HomeMy WebLinkAboutCUPA REPORT 2016Underground Storage Tank Program
DW Inspection Rep
Permission to Inspect:
BAKERSFIELD FIRE DEPARTMENT
Prevention Services Division
2101 H Street
Bakersfield, CA 93301
Phone: 661- 326 -3979
Fax: 661 -852 -2171
Business Name: 4010 ARCO AM /PM -15- 021 - 104152- RUBINA SALEEM
Date. 12/28/2016
Address Name: 4010 Wible Rd- CAL000344910
Inspector Name: Shane Gardner #8248557
Inspection Type: Routine
Report: Final
NVO = No Violation Observed OUT = Out of Compliance NA = Not Applicable UD = Undetermined
COS = Corrected On Site RPT = Repeat Violation
Violation
Program Requirement
d o
SOC
Comments
No
o
N
2%
z
O
z
c0i
a
Oj
File Review
Facility Tank Information
2030021
Facility has a valid Permit
Tank 1- 10000 -DW -REG
to Operate from the
Tank 2- 10000 -DW -REG
CUPA - 23 CCR 16 2712(1);
®
❑
❑
❑
❑
❑
None
Tank 3- 10000- DW -PRM
HSC 6.7 25284
Tank 4- 10000- DW -DSL
2010010
UST Operating Permit
Application for Facility
information and Tank
information
®
❑
❑
❑
❑
❑
None
submitted /maintained - 23
CCR 16 2711; HSC 6.7
25286 a
2010001
Current BOE number
submitted to the CUPA
®
❑
❑
❑
❑
❑
None
and /or CERS - HSC 6.7
25286(c)
2030011
UST compliance
statement and /or
Designated Operator
®
❑
❑
❑
❑
❑
None
current certification
submitted - 23 CCR 16
2715(a), 2715(b)
2030046
A complete and accurate
response plan has been
submitted, approved and
®
❑
❑
❑
❑
None
maintained - 23 CCR 16
2632, 2634(e), 2641(h),
2712(i)
2030041
A complete and accurate
plot plan has been
submitted, approved and
®
❑
❑
❑
❑
❑
Minor
maintained - 23 CCR 16
2632(d)(1 )(C , 2711(a)(8)
2010006
Owner /Operator has not
made false statements or
representation on any
®
❑
❑
❑
❑
❑
None
required document - HSC
6.7 25299
2010003
Owner /Operator has a
DO and /or informed the
CUPA of any change (s)
®
❑
❑
❑
❑
❑
None
within 30 days - 23 CCR
16 2715(x)
Violation[
_
_ Program Requirement
o_.:__
o
SOC
Comments
No
O
¢
o
O
ao
z
O
z
M
0
q:
0
Testing
2030002
Owner /Operator has
tested and certified leak
®
❑
❑
❑
❑
❑
None
detection equipment
annual) - 23 CCR 16 2638
2030048
Secondary containment
testing conducted every
36 months in accordance
®
❑
❑
❑
❑
❑
None
with requirements - 23
CCR 16 2637
2030055
Spill buckets have been
tested annually as
®
❑
❑
❑
❑
❑
None
required - HSC 6.7 25284.2
2010009
Secondary containment
test results submitted to
the CUPA within 30 days
®
❑
❑
❑
❑
❑
None
after the test - 23 CCR 16
2637(e)
2030064
CUPA was poperly
notified within the
prescribed number of
®
❑
❑
❑
❑
❑
None
hours prior to testing - 23
CCR 16 26370, 2638(e),
2643(8), 2644.1(a ) (4)
Install /Repair
2060009
Permits obtained to
install, replace, repair, or
®
❑
❑
❑
❑
❑
None
modify part of the UST
system - 23 CCR 16 2712
UST System Observation
General Monitoring
2030003
Leak detection system
maintains continuous
RD
monitoring that activates
®
❑
❑
❑
❑
❑
None
❑
an audible and visual
Yes
alarm - 23 CCR 16 2632,
2634, 2636, 2666
2030016
The annular space of the
tank, piping and sumps
RD
are continuously
monitored and activates
®
❑
❑
❑
❑
❑
None
❑
the alarm - 23 CCR 16
Yes
2631(8), 2632(c)(2)(A) &(B),
2633(c), 2636
2030017
