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HomeMy WebLinkAboutUNDERGROUND TANK-C-10/7/91 / 21'30 G Street, Bakersfield, CA 93301 ~i~,.,~/? I (805) 326-3979 ~,~ TANK REMOVAL INSPECTION FORM ~;~ ~ ~ ~ OWNER~J/p-o ~5~-/~_~L-~_ PERMIT TO OPERATE# ~- CO~CTOR ~ ~ - CONTACT PERSON ~ ~ ~O~TORY ~.~, ~ ~ OF S~PLES ~,. TEST ~THODOLOGY ~% [ ~ ~/~ ~ P~LI~ARY ASSESSMENT CO.~ CO,ACT PERSON CO2,RECIEPT ~ ' LEL% ~ 02% PLOT P~ CONDITION OF' T~Ks AZ,'- '- /~W ~1'--3- CONDITION OF pIpING CONDITION OF SOIL /t~ COMMENTS DATE INSPECTORS NA~ / ~ IGNATU~F/ 7%~-.~, Bakersfie[d Fire Dept. PE~,~lr ,'~. . ..¢-"~;,,.¢~.~"~ HAZARDOUS'MATE,RIALS DI~IS~ ~ ( ~:~'~ ~;F.'~ UNDE~GRCUND STORAG~ TANK ~RCG~AM ' PERMIT APPLICATION FO~ ~EMOVAL OF AN UNDErGrOUND STO~AGE TANK '~ SITE ~NFC~MAT~ON SiTE ADDRESS !CO ~k,~'r ZiPCODE ~~A~N FAC[L!~( NAME ~_ ~'t,,~o ~.:~')~:'~.F CSOSS STREET ~..~ i; ~< '~E ~ TANK OWNER/OPErATOR ~C~CD ./.J ~ ~m~P ~¢~er¢'r~ PHONE No. ~ ~. ~q  CONTRACTOR INFORMATION AOO~ESS ~0.','%~_' ~.~f~ - C~W ~lr~dZIP CODE & '" ~ INSURANC~CARRI~'~ '~c~ ~, '~_0;~¢ WORKMENSCOMP No. PREUMANARY ASSEMENT INFORMATION COMPANY dC ¢ bp,~ E~u~,~*d P,,ONE No.C~c)~gq'~CENSE No. INSURANCE CARRIER ~ ~.~n ~_ ~~ WORKMENS COMP No. ~ ~-~ TANK ~LEANINO INFORMATION ADDRESS F,O.(~¢ ~%%3- ' Z1.PCC. DE.R 9~ WASTE TRANSPORTER IDENTI~iCATION NUMBER ¢ ¢¢~ q~'~ W~ ~ NAME CF RINSTATE DISPOSAL FACILI~ (~;~r~,* ¢;~ ~ ~ o', , FAC~LI~FINDENTIFICATIONNUMBER ~0.~0 ~%3 ~ ~ ~ ~ ~,~ ~* ~,e~o RMAT1ON TA ............... TE~INFO _ . COMPANY ~ ~~ ~ C~¢HONE No.~¢~ ~2~LICENS:'NO. ~ ADDRESS 1DO 6~r~. ~¢~~k,~ CI~ t~ . ZIPCODE TANK INFORMATION TANX No. AGE VOLUME CHEMICAL DATES CHEMICAL " STORED STORED PRE',/IOUSLY STCRCD 4 FO,q CF~IC:AL USE ONLY .. -:. · .... . - .~ :':,~'"'?,_! c~": T i'E,,'I"~T'~i":~/?_~?"' ":' ' ...... :':': ":':': ::: ': ':::: ~t::'~ :'::~::,.:~'.::================================================~C~',TV .:~:::. :::2 :/~::=======================~:. O ~ :~'O ::':: ~o,.~ ~:":"~'~ ....... ~"'::'' ':" :~::: 7" ~fS~ ~ .e ": THE APPLICANf HAS ...... Pc~:;V~m~, UNOERSTANOS, AND WILL COMPLY WITH file A~ACHEO CCNOITtCNS CF THIS FERMI[ AND ANY OTHER' 3TALE. LOCAL AND FEDERAL REGULAfICNS. ~lS ~O~M HAS ~EEN COMPLETED UNDER PENALr( OF ~ERJU~Y, ANO ~0 fNE ~E~T CF MY ~NC',VLEDGE, tS TRUE AND C.C PRE,ST, THIS APPLICATION BECOMES A PERMIT WHEN APPROVED / CITY of BAKERSFIELD ' "WE CARE" FIRE DEPARTMENT 2101 H STREET I S.D. JOHNSON October 7, 1991 BAKERSFIELD, 93301 FIRE CHIEF 326-3911 ,/ Pedro Espericueta 100 Baker Street Bakersfield, CA 93305 CLOSURE OF 1 UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANKS LOCATED AT 100 BAKER STREET IN BAKERSFIELD, CALIFORNIA. PERMIT #'BR0006 Dear Mr. Espericueta This is to inform you that this department has reviewed the results for the preliminary assessment associated with the cloSure of the tanks located at the above stated address. Based upon laboratory data submitted, this office is satisfied with the assessment performed and requires no further action at this time. If you have any questions regarding