 5. The tank removal contractor should meet all minimum supervisorial requirements as specified in laws enforced by the Contractor's Licensing Board. 6. If any contractors other than those listed on permit and permit application are to be utilized, prior approval should be obtained by the s ecialist approving the permit. Deviation from the submitted application is not recommended without prior approval. 7. State UST regulations specify that soil samples be retrieved within the native material beneath portions of the underground storage tanks. The following are local sampling recommendations that could prevent unnecessary remediation costs: a. Tank size less than or equal to 1,000 gallons - a minimum of two samples, retrieved from beneath the center of the tank at depths of approximately two feet and six feet. b. Tank size greater than 1,000 to 10,000 gallons - a minimum of four samples, retrieved one -third of the way in from the ends of each tank at depths of approximately two feet and six feet. C. Tank size greater than 10,000 gallons - a minimum of six samples, retrieved one -fourth of the way in from the ends of each tank and beneath the center of each tank at depths of approximately two feet and six feet. THIS APPLICATION BECOMES A PERMIT WHEN .APPROVED (continued on reverse side) Memorandum KERN COUNTY ADMINISTRATIVE OFFICE General Services Division to: Amy Green, Environmental Health Specialist cc: Share Foon Ko Environmental Health Services Department project no: 8996.8435 from: James D. Colt date: November 30, 1998 subject: Kern Medical Center Emergency Fuel System Improvements As the December deadline approaches we thought it would be best to inform you of our plans for the underground tanks of the emergency fuel system at Kern Medical Center. That facility has two underground tanks that we have a project to upgrade or remove. One is a 10,000 gallon tank that supplies diesel fuel for the emergency generator, boilers and other mechanical equipment of "D" Wing, the Emergency Facility and Surgical Services. The other is a 7500 gallon tank that supplies diesel fuel to the boilers for the older parts of the hospital, and an emergency generator. I have sent a copy of the current plans with this letter. They show the locations of the tanks. The 10,000 gallon tank is single - walled fiberglass. We intend to upgrade the fill to include spill containment. We will install a Veeder -Root Mag 1 magnetostrictive probe into the tank to provide in -tank leak detection. This will be connected to an existing Veeder -Root monitoring panel in the mechanical control room. The existing steel piping will be replaced with underground, double - walled fiberglass pipe, which will have leak detection in the piping sumps. While this tank is being retrofitted, it will be out of service, and an above ground temporary tank will set up and plumbed to take its place. The 7500 gallon tank is a steel tank. We will be replacing it with a 2,000 gallon above ground tank. The piping for that tank will be underground, double - walled fiberglass. We will have a tank removal permit in effect before December 22, 1998. The tank will probably not be removed before that date. We will remove the fuel from the 7500 gallon tank as soon as possible after December 22, 1998. If the above ground tank is not in service before the fuel is removed from the existing underground tank, we will may set up a temporary above ground tank for this location also. I hope this synopsis of our proposed project is helpful. If you have any questions or comments about the plans or the project, give me a call at extensioT3027. from the desk of... James D. Colt, Engineer III General Services Division of the County Administrative Office 1115 Truxtun Avenue Bakersfield, California 93301 (805) 868 -3027 w STEVE McCALLEY, R.E.H.S., Director 2700 -M- STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (805) 882 -8700 FAX: (805) 882 -8701 TTY Relay: (800) 735 -2929 e -mail: eh @kerncounty.com Mr. James D. Colt January 11, 1999 SOURCE MANAGEMENT AGENCY loom DA VID PR /CE ///, RMA DIRECTOR Community Development Program Department Engineering & Survey Services Department Environmental Health Services Department Planning Department , Roads Department Kern County General Services Division 1115 Truxtun Avenue Bakersfield, CA 93301 SUBJECT: CLOSURE OF UNDERGROUND TANK AT KERN MEDICAL CENTER, 1830 FLOWER STREET, BAKERSFIELD, CALIFORNIA. Dear Mr. Colt: This Department has received the application for a Permit to Abandon the underground storage tank(s) at the facility noted above. The information on the application was incomplete. Before the permit can be processed the following information must be submitted. 1. The name, address, phone number, and license type and number of the contractor who will be performing the work. 2. The name, address, and phone number of the person(s) collecting the soil samples and the laboratory which will analyze the samples. 3. The name and address of the disposal facility where the tank(s) will be taken. 4. A drawing to scale of the location of the tanks, piping, dispensers, and the proposed sampling locations. The application must be completed by February 15, 1999. If the tanks are not currently in compliance with the 1998 requirements, they must be emptied of all product or wastes by December 22, 1998. As always, this Department is available to assist you. If you have any questions or comments please call Inspector Marty Brownfield at 805 - 862 -8700. cc: File #120003 Sincerely, Steve McCalley, Direcl By: Marty Brownfield, FPO Hazardous Materials Inspector II Unified Hazardous Materials Program __Ego l'�'<' • � �' � •' �.'. '!rte., q_ .1 ��� ++'.lr%%1YYe _ ur jWit• • � � it' �� '°�•• � ' , I ll���r�r -; lr �,;: -,,,; ft , iv lII try j I I I I 1 , , rr�t, O f Is ) j I J I , I R KERN COUNTY ENVIRONMENTAL INSPECTION RECORD 2700 "M" STREET, SUITE 300 HEALTH SERVICES DEPARTMENT BAKERSFIELD, CA 93301 HAZARDOUS MATERIALS PROGRAM POST CARD AT JOBSITE (661) 862 -8700 l PERMIT #: 150003M OWNER: Kern Medical Center FACILITY: Kern Medical Center CONTACT: Robert Kinsella ADDRESS: 1830 Flower Street ADDRESS: 1830 Flower Street .CITY: Bakersfield CITY: Bakersfield PHONE #: (661)326 -2000 PHONE #: (661)326 -2000 INSTRUCTIONS: Please call for an inspection or submit the requested information when ready. They will run in consecutive order beginning with number 1. DO NOT cover work for any numbered group or continue with the next phase of work until all items in that group are signed off by the Permitting Authority. Following these instructions will reduce the number of required inspection visits and therefore the assessment of additional fees. INSPECTION - TANKS & BACKFILL - DATE INSPECTOR 1 Backfill of tanks �,��,r{q 1 Copy of installation check list 2 1 Spark test certificate Yv 3 'U Oo PIPING SYSTEM - 1 Primary piping pressure /soap test �,��,r{q 2 Corrosion protection of piping & fill pipe 2 - SECONDARY CONTAINMENT, OVERFILL PROTECTION - 2 Secondary piping pressure /soap test 3 Integrity test of system 2 Sump test �- 3 'U Oo 4 Line Leak Detecto wn U. fJ 2 Drop tube valves 4 Monitoring Requirements f} l a,, ,art cj-- U % Please contact the Fire Department at (661) 391 -7082 and Building (electrical) Department at (661) 862 -8661 to schedule final inspections with them before calling this department for the final inspection. - FINAL - 3 As -built drawings 3 Integrity test of system 3 Overspill boxes �- 4 Line Leak Detecto wn U. fJ 4 Monitor System Check 4 Monitoring Requirements L4 Submittal of owner information and Form C CONTRACTOR California Hazardous Services, Inc LICENSE # 734854 -A _ CONTACT Rudy Ornelas PHONE # (714)434 -9995 A KERN COUNTY ENVIRONMENTAL A - -- - - - - - - HEALTH SERVICES DEPARTMENT. 2700 "M" STREET, SUITE 300 MRSFIELD, CA_ 93301 -. -- HAZARDOUS MATERIALS - SECTION ___ _ �)NE (805) $61- 3636• INSPECTION RECORD. :.. POST CARD AT:JOBSITE FACILITY eern Ned12271 Ce PI' PERMIT #120oa3 j'CWNER ovti erll _ ADDRESS IF90 a)f)- - ; ADDRESS v uti �2 CITY &2eer5_P1td i CITY S °e -3a / PHONE N0. 26- Z i L ;PHONE N0. - ' .2400 p 11 1,.ile/a rd' - INSTRUCTIONS: Please- call:for an'inspector - only when each group of inspections. with: the ?same. number are ready. They. will run. in consecutive order beginning with number-1.; DO NOT cover' work for any numbered group until. all- items irr•that group are signed off by the..Petmitting. Authority. Following these instructions will reduce the number of required - inspection visits and therefore prevent-. assessment. of `additional fees ": ,• ��.;.,.