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HomeMy WebLinkAboutUST 12/20/2013Owner Statements of Designated Underground Storage Tank (UST) Operator .--and Understanding of and Compliance with UST Requirements ­—.1-- ......... . . . ............. . . . ...... ..... .................. . Fa--"C'i'lity Name, CIRCLE K 2708605 ............ 1 1­1 ............. ... . . . ....... ------ Facility ID: 2708605 . ... . ....... Facility Address: 5600 AUBURN ST Reason for Submitting this Form (Check One) BAKERSFIELD, CA 93305 in Change of Designated Operator I ❑ Updated Certificate Expiration Date Facility Phone #* 6618716273 Desic ihated UST Operator(s) for this Facility PRIMARY [Designated Operator's Name: FredyBarrita Soriano . ... ......... . ... . . . ........... . . . ..... ............ Relation to the LIST Facility (Check One) ............. 1 Business Name (if different from above): Beishire Environmental Services, Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone #: (949) 460-5200 0 Service Technician IN Third-Party International Code Council Certification 8158278 Expiration Date: 519/20-14 ALTERNATE I - . . .... .... Designated Operator's Name: refer to backup document _...—T ......... Relation to the UST Facility (Check One) !Business Name (if different from above): refer to backup document ❑ Owner rl Operator ❑ Employee . ........ ..... . iDesignated Operator's Phone #: refer to backup document ❑ Service Technician a Third -Party International Code Council Certification refer to backup document . ... ............... — - --------- . .... .... . ... . .......... . . ........ .... 1 Expiration Date'. refer to backup document ALTERNATE 2 Designated Operator's Name: refer to backup document Relation to the UST Facility (Check One) ;Business Name (if different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee I Designated Operators Phone refer to backup document 0 Service Technician 0 Third-Party International Code Council Certification #: refer to backup document ... . . ... . ..... . . . ..... 1 Expiration Date: refer to backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The indMdual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Signature -of Tan Q7! Date: 12/20/2013 is Phone #: NOTE,, 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca,gov/ust/contacts/oupa_agys.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. 2'5 71 T6wne Centre. Dr• -4e, Foothill Ranch, OA 9261*0 Designated Operator Alternate List . . ... ...... Chad Armstrong 8205731 518/2015 (949) 460-5200 Kris Ashrafi i 8220287 (949) 460-5200 Jeff Badders 5252456 9/20/2015 (949) 460-5200 i Fredy Barrita Soriano 8158278 5/9/2014 (949) 460-5200 Stephen Bautista James Seek Jeremy Brenner 8214021 7/22/2015 8159612 5/18/2014 8225809 11/1/2015 (949) 460-5200 (949) 460-5200 0-5 (949) 46200 Francis Allan Cabudol 8214022 7122/2015 . (949) 460-5200 Th om as Cervantes 8222755 10/4/2015 (949) 460-5200 Oliver Cruz Andy DeGregorio 8145178 8/24/2014 8019630 10/2/2014 (949) 460-5200 (949) 460-5200 Diaz 'Jesse Diaz 8120/2015 (949) 460-5200 ;Jackie Dougherty 5234433 .6/30/2014 . .... . . ........ - ---------- (949) 460-5200 ............................... . ........... .. . ............... . ... Grasiela Gamy 8 184-1--6i 11 /27/201 4 (949) 460-5200 Noah Henning 8167941 5/7/2014 (949) 460-5200 Gary Hildenbrandt Michael Holkko 1 8222240 I 10/4/2015 8025470 1/1012014 (949) 4605200 (949) 460-5200 — -------- Kevin Hom /6/2014 8142-199 T- . . .... . ..... (949) 460-5200 �Rii Glenda Kierstead chie LeClair 8174321 9/18/201 -�- y_' ,_._ 8155188 4/17/2014 (949) 460-5200 (949) 460-5200 Santi Luangpraseut -� 8057544 2/1/2014 (949) 46.0-5200 Andrew Marvin 8146893 2/1612014 (949) 460-5200 Chukwuemeka Odunze 8105942 3/1112015 (949) 460-5200 Elizabeth Orizaga Deanna (Danielle) Palmer Cristina Pena 8220068 9/15/2015 8199069 3/19/2015 8010939 5/7/2014 (949) 460-5200 (949)460- 5200 (949) 460-5200 Edward.Ramirez 5246237 9/21/2014 (949) 460-5200 Vanessa Romero 8192165 1/25/2015 P8212371 (949) 460-5200 Philip Schwartz I Roman Shekhter 8035361- 7/3/2015 (949) 460-5200 819/2015 (949) 460-5200 Jonathan Shisler 8146894 2/16/2014 (949) 460-5200 Brandon Smith 8218428 .... ..... ...... . . 8/28/2015 1 (949) 460-5200 . . ... . . ......... .............. .... . .......... 001wner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements .......... . .. ......... . ..... ............ ...... . ................. . - ..... . ........... ...... . ....... .. . ................... . ... .. ..... Facility Name: CIRCLE K 2701270 Facility ID: 2701270 Facility Address: 5634 STINE RD Reason for Submitting this Form (Check . One) BAKERSFIELD, CA 93313 n Change of Designated Operator o Updated Certificate Expiration Date Facility Phone #: 6618348625 ^u Des! n ated.-UST.Operator(s) for this Foci rt At PRIMARY Designated Operator's Name: Fredy Barrita Soriano Relation to the UST Facility (Check One) ...­_._____. . ... . .... Business Name (if different from above): BeIshire Environmental Services, Inc ❑ Owner El Operator ❑Employee Designated Operator's Phone #: (949) 460-5200 I ❑ Service Technician IN Third-Party International Code Council Certification #: 8158278 Expiration Date: 5/9/201-4 ALTERNATE1 Designated Operator's Name. refer to backup document :,Business Name (if different from above), refer to backup document Designated operator's Phone #: refer to backup document [International Code Council Certification #: refer to backup document ALTERNATE 2 Designated Operator's Name: refer to backup document Business Name (if different from above): refer to backup document Designated Operator's Phone #: refer to backup document International Code Council Certification #: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ � I Service Technician IN Third-Party Expiration Date: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator L7- Employee ❑ Service Technician S Third-Party Expiration Date: refer to backup document I certify that, for the facility indicated at the top, of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. -n- Name of Tank Owner (print): .-k (yn Signature of TAnk Owner: Date, 12120 Phone #: D4 NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005, THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/ust/contacts/oupa_agys.htmi. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. bels-hire envi.ronmental. 