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HomeMy WebLinkAbout3601 STOCKDALE Hwy_ELD TESTING 4.15.1111111111 21 IE ❑ HOODS ALARMS SPRNKLER SYSTEMS 11I/ S SP R ° Y BOOTH AST UST Permit No. Permit No. Permit No. Permit No. Permit No. Permit No. 7 1 t� File Number: 313-2— Date Received: 41— /.S-- j Address: � ?6 a / Bakersfield, CA 933. Business Name: moo. S S aZ'c p SYSTEM: BUILDING SQUARE FEET: New Mod. ❑ ❑ Commercial Flood System ❑ ❑ Fire Alarm System ❑ ❑ Fire Sprinkler System ❑ ❑ Spray Finish System ❑ ❑ Aboveground Storage Tank ❑ ❑ Underground Storage Tank minor modification Underground Storage Tank removal Underground Storage Tank OK' Other: Comments: Building Sq. Feet: Calculation Bldg. Sq. Ft: 1. a. 3. 4. Date Time �;-A--//i C-0 1 NSQL' 1 IIIIYII� W., �el Signature Signature ❑ IIIIYII� 22 IE UNDERGROUND STORAGE TANK PERMIT APPLICATION TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD Permit # BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street a s X! P I° D Bakersfield, CA 93301 pigs Phone: 561- 325 -3979 a Fax: 661 -852 -2171 /ARra 9 Page 1 of 1. TYPE OF APPLICATION: 0 NEW TANK INSTALL/NEW FACILITY ICHEr'K nNF nN! Y) I-} Mr)DIFIC'ATInN nF FAru rry STARTING DATE/ P PROPOSED COMP FACILITY NAME � 'I j � E EXISTING FACILITY PERMIT # FACILTIY ADDRESS 3 1 Cif`(Z n Z ZIP CO�Ei5� TYPE OF BUSINESS ` # TANK OWNER t ) t � ( P PHONE ADDRESS ?1(001 O � , �, / C CITY Z ZIP CODE CONTRACTOR f I/� ,^ /' � CA 6530 I � i iCC 7 ADDRESS r(� / CFry / IVY/ QI ► • • ZIP CODq jV PHONE 0 f1„ -"C161 I. I' o I\ B BAKER FIELD CITY BUSINESS'LICENSE # W WORKMAN COMP- t I INSURREER�`�,(, - BRIEFLY DESCRIBE'THE WORK TO BE DONE: 6, J D I G S 1 � W 0 R K PUA �, 4 C WATER TO FACILITY PROVIDED BY DEPTH TO GROUND WATER ( SOIL TYPE EXPECTED AT SITE # OF TAN TO BE INSTALLED ARE7HEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? Q NS , ❑ YES ❑ NO IO YES ❑ NO THIS SECTION IS FOR STORAGE TANK IDENTIFICATION TANK Yt VOLUME UNLEADED R REGULAR PREMIUM DIESEL (OTHER 10 k U l�. Tank Testing Company NAME OF TESTING CO''MPANY!' –7 k t ♦ I / P PHONE NUMBER Q ./�/��' Q ! r ry� O NAME OF TESTER -rD FA'4 � OD DO F F7c7C, � — � 0 3 A � o . ^�I a+ t. r( THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED 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. NAME OF TESTER I ICC# THIS APPLICATION BECOMES A PERMIT WHEN APPROVED FOR OFFICIAL USE ONLY DATE APPROVED � APPR 9Y r , 9 i 9 OP•ID:.SL CERTIFICATE OF LIABILITY INSURANCE 7(04/07111 Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE, HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSLIUR(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the cortil -16te holder is an ADDITIONAL INSURED, the policy(fes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 970- 635 -9400 PFS Insurance Group - JT 4848 Thompson Pkwy, Ste 200 970- 635 -9401 Johnstown, CO 80534 Dave Janssen CONTACT PHONE FAX [rte N�- E�L41: I {AIC _No): E0MAIL ADDRESS• PRODUCER CG RS -1 INSURERS) AFFORDING COVERAGE NAIC 0 INSURED C G R S, Inc. PO Box 1489 Ft. Collins, CO 80522 INSURERA:ACEAmerican Insurance Company INSURER B:Zurich- American Ins Ca. 16535 INSURER C : EMC Insurance Companies INSURER DACE Westchester $ 1,000,00 INSURER E S 54,00 INSURER F : X COMMERCIAL GENERAL LIABILITY CLA)IAS40ADE I ,• I OCCUR I6i61•1 =:16Tn7.1 I- r��I«raT��m *IetdrA THIS IS TO CERTIFY THAT THE POLICIES' OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P.OLIC.Y, „PERIOD INDICATED. NOTWITHSTANDING ANY-REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO- WHiCKTHIS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED 'HEREIN IS SUBJECT TO ALL THE TERMS; EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. IN S LTR- TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF .. 