�•;;. TANKS & BACKFILL INSPECTION ATE INSPECTOR Backfill of asek•4 ) - rY- Spark Test Certificati n Xathodic Protection-of-Tank(s) ` � r i - - PIPING SYSTEM i y; Piping 6c4R- eeewair- w /Collection Sump- a Aw /Z - zj , �• 'Corrosion Protection of Piping, Joints, Fill Pipe; ;Electrical Isolation of'Piping From-Tank(s) >� ;Cathodic Protection Sstem -Pi in 7. -.. i - _ /',N✓1Q✓u 0i'0;xd D vile- 1<6ga ®•SECONDARY CONTAINMENT, OVERFILL PROTECTION, LEAK DETECTION - Liner Installation - Tank(s) i Liner Installation --Piping i ;Vault With Product. Compatible Sealer i ;Level Gauges or:- Sensors, Float Vent Valves '= ; ,Product Compatible Fill Box(es) ;Product Line Leak Detector(s) ;Leak Detector(s) for Annular Space-D.W. Tank(s) 1 Monitoring Well (s) /Sump(s) ; ; :- ;Leak Detection Device(s) For Vadose /Groundwater a''• i iPVC Sleeve Piping ;Leak Detector(s) FINAL �!Monitoring Wells Caps & Locks ;Fill Box Lock sMonitoring Re uirements - b i �Ctt. O rQH e i i LIS i CONTRACTOR L � Ui wee LICENSE # d CONTACT PH # 0 0 N hRTHY TANK COMPANY Phone: FAirvie.w 4 -6Z„ 030 M STREET EFFECTIV €: 1 -i1 -61 P. 0. Box 268 BAKERSFIELD, CALIFORNIA TANK CHART- 7500 GALLONS "'OIA. x 243" OVERALL*INSIOE LENGTH INCHES GALTON3 INCHES GALLONS 14 4911 3878 38 50" 3978 108 51'1 4078 5211 4178 197 53" 4278 197 54" 4378 5511 4476 56" 4574 358 57" 4572 418 5811 4769. 5911 4866 546 6011 4963 614 6141 5059 684 6211 5155 755 829 63" 5249 905 6411 5343 6511 5437 1062 6611 5529 1142 7 11 5621 1224 6811 5711 1308 6911 5801 1393 7011 5890 7111 5977 1567 7211 6063 1655 7311 6148 1745 7411 6232 836 75" 6314 7611 6395 2020 7711 6474 2113 7811 6552 2207 79" 6627 8o" 6701 2397 8111 6773 2494 8211 6843 8311 6910' 2688 841, 6975 2785 8511 7038 2883 8611 7098 2982 8711 7155 3081 8811 7209 31809 11 89 7259 9011 7306 3378 gill 7349 3478 9219 7386 3578 93" 7418 3678 9411 .7443 3778 95" 7456 D Y B I)e Y S / N b r S F RANDALL L. ABBOTT DIRECTOR DAVID PRICE III ASSISTANT DIRECTOR RESARCE MANAGEMENT AANCY Environmental Health Services Department STEVE McCALLEY, REHS, DIRECTOR Air Pollution Control District WILLIAM J. RODDY, APCO Planning & Development Services Department TED JAMES, AICP, DIRECTOR ENVIRONMENTAL HEALTH SERVICES DEPARTMENT PERMIT TO CONSTRUCT UNDERGROUND STORAGE FACILITY FACILITY Kern Medical Center 1830 Flower Street Bakersfield, CA 93305 Phone No. (805) 326 -2481 NEW BUSINESS CHANGE OWNERSHIP RENEWAL _X MODIFICATION OTHER OWNER(S) NAME/ADDRESS: County of Kern 1415 Truxtun Avenue Bakersfield, CA 93301 Phone No. (805) 861 -2111 PERMIT NUMBER 120003M CONTRACTOR: RLW Equipment Company 2080 S. Union Avenue Bakersfield, CA 93307 License # 294074 Phone No. (805) 834 -1100 PERMIT EXPIRES _September 8. 1993 APPROVAL DATE September 8. 1992 APPROVED BY � 4_1� , Bill Scheide Hazardous Materials Specialist .............................. POST ON PREMISES .............................. CONDITIONS AS FOLLOW: Standard Instructions 1. This permit applies only to the modification of an existing facility involving the installation of primary and secondary suction piping from Tank #1 generator to Tank #2 piping with a new piping monitoring sump. 2. All construction to be as per facility plans approved by this department and verified by inspection by Permitting Authority. 3. All equipment and materials in this construction must be installed in accordance with all manufacturers' specifications. 4. Permittee must contact Permitting Authority for on -site inspection(s) with 48 -hour advance notice. 5. Backfill material for piping to be as per manufacturers' specifications. 6. Construction inspection record card is included with permit given to Permittee. This card must be posted at job site prior to initial inspection. Permittee must contact Permitting Authority and arrange for each group of required inspections numbered as per instructions on card. Generally, inspections will be made of: a. Primary piping/backfill b. Piping system secondary containment C. Leak detection /monitoring requirements d. Any other inspection deemed necessary by Permitting Authority. 2700 "M" STREET, SUITE 300 BAKERSFIELD, CALIFORNIA 93301 (805) 861 -3636 FAX: (805) 861 -3429 • Standard Instructions • Permit No. 120003M 7. All underground metal connections (e.g. piping, fitting, fill pipes) to tank(s) or piping must be electrically isolated and wrapped to a minimum 20 mil thickness with corrosion- preventive, gasoline- resistant tape or otherwise protected from corrosion. 8. Primary and secondary containment of both tank(s) and underground piping must not be subject to physical or chemical deterioration due to the substance(s) stored in them. Documentation from tank, piping, and seal manufacturers of compatibility with these substance(s) must be submitted to Permitting Authority prior to construction. 9. The following equipment and materials must be identified by manufacturer and model prior to their installation: Tank liquid level gauge(s) Tank secondary containment automatic monitoring system(s) Sealer used to secure piping monitoring sump _ Piping secondary containment leak 10. Product line piping system must pass an approved integrity.test before it may operate. 11. Monitoring requirements for this facility will be described on final "Permit to Operate." ACCEPTED BY: i BS:cas \120003m.ptc DATE: �— North R Diesel UST 7500 Gal. Existing Sump U] New Piping Sump 0 Total Containment o Existing Pipes �[ I Bcflav Rant Wat0 Parking Area Generator Room REMOVE 750 Gal. Tank Cut & Remove Existing Pipes Day Tank A. Furnish & Install 2"A 0 Smith F.G. pipe with Total Containment secondary Lines will slope 114 " per foot to existing 7500 Diesel Tank Lines and piping will be backfilled with clean sand. B. Connect New F.G. lines to existing product and return lines inside of new piping sump. Note: New Sump and Secondary Containment will be water tested before covering. Product and return lines will be tested per K.C.H.D. codes. jl Furnished By: RLW Equipment Co. a C� g l RCES DEPT. St.,-Suite 300 MbC',�ORoW0 0A. 93301 GMM 861-3636 do • • crY� ,I tr Ikee/v #ej /eaL �v Pi p i iv� Sum p lq`loi /--o-- / z o o C) 3 A4 PLAN APPROVED KERN COUNTY ENVIRONMENTAL HEALTH SERVICES D07. 21r.;o °'M" St., Suite 300 Bakersfield, CA. 93301 Phone (805) 661-3636 Date: Y--k-9 Uy: , — e Aa e,�7 &I-.- ,�,- �,, , k , J--, ,, //N a T r - -7 4� 1?,-4rAV lIA'iT 4 76-00 GaL. Taws - -% n SEP - 8 "t 1 • I "o . :-L / 4., d r1vrd� d 0 7 v?/l 9 J v 6 • A Standard Compliance Check F a c i l i t y : �i��% r�' /�� CT IZ- Equips•ent to be installed: Tank(s),��Ft. of Suction C]Pressuriaed Gravity, Piping Re 'd A ro ed Proof of Contractor's License - License = Z 9 D / Type of License (- c� Proof of Contractor's Worker's Compensation Insurance Primary Containment- TamK ❑Fiberglass (FRP),, Make & Model ❑ Fiberglass -clad steel Make & Model ❑Uncoated steel Make & Model Other: Make & Model Comment: Additional: Inspection: Secondary Containment of Tank(s) ❑Double - walled tank(s) Make & Model ❑Synthetic liner Make & Model Lined concrete vault(s) Sealer used Other Type Make & Model Comment: Additional: Inspection: Secondary Containment Volume at Least 100% of Primary Tan Volume(s) Comment: Additional: Inspection: Secondary Containment Volume for More Than One Tan, Contains 150% of Volume of Largest Primary Containment o: 10% of Aggregate Primary Volume, Whichever is Greatel Comment: Additional Inspection: Inspection: Primary Containment of Piping ��S;crr Fiberglass piping Size & Make Aed ❑Coated steel piping Size & Make Uncoated steel piping Size ® 0ther Comment: Additional: Inspection: Secondary Containment of Piping � —,c/ SDouble - walled pipe Size & Make !o /mil Odi<lf �uf Synthetic liner in trench Size & Make Other Comment: Additional: Inspection: Corrosion Protection ❑Tank(s) (Piping & fittings &eji - me74_ GIJy Electrical isolation Comment: Additional: Inspection: V Manufacturer - Approved Backfill for *a4Wr & Piping Type Comment: Rea'd Approved Secondary Containment Open to Rainfall lust Accommodate Hour Rainfall Total Volume Comment: Additional: Inspection: f i/ Secondary onta nme t y n is Product -Com at b e p 1 1 Product I� /�,r Documentation Comment: Additional: Inspection: Annular Space Liquid is Compatible with Product Product Annular liquid Comment: Additional: Inspection: Primary Containment of Piping ��S;crr Fiberglass piping Size & Make Aed ❑Coated steel piping Size & Make Uncoated steel piping Size ® 0ther Comment: Additional: Inspection: Secondary Containment of Piping � —,c/ SDouble - walled pipe Size & Make !o /mil Odi<lf �uf Synthetic liner in trench Size & Make Other Comment: Additional: Inspection: Corrosion Protection ❑Tank(s) (Piping & fittings &eji - me74_ GIJy Electrical isolation Comment: Additional: Inspection: V Manufacturer - Approved Backfill for *a4Wr & Piping Type Comment: - 3 - Reg,d Approved Additional: Inspection: Tank(s) Located no Closer than 10 Feet to Building(s) Comment: Additional: Inspection: J ✓ Complete Monitoring System Monitoring device within secondary containment: ❑Liquid level indicator(s) []Liquid used []Thermal conductivity sensor(s) Pressure sensor(s) Vacuum gauge C]Su®p(s) Gas or vapor detector(s) Manual inspection do sampling if Co // C�7iloitl Visual i n s p e c t i o n SCra vl2eu Other Comment: Additional: Inspection: ✓ d Other Monitoring ❑Periodic tightness testing Method Pressure- reducing 11 leak detector s) Other f,-kd a v kt,. o ri u y. Comment: Additional: