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06-1867 (CSST)ek f. i� P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: C 06-00001867 Property Address: 79315 HIGHWAY 111 APN: 649-030-034- - Application description: NEW COMML - SERVICE Property Zoning: REGIONAL COMMERCIAL Application valuation: 125315 Applicant: t� T4ht.. 4 �u%IUCl/ BUILDING & SAFETY DEPARTMENT BUILDING PERMIT STATIONS & GARAGES Architect or Engineer: S P LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License Class: A, B, C21, C3 Li No.: 708231 . Date: L/ (OContractor. OWNS -BUILDER DECLARATION ' Ihereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason (Sec. 7031 .5, Business and Professions Code: -Any city or county that requires a permit to "construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the -permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom 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 1$500).: (_ 1 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' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within ___N 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.). (_ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). ( 1 I am exempt under Sec. , B.&P.C. for this reason C. »'� ,. Date: Owner: CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). ' Lender's Name: _ Lender's Address: LQPERMIT I _Ly_ Owner: SAM'S WEST INC 702 SW STH ST BENTONVILLE, AR 72716 Contractor: JAUREGUI & CULVER, INC. 959 W. MISSION AVENUE. ESCONDIDO, CA 92025 (760)743-0518 Lic. No.: 708231 lIJ VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 11/14/06 NOY 15 200 WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 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: Carrier STATE FUND Policy Number 1758942 _ 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 thoserprovisions. Date: �� Applicant WARNING: FAILURE TO SECURE WORKERS' C PENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this application. 1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application, the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply witti all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the above-mentioned property for inspectio purpo s. 1 Dat(../ -/j` Signature (Applicant or Agent): Application Number 06-00001867' ------ Structure Information FUEL STATION &CANOPY ----- Other struct info . . . . . CODE EDITION 01BMP04E05EN FIRE.SPRINKLERS NO MIXED-USE OCCUPANCY S -3/B OCCUPANT LOAD 3.00' PATIO SQ FTG 4971.00 -------------------------------------------------.------------- 1ST "FLOOR SQUARE FOOTAGE 224.00 -------------- Permit PLUMBING Additional desc . Permit Fee . . . . 114.00 Plan Check' Fee 28.50 Issue Date Valuation 0 Expiration Date 5/13/07 Qty Unit Charge Per Extension ` BASE FEE 15.00 4.00 6.0000 EA PLB FIXTURE 24.00 1.00 15.0000 EA PLB BUILDING SEWER 15.00 7.00 6.0000 EA PLB ROOF DRAIN 42.00 1.00 7..5000 EA PLB WATER HEATER/VENT 7.50 1.00 3.0000 EA PLB WATER INST/ALT/REP 3.00 1.00 7.5000 ------------------------------------------- EA PLB OTHER BACKFLOW <=2 INCH --------------------------------- 7.50 Permit . . . MECHANICAL Additional desc . Permit Fee . . . . 98.00 Plan Check Fee 24.50 Issue Date Valuation . . 0 Expiration Date 5/13/07 Qty. Unit Charge Per Extension BASE FEE 15.00 1.00 9.0000 EA MECH FURNACE <=100K 9.00 1.00 9.0000 EA MECH B/C <=3HP/100K BTU 9.00 1.00 6.5000 EA MECH VENT FAN 6.50 9.00 6.5000 --------------------------------- EA MECH OTHER MECH EQUIPMENT 58.50 -------------------------------------------- Permit GRADING.PERMIT Additional desc . Permit Fee 15.00 Plan Check Fee .00 , Issue Date Valuation . . . . 0 }y Expiration Date 5/13/07 Qty Unit Charge Per Extension BASE FEE 15.00 LQPERMU . � � � L.�PERMIz ' Application Number . . . . .. 06-00001867 --------------------------------------------------------- ^---_---------------^ gezmit . . . . . . ELoC-NEW COMMERCIAL ^ Additional deoo . . Permit Fee ' . . . 122.90 Plan Check nee . . 30.73 ' Issue Date . . . . Valuation . . . . o Expiration Date . . 5/13/07 _ ` Qty Unit Charge Per o��euaiou BASE Foo � � 15.00 53�5.00 '0200 -------------------------- ELoC GARAGE OR NON-RE"oIoENTzAL 107.90 ----------------------—--------------------— ~ ` ' Permit . . . . . . BUILDING PERMIT Additional deao . . ' -Permit Fee . . . . 730.50 Plan Check Fee . . 474.83 saooe Date. . . . . Valuation . . . . 125315 .Expiration Date . ' 5/13/07 Qty Unit Charge Per Extension BASE FEE 639.50 ' 26.00 3.5.000 Ta0D BLDG 100'001-500'00'0 �e1.00 ----------^---------------------------------------------------,--�---`------- 8peoial Notes and Comments FUEL STATION w/ 4971 8n CANOPY AND 224 CONTROL BLDG. S-3 occ'_TzgE zz-m CoNozRncrzom' OCCDrxuvr LOao.=' 2 � CONTROL BUILDING. 2001 CoC'CMC,CPC, 200* CEC, cOOs omoaGr CODES. **PERMIT ooEo NOT INCLUDE SIGNS AND SITE LIGarzmG°° ------------------------------- _ Otber Fees . . . .. -----------------,-------------------,------- . . . . AccE88zBzLzTz PLAN aovzE* 47.48 »uRr IN eDoLzC PLACES -COM 606.57 DIF CIVIC CENTER - COMM 34.94 ' ENERGY REVIEW FEE 47.48 DIF FIRE PROTECTION -COMM 10.08 STRONG m0TZ0m (SMI) - COM 26'31 DIF SrRoor MAzNT IAC -COMM 23.74 DIF raxm«SeDRTArz0n - COMM 589.57 Fee summary Cbarged Paid credited Due ----------------- -------------- eezmit'Fee Total ----- -------_---- 1080.40 ' - .OV ' .00 1080.40 Plan Check Total' 558.56 400.00 .00 158'56 Other Fee Total 1386.17 .00 .00 1386.17 ' Grand Total 3025.13 400.00 .Ou . ' 2625.13 44 LQPERMIT Application Number . . . . 06-00001867 s s r � P.O. BOX 1504 Building �778-495 CALLE TAMPICO Address / 7p �/J /7litlO �!/ LA OUINTA, CALIFORNIA 92253 Mailing Address CityZip Tel. �Zzl_ 72?/6Li o e2gs d Contractor uRr v2�llq _TNc Address Tel. & Classif. / i , -I I I Lic. # Designer Lic. # LICENSED CONTRACTOR'S DECLARATION affirm that I am licensed under provisions of Chapter 9 (commencing with Sec Xvision 3 of the Business and Professions Code, and my license is in full force OWNER -BUILDER DECLARATION I her y affirm that I am exempt from the Contractor's License Law for the f owing reason: (S . 7031.5, Business and Professions Code: Any city or county which r quires a permit to co truct, alter, improve, demolish, or repair any structure, prior to its iss nce also requires the a licant for such permit to file a signed statement that he is license ursuant to the provisions the Contractor's License Law Chapter 9 (commencing with Se ion 7000) of Division 3 0! the siness and Professions Code, or that he is exempt therelro and the basis for the alleged exe ption. Any violation of Section 7031.5 by any applicant for permit subjects the applicant to a c it penalty of not more than live hundred dollars ($500). ❑ I, as owner of the operty, or my employees with wages as their sole c pensation, will do the work, and the air re is not intended or offered for sale. (Sec. 7044, us1ness and Profes- sions Code: The Con for's License Law does not apply to an owner property who builds or improves thereon and ho does such work himself or through his o emplo ees, provided that such improvements a not intended or offered for sale. If, ho ver, the building or im- provement is sold within a year of completion, the owner -build will have the burden of proving that he did not buil r improve for the purpose of sale). ❑ I, as owner of the property, exclusively contracting with lice sed contractors to construct the project. (Sec. 7044, Busin s and Professions Code: The ontractor's License Law does not apply to an owner of prope who builds or improves ther n, and who contracts for such projects with a contractor(s) lice ed pursuant to the Contra or's License Law) O 1 am exempt under Sec. B. & P.C. for this r ason Date Owner WORKER'S COM NSATI DECLARATION I hereby affirm that I have a certificate o con `v to self -insure, or a certificate of Worker's Compensation Insurance, or a certified copy eof. (Sec. 3800, Labor Code.) Policy No. Company Copy is tiled with the ci/soastobecomesu e c y is hereby furnished. CEF EXE TION FROM WORENSATI N INSURANCE (This section need not be compermit is ( one hundred dollars ($100) valuation or less). I certify that in the perforwork for w h this permit is issued, I shall not employ any person in any manecome subjec 0, Workers' Compensation Laws of California. Date- NOTICE ate NOTICE TO APPLICANT.' If, fter making this Certificate of emption you should become subject to the Workers' C mpensation Provisions of the La r Code, you must forthwith comply with such provisions or this permit shall be deemed revo d. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the rformance of the work for which this per tis issued. (Sec. 3097, Civil Code.) Lender's Name Lender's Addre This is a b [ding permit when properly filled out, signed and validated, nd is subject to expiration if w k thereunder is suspended for 180 days. I certify at I have read this application and state that the above informa'on is correct. I agree to mply with all city and county ordinances and state laws relalin to building constructio , and hereby authorize representatives of this city to enter the abov entioned property for inspection purposes. Signatuof applicant Date WHITE = BUILDING DEPARTMENT 69�49K�. APPLICATION ONLY BUILDING: TYPE CONST. 2—N OCC. GRP .� A.P. Number �% - 63 n 3 dLegal Description Project Description�L� ZONE: BY: Minimum Setback Distances: Front Setback from Center Li FINAL DATE_ Issued by: Validated by: Validation: YELLOW = APPLICANT PINK = FINANCE Sq. Ft.No. No. Dw. Size Z Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation _5-g cry" PERMIT IM AMgWT Plan Chk. Dep.—� Plan Chk. Bal. IF r Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS 4 ZONE: BY: Minimum Setback Distances: Front Setback from Center Li FINAL DATE_ Issued by: Validated by: Validation: YELLOW = APPLICANT PINK = FINANCE CITY OF LA QUINTA - PUBLIC WORKS /ENGINEERING bEPARTMENT GREEN SHEET (PUBLIC WORKS CLEARANCE) FOR BUILDING PERMITS Form updated &.ef[ectivc 8/25!2005 Please DO NOT submit the Green Sheet (Public Works Clearance) Packet to Works/Engineering Department until ALL requirements listed below are complete. applications or applications which cannot be processed will be returned to Applicant. approvals will be forwarded to .the Building Department directly by p111k1;f, w„ri,� -Irl Date: 5 Tract No.: Address(s): the Public. Incomplete Green Sheet 'The following are the requirements for Public Works Clearance to authorize issuance of a building permit from the Building/Safety Department. CUSTOM HOMES: PROVIDEITEMS #2 #3 #4. AND #5 BELOW. TRACT HOMES: PROVIDE ITEMS #1 #2 #3 #4 AS APPLICABLE AND #6 BELOW. COMMERCIAL BUILDINGS/OTHER: PROVIDE ITEMS #1 #2 #3. AND #S BELOW. J. ttach�a:�:��Ievatiohertificates in compliance with the approved design elevation for uilding pad (maximum allowable .deviation of +/_ 0.1 foot). Pad Elevation Certificates must be current (within .6 months of current date).. If a precise grading plan creates the pad for approval, please withhold green sheet submittal until. a Pad Elevation Certificate can be a.. /.provided.' Ch geotechnical certification of grading plan compliance. Zhu U�/lir -iii Attach recorded final map showing proposed building locations a& legal lots. /4. Attach a completed <1 acre per lot or infill project Fugitive"Dust-Control project information form, PM10 plan &agreement or provide alternative & valid City approved PM10 plan set. reference number or hard copy plan. PM -l'0 plans for commercial and residential developments (beyond 1 lot) are submitted separately with grading' -plans and are subject to additional -r uirements. Attach an approved precise grading plan for the building location(s). AO flood, zone developments will require an approved.flood.plain development plan. 6. Attach an approved rough grading plan for the building location(s). I have reviewed and confirmed the requirements listed above as presented. and find the improvements. to be sufficiently complete for construction of the proposed. building(s)/structure(s) on the subject lot(s). Pursuant to my f ndings, the ab a project may be released forlolding permit. issuance. Recommended by: Dated: Declined for approval for reasons) as follow(s), please correct and TAPWDEPTSTAFF\Gobk\Grc Shat PW Rcksscb50824GREENSHEET COVERdoc EsGil Corporation In (Partnership with Government for Building Safety DATE: July 6, 2006 JURISDICTION: La Quinta PLAN CHECK NO.: 06-1867 PROJECT ADDRESS: 79-315 Highway 111 PROJECT NAME: Sam's Gas Station SET: II ❑ APPLICANT W JURIS. ❑ PLAN REVIEWER ❑ FILE ® The plans transmitted herewith have been corrected