this matter, please contact me at (805)-326-3797. //Joe A. Du-nwoody~ · // Hazardous Material Specialist Underground Tank Program ' ~--~. % Bakersfield Fixe Dept. ?ERMIT '~~ HAZARDOUS MATERIALS DIVlSiC UNDERGROUND STORAGE TANK PROGRA~ PERMIT APPLICATION FOR REMOVAL OF AN UNDERGROUND STORAGE TANK '( SITE INFORMATION SITE ADDRESS 1OO :~k,~f ZIPCODE ~O~APN FACILI~ NAME ~L ~o ~b~-~ff CROSS STREET ~ ' ~f ~ CONTRACTOR INFORMATION ~E PRELIMANARY ASSEMENT INFORMATION INSURANCE CARRIER ~ ~ n ~_ ~~_.~ WORKMENS COMP No. TANK CLEANING INFORMATION WASTE TRANSPORTER IDENTIFICATION N~MBER ~ ~_~ ~ q%Q ~ NAME OF RI~STATE DISPOSAL FAClLI~ (~~,3 ~;~ ~ TANE T~A NSPORTER-INFORMATION TANK INFORMATION TANK No.. AGE VOLUME CHEMICAL DATES CHEMICAL STORED STORED PREVIOUSLY ST~RCD !:':'. I · .I :.-. ::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::: ================================================================ · ":':':: , ::, 1'HE APPLICAN[ HAS RECEIVED, UNOERSTANDS, A ND WILL COMPLY WITH THE AR'ACHED CONOIflONS'OF THIS PERMIT AND ANY OTHER STATE, LOCAL AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND fO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. APPLICANT (PRINT) . ,,~PPROVED BY: j NAME I '"'A~P P L~C A IxTT'~/IS N A f U R c THIS APPLICATION BECOMES A PERMIT WHEN APPROVED BAKERSFIELD FIRE DEPARTMENT HAZARDOUS MATERIAL DIVISION 2130 G Street, Bakersfield, CA 93301 CERTIFICATION STATEMENT OF TANK DECONTAMINATION I, ~/6 ~/~A/~--7--~- an authorized agent of name /~/~/Ewv~?~o~J/~E~-~t ~g~/~here by 'attest under penalty of contracting co. perjury that the tank(s)' located at /d~O ~/~~~/~ and address being removed under Permit# ~ dDOd9~ has been cleaned/decontaminated properly and a LEL (lower explosive limit) reading of no greater than 5% was measured immediately following the cleaning/decontamination process. date n~me (print) - /signature / KERN ENVIRONMEHTAL SERVICE September 30, 1991 Mr. Joe Dunwoody CITY OF BAKERSFIELD - FIRE DEPARTMENT 2130 "g' Street Bakersfield, CA 93301 REGARDING: Underground Fuel Tank Removal Project at 100 Baker Street, Bakersfield, California, KES Project Number 91E2365 Dear Mr. Dunwoody: Enclosed please find analytical results (BC Laboratory Sample Numbers 9982-1 and 9982-2) and chain of custody record for the above referenced project. Also attached is a copy of Uniform Hazardous Waste Manifest Number 90658260, a copy of the Tank Destruction Form No. 10079 (th~ original is to be mailed~ to you by Golden State Metals, Inc., Bakersfield, California) and a copy of the Non Hazardous Waste Manifest No. 3449. Sincerely, G CORNETT, Lead Technician bd ~ Enclosures Post Office Box 5337, Bakersfield, California 93388 · (805) 589-5220 In California · (800) 332-5376 ~NVI~ONM~NTA£ LABORATORIES, INC. PETROLEUtll J' J' EGLIN, REG. CHEM. ENGR. 4100 ATLAS CT., BAKERSFIELD, CALIFORNIA 93:$08 PHONE (805) 327-4911 F.I~ (805) 327-1918 KERN ENVIRONMENTAL SERVICES Date Reported: 09/20/91 Page 1 P 0 BOX 5337 Date Received: 09/06/91 B/%KERSFIELD, CA 93388 Laboratory No.: 