Inspection: Overfill Protection ❑ Tape float gauge(s) QFloat vent valve(s) Capacitance sensor(s) High level alarm(s) Automatic shut -off control(s) Fill box(es) with 1 ft. 3 volume Operator controls with visual level monitoring Other Comment: - 3 - • Req'd Approved Additional: Inspection: Monitoring Requirements Additional Comments Inspection: Inspector W—�� G -- Date L'�= -- ------ ------ - - - - -- — — �— - 4 - 0 0 Extra Inspections /Reinspections /Consultations Date: Purpose: Comment: Date: Purpose: Comment: Date Purpose: Comment: Date: Purpose: Consent: Invoice Date: Inspector 5 - Time Utilized Time Utilized Time Utilized Time Utilized Total Time: Date: , ENVIRONMENTAL HEALTH SER P S DEPARTMENT STEVE McCALLEY, R.E.H.S., Director 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 -2370 Voice: (661) 862 -8700 Fax: (661) 862 -8701 TTY Relay: (800) 735 -2929 e -mail: eh@co.kern.ca.us FACILITY Kern Medical Center 1830 Flower Street Bakersfield, CA 93305 PERMIT TO MODIFY UNDERGROUND STORAGE FACILITY PERMIT NUMBER: 120003C OWNER(S) NAME /ADDRESS: Kern Medical Center 1830 Flower Street Bakersfield, CA 93305 Phone No. 661/326 -2000 qvil,t .r SOURCE MANAGEMENT AGENCY DAVID PRICE 111, RMA DIRECTOR Community Development Program Department Engineering & Survey Services Department Environmental Health Services Department Planning Department Roads Department CONTRACTOR: California Hazardous Services 1431 East Saint Andrews Place Santa Ana, CA 92705 License #734854 -A Phone No.714/434 -9995 NEW CONSTRUCTION PERMIT EXPIRES August 20, 1999 X MODIFICATION APPROVAL DATE Ma 17 99 _OTHER 0 APPROVED BY � L I I Mike Driggs Hazardous Ma(eiaU Specialist ............................... POST ON PREMISES .............................. CONDITIONS AS FOLLOW: Standard Instructions 1. This permit applies only to the modification of an existing facility involving 2. This permit becomes invalid if inspections are not called for as required on the Inspection Record. 3. All construction to be as per facility plans approved by this department and verified by inspection by Permitting Authority. 4. All equipment and materials in this modification must be installed in accordance with all manufacturers' specifications. 5. Permittee must contact Permitting Authority for on -site inspection(s) with 48 -hour advance notice. PERMIT TO MODIFY 44 UNDERGROUND STORAGE FACILITY (Page 2) Standard Instructions Permit No. 120003C 6. All underground metal connections (e.g. piping, fitting, fill pipes) to tank(s) must be electrically isolated and wrapped to a minimum 20 mil thickness with corrosion - preventive, gasoline- resistant tape or otherwise protected from corrosion. 7. No product shall be stored in tank(s) until approval is granted by the Permitting Authority. 8. Monitoring requirements for this facility will be described on final "Permit to Operate." ACCEPTED BY: DATE: Ll .m24 0 0 n r DJ 0 KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEF 2700 "M" STREET, SUITE 300 - - BAKERSFIELD, CA 93301 l Pty �`Y 9 10399 1 : J i 0 PERMIT NO. A5Z 0003 M APN NUMBER APPLICATION DATE: �-- / 7— F S APPLICATION- FOR - PERMIT -TO - CONSTRUCT/MODIFY UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY LJ New Facilitv 16Modification of Facility LJ New Tank Installation at Existinq Facility A. Number of Tanks To'B� Installed Existing Facility Permit # /,2 0 Type of Business ����L Facility Name Address ity T R SEC (Rural Locations only) Nearest Cross Street TZ ®�/ aoa- B. Tank Owner Phone -Z Address IAD,w City /State .,— VgaSSffzff 42 Zip 2SEgaX C. Water To Facility Provided By Depth To Groundwater 2CO ° Soil Characteristics At Facility �TA– App y =1�k &V.141, _ D. Contracto rC-, .�. ' ZzAvie.6S CA Contr tor's License No. 7 Address /4t.3 %" J >'. true eFsuS City �g nt ra it/A Zip Phone # C7 « 341-2y-75 Worker's Compensation Certification # Insurer Proposed Starting Date-4/ > 9 Proposed Completion Date E. If This Application Is For Modification Of An Existing Tank System, Briefly Describe Modifications Proposed (Excluding New Tank Installation at Existing Facilities) ��0��o�1nc�21rt� C,kz F. Tank(s) Storage (Check All That Apply): Unleaded Other* Waste Other* Other* Tank # Unleaded Plus Premium Diesel Fuel Oil Waste Product 1 1 1 1 1 1 9A ( 1 1 1 1 1 ( 1 11 I1 (1 11 (1 (1 I1 11 (1 11 (1 (1 (1 11 11 (1 (1 (1 (1 11 I1 11 1) 11 * Describe other products /waste: G. Initial Tank Integrity Test Information: Testing Company Name: Phone # Test Method: Licensed Tester: A tank integrity test is not required if the tank is equipped with an interstitial monitor certified to meet the performance standards of a "tank integrity test." This form has been completed under penalty of perjury and to the best of my knowledge is true and correct. Signature Title Date HM36 (1/29/96) 0 4 ' '. I .. tN-. ; : " t A . .'.. , . - k t N .-1 , I I I . li TANK INt'ORMATION FORM Facility ID: (Complete one form for all tanks with the same design) 1998: ❑ Yes ❑ No A- Tank Information Please Print Tank Number(s) 4 Z 0 Content (s)D /F_S' Capacity /el G Tank Manufacturer: ® C Date Installed _ /_ /Jea Tank Construction: Single -Wall ❑ Double -Wall ❑ JacketE:d • Vaulted ❑ Other Tank Material: ❑ Carbon Steel ❑ Fiberglass -Clad Fiberglass • Concrete ❑ Other Methanol Compatible ❑ Yes ❑ No Tank Interior Lining: - Unlined ❑ Lined (material) Corrosion Protection: ❑ Fiberglass -Clad ❑ Sacrificial Anode ❑ None • Polyethylene /Vinyl `Q Other GiR E2G L4_G-S' • Impressed RCurrent (describe) �l Spill Containment: (make & model) 4f 1A_1 Year Installed Overfill Prevention: (make & model) o�/7 h,/ Year Installed- Tank Repairs: (dates & descriptions) Su!U p S . /611 ✓�w�or21/- i4 T6, B Piping Information Please Print Type of System: ❑ Pressure * Suction o Gravity ❑ None Approximate length of this pipe run: Sp ' Pipe Construction: ❑ Single -Wall )( Double -Wall o Liner Raceway ❑ PVC Sleeve ❑ Other Pipe Material: ❑ Steel ` Fiberglass ❑ Flexible (list material) ❑ Other Pipe Manufacturer: .2 w3, -7-N Date Installed 5 /_LZ/9 C Monitoring Information Please Print and Check Al/ That Apply Tank Monitoring: Primary: ). Auto -Tank Gauge ❑ Manual Gauging • Statistical Inventory Reconciliation ❑ Groundwater • Vadose Zone ❑ Other Describe make and model REV t,P — i25,0.n 7-,- Secondary: Liquid Sensor ❑ Vapor Sensor ❑ Hydrostatic ❑ Other Describe make & model CE2ER- oa T- Alarm: � Yes ❑ No Pipe Monitoring: Primary: ❑ Reduced Flow ❑ Shut Down Other Line Leak Detector Line Leak Detector Describe make & model opgFgATi pa/ n Secondary: ❑ Liquid Sensor ❑ Vapor Sensor ly:. other Mo/V-ro2 /n/G Describe make & model Alarm: ❑ Yes ❑ No Pump Shut Down: ❑ Yes W—' No HM38 TANK INOF RMATION FORM Facility ID: (Complete one form for all tanks with the same design) 1998: ❑ Yes ❑ No A.- Tank Information Please Print Tank Number(s) _ Content(s) Capacity Tank Manufacturer: Date Installed Tank Construction: ❑ Single -Wall ❑ Double -Wall ❑ Jacketed ❑ Vaulted ❑ Other Tank Material: ❑ Carbon Steel ❑ Fiberglass -Clad ❑ Fiberglass ❑ Concrete ❑ Other Methanol Compatible ❑ Yes ❑ No Tank interior Lining. ❑ Unlined ❑ Lined (material) Corrosion Protection: ❑ Fiberglass -Clad ❑ Sacrificial Anode ❑ None • Polyethylene /Vinyl ❑ Other • Impressed Current (describe) Spill Containment: (make & model) Year Installed Overfill Prevention: (make & model) Year Installed Tank Repairs: (dates & descriptions) B Please Print Type of System: Pipe Construction: Pipe Material: Piping Information ❑ Pressure ❑ Suction ❑ Gravity ❑ None Approximate length of this pipe run: • Single -Wall ❑ Double -Wall ❑ Liner Raceway • PVC Sleeve ❑ Other ❑ Steel ❑ Fiberglass ❑ Flexible (list material) ❑ Other Pipe Manufacturer: Date Installed C Monitoring Information Please Print and Check All That Apply Tank Monitoring: Primary: ❑ Auto -Tank Gauge o Manual Gauging • Statistical Inventory Reconciliation ❑ Groundwater • Vadose Zone ❑ Other Describe make and model Secondary: ❑ Liquid Sensor ❑ Vapor Sensor ❑ Hydrostatic ❑ Other Describe make & model Alarm: ❑ Yes ❑ No Pipe Monitoring: Primary: ❑ Reduced Flow ❑ Shut Down ❑ Other Line Leak Detector Line Leak Detector Describe make & model Secondary: ❑ Liquid Sensor ❑ Vapor Sensor ❑ Other Describe make & model Alarm: ❑ Yes ❑ No Pumv Shut Down: ❑ Yes ❑ No HM38 ENVIRONMENTAL HEALTH DEPARTMENT 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 PERMIT NO. APN NUMBER APPLICATION DATE ° Type Of Application (check): (')New Facility >0 Modification of Facility ( )New Tank Installation at Existing Facility A. B C. Number of Tanks To Be Installed Existing Facility Type of Business 44 ° Facility Name /K- - ty 4rJ ee2g �'e�vAg Address /,F.5 4 T R SEC (Rural Locations Only) Nearest Cross Tank Owner_ :2 a jt :ou; Address /*/���-n�.r¢-�,� -- ,AI- City /Stat Permit # / e&,q_5 Street /n-A. VPP n/ow Water To Facility Provided_By . d W,4.2 fAJ �—, W ,/ Depth To Groundwater G ° , Soil Characteristics At Facility Phone #: '652 — Zip D. Contractor G I.cLE CA Contractor's License No. 4:- ' ,Y497e1-Cw11 Address �--26 50. lily/,6,00 