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HomeMy WebLinkAbout1030 OAK STREET (7)c Office Use Only Level Initials Date Reviewed HAZARDOUS MATERIALS BUSINESS EMERGENCY PLAN AND INVENTORY CERTIFICATION FORM Business Name CI y[ V, -e .21 UO 0 Facility # Owner /Operator Name 1 Telephone Facility Address _eZ City State CA Zip Code GO_j 3 t j A nual Business Emergency Plan Inventory Review and Update The information contained on the annual inventory form most recently submitted to the administering agency is complete, accurate. and up to date and complies with all of the following, statements: 1. There has been no change in the quantity of any hazardous material as reported in the most recently submitted annual inventory; 2. No hazardous materials subject to the inventory requirements of Chapter 6.95 H &SC are being handled that are not listed on the most recently submitted annual inventory form; and 3. The most recently submitted annual inventory form contains the information required by sec. 11022 of Title 42 of the United States Code. (The County /OES form 2731 meets this requirement) The inventory as previously reported has changed. Attached are new inventory reporting forms for all changes. Tr' nnial (3 Year) Business Emergency Plan Review and Certification I certify that the Business Emergency Plan has been revi w d and he information contained in it is accurate and complete as of this date I certify that I have reviewed the Business Emergency Pan and have updated the following items (updated items are attached): Emergency contacts names and /or telephone numbers. Site and /or facility map(s). Emergency procedures. Other Information: Notification should be made to this agency within 30 days if any of the following events occur: change of ownership; change of business name; mailing address; phone number; location; emergency contact person; 100% or more increase in the quantity of a disclosed material; or any handling of a previously undisclosed material subject to regulation. A copy of this form should be kept at the business and available for review upon request of this agency. This form can only be used if you have already submitted the most current version of the Chemical Inventory Form (OES Form 2731). If your business falls under EPCRA /SARA Title Ill, this Conn does not meet the annual inventory reporting requirements. I certify under penalty of law that I have examined and am familiar with the information submitted in this and all attached documents. that the information provided herein is true, accurate, and complete to the best of my knowledge. Name J V V'1-- 1\ 1 , M Signatur Title Date 02/02 Agent For Circle K Stores, Inc. e 5 UNIFIED I'110GRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION 1 Pnge 2 of 8 1. IDENTIFICATION PACII.1TY ID 4 i S3r:GINNING DA'rE I'Mi)Inu2 i*' 101 rlgoncl, Use On6,) LH 111 411 1 2- BUSINESS NAMG (Same as FocilNp A'rrnr¢ a• DRA •• Doing !Business As.) I BIISINGSS PH 'F 1u- Circle K Store 92708606 661) 861- 1,GHa, BUSINIS5 SITI: ADDRESS iw I BUSINUS FAX ++ 1030 Oak Street None BIISINFSS SITE CITY 10 1..If' CODI, 1 °` COUNTY m Bakersfield CA 93304 I Kern DUN li BRADSnurl' ma. PRIMARY SIC 107 PRIMARY NAILS w7e 10- 5457662 5541 447110 HUSINGSS MAILING ADDI?J_tiS lotu QQ BUSINESS MAILING CTI'Y • ' STA'11S ,o& ZIP CODE Corona CA j 92879 BUSINrSS OPERATOR NAME 131.11SINUS OPERATOR PHONE: 110 Circle K Stores Inc. 951 ) 270 -5193 II. BUSINESS OWNER OWNER NAME= OWNER PHONE: Circle K Stores Inc. 1(951') 270 -5193 OWNER MAILING ADDRI -S ass - f0WNER MAILING CrrY 114 STA11i „5 ZIP CODE 116 Corona CA 92879 III, ENVIRONMENTAL CONTACT CONI'ACTNAME I,l COKrI'AC'rPI•IONE „6. a u 951 270 -510b CON7'A( rMn,t1>,r ennn c ,I4 CONTACTEMAIL 1 CONTACT MAILING CrIY i'c STA'I`E I + 701 CODE Corona CA 192879 PRIMARY- 111. EMERGENCY CONTACTS - SECONDARi'- NAMr ti? NAMR Service Contact Center rrn.c 17A m, I': 24 Hoursv, a 13USINESS PHONE '' -i BLISINI:SS 131-10 = IA 866 805 -4357 24 -HOUR PHONE: ,±s 24 -1-OUR PHONE 13 I 866 8Q5 -4357 C5i 31b L1 3oj 