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2017-010 CONTRACTOR AGREEMENT
7
THIS AGREEMENT, made and entered into thitQo day o AY' 2011 ,
A.D., by and between the City of Clermont, 685 W. Montrose Street, Clermont, 'lorida
(herein after referred to as "OWNER"), and RC DEVELOPMENT GROUP, INC., 145
Hilden Road, Unit 105, Ponte Vedra, FL 32081 (herein after referred to as
"CONTRACTOR").
WITNESSETH: That the parties hereto, for the consideration hereinafter set forth,
mutually agree as follows:
SECTION I- SCOPE OF WORK
The CONTRACTOR shall furnish all labor, materials, equipment, machinery, tools,
apparatus and transportation and perform all of the work described in the specifications
entitled:
RFP NO. 17-008, 10,000 Gallon Commercial Fuel Tank
as prepared by OWNER and its agents shall do everything required by this Contract and
the other Contract Documents contained in the specifications, which are a part of these
Documents.
SECTION II-THE CONTRACT SUM
The OWNER shall pay to the CONTRACTOR, for the faithful performance of the
Contract, in lawful tender of the United States, and subject to addition and deductions as
provided in the Contract Documents,the Scope of Work,attached hereto and incorporated
herein as Exhibit "A". The total contract sum shall not exceed ONE HUNDRED
SEVENTEEN THOUSAND,NINE HUNDRED FIFTY DOLLARS AND 00/100 CENTS
(117,950.00).
SECTION III-COMMENCEMENT AND COMPLETION OF WORK
1) The CONTRACTOR shall commence work within 10 calendar days after receipt
of(i)Notice to Proceed, and (ii)receipt of all permits required to perform the work, and
the CONTRACTOR will substantially complete the same within NINETY (90) calendar
days from Notice to Proceed, unless the period for completion is extended otherwise by
the CONTRACT DOCUMENTS. Substantial Completion as provided herein shall be the
day the project or designated portion thereof is certified by the OWNER's Architect as
sufficiently complete, in accordance with the Contract Documents, so the OWNER can
occupy or utilize the work or designated portion thereof for the use for which it is intended.
Final completion shall not exceed THIRTY(30) calendar days thereafter.
2) The CONTRACTOR shall prosecute the work with faithfulness and diligence.
1
3) The CONTRACTOR further declares he has examined the project site and that
from personal knowledge and experience has made sufficient investigations to fully satisfy
himself that such site is correct and suitable for the work and he assumes full responsibility
therefore. The provisions of this Contract shall control any inconsistent provisions
. contained in the specifications. All Drawings and Specifications have been read and
carefully considered by the CONTRACTOR,who understands the same and agrees to their
sufficiency for the work to be done. It is expressly agreed that under no circumstances,
conditions or situations shall this Contract be more strongly construed against the OWNER
than against the CONTRACTOR and his Surety.
Any ambiguity or uncertainty in the Plans,Drawings or Specifications shall be interpreted
and construed by the OWNER's designated Project Manager after consultation with the
Project Architect,and the OWNER's Project Manager's decision shall be final and binding
upon all parties,provided the OWNER agrees.
It is distinctly understood and agreed that the passing, approval and/or acceptance of any
part of the work or material by the OWNER or by any agent or representative as in
compliance with the terms of this Contract and/or of the Drawings, Plans and
Specifications covering said work shall not operate as a waiver by the OWNER of strict
compliance with the terms of this Contract and/or the Drawings and Specifications
covering said work; and the OWNER may require the CONTRACTOR and/or his Surety
to repair,replace,restore and/or make to comply strictly and in all things with this Contract
and the Drawings and Specifications any and all of said work and/or materials which within
a period of one year from and after the date of the passing, approval, and or acceptance of
any such work or material, are found to be defective or to fail and in any way to comply
with this Contract or with the Drawings and Specifications. This provision shall not apply.
to materials or equipment normally expected to deteriorate or wear out and become subject
to normal repair and replacement before their condition is discovered. The
CONTRACTOR shall not be required to do normal maintenance work under the guarantee
provisions. Failure on the part of the CONTRACTOR and/or his Surety,immediately after
Notice to either, to repair or replace any such defective materials and workmanship shall
entitle the OWNER, if it sees fit,to replace or repair the same and recover the reasonable
cost of such replacement and/or repair from the CONTRACTOR and/or his Surety, who
shall in any event be jointly and severally liable to the OWNER for all damages, loss and
expense caused to the OWNER by reason of the CONTRACTOR'S breach of this Contract
and/or his failure to comply strictly and in all things with this Contract and/or his failure to
comply strictly and in all things with this Contract and with the Drawings and
Specifications.
4) As-built drawings, warranties acceptable to OWNER must be submitted to the
OWNER before final payment will be made to the CONTRACTOR.
SECTION IV -AUTHORIZED REPRESENTATIVES
1) Before starting work, CONTRACTOR_shall designate a competent, authorized
representative acceptable to OWNER to represent and act for CONTRACTOR and shall
2
•
inform OWNER in writing, of the name and address of such representative together with a
clear definition of the scope of his authority to represent and act for CONTRACTOR and
shall specify any and all limitations of such authority. At the Pre-construction Conference,
CONTRACTOR shallprovide resumes of key personnel for OWNER's approval.
CONTRACTOR shall keep OWNER informed in writing pursuant to the notice
requirements provided herein of any subsequent changes in the foregoing. Such
representative shall be present or duly represented at the site of work at all times when
work is actually in progress. •
2) From the time of execution of the Contract, the OWNER shall have the right to
remove the CONTRACTOR's representative from the project for inappropriate behavior
including, but not limited to, lack of concern for residents, or acting in an unprofessional
manner(i.e. argumentative with residents or OWNER's representative and the use of foul
language).
3) All notices, determinations, instructions and other communications given to the
authorized representatives of the CONTRACTOR shall be binding upon CONTRACTOR.
Nothing contained herein shall be construed as modifying the CONTRACTOR'S duty of
supervision and fiscal management as provided for by Florida law.
4) The OWNER shall designate a Project Manager who will have limited authority to
act for the OWNER. The OWNER will notify the CONTRACTOR in writing of the name
of such representative(s). Any other City employees are not authorized OWNER
representatives and any work performed by the CONTRACTOR without proper written
authorization from the Project Manager as approved by OWNER, is performed at the
CONTRACTOR's risk, and the City shall have no obligation to compensate the
CONTRACTOR for such work.
SECTION V- LAWS AND REGULATIONS
1) CONTRACTOR and its employees and representatives shall at all times comply
with all applicable laws, codes, ordinances, statutes, rules or regulations in effect at the
time work is performed under this Contract.
2) If,during the term of this Contract,there are any changed or new laws, ordinances
or regulations not known or foreseeable at the time of signing this Contract which become
effective and which affect the cost or time of performance of the Contract,CONTRACTOR
shall immediately notify OWNER in writing and submit detailed documentation of such
effect in terms of both time and cost of performing the Contract. Upon concurrence by
OWNER as to the effect of such changes, an adjustment in the compensation and/or time
of performance will be made, if applicable.
3) If any discrepancy or inconsistency should be discovered between the Contract and
• any law,ordinance, regulation,order or decree, CONTRACTOR shall immediately report
the same in writing to OWNER who will issue such instructions as may be necessary.
However,it shall not be grounds for a Change Order that the CONTRACTOR was unaware
3
Wiring to new electronic solenoid valve at AST
Wiring to existing card reader relocated next to AST
Wiring to new submersible pump at AST
Provide extra conduit for future area light at AST
Provide tank bonding
16. Perform start up and checkout of new system
17. Provide and install upgrade software to existing Card Reader for electronic pump
18. Purge and calibrate dispenser
19. Clean up of all debris
20. Complete all FDEP registration paperwork
21. Provide site plan and tank details showing new tank installation and removal for permitting
19. Obtain permits and pay permit fees
22. Provide training on system
23. Provide all closeout documents
Notes
1. City to cut and remove section of existing containment wall for access
2. City to provide verlflcation of existing foundation thickness and construction for bldg.dept.
3. Proposal so based on Bldg.dept.accepting existing foundation construction for new AST
4. City to provide future area and light and Installation
5. City to pour any concrete drive area outside of existing containment area
6. City to pump down existing product In AST to 12"from bottom
7. Proposal is based on site not having any discharges and thus no formal Env.Assessment required
8. Proposal based on utilizing existing power panel and Card Reader system
9. Proposal does not include any contaminated soil removal or disposal—this work to be completed on
a time and material basis
10. Proposal based on City arranging temporary fueling source while operations are down
City of Clermont
Public Works Fueling Facility
2. Tank in Existing Containment Base Bid$ 7c, o D°
Add-on Options
a.Add tank tent with door at end of AST $ 3°°
b.Add overspill box mounted to AST $
c.Add welded S.S.pipe and flange ftgs(pdct pipe only) $_ .3/ 96
d.Install Twin hose dispenser system vs suction pump $ /5-,
/111/ "~
Fill pipe in black steel and bravo sump under dispenser
e.Complete removal of existing underground piping $ 370 °-
f.
f. Remove existing island form and repour conc. $
g.(2)spring rewind hose reels with 25'hose&hardware $ ,3/ 0&y —
h. Move card reader system to proposed location and
Provide extra conduit for future area light $ r� r'$
Total S 117, M
Note: this option will require the County to supply a source of temporary fueling during the time of
construction as the existing AST will be removed from the containment dike early in the project
commencement.
Note: During the pre-bid meeting it was submitted that the existing double walled system has never had
a discharge which produced soli or groundwater contamination. Therefore,a formal closure assessment
is not required upon abandonment&removal of the old system.
Note: City of Clermont to cut opening in existing containment wail opening and perform concrete boring
on foundation.
BidSync: View Order Page 1 of 2
p City of Clermont PURCHASE ORDER NO:2017-0165
CLERWONT 685 West Montrose Street THIS NUMBER MUST APPEAR ON ALL INVOICES,
l toch."P' Clermont FL 34711
PACKAGES AND CORRESPONDENCE.
SUPPLIER: RC Development Group
JACKSONVILLE FL 32226 BILL TO: 3335 Hancock Road
Clermont FL 34711
CONTACT: Heather Wooding Order Date:Mar 6,2017
Phone:352-241-0178 x601 Req No: 820170168
Email:hwoodingPclermontfl.org •
SHIP TO: Environmental Services Department Delivery Date:Mar 17,2017
3335 Hancock Road
Clermont,FL 34711
Line Item Code Description Qty Unit Unit Price Total Price
1 Removal and Installation for 10,000 Fuel Tank 1 lump sum $117,950.00 $117,950.00
Removal of existing 10,000 gallon diesel fuel tanks and installation of new
self-contained diesel fuel tank.
Total PO Price $117,950.00
Special Instructions:
This purchase order is being issued as per all terms and conditions contained in quote or bid number RFP 17-008 to acquire
10,000 gallon fuel tank as provided there in.Please contact Brian Camp at 352-241-0178 to schedule a delivery date.
Attachments •
Please review the following PO documents online:
Revised Scope and Price Fuel Tank.pdf
RFP 17-008 Evaluation Summary Fuel Tank.pdf
PURCHASE ORDER TERMS AND CONDITIONS
•
Vendors providing goods or services to the City of Clermont acknowledge that by delivering such goods or services agree to
the following terms and conditions.Should a formal contract be executed between the City of Clermont and the vendor
(whether as a result of a formal bid or not),the terms and conditions defined in that contract shall prevail over those listed
here in any case of conflict.
1.Acceptance of this Purchase Order,including the terms and conditions set forth herein,shall constitute the formation of a
binding and enforceable contract between City and vendor.Buyer hereby objects to and will not be bound by any different
or additional terms and conditions contained in the acceptance unless each such different or additional term is expressly
agreed to in writing by the City.Vendor's action in(a)accepting this order,(b)delivering materials,or(c)performing services
called for hereunder shall constitute an acceptance of terms and conditions below on this order.
2.All insurance requirements applicable shall be fulfilled prior to the issuance of this Purchase Order.Vendor is responsible
for keeping required insurance current until service is complete.
3.Upon delivery of goods and/or services as described on the purchase order the vendor shall submit a"proper invoice"to
the Department stated on the front of the purchase order.The invoice shall contain the following minimum information to
be processed for payment:
a)Name of vendor and remittance address of vendor;
b)Date of invoice;
c)Purchase Order number;
d)Quantity of items delivered,item description,unit price,extended price for each item;
•
https://www.bidsync.com/DPXOrder?ac=orderview&print=ves&orderid=27R229R z/0/1f11 7
BidSync: View Order Page 2 of 2
e)Total amount of invoice.
4.No modifications and/or changes shall be binding upon the City unless approved in writing by the City through a revised
purchase order.Quantities specified in the purchase order cannot be changed without writing approval by the City which
will be provided through a new modified/revised purchase order.
5.City is tax exempt from Federal and State taxes for tangible personal property.Invoices shall not include sales tax.
6.Vendor warrants that all goods or services supplied hereunder shall conform to the proposed specifications and be free
from all defects in material,workmanship and title.
7.All prices must be F.O.B.destination.No boxing or packing charges will be allowed by City unless specifically authorized
on the face of this order.Delivery shall not be made to any place other than the destination indicated on the Purchase
Order.
8.The vendor agrees to indemnify,defend and hold harmless the City of Clermont,including,but not limited to its public
officials,City employees,and City Departments,against all damages,claims,liabilities and expenses of any nature
whatsoever,including,but not limited to personal injury,death and property damage,arising out of or in connection with
any actions by the vendor including,but not limited to its owners,officers,employees,subcontractor and agents during the
performance of this order.Additionally,the vendor will indemnify the City,including,but not limited to its public officials,
City employees,and City departments,based on a claim that the supplies or services furnished infringes a United States
Patent or Copyright or constitutes misuse or misappropriation of a trade secret.
9.Public Records:CONTRACTOR expressly understands records associated with this project are public records and agrees
to comply with Florida's Public Records law,to include to:
(a)Keep and maintain public records that ordinarily and necessarily would be required by the CITY in order to perform the
services contemplated herein.
(b)Provide the public with access to public records on the same terms and conditions that the CITY would provide the
records and at a cost that does not exceed the cost provided in this Florida's Public Records law or as otherwise provided by
law.
(c)Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are
not disclosed except as authorized by law.
(d)Meet all requirements for retaining public records and transfer,at no cost,to the CITY all public records in possession of
CONTRACTOR upon termination of the contract and destroy any duplicate public records that are exempt or confidential
and exempt from public records disclosure requirements.All records stored electronically must be provided to the CITY in a
format that is compatible with the information technology systems of the CITY.
(e)If Contractor has questions regarding the application of Chapter 119,Florida Statutes,to the Contractor's duty to provide
public records relating to this Contract,Contractor shall contact the City's custodian of public records at City Clerk's Office,
(352)241-7331.
11-)&6th-T.
Authorized Signature
Print Page Close
httns://www.bidsvnc.com/DPXOrder?ac=orderview&print=ves&orderid=2782298 1/9/9017
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PIREGAIARD The only tank that meets
all of -these standards:
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Compatible With a Wide Range of Fuels and •
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S YOUR ABOVEGROUND TANK EV:•`NYTHiNG I r'S CRACKED UP TO BE?
•Secondary containment is testable on-site using standard; •The secondary containment on certain designs may require
economical testing procedures elaborate and expensive procedures to-be tested on-site
•Impermeable,crack resistant steel outer tank which encloses •Exposed concrete outer wall Is susceptible to cracking,
the concrete encased primary tank spelling and weathering-problems that are expensive to
correct and are typically not covered by warranty
•Steel secondary containment provides added strength, •Polyethylene sheeting depends on concrete for strength
security and is easily recycled and takes years to decompose
•The lightweight monolithic thermal Insulation material •An average 12,000 gallon concrete encased tank weighs
Fireguard"uses Is a specialized concrete that Is part of a approximately 100,000 pounds-increasing costs in
patented process resulting in a lighter material weight transporting and setting the tank In a new location
than concrete alone
(.../...„„--!----)
asYY•.
A division of ST!/SPFA 944 Donata Court Lake Zurich,IL.60047 Ph:(847)438-8265 Fx:(847)438-8766 Web:www.steeltank.com
Fireguard'is availablefrom an extensive group of Steel Tank Institute fabricators who particOate in the STl Qiurlity ntssterance Program,
Under the program,independent quality control inspectors make tsnamturenced visits to STI members,ensuringfabriastion to the highest possible standards.
9/09-2M-Item#130-50-0001
Table ��������
of ��w*..�"°,"��
Safety Instructions
Introduction for the 3008series Electronic Retail Dispensers
--_-_--__'---_----_---_-----_-'4
Product Specifications
- ..... '----'----_--'-----'-'-----'_'--_-_-'4
Features and Capabilities_ '----'-------- -----__------'---------------'-__----'4
Determining the Model Number____-'__--__ '-__-'--_'--'_'__-----'-_-_-'_----'__-'8
Pump Control Devices
____'__________________________ ___________________________g
How toOperate the Dispenser __--__________ ___-___-'-__-_-___'_._-_--'_ _18
How 0oDispense Fuel __ __ __._______'---_ ----__---- _-__ _1O
How tnread the Electro-Mechanical Totalizer _________________----_'---__-- _-______1O
Displaying Electronic Totals-__''-----_--_--_-_--_---____---_---_---_--_-____'___ii
How to Read Electronic Totals
_11
How to Read Last Sale During a Power Failure . _ _11
How to Prepare the Dispenser for Programming -_- --'12
vv
Ho &oPnapomfor -�----
--------------------_ 13
CPU Board Jumper Configuration
-------' ---- __13
Dispenser Address Jumper Setting Chart _._ .. 15
How boView the Hose Electronic Calibration ____ -____ __17
Setting the Jumpers on the Pulse Output Board
'-----'----'---- i8
How boMechanically calibrate the SB4OUMeter 19
Electronically Calibrating the SB-100 and FPP(High Flow Meter) -------'-'
---- ___20
Error Codes
_22
Audit Form
----- ----�-'------ -23
mamonty8tatemmnL___-
. ''----'----'---- ------'--------- _--_'___25
NOTICE
Not all equipment covered in this manual is listed by Underwriters Laboratories. Only those products that
bear the Listing Mark of Underwriters Laboratories are listed.
IMPORTANT
Examine the shipment immediately upon arrival to make certain there has been no damage transit.orloss |n
Benne� Pump Co y. omohiupe� iunot|iab|eomrtbehaaa,duofbnnspo��ion. P�msemake damagoda|m~
dino��tnthe�uxk|inm.
- _ .� 2 � 1O8785�mv�O51314 _� _� ��
•
� �
Bennett 3000 Series Electronic
Commercial Dispensers with 531 Electronics
Operator's Manual
Only Trained Personnel May Work on This Equipment
Includes Instructions For:
Standard 3700 Electronic Commercial Dispensers
3700 Little Squirt - Commercial Dispensers
3700 Big Squirt - Commercial Dispensers
Bennett
Remote Dispensers 111
and
Self-Contained Pumps
r: . In'
F
0 ®
u4
READ THIS BOOK
This book has important information for safe installation and
operation of this equipment. Read and understand this book
before applying power. Keep this book and tell all service
personnel to read this book. If you do not follow the ecl n
instructions, you can cause bodily injury, death or damage to
the equipment.
For new books visit our web page at:
http://www.bennettpump.com ae
108795 Rev C 05.1314
Bennett 1218 E Pontaluna Road.Spring Lake MI$9»55
USA 800-235-7G18-Outside USA 231.798"1310
Safety Instructions
WARNING ADVERTISSEMENT ADVERTENCIA
For the safe installation of this equipment, read and understand all warning and cautions. Look for these
warnings:
0 "DANGER"means: If you do not follow the instructions, severe injury or death will occur.
Q "WARNING"means: If you do not follow the instructions, severe injury or death can occur.
"CAUTION"means: If you do not follow the instructions, damage can occur to the equipment.
DANGER: Fire, explosion, injury or death WARNING: Electronic components are
wi I occur if fuel filters are changed by untrained static sensitive. Use proper static precautions
personnel. Make sure only trained personnel (static straps)before working on the equipment.
change filters.
A WARNING: The emergency shut-off valve
! DANGER: To prevent injury to you from (also called the fire valve, shear valve or impact
ve idles and onlookers, always place a barrier valve) must be closed when service or
around this equipment before performing service maintenance is performed on this equipment.
or maintenance.
A WARNING: You must have training in the
DANGER: Gasoline is flammable. operation and programming of this dispenser
SMOKING OR OPEN FLAME. before using it. READ THE OPERATORS
MANUAL.
0 DANGER: Disconnect all power to this
equipment and associated submerged pump(s) A WARNING: Make sure this equipment is
during installation, service or any maintenance, correctly grounded. Failure to do will cause
i.e., changing filters. injury or damage equipment or improper
operation. Improper grounding voids the
A WARNING: You must have training in the warranty.
installation, service or maintenance of this
equipment (dispenser, pump, console, control A WARNING: When anchoring the dispenser,
box or submerged pump) before working on it. always level the dispenser with shims before
Maintenance repairs must be done by bolting to the island. DO NOT shim just the
authorized personnel only. Warranty work may middle of the dispenser and bolt down.
only be performed by Bennett certified
technicians. a CAUTION: Do not drill holes in fuel
dispensers. Holes can cause failure of the
AWARNING: To prevent electric shock, keep electronic equipment. The warranty will become
the electrical parts of the dispenser dry. void. Use only adhesive backed sign mounting
brackets.
READ AND UNDERSTAND ALL WARNING LABELS ATTACHED TO THE DISPENSER
3 108795 Rev C 05 1314
__
Introduction
All of the dispensers shown in this book can be operated in the "Stand Alone" mode (no control
console), OR RS485 interface to a Fleet Management System where only volume data is recorded OR
Dual Pulse Output to a Fleet Management System where only volume data is required.
Product Specifications
POWER REQUIREMENTS
AC Power Input, Electronic________. _._.____._Universal Input 85-270 Volts A.C. 50/60 Hz.
DC Power Supply Outputs.- _.__ +5VDC 100mA Max, +12 VDC 100mA Max.
DC Power Supply Outputs +24 VDC 1.0 Amps Max., +5VDC Isolated 50mA Max
Nickel-Cadmium Battery Output +10.8VDC,40 Milliamp Hours
NOTE: Self-Contained dispenser motors are set at the factory at 115V.