Ave,City. L-l" . -/ Zip !2S-s_oiPhone Worker's Compensation Certification �� a" A, Z= Insurer q Proposed Starting Date, �A P— Proposed Completion Date E. If This Applicatiori..Is For Modification Of An Existing Tank System, Briefly Describe' Modifications Proposed (Excluding ew Tank Installation at Existing Facilities) 72i .o,, - / i .ei ss � rr..,h � S t) 6&1 o. 1. M, Y P ) 75r 0 F. Tank (s) Storage (Check All That A42._L): (If* - Complete Section G) Other* Other* Tank # Ilnleaded Regular Premium j2jj.esel Othe Fuel* Waste Oil Waste Product G. Chemical Composition Of Materials Stored ;For Products Or Waste Marked With. *) Tank Chemical Stored (non - commercial name CAS # NJ known) Chemical Previously Stored, (if different) This form has been completed under penalty of perjury and to the best of my knowledge is., true and correc Signature_ Title Date Permit #� TODD 3 TANK INFORMATION FORM Contents (FILL OUT SEPARATE FORM FOR EACH TANK) Tank # FOR EACH SECTION, CHECK ALI APPROPRIATE BOXES H. 1. Tank is: () Vaulted () Jacketed () Double -Wall () Single -Wall 2. Tank Material () Carbon Steel () Stainless Steel () Fiberglass- Reinforced Plastic () Fiberglass -Clad St( () Concrete () Unknown () Other (Describe) 3. Primary Containment _ Date Installed Thickness (Inches) Capacity (Gallons) Manufacturer 4. Tank Secondary Containment () Double -Wall () Synthetic Liner () Lined Vault () None () Unknown () Other (describe): Manufacturer: () Material Thickness (Inches) Capacity (Gallons) 5. Tank Interior Lining ( ) Unlined ( ) Unknown () Lined (describe) 6. Tank Corrosion Protection () Galvanized () Fiberglass-Clad () PolyethyleneNinyl (Wrapped or Jacketed) () Tar or Asphalt () Unknown () None ( ) Other (describe): Cathodic Protection: () None () Impressed Current System () Sacrificial Anode System Describe System and Equipment: 7. Leak Detection. Monitoring, and Interception * (Must be described below) a. Tank: () Vapor Detector * () Liquid Level Sensor * () Conductivity Sensor () Vadose Zone Monitoring Weil(s) () U -Tube with Liner ( ) U -Tube without Liner () Visual Inspection (Vaulted tanks only) () Groundwater Monitoring () Sensor in Annular Space () Vapor () Liquid () Pressure () Other () Regular Monitoring of U -Tube, Monitoring Well or Annular Space () Daily Gauging & Inventory Reconciliation () Periodic Tightness Testing () None ( ) Unknown () Other *Describe Make & Model: b. Piping: () Flow- Restricting Leak Detector(s) for Pressurized Piping* ( ) Sealed Concrete Raceway Monitoring Sump with Raceway ( ) Complete Containment Liner with Sumps () Half -Cut Compatible Pipe Raceway () Synthetic Liner Raceway () None () Unknown ( ) Other *Describe Make & Model: -Z-:&, �7.G /'234 8. Tank Tightness Has This Tank Been Tightness Tested? W Yes () No () Unknown Date of Last Tightness Test Results of Test _ 77 4 L Test Name 2' b e ,c Testing Company B r me t-mi a 9. Tank Repair () Yes () No (A) Unknown Date(s) of Repair(s) Describe Repairs 10. Overfill Protection (Must describe below) (� Operator Fills, Controls, & Visually Monitors Level () Tape Float Gauge () Float Vent Valves () Auto Shut -Off Controls () Capacitance Sensor () Sealed Fill Box None () Unknown () Other () List Make & Model for all Devices *Describe other Protection System 11. Pi in a. Underground Piping: Yes' () No () Unknown Material Thickness (inches) Diameter Manufacturer. o b. Type of piping System O Pressure Suction O Gravity Approximate Length of this Pipe Run _7 C. Underground Piping Corrosion Protection: () Galvanized ('1 Fiberglass -Clad () Impressed Current () Sacrificial Anode () Polyethylene Wrap ( ) Electrical Isolation ( ) Vinyl Wrap ( ) Tar or Asphalt () Unknown None () Other (describe): d. Underground. Piping, Secondary Containment: (�Q Double -Wall () Synthetic Liner System () None () Unknown HM21 ( Make & Model (describe): /" 2:-2,,,,, m2,,,,.,4 moo 00-3 tyouR es QATE STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 0 I NEW PERMIT 0 3 RENEWAL PERMIT 0, 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE ITEM [::] 2 INTERIM PERMIT 0 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR !< PHONE # WITH AREA CODE ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) PHONE # WITH AREA CODE �,COUNTY-AGENCY FEDERAL- AGENCY CITY NAME , CITY NAME STATE ZIP CODE .... SITE PHONE # WITH AREA CODE CAA �a� TOINDIC ATE O CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY I3`COUNTY-AGENCY Q STATE - AGENCY Q FEDERAL - AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION = 2 DISTRIBUTOR 0 ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) Q 3 FARM 4 PROCESSOR Q 5 OTHER RESERVATION OR TRUST LANDS L EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) F � i• c , l �. Y �' � � `�� f/� PHONE # WITH AREA CODE 4- �' w) 2��; lF• ✓ t�l d DAYS: NAME (LAST, FIRST) C'_�C`= �/� � d PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION f (( MAILING OR STREET ADDRESS_ ✓ box to Indicate INDIVIDUAL D LOCAL- AGENCY (] STATE- AGENCY � P �._.• 1 n by.: .S CORPORATION PARTNERSHIP �,COUNTY-AGENCY FEDERAL- AGENCY CITY NAME , STATE� ZIP CODE ZIP CODE PHONE # WITH AREA CODE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION f (( MAILING OR STREET ADDRESS box to Indicate 0 INDIVIDUAL LOCAL - AGENCY STATE - AGENCY CORPORATION Q PARTNERSHIP Q COUNTY- AGENCY FEDERAL - AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739 -2582 if questions arise. TY (TK) HQ 4 4 - V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNT Y # JURISDICTION # FACILITY # LOCATION CODE -OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (9 -90) FOR0033A -R2 I. One I.-ORM. A" Shall be completed for W] r my PF f,)- a 71 1t -urn or .-nd wi I i �tw Ik. .r, ;iaj r,0 .I Ili's 4 hoo, 11 lci '011 C 'L!f C W T1 11 p 1. oc if :i-. Al 4; 0 -1 �` • STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. GsouRCes v t' s ,a� i 0 o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. B. MANUFACTURED BY: / alt f7 J /�' cv C. DATE INSTALLED (MO /DAY/YEAR) / J D. TANK CAPACITY IN GALLONS: II TANK CONTENTS IFA -11S MARKED_ OOMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a R ULAR ® 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT UNLEADED ❑ 5 GETFUEOL ❑ 7 METHANOL ❑ 1bUN 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN O 2 WASTE O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 1009% METHANOL COMPATIBLE W /FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING a 6 UNLINED ® 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE a 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) I%1,� IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U 1 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL WI COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE B 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING � 99 OTHER lV gft� V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK DRr2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING E] 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO /DAY/YR) 2. ESTIMATED QUANTITY OF ® 3. WAS TANK FILLED WITH YES ❑ NO 5-19--77— SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED a SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# U O I a ,e/ 151 -,,/1 S 131 loic'.1 C PERMIT NUMBER PERMIT APPROVED BY /DATE 1 PERMIT EXPIRATION DATE FORM B (7 -91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION • FORMA, UNLESS A CURRENT FORMA HAS BEEN FILED. O FORD034B -R5 00 *0 QaIlRv?➢3.I6::.Nz >> "' %�Uc; `�'a 4itZi$:: L One FORM "I3" shall be completed for each tank for all NEW P ➢?RMFn,, a E- '3V71' — HANS3 ➢'?S, anu /or any other TAN (M➢ANGIE 1 '11iis form should be completed by either the PER W1' A.PPI.HC,AN'1' or the LOCAL ACT1?.NCy UNIITERUXlROUND TANK ,NTS717i ➢73 73. 1 Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: 'MARK ON 7:Y ONE L:lI 3M' 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. ➢. 'FANK ➢DIaSCRI IlTON - C;C.)KPLHP7 ALL TFEMS - IF UNKNOWN - SO S➢'b? , VY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. A1370789). I3. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG.). C. Indicate the ;car the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). H➢. TANK C'.wIM71's`,YPS A. 1. If MOTOR VEHICLE FUFL, check box 1 and complete items I3 & C. 2. If not MO'T'OR VEHICLE, FULL, check the appropriate box in section A and complete items I3 & D. 13. Check the appropriate box. C. Check the type of MOTOR VEHICLE FIJI:.L (if box I is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S. #. (Chemical Abstract Service number), if box 1 is NOT checked in A. III. TANK C: ®NS113UC"HHC3 J - R1ARDC ONE 17THIM CDMY EN W)X A, 113, C: a ED 1. Check only one item in TYPE OF SYSPEM, TANK MATE'RIAL., INTERIOR LINING and CORROSION PR01'ECI'ION. 2. If 0111ER, print in the space provided. IV. PEPTiNG ENE�DL31l1AEECDN 1. Circle A if above ground; circle U if underground; and circle both if applicable. Z If UNKNOWN, circle; or if 01111."R. print in space provided. 