9982-2 Attn.: FRA1TK ROSENLIEB 589-5220 Sample Description: 91E2365 ELP: EL-2, 6-SOIL, 9/6/91 SAMPLE COLLECTED BY CORNETT CHEMICAL ANALYSIS Method Constituents SamDle Results Units P.Q.L. Method Total Petroleum Hydrocarbon None Detected mg/kg 20. EPA-418.1 REFERENCES: EPA = "Methods for Chemical Analysis of Water and Wastes", EPA-600, 14-79-020. Department S~p~ ENVIRONMENTAL LABORATORIES, INC. PETROLEUt, t J' J' EGLIN, REG. CHEM. ENGR. 4100 ATLAS CT., BAKERSFIELD, CALIFORNIA 93~08 PHONE (805) 327-4911 F~0~ (805) 327-1918 KERN ENVIRONMENTAL SERVICES Date Reported: 09/20/91 Page P O BOX 5337 Date Received: 09/06/91 BAKERSFIELD, CA 93388 Laboratory No.: 9982-1 Attn.: FRANK ROSENLIEB 589-5220 · Sample Description: 91E2365 ELP: EL-l, 2-SOIL, 9/6/91 SAMPLE COLLECTED BY CORNETT CHEMICAL ANALYSIS Method Constituents Sample Results Units P.Q.L. Method Total Petroleum Hydrocarbon 20. mg/kg 20. EPA-418.1 REFERENCES: EPA = "Methods for Chemical Analysis of Water and Wastes", EPA-600, 14-79-020. CHAIN OF CUSTODY RECORD :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Sampicr(s) (_..'o]2/,/</_,-i-~ ~ ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .>. : .>...'i: ::: .-...~ :i :i:i i:~: :.: :i:i:~ ~::. ~:~:'.. :i:~ g::~ :g: i:~.'.:: ~ : : ::: :::.-.::: .2.- : i:~[..:! ...?::~:? :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::..:~::::::::~:::::::::::::::::::::::: :: ...::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~ [~[~[[ii!i~i[ii~}iiii!i!i~i[i!i'.-iii!i¢~i!~i~i!i~i~}iiii!iii :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ,~,,.,,,,~,,,,., ,,,,, ~(~ ~...'.. (~:. ....,. ~ /-/'~:: ,~.- ~.._ ¢/ /2; ,¢_~ " Rclinqu~d~d i~ i }i{i}:i}:!!!ii~![: ~~iii~~} i~ ~i}~:i~[:::~iiii : i:i: :.:¢i:~: i~:~: :.::~:!:i:~:!: :!:i:i::;-::i-'.'< g.::[:i:!:i i:i:!:~:!::;~:[: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .~'I'~; NO KERN ENVIRONMENTAL SERVICE Post Office Box 5337' Bakersfield, California 93388 In California (800)332-5376 ~' St~,te of California--Health and Welfare Agency See Instructions on Back of Page 6 Departme~'~f Health Services Toxic Su~l~,'~ajl[,~,Controt Division Form Approved. O~B No. 205~39 (Expires 9-~-91) and Front of Page 7 ~ra~ento, california A. State Man,em ~ment ~ ~., Generator's. . Name and Mailing Address EL PRiG AUTO CENTER 9 0 6 5 8 2 6 0 100 B~ER STREET s. state ~n~at~l ~ ~.~e,~.~',Pho.eM05) 325-0C95 B~ERSFIELD, CA 93305 I ~ I I I ~ I I I I I I ~ ~S T~ORT~T~O~, ~C. IC1~1DI91~121~191516101 589-522fl ~ ~. UM EPA ID Number E. Mt~te T~ ~ $: ~l~t~ ~1~ Nlme i~ ~e Address 10. U8 EPA ID Number ~. Miata ~'1 ~ GIBSON OIL & ~FINING H. E~ OF CO~RCI~ DRI~ B~SFIE~, CA 93308 IG IA ~D I9181018 i813 11717 f~fl~ 12. Cofltaifler~' ~. Total 14. I. Ouant~ Un~ W~t~ !