ENVIRONMENTAL REQUIREMENTS
Operating Temperature Range:_____ -_ -30 to+50°C
Humidity: _0-95%condensing
DIMENSIONS
3700 Series Low Hose___.. ____*60"H x 30"W x 20" D
3700 Series High Hose __ *88"H x 30"W x 20" D
*Without Valance.
Notice
This equipment generates and uses radio frequency energy. If not installed and used properly, i.e., in
strict accordance with the instructions in the installation manual, it may cause interference with radio
communications. It has been tested and found to comply with the limits for a Class A computing device
in accordance with Subpart J of part 15 of FCC rules. Class A computing devices are designed to
provide reasonable protection against such interference when operated in a retail environment.
Operation of the equipment in a residential area may cause unacceptable interference to radio and TV
reception. In such Instances, any necessary corrective measures must be accomplished at the owners
expense.
Features and Capabilities
1. A self-monitoring pulser will prevent product flow in the event of a malfunction.
2. 1"high LCD displays which are lighted from the back with high efficiency, low power LEDs for easier
viewing.
3. A DC battery retains totals and programmed information in the RAM memory during power failures
for up to 10 days.
4. On board battery that maintains last sale information for 15 minutes in the event of power loss.
5. All units have conformal coated electronic boards to help protect them from moisture or foreign
material damage. All major electronic board assemblies are environmentally tested and
temperature cycled.
6. All major low voltage connectors incorporate gold on gold contacts to prevent oxidation and promote
reliability.
7. The dispenser meets or exceeds FCC Emission Standards and UL specifications.
8. Dispenser programming is performed using jumpers on the CPU board.
4 108795 Rev C 0513 14_
GoPump-C 3000 Electronic Dispensers Specification Sheet
Commercial/Industrial Volume Only Display
Standard Features Computer(cont'd)
• Simple electronic computer • Electronic hose totals of:
• Stand-alone or Interfaced to Control Device • 99999999.999 for gallons(8.3) Bennett
• RS485 Interface or dual pulse output • 999999999.99 for liters(9.2)
• Exclusive eCaI (Electronic Calibration) • Built-in diagnostics with error codes
• Magnet activated totals display
• Programmable unit of measure for US Hydraulics
gallons,liters,or imperial gallons • Precision Bennett SB100 Meter, 4-piston,
• Operates from 115/230Vac, 60/50Hz, or positive displacement design
380 Vac,50Hz • Type 75 or type 75-HD Bennett sliding vane
• Self contained (suction) models feature pumping unit with integral vortex air CCM
eliminator
standard 1-HP continuous duty motor(s) •
• Back lit LCD displays • SB100 meter is electronically calibrated
(eCal). Mechanically calibrated meter is
• Satellite Outlet Connection(except Quad) optional.
• Self-contained (suction) models: single, • All remote units include bulk-in inlet check
1-product twin,or 2-product twin valves to keep the hydraulics full and
• Remote models: single, 1-product twin, or prevent meter/pulser count-up when the
2-product twin submersible pump pressurizes the system
• Quad"Active-4 hose"remote or suction • Remote units use replaceable paper filter
• Suction pumps use a reusable strainer
Construction • All units feature 1" hose outlets with a
• Low Hose Cabinet Design or 1'x3/4"reducer bushing
• High Hose Cabinet Design • 1-1/2"ground joint union inlet .. ••
• Front or side mount nozzle boots
• Long-life cabinet construction using Options
galvaneal components and powder coated • Programmable Dual Pulse Output Board to 1
panels interface to fleet management systems &
• Black end panels&top tank monitoring system if RS485 is not used
• Black dial face covers • 2-Stage prepay/preset electric solenoid
valve for 1-product, 1-hose or 2-product, 2-
• Red lower doors(optional colors available) hose suction pumps. (valve is standard on
• Hinged swing out lower door all other models)
• Hinged swing down upper door • Internal spin-on filter & adapter for remote
• Heavy duty hose hook (optional internal models
spring rewind retractor available) • For high hose models: balance vapor coax
hose outlet&internal vapor return piping
Computer • Healy active vapor system for high hose
• Simple single board design electronics. • Subpump relay 3-phase contactor
Includes CPU,power,display,eCal,RS485 • Intercom speaker for high hose models
connection, electromechanical analog For information on flow rates,
totalizer, push-button programming • Brushed stainless steel lower doors motor sizes, and model
switches,wiring terminal strip • Brushed stainless end panels configurations see our Model
• LED Backlighting board for the LCD display • Custom lower door colors and/or graphics Configuration Chart 8
• Optical pulser • Mechanical calibration dial for SB100 meter Specification Sheet
• Designed for temperature extremes—no • Hose clamp for 5/8",314",or 1°I.D.hose ULT"listed
heaters or cooling fans required • Explosion proof junction box for lower
• Long life,highly visible back lit LCD display, hydraulic area Certified for resale applications.
1"(2.54cm)numerals • 380 Volt 3-Phase Motors The N.T.E.P. Certificate of
• Battery Backup for last sale recall Burin Conformance is available upon
g • E85 alcohol blend compatibility option request
power outage(required for resale of fuel)
• Internal hose retractor
• Simple 2-command protocol via RS485 Units have been tested and
interface to fleet management systems • Strainer in lieu of filter wl or w/o cloth sack found to comply with the limits
supplies pump status, pulses, volume sale • Satellites(requires satellite board in master. for a Class A computing device
&volumetotals Order from service parts.) in accordance with Subpart J of
• Field wiring goes directly to terminal strip on Part 15 of FCC Rules regarding
Computer (for new installations pull 72" of radio frequency interference.
wire above grade level)
• Transaction display of: 999.999 for gallons, Specifications In this document
9999.99 for liters are subject to change without
notice.
GoPump-C 3K Marketing Specs Rev 2-102604
5 108795 Rev C 05 13 14
Big Squirt 3000 Electronic Dispensers Specification Sheet
Commercial/Industrial Volume Only Display
Standard Features Computer(cont'd)
• Simple electronic computer • Field wiring goes directly to terminal strip on
• Stand-alone or Interfaced to Control Device Computer (for new installations pull 72" of Bennett
wire above grade level)
• Retail Version: RS485 Interface or current • Transaction display of: 999.999 for gallons,
loop or dual pulse output
• Commercial/Industrial Version: RS485 9999.99 for liters
interface or dual pulse output • Electronic hose totals of:
• Exclusive eCalTM(Electronic Calibration) • 99999999.999 for gallons(8.3) 111
• Magnet activated totals display • 999999999.99 for liters(9.2)
• Programmable unit of measure for US • Built-in diagnostics with error codes
gallons,liters,or imperial gallons Hydraulics QC,^,R
• Operates from 115/230Vac, 60/50Hz, or • meter rated at m maximum
380 Vac,50HzRotary �p [ r 1
• Back lit LCD displays • Built-in Inlet check valves to keep the rk r
• Satellite Outlet Connection hydraulics full and prevent meter/pulser i I
count-up when the submersible pump
• Remote dispensers only pressurizes the system
• Single Master, dual master, or master! • 1-1/2' 2-Stage prepay/preset electric •
satellite combination solenoid valve
• Field configurable for single point or • Metal Y-strainer
simultaneous master 8 satellite fueling • 1-1/4"elbow hose outlet(s) with 1-1/4"x 1'
reducer bushing
i
Construction • 1-1/2"ground joint union inlet. FnrF'
• Low Hose Cabinet Design or
• High Hose Cabinet Design Options
• Front or side mount nozzle boots • Programmable Dual Pulse Output Board to
• Heavy duty lift-to-start nozzle boots Interface to fleet management systems &
• Long-life cabinet construction using tank monitoring system if RS485 is not used
galvaneal components and powder coated • 2-Stage prepay/preset electric solenoid
panels valve for 1-product, 1-hose or 2-product,2-
• Black end panels&top hose suction pumps. (valve is standard on
all other models)
• Black dial face covers • Subpump relay 3-phase contactor
• Green lower doors (optional colors • Intercom speaker for high hose models
available) • Explosion
• Hinged swing out lower door p proof junction box for lower
hydraulic area
• Hinged swing down upper door • Brushed stainless steel lower doors
• Heavy duty hose hook • Brushed stainless end panels
Computer • Custom lower door colors and/or graphics
• Simple single board design electronics. • Hoses,nozzles,swivels For Information on flow rates,
Includes CPU,power,display,eCal, RS485 • Satellite-in-use light motor sizes, and model
connection, electromechanical analog • Satellites(requires satellite board In master. configurations see our Model
totalizer, push-button programming Order from service parts) Configuration Chart &
switches,wiring terminal strip Specification Sheet
• LED Backlighting board for the LCD display ULTM listed •
• Optical pulser
• Designed for temperature extremes—no Certified for resale applications.
heaters or cooling fans required The N.T.E.P. Certificate of
• Long life,highly visible back lit LCD display, Conformance is available upon
1"(2.54cm)numerals request
• Battery Backup for last sale recall during Units have been tested and
power outage(required for resale of fuel) found to comply with the limits
• Simple 2-command for a Class A computing device
p protocol via RS485 in accordance with Subpart J of
interface to fleet management systems Part 15 of FCC Rules regarding
supplies pump status, pulses, volume sale
and volume totals radio frequency interference.
Specifications in this document
are subject to change without
notice.
Blg Squirt 31(Marketing Specs Rev 2-102604
6 108795 Rev C 05 13 14
Little Squirt 3000 Electronic Dispensers Specification Sheet
Commercial/Industrial Volume Only Display
Standard Features Computer(cont d)
• Simple electronic computer • Simple 2-command protocol via RS485
• Stand-alone or Interfaced to Control Device interface to fleet management systems Bennett
supplies pump status, pulses, volume sale
• Retail Version: RS485 interface or current and volume totals
loop or dual pulse output
• Field wiring
• Commercial/Industrial Version: RS485 goes directly to terminal strip on
Computer (for new installations pull 72" of
interface or dual pulse output wire above grade level)
• Exclusive eCaITM(Electronic Calibration) • Transaction display of: 999.999 for gallons,
• Magnet activated totals display 9999.99 for liters
• Programmable unit of measure for US • Electronic hose totals of:
gallons,liters,or imperial gallons • 99999999.999 for gallons(8.3) LiC'nnetr
• Operates from 115/230Vac, 60/50Hz, or • 999999999.99 for liters(9.2)
380 Vac,50Hz • Built-in diagnostics with error codes
• Back lit LCD displays !
• Satellite Outlet Connection Hydraulics Y
• Remote dispensers only • Rotary meter rated at 40gpm maximum
• Single Master, dual master, or master/ • 1" 2-Stage prepay/preset electric solenoid •
satellite combination valve for Remote models (optional on
• Field configurable for single point or Suction models)
simultaneous master&satellite fueling • Built-In Inlet check valves to keep the
hydraulics full and prevent meter/pulser t
I
Construction count-up when the submersible pump l
• Low Hose Cabinet Design or pressurizes the system
• High Hose Cabinet Design • Metal Y-strainer
• Front or side mount nozzle boots • 1"elbow hose outlet(s)
• Heavy duty lift-to-start nozzle boots • 1-1/2°ground Joint union inlet
• Long-life cabinet construction using Options
galvaneal components and powder coated • Programmable Dual Pulse O
panels ro9 Output Board to
• Black end panels&top Interface to fleet management systems &
tank monitoring system if RS485 is not used
• Black dial face covers • 1" 2-Stage prepay/preset electric solenoid
• Green lower doors (optional colors valve for 1-product, 1-hose Suction model.
available) (valve Is standard on all other models)
• Hinged swing out lower door • Subpump relay 3-phase contactor
• Hinged swing down upper door • Intercom speaker for high hose models
• Heavy duty hose hook • Explosion proof junction box for lower
hydraulic area
Computer • Brushed stainless steel lower doors
• Simple single board design electronics. • Brushed stainless end panels For information on flow rates,
Includes CPU,power,display,eCal,RS485 motor sizes, and model
connection, electromechanical analog • Custom lower door colors and/or graphics configurations see our Model
totalizer, push-button programming • Hoses,nozzles,swivels Configuration Chart &
switches,wiring terminal strip • Satellite-in-use light Specification Sheet
• LED Backlighting board for the LCD display • Satellites(requires satellite board in master. ULTM listed
• Optical pulser Order from service parts)
• Designed for temperature extremes—no Certified for resale applications.
heaters or cooling fans required The N.T.E.P. Certificate of
• Long life,highly visible back lit LCD display, Conformance Is available upon
1°(2.54cm)numerals request
• Battery Backup for last sale recall during Units have been tested and
power outage(required for resale of fuel) found to comply with the limits
• Simple 2-command protocol via RS485 for a Class A computing device
interface to fleet management systems in accordance with Subpart J of
supplies pump status, pulses, volume sale Part 15 of FCC Rules regarding
and volume totals radio frequency interference.
Specifications in this document
are subject to change without
notice.
USe Squirt 31(Marketing Specs Rev 2-102604
7 108795 Rev C 05 13 14
Materials , ` 821-0200AC OPW 821 Solenoid Valve
2"
Body:Aluminum The OPW 821 Solenoid Valve is designed
821-0075AC to prevent accidental siphoning of
Diaphragm:Viton' ,:+. 3/4'
above ground storage tanks if a leak
Seals &Disc:Viton' .fid,,. = `4,
olL, ;, ;, R .-4." or break occurs in the fuel supply line.
Spring: Stainless steel t = _- ,� 4. The 821 valve is a two-way,normally
Rider Rings:Teflon' closed diaphragm valve that opens when
Disc Holder: Nylon moi;. f
- energized to allow fuel to flow to the
Core Guide:Acetal,delrin L,,, pump or dispenser.Available in female
.. i NPT threads.
Core&Plugnut:Stainless steel
•
Features 821-0150AC
1-1/2" lel821-0100AC a11
•Aluminum Body-compatible with 1. Illi�; . 1`a
gasoline,diesel,kerosene,low grades .Q. jj•
ethanol/methanol,fuel oil and "��"' Bc .m�"'
jet fuels. • Explosion Proof Shell &Water-TightdiMiFrairi• Standard 0 �• Strainer strainer with 100 mesh Aeration 120/60 volts AC. n
screen is recommended at the inlet. •Thermal Expansion A D
• Mount-vertical. • Power Draw-20 Watts @ 60 Hz. 82RV 2505 Series Pressure Relief Valve
Instruction Sheet Order Number:200517
Ordering Specifications
Operating Operating OPW 82RV OPW 821
Pressure Pressure Thermal Pressure Solenoid Valve
NPT Size General 'CV Fluid Differential Differential
lal Weight Mounting Relief Valve Aw►
(PSI)
Product# In. Purpose Flow Temp. Min. Max. Min. Max. lbs. kg Position 11.1k
i1111/08.4.11 '
821.0075AC t/. AC 5.1 125 0 50 0 3.4 2.75 1.25 Any Position AF ioi-*7 4/"°+.l1
821-0100AC 1 AC 21 125 0 25 0 1.7 5.25 238 Upright&Vertical 17
821-015OAC 11/4 AC 35 125 0 25 0 1.7 7.25 3.29 Upright&Vertical
821-0200AC 2 AC 60 125 0 25 0 1.7 7.25 3.29 Upright&Vertical
'CV Flow:GPM 0 1 psi Pressure Drop '.,
Dimensions
A B C D --
Product Si in. mm in. mm in. mm in. mm To Dispenser -
821-0075AC 3.31 84 3.64 92 4.46 113 2.33 59 •
821-0100AC 5.00 127 5.59 142 6.84 174 5.38 137 OPW 82RV
821-0150AC 5.00 127 5.59 142 6.84 174 5.38 137
821-0200AC 6.09 155 5.94 151 7.47 190 6.31 160 The 82RV is designed to give thermal
pressure relief to our 821 Series Solenoid
Valve line.Made of all stainless steel
OPW 82RV -Thermal Pressure Relief Valve construction with a viton®seal,it is
NPT Size Operating Pressure Weight _ suitable for all petroleum products.The
Product 11 Pe+ 9 - _ ,
in. 25 psi,Stainless Steel lbs. kg 1 82RV is precision set at the factory at 25
82RV-2505 'h Construction .25 .113 yl PSI (1.7 bar),and is field adjustable from
5 to 30 psi(.34 to 2 bar).
Listings and aCertifications
110
CSA Certified UL Listed
9393 Princeton-Glendale Road+ Hamilton Ohio HA 45011 ♦ Phoney :1T11 252....--17.7r0:1-2-`r"*"' www.opwglobal.com 231
I
i
s a
Tank Fill. Systems
. .
or Petroleum Pr°ducts 1
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Insight -E:--- - Onsite ,
- _ .,
Tank Filling- Systems
for Petroleum Products • Page 2 j sImPLEx
What is it used for?
Generally used with aboveground storage tanks,
although some underground uses as well.
•
C •
What is it?
An easy means of filling above
ground storage tanks from
.,, in!
delivery trucks.
From pumpers...
From gravity trucks...
•
With manual shutoff
With automatic shutoff ■
One Tank or Multiple Tanks
Y i•
What kinds of products can I deliver with this system?
Petroleum products and automotive products
• Fuel Oils • Hydraulic Oils
• Jet Fuel • Brake Fluid
• Gasoline • Antifreeze
• Lube Oils • Contact Simplex for other products
• Transmission Fluid
Why do I need this Simplex system?
• Easy fill of aboveground storage tanks CODES:
• Eliminates ladders,top fill FP and FFP: EQ 481
• Allows use of gravity truck with tall AFP,SP,CAFP,and MSP: EQ 706
aboveground storage tanks Non-Explosion Proof Controller:
• Controls and prevents spills UL 508A
• Provides fill shutoff Spill Containment: UL 6M86, United
States and Canada
• Allows multiple tank filling
• Factory standard,packaged
• Highly engineered
• Economical
SIMPLEX INC.(s mplexdiaect.com)I SIMPLEX ONSITE INC.(simplexonsite.com) ®2016 Simplex,Inc. All Rights Reserved.
Nationwide Manufactuiig(1509001:2006 vel,Services and Reseals.(800-637.6603) Printed in the USA • 1102-12.04
Spexilleld,R.(Home)*Meta.GA•Boston,MA•Oeveland,OH•Deaver CO•Houston,TX•INnneepord,MN Design subject to change without notice.
Tank Filling Systems
for Petroleum.Products • Page 4 S 1 R1?LEX
FuelPort Description
The Simplex FuelPort is ....v..-- --00-----..-
a compact,economical
solution for simple filling
o q.�'— and spill prevention for _7
aboveground storage Q
IMP X. tanks.The FuelPort
a. § includes all valves and •
fittings necessary forOral i
hose connection from
a pumper truck to an
above ground storage o
P DIESEL tank,packaged within a
lockable,weatherproof _»
spill containment box.
The FuelPort can be bolted to the tank, Specifications:
® hung from the fill pipe,or attached via
clamps to a 3"post.The FuelPort is Fitting size: 1.5",2",3"or 4"
suitable for use with fuel oil,gasoline, Hand pump capacity: 1 gpm
-= automotive products,or certain Paint:white
chemicals.An optional vapor recovery
adaptor is available. Spill containment:
Compact FuelPort-7 gallons
Full-Size FuelPort-20 gallons
Includes:
Net weight:
• Weatherproof,lockable box with spill Compact FuelPort- 129 lbs.
SIMPLEX' I containment Full-Size FuelPort-250 lbs.
• Tank mounting weld brackets(2)
• FuelPort mounting tabs to accept Fittings: 1.5", 2", 3" or 4"
weld brackets(above)or optional 3"
post clamps Inlet to accept:
' i, II DIESEL • Quick disconnect hose coupling with • Standard fitting:Quick detachable
dust plug coupling with check valve,shutoff ball
• Hand pump for spill containment,with valve
shutoff and check valve • Optional fitting:Buyer specified dry
I • Check valve disconnect
• Shutoff valve Outlet fitting:
~" • Ground stud • Threaded pipe welded in top panel,3"
NPT threads
• • Optional gasoline vapor recovery
adaptor
FuelPort with optional Flush
Wall-mounting Flange
I 11
iii ./-7-;
/ r
te.'// ��i �:./../::
//....,-,-. ../,/, /,.///////,////,-//7...z..,.,...:Pedrisre_... ii ,
SIMPLEX INC.(skriPlexdirect.com)i SIMPLEX ONSITE INC.( -corn) , ®2016 Simplex,Inc. All Rights Reserved.
Neilonwrlde PAanufacturing(IS09001:2008 cediId),Services and Rainiiii.000.637403j Printed in the USA • 1102-12.04
WON.ILOtime0tloy•Alenia.GA-Boston.NA•DereNnaOH•Deiwa►.CO•iambri.TX•tlirnegiols,AN Design subject to change without notice.
TankF.11hing. Systems
insight r-'.--- °eats forPelttoleum Products • Page 5
FuelPort FuelPort Installation:
0375•$250 0.11) DAO"571
LEW
I 1� 1 or i--• 4.r0' • Mount to side of tank
• + R +• • - '=' _Iio using weld brackets I ril
i ;, I (included with FuelPort) �I
1 ,
Inl
I KM 21430
—
==4=9a
yya
o ' `I _ y 9 I
•• Hang from Fill Pipe
�� _, (pipe hanger required)
i M 4b aoo5 .11
aa00
nom •ns ,500
Nm0
Ilia!
FuelPort with Flush Wall-Mounting Flange
17 76] � 07.E•, • Clamp to Post1111
(see options list)
1 1 .r rr
5.010
1-1L-4.- •
12 8 ,2,,° —
-ss0o-- '7 fir;,:n::.i.
ila
Via ; n i-
• Mount on Stand
�#r „
iiii
sR ��Mmums 1Z.., • (see options list)
1:1_44:#1 ,III; .-0-'
J
I.
IIIIIIIIMMIIIIIIII 1.255 FuelPort Order Checklist
14. • 4. 1.000
30.0oo U Specify fitting size: 1.5",211 3"or 4"
Full-Size FuelPort ❑ If gasoline use,is vapor recovery required?