3. Indicate the LEAK DEFECI]ON system(s) used to comply with the monitoring requirement for the piping. V. ')TANGS LIWd 1)ILP M -ITON 1. Indicate the LEAK DETECHON system(s) used to comply with the monitoring requirements for the tank. VL 1NFORMA'11➢ON ON TANK PEIRMANEWE LY C IA SH:D IN PEACE 1. ESI'IMATID DATI3 LAST USED - MONT'II /YEAR (January, 1988 or 01/18). 2. ES'I'IMA'I17.1) QUANTI'T'Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INER"I' MATERIAL? Check 'Yes' or 'NO'. APPI,➢CANE' MUSE' SIlGN AM) 1GDRIE 1TTIE FORM AS It`DIC:f+ IE71). 1NS.I7RUC`1TON FOR 171F 71F LOC J. AGE?NCII-IS 'I'hc state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and The six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739 -2421. The facility number must be the same as shown in form "A ". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Hoard to assign the tank number, please leave it blank. TI' IlS dTRE R11 SPONSEE31[11'1'IC OF'ITI E LOCAL AG1?Nd.'Y '1' 1XF HNSPECI'S 111H FACILTI'Y TO 'VI?RHI -Y `IlHE ACCURACY 017779E INFO RMTKA1CDN. THP 9.C3C.AI. AGPFHCY IS RESPONSIBLE FOR11113 CCIMPI.d311ON OF'1T 1 °IldDCAIl. AGENCY UST! ONLY' BOX AND FOR FORWARDING ONE 17ORM °AQ AND AS.'iC)C;IA'I' m FORM THE FOLEA)WUN 'p ADDRESS. 1717A'H'E3 OF C'. E.IlFGEBNIA ErA'E'E: VJA7T .iR MI SOUIRC:M CCDRTFROL BOARD C/o S.VY.k n.P.S. EDKFA PROCMSSING CIFWM-P8 P.O. BOX 527 PARAMOUNT, CA 153M 'R OFFICE M E M 0 R A N D U H KERN COUNTY To: Ann Boyce Date: August 11, 1986 Kern County Health Department From: H. L. (Lee) Willeford Telephone: 326 -2122 Assistant Medical Center Facility Manager Subject: Underground Hazardous Substances Storage Facilities Per our phone conversation of August 11, 1986, you will find enclosed a copy of our (Kern Medical Center) Permit Checklist, Agreement Between Owner and Operator and Calibration charts for our three (3) fuel tanks. At this time, I would like to return to you for redirection Handbook #LJT -10, Action Chart, Trend Analysis Worksheet, Inventory Recording Sheet and Inventory Reconciliation Sheet. I would also like to request that you supply Kern Medical Center with the appropriate information to operate and monitor our fuel system under the modified program. Kern Medical Center utilizes our fuel system strickly as a source of fuel for our emergency generators. The generators are infrequently operated (30 minutes, once a week); and due to the fact that KMC will be moving into a new plant facility with the next 24 months, where our fuel storage system will be double wall tanks. Therefore, rendering our present tank system non- operational and allowing KMC to remove them from service. A Modified Program seems more appropriate. I hope you will continue to assist us in this program so that we may comply with the monitoring program as soon as possible. Should you have any questions or need assistance please contact me at 326 -2482 Thank you. Lk..XLee) Willeford sistant Medical Center F cility Manager HLW:bs Facility • KERN MEDICAL CENTER PERMIT CHECKLIST • Permit # 120003C This checklist is provided to ensure that all necessary packet enclosures were received and that the Permittee has obtained all necessary equipment to implement the first phase of monitoring requirements. Please complete this form and return to KCHD in the self - addressed envelope provided within 30 des of receipt. Check: Yes No A. The packet I received contained: 1) Cover Letter, Permit Checklist, Interim Permit, Phase I Interim Permit Monitoring Requirements, Information Sheet (Agreement Between owner and Operator), Chapter 15 (KCOC #G- 3941), Explanation of Substance Codes, Equipment Lists and Return Envelope. 2) Standard Inventory Control Monitoring Handbook #UT -10. 3) The Following Forms: a) Inventory Recording Sheet b) Inventory Recording Sheet with summary on reverse c) Trend Analysis Worksheet 4) An Action Chart (to post at facility) B. I have examined the. information on my Interim Permit, Phase I Monitoring Requirements, and Information Sheet (Agreement between Owner and Operator) , and find owner's name and address, facility name and address, operator's name and address, substance codes, and number of tanks to be accurately listed (if "no" is checked, note appropriate corrections on the back side of this sheet). C. I have the following required equipment (as described on page 6 of Handbook): _ X 1) Acceptable gauging instrument _ X 2) "Striker plate(s)" in tanlc(s) X 3) Water - finding paste X D. I have read the information on the enclosed "Information Sheet" pertaining to Agreements between Owner and Operator and hereby state that the owner of this facility is the operator (if "no" is checked, attach a copy of agreement between owner and operator). X E. I have enclosed a copy of Calibration Charts for all tanks at this facility (if tanks are identical, one chart will suffice; label chart(s) with corresponding tank numbers listed on permit). X F. As required on page 6 of Handbook #UT -10, all meters at this facility have had calibration checks within the last 30 days and were calibrated by a registered device repairman if out of tolerance (all meter calibrations must be recorded on "Meter Calibration Check Form" found in the Appendix of Handbook). X G. Standard Inventory Control Monitoring was started at this facility in accordance with procedures described in Handbook #UT -10. Date Started See Reverse Signature of Person Completing Checklist. aro illeford Title: Assistant Medi al Center Facility MaAager Date: 8/11/86 • 0 C. Items required to comply are on order from RLW Equipment,.Order No. 0 -2362. F. The tanks located at Kern Medical Center facility are not used as a fueling system for vehicles. The tank systems are used as an emergency supply system for the KMC emergency generators. G. Per Ann Boyce, Kern County Health Department, Kern Medical Center, as stated in attached letter, will be utilizing the modified monitoring system. Ll • %PERMIT CHECKLIST Facility �C � ��a�.� (��•t/ Permits l Z rn C) a 3 C This checklist is provided to ensure that all necessary packet enclosures were received and that the Permittee has obtained all necessary equipment to implement the first phase of monitoring requirements. Please complete this form and return to KCHD in the self - addressed envelope provided within 30 days of receipt. Check: Yes No _ A. The packet I received contained: 1) Cover Letter, Permit Checklist, Interim Permit, Phase I Interim Permit Monitoring Requirements, Information Sheet (Agreement Between Owner and Operator), Chapter 15 (KCOC *G- 3941), Explanation of Substance Codes, Equipment Lists and Return Envelope. r/ 2) Standard Inventory Control Monitoring Handbook *UT-10. _ 3) The Following Forms: a) Inventory Recording Sheet , b) Inventory Reconciliation Sheet with summary on reverse c) Trend Analysis Worksheet _ 4) An Action Chart (to post at facility) _ B. I have examined the information on my Interim Permit, Phase I Monitoring Requirements, and Information Sheet (Agreement between Owner and Operator), and find owner's name and address, facility name and address, operator's name and address, substance codes, and number of tanks to be accurately listed (if "no" is checked, note appropriate corrections on the back side of this sheet). C. I have the following required equipment (as described on page 6 of Handbook): 1) Acceptable gauging instrument 2) "Striker plate(s)" in tank(s) 3) hater- finding paste D. I have read the information on the enclosed "Information Sheet" pertaining to Agreements between Owner and Operator and hereby state that the owner of this facility is the operator (if "no" is checked, attach a copy of agreement between owner and operator). E. I have enclosed a copy of Calibration Charts for all tanks at this facility (if tanks are identical, one chart will suffice; label chart(s) with corresponding tank numbers listed on permit). '! F. As required on page 6 of Handbook sUT46, all meters at this facility have had calibration checks within the last 30 days and were calibrated by a registered device repairman if out of tolerance (all meter calibrations must be recorded on "Meter Calibration Check Form" found in the Appendix of Handbook). G. Standard Inventory Control Monitoring was started at this facility with procedures i Date Startec Signature of Person Complei Title: Date: In accordance 7 .VL V JAN 1 9 1987 KERN COUNTY HEALTH DEPT. K4 -- Information Sheet -- Agreement Between Owner and aerator Chapter 12 of Kern County Ordinance Code #G -3941 consists of the following two sections: Section 3912.12.01. The operator of the under - groun storage aci. i.ty shall monitor the facility using the method specified on the-permit for the facility. Records shall be kept in sufficient detail to enable the Permitting Authority to determine that the operator has undertaken all monitoring activities required by the Permit To Operate. Section 3912.12.02. If the operator is not the owner, the owner s al provide a copy of the Permit To Operate, enter into a written contract with the operator which requires the operator to monitor