HomeMy WebLinkAbout 23 STREET APPLICATION 2009UNDERGROUND STORAGE TANKS K BAKERSFIELD FIRE DEPT.
UNIFIED PROGRAM CONSOLIDATED FORMS k Prevention Services
B 1501 TCUxtun Ave., I" Fl or
L I ® M ,
Bakersfield, CA 93301
I Tel.: (661) 326 -3979
TANK - (STATE FORM B)
LOCATION WITHIN SITE (Optional) 431
Fax: (661) 852 -2171
I,TANK% -L
TANK ID NO S dGO ovv3 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes No
C7 /s a07- IIf n0 P O O Z If 'Yee, complete one page for each compartment. V0
o a e
Page 1 of 4
TYPE OF ACTION (Checkone Rem onty): T. NEW SITE PERMIT 4. AMENDED PERMIT 5. CHANGE OF INFORMATION
2. INTERIM PERMIT Specify reason - for local use only) 6. TEMPORARY SITE CLOSURE
3. RENEWAL PERMIT
rE 431 PETROLEUM TYPE 2 LEADED Q 99. OTHER J 44
7. PERMANENTLY CLOSED ON SITE
Irmarkeq complete Petroleum Type)
2. N014-FUEL PETROLEUM
4. GASOHOL440
v0 tb. PREMIUM UNLEADED 5. JET FUEL
3. CHEMICAL PRODUCT
B. TANK REMOVED 430
BUSINESS NAME (Sameas FACILITYNAMEorDBA -Doirp Business As) J FACIL(tY pt. 4(3rJ3{
LOCATION WITHIN SITE (Optional) 431
s ry S.Jw ,jg r - -'li L`r'. .T-IJ' (:,'-s•9 .l z. ,. -a.. ;.._.. ... ... ..
DESCRIPTION'r.;+. I,TANK% -L
TANK ID NO S dGO ovv3 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes No
C7 /s a07- IIf n0 P O O Z If 'Yee, complete one page for each compartment. V0
o a e
DATE INSTALLED (YEARIMO) 439 TANK CAPACITY IN GALLONS e ik rg+a N .r rv13 NUMBEROF COMPARTMENTS 3 fi1r
4311ADDITIONALDESCRIPTION (Forbcal useonly)
pp.. .t ti::.y -r° %t : i' -P-,4 - Ko ,• " a+ '• ,.`i.: lb 1'b'W,' `-:._ .[3 _ is 7y1( h.; 7l.' f-i! .a .,.,- 0 -W' ' .. , iri:(+rt°C -,N4/ H.ff.• ' iTF Y: "Y1 .?" {! R fMr„"y ,aK`'Y ^dr:1y .r* `Lairy .. Y a :» _. uit' F'F. i.:^ +«5y14 5z^3• M `is:?: 'S `C viif•frn CYAlikU?7. S+'d I . 151tCt5'C' i'1 %f - fl+".S. n e h . Y' , r r.;r?I:YS, rx,;tl TANK /CONTENTS'= _.a_
rE 431 PETROLEUM TYPE 2 LEADED Q 99. OTHER J 44
W4
1, MOTOR VEHICLE FUEL 3. DIESEL n S 14 - S-_.2XKIa. REGULAR UNLEADEDIrmarkeqcompletePetroleumType)
2. N014-FUEL PETROLEUM
4. GASOHOL440
v0 tb. PREMIUM UNLEADED 5. JET FUEL
3. CHEMICAL PRODUCT 1c. MIDGRADE UNLEADED 6, AVIATION FUEL
4. HAZARDOUSWASTE (Includes Used Oil)
5. UNKNOWN
COMMON NAME (hom HazardousMaterials Inventory page) 441 CAS NO. (boar HazardousMaterials Inventorypage) 44
t706 • 61 -
5`i tea; w' :,...III.:tANKT.CONS1Rt1G7ION.
