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Home My WebLink AboutBUSINESS PLANi _ F ~ ~V~ ~. ~ZW ' ,.., H ;~ W W awl as ~~ j ;~ N x~ _Z ; ~_ Hazardous. Materials/HaZardous Waste Unified Permit .~ CONDITIONS OF,~PERMIT ON REVERSE SIDE .' ~ H~ous ~al9 P~n Permit ID ~:: 015~00~00621 ~ Risk~~tP~mm HOWARDS MINI MARKET ~6 LOCATIOn: 4201 BfiLLfi TER~G~ 015-000-000621-0001 UNLADED GAS~t~;, ' ,Z "-~:~ ~~LINER MoN:I~I,~G~ 015-000-000621-0002 UNLADED PLU~?,.;' 015-000-000621-0003 UNLADED REG~It 015-000-000621-0004 UNLEADED PREh 1U~ ~': [':~ .... ,:;'' 'T~'~2~ " I~u~ by: Ba[er~field Fire D~paament OFFICE OF EN~R ONMENTAL SER ~CES' ' 1715 Chester Ave., 3rd Floor .: Appmv~by: Bakersfield, CA 93301 . Voice. {661) 326-3979 " ~ F~ (661) 326-0576 ~... · .- ..',:~'~;,~:'-Expmt~on Date: . Permit Opera :e Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE [ ............ ;~,,,?~,~,~,,~,,,~,~,~,, ................ This permit is issued for the following: UNLEADED GASOLINE GAL""~::,,, 10/1~'"~':'"'~::~, FCS ATG /~7~' LPT F PRESSURE ALD 0003 UNLEADED PLUS 12,000'~[00:~GAL .:'5~:,::,.40/!/84 %,.SW' FCS A~ /~,.",,f: LPT F PRESSURE ALD 0004 UNLEADED REGULAR 000.00: 'GAL~'.' '~ ']=01;~/8~:' r,. SW ECS::~'~:5 ,,,,:~:.:,5' ATG .,,(L'::~ ,~" LPT F PRESSURE ALD ls~ by: ~ ~~ B~er~field Fke D~a~ment Approv~ by: ~~~' O~CE OFE~RO~AL S~ B~e~el~ CA 9~301 Voice (805) 3~979 FAX (80S)~16-0S76 Expiration Date: ~n~ ~O~ ~000 City of Bakersfield Office of Environmental Services 1715 Chester Ave., Suite 300 Bakersfield, California 93301 (805) 326-3979 An upgrade compliance certificate has been issued in connection with the operating permit for the facility indicated below. The certificate number on this facsimile matches the number on the certificate displayed at the facility. Instructions to the issuing agency: Use the space below to enter the following information in the format of your choice: name of owner; name of operator; name of facility; street ad&ess, city, and zip code of facility; facility identification number (from Form A); name of issuing agency; and date of issue. Other identifying information may be added as deemed necessary by the local agency. This permit is issued on this 2nd day of November, 1998 to: HOWARDS MINI MARKET #6 Permit #015-021-000621 4201 Belle Terrace Bakersfield, California 93309 - :~rv- - _ Prevention Services UNIFIED PROGRAM INSPECTION CHECKLIST ` ~ B F R S, n 900 Truxtiin Ave., Suite 210 - FARE Bakersfield, CA 93301 SECTION 1: Business Plan and Inventory Program ° aRrIN Tel.: (661) 326-3979. - - ~ Fax: , (661) 872-2171 FACILITY NAM ~ - - INSPECT N ATE INSPECTION TIME ~~ 8 6 0 7 ADDRESS ~~ ~ ( ~ ^ P~~~ ~ OOFF~pPLOYEES C{ ., © ~ ~~ ~ \ ~~~ ' J FACILITY CONTACT BUSINESS ID NUMBER 1.5-021- ~ ~, f -- - Section 1: Business Plan and Inventory Program ~ . ^ ROUTINE ,,., L`YCOMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V (c=Compliance OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND ^ BUSIrIeSS PLAN CONTACT INFORMATION ACCURATE - ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION - / LX ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITY ~ _ -` ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? ^ YES ~NO EXPLAIN: / l QUESTI~NS REG~RDI~1G THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 Inspector (Please Print) Fire ~t?Cention / 1" In /Shift of Site/Station # _ - _ White -Prevention Services - .Yellow -.Station Copy Pink -'Business Copy- fD 2155 ~~ (Rev. 09105 - ~~ INSPECTIONS BUSINESS PLAN & INVENTORY PROGRAM UNIFIED PROGRAM INSPECTION CHECKLIST 1 B D E R S F I L D P/BE AIirTM T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 FACILITY NAME: ~til[~ u-c~S INSPECTION DATE: ~ b 8 Section 2: Underground Storage Tanks Program ^ Routine m/Combined ^ Joint Agency ^ Multi-Agency ^ Complaint ^ Re-Inspection Type of Tank ~ .~~ Number of Tanks Type of Monitoring t, Type of Piping OPERATION C V COMMENTS Proper tank data on file Proper owner /operator data on file Permit fees current Certification of Financial Responsibility Monitoring record adequate and current Maintenance records adequate and current Failure to correct prior UST violations Has there been an unauthorized release? ^ Yes ^ No Section 3: Aboveground Storage Tanks Program Tank Size(s) Type of Tank Aggregate Capacity Number of Tanks OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MVF?) If yes, does tank have overfill /overspill protection? C =Compliance V =Violation Y =Yes N = No Inspector: Questions regarding this inspection? Please call us at (661) 326-3979 White -Prevention Services Pink -Business Copy KBF-7335 FD 2156 (Rev. 09/05) HOWARDS 6 SiteID: 015-021-000621 Manager JUSTINE SOR Location: 4201 BELLE TERR City BAKERSFIELD BusPhone: (661) 397-7600 Map 123 CommHaz Moderate Grid: 02C FacUnits: 1 AOV: CommCode: BFD STA 07 EPA Numb: SIC Code:5541 DunnBrad:l7-364-9625 Emergency Contact / Title Emergency Contact / Title KEVIN CHEA / OWNER JUSTINE SOR / MANAGER Business Phone: (661) 397-7600x Business Phone: (661) 397-7600x 24-Hour Phone (661) 632-6629x 24-Hour Phone (661) 632-6631x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact KEVIN CHEA Phone: (661) 39'7-7600x MailAddr: 4201 BELLE TERR State: CA City BAKERSFIELD Zip 93309 Owner KEVIN CHEA Phone: (661) 397-7600x Address 4201 BELLE TERR State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif ' d: RSs : No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD ENfi'~ J U L 1 ~ 2Q07 PROG U - UST ''~ ck:o on my inquiry of those individuals responsibie for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true , arcura'e, and ~ m ate. /~ ~ C . ~~ ° G~ Si nat ~- g ure Datt -1- 07/12/2007 (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFIED PROGRAM CONSOLIDATED FORM) ";APPLICATION BISIVESS ONIMBt/OPBtATOR DBVTFX',ATION FORM (HAZARDOUS MATERIALS FACILITY INFORMATION) H R F I_ D P/Brs ~r><rr r BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301• Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 ' I. FACILITY IDENTIFICATION FACILITY ID NO. t Year Beginning t00 Year EnUing tOt BUSINESS NAME (Stam~~FACILITY NAME or DBA- Doing Busi as As) ~ !, a BUSINESS PHONE ~ toz SITE ADDRESS _~, C ~ \ 103 toa CITY C . \ ~. CA Ip ~..~ ` Q tos DUNN 8 BRADSTREET 1t>a SIC CODE (4 Digit #) toy COUNTY ~. ~ e ~ t08 ' OPERATOR NAME tos OPERATOR PHONE Ito .. ... :... ~ , . ,:. ~ ; F ..; :. ,.. ~~ .. ~.- 11: OWNER INFORMATION :_.:; ." . :::., ~, . OWNER NAME `` ',~ ~ /~ ~ /~ ttt '~V 1 Y 1 ~ V ~ OWNER PHONE r` ~ .- tt2 OWNER MAILING ADDRESS 100 `~ ~bb~e5~,-~~~. -v-~. tta CITY tta STATE ~~ Its IP~ ~ ~, tt8 ' ~ ~ ~ III. ENVIRONMENTAL CONTACT . :,_• . _ CONTACT NAME tt7 CONTACT PHONE NQ CONTACT MAILING ADDRESS tt9 CITY 120 STATE t2t ZIP t22 '- PRIMARY- " ~~ ..' ~~ IV. EMERGENCY.CONTACTS =SECONDARY=`. . NAME ~~ \ ~ ~~ ~ 123 NAME ~ _ ~ ~ ; ~ ~ ~ r' ~ V 128 TITLE '~(~ ~ 124 TITLE S\J~\ ~ /~ 129 BUSINESS PHONE .- ~ ~ i- ~ 125 V BUSINESS PHONE 130 126 24-HOUR PHONE (' 24-HOUR PHONE ~ ~ 131 PAGER NO. 127 PAGER N0. 132 133 ~' ` `' ~ ~ ~ ~ V:CERTIFICATION ~` Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am fa iliar with the information submitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE 0 I ER 1 ~ i~L~ DATE 134 NAME OF DOCUMENT PREPARER 135 NAME OF OWNER/OPERATOR (SDIGNATURE & PRINT) 137 TITL OF O ER/OPERATOR 138 FD 2142 (Rev. 09/05) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN APPLICATION FOR SECTION DISCOVERY AND NOTIFICATION (FORMS) rw-RI A~ T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (6611852-2171 INSTRUCTIONS Page 1 of 2 1. To avoid further action, return this form within 30 days of receipt. 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as ssible. ,,,. '~~ ;SECTION I FACILITY IDENTIFICATION BUSINESS NACM~E (_ S ~ e a~s `F`A`CIL~' AME or DBA -Doing Busi \ As) ~~`~~ W `\ ADDRESS (FOf /oca l use only) FACILfrY ID NO. ~ T'" 'rLL', ~ '' ~~;~~~'~~'3ECTION U 1 '-;DISCOVERY~AND NOTIFICATIONS` A LEAK DETECTION(A~N~D MONITORING PROCEDURES: p `~~$ 60~ ~S~ ~~550 ~o-L` ~'~~~ ~6~0 ~ t~ ~1 B. EMPLOYEE AND AGENCY NOTIFICATION: c (~ C. ENVIRON,M,`ENT~AL RESPONSE MANAGEMENT: `^ f ~/~ p , / r ( ,~ CC` ,QS `~eS D. EMERGENCY MEDICAL PLAN: ~ ~c~.-Q.`~i ~\ ~~CC ~ ~-~~~ b~ q- ~ ~ L-l ~~ ~ C ~. ~~ ~ J 4~ ~ ~~ ~ ~ :SECTION 112 RELEASE ESPONSE PLAN i .. .~. _,.. •........... i., ... ~ ,. ~ .d, i .. ' . ....... A. HAZARD ASSESMEN ~ D PREVENTION MEA~ ES '~ ~` '~+( ~p~s ~~C~'~' ~\.e~1~ e r~ c~,c-~.c- ~ Q k Q `~ ~~ ~. ens e 2. ~~ s1~ e,~~ a e~ ~~ St~ ~ S~ ~ ~1 B. RELEASE CONTAINMENT AND/OR MfTIGATION: !'' y~„ 0.` \ ^ t ~\ ~r. ~ ~~~~ ~G~` /~ ~~~\/~ ~W, ~/ ` ~ ~' ~ C\ i ` - ~~oQ~,~~`l. ~sG , ~ ~ e~~ a. s p~~e ~a p~c SQ,~~a ~1. C. CLEAN-UP AND RECOVER PROCEDU ~, ~ ~~+ c~\ ° ~ `Qr i vim- ~`C~ ~ ~ ~ d 22\ ~ Tz ~7 ~ ~~'~ e `. S~~S~ ~,tiC'c~1 -y .e Q ~ C s ~ ~.c~ec S ~ ~d Ul~ ` t ~~~ ~~ ~e~ r EC` ~ ~~ ~I ~I :~~ ~`_ i ~`~ ~ Q~ 0. ~ ~~ ~~.1LVI'l ^ ~~~(~ ~~~~~( n~ FD 2169 (Rev. os/os~ ~~ L ~.. J C~.~~ p ~ e~~~-~ S '~~~ . tea. ~ C.~YI_~C ~ ~ '~ `~ ~~~,\ ~~v~~ ~~~ ~~ ~S~s-mac' - ~o~-~~ ~ ~~ ~Q-~~ ~~ Page 2 of 2 ``;: ~ro;.c ~ ~;p;a r r .rA. .a::e a s c S -~a :a Ati ,u. z~,4 'tr, _- rv,rr^.n.: _.-°~F; w. •7 i, bra . cars Y Y~~r , EASE:~i~ESPaNSE-P ~lA~t==G'ON'd'~;~~~.~~il~~~,~i~''~, ~, ~ '~ :~~' ~ h ~''SEGI~ION`1121REL` ~ r ' '< ' F ~ ~ , , F x 4s, .+.J. C,~:~.~t~~.. ; ..4t_. sf.4.~..,<, r s..~.~ ti.a~r..r,~,,,~....,?...r.,~ ~,.. .,4...~x~ ~ ~: ~"., ~r~~~: : # ,.t ~g~~!r.x, UTILITY SHUT-0FFS (LOCATION OF SHUT-0FFS AT YOUR FACILITY) -. ~~~ ~ ~ NATURAL GAS/PROPANE: ~\J ~L ~ ~ C.~ \ \ ~ ~ h ELECTRICAL: \ \ C., Q ~ \ WATER: SPECIAL: ~~ \ PRNATE FIRE PROTECTIONNVATERAVALLABILITY: `r 1 ~p~ ~- ~~..~,~ ~l A PRNATE FIRE PROTECTION: \ ~~ ` ~" ~'~~~1~'~1~~15~~ `~C~~4' \ " ~ ~ e ~~ \ `'' `\ 1 , , ~~ ( ~ .~c~j~f~`V~. C~ ~ ~ t~ \ C9'~ ~~'\S ~t~ `~^~l.` ~ ~1 ~ `~.. ~` ~ 9e\<< ~eQ0.~` ~~ ~- :vt ~ z s~ ~ ~ ~ ~i~~sc ~ ~~ ~ m~ r k C ~ t ~ -~ ~ ~ r,~ ~~-- ~ a ®~ ~C ~v c\ Cm B. WATER AVAILABILITY (FIRE HYDRANT): 25~' ~ ~ ~~~~~5~ ~~~ ~~ cQ ~ 4~c. PJ ~~x~- ~ ~~~ ~s~~~~ 'n ` f° J ^2 Y nL r ~ }~ Y? 8iF Y P4 .+. '?. hd H z # ert 1r t~. '$ ,. ~ .. ° _ ~i , _ .. ~~ , ... `rr ...~,¢;; r,.._F;~~..3SECTIQN III.q~TRAI,NINSG F~ `_{~j,.r v:~~a7~~.:~, ~~. r~}~ .. NUMBER OF EMPLOYEES: MATERIAL SAFELY DATA SHEETS ON FIL~ ~ ~ 5 ~ ~~~ ~ ~ w ~ e~ ~ BRIEF SUMMARY OF TRAINING PROGRAM: c ~ y °~ ~~ S ~ . ~ t ~ ~ d ~ 1r~ G•Z~r c~ GCS ~ ~ ~~~ S ~ ~ ~ . ~ ~. ~ ~ a~~~ ~vl ~ ~ ~h~ ~ ~~ ~ . ~jtti~..~ ~S C~ 1 \ ~'c~ S a'-~ \ ~ C~\~_ s~ ~ Ci . ~ V~'l c~.~~ ~~ ~~~y ~.~ ~,~~~ ~ ~~ Lb~w~- ~ ~ ~~~ `~~~~ ~a ~ .~~-teS i .r~.1 . tt .. + ~ ~ 4 7 h:~+" ;~ C;ERTI~FIGAT ION ~~: : y •, , , ~ r, .~ ~ .. , r.~ s~ Based on my inquiry of those individuals responsible for obtaining the information, 1 certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. SIGNATUR~A WNER / OPERAT 0 ESIGNATED REPRESENTATNE DATE / / ~ 477 C , ~ ~ mil" NAME OF SIG (print) 478 TITLE OF SIGNER 479 FD 269 (Rev. 09/05) EMERGENCY RESPONSE PLAN UNDERGROUND STORAGE TANK MONITORING PROGRAM This monitoring program must be kept at the UST location at aU times. The information on this monitoring program are conditions of the operating permit. The permit bolder must notify the Office of Environmental Services within 30 days of any changes to the monitoring procedures. unless required to obtain approval before making the change. Required by Sections 2632(d) and 2641(b) CCR Facility Name ---.J.{l\lJ"H'Á t; [Lt ( N, &x.t Facility Address LlJ..O , ~I' ~Tf f{lÁ(c- 1. If an unauthorized release occurs, how 'Will the hazardous substance be cleaned up? Note: If released hazardous substances reach the environment, increase the fire or explosion hazard., are not cleaned up from the secondary containment within 8 hours, or deteriorate the secondary containment, then the Office of Environmental Services must be no¡tified within 24 hours. ~1 ~\~(r It. c.Lt,u( 4.~ aN ð~ lUt1.1(fl(( {or ~lN\/ill c..o.lt,. ~(JCft ¡n(ll~ ~~ If till J...'¡:¡'; (),nf. f 1 ' 2. Describe the proposed methods and equipment to be used for removing and pro erly disposing of any hazardous substance. -d- r- 3. Describe the location and availability of the required cleanup equipment in item 2 above. O~ ,,~ d- H" rfø. '" 4. Describe the maintenance schedule for the cleanup equipment: s. List the name(s) and title(s) of the person(s) responsible for authorizing any work nece~sary under the resP}o~ plan: J~ü~;~5{l)~; ~ U\ttr WRITTEN MONITORING PROCEDURES UNDERGROUND STORAGE TANK MONITORING PROGRAM TbillDOnicolÙl' propuIlIIUII be kepc II die UST locaàoa II aU limes. TbeiDtbrmalioa oa thiJ """'ÏfIarúI¡ prvpam are coodiàoDl, of die opcrIIi.q permit Tbo pcrIIIÌt bolder muIt ~ tile OftIœ alE!l\'úO....·.~·I_~ ScMca widWa 30 days of any çhA..... CO die IDODiCOIÙI' proœdures. W1JcII required CO obcaia approyaJ Wore nulri~, the chaDF. Required by Sccâou2632(d) and 2641(h) CCR. Facility Name ---I10uJ{HJ~ ~(Å l t\A~t -__ Facility Address U.1l\ I L~t{\L \f ('(Iff t. E. F. G. A Describe the frequency of performing the monitoring: Tank ~nll\\\\I\(()'ll ~ . Piping ð OV\.\-'v\.c\\1 C, B. What methods and equipment, identified by name aDd model, will be used for pedbmiøa the monitoring: Tank lJaA,n" Q()o+ TLS . 2.Ç() Piping (}If Al \". l2C\o r Tl...b t ~~ () c. Describe the location(s) where the monitoring will be performed (fååJity plot plan should be attached): ~eh\ ~J. "(\"f'I t- 0lh"",A·( r .sce.. 6P W- . 1t111 r ~ lJ r ) r .fJl D. List the name(s) and title(s) of the people responsible for performing the monitoring and/or maintaining the equip~ent: j l OAf," ~~ð..\ '('1 QfP . lL P. A NN fA.. l3 Id±u..+OH I ~ t\q V'. Reporting Fonnat for mOlÛtoring: Tank ð..; Wl Piping f' J_ M Describe the preventive maintenance schedule for the monitoring equipment. Note: MaiDtenuce mot be in accordance with the manufacturer's malatea.nee schedule but Dot lea than every 12 moath.. --.ek~rr( ~l1-r I'~ 'it' /I v- Describe the training njS8J'Y for the. operation oft.(ST system, including piping, and the monitoring equipment: f\ dJl.(.