the tank as set forth in the permit, and provide the opera- tor with a copy of Chapter 15. The owner shall notify in writing the Permitting Authority of any change of operator. The operator listed in our records for the permitted facility in this packet is: PERMIT #120003C OPERATOR: KERN MEDICAL CENTER 1830 FLOWER STREET BAKERSFIELD, CA 93305 If the operator is different than the owner listed on the permit, provide a copy of the required written agreement to the Permitting Authority within 30 days. An example contract is shown below. EXAMPLE Written Contract: I, County of Kern owner of underground storage tanks located at 1830 Flower Street have entered into this written contract with Kern Medical Ctr;.th'e operator of same, to fulfi.11 a requirement of my Permit to operate, 1120003C I have provided the 'operator with a copy of the Permit to Operate and Chapter 15 of the Ordinance. I, Kern Medical Ctr,- operator of underground storage tanks located at 1830 Flower Street have received from County of Kern , owner of same, a copy of Permit to Operate 11 2 0 0 0 3 C and Chapter 15 of the Ordinance describing fines and penalties for non - compliance. I have read and understand my responsibilities under this Permit and agree to do the following: -- monitor the underground tanks as specified in the Permit to Operate. -- maintain appropriate records as required by the Permit to Operate. -- implement all reporting procedures as required by the Permit to Operate. -- properly close the underground tanks as required by Permit to Operate. Signed owner operator date 8/ /86 date 46 741.3 -- 47 748.21 --- 48 752.02 - -' '- lume 752.03 Gallons - For I f � �3- -- -----'- -'--- -'---'-' �-------------�------8--''--'' ------- -------82�39----'-- --� --- - -------'-��--'---- 9 - -- -- --' -�-97.81-'--- -----�--------------�l0-----'-----'-- �-------'i�3�5i--'- ' '� - -- ' ---'- --- 11 -- - 130 ' 12 147.02 - - ' 13 ' 164.53 �---- - 14 -| 182.4G '---' - ' 15 200.78 ---| -------- '- ' - 16 219.43 ---1 -'�'-- 17 ' 238.38 - '- --�---�---�---' 18 - - - -- �257.58 -- ----' -- ----'-`� 19 - 277 -- ------�--�-----'--�2O} - --- - -' -' ��96.59 ---- --- -''--- ' ' '-�---'--- 2 13 3i6�. - - - ----------'It -- - -- ' --- 336.16- -'- ----' -------'--- '-- - -23 ' 356.07 - '-'---- - - ------ - 24 -- -'----- ----- '76.01 25 395.96 - --�� 415.86 -- '---� -- --- --'- 27 ' - - 435.7 - --',-� '---------------28-- - '- -- -- -455M ---------'------------ --'--------------��9-- ' - ' -- -475.N3 - -- ---- ---�------ ---- ---��---�-- - --- -'-'-- 494.44 -- ---�- ---- - -'- ' -31 '- - - � - 513.64 -----' -- ------ '----------�--r-�����-' ---- ----- 532. 59 -----' --------------- -------_ -- '---33- -'-- ' -'-----� '551.E4--- '----'----'------- � '^"--'--'---'--'--------�4-----'---------------�---�J�9.�56----------- - -'-------------- -'--- -' ------ 587'5 --- -' - -----''----�' -------------'---��-- -� - ' - --' - 605 - - ' --- -- ---- ----- -� -�-37 - -_- 622.03 -- -'--'-- --' - -� - 38 - - 638.52' _ -'-- - --- -' --'--�-----39- _ - 654.41 - ---- �--- �'' - --------'----�0-- - - -� 669:64-' - - 41 684.12 697.77 -' - 43 710.47 44 - 722.09 --- 45 _ 732.45 - 46 741.3 -- 47 748.21 --- 48 752.02 - -' '- lume 752.03 Gallons - For I f Fibulas* Tanks This chart for Fuel Storage can be used to gauge model Calibration Chart G-6 tanks. Model G-5 10,000 Gallon Tanks Model G-5 10,000 Gallon Tanks/Tank Size and Capacity in Gallons Calibrations for Level Tanks' 'D W 6, 'I'AAIX Actual Capacity 9728 Gallons Dipstick 6;110�nZDipstick �ajl4� - Dipstick G Ions Dipstick Gal ons Dipstick a G Ilon' s_ Dipstick Gal n S Dipstick Gallon 8 +-"V 61/2" _x281: 127/e" 771. = 191/4 411401,--.,'" 255/8" "2128 32" 2931 383/8" t,3790 V- 2 65/8" -1~189 13" 782 193/a" -1414.*'-� 253/4" '2143 321/8" -'2948."� 3B'/2" 3/8 4 63/4" ."297 131/8" 4`793 •191/2 1428 257/8" �2158 321/4" .2964 ',4. 385/6" -3825 1/2" N 6 67/6" 21;305 131/4 ...804 195/8" 1 1441 26" .2174 323/8" 2981 383/4" 38491 5/8" 8 7" 313 133/e" '816 193/4" 1455 261/8" 2189 321/2" 2997 387/8" 3859 3/4" X11 71/6" :321 ai 131/2" ,827 197/8" 1468 261/4" 2204 325/6" 3014 39" 1 - 387 7 741 718" 4 71/4" -,330 - 135/e" -838 20" 1482 263/8" 2219 323/4" 3030 391/6" :3894 :1 ill -`17 73/8" 338 133/4" .850 201/8" 1495 261/2" 2234 327/6" 3047 391/4" 39118 11/8" '!�'20 71/2" 347 137/6" '862 201/4" 1509 265/9" 2250 j 33" 3063 393/8" 3929 11/4" 24 75/6" 355 14" 873 203/6" 1523 263/4" 2265 " 331/8" 3080 391/2" 3946 13/8 28 73/4" 364 141/6" 885 201/2" 1536 267/8" 2280 331/4" 3096 395/8" 3964 11/2" 32 77/8" 373 141/4" 1-897 205/8" 1550 27" 2296 333/6" 3113 393/4" '3981 15/8 36 8" 382 143/a" 909 203/4" 1564 271/6" 2311 331/2" 3129 397/6" 3998 13/411 ',40 81/8" 391 141/21' 920 207/8" 1578 271/4" 2327 335/8" 3146 40" 4016 17/8" 44 8'/4" 400 145/8" 932 21 " 1 1592 273/8" 2342 1 333/4" 3163 401/8" 4033 _j 2" 48- 83/8" 409 143/4" - 944 21118" 1606 271/2" 2358 1 337/8" 3179 401/4" 4051 .1 21/6" 53 81/2" 418 147/8" 956 211/4" 1620 275/8" 2373 1 34" 3196 403/8" 4068 'a, 21/4" -."58 85/81, 427 15" 968 213/8" 1633 273/4" 2389 341/8" 3213 401/2" 4086 23/6" 63 83/4" 436 151/8" .980 211/2" 1647 277/6" 2404 341/4" 3229 405/a" 4103 21/2" 68 87Ah" 445 151/4" 992 215/8" 1662 28" 2420, 343/8" 3246 403/4". 4121 25/8" 73 91, 454 153/8" 1005 213/4" 1 1676 281/8" 2435 341/2" 3263 407/6" 4138 23/4" 78 91/8'.. 464 151/2" 1017 217/8" 1690 281/4" 2451 345/8" 3280 41" 4156 27 /e" 83 9'/4" 473 155/a" 1029 22" 1704 283/6" 2467 1 343/4" 3296 411/8" 4173 3" ..89 93/8" 483 153/4" 1041 221/8" 1718 281/2" . 2482 347/8" 3313 411/4" 4191 31/8" `94 9112" .492 157/8" 1053 221/4" 1732 285/8" 2498 35" 3330 413/8" '4208 4 31/4" 100 95/8" 502 16" 1066 22316" 1747 283/4" 2514 351/8" 3347 411/2" '4226 1 33/e" 106 93/4" 512 161/a" 1078 221/2" 1 1761 287/8" 2530 351/4" 3364 415/8" 4243 i 31/2" A 12 97 /e" 521 161/4" 1091 225/8" 1775 29" 2545 353/6" 3381 413/4" 4261 35Ah" 116 1011 531 163/8" 1103 223/4" 1789 291/8" 2561 351/2". 3397 417/a" 4278 33/4" .124 1 101 /6" 541 161/2" 1116 227/8" 1804 291/4" 2577 355/6" 3414 42" 4296 37/8" 130 10114" 551 165/8" 1128 23" 1818 293/8" 2593 353/4" 3431 421/8" 4314 4" 136 103/8" 561 163/4" 1141 231/8" 1833 291/2" 2609 351/8" 3448 421/4" 4331 41/8" '143 10'/2" 571 167/8" 1153 231/4" 1847 295/8" 2625 36" 3465 423/6" 4349 41/4" 149 105/8" 581 17" 1166 233/e" 1862 293/4" 2641 361/8" 3482 421/2" 4367 43/8" 156 103/4" 591 171/e" 1179 231/2" 1876 297/8" 2657 361/4" 3499 425/e" 4384 41/2" 162 1 107/8" 601 171/4" 1191 235/8" 1891 30" 2673 1 363/8" 3516 423/4" 4402 45/6" 169 1 11 " 611 173/6" 1204, 233/4" 1905 301/8" 2689 1 361/2" 3533 427/8" 4420 i 43/4" 176 1 111/8" 622 171/2" 1217 237/6" 1920 301/4' 2705 1 365/8" 3550 43" 44.37 47/8" 1153 1 111/4" 632 175/9" 1230 24" 1935 303/8". 2721 363/4" 3567 431/8" 4455 5" 190 1 113/6" 642 173/4" 1243 241/4" 1949 301/2" 2737 361/8" 3584 43144" 4473 51/8" 197 111/2" 653 177/8" 1256 241/4" 1964 305/8" 2753 37" 3601 433/6" 4490 1 51/4" 204 115/811 663 18" 1269 243/8" 1979 303/4" 2769 371/6" 3618 431/2" 4508 5316" 212 113/4 674 -181/8" 1282 241/2" 1994 1 307/8" 2785 371/4" 3636 435/8" 1 4526 51/2" 219 117/8 684 181/4" 1295 245/8" 2009 31 " 2801 1 373/611 3653 433/4" 4543 55/8" 226 12" 695 183/8" 1308 243/4" 2023 311/8" 2818 37112" 3670 437/8" 4561 53/4" 234 121/8" 706 1812" 1321 247/8" 2038 311/4" 2834 375/6" 3687 44" 4579 57 /e" 241 12!/4" 717 185/8" 1334 25" 2053 313/e" 2850 373/4" 3704 441/8" 4597 6" 249 123/6" 727 183/4" 1347 251/8" 2068 31'12" 2866 377/8" 3721 441/4" 4614 61/6" 257 121/2" 738 187/811 1361 251/4" 2083 1 315/8 2883 38" 3739 443/8" 4632 1 61/4" 265 125/a" --------- 749 19" 1374 253/e" 2098 313/4" 1 2899 3811s" 3756 441/2" 4650 6 3/9 - 2 7 31e � �2 760 19 F/8 1387 2113 1 317/8" 2915 1 1 381/4' 3773 445/8" 4668 Illy noergias uwporation 0 r wIoJ (wP. T ,4#i10 Model G -5 10,000 Gallon Tanks /Tank Size and Capacity in Gallons Calibrations for Level Tanks Actual Capacity 9728 Gallons Dipstick Gallons" Dipstick Gallons Dipstick Gallons Dipstick Gallons Dipstick Gallons Dipstick Gallons Dipstick Gallons 443/4" 4685 515 /e" 5660 581h" 6599 653/8" 7478 721/4" 8273 791/8" 8957 86" 9479 a 447/8" 4703 513/4" 5677 585/6" 6615 651/2" 7494 723/8" 8287 791/4" 8968 861/8" 9487 45" 4721 517/811 5695 583/4" 6632 655/6" 7509 72'/2" 8300 793/8" 8979 8614" 9494 451/8" 4739 1 52" 5712 587/6" 6648, 653/4" 7524. '725/V" -- 8314 791/2" 1 8990 863/e" 9502 4514" 4757 521/8" 5730 ` 59 ". 6665 657/6" `753 9' 72314" 8327 795/8" 9001 861/2" 9509 .� 453/8" 4775 521/4" 5747 5916" 6681 66" 7554 727/8" 8341 793/4" 9011 865/6" 9516.1 451/2 ". 4792 523/8" 5764' = 591/4" .6698 661/8" 7570 73" 8354 797/8 9022 863/4" 9524 , 455/8" 4810, 521/2" 5782 . 593/8" 6714 ' 661/4" 7585 731/8" 8367 80" 9033 867/6" 9531 ' 453/4" 4828 525/8" 5799 591/2" 6731 663/8" 7600 73'/4" 8381 801/8" 9044 87" 9538 457/6" 4846 ' 523/4" 58171' 595/8" 6747 6612" 7615 733/8" 8394 80'/4" 9054 871/8" 9545 ' 46" 4864 5276" ' 5834 593/4" 6764 665/8" 7630 731/2" 8407 803/8" 9065 871/4" 9552 461/8" 4882 53" 5851 ' 597/6" 6780 663/4" 7645 735/6" 8420 801/2" 9075 873/8" 9559 " 461/4" 4900 531/8" .5869 60" 6797 667/8", 7660 733/4" 8433 805 /8" 9086 871/2" 9566 ' 463/6' ' 4918 531/4" 5886. ' 601/8" 6813 67" 7675 737/6" 8446 8034" 1 9096 875 /e" 9572 461/2" 4936 533/8" 5903 601/4" 6829 671/8" 7690 74" 8459 807/6" 9106 873/4" 9579 -:� 465/6' 4953. 