Product piping outside the
UDC is fail -safe and shuts
down the pump or
®
❑
❑
❑
❑
❑
None
restricts flow - 23 CCR 16
2636(1) (5)
2030018
Turbine sump monitor
RD
activates an audible and
visual alarm or stops the
®
❑
❑
❑
❑
❑
None
❑
flow of at the dispenser -
Yes
23 CCR 16 2636(1)(1)
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
m o
SOC
Comments
No
M
4
0
O
a
a"o
Z
O
z
M
U
W
�>
2030019
Monitoring system in the
UDCs activates an
audible and visual alarm
Z
❑
❑
❑
❑
❑
None
or stops the flow at the
UDC -23 CCR 16
2636 (0(1)
2030043
Leak detection equipment
RD
properly programmed or
properly operated - 23
Z
❑
❑
❑
❑
❑
None
❑
CCR 16 2632, 2634, 2636,
Yes
2666
2060005
System constructed with
a monitoring system
capable of detecting entry
®
❑
❑
❑
❑
❑
None
into secondary
containment - HSC 6.7
25291(b)
2060014
Correct leak detection
equipment installed for
RD
the type of system
®
❑
❑
❑
❑
❑
None
❑
present - 23 CCR 16 2638,
Yes
HSC 6.7 25290.1, 25290.2,
25291
2060015
Sensor located in the
RD
proper position /location -
®
❑
❑
❑
❑
❑
None
❑
23 CCR 16 2630(d), 2641(a)
Yes
2030062
Facility is in compliance
RD
with not tampering with or
disabling leak detection
®
❑
❑
❑
❑
❑
None
❑
devices or alarms - HSC
Yes
6.7 25299 a 9
2060022
System constructed with
a monitoring system
capable of detecting entry
®
❑
❑
❑
❑
❑
None
into secondary
containment - HSC 6.7
25290.2(d)
2030034
Tag /sticker on affixed
monitoring equipment
being certified, repaired,
®
❑
❑
❑
❑
❑
None
or replaced - 23 CCR 16
2638(
VPH Monitoring VPH
2030065
Interstitial monitoring of
RD
the annular spaces of the
UST is properly
❑
❑
®
❑
❑
❑
None
❑
maintained - HSC 6.7
Yes
25290.1 e
2060023
System constructed with
a monitoring system
capable of detecting entry
into secondary
❑
❑
®
❑
❑
❑
None
containment - HSC 6.7
25290.1(d)
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
d o
SOC
Comments
No
p
=
a
o
Cl)
go
M
~ .
a
Z
O
z
Line Leak Detector
2060012
Line leak detector
installed on pressurized
RD
piping system - HSC 6.7
0
❑
❑
❑
❑
❑
None
❑
25290.1(h), 25290.2(8),
Yes
25291(1), 25292(e),
26360 (2)
2030026
Line leak detectors detect
a 3 gph leak and /or
RD
audible and visual alarm
®
❑
❑
❑
❑
❑
None
❑
function properly - 23
Yes
CCR 16 26360(6),
2666(c)
2030027
Turbine shuts down when
a leak is detected or
RD
when line leak detector is
❑
❑
®
❑
❑
❑
None
❑
disconnected - 23 CCR 16
Yes
2666 c
2030025
Pressurized piping able to
detect a 3.0 gph leak
RD
within an hour, and
®
❑
❑
❑
❑
❑
None
❑
restricts the flow or
Yes
alarms - 23 CCR 16
2636(1)(2)
Secondary Containment
2060010
UST storing a hazardous
RD
substance has secondary
®
❑
❑
❑
❑
❑
None
❑
containment - HSC 6.7
Yes
25292
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
40 ).0
SOC -
Comments
No
O
=
Q
p
O
CL
as
o
Z
O
z
p
V
p>
2030008
UDC, sumps, and /or
other secondary
containment in good
®
❑
❑
❑
❑
❑
None
condition and /or are free
of debris /liquid - HSC 6.7
25290.1, 25290.2, 25291
2030040
Secondarily contained
RD
piping maintained to allow
®
❑
❑
❑
❑
❑
None
❑
liquid to drain into sump -
Yes
23 CCR 16 2630(d), 2641(a
2060006
Secondary containment
piping slopes back to the
®
❑
❑
❑
❑
❑
None