~ C fJ,AJuu( ~~ Environmental Management Three SBC Plaza South Region Room 900 Dallas, TX 75202 ~;~~ January 03, 2006 Ray Rodriguez Fire Prevention Env Officer Bakersfield Fire Dept 900 Truxtun Ave., Room 200 Bakersfield, CA 93301 RE: Certification of Financial Responsibility -Underground Storage Tanks Enclosed please find a copy of our annual State of California Water Resources Control Board Certification of Financial Responsibility and a Certificate of Insurance with attached language to demonstrate the financial responsibility of SBC/Pacific Bell and/or its affiliate company for its underground storage tanks. Also enclosed please find a list of the SBC/Pacific Bell sites that are covered by insurance and that have underground storage tanks on the premises in your area of jurisdiction. I can be reached at (214) 464-1917 if you have questions regarding this matter. Thank you for your help complying with this requirement. J A. Stehr, AIA Environmental Manager SBC Environmental Management On behalf of Cheryl Allen Attachment: Certification of Financial Responsibility List of insured sites with tanks Certificate of Insurance with attached language .. For State Use Only State of California State Watet Resources Control Board Division of Clean Water Programs P.O. Box 944212 Sacramento, CA 94244-2120 CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I am required to demonstrate Financial Responsibility in the required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: ^ 500;000, dollars per occurrence ^ 1 million dollars annual aggregate or AND' or ®1 million"dollars per occurrence ®2 million dollars annual aggregate B. Pacific Bell Telephone Company . hereby certifies that it is in compliance with the requirementsof Section 2807, (Name of tank Owner orOpemtor) ~ ~ ~ ~ Art1elC 3, Chapter 18, Division 3, Title 23, Califomia Code of Regulations. The mechanisms used to demonstrate ftnancial res onsibili as re wired b Section 2807 are as follows: C. Mechanism . Name and Address of Issuer- Mechanism . Coverage .Coverage Corrective Third Party T e Number Amount Period Action Compensation Certificate of Gateway Rivers Insurance $1,000,000 Per 12/31/2005- . Yes Yes .Insurance Company Occurrence & 12/31/2006 76 St. Paul Street, Suite 500, $2,000,000 Burlington VT 0540.1-4477 Annual Aggregate Note: If you are u +ng the State Fund as any part of your demonstration of financial responsibility, your execution and submision of this certification also certifies that ou are in com liance with all cond+tions for artici anon in the Fund: D Facility Name ~ - ~ _ Facility Address . Pacific Bell Tele hone Com an See Attachment Facility Name Facility Address Facility Name - ~ ~ Facility Address Facility Namc ~ ~ ~ _ Facility Address :A, . Facility Name Facility Address Facility Name Facility Address Facility Name Facility Address E- Signatum o k Owner or Operat Date ~`~ Name and Title of Tank Owner or Operator 12-14-2005 Kenneth C. Lon ,Vice President & Treasurer. azure of Wit+lci9 or o ... ~ Daze ~ Name of Witness or Notary 12-14-2005 Barbara L. Hohman "" VSubmit original to local UST regulatory agency. Keep a copy at each UST facility. UN-049 - 1(3 www.unidocs.org 01/24/02 1 I. CERTIFICATE OF INSURANCE ^ISSUE DATE 12/14/2005 PRODUCER ~ - . ~' ~ ~ ~' ~ ~ -~ THIS CERTIFICATE IS LSSIJED AS A MATTER OF INFORMATION ONLY AND . ~ - - ~ ~ ~ ~ CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE TD Dli\EC'I` ~ ~ DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE ~ ~ - , - POLICIES BELOW COMPANIES AFFORDING COVERAGE . ~ ~ _ - ~ COMEANY ~ ~ ~ . A GATEWAY RIVERS INSURANCE CO . LHTIER COMPANY INSURED B LHTTER SBC Communications Inc . coMPANr Pacific Bell Telephone Company LE7THR C 175 E Houston Street . coMEnNY San Antonio, TX 78205 - LE,-rER D coMPANY LETTER E CO~');RAGE$ THIS IS TO CERTQ+Y 7IIAT THE POLICffS OF INSURANCE LISTED BELOW GAVE BEEN LSSUED TO THE INSURED NAMED ABO VE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ~. ~ ~ ~ ~ - CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICINS DESCRHSED HEREIN IN SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLADNS. CO ~ TYPH OF INSURANCE - POLICY NUMBER POLICY EFF. POLICY HXP. - ~ LB1UT5 LTR ~ ~ DATE MM/DD DATE MM/DD - - ~ ~ ~ ~ ~ ~ ~ GENERAL AGGREGATE - COMM. GENERAL LIABH.ITY ~ ~ - , PROD-COMP/OP ACC. - ~, ~~..~ CLAIINS MADE ^ OCC ~ ~ ~ ~ ~ _ ~ PERS. & ADV. INJURY - OWNER'S & CONTACT'S PR07- ~ ~ - ~ - EACH OCCURRENCE - - - ~ - FHUsD DAMAGE tone naef MED. EXP. ~onc rea AU TO LIABH,IIY - . COMBINED SINGLE - ANY AUTO - ~ ~ ~ - ~ LBNIT ALL OWNED AUTOS - - ~ ~ - - BODH.Y INJURY SCHEDULED AUTOS ~ ~ ~ ~ ~ RER PEasorp ~ ~ _ . HHIED AU705 ~ ~ ~ ~ ~ ~ ~ BODn.Y INJURY NON-0WNED AUTOS ~~ ~ ~ ~ ~ Rea ACCIDtNT7 ' GARACH LIABH.ITY - - ~ - PROPERTY DAMAGE .. , - EXC&SS LIABILrIY ~ ~ - .. ~ EACR OCCURRENCE UMBRELLA FORM ~ ~ ~ ~ ~ ~ 4I;I;RFl:4TF OTNER THAN UMBRELLA FORM '4 OTHER 409-1UST001 12/31/05 12/31/06 $1,000,000 Per Occurrence Environmental Impairment Liability for Underground and Above Ground $2,000,000 Annual Aggregate Storage Tanks ' DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS As pertains to the covered location(s) referenced in the attached list. ~~,c FKniac. ~~ rf. uoi_[~~ r; c:LyC11.r.e rro~~ i / ' State Of CallfOrnla ~ SHOULD ANY OF THE ABOVE DHSCRBHD POLICIES BE CANCELLED BEFORE THE State. Water RCSOUrCeS COntrOl BOard - EXPIRATION DATE THEREOF, THE ISSUING COMPANY WH.L ENDEAVOR TO l I~1V1$lOn.Of Clean WateI PrOgram$ MAIL so DAYS WRITTEN NOTICH TO T~E CERTH~7CATE HOLDER NAMED TO THE P.O. Box 944212 LEFT, BUT FAn.URE TO MAa SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR Sacramento CA 94244-2120 , LIABH.rrY OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES. Certificate no: OS-150 with attached Endorsement Replacing: New Au7HORIZED REPRESEN IVE AGOIiD,25~5' /991 40 CFR, 280.97 [bl [21 Pacific Bell Telephone Co. CERTIFICATE OF INSURANCE Name: [name of each covered location] See attached list. Address: [address of each covered location] See attached list. Policy Number: 409-1UST001 Endorsement (if applicable): Not Applicable Period of Coverage: 12/31/2005 -12/31/2006 Name of Insurer: Gateway Rivers Insurance Company Address of Insurer: 76 St. Paul Street, Suite 500, Burlington VT 05401-4477 , - ' 'Address of Insured: per Certificate of Insurance Certification: 1. Gateway Rivers Insurance Company, the "Insurer," as identified above, hereby certifies that it has issued liability insurance covering the following underground storage tank(s): See attached list of sites. for taking corrective action and/or compensating third parties for bodily injury and property damage caused. by either sudden accidental releases or non-sudden accidental releases or accidental releases; in accordance with and subject to the limits of liability, exclusions, conditions, and other terms of the policy; arising from operating the underground storage tank(s) identified above. The limits of liability are $1,000,000 each occurrence and $2,000,000 annual aggregate, exclusive of legal defense costs, which are subject to a separate limit under the policy. This coverage is provided under policy number 409-1UST001. The effective date ofsaid policy is ].2/31/2005,to .12/31./2006. ~. .. 2. The Insurer further certifies the following with respect to the insurance described in Paragraph 1: a: Bankruptcy or insolvency of the insured shall not relieve the Insurer of its.obligations under the policy to which this certificate applies. b. The Insurer is liable for the payment of amounts within any deductible applicable to the policy to the provider of corrective action or a damaged third-party, with a right of reimbursement by the insured for. any such payment made by the Insurer. This provision does not apply with respect to that amount of any deductible for which coverage is demonstrated under another mechanism or combination of mechanisms as specified in 40 CFR 280.95-280.102: c. Whenever requested by a director of an implementing agency, the Insurer agrees to furnish to the director a signed duplicate original of the policy and all endorsements. Page 1 of 2 d. Cancellation or any other termination of the insurance by the Insurer, except for non-payment of premium or misrepresentation by the insured, will be effective onl u on written notice and onl after the. Y P Y expiration of 60 days after a copy of such written notice is received by the insured. Cancellation for non- ~, payment of premium or misrepresentation by the insured will be effective only upon written notice and . only after expiration of a minimum of 10 days after a copy of such written notice is received by the insured. e. The insurance covers claims otherwise covered by the policy that are reported to the Insurer" within six months of the effective date of cancellation or non-renewal of the policy except where the new or renewed, policy has the same retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered occurrence that commenced after the policy retroactive date, if applicable, and prior to such policy renewal or termination date. Claims reported during such extended reporting period are subject to the terms,. conditions, limits, including limits of liability, and exclusions of the policy. I hereby certify that the wording of this instrument is identical to the wording in 40 CFR 280.97(b)(2) and that the Insurer is licensed to transact the business of insurance, or is eligible to provide insurance as an . excess or surplus lines insurer, in one or more states. . Sign re of au~~ orize reps m ative of Insurer: Type Name: Kenneth C. L g Title, Authorized Representative of Insurer: Vice President & Treasurer . Address of Representative: 175 E. Houston, 7-P-60, San Antonio, Texas 78205 ~* Page 2 of 2 EXHIBIT A 2006 UST FINANCIAL RESPONSIBILITY KERN COUNTY Agency Bakersfield Fire Uept Location 3221 So. "H" Street I City Bakersfield Site Contact Sharon Ramirez Bakersfield Fire Dept _ 1918 "M" Street ~ Bakersfield Sharon Ramirez Kern County EHD _ 925 Jefferson St Delano Sharon Ramirez Kern County EHD 1021 California St Oildale Sharon Ramirez Page 1 of 1 'rom: Donnie Diaz At: Thomc;o Insurance FaxID: To: KevinlJustine ~- Date: 11/"72005 02:58 FM F'age: 2 012 ~.a~oRD EVID E dV ~ E '~ F P ~~ ~' E f~~'Y 6 IU 5 R~ RAN ~'E ~r ID U~ C1ATE (MMiDDrYYI 0 11%1?f 5 _ __, THIS IS E~!IDcIVCE THAT INSURANCE AS IDEPJTiFIE~ BELOW HAS BEEP) ISSUED, IS IPJ FORCE, ANC CONVEYS ALL 7HE„ RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY. ' -- -i ---- --- -~---- PRODUCER ~ o~saY -- -- ---- ,,,m,„,,,~„ 559-226-10011559-226-•180 COMPANY - - T~omCo'I surance Assoc. Inc. License 0791289 One Beacon Insuraace 4333 N West Ave Fresno CA 93705- Jay CDiaz CODE: _ __15U8 CURE` _ __ CUSTOMER ID ~~ HOWAR~4 _ ___ ______________ ___ _ _________ _ INSURED J ~ ~ LOAN PLUMBER P LICY NUMBER ' Haward~ s Mini Mart FF1U169B7 _____ __ I{eVln Chy Chea ___ EFFECTIVE DATE i EXPIRATION DATE I :;ON7INIJCL UI~ITI: 4201 Belle Terrace I ~ TEn,~IId~;TE:,F c-~;:~:ec 11/01/05 ~_ 11/01/06 ~ I __ Bakersfield CA 93309 I THIS REPLACES PRIOREJIDENCEDATED: t5C20PE~tT1' INFbRMATfON ..~ _ ,. _. ... _. LOCATIONJOESGRIPTION 001 4201 Belle Terrace Bakersfield CA 93309 - - " COi1ERf~rE,INFORM.4TIUN ~ ~ ~ ~j AMCKlNTOFINSURANCE DEDUCTIBLE ~ COVERAGEIPERILS/FORMS -- '-- ----- - --- -- --- - ---- ---- - - - Building/FtC/Special Form i $1,112,100 $1000 Business Personal Property/RC/Special Form $240,000 $1000 Business Income/Special Form/ 12 Months ~ AL5 C•feneral Liability I $1,000 000 Hired and Non Own®d Auto Liability I $1,000,000 Liquor 3,iability ,.'' $1,000,000 -. 1 I R EMAR KS {including`Speclal Gonaiitone~ C4NCELkATION ' 7HE POLICY IS SUBJECT TC T,~IF_ ~REP/IIUMS, FORMS: APED RULES IN EF=ECT FOR EACH POLICY PERIOC. SHOULR THE POLICY BE TERPrI!PIATED, THE COMPANY `~JIIL GIVE THE ADDITIONAL INTEREST ICENTIFIED BELOW 30 DAYS U'JRITTEN NOTICE, ANU Vl9LL SENU tJOTGiCATION 0~= ANY CHANGES Ti: THE POLICY THA.1 WOULC AFFECT THAT INTEREST. IPJ ACCORDANCr'JVITH THE PO'~I%Y PROVISIONS OR AS REQUIRED BY LAl1i r~OC~1TI0NAL'INTcREST ~~ _.... ,, , i NAMEAtJDADDRESS .. Il _F ~ C~ I IrdJAL IJ~ IRL~ Lc ~ f ~ EE---~---- -- - Howards Mini Mart w,=ray -4201 villa Terrace Bakersfield CA 93309 i AUTHORIZr7ED~RE~PR/EfSENTATIVE ,Jw ACCJR62i'1;31a3~ ~ AC(~RDCGRPQRFTIC~N199~ FIRE PREVENTION INSPECTION ` >3 E R S F t L D P/RE ARTM T BAKERSFIELD FIRE DEPT. /J 0~ Prevention Services ~ ~ I 900 Truxtun Ave., Ste. 210 ~/1i Bakersfield, CA 93301 Tel.: (661) 326-3979 ^ Fax: (661) 852-2171 DISTRICT ~ BLOCK NO. DATE `~ 1 O ` EE FACILITY ADDRESS ~ 7 ~ ~ (~ !1 ' ~Q f f ~~ ` CITY, STATE, ZIP ;~ ~ _ ~ ~~~ ~~\ r l • tR ) C•, FACILITY NAME ~~ C O.~S ~ ( LtZ C%-v C~~' F ' l T HON N MANAGER'S NAME C`~ e. ~t ' BUSINESS OWNER'S NAME AND ADDRESS . CITY, STATE, ZIP R' PHON N BILL TO: (IF DIFFERENT FROM ABOVE) NAME, ADDRESS CITY, STATE, ZIP, BILLING PHONE NO. OCC TYPE OCC LOAD NO. OF FLOORS HIGH RISE BLDG RISER D /~ ^ YES ^ NO VX CORRECT ALL VIOLATIONS VIOLRTION REQUIREMENTS CHECKED BELOW no. COMBUSTIBLE WASTE I DRY 1 Remove and safely dispose of all hazardous refuse and dry vegetation on the above premises (U.F.C.) VEGETATION ~ 2 ~ provide non-combustible containers with tight fitting lids for the storage of combustible waste and rubbish pending its ~ safe disposal. (U.F.C.) COMBUSTIBLE STORAGE 3 Relocate combustible storage to provide at least 3 feet clearance around motor fuse box/fire door (N.E.C.) (U.F.C.) 4 Relocate fire extinguisher(s) so that they will be in a conspicuous location, hanging on brackets with the top to the extinguisher not more than 5 feet above the floor. (N.F.P.A. No. 10) EXTINGUISHERS 5 Provide and install (amount) _____ approved (type & size) __________________ portable fire extinguisher to be immediately accessible for use in (area) ____ ___________________ (U.F.C.) g Re-charge all fire extinguishers. Fire extinguishers shall be serviced at least once each year, and/or after each use, by a person having a valid license or certificate. (U. F. C.) 7 Provide and maintain "EXIT" sign(s) with letters 5 or.more inches in heigl~~~a it it window) to SIGNS fire escape. (U.F.C.) 1... g Provide and maintain appropriate numbers on a contrasting background and visible from the street to indicate the correct address of the building. (B. M.C.) (U.F.C.) a g Repair all (crackslholes/openings) in plaster in (location) ______________________________________. Plastering FIRE DOORS/ FIRE SEPARATIONS shall return the surface to its original fire resistive condition. (U.B.C.) 10 Remove/repair (item & location) ________ ________________ ________________________. Self-closing doors shall be designed to close by gravity, or by the action of a mechanical device, or by an approved smoke and heat sensitive device. Self-closing doors shall have no attachments capable of preventing the operation of the closing device. (U. F. C.) EXITS 11 Remove all obstruction from hallways. Maintain all means of egress free of any storage. (U.F.C.) 12 Provide a contrasting colored and permanently installed electric light over or near required exit (location) ________ to clearly indicate it as an exit. (U.F.C.) STORAGE . 