531/2" 5920 603/8" 6846 671/4" 7705 74118" 8472 81 " 9117 877/e" 9585 463/4" 4971 535/8" 5938 ::. 601/2" 6862 673/8" 7719 741/4" 8485 811/8" 9127 88" 9592 ` 467/8" 4989 533/4" 5955 605/6" 6678 6712" 7734 743/x" 8498 81'/4" 9137 881/8" 9598-.1 47" 5007 537/6" 5972 603/4" 6894 675/8" 7749 741/2" 8511 813/6" 9147 881/4" 9604 .1 471/6" 5025 54" 5989 607/8" 6911 673/4" 7764 745/8" 8524 81'12 9157 883/8" 9610 471/4" 5043 541/8" 6007 61 " 6927 677/8 7779 743/4" 8537 815/6" 9167 881/2" 9616 1 473/8" 5060 541/4" 6024 611/8" 6943 68" 7793 747/6" 8549 813/4" 9177 885 /8" 9622 ; 471/2" 5078 543/8" 6041 - 611/4" 6959 681/8" 7808 75" 8562 817/8" 9187 883/4" 0628 ; 475/6" 5096 541/2" . . 6058, 613/8" 1 6975 681/4" 7823 751/8" 8575 82" 9197 88718" 9634 473/4" 5114.... 545/8" 6075 611/2" 6991 683/8" 7837 751/4" 8587 821/8" 9207 89" 9639 477/4" 5131. 543/4" 6092 615 /e" 7007 681/2" 7852 753/6" 8600 821/4" 9216 891/e" 9645 48 . 5149 547/8 ".,, 6110 613/4" 7023 685/8" 7866 751/2" 8612 823/8" 9226 891/4" 9650 1 48'/6" 5167 55" 6127 617/6" 7039 683/4" 7881 755/8" 8625 821/2" 9236 893/8" 9655 ' 481/4" 5185 551/6" 6144 62" . 7055 687/8" 7895 753/4" 8637 825/8" 9245 891/2" 9660 .1 483/8" :.5202 551/4" 6161 621/8" 7071.., 69" 7910 757/8" 8650 823/4" 9255 895/6" 9665 48112" 5220 553/8" 6178, 621/4" 7087 691/8" 7924 76" 8662 827/8" 9264 893/4" 9670 485/8' 5238 5512" 6195 7103 691/4" 7939 761/8" 8675 83" 9274 897/8 9675 j 483/4" 5255 555/8" 6212 _623/6" 621/2" 7119 693/8" 7953 761/4" 8687 831/6" 9283 90" 9680 487/8" 5273. 553/4" 6229 625/6" 7135 691/2" 7967 763/8 8699 831/4" 9292 901/8" 9684 49 ", _.5291 .' 557/8" 6246 623/4" 7151 695/8" 7981 761/2" 8711 03316" 9301 90'/4" 9688 1 491/8" .. 5309 56" 6263 ,• 627/8" 7167 693/4" 7996 765/8" 8723 831/2" 1 9310 903/8" 9693 5326 561/8" 6280. 63" .. 7183 697/8 8010 763/4" 8736 835/8" 9319 901/2" 9697 _4.91/4" 493/6!: ... 5344 561/4" 6297 631/6" 7198 70" 8024 767/8" 8748 833/4" 9328 905 /8" 9700 1 491127: 5361.. 563/6 ". 6314: 631/4" 7214 701/8" 8038 77" 8760 837/8" 9337 903/4" 9704.:1 495/8" 5379 5612" 6331" 633/8" 7230 701/4" 8052 771/8" 8772 84" 9346 901/8" 9708 4 .493/4" 5397 565/8" 6348 631/2" 7246 703/8" 8066 77'/4" 8784 841/8" 9355 91" 9711 497 /4" .5414 563/4" 6364" 635/8" 7261 701/2" 8081 773/8" 8796 841/4" 9364 91'/8" 9714 50" 5432 567/8" 6381, ,. 633/4:' . 7277 705 /8" 8095 771/2" 8808 843/8" 9373 91'/4" 9717 501/8" 5450, 57", .` 6398 637/s ".... 7293 703/4" 8109 775/6" 8819 841/2" 9381 913/8" 9720 T 501/4" 5467. 571/6" 6415 64" 7308 707 /8" 8122 773/4" 8831 845/8" _ 9390 911/2" 9722 503/8" 5485, 571/4" 6432 641/8" 7324 71 " 8136 -777/6" 8843 843/4" 9398 915/8" 9724 501/2 "... 5502 573/8" 6448 .641/4" 7339 71'/6" 8150 78" 8855 847/6" 9407 913/4" 9726 505 /8" 5520 571/2" 6465 643/6" 7355 711/4" 8164 781/8" 8866 85" 9415 911/8" 9727 503/4" 5537 575/8" 6482 641/2" 7370 713/8" 8178 781/4" 8878 851/8" 9423 92" 9728 507/6" 5555 573/4:' 6499 645/6" 7386. 711/2" 8192 78318" 8890 851/4" 9431 51." 5572 577/8 6515. ...543/4" 7401 715/6" 8205 781/2" 8901 853/6" 9439 511/8" 5590 .. 58" 6532. 647/8'.' 7417 713/4" 8219 785/8" 8912 851/2" 9447 511/4" 5.607 581/8" ..6549 65'.'. 7432 717/8" 8233 783/4" 8924 855/8" 9455 513/6" 5625 58'/4" 6565 651/8" 7448 72" 8246 787/8 " 8935 853/4" 9463 511/2" 5642 583/6" 6582 651/4" 7463 1 721/6" 8260 79" 8946 T 857/8" 9471 -+ t i �t r �`� �lt' Yi ! i .• •� ., i �:,{ 5 Y at �µ 1 ) , , 11 ,1 i1 a. , M � t, 1 ' a` ' p ` t = ) t =,. � .,.«f% � � Y�• � ° +,� is .j 3 =� ,.� ,t t 1� � , 1�'. 1 • 1, �' ` . � ! 1 � ¢ 1 �4 (.i1 .�� i 719 u!'� �•; •ih' a..r... i , y t t .1. y ; . •', � ! � IY� � � ! 1�1 ��'I � �t i�, ter .l._ :tl.l:i''1; S;r,: v= P71, a4o =17= 'r+.u••7M �' h. 4Tl��i t K 6 A RY! 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't��•1` C {111 l; 1,11 =t ti C t`I t• Y{ )i�. t�av�l,:a "'j ti O i 'IMP SI 1 �i t''. .�t �, t,i {.l •..i�. ,•��i'+ � }��" 7��t �E � +�'-�h1•ti ��`i� }ti= cl S YtS'1 �t'; �, 4,1 }t.- tll �l,i { ly l• • `li .. ' �,,�, � ¢A` �. 1t'� , I ;x141 -Iti'` , i .YJ •1t� • ' t PI,t1 1' ,1 { A i =i , i' , �"r,i, _ � ti ,1 �, is If _,, ji; il� 7 {yfa4._•. tt} rY ,11� ; t•- ,, Y:4)�id- ;f 't {; 7• ,lei �' �t 1 t , ,�: �•Yo,•1'i•,(+ _, +.. )t It �� . . ; t1, {'17 +ISr.l i'.; ,'P �11tt'., ,'$;+e. • ?� ` %.t , ` �, _ i. '� i` SAi i �. Kern - Count Health Department Division o Environmental Health 1700 Flower Street, Bakersfield, I_. 93305 Permit No. la &1- -0a C /X Application .Dates arc`h—ZT, m~ APPLICATION FOR PERMIT TO OPERATE UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY Tie of Application (check): O New Facility r] Modification of Facility t3 Existing Facility []Transfer of Ownership Joseph Wm. Hummel, Chief Executive A. Emergency 24 -Hour Contact (name, area code, phone): Days Officer 326 -2101 Nights Same ...---Facility Name Kern Medical Center No. of Tans 3 Type of Business check): E3—Gasoline Station 00ther (describe) Hospital Is Tank(s) Located on an Agricultural Farm? []Yes E;No Is Tank(s) Used Primarily for Agricultural Purposes? []Yes X® No Facility Address 1830 Flower St., Bakersfield, CA Nearest Cross St. Mt. Vernon T R SEC (Rural Locations Only) Owner County of Kern Contact Person Ronald S. Holden Address 1415 Truxtun Ave., Bakersfield, CA Zip 93301 Telephone (805 ) 861 -2371 Operator Kern Medical Center Contact Person Joseph Wm. Hummel Address 1830 Flower Street, Bakersfield Zip 93305 Telephone (805) 326 -2101 B. Water to Facility Provided by Well, NW section of grounds Depth to Groundwater 300 feet Soil Characteristics at Facility Silty sand, Sand and Silt ,Basis for Soil Type and Groundwater Depth Determ nat ons Water level - PG&E will-report . Contractor NA CA Contractor's License No. 'Address Zip Telephone •Proposed Starting Date ProposM Completion Date .Worker's Compensation Certifica t on # Insurer D. 'If This Permit Is For Modification Of An Existing Facility, Briefly Describe Modifications Proposed NA E. Tank(s) Store (check all that apply): Tank # Waste Product Motor Vehicle Unleaded Regular Premium Diesel Waste Fuel`! -Sir 1 2 El ❑ 13 3 13 0 11 ❑ ❑ ❑ F. Chemical Composition of Materials Stored (not necessary for motor vehicle fuels) Tank # Chemical Stored (non - commercial name) CAS # (if known) Chemical Previously Stored (if different) 1 No. 2 Diesel Fuel NA 2 No. 2 Diesel Fuel NA 3 No. 2 D esel Fuel NA G. Transfer of OOw�_n__e_r_s�hiv Date orTrans of f NA Previous Owner Previous Facility Name I, accept fully all obligations of Permit No. issued to I understand that the Permitting Authority may review and iROify or terminate the transfer of the Permit to Operate this underground storage facility upon receiving this completed form. This form has been completed under penalty of perjury and to the best of my knowledge is true and correct. `'Si nature ..,j.. 9 Title Chief Executive Date 7� " Officer 0 0 MAR 2,5-� T�C qqfc,'AJT4 � DER; Facility Name Kern Medical Center Permit No.laoo Q,3 C TANK I 1 • (FILL OUT SEPARATE FORM FOR # CH TANK) FOR EACH SECTION, CHECK ALL APPROPRIATE BOXES H. 1. Tank is: ❑ Vaulted )GNon- Vaulted [Double -Wall ® Single -Wall 2. TanT Material Carbon Steel []Stainless Steel [Polyvinyl Chloride [] Fiberglass -Clad Steel Fiberglass - Reinforced Plastic (] Concrete ® Aluminum ® Bronze ® Unknown Other (describe) 3. Primary Containment Date Installed Thickness (Inches) Capacity (Gallons) Manufacturer 1954 Unknown 750 Unknown 4. Tank Second Containment ® Double - Wall [] Synthetic Liner ❑ Lined Vault ❑ None ® Unknown J] Other (describe): Manufacturer: ® Material Thickness (Inches) Capacity (Gals.) 5. Tank Interior L n nn — Rubber []Alkyd ® Epoxy []Phenolic ® Glass ® Clay []Unlined ®Unknown ® Other (describe) : 6. Tank Corrosion Protection —3Ga van z F erg ass -Clad []Polyethylene Wrap ® Vinyl Wrapping ❑ Tar or Asphalt ®Unknown []None []Other (describe): Cathodic Protection: ❑None ®Impressed Current System Macrificial e system Descry System & Equipment: 7. Leak Detection, Monitories, and Interce t on a. Tank: ❑ Visual (vaulted tanks only) Groundwater Monitoring Well(s) ® Vadose Zone Monitoring Well(s) [3U-Tube Without Liner 11U-Tube with Compatible Liner Directing Flow to Monitoring Well(s)* ® Vapor Detector* ❑ Liquid Level Sensor ®Conductivity Sensor* ® Pressure Sensor in Annular Space of Double Wall Tank ® Liquid Retrieval & Inspection From U Tube, Monitoring Well or Annular Space ® Daily Gauging & Inventory Reconciliation ® Periodic Tightness Testing ® None ® Unknown Q Other b. Piping: Flow- Restricting Leak Detector(s) for Pressurized Piping []Monitoring Swap with Raceway []Sealed Concrete Raceway ® Half -Cut Compatible Pipe Raceway ❑,Synthetic Liner Raceway [3 None ® Unknown ® Other *Describe Make & Model: 8. Tank Tightness s This Tanx Been Tightness 