TYPE OF TANK 1. SINGLEWALL C3 4. SINGLE WALL IN A VAULT 99. OTHER *
1
Checkone damDory) . DOUBLE WALL 5. SINGLE WALL WITH INTERNAL BLADDERSYSTEM
3. SINGLEWALLWITH EXTERIORMEMBRANE LINER 95. UNKNOWN
TANK MATERIAL-Primarytank 1. BARE STEEL 134. STEELCLAD WrFIBERGLASS 98. OTHERClockckonegavelorlyl1:1 2 STAINLESS STEEL REINFORCEDPIASTICoRP)
9&3. FIBERGLASS/ PLASTIC 05. CONCRETE
136. FRP COMPATIBLE W /100% METHANOL
95. UNKNOWN
TANK MATERIAL-Secondarytank 44
1. BARE STEEL 4. STEEL CLADWIFl 10. COATEDSTEELC onegam Y) rICIRP) 2. STAINLESSSTEEL RE1NFDf1CFDPLfISfIC '1 95. UNKNOWN
99. OTHERFIBERGLASSIPLASTIC5. CONCRETE
B. FRP COMPATIBLEW1100% METHANOL
9. FRP NON-CORRODIBLE JACKET
TANK INTERIORLINING 1. RUBBER LINES 134. PHENOLIC LINING 99. OTHERORCOATING2, ALKYDLINING 5. GLASS LINING Q(JCfkonegemY) DATE INSTALLED •3 ^ •' /O 2 44
3. EPDXY LINING B UNLINED
NKNOWN (Forbcal use A*)
OTHER CORROSION
448
PROTECTION IFAPPLICABLE 1. MANUFACTURED CATHODIC PROTECTION 4. PIMPRESSEDCURRENT QQ 44
ATE INSTALLED
Checkonegem only) 2. SACRIFICIAL ANODE 121x. UNKNOWN For boaluseonly! 3. FIBERGLASS REINFORCED PLASTIC 99. OTHER
SPILLANDOVERFILL 1 SPILLCONTAINMENT YEAR INSTALLED 450
that
TYPE (ihrbcaluseonly) 451 2YESPePROTECTION EQUIPMENT YEAR INSTALLED 452
Check all appty) 1 DROP TUBE ALARM
3. STRIKER PLATE 2. FILLTUBE SHUTOFF VALVE
M 4. EVRUPGRADE 3. SALL FLOAT
4. EXEMPT
5
r " rY` 34,J` ' i` -tlr + 3i'`s 1",hi'.i 4'st "i t+,. ' {J3 r'+n. i C't¢ • ,-+F h7 K '$R'"x+ f.
IF SINGLEWALL TANK (Checkag thatapply): 453 IF DOUBLE WALLTANK OR TANKWITH BLADDER (Cfnck onegem only): 45d
1. VISUAL (EXPOSEDPORTION ONLY) 5. MANUALTANKGAUGING (MTG) 1. VISUAL (SINGLEWALLINVAULT ONLY)
2. AUTOMATIC TANKGAUGING (ATG) 8. VADOSE ZONE 2. CONTINUOUS INTERSTITIALMONITORING
3. CONTINUOUS ATG 7. GROUNDWATER 3. MANUAL MONITORING
4. STATISTICALINVENTORY RECONCILIATION (SIR) * 8. TANKTESTING
BIENNIAL TANK TESTING ( 99. OTHER
trW"A ;401, l CLOSURE IN;P'WLACE ANKGLOSURE INFORMATION PERMANENT
ESTIMATED DATE LAST USEDOnMO/DAY) 455 458 TANK FILLEDWITHINERTMATERIAL? 45EITIMATEDIIUANTIrYOI:SLIISTANCaREMAININI
gallons- Yes No
FD 2094 (Ra{r.o91o8)
UNDERGROUND STORAGE TANKS
3TANK (STATE FORM B) <<!
INSTRUCTIONS
BAKERSFIELD FIRE DEPT.
Prevention Servicesf411141
n 1501 Truxtun Ave., lst Floor
Bakersfield, CA 93301
T Tel.: (661) 326 -3979
Fax: (661) 852 -2171
Page 2 of4
Complete the UST -Tank pages for each tank for all new
permits, permit changes, closures and /or any other tank
information change. This page must be submitted within 30
days of permit or facility information changes, unless approval is
required before making any changes. For compartmentalized
tanks, each compartment is considered a separate tank and
requires completion of separate tank pages.
Refer to 23 CCR 32711 for state UST information and permit
application requirements.
Note: the numbering of the instructions follows the data
element numbers that are on the UPCF pages. These data
element numbers are used for electronic submission and are the
same as the numbering used in 27 CM Appendix C, the Business
Section of the Unified Program Data Dictionary.)