13 Remove all storage and/or other obstructions from fire escape landings and stairways stair shafts. (Fire escapeslstair shafts are to be maintained free from obstructions at all times.) (U.F.C.) 14 Extension cords shall not be used in lieu of permanent approved wiring. Install additional approved electrical outlets ELECTRICAL APPLIANCES where needed. (N.E.C.) (U.F.C.) 15 Remove multiple attachment cords from specific electrical convenience outlet (one plug per outlet) (N.E.C.) (U.F.C.) OUTDOOR BURNING 16 Violation of Section 1102 dealin with recreational fires or o en burnin U.F.C. FIREWORKS 17 Violations of Section 7802 U.F.C. or 8.49.040 of the Bakersfield Munici al Code B.M.C. re ardin fireworks. OTHER 18 ~~ d c. s ., Sc ! V ~ t_c c~d°R S ~ 6 e? Sc, 1 u C ~ t. ~'~"-" a ,; L ' ~ f ) ~..~- ~ ¢ ~r ~J 1 R.... an ti C~'~" , ~ ~ C. a r u GIC,~ t c.,4.. -Try ~li Cc'~. C,~r6~faSS\ a `} !{~~~ (' _ } y 1 J ~ i CUSTOMER: ~ ,-"r-('-~ '~/ / ~ j f~ ~ / ~-~ ' ~ LEGEND: (Signature) (Please Print Name Legibly, Title) C.F.C. CALIFORNIA FIRE CODE U.B.C. UNIFORM BUILDING CODE ` ~.,, , ~ ~ ~ B.M.C. BAKERSFIELD MUNICIPAL CODE INSPECTOR: t ~/r -- AP NO.: ~ f N.F.P.A. NATIONAL FIRE PROTECTION (Signature) ~ ASSOCIATION N.E.C. NATIONAL ELECTRIC CODE ~~~ „~~ ~ 1\ PAC' White -Customer/Original Yellow -Station Copy Pink -Prevention Services FD 2022 (ReV. 09/05) FIRE :PREVENTION INSPECTION ~ / ,~'~~ • BAKERSFIELD FIRE DEPT. '~ ~ ~~'' t, ti B S F t L D Prevention Services ' PARE 900 Truxtun Ave., Ste. 210 ~~~ ARTM T Bakersfield, CA 93301 Tel.: (661) 326-3979 ^ Fax: (661) 852-2171 DISTRICT BLOCK NO. DATE q ZZ ~ G/'1 ! EE ~ ~~ FACILITY ADDRESS ~\\ ; !~ CITY, STATE, ZIP 2 _ ~ ` ~~ \~ y ~~ ~ ~ i r ~ ~~ r` ~ t `~ C~ 1. FACILITY NAME ~ /'"~ ~~.~~ ~t cz.U` ~C/ MANAGER'S NAME FAAC'ILITY PHONE NO. ~+ ~ ~l~ ~ `s~Z~ ~ BUSINESS OWNER'S NAME AND ADDRESS _ CITY, STATE, ZIP OWNER'S PHONE NO. BILL TO: (IF DIFFERENT FROM ABOVE) NAME, ADDRESS CITY, STATE, 21 P, BILLING PHONE NO. ~u OCC TYPE OCC LOAD NO. OF FLOORS HIGH RISE BLDG RISER DATE ^ YES ^ NO CORRECT ALL VIOLATIONS VIOLRTION REQUIREMENTS ~~ CHECKED BELOW No.- COMBUSTIBLE WASTE /DRY 1 Remove and safely dispose of all hazardous refuse and dry vegetation on the above premises (U.F.C.) VEGETATION 2 . Provide non-combustible containers with tight fitting lids for the storage of combustible waste and rubbish pending its safe disposal. (U.F.C.) COMBUSTIBLE STORAGE 3 Relocate combustible storage to provide at least 3 feet clearance around motor fuse box/fire door (N.E.C.) (U.F.C.) q Relocate fire extinguisher(s) so that they will be in a conspicuous location, hanging on brackets with the top to the extinguisher not more than 5 feet above the floor. (N.F.P.A. No. 10) ~ ' EXTINGUISHERS 5 Provide and install (amount) _____ approved (type & size) __________________ portable fire extinguisher to be immediately accessible for use in (area) _ U ---------------------- g Re-charge all fire extinguishers. Fire extinguishers shall be serviced at least once e c e after each use, by a person having a valid license or certificate. (U.F.C.) 7 Provide and maintain "EXIT" sign(s) with letters 5 or more inches in height over each required exit (doorlwindow) to SIGNS fire escape. (U.F.C.) 8 Provide and maintain appropriate numbers on a contrasting background and visible from the street to indicate the correct address of the building. (B. M.C.) (U.F.C.) g Repair all (cracks/holes/openings) in plaster in (location) _ __________. Plastering --------------------------- FIREDOORS/ ~ FIRE SEPARATIONS Shall return the surface to its original fire resistive condition. (U.B.C.) 10 Remove/repair (item 8 location) _________________________ ______________________. Self-closing doors shall be designed to close by gravity, or by the action of a mechanical device, or by an approved smoke and heat sensitive device. Self-closing doors shall have no attachments capable of preventing the operation of the closing device. (U.F.C.) ~ J EXITS 11 Remove all obstruction from hallways. Maintain all means of egress free of any storage. (U.F.C.) - ~ ~ ~ ~ 12 Provide a contrasting colored and permanently installed electric light over or near required exit (location) --% '~ , l _________ to clearly indicate it as an exit. (U.F.C.) ~/ 3 ~' --------------------- STORAGE 1g Remove all storage and/or other obstructions from fire escape landings and stairways stair shafts. (Fire ~ escapes/stair shafts are to be maintained free from obstructions at all times.) (U. F.C.) r 14 Extension cords shall not be used in lieu of permanent approved wiring. Install additional approved electrical outlets ELECTRICAL APPLIANCES where needed. (N.E. C.) (U,.F. C.) 15 Remove multiple attachment cords from specific electrical convenience outlet (one plug per outlet) (N.E.C.) (U.F.C.) OUTDOOR BURNING 16 Violation of Section 1102 dealin with recreational fires or o en burnin U.F.C. FIREWORKS 17 Violations of Section 780 2 U.F.C. or 8.49.040 o f the Bakersfield Munici al Code B.M.C. re ardin fireworks. OTHER 18 -g o j ~p r~~~ ~~"C\ \G~i~\pn. '-,tGd e GC C7 ~~~Ll' ~"~~I~SSV 0•--~ e y+ d 0 a.. ~ ~ ~ ¢._ ~ ~ ~ O r ~ ~ .-_, °` S ~d Sid ..r, 1 a."i'e G tom' ~~S ~x-~ a f ~ U ~ - ~r t 0 ~'' .~G d ~. CUSTOMER: f ~r+ GZ ~ Q~r,i nA~ ~~ Y LEGEND: a (Signature) (Please Print Name Legibly, Title) C.F.C. CALIFORNIA FIRE CODE U.B.C. UNIFORM BUILDING CODE ~ 0, B.M.C. BAKERSFIELD MUNICIPAL CODE G ~ , 4 ~ INSPECTOR: ~.„ ~ AP NO.~ / . N.F.P.A. NATIONAL FIRE PROTECTION (SlgnatUre) ASSOCIATION N.E.C. NATIONAL ELECTRIC CODE t I White -Customer/Original Yellow -Station Copy Pink -Prevention Services FD 2022 (Rev. 09/05) HOWARDS 6 SiteID: 015-021-000621 Manager JUSTINE SOR Location: 4201 BELLE TERR City BAKERSFIELD BusPhone: (661} 397-7600 Map 123 CommHaz Moderate Grid: 02C FacUnits: 1 AOV: CommCode: BFD STA 07 EPA Numb: SIC Code:5541 DunnBrad:l7-364-9625 Emergency Contact / Title Emergency Contact / Title KEVIN CHEA / OWNER JUSTINE SOR / MANAGER Business Phone: (661) 397-7600x Business Phone: (661) 397-7600x 24-Hour Phone (661) 632-6629x 24-Hour Phone (661) 632-6631x Pager Phone ( ) - x Pager-Phone ( ) - x Hazmat Hazards: ~ Fire Press ImmHlth DelHlth "-Contact- `°KEVIN~=CHEA~_----=--_ _-~~='= ----i ~----- _~--°-=~-Phone-:- --(663)- -3.97--76-00x- MailAddr: 4201. BELLE TERR State: CA City BAKERSFIELD Zip 93309 Owner. KEVIN CHEA Phone: (661) 397-7600x Address 4201 BELLE TERR State: CA City BAKERSFIELD Zip 93309 Period - to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD PROG U - UST ENT D Based on my -inquiry of those indivrduals - - - -~ ~ - - - - - -- responsible for obtaining the information, I certify ~ ~ under penalty of law that f have personally ,G ~On examined and am familiar with the information ~ U sub d and b 'eve the information is true, ac r te, a .d ete. U~ ignature Date -1- 02/01/2007 ~'{ ~-- Prevention Services UNIFIED PROGRAM LNSPECTION CHECKLIST B._... E..R-_s F t 9ooTruxtun Ave., suite 210 _ .___ ._...I? -- - =--~- -~ ~==------- ---~~ -~ °~ ~- -- ! FARE Bakersfield, CA 93301 SECTION. 1: Business Plan and Inventory Program ~" ARTM r Tel.: (661) 326-3979 - ~ Fax: (661) 872-2171 FACILITY NAME - - INSP E ION D TE INSPECTION TIME ~I //~~ c~-v~ ~Q~s ~ b ~ ~ 11 S tY ~y ~b /r. ADDRESS 2a ~~I~ ~ PHONE NO. `3~ ~ Gad NO OF EMPLOYEES s ~ ~ . FACILITY CONTACT BUSINESS ID NUMBER „ 15-021- Section 1: Business Plan and Inventory Programs ^ ROUTINE COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V (C=Compliance` OPERATION V=Violation / COMMENTS ^ APPROPRIATE PERMIT ON HAND ,~ . ^ BUSIfI@SS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY /~ ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL A 006 ~} ^ VERIFICATION OF MSDS AVAILABILITY ` ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~, ^ EMERGENCY PROCEDURES ADEQUATE t , ~f' ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ .~ SITE DIAGRAM ADEQUATE & ON HAND Qtly»~ 1°,iY~.+wco.,., Lor.~ ~ `3 ~4nr ..a~~.,_ ANY HAZARDOUS WASTE ON SITE? EXPLAIN: QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US A7 (661) 326-3979 Inspector (Please Print) Fire Prevention / 1~` In /Shift of Site/Station # ^ YES -I~10 cv,[ Iti(c,1^ 7' ~11~-`Gl~ KBF-6013 _ White -Prevention Services Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 • • INSPECTIONS BUSINESS PLAN & INVENTORY PROGRAM UNIFIED PROGRAM INSPECTION CHECKLIST FACILITY NAME: 1-al o w a~ ~ S l~ B E R S F I L D PIPE A/PTM T Section 2: Underground Storage Tanks Program INSPECTION DATE: ~ C / y DG ^ Routine {~ Combined ^ Joint Agency ^ Multi-Agency ^ Complaint ^ Re-Inspection Type of Tank ~ W .S"7=<< Number of Tanks Type of Monitoring ~.o Type of Piping Qy~Su.R,ce P...-- ) 1 1 flL OPERATION C V COMMENTS Proper tank data on file Proper owner /operator data on file Permit fees current Certification of Financial Responsibility Monitoring record adequate and current Maintenance records adequate and current Failure to correct prior UST violations Has there been an unauthorized release? ^ Yes o Section 3: Aboveground Storage Tanks Program Tank Size(s) Type of Tank BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placardingllabeling Is tank used to dispense MVF?) If yes, does tank have overfill /overspill protection? C =Compliance V =Violation Y =Yes N = No Inspector: Questions regarding this inspection? Please call us at (661) 326-3979 KBF-7335 White -Prevention Services Aggregate Capacity Number of Tanks Busi ess i e Responsi rty Pink -Business Copy FD 2156 (Rev. 09/05) v ~~- - -`~a...~~_ -S_ ~' ~ =^•~i ~--r- ---- - - ._-,~- ---.... ..._- _ ... s __ - - ~..... Ht +4JARLIS I'9 I hJ I h1r';R`f 42L11 EIELLE TEkRA~E BA};ERSF I ELI: . CA 93:, 0'=~ 661--3'~?-?b0U I ~~'';=,TEP9 STA T'LI~ REF'~~?RT 1 ALL FUIVi_'T I t'+fJ ~ P~kiRt~9AL I t'Jt1EtVTuR1' RE F'~~+RT T I:REGULAR ;~ Vt~LUN1E _ ?~ ii ~ raAL;~~ ULLHGE _ -;; ` ,:_~; s i SAL 90'. ULLri_;E= ~ ~ `_aCl ~ SAL:. TC' '~JL~LUI"lE = 7r,r,~J ~7HL~ ~ i HE I i~HT = Ft~ . J >_~ I h~iC.,~ES WATER '~JvL = 0 GAI_;~ WATER = 0.00 I1•Jt'HE~_ T 2 : Li 1 E;~EL l?ULUN1E _ '759 GAI=;z,: TILLAGE = 4'~?I~ G~;, .7nn.4 ~ 9 . , EM h~ = HEIGHT = ?3.6? ~ H I 4•JATER 1?UL = u i-~;-;LS WATER = LI.00 I PJCHE~: TE!°1F' _ ?'' . 9 LEG F 1+f?LUt°IE = 545' GALS ULLAGE = 462 GALS, " 90s~ ULLAi;E= ,3614 ~>>ALE~ TC' Vt}LLINIE = 5405 i;AL HEIGHT = i=~U.56 IPi~'HE~ WATER VUL = 0 i=~AL~ WATER = U . 00 I NC'HES ~x ~ * n f EfdLi ~ n i ` ~ :{ . s UNDERGROUND STORAGE TANK ~~ 'PERMIT APPLICATION ~ TO OPERATE AN UST B B R S F I D FIRS ABTA/ T PERMIT NO. TYPE OF APPLICATION (CHECK) OPERATE NEW FACILITY TRANSFER OF OWNERSH{P BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 ^ TO OPERATE AN EXISTING FACILITY ., . - __ .. .. .. - , P,_- • 10 S T NK-OWNER. Aa ~"litable : ^• ~- -. - , . .: NAt~1E ~ ~ "\` n_ ~ q V _ ` !v\\ ~ HONE NO ADDRESS ITY IP CODE _> ` ' ~ I .. _ • -.. . , .. .~..~.. NEW TANK OWNER . . . ~ \ HONE NO DDRESS \ ~~ ~ \~ ITY ~ ~ IP CODE 2 (~ ' ~ ~ ~'~~ ~ ~ i`~ ~ S S "\ J V R_LING AgeRESS ~ (~, ITY \ ` ~ ( IP CODE ~' ~, ~ ~ ~ TANK~:OPERA'[OR'(if differentfrom ovmer)' ;'"- ' AME HVNENO DDRESS CffY IP CODE - -- - _- - -- - APPLICANT'S'N:4MEt(ifdifferentfromowner) ~ - ~ ~ . ------ - AME . HONE NO DDRESS - - - ITY IP CODE - - "` _ - - ACI ITY NAME _ __. PPERATOR NAME HO NO DRESS - - ITY IP CODE .: - - -- .~ AME . ~, ~n ..... ;~ .EMERGENCY~CONTAGT _ ... - ~.. HONE NO D l~~\ ~ CO/~,'~.J~~--Y` Q ~ y~ ITY IPCODE ~a~~~F~~L~ a~~l~ :: TANK INFORMATION ~ , ~ ~ .. ,: TANK N0. VOLUME 'BATE INSTALLED SUBSTAIJCE STORI_D ' - STANCE PREVIOUS SUB ~ o 2 ~ opO ~ ~ 3 a6 c~ Do you have a HAZARDOUS MATERIAL RESPONSE PLAN? Do you have an OWNER -OPERATOR AGREEMENT? Have you filled out a HAZARDOUS MATERIAL BUSINESS PLANT FOR OFFICIAL USE ONLY '~ YES ^ NO `~' YES ^ NO J~ YES ^ NO The applicant has received, understands, and wiU comply with the attached conditions of the permit and any other state, local and federal regulations. This form has been completed under penalty of perjury, and to the best of my knowledge, is-true and correct - v ~~ C~ E' APPLICANT SIGNATURE: APPLICANT NAME (PRINT:) APPROVED BY: THIS APPLICATION BECOMES A PERMIT WHEN APPROVED ....^ -' FD2087 (Rev. 09105) .. ,~~^, . ~ ' . ~ti _-:r R, ._ _._,.,r,r - :.- -" ~~,-~..;;,,,..v.r T -.,:.....,.,,~•=,`«.^r ~ -..~.-..:'.v.,.;,;'s.:...,,,.v..! ..~i:_c,,:;.,...:.,,:...- ~,,...,;..:_.-... w `tir,:-,.~...~ - wc..i3::•..,.-.- . . u:^ - ..::a: y.; ~,,,,; .;,~.~;M~l-+"':•+v+~y..,,~.f' ~~, Bakersfield Fire Dept. UNIFIED PROGRAM INSPECTION CHECKLIST Enironmental Services 1715 Chester Ave SECTION 1 Business Plan and Inventory Program Bakersfield, CA 93301 ~ ~ ~p,~,};~~',~n ; ~„ Tel: (661)326-3979 FACILITY NA ma i iu uHi t marts, i ivn i imc _ _ ___ ow _s___ ~~.__1~k~-- ----- ---- ---- - --- -------- -_ --- -- ---- - - -- ~ ? -Q-~------ ----- ---------- -- _ ADDRESS PH E No. No. of Employees ~"'" FACILITYCONTAC Business ID umber 15-02 l - ~~.