.675335
.67 34H50 Options:
,I 3.400 lin ❑ Fire rated valves
a`w. 1•! - - � _ L• ❑ Dry disconnect adapter
- I•i1 i (Full-Size FuelPort only)
J 1I 1 ❑ Fuel strainer(Full-Size FuelPort only)
-
1 , •
- 0): ;- U Hydrostatic level gauge
�. m I.: , ❑ Flush wall-mounting flange
4a. I•
--At- i., _ ` 1:1 Post assembly with base,48"high,w clamps
' r• ❑ Post clamps
U Stand
•
_ N 7.500 U Fusible link fire valve on outlet
N2.227 ❑ Stainless steel cabinet construction
0.675
©2016 Simplex,Inc.All Rights Reserved. SIMPLEX INC.(simplexdiredtcom)/SIMPLEX ONSITE INC.(simpkxonsite.com)
Printed in the USA • 1102-12.04 Nationwide Manole luring(IS09001:2008 certify.Services and Rentals.(800-837-ee03)
Design subject to change without notice. Sp tt, *Cleveland,01
ete,lL(HomeOfice)•MoteGA•gost MI4•Dower,CO.14au on,TX•MInneapofsMx
?colour -1)t_
3Thwi1) i,N)
AsT, VAL E ROT.
Marketing and Supply Company
MATERIAL SAFETY DATA SHEET
1. CHEMICAL PRODUCT AND COMPANY IDENTIFICATION
MSDS NUMBER: V7770
MSDS DATE: 01-01-02
PRODUCT NAME: #2 DIESEL FUEL
24 HOUR EMERGENCY PHONE : (210) 979-8346
TRANSPORTATION EMERGENCIES: CALL CHEMTREC AT 1-800-424-9300
MSDS ASSISTANCE: (210)592-4593
MANUFACTURER'S NAME/ADDRESS:
VALERO MARKETING& SUPPLY CO.
P.O BOX 696000
San Antonio, Texas 78269-6000.
CHEMICAL NAME: Diesel Fuel,No.2 CAS NUMBER: 68476-34-6
SYNONYMS/COMMON NAMES: This Material Safety Data Sheet applies to the following product
descriptions for Hazard Communication purposes only. Technical specifications and formulations vary
greatly and are not reflected in this document. Consult specification sheets for technical information.
ULTRA LOW SULFUR DIESEL—Low emission diesel fuels,< 15 parts per million
01-01-02 MSDS Assistance (210) 592-4593 Page 1 of 8
VALERO Marketing & Supply Company Page 2 of 8
MSDS Number: V7770 Product Name: #2 DIESEL FUEL
2. COMPOSITION, INFORMATION ON INGREDIENTS
PRODUCT USE: This product is intended for use as a fuel in engines and heaters designed for diesel
fuels, and for use in engineered processes. Use in other applications may result in higher exposures and
require additional controls, such as local exhaust ventilation and personal protective equipment.
DESCRIPTION: Ulta Low Sulfur Diesel fuel is a complex mixture of hydrocarbons which are
hydrofinished to remove sulfur. Composition varies greatly and includes C9 to C20 hydrocarbons with a
boiling range of about 325-675° F. The following is a non-exhaustive list of common refinery process
components,typical percentages, and exposure limits for each.
Component or CAS ACGIH Limits OSHA Exposure Limits
Material Name % - Number TLV STEL Units PEL l STEL C/P Units
Hydrotreated middle 100 64742-46-7 100* NA mg/m3 NA NA NA NA
distillate
*NIOSH recommends an exposure limit of 100 mg/m3 for kerosene, which is similar to these components.
The ACGIH has proposed an exposure limit of 100 mg/m3 for Diesel Fuel products,but it has yet to be
adopted and has been placed on the Notice of Intended Change list.
3. HAZARDS IDENTIFICATION
HEALTH HAZARD DATA:
The major effect of exposure to this product is that it may cause giddiness,headache,central nervous
system depression;possible irritation of eyes,nose,and lungs;and dermal irritation. Signs of kidney and
liver damage may be delayed. Pulmonary irritation secondary to exhalation of solvent.
HAZARDS OF COMBUSTION PRODUCTS: Carbon monoxide and carbon dioxide can be found in
engine exhaust and other forms of hydrocarbon combustion. Carbon Monoxide in moderate concentrations
can cause symptoms of headache,nausea, vomiting, increased cardiac output,and confusion. Exposure to
higher concentrations of carbon monoxide can cause loss of consciousness,heart damage, brain damage;
and/or death. Exposure to high concentrations of carbon dioxide can cause simple asphyxiation by
displacing available oxygen. Combustion of this and other similar materials should only be carried out in
well ventilated areas.
MEDICAL CONDITION GENERALLY AGGRAVATED BY EXPOSURE: Medical conditions
which have the same symptoms and effects as those outlined under the health hazard information section
can be aggravated by exposure to this product.
MEDICAL LIMITATION: N/A
•
ROUTES OF EXPOSURE
INHALATION: Irritation of the upper respiratory tract and eyes,with possible euphoria, dizziness,
headache,discoordination,ringing in the ears,convulsions,coma,and respiratory arrest in extreme cases.
01-01-02 MSDS Assistance (210) 592-4593 Page 2 of 8
VALERO Marketing & Supply Company Page 3 of 8
MSDS Number: V7770 Product Name: #2 DIESEL FUEL
SKIN CONTACT: Defatting of the skin may occur with prolonged or repeated contact. Irritation and
burning sensation may occur on exposure to the liquid or mists.
SKIN ABSORPTION: Not significant.
EYE CONTACT: Severe burning sensation with temporary irritation and swelling of lids.
INGESTION: Irritation of the mucous membranes of throat, esophagus and stomach which may result in
nausea and vomiting; central nervous system depression may occur, if absorbed(see Inhalation above). If
aspirated,chemical pneumonitis may occur with potentially fatal results. Possible kidney and liver
damaged may be delayed. (See Notes To Physician in Section 5)
CARCINOGENICITY STATEMENT: Diesel Fuel is not listed as carcinogenic by NTP, OSHA,
ACGIH.
4. FIRST AID MEASURES
•
EYES: Immediately flush eyes with large amount of water for at least 15 minutes holding lids apart to
ensure flushing of the entire eye surface. SEEK IMMEDIATE MEDICAL ATTENTION.
SKIN: Wash contaminated areas with plenty of soap and water. A soothing ointment may be applied to
irritated skin after thoroughly cleansing. Remove contaminated clothing and footwear. SEEK
IMMEDIATE MEDICAL ATTENTION.
INHALATION: Get person out of contaminated area to fresh air. If breathing has`stopped resuscitate
and administer oxygen if readily available. SEEK MEDICAL ATTENTION IMMEDIATELY.
INGESTION:Never give anything by mouth to an unconscious person. If swallowed,do not induce
vomiting. If vomiting occurs spontaneously,keep airway clear. SEEK MEDICAL ATTENTION
IMMEDIATELY.
NOTES TO PHYSICIAN: Do not induce vomiting, use gastric lavage only. Aspiration of liquid into the
lungs could result in Chemical Pneumonitis. Use of Adrenaline is not advised. Treat symptomatically.
5. FIRE AND EXPLOSION DATA
FLASH POINT: 100°F (PM)minimum AUTOIGNITION TEMPERATURE: 494°F
FLAMMABLE LIMITS IN AIR: UEL: 5 %
LEL: 0.7
EXTINGUISHING MEDIA: Dry chemical, carbon dioxide,foam or water spray. Water may be
ineffective in fighting fires of liquids with low flash points,but water should be used to keep fire-exposed
containers cool. If a leak or spill has not ignited,use water spray to disperse vapors and to protect persons
attempting to stop a leak.
SPECIAL FIRE FIGHTING PROCEDURES:Pressure-demand, self contained, breathing apparatus
should be provided for fire fighters in buildings or confined areas where product is stored.
UNUSUAL FIRE AND EXPLOSION HAZARD: Vapor accumulation is possible,and flashback can
occur with explosive force if vapors are ignited.
6. ACCIDENTAL RELEASE MEASURES
01-01-02 MSDS Assistance(210) 592-4593 Page 3 of 8
1 I.
VALERO Marketing & Supply Company Page 4 of 8
MSDS Number: V7770 Product Name: #2 DIESEL FUEL
If material is spilled, steps should be taken to contain liquid and prevent discharges to streams or sewer
systems and control or stop the loss of volatile materials to the atmosphere. Spills or releases should be
reported, if required to the appropriate local,state and federal regulatory agencies.
SMALL SPILLS: Remove ignition sources. Absorb spilled material with non-combustible materials such
as cat litter, dirt, sand, or petroleum sorbent pads/pillows. Do not use combustible materials like rags,
wood chips,or saw dust. Remove contaminated materials to an appropriate disposal container.
LARGE SPILLS: Remove ignition sources. Dike spill area with sand or dirt to contain material and
cover sewers/drains. Remain upwind and keep unnecessary people away. Contact trained emergency
response team for cleanup. Remove liquid using grounded suction pumps, isolate hazard area and deny
entry.
7. HANDLING AND STORAGE INFORMATION
Store only in approved containers. Protect containers against physical damage. Outside or detached storage
is preferred. Separate from oxidizing materials. Store in cool,well ventilated area of non-combustible
construction away from possible sources of ignition. Keep away from incompatible materials and follow
OSHA 29 CFR 1910.106 and NFPA 30 for storage requirements.
•8. EXPOSURE CONTROLS/PERSONAL PROTECTION
VENTILATION REQUIREMENTS: Work in well ventilated areas using good engineering practices to
process,transfer and store. Special ventilation is not required unless product is sprayed or heated. High
volume use may require engineering controls.
SPECIFIC PERSONAL PROTECTIVE EQUIPMENT
RESPIRATORY: Respiratory protection is not required unless exposure levels exceed 100 mg/m3. Use
NIOSH approved respiratory protection following manufacturer's recommendations where spray,mists,or
vapors may be generated above the applicable exposure limits. Supplied air respiratory protection is
required for IDLH areas. See 29 CFR 1910.134 for OSHA Respiratory Protection regulations.
EYE: Face shield and goggles or chemical goggles should be worn where mist or spray may be generated,
and where splashing occurs. Shower and eyewash facilities should be accessible.
GLOVES: Impermeable protective gloves such as nitrile gloves should be worn during routine handling of
this product. Barrier creams may also be appropriate where tactile sensitivity is required.
OTHER CLOTHING AND EQUIPMENT: Clothing contaminated with this product should be removed
and laundered before reuse. Items which can not be laundered should be discarded. Allow contaminated
items to air dry or hang in a well ventilated area. Spontaneous combustion or fire may result from
contaminated materials being placed together before drying.
EXPOSURE MONITORING
BIOLOGICAL:No applicable procedure,breath analysis for hydrocarbons has been suggested.
01-01-02 MSDS Assistance (210) 592-4593 Page 4 of 8
VALERO Marketing & Supply Company Page 5 of 8
MSDS Number: V7770 Product Name: #2 DIESEL FUEL
PERSONAL/AREA: Based on similarity to kerosene, both active and passive monitors employing
charcoal adsorption follow by gas chromatography. An average molecular weight of 170 has been
suggested as the average value to convert the determined weight of hydrocarbons to ppm. Direct reading
colorimetric tubes are available to evaluate short term exposure.
•
9. PHYSICAL AND CHEMICAL PROPERTIES
APPEARANCE AND ODOR: Colorless to straw or red oily liquid with characteristic kerosene-like odor.
VISCOSITY: Spec. dependent, 1.7 -3.4 cSt @ 104° F pH:NA
BOILING RANGE @ 760 mm Hg: 302-644°F SOLUBILITY IN H2O(wt. %): Insoluble
. VAPOR DENSITY (Air=1): 4.5 (kerosene) FREEZING POINT: -51°F
EVAPORATION RATE (BuAc=1):N/A VAPOR PRESSURE: 0.5 mmHg @ 20°C
SPECIFIC GRAVITY (H20=1): 0.865 %VOLATILES BY VOL.:NA
BULK DENSITY AT 60°F: 6.8-7.2 lbs.lgal. API GRAVIY: Specification dependent
10. STABILITY AND REACTIVITY INFORMATION
CONDITIONS CONTRIBUTING TO INSTABILITY: Under normal conditions,the material is stable.
Avoid sources of ignition such as flames,hot surfaces,sparks,and electrical equipment.
INCOMPATIBILITY: Avoid contact with strong oxidizers such as chlorine,concentrated oxygen,and
sodium hypochlorite or other hypochlorites.
HAZARDOUS DECOMPOSITION PRODUCTS: Thermal decomposition products may include carbon
monoxide and carbon dioxide,oxides of sulfur and nitrogen,and other toxic gasses.
HAZARDOUS POLYMERIZATION: Material is not known to polymerize.
11. TOXICOLOGICAL INFORMATION
1. NIOSH recommends that whole diesel exhaust be regarded as a potential occupational carcinogen;
follow OSHA and MSHA rules where exhaust fumes may be generated.
2. A life time skin painting study by the American Petroleum Institute has shown that similar naphtha
products with a boiling range of 350-700°F usually produce skin tumors and/or skin cancers in
laboratory mice. Only a weak to moderate response occurred. The effect to humans has not been
determined.
3. Positive results at 2.0 inUkg and 6.0 ml/kg noted in mutagenesis agenesis studies via in-vivo bone marrow
cytogenetics assay in rats.
For more detailed information,contact MSDS Assistance at(210)592-4593.
12. ECOLOGICAL INFORMATION
01-01-02 MSDS Assistance (210) 592-4593 Page 5 of 8
VALERO Marketing & Supply Company Page 6 of 8
MSDS Number: V7770 Product Name: #2 DIESEL FUEL
For detailed information,contact MSDS Assistance at(210) 592-4593.
13. DISPOSAL CONSIDERATIONS
Shipment, storage,disposal, and cleanup actions of waste materials are regulated under local,state and
federal rules. Contact the appropriate agencies if uncertain of applicability. Waste product and
contaminated material having a flash point below 140°F is considered a hazardous waste. DOT Hazardous
Waste Number D001 applies. Consult 40 CFR 262 for EPA disposal requirements.
•
14. TRANSPORT INFORMATION
DOT PROPER SHIPPING NAME Combustible Liquid,n.o.s. Diesel fuel
DOT HAZARD CLASS* Combustible Liquid 3*
DOT PACKING GROUP(PG) III Ill
I.D. NUMBER NA1993 NA1993
REQUIRED LABELING None Flammable Liquid
* Since this product has a flash point>100°F and no other hazard class applies,it may be reclassed as a
Combustible Liquid and NA 1993 substituted for the product specific I.D.Number above. Consult 49 CFR
173.120 for specific details.
15. REGULATORY INFORMATION
TSCA(Toxic Substances Control Act) Inventory
Diesel Fuel is listed in the TSCA inventory.
SARA(Superfund Amendments and Reauthorization Act)TITLE III
This product is reportable under SARA Title III, Sections 311 &312 as a hazardous substance.
Hazard Categories Applicable under 40 CFR 370.2 (SARA Section 311):
Acute Health Chronic Health Pressure Fire Reactive
Yes Yes No Yes No
Components listed under 40 CFR 372.65(SARA Section 313):
This product does not contain chemicals identified as toxic by EPA under 40 CFR Part 372 and is
not subject to the reporting requirements of this section.
STATE REGULATIONS:
California Proposition 65: This product does not contain chemicals known to the State of California to
cause cancer,birth defects,or other reproductive harm.
01-01-02 MSDS Assistance(210) 592-4593 Page 6 of 8
VALERO Marketing & Supply Company Page 7 of 8
MSDS Number: V7770 Product Name: #2 DIESEL FUEL
16. OTHER INFORMATION
NFPA (National Fire Protection Association)Hazard Ratings Codes
Health Fire Reactivity Other
1 2 0
Based on "Standard System for the Identification of the Fire Hazards of Materials,NFPA No. 704 M
THIS MATERIAL SAFETY DATA SHEET WAS PREPARED BY VALERO MARKETING & SUPPLY CO. IN
ACCORDANCE WITH 29 CFR 1910.1200. ALL INFORMATION, RECOMMENDATIONS AND
SUGGESTIONS APPEARING HEREIN CONCERNING THIS PRODUCT ARE BASED UPON TESTS AND DATA
BELIEVED TO BE RELIABLE, HOWEVER, IT IS THE USER'S RESPONSIBILITY TO DETERMINE THE
SAFETY, TOXICITY AND SUITABILITY FOR HIS OWN USE 01? THE PRODUCT DESCRIBED HEREIN.
SINCE THE ACTUAL USE BY OTHERS IS BEYOND OUR CONTROL, NO GUARANTEE EXPRESSED OR
IMPLIED IS MADE AS TO THE EFFECTS OF SUCH USE, THE RESULTS TO BE OBTAINED OR THE
SAFETY AND TOXICITY OF THE PRODUCT NOR DOES VALERO MARKETING & SUPPLY CO. ASSUME
ANY LIABILITY ARISING OUT OF USE BY OTHERS OF THE PRODUCT REFERRED TO HEREIN. NOR IS
THE INFORMATION HEREIN TO BE CONSTRUED AS ABSOLUTELY COMPLETE SINCE ADDITIONAL
INFORMATION MAY BE NECESSARY OR DESIRABLE WHEN PARTICULAR OR EXCEPTIONAL
CONDITIONS OR CIRCUMSTANCES EXIST OR BECAUSE OF APPLICABLE LAWS OR GOVERNMENT
REGULATIONS.
•
01-01-02 MSDS Assistance (210) 592-4593 Page 7 of 8
I..
VALERO Marketing & Supply Company Page 8 of 8
MSDS Number: V7770 Product Name: #2 DIESEL FUEL
Definitions of Material Safety Data Sheet Terminology
GOVERNMENT AGENCIES AND PRIVATE ASSOCIATIONS
ACGIH- American Conference of Governmental Industrial Hygienists,(private association)
DOT -United States Department of Transportation
EPA-United States Environmental Protection Agency
IARC -International Agency for Research on Cancer, (private association)
NFPA-National Fire Protection Association, (private association)
MSHA-Mine Safety and Health Administration,U.S. Department of Labor
NIOSH-National Institute of Occupational Safety and Health,U.S.Department of Health and
Human Services -
NTP-National Toxicology Program, (private association)
OSHA- Occupational Safety and Health Administration,U.S.Department of Labor
HAZARD AND EXPOSURE INFORMATION
Acute Hazard-An adverse health effect which occurs rapidly as a result of short term exposure.
CAS#-American Chemical Society's Chemical Abstract service registry number which identifies the
product and/or ingredients.
Ceiling-The concentration that should not be exceeded during any part of the working exposure
Chronic Hazard-An adverse health effect which generally occurs as a result of long term exposure or
short term exposure with delayed health effects and is of long duration
Fire Hazard-A material that poses a physical hazard by being flammable,combustible,phyrophoric or an
oxidizer as defined by 29 CFR 1910.1200
Hazard Class-DOT hazard classification
Hazardous Ingredients-Names of ingredients which have been identified as health hazards
IDLH-Immediately Dangerous to Life and Health,the airborne concentration below which a person can
escape without respiratory protection and exposure up to 30 minutes, and not suffer debilitating or
irreversible health effects. Established by NIOSH.
mg/m3-Milligrams of contaminant per cubic meter of air, a mass to volume ratio
N/A-Not available or no relevant information found NA-Not applicable
PEL -OSHA permissible exposure limit; an action level of one half this,value may be applicable
ppm-Part per million(one volume of vapor or gas in one million volumes of air)
Pressure Hazard-A material that poses a physical hazard due to the potential of a sudden release of
pressure such as explosive or a compressed gas as defined by 29 CFR 1910.1200
Reactive Hazard-A material that poses a physical hazard due to the potential to become unstable reactive,
water reactive or that is an organic peroxide as defined by 29 CFR 1910.1200.
STEL-The ACGIH Short-Term Exposure Limit,a 15-minute Time-Weighted Average exposure which
should not be exceeded at any time during a workday,even if the 8-hour TWA is less than the TLV.
TLV-ACGIH Threshold Limit Value,represented herein as an 8-hour TWA concentration.
8-hour TWA-The time weighted average concentration for a normal 8-hour workday and a 40-hour
workweek,to which nearly all workers may be repeatedly exposed,day after day, without adverse effect.
W-DO NOT ADD WATER-water reactive materials may produce toxic gas,extreme heat,or
chemical reaction on contact with water.
01-01-02 MSDS Assistance (210) 592-4593 Page 8 of 8
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3
Brian Camp
From: Brian Camp
Sent: Monday, March 27, 2017 8:41 AM
To: 'Roger Combs'
Subject: parcel #
Good morning Roger here is the parcel # 232225040014200100 and the alt. key# 17622816. Hope this works
for you will see you tomorrow.
Thanks,
Brian R. Camp
Environmental Services Manager Sanitation Department
3335 Hancock Road,Clermont, FL 34711
Tel 352-241-0178 I Fax 352-241-0542
Bcamo(a�clermontfl.orq
Choice ofthar ions `_ www.ClermontFL.qov
Our mission: To preserve and enhance the quality of life for the
Clermont community by providing exceptional services.
1
6...;
Mark Griffin
1 - Environmental Services Coordinator
CLER1 352-241-0178
Choice of Champions' - Mgriffin@clermontfl.org
NOTICE TO PROCEED
March 28, 2017
RC Development Group, Inc
145 Hilden Road, Unit 105.
Ponta Vedra, FL 32081
Re: RFP NO. 17-008 .10,000 Gallon Commercial Fuel Tank
Contract Amount:$ 117.950
You' are hereby notified to commence' work on the above reference contract on or before
Arrl t 24, 2ot7 and are to substantially complete the work within ,EQ consecutive calendar _
days thereafter. SUBSTANTIAL COMPLETION shall be the day the project is certified as accepted by the'.
OWNER as sufficiently complete. FINAL COMPLETION shall be _Q_ consecutive calendar days
thereafter.
The contract provides for assessment of liquidated damages of jEL for each consecutive calendar day
after the above final completion date,that the work remains Incomplete.
Dated this 11 tk day of A Pi'1 I 2017 ,° oX'-`dilrik
Mark Oran,Env! tal Services Coordinator
ACCEPTANCE OF NOTICE - -
Re«= �
ipt of e the foregoing Notice To Proceed .is hereby acknowledge this 1 — day of
II K' t-�" 2017.
,,,,,0_,.... m:....