where necessary and substantially comply With the jurisdiction's building codes. PLEASE SEE REMARKS BELOW. ❑ The plans transmitted herewith will substantially comply with the jurisdiction's building codes when minor deficiencies identified below are resolved and checked by building department staff. ❑ The plans transmitted herewith have significant deficiencies identified on the enclosed check list and should be corrected and resubmitted for a complete recheck. ❑ The check list transmitted herewith is for your information. The plans are being held at Esgil Corporation until corrected plans are submitted for recheck. ❑ The applicant's copy of the check list is enclosed for the jurisdiction to forward to the applicant contact person. ❑ The applicant's copy of the check list has been sent to: ® Esgil Corporation staff did not advise the applicant that the plan check has been completed. ❑ Esgil Corporation staff did advise the applicant that the plan check has been completed. Person contacted: Telephone #: Date contacted: (by: ) Fax #: Mail Telephone Fax In Person ® REMARKS: The City Building Official shall review the special inspection program submitted by the applicant. By: Abe Doliente . Enclosures: Esgil Corporation . ❑ GA ❑ MB ❑ EJ ❑ PC 6/26/06 trnsmtl.dot 9320 Chesapeake Drive, Suite 208 ♦ San Diego, California 92123 ♦ (858) 560-1468 ♦ Fax (858) 560-1576 La Q.uinta 06-1867 May 17, 2006 SPECIAL INSPECTION PROGRAM ADDRESS OR LEGAL DESCRIPTION: 79-315 Highway 111 PLAN CHECK NUMBER: .06-1867 OWNER'S NAME: I, as the owner, or agent of the owner (contractors may not employ the special inspector), certify that 1, or the architect/engineer of record, will'be. responsible for employing the special inspector(s) as required by Uniform Building Code (UBC) Section 1701.1 for the construction project located.at the site listed above. UBC Section 106.3.5. Signed 1, as.the engineer/architect of record, certify that I have prepared the; foliowing special. inspection program as required by UBC Section 106.3 .5 for the construction project located at the site listed above. G e _ •soi 1. List of work. requiring special inspection: 11-31-07 ® Soils. Compliance Prior to Foundation Inspection ® Field Welaiti , i! :.Au 'Joll-le-04 Structural Concrete Over 2500 PSI ® High Strength .Bolting ❑ Prestressed Concrete ❑Expansion/Epoxy Anchors ❑ Structural Masonry ❑ Sprayed -On Fireproofing ❑ Designer Specified ❑ Other 2. Name(s) of Individual(s) or firm(s) responsible for the special inspections listed above: B. C. 3. Duties of the special inspectors for the work listed above: FI -11 B. C. Special inspectors shall check in with the City and present their credentials for approval Prior be ginning work on the job site. <0 Ju 1 1,6,.2013 4:52:17 PM PDT O'd Th6 Edit 6.0mrn"an6s, 'Help SOMARWPUBUC SECTOR Naviune S! v 30 Application 06-00001867 Bonds ontractorescrow !s Global balance due Inspection -1 U-1ktoff-M v�9,q:;� M.Miscell :,aneous inform/ �ames , ► Property Information- Address AY Location -ID: 6908 Ovner�name,:� MALM� C: hl 649-,G_q0,--,0347.,. F Ali 6 Irni4t'e !V,:� �pliqation -lnforiationM � Application -desc-' FUEL'STATION;4CO1 sf PY, �.Application '. stat us': 30/2007 CO- ;type: NL L M =;,SERVICE,STATIONQ 1: .Apolicat-iom,date - E�-Otii2b*66 -naWnumber,- M -S CWa W F.0 Permits Plantracking. ...... .... ....... ...................... .... .. .......... ............ ......... ...... . ......... ............... ...... J111110101193AU �IMM ME L M Receipts 0 Sq'uare footage calcul/ M sirdctures valu*atio'n calculations 66, TEMPLATE_ FOOTING f F .. . . . . .. . ........... ...... . ......... ST 1271.172-00-6 6 JDRYPACK 700-01. F---,E—Tl I< 10/.2007 "AP F 7171672007 1-6 -00: PIERS. ---- ----. .. ........... . J� 12/1,3/2006, 12/13/200,6 P F- S T F -77E F- -f- Z74E f /i4/M6 2007 AE IBADA' 00..FSL—AB ;0002--- --.1 1 AP,,, 007 RADA ROOF NAIL 10001 —ST 1/30/-2007 —--- --XP—(-1f30/2007— — . . .................... . ....... ................. . .. ... . .......................... ........ ... . .......... . ............. . raauf 1 /1- .1 * ST. AP; 1*'---* 7 — IBADA'-00 FRAMING DOO 1 STT 17,30 2-/aQ/2�007 077 007 1 FIBADA-OOL DRYWALL' NAIL Fl T17 -TO -07-7 ;1131/200'7 1/31%2.007 -- BADA .00 BOND BEAM� -.12 2/2006 !0001 —12/Y-2/-2006 .:6 F uADA'; F INAL. F00- -- 01 ST -'-- IBADAi.,. CQMUNITY DEVELOPMENT FINAL -11U-001 ST 3 /�2 007 AP /2 3 /2 (TT7 — (HADA ,ADA �UP� FINAL ......... . ..... �1� .223/200?-- --j�p--, �-,6 2/.23/2007., E03, ..00, --00,--, UNDERGROUND ELECTRICAL f :�-,± ....... ... ....... ..... . . .. ..... 1-27,2- /2006 Ft 03 OqROU FUN E 90 ELECTRICAL' --00 .02 ST 2007 6 kijT� .......... .0 ................. fPflltt EO3 -00, . ELECTRICAL------. JELECTRICAL FINAL 7- . . ....... f0001 ....... . r ;- -- L Z.- - -*--",** . .......... - : 7, 1' 30 2007 2/23/-2007 F —ST,272372007- - ...... .....1/30/2007......... 1 AP, * AP.; ! Z [ ' --3/Y-6 -0GP .00 (GRADING FINAL 100,0 1 Z ST 7--- ---Kp— 0 61 2? —0Q 7 AP fP 0 ffDERGKO1Fbff PLtRIBI -9G— 113 1 ST 30/2007-1'/ WTER 6-1-60-- '.'1 —IM E :;0001 1.12 1 -12 -17 -MO-7— [76 FP -U I UU' ISETAER CONNECTION ST 7-2 n-3 -(T7- 16 jO f /To i. AP f�i M007 Landinquiry- r Rol 00-.-------....---.._....._._:=0001 IROOOZ DRAIN10-,� - - ---------- - 1� 2007 I . . . ....... 3 0 261�7 — F]�O 1 00 JPLUMBING FINAL ST 11 2/23/2007 --XP— - F�2/2�3/Z7007 Docuinei - ...... . ..... -------------------------- �IiE COPY Ll 0 1 CCk-e,CAINIPic( Ls— jkt 0 6- 1967 06 062 L, A 4 `„ k4 • UNIFIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION Poge of I. IDENTIFICATION FACILITY ID# <fi';L t BEGINNING DATE 100 ENDING DATE 101 } 3 BUS IN ESS NAME (Same as FACILITY NAME or DBA— Doing Business As) 3 BUSINESS PHONE 102 Sam's Club #4941 new station BUSINESS SITE ADDRESS 103 79-315 Highway 111 CITY 104 ZIP CODE 105 La Quinta CA 92253 DUN & BRADSTREET 106 SIC CODE (4 digit #) 107 05-195-7769 5541 COUNTY 108 Riverside BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE 110 Sam's West, Inc 479-204-2280 II. BUSINESS OWNER OWNER NAME 111 OWNER PHONE 112 Sam's West, Inc 479-204-2280 OWNER MAILING ADDRESS 113 702 SW 8th Street CITY 114 _J_STATE u5 ZIP CODE 116 Bentonville AR 72716-0500 III. ENVIRONMENTAL CONTACT ONTACT NAME u7 CONTACT PHONE 118 Pam Wilmott 479-204-2280 NTACT MAILING ADDRESS 119 702 SW 8th Street CITY 120 Bentonville STATE 121 ZIP CODE 122 AR 72716-0500 -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- NAME 123 NAME 15— TBD-New Club Alarm Central TITLE 124 TITLE 129 Club Manager BUSINESS PHONE 125 TBD -New Club BUSINESS PHONE 130 479-273-4600 24-HOUR PHONE 126 800-530-9924 24-HOUR PHONE 131 800-530-9924 PAGER # 127 PAGER # 132 ADDITIONAL LOCALLY COLLECTED INFORMATION: 133 Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with th information submitted and believe the information is true, accurate, and complete. SIGNATURE OFER/OPER�OR GNATED REPRESENTATIVE DATE 134 NAME OF DOCUMENT PREPARER 135 Cinthia Bridqes NAME OF SIGNE nnt) I36 TITLE OF SIGNER 137 Pam Wilmott Licensing Analyst qMW UPCF ( 1/99 revised) 4 OES FORM 2730 (1/99) V / t UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS ,. HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION one page per mata &21 ADD ❑ DELETE ❑ REVISE 200 I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA— Doing Business As) Sam's Club #4941 CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIA 79-315 Highway 111 La Quinta 92253 ❑ YES m NO FACILITY [D # 1 MA.P# (optional) 203 GRID# (optional) `.,.r.� .. ofd 3 II. CHEMICAL INFORMATION CHEMICAL NAME #2 Diesel Fuel 205 TRADE SECRET 0 Yes liNo 206 If Subject to EPCRA, refer to instructions COMMON NAME 207 Fos #2 Diesel Fuel EHS* ❑ Yes gf No CAS# 209 6847-34-6 *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210 HAZARDOUS MATERIAL TYPE (Check one item only) ❑ a. PURE 121b. MIXTURE ❑ C. WASTE 211 RADIOACTIVE 13 -Yes QrNo 212 CURIES N/A 213 PHYSICAL STATE (Check one item only) ❑ a. SOLID &ff b. LIQUID ❑ c. GAS 214 LARGEST CONTAINER 12,000 215 FED HAZARD CATEGORIES 216 (Check all that apply) I6 a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE V d. ACUTE HEALTH 9 e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT WASTE AMOUNT 219 STATE WASTE CODE 220 2,000 12,000 7218ARN-UAL. /A N/A 221 UNITS* in a. GALLONS ❑ b. CUBIC FEET ❑ C. POUNDS ❑ d. TONS DAYS ON SITE: 222 (Check one item only) • If EHS, amount must be in pounds. 365 STORAGE CONTAINER ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ RAIL CAR jn b. UNDERGROUND TANK ❑ f. CAN q. ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ 9. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM ❑ It. SILO ❑ I. CYLINDER ❑ p. TANK WAGON 223 STORAGE PRESSURE, a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 229 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # I 1-100 226 Cat cracked distillate, light 227 O Yes Cif No 228 64741-59-9 229 2 1-100 230 Hydrotreated distillate, middle 231 ❑ Yes m No 232 6474246-7 233 3 1-100 214 Hydrotreated distillate, light 235 ❑ Yes fd No 236 64742-47-8 217 4 1-100 211 Gas oil, light 239 ❑ Yes Cff No 240 64741-44-2 241 5 242 243 ❑ Yes Cl No 244 245 ... ,...._...._..._...... .... 1 1_ �ttvttr_ Jt-G6,IAL1.7HL.AMU_ 246 HAZARD CLASS OR DIVISION # UN# If EPCRA, Please Sign Here 4 Revised (5/03) OES Form 2731 UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY — CHEMICAL DESCRIPTION J i — - _ (one page per material per buildin¢ or area J4 ADD ❑ DELETE ❑ REVISE 200 Page 3— of 1i I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA— Doing Business As) 3 Sam's Club #4941 CHEMICAL LOCATION 201CHEMICAL LOCATION CONFIDENTIAL EPCRA 202 79-315 Highway 111 La Quinta 92253 ❑ YES m NO rg I MAP# (optional) 203 GRID# (optional) 204 FACILITY ID ##,; II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET 0 Yes No 206 Gasoline Range Organics If Subject to EPCRA, refer to instructions COMMON NAME 207 208 California Reformulated Gasoline EHS* ❑ Yes Ud No. *If EHS is "Yes", all amounts below must be in lbs. (Complete if required by CUPA) HAZARDOUS MATERIAL TYPE (Check one item only) ❑ a. PURE m b. MIXTURE ❑ C. WASTE 211 RADIOACTIVE ❑ Yes Qf No 212 CURIES N/A 213 PHYSICAL STATE 215 (Check one item only) ❑ a. SOLID b. LIQUID ❑ c. GAS 214 LARGEST CONTAINER 20,000 FED HAZARD CATEGORIES 216 (Check all that apply) (Q a. FIRE ❑ b. REACTIVE ❑ C. PRESSURE RELEASE is d. ACUTE HEALTH e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 8,000 48,000 1 N/A N/A UNITS' in a. GALLONS ❑ b. CUBIC FEET 13c. POUNDS 13d. TONS 221 DAYS ON SITE: 222 (Check one item only) • If EHS, amount must be in pounds. 1 365 STORAGE CONTAINER ❑ a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE jn ❑ ❑ q. RAIL CAR b. UNDERGROUND TANK f. CAN ❑ j. BAG O.n. PLASTIC BOTTLE ❑ t. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ it. BOX ❑ o. TOTE BIN D d. STEEL DRUM ❑ It. SILO ❑ I. CYLINDER ❑ p. TANK WAGON 223 STORAGE PRESSURE Ql a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOWAMBIENT Y24 STORAGE TEMPERATURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 1 1-9 226 Toluene (a,b,c,e,f,g) 227 ❑ Yes G6 No 228 1087-88-3 229 2 1-14 230 Xylene (a,b,c) 231 ❑ Yes cd No 232 1330-20-7 233 3 1-5 274 1,2,4-Trimethyl Benzene 235 ❑ Yes 46 No 236 95-63-6 237 4 1-5 J 238 Ethyl Benzene 239 ❑ Yes D! No 240 100-41-4 241 5 <1.3 242 Benzene 243 ❑ Yes m No 244 71-43-2 245 more hazardous componen s are presentat grea er an , y wetg t i non -carcinogenic, orO.1% y weight if carcinogenic, attach additional sheets o paper captunng therequired information. _ 246 HAZARD CLASS OR DIVISION # I LIN# If EPCRA, Please Sign Here 4 Revised (5/03) OES Form 2731 1 2 E 4 "5 6 A ATED SITE MAP Business Name: SAM'S CLUB B (' n Site Address: 79315 HWY 111 lA QUINTA CA 92253 Map Y T X Scale: 1"= 50 Feet North T Revised (5/03) r 3 4 5 6 OTATED STORAGE MAP Business Name: SAM'S CLUB #4941 Site Address: 79315 HWY 111 LA QUINTA CA 9253 A B r n r 0 U L Scale: 1"= 3 Feet North T Map #: 2 v n 1 'd 4 4 4 . State of California State of Water Resources Control Board r•: 3M1;?:iar t=: ri ; ` i;; aye i;i'`r'z;i1, ;;5a: t?"rrF�onStateUseUnly „ " Division of Financial Assistance �2i} s a n err P.O. Box 944212 Sacramento, CA 94244-2120 . (Instructions on reverse side) CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: El500,000 dollars per occurrence Ell million dollars annual aggregate or AND or ® 1 million dollars per occurrence � 2 million dollars annual aggregate B. San's Vhst, Inc. hereby certifies that it is in compliance with the requirements of Section 2807, (Name of Tank Owner or Operatot) Article 3, Chapter 18, Division 3, Title 23, Califomia Code of Regulations. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: .. _. , .•.i 1C: - - •.. i. t�, la7:bl ��'srw . �:•' _ IJ if �:.a, :•..,�:��, ;,,,�n't ,3•�r~ .. A.:i +• yi .,�„�dv �t�Si\ y},. « t iui Ir,Y hk '�{/ rJ�� 1�6"\'\l �r�i�k>I��)•iY�;,• Cpvera Ort: ,ITS �} �ectiv's;;>: fi`•`,'...,t:••SSi� -i: - .,.. ,•.,: _T. f `•'� '�` ' e.. r :.. ,..t.�,_.��,,.x•cr;; Name ar,d Addre'ss;,of.,lssuer,� zc�,�echanism �, rr,,.�N;umberam, fr:�'«_C'ove�age's. :t,�a., .,•:./} lraIsy-'ss.;,k �,4.;.�'.�Arriounf�,,��;�ti �� 9 e' t �..�eraodrt•'�, �;Co aX, e; T;hard a' J. V I :. G11O• V,y,fi O State LST QBx1p for UST State [ST State UST Fi.md 995,0001 -per FO Box %Q12F�.II13 � Rn I � M S�cr�to, CA 9�'+244- Clearup Ft lad occt�lce &�� i B ill -Mut Stores, R-c.miLHion do Corprate 702 S.W. 8th St. for this )IS (��►tee DPX occura r_e & Bentawiile,.AR 72716-0 -W mini ANNLIAL Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certifies that you are in compliance with all conditions for participation in the Fund. D. Facility Name Facility Address SFE ATDNGO AEDENM Facility Name Facility Address Facility Name Facility Address E. Signature of Tank Owner or Operator , L Date ' Name and Title of Tank Owner or Operator '7 i2 ell Iori Cnttrell DuroctOr of Livens' pg S. nat re of Witness or Notary Date Name of Witness or Notary -- - ••--. ■ .mv �.,gmai - i ocai agency Copies - Facility/Site(s) IINIFIF.D PROGRAM C'ONSOLMATED FORM TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page 55 of 17 PE OF ACTION 121 I. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE heck one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED ❑ 6.TEMPORARY SITE CLOSURE 400 I. FACILITY / SITE INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 FACILITY ID# F7 Sam's Club.#4941 I 1 I NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT• Dune Palms Drive [Z 1. CORPORATION ❑ 5. COUNTY AGENCY* ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY' BUSINESS 1. GAS STATION ❑ 3. FARM 5. COMMERCIAL TYPE ❑ 2. DISTRIBUTOR [14. PROCESSOR ❑ 6. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency: name of supervisor of division, section or office which REMAINING AT SITE trustlands? operates the UST (This is the contact person for the tank records.) Three (3) 404 ❑ Yes 19 No 405 N/A 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 MAILING OR STREET ADDRESS 409 CITY 410 1 STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE 211. CORPORATION [12. INDIVIDUAL 4. LOCAL AGENCY/ DISTRICT ❑ 6. STATE AGENCY ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 III. TANK OWNER INFORMATION ANK OWNER NAME 414 PHONE 415 Sam's West, Inc 479-204-2280 AILING OR STREET ADDRESS ale 702 SW 8th Street CITY an STATE ala ZIP CODE 419 Bentonville AR 72716-0500 TANK OWNER TYPE 1. CORPORATION El 2. INDIVIDUAL 0 4. LOCAL AGENCY / DISTRICT El 6. STATE AGENCY 420 ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- Call 916 322-9669 if questions arise 421 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM ® 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: ❑ 3. INSURANCE d 6. EXEMPTION ❑ 9. STATE FUND & CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. El 1. r 1. FACILITY ❑ 2. PROPERTY OWNER 3. TANK OWNER 423 VII. APPLICANT SIGNATURE Certification - 1 certify hat the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF P LICA T DATE 424 PHONE 42s y - \3 - 6 479-204-2280 NAME OF APPL A T (print) 426 TITLE OF APPLICANT 427 Pam Wilmott Licensing Analyst ATE UST FACILITY NUMBER (For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 UPCF (1/99 revised) Formerly SWRCB Form A i UNIFIED PROGRAM CONSOLIDATED FORM ` TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) PE OF ACTION m 1 NEW SITE PERMIT PageoC ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason - for local use only) (Specify reason - for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 FACILITY ID: Sam's Club #4941 LOCATION WITHIN SITE (Optional) 431 1. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑ Yes No 434 T1 XERXES If "Yes", complete one page for each compartmenL DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 2006 20,000 0 ADDITIONAL DESCRIPTION (For local use only) 438 II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE iZI I. MOTOR VEHICLE FUEL 440 iM la, REGULAR UNLEADED ❑ 2. LEADED ❑ 5, JET FUEL (If marked complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) California Reformulated Gasoline 8006-61-9 ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK I. SINGLE WALL 03. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN 2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER NK MATERIAL -primary tank Lj 1. BARE STEEL V 3. FIBERGLASS / PLASTIC 0 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL -secondary tank 0 1. BARE STEEL 73. FIBERGLASS /PLASTIC 0 5. CONCRETE 0 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ L RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED t 447 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING 0 6 UNLINED ❑ 99 OTHER NIA (Check one item only) (For local use only) ,,-..,, OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC 0 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER 2006 (Check one item only) ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) It I SPILL CONTAINMENT 2006 5 qal spill bucket 19 1 ALARM 2006 ❑ 3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE 2006 V 2 BALL FLOAT 2006 ❑ 4 EXEMPT m 3 STRIKER PLATE 2006 IV. TANK LEAK DETECTION (A description ofthe monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL (EXPOSED PORTION ONLY) 0 MANUAL TANK GAUGING (MTG ) (Check one item only) ❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE 912 CONTINUOUS INTERSTITIAL MONITORING ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 3 MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER IV. TANK CLOSURE INFORIMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons [1 -Yes ❑ No UPCF (12/99 revised) 10 Formerly SWRCB Form B UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 yr UTPr�t/_ rnvcrnrrnr><e�,.r 17mut Number (For iocai ave only) 473 Permit Approved (For local use only) 474 Permit Expiration Date (For local use only) 475 UPCF (12/99 revised) 12 Formerly SWRCB Form B . _. . .. ...... ..................... ....axunmalapply) Pagewof 3-7 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTENI TYPE m 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION ❑ I. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 MANUFACTURER &6 2. DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ I. BARE STEEL ❑ 6. FRP COMPATIBLE w/100% METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ Unknown ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. Other ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER to 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ S. STEEL W/COATING ❑ 95. UNKNOWN 465 VII. PIPING LEAK DETECTION Check all that apply) A descri tion of the monitoring program shall be submitted to the localagency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) ❑ 3. ANNUAL INTEGRITY TEST (0.IGPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPNG): GRAVITY FLOW ❑ 7. SELF MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS QJ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM ❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION ❑ It. AUTOMATIC LEAK DETECTOR m 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST (0.l GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0.GPH TEST) WITHOUT FLOW AUDIBLE AND VISUAL ALARMS SHUT OFF OR RESTRICTION ❑ I5. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TES (. T) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE NSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/ MONITORING 3. CONTINUOUS DISPENSER PAW SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS Cl 6. NONE 469 IX. OWNER/OPERATOR SIGNATURE 1 certify that the information provided herein i e and accurate to th%best of my kno ledge. SIGNATURE OF OWNER/OPERATDATE 470 \1 - ` WSJ "AME OF OWNER/OPRATOR (prin Pam Wilmott 471 TITLE OF OWNER/OPERATOR 472 aO Licensing Analyst 17mut Number (For iocai ave only) 473 Permit Approved (For local use only) 474 Permit Expiration Date (For local use only) 475 UPCF (12/99 revised) 12 Formerly SWRCB Form B UNIFIED PROGRAM CONSOLIDATED FORIM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page � of PE OF ACTION 0 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason - for local use only) (Specify reason - for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NA ME (Same as FACILITY NAME or DBA- Doing Business As) FACILITY 1 Sam's Club #49413 11".11 ITI I I I LOCATION WITHIN SITE (Optional) 431 1. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) . TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK C] Yes No 434 T2 XERXES If "Yes", complete one page for each compartment DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 2006 20,000 0 ADDITIONAL DESCRIPTION (For local use only) 438 II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 1. MOTOR VEHICLE FUEL440 (d la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked complete Petroleum Type) ❑ 1 b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAMEfrom Hazardous Materials Inventory ry page) 441 CAS# (from Hazardous Materials Inventory, page) 442 ❑ 4. HAZARDOUS WASTE (includes Used Oil) California Reformulated Gasoline 8006-61-9 ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 0 1. SINGLE WALL LJ 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN Qi 2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER NK MATERIAL - primary tank 01. BARE STEEL 3. FIBERGLASS /PLASTIC U 5. CONCRETE 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS Cl 8. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL -secondary tank 0 I. BARE STEEL V 3. FIBERGLASS / PLASTIC 0 5. CONCRETE 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS E-18. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING m 6 UNLINED ❑ 99 OTHER N/A (Check one item only) (For local use only) r,,rt OTHER CORROSION ❑ I MANUFACTURED CATHODIC � 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 y PROTECTION IF APPLICABLE PROTECTION ❑ 4IMPRESSED CURRENT ❑ 99 OTHER 2006 (Check one item only) ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check ail that apply) 911 SPILL CONTAINMENT 2006 5 qal spill bucket (j( I ALARM 2006 ❑ 3 FILL TUBE SHUT OFF VALVE 0 2 DROP TUBE 2006 2 BALL FLOAT 2006 ❑ 4 EXEMPT 0 3 STRIKER PLATE 2006 IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) (Check one item only) ❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE Z 2 CONTrNUOUs INTERSTITIAL MONITORING ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 3 MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER IV. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑ Yes ❑ No UPCF (12/99 revised) 10 Formerly SWRCB Form B UNIFIED PROGRAM CONSOLIDATED FORM • TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION Cheekallthat apply) Pagel -1 of 17 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE tat I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION ❑ I. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 MANUFACTURER 912. DOUBLE WALL ❑ 95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER 461 MANUFACTURER 467 ❑ I. BARE STEEL ❑ 6. FRP COMPATIBLE w/100% METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ Unknown [12. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. Other ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465 VII. PIPING LEAK DETECTION Check all that apply) A description of the monitoring program shall be submitted to the local agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.IGPH) ❑ 3. ANNUAL INTEGRITY TEST (0.IGPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS (NO VALUES N BELOW GRGUNDPIPING): ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) ❑ 7. SELF MONITORING SAFE SUCTION SYSTEMS (NO VALVES N BELOW GROUND PIPING): GRAVITY FLOW ❑ 7. SELF MONITORNG ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS Vr It. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM ❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF m 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST (0. t GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW C315. AUTOMATIC LINE SHUT OFF OR RESTRICTION LEAK DETECTOR (3.0 GPH TES T) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING Rl 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6. NONE DISPENSER + AUDIBLE AND VISUAL ALARMS a69 IX. OWNER/OPERATOR SIGNATURE I certify that the information pr v ed herein is hue nn accurate to the best of my knowledge. SIGNATURE OF OWN PERATOR DATE 470 O� `LAME OF O�VNER/OPRA (print) 471 Pam Wilmott TITLE OF O R/OP TOR 472 Licensing Analyst emtit Number (For local use only) 477 Permit Approved (For local use only) 474 Permit Expiration Date (For local use only) 475 UPCF (12/99 revised) 12 Formerly SWRCB Form B 4 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) 17 PE OF ACTION [� I NEW SITE PERMITPage�of ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERb1ANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason - for local use only) (Specify reason - for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As)FACILITY 3* ID: i' •`'" I Sam's Club #4941 LOCATION WITHIN SITE (Optional) 431 1. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK 0 Yes ❑ No 434 T3A XERXES If"yes", complete one page for each compartment. DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 416 NUMBER OF COMPARTMENTS 437 2006 8,000 2 ADDITIONAL DESCRIPTION (For tocol use only) 438 Tank is split tank, 8,000 gal super-unleaded/12,000 gal diesel II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE m I. MOTOR VEHICLE FUEL 440 ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked complete Petroleum Type) JZ lb. PREMIUM UNLEADED &d 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER [13. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) California Reformulated Gasoline 8006-61-9 ❑ 95. UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK 01. SINGLE WALL 0 3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN I9 2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER NK MATERIAL - primary tank 01. BARE STEEL 173. FIBERGLASS / PLASTIC U 5. CONCRETE 0 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL E-14. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL - secondary tank 1. BARE STEEL 3. FIBERGLASS/ PLASTIC 0 5. CONCRETE 0 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ L RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING 0 6 UNLINED ❑ 99 OTHER N/A (Check one item only) (For local use only) OTHER CORROSION ❑ I MANUFACTURED CATHODIC I6 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER 2006 (Check one item only) ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) . 0 1 SPILL CONTAINMENT 2006 5 qal spill bucket 911 ALARM 2006 ❑ 3 FILL TUBE SHUT OFF VALVE �{ 2 DROP TUBE 2006 W U 2 BALL FLOAT 2006 ❑ 4 EXEMPT I71 3 STRIKER PLATE 2006 IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ' ❑ I VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) ❑ 1 VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE t0 2 CONTINUOUS INTERSTITIAL MONITORING ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 3 MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER IV. TANK CLOSURE INFORIVIATION / PERMANENT CLOSURE IN PLACE _ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons 1 ❑ Yes ❑ No C. UPCF (12/99 revised) 10 Formerly SWRCB Form B UNIFIED PROGRAM CONSOLIDATED FORM I UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCT UNDERGROUND PIPING SYSTEM TYPE m I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION ❑ I. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER MANUFACTURER 02. DOUBLE WALL ❑ 95. UNKNOWN TANKS of ABOVEGROUND PIPING 458 ❑ I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 ❑ 2. -DOUBLE WALL ❑ 99. OTHER MANUFACTURER 461 1 MANUFACTURER 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/100% METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ Unknown ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS [199. Other ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER a] 4. FIBERGLASS ❑ S. FLEXIBLE (HDPE) ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465 VII. PIPING LEAK DETECTION Check all that a I A description of the monitoring oroamm shall be submitted to the Inca[ „oen..,, a SINGLE WALL PIPING 466 PRESSURIZED PIPING (Check all that apply): ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1GPH) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) W SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION m 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW (Check all that apply): [18. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ' ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS ❑ I5. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 Cl 2. CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING 3. CONTINUOUS DISPENSER PARI SENSOR WITH AUTO SHUT OFF FOR DISPENSER+ AUDIBLE AND VISUAL ALARMS ❑ 6. NONE 469 IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein i e nd accurate tot a best of my knowledge. SIGNATURE OF OWNER/OPERAT DATE 470 AME OF OWNER/OPRATOR (print) para Wilmott 471 TITLE OF OWNER/OPERATOR 472 Licensing Analyst unit Number (For local use only) 473 Permit Approved (For local use only) 474 Permit Expiration Date (For local use only) 475 UPCF (12/99 revised) 12 Formerly SWRCB Form B r UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE i (two pages per tank) Page o! PE OF ACTION (A I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason - for local use only) (Specify reason - for local use only) C38 TANK REMOVED 430 BUSINE$SNAME(SamensFACILITYNAMEorDBA-Doing Business As) 3y FACIL[TYID: I Sam's Club #4941 LOCATION WITHIN SITE (Optional) 431 1. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID # 432 TANK MANUFACTURER 413 COMPARTMENTALIZED TANK 0 Yes ❑ No 434 T313 XERXES if "Yes", complete one page for each compartment. DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 2006 12,000 2 ADDITIONAL DESCRIPTION (For local ase only) 438 Tank is split tank, 8,000 gal super-unleaded/12,000 gal diesel II. TANK CONTENTS - TANK USE 439 PETROLEUM TYPE m 1. MOTOR VEHICLE FUEL 440 ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (Ifmarked complete Petroleum Type) ❑ lb. PREMIUM UNLEADED L4 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ Ic. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used oil) #2 Diesel 68476-34-6 ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL 03. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN QI 2. DOUBLE WALL ❑ 4. SIGNLE WALL IN VAULT ❑ 99. OTHER NK MATERIAL -primary tank 1. BARE STEEL 3. FIBERGLASS / PLASTIC 5. CONCRETE U 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL -secondary tank 0 1. BARE STEEL 03. FIBERGLASS/ PLASTIC 5. CONCRETE C1 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTiBLE W/100% METHANOL ❑ 99. OTHER REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING QJ 6 UNLINED ❑ 99 OTHER N/A (Check one item only) (For local use only) �r,,tt OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC Gd 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 408 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER 2006 (Check one item only) ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) 01 SPILL CONTAINMENT 2006 5 gal spill bucket Gff I ALARM 2006 2 DROP TUBE 2006 ❑ 3 FILL TUBE SHUT OFF VALVE 2 BALL FLOAT 2006 ❑ 4 EXEMPT m 3 STRIKER PLATE 2006 IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) (Check one item only) ❑ I VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE 912 CONTINUOUS INTERSTITIAL MONITORING ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑ 3 MANUAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR) BIENNIAL TANK TESTING E:1 99 OTHER IV. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE STIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 A NK FILLED WITH INERT MATERIAL? 457 gallons ❑ Yes ❑ No UPCF (12/99 revised) 10 Formerly.SWRCB Form B UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 . UNDERGROUND PIPING SYSTENI TYPE m I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION ❑ I. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER MANUFACTURER 0 2. DOUBLE WALL ❑ 95. UNKNOWN MANUFACTURER ❑ [.BARE STEEL ❑ 6. FRP COMPATIBLE w/l00% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ Unknown ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 99. Other tW 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ S. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 VII. PIPING LEAK DETECTION Wheek at TANKS Check all that apply) Pagel B orL ABOVEGROUND PIPING 458 ❑ L PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 460 ❑ L SINGLE WALL ❑ 95. UNKNOWN 462 ❑ 2. DOUBLE WALL ❑ 99. OTHER 461 1 MANUFACTURER 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100 METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465 that SINGLE WALL PIPING 466 PRESSURIZED PIPING (Check all that'apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST SII AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (O.IGPH) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING GRAVITY FLOW [19. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all thatapply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION m 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF " AUDIBLE AND VISUAL ALARMS Cl 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK be submitted to the local aaenev.l SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 6. TRIENNIAL INTEGRITY TEST (0.l GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST A I GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 'Cl b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑e NO.AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF " AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) Cl 16. ANNUAL INTEGRITY TEST (0.1 GPH) Cl 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/ MONITORING RJ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6. NONE a69 DISPENSER + AUDIBLE AND VISUAL ALARMS IX. O WNER/OPERATOR SIGNATURE I certify that the information prov�fd herein is true and accurate ti; the bes) of my knowledge. AI UKb; Ut UWNIz K/ -KA FUR DATE 1 470 E OF OWNER/OPRA R rint) Pam Wilmott 471 TITLE OF OWNER/OPERATOR Llcensing Analyst 472 Number (For local use only) 473 Permit Approved (For local use only) 474 Permit Expiration Date (For local use only) 475 UPCF (12/99 revised) 12 Formerly SWRCB Form B UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - INSTALLATION CERTIFICATE OF COMPLIANCE (one page per tank) Pagel? of 47 7NAME I. FACILITY IDENTIFICATION BUSINESS (Same as FACILITY NAME or DBA—Doing Business As) Sam's Club #4941 - 3 ADDRESS (For local use only) 476 79-315 Highway 111 La Quinta 92253 FACILITY ID# ('3 T' I TANK ID # 477 T3B II. INSTALLATION (Check all that apply) ❑ The installer has been trained and certified by the tank and piping manufacturers. 478 ❑. The installation has been inspected and certified by a registered professional engineer having education and experience 479 with underground storage tank installations. ❑ The installation has been inspected and approved by the Unified Program Agency. 480 ❑ All work listed on the manufacturer's installation checklist has been completed. 481 ❑ The installer has been certified or licensed by the Contractors' State License Board. 482 The underground storage tank, any primary piping, and secondary containment was installed according to applicable 483 voluntary consensus standards and written manufacturer's installation procedures. Description of work being certified: Installation of three 20,000 gallon underground storage tanks (two unleaded and one split 8,000 super -unleaded/ and 12,000 diesel) with associated piping and containment. III. TANK OWNER/AGENT SIGNATURE I certify that the informa provided rerein is true and accurate to the best of my knowledge. SIGNATURE OF TAN O ER/A NT DATE rr 484 NAME OF TANK O A ENT (print) 485 TITLE OF TANK OWNER/AGENT 486 Pam Wilmott Licensing Analyst UPCF (1/99 revised) 14 Formerly SWRCB Form C UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - INSTALLATION CERTIFICATE OF COMPLIANCE (one page per tank) page or 17 I. FACILITY IDENTIFICATION B USINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) Sam's Club #4941 3 ADDRESS (For local use only) 476 79-315 Highway 111 La Quinta 92253 FACILITY ID#,;,r Y t TANK ID # 477 T3A II. INSTALLATION (Check all that apply) ❑ The installer has been trained and certified by the tank and piping manufacturers. 478 ❑ The installation has been inspected and certified by a registered professional engineer having education and experience 479 with underground storage tank installations. ❑ The installation has been inspected and approved by the Unified Program Agency. 480 ❑ All work listed on the manufacturer's installation checklist has been completed. 481 ❑ The installer has been certified or licensed by the Contractors' State License Board. 