~~ ' f Section 1: Business Plan and Inventory Program ^ Routine ombined ^ Joint Agency ^Mnlti-Agency ^ Complaint ^ Re-inspection i ~% V \V=Vioatiolnnce~ OPERATION COMMENTS ~ ' ~ ' ~^ APPROPRIATE PERMIT ON HAND ~~ --,~---j- - ------ ------_------- ------------_- __- ---.. _._ ....... ...........-- - --- -- LY' ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE i.~/ ^ VISIBLE ADDRESS LAY ^ CORRECT OCCUPANCY I l11/ ^ VERIFICATION OF INVENTORY MATERIALS -. ._ LSV ^ VERIFICATION OF QUANTITIES ~^ VERIFICATION OF LOCATION ^ P ROPER SEGREGATION OF MATERIAL L'?" ^ VERIFICATION OF MSDS AVAILABILITYE ---- A ?~ ---/--------- ----------------------- _- ----- ---- --- -- tSY ^ VERIFICATION OF.HAT MAT TRAINING _ _ --- - --- -- - _. _ _-- --- -_ -~ -- ---- -- --- ~ ~ 206 C~" ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE . Ld" ^ CONTAINERS PROPERLY LABELED © O HOUSEKEEPING --J- -------------------- --------------..------------ U ^ FIRE PROTECTION ---------------------- ------- ----- - ------- ------___.. ~^ SITE DIAGRAM ADEQUATE & ON HAND i ANY HAZARDOUS WASTE ON SITE: OYES LW NO EXPLAIN: QUESTIONS R~GARDING T IS INSPEC710N~ PLEASE CALL US AT ~C6'I) 3Z6-3979 Inspector Badge No., White -Environmental Services Yellow - Stetbn Copy usiness Site Responsible Party Pink -Business Copy ~~ i i ~ ! ~,~ T~xa .w ` `•. i 0'~' T ~ C[TY OF BAKERSFIELD FIRE DEPARTMENT 1~ ~ ~~~, ~ ~~~ OFFICE OF F,NVIRONMENTAL SERVICES ` ~`° , y~`1 UNIFIED PROGRAM INSPECTION CI~~CKL.IST ~w ~g~,0'~ 1715 Chester Ave., 3r`' Floor, Bakersfield,`" ~A 93301 -,.. FACILITY NAME ~ocilac~.'~ Itnlul ~'~~C-~ INSPECTION DATE_ ~~~~C-~_~___ ,.- Section 2: Underground Storage Tanks Program ^ Routine ~ombined ^ Joint Agency ^MultrAgency ^ Complaint ^ Re-inspection Type of Tank t1,~,FC ~ Number of Tanks ~ Type of Monitoring CL1~ Type of Piping ~(_ ~ ~~ t ~ ~1 OPERATION C V t COMMENTS Proper tank data on the Proper owner/operator data on file Permit tees current Certification of Financial Responsibility, Monitoring record adequate and current Maintenance records adequate and current / Failure to correct prior U5T violations Has there been an unauthorized release? Yes No ~~ Section 3: Aboveground Storage Tanks Program TANK SIZES} Type of Tank OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MVF? If yes, Does tank have overfill/overspill protection'? C=Compliance V=Violation Y=Yes N=NO Inspector: ul,~~ ~ ~~LUY~/I ~ Office of Environmental Services (661) 6-3979 White - env, Svcs. AGGREGATE CAPACITY Number of Tanks _--- usiness Site Responsible Party Vink - ftusiness Cory / r ~Y..- , ,~ , + HOWARDS 6 ___________________________________________ SiteID: 015.-021-000621 + Manager BusPhone: (661) 397-7600 Location: 4201 BELLE TERR Map 123 CommHaz Moderate City BAKERSFIELD Grid: 02C FacUnits: 1 AOV: CommCode: BFD STA 07 SIC Code:5541 EPA Numb: DunnBrad:l7-364-9625 Emergency Contact / Title ~ 4,,,^ ~~ Emergency Contac ~~ Title d3P~~ ~,~1~~ v~~~~~ C~F9~ / MANAGER Business Phone: (661) 397-7600x Business Phone: (661) 397-7600x 24 -Hour Phone ( 661) _.-23~"'6~ 24 -Hour Phone ( 661) °-~~~x-~.3c~r-~O 3 ` ~ Pager Phone (661) f Pager Phone (661) - x ' Hazmat Hazards: Fire Press ImmHlth DelHlth Contact ~e'~J~~ ~~^~ ~'`- Phone : ( 661) ~ MailAddr: 4201 BELLE TERR State: CA 3~~~`76Qc~ City BAKERSFIELD Zip 93309 -------=--------------------------- ---------------------------- + Owner ~~v.,'v~ C~~~ Phone : ( 661) ~~~ ~ - -+ Address 4201 BELLE TERR State: CA City BAKERSFIELD Zip 93309 Period to Preparers Certif'd:_ ParcelNo: TotalASTs: _ TotalUSTs: _ RSs: No Gal Gal Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD PROG U - UST ENT A ~~ ~ ~ X006 Based on my inquiry of those indlvlduals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and co lete. !fr ~ ~ D~ Signature Date ~ ~ 1 -1- 03/31/2006 Bakersfield Fire Dept. UNIFIED PROGRAM INSPECTION~CHECKLIST Enironmental Services i 1715 Chester Ave SECTION 1 Business Plan and Inventory Program Bakersfield, CA 93301 ~~ Tel: (661)326-3979 FACILITY NAME INSPECTION DATE INSPECTION TIME -----~1 ot~a~ ~__ _1~~ ~ ~~ ~ --~~--- ---- -- ------------ _ _-- --~--- -._.-..------------ -- _ Q'~-~ '-o-~~- _ ----- - ----- --_ ADDRESS HONE No. No. of E~loyees -- ----y 0 ( . c (~ Te c ~r~-~-- ----__ _- ----- ---- --- _- --- ------- 397 ' 7` 00 - - _-. - ~- - -- - - FACILITYCONTACT Business ID Number 15-42 l - Section 1: Business Plan and Inventory Program ^ Routine L~-Combined ^ Joint Agency ^Mutti-Agency ^ Complaint ^ Re-inspection ,~C/~V \ V=Vio aponnce l OPERATION C1 ^ APPROPRIATE JPERMIT ON HAND LV~ ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE H' ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ~/' ^ VERIFICATION OF QUANTITIES I.~ ^ VERIFICATION OF LOCATION LU/ ^ PROPER SEGREGATION OF MATERIAL ^ I.~ VERIFICATION OF MSDS AVAILABILITYE ^ VERIFICATION OF HAT MAT TRAINING ^ L9~ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ (EMERGENCY PROCEDURES ADEQUATE m/^ CONTAINERS PROPERLY LABELED L`-f ^ HOUSEKEEPING L4V ^ FIRE PROTECTION LW ^ SITE DIAGRAM ADEQUATE 8c ON HAND COMMENTS ANY HAZARDOUS WASTE ON SITE?: ^ YES ~ NO EXPLAIN: QUESTIONS REGARDING T . S IN ~ ECTlON~ PLEASE CALL US AT ~C)6'I ~ 3Z6-3979 ~ I Ins ector Bad a No... ~ Bu iness i ' n ' P P 9 s Ste Respo slble arty White -Environmental Services Yellow -Station Copy Pink -Business Copy Ptw~~' `~ ~~\ CITY OF BAKERSFIEi.D FIRE DEPARTMENT ~~ ~ M~ OFFICE OF ENVIRONMENTAL SERVICES y~' UNIFIED'PROGRAM INSPECTION CHECKLIST =;wE'~g~,~~'~ 1715 Chester Ave., 3r`' Floor, Bakersfield, CA 93301 FACILITY NAME ~otya r S !'Zt t~tt l~inr~' INSPECTION DATE ~ O ~ (~ ' O ~' Section 2: Underground Storage Tanks Program ^ Routine '~ Combined ^ Joint Agency ^Mulfi-Agency ^ Complaint ^ Re-inspection Type of Tank S itI% Number of Tanks `~ Type of Monitoring -~T~° Type of Piping ~' OPERATION C V COMMENTS Proper tank data on file Proper owner/operator data on file Permit fees cun-ent Certification of Financial Responsibility Monitoring record adequate and current Maintenance records adequate and current Failure to correct prior UST violations Has there been an unauthorized release? Yes No Section 3: Aboveground Storage Tanks Program TANK SIZE(S) Type of Tank AGGREGATE CAPACITY Number of Tanks OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MVF? If yes, Does tank have overfill/overspill protection'? C=Compliance V=Violation Y=Yes N=NO ~ % I Inspector: ~ ~ Office of Environmental Services (661) 326-3979 Business Site Responsible Party white - inv. Svcs. Pink -Business Copy _ r ~ ~` F~AZARDOUS MATERIALS ~~ ,~~,,,,~~MANAGEMENT PLAN f ~_ - SITE & FACILITY DIAGRAM Page 1 of 1 Bakersfield Fire De t ~~~ s e x s p i n FIRE PREVENTION p P~Ra 900 Truxtun Ave., Suite 210 rr r Bakersfield, CA 93301 Tel: (661) 326-3979 Fax: (661) 852-2171 SITE DIAGRAM ~ ~~ FACILITY DIAGRAM Business Name: ~aw~~~~ 6l~tr~a tt~,k~ Business Address: ~~.~t ~L~~~ lc~P~.c.c._, ~ n v N d u Q ~ ~ ~_ _ _ ,,, ~J t ~ Intl®U~~~ C v~•1,~~ ~lw~~~~~'- -=~__~_ _ (HMMP) 4 r~ f r . J NORTH 1--- __ Please indicate direction of North=~~ ~-- -' ~-` -- - ~~ ~-" CITY OF BAKERSFIELD (9 OFFICE OF ENVIRONMENTAL SERVICES . ~. 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 UST Tank - 1 OS CHANGE OF INFORMATION (SlIle Iype 01 change) Peg. 01 o 7 AERMANENTI.. Y CLOSEO ON SITE TYPE OF ACTION Check one ilem only o 1 NEW SITE PERMIT 0 3 RENEWAL PERMIT 08 TANK REMOVEO o 4 AMENOEO PERMIT ãÜSINESS NAME (Same a. FACILITY NAME 0' OBA . Doing 8ualneu A.) l ~t ßC (\L \Z NìtCJ..- TANK 10. 3 OATEINSTALLEO(Y AOOITIOw.:. OESC /TANK USE ~OTOR VEHICLE FUEL (II martce<!. complele Vehicle Fuel Type) o 2 USED OIL o 3 CHE'.::":' L PRODUCT o 4 HAZARDOUS WASTE o 95 UI·~. '::WN TYPE OF TANK Check one it""' only TANK MATERIAl (primary lank) Check one nem only TANK MATERIAl (secondary tank) Check one nem only INTERIOR LINING OR COATING Check one !lem only OTHER CORROSION PROTECTION IF APPlICABlE Check one Ilem only SPILL AND OVERFILL 430 03 o 8 TEMPORARY SITE CLOSURE 3 FACILITY 10 , 429 I. TANK DESCRIPTION 431 COMPARTMENTALIZED TANK Yes 0 No 1/ "Yes', complete one lonn 10' each compartmenl. 434 N MBER OF COMPARTMENTS 'L 432 435 436 II. TANK CONTENTS VEHICLE FUEL TYPE o la REGUlAR UNlEAOEO o Ib PREMIUM UNlEAOEO o Ic MIOGRADE UNLEAOED DROP TUBE STRIKER PlATE IF SINOLE WALL TANK (Check .U tNlapply): o 1 VISUAL (EXPOSEO PORTION ONLY) 02 AUTOMATlCTANKGAUGINO(ATG) o 3 CONTINUOUSATO· o 4 STA TISTICALINVENTORY RECONCILIATION (SIR) + BIENNIAL TANK TESTING 437 438 o 5 JET FUEL 08 AVIATION FUEL o 99 OTHER o 2 LEADED ~ o 4 GASOHOL COMMON NAME (/rom Hazatdous Malenals Inventory page) o 1 S~E WAlL D-tOOuBLE WAlL 1 BARE STEel 02 STAINlESS STEEL o 1 BARE STEEL o 2 STAINLESS STEEL o 1 RU8BER lINEO o 2 AlKYD LINING o 1 MANUFACTUREO CP o 2 SACRIFICIAl ANOOE *=-1 CAS " (from Hazardous Matenals Inventory page) 440 III. TANK CONSTRUCTION o 3 SINGLE WAlL WITH EXTERIOR MEMBRANE LINER o 4 SINGLE WALliN A VAUlT o 4 STEEL CLAD WI FA? o 3 FIBERGLASS ro...-sTE~ ClAD WI FA? o 3 FIBERGLASS 05 CONCRETE o 3 EPOXY LINING 04 PHENOliC UNING o 5 INTERNAl BLADDER SYSTEM 095 UNKNOWN 099 OTHER 05 CONCRETE 08 FA? COMPATIBLE WI100% METHANOL 442 441 o 95 UNKNOWN o 99 OTHER o 95 UNKNOWN 099 OTHER 08 FRP COMPATIBLE W/100% METHANOL o 9 FRP NON-CORRODIBLE JACKET 0,0 CoATED STEEL 443 o 5 GlASS LINING ~INED o 95 UNKNOWN 099 OTHER 095 UNKNOWN o 99 OTHER 444 BERGlASS REINFORCEO PlASTIC o 4 IMPRESSED CURRENT 445 SPILL CONTAINMENT INSTALLED (YEAR) 447 Check all thai apply .~ ~ 448 448 449 OVERFILL PROTECTION EQUIPMENT INSTALLED (YEAR) ~LARM ~LLFLOAT 03 FILL TUBE SHUT OFF VALVE DNa ONo IV. TANK LEAK DETECTION .#... o 5 MANUAl TANK GAUGING (MTG) o 8 VADOSE ZONE o 7 GROUNDWATER o 9i! OTHER IF DOUBLE WALL T AHK (Check one item only): 450 o 8 VISUAL (SINGLE WAlL IN VAULT ONL V) o 9 CONTINUOUS INTERSTITIAL MONITORING V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMA TED OA TE lAST USEO (YRlMOIOA Y) 451 ESTIMATEO QUANTITY OF SUBSTANCe REMAINING 452 GAS TANK FILLED WITH INERT MATERIAL? 453 oal OVaa ONo ,--------- "onnS ----- Î' CITY OF BAKERSFIELD . OFFICE OF ENVIRONMENTAL SERVICES 1715 Ch..t.r Av... B.k....fI.ld. CA 93301 (805) 326·3979 ~ " f ( UST. TANK PAoe 2 Of Pig. .,.-.---- ..- .------.- VI. PIPING CONSTRUCTION _. _ABOVEGR~D PiPING INFORMATION ¡ (1}{" PRESSURE 0 3 GRAVITY 454 i , I I I SYSTEM type--: -0--;- SUCTI~' C~NST~~CTI~~'~ ~ I s~Lë-';;~~---- ~~LEWALL . -1M tëRlALS AND' 0, BARE STEEL CORROSION , PROTECTION 0 2 STAINLESS STEEL 0 7 GALVANIZED STEEL 03 PVC COMPATIBLE WITH CONTENTS 095 UNKNOWN ~GLASS 0 8 FLEXIBLE 0 99 OTHER o 5 STEEL WI COATING 0 9 CA THOeIC PROTECTION 455 o 95 UNKNOWN o SKI OTHER 450 o II FRP COMPATIBLE W/I00% METHANOL I, lCheçk all that ~Jïl UNDERGROUND PIPING INFORMATION o 1 SUCTION o 2 PRESSURE o 3 GRAVITY 455 o 99 OTHE~ o 1 SINGLE WALL 0 3 LiNED TRENCH o 2 DOUBLE WALL 0 95 UNKNOWN o , BARE STEEL 0 II FRP COMPATIBLE WI 100% METHANOl 02 STAINLESS STEEL 07 GALVANIZED STEEL o 3 PVC COMPATIBLE WITH CONTENTS o 4 FIBERGLASS 0 8 FLEXIBLE o 5 STEEL WI COATING 0 9 CATHODIC PROTECTION 454 o 95 UNKNOWN 099 OTHER 456 VII. PIPING LEAK DETECTION (Check all that aoolY) ABOVEGROUND PIPING INFORMATION I SlNGU! WALL PIPING 457 I' PRESSURIZED PIPING (Check an that apply): o 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST mII:1AUTO PUMP SHUT OFF FOR LEAK. SYSTEM FAil URE. AND SYSTEM DISCONNECTION. AUOI8LE AND VISUAL AlARMS o 2 MONTH\. Y 0.2 GPH TEST o 3 ANNUALlNTEGRITY TEST (0.1 GPH) o 4 CAlLY VISUAL CHECK CONVENTIONAL SUCTiON SYSTEMS (Check allhsl apply): o 5 CAlLY VISUAL MONITORING OF PUMPING SYSTEM o 8 TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYS··......õ;S: o 7 SELF MONITORING GRAVITY FLOW (Ch..."..:.Ø Ih8t apply): o 8 CAlLY VISUAL MONITORING o 9 BIENNIAL INTEGRITY TEST (0.1 GPH) SECOHDARIL Y CONTAINED PIPING PRESS~IZED PIPING (Check an Ih8I apply): Q-1O CONTINUOUS TURBINE SUMP SENSOR m!!::1 AUDIBLE AND VISUAL ALARMS AND (check one) o a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o b AUTO ;.>UMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION ~-c NO AUTO PUMP SHUT OFF ~ AUTOMATIC LEAK DETECTOR o 12 ANNUAL INTEGRITY TEST (0.1 GPH) SUCTIONIGRAVITY SYSTEM: o 13 CONTINUOUS SUMP SENSOR. AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Ch8c:k aa Ih8t apply) o 14 CONTINUOUS SUMP SENSOR mJ1!2!o!! AUTO PUMP SHUT OFF · AUDIBLE AND VISUAL ALARMS o 15 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 18 ANNUALlNTEGRITY TEST (0.1 GPH) o '7 DAILY VISUAL CHECK DISPENSER ~TAINMENT l1L'Y8S 0 No -. VII DISP o 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE o 2 CONTINUOUS ELECTRONIC SENSOR. AUDIBLE AND VISUAL AlARMS I ëi¡rtity tNlll/1e inlormøtJon provided herein i. true & ac:curale to II'MI be.t 01 my knowledge. ~GNA~OF~WNE~OPERATOR NAME ~~PERATOR (pr! _...:tf'\ Q. 'h.", UNDERGROUND PIPING INFORMATION SINGLE WALL PIPING 456 PRESSURIZED PIPING (Chec:Ic all that apply): o 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST m!!::1 AUTO PUMP SHUT OFF FOR LEAK. SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL A1.AIWS o 2 MONTHLY 0.2 GPH TEST o 3 ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS: o 4 CAlLY VISUAL MONITORING OF PUMPING SYSTEM. TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS: o 5 SELF MONITORING GRAVITY FLOW: o 8 BIeNNIAL INTEGRITY TEST (0.1 GPH) SECONDAl'ú:''!' CONTAINED PIPING PRESSURIZED PIPING (Chec:Ic aD thaI ap¡:~., o 7 CONTINUOUS TURBINE SUMP SENSOR m!!::1 AUDIBLE AND VISUAL ALARMS AND (Check one) o a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o b AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION o c NO AUTO PUMP SHUT OFF o 8 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 9 ANNUAL INTEGRITY TEST (0.1 GPH) EMERGENCY GENERATORS ONLY (CI'Ieck aa Ihst apply) o 10 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF. AUDIBLE AND VISUAL ALARMS o 11 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 12 ANNUALlNTEGRITY TEST (0.1 GPH) o 13 DAILY VISUAL CHECK TAINMENT CONTINUOUS DISPENSER PAN SENSOR ~ AUTO SHUT OFF FOR DISPENSER . AUDIBLE AND VISUAL ALARMS o 4 DAILY VISUAL CHECK NATURE 462 DATE 1'2~ r¡.