0
Contractor Signature Title, '
685 W. Montrose Street • Clermont, FL 34711 :a www.CiermontFL.gov
Brian Camp
From: Brian Camp
Sent: Wednesday, April 19, 2017 12:53 PM
To: Environmental Srvcs Department; Public Works Department; Fire Department
Cc: James Kinzler; Stoney Brunson
Subject: Fuel System Public Works
Good afternoon all, the diesel fueling system at public works is finally being replaced and upgraded. The old
system will be removed including the pumps, piping and storage tank. The construction will begin on Monday
April 24, 2017. We are asking anyone that needs diesel fuel to stop by today, Thursday and Friday to use as
much fuel as possible to empty the tank. After the fuel runs out diesel will be available at 3335 Hancock Road
(Environmental Services) until the new system is up and running. The DEF tank will be moved to Hancock
Road as well, upon completion of the upgrade there will be a DEF tank at both locations. If there are any
questions please let me know how I can help.
Thanks,
Brian R. Camp
Environmental Services Manager Sanitation Department
3335 Hancock Road,Clermont, FL 34711
CLER D Tel 352-241-0178 I Fax 352-241-0542
Bcamp(a�clermontfl.orq
eafCtwnp�onS www.ClermontFL.qov
Our mission: To preserve and enhance the quality of life for the
Clermont community by providing exceptional services.
•
1
ti
721-
30/
2130/ 10/ 18 HOUR COMMENCEMENT NOTICE
COUNTY AGENCY: 0/1444(4.E Cot./4/P-1
Email or Faz: c 4/yea's. Con- c! o c hL , ,V 1
ir /; 8cc4ci. e_ 0c �l : ..v� 7`
This notice is submitted in compliance with Rule 62-761.450(1)(a) 3 F.A.C. which
requires notification be given to the county"at least 48 hours before:
a. Initiating activities specified in subparagraphs 1. or 2. above,to confirm the date
and time of the scheduled activities.
This notice is hereby submitted for the following facility:
DEP FACILITY ID: 910 j : / y. 7 '7
FACILITY NAME: . C l i' aev rC.t` Tv.�/i L tt), is is f
FACILITY ADDRESS: .
PROJECT DESCRIPTION: �-'£'.rvG rrz. dI zd(s1- of X.7 4- /"'`•set7
yl o,( es/wf v t 4' 6-6 UA-af r5"U^- r✓o<<..v, �►+-�- ��/r PI'
Ivs/ Lf . 1/4, Mo Vt-v -�h{, v4)1- 'si' k(
e.$r„I art c vri of. 19 _ 5 vv. c4-7- 6,47/ 5i fc-4f4:'-'ser-i/
TED START DATE AND TIME:
8 S UR NOTICE START DTIME. "44 "6-r."6-r. '
" '. MLl o-kJ
.
*,..t4artiv/te zoi7
This notice satisfies the reporting requirement of Rule 62-761.450(1)(a)F.A.C. Itis explicitly
understood by the agency receiving this notice that this notice meets the requirements of the Rule
of"at least 48 hours"and covers all activities which may subsequently be undertaken in Rule
62-761.450(1)(a)3.a.and c,to complete the task or project. If this understanding of the Rule is
not consistent with that of the agencies or,additional dttronal information is needed,please fax your
request,signed by an authorized representative of the requesting agency,to the attention for
Project Administrator,904-674-0548 ph.,fax 374-0987.
PLEASE ACKNOWLEDGE YOUR RECEIPT OF THE NOTICE
'BY RETURN FAX TO (904)374-0987
RC Development Group,Inc. PCC 050650
/ Or e-mail Terri rr,RCDevGroup.com
•
•
.
DIP?mai tog poi'
= � nt
tt` Florida Department of Environmental Protection f,,,,,5„,„, a,,,,,,,,,fe
;- 1 Twin Towers Office Bldg.•3600 Blair Score Road•Tallabanee.Florida 32309.2400
EIt 1
dretMr Dar lick.
ApelStorage Tank Facility Registration Form °I' '°"°" MIA,ree,DEM -I
Submit a completed form for the Willy when registration of storage tanks or compression vessels Is required by Chapter 376.303,Florid&Statutes
Please review Registration Instructions before completing the form. .
. I Please check a5 that apply 1 I I Naw Registration I U New Owner 1 1 New Tanks
_LQ Fedlity info UpdateFcolreelion II I Owner I(1fo Updale/Corraedon -SCJ Tank into Updaie/corredion
A. FACILITY INFORMA110N rr County: L x1 i DEP Facility ID:
910/ 997
Facility Name: a Lc r.w 1 r T e r#'Y A-44e. 44..t..1 Jt1 !1 ErT.
Fealty Address: YDO J . SIC. City: t lrA•1bM?' Zip: 3V7//
Fadity Contact 7j cA .3 da. Buelness Phone: (3(4) .fid/-7171
Faulty lype(e): 7► NAICS Code: Finandel Responsibitty: •
24 Hour Emergency Contact a1.1 0% Emergency Phone: (lit)cu -goc, '
a RESPONSIBLE PERSON INFORMATION-identify Indhduai(e)or Suelness(es)responsible for storage lank management,fueling operations,andior
cleanup activttiea at Ute facility location named above. Provide additional infomfation In en attachment If necessary.
Nance: ,.l e„' -v.,1- Fadlty-Responsible Person Relation Type: Eliotdye Date
Mall add , G�f41 IgfitalAt� ri ( d) Fluky Account Owner(pays fees)
cis',ST'ZIP. C 1+RnAt.u4- FL 3 ca"f t i. Facility Account Owner Information must be provided when the
Cotac- my. CNfacility contains alive or out of service storage tanks on site.
Telephone'3 - s a u '1 i"1'1 STCM Account Number(If known) I t{2 a
identify other appropriate he ity relationships forthis party: yFacility OwmerrOperator [ ] Property Owner ( ) Storage Tank Owner _
Name: Other owner,relationship types) Effective Date
Mall address: [ ] Facility Owner/Operator
( City.ST,Tip: [ ] Property Owner '
Contact: - ( ) Storage Tank Owner,
. Telephone: [ ] Other -
C.TANK/VESSEL INFORMATION-Complete one row for each storage tank or compression vessel system located at thio facility.
Tank 1D TN AN I Capacity installed Content ' Statua/Etfa Construction Piping Monitoring
Z -I . er A la veto l94/ 1� i $ yle .
� J�' .I saw 4"17 D L! !fit/,7 LX,. XA' F11!^Ai Z +
i_
•
•
Certified Contractor(pawning tank Installation or removal): 60 slot IteeMaer &flap DOPR License No.: C 0 rpb v
•
Registration Certification: To the best rif^t knowledge and 1 on submitted on this form le true,accurate,and co pleta.
i. Cadie4 I VA,. / '
Printed Name IL Title Signature • Da
DEP 62.781.1130r2) - .
rlerieeeet pnrlet Whoa 4tc1 Carte Osaiei Foo/7766006074% aprl—m basic Swat Mad Mond=Brom 0,00o
UM Oetafrwrrartal Mow a7d 75 Bayoma amws Way. - 22311 311 Mapco taro: 3104 C000rut Pim Was 400 t r Conon Ave, 2210 661 Ay*, 271S trot Hoy..
'snow..Ft 22501 Jadtsr leelk FL 3x]89 Womb,Pt. 3x103 Two.FL 97071 ry Pala Bandl FL 35415 Fon Myers,rt 3310101111171L F1 31104
166495413130 . 90444/1200 ' 407404.7666 5154141100 01 t411.4100 641.51x4176 31154154310
Tank Invoice
State of Florida
Department of Environmental Protection
Storage Tank Registration Account Statement
Rick Scott Ryan E. Matthews
Governor Interim Secretary
Fiscal Year: 2016-2017
Storage Tank Account#: STCM-4222 Invoice Date: April 25, 2017
CLERMONT CITY PUBLIC WORKS Invoice Number: 561202
ATTN: STORAGE TANK REGIS Invoiced Facilities/Tanks: 1/2
685 W MONTROSE ST
CLERMONT,FL 34712 Total Registration Fees Due: $50.00
Email: HWOODING@CLERMONTFL.ORG Amount Submitted:
Cut Along This Line and Return Top Portion With Your Payment Within 30 Days... Thank You
State Government Agencies -
Use Journal Transfer Number: 37 20 2 212001 37450300 00 000200 00
Please remit payment to:
Electronically: http://www.dep.state.fl.us/waste/categories/tanks/default.htm
or
Mail to: DEP-Storage Tank Registration- PO Box 3070 -Tallahassee, FL 32315-3070
Registration Assistance: (850)245-8839 or email us at tankregistration@dep.state.fl.us
******************************************************************
Owner Account#: STCM-4222 CLERMONT CITY PUBLIC WORKS
Invoice Number: 561202 Invoice Date: April 25, 2017
Invoiced Facilities/Tanks: 1/2 Total Registration Fees Due: $50.00
Facility ID
9101997: Clermont City-Public Works Dept Facility Type: H-Local Government
400 12th St,Clermont County: 35 - Lake
Above/ Install Charge Type
Tank ID Size Under Contents Date (For Year) Fee Penalty Due
1 10000 A Vehicular Diesel 05/1991 Renewal(2016-2017) 25 25
3 10000 A Vehicular Diesel 04/2017 Initial(2016-2017) 50 50
Payments: $25.00 Charges: $75.00
Collection Fees: $0.00 Balance Due: $50.00
https://fldep.dep.state.fl.us/...ansactional_Reports/Single_Tank_Invoice_R.asp?txtlnvoice=561202&cboOutput=B&cmdCheckForm=Submit[4/25/2017 12:13:35 PM]
•
Financial instruments kept off-site shall be made pEP Form 62-761,900(31 ,
available for inspection upon five business days notice Form Title:Financial Mechanisms for Stocaoe Tanks
Part D:ST Certificate of Insurance
Guidance
Form Effective Date 41011004 2017
http•//vnw+.dep.state.fl.uslwaste/catecioriesftanksfddefaulLhtm - Incorporated inRules 62-761.420 and 62-762.421.FAC
STATE OF FLORIDA
STORAGE TANK CERTIFICATE OF INSURANCE
• Reference:40 CFR 280.97(b)(2)
Insurer or Risk Retention Group: FL Insurance Companies
Commerce and Industry Insurance Company , (herein referred to as"Insurer"),
[Name of Insurer or Risk Retention Group]
175 Water St., New York, NY 10038 •
[Business address of Insurer or Risk Retention Group]
"Insurer"is a(n) insurer •
[Enter"insurer"or"risk retention group"]
Insured: Sunbiz
City of Clermont
[Name of owner or operator]
PO Box 120219
•
Clermont, FL 34712
[Business address of owner or operator]
Policy Number 008084040 Endorsement Number Not applicable
. [If applicable]
Period of Coverage: 10/20/16 - 10/20/17 Policy Effective Date: 10/20/16
[Current policy period]
Covered Locations:
[List for each facility covered:the FDEP Identification number and the name and site address of the facility where tanks assured by this instrument are
• located and the number of tanks at that site.If separate mechanisms or combinations of mechanisms are being used to assure any of the tanks at this
facility,list each tank assured by this instrument by the tank identification number provided In the notification submitted pursuant to Rules 62-761.400
and 62-762.401,F.A.C.If coverage is different for different tanks or locations,indicate the type of coverage applicable to each tank or location.
Indicate"See attachment"if required.]
FDEP FaciD Facility Name and Site Address Number of Tanks or Tank I.D. Nos.
• See Attachment(s)
•
•
•
•
Certification:
1. "Insurer"hereby certifies that it has issued to the Insured•the liability insurance identified above to provide financial
assurance for corrective action and compensating third parties for bodily injury and property damage caused by
[Insert "corrective action" and/or "compensating third parties for bodily injury and property damage"]
accidental releases in accordance with and subject to the limits
[Insert "sudden accidental releases" or "nonsudden accidental releases" or "accidental releases"]
of liability,exclusions,conditions, and otherterms of the policy arising from operating the facilities/tanks identified above. •
The Insurer further warrants that such policy conforms in all respects with the requirements of 40 CFR 280.97(b), as
adopted by reference in Rule(s)62-761.420 and/or 62-762.421, Florida Administrative Code(F.A.C.)for the above
specified financial assurance. It is agreed that any provision of the policy inconsistent with such regulations is hereby
amended to eliminate such inconsistency.
• Part D page 1 of 2
DEP Form 62-761.900(3)
The limits of liability are:
Each Occurrence:$ 1, 000, 000 Annual Aggregate:$ 2 . 000 . 000
of the amount of coverage is different for different types of coverage or for different storage tanks or locations,indicate on the facility list above or
by separate attachment the amount of coverage for each type of coverage and/or for each storage tank or location.]
exclusive of legal defense costs,which are subject to a separate limit under the policy.
2. "Insurer"further certifies the following with respect to this policy:
a. Bankruptcy or insolvency of the insured shall not relieve"Insurer"of its obligations under the policy to which this
certificate applies.
b. "Insurer"is liable for the payment of amounts within any deductible applicable to the policy to the provider of
corrective action or a damaged third-party, with a right of reimbursement by the insured for any such payment
made by"Insurer. This provision does not apply with respect to that amount of any deductible for which coverage
is demonstrated under another mechanism or combination of mechanisms as specified in
40 CFR 280.95-280.102 and 280.104-280.107.
c. Whenever requested by the Florida Department of Environmental Protection(FDEP)Secretary or the Secretary's
designee("designee"),"Insurer"agrees to furnish,to the FDEP Secretary or designee, a signed duplicate original
of the policy and all endorsements.
d. Cancellation or any other termination of the insurance by"Insurer"except for non-payment of premium or
misrepresentation by the insured, will be effective only upon written notice and only after the expiration of 60 days
after a copy of such written notice is received by the insured. Cancellation for non-payment of premium or
misrepresentation by the insured will be effective only upon written notice and only after expiration of a minimum
of 10 days after a copy of such written notice is received by the insured.
❑✓ Check this box if the following paragraph,for claims-made policies,applies
e. The insurance covers claims otherwise covered by the policy that are reported to"Insurer"within six months of
the effective date of cancellation or non-renewal of the policy except where the new or renewed policy has the
same retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered
occurrence that commenced after the policy retroactive date, if applicable, and prior to such policy renewal or
termination date. Claims reported during such extended reporting period are subject to the terms, conditions,
limits, including limits of liability,and exclusions of the policy.
The person whose signature appears below hereby certifies that the wording of this instrument is identical to the wording as
adopted and incorporated by reference in subsection(s)62-761.420(4)and/or 62-762.421(4), F.A.C.,and that"Insurer"is
licensed to transact the business of insurance
[Insert"licensed to transact the business of insurance°orerligible to provide insurance as an excess or surplus lines insurer in Florida"]
Embossed seal of"Insurer must be included.
[Signature of Authorized Representative of Insurer]
,alternative used, per DEP website:
Sean M.Pattwell,Co-CEO "Signature matches signature on policy (no seal required)"
[Name and Title]
20 Commerce Drive, Floor 2, Cranford, NJ
07016
[ ]
800-475-4055
[Telephone Number]
� aunrari
ggardner( policvmanagers.com e{`1'•� r,A ; '!0,,
AIIJO
n �a
,111► `1 n1. .l ii ! ! 1 �v? i TA!l k
S natu -of s or Notary] "�
[ i9 [Date of fitness r Notary] ;
club
[Printed Name •
itness or include Notary Seal] ••.r-c^ `
RUBY A. KULL fnr►i iriks„ye.*.*
Commission#2356519
Notary Public,State of New Jersey
My Commission Expires Part Dpage 2of2
February 26,2022
DEP Form 62-761.900(3)
ENDORSEMENT
This endorsement; effective 12 : 01 AM, 10/20/16
Forms a part of Policy- No: 008084040 -
Issued to: City of Clermont
By: Commerce. and Industry Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SCHEDULE OF COVERED STORAGE TANK SYSTEMS
•
It is agreed that any previous Schedule of Coverage Storage Tank Systems
is deleted in its entirety and replaced with the following:
The following Storage Tank System(s) are included in Item 5 . COVERED
STORAGE TANK SYSTEM(S) of the Declarations, subject to all of .theterms
and conditions of the Policy and the Policy Period and Retroactive date
indicated below. If no dates are indicated below for Policy Period for
a subject Storage Tank System, the dates indicated in Item 2 . Policy
Period of the Declarations shall apply. If. no date is indicated below
for Retro Date for a subject Storage Tank System, the date indicated in
Item 6 . Retroactive Date of the Declarations shall apply. If a Policy
-Period is indicated below for a subject Storage Tank System, Item. 2
Policy Period of the Declarations is deleted in its entirety and replaced
•
with the Policy Period, below, for such Storage Tank System. If a date
, is indicated below for Retro Date for a subject Storage Tank System, the
date indicated in Item 6 . Retroactive Date of the Declarations is deleted
in its entirety and replaced with Retro Date, below, for such Storage
' Tank System.
Site* Tank AST/ Install Capacity Tank ' Effective Expiration Retro
# # UST Date (Gal . ) Const . Date Date Date
1 1 AST 2017 10, 000 5/01/17 10/20/17 5/01/17
2 1 AST 2009 8, 000 10/20/16 10/20/17 4/28/09
2 2 AST 2009 1, 150 10/20/16 10/20/17 4/28/09
2 3' AST 2009 1, 150 10/20/16 10/20/17 4/28/09
3 1 AST 2002 6, 000 10/20/16 - 10/20/17 10/20/04
3 2 AST 2007 6, 000 10/20/16 10/20/17 10/20/07
3 3 AST 2009 5, 000 10/20/16 10/20/17 4/28/09
3 4 AST 2009 5, 000 , 10/20/16 10/20/17 4/28/09
3 5 ` AST 2009 6, 000 10/20/16. 10/20/17 4/28/09
3 6 AST 2009 6, 000 10/20/16 10/20/17 4/28/09
3 7 AST 2011 6, 000 10/20/16 10/20/17 10/06/11
4 1 AST 2007 5, 000 10/20/16 . 10/20/17 9/25/07
4 2 - .AST ' • 2013 2, 000 .10/20/16 10/20/17 10/20/16
4 3 AST 2013 2, 000 10/20/16 10/20/17 ' 10/20/16
5 1 ' AST 2016 2, 600 10/20/16 10/20/17 9/16/16
- *Site#, name and address are located within the Site Schedule attached
to ,the Policy.
All other terms, conditions, and exclusions shall remain the same .
ENDORSEMENT
This endorsement, effective 12 : 01 AM, 10/20/16
Forms a part of Policy No: 008084040
Issued to: City of Clermont
By: Commerce and Industry Insurance Company
AIG STORAGE TANK
THIRD-PARTY LIABILITY AND CLEAN-UP COSTS POLICY
SITE SCHEDULE
Site# Facility Name/Address, City, State, Zip
1 Clermont City-Public Works
Dept
400 12th St
Clermont, FL 34711
Location ID#: 9101997 #Of Tanks: 001
2 Clermont City Greater Hills WTP
15512 Charter Oaks Tr
Clermont, FL 34711
Location ID#: 9400205 #Of Tanks : 003
3 Clermont City East Side Wtr
Reclaimation Fac
3335 Hancock Rd
Clermont, FL 34711
Location ID#: 9805153 #Of Tanks : 007
4 Sunburst Lane Water Treatment
Plant
15100 Sunburst Ln
Clermont, FL 34711
Location ID#: 9808371 #Of Tanks : 003
5 City of Clermont Police Department
3600 S Hwy 27
Clermont, FL 34711
Location ID#: 9815177 #Of Tanks : 001
All other terms, conditions, and exclusions shall remain the same.
AUTHORIZED REPRESENTATIVE
or countersignature (in states where applicable)
81029 (08/09)
CI4063
//e11-- //t4g1-fs•
AUTHORIZED REPRESENTATIVE
or countersignature (in states where applicable)
81017 (10/02)
CI2253
ENDORSEMENT
This endorsement, effective 12:01 AM, 05/02/17
Forms a part of Policy No. : 008084040
Issued to: City of Clermont
By: Commerce and Industry Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
STORAGE TANK AND SITE ADDITION/DELETION ENDORSEMENT
In consideration of a return premium of $ 0.00, it is hereby
agreed that the policy is amended as reflected below only where an "x"
is shown in the box provided:
{ X J Storage Tank System(s) is/are added to existing site (s) #
001,
Refer to SITE SCHEDULE, for site references and SCHEDULE OF
STORAGE TANK SYSTEM, effective 5/02/17 for Storage Tank
System(s) added.
All other terms, conditions, and exclusions shall remain the same.
AUTHORIZED REPRESENTATIVE
or countersignature (in states where applicable)
83601 (11/03)
CI2197
YY: 16
ENDORSEMENT
This endorsement, effective 12:01 AM, 05/02/17
Forms a part of Policy No: 008084040
Issued to: City of Clermont
By: Commerce and Industry Insurance Company
AIG ENVIRONMENTAL STORAGE TANK
THIRD-PARTY LIABILITY AND CLEAN-UP COSTS POLICY
SITE SCHEDULE
Site# Facility Name/Address, City, State, Zip
1 Clermont City-Public Works
Dept
400 12th St
Clermont, FL 34711
2 Clermont City Greater Hills WTP
15512 Charter Oaks Tr
Clermont, FL 34711
3 Clermont City East Side Wtr
Reclaimation Fac
3335 Hancock Rd
Clermont, FL 34711
4 Sunburst Lane Water Treatment
Plant
15100 Sunburst Ln
Clermont, FL 34711
5 City of Clermont Police Department
3600 S Hwy 27
Clermont, FL 34711
All other terms, conditions, and exclusions shall remain the same.
AUTHORIZED REPRESENTATIVE
or countersignature (in states where applicable)
81029 (10/02)
CI1907 YY: 16
ENDORSEMENT
This endorsement, effective 12:01 AM, 10/20/16
Formsa part of Policy. No: 008084040
Issued to: City of Clermont
By: Commerce' and Industry Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SCHEDULE OF COVERED STORAGE TANK SYSTEMS
It is agreed that any previous Schedule of Coverage Storage Tank Systems
is deleted in its entirety and replaced with the following:
The following Storage Tank System(s) are included in Item 5. COVERED
STORAGE TANK SYSTEM(S) of the Declarations, subject to all of the terms
and conditions of the Policy and the Policy Period and Retroactive date
indicated below. If no dates are indicated below for Policy Period for
a subject Storage Tank System, the dates indicated in Item 2. Policy
Period of the Declarations shall apply. If no date is indicated below
for Retro Date for a subject Storage Tank' System, the date indicated in
Item 6. Retroactive Date of the Declarations shall apply. If a Policy
Period is indicated below for a subject Storage Tank System, Item. 2
Policy Period of the Declarations is deleted in its entirety and replaced
with the Policy Period, below, for such Storage 'Tank System. If a date
is. indicated below for Retro Date for a subject Storage Tank System, the
date indicated in Item 6. Retroactive Date of the Declarations is deleted
in its entirety and replaced with Retro Date, below, for such Storage
Tank System.