1 POLICY EXP LIMrr$, GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 PREMISES EaoauR~ rr S 54,00 D X COMMERCIAL GENERAL LIABILITY CLA)IAS40ADE I ,• I OCCUR G22071798005 03/01/10 03/01/12 MEDEXP Omaha parson), S 5;00 PERSONAL 8ADV INJURY •s 1,000;00 X POLLUTION/PROF BLKT ADUL INS - ENV310 CLAIMS MADE GENERALAGGREGATE 6 2,000;00 WAIVER - ENV3101 (08 -04) GEN- LAOrREGATELurrAPPLIES?ER PRODUCTS - COMPiOPAGG S -2,_00;00 POLICY n F° LOC Polt/Prof $ 1,_OO;Oti A AUTOMOBILEUABit)'iY X ANY AUTO 1­10841564A005 03 /16111 03/01/12 COMBNEDSPtGLELIMrr (Ea ocsidant ) 5 1,000,00 BODILY INJURY (Par parson) S ALL OWNED AUTOS BODILY INJURY (Per accident) $ A X SCIHEDULED AUTOS HIREDAUTOS PROPERTY DAMAGE (Peraccleant) $ A X NON- AWNEDALITOS UMBRELLA LIAR X OCCUR EACH OCCURRENCE S. 1;000;00 AGGREGATE S 1,000;00 D EXCESS uaa CLAIMS MADE G 24117868002 03101/11 03/01/12 rX DEDUCTI6LE 5 RETENTION S S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIEroPiPARTNERe— _orIvE YIN OFFICER /lArN 6ER DCLUDrb? (Mandatory In NH) NIA C4632690 -00 BLANKET WAIVER 01101111 01/01/12 X WC L M� X O R l E_L_ EACH ACCIDENT Is 1,0000G E.L DISEASE -EA EMPLOYE s 1,000,00_ It yye�s, describe under Dr""SCRPTIONOFOPERATIONS.b,,0ow EL_ - DISEASE - POLICY LIMIT S 1,000;00 D G2207179RO05 03/01/10 03/01112 EachClairn 1;000,00 C IPROFEStPOLLUTION Equipment Floater C48945 03/16/11 I 03/01/12 Rented 200;0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, Ir mom space Is required) If reqquired by written agreement, the certificate holder is included as dditional insured for ongoing operations under general liability. ACORD 25 (2009109) L:ANLLLLA I IUN - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED, BEF ORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVisiONS. AUTHORIZED REPRESENTATIVE ©1988 -2069 ACORD CORPORATION. All rlalits reserved_ The ACORD name and logo are registered marks of ACORD L t i 1 f, i� f 1 CITY OF BAKERSFIELD *POST CONSPICUOUSLY* *NON- TRANSFERAB .Business name ..: C G R S INC �; a i Location address .: OUTSIDE CITY Lic Nbr /Class ..: 11 00108351 SERVICE OR MANUFACTURING MISCELLANEOU t Fo Issue date ....: 5/31/10 Expiration date .: 6/30/11 License comment .: ENVIRONMENTAL CONSULTING CG R S INC Owner /Officer _ 5444 DRY CREEK. RD CGRS INC j S-ACRAMENTO CA 95838 MICK, ERIC L BUSINESS TAX CERTIFICATE IS HEREBY GRANTED. UCENSEE IS TO COMPLY WMI ALL LAWS AND ORDINANCES. ISSUANCE OF THIS UCENSE DOES NOT.CONSTmjTE AumORITAi1ON TO CONDUCT BUSINESS IF UCENSEE HAS NOT COMPLIED WITH ALL APPUCABLE LAWS AND ORDINANCES. THIS UCENSE IS ISSUED WITHOUT VERIFICATION THAT THE UCENSEE IS SUBJECT TO OR EXEMPT FROM UCENSING SY THE STATE OF CAUFORNIA. i .-.e 00(do 4A WATER ump-W(*E_)pqD.*CRA4f tAtik, TESIM wc Vise T% 014 & -5K Yta .AA Date: REV. December 17, 2007 Revised by: Randy Golding Approved by: Randy Golding Work Plan Site Name 7 -11 #17721 Address 3601 Stockdale Hwy City and State Bakersfield CA. 93309 introduction Praxair Services, Inc. QA Tracer Tight® Version ti Owner 7 -11 #17721 3601 Stockdale Hwy Bakersfield, CA 93309 In Service Enhanced Leak Detection Protocol (IS -ELD) (The 1S -.CLD Method Utilizes an Onsitc Site Laboratory for Real -Time Results) In Servicc.Cnhanced Leak Detection (IS -ELD) means a test method which is approved by the California Water Resources Control Board that ascertains the physical integrity of an underground tank system by introduction, and external detection, of a substance that is not a component of the Fuel formulation that is stored in the tank system while the systern is. service. The test method is third party certified for the capability of detecting both vapor and liquid phase releases -from the underground storage tank system, - The Enhanced Leak Detection test method is capable of detecting a leak rate of at least 0.005 gph or less; with a probability of detection of at least 95% and a probability of false alarm no greater than 5 %. Concept Tracer Tighte is a unique method of testing underground storage systems for tightness. A unique chemical called a tracer. is added to the product. stored in the tank. The tracer is an inert chemical that evaporates readily from the fuel. Afters" tracer is added to the system, it is distributed between the vapor and liquid inside the tank. Use of the system carries the tracer throughout. the piping. if any small leak exists in the system, the tracer is allowed to escape from the system'; either as a vapor or as a dissolved component of the liquid. Once outside the system, the dissolved tracer evaporates from the liquid and the tracer vapors begin to migrate away from the location of the leak in all directions. After all appropriate waiting period, the tracer vapors are detectable at least ten .Feet or more away from the leak in all directions. Samples of air collected from tite soil within the radius of detection of the tracer reveal the leak as a presence of the tracer chemical. Because the tracer chemical is not normally found in the