-,ey 463 TITLE OF OWNERlOPERATðR VI d- 8l111li AppIOY8CI FormB 484 {/i CITY OF UJAKERSFIELD f) OFFICE OF ENVIRONMENTAL SERVICES. ~. 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 . UST Tank - 1 TYPE OF ACTION Check one ;Iem only ~ 1 NEW SITE PERMIT 0 3 RENEWAL PERMIT o 4 AMENDED PERMIT 05 CHANGE OF INFORMATION (Slale tyøe 0' change) Pege 0' o 7 RERMANENTl Y CLOSED ON SITE o 8 TEMPORARY SITE CLOSURE 3 08 TANK REMOVED 429 ~ \ {.l'~tL- TANK 10_ 430 431 COMPARTMENTALIZED TANK 0 Yes 0 No If "Yes·. complete one form for each compartment. 432 433 k. 434 NUMBER OF COMPARTMENTS ( 435 Ii , I I 438 /TANK USE ~OTOR VEHiClE FUEL (If marked. complete Vehicle Fuel Type) o 2 USED OIL o 3 CHEI.::':' L PRODUCT 04 HAZAROOUS WASTE o 95 U/·~. '~WN 437 II. TANK CONTENTS . /" VEHICLE FUEL TYPE ~ REGUlAR UNLEADED o Ib PREMIUM UNlEADED o Ie MIOGRADE UNLEADED 438 o 2 LEADED o· 3 DJE:SEL o 4 GASOHOL o 5 JET FUEL 08 AVIATION FUEL o 99 OTHER COMMON NAME (from Hazaldous Malerials Inventory page) _~:J CAS II (from Hazardous Materials Inventory page) 440 III. TANK CONSTRUCTION TYPE OF TANK Check one jl"m only o 1 SINGLE WALL ~2 OOUBLE WALL o 3 SINGLE WALL WITH EXTERIOR MEMBRANE LINER o 4 SINGLE WALL IN A VAUlT D 5 INTERNAL BLADDER SYSTEM 095 UNKNOWN 099 OTHER «1 TANK MATERIAL (primary tank) .1!I' BARE STEel o 4 STEEL CLAD WI FRP 05 CONCRETE o 95 UNKNOWN 442 Check one item only o 2 STAiNlESS STEEL o 3 FIBERGLASS 08 FRP COMPATIBLE W/100% METHANOL o 99 OTHER TANK MA TERIAL (secondaIy tank) o 1 BARE STEEL 'Pt4 STEEL ClAD WI FRP D 8 FRP COMPATIBLE W/100% METHANOL 095 UNKNOWN 443 Check one item only o 2 STAINLESS STEEL o 3 FIBERGLASS o 9 FRP NON.coRRODIBLE JACKET o 99 OTHER o 5 CONCRETE 010 èOATED STEEL INTERIOR LINING OR COATING o 1 RUBBER UNED o 3 EPOXY LINING o 5 GLASS LINING o 95 UNKNOWN 444 Check one !Iem only o 2 AU<YO LINING 04 PHENOLIC UNING 1iite UNlINED o 99 OTHER OTHER CORROSION o 1 MANUFACTURED CP )9 3 FIBERGLASS REINFORCED PlASTIC o 95 UNKNOWN 445 PROTECTION IF APPUCASLE Chad< one Item onty o 2 SACRIFICIAL ANODE o 4 IMPRESSED CURRENT o 99 OTHER SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PROTECTION EQUIPMENT INSTALLED (YEAR) 4411 447 Check all that apply DROP TUBE '~es DNa 4411 ~LARM STRIKER PLATE ~es oNo 44!1 2 BALL FLOAT ~;LL TUBE SHUT OFF VALVE -.. .. .. ,. ,. .. ..... IV. TANK LEAK DETECTION .. . IF SINGLI! WALL TANK (Check aU that apply): IF DOUBLI! WALL TANK (Check one Ilem only): 450 0, VISUAL (EXPOSED PORTION ONL YI 05 MANUAL TANK GAUGING (WO) o 8 VISUAL (SINGLE WALL IN VAULT ONLY) 02 AUTOMATIC TANK GAUGING (ATG) o e VADOSE ZONE o 9 CONTINUOUS INTERSTITIAL MONITORING 03 CONTINUOUS A TO 07 GROUNDWATER o 4 STATISTICAL INVENTORY RECONCILIATION (SIR) + o 99 OTHER BIENNIAL TANK TESTING V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ._._----- . ESTtMA TEO OA TE LAST USED (YRlMOIDA Y) 451 eSTIMATED QUANTITY OF SUBSTANCE REMAINING 452 GAS TANK FILLED WITH INERT MATERIAL? 453 aal DVe. DNa ,..-'-- .- - I'orm8 ·1 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Ch..t.r Av... B.k....fI..'d. CA 93301 (80S) 326·3979 ~i . ...-.---- UST. TANK PAGI! Z P8ge Of VI. PIPING CONSTRUCTION lCh~ck all that ~M ABOVEGROUND PIPING INFORMATION i UNDERGROUND PIPING INFORMATION SYSTEM 1'YPË-~-b-;- SUCTlOO' ---- I!91';RESSURE 0 3 GRAVITY 4:~O , SUCTION 02 PRESSURE o 3 GRAVITY _ ________.___ ___n_'.·___ -r-:' CONSTRUCTION : 0 1 SINGLE WALL 0 gs UNKNOWN I 0, SINGLE WALL .. _ __ ~UBLE WALL 0 iQ OTHER 450 0 2 DOUBLE WALL MA TERIALS AND I· 0 1 BARE STEEL 0 IS FRP CQMPA TIBLE WI 100% METHANOL I 0 1 BARE STEEL CORROSION , PROTECTION 02 STAINLESS STEEL 07 GALVANIZED STEEL 02 STAINLESS STEEL 07 GALVANIZED STEEL I : ¡ 0 3 ~ COMPATIBLE WITH CONTENTS 095 UNKNOWN 03 PVC COMPATIBLE WITH CONTENTS I ID,flIBERGLASS 0 8 FLEXIBLE 0 iQ OTHER 0 4 FIBERGLASS 0 8 FLEXIBLE 05 STEEL WI COATING o 9 CATHODIC PROTECTION 4SS 0 5 STEEL WI COATING 0 9 CATHODIC PROTECTION 4.. ._____0._ ~ o iQ OTHER o 3 LINED TRENCH o 95 UNKNOWN 0" FRP COMPATIBLE WI 100% METHANOL .s. o 95 UNKNOWN o 99 OTHER 456 VII. PIPING LEAK DETECTION (ChBCk all that aDDIy) ABOVEGROUND PIPING INFORMATION SlNOU! WALL PIPINO 4!i7 i PRESSURIZED PIPING (Check aU that apply): i 0 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST mIt1 AUTO PUMP SHUT OFF FOR LEAK. I SYSTEM FAil URE, AND SYSTEM DISCONNECTION + AUOf8t.E AND VISUAL ALARMS ,¡ 0 2 MONTHLY 0.2 GPH TEST ! i 0 3 ANNUAL INTEGRITY TEST (0. f GPH) I: 0 4 CAlLY VISUAL CHECK _.__ IX. OWNER/OPERATOR SIGNATURE I certlly thel the intormetkln provided herein la tn¡e & accurate to the be.t ot my knowted ŠïGNATURE OF 0 ERlOPERATOR DATE CONVENTIONAL SUCliON SYSTEMS (Check at the! apply): o 5 CAlLY VISUAL MONITORING OF PUMPING SYSTEM o 6 TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYS""_\;S: I 0 7 SELF MONITORING GRAVITY FLOW (Ch..:.:.Ø that apply): o 6 DAILY VISUAl MONITORING o 9 BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PR~RIZED PIPING ¡':heck aU that apply): Ø',0 CONTINUOUS TIJRèlNE SUMP SENSOR ~ AUDIBLE AND VISUAL AlARMS AND tcheck OM) c:;;r-ã" AlÌTO PUMP SHUT OFF WHEN A LEAK OCCURS [].1) AUTO ,>UMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION /. . 0{ NO AUTO PUMP SHUT OFF 6 11 AUTOMATIC LEAK DETECTOR o 12 ANNUALlNTEGRITY TEST (0.1 GPH) SUCTIONlGRAVlTY SYSTEM: ~ONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY tChedc .11hIt apply) o 14 CONTINUOUS SUMP SENSOR ~ AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS o 15 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 16 ANNUALlNTEGRITYTEST(0.1 GPH) o 17 DAILY VISUAL CHECK ~ISPE SER CO INMENT Yes 0 No -. vii DISP o 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE o 2 CONTINUOUS ELECTRONIC SENSOR + AUDIBLE AND VISUAL AlARMS 483 FormB UNDERGROUND PIPING INFORMATION . SINGU! WALL PIPING PRESSURIZED PIPING (Check aU thet apply): o 1 ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST Y:aI!:1 AUTO PUMP SHUT OFF FOR LEAK. SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAl AlARMS 2 MONTHLY 0.2 GPH TEST 456 o o 3 ANNUAl INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS: o 4 CAlLY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS: o 5 SELF MONITORING GRAVITY FLOW: o 6 BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDArú:"~ CONTAINED PIPING PRESSURIZED PIPING (Check aU the! apç~< o 7 CONTINUOUS TURBINE SUMP SENSOR:i!!Itl AUDIBLE AND VISUAl AlARMS AND (Check one) o a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION o c: NO AUTO PUMP SHUT OFF o 8 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 9 ANNUAl INTEGRITY TEST (0.1 GPH) EMERGENCY GENERATORS ONLY (Check aD that apply) o 10 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS o 11 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o '2 ANNUALlNTEGRITY TEST (0.1 GPH) o 13 DAILY VISUAL CHECK NTA NMENT 3 CONTINUOUS DISPENSER PAN SENSOR ~ AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS o 4 DAILY VISUAL CHECK ~2 I \ 484 fr-~j I k1 Jr 2 f CITY OF BAKERSFIELD e OFFICE OF ENVIRONMENTAL SERVICES . ~. 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 UST Tank· 1 ,0 S CHANGE OF INFORMATION (State type of change) Pege of o 7 PERMANENTlY CLOSED ON SITE TYPE OF ACTION Check one item only o 1 NEW SITE PERMIT 0 3 RENEWAL PERMIT 429 o 8 TANK REMOVED o 8 TEMPORARY SITE CLOSURE 3 o 4 AMENDED PERMIT BUSINESS NAME (Same al FACILITY NAME or DBA . Doing BuaIneIa AI) TANK 10 II c9- DATEINSTALLED(V ~O) tJ~Ot.{ ADDITIONJ.:. DESCRIPTION (For local use only) ~ ßc\\L \ I\\'\¿ t .-.--- ~ ( t\!'o..{l-- 431 COMPARTMENTALIZED TANK ~ Yes 0 No If ·Vas·. completa one fonn for each compartment. 434 NUMBER OF COMPARTMENTS 435 432 ;\- c.... 430 433 438 : /" TANK USE i ..g.1"MOTOR VEHICLE FUEL . (If marked. complete Vehicle Fuel Type) o 2 USED OIL o 3 CHE/.:;';' -L PRODUCT o 4 HAZARDOUS WASTE o 95 ur'~' '~WN II. TANK CONTENTS VEHICLE FUEL TYPE o 1aßE'GULAR UNLEADED IO-1'b PREMIUM UNLEADED o 1c MIOGRADE UNLEADED 437 438 o 5 JET FUEL 08 AVIATION FUEL o 99 OTHER o 2 lEADED d 3 DIESEL o 4 GASOHOL COMMON NAME (from Hazatdous Materials Inventory page) ~ CAS # (from Hazardous Materials Inventory page) 440 III. TANK CONSTRUCTION TYPE OF TANK 441 Check one iloom only TANK MATERIAL (primary tank) Check one nem only ¡ TANK MATERIAL (secondary tank) Check one item only o 1 SINGLE WALL ~2DOUBlEWALl 1ì 1 BARE STEEL o 2 STAINLESS STEEL o 1 BARE STEEL o 2 STAINLESS STEEL D 4 STEEL CLAD WI FRP D 3 FIBERGLASS ~ STEEL CLAD WI FRP D 3 FIBERGLASS D 5 CONCRETE D 5 INTERNAl BLADDER SYSTEM 095 UNKNOWN D 99 OTHER D 5 CONCRETE D 8 FRP COMPATIBLE W/100% METHANOL 442 D 3 SINGLE WALL WITH EXTERIOR MEMBRANE LINER D 4 SINGLE WALL IN A VAULT D 9S UNKNOWN D 99 OTHER D 9S UNKNOWN D 99 OTHER D 8 FRP COMPATIBLE W/100% METHANOL D 9 FRP NON-CORRODIBlE JACKET D 10 COATED STEEL 443 INTERIOR liNING OR COATING 444 Check one !tem only OTHER CORROSION PROTECTION IF APPLICABLE Check one Item only D 1 RUBBER LINED D 2 ALKYD liNING D 1 MANUFACTURED CP D 2 SACRIFICIAL ANODE D 3 EPOXY liNING D 5 GlASS LINING D 4 PHENOLIC LINING 'fa 8 UNLINED ~ FIBERGLASS REINFORCED PlASTIC D 4 IMPRESSED CURRENT D 95 UNKNOWN 099 OTHER D 95 UNKNOWN o 99 OTHER 445 447 SPill AND OVERFilL Check all that apply ',. '",," .f J" SPill CONTAINMENT INSTALLED (YEAR) DROP TUBE STRIKER PLATE g..¿s ~ ..' . IF SINOLl! WALL TANK (Check aU that apply): D 1 VISUAL (EXPOSED PORTION ONLY) 02 AUTOMATlCTANKGAUGING(ATG) D 3 CONTINUOUS ATG o 4 STATISTICAL INVENTORY RECONCILIATION (SIR) + BIENNIAL TANK TESTING ESTIMATED DATE lAST USED (YRlMOIDAŸ) OVERFILL PROTECTION EaUIPMENT INSTAllED (YEAR) ONo DHo 448 448 449 BfALARM ~ BALL FLOAT ~L TUBE SHUT OFF VALVE IV. TANK LEAK DETEè'Ï1ÒN IF DOUBLE WALL TANK (Check one Item only): 450 D 8 VISUAL (SINGLE WALL IN VAULT aNL Y) o 9 CONTINUOUS INTERSTITIAL MONITORING o 8 MANUAL TANK GAUGING (MTG) o 8 VADOSE ZONE 07 GROUNDWATER o 99 OTHER v. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE 452 GAS TANK FillED WITH INERT MATERIAL? 453 . 481 ESTIMATED QUANTITY OF SUBSTANCE REMAINING aal oYel DNa 1'0""8 t- iff CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Ch..t.r Av.., B.k....f1.ld. CA 93301 (805) 326·3979 uaT· TANK PAGE 2 .¡ Page 01 VI. PIPING CONSTRUCTION (Cheçk all that Illmly) ABOVEGRC}'ND PIPING INFORMATION ¡ UNDERGROUND PIPING INFORMATION - I SYSl'E: 1YP~~-Õ 'S~:~~·.~=:____ q¡6RessuRe 03 GRAVITY 4~ kC? 1 SUCTION 02 PReSSURe 03 GRAVITY I 0, SINGLE WALL 0 95 UNKNOWN I 0 1 SINGLe WALL 0 3 LINeD TRENCH 0 99 OTHER CONSTRUCTION : ~ ,_ _ . I . 2 DOUBLe WALL 0 99 OTHeR 450 I 0 2 DOUBLe WALL 0 95 UNKNOWN . MATERIALS AND' 0, BARE STEEL 0 e FRPCOMPATIBLEW/I00% METHANOL 0, BARE STEEL 0 e FRPCOMPATIBLEW/I00% METHANOL , CORROSION i PROTECTION 02 STAINLESS STEEL 07 GALVANIZED STEEL 02 STAINLESS STEEL 07 GALVANIZED STEEL 03 PVC COMPATIBLE WITH CONTENTS, 095 UNKNOWN 03 PVC COMPATIBLE WITH CONTENTS ~ERGLASS. 0 8 FLEXIBLE 099 OTHER 04 FIBERGLASS 0 8 FLEXIBLE 05 STEEL WI COATING 09 CATHODIC PROTECTION 455 05 STEEL WI COATING 09 CATHODIC PROTECTION ? .. --.----- ---~. ----.-- 455 4S4 o 95 UNKNOWN 099 OTHER 456 . :' "" ,~:;; .:, VII. 'DISPE ONTAINMENT o 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER o 2 CONTINUOUS ELECTRONIC SENSOR + AUDIBLE AND VISUAL ALARMS + AUDIBLE AND VISUAL ALARMS o 4 DAILY VISUAL CHECK . . VII. PIPING LEAK'DETECTION ABOVEGROUND PIPING INFORMATION SlNGI.£ WALL PIPING 457 PRESSURIZED PIPING (Check aU that apply): o 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST mII:1 AUTO PUMP SHUT OFF FOR LEAK. SYSTEM FAil URE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS o 2 MONTHLY 0.2 GPH TEST o 3 ANNUAL INTEGRITY TEST (0.1 GPH) o 4 CAlLY VISUAL CHECK CONVENTIONAL SUCliON SYSTEMS (Check aU that apply): o 5 CAlLY VISUAL MONITORING OF PUMPING SYSTEM , 0 8 TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYS··"'!I.;";: o 7 SELF MONITORING GRAVITY FLOW (Ch.;':"'~ that appty): o 8 DAILY VISUAL MONITORING o 9 BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING I PRES§I.IRIZED PIPING (ChedI aU that apply): I i g..fo CONTINUOUS T1JRBINE SUMP SENSOR ïa!!::I AUDIBLE AND VISUAL ALARMS AND (check one) ~ AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ab AUTO ;>UMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION ~ NO AUTO PUMP SHUT OFF ~ AUTOMATIC LEAK DETECTOR o 12 ANNUAL INTEGRITY TEST (0.1 GPH) SUCTlONlGRAVITY SYSTEM: [3 13 CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check aD that apply) o 14 CONTINUOUS:SUMP SENSOR ~AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS o 15 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 16 ANNUALlNTEGRITY TEST (0.1 GPH) o 17 DAILY VISUAL CHECK DISPENSER ~AINMENT I)(l Yes 0 No (Check all that aDDM UNDERGROUND PIPING INFORMATION SINGI.£ WALL PIPING 456 PRESSURIZED PIPING (Check all that apply): o 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST ïa!!::I AUTO PUMP SHUT OFF FOR LEAl<. SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL AI.ARMS o 2 MONTHLY 0.2 GPH TEST o 3 ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS: o 4 CAlLY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS: o 5 SELF MONITORING GRAVITY FLOW: o 6 BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDArú::'~ CONTAINED PIPING PRESSURIZED PIPING (Check all that apç~:< o 7 CONTINUOUS TURBINE SUMP SENSOR ~ AUDIBLE AND VISUAL A1.ARMS AND (Check one) o a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o b AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION o c NO AUTO PUMP SHUT OFF o 8 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 9 ANNUAL INTEGRITY TEST (0.1 GPH) EMERGENCY GENERATORS ONLY (Chec:k an that apply) o 10 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL AlARMS o 11 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 12 ANNUAL INTEGRITY TEST (0.1 GPH) o 13 DAILY VISUAL CHECK OR SIGNATURE 462 DATE ¡,;¿ - ¡- 463 TITLE OF OWNER/OPERATOR FormS 484 ~EW SITE TYPE OF ACTION (Check one item onlyl PERMIT I. FACILITY I SITE INFORMATION 3 FACILITY 10 II CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 UNDERGROUND STORAGE TANK FACILITY o 3 RENEWAL PERMIT o 4 AMENDED PERMIT o 5 CHANGE OF INFORMATION (State type 01 change) o 7 PERMANENTLY CLOSED SITE o 8 TANK REMOVED 400 o 8 TEMPORARY SITE CLOSURE 401 FACIL~ OWNER TYPE [);("CORPORATION 02 INDMDUAL o 3 PARTNERSHIP 402 o 4 LbcAL AGENCYIDISTRICr- o 5 COUNTY AGENCY' 08 STATEAGENCr o 7 FEDERAL AGENCY' (i3..