462 The underground storage tank, any primary piping, and secondary containment was installed according to applicable 483 voluntary consensus standards and written manufacturer's installation procedures. Description of work being certified: Installation of three 20,000 gallon underground storage tanks (two unleaded and one split 8,000 super-unleaded/and 12,000 diesel) with associated piping and containment. III. TANK OWNER/AGENT SIGNATURE I certify that the informatio rovided hereinVue and accurate to the best of my knowledge. SIGNATURE OF TANKER/AGM DATE �,4 " 484 y" ) L/LP# I � -- o c� NAME OF TANK OWAGENT (p 485 N TITLE OF TANK OWNER/AGENT 486 Pam Wilmott Licensing Analyst UPCF (1/99 revised) , 14 Formerly SWRCB Form C UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - INSTALLATION CERTIFICATE OF COMPLIANCE (one page per tarn) rag45 etV I. FACILITY IDENTIFICATION BUSINESS NAME (Same as FACILt7Y NAME or DBA — Doing Business As) Sam's Club #4941 3 ADDRESS (For local use only) 476 79-315 Highway 111 La Quinta 92253 FACILITY ID#�r air ?�•`'� I TANK ID # 477 a} T2 . II. INSTALLATION (Check all that apply) ❑ The installer has been trained and certified by the tank and piping manufacturers. 478 ❑ The installation has been inspected and certified by a registered professional engineer having education and experience 479 with underground storage tank installations. ❑ The installation has been inspected and approved by the Unified Program Agency. 480 ❑ All work listed on the manufacturer's installation checklist has been completed. 461 ❑ The installer has been certified or licensed by the Contractors' State License Board. 492 The underground storage tank, any primary piping, and secondary containment was installed according to applicable 483 voluntary consensus standards and written manufacturer's installation procedures. Description of work being certified: Installation of three 20,000 gallon underground storage tanks (two unleaded and one split 8,000 super-unleaded/and 12,000 diesel) with associated piping and containment. III. TANK OWNER/AGENT SIGNATURE I certify that the info r tion provided herein is true and accurate to the best of my knowledge. SIGNATURE OF T N 0 E GENT DATE' 494 l` NAME OF TANK ER/AGE T (prin—tp 485 TITLE OF TANK OWNER/AGENT 496 Pam Wilmott Licensing Analyst LA UPCF (1/99 revised) 14 Formerly SWRCB Form C A UNIFIED PROGRAM CONSOLIDATED FORM s TANKS ' UNDERGROUND STORAGE TANKS - INSTALLATION CERTIFICATE OF COMPLIANCE (one page per tank) Pagel A of 17 I. FACILITY IDENTIFICATION BUS (NESS NAME (Same as FACILITY NAME or DBA — Doing Business As) Sam's Club #4941 3 ADDRESS (For local use only) 79-315 Highway 111 La Quinta 92253 . 476 FACILITY 1D# a° I TANK [D # 477 T1 II. INSTALLATION (Check all that apply) ❑ The installer has been trained and certified by the tank and piping manufacturers. 478 ❑ The installation has been inspected and certified by a registered professional engineer having education and experience 479 with underground storage tank installations. ❑ The installation has been inspected and approved by the Unified Program Agency. 480 ❑ All work listed on the manufacturer's installation checklist has been completed. 481 The installer has been certified or licensed by the Contractors' State License Board. 482 ❑ The underground storage tank, any primary piping, and secondary containment was installed according to applicable 483 voluntary consensus standards and written manufacturer's installation procedures. Description of work being certified: Installation of three 20,000 gallon underground storage tanks (two unleaded and one split 8,000 super-unleaded/and 12,000 diesel) with associated piping and containment. III. TANK OWNER/AGENT SIGNATURE I certify that the informatiom provided herein is true and accurate to the best of my knowledge. SIGNATURE OF TANK O AGENT DATE ` ' l 49.4 NAME OF TANK OWNER/AGENT (print 485 TITLE OF TANK OWNER/AGENT 486 Pam Wilmott Licensing Analyst UPCF (1/99 revised) 14 Formerly SWRCB Form C John R. Hawkins Fire Chief Proudly serving the Unincorporated Areas of Riverside County and the Cities of: Banning 4. Beaumont 4. Calimesa Canyon Lake 4. Coachella Desert Hot Springs 4. Indian Wells .- Inl Ind' La Quints Moreno Valley Palm Desert Penis 4. Rancho Mirage San Jacinto 4 - Temecula Board of Supervisors Bob Buster, District 1 John Tavaglione, District 2 Jim Venable, . District 3 Roy Wilson, District 4 M Ashley, District 5 RIVERSIDE COUNTY .FIRE DEPARTMENT In cooperation with the C'alifornia Department of Forestry and Fire Protection 210 West San Jacinto Avenue • Perris, California 92570 • 909 940-6900 • Fax (909) 940-6910 Date_ City of LaQuinta Building Department RE �Q�rx 4 case aN�iorr The Riverside Please call if you should have any .M/ is gIapting the Fire clearance for the following 760-863-8886 Respectfully D Terry DeSo y Fire Syste s Inspector EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE 82-675 Highway 111, 2"d R., Indio, CA 92201 • (760) 863-8886 • Fax (760) 863-7072 Reference Date 3 13 0 7 Name K 1 C ✓ Certified Unified Program Agency County of Riverside Community Health Agency Department of Environmental Health Hazardous Materials Management Division - SUPPLEMENTAL REPORT Page_of pages Address CA, (,Z..� K .( q Re: I't Remarks: VST i Facility #_ g l 3 a 7 aI j --i 1111 h f rC�r�•M i nL(, , y ��- P,ASSrn -� ,excto1��, V e c- Dc n /Lvo- fpee.4-1V- i.S —ice c e�-�� {� �- �. -1k �Sr _ All f vtic-rt C/ Nvt1 AA/I C '3 Z3((/�-�iNL-`Ss AIt F�Nc't�uti.s p.Or.MtC.G;ti �,..,LL /A L. w,A-L M1) — (:F f --I 6� L pecialist DEH-HEH-O , rev 5/02) HMHC 2002 Received By� �' white -specialist; yellow -operator; pink -file i' Certified Unified Program Agency County Ij- t of Riverside Community Health Agency Facility # Department of Environmental Health Hazardous Materials Management Division ., UNDERGROUND STORAGE TANK INSTALLATION/UPGRADE/MODIFICATION/REPAIR INSPECTION ►" a/DBA \ Plan Check # Address Contractor Name _) Contractors State License Board # Phone ) �:,..y . I . tl eUfk,,- i+ [i C3G (f)t (C(i19LdL, 1-1,17- _2(U 1-(} 0; Type of Work Completed roc c k.j � k\ '� 1 Type of USTs (Attach Photos) Number of USTs -44nstallation C Upgrade CModification 71 Repair C Other Y N n/a - '" Y N n/a 1.. SETTING OF UST(S) - , � ' ` J" fl 4. FINAL INSPECTION a. Approved plans on site a. Operational sensors in annular(s) and sump(s)/ b. Primary and secondary tank pneumatically tested as per Positive shut -down demonstrated if required b. Electronic monitor secured/ accessible to operator manufacturer's specifications and operational c. UST(s) arrived on site with vacuum intact if required ✓ c. All sensors will detect earliest possible release d. Approved backfill material used 1 f y` i d. Operational leak detectors on turbine(s) r e. Filter fabric used if required e. Fill pipes and monitoring well(s) labeled f. Distance between UST(s) per manufacturer's specifications f. Operational spill container(s) in place at fill(s) g. UST(s) marked with UL stamp g. Overfill prevention valve or overfill alarm bnd ball float vent/valve in place test overfill alarm)"/( 2. PRIMARY INSPECTION; 1 F h. Concrete slopes away from all UST manways d a. Required forms issued' i. Impact valve chains set and operational b. All piping sloped back to UST/Piping marked with UL stamp j. Emergency shut-off switch operational c. All primary piping tested pneumatically at 110% of designed ✓ k. All monitoring equipment components have tag/sticker operating ressure for a minimum of 30 minutes affixed b Licensed Technician d. Vent and vapor piping tested as per manufacturer's I. Containment drains into a monitored sump cifications ints soaped and checked i.e. boots pulled back, drain valves open, etc. 'm. ti Unauthorized release response plan submitted f. Distance between piping per manufacturer's specifications •n. Valid Test of Tank System submitted if required g. All connections to stationary objects consist of approved 'o. Continuous Monitoring Device Certification submitted flexible connectors include leak detector test if required)=i h. Vapor recovery piping sloped back to lowest octane UST 'p. Pipeline Integrity Test submitted if required i. Soil samples witnessed if required 'q. Unified Program Consolidated Forms A, B and C submitted as required '. ELD workplan submitted if required R cvr I z /-I w ,/ 3. SECONDARY INSPECTION r. Financial Responsibility statement submitted a. Approved secondary containment in place to grade s. Monitoring Option form completed b. Secondary piping system tested per manufacturer's t. As Builts requested/submitted if required specifications (5 psi) for a minimum of 30 minutes , , l 1 u. Passing ELD test results submitted if required c. All joints soaped and checked v. Soil sample results submitted if required d. No exposed steel ADDITIONAL INFORMATION: e. Impact valves present and secured a. Reinspection Fee/ Additional hours v COS Form submitted b. 9 notification for UST d it / Billing b f. All sumps hydrostatically tested for 30 min. above the highest penetration (turbine, fill, spill container and UDC) Operating Permit c. UST File update (include photos)/ File plans SUPPLEMENTAL NOTES: , (Use additional Supplemental Forms if needed.) I CTOR: RECEIVED BY: Riverside Office Hemet Office Indio Office Website: www.rivcoeh.org (951) 358-5055 (951) 766-6524 (760) 863-8976 DEH-HEH-020 (Rev 3/04) Distribution: WHITE -File; CANARY-Owner/Operator/Contractor at Final; GOLDENROD-Owner/Operator/Contractor at Secondary; PINK-Owner/Operator/Contractor at Primary = KraZan & Associates, I n C , DSA File/Appl. No. GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING AND INSPECTION OSHPD No. Permit No. Or ' / CONTRACTOR: PECT #: j�(, i� r , L / % I.O.R.: PROJECT: �'• /� ! tj jt, ,- ;r� PRESENT AT SITE: i'l'l.. h LOCATION: L COPIES TO: �� r, --'r KRAZAN PROJECT MANAGER: WEATHER: (/ p„ r i TEMP: EARTHWORK11 Performed compaction testing on the following: ❑ Performed observation for the following: v� ❑ The following tests/DlD'Z7 DID NOT meet required percent compaction: E Pending lab tests ❑ Phone results ASAP to: Verbal results transmitted to: ONOTES ❑ DISCREPANCIES t 1 .' ❑ % COMPLETE /Jf f ice' �' d �i>��Pf ,� `S % 1 LG LJ�/�rlf�[7^!�,•� �r�A.fOclf'1`rurt-f'P 'i/Z. �` -Nrro It % /`7,SLI o d „10 'I C / All f'�,/17A'� r&f,jGi /'nnr< r'!°�P r►;'iAc r��/6(��( n aT a 7%4 In /- `7 7 ')1 -1.4 ini tl To d'best'of my knowledge, the abov Superintendent/Representative: Phone: T- T-, 'r 1y Description Depth of Testing % Required Curve Sampled Lab No(s). ❑ Building Pad(s): • (559) 348-2200 1-2205 Coy Avenue, Bakersfield, CA 93307 �'--•t7 Imo..•-,� • (209) 572-2200 17- Paved Area(s): r ;J 61,J /^J({t' i�,�� '� G`��,o I,� J�f� /J-0 • (602) 265-7090 ❑ Trench(es): ❑ Excavation(s)/Other: v� ❑ The following tests/DlD'Z7 DID NOT meet required percent compaction: E Pending lab tests ❑ Phone results ASAP to: Verbal results transmitted to: ONOTES ❑ DISCREPANCIES t 1 .' ❑ % COMPLETE /Jf f ice' �' d �i>��Pf ,� `S % 1 LG LJ�/�rlf�[7^!�,•� �r�A.fOclf'1`rurt-f'P 'i/Z. �` -Nrro It % /`7,SLI o d „10 'I C / All f'�,/17A'� r&f,jGi /'nnr< r'!°�P r►;'iAc r��/6(��( n aT a 7%4 In /- `7 7 ')1 -1.4 ini tl To d'best'of my knowledge, the abov Superintendent/Representative: Phone: T- T-, 'r 1y WAS NOT peiformed in accordance with the approved plans, specifications, and regulatory requirements. (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 (, I ijl r0 • (559) 348-2200 1-2205 Coy Avenue, Bakersfield, CA 93307 �'--•t7 Imo..•-,� • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 WAS NOT peiformed in accordance with the approved plans, specifications, and regulatory requirements. Technician: 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 215 West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 1-2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 Technician: 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 a (425) 485-5519 11616 E. Montgomery Dr., Ste 31, Spokane Valley, WA 99206 • (509) 534-9711 4Z$Z 1<raZan & Associates, Inc. GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING AND INSPECTION DSA FilelAppl. No. OSHPD No. Permit No. � I I -01 �ulo ''1lil�j CONTRACTOR:+JL4,1 PROJECT#: PROJECT:k,t PRESENT AT SITE:?� f; tT i rpt LOCATION:. LA QL COPIES TO: KRAZAN PROJECT MANAGER: WEATHER: TEMP: &&V / EARTHWORKEd Performed compaction testing on the following: ❑ Performed observation for the following: The following tests DID 1( DID NOT meet required percent compaction: # %3 Ell Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: ONOTES ❑. DISCREPANCIES ❑ vKIWA 1�1r.1 �t%l�. � ��St`�r �rT-1<4'. ��;t;V� h ►R�c�(S�ti _ 1i;11 ('LY' 4 C U It�1fi� h ll U,*-, �,? • • C J 7 r? r. • I� U� l`Itll/C' .