Please number all pages of your submittal. This helps your
CUPA or local agency identify whether the submittal is complete
and if any pages are separated.
1. FACILITY ID NUMBER -Leave this blank. This number is
assigned by the CUPA. This is the unique number which
identifies your facility.
3. BUSINESS NAME -Enter the full legal name ofthe business.
430. TYPE OF ACTION -Check the reason the page is being
completed. For amended permits and change of information,
include a short statement to direct the inspector to the amendment
or changed Information.
431. LOCATION WITHIN SITE -Enter the location of the tank
within the site.
432. TANK ID NUMBER -Enter the owner(s) tank ID number.
This is a unique number used to Identify the tank. It may be
assigned by the owner or by the CUPA.
433. TANK MANUFACTURER -Enter the name of the
company that manufactured the tank.
434. COMPARTMENTALIZED TANK -Check whether or not
the tank is compartmentalized. Each compartment is
considered a separate tank and requires the completion of
separate tank pages.
435. DATE TANK INSTALLED -Enter the year and month the
tank was installed.
436. TAW CAPACITY -Enter the tank capacity in gallons.
437. NUMBER OF TANK COMPARTMENTS -If the tank is
compartmentalized, enter the number of compartments.
438. ADDITIONAL DESCRIPTION -Use this space for
additional tank or location description.
439. TANK USE- Check the substance stored. If MOTOR
VEHICLE FUEL, check box 1 and complete Rem 440,
PETROLEUM TYPE.
440. PETROLEUM TYPE -If box 1 is checked in Rem 439,
check the type of fuel.
441. COMMON NAME -For substances that are not motor
vehicle fuels (box 1 is NOT checked in item 439), enter the
common name of the substance stored in the tank.
442. CAS No. -For substances that are not motor vehicle fuels
box I Is NOT checked in item 439), enter the CAS (Chemical
Abstract Service) number. This is the same as the CAS No. In
item 209 on the Hazardous Materials Inventory- Chemical
Description page.
443. TYPE OF TANK -Check the type of tank construction. If
type of tank is not listed, check other and enter type.
444. TAW MATERIAL (PRIMARY TANK) -Check the
construction material of the tank that comes into immediate
contact on its inner surface with the hazardous substance being
contained. If the tank is lined do not re the lining material in this
Rem. Indicate the type of lining material in item 446. If type of
tank material is not fisted, check r other and enter material.
445. TANK MATERIAL (SECONDARY TANK) -Check the
construction material of the tank that provides the level of
containment external to, and separate from, the primary
containment. If type of tank material is not listed, check other
and enter material.
446. TANK INTERIOR LINING OR COATING -If applicable,
check the construction material of the interior lining or coating of
the tank. If type of Interior fining or coating is not listed, check
other and enter type.
447. DATE TANK INTERIOR LINING INSTALLED -If
applicable,, enter the date the tank interior lining was installed.
This is to assist the CUPA to develop an Inspection schedule.
448. OTHER TANK CORROSION PROTECTION -If
applicable, check the other tank corrosion protection method
used. If other corrosion protection method is not listed, check
other and enter method.
449. DATE TANK CORROSION PROTECTION INSTALLED -
If applicable, enter the date the tank corrosion protection
method was installed. This is to assist the CUPA to develop an
inspection schedule.
450. YEAR SPILL AND OVERFILL INSTALLED -Check the
appropriate box and enter the year in which spill containment,
drop tube, and /or striker plate was installed. CHECK ALL
THAT APPLY.
451. TYPE OF SPILL PROTECTION -Enter the type of spill
containment, drop tube, and /or striker plate. FOR CUPA USE
ONLY.
452. YEAR OVERFILL PROTECTION EQUIPMENT
INSTALLED -Check the appropriate box and enter the year in
which overfill protection was installed or whether there is an
exemption from overfill protection. CHECK ALL THAT APPLY,
unless tank is exempt.
453. TANK LEAK DETECTION (SINGLE WALL)-For single
walled tanks, check the leak detection system(s) used to comply
with the monitoring requirements for the tank. CHECK ALL
THAT APPLY. If leak detection system is not listed, check
other and enter system. .