2:5971-Towne Centre Drive octhilll Ranch, CA 92610 mom, Ab Chad Armstrong i 8205731 5/812015 (949) 460-5200 Kris Ashrafi 8220287 9/13/2015 (949) 460-5200 . ..................... Jeff Badders 5252456 9/20/2015 i (949) 460-5200 Fredy Barrita Soriano 8158278 5/9/2014 (949) 460-5200 Stephen Bautista 8214021 7/22/2016 (949) 4605200 , James Beck 8159612 5/18/2014 1 (949) 460-5200 Jeremy Brenner 8225809 11/112015 z (949) 460-5200 460-5200 Francis Allan Cabudol ^ 8214022 7122/2015 (949) Thomas Cervantes 8222755 10/4/2015 (949) 460-5200 Oliver Cruz 8145178 8/24/2014 (949) 460-5200 1 Andy DeGregorio 8019630 10/2/2014 (949) 460-5200 1 460-5200 Jesse Diaz 8217427 8/20/2015 (949) rJaakie Dougherty ------ Grasiela Gama . ........ .... ........ ... . . ............. . . 5234433 8�84197 6/30/2014 .......... . 11/2712014 (949) 460-5200 (949)-460-5200 Noah Henning 'Gary Hildenbrandt 8157941 8222240 �949 5)7/2014 )460-5200 10/4/2015 (949) 460-5200 . ... . ....... . Michael Holkko 8025470 1/1012014 (949) 4605200 I Kevin Ham. 8142199 116/2014 (949) 460-5200 1 Glenda Kierstead 8174321 9/1812014 (949) 460-5200 Richie LeClair 8155188 4/17/2014 (949) 460-5200 Santi Luangpraseut 8057544 2/1/2014 (949) 460-5200 .Andrew Marvin 8146893 2116/2014 (949) 460-5200 Chukwuemeka Odunze 8105942 311112015 (949) 460-5200 Elizabeth Orizaga 8220068 9116/2015 (949) 460-5200 i -- -4 Deanna (Danielle) Palmer Cristina Pena 8199069 8010939 3!1912015 .5/7/2014 (949) 460-5200 (949) 460-5200 Edward Ramirez 5246237 9/21/2014 (949) 460-5200 Vanessa Romero 8192165 1/25/2015 (949) 460-5200 Philip Schwartz Roman Shekhter 8212371 8035361 713/2015 819/2015 (949) 460-5200 (949) 460-5200 Jonathan Shisler 8146894 2/16/2 014 i (949) 460-5200 Brandon Smith ....... ...... . ..... . ..... . . . . ..... ..... . ....... .. . ....... 8218428 8/28/20115 ----.. 1 (94 460-5200 .I...-- _..._........__._._..... Circle K Stores Inc. — West Coast Business Unit 255 East Rincon, Suite 100 Corona, CA 92879 January 10, 2013 Bakersfield Fire Department Prevention Service Division 2101 H Street Bakersfield, CA 93301 Attn: Ernie Medina RE: CIRCLE K STORE NO. 2708605 5600 AUBURN ST. BAKERSFIELD, CA 93306 NOTICE TO COMPLY /SUMMARY OF VIOLATIONS Dear Inspector: I wish to take this opportunity to respond to the issues noted on the Notice to Comply /Summary of Violations dated 12/18/12 issued to the subject store. The issues with responses follow: Issue# 1: Permit to Operate Expired 6/30/12 Response: Please see the enclosed Statement of Account from City of Bakersfield for the subject site. The statement date was 11/01/12 with a due date of 12/03/12 to pay for the permits. Please see the enclosed copy of check #1449435 made out to City of Bakersfield dated 11/15/12 showing that payment has been made and was made early for the subject site. The City has not issued the permits but they were paid for 16 days before the due date. Issue #2: Need to update Emergency Response Plan to current version onsite Response: Please see the enclosed updated Emergency Response Plan for the subject site. A copy of this updated plan has been provided to the site and been placed in the Safe Zone Records Binder. Issue #3: Site plan does not include UST piping Response: Page 1 of 2 Circle K Stores Inc. — West Coast Business Unit 255 East Rincon, Suite 100 Corona, CA 92879 Please see the enclosed updated site map for the subject site. A copy has been provided to the site and place in there Safe Zone Records Binder. Issue #4: Certificate of Financial Responsibility expired 12/1/12 Response: Please see the enclosed Certificate of Financial Responsibility with expiration of 12/1/13. A copy of this Certification of Financial Responsibility has been previously submitted to all agencies. I have enclosed a copy for your review as well as providing the site with another copy to keep onsite at all times in the Safe Zone Records Binder. I believe this addresses the issues indicated on the Notice to Comply /Summary of Violations. Circle K Stores assumes that the issues regarding this Notice to Comply /Summary of Violations have been resolved. Please contact me at 951- 270 -5104 or at tpiceno acirclek.com should you have any questions or require further information. Sin��--�' ,V Tor Environmental Compliance Specialist Enclosures Page 2 of 2 J,?-,a,Q2A510a' 31 P John G. Sherwood UNIFIED PROGRAM WSPECTION CHECKLIST Underground Storage Tank Program 661-663-7147 p.2 BAKERSF115ILD FIRE DEPARTMENT Prevention Services Division 2101 H street FIRE Bakusfield, CA 93301 VE0A R 7XjrffT Phone; 661-32G-3979 Fax, 651-852-2171 NOTICE TO COMPLY I SUMMARY OF VIOLATIONS MINOR VIOLATIONS 0 ❑ FaCiLity'. —C R-d&Ll< 2-01? Address'. There were NO violations observed during this inspection_ Notice to COMPIY: Minor Violation s were found during this inspection as notea in ine WILUMIN Sum IS. The violations indicated in this inspection report must be corrected within 30 days, unless otherwise noted. Form . ;al enforcement may be initiated for any violations noted, and for those not corrected in a timely manner. This report does not represent that there are no other violations at this facility. A re-inspection ma V occur to determine compliance status- ........ .... 4 SUMMARY OF VIOLATIONS FOR CORRECTION OF DATE FOR M VIOLATION VIOLATION------ CORRECTION R 4. ev. A '-6 .0 Orm 17" 1,m Ai,eZA .62-571-0 421V Inspectors �Rece�ived bA–:�J�, Signature: Phone: LZ Print Name, 'V>CXQ ,0% Date: Date: \,;L E CERTIFICATION OF RETURN TO COMPLIANCE I certify that the violations noted above on this Notice to Comply/Summary of Violations have been corrected. I have personally examined any documentation attached to the certification to establish that the violations have been corrected, ........ �i nature: Title: Print Name: WS W-A0 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD P 0 BOX 2057 BAKERSFIELD, CA 93303 -2057 (661) 326 -3979 TO: CIRCLE K STORE 2708605 255 E RINCON ST STE 100 CORONA, CA 92879 PAGE Will - DATE : 11/01/12 CUSTOMER NO: 3380/3380 ` W ES _ - _ENVIRONMENTA.L � SERVICES _ M - CHARGE ��'�DATE _ _ _ _ _ _ _ .. _ _ . .. _ _ _ -TYPE TOTAL AMOUNT DESCRIPTION ____�_____ REF- NUMBER. DUE ^DATE - � � 6/01/12 BEGINNING BALANCE .00 25. 0 0 g� { S S 0 0 7 7/01/12 CER.S -� STATE SURCHARGE 571.00? -1 HMO15 11/01/12 HAZ MAT FEE GROUP 15 96.00ut�, H.M017 11/01/12 HAZ MAT ANNUAL INSPECTION 7 2. 