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HAZARDOUS MATERIALS
BUSINESS EMERGENCY PLAN AND INVENTORY CERTIFICATION FORM
Business Name k S Y 4 23 0 Facility 4
Owner /Operator Name IV)(, Telephone
Facility AddressG J 0l/t(.
City State Zip Code .d 1
Annual Business Emergency Plan Inventory Review and Update
Y 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.
Triennial (3 Year) Business Emergency Plan Review and Certification
I certify that the Business Emergency Plan has been reviewed and the information
contained in it is accurate and complete as of this date U U
I certify that I have reviewed the Business Emergency Plan 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 ofa 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 form 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 ` 1 I Signature
t
Title Date 02/02
Agent For Circle K Stores, Inc.
UNIFIED PROGRAM CONSOLIDATED FORM
FACILITY INFORMATION
BUSINESS ACTIVITIES
Page 1 of 71
I. FACILITY IDENTIFICATION i
FACILl1'1' Il) N GPA 11) it (I lazardous Waste Only) =
Agency Use Only) CAL000278585
BUSINESS NAMF (Sant as Facili(pNunn or UBA • Doing busimrs As) 2 i
Circle K Store #2701270
13usINesS SITE ADDRESS 5634 Stine Road
Bus1NESS S1Tr cITY Bakersfield CA cone. 93313
IL ACTIVITIES DECLARATION
NOTE: If you check YES to any part of this list, i lease submit the Business Owner/Operator Identification page.
Goes )VIT facilh,-'... If Yes. please complete these papev ofthe
A, HAZARDOUS MATERIALS
i•inve on site (For any purpose) at any one time, hazardous materials at or
abovo 55 gallons for liquids, 500 pounds for solids, or 200 cubic feet for
compressed gases (include liquids in ASTs and USTs); or the applicable t
YI'_'S NQ + HAZARDOUS MA'ITRIALS INVENTORY -
Federal threshold quantity for an extremely hazardous substance specified in CHEMICAL DESCRIPTION !
40 CFR Part 355, Appendix A or B; or handle radiological materials in
quantities for which an emergency plan is required pursuant to 10 Crli Parts
30. 40 or 70? I
B. CaIARP REGULATED SUBSTANCES
Have Regulated Subsuinces stored onsile in quantities 91-oale; than llte YES ® NO „ Coordinatc with yrnrr local agency responsible rot
threshold quantities established by the California Accidental Release CaIARP.
Prevention Pro n (CaIARP )?
C. UNDERGROUND STORAGE TANKS (USTs) YFS NO s lls'r FACILITY (riumar3"en roan, A)
Otvn or operate uncle round storage tanks? USI' TANK toutpap Pei aoLnnW,;yfwrr ar
D. ABOVE GROUND PETROLEUM STORAGE
Own or operate AS rs above t)tcsc thresholds: YES m NO a No form required to L'UPAsStoregreaterthan1,320 gallons of petroleum products (new or used) in
abovecmund tanks or containers?
E. HAZARDOUS WASTE
Generate haettrdous waste? I ® YES NO o EPA ID NUMBER - provide at top of this page
Recycle more than 100 kg/month of =,eluded or mempted recyclable YF:S ® NO to RECYCLABLE MATERIALS ItiiPORT
materials (per HSC §25143.2r e wxyckll
Treat hazardous waste onsile? YFS ® NO owsi I "s ) IAA- AItDOUS WASTE- TREATMENT
FACIIJTY
ONSITE IIAZ.ARDOUS WASTT TItI3ATM1_N'1'
UNIT (oropauo0cra0
Perform treatment subject to financinl assurance requirements (for Permit by YES ® NO 12. CrRTIFICATION CA' FINANCIAL ASSURANCE
Rule and Conditional Authorization)?