1 PAGER li PA(iL-R ay ua ADDITIONAL. LOCALLY COLLECTED INFORMATION: u Billing Address: Property Owner. Phone No.: ( ) Certification: Bascd an my inquiry orthose individuals respa,sible for obtaining the infonnation. I =06, undL9• penally ofLaw that I have personally emuitied and an familinr %%iih the inronimion wbmilted and believe die infornunion is vuc, am,rme and complete. t nc r fNC1 1 Pr 2 !] •SIGN 'lr.E) J}''PR iSFN1'A'I'1VF D,A)1;. + NAM6 OF DCY IIMEM' PREPARI 1t s AfA .c-YPi I'IIN;n ineerin ML OF SI i lnriml ,6 I rdl OF ST'•'R s' Environmental Compliance UPCI' 1tev. (1212007) - U2 www.unidumarg UNIFIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS ACTIVITIES Page 1 of s I. FACILITY IDENTIFICATION i'ACIU'1'Y 11) 0 t EPA iD 11 (liarard,ws Waste Dniy) '- Igenn Use 0)1/19 BUSINESS CAL000278511 -- NAME (Saone as FrrdH(p A'anre or DIM - Doing Humness /it) Circle K Store 42708606 13USiNr -SS SITE ADDRESS 1030 Oak Street suSlNESS SIl'[: ciTY Bakersfield ' CA m soul- 93304 10` II. ACTIVITIES DECLARATION NOTE: If you check YES to any part of this list, lease submit the Business Owner/Operator Identirication viage. Does your facility... if Yes, please com iete these aucs of the UPCF... A. HAZARDOUS MATERIALS Have on site (for.any purpose) ni any one time, hazardous materials ni ar above 55 gallons for liquids; 500 pounds for solids, or 200 cubic feet for compressed gases (include liquids in AS'rs and US1's); or lttc applicable YLS NO ° HAZARDOUS MA'I'IiRIALS INVI- N'I'URY - Pederal threshold quantity for sit extremely hazardous substance specified in CHEMICAL DUSC:RIM ION 40 CFR Pan 355, Appendix A or 13: or handle radiological materials in quantities for %vitich an emergency plan Is required pursuant to 10 CFIt Parts 30. 40 or 70? B. CAIARP REGULATED SUBSTANCES Have Regulated Substances stored onsite in quantities greater than the YES NO I Coordinate with vour local ngcncy resxvtsible lot threshold quanihies established by the California Accidental Release CaIARP. Prevention Program CalARP)? C. UNDERGROUND STORAGE TANICS (USTs) YES NO t USI' FACILITY (t'u,nerty7iwR('a Fmm A) Ot +m or operate underground storarte tanks? UST TANK 1"0 929c W Wa ) (FwmvayRM al D. ABOVE GROUND PETROLEUM STORAGE Own or operate AST% above these thresholds: Yr-S ® No : l No fonn required to CUPAsStoregreaterthan1.320 gallons of petroleum products (new or used) in aboveground tanks or containers? E. HAZARDOUS WASTE Generale hazardous av9ste? YGS NO v EPA IU NUM©CR - provide attop of this page Rer•cle more than 100 kg/month of excluded of exempted recyclable YES 01 NO rte RECYCI,Al LF MA11:RIALS REPORT ' materials (per HSC §25143.2)? Wow N' M'C'r Trent hazardous wasto onsile? YES ® NO it ONSrrl' HAZARDOUS WASI*E 'IREATMENT FACILITY ONSITE HAZARDOUS WASTE 'rREAI'MENT UNil' irmr pyeef-a -it 1 Perform Irminicni subicet to fmancia) assurance requirements (far Penult by M YLS 0 NO t? CERTIFICATION Of FINANCIAL ASSURANCE Rule and Conditional Authorization)? Consolidate hazardous %taste gcnernted at a remote site? YFFS [j NO a R(:MOTTi WAS'ri? CONSOLIDATION WE ANNUAL NOTIFICATION Need to report the closurdremoval of tank that was classified as hazardous YLS ® NO u HA7J11U)0US WASTE TANK CLOSURE taste and cicamxl onsite? i CCRTIRCATION grams (k 2,200Generateinan' single calendar month i 000 kilo g) ( Y1SS NO tea i Uhtaitt federal 1:PA 11) Nntnbor, GIC Rietwial pounds) or more of federal RCRA hazardous waste, or in I Report (EPA Form 9700- 13A)B), mnd satisfygenerate any single calendar month, or accumulate at any rime, I kg (2.2 requirommns for RCRA Large QuantnyGetterator. pounds) of RCRA acute hazardous waste; or generate or accumulate at any time more then 100 kg (220 pounds) of spill cleanup materials contaminated with RCRA acute hazardous waste? Serve as a Household Hazardous Waste (Hl-iW ) Collection site? YrS Z NO ob. CcCUPA formquirod forms. F. LOCAL REQUIREMENTS (You nt y also be rnquirrd to pnr4k additional uifammtion In• your CVPA or locni.Amer.) a3 13 PCF Rev. (1212007) - 1/2 www.mtidocsmrg