~. ~ ~T ~t~ (Including Proper $hlppl~g Name. Hazard Ciasa. and ID Number) No. Type Wt/V~ _ ~ NON-RC~ ~OUS WASTE LIQUID 223 , ~ ' (~ROC~ON CUlmINATED WATER) ~,f~ ~X/~ .' ; ml~lt vl? ~1~ c ,NO~ N : Still :' '.' T I I I I I I I ":~ .... - 0 ~ '... I I, I III I .... I I I I i I I ~ ., (GASOLINE & 'DIEgEL) + 99% .WATER :&:+ 1% ~ c. O 15. Special ~ndllng Inst~uctiona and Additional Info~aflon . ~ ~BSON R~L~AS~ ~/90~5-1 JOB ~ 18. GENERATOR'5 CERTIFICATI~: I hereby declare that lhe contents of this conal~nme~l a~e fully and accurately described a~ve by prier ~hlpping name ~ and are classified, packed, ma~ed, and labeled, and a~e In all reapers In prope~ condition fo~ lranapo~ by highway acceding to applicable international and ~ national government regulations. If I am a la,ge quantify generator, I ce~ tha~ I have a program i~ p~ace fo re~ca ~e ~o~me a~ toxicity o~ wasle ~e~e~efe~ 1o Ihs ~e~ee ~ have ~ to be economically p~acticable and that I have selected the practicable method of Vestment, storage, or disposal currentN available to me ~ich minimizes the O p~esent and future th~eal Io human health and the environment: ~, if I am a small quantity generator, I have made a g~ fasb e~o~ to. minimize my wasle ~ ~eneration and select the beat waste management method lhat ia avai~ble to me and lhat I can a~ord. m Print ed~yped Name r _ _ . . A P~inted/T~d Name ~ Sign Month Day Year ~ ~ 18. Tranapo~et 2 Acknowledgement bf Receipt o{ ~a{edaI{ ' , 19. Discrepancy Indication 8pace / F A I L I 20. Facil~y ~ner or Operator Ce~ication of receipt of hazardous materials covered by this manifest except as noted in ~em 19. PHS ~022 A Do Not Wrife ~10~ ~is Line ~ EPA 87~22 (Rev. e-89) Prevlou, edi,on, are ob,Glare. ~e= TSDF SENDS THI ~Y TO ~S WITHIN 30 DAYS Kern Backhoe Service, Inc. Kern IZacuum Service . Well, Tank No. P.O. BOX 5337 · BAKERSFIELD, CALIFORNIA 93388 -~ Field or Area__ (805) 589-5220 N.° 3 4 4 9 " To Be Used For NON.HAZARDOUS Wastes Only WASTE HAULER RECORD GENERATOR (Generator Must Complete) WASTE TO BE DISPOSED ~1~ Name ~/ /.~,~,//v,]~ /~(/?O c~ ,,v.r.~ ~. ~ Type 7-,~,~//~ - ~,/~-~'TO o/t.. Field Address /0o ~~ ~ Generating Location ~~ Special Handling Instructions: City, State, Zips., _N' ~/~IEL~ ~,~ ~O-~ -~ Gloves ~ Goggles ~ Other. Phone CvO~j ~Z~- ~0~ Quantity /-- ~ ~ Bbls. Order Placed By ~ ~ ~ ~ ? ~ (; c ~ ~ ~ q ~ DESIGNATED FACILITY Signature of Authorized Agent ~.~~~.~,~ Name ~-.~ ~ ~~ Address ~0~o ~. ~~ C~ ~ Date ~- ~ ~ ~ ~ City, State, Zip ~/4~~i~ ~ ~~ Title ~ ~_ ~ 3 Phone TRANSPORTER ~ (Hauler Must Complete) Ticket ~ .Unit No. ~ ~ /. Name ~.~ ~~~-~ ~--/~'~ ~AM Address ~ ~ ~ .~~ PickUpDate ~/~ ~. [~?. .~ime .//;/~ D PM NOTE: This form to be used in lieu of the California Depa~ment of Health Set- City, State,Zip ~-/~/~ ~ ~ ~ vices H~ardous Waste Manifest for NON-H~RDOUS wastes only. Phone ~~--,.~ZZO_ REMARKS: Signa~e of Aut~ed Agent or Driver Date ~D ~ , /q~l DISPOSAL FACILITY ~ (Facility Operator Must Complete) Q.an,t ?/ Address.Name ~~S~c~ ~ ' Time t ~ .'