Consolidate hazardous Waste generated at a remote site? NT; ® NO n REMOTE WA.SIT CON5ot.1DA'nON SITE
ANNUAL NOTIFICATION
Need to repon the clttsttre/ removal of a tank that was classificd as hazardous YES ® NO w I•IAZARDOUS WASTE- TANK CLOSURE
nacre and cleaned onsilc? CERTIFICATION
Generate in any single calendar month 1,000 kilograms (kg) (2,200 Y0; (D NO i4d Obtain federal EPA ID Number, life Biennial
pounds) or more of federal RCRA hazardous waste, or generate in Rtror( (L-PA form E700- 13103), and sansfy
any single calendar month, or accumulate at any time, I kg (2.2 requirements for RCRA Largo Quantity Generator.
pounds) of RCRA acute hazardous waste; or generate or accumulate
at any time more then 100 ,, (220 pounds) of spill cleanup materials
contaminated with RCRA acute hazardous waste?
Serve as a Household Hazardous Waste HHW Collection site? YES IR NO ion. I See CUPA far required romis.
F. 1,OCAL REQUIREMENTS (Yrna may Also be ro"hicd io rnuvidc additional udornmaion by yourCUPA or local ap=y.) ri
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UNIFIED PROGRAM CONSOLIDATED FORM
FACILITY INFORMATION
BUSINESS OWNEWOPERATOR IDENTIFICATION
Page 2 of 7
I. IIDENTIFICATION
r- Acn.rr), ID d i IlrtrttNlJtUr v r_r I- lrt`u,I>w-. INA117 of
rAgenq, L4rr Onl)J d I d i i '
BUSINI'SS NAME r-unte enFadlio, Nome or 08A - Doing Husincrr A, - HIJSINI'SS PHO NI: w +_
Circle K Store #2701270 669 834 -8625
RUSINESN' SITE. ADDRESS 103. BUSINESS FAX tm,
5634 Stine Road None
13USINEss StTE CrrY 10a I 'LIP C'OOI' Ios Co"'rY 101
Bakersfield CA 93313 Kern
DUN & BRADSTRGET tot ' PRIMARY SIC 107 PRIMARY NAILS 1078 j
10- 5457662 5541 447110 1
BUSINESS MAII .1W ADI)R.Ss 1oG.
ate 'F-
HUSINI:5S MAILING Crr)' iotb STA'rL•' toto 71P CODE 3ww
Corona CA I 92879
BUSINESS OPERATOR NAME: 109 IiUSINI:.Ss OPI:R,CI'UR PHONE 110
Circle K Stores Inc. 951 270 -5193
II. BUSINESS OWNER
OWNER NAME t1 OWNER PHONE tit
Circle K Stores Inc. 951 270 -5193
OWNER MAILING ADDRESS ,- 10
OWNI.R MAILING CrrY 114 STATE Its '!_IP CODE: t16•
Corona 1 CA 92879
III. ENVIRONMENTAL CONTACT
CONTAC-rNAME 117 WNTACI'PHONE lit
Lkryr 1 951 270 -510e,
CPNTAPl .MAILING ADDRSSS Ito COWACr EMAIL. 11%
COWAC'r MAULING Cl'rY 17U STA'1'I °. 13, 2111 CODs: — 122
Corona 1 CA 92879
PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY -
NAW 11? rlAAAr 1n
Service Contact Center
1TI'LE
24 Hours
114 TITLI'
fin \AcunrvQ0- A-c.,\
129
HUSINBS PHONE 12-1 1 BUSINESS PHONE I;0
866 805 -4357 i 0151 7) .-5^1G 3
24•14OUR 11HONE 116. t4- I1u0It PHONE
866 805 -4357 Rg51 2,I o- yam
PAGER a 17 PAGER n 132
ADDITIONAL LOCALLY COI.l..IicnTj) INFORMATION:
Billing Address:
Property Owner: Phone No.: S
Certd6catiou: Based on my inquiry or those individuals responsible for obusining the information, I cortiry under penalty or Ina• that 1 have perscmalty examined surd
am familiar with the inronnation submitted and bclicvc the iolbmlmion is trite, acc=tt, and complete.
INA 1 IH')-PA•i'J 01!DI "tiN TwREMM's` 'A•rtvr• n 1a4 1 NAME: 017I)OClJM1:N1'PREPARE• "R 11•`
I A & S Engineenn
M [.,,>I NC (urin) lk rum GPSIGNER 1i7
obd i!f°(Q Lf± Environmental Compliance
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