collection sump - 23 CCR
16 263(c
2030047
Secondary containment
maintained tight and has
been confirmed by testing
®
❑
❑
❑
❑
❑
None
- 23 CCR 16 2662; HSC 6.7
25290.1(c)(2), 25290.2(c)(2),
25291(a), 25292 e
2030060
Entry fittings in secondary
containment for UST
system maintained
®
❑
❑
❑
❑
❑
None
tight/sealed - 23 CCR 16
2630, 2635(d), 2636(c),
2666
2060020
Spill bucket is installed
RP
and has a functional drain
valve or other means to
®
❑
❑
❑
❑
❑
None
❑
remove liquid - 23 CCR 16
Yes
2635(b), 2665
2030054
Spill bucket maintained in
RP
good condition and free of
®
❑
❑
❑
❑
❑
None
❑
debris and /or liquid - 23
Yes
CCR 16 2635(b), 2715(c)(2)
2060019
Spill bucket to has a
minimum capacity of five
®
❑
❑
❑
❑
❑
None
gallons - 23 CCR 16
2635(b), 2665
Overfill
2030035
UST system is operated
RP
to prevent unauthorized
release, including spills
®
❑
❑
❑
❑
❑
None
F1
and overfills - HSC 6.7
Yes
25292.1 a
2030036
Overfill prevention system
RP
has not been overridden
and meets overfill
®
❑
❑
❑
❑
❑
None
❑
requirements - 23 CCR 16
Yes
2635(b)(2), 2665
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
d0 ).0
SOC
Comments
No
p
D
¢
o
O
ao
z
O
z
v
o
On Site
Records
Certifications
2030023
Required designated
operators or contractors
maintain a proper and
®
❑
❑
❑
❑
❑
None
current ICC certification -
23 CCR 16 2715
2030024
Service technician,
installer, and/ or
employee maintain a
®
❑
❑
❑
❑
❑
None
proper license - 23 CCR
162715
2030031
Employee or contractor
obtained and maintained
proper manufacturer
®
❑
❑
❑
❑
❑
None
certification - 23 CCR 16
2715
2010007
Submit/maintain current
Certificate of Financial
Responsibility /mechanism
of financial assurance -
®
❑
❑
❑
❑
(�
None
23 CCR 16 2711; 23 CCR
18 2808.1, 2809 - 2809.2,
HSC 6.7 25292.2; HSC
6.75 25299.30- 25299.34
Designated Operator
2010004
Copies of DO inspections
for last 12 months and list
of trained employees
®
❑
❑
❑
❑
❑
None
maintained - 23 CCR 16
2715
2030013
Designated operator
properly conducted the
monthly inspection and
❑
❑
❑
❑
❑
None
the reports are complete -
23 CCR 16 2715
2030010
DO notified operator of
any condition observed
during the monthly
®
❑
❑
❑
❑
❑
None
inspection that may
require action - 23 CCR 16
2715(d)
2030012
DO employee training
performed, current for at
least one employee on
®
❑
❑
❑
❑
❑
None
site, and a log kept - 23
CCR 16 2715(c)(6), 27150
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
° o
SOC
Comments
No
p
_
a
o
0
a
�c
Z
O
z
M
y
oc
o
Logs
2030001
Leak detection alarm
logs, maintenance and
RD
records of appropriate
®
❑
❑
❑
❑
❑
None
❑
follow -up actions
Yes
maintained - 23 CCR 16
2632, 2634, 2712(b)
Maintenance/Tests
2010008
Monitoring, maintenance,
repairs, linings, and
RD
upgrade records
®
❑
❑
❑
❑
❑
None
❑
maintained for the proper
Yes
time period - 23 CCR 16
2712(b)
Documentation
2030033
Failure to maintain on site
an approved monitoring
®
❑
❑
❑
❑
❑
None
plan - 23 CCR 16 2632,
2634, 2711, 2712(1)
2030037
Written agreement
between the tank owner
and tank operator to
monitor the tank system
®
❑
❑
❑
❑
❑
None
is maintained - 23 CCR 16
2620(b); HSC 6.7
25284 (a) (3)
2030061
Suspected or actual
RD