environment or in fuel products, the Tracer Tighte method is able to discri- minate between previous contamination and current leakage. Contractor It is important that before Praxair arrives on site that the tanks receive enough fuel to avoid deliveries until the test is completed. If a fuel drop becomes necessary in order to keep the station open then contact Praxair's site projectmanager and schedule the drop while the crew is onsite. A clean fuel drop reduces the possibility of having to retest: the site. A contractor capable of repairing any exposed component in the system including having spare parts must: be onsite to expedite repairs. The contractor skills must include the ability to operate and make adjustments to the settings of the electronics controlling the fueling system. The contractor must be capable and committed to working longer hours and extended days outside of normal work week. The owner's contractor will be in complete control of the fueling system and it is the contractor's responsibility to operate the fueling system properly and to reassemble the system back into a pretest configuration. Praxair Service, Inc. is only responsible .for testing the fueling system and is not responsible for its operation. TIIIS INFORAIA7 /ON ISTHh, PROPERTY OF PRAXA1R SERVICES, INC.. 1 of Date: December 17, 2007 hraxair Sewices, Inc. QA. Revised by: Randy Golding Tracer Tight® Approved by: Randy Golding Version G Description The process is described in the following steps: • 'Preparation • Probe Array Installation • Confirmation "rest • Inoculation • Leak Simulation • Sample Collection • Analysis • Spill Bucket Test • Reporting Preparation All necessary permits must be acquired and appropriate notices to local regulators Must be given prior to arrival at the site. Upon arrival, the crew reviews the tank information that has been made available and uses this information, to plan the installation.of the sampling probe array. 'if "as built." plans or site plans have not been made available, the crew inspects all accessible portions -of the system to learn as much as possible about the location of all UST system components. If the site is udder remediation, soil vapor extraction systems, air- sparging systems and bio- venting systems must be turned off during die test. Groundwater measurements are to be taken within the tank excavation zone. Probe Array Installation The following ELD probe installation was approved by the Water Resources Control Board. Vertical PVC sampling. probes are installed within eight horizontal feet of all possible leak locations (a maximum of 1.5 feet apart). In situations, where tank pits and piping trenches do not contain cnginecred backfill (sand or pea- gravel), the sampling probes are installed with a maximum 10 -foot spacing. Tank probes are installed along the side of each tank, generally at a -depth centered on the tanks. Maximum probe depth is 15 feet (or just above the water table if applicable): Additional probes are installed near any appurtenances along the tank ridge where a containment sump is not present. Piping probes are placed ,r along the product distribution, vapor recovery and vent piping trenches; to one half the depth of the piping or until the end of the probe is within engineered backfill..Probes are generally installed at a depth of I to L5 feet below grade. Probes are installed by coring a hole in the pavement and inserting a sampling probe into the excavation zone of the tank or pipe. The top of each probe is fitted with a PVC sampling cap that will allow access for the collection of samples. . Confirmation Test Confirmation Test (Pre - certification tightness test) is completed before the system is inoculated. The test is used to confirm the tightness of all the accessible fittings. This is done to ensure that the facility is tight before adding the tracer. A repair technician should be on site with all tools and parts to .complete repairs to any and all components that are accessible. The technician should be qualified /certified to program and operate the electronics controlling the fueling system. Lnocidation inoculation is the process of adding chemical tracer to the product in the system to be tested. Product is inoculated with a predcternined amount of tracer, though the tall riser. Tracer is mixed with the product by using