0 0 HM018 11/01/12 SM QUANTI'T'Y HAZ WASTE GEN THIS FEE IS FOR SMALL QUANTI'T'Y GENERATORS OF HAZARDOUS WASTE. 2 4 . 0 0 t S S 0 01 11/01/12 CA STATE SURCHARGE 45.0031S S S 0 0 2 11/01/12 UST S'T'ATE SURCHARGE THIS FEE IS A. STATE SURCHARGE OF $15.00.-FOR EACH UNDERGROUND STORAGE TANK. 288.00��� UT001 11/01/12 UNDERGROUND TANK ANNUAL OPERATING PERMIT FEE ANNUAL BILL FOR THE FISCAL YR 7/1/12 - 6/30 -13 IF RECEIVED IN ERROR PLEASE CALL (661) 326 -3659 -------------- CUR.R.EN'T -_ -_ -- OVER 30 -_ -_� OVER 60 ___ -OVER 90 1121.00 DUE :..< .. ..::::.:....::..:.............. DATE: '• ?:" 7 • .;....::::;.:;.;; PAYMENT DUE.- '.t 3 ° ;;';, ",: TOTAL DUE- 11121-00 $1,121.00 CALIFORNIA ENVIRONMENTAL REPORTING SYSTEM (C'ERS) CONSOLIDAT1,D EMERGENCY RESPONSE / CONTINGENCY PLAN Prior to colnj)leting this Plan, please re fix to [he, JAISTRUCTIOAS P' OR (.-'0k1P1.E77N0 A CONW1.1114TED ('.0N77NGEAf(.'T PLAN A. FACILITY IDENTIFICATION AND OPERATIONS OVERVIEW r A2. FACILITY 11) it At- DATE OF PLAN I'REPARA'I'ION/IZI.'-V [SION 10023802 ___10110412013 BUSINESS NAME (Same as Paciliti, Ala if? or DR/f Doing Busim,SNAN.) Circle K Store #2708605 BUSINESS SITE ADDRESS 5600 Auburn St BUSINESS SITE CITY COD F, Bakersfield . . .......... . ...................... CA INC[DE"N'T"Al., 0111 ""RATIONS Flect Maintenance) A-1. TYPE OF BUSINESS Painting oinamr) Retail Fuel Dispensing Facility Sale of Unleaded Fuel THIS PLAN COVERS CHEMICAL SPILLS, FIRE'S, AND LVING: (Check all that apply) ti7 JE 1. HAZARDOUS MATERIALS; ❑ 2, HAZARDOUS WASTE,'S B. INTERNAL RESPONSE INTERNAL FACILITY EMERGENCY RESPONSEWILLOCCUR VIA, (Clieck till that apply) Z 1. CALLING PUBLIC EMERGENCY RESPONDERS (i.e., 9 -1 -1) ED 2. CALLING HAZARDOUS WASTE CONTRACTOR 3. ACTIVATING IN-HOUSE EMERGENCY RES PONS E,1'1--,AM C. EMERGENCY COMMUNICATIONS, PHONE NUMBERS AND NOTIFICATIONS Whenever there is all imminent or actual emergency situation such as all explosion, fire, or release, the Emergency Coordinator (or his /her designee when lite Emergency Coordinator is on call) shall: 1. Activate intemal facility alarms Or communications systems, where applicable, to notify tell racility personnel. 2. Notify appropriate local authorities (i.e., call 9-1-1), 3, Notify the Califomia Emergency Managenlem Agency at (800) 852-7550. Beforo facility operations are NSUlned in areas of' tile facility "iffiected by the incident, the emergency coordinator shall notify the California Department of'l'()xic Substance, Control (D'I'SC), the local Unified Pr' gnam Agency (UPA), and flick local fire department's hazardous materials prOgn,1111 that the. 111cflity iS ill CORIpliallec with requirements to: 1. Provide for proper storage and disposal of recovered waste, contaminated soil ot- surl',ke water, orally other material that results from all explosion, ffi-e, or release at the facility; and 2. Ensure that no material that is incompatible with the releimed material is 111111"fielTed, stored, or- (jjsp()se(I of in areas of the facility affected by tile. incident until cleanup procedures are completed. CL INTERNAL FACILITY EMERGENCY COMMUNICATIONS OR ALARM NOTIFICATION WILL OCCUR VIA: (Check all that apply) J9 1. VERBAL WARNINGS; ❑ 2. PUBLIC ADDRESS OR INTERCOM SYSTEM; 3.TELEPI•IONE, ❑ 4. PAGERS: 5. ALARM SYSTEM; 6. PORTABLE RADIO NOTIFICATIONS TO NEIGHBORING FACILITIES THAT MAY BE AFFECTED BY AN OFF-SITE RELEASE WILL OCCUR BY: (Check all that apply) C2. 10 1. VERBAL WARNINGS; ❑ 2. PUBLIC ADDRESS OR INTERCOM SYSTEM; 3. TELEPHONE; ❑ 4. PAGERS; S. ALARM SYSTEM; 6. POTABLE RADIO EMEK(jL-NC'Y AMBULANCE, FIRE, POLICE AND CHI ....................................... I ......... PHONE NUMBERS: CALIFORNIA EMERGENCY MANAGEMENT AGENCY (CAUEMA) ............. ....... (800) 852-7550 NATIONAL RESPONSE CENTER (NRC) ............................................. (800) 424-8802 POISON CONTROL CENTER ........................................................ (800) 2._._._..__._.._.._._,.; 22-1222 ........... ___ . .. (661) 326-3979 LOCAL UNIFIED PROGRAM AGENCY (UPA/CUPA) ........... ............ :_* *_.:..__'_'... ....... ..... . ... ................ . .... ­........._'� ........ ..... .... ..... I ...... .... .... .. ......... .. ........ ............. ...... .............. .. .. .. .... .... 4 ..... .. ............. C4. C 5. -3979 OTHER (Specify}: 13AKERSFIELD FIRE DEPARTMENT .... .. ....... .. . . ......... ..... . .. ......... ........... ............ ........... ­......1-1 ...... ...... .... .. ... . ...... ...... ....... C6. C7, (661) 326-2000 NEAREST MEDICAL FACILITY / HOSPITAL NAME: KERN MED)CAL CENTER .. .. . .... ................... . . ­­ ................ ........... . ......... ........ ................ .... . . .......... ­.1 ......... . ..... ....... .... ......... . ... ........... . .... ... . .. . . .. ........... . . . ................ ...... . .. .................. AGENCY NOTIFICATION PHONE NUMBERS: CALIFORNIA DEPT. OF TOXIC SUBSTANCES CONTROL (Disc) (916) 255-3545 CS, 'Al. WATER QUALITY CONTROL BOARD ................. REGIO' .............. . ........... .. ............... ................ U.S. ENVIRONMENTAL PROTECTION AGENCY (US EPA) ........... (800) 300-2193 CALIFORNIA DEPT OF FISH AND GAME (DEG) .................... (916) 358-2900 U. S. COAST GUARD ............................................. (202) 267-2180 CAL/OSHA ..................................................... (916) 263-2800 STATE FIRE MARSHAL .......................... (9 6) 4-45-820.0 . . .. . ........... ..... ....... - .. ........... ......... ...... ........ ..... ........ ........ ..... ............... . ............... . .... . ... . . . .................... ......... .. ......... ......... E ........ ......... c. C9. o. OTHER( Specify): ....... . . ...... ..... ............ .. ...... ............. ...... . .. .. . ........... ................. .... .. ............. cit. OTHER (Specify):- Rev. 06/27111 CE16 Consolidated E'nicrgency lZesponme / Confingeney Plan -- Page 2 of 2 Rev. 06/27111 - ----- - -------- - - - ----------- FFS: '.'Iicck- all boxes that apply to indicate your procedures fbr Containing Spills, releases, SPILL PREVENTION, CONTAINMENT, AND CLEANUP PROCI.';[YCJKFS—"'. fires or explosions, and. pre c iting and mitigating D. EMERGENCY CONTAINMENT AND CLEANUP PROCEDURES t J?�-.qmms' pwpeny, and the enviamment.) .... ....... ..... .... 