Site* Tank AST/- Install Capacity. Tank Effective Expiration Retro
# # UST Date (Gal. ) Const. Date ' Date Date
1 1 , AST 2017 10, 000. 5/01/17 10/20/17 5/01/17
2 1 AST 2009 ' 8, 000 10/20/16 10/20/17 4/28/09 .
2 2 AST . 2009 1,150 10/20/16 - 10/20/17 4/28/09
2 3 AST 2009 1,150 10/20/16 10/20/17 4/28/09
3 1 AST 2002 6, 000 10/20/16 10/20/17 10/20/04
3 2 AST 2007 6,000 10/20/16 10/20/17 10/20/07
3 3 . AST 2009 5, 000 10/20/16 10/20/17 4/28/09
3 4 ' AST 2009 5,000 10/20/16 10/20/17 4/28/09'
3 5 AST 2009 6,000 10/20/16 10/20/17 4/28/09
3 6 AST . 2009 . 6, 000 10/20/16 10/20/17 4/28/09
3 7 AST 2011 ' 6,000 10/20/16 10/20/17 10/06/11
4. 1 AST 2007 5, 000 10/20/16 10/20/17 9/25/07
4 - 2 ' . AST 2013 2, 000 10/20/16 10/20/17 10/20/16
4 3 AST 2013 2, 000. , 10/20/16 10/20/17 10/20/16
5 1 AST ' 2016. 2, 600 10/20/16 10/20/17 9/16/16
*Site#, name and address are located within the Site Schedule attached
to the Policy.
All other terms, conditions, and exclusions-shall remain the same.
AUTHORIZED REPRESENTATIVE
or countersignature (in states where applicable)
81017 (10/02)
CI2253
APR/04/2017/TUE 10: 18 AM FAX No. P. 001/001
71/(-1)4,04 41111
— iW o
New UST Closure Requirements 7szrt.-
Note:The Florida Department of Environmental Protection storage tank system closure procedures have
changed as per the recently revised Underground Storage Tank System Rule, Chapter 62-761 F.A.C.that
became effective on 1/11/2017. The owner/operator is now required to have a Closure integrity Evaluation
Report Form completed and submitted to Broward County prior to initiation of closure or replacement
activities. If this Form is not submitted, a Closure Report shall be submitted following the completion of
closure or replacement activities.
Specifically,a Closure Integrity Evaluation, to be performed by a third-party inspection or testing entity,
must be performed no more than 45 days prior to closure, replacement, or change in service from a
regulated substance to a non-regulated substance for all double-walled storage tanks; double-walled
integral piping,piping sumps,dispenser sumps,and spill containment systems that are in contact with the
soil.
The dosure Integrity Evaluation Report Form for USTs 162-761.900(7)) is to be submitted In writing or
electronic format as part of the notification,and received by Broward County between 30 to 45 days before
the initiation of the work related to the change in service status or closure. In Cases where the Closure
Integrity Evaluation passed,or where a failed Closure Integrity Evaluation was investigated prior to closure
and it was demonstrated that a discharge did not occur,Form 62-761.900(8),Limited Closure Report Form
for USTs shall be submitted to Broward County within 60 days of completion of the dosure,replacement,
or change In service from a regulated substance to a non-regulated substance.
A failed Closure Integrity Evaluation requires the reporting of the failed evaluation as an Incident In
accordance with subsection 62-761.405(3), F.A.C,,and the investigation of the incident in accordance with
subsection 62-761.430,F.A.C. If sampling is necessaryto determine whether a discharge has occurred,then
an Investigation shall be conducted during closure In accordance with Instructions for ConductingSampling
During Underground Storage Tank Closure April 2016 Edition,and a Closure Report shall be submitted in
writing or electronic format to Broward County within 60 days of completion of the closure,replacement,
or change in service from a regulated substance to a non-regulated substance.
Regardless of the date of Installation of the storage tank system or component,owners/operators who do
not have a Closure Integrity Evaluation conducted prior to the storage tank system or system component(s)
has been removed or closed-in-place,shall conduct an investigation at the time of closure In accordance
with 'Instructions for Conducting Samoliaiz_During Underground Storage Tank Closure',
Jlplil 2016 Edition
and a Closure Report shall be submitted in writing or electronic format to Broward County within 60 days
of completion of the closure, replacement, or change in service from a regulated substance to a non-
regulated substance.
In addition,notification shall be received by Broward County in writing or electronic format between 48 and
72 hours prior to the initiation of the dosure or replacement work to confirm the date and time of the
scheduled activities. Please notify Mr. Alfred Reid and Mr. Al Gomez at the following email addresses,
areidQbrowarg,org and agomez@broward.orR,respectively.
The revised Chapter 62-761 F.A.C.,Closure Integrity Evaluation and aforementioned forms and procedures
may be viewed online at the following websites: .
https://www.firules.orgigateway/ChaoterHome.asa7Chaptel=62-7%
https://www.firules.oregatewav/reference.asp?NonRef-07662
j1�
CHANGE ORDER FORM
Purchase Order Number: Bid Number. /7. 0 0 k
Change Order Nummber. Change Order Date: y-. -/7
Project Name: G ft-1/ ,'V� Department:
Job Location: '=/Ou /2,72'
VENDOR INFORMATION:
Company Name: 12.C- / '14 ►-T 41201/P ZK(
Address: l ir ,#,/d cv PP 3 /I S' City, St.,Zip: I A 7t r
Contact Name: /2b4&Z- L . C►''4 bS ,. 3 '°&/ Telephone: 1f0 Zq '6 zf,f
DESCRIPTION OF CHANGE:
Alteration,deviation,addition,or deletion caused by conditions encountered during construction not covered by the spedflcations and
drawings of the project(attach additional pages if necessary).
p ficgis-/ ecP "71-5'F'1044 tja JccA'A-041-?
r C'
r?c vc- !•p 1,44 49 i i At/SSA_ jvitioS , rb V/c&c... 4J-4..i')
c/mis S G,r L aN Cr-114. MA )f G� a/4— 41
1p•t. . a✓tR- tJ4hif J7n - Cd7 tt) — /Z vKJ"
JIM f J AbiQUI E
A. ORIGINAL CONTRACT VALUE $ /17 95b r
B. .01
AMOUNT OF THIS CHANGE ORDER:Council approval required if over 16%of contract
prig,not to exceed$49,999 OR if funds we not available In the approved budget for the Department $ S-Do �.
C. PERCENT OF CONTRACT VALUE THIS CHANGE ORDER(B/A) % Z Ufa
D. AMOUNT OF PREVIOUS CHANGE ORDERS: $
E. TOTAL AMOUNT OF ALL CHANGE ORDERS(B+D) - $
F. PERCENT OF CONTRACT OF ALL CHANGE ORDERS(E/A): 15%Maximum "/o..
G. NEW CONTRACT VALUE(A+E) _$ Z/ 7S
This C ge9 er is not valid without the following sianatureg;
4- z d-t7
CONTRA TOR Date PROJECT ARCHITECT/ENGINEER Date
DEPARTMEN (RECTOR Date PURCHASING DIRECTOR/CITY MANAGER Date
Change Orders over 15%,not to exceed$49,999 of the original contract OR not budgeted,require the following signatures:
CITY OF CLERMONT ATTEST:
Gall L.Ash,Mayor Date Tracy Ackroyd,City Clerk Date
Rev.9-29-15
tz.'+�4e p•►arl„,. DEP Form:62-762.901(7)
Department of Form Title:Closure lntegrkv Report
Effective Date:!Effective
Environmental Protection
w t
e Incorporated in Rule 62-762.411.F.A.C.
q-... ��.., 2600 Blair Stone Road4Tallahassee,Florida 32399-2400
""*brat Vr
closure Integrity Evaluation Report Form for ASTs
This form is required to be completed for facilities performing an aboveground storage tank(AST)closure in accordance with Rule subsections 62-762.801(2)and
62-762.802(3),F.A.C.This form Is only required to be completed If the storage tank system or system component being dosed Is In contact with the soil,and for spill
containment systems If they are completely below-grade.The Closure Integrity Evaluation must be performed not more than 45 days prior to dosure,replacement,or change
In service from a regulated substance to a non-regulated substance.A copy of this Closure Integrity Report shall be provided to the County via email or mail with notification
of closure,In accordance with paragraph 62-762.411(2)(c),F.A.C.,and also as an attachment to the Closure Report or limited Closure Report Form for ASTs 62-762.901(8),
along with any additional attachments.
Complete All Applicable Blanks
(Print or Type)
g0 7
'. FDEP Facility ID Number: /L 7 Proposed Date of Closure: y ' `l
•
Facility Address: 11.. sq- •
Owner Name: ekfMDA.71 C'17 -/v,1 1 C (✓a/f/J%Owner Phone Number: '3S2— Z-47- 1,
Owner Mail or Email Address: 5e#41P4 Cl ofr'"j- (z.. qit,
I. Storage Tank System Closure Information �' /7/Z/4/4/4 C,+A-?P
The following are to be closed:(Fill In ID of the component being closed and check appropriate box)
a.Tank Registration IIdentiflcati/o�nnumber(s): I I
S 1�/ f.l,A/C. c G,�.�' Removed ��
/f _____... Fl Closed In Placeb•Plpingassodated with tank number(s)
-birt e/ i+1(4 Removed ElR____ ___R
u
Closed In-Place141- _
H _ ,,
CI
c. Piping with tank number(s): ll 11
ipi
r
( Removed
r T n
Closed In-Place
d.Spill Containment Systems associated with tank "
number(s): /�� L 1
Til 4 WNTR 1 4,0,0iT Removed
D,#ec- Closed In-Place .
R
e.Dispenser Sumps associated with dispenser 111
(I:number(s):
D d iil. SIOlf/LI Removed
Closed In-Place
E H H 1 1.-.E.---
1 II. Closure Integrity Evaluation Information
A Closure Integrity Evaluation is required prior to the closure of the system components listed above if the system components are In contact with
soil,and for spill containment systems if they are completely below-grade.
l
Date of closure Integrity Evaluation: j' /a i/ // 7
Did the Closure Integrity Evaluation demonstrate that the system components being closed passed the
evaluation? Attach a summary of the evaluation conducted and the results. Previous annual operability
reports, monthly visual/electronic Inspection results, or any other supporting documentation to support the
summary conclusions may be submitted with this evaluation.
DYes KNo
If Yes,attach copy of documentation discussed above and proceed to Section 111.Closure Integrity Evaluation Methodology
and Results,
No,then answer the following (Proceed to (Proceed to
If questions:
Section Ill.) II.1.)
1 •
i
1. Was an Incident Notification Form(INF)submitted to the County[Form 62-762.401(6)]?
Yes No
If No,complete iNF and attach,or attach response as to why INF not being submitted.
2. Was an incident investigation completed PRIOR to closure?
If No,then investigation Is required in accordance with"instructions for Conducting Sampling During
Aboveground Storage Tank Closure"at the time of closure. .Yes14'-No
If Yes,attach copy of incident investigation with results and answer the following question:
> Did the investigation confirm the discovery of a discharge?
If Yes,then proceed to Section III.,and submit either a Discharge Report Form[Form 62-762.901(1)]or
documentation supporting the position that the discovery is thought to be a previously reported discharge. ED Yes No
If No,then proceed to Section IiI.,below. kr
Ill. Closure Integrity Evaluation Methodology and Results: Include a short narrative of the Closure Integrity
Evaluation detailing test methods used, calibration of equipment, summary of results Including information about who performed the
Closure integrity Evaluation,and the dates the tsting was perform d. �'
£ ly /eC 3L y„LO("l�1 NT C�/►'r'”4. jc4c/tq /?rcI.
(CC_ o c'
��i 4s p L rd l' J T
r)
1 j,,16 - / 7iiiv/ Q/1(-- 7£3
(/' tt,.. , /2 (laietir4
'1 ' 001-5
4-44-
I^
n
f
1*
4.?1) s�� i 4V 9 /p/A)6 Lif Go..v ?/m
7
j IV AI I
ar ,e11---C
r—c / 6-572
j3 n271' 1(- - .
This form is required for facilities performing a closure In accordance with Rule subsections 62-762.801(2)and 62-762.802(3),F.A.C.
• Documentation of the Closure integrity Evaluation shall be reported on this form, along with any attachments. This form shall be
submitted to the County via email or mail along with the notification of closure between 30 and 45 days before Initiation of the closure.
Owner or Operator Signature Signature of person pert'. I Closure Integrity Evaluation
Owner or Operator Name Name of person pe rming dos Integrity Evaluation
(Print or Type)
(Print or T )
•
Date Date
C Dc>rt 4a�' <4T. Say
c o i'""a b s`D
•
Florida Department of Environmental Protection DEP Form#62-761.900(5)enrur _
Twin Towers Office Bldg•2600 Blair Stone Road•Tallahassee,Florida 32399-2400 Form Title: UST Contractor Form
n
� Sffecdve Date: July 13.1998
iiiir
Underground Storage System Installation and Removal Form
for Certified Contractors
Pollutant Storage Systems Contractor as defined in Section 489.113,Florida Statutes(certified contractors as defined in Section 62-
761.200,Florida Administrative Code)shall use this form to certify that the installation,replacement or removal of the underground
storage tank system(s)located at the address listed below was performed in accordance with Department Reference Standards. This
includes system components such as dispenser liners,piping sumps,and overfill protection devices.
General Facility Information Facility Name: C4-1/ at ClIE(MQ DEP Facility Identification No. : il 0 I'I R 7 `
Street Address(physical location): i Z 54- ,
County: �� f- Telephone#: (35-4 4p7 ZS S g
Owner t ak C l L/At o ti'"±"." Telephone#: ( ) S 4ot 9 .
Name: -
++ ' f
Owner Address: "'1 L'`7 1 Z S1 „ 1, 1 f/tif u n. -' '( '. ( l�
Storage Tank System Informatio V 1
Number of Tanks Installed: Number of Tanks Removed: C�
-Date Work Initiated: Date Work Completed: 4/Z$ J
l
Tank(s)Manufactured by: Li/to i-tU 0 W/"
Description of work Completed: no
.b (I) � 0-0 a) II-„- p
i4* L c . 1ci
A-A-6) 1d\ N L ow t_+fdity.u,L.J
flew() r ois 1s`i-j( S`ve. pS
- Certification
I hereby certify and attest that I am familiar with the facility that is registered with the Florida Department of Environmental
Protection;that to the best of my knowledge and belief,the storage tank system installation,replacement or removal at this facility
was conducted in accordance with Chapter 489,Florida Statutes,Section 376.303,Florida Statutes,and Chapter 62-761,Florida
Administrative Code,and its adopted reference standards and documents for underground storage tank systems.
tea )1- r£ Ltlr, ic 7 r� s CCi 'b
(Type or Print) PSSC Number •
Certified Pollutan Contractor Name - Pollutant Storage Systems
Contracto License Number
-. 1f/f 7
Certified Tank Contrac .r Signature Date/ve'
S/ 1 / J7
Field Supervisor Nam Date
The owner or operator of the facility ust register the tanks with the Department upon completion of the installation. The installer must
submit this form to the County no more than 30 clays after the completion of installation,replacement,or removal of a storage tank
CHANGE ORDER FORM
Purchase Order Number: Bid Number. /7- DO
Change Order Number: Z Change Order Date: 2(• 7- -1 7
T
Project Name: tv L. S4e0-.- /MIX f : Department:
Job Location: bl4D 1 Z- 4. 4,
VENDOR INFORMATION:
Company Name: '-C )t kT D 1.41c..4.-
Address: / .. • . .. /ar City,St.,Zip: /14/7f- Ke
Contact Name: ' &ex- L - tom ], 5 z.o 8/ Telephone: ?`'Y'-2-71/4"1"
DESCRIPTION OF CHANGE:
Alteration,deviation,addition,or deletion caused by conditions encountered during construction not covered by the specifications and
drawings of the project(attach additional pages tnecessary).
eNf RDA MEv Z. irt'ESSfuS. r' Re p vj r[,£!> /Pl14v6
,1 07Yegtis jv rif
ECM MOM
A. ORIGINAL CONTRACT VALUE $
B 15)
AMOUNT OF THIS CHANGE ORDER:co maP a�pprovairequhed t over 15%of antrac f/
price,not to exceed$49,989 OR If funds ea not evallable in the approved budget for the Deperbnent $ lL)
C. PERCENT OF CONTRACT VALUE THIS CHANGE ORDER(B/A) . '%
D. AMOUNT OF PREVIOUS CHANGE ORDERS: $ 2 5b
E. TOTAL AMOUNT OF ALL CHANGE ORDERS(B+D) $ OdU
F. PERCENT OF CONTRACT OF ALL CHANGE ORDERS(E/A): 15%Maximum % t O r
G. NEW CONTRACT VALUE(A+E) $ / 7,9. r
CONTRACTOR Date PROJECT ARCHITECT/ENGINEER Date
DEPARTMENT DI R Date PURCHASING DIRECTOR/CITY MANAGER Date
Change Orders over 15%,not to exceed$49,999 of the originalcontract OR not budgeted,require the Mowing signatures:
CITY OF CLERMONT ATTEST:
Gall L.Ash,Mayor Date Tracy Ackroyd,CRY Clerk Date
is
Rev.9,29-15
}
1
n V� Ce RC Development Group
145 Hilden Road,Suite 105
Ponte Vedra,Florida 32081
office(904)674-0548
fax(904) 374-0987
DEVELOPMENT GROUP www.rcdevgroup.com
Date Invoice Number
5/5/2017 3383
Bill To Ship To
City of Clermont
685 w.Montrose St Fuel storage tank
Clermont,FL 34711 Project 17-008
P.O. No. Terms
620/7- 0/4,5 Net Upon Receipt
Description Amount
Original contract 117,950.00
Change Order#1 2,500.00
Change Order#!2 3,500.00
•
E-mail Phone#
rIcombs@comcast.net 904-294-0299 cell Total $123,930.00
rr
CHANGE ORDER FORM
Purchase Order Number Bid Number /7. o 0 i
Charge Order Number: I Change Order Date: Y- -/7
Project Name: f c. 57 l f %o&VIC Department:
Job Location: "jk30 !Z •
VENDOR INFORMATION:
•
Company Name: AC AIN
✓.14967 4Ieoi,P �iVC .� '! /f
1
Address: 'r 1l�AI N 0 3 /if City,St.,Zip: 6Ant /to('! r
Contact Name: A4 fit._ L . C444 d b. ,. 3 zo Bl Telephone: for, 29 y-a zy
DESCRIPTION OF CHANGE
AIteraior;&v►aon,addition,ordeletion caused byconditions during consiniction not covered by the a1ceheneand
drawings o the projed(attach additions pages Bn000aaay).
�
ft;fill ate p Az 913 ec) es-rigqQQc ' kftco�
?Peva— P/eiwy 4 )/) o Jot s. d-rbv/CLc:• jig-it)
clik,rif'lc its etip€ 0,4) AK/ DIC otal taw►' ; /
.t rt/41/41#7- ,n7r1, - C ki — / > v
tt�4 A
A. ORIGINAL CONTRACT VALUE /l 75$
AMOUNT OF THIS CHANGE ORDER:Council approvd nea+dred Rover 1696 of .. •
/: ••
B &them ..... ... .
pdcq,notbaxoeedj�aboOtrlJFa«b,arenaravaPabllarntha _��;,•�
. .
C. PERCENT OF COMRAC,'T VALUE THIS CHANGE ORDER(EVA) 1$1. 7•
D. AMOUNT OF PREVIOUS CHANGE ORDERS: $
E. TOTAL AMOUNT OF ALL CHANGE ORDERS(B+D) $ .
F. PERCENT OF CONTRACT OF ALL CHANGE ORDERS(E/A): 15%Aimdrnurn ica. .2-
G. NEW CONTRACT VALUE(A+E) $ _
it ,.•. ,..,
.40
¢' ad-r7
co - TOR DamARCHITE / ENGIN Date
4-26-1'y
DEPARTM "RECTOR f7 11� I -.
PURCHASING l ,CRY Dace
Change •. , over 15%,not to exceed$49,999 of the a1Aiat contract OR not budgeted,require the Wowing*whew
CITY OF C LERMONT ATTEST:
Galli L.Ash.Mayor Date Tracy Ackroyd,City Cork Date ,
Rev.8-28-16
. .•
CHANGE ORDER FORM
Purchase Order Number RI Matthew. /7- DOX
Charge Order Number, 2.." Change Cider Date: le*
Project Name:, ft—/Ti.. SnitorW. rowit.1
j 1111ment:
Job Location: Y4170 /2-T,F. fit ehic‘Ivel-7 et .
i
VENDOR INFORMATION •
• Company Name: .:44ean 4 6 ' it- /1 • " A
Address: /iit g: :PM • fir Cliy,St,Ex Heft Va' P.
Contact Nunn): ba- t- CoA4thi i 3 La'V rekoone: 90Y-20-Da)
DESCRIPTION OF CHANGE:
Afterstlan,dead"wham,crania"caused by canal,"aricconbred dame:Jaffa:an Wowed bye+,otuallagrona end
,6"wkiga onto pcisal WWI calllana I mom Ineassray).
eitiV I RDA 1 Ade9/Pt r- dfrESS#140.1e Ref vlitie 01-r Api)Aiti
Zorpicip r4A/ UirtrAiscx. retyri. -
1
.•
JIMI
mum ,
A. ORIGINAL CONTRACT VALUE $//7
1
AMOUNT OF THIS CHANGE ORDER:ottutta!germ!lepeed 1 mar 16%alaankaol . A
B.
Pite,/nib moved MOW OR anis ere rot akelidith Me'ppm*/budget for ihe Depwlfratt '' Ji$U I°
C. PERCENT OF CONTRACT VALUE THIS CHANGE ORDER(WA) % ,D2-,
D. AMOUNT OF PREVIOUS CHANGE ORDERS; $ 2.,514 ..
.