the system: Once sufficient amount of tracer labeled product has been moved through each dispenser, the product is tested at each dispenser to confirm that tracer is present. By keeping the dispenser nozzle inside a receiving container, additional product is pumped into the container to push tracer labeled vapors through the vapor return piping back to the tank. The tracer /vapor mixture is then pushed from the UST out to the vent riser into a container of sufficient size that the tracer /vapor mixnure Trans IATORMATION rs 7711: PROPENT r Or Pert x uR SERVICES INC.. 2 of 3 Date: December 17, 2007 Revised by: Randy Golding Approved by: Randy Golding Praxair Services, Ind. QA Tracer Pglaib Version 6 has displaced the entire volume of the vent piping. The concentration of the tracer in the receiving container is then measured. Leak Simulation Injecting a tracer into the back-fill performs a leak simulation. The leak simulation tracer is not one of the tracers used in testing the system. The migration period of the leak. simulation tracer is monitored through the sampling probes. The minimum migration time required for the test is equal to die time required for the leak' simulation tracer to move an acceptable distance. The minimal acceptable distance is the longest distance that the test tracer would have to travel from any leak location to the location of a sampling probe. Sample Collection Once the Icak simulation, migration period is determined, the inoculation and waiting period is completed and samplirg can begin. Vapor samples are collected from all sampling probes. Additional vapor samples may be collected -from sumps containing uS'r components, under dispenser containers ([TDCs) and from the interstitial spaces of double %valletl components. Sample Analysis Samples are analyzed using an on site laboratory grade gas chromatograph (GC). The GC is calibrated using.an ehteraal bas standard. Samples are analyzed by direct injection into the GC. The results are evaluated by comparison to the analytical standard. Whenever tracer is detected in the subsurface samples, blanks are run to validate the tracer detection. Spill - Bucket Testing Over - spill - buckets are tested hydro - statically. A decrease in water level indicates a leak. If leaks occur, spill bucket seak should be repaired or replaced. Reporting The findings of the Tracer Tighto LLD test and site evaluation will be summarized in a written report and sent to (lie client within two weeks of the completion of the fieldwork. All data acquired from probe and sump samples will be reported along with spill bucket hydro -test results. THIS INFORMATION IS THE PROPERTY OF PRAXAIR SERVICES, INC.. 3 of 3 Stephanie Birch From: Stephanie Birch Sent: Thursday, April 07, 2011 3:44 PM To: 'OTTL OTTL' Cc: 'hazmatprogram @co.kern.ca.us'; 'Stephen Coulter'; Jared Beavers; Mark Lindsey; Chris Murphy Subject: Well Proximity ELD Testing - 7 -11 #17721 in Bakersfield; CA Hello Everyone, The following site is scheduled for its final ELD test at Sam Wednesday, April 20, 2011. Please let me know if I should forward this information onto anyone else. °Site dame 7 -11 #17721 Street Andress 3601 Stockdate Hwy City State County Zip code' Bakersfield CA [Kern 93309 Thank you. Stephanie Birch CA Service Coordinator CGRS, Inc: 916.991.1100 Fax: 916.991.1177 www. c g rc�.crnl stephanie(cDcprs. corn Please note that my office fours are Monday, Wednesday, Thursday 8am - 5pm CGRS is open Monday - Priday 8am - 5pm I CONSTRUCTION PERMIT BAKERSFIELD FIRE DEPARTMENT PREVENTION SERVICES B E R S P I D 1501 TRUXTUN AVENUE, 11T FLR FIRE BAKERSFIELD, CA 93313 k.- T Office Phone: (661) 326 -3979 Application Number . . . . . Property Address . . . . . . ATN (11 Digits): Application type description Subdivision Name . . . . . . Property Use . . . . . . . . Application valuation . . . . Owner ------------------------ JAPAGE PARTNERSHIP P O BOX 711 DALLAS TX 75221 11- 10000131 Date 4/19/11 3601 STOCKDALE HWY 149 - 222- 29 -00 -7 FIRE DEPT 0 Contractor ------------------ - - - - -- OWNER ---------------------------------------------------------------------------- Permit . . . MANDATED LEAK DETECT TEST Additional desc . . Phone Access Code . 1089127' Permit Fee . . . . 96.00 Plan Check Fee 96.00 Issue Date . . . . 4/19/11 Valuation . . . . 