01. MONITOR FOR LEAKS, RUPTURES, ❑ 2. PROVIDE STRUCTURAL PHYSICAL BARIZ11"RS (e.g., Portable spili containment walls); 0 1 [IROVIL)[-'ABSOIZBI--N'1'1)1-IYS1('Al, BARRIERS (e.g., Pads, pigs, pillows), 04. COVER OR BLOCK FLOOR AND/ OR STORM DRAINS; 5. BU113'-IN BERM IN WORK / STORAGE AREA; ❑ 6, AUTOMATIC FIRI"SUPPIZESSION SYS'I'f---'M-, 7. ELIMINATE SOURCF.-,S Of: IGNITK)N [-OR FLAMMA131.1-l' HAZARDS (c.g. Elan mablo liquids, Propane); 08. STOP PROCESSES AND/OR OPERATIONS; Z 9. AUTOMATIC / ELEC'T'RONIC EQUIPM [�N'l"Sl-itJ'I"-0I'1,-.SYS'1'1'-M; 19 10. SHUT-OFF WATER, GAS, ELECTRICAL UTILITIES AS APPROPRIA-rc'-, 11. C ALI, tm -I FOR i>uBuc i7-mF-.RCyENCY RESPONDER ASSIS'I'ANCI*--'/ mr--'DICAL AID; 12, NOTIFY AND EVACUATE- PERSONS IN ALL,1•-IREATI-ENED ARI'-'AS; 13. ACCOUNT FOR EVACUA'I'I'-'D PERSONS IMMEDIATELY M11 ';R I';1VACUATION CALL-, 0 14. PROVIDE" PROTECTIVE EQUIPMENT FOR ON-SITE RE.SPONSF *TEAM; 0 15. REMOVE OR ISOI.ATECONTAINERS / AREA AS APPROPRIATF; ED 16. HIRE LICENSED HAZARDOUS WASTE CONTRACTOR; 0 17. USE ABSORB r- NTM A*1'1'--'RIA L FOR SPILLS WITH SUBSI3QUFNT PRO)"FIZ LABELING, STORAGE, AND HAZARI)OOs WASTf- DISPOSAL. AS APPROPRIATE; 18. SUCTION USING SI-1011 VACUUM WI-1-1-1 SUBSEQUENT PROPER LABELING, STORAGE--, AND HAZARDOUS WASTE, DISPOSAL, AS APPROPRIATE; 19. WASH / DECON'FAMINA:I'L EQUIPMENT W/ CONTAINME"N'I'and DISPOSAL OFEFTLOENT/ RINSATE AS HAZARDOUS WASTF; 20, PROVIDE SAFE TEMPORARY STORAGE 01- EMERGENCY - GENE'RA'TED WASTES; 2LOTHER(Specil'y): PLEASE SEE EMERGENCY RESPONSE PROCEDURES D2, E. FACILITY EVACUATION THE FOLLOWING ALARM SIGNAI. S) WILL BE USED TO BEGIN EVACUATION OF '1 HE' (CHECK ALL THATAPPLY): ❑ 1, BELLS; ❑ 2. HORNS/SIRENS; 3. VERBAL (i.e., SHOUTING); 4. OTHER (Specify): ALARM THE FOLLOWING LOCATION(S) IS/ARE EVACUFE EMERGENCY ASSEMBLY AREA(S) (i.e., Front parking lot, specific Street corllei• etc.) NORTH SIDE OF LOT Notc:'rlie Emergency Coordinator must account for all on site employees and/or site visitors after MICLIatioll. 0 EVACUATION ROUTE MAP(S) POSTED AS REQUIRED 1,4, Note: The map(s) must show piniaryand alternate. evacuation routes, emergency exits, and primary and alternate staging areas, and must be prominently posted throughout tile fiaoiji!x in locations where it will be visible to eg)loyces and visitors. F. ARRANGEMENTS FOR EMERGENCY SERVICES Explanation of Requi•emenvAdvance arrangements with local fire and police depailments, hospitals, and/or emergency services contractors should be made as appropriate for your facility. You may determine that such arr-angements are riot necessary. ADVANCE ARRANGEMENTS FOR LOCAL EMERGENCY SERVICES (Check one ol'the following) ❑ 1. HAVE BEEN DETERMINED NOT NECESSARY; or 2. THE FOLLOWING ARRANGEMENTS 14AVE BEEN MADE (Specify): PLEASE SEE EMERGENCY RESPONSE PROCEDURES CERS Consolidated Emergency Response I Contingency 11:111 --- Page 3 oi'3 Rev. (16/27/11 G. EMERGENCY EQUIPMENI Check all boxes that apply to list emergency 1'esponse equipine.10 available M the facility and identify [tic localion(s) wlicre Cite equilmkont is ke))( and the equipment's capability, if applicable. le.g., 19 (.111NICAI., I'lzo-DiClIvii (j1'0v1;S I Spill response kit One tinie use, Oil & solvent resistant only.) ................ ... ................ ......... .. .... . .. . I . . '�;[. . .. .1. .. ... . . .......... . TYPE EQ(JIPMI,"NI'AVAII,AI31.li"----- --- LOCATION CAPABILITY (l I*qpplicdbh ) Safety and 1. ❑ CHEMICAL SUITS, APRONS, OR Vl-*','S*I*S 62. (0. First Aid 2• 0 CHEMICAL PROTECTIvr... GLOVFS BACKROOM IMPERMEABLE 65. 3. ❑ CH EM ICA L E BOOTS 07. 4. 2 SAFETY GLASSES / GOGGLES /SI-111"LDS BACKROOM IMPERMEABLE, PROTECTANT 0). 5. ❑ HARD HATS 010. 611. 6. Q CARTRIDGE, R E-S I ) I I Z ATO 16 G12. 7, ❑ SELF-CONTAINED BREATHING APPARATUS (SC13A) 614. 8. I"IRSTAID KITS / STATIONS STORAGE ROOM G I& STANDARD KIT G17. 9. ❑ PLUMBED EYEWASH FOUNTAIN / SHOWER G 18, Oltl. 10.9 PORT ABLE EY EWAS I-I KITS STORAGE ROOM 620. STANDARD KIT, BOTTLE :I I. ❑ 0*1,1.1 I.-R G22, 023. 12. ❑ OTHER (324. 02�. Fire Fighting 13. PORTABLE FIRE_' EXTINGUISHERS INSIDE STORE & AT PUMPS G20- DEVICE TO STINGUISH FIRE G27. 14. ❑ FIXED 11RE SYSTEMS / SPRINKLE-16 FIRE HOSES G29. 15.0 FIRE ALARM BOXES OR STATIONS INSIDE STORE VEEDER-ROOT TLS-350 MONITORING PANEL 031. 16. ❑ OTHER Spill Control 17.19 ALL-IN-ONE SPILL KIT STORAGE ROOM CAT LITTER/OIL DRY and 18. Z ABSORBENT MATERIAL. STORAGE ROOM 0 76. - L CAT LITTER/OI DRY G37. Clean-Up 1-§. Z CONTAINER FOR USED ABSORBENT OUTSIDE OF BUILDING ;M. : 55 GAL. LABELED BARREL G-19. 20. El BERMING / DIKING EQUIPMENT G40. Gal. 21. JZ BROOM STORAGE ROOM 042. CLEANNINGISPILL EQUIPMENT c43. 22. ED SHOVEL STORAGE ROOM 044. CLEANNINGISPILL EQUIPMENT DIS, 23. ❑ SHOP VAC 046. (347, 24. ❑ EXHAUsTHOOD 25. ED EMERGENCY SUMP I HOLDING TANK UST'S, DISPENSERS (350. PREVENT MAJOR SPILL, SENSORS (051. 26.0 CHEMICAL NEUTRALIZERS STORAGE ROOM 052. EMERGENCY RESPONSE EQUIPMENT /ABSORBENTS cG51• 27. ❑ GAS CYLINDER LEAK REPAIR KIT C54. Gss. 28. ❑ SPILL OVERPACK DRUMS 0.56. 057, 29. El OTHER STORAGE ROOM G-58 - EMERGENCY RESPONSE EQUIPMENTIABSORBENTS 0s9' Commurij- 130- ED TELEPHONES (Includes cellular) INSIDE STORE 060- COMMUNICATING DEVICE TO ANNOUNCE EMERGENCY G61. cations and 31.0 INTERCOM / PA SYSTEM 062. GO. Alarm 32. ❑ PORTABLE RADIOS Systems 004. 065. 33. N AUTOMATIC ALARM CHEMICAL MONITORING EQUIPMENT INSIDE STORE 066• VEEDER-ROOT TLS-350, MON. .--PANEL TO ALERT SPILL G67. Other 34. ❑ OTHER GO. C161). CERS Consolidated Elmergency Response / Contingency Flare — ['age 4 cal' 4 Rev. 06/27111 CE1ZS Consolidated 1 mergeney Itespouse / Contingency Plan -- Page 5 of• 5 Rey. 06/27/11 11. EARTI]QUAKE VULNERABILITY Identify areas of the illcility that are vuhim,lble. to hazardous materials releases I spills duo to catiliquake-rcia(ed motion. These areas require ininiediate isolation and inspection. . ------ -- ............. . . ... ............ VULNERABLE-' AREAS: all that apply) Ili i LOCATIONS 0.p,, shop outdoor shed, tinellsic , 1,11)) Z I. HAZARDOUS MA'I'LZIAI-S/WAS']'r-S'1'0[tACl-AIZI-A SEE SITE MAP U. 2. PROCESS LINES / PIPING S, E, SITE , , A'P' .. ............ ❑ 3. LABORATORY 115. 4. WAS'1'1:-,'I*Rr-,A'I'MEN'['Al�l-','A . . ....... . ........ Identify inechanioal Systems vultiet-able to releases Spills duC to earthquake .,related Illotioll.Thesc. Systellis rc(Luire immediate isolation and VULNERABLE SYSTEMS: (Check all that apply) 116• LOCATIONS 1. SHELVES, CABINETS AND RACKS SEE SITE MAP 2. TANKS (EMERGENCY SHUTOFF) ;SEE SITE MAP rts. .................. .... ❑ 3. PORTABLE GAS CYLINDERS 4. E'M ERG E NCY S 1-1 UT011" AN 010 R UTILITY VALVE;. SEE SITE MAP III0. ...... ....... ......... ................... .. . ............... .... .................. 5. SPRINKLER SYSTEMS ❑ G. STATIONARY PRESSURIZED CON'T'AINERS (e.g., Propane dispensing Milk) I. EMPLOYEE TRAINING P,xplanafion of Requirement: Employee training-, is required for all employees handling hazardous materials and hazill-dous Wastes ill day-to-day or clean -lip openations including volunteers and/or conti-actom. Training inusl be: • Provided within 6 montlis for new hires; • Amended as necessary prior to chatige in process or work assignment; 0 Giver) LIJ)011 modification to the Einergency Response / Contingency Plan, and for all employees, Required content includes all of the Ibliowing: • Material Safety Data Sheets; * Communication and alarm systems; • Hazard communication related to health andsal'ety; - • Personal protective equipillent-) Methods, for safe, handling oflivardous substances; • Use of elliergency respollse equipment (e.g. Fire extinguishers, •espiratons, • Fire hazards of materials / processes; • Conditions likely to worsen 0 Decontall1i ilati Oil procedures; • Coordination of emergelicy response, • Eviicuation procedures; • Notification procedures; * Control and containinent procedures; • Applicable laws and regulations; * UST monitoring system equipment and procedures (ifapp[icablc). INDICATE HOW EMPLOYEE TRAINING PROGRAM IS ADMINISTERED (Check all that apply) ❑ 1. FORMAL CLASSROOM; 10 2. VIDEOS; 3. SAFETY / TAILGATE* MEETINGS; ❑ 4. STUDY GUIDES / MANUALS (Specify): p. .12 5. OTHER (Specify): PLEASE SEE EMERGENCY RESPONSE PROCEDURES [16. NOT APPLICABLE BECAUSE FACILITY HAS NO EMPLOYEES Large Quantity Generator (I,QG) Training Records: Large quantity hazardous waste generators (i.e., who generate more than 270 gallons/1,000 kilograms of hazardous waqe per month) must retain written documentation of employee hazardous waste management I,-,Iillillg sessions which includes: • A written outline/agenda of the. type and amount of both introductory and continuing training that will be given it) pemons filling each job position having responsibi lily for the managenient of hazardous waste (e.g., labeling, mailifesling, compliance with accumulation lime limils, etc.). • The name, job title, and date of training for- each hazardous waste mallagellielit tnlillilig session given to an employee filling such a job position; and • A written job description for- each of the above job positions, that describes job duties and the skills, education, or other qualifications TCqLli1'Cd of personnel assigned to the Position. • Current employee uJilling records must be retained until closure of the facility. • Foriner employee training records must. be retained at least three years after termination ofemploynicill. J. LIST OF ATTACHMENTS (Check one of the following) it. ❑ 1. NO A17ACHM ENTS ARE REQUIRED; or 32. 2. THE FOLLOWING DOCUMENTS ARE ATTACTIED: EMERGENCY RESPONSE PROCEDURES DOCUMENT PREVENTION, MITIGATION & ABATEMENT DOCUMENT K. SIGNATURE/ CERTIFICATION ............... ..... . ..... __­____......_._ .........•.___...___..__.._.... . Certification: Based on my inquiry of those individLWIS responsible for obtaining the information, I cellify under penalty of law that I have petsonally examined ztiid am familiar with the ifflormaiion submitted and believe (fie infbi-ination is true, accurate, and complete, and that a copy is available on site. SIGNATURE OF OWNER/OPERATOR DATE SIGNED Ki. eo A� 01/04/2013 NAME OF SIGNER (print) K2• TITLE OF SIGNER 05. Gregory Grover g, � T Environmental Construction & Service Manager EMERGENCY RESPONSE PROC✓ED1JRE'S MAJOR INCIDENT; FIRE, SPILL OR S[JSPECI`ED LEAK MINOR. INCIDENT: less than 5 gallons 1. DIRE: 1 xtiiiguish with fire extinguisher. Recharge fire extinguisher, if Used 2. SPILLS: Clean tip with absorbent inaterials on site anci dispose of according to all regulations, Have .a fire extinguisher really for spills of fl�uninable inat.e:rials. Restock absorbent as necessary. See the l;:mergency Equipment Section for additioniil iniornlatioil 3. MEDICAL: "Treat with on site first aid kit or take to nearest hospital. Employee training plan list the nearest hospital. 4. RECORD: Record the event in the Daily System Inspection Lorin. 5. NOTIFY: The Service Contact Center if the spill bows off site, enter a storm drain or contacts bare soil or groundwater. MAJOR INCIDENT: more than 5 gallons) Any incident than can not be contained and cleaned up-as paid of the routine operations, should be considered a major release and use the following procedures. 1. TURN OFF PUMPS using the Emergency Pump Shut -Off Switch. 2. EVACUATE: Verbally ANNOUNCE to all persons on the site: "This is an emergency. please turn off your engines and leave the station on foot immediately All employees meet at the emergency assembly are." 3. Call 9- 1-1: Give the following information: "THERE IS A FIRE /GASOLINE SPILL at the Circle K Store #2708605 service station at 5600 Auburn St., Bakersfield CA 93306. If anyone is trapped or needs medical attention, tell the answering dispatcher. Stay on the phone and be prepared to answer- any questions concerning the situation. 4. A'T'TEMPT to contain the spill if you can do it safely. S. LOON. AROUND to ensure that everyone has left the station, particularly those in vehicles who may need assistance or may not have heard the emergency announcement Assist or direct assistance to anyone having difficulty leaving the station are and Anyone who may be injured 6. REPORT to arriving emergency response personnel to provide their with any information or assistance they might need. Immediately notify the Service Contact Center. EMERGENCY PI-IONENUMBERS E'M I +, R Q EN C Y I Z I ""' S P 0 NSE. C 0 NTI I A CTO R Service Contact 24-Hour Center Dispateli: 1-866-805-4357 CIRCLE K STORE PERSONNEL Market Manager: 661-203-6941 Environmental Compliance Specialist: Trisha Yaliner 951 270-5193 FACILITY CONTACTS Primary: Service Contact Center 24 Hours D(ay: 866-805-4357 24-hours: 866-805-4357 Secondary:'rrisha Yaline r Environmental Compliance S)ccialist Day: 951-270-5193 24-hours: 951-270-5193 Circle K Stores, Inc. will notify