("GAS STATION o 2 DISTRIBUTOR TOTAL NUMBER OF TANKS REMAINING AT SITE o 3 FARM 0 !I OTHER 403 04 PROCESSOR 08 COMMERCIAL Is I8ciIIIy on indian Rese1vatlon 01' 'If owner 01 UST a public agency: name 01 supervisor 01 1IUsIIanda? dMsJon. section 01' olllce which operates the UST. (This is the contact peISOIIlor the tank records.) BUSINESS TYPE 3 404 DYes I ! PROPERTY OWNER NAME ì W\ILlNG'h~1Pt'~~~ss R ,"\-.I~ " t.(;}.O \ ~d\t- ~ t'Îð.ti." CITY _ ß'L'-d PROPERTY OWNER TYPE ~RPORATION . ~ 406 405 II. PROPERTY OWNER INFORMATION 407 I 406 PHONE 5JÄì ' IJ. 4t( 409 o 2 INDIVIDUAL o 3 PARTNERSHIP 41:.J S~À o 4 LOCAL AGENCY I DISTRICT o 5 COUNTY ".GENCY 413 411 ZIP 412 ~ 33 () 7 06 STATE AGENCY o 7 FEDERAL AGENCY 414 PHONE 415 III. TANK OWNER INFORMATION r MAILING OR STREET ADDRESS I , : CITY -SlWlL A-~ A~~V-L- 416 TANK OWNER NAME TANK OWNER TYPE o 1 CORPORATION 417 STATE 418 ZIP <:19 o 2 INDIVIDUAL o 3 PARTNERSHIP o 4 LOCAL AGENCY I DISTRICT o 5 COUNTY AGENCY 08 STATE AGENCY o 7 FEDERAL AGENCY 420 IV. BOARD OF F .~IJALIZATlON UST STORAGE FEE ACCOUNT NUMBER TY (TK) HQ INDICATE METHOO(S) 1 SELF-INSURED o 2 GUARANTEE o 3 INSURANCE Call (916) 322-9669 if questions arise 421 V. PETROLEUM UST FINANCIAL RESPONSIBILITY o 4 SURETY BOND o 5 LETTER OF CREDIT o 8 EXEMPTION o 7 STATE FUND o 8 STATE FUND & CFO LETTER 09 STATEFUND&CD o 10 LOCAL GOV'T MECHANISM o 99 OTHER: 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one bo. to Indicate which addre.. should be used lot legal notifications and maUlng. Legal notification and mailing will be sent to the IIInk owner unIe.. bo. 1 01' 2 Is checkad. 1 FACILITY o 2 PROPERTY OWNER o 3 TANK OWNER 423 Form.A VII. APpLICANT SIGNATURE & accurate to the best 01 my knowIadge 425 DATE 424 PHONE C e- hiIJ{. 7GéO qaJ-:lfjo{f 4ZT 426 1c:2-\?rV TITLE OF APPLICANT v ec... JuT ( or local use only) From: Jessica Hicks At Hay Insurance Agency, Inc. FaxID: 6613242013 To: Howards Mini Mart Date: 10120104 01:44PM Page: 2012 ACORD. CERTIFICATE OF LIABILITY INSURANCE OPID~ DATE (MMIOOI'NVV). HOWAEtDS 10/20/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF IN FORMA TlON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hay Insurance Agency Inc./T.NIS HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2001 F Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BfLOW. BAKERSFIELD CA 93301 ~hone:661-324-9614 Fax:LXC #0308408 INSURERS AFFORDING COVERAGE NAlC# INSURED INSURER A: ~lied Insurance Group INSURER B: HowardsMîni Mart INSURER C Mohamed. Rahimi 4201 Belle Terrace INSURER D: Bakersfield CA 93309 INSURER E: COVERAGES THE POLICIES OF INSURANCE lIS1"ED BELOW HA.VE BEEN ISSUED TO THE INSURED NAMEOABOVE FOR THE POLICY PERIOD INDICATED. NOìWlTHSTANDING IINY REQUIREMEm, TERM OR CO~DITION OF ".NY CDr,'T?ACT OR·01l4ER DOCUMENT WIn.¡ RESPECT TO WHICH THIS CERTIFICATE MIIY BE ISSUED OR MAY PERTAIN. mE INSURANCE AfFORDED BY 1HE POliCIES DESCRIBED HEREIN IS SUBJECT TO i>I..l.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. / I'LTR ~ lYPE OF INSURANCE POLICY NUMBER DATE (MM/OOIYY) DATE (MMIDDJYYI .~ LIMITS GENERAl. LIABILITY EACH OCCURRENCE 1$ 1000000 I-- A ~ COMMERCiAl GENERAl LIABILITY ACI??830E$76198 10/01/04 10/01/05 PREMISES (Eá ocGur9nGa) é ,"$ 300000 I-- b ŒAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 5000 X Liquor Liability PERSONAL & />JJV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPliES PER: PRODUCTS - COMPIOP AGG $2000000 I POLICY n 'ï& nLOC . AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - $ ANY AUTO (Ea accident) - AlL OWNED AUTOS BOOIL Y INJURY - $ SCHEDULED AUTOS (Par person) c--- HIRED AUTOS BOOIL Y INJURY f-- $ NON-OWNED AUTOS (ParaccicJQnt) ,.....- PROPERTY DAMAGE $. (Par accldant) GARAGe LIAfl/LITY AUTO ONLY - EA ACCIDENT $ =i ANY AUTO OTHER TH.AN EAACC $ AUTO ONLY: AGG $ ExCESSIUMBRCLlA LIABILITY ' EACH OCCURRENCE $ ~ OCCUR 0 CLAIMS MADE AGGREGATE $ $ =i DEDUCflBLE $ RETENIlON $ $ WORKERS COMPENSATION AND hORY tìMiTs I 1°Ë't EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERÆXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? E.l. DISEASE - EA EMPLOYEE $ If yas, dascribe under SPECiAl PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCA.TlONS ¡VEHICLES lEXCLustONSA.DDED BY ENDORSEMENT I SPECIAL PROVISIONS ~roof of Insurance. CERTIFICATE HOLDER CANCELLATION HOWARDS SHOULD AN( OF tHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1HE EXPIRATION DATE THEREOF, THE 199U1NGIN9URER WILL ENDEAVOR TO MAIL 30 DAY9 III/RITTEN For insured to show - proof of insurance NOTlCIî TO·rnlî ClîRilFICATEHOlDER NA!ÆDTOrnlî LEFT, sur FAIlI1RETO DQSOSHALL IMPOSE· NO· OBlIGATION OR LIABILITY OF ANY KINO UPON 1HE INSURER, ITS AGENTS OR / REPR.ESEJI{1'A~~.n_ . AUJHORIZEDREPRESENTA~ . t.t- ---- _0' --- ... "... -,..... ..... ---' ACORD 75 (7001/0S) @ ACORDCORPORATlQN 198R State of California State of Water Resources Control Board Division of Financial Assistance P.O. Box 944212 Sacramento, CA 94244-2120 For State Use Only (Instructions on reverse side) CERTIFICATION OF FINANCIAL RESPONSIBiliTY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: D 500,000 dollars per occurrence - or ~illion dollars per occurrence AND D D I million dollars annual aggregate or 2 million dollars annual aggregate B. hereby certifies that it is in compliance with the requirements of Section 2807, Tn "In. (N8tT16 of Ta k Owner or Operator} Article 3, Chapter 18, Division 3, Title 23, California Code of Regulations. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective T e Name and Address of Issuer Number Amount Period Action Third Party Com ~A. '( ):M"t ctNe ~d+ l """l \('0 ~( t{}(~(ot/ I o( 210ç Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certifies that you are in compliance with all conditions for participation in the Fund. D. Facility Name Facility Address Facility Name Facility Address Facility Name Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator /.Q. .Fs-,-ðlj Date Name of Witness or Notary CFR (Revised 04/95) FILE: Orlginal- Local Agency Copies - Facillty/Site(s) HOWARDS MINI MARKET #6 SiteID: 015-021-000621 Manager : BusPhone: (805) 397-7600 Location: 4201 BELLE TERRACE Map : 123 CommHaz : Low City : BAKERSFIELD Grid: 02C FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 07 SIC Code:5541 EPA Numb: DunnBrad:17-364-9625 Emergency Contact / Title Emergency Contact / Title -=~.~iL___--- / OWNER JOHN KERLEY / OPERATIONS MNGR Business Phone: (805) 397-7600x Business Phone: (805) 393-7000x 24-Hour Phone : ~-~-~ ~ ~4- 24-Hour Phone : (805) 393-7000x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact : Phone: ( ) - x MailAddr: PO BOX 1807 State: CA City : BAKERSFIELD Zip : 93303 Owner JACO - HILL 300 Phone: (805) 393-7000x Address : 3101 STATE RD State: CA City : BAKERSFIELD Zip : 93308 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: !, ~'i ~'~ ~' Do hereby certify thru I have (Type ?~print name) reviewed the attached hazardous, r~ateria Is manage- ment plan for HOU.3(:i.~r'_'! /~..;~, and that along with (Name or' uusiness/ any corrections constitute a complete and, orrect man- agement plan ~or my facility. Date 10/26/2000 HOWARDS MINI MARKET #6 ! SiteID: 015-021-000621 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: HOWARDS MINI MARKET #6 Cross Street : Business Type: Org Type: Total Tanks : 4 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : JOHN KERLEY Phone: (805) 393-7000x Address: City : State: Zip: Type : INDIVIDUAL TANK OWNER INFORMATION Name : JOHN KERLEY Phone: (805) 393-7000x Address: City : State: Zip: Type : BOE UST Fee# : 019753 Financ'l Reap: SELF INSURED Legal Notif : Property Owner Mailing Address Date:04/28/2000 Phone: (661) 393-7000x Name:JOHN KERLEY Ttl:VP State UST # : 1998 Upg Cert#: 00760 ---- Hazmat Inventory One Unified List -- As Designated Order Ail Materials at Site Hazmat Common Name... ISpocHazIEPA Haza!rdsI Frm DailyMax Unit MCP I/NLEADED GASOLINE F IH DH L 12000.00 GAL Mod CARBON DIOXIDE F P IH G 1700.00 FT3 Min UNLEADED PLUS F IH DH L 12000.00 GAL Mod UNLEADED REGULAR F DH L 12000.00 GAL Mod UNLEADED PREMIUM F IH DH L 12000.00 GAL Mod 2 10/26/2000 HOWARDS MINI MARKET #6 , SiteID: 015-021-000621 = Inventory Item 0001 Facility Ur.it: Fixed Containers on Site ~UtVUVl~ ~Vl~ / ~I~./'*~L~ ~./'-UVl~ UNLEADED GASOLINE Days On Site 365 Location within this Facility Unit Map Grid: UNDERGROUND TANKS CAS# 8006-61-9 Liquid Pure Ambient Ambient fINDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average j 12000.00 GAL 12000.00 GAL 4250.00 GAL HAZARDOUS COMPONENTS %Wt. I RSI CAS# 100.00 Gasoline No 8006619 HAZARD ASSESSMENT~ TSecret RS BioHaz Radioactive/Amount EPA Hazards I NFPA USDOT# MCP No N° No No/ Curies F IH DH / / / Mod ! = Inventory Item 0002 Facility U~it: Fixed Containers on Site 9 CARBON DIOXIDE Days On Site 365 Location within this Facility Unit Map: Grid: SW CORNER OF STRUCTURE CAS# 124-38-9 V STATE TYPE PRESSURE ~ TEMPERATUR~ CONTAINER TYPE Gas Pure Above Ambient Above Ambi~ntl PORT. PRESS. CYLINDER I AMOUNTS AT THIS LOCAtION- Largest Container Daily Maximum ! Daily Average FT3 1700.00 F~3 1275.00 FT3 HAZARDOUS COMPONENTS I 100.00 Carbon Dioxide N 124389 HAZARD ASSESSMENT~ I TSecret INo N~S I Bi°HasINO Radioactive/AmountNo/ Curies EPAF P HazardsII~ NFPA/// I USDOT# MOPMiB -3- 10/26/2000 HOWARDS MINI MARKET #6 SiteID: 015-021-000621 = Inventory Item 0003 Facility Unit: Fixed Containers on Site ~lVUVl~ ~Vl~ / ~ ~ ~Vl~ UNLEADED PLUS Days On Site 365 Location within this Facility Unit Map: Grid: UNDERGROUND TANK CAS# 8006-61-9 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 12000.00 GALI 12000.00 GAL 4250.00 GAL HAZARDOUS COMPONENTS %Wt. ~S CAS# 6619 100.00 Gasoline N 800 HAZARD ASSESSMENTSI MCP TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA , USDOT# No N° No No/ Curies F IH DH / / /I Mod ~- Inventory Item 0004 Facility Unit: Fixed Containers on Site ~,.)lVUVll,.)/~J i%J_-r--%lVll"; / ~l"ll";lVl.L ~Z--x_.I~ UNLEADED REGULAR Days On Site 365 Location within this Facility Unit Map: Grid: UNDERGROUND TANK CAS# 8006-61-9 F STATE ~ TYPE i PRESSURE i TEMPERATIIRE CONTAINER TYPE Liquid /Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 12000.00 GALI 12000.00 GAL 4250.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS TSecretI RSIBioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP NoIN°I No No/ Curies F DH / / / Mod -4- 10/26/2000 HOWARDS MINI MARKET #6 SiteID: 015-021-000621 = Inventory Item 0005 Facility Unit: Fixed Containers on Site UUIVUVlU~ ~Vl~ / U~IU.~k[.~ UNLEADED PREMIUM Days On Site 365 Location within this Facility Unit Map: Grid: UNDERGROUND TANK CAS# 8006-61-9 F STATE ~ TYPE i PRESSURE i TEMPERATURE CONTAINER TYPE Liquid /Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 12000.00 GALI 12000.00 GAL 4250.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS TSecret ~S BioHaz Radioactive/Amount I EPA HazardsI NFPA USDOT# I MCP No N No No/ Curies F IH DH / / / Mod -5- 10/26/2000 F HOWARDS MINI MARKET #6 SiteID: 015-021-000621 Fast Format = Notif./Evacuation/Medical Overall Site --Agency Notification 12/05/1994 CALL 911 IF NEED, CALL STATE EMERGENCY OFFICE: 1-800-852-7550 1-619-262-1621 -- Employee Notif./Evacuation 12/05/1994 CALL FIRE DEPT 911. SHUT OFF (IF POSSIBLE) MAIN POWER BREAKER. EVAUCATE THEMSELVES & OTHERS IN OR AROUND PREMISES NOTIFY CLOSE NEIGHBORS TO EVACUATE IF NECESSARY. -- Public Notif./Evacuation 12/05/1994 NOTIFY NEARBY RESIDENTS & SURROUNDING FACILITIES. Emergency Medical Plan 12/05/1994 BAKERSFIELD OCCUPATIONAL MEDICAL GROUP 4580 CALIFORNIA AVE (805) 327-4527 (805) 327-4535 MEMORIAL MEDI CENTER 5201 WHITE LANE 805-398-1800 MERCY HOSPTIAL 2215 TRUXTUNAVENIIE 805-327-3371 -6- 10/26/2000 HOWARDS MINI MARKET #6 SiteID: 015-021-000621 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site -- Release Prevention 12/05/1994 ALL AREAS KEPT CLEAR OF COMBUSTIBLE PRODUCTS PUMPS HAVE EMERGENCY SHUTOFF SWITCH ABSORBENT MATERIALS STORED ON PREMISES. --Release Containment 12/05/1994 SMALL SPILAGE, SHUT DOWN MAIN SWITCH, CLEAN AREA, DISPOSE OF WASTE PROPERLY. MAJOR SPILLAGE, NOTIFY FIRE DEPARTMENT FOR ASSISTANCE, CALL OPERATIONS MANAGER 805-393-7000. -- Clean Up 12/05/1994 VEHICLE OVERFILL: CLEAN AREA, DISPOSE OF WASTE (IF NEEDED) PROPERLY DIRVE-OFF WITH NOZZLE: SUBSTANTIAL SPILL, SHUT DOWN ENTIRE SYSTEM. VEHICLE DAMAGE TO PUMP LEAK RESULTING: SHUT DOWN POWER TO PUMP(S), CLEAN AREA, CALL OPERATIONS MANAGER ADJACENT TO BUILDING(S) FIRE, FIRE DEPARTMENT WILL ADVISE WHEN TO RESUME NORMAL OPERATIONS. Other Resource Activation 12/05/1994 NOTIFY DISTRICT (OPERATIONS) MANAGER TO CALL OUT RESPONSE EMERGENCY -7- 10/26/2000 F HOWARDS MINI MARKET #6 SiteID: 015-021-000621 Fast Format ~ Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs 02/20/1990 A) GAS - CONSOLE INSIDE STORE AT REGISTERS B) ELECTRICAL - DELI BACK ROOM C) WATER - BEHIND BUILDING D) SPECIAL - NONE E) LOCK BOX - NO Fire Protec./Avail. Water 02/20/1990 PRIVATE FIRE PROTECTION - 1 FIRE EXTINGUISHER LOCATED AT WEST GAS ISLAND DOOR ON INSIDE WALL; 1 FIRE EXTINGUISHER LOCATED ON EAST END OF DELI PREPARATION COUNTER APPROXIMATELY 20 FEET FROM C02 CYLINDERS IN STORAGE ROOM. Building Occupancy Level -8- 10/26/2000 HOWARDS MINI MARKET #6 SiteID: 015-021-000621 Fast Format = Training Overall Site -- Employee Training 03/19/1991 WE HAVE 9 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE ALL NEW EMPLOYEES GET ROUTINE TRAINING ON HAZARDOUS MATERIALS ON LOCATION. MANUALS ON MATERIALS SUCH AS OIL & GAS ARE LOCATED IN EMPLOYEE BREAK AREA. CO2 MANUAL LOCATED ON WALL BEHIND CO2 BOTTLES. -- Page 2 -- Held for Future Use Held for Future Use -- -9- 10/26/2000 Manager : ~usPhone: (805) 397-7600 Location: 4201 BELLE TERRACE 8¥_ ~ap : 123 CommHaz : Low City : BAKERSFIELD ~rid: 02C FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 07 SIC Code:5541 EPA Numb: DunnBrad:17-364-9625 Emergency Contact / Title Emergency Contact / Title SKIP WILLIAMS ~ / OWNER JOHN KERLEY / OPERATIONS MNGR Business Phone: (805) 397-7600x Business Phone: (805) 393-7000x 24-Hour Phone : (805) 845--~~ 24-Hour Phone : (805) 393-7000x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHlth Agency-Defined Topic Title = Hazmat Inventory One Unified List -- MCP+DailyMax Order Ail Materials at Site Hazmat Common Name... ISp~HazlEPA HazardsI Frm DailyMax Unit MCP UNLEADED GASOLINE ~ F IH DH L 12000 GAL Mod UNLEADED PLUS F IH DH L 12000 GAL Mod UNLEADED REGULAR F DH L 12000 GAL Mod UNLEADED PREMIUM F IH DH L 12000 GAL Mod CARBON DIOXIDE F P IH G 1700 FT3 Mit menI plan lot/'~~~2,mAand thru it along ~h .... ~;.