E. TOTAL AMOUNT OF ALL CHANGE ORDERS PO
*
F. i k fru "•
PERCENT OF CONTRACT OF AU.CHANGE ORDERS(E/A): Fte%Aeadmum % DS'
G. NEW CONTRACT VALUE(ME) $ ar 79 .- 1
I..... ..
f• asi-if
CONTRACTOR Dale PROJECT ARCHITECT/ENGINEER Date
H4d171r :)
PURCHASING DIRECTOR/MN MANAGER Date
Change&dere over 15%,not to exceed$40,099&the WOW contract OR not budgeted,mash,the foilowitg elpodunde
CITY OF CLERMONT ATTEST:
Gal L.Asti,hivio MN • nay Acilacyd,Cly CID* Die
--1
Aim 0-29.18
Fireguard® Limited Warranty Validation Card _
Please complete this form to validate your tank manufacture's Limited Warranty.This card must be completely and accurately filled
out and returned to STI within 30 days after the tank is installed,or within 90 days after the tank is shipped from the manufacturer,
whichever comes first.Warranty limitations may exist based on the product stored in the tank, please refer to the limited warranty
document supplied with this form. By signing this form, the tank owner verifies that the tank was installed in accordance with STI
Installation Instructions, the product stored is compatible with the tank, and the owner has read and agrees with the terms of the
Limited Warranty,induded with t ' form.
Manufacturer's /
Nam : � r •� Fireguard Label: �LQ 3sS"--
v i
INSTALLER INFORMATION-name of company that installed the tank
Warranted Date: - 028-117 Date Installed: y - p26
Installer //++ n
Name: �f ' /�e'fft-�0� /7I SAN Phone: 90q- or??- d 19/
•
TANK LOCATION INFORMATION-where tankwasinstalled
Name of Facility(where tank is Installed): (,r[ i y Q C��°�t`r•�o w i
Street address: LI bC, Ia/*h / Suite: � �
Contact Name K 'j A h G A Phone: 3�a _c�1(0�07.5-'{{
City: C.! Q r t-"4,... State: 1 ZIP: R 419 I/ _Country: :L
TANK OWNER MAILING ADDRESS-how do we contact theeoow—n—er of the tank
Owner name: G ril y CP P.17),An t7 - IL
rg
Mailing address: 90 0 /7-— SI/ - Suite:
Sri
Contact Name: l '/el 4A/ Ci'W1 P Phone: 3SZ�267 Z Fax No:
City: a All-44P-4, f" State: Zip: 3 IP/ Country: - £
Email address: •
•
TANK USAGE INFORMATION PLEASE TELL US.ABOUT WHAT.THE TANK WILL STORE&THE TYPE OF FACILITY ..
Check Products)Stored in this Tank: Cheek Type of Facility Where Tank is Installed:
O Gasoline 0 Gas Station 0 Marina
O Heating Oil(Petroleum Si,#2,$4,#5 WHICH IS NOT HEATED) O Private Residence 0 OII Company
Air Diesel fuel or kerosene for powering motor vehicles •0 Car Dealer 0 Fedi Gov't(military,postal,parks,banks)
O Generator Power Fuels 0 Convenience Store 0 State Gov't(}ails,parks,hwy,banks,etc)
O Diesel fuel or kerosene for heating premises 0 Quick Lube 0 Local Gov't(hwy,fire,police,parks,etc)
0 06 Heating CII 0 Chemicals 0 Industrial Site 0 Schools(univ,college,highljr high,grade)
0 Aviation Gas 0 Jet Fuel 0 .Hospital 0 Apartment
Blodiesel 0 E85 • 0 Airport 0Fleet Owner
O Crude Oil 0 Waste Oil 0 Utility Site 0 Jobber
O ON/Water Separator 0 Alcohol Blended Gasoline O Farm/Nursery
O Water or Wastewater D Fertilizers 0 Other
CI Product which Is heated during storage:
O Other.
SIGNATURE REQUIRED
My signature below verifies that this tank was installed in accordance with STI Installation Instructions,the product
stored is compatible with the tank and I have read and agree with the terms of the Limited Warranty, provided with this
document. 1M/ 1'
Signature.(of person providing this information):st4 ��� ' iJ ' Date: :S q �j
'f
Please Print Name: C-v!ri Qi A ko c+ P"-
Company Name: 1. C'.. pe- '-4 I es QV►,�.e q)' G?',.tip . Phone: 5O'/- p9./`7eD tf,ci
Thank you for completing this document and returning it to the STI address below:
STEEL TANK INSTITUTE •944 Donate Court•Lake Zurich,IL 60047 •8471438-8265•FAX 847/438-8766
E-MAIL: kmann@steeltank.com
01-10 This document is furnished as a service to a Steel Tank Institute member 130-40-0006
Fireguard LIMITED WARRANTY
Limitations of liability and Disclaimer
What is Covered by this Warranty
Provided tut the conditions set forth below are satisfied,the steel tank manufacturer identified with the tank(hereinafter referred to as"Warrantor")warrants the
Fireguard tank for 30 years following delivery of the tank to the tank owner at the time of the original Installation("the Owner"),against any of the following events
which may occur,provided the event occurs under conditions covered by this Warranty:(I)the release of stored product from any secondary containment tank;or(U)the
non-corrosive related structural failure such as cracking,breakup or collapse;or(Iii)t h e perforation of the primary tank caused by internal corrosion as long as the
product stored withinthetankis not corrosive to steelLor(iv)compatibility failures with the Internal tank wall(such as biistering,cracking of the tank wall and
stiffeners,permeation of product through the tank wall,delamination,and loss of tank wall due to crazing,solvation or dissolvement). Water which accumulates in
the primary tank solely as a result of incidental or natural accumulation due to condensation or sediment arising from the product shall not be considered a corrosive
product.In addition,the Warrantor warrants the tank against failure due to defective materials and workmanship for up to 1 year following the delivery of the tank to
the Owner.
Conditions to Warranty Effectiveness
' The limited warranties set forth herein are subject to the following conditions:
1.The Fireguard•tank must be:(i)the original aboveground installation within the Continental United States of America,Alaska,Hawaii,and the Commonwealth of
Puerto Rico or Canada;(ii)the tank was fabricated by the Warrantor so as to meet the Fireguard*Specifications;and MI)thetank was installed and maintained In
accordance with the applicable Fireguard*specifications and the applicable Fireguard'Installation Instructions that were in effect on the date of shipment by the
Warrantor,any subsequent maintenance procedures of which the Owner has written notice,and any applicable governmental codes and regulations.Refer to the
Installation Instructions attached to this document for technical requirements concerning relocation of this tank by the original owner,in order to retain warranty
eligibility.Tanks remaining in their original installation location will retain warranty eligibility If the facility where the tank Is installed is sold to a new owner.
2.This Limited Warranty isnot valid unless,and until,the Warranty-Validation Card is fully completed by the Owner and returned to theaddressee set forth ontheWarranty
ValidationCard within 30 days after the date of tank installation,or 90 days after the Warrantor's shipment of the tank,whichever comes first.
3.Upon discovery of a suspected tank failure or leak by the Owner,the Owner shall give the Warrantor written notice of the suspected tank failure or leak and permit the
Warrantor or Its designated representative to Inspect the tank site prior to,during and after removal of the tank. The tank owner tears the responsibility to identify
that the cause of the failure is from one of the events within the Conditions covered by the Warranty.
4.Upon the Warrantor's determination that the tank failure or leak Is covered by this Limited Warranty,the Warrantor at its sole option shall:(I)repair the tank; or(ill
replace it with a tank of apprwdmately the same size,design,quality of material and workmanship specified for the original tank;or(Ill)refund the purchase price of the
original tank. If the Warrantor is unable to repair or replace the tank,it shall refund the original purchase price of the tank.
What is Not Covered by this Warranty
Warrantor does not warrant any piping system or any other attachments connected with the tank.Underno clrcumstances shall the Warrantor be ilablefor(I)the cost of
repair or replacement of any piping system or other attachments to thetank;or(U)labor costs or other Installation costs for tank repair or replacement;or(ill)damages
to the tank or other property resulting from the accumulation of water in the tank,unless such accumulation Is solely the result of Incidental or natural accumulation
due to condensation or sediment arising out of the storage of product that is compatible with the tank and not corrosive to steel;or(iv)tank failures caused,in whole or
In part,by the tank owner's faUure to adhere to proper tank maintenance procedures as described In the Installation Instructions provided with the tank or otherwise
made available to the tank;or(v)tank failure caused,In whole or In part,by the tank owner's failureto follow applicable statutes,codes,ordinances and regulations
regarding tank maintenance;or(vi)damage caused by other improper operating practices;or(vii)tank failure due to defective materials and workmanship tater than
one year following delivery of the tank to the Owner;or(viii)cost of repair or replacement of Internal linings or external coatings.This Warranty does not cover ST1
Generator Base Tanks.
Limitation of Uabilityand Exclusion of Other Remedies and Damages
The foregoing remedy of repair,replacement or refund shall constitute the sole and exclusive remedy to the Owner.Under no circumstances,shall the liability of the
Warrantor,or Its affiliates or subsidiaries,under this warranty,exceed the purchase price of.the tank.
IN NO EVENT SHALL THE WARRANTOR,OR ITS AFFILIATES OR SUBSIDIARIES,BE LiABLE FOR CLAIMS OF PERSONAL INJURY OR FOR SPECIAL,INCiDENTAL,INDIRECT OR
CONSEQUENTIAL DAMAGES,INCLUDING,BUT NOT LIMITED TO,LOSS OF PROFITS OR REVENUE,LOSS OF USE OF THE TANK OR ANY ASSOCIATED EQUIPMENT, COSTOF
CAPITAL,COSTOFTHESUBSTiTUTEEQUIPMENT,FACIUTIESORSERVICES,DOWNTIMECOST,CLAIMSOFCUSTOMERSOFTHEOWNERFORSUCHDAMAGES, OR FOR
DAMAGE TO PROPERTY,WHETHER SUCH CLAIM SHALL BE FOR BREACH OF CONTRACT,BREACH OF WARRANTY,NEGLIGENCE OR STRICT UABILfTY,AND WHETHER
SUCH CLAIM ARISESOUT OF OR RESULTS FROM THIS UMITED WARRANTY,OR EXPRESSOR IMPLIEDWARRANTIES,OR FROM THE DESIGN,MANUFACTURE,SALE,DELIVERY,
RESALE,INSTALLATION,TECHNICAL DIRECTION OF INSTALLATION,INSPECTION,REPAIR,OPERATION OR USE OF THE TANK.
Consumer Notice •
The exclusion of Indirect orconsequentialdamagesandthelimItatton of implied warranties herein may not be applicable to purchaserswhoaredeemed'consumers"and
who reside in states that do not allow the limitation of Implied warranties or the exclusion of Indirect or consequential damages otherwise applicable to consumers.
Moreover,ifyou aredeemeda"consumer",you may have specific legal rights inaddition tothoseset forth Inthis warranty,which rights vary from state to state.
Disclaimer of Other Warranties
THE FOREGOINGL/MITEDINARIMNTY IS THE ONLY WARRANTY MADE.THERE ARE NOOTHEII WARRANTIES,EXPRESS OR IMPLIED,INCWDING,BUT NOT UMITED TO,
ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FORA PARTICULAR PURPOSE.
•FinandalAssurance
Warrantor may have purchased Insurance to cover some of its warranty obligations under this Limited Warranty.Such insurance would provide financial assurance for
Warrantor's warranty obligations,but would not Insure the Owner directly. If the Warrantor has purchased such Insurance coverage,the Owner may request that the
• Warrantor provide a certificate of insurance to evidence Warrantor's purchase of such insurance.
Effective with Installations on or after January 1,2017
Item#130.40-0005 1/17
science
flit AND ENGINEERING
Environmental Science with Integrity
May 8, 2017
Orange County Environmental Protection Division
3165 McCrory Place, Suite 200
Orlando, FL 32803
Attention: Glen Becker
Dispenser and Piping Closure Assessment
City of Clermont Public Works
400 12th St
Clermont, FL
Facility Id: 9101997
AS&E Project# 10777T FEl
Dear Mr. Becker:
Applied Science and Engineering (AS&E) is pleased to submit this Dispenser and Piping Closure
Assessment Report documenting closure assessment activities at the above-referenced site. RC
Development Group was onsite in April 2017 to replace one aboveground storage tank(AST),two
dispensers,and associated piping. Closure assessment of the AST was not required because it was
inside a containment area and not in contact with soils per Glen Becker with Orange County.
Closure assessment of two dispensers was required after the dispenser sumps did not pass hydro
testing. Additionally, closure of the piping was required when the secondary piping did not pass
air tightness testing.An Underground Storage System Installation and Removal Form for Certified
Contractors is included as Appendix A along with the Closure Integrity Evaluation Report Form
for ASTs. A site map depicting the UST and dispenser areas is included as Figure 1.
AS&E personnel were onsite April 26, 2017 to conduct closure assessment. AS&E personnel
screened the soil every 20 ft along the piping trench and underneath each dispenser. The soil was
field screened with a Photovac MicroFID as per Chapter 62-780.200(15)F.A.C.No apparent odors
or staining were present. MicroFID readings ranged from 0.0 per million (ppm) - 2.0 ppm and
summarized in Table 1 and presented on Figure 2. The MicroFID calibration log has been
included as Appendix B.
Two soil samples were taken, SS-P and SS-D,to confirm OVA readings. SS-P was taken adjacent
to SB-4,the location with the highest OVA reading along the piping trench,at 1 ft below the piping
for a total of 5ft below land surface (bls). SS-D was taken adjacent to the SB-2 at 2 ft bls. The
samples were packed on ice and shipped to Lakeland Laboratories, Inc. to be analyzed by EPA
Method 8260 for BTEX/MTBE, by EPA Method 8270 for PAHs, and by FL-PRO for TRPH.
Analytical data are summarized in Tables 2A-2B, attached in Appendix C and presented on
Figure 3.
550 North Reo Street,Suite 105 Tampa, Florida 33609 813.207.5657
Analytical results indicate all soil samples are below the Soil Cleanup Target Levels (SCTLs).
Therefore, AS&E recommends No Further Action at this time.
Sincerely,
Daphanee Waters
Project Manager
FIGURES
N rc w
W ---"" .� E LL LL
11117#411111 B
W
ABOVEGROUND p 0 S
J
10,000 GALLON 0 0 0 a 0 o a a o p 0 0 0 0 0 0 0 0 0 o U i P
DIESEL 1 CANOPY LEGEND y
\ ASPHALT PROPERTY BOUNDARY
' GRASS GRASS
FENCE
• AST \ PIPELINE a o Q -�
CONTAINMENT \ 1
D. K V~j LL
AREA \\ DISPENSERS Q R 0==1-
\\\ W U U ry 2
\ y LOm ow
�- a V
U•
ASPHALT
I,
ASPHALT (// W r r
1
U O Q Q
0 m co
O z m
GRASS GRASS Z r m o r
Ci W Y p
•
/ - U
\ w O w
w Cl. o 0 0
ASPHALT V :
= F
CD s
U " 3
c1i
, Zi
Q 0
i
•
•
N M
w
it
11.170-
ABOVE GROUNDiii 11 a
10,000 GALLON / —-_. 4. W
DIESEL / CANOPY SU Xi
•
111 \ LEGENDCO
ASPHALT o
GRASS PROPERTY BOUNDARY
• ASTS'.5PIPELINE —-__ Z da F
CONTAINMENT PENCE L L 0:2t7
gREA •� DISPENSERS
-0--0—.
1-re.SSB 4y F
w �ft O Z
��s:a SOIL BORING LU u U r
_ U Omow
•
IJ Q J
:_1 � O �per, U
U
ASPHALT
I'S)rl+itl UElrldfG KW.ifY1
FYSl.1 Flii�7 6Yt4b1 [ frZ It1
AI/�A� �9i1:4t
tl��Ii IA[d�
ASPHALT MI.marr
:1,1, / o
m
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m o 0 0
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GRASS z z co
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wa w !0
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ASPHALT
r
a) 44
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CO W k
Z
'
I
X/5/08 I a SSAMPLE DATE
SIO
,‘
SAMPLE DEPTH (ft) I CORRECTED READING
OVA READING IN ppm +
M
N K w
D Cf
VV l.
b�r Ai E LL L9
LL
, I•. R
ABOVE GROUND t" W
ABOVE GALLON - — — S y
DIESEL CANOPY 3
LEGEND
\
ASPHALT e
•� g PROPERTY BOUNDARY
O4 �i7 GRASS
• AST PIPELINE '1'i"''"' —_-- 2 Z
CONTAINMENT 3 j;i;t;}}� FENCE Q Y F LL
I DISPENSERS •
allihl
AREA ..,SB-4 ;I; Y7.7L O W O Z
�sB 3 �An:B[:IF
...
SOIL BORING -I U U N M
\ -F,I41 Q OmoW
Gfl- U
1'1'41,1
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FA
/ f�
ASPHALT U1t�:�::Yk111
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E P-
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m 03 O o
O
GRASS GRASS z r m o r
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\ m/1AA1 SAMPLE DATEI WALE DEPTH {�{uu a 3 x 3
N a 0 0 0
ex roTMOM BENZENE
CiA NXYLZEN6 a)
ASPHALT me MTBE C...) r
IS NAPHTHALENE C $
TN
>1 I-METHYL NAPHTHALENE
{
IA 2-METHYL NAPHTHALENE • u 3
CONCENTRATIONS IN mg/kw
y w
ZI
ABOVE DATA REPRESENT THE SOIL CONTAMINANT - L7 5
TARGET LEVELS BASED ON GROUNDWATER CRITERIA: LZi F�
THE"CIL WAS EXCEEDED p 1Ua NA
COMPOUND WAS/WALTZED FOR BUT NOT DL,LxnND __.a
AT THE MDL LEVEL.
OV THE SAMPLES WERE DILUTED DUE TOTARGETS DETECTED
OVER THE NXPOINT OF THE CTOB CURVE,OR -41
ATDIHTFRFERDCE.DILUTION FACTORS ARE INCLUDED IN
THE FINAL RESULTS.RESULT IS FROM A DILUTED SAMPLE
TABLE 1: SOIL SCREENING SUMMARY
Facility Name:City of Clermont Public Works Facility ID#9101997
Results=ppm
Filtered Corrected
Soil Sample Sample Date Sample Depth(ft) Gross Reading Reading Reading
SB-1/Dispenser 1 4/26/2017 1 0 - 0
2 0 - 0
3 0 - 0
4 0 - 0
SB-2/Dispenser 2 4/26/2017 1 _ 0 - 0
2 0 - 0
3 0 - 0
4 0 - 0
SB-3 4/26/2017 5 0 - 0
SB-4 4/26/2017 5 2 - 2
SB-5 4/26/2017 5 1 - 1
TABLES
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1
y . - Florida Department of Environmental Protection EP Ferro#4z-761.900M
Twin Towers Office Bklg.•2600 Blair Stone Road•Tallahasseo,Florida 32399-2400 orm Title: UST CoatractotPorm
r641:4 &cave Date: July 13.1998
Underground Storage System Installation and Removal Form
for Certified Contractors
Pollutant Storage Systems Contractor as defined in Section 489.113,Florida Statutes(certified contractors as defined in Section 62-
761.200,Florida Administrative Code)shall use this form to certify that the installation,replacement or removal of the underground
storage tank system(s)located at the address listed below was performed in accordance with Department Reference Standards. This
includes system components such as dispenser liners,piping sumps,and overfill protection devices.
General Facility Information
Facility Name: L 6-- "e I 1,f'
i f SMO, ' DPP Facility Identification No. : /I 0 I 7 q 7
-14
Street Address(physical location): (2 5 4- , .
County: L MC.
Telephone#: (3 5.-4 407 — 2.5-s.g
Owner C Iti, o4 C it/aro ..-'"-)--"- Telephone#: ( ) S 4'!t.,,
Name:
Owner Address: Li t3, 1 Z- S71
. C firm a„,, 'EEC . ?ti—1( j
Storage Tank System Informatio
�
I
Number of Tanks Installed: Number of Tnks Removed: f ( 7c7
Date Work Initiated: Date Work Completed: 4/Z 8 (7
Tank(s)Manufactured by: L1, )K._N G um
Description of work Completed: b i /� S (1) �'5 (I t t>s i a i'l4 p
liltro L cl . -7624. i4-L-6) )L 41 uiticht5ii-uJ
et phkiti 1 '6iseS1.K. '..c p.s
~
Certification
I hereby certify and attest that I am familiar with the facility that is registered with the Florida Department of Environmental
Protection;that to the best of my knowledge and belief,the storage tank system installation,replacement or removal at this facility
was conducted in accordance with Chapter 489,Florida Statutes,Section 376.303,Florida Statutes,and Chapter 62-761,Florida
Administrative Code,and its adopted reference standards and documents for underground storage tank systems.
AC . 1.Yt L6fn &f..., /c)G L 00 i
(Type or Print)
PSSC Number
Certified Pollutan Contractor Name Pollutant Storage Systems
Contract° License Number
`/ Z h 7.
Cetified Tank Contrac .r Signature Dte
../..e
Field Supervisor N., 3--/ / 7
Date
The owner or operator of the facility ,,ast register the tanks with the Department upon completion of the installation. The installer must
submit this form to the County no more than 30 days after the completion of installation,replacement,or removal of a storage tank
APPENDIX A
UNDERGROUND STORAGE SYSTEM INSTALLATION&.REMOVAL FORM FOR
CERTIFIED CONTRACTORS
i
onh.•iwlltdaL
Florida Department of Environmental Protection ,�,,,,,
Twin Tema teal 81dt.•MOD ltlair8eme Aced•walla�ee$a,PkiM,d. emva�mitigm e
tleeu.oa
Storage Tank Facility Registration Form ee"'"`°'`"�'-_-
JWbmea completed bmm kr the Why neon repbUedon of eeseye prow or oernpreedat mos k ROI.er Chador Wa,ioa,Ha l&Malmo
Phone rovlew RogIghtion Miasma's*before
_ 001100111 the form.