454. TANK LEAK DETECTION (DOUBLE WALL) -For double
walled tanks or tanks with bladder, check the leak detection
system(s) used to comply with the monitoring requirements for
the tank. CHECK ONE ITEM ONLY.
455. ESTIMATED DATE LAST USED -For closure in place,
enter to date the tank was last used.
456. ESTIMATED QUANTITY OF SUBSTANCE REMAINING
IN TANK -For closure in place, enter the estimated quantity of
hazardous substance remaining in the tank (in gallons).
457. TANK FILLED WITH INERT MATERIAL -For closure in
place, check whether or not the tank was filled with an inert
material prior to closure.
ATTACHMENTS 1. Provide a scaled plot plan with the location
of the LIST system, including buildings and landmarks. 2.
Provide a description of the monitoring program. USTTank
Page 2
Note: the numbering of the instructions follows the data
element numbers that are on the UPCF pages. These data
element numbers are used for electronic submission and are the
same as the numbering used in 27 CCR, Appendix C, the
Business Section of the Unified Program Data Dictionary.)
Please number all pages of your submittal. This helps your
CUPA or local agency identify whether the submittal is complete
and if any pages are separated.
FD 2094 (raev.mos)
UNDERGROUND STORAGE TANKS
TANK — APPLICATION (CONT.D) (STATE FORM B)
Page 3 of 4
f h5.- S;((k...i Y..°"-lw f k f 2 ^T i f'T 4'F .avr Y', 7 tt:..:.r L.1 uYC. .}f YY _.A
iVl
b4 L$r ?ji .s'}..t,ylsk y Y+'d- :'7 1i iY .1:f >L,35 -fi I2 ICY ..4 JaC lFfr' VI 'PIPING`CONS'IRUCTION }' Check;Eall that a I. { x,,kx`'
ABOVEGROUND PIPING INFORMATION UNDERGROUND PIPING INFORMATION
SYSTEM TYPE G 1 SUCTION G 2 PRESSURE c 3 GRAVITY 459 c 1 SUCTION G 2 PRESSURE G3GRAVITY 458
G 1 SINGLE WALL G 95 UNKNOWN G 1 SINGLE WALL c 3 LINED TRENCH G 99 OTHER
CONSTRUCTION G 2 DOUBLE WALL G 99OTHER 462 G2 DOUBLEWALL G 95UNKNOWN 460
MANUFACTURER 463 MANUFACTURER 461
MATERIALS G 1 BARE STEEL G 6FRP COMPATIBLEWI 100% METHANOL G 1 BARE STEEL G6FRP COMPATIBLEWI 10D% METHANOL
AND G2STAINLESS STEEL G7GALVANIZED STEEL G2 STAINLESSSTEEL G7 GALVANIZED STEEL
CORROSION G3PVC COMPATIBLE WITH CONTENTS G 8 FLEXIBLE G3 PVCCOMPATIBLEWITHCONTENTS GB FLEXIBLE
PROTECTION G4FIBERGLASS G 9 CATHODIC PROTECTION G4 FIBERGLASS G 9 CATHODIC
G5STEELWI COATING G95 UNKNOWN c 5 STEELWICOATING G95 UNKNOWN PROTECTION
G99 OTHER 465 G 99 OTHER 464
Y' Y ,(S 1 'F .Sws. $- -..TX Y FY..:. 3 k f - -. #fin '
Yn'^
r4 -'
at.aih,tF>' VII:'YPIPING. LEAK' DETECTION Chck.all tl PONY, ,irL v: .5N
ABOVEGROUND PIPING INFORMATION t UNDERGROUND PIPING INFORMATION
SINGLEWALL PIPING SINGLEWALL PIPING
467 488
PRE'qt)Rt7FDPIPIN • (Checkall that apply): PRESSURIZED PIPIN • (Cheek all that apply):
G 1 ELECTRONIC LINE LEAK DETECTOR 3.0GPH TESTMW AUTO PUMPSHUT OFF FOR LEAK, G1 ELECTRONIC LINE LEAKDETECTOR 3.0GPH TEST1011T1i AUTO PUMP SHUT OFF FOR LEAK.
SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUALALARMS SYSTEM FAILURE, AND SYSTEM DISCONNECTION +AUDIBLEAND VISUALALARMS
G 2 MONTHLY 02 GPH TEST
G2 MONTHLY 0.2 GPH TEST
c3 ANNUAL INTEGRITY TEST (G.I GPM) G3 ANNUAL INTEGRITY TEST (0.1 GPH)
G 4 DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: (Checkallthat apply):
CONVENTIONAL SUCTIONSYSTEMS: (Check all that app$yx G4 DAILYVISUAL MONITORING OF PUMPING SYSTEM+ TRIENNIALPIPING INTEGRITY
TEST (0.1 GPH)
G 5 DAILYVISUAL MONITORING OF PUMPING SYSTEM
TRIENNIAL INTEGRITYTEST (0.1 GPH) SAP SUCTION SYST c: (Check all that apply)
c8 G5 SELF MONITORING
SAFE SUCTION SYST Mc. (Check all that apply)
SELF MONITORING GRAVITY FLOW: (Check all that apply):
G 7
G6 BIENNIAL INTEGRITY TEST (0.1 GPH)
GRAVITY FLOW : (Check all thatapply):
GB DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING
G9 BIENNIAL INTEGRITY TEST (O.i GPH) PRESSURIZED PIPING: (Check all thatapply)
SECONDARILY CONTAINED PIPING G7 CONTINUOUS TURBINE SUMP SENSOR MMAUDIBLE AND VISUAL ALARMSAND
G a AUTO PUMP SHUT OFF WHEN A LEAKOCCURS
PRESSU I7ED PIPING: (Check all that apply) G b AUTO PUMP SHUTOFF FOR LEAKS, SYSTEMFAILURE AND SYSTEM DISCONNECTION
G c NO AUTO PUMP SHUTOFF
CONTINUOUS TURBINESUMPSENSORWJWAUDIBLEAND VISUAL ALARMS AND (check one )
G10 c a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS G8 AUTOMATIC LINE LEAKDETECTOR GPH TES3.0 T) 70(QHFLOW SHUT OFF ORRESTRICTION
G b AUTO PUMPSHUTOFFFOR LEAKS, SYSTEMFAILURE AND SYSTEMDISCONNECTION G9 ANNUAL INTEGRITY TEST (0.1 GPH)
G11 G c NO AUTOPUMP SHUT OFF
G12 AUTOMATIC LEAKDETECTOR S I -TIONI GRAVITY SYSTEM: (Check all that apply)
ANNUALINTEGRITYTEST (0.1 GPH) CONTINUOUS SUMP SENSOR+ AUDIBLE ANDVISUALALARMSG10
G13 SUCTIOWGRAVrTY SYSTEM (Check d that apply) DISCONNECTION: (Check all thatapply)
CONTINUOUS SUMP SENSOR +AUDIBLE AND VISUALALARMS
G11 NO AUTO PUMP SHUT OFF
EMERGENCY GENERATORS ONLY (Check an thatapply) G12 AUTOMATIC LINELEAKDETECTOR (3.0 GPHTEST)
G14 ANNUAL INTEGRITYTEST (0.1 GPM)
CONTINUOUS SUMP SENSORb(1 1VI AUTO PUMP SHUT OFF -AUDIBLEAND G13
VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check allthat apply)
G15 AUTOMATIC LINELEAK DETECTOR (3.0GPHTEST) CONTINUOUS SUMP SENSORh1IHQ11IAUTOPUMP SHUT OFF. AUDIBLE AND VISUALG16ANNUALINTEGRITYTEST (0.1 GPH) G14 ALARMS
G17 DAILY VISUALCHECK AUTOMATICLINE LEAK DETECTOR (3.0GPH TEST)
G15 ANNUAL INTEGRITY TEST (0.1 GPH)
Gte DAILYVISUALCHECK
G17
r r VIII DISPENSER CONTAINMENTatkr
DISPENSER 488 G 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE G4 DAILY VISUAL CHECK
CONTAINMENT G2 CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLEAND VISUALALARMS GS TRENCH LINERIMONITORING
G Yes G No G3 CONTINUOUS DISPENSER PAN SENSOR W1IHAUTO SHUT OFF FOR GO NONE 469
DATEINSTALLED: DISPENSER+ AUDIBLE ANDVISUALALARMS
iX.OWNER/OPERATOR SIGNATURE
I certify thattheInformation provided herein Is true & accuratetothe boatof my knov4edge.