the State and Local administering agencies within an appropriate time frame unless the situation requires urgent immediate resl2onse by the agencies, in which case the Operator should notify these agencies. a) LOCAL AGENCY: Bakersfield Fi le-Depatlil.git PHONE NUMBER: 661-326-3979 b) CALIFORNIA OFFICE OF EMERGENCY SERVICE: (800) 852-7550 or (916) 845-8911 c) LOCAL POLICE AND FIRE DEPARTMENTS: 9-1-1 d) NATIONAL RESPONSE CENTER: (800) 424-8802- (24-Hours) Spill/ Release Response Procedures for Propane The Propane used can be hazardous in the event of a spill or release;, or if there is a fire at the facility. Propane is flammable, in the event of a fire; the container could explode violently due to the high heat of the fare;. Propane is an odorless, color less, f arninable gas. Often an odorant is added for fuel purpose. A release in a confined are may cause rapid breathing, diminished mental alertness, impaired muscular coordination, faulty judgment, depression of all sensations, emotional instability and fatigue. As asphyxiation progress, nausea, vomiting and loss of consciousness may result. SpiII or Release: In the event of release from the propane tank /cylinder, do the following: 1. Evacuate all personnel from the affected area. 2. Stay upwind of the release and out of low -lying areas. 3. Avoid breathing gases. 4. If the leak is in a container or valve, contact the propane supplier for assistance. S. 'Ventilate the area before attempting the re -enter the area. 6. Do not enter the building until emergency personnel have notified you that it is safe. 7. Contact management using the emergency phone list procedure. Fire: 1. Follow the Fire And Explosion evacuation procedures. 2. /Notify emergency personnel of the tank location. Preventimi Procedures: 1. Store tank and/or cylinders with valve protection caps installed. 2. Tank and cylinder should be stored upright and firmly secured to prevent falling or being knocked over. 3. Containers should be stored in a cool, dry, well ventilated area away from source of heat or ignition and direct sun light. 4. If you suspect any problems with the tank notify the supplier immediately to have the system inspected. Spliii /Release Response Procedures for Carbon Dioxide (CO2 The CO2 used at rnany locations o produce; carbonated beverages can be hararde)liS in the event of a spill or release, or if there is a fire at the; station. Although CO2 is not flarninable) in the event of a fire, the container could explode due to the high heat of the fire. Release and spill of the CO2may cause dizziness or suffocation without warning. When release, the vapors are initially heavier than air spread along the ground. Contact with the gas as it escapes the tank may cause burns, sever injury and/or frostbite. Spill or Release In the event of a. spill or leak from the CO2 container, do the following: 1. Dial 911- inform emergency personnel that there is a release from the CO2 tank and the location of the tank. 2. Evacuate employees and customers from the site and deny entry to unauthorized people. 3. Stay upwind of the spill and put of low -lying areas. 4. Do not touch or walk through spilled material. 5. Avoid breathing gases. 6. Do not enter the building until emergency personnel have notified you that it is safe. 7. Contact management using the emergency phone list procedure. Fire: 1. Follow the fire and Explosion evacuation procedures. 2. Notify emergency personnel of the tank location. .Prevention. Procedures: 1. Store Tank and /or cylinders with valve protection caps installed. 2. Tank and cylinders should be stored upright and firmly secured to prevent falling or being knocked over. 3. Containers should be stored in a cool, dry, well ventilated area away from sources of heat or ignition and direct sun light. 4. If you suspect any problems with the tank notify the supplies- immediately to have the system inspected. Training: 1. Employees shall be trained on the above hazards associated with carbon dioxide gas and the preventative measures to prevent a release. 2. Training shall include evacuation procedures in the event of a release. 3. If compressed gas cylinders are present, employees shall be training on the handling of the cylinders and the use of the valve caps to prevent accidental damage to the valve. M PLO 1 E'E '1.yRAIN ING PLAN Employees must be given this training before starting work, and refi-eshcr cOL11-,Se' must be provided annually. Record 1171Llst be kept to show when each, station employees has been given leis /her safety training;. L)se the following outline and Male copies as needed. I -lave employee date and sign the attached training log; upon completion of training;. Retain these records for a minimum of tree ,years. All employees should review fhe: l- lazardous Material Plan, (this document). Specifically, each employee should understand the procedures to the used in responding to various kinds of emergencies, and know how to monitor the site for leaks of hazardous materials. As a supplement to this package, employees should also review and have access t. to the Emergency Response Plan and the Materials Safety Data Sheets. Each employee must be drilled in all emergency response procedures contained herein. UTILITTY SHUT -OFFS PUMPS SHUT -OFF: This turns off the turbine pumps that provide flow to the dispensers from the underground storage tanks. Shut -Off pumps in case of a leak to help prevent spills. Location: 1- CONSOLE I - FFRON'1' 017 FOODMAIZ'f',,...1 -PtJMP TANK MONITORING ALARM[: This is used to monitor the Underground .Storage Tanks. This panel may indicated when a potential leak is detected by a A visual and audible alarm Location: STORE ROOM ELECTRICAL. PANEL: The panel allows you to selectively cut power to lights, signs, and pumps. The main switch allows you to cut -off all power at the site. Location: STOIZE ROOM WATER. SHUT -OFF: The water shut -off may be necessary in some cases. Location: SIDEWALK ON SLAUSON�AVENUE NA'T'URAL GAS SHUT-OFF: If your facility has natural gas, it may be necessary to shut -off the flow in case of an emergency. Location: NONE PROPANE /LPG SMUT-OFF: If your facility has propane or liquefied petroleum gas, be sure to turn off the manual valves and shut off the power to the dispensing pumps in case of a release or fire. Call your supplier or dial 9 -1 -1 as necessary. EME RGENCY EQUIPMENT FIRE EXTINGUISHER: tJse only on small fires that you can contain.. Do not attempt to extinguish large fire oil your own; call 9-1-1 for help. Location: I -SALES AREA, I -STOIZA(A`,� I -1,S1,.,AND, I ........ ..... ............ .... .................... ... .. .. .................. ........ .. SPILL/CLEAN UP KIT: This can soak up small of gasoline, diesel fuel, or other petroleum products. Absorbent should be used rather than washing spills down a drain. In case of large spill, see the "Major Incident" section oil the previous page. Location: ST.O.R17-, ROOM. RESPONSE EQUIPMENT: These items are to be used to prevent skin with hazardous materials Broom: BA.C.K-R.0.0M Shovel: BACK ROOM Gloves: BACK ROOM Goggles- BACK ROOM *FIRST AID KIT: Used for minor incidents and treatment. Location: I -STORAGE AREA EVACUATION ASSEMBLY AREA: All employees must know where to meet in the event of an emergency. Location: NORTH SIDE OF LOT *ENVIRONMENTAL DOCUMENTS/HMMPMSDS SHEETS: Location: CASHIER. AREA I;1IVIPLOYI+.E I,RAINNING PLAN (con't) MEDICAL FACILITIES: PRIMARY IZAC.ILITY: KERN MEDICAL C EN'I`ER 1 830 1 "LOWER ST., 13AK 1ZS1`1EL1) ( A 661- 326 -2000 ALTERNATE FACILITY: FIRST AID PROCEDURES (for gasoline and/or diesel fuel): For further information, refer to the MSDS sheets. EYE CONTACT: If irritation or redness develops, move victim away from exposure and fresh air. Flush eyes with water clean water. If symptoms persist, seek medical attention Immediately. SHIN CONTACT: Removing contaminated clothing and shoes, flush affected area (s) with large amount of water. If skin is not damaged, proceed to cleanse the affected area with mild soap and water. If symptoms beeonhe worse, seek medical attention immediately. INHALATION (B reathinp,): Remove victim from source of exposure and into fresh air. If victim is not breathing, Give artificial respiration and seek medical attention immediately. INGESTION (Swallowing): .Aspiration Hazard: DO NOT INDUCE VOMITING. Do not give anything by mouth because it can enter the lungs and cause severe lung Damage. If victim is drowsy or unconscious and vomiting, place on the left side with The head down Seep medical attention immediately FIRST AID FOR EXPOSURE TO OTHER MATERIALS: Consult the warning advice on container labels or refer to the Material Safety Data Sheet (MSDS) for that product :Hazardous Material Training Requirements As the owner/operator of a business that handles hazardous material, you must have the following: * A Hazard Communication Plan (also know as an l-,mployee lZight -to Know Plan 'Fhe hazardous Material Management Plan- Chemical Inventory, also known as the CA Business Emergency flan) * A release Reporting Plan Each of these plans requires employee training. 'Graining must be documented by a written description of the topics covered and by a dated signature of the employees receiving the training. Annual refresher training is required. The introduction of new hazardous material or changes in procedures requires immediate retaining. Training requirements that are common to more than one of these plans only needs to be given once to satisfy all of the plans containing that requirement as long as the training addresses the concerns of each plan. * Training for the hazard Communication Plan must included the following elements: An overview of the requirements contained in the hazard Communication Regulation and the worker's rights under the Regulation. * Locations of any operations in the work area where hazardous substances are present. Location where a copy of the written Hazard Communication programs is made available to them. How to read labels and Material Safety Data Sheets (MSDS) to obtain appropriate hazard information, including physical and health effects of hazardous substances in in the work place. * How to detect the presence of or the release of hazardous substances in the work place. Emergency and first aid procedures to follow if employees are exposed to hazardous substances. CATAFRONIA ON-SITE, STATIONTRAININCI FORM Site Naine..._ ............ ... ..... . ......... Street. AdcltLSs ....................... _."_ ........... City, Zip .......... ............................. . ........... . ........ _ .......... ....... . .......... __ ... ..................... . ........... . ............ Employ= Name ( Print}.-.._:.._.-_......_ . . ................................................... ......... .... . ......... ...... . ........... ............ I acknowledge that I have received and UFUICI-Staild ellVil-01111110ital compliance training it) (lie following areas (please initial); UST System Operations 1. The types and locations of the tanks at the station Initial Date 2. For electrical monitors, daily monitoring check loci and alarm I 3. For electronic monitors, who to call in the event of a alarm . ........ Hazardous Material Management (Hazardous lVlaterial/Busines,s.Plan).___ 1. Which material at the station are hazardous 2. Where these material are stored 3. How these material are to be handle, stored, and disposed of 4. What Material Safety Data Sheets (MSDS) are and where they are kept at the station 5. Proper use of Fire Extinguishers 6. Training topic included in the HMMP, including review of MSDSs and the emergency, response plan Waste Management Procedures 1. The correct management for products in the station 2, Proper labelin2 of wastes 3. The importance of manifesting or having a receipt for all hazardous material that leave the site (store personnel store not to sign hazardous waste manifests) Spill and Leak Response (Spill Response Plan) 1. Location of spill response equipment 2. Location of spill or leak contact list, reporting procedures 3. Location of emeMency fuel shut-off switch Inventory Reconciliation 1. How to perform accurate fuel inventory control 2. Follow-up of gasoline inventory overa2e/shorta2e (variance) 3. Reportigg and maintaining inventory records and fuel defivery. receipts_____ Daily Self Inspection* y equipment at the facility I.Type and operation of vapor recover 2. How to perform daily inspection of equipment 3. Procedures for non-compliance equipment (tag out of order), complete maintenance log Record Keeping (Maintenance, monitor, testing, wastes, inspections, inventory, permits, training, etc. 1, Location where records are kept 2. Types of records