11fLt'-•'I'"L71.1^."r-!. i-,�''11/11C=,,1! ter;. ,- , vs
A FACUJTY INFORIV4710N QOM
NE Ice oennylDl 1 wp/9l7
Redly' Norm etc r.44.0/- L"r "Mt Vox k1 e3for
Foolity Address: / O / ?N Yek_ Cky, C aeI Arta____,_
Friday Comet OP
F1YPe�S unseen Phone: title)104e-7/11
NAiCB Cab: humid P :
ee Neor t3trwry.ney oor OU C4(�
t+reneryenoyPhone: I3%&51( O43
B. .....k W.!PERSON JNFORIAATION•Mordly Ind elOn 7 or
deart eta et Ile hong b0aflan owned above, �e�Pp O tacetanon and soy.trent,e,alletp epexetbns,senior
Malin eddMlemmel betorehutes b an alpeektasat K aaoeeahsy. -
Rim: MAIM) Fe ---..Fowler ' TyTypo - DsleMall •
• • 6 efill eftwifierva.t,4
----------O�'•Sr'47I )Pad*Mooned Owner�.ya treo)
cnwaa—TC I ilea a ••+• pt 3 P.t`11 t -Forte Aeoaee Owner Informaian mato pr ' when Mr
•
iAA C: -p� Wig oadwse*dhow out of union Monde pries on eke. •
TtiepkoeN �94 ee S011 Account Number
Pim: Pm**• • Tank Orme-
>r�eadrso►; *Mr neew,telliborsbIP lrPscsf -6', id*Det,'
•
Corti* ( I Property Owner
11not 1 Blonde Teaktltrtwr
! 1 Ohm m
C.imi iv 1UL IMPOMIIATloN•complete one row for soak storage lank or oompewelon vessel system Ioealnd al this hgltly.
Trek ID 1E-MI /IN • •�K, �"r"n'*1111 .. ,. .
�I1Ein .
11111F11111111=r te =—IIIIIIIIIIMNNIIER« . :�■r=EY►�cr,.,.
�■���
����r~
Cedlied Com :kw(piano*lank Irwtellatlon Or remeedy .QC &Pt 4/.t11uq 1:fi/p DePR Moose No.:. i4 C b PAP
=on Cettllade/n�o Ye the hest ot kwledge and on esbmIUdd on this form M
Pilotedfa— £,. rrtL 7
,no , true,Nun ani ono lila
NMN$Tide alenelem
oeraregpeem
• ND o.a amarwrrcrweyd MOW Osevi in "Aliningown own noiemGao gene,,,
elmWefts .. VV.PK. 1Como Feta era (OD tliih Corms Me. me serer Ala, sea arrel
�� tReo1 4�rrwmrhr,r4 ooze 1ye�e Hier
AMMee I 4esse.aeoa =veto . arai+ratton' :Pen.iinn aestia Peet ere a aeon a gesso
etts�Oea e
•
ar�1e,�• e�r+a DEP Form;62-762901(71
• Department of FormTltk:Closure MrtegrltyReport
Environmental ProtectionNeDete'IENectiveDate o/Rule?
�' Incorporated in Rule 62-762.411,FAC
S4 •° I600 Blair Stone Road 4 Tallahassee,Florida 32399-2400
Closure Integrity Evaluation Report Form for ASTs
This form Is required to be completed for facilities performing an aboveground storage tank(AST)closure In accordance with Rule eubsectIons 62-762.801(2)and
62.762.802(3),F.A.C.This form Is only required to be completed If the storage tank system or system component being dosed is In contact with the sob,and for spill
containment systems If they are completely bekrwgrade.The Closure Integrity Evaluation must be performed not more than 45 days prior to Closure,replacement,or change
In service from a regulated substance to a non-regulated substance.A copy of this Closure Integrity Report shall be provided to the County via email or mall with notification
of dosure,In accordance with paragraph 62.762.411(2)(c),FA.C.,and also as an attachment to the Closure Report or Limited Closure Report Form for ASTs 62-762.901(8),
along with any additional attachments.
Complete All Applicable Blanks
Q (Print or Type)
FDEP Facility ID Number: •• eI�0 /[ 9 7 Proposed Date of dosure: y25-- -/7
• Facility Address: 17400 I Z-I,- sq-. '
I Owner Name: effri6A C147` -/ 11
C. &I
owner Phone Number: i3S -'- Z-47 - Z. r1
Owner Mail or Email Address: e/�4'!/A� C JL'/iflaNT (4. o A'
I. Storage Tank System Closure Information " 17IZ/ vi CA-m P
The following are to be closed:(Fill In ID of the component being closed and check appropriate box)
a.tank.Reglgtratlonnldentlfeatloo�otnmtber(s): 4- / — j
/ts1 fl LGA/C. �d,✓�• Removed ' _'/� H
""'�-�ba.1— aimed in-Placei�b.Plplrgl assadated with tank number(:): l -i
• • •r >5/�i4/4 Removed r IIII ■
Closed In-Place —
c.PlpIng" rlated with lank notnber(s):
.p Removed Ip�j HClosed In Place 'L Idran.SplfContaient Systems associated with tank
numbee ):
rrfs /
5S./ t.L4• Nl ai 4/i't 4. 7 Removed
/�r,EG Closed In Place_ - L 1 . F...L
e-Dispenser sumps associated with dispenser 1 111��1
•
D lr fY r� closed In-Place
H 1--
. HH H
II. Closure Integrity Evaluation Information
A Closure Integrity Evaluation is required prior to the closure of the system components listed above If the system components are In contact with
soil,and for spill containment systems if they are completely //below-grade.//
f'Date of Closure Integrity Evaluation: /..// 7 '
Did the Closure Integrity Evaluation demonstrate that the system components being closed passed the
evaluation? Attach a summary of the evaluation conducted and the results. Previous annual operability
reports, monthly visual/electronic Inspection results, or any other supporting documentation to,support the
summary conclusions may be submitted with this evaluation.
If Yes,attach copy of documentation discussed above and proceed to Section AI.Closure Integrity Evaluation Methodology ❑Yes No
and Results.
f/No,then answer the following questions: (Proceed to (Proceed to
Section III.) II.1.)
1
APPENDIX B
PHOTOVAC MICROFID CALIBRATION RECORDS
1. Was an Incident Notification Form(INF)submitted to the County[Form 62-762.901(6)1?
No,complete NV and attach,or attach response as to why fMf not belting Q Yea No
if submitted,
Ni
2. Was an Incident Investigation completed PRIOR to closure?
if No,then investigation is required in accordance with instructions for Conducting Sampling During
Aboveground storage Tank Closure"at the time of closure. 0 Yes kl
No
if Yes,attach copy of incident investigation with results and answer the following question:
> Did the Investigation confirm the discovery of a discharge?
if Ye,then proceed to Section ill,and submit either a Discharge Report Form(Form 62-762.901(1)]or
documentation supporting the position that the discovery is thought to be a previously reported discharge. El Yes No
ff No,then proceed to Section ill.,below.
111. Closure Integrity Evaluation Methodology and Results: Include a short narrative of the Closure Integrity
Evaluation detailing test methods used, calibration of equipment, summary of results Including Information about who performed the
Closure Integrity Evaluation,and the dates the testing was perform
AST e.r4/14 gr141/f
(cc s .
r/tir S-
/ -
✓I2 ry J T--
57-eif:it- 7/171-
r.
P,017f- ? WZ— Qi
V/11(s 4 P/ nl c-oionfz7
A-276 rE
*6)7) A/O,--
This form Is required for facilities performing a closure In accordance with Rule subsections 62-762.801(2)and 62-762.802(3),F.A.C.
Documentation of the Closure Integrity Evaluation shall be reported on this form, along with any attachments. This form shall be
submitted to the County Na email or mail along with the notification of closure between 30 and 45 days before initiation of the closure.
Owner or Operator Signature Signature of person perf. , .Closure integrity Evaluation
Owner or Operator Name Name of person Ing Integrity Evaluation
(Print or Type) (Print or T )
Date 4te- /7
Date
2 Rethi z L 6,tt C11-'
ie-C DcArfcOEM 447' C ft/
frc ob
APPENDIX C
SOIL LABORATORY ANALYTICAL REPORT
DEP-SOP-001/01 •
FT 1600 Field Measurement of Turbidity
Form FD 9000-8: FIELD INSTRUMENT CALIBRATION RECORDS
INSTRUMENT(MAKER/MODEL#) 17l fbt/a C >YI.?)(;y( INSTRUMENT# 9.11
I�3 Z7'
PARAMETER: (check only one]
❑TEMPERATURE 0 CONDUCTIVITY ❑SALINITY 0 pH ❑ORP
❑TURBIDITY ❑RESIDUAL CI ❑DO in OTHER OVA
STANDARDS: (Specify the type(s)of standards used for calibration,the origin of the standards,the standard
values,and the date the standards were prepared or purchased)
Standard A 9 i )YL2 cfTQ
Standard B
Standard C
DATE TIME =` STD'..' STD •INSTRUMENT CALIBRATED. WM..,.'1 $AMPLER
(yylmrntdd) (hrmun) (A,B C). VALUE RESPONSE %'.DEV (YES.NO) (INIT,CONT): INITIALS .?
V(20/ z, fyg t,c 0.1 ye 3 Gci,1
W26%17 1o'2 A- 5 y18, 5 p , : 1,1011 ,1-
Page 8 of 8 Revision Date: February 1,2004
A44L 1910 Harden Boulevard
Suite 101
Lakeland,FL 33803
LAK E LAN D (863)686-4271 Phone
(863)686-4389 Fax
NELAP Certificate NovE84880 LABORATORIES
Daphanee Waters 27 April 2017
Applied Science&Engineering,Inc. Lab Work Order(COC):1704105
550 North Reo Street,Suite 105
Tampa, FL 33609
RE: City of Clermont Public Works
Project Location: 400 12th St,Clermont,FL
Project Number: 10777T FE1
Dear Daphanee Waters:
This report details the analytical results of samples collected at the above-referenced project location as well as the
results of any associated quality control samples. These samples were taken into custody by Lakeland Laboratories at
26-Apr-17 14:25.
The work detailed herein has been conducted in accordance with generally accepted professional standards using
recognized testing methodologies and quality control measures. It must be noted that the results detailed within this
final report apply only to those samples submitted for analysis and reported here. When the NELAP logo is affixed to
this report, these test results meet all requirements of the National Environmental Laboratory Accreditation Conference
(NELAC).
Your samples will be retained by Lakeland Laboratories for a period of at least 30 days following sample receipt or until
the longest of the preparation and/or analytical hold times expires, whichever is shorter. After that time, they will be
properly disposed without further notice, unless there exists an explicit contractual agreement to the contrary. We
reserve the right to return any unused samples, extracts, or related materials or solutions to you if we consider it
necessary. Examples might include those samples identified as hazardous wastes, submissions where the sample
sizes significantly exceed those required for analysis,samples containing controlled substances,etc.
The validity and integrity of this report will remain intact as long as it is accompanied by this letter and reproduced in
full. We will maintain a copy of this report, electronic or otherwise, in our files for at least five years, after which time it
may be destroyed without further notice,unless there exists an explicit contractual agreement to the contrary.
We thank you for selecting Lakeland Laboratories to serve your analytical needs. Should you have any questions or
require additional information regarding any of the information in this report, please feel free to contact us at any time.
We appreciate the opportunity to be of service.
Sincerely,
Technical Director
Jim Crawford For Chris E. Harris
Page T(Al 4.
yez
:/-1-1, 1910 Harden Boulevard
Suite 101
LAKE LAND Lakeland,FL 33803
` -"' (863)686-4271 Phone
LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number. 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
ANALYTICAL REPORT FOR SAMPLES
Sample ID Laboratory ID Matrix Date Sampled Date Received
SS-P 1704105-01 Soil 26-Apr-17 10:19 26-Apr-17 14:25
SS-D 1704105-02 Soil 26-Apr-17 10:11 26-Apr-17 14:25
?age 2 014
; :il,r 1910 Harden Boulevard
r'-- ''•,,,%,;]'..-', ' .41446. Suite 101
IA; - LAK E LA 1 IID Lakeland, FL 33803
(863)686-4271 Phone
' LABORATORIES
(863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
ss-P
1704105-01 (Soil)
%Rec
Analyte Result PQL MDL Units Dilution %Rec Limits Qualifiers .
Prepared: 27-Apr-17 09:16
EPA Method 8260C-VOA/STEM-MTBE Analyzed: 27-Apr-17 10:33 Batch:B704144
Methyl tert-Butyl Ether(MTBE) 0.000492 U 0.00197 0.000492 mg/kg dry 0.943
Benzene , 0.000712 U 0.00197 .0.000712 mg/kg dry , 0.943
Toluene 0.00130 0.00197 0.000626 mg/kg dry 0.943
Ethylbenzene 0.000950 0.00197 0.000492 mg/kg dry 0.943
m-&p-Xylenes 0.00245 0.00492 0.00104 mg/kg dry 0.943.
o-Xylene 0.00116 0.00197 0.000990 mg/kg dry 0.943
Surrogate:Toluene-d8 0.0553 mg/kg dry 106%80-120 Prepared: 26-Apr-17 15:05
EPA Method 8270D-PAHs Analyzed: 27-Apr-17 04:47 Batch:B704140
1-Methylnaphthalene •, 0.00598 U 0.0522 0.00598
mg/kg dry 1
2-Methylnaphthalene 0.00673 U ' 0.0522 0.00673 mg/kg dry 1
Acenaphthene 0.00724 U 0.0522 0.00724
mg/kg dry 1
Acenaphthylene 0.00634 U 0.0522 0.00634 mg/kg dry 1
Anthracene 0.00599 U 0.0522 0.00599
mg/kg dry 1
Benzo(a)anthracene 0.00578 U 0.0522 0.00578
mg/kg dry 1
Benzo(a)pyrene '0.00569 U 0.0522 0.00569 mg/kg dry 1
Benzo(b)fluoranthene 0.00670 U 0.0522 0.00670 mg/kg dry 1
Benzo(g,h,i)perylene 0.00502 U 0.0522 0.00502 mg/kg dry 1
Benzo(k)fluoranthene 0.00979 U '0.0522 0.00979 mg/kg dry _ 1
Chrysene , 0.00542 U 0.0522 0.00542 mg/kg dry 1
Dibenzo(a,h)anthracene 0.00486 U 0.0522 0.00486 mg/kg dry 1
Fluoranthene . 0.00653 U 0.0522 .0.00653 mg/kg dry 1
Fluorene • 0.00668 U 0.0522 0.00668
mg/kg dry 1
Indeno(1,2,3-cd)pyrene 0.00515 U 0.0522 0.00515 mg/kg dry 1 I
Naphthalene 0.00624 U 0.0522 0.00624 mg/kg dry 1
Phenanthrene 0.00594 U 0.0522 0.00594 mg/kg dry 1
Pyrene -_ 0.00585 U 0.0522 0.00585 mg/kg dry 1
Surrogate:2-Fluorobiphenyl 0.111 mg/kg dry 64%23-107
Surrogate:Nitrobenzene-d5 0.0741 mg/kg dry 43% 17-111
Page 3 Of 1'4 •
•
1910 Harden Boulevard
NiG Suite 101
LAKE LAND Lakeland,FL 33803
' (863)686-4271 Phone
LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager Daphanee Waters Lab Work Order(COC):1704105
SS-P ---
1704105-01(Soil)
%Rec
Analyte Result PQL MDL Units Dilution %Rec Limits Qualifiers
Prepared: 26-Apr-17 15:15
Petroleum Hydrocarbons by GC/FID Analyzed: 26-Apr-17 21:22 Batch:B704137
FL-PRO(C8-C40) P.76 U 4.18 2.76 mg/kg dry 1
Surrogate:o-Terphenyl 3.53 mg/kg dry 102% 62-109
Surrogate:n-Heptatriacontane 12.5 mg/kg dry 60% 60-118
Prepared: 26-Apr-17 15:54
SM 2540G-%Dry Solids Analyzed: 27-Apr-17 11:21 Batch:B704141
%Dry Solids 95.8 0.100 0.100 %by Weight 1
PAO4Qfis ..I
•
^m s
.*A4 . 1910 Harden Boulevard
Suite 101
LAKE LAND Lakeland,FL 33803
(863)686-4271 Phone
LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
-- _ -- _-,
-
SS-D
1704105-02(Soil)
%Rec
Analyte Result PQL MDL Units Dilution %Rec Limits Qualifiers
Prepared: 27-Apr-17 09:16
EPA Method 8260C-VOA/BTEX+MTBE Analyzed: 27-Apr-17 11:01 Batch:B704144
Methyl tert-Butyl Ether(MTBE) 0.000625 U 0.00250 0.000625 mg/kg dry 1.163
Benzene 0.000904 U 0.00250 0.000904 mg/kg dry 1.163
Toluene 0.000795 U 0.00250 0.000795 mg/kg dry 1.163
Ethylbenzene 0.000625 U 0.00250 0.000625 mg/kg dry 1.163
m-&p-Xylenes 0.00132 U 0.00625 0.00132
mg/kg dry 1.163
o-Xylene 0.00126 U 0.00250 0.00126 mg/kg dry 1.163
Surrogate:Toluene-d8 0.0557 mg/kg dry 104% 80-120
Prepared: 26-Apr-17 15:05
EPA Method 8270D-PAHs Analyzed: 27-Apr-17 05:16 Batch:B704140
1-Methylnaphthalene 0.00616 U 0.0537 0.00616 mg/kg dry 1
2-Methylnaphthalene 0.00693 U 0.0537 0.00693 mg/kg dry 1
Acenaphthene 0.00746 U 0.0537 0.00746 mg/kg dry 1
Acenaphthylene 0.00652 U 0.0537 0.00652 mg/kg dry 1
Anthracene 0.00617 U 0.0537 0.00617 mg/kg dry 1
Benzo(a)anthracene 0.00595 U 0.0537 0.00595 mg/kg dry 1
Benzo(a)pyrene 0.00586 U 0.0537 0.00586 mg/kg dry 1
Benzo(b)fluoranthene 0.00690 U 0.0537 0.00690 mg/kg dry 1
Benzo(g,h,i)perylene 0.00517 U 0.0537 0.00517 mg/kg dry 1
Benzo(k)fluoranthene 0.0101 U 0.0537 0.0101 mg/kg dry 1
Chrysene 0.00558 U 0.0537 0.00558 mg/kg dry 1
Dibenzo(a,h)anthracene 0.00501 U 0.0537 0.00501 mg/kg dry 1
Fluoranthene 0.00673 U 0.0537 0.00673 mg/kg dry 1
Fluorene 0.00688 U 0.0537 0.00688
mg/kg dry 1
Indeno(1,2,3-cd)pyrene 0.00530 U 0.0537 0.00530
mg/kg dry 1
Naphthalene 0.00642 U 0.0537 0.00642 mg/kg dry 1
Phenanthrene 0.00611 U 0.0537 0.00611 mg/kg dry 1
Pyrene 0.00602 U 0.0537 0.00602 mg/kg dry 1
-- ------------------- -
Surrogate:2-Fluorobiphenyl 0.119 mg/kg dry 67% 23-107
Surrogate:Nitrobenzene-d5 0.0791 mg/kg dry 44% 17-111
�4.
W V A44 • 1910 Harden Boulevard
Suite 101
4! LAK E LA N D Lakeland, FL 33803
� ' (863)686-4271 Phone
LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
SS-D
1704105-02(Soil)
%Rec
Analyte Result PQL MDL Units Dilution %Rec Limits Qualifiers
Prepared: 26-Apr-17 15:15
Petroleum Hydrocarbons by GC/FID Analyzed: 26-Apr-17 21:55 Batch:B704137
FL-PRO(C8-C40) 2.84 U 4.30 2.84 mg/kg dry 1
Surrogate:o-Terphenyl 3.65 mg/kg dry 102% 62-109
Surrogate:n-Heptatriacontane 12.98 dry 60% 60-118
Prepared: 26-Apr-17 15:54
SM 2540G-%Dry Solids Analyzed: 27-Apr-17 11:23 Batch:B704141
%Dry Solids 93.1 0.100 0.100 %by Weight 1
• Page 6.;of.14- .