SIGNATUREOF OWNERIOPERATOR 470 DATE 471
NAME OF OWNERIOPERATOR(print) 472 TITLE OF OWNERIOPERATOR 473
PamA Number (For total useonly) 474 1 Permit Approved 475 Permit Expiration Data 478
FD 2094 (Rev. 09/05)
UNDERGROUND STORAGE TANKS
TANK - INSTRUCTIONS (STATE FORM s)
Page 4 of 4
58. PIPING SYSTEM TYPE (UNDERGROUND )—For items 458 and
459, check the tank(s) piping system
459. PIPING SYSTEM TYPE (ABOVEGROUND) information. CHECK
ALL THAT APPLY.
460. PIPING CONSTRUCTION (UNDERGROUND)—Check the
tank(s) piping construction information. CHECK ALL THAT APPLY.
461. PIPING MANUFACTURER (UNDERGROUND )—Enter the name
of the piping manufacturer.
462. PIPING CONSTRUCTION (ABOVEGROUND) —Check the
tank(s) piping construction information. CHECK ALL THAT APPLY.
463. PIPING MANUFACTURER (ABOVEGROUND) —Enter the name
of the piping manufacturer.
464. PIPING MATERIAL AND CORROSION PROTECTION
UNDERGROUND) —For items 464 and 465, check the
465. PIPING MATERIAL AND CORROSION PROTECTION
ABOVEGROUND) tank(s) piping material and corrosion protection.
466. PIPING LEAK DETECTION (UNDERGROUND)-For items 466
and 467, check the leak detection system(s) used
467. PIPING LEAK DETECTION (ABOVEGROUND) -To comply with
the monitoring requirements for the piping.
468. DATE DISPENSER CONTAINMENT INSTALLED —If applicable,
enter the date that dispenser containment was installed.
469. DISPENSER CONTAINMENT TYPE —Check the type of
dispenser containment monitoring system.
470. SIGNATURE OF OWNER/OPERATOR —The owner or agent of
the owner shall sign in the space provided. This signature certifies that
the signer believes that all the information submitted is true and accurate.
471. DATE CERTIFIED —Enter the date the page was signed.
472. OWNER/OPERATOR NAME —Print the name of signatory
473. OWNER/OPERATOR TITLE -Enter the title of the person
signing the page.
474. PERMIT NUMBER -Leave this blank, this number is
assigned by the CUPA.
175. PERMIT APPROVED BY -Leave this blank, this is the name of
he person approving the permit.
476. PERMIT EXPIRATION DATE -Leave this blank, this is
completed by the CUPA.
FD 2094 (Rev. 09105)
d ,
UNDERGROUND STORAGE TANKS
UNIFIED PROGRAM CONSOLIDATED FORMS
APPLICATION '
UST FACILITY (STATE FORMA)
TYPEOF ACTION: (Check one item only) 1. NEW SITE PERMIT
2. INTERIM PERMIT
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
ZjrFA 8 P I D D 1600 Truxtun Ave., Suite 401
RQ Bakersfield; CA 933DI
TMN T phone: 661 - 326 -397 a Fax: 661 - 852 -2171
v Page 1 of 2
3. RENEWALPERMIT 5. CHANGE OFINFORMATION (Specifychange- 7. PERMANENTLY CLOSED SITE
4. AMENDEDPERMIT bcaluseony) S. TANK REMOVED 400
6. TEMPORARYSITE CLOSURE
I. FACILITY /SITE INFORMATION
BUS9JESS NAME (Same as FACILITY NA'NIEEE orrDDBByA - Doing Business As) 3 FACILITY ID No 1
y
NEAREST CROSS STREET 40t FAC r, OWNER
S,
CORPORATION 4. LOCAL AGENCY /DISTRICT'
2. INDIVIDUALr 5. COUNTY AGENCY'
3. PARTNERSHIP 6. STATE AGENCY*
7. FEDERAL AGENCY' aoz
BUSINESS TYPE rff' 1. GAS STATION 11 3. FARM 5. COMMERCIAL
2. DISTRIBUTOR 4. PROCESSOR 6. OTHER
TOTAL NUMBER OF TANKS Is facility 0n Indian Reservation or If owner of UST a public agency: Give the
EMAINING ATSITE 4oa Trust lands? Yes (,LJO 405 Nameof supervisor of division, section or office
ich operates the UST. (This isthe contact
arson for the tank records.) (Please print Contact person's name)
J11 PROPERTY OWNER INFORMATION
PROPERTY OWNER NAME 407
V\n CO Gas w a s• 661 `l