/0 ~;: City, State, Zip , 3~OQ DISPOSAL METHOD: n Sudacolm~undment n Injection Phone ~. ~~ / Oisp. Ticket 8 /~ ~ ~ndfill ~ Other ~~~~ ~ ~Date Re tum~yTo: G ENE~TOR UN'SS OTHERWISE SPECIFIED ~ ~ ~ NOTE: It is not necessary to send copy to DOHS / ~/ - ' ' NO HAZARDOUS ~ES SHOULD BE LEVIED N_© 10079 GOLDEN STATE METALS, INC. TANK DISPOSAL FORM P. °. B°x 7°158 ° 2°°0 E' Brundage Lane D a t e~,~:~~ ~) ,19 (~ Bakersfield, California 93387 Phone (805) 327-3559 · Fax (805) 327-5749 Contractor'~ Scrap Metals, Processing & Recycling License No. Contractor's Phone No. J CONTRACTOR: ~~ DESTINA~ON: G.S.M. · 2000 E. BRUNDAGE LANE · BAKERSFIELD, CA 93387 , . . TOTAL QTY GALLONS SERIAL NO. NET TONS EHSD PERMITNO: ~ ~O~ j , 25o 550 .24 1000 - 6 ff .61 ~ RESIDUALS PRESENT (REJECT) 3ooo 1.32 O LEL READ~.G .... ~ 2.,2 ...... OXYGEN CONTENT 7500 3.2s __ DISPOSAL FEE 9000 3.82 ~ SCRAP VALUE ~::' ......................... : .............................................................................................................................................. 12000 ~.93 TOTAL n,t 30 day~ [rom rocoipt ol tank. Contractor's ~i~natur, represents accepta.ce of terms for payment, and confirms ~ i~~ lhal tank r~moval compli~s wilh Slal~ laws, CONTRACTOR'S SIGNATURE CERTIFICATE OF TANK DISPOSAL / DESTRUCTION ~ ~ ~U~E~.. D~E W~ITE-- Con~clor Copy · ?ELLOW-- BI~ CopJ · ~INK-- ~erm~nl Copy STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY [] 1 NEW PERMIT [] 3 RENE~NAL PERMIT [] $ CHANGE O~ INFORMATION [] 7 PERMANENTLY CLOSED'ON SITE ONE ITEM [] 2 INTERIM PERMIT [] 4 AMENDED PERMIT [] 6 TEMPORARY TANK CLOSURE ~'TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.#// B. MANUFACTURED BY: ~t C. DATE' INSTALLED (MO/DAY/YEAR) 7 D. TANK CAPACITY iN GALLONS: ~..~"~____~ II. TANK CONTENTS ~F A-1 IS MARKED, COMPLETE ITEM C. ~ ........ A. []' MOTOR VEH,CLE FUEL B. C..[] ,a REGULAR D,ESEL [] 6AV,AT,ONGAS · UNLEADED ~' ' E3'2 PETROLEUM [] D. [F (A.1) tS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A. III. TANK CONSTRUCTION : A. ~PE OF ~OUaLE WALL ~ 3 SINGLE WA~ Wl~ E~ERIOR LINER ~ 95 UNKNOWN SYSTEM ~~E WALL -- ~ 4 SECONDARY coNTAINMENT (VAULTEDTAN~ ~ 99 OTHER ~ ~ 1 BARE STEEL ~ 2 STAINLESS STEEL ~ 3 FIBERGLASS ~ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ~ B. TANK :~ MATERI~ ~ 5 CONCRETE ~ 6 ~LWlNYL CHLORIDE ~ 7 ~UMINUM ~ 8 1~/~ ME~ANOL COMPATIBLEW/FRP C. INTERIOR' LINING . . IS LINING MATERIAL COMPATIBLE WITH 1~ ME~ANOL ? YES__ NO__ D. CORROSION [] 1 POLYETHYLENE WRAP ~ING [] 3 VINYL WRAP [] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [] 5 CATHODIC PROTECTION~.J 91 NONE ~']. 95 UNKNOWN [] 99 OTHER E. SPILL AND OVERFILL SPILL CONTA!NMENT INSTALLED (YEAR) ;- - OVERFILL PREVENTION EQU{PMENT iNSTALLED [YEAR) -~ IV, PIPING INFORMATION CmCLE A IFABOVEGROUNDOR U IF UNDERGROUND BOTH IF APPLICABLE A. SYSTEU TYPE A U 1 SUCTION A U 2 PRESSURE ~ GRAVI'~f A U gg OTHER B, CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U '99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIOE(PVC)A U a, FIBERGLASS PIPE CORROSION A U § ALUMINUM A D 6 CONCRETE ~, I.I 7 STEEL WI COATiNG A U 8 10~o ME~ANOL COMPATIBLEW/FRP PROTE~ION A ~ 9 GALVANIZED S~EL A U 10 CATHODIC PROTECTION A ~ 95 UNKNOWN A U 99 O~ER D. LEAK DETECTION ~ 1 AUTOMATIC L{NE LEAK DETECTOR ~ 2 LINE T~HTNESS TESTING ~ 3 INTERSTITIAL ~ V. TANK LEAK DETECTION ~ 1 VISUAL