~.:.- ... any corm~ior~s co~¥[~e a complete and ~rrect man- agem~nt plan for my facil~. 1 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site UNLEADED GASOLINE Days On Site 365 Location within this Facility Unit UNDERGROUND TANKS CAS# 8006-61-9 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS STORED AND IN USE Lrgst Cont.this Loc GAL DailyMax this Loc GAL DailyAvg this Loc GAL 12000.00 4250.00 DailyMax Stored GAL DailyMax Open Use GAL DailyMax Closed Use GAL HAZARDOUS COMPONENTS %Wt. EHS CAS# 100.00 Gasoline No 8006619 2 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 = Inventory Item 0003 Facility Unit: Fixed Containers on Site UNLEADED PLUS Days On Site 365 Location within this Facility Unit UNDERGROUND TANK CAS# 8006-61-9 F STATE TYPE i PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS STORED AND IN USE Lrgst Cont.this Loc GAL DailyMax this Loc GAL DailyAvg this Loc GAL 12000.00 4250.00 DailyMax Stored GAL DailyMax Open Use GAL DailyMax Closed Use GAL HAZARDOUS COMPONENTS %Wt. EHS CAS# 100.00 Gasoline No 8006619 -3- 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 ~ Inventory Item 0004 Facility Unit: Fixed Containers on Site UNLEADED REGULAR Days On Site 365 Location within this Facility Unit UNDERGROUND TANK CAS# 8006-61-9 r STATE -- TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS STORED AND IN USE Lrgst Cont.this Loc GAL DailyMax this Loc GAL DailyAvg this Loc GAL 12000.00 4250.00 DailyMax Stored GAL DailyMax Open Use GAL DailyMax Closed Use GAL HAZARDOUS COMPONENTS %Wt. EHS CAS# 100.00 Gasoline No 8006619 -4- 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 ~ Inventory Item 0005 Facility Unit: Fixed Containers on Site UNLEADED PREMIUM Days On Site 365 Location within this Facility Unit UNDERGROUND TANK CAS# 8006-61-9 STATE TYPE i PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS STORED AND IN USE Lrgst Cont.this Loc GAL DailyMax this Loc GAL DailyAvg this Loc GAL 12000.00 4250.00 DailyMax Stored GAL DailyMax Open Use GAL DailyMax Closed Use GAL HAZARDOUS COMPONENTS %Wt. EHS CAS# 100.00 Gasoline No 8006619 -5- 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 = Inventory Item 0002 Facility Unit: Fixed Containers on Site CARBON DIOXIDE Days On Site 365 Location within this Facility Unit SW CORNER OF STRUCTURE CAS# 124-38-9 r STATE -- TYPE PRESSURE TEMPERATURE CONTAINER TYPE Gas Pure Above Ambient I Above Ambient PORT. PRESS. CYLINDER AMOUNTS STORED AND IN USE Lrgst Cont.this Loc FT3 DailyMax this Loc FT3 DailyAvg this Loc FT3 1700.00 1275.00 DailyMax Stored FT3 DailyMax Open Use FT3 DailyMax Closed Use FT3 HAZARDOUS COMPONENTS %Wt. EHS CAS# 100.00 Carbon Dioxide No 124389 -6- 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 Fast Format Notif./Evacuation/Medical Overall Site Agency Notification -- Employee Notif./Evacuation Public Notif./Evacuation Emergency Medical Plan -7- 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 Fast Format Mitigation/Prevent/Abatemt Overall Site Release Prevention -- Release Containment -- Clean Up Other Resource Activation 8 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 Fast Format Site Emergency Factors Overall Site Special Hazards Utility Shut-Offs Fire Protec./Avail. Water Building Occupancy Level -9- 05/09/1997 HOWARDS MINI MARKET #6 SiteID: 215-000-000621 Fast Format Training Overall Site iEmployee Training -- Page 2 -- Held for Future Use Held for Future Use -10- 05/09/1997 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA c~3301-5~01 DATE: c~/O1/c78 TO: HOWARDS MINI MARKET 6 4~01 BELLE TERRACE BAKERSFIELD, C~A ~330~ ..... CUSTOMER NO~ ~301~ cusToMER TYPE~ ES7 301~ CHAR9E DATE DESCRIP~T~ION REd,NUMBER DUE DATE TOTAL AMOUNT 8/01/98 BEO-INNINO BALANCE .... O0 7/G0/~8 PAYMENT 474.50-- REFND 8/1~/~8 MR INT REFUND VCHRS 474.50 FOR GUEST IONS DR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUM]~ER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER ~0 DUE DATE: 10/0i/78 PAYMENT DUE: 474.50- TOTAL DUE: $474.50- CITY OF BAKERSFIELD CLAIM VOUCHER IVendor No. I certify that this claim is correct and valid, and is a proper charge against the City Agency and account indicated. CLAIMANT'S NAME AND ADDRESS: Howards Mini Market #6 (AUTHORIZED SIGNATURE OF CITY AGENCY 4201 Belle Terrace Bakersfield, CA 93309 Date: 08-12-98 Initials of Preparer CITY DEPARTMENT: FINANCE PLEASE PROVIDE SHORT EXPLANATION OF PAYME (Including Contract Number if Applicable) This business double paid their Hazardous Materials bill. For that reason they now have a credit of $474.50 which we will be refunding. Dept. El / Obit Project # Invoice # Amount Date of Invoice 7900 $474.50 VOUCHER TOTAL $474.50 SECTION 72, PENAL CODE FINANCE DEPT. USE ONLY Section 72, Presenting False Claims. Every person who with intent to defraud, presents for allowance or for payment to any state board or officer, or any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, Examined & Approved for Payment Amount or writing, is guilty of a felony. BAKERSFIELD FIRE DEPARTMENT MEMORANDUM DATE: August 5, .1998 TO: Susan Chichester FROM: Esther Duran SUBJECT: Claim Voucher Please issue a Claim Voucher to refund over payment of $474.50 paid by Howards Mini Market #6. They made a payment on 6/29/98 of $474.50 and again on 7/30/98. The second payment created the credit of $474.50. Please send a refund of $474.50 to: Howards Mini Market #6 4201 Belle Terrace Bakersfield, CA 93309 Thank you, /ed ~. ~ ~T~\TEI~tl~\~T OF ACCOUNT CITY OF BAKERSFIELD i501 TRUXTUN AVE BAKERSFIELD, CA 9330i-520i (805) 326-3~79 DATE: 8/01/98 TOi HOWARDS MINI ?IAR',~ET 6 4201 BELLE TERRACE .......... iE .... CA 93309 CUSTOMER NO' 3019 CUSTOMER TYPE' ES/ 3019 CHARGE DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL AMOUNT .:~0;,8 BEgINNINg BALANCE 474. 50 6/29/98 PAYMENT 474. 50- 7/30/98 PAYMENT 474. 50- FOR ~UESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE ~'~ ,,,E TOP OF THIS STATEMENT. .... L THE NUMBER AT ~u CURRENT OVER 30 OVER 60 OVER 90 DUE DATE: 8/3i/98 PAYMENT DUE' 474.50-- TOTAL DUE' $474.50- "' ' "' ' PLEASE DETACH AND SEND THIs COPY WITH REMITTANCE DATE: S/O1/9S DUE DATE: REMIT AND MAKE CHECK PAYABLE TO: CITY OF BAKERSFIELD PO BOX 2057 BAKERSFIELD CA 93303-2057 CUSTOMER ND: 3019 CUSTOMER TYPE: ES/ 3019 TOTAL DUE: $474. 50- page: 1 Account Billing/Collection Activity Inquiry SUTL108 Acct : 754701 Cyc St: OK Bill St: NO Cyc: 6 Rt: 1 Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI MARKET.#6 Svc ~Add: 4201 BELLE TERRACE Amt due: 0.00 Current Period Postings Lst Pmt: -264.00 Type Desc Date Amount Receipt # Pmt Dte: 02/24/94 99 PAYMENT 02/24/94 -264.00 85848 -- Prior Bills -- Date Balance 01/01/94 0.00 01/01/93 0.00 Enter '/' For Billing History, 'P' To Print Report, 'D' For Detail Page, or '/C' For Credit and Deposit History or 'XX' To Exit Page: 2 Account Billing/Collection Activity Inquiry SUTL108 Acct : 754701 Cyc St: OK Bill St: NO Cyc: 6 Rt: 1 Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI MARKET #6 Svc Add: 4201 BELLE TERRACE Readings Cons Prey Rdg Curr Rdg cons 01/01/94 Amount Misc Transactions Fwd: $200.00 Type Desc Date Amount Receipt Water: $0.00 99 PAYMENT 01/22/93 -200.00 64577 Sewer: $0.00 T04 4 UNDERGROUND TANKS 01/01/94 264.00 Misc: $264.00 Cred: $-200.00 Total: $264.00 Enter '/' For More Billing History, 'D' For Detail Postings, '/C' for Credit and Deposit History or 'XX' To Exit Page: 3 Account Billing/Collection Activity Inquiry SUTL108 Acct : 754701 Cyc St: OK Bill St: NO Cyc: 6 Rt: 1 Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI MARKET #6 Svc Add: 4201 BELLE TERRACE Readings Cons Prev Rdg Curr Rdg Cons 01/01/93 Amount Misc Transactions Fwd: $0.00 Type Desc Date Amount Receipt # Water: $0.00 T04 4 UNDERGROUND TANKS 01/01/93 200.00 Sewer: $0.00 Misc: $200.00 Cred: $0.00 Total: $200.00 Enter '/' For More Billing History, 'D' For Detail Postings, '/C' for Credit and Deposit History or 'XX' To Exit Page: 3 Account Billing/Collection Activity Inquiry SUTL108 Acct :. 412101 Cyc St: CL Bill St: NO Cyc: 5 Rt: Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI MARKET #6 Svc Add: 4201 BELLE TERRACE Readings Cons Prev Rdg Curr Rdg Cons 01/01/93 Amount Misc Transactions Fwd: $294.00 Type Desc Date Amount Receipt Water: $0.00 99 PAYMENT 02/06/92 -294.00 48222 Sewer: $0.00 F05 HAZ MAT HANDLING FEE 01/01/93 99.00 Misc: $99.00 Cred: $-294.00 Total: $99.00 Enter '/' For More Billing History, 'D' For Detail Postings, '/C' for Credit and Deposit History or 'XX' To Exit Page: 4 Account Billing/Collection Activity Inquiry SUTL108 Acct : 412101 Cyc St: CL Bill St: NO Cyc: 5 Rt: Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI MARKET #6 Svc Add: 4201 BELLE TERRACE Readings Cons Prev Rdg Curr Rdg Cons 01/01/92 Amount Misc Transactions FWd: $87.00 Type Desc Date Amount Receipt # Water: $0.00 99 PAYMENT 01/24/91 -87.00 27797 Sewer: $0.00 T04 4 UNDERGROUND TANKS 01/01/92 200.00 Misc: $294.00 F05 HAZ MAT HANDLING FEE 01/01/92 94.00 Cred: $-87.00 Total: $294.00 '/C' for Credit and Enter /' For More Billing History, 'D' For Detail Postings, Deposit History or 'XX' To Exit B A K E R $ FI i~ L D ,.,o~r ~.ee~ CALI~OgN'IA Bakersfield Fire Dept. Hazardous Materials Division 1715 Chester Ave. · Bakersfield, CA 93301 FAX No. (805) 326-0576 · Bus No. (805) 326-3979 'r'octay's Date "~ - ?- ~ - ~/-~ Time No. of Pages F~ No::: - 07/29/94 09:03 .'~805_326 0576 BFD HAZ MAT DIV ~001 *** ACTIVITY REPORT *** TRANSMISSION OK TX/RX NO. 3299 CONNECTION TEL 3938738 CONNECTION ID JACO 0IL COMPANY START TIME 07/29 08:58 USAGE TIME 04'56 PAGES 9 RESULT OK ~EMORANDUM .... April 27, 1992 TO: PLANNING STAFF 9' FROM: MARTIN OR,, , ASSOCIATE PLANNER SUB3ECT: ANNEXATIONS COMPLETE As of April 24,1992, Reina # 1 Annexation and Stine #8 Annexation were complete and within the city. See attached maps of the specific areas. Attachment .~NNEXATICN NO. 259 A 90 f~o~-wzde strip of land si%ua%ed in ?m sour.nwest i/4 of Section ', Tcwnsnip 30 Sour_n, PanGe 27 East, M. D. M., Cc~znty of Kern, State of Callfornia, ~nore .oartic.~lariy descriDed as.follows: " 5eginning a*. ~ne point~cf'-intersection'of 'tine Sour. h iine of ~ .~kDr~. 45-feet cf Parcel i per Parcel Map No. 6951 (filed in Book 29 of Parcel ~aps, ?age 195 in ~ne Office of t_he K~rn County Recorder) and the Westerly right of way line of t.he Stine Canal, also ~eing a .coin% on t. he Sour.~. -~ht.__ of way. line of 5elle Terrace =_nd a .point on the existing corporate boundary of the City of BaKersfield; _.'SgFNCE [!) South 89" 22' !5" ?_asr, along said Sourin (Right of Way) line, 92.88 feet ~o a .point on r-ne Easterly Richt of Way line of the Stine Canai, aiso toeing on r,n~ Westerly RiG. hr cf Way line of Stine Roa~ (County .Road No. i57); ..TgWNCE (2) Sour_h 14" 56' 22" West along said Stine Canai and Stine Road Rig,~t of Way i/ne, 629.40 feet; ~"Tql~qCE (3) Norr_h 89" 22' 15" West, 92.88 feet to a point on-the Westerly Right'of Way line of ~ Stine Canal, also being t.~ Northeast corr~r of the bou~a~ line of Tract No. 3813 (per .map filed in Book 26 of maps, Pa.oe 128 in t_he Office of ~ Kern County Recorder) and a poir~t on .t. he. exis ~%ing co .rpora~e boundary of the City of Bakersfield; . . .-.ne %o t~he point of THENCE (4) Northeaster!v along said corporate boundary ~; beginning. Containing 1.30 Acres (more or less) ~ ..... ~ ......... ~ .......... ~ ........................... B~LLE TEA~ACE.~ R O. ~ .,. - .... ~ ~ ~ ~C~t ~:',' ~~- -. ~ ':- ~ ~~ ~ { -~--.r--~ ....... ..... -~=: -.. ~,> ~ ~ i" -., . ~,, , ~ u ~OOD /~:-~i~-~ ...... '"~ ~ il ' ' ~ ' "'" 'l " '~' ,-' ~;-- , - = ..... -'~ ,, , ~ PA~WO00 '~ ~ '~' '~ COURT ~-.~ ~ fi-.~ ~ ~s :~' ~ RENO i AVE. :- ---~'---- '~ :] CQ~ ~&~NE ANNEXATION NO, 35~ RESOLUTION NO, ____ ~z' ~ ~, ~ ~: .1 ANNEXATION OF ; .... ~ ,,.. ,, ~ ,,.. , ~.. ST/NE No. 8 ~ '~ TO THE CITY OF BAKERSFIELO ; "'" ' L~-:~ ..... ?~ ...... ~s~ .......... { .~0 ~ ~cm~s .../.. ~"~ ,~ ',~ ,.~ SCALE: -' ' "- ,~ ~' lO0 0 100 ~00 300 -~. .......... +~..r ~.'~' , ~,~ ...... EXI~ C~RA~ B~~ .--:'~'-' '~ / EXHIBIT "B" ~ ~ "': 6664 ~'~- 2~89 RESOLUTION NO. 52-92 A RESOLUTION MAKING FINDINGS AND ORDERING THE TERRITORY DESIGNATED AS PROCEEDING NO. 1094, ANNEXATION NO. 359 (STINE NO. 8), ANNEXED TO THE CITY OF BAKERSFIELD. WHEREAS, Resolution of Application No. 202-91, dated October 2, 199'1, was submitted to the Local Agency Formation Commission of Kern County ("Commission") for the annexation of territory of the City of Bakersfield designated as Proceeding No. 1094, Annexation No. 359 (Stine No. 8); and WHEREAS, a duly noticed public hearing upon said proposal was held before the Commission on March 24, 1992; and ~VHEREAS, following said public hearing the Commission on March 24, 1992. adopted its Resolution Making Determination. being Resolution No. 92-9, recorded in Minute Book 39 of said Commission: and WHEREAS, proceedings have been commenced for the annexation of certain unincorporated territory, designated as Stine No. 8 to the City of Bakersfield. NOW, THEREFORE, BE IT RESOLVED by the Council of the City of Bakersfield as follows: 1. In accordance with Sections 57075 and 57078 of the GoVernment Code, it is hereby found that written protests, if any, filed and not withdrawn prior to the conclusion of the hearing represent landowners owning less than 50 percent of the assessed value of the land within the territory to be annexed. 