(.11. )K' 1'�1_ t;:t�^i�t�l. ► v : S�: � `fY�t<,: r,1 t\ -i r. - A' f� 4-'T � J, :' 1 L1 i �- �,.Y'�•.�r di c i � i tts) � ` t` +.�li: �� .i'lf2 �i;(' 1��r{' �<.�k r�tr..�a�t� (�• u t✓1( �1'�lh ;:d;,• !';i fl l,"nJG ?iY�m1A.:1 t';i'tc�1L{ % COMPLETE Location of tests Phone: U) To the best of my knowledge, the above WAS /WAS NOT performed in accordance with the approved plans, specifications, and regulatory requirements. Superintendent/Representative: Technician: 2 ,� West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 59822126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montgomery Dr., Ste 31, Spokane Valley, WA 99206 • (509) 534-9711 Description Depth of Testing % Required Curve Sampled Lab No(s). Building Pad(s): al ❑ Paved Areals): ❑ Trench(es): ❑ Excavation(s)/Other: The following tests DID 1( DID NOT meet required percent compaction: # %3 Ell Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: ONOTES ❑. DISCREPANCIES ❑ vKIWA 1�1r.1 �t%l�. � ��St`�r �rT-1<4'. ��;t;V� h ►R�c�(S�ti _ 1i;11 ('LY' 4 C U It�1fi� h ll U,*-, �,? • • C J 7 r? r. • I� U� l`Itll/C' .(.11. )K' 1'�1_ t;:t�^i�t�l. ► v : S�: � `fY�t<,: r,1 t\ -i r. - A' f� 4-'T � J, :' 1 L1 i �- �,.Y'�•.�r di c i � i tts) � ` t` +.�li: �� .i'lf2 �i;(' 1��r{' �<.�k r�tr..�a�t� (�• u t✓1( �1'�lh ;:d;,• !';i fl l,"nJG ?iY�m1A.:1 t';i'tc�1L{ % COMPLETE Location of tests Phone: U) To the best of my knowledge, the above WAS /WAS NOT performed in accordance with the approved plans, specifications, and regulatory requirements. Superintendent/Representative: Technician: 2 ,� West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 59822126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montgomery Dr., Ste 31, Spokane Valley, WA 99206 • (509) 534-9711 aZa11 Associates, Inca GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING AND INSPECTION 1 c PROJECT: -bti-t'� 'r �•1 �} iii 1a1 i r' �f�r� r (r LOCATION: 1 .r,. f L,; KRAZAN PROJECT MANAGER: DSA File/Appl. No. OSHPD No. Permit No. CONTRACTOR: ,'l�U fit; COLI I C'v t Vt^ I.O.R.: PRESENT AT SITE:, P COPIES TO: WEATHER: TEMP:f EARTHWORKPerformed compaction testing on the following: ❑ Performed observation for the following: UJ The following testsDID / DID NOT meet required percent compaction: f I r t ❑ Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: OTES ❑ DISCREPANCIES ❑ % COMPLETE ! , Y(�%1_d1�za1,�. � ��;�' 1.1�r'r� t � iR 6�,r-��yf- !/ie• � aS )(►Y� � . ltz �'r�1 �^.� s Fi t=10 (..V 7f°S?'�.., l i.: I •:'� f 1t � '� ��•.r;ke �• �^K i f1�L, *,�' d � , f% N�r1t,�, A 40.E A' RjaA �u (,� 'q) I �� t�r��2h4 SL44i .CIC i,,Ar• y-rrZ l �' (^�� C:� �. (1 'I. t ►:a,D6Vt (,i SEin �� ri;-irR.n A., -T, c. �'Yflr"� ci,- "r' i ( Al 1.1 't rldln ecll t�i%Y rtni E'j/j �� tib 1� V;46 `114k Location of tests Phone: To the best of my knowledge, the above WAS /''IWAS NOT performed in accordance with the approved plans, specifications, and regulatory requirements. Superintendent/Representative: Description Depth of Testing % Required Curve Sampled Lab No(s). ❑ Building Pad(s): (360) 598-2126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montgomery Dr.. Ste 31. Sookane Vallev. WA 9971716 • rsngi 1;aa-g71r ❑'Paved Area(s): • (559) 348-2200 2265 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 ❑ Trench(es): • (408) 271-2200 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, A2 85017 • (602) 265-7090 Excavation(s)/Other: UJ The following testsDID / DID NOT meet required percent compaction: f I r t ❑ Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: OTES ❑ DISCREPANCIES ❑ % COMPLETE ! , Y(�%1_d1�za1,�. � ��;�' 1.1�r'r� t � iR 6�,r-��yf- !/ie• � aS )(►Y� � . ltz �'r�1 �^.� s Fi t=10 (..V 7f°S?'�.., l i.: I •:'� f 1t � '� ��•.r;ke �• �^K i f1�L, *,�' d � , f% N�r1t,�, A 40.E A' RjaA �u (,� 'q) I �� t�r��2h4 SL44i .CIC i,,Ar• y-rrZ l �' (^�� C:� �. (1 'I. t ►:a,D6Vt (,i SEin �� ri;-irR.n A., -T, c. �'Yflr"� ci,- "r' i ( Al 1.1 't rldln ecll t�i%Y rtni E'j/j �� tib 1� V;46 `114k Location of tests Phone: To the best of my knowledge, the above WAS /''IWAS NOT performed in accordance with the approved plans, specifications, and regulatory requirements. Superintendent/Representative: (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 ' • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 (360) 598-2126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montgomery Dr.. Ste 31. Sookane Vallev. WA 9971716 • rsngi 1;aa-g71r /f / 215.West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 2265 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, A2 85017 • (602) 265-7090 Technician: 1 4221 Brickell St., Ontario, CA 91761 (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 ' • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 (360) 598-2126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montgomery Dr.. Ste 31. Sookane Vallev. WA 9971716 • rsngi 1;aa-g71r RQMKrazan & Associates, Inc. GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING AND INSPECTION U(�o --"A E--- PROJECTN: ij(.G 0(00165 PROJECT: Y�r'�.S 494 ( LOCATION: LA Q), r,_t,-21. ( A DSA File/Appl. No. OSHPD No. Permit No. CONTRACTOR: I.O.R.: PRESENT AT SITE: C COPIES TO: KRAZAN PROJECT MANAGER: WEATHER: TEMP: EARTHWORKN Performed compaction testing on the following: ❑ Performed observation for the following: The following testsID DID NOT meet required percent compaction: ❑ . Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: &OTES ❑ DISCREPANCIES ❑ Phone: % COMPLETE Location of tests pets N A To the best of my knowledge, the ,above WAS / S NOT performed in accordance with the approved plans, specifications, and regulatory requirements. Superintendent/Representative: Technician:.., ?� 215 el4rst Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 4221 Brickell S[., Ontario, CA 91761 • (909) 974-4400 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 43218 Business Park Dr., Ste 109, Temecula, .CA 92590 • (951) 694-0601 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 1501 15th Street•NW, #106, Auburn, WA 98002 • (253) 939-2500 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 11616 E. Montgomery Dr., Ste 31, Spokane Vallev, WA 99206 • (509) 534-9711 Description Depth of Testing % Required Curve Sampled Lab No(s). ❑ Building Pad(s): ❑ Paved Area(s): ❑ Trench(es): Excavations)/Other. C �-t 6-� _ s all (� The following testsID DID NOT meet required percent compaction: ❑ . Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: &OTES ❑ DISCREPANCIES ❑ Phone: % COMPLETE Location of tests pets N A To the best of my knowledge, the ,above WAS / S NOT performed in accordance with the approved plans, specifications, and regulatory requirements. Superintendent/Representative: Technician:.., ?� 215 el4rst Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 4221 Brickell S[., Ontario, CA 91761 • (909) 974-4400 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 43218 Business Park Dr., Ste 109, Temecula, .CA 92590 • (951) 694-0601 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 1501 15th Street•NW, #106, Auburn, WA 98002 • (253) 939-2500 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 11616 E. Montgomery Dr., Ste 31, Spokane Vallev, WA 99206 • (509) 534-9711 Krazan & As-ociates, Inc. - C+EOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING AND INSPECTION PROJECT #: PROJECT: l LOCATION: } A (i) u I S -1-1P , (:P DSA Filet No. OSHPD No. Permit No. CONTRACTOR: I.O.R.: PRESENT AT SITE: IL - COPIES TO: KRAZAN PROJECT MANAGER: WEATHER: L F,,;`i TEMP:j1` i` i Curve Sampled Lab No(s). EARTHWORK❑l Performed compaction testing on the following: ❑ Performed observation for the following: The following tests �ID DID NOT meet required percent compaction:} } " f ❑ Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: L�NOTES ❑ DISCREPANCIES ❑ f 4�4J Description Depth of Testing % Required Curve Sampled Lab No(s). Building Pad(s): ('-T''r?�(tN� 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 ❑ Paved Area(s): ❑ Trench(es): ❑ Excavation(s)/Other: The following tests �ID DID NOT meet required percent compaction:} } " f ❑ Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: L�NOTES ❑ DISCREPANCIES ❑ f 4�4J • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 \j ffo C,r✓o rnrrRa !?f C N F1 'r' I" I. ,nr coy) .PrT S 1.54V'i ;L..) i�nN I iti. 1 E a3::C (IPV / t 3f F► t.L f W?"Ct%y) �1 I Yui O X �e0 ( )ti\l� t l)Wt!'l�('.rFi' 1 tw!'al'1.' � Aim-, ti ()(` CAT AA L.o�rrrz I ?iM b % COMPLETE Location of tests Phone: A To the best of my knowledge, the above WAS / WAS NOT performed in accordance with the approved plans, specifications, and regulatory requirements. Superinte ent/Representative: 21 West kota Avenue, Clovis, CA 93612 • (559) 348-2200 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 Technician: 1 Brickell St., Ontario, CA 91761 , • (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montgomery Dr.. Ste 31. Sookane Vallev. WA 99206 • (.509) .5.34-.9711 KraZan & As'. aciates, Inc. I GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING AND INSPECTION DSA File/ No. OSHPO No. Permit No. CONTRACTOR: � �„�•��,1 ��y • PR CT b: { ! t U�� (°% I.O.R.: PROJECT:y?.-� 5 y�! I �1 '1� r•�G PRESENT AT SITE: LOCATION: i p. Qu, ,� 1 i COPIES TO: KRAZAN PROJECT MANAGER: WEATHER: TEMP - EARTHWORKPerformed compaction testing on the following: ❑ Performed observation for the following: The following tests (DID) DID NOT meet required percent compaction: H I - 34 ❑ Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: 01OTES ❑ DISCREPANCIES ❑ % COMPLETE 14 KIS fl2M�,., [ If �J �� F-rl�l// :.?l,�"i71`-t Description Depth of Testing % Required Curve Sampled Lab No(s). ❑ Building Pad(s): CSF • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 ❑ Paved Area(s): • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 ❑ Trench(es): Excavations)/Other: c The following tests (DID) DID NOT meet required percent compaction: H I - 34 ❑ Pending lab tests ❑ Phone results ASAP to: ❑ Verbal results transmitted to: 01OTES ❑ DISCREPANCIES ❑ % COMPLETE 14 KIS fl2M�,., [ If �J �� F-rl�l// :.?l,�"i71`-t 1,ytlr i �l^�= <:+�,. ►iT �-fL +�I' (V' L` i �i , -• r ` Lf- +'v -t -� Jl't Location of tests (951) 694-0601 i`1`� ftIk , ,rY7 St `7 16' 0 L r uv, dlgi,. rrt ln'1i:+ira rr'tw} OY S�KOY Li jGI L(, -A-0 51t3...ylow, 1 CSF • (661) 837-9200 Phone: 7-It—j' Uy of: -i:1 -L,. , — rlT - A To the best of my knowledge, the above( WAS NOT performed in accordance with the approved plans, specifications, and regulatory requirements. Superintendent/Representative: (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 5 West Dakota Avenue, Clovis, CA 93612 (253) 939-2500 • (559) 348-2200 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 Technician: 4221 Bnckell St., Ontario, CA 91761 1 • (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montqomery Dr.. Ste 31. Sonkane Vallev WA gg,?nA 0 icnoi c2e-0711 4"Kra.Zan' & Ass.ociates,'Inc. GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING AND INSPECTION DSA File/Appl. No. OSHPD No. Permit No. t (� CONTRACTOR: '� k t e i t ruty�� i`i ri 1 (1 �-�Uy�i I�tar.:(� PROJECT #: , t i" . •-)�' I.O.R.: - PROJECT: ll I r,':_��1,,ar \ ti,PRESENT AT SITE: LOCATION: (-;�: (, , ;^J� COPIES TO: KRAZAN PROJECT MANAGER: WEATHER: i h'%h1 TEMP: ! C; EARTHWORK1 � Performed compaction testing on the following: ❑ Performed observation for the following: B #� The following tests DID/, DID NOT meet required percent compaction: a Pending lab tests ❑ Phone results ASAP to: Phone: Verbal results transmitted to: ONOTES ❑ DISCREPANCIES ❑ _ %. COMPLETE KPT-THk a'Ty-,_ Location of tests 9 4'Yz� Ar-' VM lil e�+'v�,rr.. '1�' r'�'`, 1 !� ( �:il, it .�:.�C � aa— IA t !AAAHr , i`•1l',1 4, f�ti(_r� V I ,jt .► li...�.b ft, a.'.e� rrr.' <nl�..��e-�.� (_�`�• �,� `:G�e r') CI \�ih))/: ��,[ � jl�'i•'(�1j 'Tl, i1 % ' {�k+,<l.;�i n . e•-er (,t (. ;'t: sr r� .`V� }�h '/� �d''!•� t?iL.l To the best of my knowledge, the Superintendent/Representative: A NOT performed in accordance with the approved plans, specifications, and regulatory requirements. 215 West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 Technician: j ;r ;�•-✓ tom% l.. 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montgomery Dr., Ste 31, Spokane Valley, WA 99206 • (509) 534-9711 Description Depth of Testing % Required Curve Sampled Lab No(s). ❑ Building Pad(s): ❑ Paved Areals): ❑ Trench(es): Excavation(s)/Other: ��, 1ta.lf �•;r r B #� The following tests DID/, DID NOT meet required percent compaction: a Pending lab tests ❑ Phone results ASAP to: Phone: Verbal results transmitted to: ONOTES ❑ DISCREPANCIES ❑ _ %. COMPLETE KPT-THk a'Ty-,_ Location of tests 9 4'Yz� Ar-' VM lil e�+'v�,rr.. '1�' r'�'`, 1 !