maintained at the facility/ length of time each record should be kept Employee Signature _§WL _1D _'#_ Date IX5 J Designated Operator Name Certificate ## Date For facilities within 1liciuriscliction of the South Coast Air Quality Management District,'the ti-aining provided to employces must be certified by the agency. MAINTAIN THIS FORM THE ENTIRE TIME EMPLOYEE WORKS AT THE FACILITY California On-Site Training Log Site Address: Regulations require a listing of all eniployces trained for Designated Operator Requirements. Complete list and save in Safe Zone Records Box Training Records Folder (File # 4) Name: Name: Name: Name: Date: Name: -Date: Name: _Date: Name: -Date: Name: —Date: Name: -Date: Name: Date: Name: Date: Name: Date: Name: Date: Name: Date: Name: Date: Name: Date: Dame: Pate: Name: Date: 1.I'ItEV NnON The hazards present at this f'tacility are fire &. spill hazfards associated with gasoline dispensing & the sale of automotive products. The station also has a pressure- release. }hayard associated with the carbon dioxide, & a fire & pressure release hazard associated with tile propane cylinders. Gasoline dispensing is supervised by trained personnel & all above round storage of hazardous materials is stored in minimum quantities for retail sale. Most iaterials fire stored in small unbreakable contaiIlers. All underground tanks are monitored using; an (approved monit.oI' method. The product supplies' only handles the carbon dioxide during re- filling operations. The tank is fixed &. securely braced to prevent tipping. 'rrained personnel oIlly handle the propane cylinders oil an exchange basis. file product supplier, not. the station employees, performs re- filling of the cylinders. 2.MITIGATION Small incidents: For leaks & spills contain with absorbeIlt material to prevent from spreading &. Prevent tlhe release from eI1tering any storm drains oI' leaviIlg the property. Isolate the area to prevent customers from entering until the spill call be cleaned lip. For larger iIcidents: TurIh off pimps using emergency ptiilip split -ofd, call 9 -1 -1, evacuate to emergency assembly area, wait for einergenc:y personnel to respond, call the maIlager & tile. Circle K Service Contact 24 hours Center. For fires, turn off pumps, use fire extinguisheI' & call 9-1 -1 for assistance. For airborne release from the propane or carbon dioxide isolate & evacuate the area until the gas has dissipated. 3. ABATEMENT Small incidents will be haIldled with the oil -site clean -up equipment, i.e., brooms, shovel, absorbent material, mops, etc. if the incident is not small, the dealer will turn off the pumps & call 9-1 -1. Circle K Stores Inc. will assist in abating the hazard. For suspected leaks the Manager will notify the Service Contact 24 Hours Center, his District Manager & the Environmental Compliance Coordinator who will investigate the incident. If a UST leak is confirmed, then reporting will be done by Circle K. Stores Inc. which complies with UST regulations. Circle K Stores Inc. will coordinate with any contractors required to stop a release, clean up a release or dispose of materials, All materials will be disposed of in accordance with state, federal & local laws & regulations. V 01 t7t �` ca N _' to tz cn CC4 . SHOPPING CENTER PARKING LOT cn w tv � n n rn 1> m I c ° i --i p z I-,-I Q (f) N c /) n m O � ' Nrl-o� m D � CTJ w r m ' r , v o c D i c Z p m G7 i z m rn � ' m �N \\ ! O Z Q! lip I I rn m o == — =v�'X /-------------- ------- -- - -+� , -_-" - --- - - a � o p Xd�b�d� D m z c o w cyd� o�z�Z 4 z z o n _ r z � 0 Z 0 POSTAL CENTER A m > r > o m p _ m g�Z mgp D I I I I i i m °x® D oCv>�> o00 0 I I < o + v � 1 I I I = n A ti n <^.� v A r A z ,- p A p 0 o m r A 0, 0 m -n cn c to A -1 z -01 c Z C7% AA z c m N M >V Z 2 D =D =rn r DZ c m c cm T� V $° >g N= m z -i Vl D ° �° m m r °r c m rn °m m= -A_t ° cC) - m rn n ° �x I I i + z ZD 1, v r m z c m G) y D N DO rn Dm P��IZ vCip cCi) Dm m 2 m ,= N m p ,= W >m 0 Im � m z � zA �� � v � o rn rn n O p D D z Z �O �z t/� g'�r �n m Z m C *l 0 1 r '77 ul sr�� x o ITl .t7 rn p p -1 rn En K r c 'C moo .0 m m m0 WN W m rn n v x m m ,- A c --'c Z zm m z C D z A �q i O -' A v D I rn W wmoz w c Z 0 D � a° r ,- aN o n 0 p G)m C: r: r 0 z zv X° NN v 7Ct = En y z � °m ,? C) o n � �m> _ m om n o D v v c:a) v -14 `� z v v �. � m p � m z r r` Nx � Z � z .u) c z N .noy Zm y'� o�g -� z tn u> For State Use Only State of Califoraia Control Board ;..�;.��•:- �:M�:. .,-��, 5#atc; of V�/a #et• Resources Division of Financial Assistance P.O. Boa 944212 Sacrainento, CA 94244 -2120 :.,,. <``� w:,. >,.•_'- . - %'`�, (jt#Si7'11C1].OriS on reverse S1C1E) CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I am required to demonstrate Financial Responsibility in the required amounts as speci#Ied in California Code of Regulations (CCR), Title 23, Division 3, Chapter 18. Section 2807, Q 5©4,000 dollars per occurrence I million dollar's annual aggregate or AND or � I million dollars per oc »urrenca 2 trillion dollars annual aggregate _ hereiiv certifies that it is in Cosxpliance with the regiriremenfr of Section 2807, B. IName of Tank thtare, ur Capercrtor'J California Code of Regulations, 71tie 23, Division 3, Chapter 1 S, Artbcle 3, Section 2807. The mechanisms used to dernonstrafefinancial responsibility as required by Section 2807 are m follows: Meelmnism Coverage Coverage Corrective Third Party C. Mechanism Number Amamst Ptriod Action Type Name and Address of Ixsuer � Chubb Custasn ltuuraace Company Policy # F��� �� '121112012- 'YES YES 15 Mountain view Read 37.11:3%4;0 12/112013 W in -en, NJ 07054 T.f1C}4«� $t2, -. ck> COD YESINO I YESINO YESINO 1 YESINO YES /NO I YESINO Note: tfYou are using the State Fttrrd as any part tsf'your dem.nrtstration. of f:r�ancial responsibility, your amcrttion and submission of this certification also certifies that you are ir, conpliance and shall ntainlairr compliance with a(l conditions for participation in the Fund. See iris €1vCdons. Facility Address D. Facility Name Circle K Stores Inc. Facility iVaTne Facility Name See attached List Facility Address Facility Address - Date :lame and'Title of Tank Owner or OM M7 E, Si<snature oi'Ta»k Owner or Operator „ .Greg Grover-Environmental Manager Signature o tress or : iotary Date Name of Witness or Notary FILE: Original -Local Arcncy copses - Facility /sires(s) CM #16