unauthorized release
reported in appropriate
❑
❑
Z
❑
❑
❑
None
❑
time frame - HSC 6.7
Yes
29294, 29295
1
1
1
1
1
1
1
General Operating Requirements
Permit Condition /Approval
2030039
Compliance with all
operating permit
®
❑
❑
❑
❑
❑
None
conditions - 23 CCR 16
2712; HSC 6.7 25299
2030059
UST system maintained
in accordance with
exclusion /exemption
®
❑
❑
❑
❑
❑
None
status - HSC 6.7 25281.6,
25283.5
2030014
Owner /Operator received
approval and has
implemented a training
❑
❑
®
❑
❑
❑
None
program at an unstaffed
facility - 23 CCR 16
2715(0(2
2030015
Facility exhibited that the
method used to monitor
the tank meets the
monitoring methods in
❑
❑
❑
❑
❑
None
2643(f - 23 CCR 16 2643
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
° o
SOC
Comments
No
Q
o
O
a
ago
z
O
z
M
0
W
�j
Red Tag
2030045
Red Tag information is
legible and has not been
❑
❑
®
❑
❑
❑
None
tampered with - 23 CCR
16 2 717. 1
2030044
Facility did not allow for
deposit of petroleum into
a UST that has a red tag
❑
❑
®
❑
❑
❑
None
affixed to the fill - 23 CCR
162717.1(0
Install /Repair
2060024
UST system is made of or
lined with materials that
are compatible with the
E
❑
❑
❑
❑
❑
None
substance stored - 23
CCR 16 2631.1
2060021
Striker plate installed and
positioned correctly - 23
®
❑
❑
❑
❑
❑
None
CCR 16 2631(c), 2662 d
® There were no violations noted for this inspection.
❑This report shall serve as a "NOTICE TO COMPLY" for Minor Violations, and a "NOTICE OF VIOLATION" for
Major violations. You are, hereby, ordered to correct the above noted violations within 30 days, or according to
correction summaries provided. Formal enforcement and/or penalty assessment may be initiated for any
violations noted, and for those not corrected in a timely manner. (NOTE: If this is a preliminary report, a final report
will follow.)
Inspectors Signature: �� `--° Date: 1 Z. zz__ ' t /
P 9
Inspector: Enter # of Violations: RD: <Q—� RP:
Check one box for facility Significant Operational Status (SOC) to be reported to SWRCB and US EPA:
HOC with both Release Detection and Release Detection (Facility has no Release Prevention and no Release
Prevention Violations)
❑ Not in SOC (Facility has both Release Prevention and Release Detection Violations).
❑SOC with Release Detection only (Facility has no Release Detection violations but one or more Release Prevention
violations)
❑ SOC with Release Prevention only (Facility has no Release Prevention violations but one or more Release Detection
violations)
Underground Storage Tank Program - DW Inspection Report v 2.0
FACILITY NA
INSPECTION DATE
INSPECTION TIME
rr
V Iz r
"
COMMENT
ADDRESS
PHONE NO.
NO OF EMPLOYEES
APPROPRIATE PERMIT ON HAND (BMC:15.65.080)
FACILITY CONTACT
BUSINESS ID NUMBER
/ yy
onsent-to,hispect Na e/Title
�.. t
fi
„ •� :.
.YV:e%:. ..44,. ..: .✓2 �v,'..v. .0 .�. .. ! .., :.,< f.t . t .r ..... .. ,4.. .� ... .. ,,. ...- .
�..
"Ilk
r. .... ... - pfiMi ,w::,r � ,....F., -.. .,. ;. ...x ... �.. < .�h b: 3 � T �, .. •'> .. -.. <.
. ?N: c . -,. �..v � .-5.. .?Fr Y<•
.,..;v.
_. .3 .,. r' .. ;r.. .. >. .,... f. .. :��.,.. lt. �; ,�: ... Y•s,.- .;.,... SM:... �{ 2.. i n .y .,.. .�.°�.. -:..