� ( �:il, it .�:.�C � aa— IA t !AAAHr , i`•1l',1 4, f�ti(_r� V I ,jt .► li...�.b ft, a.'.e� rrr.' <nl�..��e-�.� (_�`�• �,� `:G�e r') CI \�ih))/: ��,[ � jl�'i•'(�1j 'Tl, i1 % ' {�k+,<l.;�i n . e•-er (,t (. ;'t: sr r� .`V� }�h '/� �d''!•� t?iL.l To the best of my knowledge, the Superintendent/Representative: A NOT performed in accordance with the approved plans, specifications, and regulatory requirements. 215 West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 5044 Bailey loop, McClellan, CA 95652 • (916) 564-2200 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 Technician: j ;r ;�•-✓ tom% l.. 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 11616 E. Montgomery Dr., Ste 31, Spokane Valley, WA 99206 • (509) 534-9711 'raKY-aZan & Associates, Inc. GEOTECHNICAL ENGINEERING' • ENVIRONMENTAL ENGINEERING ' CONSTRUCTION TESTING AND INSPECTION DSA FilelAppl. No. OSHPD No. Permit No. CONTRACTOR: PRO CT N: , f ( / ._.7 I.O.R.: PROJECT: PRESENT AT SITE: ) i LOCATION: COPIES T0: _ J" KRAZAN PROJECT MANAGER: WEATHER: TEMP: 6 t' EARTHWORKM Performed compaction testing on the following: ❑ Performed observation for the following: _r ❑ The following tests, Dib'!, DID NOT meet required percent compaction: i •> Pending lab tests . ❑ Phone results ASAP to: Verbal results transmitted to: *NOTES ❑ DISCREPANCIES ❑ Description Depth of Testing % Required Curve Sampled Lab No(s). ❑ Building Pad(s): - . % f G ..� .1 ;.7�iC"i'u ♦ �•!'t � , I S �-4 A -.J i''y'.}� r..'x..•��;C e�fft 9 4�ri�/ .�" hl—.•:.�:\. :-7f��/•. © Paved Area(s): ,.; . s . f r .... ' i �/ r c i e, 4.'0 3 • (209) 572-2200 ❑ Trench(es): (253) 939-2500 r I • (408) 271-2200 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 ❑ Excavation(s)/Other: • (916) 564-2200 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 _ _r ❑ The following tests, Dib'!, DID NOT meet required percent compaction: i •> Pending lab tests . ❑ Phone results ASAP to: Verbal results transmitted to: *NOTES ❑ DISCREPANCIES ❑ %u r '�i,-!. `i 9•'if�-I ri'r�•:t 1e"7-.a.J`�, ftIF�CTL''JA�'�( �i/i�lrl (' .(Y'J �;'!�� r 1. / . / i �fl �,. I ,.f•�/�' �� f; 1< % COMPLETE Location of tests Phone: J! ~N i !-(' To the best of my knowledge, the above WAS,;/ WAS NOT performed in accordance with the approved plans, *specifications, and regulatory requirements. Superintendent/Representative: Technician: r - . % f G ..� .1 ;.7�iC"i'u ♦ �•!'t � , I S �-4 A -.J i''y'.}� r..'x..•��;C e�fft 9 4�ri�/ .�" hl—.•:.�:\. :-7f��/•. ! J %• r,{ r{� / �.� �rl.�7C f� ';'ri ti 4.'0 , • (209) 572-2200 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 r I • (408) 271-2200 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 %u r '�i,-!. `i 9•'if�-I ri'r�•:t 1e"7-.a.J`�, ftIF�CTL''JA�'�( �i/i�lrl (' .(Y'J �;'!�� r 1. / . / i �fl �,. I ,.f•�/�' �� f; 1< % COMPLETE Location of tests Phone: J! ~N i !-(' To the best of my knowledge, the above WAS,;/ WAS NOT performed in accordance with the approved plans, *specifications, and regulatory requirements. Superintendent/Representative: Technician: 215 West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602) 265-7090 _ T 11616 E. Montgomery Dr., Ste 31, Spokane Valley, WA 99206 9 (509) 534-9711 & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 0 SPECIAL INSPECTION REPORT DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Building Permit No. el, /f67 Job No. A/ l7�5 Date /. y - Job Identification /Address —2-,M s c% /- f . S7ei 1/-q— / /. /,/x-, ,- General Contractor / Address k Z1,_,,,,- e re/�/ Sub -Contractor / Address /Y,/> 'Structural "Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING --57 GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED • J 74e&> /r U /y') n /7i7 / D� C/ !U/ !C/) u /e o� r /� .1 n o Fti//C f<v� i • i/D moi' � /�D%Gl H i /2 / / ,G C ,r 7, �{1 F! G .L!/ �C�-�i :F✓ ('G/s) O � c, � U , v � � � � c,n �u .vQ (f�✓� l � f'.� �,Jiil� .-�ar o f b r , ezzvz vv I 1110AFL !? 7 /O/2 M/14,-. G io/l 44,0, m)P2 / 40yr)_ 11)4- /, E /r? df J d G N 4/ m"? A/f�DGnt � Q 6S &_ -_7 � �/ ;l) &-)I) --/ / ,a / %1111/z ADhD/JV ❑ Set (s) of Concrete / Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE �stered Deputy Building Inspector's certificate Signed by Inspector �- I.U.��' has been filed and it states that the above work was inspected by him and complie withl he provisions of the Building Code applicable t e�eto. Approved by: By Project Superintendent Krazan & Associates, Inc. 40 `L h DSA File/Appl. No. VERIICAL 1,razan~& _ t OSHPD No.i"---C # . ,Associates, Inch - _ Permit No. f 56-7 el i�3 GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING ANNNSPECTION t k -'- 4 FILLET DATE: ) P k r ►^-=i CONTRACTOR t -'p U AE G UT c V.l V E �_ PROJECT#: I.O.R.: 3/16" PROJECT M S C L u Q 1" l a E j 1 f N Cr Si F' T, G n PRESENT AT SITE: MR I'T- I T;PA 3/8" LOCATION: % °i t,c flu t ry"t A CP .. COPIES T0: F, u RE Cz u -L K `R A2—A(J ; KRAZAN PROJECT MANAGER:1F. R ►`�� r`� WEATHER: C � E P fl- TEMP: (::)6 J TITLE 21 TITLE 24 UBC ASME ,1Z STRUCTURAL STEEL ` ��FELD)/SHOP WELDING 16, V.T` ❑ MATERIAL ID ❑ U.T. ❑ M.T. ❑ P.T. It2m(s) inspected: ` r' c- p t )! L t�% >� F E E— 7 �•° Tt c A �IFtF rfnc;i� G1'tE/� SIDE hT' }C �C'P nr.n Gl�G/Y) t' � � r.� E� F _ '1, C fL. ! • F t A � L. �, I -I � CSN c, Location e AA n! c 7 1rr.IfGufvll^D �� >U� J� ;,ir tE !`� %� c. )I �X 3 -A rv) v f+. ;S U x [�. Welder qualification/certification verified for: c1 C`J C rZ T- ��n Ni�iFi F R F: 5 3 r L� c. F j/PJ ='iF�44J' x ❑'Position: FLAT-- VERIICAL HORIZONTAL— OVERHEAD- IX Filler Metal: E' 7 1 T r -j rri s -3 ®Process: SMAW FLAW- GMAW SAW ❑ Other: Cl' Weld Type: FILLET C.P. P.P. PLUG ❑ Other: a Weld Size 3/16" 1&1 5/16" 3/8" ❑ Other: Q� Codes: AWS AISC TITLE 21 TITLE 24 UBC ASME ❑ NOTES ❑ DISCREPANCIES ❑ % COMPLETE To the best of my knowledge, the abo ed��S�/ WAS NOT performed in'accordance wthe approved plans, specifications, and regulatory requirements. Supondent/Representative. Technician: l5- 5 2 V 67 2'5- 2 15 215 West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 2205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 _ , 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 545 Parrott St., San Jose, CA 95112 • (408) 271-2200 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 2979 W. Fairmount Avenue, Phoenix, AZ 85017 • (602126$ zQ ATO T I A 9 �9fff ery Dr., Ste 31, Spokane Valley, WA 99206 -• (509) 534-9711 DSA File/Appl. No. OSHPD No. r�Krazan & Associates, Inc. Permit No. Oho GEOTECHNICAL ENGINEERING • ENVIRONMENTAL ENGINEERING CONSTRUCTION TESTING AND INSPECTION • DATE:� U CONTRACTOR: �I� V< (�E G uT C--k-"A u L t1� PROJECT#: 0�0 6F I.O.R.: PROJECT:-' PAIS C L(A ( I v-c(1,J6 5T -`i I a� PRESENTATSITE: /'AAS LOCATION: -7 flu,q / i I I A COPIES TO: C. (- rJn i1 f, C 1 V02 r" 2 A N KRAZAN PROJECT MANAGER: WEATHER---- TEMP: STRUCTURAL STEEL FIELD / SHOP WELDING f5a. V.T. E) MATERIAL ID ElU.T. ((❑ M. T. ElP.T. ��item(s) inspected: QS l) f C. I� (a) L I Ci-- 0 % X (f/�-- J1 IK<C IN.c�( �� ( nit�� f�,7 C<v-.�4n`(C�> G� C CC��S NG' < T rJ S w oyC�z t}t� C 6) l (,j fir- iTC n L oLt�/V1 C N rj - P (C i C- _ Lit- 0 > (s �T - j Welder qualification/certification verified for: • ©/Position: _FLAT VERTICAL I HORIZONTAL OVERHEAD P' Process: SMAW F -CAW GMAW SAW R -Weld Type: FAL-L-ET" C.P. P.P. PLUG -Weld Size 3/16" 1/4" 5/16" 3/8" Codes: _AWS- AISC TITLE 21 TITLE 24 r"I C) �rI urMtJ C C -V3535 1y In (1 I No U Filler Metal: "If 0 2 j ❑ Other: ❑ Other: ❑ Other: U,BC ASME ❑ NOTES ❑ DISCREPANCIES ❑ % COMPLETE I `i C— (4 ST P-C(`-iE GrJt�CCTIGN Z t-- C— L & C r At iT.c if Et�J51c.IOGD (1 S t .,3Q 1 C��C `� 15 D r 1_ to �Q� `� %I t rt,) Cc_MP(15r C . To the best of my knowledge, the above WAS'/ WAS NOT performed iri•accordance with the approved plans, specifications, and regulatory requirements. Su endent/Representative: Technician: '-C? 4 L�-7 5 TJ 215 West Dakota Avenue, Clovis, CA 93612 • (559) 348-2200 4221 Brickell St., Ontario, CA 91761 • (909) 974-4400 12205 Coy Avenue, Bakersfield, CA 93307 • (661) 837-9200 43218 Business Park Dr., Ste 109, Temecula, CA 92590 • (951) 694-0601 448 Mitchell Rd., Ste. C, Modesto, CA 95354 • (209) 572-2200 1501 15th Street NW, #106, Auburn, WA 98002 • (253) 939-2500 545 Parrott St., San Jose' CA.95112 • (408) 271-2200 20714 State Hwy 305 N.E., Ste. 3C, Poulsbo, WA 98370 • (360) 598-2126 5044 Bailey Loop, McClellan, CA 95652 • (916) 564-2200 19501 144th Avenue NE # F-300, Woodinville, WA 98072 • (425) 485-5519 2979 W. Fairmount Avenue, Phoenix, AZ 8501.7 0 (60Z1ZbS Z09 TO T1 09 �Mp ffery 1,Ite 31, Spokane Valley, WA 99206. • : (509) 534-97.11 Krazan & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 DEPT. OF BLDG. & SAFETY COUNTY / CITY OF • SPECIAL INSPECTION REPORT 1 ! Building Permit No. / �� ' Job No. //I" - C (12K__ir�'(� Date Z2� -,` Job Identification / Address -%� /fr.L��/ %// 1 /' (�1 r 1 ;� /,C� . e -,P1 7-( 4�7 7f i i _C/0 General Contractor / Address 1 Sub -Contractor / Address AC 'Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED t7 <16 tP ' �Jl� /� �' /��%i!/ I % 7�.!(t �,f �cl�.�f � (r^ � � ,t�,✓ /i t /,L�. r ,! i 1, c.� r,?rl a' l ! t f Z ' - 1 r 7_ t/,, S 9 x (/5-,) S re, l�A#el k (. C f I e'. F 7 X- ( I K;?� Ire & � `7FFrz 17ro (�fe-(WfLl;'-r��.�s 77 A�-J /v Al r w � Samples O� Set (s) of !Concrete/ Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE • s � i °j �stered Deputy Building Inspector's certificate Signed by Inspector/X 1/Z has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable•thereto. Approved by: �`� ,r -� - : B PP Y Project Superintendent Krazan & Associates, Inc. _ = DEPT. OF BLDG. & SAFETY __ azari & ASSOCIATES, INC. COUNTY i CITY OF (909) 974-4400 - Fax (909) 974-4022 • SPECIAL INSPECTION REPORT Building Permit No. 61f 7 Job No. �� l � - Date r Job Identification /Address f`r'-�� ✓%«- `� ! �j ��'`' (; ' ' rEa = " r f _ fr 1 t F'1.i.1 General Contractor / Address At x,, s= {i'.T Sub -Contractor / Address �` r Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE � MASONRY HI -TENSILE BOLTING PRESTRESSED. CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED 1 i ♦/f a fi t' l�i�' .�� Y`r •� .J�, /YcFi'i�A�P`f I /` 'I ��ffY 1'' `r 1 r'/ ?rf•�,P t1�:► �l t r'%r! %-- /� r %� �i7�✓^• ii L :�`.c��Jr`�r L� _ !%� -elf- 11- 7-4 Samples n `-` Set (s) of Concrete /:Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE ��'stered Deputy Building Inspector's certificate Signed by Inspector ! (f �'' I�IVO:� �'�`��' yf has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by: fly - By Project Superintendent Krazan & Associates, Inc. -Krazan & ASSOCIATES, INC. (909) 974-4400 - Fax (909) 974-4022 DEPT. OF BLDG. & SAFETY COUNTY / CITY OF ` SPECIAL INSPECTION REPORT Building Permit No.. Job No. Date,/�� Job Identification / Address General Contractor/Address Sub -Contractor / Address "Structural Engineer/ Address 44 TYPE OF WORK: REINFORCED CONCRETE 2f MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED �r`/`rf'itri' �IP'.f��lrt� 11 1%. !fi J�i�l,li rU %iJ/'r 41 tC 7✓ -;i., f t�.'.ti'r —t s,I,: d��r 'r ! 1f f,/ l_ �" L ! /�'� -. � G;' /, fi:%' (.. �r � ,�f f� � 1'� �t-i� ` l C{J}•� �,. 0 AAo64 r- f -7 KA/5 �'',�'f � a„=�r� A ,-�J /�.� rrl- i 7_.lt' All Samples ❑ Set (s) of `""`""""""Concrete / Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE ,�' ' ff R'stered Deputy Building Inspector's certificate Signed by Inspector /.J/ I. O. / 5'r --has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by: /' j /;;r:r;- ✓cam , By f� Project Superintendent Krazan & Associates, Inc. r KXaZan & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 SPECIAL INSPECTION REPORT DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Building Permit No. Job No. �� r` �! 4-- r Date Job Identification/ Address �'� C �'% ��' ��+" / 1, 71 General Contractor / Address ' h ► !�' ! r �'! ' Sub -Contractor /Address + k t Structural Engineer/ Address % 1 // L 1 TYPE OF WORK: REINFORCED CONCRETE � MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED ' r / Samples Set (s) of 1f Concrete / Mortar / Grout / Prisms (Circle one) _ CERTIFICATE OF COMPLIANCE` V0. tered Deputy Building Inspector's certificate Signed by Inspector f { Vhas been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by: Project Superintendent Krazan & Associates, Inc. --==<raZ;an & ASSOCIATES, INC. (909) 974-4400 - Fax (909) 974-4022 DEPT. OF BLDG. & SAFETY COUNTY / CITY OF r SPECIAL INSPECTION REPORT Building Permit No. ! ` '- 7. Job No. / , (Xt � Date Job Identification / Address , �. General Contractor/ Address ?