AILING OR STREET ADDRESS 409
2 2 7 Z
ITY 410 STATE 411 CODE 41
PROPERTY OWNER TYPE 604. CORPORATION 2• INDIVIDUAL 4. LOCAL AGENCY/ DISTRICT 6. STATE AGENCY
3 . PARTNERSHIP 5. COUNTY AGENCY 7. FEDERAL AGENCY 413
III. TANK OWNER INFORMATION
TANK OWNER NAME a14
Rg Co s
P 41
bbl 3Z V ;ad
AILING OR STREET ADDRESS 4ts
2Z2Z S
CITY 417 STATE • ata ZIP CJ3
TANK OWNER TYPE ORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY/ DISTRICT 6. STATE AGENCY
3. PARTNERSHIP 5. COUNTY AGENCY 7. FEDERAL AGENCY 420
IV, BOARP Q EQUALIZATION UST STORAGE FEE
Y (TK) HO 4 4 y j Call (916) 322 -9669 if questions arise 421
V. PETROLEUM UST FINANCIAL R NSIBILITY
1. SELF - INSURED 5. LETTER OF CREDIT 9. STATE FUND & CD
INDICATE METHOD(S) 2. GUARANTEE 6. EXEMPTION 10. LOCAL GOV'T MECHANISM
g'9,. INSURANCE 7. STATE FUND Q49B. OTHER:
114. SURETY BOND 118. STATE FUND & CFO LETTER K 'V 145A a 4
VI. LEGAL NOTIFICATION AND MAILING ADDRESS
Check one box to indicate which address should be used for legal notifications and mailing.
Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. C41. FACILITY 2. PROPERTY OWNER 3. TANK OWNER a
VII. APPLICANT SIGNATURE
Corlificafforr-f-ced1tv that the Information provided hereln Is true and accurate to the beatof m knowledge.
IGNATURE OF APPLI NT aza DATE
1/- ` 0
4 PHUNE a
ME OF A .PL -ICA (print) 4' TITLE OF APPLICANT , a
CQQ Y- -k C/ 9."m Cd-s'
STATE UST FACILITY NUMBER (For local use only) 429 1998 UPGRADE CERTIFICATE NUMBER (For local use only)
FD 2093 (Rev. os/W
UNDERGROUND STORAGE TANKS !'
UNIFIED PROGRAM CONSOLIDATED FORMS E-
INSTRUCTIONS
UST FACILITY (STATE FORMA) I i
j
I_ B_
NIRS
AATM T
Complete the US T Facilitypage for all new permits, permit
changes any facility information changes. This page must be
submitted within 30 days of permit orfacility information changes,
unless approval is required before making any changes.
Submit one UST- Facility page per facility, regardless of the number
of tanks located at the site. This form is completed by either the permit
applicant or the local agency underground tank inspector. As par ofthe
application, the tank owner mustsubmitascaled facility plot plan to the
local agency showing the location of the US Ts with respect to buildings
and landmarks [23 CCR 2711(a)(8)], a description of the tank and ping
leak detection monitoring program [23 CCR 32711(a)(9)], and, for
tanks containing petroleum, documentation showing compliance with
statefinancial responsibility requirements [23 CCR271 1 (a)(1 1)].
Refer to [23 CCR 27111 for state UST information and permit
application requirements.
Note: The numbering of the instructions follows the data element
numbers that are on the UPCF pages. These data element numbers are
used for electronicsubmission and are the same as the numbering
used in 27 CCR, Appendix C, the Business Section of the Unified
Program Data Dictionary.)
Please number all pages of your submittal. This helps your CUPA or
local agency identify whether the submittal is complete and if any
pages are separated.
1. FACILITY ID NUMBER - Leave this blank. This number is
assigned by the CUPA. This is the unique number which identifies your
facility.
3. BUSINESS NAME - Enter the full legal name of the business.
400. TYPE OF ACTION - Check the reason the page is being
completed. CHECK ONE ITEM ONLY.
401. NEAREST CROSS STREET - Enter the name of the cross
street nearest to the site of the tank.