CHECK ~ 2 INVENTORY RECONCILIATION ~ZEMONiTORING ~ ~ AUTOMATIC TANK~UGING ~ 5 GROUNDWATER MONITORING VI. TANK CLOSURE INFORMATION I1. ESTIMATED OATE LAST USED (MO/DAY~R, I 2. ESTIMATED QUANT'~ OF ~ 3. WAS TANK FILLED WITH YES ~ NO~ ~/~, ~/~ / SUBSTANCE REMAINING GALLONS INERT MATERIAL ? THIS FORM HAS BEEN COMPLETED UNDER PENAL~ OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT I DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS CO~D OFTHE FOUR NUMBERS BELOW · COUN~ ~ JURISDICTION 8 FAClLI~ · TANK ~ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION BATE FORM G ¢-91) THIS FORM MUST BE ACCOMP~IED BY A PERMff APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. _~..~.._-~-'~ STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY [] 1 NEW PERMIT . [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION ~;~ PERMANENTLY CLOSED SITE ONEITEM [] 2 iNTERIM PERMIT ~ 4 AMENDED PERMIT [] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS -(MUST BE-COMPLETED) DBA OR FAClLI'~NAME NAME OF OPERATOR NEAREST ~RO~, STRE"-E'~ PARCEL # (OF'FIONAL) NAME . /""~ j~,~ /~ STATE ZIP CODE SITE PHONE # WITH AREA CODE · / BOX - /V ~ ~ TO tNDICATE ~ CORPORATION~ IDUAL ~'~ PARTNERSHIP I-~ LOCAL.AGENCY ~ COUNTY-AGENCY I'~ STATE-AGENCY r'-I FEDERAL.AGENCY DISTRICTS ,  RESERVATION ~ 3 FARM [~ 4 PROCESSOR ER ORTRUST LANDS EMERGENCY CONTAC'r PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY). optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHC)HI= # WITH ARFA NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION- (MUST BE COMPLETED) I I _ CAREOFAODRESS.NFORMAT.ON . . I MAILING OR STREETADDRE~S --/-- ' -- I ./ box to ind[cate [~ INDIVIDUAL [~] LOCAL-AGENCY [~ STATI:-AGI:NCY oI co,PO,A.O. ,ARTNI:RS.., COU, Y-A I:NC ,EDI:RAL-AGI:NC¥ III. TANK OWNER INFORMATION- (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS . ./ box to indicate E~] INDIVIDUAL [~] LOCAL-AGENCY E~ STATE-AGENCY [~ CORPORATION ~ PARTNERSHIP E~ COUNTY-AGENCY ~ FEDERAL-AGI:NCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. (TK) HQ 1414~- TY V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S)USED I ,/ box toind~cate ['~l 1 SELF-INSURI:D F-"l 2 GUARANTEE [~ 3 INSURANCE r'~l 4 SURI:TY BOND ~ 5 LETrEROFCREDIT [~ 6 EXEMPTION ,~ER VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be s&nt to the tank owner unless box I or II is checked. THIS FORM HAS B~£N COMPt~T£D UND£R P£NALT¥ OF PEFIdUR¥, AND TO Tt'l~ B£ST OF MY KNOWL~DG£, I$ TRU£ AND COFIFI~CT LOCAL AGENCY USE ONLY(,~/// COUNTY # JURISDICTION # FACILITY # LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE . OPTIONAL THIS FORM MUST BE ACCOMPANIED BY.AT LEAST (1) OR MORE PERMIT APPLICATION · FORM B~ UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, FORM A (5-91) FOROO33A-5 Bakersfield Fire Dept. HAZARDOUS MATERI,,ALS DIVISION · ' 2130 G Street, Bakersfield, CA 93301 . (805) 326-3970 . UNDERGROU_ND TANK QUESTIONNAIR~ /O~ 0 3..1991 / HAZ. MAT. DIV. I. FACILITY/SITE No OF TANKS t DBA OR FACILITY NAME ~,M~E ,OF OP. ERATOR 'EL. - -- ' I NEAREST CRp~ JI~REET , I// PARCEL No.