1
'.cam 1910 Harden Boulevard
Suite 101
y=` LAK E LAN D Lakeland, FL 33803
(863)686-4271 Phone
LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 107771 FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
EPA Method 8260C-VOA/BTEX+MTBE-Quality Control
Lakeland Laboratories, LLC
Spike Source %Rec RPD
Analyte Result PQL MDL Units Level Result %Rec Limits RPD Limit Qualifiers
Batch:B704144-Prep Method:5035(low)
Blank(B704144-BLK1) Prepared:_27-Apr-17 03:51 Ana_lyzed_27-Apr-17 03:51_
Methyl tert-Butyl Ether(MTBE) 0.000500 U 0.00200 0.000500 mg/kg wet
Benzene 0.000724 U 0.00200 0.000724 mg/kg wet
Toluene 0.000636 U 0.00200 0.000636 mg/kg wet
Ethylbenzene 0.000500 U 0.00200 0.000500 mg/kg wet
m-&p-Xylenes 0.00105 U 0.00500 0.00105 mg/kg wet
o-Xylene 0.00101 U 0.00200 0.00101 mg/kg wet
Surrogate:Toluene-d8 0.0513 mg/kg wet 0.0500 103 80-120
LCS(8704144-BS1) Prepared: 27-Apr-17 04:18 Analyzed: 27-Apr-17 04:18 _
Methyl tert-Butyl Ether(MTBE) 0.0391 0.00200 0.000500 mg/kg wet 0.0400 98 65-126
Benzene 0.0384 0.00200 0.000724 mg/kg wet 0.0400 96 80-120
Toluene 0.0365 0.00200 0.000636 mg/kg wet 0.0400 91 80-120
Ethylbenzene 0.0373 0.00200 0.000500 mg/kg wet 0.0400 93 80-120
m-&p-Xylenes 0.0727 0.00500 0.00105 mg/kg wet 0.0800 91 80-121
o-Xylene 0.0368 0.00200 0.00101 mg/kg wet 0.0400 92 78-124
Surrogate:Toluene-d8 0.0500 mg/kg wet 0.0500 100 80-120
Matrix Spike(B704144-MS1) Source:1703071-02 Prepared: 27-Apr-17 05:13 Analyzed:27-Apr-17 05:13 _
Methyl tert-Butyl Ether(MTBE) 0.0396 0.00208 0.000520 mg/kg dry 0.0416 0.000520 U 95 65-126
Benzene 0.0412 0.00208 0.000753 mg/kg dry 0.0416 0.000753 U 99 79-124
Toluene 0.0401 0.00208 0.000662 mg/kg dry 0.0416 0.00367 87 81-121
Ethylbenzene 0.0393 0.00208 0.000520 mg/kg dry 0.0416 0.000739 93 38-177
m-&p-Xylenes 0.0683 0.00520 0.00110 mg/kg dry 0.0833 0.00128 80 76-130
o-Xylene 0.0394 0.00208 0.00105 mg/kg dry 0.0416 0.00105 U 95 66-142
Surrogate:Toluene-d8 0.0527 mg/kg dry 0.0520 101 80-120
Matrix Spike Dup(8704144-MSD1) Source:1703071-02 Prepared: 27-Apr-17 05:41 Analyzed: 27-Apr-17 05:41 __
Methyl tert-Butyl Ether(MTBE) 0.0374 0.00208 0.000520 mg/kg dry 0.0416 0.000520 U 90 65-126 6 20
Benzene 0.0342 0.00208 0.000753 mg/kg dry 0.0416 0.000753 U 82 79-124 18 21
Toluene 0.0333 0.00208 0.000662 mg/kg dry 0.0416 0.00367 71 81-121 19 21 J2
Ethylbenzene 0.0325 0.00208 0.000520 mg/kg dry 0.0416 0.000739 76 38-177 19 20
m-&p-Xylenes 0.0559 0.00520 0.00110 mg/kg dry 0.0833 0.00128 66 76-130 20 20 J2
o-Xylene __ _ _ _ 0.0327 0.00208 0.00105 mg/kg dry 0.0416 0.00105 U 78 66-142 19 20
Surrogate:Toluene-d8 0.0538 mg/kg dry 0.0520 103 80-120
I Oao 7 of'1;4_
1 , A44m ,
1910 Harden Boulevard
4 Suite 101
��� r ��i D Lakeland, FL 33803
ti LABORATORIES
1 V (863)686-4271 Phone
`` -- ' LABORATORIES (863)686-4389 Fax
• NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL. 27-Apr-17 15:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
EPA Method 8270D PAHs-Quality Control
Lakeland Laboratories,LLC
Spike Source %Rec RPD
Analyte • Result PQL ` MDL Units Level Result %Rec Limits-RPD Limit Qualifiers
Batch:B704140-Prep Method:3550C ,
Blank(8704140-BLK1) Prepared: 26-Apr-17 15:05 Analyzed:27-Apr-17 02:51
1-Methylnaphthalene 0.00573 U 0.0500 0.00573 mg/kg wet
2-Methylnaphthalene ' 0.00645 U 0.0500 0.00645 mg/kg wet
Acenaphthene 0.00694 U 0.0500 0.00694 mg/kg wet
Acenaphthylene 0.00607 U 0.0500 0.00607 mg/kg wet
Anthracene 0.00574 U 0.0500 0.00574 mg/kg wet
Benzo(a)anthracene 0.00554 U 0.0500 0.00554 mg/kg wet
Benzo(a)pyrene 0.00545 U 0.0500 0.00545 mg/kg wet
Benzo(b)fluoranthene 0.00642 U 0.0500 , 0.00642 mg/kg wet
Benzo(g,h,i)perylene 0.00481 U 0.0500 0.00481 mg/kg wet
Benzo(k)fluoranthene 0.00938 U 0.0500 0.00938 mg/kg wet
Chrysene 0.00519 U 0.0500 0.00519 mg/kg wet
Dibenzo(a,h)anthracene 0.00466 U 0.0500 0.00466 mg/kg wet
Fluoranthene . -0.00626 U 0.0500 0.00626 mg/kg wet
Fluorene 0.00640 U 0.0500 0.00640 mg/kg wet
Indeno(1,2,3-cd)pyrene 0.00493 U 0.0500 0.00493 mg/kg wet
• . Naphthalene 0.00598 U 0.0500 0.00598 mg/kg wet
Phenanthrene 0.00569 U 0.0500 0.00569 mg/kg wet
• Pyrene0.00560 U 0.0500 0.00560 mg/kg wet
Surrogate:2-Fluorobiphenyl 0.125 mg/kg wet . 0.167. 75 23-107
Surrogate:N1trobenzene-d5 0.0903 mg/kg wet 0.167 54 17-111
LCS(8704140-BSI) • _Prepared: 26-Apr-17 15:05 Analyzed: 27-Apr-17 03:20
1-Methylnaphthalene ' 0.234 0.0500 0.00573 mg/kg wet 0.400 59 46-119 i
2-Methylnaphthalene 0.204 0.0500 0.00645 mg/kg wet 0.400 51 ,45-117
• • Acenaphthene 0.250 0.0500 0.00694 mg/kg wet. 0.400 63 47-122
. Acenaphthylene 0137 0.0500 0.00607 mg/kg wet 0.400 59 50-119
Anthracene 0.198 0.0500 0.00574 mg/kg wet 0.400 50 52-120 J2
Benzo(a)anthracene 0.227 0.0500 0.00554 mg/kg wet 0.400 57 56-130
Benzo(a)pyrene 0.228 0.0500 0.00545' mg/kg wet 0.400 57 54-116
Benzo(b)fluoranthene 0.226 0.0500 0.00642 mg/kg wet 0.400 57 52-118
Benzo(g,h,i)perylene 0.320 0.0500 0.00481 mg/kg wet 0.400 80 50-111
Benzo(k)fluoranthene 0.192 0.0500 0.00938 mg/kg wet 0.400 '48 51-119 J2
Chrysene 0.228 " 0.0500 0.00519 mg/kg wet 0.400 57 55-123
Dibenzo(a,h)anthracene 0.326 0.0500 0.00466 mg/kg wet 0.400 . 82 ' .51-115
•
Page o114.
1910 Harden Boulevard
Pt Suite 101
LAKELAND
Lakeland, FL 33803
LD p p c (863)686-4271 Phone
ABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager: .Daphanee Waters Lab Work Order(COC):1704105
EPA Method 8270D-PAHs-Quality Control
Lakeland Laboratories,LLC
Spike Source %Rec RPD
Analyte Result PQL MDL Units Level Result %Rec Limits RPD Limit Qualifiers
Batch:B704140-Prep Method:3550C
LCS(8704140-BS1) Prepared: 26-Apr-17 15:05 Analyzed: 27-Apr-17 03:20
Fluoranthene - 0.225 0.0500 0.00626 mg/kg wet 0.400 56' 54-119
Fluorene • . 0.234 0.0500 0.00640 mg/kg wet 0.400 58 50-121
Indeno(1,2,3-cd)pyrene 0.320 0.0500 0.00493 mg/kg wet 0.400 80 52-115
Naphthalene 0.209 0.0500 0.00598 mg/kg wet 0.400 52 46-114
Phenanthrene 0.223 0.0500 0.00569 mg/kg wet 0.400 56 52-122
Pyrene 0.302 0.0500 0.00560 mg/kg wet 0.400 76 .53-122
Surrogate:2-Fluoroblphenyl 0.102 mg/kg wet 0.167 61 23-107
Surrogate:Nitrobenzene-d5 0.0752 mg/kg wet . 0.167 45 17-111
Matrix Spike(B704140-MS1) _Source:1704105-01 Prepared: 26-Apr-17 15:05 Analyzed: 27-Apr-17 03:49
1-Methylnaphthalene 0.269 0.0522 0.00598 mg/kg dry 0.418 0.00598 U 64 53-117
2-Methylnaphthalene- 0.232 0.0522 0.00673 mg/kg dry 0.418 0.00673 U 55 51-118
Acenaphthene 0.284 0.0522 0.00724 mg/kg dry 0.418 0.00724 U 68 45-126
Acenaphthylene 0.272 0.0522. 0.00634 mg/kg dry 0.418 0.00634 U 65 54-118
Anthracene 0.213 0.0522 0.00599 mg/kg dry 0.418 0.00599 U 51 58-117 J2
Benzo(a)anthracene 0.240 0.0522 0.00578 mg/kg dry 0.418 0.00578 U 58 53-129
Benzo(a)pyrene 0.240 0.0522 0.00569 mg/kg dry 0.418. 0.00569 U 57 48-116
Benzo(b)fluoranthene 0.238 0.0522 0.00670 mg/kg dry 0.418 0.00670 U .57 44-119
Benzo(g,h,i)perylene 0.340 0.0522 0.00502 mg/kg dry 0.418 0.00502 U 81 47-111
Benzo(k)fluoranthene 0.208 0.0522 0.00979 mg/kg dry 0.418 0.00979 U 50 36-126
Chrysene 0.240 0.0522 0.00542 mg/kg dry 0.418 0.00542 U 58 48-125
Dibenzo(a,h)anthracene 0.349 0.0522 0.00486 mg/kg dry 0.418 0.00486 U 84 54-113
Fluoranthene . 0.238 0.0522 - 0.00653 mg/kg dry 0.418 0.00653 U 57 41-128
Fluorene 0.262 0.0522 0.00668 mg/kg dry 0.418 0.00668 U 63, 48-125
tndeno(1,2,3-cd)pyrene 0.384 0.0522 0.00515 mg/kg dry 0.418 0.00515 U 92 50-114
Naphthalene - 0.239 0.0522 0.00624 mg/kg dry 0.418 0.00624 U 57 47-120
Phenanthrene 0:241 0.0522 0.00594 mg/kg dry 0.418 0.00594 U 58 51-122
Pyrene _ 0.321 0.0522 0.00585 .mg/kg dry 0.418 0.00585 U 77 42-125-
Surrogate:2-Fluoroblphenyl 0.121 mg/kg dry 0.174 70 23-107
• Surrogate:Nitrobenzene-d5 0.0875 mg/kg dry 0.174 50 17-111
t'-'o 9.1:14
` 1910 Harden Boulevard
r- y Suite 101
LAKE LAND Lakeland, FL 33803
(863)686-4271 Phone
LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
EPA Method 8270D-PAHs-Quality Control
Lakeland Laboratories,LLC
Spike Source %Rec RPD
Analyte Result PQL MDL Units Level Result %Rec Limits RPD Limit Qualifiers
Batch:B704140-Prep Method:3550C
Matrix Spike Dup(6704140-MSD1) Source:1704105-01 Prepared: 26-Apr-17 15:05 Analyzed:27-Apr-17 04:18
1-Methylnaphthalene 0.250 0.0522 0.00598 mg/kg dry 0.418 0.00598 U 60 53-117 7 25
2-Methylnaphthalene 0.218 0.0522 0.00673 mg/kg dry 0.418 0.00673 U 52 51-118 6 25
Acenaphthene 0.263 0.0522 0.00724 mg/kg dry 0.418 0.00724 U 63 45-126 8 25
Acenaphthylene 0.247 0.0522 0.00634 mg/kg dry 0.418 0.00634 U 59 54-118 9 25
Anthracene 0.197 0.0522 0.00599 mg/kg dry 0.418 0.00599 U 47 58-117 8 25 J2
Benzo(a)anthracene 0.226 0.0522 0.00578 mg/kg dry 0.418 0.00578 U 54 53-129 6 25
Benzo(a)pyrene 0.226 0.0522 0.00569 mg/kg dry 0.418 0.00569 U 54 48-116 6 25
Benzo(b)fluoranthene 0.221 0.0522 0.00670 mg/kg dry 0.418 0.00670 U 53 44-119 7 25
Benzo(g,h,i)perylene 0.314 0.0522 0.00502 mg/kg dry 0.418 0.00502 U 75 47-111 8 25
Benzo(k)fluoranthene 0.202 0.0522 0.00979 mg/kg dry 0.418 0.00979 U 48 36-126 3 25
Chrysene 0.228 0.0522 0.00542 mg/kg dry 0.418 0.00542 U 55 48-125 5 25
Dibenzo(a,h)anthracene 0.322 0.0522 0.00486 mg/kg dry 0.418 0.00486 U 77 54-113 8 25
Fluoranthene 0.223 0.0522 0.00653 mg/kg dry 0.418 0.00653 U 53 41-128 7 25
Fluorene 0.243 0.0522 0.00668 mg/kg dry 0.418 0.00668 U 58 48-125 8 25
Indeno(1,2,3-cd)pyrene 0.314 0.0522 0.00515 mg/kg dry 0.418 0.00515 U 75 50-114 20 25
Naphthalene 0.223 0.0522 0.00624 mg/kg dry 0.418 0.00624 U 53 47-120 7 25
Phenanthrene 0.224 0.0522 0.00594 mg/kg dry 0.418 0.00594 U 54 51-122 7 25
Pyrene 0.301 0.0522 0.00585 mg/kg dry 0.418 0.00585 U 72 42-125 6 25
Surrogate:2-Fluoroblphenyl 0.115 mg/kg dry 0.174 66 23-107
Surrogate:Nitrobenzene-d5 0.0808 mg/kg dry 0.174 46 17-111
'`` ge'7#f'of.14. 1
ISI‘^ 1910 Harden Boulevard
Suite 101
- LAK E LAN D Lakeland,FL 33803
w � (863)686-4271 Phone
`-` =
• • gib' LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager. Daphanee Waters Lab Work Order(COC):1704105
Petroleum Hydrocarbons by GC/FID-Quality Control
Lakeland Laboratories, LLC
Spike Source %Rec RPD
Analyte Result POL MDL Units Level Result %Rec Limits RPD Limit Qualifiers
Batch:B704137-Prep Method:3550C
Blank(8704137-BLK1) - - Prepared: 26-Apr-17 12:43 Analyzed:26-Apr-17 18:04
FL-PRO(C8-C40) 2.64 U 4.00 2.64 mg/kg wet
Surrogate:o-Terphenyl 3.54 mg/kg wet 3.33 106 62-109
Surrogate:n-Heptatriacontane 12.1 mg/kg wet 20.0 60 60-118
LCS(6704137-BS1) -- Prepared: 26-Apr-17 12:43 Analyzed: 26-Apr-17 18:37
FL-PRO(C8-C40) 76.1 4.00 2.64 mg/kg wet 90.7 84 63-153
Surrogate:o-Terphenyl 3.86 mg/kg wet 3.33 116 62-109 J2
Surrogate:n-Heptatrlacontane 13.1 mg/kg wet 20.0 66 60-118
Matrix Spike(8704137-MS1) Source:1704100-01 Prepared: 26-Apr-17 12:43 Analyed_26-Apr-17 19:10 _
FL-PRO(C8-C40) 72.6 4.04 2.67 mg/kg dry 91.5 9.94 68 62-204
Surrogate:o-Terphenyl 3.54 mg/kg dry 3.37 105 62-109
Surrogate:n-Heptatriacontane 12.5 mg/kg dry 20.2 62 60-118
Matrix Spike Dup(B704137-MSD1) _ Source:1704100-01 Prepared: 26-Apr-17 12:43 Analyzed:26-Apr-1719:43 _
FL-PRO(C8-C40) 76.3 4.04 2.67 mg/kg dry 91.5 9.94 72 62-204 5 25
Surrogate:o-Terphenyl 3.51 mg/kg dry 3.37 104 62-109 - -
Surrogate:n-Heptatriacontane 12.5 mg/kg dry 20.2 62 60-118
. Page 1 I�o;14.
A4W .
.,.': x 1910 Harden Boulevard
Suite 101
LAKE LAND Lakeland, FL 33803
> (863)686-4271 Phone
LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-17 15:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
SM 2540G-% Dry Solids-Quality Control
Lakeland Laboratories, LLC
Spike Source %Rec RPD
Analyte Result PQL MDL Units Level Result %Rec Limits RPD Limit Qualifiers
Batch:B704141-Prep Method:%Solids
Duplicate(8704141-DUP1) Source:1704105-02 Prepared: 26-Apr-17 15:54 Analyzed: 27-Apr-17 11:25
%Dry Solids 95.4 0.100 %by 93.1 2 5
Weight
1910 Harden Boulevard
e4MSuite 101
e LAK E LAl Y D Lakeland,FL 33803
.
(863)686-4271 Phone
LABORATORIES (863)686-4389 Fax
NELAP Certificate No.E84880
Applied Science&Engineering,Inc. Project Name: City of Clermont Public Works
550 North Reo Street,Suite 105 Project Number: 10777T FE1 Reported:
Tampa,FL 33609 Project Location: 400 12th St.,Clermont,FL 27-Apr-1715:18
Project Manager: Daphanee Waters Lab Work Order(COC):1704105
Notes and Definitions
J2 The reported value failed to meet the established quality control criteria for precision and/or accuracy.
Result is between LOQ/PQL and LOD/MDL.
DET Analyte DETECTED
U Analyte NOT DETECTED at or above the MDL
NR Not Reported
dry Sample results reported on a dry weight basis
RPD Relative Percent Difference
PQL Practical Quantitation Limit
MDL Method Detection Limit
MRL Method Reporting Limit
Results of liquid samples are reported on a wet-weight basis unless otherwise indicated.Results of solid samples are
reported on a dry-weight basis unless otherwise indicated.
Page'13 of 14'
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`�a, °•"••e4, • Florida Department of Environmental Protection
4
Twin Towers Office Bldg.2600 Blair Stone Road,Tallahassee,Florida,32399-2400
. Division of Waste Management
Petroleum Storage Systems
Storage Tank Facility Closure Site Inspection Report
'''•nt.1 P'°
Facility Information:
Facility ID: 9101997 County: LAKE Inspection Date: 04/26/2017
Facility Type: H- Local Government
Facility Name: CLERMONT CITY-PUBLIC WORKS DEPT #of Inspected ASTs: 1
400 12TH ST USTs: 0
CLERMONT, FL 34711 Mineral Acid Tanks: 0
Latitude: 28°33'27.5872"
Longitude: 81°46'35.6775"
LL Method: DPHO
Inspection Result:
Result: In Compliance
Also Performed:
Financial Responsibility:
Financial Responsibility: INSURANCE
Insurance Carrier: COMMERCE& INDUSTRY
Effective Date: 10/20/2016 Expiration Date: 10/20/2017
Findings:
Signatures:
TKOREP-ORANGE CNTY ENVIRONMENTAL PROTECTION DIVISION
Storage Tank Program Office
(407)836-1499
Storage Tank Program Office Phone Number
Activity Opened 04/26/2017 Page 1 of 3 Charles D. Cox
Facility ID: 9101997
Charles D. Cox Brian Camp
Inspector NAME Representative NAME
/ 2",
Inspector Signature Representative Signature
Completed System Tests
Type Date Results Reviewed Next Due Comment
Completed Date
Annual Operability 05/04/2017 Passed 06/05/2017 05/04/2018 Krueger gauge
Test
Site Visit Comments
04/26/2017
On site for the removal and closure activities associated with removing the last of the ASTs in
secondary containment and the associated underground piping.
Proper notice was given.
The integrity tests failed and Applied Science and Engineering was called in to conduct a closure
assessment. Reportedly the closure screening found a maximum 2 ppm reading.
Forward the closure assessment to Orange County within 60 days.
Inspection Comments
06/05/2017
A signed copy of this report was e-mailed to Brian Camp, Bcamp@clermontfl.org.
Activity Opened 04/26/2017 Page 2 of 3 Charles D. Cox
Facility ID: 9101997
Inspection Photos
Added Date 04/27/2017 Added Date 04/27/2017
2017/04/26, Site 2017/04/26, Old piping run
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Added Date 04/27/2017
2017/04/26, Old tank
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Activity Opened 04/26/2017 Page 3 of 3 Charles D. Cox
04\6.
a• ' Florida Department of Environmental Protection
Twin Towers Office Bldg.2600 Blair Stone Road,Tallahassee,Florida,32399-2400
Division of Waste Management
Petroleum Storage Systems
ze
1.64 Storage Tank Facility Installation Site Inspection Report
4'•ntal Vt
Facility Information:
Facility ID: 9101997 County: LAKE Inspection Date: 04/26/2017
Facility Type: H- Local Government
Facility Name: CLERMONT CITY-PUBLIC WORKS DEPT #of Inspected ASTs: 1
400 12TH ST USTs: 0
CLERMONT, FL 34711 Mineral Acid Tanks: 0
Latitude: 28°33'27.5872"
Longitude: 81°46'35.6775"
LL Method: DPHO
Inspection Result:
Result: In Compliance
Also Performed:
Financial Responsibility:
Financial Responsibility: INSURANCE
Insurance Carrier: COMMERCE& INDUSTRY
Effective Date: 10/20/2016 Expiration Date: 10/20/2017
Findings:
Signatures:
TKOREP-ORANGE CNTY ENVIRONMENTAL PROTECTION DIVISION
Storage Tank Program Office
(407)836-1499
Storage Tank Program Office Phone Number
Activity Opened 04/26/2017 Page 1 of 5 Charles D. Cox
Facility ID: 9101997
Charles D. Cox Brian Camp
Inspector NAME Representative NAME
Inspector Signature Representative Signature
Completed System Tests
Type Date Results Reviewed Next Due Comment
Completed Date
Annual Operability 05/04/2017 Passed 06/05/2017 05/04/2018 Krueger gauge
Test
Site Visit Comments
04/26/2017
On site for the installation of a double wall fuel tank in the existing secondary containment. The
end of the containment was removed, so it's just a concrete pad now.
04/28/2017
Tank arrived on site and was put into the existing containment. The tank is a double wall STI,
Fireguard tank, EQ-400.
05/04/2017
On site with RC Development, the contractor, to test the tank and the dispenser sump.
The tank vacuum test is not holding a constant vacuum due to the concrete in the interstice of the
Fireguard tank. The dispenser sump was hydro-tested to check the entry boots. No leakage was
found.
The product line was pressure tested ok.
Activity Opened 04/26/2017 Page 2 of 5 Charles D. Cox
Facility ID: 9101997
A Krueger gauge will be used to monitor the tank's interstice.
The tank is labeled and ok to put in service.
Inspection Comments
06/05/2017
A signed copy of this report was e-mailed to Brian Camp, Bcamp@clermontfl.org.
Inspection Photos
Added Date 04/28/2017 Added Date 04/28/2017
2017/04/28, Tank 2017/04/28, Tank label
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Activity Opened 04/26/2017 Page 3 of 5 Charles D. Cox
Facility ID: 9101997
Added Date 05/04/2017 Added Date 05/04/2017
2017/05/04, Attempt to vacuum test 2017/05/04, Krueger gauge
i
MAXIMUM
CAPACITY
[IIILI 3 `.
Vic ) �
Added Date 06/05/2017 Added Date 06/05/2017
2017/05/04, Backside of dispenser 2017/05/04, Pressure test of product line
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Activity Opened 04/26/2017 Page 4 of 5 Charles D. Cox
Facility ID: 9101997
Added Date 06/05/2017
2017/05/04, Tank
MAXIMUM
CAPACITY
iN
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Activity Opened 04/26/2017 Page 5 of 5 Charles D. Cox
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VOL 41 E'w;NIXCIi ORAN All QBNE'Y BEFORE RECORDING.YOUR NOTICE OF'COMMENCEMENI. I S.713.13SS
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