'bested? []Yes []No ®Unknown Date of Last Tightness Test Results of Test Test Name 'besting Company 9. Tank Repair i'ar:Tc Repaired? ❑ Yes ®No ®Unknown Date (s) of Repair (s) Describe Repairs 10. Overfill Protection [Operator Fills, Controls, & Visually Monitors Level []Tape Float Gauge ❑Float Vent Valves []Auto Shut- Off Controls ❑ Capacitance Sensor ® Sealed Fill Box ®None ❑Unknown ®Other: List Make & Model For Above Devices 11. Piping a. Underground Piping: ® Yes ®No []Unknown Material Unknown Thickness (inches) Diameter Manufacturer ®Pressure ®Suct on Gravity Approximate Length of Pipe Run b. Underground Piping Corrosion Protection : ❑Galvanized ®Fiberglass -Clad []Impressed Current ® Sacrificial Anode ® Polyethylene Wrap ®Electrical Isolation ® Vinyl Wrap ❑ Tar or Asphalt ®Unknown ❑None ❑Other (describe) : c. Underground Piping, Secondary Containment: ❑Double -Wall ® Synthetic Liner System G None ❑ Unknown ®Other (describe): MAP 2 DEP • Facility Name Kern Medical CentFr Permit No.1d Q 0-03, -° TANK 2 (FILL OUT SEPARATE FORM FOR CH TANK) FOR EACH SECTION, CHECK ALL APPROPRIATE BOXES H. 1. Tank is: ❑Vaulted ®Non - Vaulted [Double -Wall ❑Single -Wall Uhl�HOwv4 2. TanTc Material [M Carbon Steel p Stainless Steel ❑ Polyvinyl Chloride ❑ Fiberglass -Clad Steel t]Fiberglass- Reinforced Plastic 0 Concrete 0 Aluminum ❑ Bronze ❑ Unknown ❑ Other (describe) 3. Primary Containment Date Installed Thickness (Inches) Capacity (Gallons) Manufacturer 1964 Unknown 7,500 McCarthy Tank & Steel 4. Tank Secondary Containment ❑ Double -Wall Synthetic Liner ❑ Lined Vault []None ® Unknown ❑ Other (describe): Manufacturer: ❑ Material Thickness (Inches) Capacity (Gals.) 5. Tank Interior Lining [3 Rubber Alkyd []Epoxy ❑ Phenolic ❑ Glass [:]Clay ❑ Unlined E]Unknown ❑ Other (describe) : 6. Tank Corrosion Protection [Ga van z F erg ass -Clad ❑ Polyethylene Wrap []Vinyl Wrapping ❑Tar or Asphalt ®Unknown ❑None []Other (describe) : Cathodic Protection: ®None ❑Impressed Current System Macrificial Anode System Describe System & Equipment: 7. Leak Detection, Monitoring, and Interception a. Tank: ❑ Visual ((vaulted tanks only) Groundwater Monitoring Wells) ❑ Vadose Zone Monitoring Wells) [3U-Tube Without Liner ❑ U -Tube with Compatible Liner Directing Flow to Monitoring Well(s)* []Vapor Detector* []Liquid Level Sensor ❑ Conductivity Sensor* ❑ Pressure Sensor in Annular Space of Double Wall Tank ❑ Liquid Retrieval & Inspection From U -Tube, Monitoring Well or Annular Space ❑ Daily Gauging & Inventory Reconciliation ❑ Periodic Tightness Testing ® None ❑ Unknown []Other b. Piping: Flow - Restricting Leak Detector(s) for Pressurized Piping w. []Monitoring Sump with Raceway ❑ Sealed Concrete Raceway ❑ Half -Cut Compatible Pipe Raceway []Synthetic Liner Raceway [:]None ® Unknown ❑ Other *Describe Make & Modems -' -� 8. Tank Tightness eras znis ianK Been Tightness Tested? []yes []No ®Unknown Date of Last Tightness Test Results of Test Test Name Testing Company 9. Tank Repair Tank Repaired? ❑ Yes ®No []Unknown Date (s) of Repair (s) Describe Repairs 10. Overfill Protection JjOperator Fills, Controls, & Visually Monitors Level []Tape Float Gauge []Float Vent Valves ❑ Auto Shut- Off Controls 8 Capacitance Sensor ❑ Sealed Fill Box ®None ❑Unknown Other: List Make & Model For Above Devices 11. Piping a. Underground Piping: ® Yes ❑No ❑Unknown Material Unknown Thickness (inches) Diameter Manufacturer ❑Pressure ® Suction Gravity Approximate Length of Pipe Run b. Underground Piping Corrosion Protection : ❑Galvanized ❑ Fiberglass -Clad ❑Impressed Current ❑ Sacrificial Anode []Polyethylene Wrap []Electrical Isolation ® Vinyl Wrap ®Tar or Asphalt ®Unknown []None ❑ Other (describe): c. Underground Piping, Secondary Containment: ❑Double -Wall []Synthetic Liner System [None ❑Unknown []Other (describe): �� �!�1� MAR 2 1Q, "F P--� Facility Name Kern Medical Center Permit No. /- ;Z00C3C1 TANK # 3• (FILL OUT SEPARATE FORM FORti TANK) FOR EACH SECTION, CHECK ALL APPROPRIATE'BOXES H. 1. Tank is: ❑ Vaulted ®Non- Vaulted ❑Double -Wall ❑ Single -Wall UV41�40u►I4 2. TanTc Material Carbon Steel ❑ Stainless Steel [] Polyvinyl Chloride ❑ Fiberglass -Clad Steel Fiberglass- Reinforced Plastic ❑ Concrete ❑ Aluminum ❑ Bronze ❑ Unknown Other (describe) 3. Prima[ Containment _. ...Date Installed Thickness (Inches) Capacity (Gallons) Manufacturer 1982 Unknown 10,000 Owens - Corning 4. Taman �Secondary Containment ❑ Double -Wall 0 Synthetic Liner []Lined Vault ❑ None ® Unknown []Other (describe): Manufacturer: ❑Material Thickness (Inches) Capacity (Gals.) 5. Tank Interior L n ng r3Rubber Alkyd ❑Epoxy ❑Phenolic ❑Glass ❑Clay ❑Unlined [3Unknown ❑ Other (describe) : 6. Tank Corrosion Protection —3Ga van z LIFiserglass -Clad ❑Polyethylene Wrap ❑Vinyl Wrapping ❑ Tar or Asphalt []Unknown None ❑ Other (describe) : Cathodic Protection: []None UImpressed Current System Macrificial Anode System Describe System & Equipment: 7. Leak Detection, Monitoring, and Interce t on a. Tank: Visua (1 -( vaulted tanks only) []Groundwater Monitoring Wells) ❑ Vadose Zone Monitoring Well(s) [3U-Tube Without Liner ❑ U -Tube with Compatible Liner Directing Flow to Monitoring Well(s)* ❑ Vapor Detector* []Liquid Level Sensor ❑ Conductivity Sensor* ❑ Pressure Sensor in Annular Space of Double Wall Tank ❑ Liquid Retrieval & Inspection From U -Tube, Monitoring Well or Annular Space ❑ Daily Gauging & Inventory Reconciliation ❑ Periodic Tightness Testing (!]None ❑ Unknown []other' b. Piping: Flow - Restricting Leak Detector(s) for Pressurized Piping []Monitoring Sump with Raceway []Sealed Concrete Raceway ❑ Half -Cut Compatible Pipe Raceway []Synthetic Liner Raceway ❑ None E] Unknown ❑ Other *Describe Make & Model: B. Tank Tightness Has This Tank Been Tightness Tested? ❑ Yes ❑ No ®Unknown Date of Last Tightness Test Results of Test Test Name Testing Company 9. Tank Repair Tank Repaired? ❑ Yes ®No []Unknown Date (s) of Repair (s) Describe Repairs 10. Overfill Protection Operator Fills, Controls, & Visually Monitors Level []Tape Float Gauge []Float Vent Valves [:]Auto Shut- Off Controls 8 Capacitance Sensor []Sealed Fill Box ®None ❑Unknown Other:. List Make & Model For Above Devices 11. Piping a. Underground Piping: ® Yes ❑No []unknown Material Unknown Thickness (inches) Diameter Manufacturer ❑Pressure ®Suct on Gravity Approximate Length of Pipe Run b. Underground Piping Corrosion Protection : ❑Galvanized ❑Fiberglass -Clad ❑Impressed Current ❑ Sacrificial Anode []Polyethylene Wrap []Electrical Isolation ❑ Vinyl Wrap []Tar or Asphalt ®Unknown []None ❑ Other (describe) : c. Underground Piping, Secondary Containment: ❑Double -Wall []Synthetic Liner System ® None ❑Unknown []Other (describe): NO DEP • CALFORNA WATER SERVICE PROPERTY JJVENLE HALL PROPERTY PROPERTY SERVICE BUILDINGS TANKS G" WARD O FNIGATION POOL TAW WELLCI I OWEN RESIDENTIAL T' WARD (71 CARS) CENTER •G' WARD LOT ( 60 CARS] IMUOF FLOWER STREET 10:1111111t:: n FN% MENTAL U mom ..................... UNDERGROUND FUEL TANKS EXISTING CONDITIONS #2 - 7,500 Gallons Gallons KMCKERN MEDICAL CENTER #3 - 10,000 Gallons EAST EIAKERSFELO "GH SCHOOL EXISTING BULZINGS JAI�� 11 32 " 128 192 n-rl--r7 1�r Sivr-a d3a dl:�, zom zu&, X8663 dvim 17\ Ll CLAIM FOR PAYMENT. COUNTY OF KERN STATE OF CALIFORNIA CLAIM OF i f �'t/��' �ti' /y/�tf� , r/' t/��� Mt%�'' DATE �' -/22?"5 DEPARTMENT ADDRESS 270 D- >DU��1> INSTRUCTION//)S TO CLAIMANT l (1) CLAIMS MUST BE SIGNED BY THE CLAIMANT AND APPROVED BY THE HEAD OF THE DEPARTMENT BEFORE SUBMISSION TO THE COUNTY AUDITOR - CONTROLLER. (2) CLAIMANT PERFORMING SERVICES TO TWO OR MORE COUNTY DEPARTMENTS MUST MAKE SEPARATE CLAIMS FOR EACH DEPARTMENT. (3) CLAIMS FOR REIMBURSEMENT OF TRAVEL EXPENSES MUST INCLUDE A STATEMENT OF THE PURPOSE OF COUNTY BUSINESS. (4) NO CLAIMS WILL BE AUDITED OR ALLOWED UNTIL THE ABOVE REQUIREMENTS HAVE BEEN MET. DATE 19 DESCRIPTION DOLLARS CENTS P%F Fund No , ' & O o 0 FO 13 008 014 DODO j dD0 000 //� —� O�-/•� --e-r- Issue Dore Vendor No Descnpeve Purpose of Claim - L-1 in 30 Spoce% 0091 1 023 TOTAL moo► / a The undersigned, under penalty of perjury, states: That the above clam and the items ore therein set out ore true and correct; that no part thereof has been hereto- fore paid; that the amount therein is justly due; and that the some is presented not later than one year after the accrual of the cause of action. DONT sign Firm name • • sign YOUR name here. if FOR FILING STAMP ONLY CLAIMANT SIGNATURE DATE I� 6EL0 W FOR COUNTY USE ONLY Expenditure Authorized and Approved By: UPER VISOR Deportment No. Cloim No. S,gnorure Dore Con+Loct No P%F Fund No 3 -6 11 FO 13 008 014 DODO j dD0 000 //� —� O�-/•� --e-r- Issue Dore Vendor No Descnpeve Purpose of Claim - L-1 in 30 Spoce% 0091 1 023 r Lo-11 /�?OD 1 If as stored, above is o LEGAL CHARGE against the County for the sum of S II E +p. Code Amouw,r PY Dry s.on Project Act..oy a Fculny a 1 02 & a & Auditod and Allowed Auditor- Conttoller BY AUDITOR CONTROLLER County Cuu'net Date 102 & & & & & 1021 1& & I& I& & T0TALI006[$ �D & 1& 1& I&