~OPTIONAL) · I STATE Z~ CODE - / ~' BOX TO INDICATE [~ CORPORAT. ION ~IVIDUAL [~ PARTNERSHIP _O LO_CAL AGENCY DIST..RICTS .~J COU_NIY·AGENCY. O STATEAGENCY- TYPE OF BUSINESS , ~ 1 GAS STATION [~ 2 DISTRIBUTOR I KERN COUNT/PERMIT . TO OPE~P, ATE No. / EMERGENCYCONTACTPERSON(PRIMARY) ' EMERGENCY (S~CONDARY) optional DA~yS: N,AME (LAST. F,~IRST) PHONE No. WITH AREA CODE DA~: NAME (LAST. FIRST) PHONE NO. WITH AREA CODE NIGH1;S: NAME (LASI,~I~ST) PHONE NO. WfI'H ARE.,~ CODE PHONE NO. WIT AREA CODE MAILING OR STREET ADDRESS ~/~ BOX ~fDIVIDUAL ~ LOCAL AGENCY ~ STATE AGENCY TO INDICATE ~J PARTNERSHIP ~J COUNTY AGENCY ~ FEDERAL AGENCY CITY NAME ZIP CODE I. PHONE N~ WITH AREA CODE III. TANKOWNER (M BE COMPLETED) CARE OF ADDRESS INFORMATION MAILING OR STRE [ ~/~ BOX UAL ~ LOCAL AGENCY ~ STATE AGENCY .- .o,.0,.....,.,,,?,s,.,:,. ZIP CODE PHONE No. WITH AREA CODE OWNER'S DATE VOLUME PRODUCT IN TANK No. INSTALLED STORED SERVICE [ YIN / YIN Y/N Y/N DO YOU HAVE FINANCIAL RESPONSIBILITY? Y TYPE .. Fill one segment o~or each tank, unless all~Lks and piping are constructed of the~ame materials, style andt~,~, then only fill one segment out. please identify tanks by owner ID #. A. OWNER'S TANK I. D. # -' B. MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) U ~'~ ~;(~0('%) ~' D.. TANK C~AO,~' IN G~ONS: ~ ~ O II1. TANK CONSTRUC~0N UA.~ ON~ ,TE. O.~V,. nOXES ~ ,. A.O C. ~ A~ THAT AP~L,~S ,, aOX O A..PEOF ~/1 DOUB[EWALL ~ ~ SmNGLEWA~W,.E~ERmORUNE. ~ g5 UNKNOWN SYSTEM ~ SINGLE WALL ~ 4 SECONDARY ~NTAINMENT (VAUL~DTAN~ ~ 9, O~ER BARE STEEL ~ 2 STAINLESS S~EL ~ 3 FIBERG~S ~ 4 STEEL C~D Wl FIBERG~SS REINFORCED P~STIC B. TANK MATERI~ ~ 5 CONCRETE ~ 6 mLWINYL CHLORIDE ~ 7 ~UMINUM ~ 8 1~. ME~ANOL ~MPATIBLEW/FRP C. INTERIOR ' ': IS LINING MATERIAL ~MPATIB~ WITH 1~ ME~ANOL ? YES__ ~__ D. CORROSION ~ 1 ~LYE~LENE W~AP ~/ ~ATI~ , ~' ~ 3 ~t ~ ."~ ~ ~_ ~I~ERG~S~REIN~ORC~D-~STIC ..... ........... PRO~ECTIOH -~-S-CATHOD~C-P~OTECTION ~-9~-NONE ' .~ ~ UN~WN ? ~ ~ O~ER ; IV. PIPING INFORMATION cmc~ A ~FAaOVEGROUNDOR U ~UNOEnanOUNO. nO~UC~aLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 G~VIW A U ~ O~ER  ~NSTRUCTION A ~ 1 SINGLE WALL ~ U 2 ~LE WALL ~ U 3 LIN~ TRENCH ~ U g5 UNKNOWN C. MATERIAL AND A U 1 GARESTEEL A U 2 STAINLESS S~EL A U 3 ~LWINYL CHLORIDE (PVC)A U 4 FIBERG~S PIPE CORROSION A. U 5 ~UMINUM A U 6 CONCRE~ A U 7 STEEL W/ COATING A U 8 I~ ME~ANO~ ~MPATIBLEW/FRP PROTECTION A U 9 ~LVANI~D S~EL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U ~ O~ER V. TANK LEAK D~ECTION ~6 TANK TESTING ~ 7 INmRSTITIALMONIToRING ~ gl NONE ~ 95 UNKNOWN ~ 9g omen A. OWNER'S TANK L-D. ~ B. MANUFAC~RED BY: C. DATE INSTALLED (MO/DAY. EAR) x D. TANK C~ACI~ iN G~LONS: II1. TANK CONSTRUCTION MA.KON~MONLV~NaOX~S~a. ANOC.