` ^: r_ t T, Sub -Contractor / Address L_ 'Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE �' MASONRY HI -TENSILE BOLTING — PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED 1T �� f rel Samples ❑. � Set (s) of ----:-Concrete / Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE" I stered Deputy Building Inspector's certificate Signed by Inspector / f % t: i {rZ- :'-�'�r,t�(�1%°•��' has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by:i By Project Superintendent Krazan & Associates, Inc. DEPT. OF BLDG.. & SAFETY COUNTY / CITY OF ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 SPECIAL INSPECTION REPORT d� /n/- Bui o. Date��/ Q� Job Identification /Address ��} �� %� �/% L (r)i f I dff r" General Contractor/ Address ' �3L-r• ��(y G�� /iii Sub -Contractor/ Address Structural Engineer/ Addresse:' TYPE OF WORK: REINFORCED CONCRETE,!t MASONRY''^ HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED zg l%fit. Yer,1 7r, o�'lC/ Samples C Set (s) of ___Concrete / Mortar / Grout / Prisms (Circle ones I CERTIFICATE OF COMPLIANCE Re 'stered Deputy Building Inspector's certificate Signed by Inspector been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by. f', 7 By P rojeee§ uperintendent Krazan & Associates, Inc. r KxaZan& ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 DEPT. OF BLDG. & SAFETY COUNTY / CITY OF SPECIAL INSPECTION REPORT Building Permit No.' ' Job No." r' Date Job Identification / Address r ' f // % rc /%� �= ' -� r i� f �' _ . , t i i? A/ General Contractor / Address -n-', Sub -Contractor/ Address 'r� r ' % Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE 't MASONRY_,. HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED r .. ;..,. r !: / `1, j r Samples ❑ Set (s) of i-' Concrete / Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE, tered Deputy Building Inspector's certificate Signed by Inspector I.D!NO. 5 . ' 'f" %"'Ahas been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by: �--� By Project Superintendent Krazan & Associates, Inc. Krazan & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 • SPECIAL INSPECTION REPORT DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Building Permit No. ! r Y A�, 7 Job No. f6, -(i s Date % _ X5 ` Job Identification /Address �'`ji� {'�� t Tf 1,A4, General Contractor / Address % 1`, f f ' ! �� 14 c Sub -Contractor / Address''! "Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE MASONRY'''' HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED ! C } l! f��l V�� {�� 2` - �i 1� Samples D' f` Set (s) of 3 Concrete(/Mortar,/ Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE tered Deputy Building Inspector's certificate Signed by Inspector I. O. -.- has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by: .f` ` fir_= -'"'_-7 By Project Superintendent Krazan & Associates, Inc. e 4 ff (raZa__n_ & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 Ah SPECIAL INSPECTION REPORT DEPT. OF BLDG. & SAFETY COUNTY / CITY OF � - /Gly >,� /� - ('rrri' _ "'�� Building Permit No.� Job No.. f , Date � *x- Job Identification /Address � [%.l 1. A -i General Contractor/ Address Sub -Contractor/ Address ! ' 'Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED /7��!-� � l J:� .�;%%' (.!• fJ fes'! r'�r/fit�`� r' ( /�/I_ e r-- rtx .f -1 -t( Samples Set (s) of Concretes/ Mortar /iGrout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE J � / l R ' tered Deputy Building Inspector's certificate Signed by Inspector ! ,� (le E,i_ f �' I.*, . O._,5�� 73r -,� Chas been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by: By `Project -Superintendent Krazan & Associates, Inc. _ DEPT. OF BLDG. & SAFETY Im amp -2 COUNTY / CITY OF ?—�--Kxazan& ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 • SPECIAL INSPECTION REPORT f�7 Building Permit No.'_2t Job No. � �� % ' %'s Date la'-"rf Job Identification /Address ✓- '' �'�!'- -��1 • .�'�i 61 %A l %. General Contractor / Address 7' Sub -Contractor / Address' 'Structural Engineer/ Address 41,- l -, TYPE OF WORK: REINFORCED CONCRETE MASONRY `' ,' HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OFF INSPECTION DESCRIPTION OF WORK INSPECTED 42/ r t Samples Set (s) of Concrete / Mortar y[ Prisms (Circle one) CERTIFICATE OF COMPLIANCE Qistered Deputy Building Inspector's certificate Signed by Inspector NO., W,7?e,i` .''/ has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by:/" By /Project Superintendent Krazan & Associates, Inc. Krazan (909) 974-4400 • Fax (909) 974-4022 & ASSOCIATES, INC. a SPECIAL INSPECTION REPORT DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Building Permit No.r ' j Job No. � r Date,`="�-S`fE Job Identification / Address r �` < 'ter �- General Contractor / Address { �= Z-. r Sub -Contractor / Address %c <' r`'t i.• .G_ Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE -'�- MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED f �.��t/�. x T��r�'.�S :�Y.r.�.�/" �,.' 6J.?e�' - �% ,C� / l(r/ ' .1 �1�,✓.� s' /i�.,�`�•'��/ -- Samples Set (s) of oncre Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE tered Deputy Building Inspector's certificate Signed by Inspector/ I.D!N0. ' a =r ` has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable Approved b : .'' `- l B PP Y � Y Project Superintendent Krazan & Associates, Inc. DEPT. OF BLDG. & SAFETY fi== Kr'azan & ASSOCIATES., INC. COUNTY / CITY OF (909) 974-4400 • Fax (909) 974-4022 • SPECIAL INSPECTION REPORT Building Permit No. �_ - %�� Job No. 11fl 61- ' a Date Job Identification /Address General Contractor/ Address f; Sub -Contractor / Address %�t " % �7 'Structural Engineer/ Address j ter - TYPE OF WORK: REINFORCED CONCRETE MASONRY._ HI -TENSILE BOLTING PRESTRESSED CONCRETE I WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK �� • / -Zle / {INSPECTED ( 1: �/ a{ J./ �1!'l /�' (f l�i� �• tfr E.J 6 /, �'t t� i ^ (/y��itr�� /r�J f• i i � iF ��(.`?/C /� � (Oir� l !f e• '!yt �: Samples Set (s) of Concrete / MortarV Grout Prisms (Circle one) CERTIFICATE OF COMPLIANCE�— f altered Deputy Building Inspector's certificate Signed by Inspector X <,4as been filed and it states that the above work was inspected by of the Building Code applicable thereto. i Approved by: �- By and complies with the provisions / Project Superintendent Krazan & Associates, Inc. =_t Kraz n & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 SPECIAL INSPECTION REPORT Building Permit No." r r"r Job No.-/ Job Identification /Address General Contractor / Address'', -.r Sub -Contractor / Address DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Date Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED (7 f f'�1 Ji/i(:t '(r ♦:.l.� �.•i r[/�- , A_,J♦i/C{ 7PI—• �( jr t �' �- / '%'/ � f r /fir f!� .-c i �f- �. r.%✓ rim." t?�•�� f�� fJ ' {1' �, i/f !�! i ( i ' S / / • I' r .i K � � _ c , r r w � � it � 1.� i * t 7 Z l�ii •. M �. V, Samples ❑ - Set (s) of Concrete / Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE, % f � tered Deputy Building Inspector's certificate Signed by Inspector f �J !'!- �z • I.D. 0. `- -C' has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable there o. Approved by: �•`' By 9 ;Project Superintendent Krazan & Associates, Inc. Krazan & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 DEPT. OF BLDG. & SAFETY COUNTY / CITY OF SPECIAL INSPECTION REPORT 17 Building Permit No. Job No. '�`!�� l' - Date Job Identification /Address l/ �i L' r ! S'-� / r ► 1 r • . ' - < t r`(:G� General Contractor / Address - -� ` ` - r < < ` r f .fes Sub -Contractor / Address 'Structural Engineer/ Address j(A" r c' TYPE OF WORK: REINFORCED CONCRETE MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED � X ,' ,� r r� �,•d ((_j �' y 1} � / f ( vj% fit/� f .}i< 100 i�� fir ' Samples ❑ r_____ Set (s) of Concrete / Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE ,�,'/` WO. tered Deputy Building,lnspector's certificate Signed by Inspector `.4 e`` - r s rr < r/ Chas been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. <f Approved by: % By Project Superintendent Krazan & Associates, Inc. MEOW-ROL. y.MEM IM : AM.,. & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 DEPT. OF BLDG. & SAFETY COUNTY / CITY OF • SPECIAL INSPECTION REPORT f Building Permit No. , A�� - Job No. ff°lr rl�� Date Job Identification /Address ' 's' r ��` rrj,� d General Contractor / Address - �! / % i tf f / r' { 11z Sub -Contractor / Address Al 'C Structural Engineer/ Address-/// TYPE OF WORK: REINFORCED CONCRETE _ A' MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED I+Lr- Samples �= l Set (s) of < f C ncrete _,Mortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE R 'stered Deputy Building Inspector's certificate Signed by Inspector i ,IIV , I.I O. _`Y 7'rri • '/? has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable, thereto. Approved by:,%`�` ! "� By Project Superintendent Krazan & Associates, Inc. Q'_Kr'aZan & ASSOCIATES, INC. (909) 974-4400 • Fax (909) 974-4022 a I SPECIAL INSPECTION REPORT DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Building Permit No. Job No. Date r Job Identification / Address x General Contractor/ Address Sub -Contractor / Addressf Structural Engineer/ AddressIf%� �- TYPE OF WORK: REINFORCED CONCRETE A' MASONRY HI -TENSILE BOLTING -PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF (INSPECTION DESCRIPTION OF WORK INSPECTED r Samples El' Set (s) ofConcrete/ Mortar / Grout / Prisms (Circle one) OF COMPLIANCE P tered Deputy Building (Inspector's certificate Signed by Inspector I. O. VZhas been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by:�,' �1 By Project Superintendent Krazan & Associates, Inc. .Krazan & ASSOCIATES, INC. • . ' \ (909) 974-4400 • Fax (909) 974-4022 M SPECIAL INSPECTION REPORT DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Building Permit No.C` - "/fir �' Job No.As _4/,�LA Date,,// Job Identification / Address General Contractor/ Address -Jt t r' i L'=- c Sub -Contractor / Address 'Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE �`� MASONRY PRESTRESSED .CONCRETE WELDING HI -TENSILE BOLTING GYPSUM -CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED I'/�,r Samples ❑ _ —Set(s)of T' -''Concrete / Mortar / Grout/ Prisms (Circle one) CERTIFICATE OF COMPLIANCE/` tor I.�ut Buildin9 Ins ectors certificate Si ned b Ins O_ 1! ` r.� `" Chas been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. 01 Approved by: By Project Superintendent Krazan & Associates, Inc. MENU -OIL. 11MMAINE AER Krazan. Fax (909) 974-4022 & ASSOCIATES, INC. (909) 974-4400 49 SPECIAL INSPECTION REPORT Building Permit No. l � Job No. li'l� - C ",," / DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Date -� '� 4 Job Identification/ Addressr % -'� ''- ' ��' t !fity (-7 /1. General Contractor / Address.- Sub-Contractor/Address !.s "r ✓`'�� Structural Engineer/ Address �%il�`X>��' TYPE OF WORK: REINFORCED CONCRETE f:fy MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED J' ,'�L: �<flf!" � (t-_ °.�" 'r .�,=-� ``�fiC"��6•�'.r-T C f` �'lrr- ,"' �'^ � r .%/�ir''�%� //' f aC.� .K! /:,j %-` s _ r Samples ,0 Set (s) of `� t`Concrete,_hMortar / Grout / Prisms (Circle one) CERTIFICATE OF COMPLIANCE R' tered Deputy Building Inspector's certificate Signed by Inspector L O. 3q_� has been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicable thereto. Approved by: �" f By Project Superintendent Krazan & Associates, Inc. i'1! razari & ASSOCIATES, INC. n 1 (909) 974-4400 • Fax (909) 974-4022 i SPECIAL INSPECTION REPORT DEPT. OF BLDG. & SAFETY COUNTY / CITY OF Building Permit No.( If /r; -Z' Job/No. • ��, rj DateeZ/ _ �, t/ / ff / Job Identification / Address `• ��/ �' >�w• %•. : l z r (1/,, ' /- /s .�/ r F Tear General Contractor/ Address Sub -Contractor / Address s _ Structural Engineer/ Address TYPE OF WORK: REINFORCED CONCRETE'S MASONRY HI -TENSILE BOLTING PRESTRESSED CONCRETE WELDING GYPSUM CONCRETE DATE OF INSPECTION DESCRIPTION OF WORK INSPECTED l s�.�,-�/. �-� i �� l Csr /l /.r' /1% /' % ^. !� s • / T �' tc / , r� jj `�Tt!V LAO pu Samples I ❑ —_Set (s) of - Concrete / Mortar / Grout / Prisms (Circle one) 110 CERTIFICATE OF COMPLIANCE / tered Deputy Building Inspector's certificate Signed by Inspector I.D1V0. ' Whas been filed and it states that the above work was inspected by him and complies with the provisions of the Building Code applicableAhereto. i Approved by: - "�By Project Superintendent Krazan & Associates, Inc.