0 Expiration Date 10/16/11 ---------------------------7------------------------------------------------- Fee summary ----------- - - - --- Charged ---- - - - --- ---- Paid Credited - - - - -- Due' Permit Fee Total 96.00 ---- - - - - -- ---- 96.00 .00 - - - - -- .00 Plan Check Total 96.00 96.00 .00 •.00 Grand Total 192.00 192.00 .00 .00 CALL FOR INSPECTION (661) 326 -3979 Please state the Permit Number, the Job address, and the Type of Inspection. Requests for inspections should be made at least 48 hours in advance. DECLARATIONS Permit is issued in accordance with all applicable Federal, State and Local Ordinances. The permittee has properly signed and dated the reverse side of this form. This Permit expires after180 days of inactivity. I have reviewed the above application, and find it to be correct/complete. Permittee: Date: HAZARDOUS MATERIALS STATEMENT —Yes—No Will the applicant or future occupant handle hazardous material or a mixture containing a hazardous material equal to or greater than the amounts specified on the list of extremely hazardous substances? See checklist for guidelines. _ Yes — No Will the proposed building or modified facility be within 1000 feet of the outer boundary of a school? —Yes—No Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the Kern County Air Pollution Control District ( KCAPCD) or from the Bakersfield Fire Dept? See checklist for guidelines. —Yes—No I have read the Hazardous Material Guide and KCAPCD Permitting Checklist. I understand my requirements under the Calif. Health and Safety Code Sec. 6.95 and Calif. Govt. Sec. 65850 and the requirements of the City of Bakersfield Fire Dept. regarding hazardous materials. Owner or Authorized Agen hone No. Date DECLARATIONS: The declarations below are mandated by the State of California under Section 19825 of the Health and Safety Code. LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of the Division 3 of the Business and Professions Code and my license is in full force and effect. Lic. Class Lic. No. Exp. Date Contractors Signature Date OWNER - BUILDER DECLARATION I hereby affirm that under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Sec. 7031.5 Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 commencing with Section 7000 of Division 3 or the Business and Professions Code) or that he or she is exempt there from and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)): I, as owner of the property or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he or she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who.contracts for such project with a contractor(s) licensed pursuant to the Contractor License, Law). I am exempt under Sec. B. & P. C. for the reason Owner Signature I Date WORKERS COMPENSATION DECLARATION I hereby affirm that under penalty of perjury one of the following declarations: Carrier I have and will maintain a certificate of consent to self - insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Policy No. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions. Applicant: Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000) IN ADDITION TO COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097 Civ. C.) Lenders Name Lenders Address 1 certify that 1 have read this application and state that the information contained herein is correct. 1 agree to comply with all city ordinances and state laws relating to building construction and hereby authorize representatives of the city to enter the above mentioned - property for inspection purposes. . Signature of Applicant or Agent I Date BAKERSFIELD CITY FIRE DEPARTMENT -- INSPECTION RECORD Post this Card at the Job Site and DO NOT Remove for Duration of Work Inspection Request Phone No. (661) 326 -3979 UST NEW INSTALL DESCRIPTION DATE SIGNATURE BACKFILL PRIMARY PIPE SECONDARY PIPE SECONDARY CONTAINMENT SENSORS AUTHORIZATION FOR FUEL ELECTRICAL SEAK -OFF - TANK TESTING UST REMOVAL DESCRIPTION DATE SIGNATURE EVR UPGRADE MISC. ACTIVITY tEMARKS: AST NEW INSTALL DESCRIPTION DATE SIGNATURE MODIFICATIONS MINOR / MAJOR AST REMOVAL DESCRIPTION DATE SIGNATURE PRIOR TO OPERATION OF ANY SYSTEM, ALL UST AND /OR AST SYSTEMS SHALL BE-, INSTALL, COMPLETE AND ACCEPTED BY, ,THE BAKERSFIELD CITY FIRE DEPARTMENT. FIRE DEPARTMENT (FINAL) WILDING ADDRESS: JOB DESCRIPTION: �'G.D O CUPANCY TYPE: DWNER: PERMIT NO. CONTRACTOR: Cts'W S PHONE /- QQ rU 1/4,3 CGRS, INC. 55221 .t_