~OALL~ATAP.U~S~NaOXO A. ~PE OF ~ 1 DOUBLE WALL ~ 3 SINGLE WA~ WI~ E~ERIOR LINER ~ 95 UNKNOWN SYSTEM ~ 2 SINGLE WALL ~ 4 SECONDARY CONTAINMENT {VAUL~D TAN~ ~ 99 O~ER a. TANK ~ ~ BARE STEEL ~ 2 STAIN~S-STE~L '-~ 3 FIBERG~S ~ 4 STEEL C~D W/FlaEhG~S~REINFORCEDP~STIC MATERIAL ~ 5 CONCRE~ ~ 6 ~LWINYL CHLORIDE ~ 7 ~UMINUM ~ 8 1~. ME~ANOL COMPATIBLEW/FRP ~ ~ .u~. UN~O ~ ~ ~ UN,Ne ~ 3 EPO~ UN,Ne ~ 4 P. ENOL~ UN,Ne C. INTERIOR ~ 5 a~ UN~NG ~ S UNLINED ~ 9S UN~OWN ~ ~ O~ER LINING Is LINING MATERIAL COMPATIBLE WITH 1~ ME~ANOL ? YES~ NO~ D. CORROSION ~ 1 POLYETHYLENE WRAP [] 2 C. OATING [] 3 VINYL WRAP [] 4. FIBERGLASS REINFORCED PLASTIC PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE ' [] 95 UNKNOWN [] 99 OTHER . IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U ;i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER. B. CONSTRUCTION A I.~ 1 SINGLE WALL ~ ~J 2 DOUBLE WALL kit U 3 LINED TRENCH ,8, U g5 UNKNOWN J~ U 99. OTHER ' C. MATERIAL AND A u 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [] 1 AUTOMATIC LINE LEAK DETECTOR [] 2 LINE TIGHTNESS TESTING [] 3 INTERSTITIAL MONITORING [] 99 OTHER V. TANK LEAK DETECTION ~,'~] 1 VISU'AL CHECK [] 2 iNVENTORY RECONCILIATION [] 3 VAPOR MONITORING ~ 4 AUTOMATIC TANK GAUGING [] 5 GROUND WATER MONITORING' "~.-I 6 TANK TEST'NG ~ 7 'NTERSTITiALMONITORING [~ gl NONE ~ g5 UNKNOWN ~-~ gg OTNER UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES DISTRIBUTICN SHOWN. ON:;THE INSTRUCTION SHEET:ON THE:BACK PAGE OF ~HIS:FORM~!:21!i! ;!i: NAME OF INDIVIDUAL FLUNG REPORT PHONE ~ ( )  REPRESENTING [] OWNER/OPERATOR [] REGIONAL BOARD I COMPANYOR AGENCY NAME ALAGENCY [] OTHER ~ ADDRESS ~ NAME I CONTACT PERSON PHONE ~ ~ [] UNKNOWNJ ( ) ~ ADDRESS  om cou~ zip CROSS STRFET f O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE ~ .. ( ). ~o REGIONAL BOARD PHONE :~ L~ (1) l / NAME QUANTITY LOST (GALLONS) co [] UNKNOWN DATE DISCOVERED Y HOW DISCOVERED [] INVENTORY CONTROL [] SUBSURFACE MONITORING [] NUISANCE CONDITIONS ~ DATE DIe, CHARGE BEGAN METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) .I .I om ~1 ,I ,I ~UNKNOWN [] REMOVE CONTENTS~E TANK & REMOVE [] REPAIR PIPING ~ HAS DISCHARGE BEEN STOPPED ? [] REPAIR TANK [] CLOSE TANK & FILL IN PLACE [] CHANGE PROCEDURE ~ ~ [] ,O IF YES, DATE taI af DI ~ Yt Y [] REPLACE TANK [] OTHER ~ ~ SOURCEOF DISCHARGE ~ CAUSE(S) .~ ~ [] TANK LEAK~UNKNOWN [] OVERFILL [] RUPTURE/FAILURE [] SPILL ~O o [] PIPING LEAK [] OTHER [] CORROSION ....~3~OWN [] OTHER ~ ~ CHECK ONE ONLY [] UNDE RM,NED O,L ONLY [] GROUNDWATER [] DR,NK,NG WA, ER- ICHECK ONLY,F WATER WEL,S ACTUALLY BEEN AFFEC D CHilLY ~m ~ NO ACTION TAKEN [] PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMI3-FED [~ POLLUTION CHARACTERIZATION ~ ~ [] LEAK BEING CONFIRMED [] PRELIMINARY SITE ASSESSMENT UNDERWAY [] POST CLEANUP MONITORING iN PROGRESS [] REMEDIATION PLAN [] CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) [] CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) [] EXCAVATE & DISPOSE (ED) [] REMOVE FREE PRODUCT (FP) [] ENHANCED BIO DEGRADATION (IT) ~O~ z~iTE (CD) [] EXCAVATE & TREAT (ET) [] PUMP & TREAT GROUNDWATER (GT) [] REPLACE SUPPLY (RS) ~:~ o [] CONTAINMENT BARRIER (CB) [] NO ACTION REQUIRED (NA) [] TREATMENT AT HOOKUP (HU) [] VENT SOIL (VS) [] VACUUM EXTRACT (VE) [] OTHER (CT) HSC 05 {~0)