.�, r .: .... 7 f..., :.., :. rc. , .s ., :,s -.,, rx .� ,. `ic .. ,. ,a.. > .• xr.•�iteY. .a., ,.. ,. . >, '�.± �_�.,� :.�. t . "N• � 3.. A^,.,.. �s
es..as .... .;... e.. sx -:. .:.....,. �..�r ;s. ,:...4 ,. M�`. w.. ,.,. :r. ,z,<e. :. ..- �, n..5,. �°t .... f. M : fi'ux� xi ^'tia: F. :•� � � ?�
.. : s .� : � ..� . < <. �, - , ;.;u ,. .. � ,. r - >.� :'� . "' >., �` s >•. ,> .: ,
n
�
�Invento Pro• .rare , <. .�µ � � .�
>�SeGt o
:.,. .v �%.< '',;. . 9 .v?3�^,t. -,. k 4�.w..w. r F v v ...... ,t,.... r s ,: .. , . fi... S :. + ,,.... . f .•:.., .. d <,:, -. .::. .. �- , . •. f.:. 3`. G 2.: g i a 't
. t��z«k ,.s�..4i'Sre�_.x..rrs:za4'3�'x,: .�:53,;r.,�f s.w»�•S,r ��h;a..n ��FO?s.', pa :,ts�..f.,�S::zk�, >�r;:y,hhx > >m �aS..au..r.E�.,;':ur..s�',. x::,.,'£?a;?a >s.,.a•� <. A.. ve;:"* �... ��:,< az�; rf..; h. ua. vR. x: .�r��..�#e.JR,.�e^..:,<`�.f,Y`2 ? i.. z: w.. .,wsvcw....:,,a:.,.am.sib,.:K�, Fmk., s' �. �', S< �. ys�. �^ �i:, .,.f- ._]�.',a.�.v...L:.�wz�,z>. €e. . "on. 'c�.�i.
❑ ROUTINE COMBINED- ❑ JOINTAGENCY ❑ MULTI- AGENCY ❑ COMPLAINT ❑ RE- INSPECTION
C V G=Gompfiance OPERATION
CERS
V =violation; 1,11 Minor
Violation
COMMENT
APPROPRIATE PERMIT ON HAND (BMC:15.65.080)
3010001
BUSINESS PLAN CONTACT INFORMATION ACCURATE (CCR: 2729.1)
1010008
VISIBLE ADDRESS (CFC: 505.1, BMC:15.52.020)
CORRECT OCCUPANCY (CBC: 401)
VERIFICATION OF INVENTORY MATERIALS (CCR: 2729.3)
1010004
VERIFICATION OF QUANTITIES (CCR: 2729.4)
, 1010006
VERIFICATION OF LOCATION (CCR: 2729.2)
PROPER SEGREGATION OF MATERIAL (CFC: 2704.1)
VERIFICATION OF SDS AVAILABILITY (CCR: 2729.2(3)(b))
VERIFICATION OF HAZ MAT TRAINING (CCR: 2732)
1020002
VERIFICATION OF ABATEMENT SUPPLIES & PROCEDURES (CCR: 2731(c))
EMERGENCY PROCEDURES ADEQUATE (CCR: 2731)
1010010
CONTAINERS PROPERLY LABELED (CCR: 66262.34(f), CFC: 2703.5)
3030007
HOUSEKEEPING (CFC: 304.1)
FIRE PROTECTION (CFC: 903 & 906)
3030032
SITE DIAGRAM ADEQUATE & ON HAND (CCR: 2729.2)
1010005
ANY HAZARDOUS WASTE ON SITE? 9YES ❑ NO
Siena tureof
Explain:
j
Inspector: /- /,4,eVe7 P.
POST INSPECTION INSTRUCTIONS:
• Correct the violation(s) noted above by
• Within 5 days of correcting all of the violations, sign and return a copy of this page to: Signature (that all violations have been corrected as noted)
Bakersfield Fire Dept., Prevention Services, 2101 H Street, Calif6mJa ;93301,,
Date -
White— Business Copy Yellow Station Copy Pink — Prevention Services FD2155 (Rev 8H14)
HAZARDOUS WASTE BAKERSFIELD FIRE DEPARTMENT
UNIFIED PROGRAM CONSOLIDATED FORMS, Prevention Services
a >e n 's F[ D 2101 H Street
SMALL QUANTITY HAZARDOUS Flip Bakersfield.. CA 93301
WASTE GENERATOR INSPECTION A&rm "` Phone: 661- 326 -3979 • Fax: 661 - 852 -2171
f
Facility Name: 4/0 r9 r<� C C3 Date: 17—
Site Address I c t�Aj / A'/— T Time In: Time Out:
Owner /Operator: P, u R, / �4 'e— Phone: EPA ID # 0 0" � `c/ 9/6
Type of Inspection
D Routine D Re- inspection /Follow -up ,,'"Combined Routin spection d oiptJnst ection D Complaint D Focused D Other
CONSENT TO INSPECT GRANTED BY (Name / Title):
Inspection may involve obtaining photographs, review and copying of records, afid, determination of compliance with hazardous waste handling requirements.