402. FACILITY OWNER TYPE - Check the type of business
ownership.
403. BUSINES S TYPE - Check the type of business.
404. TOTAL NUMBER OF TANKS REMAINING ATSITE -
Indicate the number of tanks remaining on the site after the requested
action.
405. INDIAN OR TRUST LAND - Check whether or not the facility
is located on an Indian reservation or other trust lands.
406. PUBLIC AGENCY SUPERVISOR NAME - If the facility
owner is a public agency, enter the name of the supervisor for the
division, section oroffice which operates the UST. This person must
have access to the tank records.
407. PROPERTY OWNER NAME- Complete items 407 -412 for
the property owner, unless all items are the same as the Owner
Information (items 111 -116) on the Business Owner /Operator
identification page.
408. PROPERTY OWNER PHONE -Owner /Operator identification
page, if the same.
409. PROPERTY OWNER PROPERTY OWNER MAILING OR
STREET ADDRESS-Owner/Operator identification page, if the same.
410. PROPERTY OWNER CITY -Owner /Operator identification
page, if the same.
411. PROPERTY OWNER STATE -Owner /Operator identification
page, 'If the same. - Owner /Operator identification page, if the same.
412. PROPERTY OWNER ZIP CODE- OwnerlOperator
identification page, if the same.
413. PROPERTY OWNER TYPE - Check the type of property
ownership.
414. TANK OWNER NAME -Complete items 414- 419 forthe
tank owner unless all items are the same as the Owner Information
items 111 -116) on the Business Owner /Operator Identification page), if
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1600 Truxtun Ave., Suite 401
Bakersfield, CA 93301
Phone: 661 - 326 -3979 s Fax: 661 - 852 -2171
Page 2 of 2
the same.
415. TANK OWNER PHONE -Owner /Operator identification page,
if the same.
416. TANK OWNER MAILING OR STREET ADDRESS -
Owner /Operator Identification page (OES Form 2730), if the same.
417. TANK OWNER CITY-Owner /Operator identification page,
if the same.
418. TANK OWNER STATE -Owner /Operator identification page,
if the same.
419. TANK OWNER 23P CODE -Owner /Operator identification
page, if the same.
420. TANK OWNER TYPE - Check the type of tank ownership.
421. BIDE NUMBER - Enter your Board of Equalization (BOE)
UST storage fee account number. This fee applies to regulated LISTS
storing petroleum products. This is required before your permit
applicattion can be proms. Ifyou do not have an account numberwith the
BOE orifyou have any questions regarding the fee or exemptions, please
call the BOE at (916) 322 -9669 or write to the BOE at Board of
Equalization, Fuel Taxes Division, P.O. Box 942879, Sacramento, CA
94279-0030.
422. PETROLEUM UST FINANCIAL RESPONSIBILITY CODE -
Check the method(s) used by the owner and/or operator in meeting the
Federal and State financial responsibility requirements. CHECK ALL
THAT APPLY. If the method is not listed, check (r other) and enter the
method(s). USTs owned by any Federal or State agency and non -
petroleum LISTS are exemptfrom this requirement
423. LEGAL NOTIFICATION AND MAILING ADDRESS -
Indicate the address to which legal notifications and mailings should be
sent. The legal notifications and mailings will be sent to the tank owner
unless the facility (box 1) or the property owner (box 2) Is checked.
424. SIGNATURE OF APPLICANTThe business
owner /operatorof the tank facility, or officially designated representative
of the owner/ operator, shall sign in the space provided. This signature
certifies that the signer believesthat all the information submitted Is
accurate and complete.
425. DATE CERTIFIED - Enter the date that the page was
signed.
426. APPLICANT PHONE - Enter the phone number of the
applicant (person certifying).
427. APPLICANT NAME - Enter the full printed name of the
person signing the page.
428. APPLICANT TITLE - Enter the file of the person signing the
page.
429. STATE UST FACILITY NUMBER - Leave this blank. This
numberis assigned by the CUPAas follows: the number is composed of
the two digit county number, the three digitjurisdiction number, and a six
digit facility number. The facility number must be the same as shown in
item 1.
430. 1998 UPGRADE CERTIFICATE NUMBER - Leave this
blank. This number is assigned by the CUPA.
FD 2093 (Rev. 09/05)