17 - nt....., 1 TY -- 1k.1: ---
C
V I
- - - -- -
HAZARDOUS WASTE REQUIREMENT
N/A
CERS
Violation #
COMMENTS
Recordkee in documentation
Generator has an EPA ID number . [HSC 25143.131
3010002
Hazardous waste determination made for all wastes
D Anal sis %Generator Knowledge [CCR 66262.40]
303,0005
X
Contingency lan information pos ted near phone [CCR 66262.34(d)(2)]
3010022
Facility personnel demonstrate trainin awareness [CCR 66262.34(4)(2)]
3020001
Manifests/Consolidated Manifest receipts complete [CCR 66262.23(a)]
3010008
Blue co (s) of manifest mailed to DTSC [CCR 66262.23(a)(4)]
3010011
Bills of Lading/receipts available [CCR 66262.40(a)]
3010010
LDRs available and complete [CCR 66268.7 (a) ].
3030006
Onsite recycling reported using UPCF HSC 25143.101
3030001
Container /tank management
Containers are in good condition CCR 66262.34(d)(2)]
3030013
Containers are closed except when addin rernovin [CCR66262.34(d )(2)]
3030017
Satellite containers at or near point of generation [CCR 66262.34(e) 1 A)]
Empty containers are .empty [CCR 66262.34(l)]
3030007
Containers inspected weekly [CCR 66262.34(4)(2)
3030019
Tanks inspected daily CCR 66262.34 d 2 , 40CFR 265.201
3030027
One container per waste stream at satellite area CCR 66262.342(2)]
3030022
Exclude recyclable materials stored in accordance with local
ordinance/hazardous materials codes HSC 25143.101
3010016
Accumulation Time Limits
Waste is accumulated not more than 90(" 8 )270 CCR 66262.34(d)]
3030010
Empty containers managed within one year CCR 66262.34(4)]
3030010
Universal waste accumulated less than one ye ar [CCR 66273.15(a)]
3030011
Used oil filters offsite within 180(1 year <1 ton) [CCR 66266,130(c)(4)]
3030004
Pb -acid batteries offsite within 180 (1 yr. < 1 ton) [CCR66266.81(a)(3)]
3030002
Labeling/Marking
Containers are properly labeled [66262.34(f)]
3030007
Excluded recyclable materials marked properly [HSC 25143.9(a)]
3050005
Universal .waste container properly labeled (CCR 66273.341
3030008
Used oil filters marked "drained used oil filters" [CCR 66266.1301
3030004
Date written on spent lead -acid batteries [CCR 66266.8 1 (a)(6)(B)]
3030003
"Used Oil" marked on all used oil tanks /containers CCR 66279.21
3030007
Tank marked with "haz waste" , contents, start date (66262.34(D]
3030007
Treatment Transport and Disposal/Other
Have permit/authorization to do treatment [HSC 25136.21
3040003
Waste sent with authorized transport (gen. eli ible) [CCR 66263.411
3050001
Waste disposed of to authorized point/ party [HSC 25189.5(a)]
3050002
Failed to properly handle appliance wastes CHSC 25212 a
Fire Protection [66262.34(d)(2)]
3030032
Print and sign in this box for receipt of this report. Signature does not imply agreement with findings only, receipt of report.
INSPECTOR»
POST INSPECTION INSTRUCTIONS:
• Correct the violation(s) noted above by
0 Within 5 days of correcting all of the violations, sign and return a copy of this page to:
Bakersfield Fire Dept., Prevention Services, 2101 H St. Bakersfield, CA 93301
White Business Copy Yellow- Station. Copy
Signature (that all violations have been corrected as noted)
Date
FD2171 (Rev 9/14)
Pink - Prevention Services Copy
tk
tt