2. The description of the exterior boundaries of the territory annexed is contained in Exhibit "A" and shown on Exhibit 'B', attached hereto and incorporated in this Resolution as though fully set forth herein. 3. That the said territory designated as Proceeding No. 1094, Annexation No. 359 (Stine No. 8) and described herein, and every pan thereof, is hereby ordered annexed to the City of Bakersfield, subject to following conditions: 4. That the Clerk shall forthwith transmit a certified copy of this resolution ordering a change of organization, along with any required remittance to cover the fees required by Section 54902.5 of the Government Code, to the Executive Officer of the Local Agency Formation Commission of Kern County. s~.~ 6664 ~..r.~ 2190 5. That the Executive Officer of the Commission is hereby requested to prepare and execute a certificate of completion and make the filings required by Part 4, Chapter 8 of the Cortese-Knox Local Government Organization Act of 1985 and record a certified copy of the certification of completion with the recorder of Kern County. with the surveyor of Kern County and with the Clerk of the City of Bakersfield. .......... o0o .......... I HEREBY CERTIFY that the foregoing Resolution was passed and adopted by the Council of the City of Bakersfield at a regular meeting thereof held A PR - 8 m~_ by the following vote: CITY CLERK and Ex Officio Clerk of the Council of the City of Bakersfield APPROVED CLARENCE MEDDERS ,MAYOR of the City of Bakersfield ~PROVED as to fo~: W~~~ARD~ CI~ A~ORNEY of~he-ci~ of Bakersfield BAKERSFIELD FIRE DEPARTMENT MEMORANDUM DATE: February 7, 1997 TO: Susan Chichester -FROM: Esther Duran SUBJECT: Claim Voucher Please issue a Claim Voucher for refund of overpayment made by Howards Mini Mart #6. The overpayment was made on account # ES 3803 on March 7, 1996. Due to the unified billing that overpayment was transferred to account # ES 3019. The amount of the overpayment was $264.00. The refund can be sent to the following location: Howards Mini Mart #6 4201 Belle Terrace Bakersfield, CA 93309 Thank you, /ed Page: 2 Account Billing/Collection Activity Inquiry SUTL108 Acct .: 412101 Cyc St: CL Bill St: NO Cyc: 5 Rt: Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI MARKET #6 Svc Add: 4201 BELLE TERRACE Readings Cons Prev Rdg Curr Rdg Cons 01/01/94 Amount Misc Transactions Fwd: $99.00 Type Desc Date Amount Receipt # Water: $0.00 99 PAYMENT 01/26/93 -99.00 65395 Sewer: $0.00 F05 HAZ MAT HANDLING FEE 01/01/94 110.00 Misc: $110.00 Cred: $-99.00 Total: $110.00 '/C' for .Credit and 'D' For Detail Postings, Enter '/' For More Billing History, Deposit History or 'XX' To Exit Page: 1 Account Billing/Collection Activity Inquiry SUTL108 Acct : 412101 Cyc St: CL Bill St: NO Cyc: 5 Rt: Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI MARKET #6 Svc Add: 4201 BELLE TERRACE Amt.due: 0.00 Current Period Postings Lst Pmt: -110.00 Type Desc Date Amount Receipt Pmt Dte: 03/01/94 99 PAYMENT 03/01/94 -110.00 86096 -- Prior Bills -- Date Balance 01/01/94 0.00 01/01/93 0.00 01/01/92 0.00 01/01/91 0.00 02/15/90 0200 'D' For Detail Page or Enter '/' For Billing History, 'P' To Print Report, , '/C' For Credit and Deposit History or 'XX' To Exit Page: 3 Account Billing/Collection Activity Inquiry SUTL108 Acct : 412101 Cyc St: CL Bill St: NO Cyc: 5 Rt: Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI.MARKET #6 Svc Add: 4201 BELLE TERRACE Readings Cons Prev Rdg Curr Rdg Cons 01/01/93 Amount Misc Transactions Fwd: $294.00 Type Desc Date Amount Receipt# Water: $0.00 99 PAYMENT 02/06/92 -294.00 48222 Sewer: $0.00 F05 HAZ MAT HANDLING FEE 01/01/93 99.00 Misc: $99.00 Cred: $-294.00 Total: $99.00 , , '/C' for Credit and Enter / For More Billing History, 'D' For Detail Postings, Deposit History or 'XX' To Exit Page: 4 Account Billing/Collection Activity Inquiry SUTL108 Acct : 412101 Cyc St: CL Bill St: NO Cyc: 5 Rt: Seq: SSN : Parcel: .... Svc Cls :e Name : HOWARDS MINI MARKET #6 Svc Add: 4201 BELLE TERRACE Readings Cons Prev Rdg Curr Rdg Cons 01/01/92 Amount Misc Transactions Fwd: $87.00 Type Desc Date Amount Receipt # Water: $0.00 99 PAYMENT 01/24/91 -87.00 27797 Sewer: $0.00 T04 4 UNDERGROUND TANKS 01/01/92 200.00 Misc: $294.00 F05 HAZ MAT HANDLING FEE 01/01/92 94.00 Cred: $-87.00 Total: $294.00 Enter '/' For More Billing History, 'D' For Detail Postings, '/C' for Credit and Deposit History or 'XX' To Exit ] ;- I 10/f8194 ~... ~ HOWARDS MINI MARKET #6 215-000-000621 Page 1 Overall Site with 1 Fac. Unit General Information Location: 4201 BELLE TERRACE Map:123 Haz':.2 Type: 3 City : ~/~F~> ~/~ ~~~ Grid: 02C F/U: 1 AOV: 0.0 Contact Name Title Contact Name Title I SKIP WILLIES / OWNER 5D~N' ~C~y~' /~~ ~,~ Business Phone: (805) 397-7600x Business PhoHe: (805)~~~ '~ 24-HoUr Phone : (805)845-7205x 24-Hour Phone : (805~'%/~~ Pager Phone : ( ) - x Pager Phone : ( - ) ~- x Administrative Data s~a~e: c~ z~:~3~./ City: BAKERSFIELD - Co~ Code: 215-007 BAKERSFIELD STATION 07 SIC Code: 5541_ ~d~ress: ~(OI ~~ ~~ / sta~e: c~ / Sugary ~, _3Df~H., ~~, Do hereby certify that i have (Type or print name) reviewed the attached hazardous materials manage- ment plan for~/.zJ~%~--~'~'-~, and ~ha~ i~ along ~. (N~e of 8~) 16/I8/94 ~ ~ HOWARDS MINI MARKET #6 215-000-000621 Page 2 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site Pln-Ref Name/Hazards Form Max Qty MCP 02-001 UNLEADED GASOLINE Liquid 12000 Moderate · Fire, Immed Hlth,'Delay Hlth GAL 02-003 UNLEADED PLUS Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL 02-004 UNLEADED REGULAR Liquid 12000 Moderate · Fire, Delay Hlth GAL 02-005 UNLEADED PREMIUM Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL 02-002 CARBON DIOXIDE Gas 1700 Minimal · Fire, Pressure, Immed Hlth FT3 16/I8/94 . · HOWARDS MINI MARKET #6 215-000-000621 Page 3 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order 02-001 UNLEADED GASOLINE Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL Daily Average GAL I Annual Amount GAL 12,000 I 4,250.00 207,388.00 Storage~~Press T Temp Location UNDER GROUND TANK IAmbient/AmbientlUNDERGROUND TANKS -- Conc Components MCP ---~uide 100.0% IGasoline IModeratel 27 02-003 UNLEADED PLUS Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL Daily Average GAL I Annual Amount GAL 12,000 I 4,250.00 207,338.00 Storage Press T Temp Location UNDER GROUND TANK AmbientlAmbientlUNDERGROUND TANK -- Conc Components MCP ---7Guide 100.0% IGasoline IModeratel 27 02-004 UNLEADED REGULAR Liquid 12000 Moderate · Fire, Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL Daily Average GAL I Annual Amount GAL 12,000 I 4,250.00 207,338.00 Storage ~ Press T Temp Location UNDER GROUND TANK IAmbientlAmbientlUNDERGROUND TANK -- Conc Components MCP ---~uide 100.0% IGasoline IModeratel 27 16/I8/94 · HOWARDS MINI MARKET #6 215-000-000621 Page 4 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order 02-005 UNLEADED PREMIUM Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL I Daily Average GAL 1 Annual Amount GAL 12,000 ! 4,250.00 207,338.00 Storage ~~Press T Temp Location UNDER GROUND TANK IAmbientlAmbientlUNDERGROUND TANK -- Conc Components MCP ---TGuide 100.0% IGasoline IModeratel 27 02-002 CARBON DIOXIDE Gas 1700 Minimal · Fire, Pressure, Immed Hlth FT3 CAS #: 124-38-9 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: WATER TREATMENT Daily Max FT3 I Daily Average FT3 I Annual Amount FT3 -- 1,700 ~ 1,275.00 10,200.00 Storage ~ Press T Temp~ Location PORT. PRESS. CYLINDER IAbove IAbove ISW CORNER OF STRUCTURE -- Conc Components MCP -~Guide 100.0% ]Carbon Dioxide ILow ~ 21 16/I8/94 · HOWARDS MINI'MARKET #6 215-000-000621 Page 5 00 - Overall Site <D> Notif./Evacuation/Medical <1> Agency Notification CALL 911 <2> Employee ~.CALL FIRE DEPT <3> Public Notif./Evacuation ;... <4> Emergency Medical Plan aA~ERSFZELD OCCUPA~ZONAL MEDICAL ~580 C~Z~O~Z~ (805) 327-4527 (805) 327-4535 5~1 ~t ~ 10/~8/94 ~ ~, ~ HOWARDS MINI MARKET #6 215-000-000621 Page 6 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention <2> Release Containment · ' oF ~otSs~ -PPoP~~"~'' :' -'-' ~'~" <3> Clean Up <4> O~h~ ~ou~ 16/2'8/94 ~, ~. '~ HOWARDS MINI MARKET #6 215-000-000621 Page 7 00 - Overall Site <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - CONSOLE INSIDE STORE AT REGISTERS B) ELECTRICAL - DELI BACK ROOM C) WATER - BEHIND BUILDING D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - 1 FIRE EXTINGUISHER LOCATED AT WEST GAS ISLAND DOOR ON INSIDE WALL; 1 FIRE EXTINGUISHER LOCATED ON EAST END OF DELI PREPARATION COUNTER APPROXIMATELY 20 FEET FROM C02 CYLINDERS IN STORAGE ROOM. FIRE HYDRANT - WEST OF NORTHEAST ENTRANCE RAMP, NEXT TO GAS ISLAND <4> Building Occupancy Level 10/~8/94 in ' HOWARDS MINI MARKET #6 215-000-000621 Page 8 ~ ~ 00 - Overall Site <G> Training <1> Employee Training WE HAVE 9 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE ALL NEW EMPLOYEES GET ROUTINE TRAINING ON HAZARDOUS MATERIALS ON LOCATION. MANUALS ON MATERIALS SUCH AS OIL & GAS ARE LOCATED IN EMPLOYEE BREAK AREA. CO2 MANUAL LOCATED ON WALL BEHIND CO2 BOTTLES. <2> Page 2 <3> Held for Future Use <4> Held for Future Use I-iONARI])S MINi[ MAR'I" g6 015.-010-.002977 F)verall Site w~th 1 General Information Location: 4201 E~ELL. E TERRACE Map: 123 Hazard: Unrated I ~";ity : · - Grid: 02.('; : 1 AOV: 0.0 _.:. ......................... ~ : ~ . '.~. _ ~ ,¢. . _~ ~ ...... _ ,~. . ,_ ..,. ~ ~ ~ .0, _ ¢. ....................................................... ~ ,: ................................ : .................... .......... Contact Name .................."l'tt'le ............................. Contact Name -.:-~ .... .- .... 't'~tle ......... LI Bustness Phone: (805) 39't-'7800x Business Phori¢~(~.05) '~';'-'780(.~x~¢)-~-/~6[, _ '--- =~- ~ '"' ' ~7~ 24..-Hour Phone : (805) 845--.3968x 24-.Hour vnone : ~,.~ :~-..~0~ Page~ Phone = ( ) .... ~ Page~ Phone = ( ) .............................................................................................. _ ............................................................................................................... ............................................. ~ .-,.~,~ ~-~ ............. Ad~ ~ ~~-. ~ ~ ~ ~ ~:'~ ........................................................................................... City: 8AKEIRSFIELD State: CA Zip.. 'S:,: ..... Corem Code: 015--90'7 COUN"f'Y/BFD.-STA '7 RESPONSE. SIC Code: 5541 Addmess: 3'101 S'I"ATE RD State, (":A City: BAKE. RSFZELD Zdp: 93308-- Summary ............................................................................................................. : ............................................................................................ CRNR MZNZ MAR"f' NITH GASOI_INE PUMP ZSLANDS L. OCATED ON N SZDE OF STORE ISLAND. CARBON DIOX]:DE CYLZNDERS LOCA"I'ED ZN BACK STORAGE ROOM, CHAINED HOWARDS IvlINI MART ~$ 015-..010--0029"!'7 02, ,.- Fixed Containers mt Site Hazmat Inventor~ Detail in R~f~r~nc~ Number Order > Fire, De~ay H~th 'GAL, CAS ~: 8866!g 'Trade Secret: No Form: I.,fiqufid Type: Pure Days: :365 Use: FUEL ........ E)a~]y Nax GAL - .......... I .....Da~]y Average GAL . ....... I ........ Annua~ Amount GAL . 12,000.00 I 5,500,00 I 200,000.00 .................. Storage ........................ ! Press I Temp ..~1 ....................................... Location .......................... UNDER GROUND TANK JAmbfientjAmbfient J .... C:onc ..-! ..................................................... Component~ ........................................ I"" ~CP ---IGuide 100.0~ IGaso] 1ne I Node~ateI 02-..002 ::Ui~i_EADED GASOLINE ~~~~./ L. iquid 12000 > Fire, De~ay H]th v GAL CAS ~: 888819 Tnade Secret: No F:opm: L. iquid Type: Pune Days: 385 Use: F:UEL ........... E)ai3y ~ax GAL · ........ J .....Da4]y Avepage GAL - ..... J ...... Annua] Amount GAL - .... 12,000.00 J 6,000.00 j 400,000.00 ............ StoPage ................... J PPe~s J Temp .... j .......................................... Location ........................... UNDER GROLIND TANK JAmbfient JAmbient J .- Conc J .................................................................... Components ............................................. j.- ~CP ...... jGuide IO0.0A JGaso31ne j ~lodenate J 2'7 Farm and Agriculture [ ] KERN COUNTY FIRE DEPARTMENT HAZARDOUS MATERIALS INVENTORY DUN AND BRADSTREET NUMBER Standard Business ~] FORM 4 /~/ BUSINESS N ~A~E:./~]~F~ ~//~/ /~r ~ OWNER NAME: LOCATION: ~'~9/ ,~7~ ~~~ ADDRESS: Page 1 of ciT~, zIP:'.~4~S~/~z~ rjq ~3D? CIT~, ZIP.' PHONE ~: ~0,~-,-~'-~0 PHONE ~: [ [ ........ I 1 2 3 4 5 6 7 8 9 10 11 12 ~rade I?rens Type #ax ~verege Annual #eesure Cont Cont Cont Use % by #ames of #i~ture/Compone~ts Secret ICode Code Amt Amt Est Units Type Press Tamp Code Mt See Instructions Y/N [ [ ] In.edibLe HeaLth [ ~ocetion [ Component & CAS I I I I Co~po~q~t & CAS I I I t I I[ ]Reectivity [ ]Sudden ReLease of Pressure ft Days on Site [ ~ I Coe~xN~ent & CAS I , , , , , , , I I I I I I i i I I I I I I P~d~t .-- I I [ ] lfl~nediate HeaLth I Location I Cc~q~o~ont & CAS I ' I I I I I[ ]Fire [ ]DeLayed HeaLth CAS #c~ber i Component & CAS I I. I I I I£ ]Reactivity [ ]Sudden ReLease of Pressure fl Days on Site [ ] I Component & CAS I , , , , , , , , { I I I ' ' I ' ' ' ' ' ' : t I I I[ ] l~ediate HeaLth [ Location ] Congmnent & CAS I I I I I IL ]Fire [ ]DeLayed HeaLth CAS N~J~ber I I CoflgKN~flt & CAS I I I I I I[ ]Reactivity [ ]Suddefl ReLease of Pressure fl Days on Site [ ] I I Cofl~x~neflt & CAS I I I I I E#ERGENCY CONTACTS I Name TitLe 14 Hr Phone I I Name TitLe 24 Hr Phone I I Certificetion (Reed and ~i~in pfter compLetir~ ail sections) I I ! certify under penalty of L~u thet ! here personaLLy ex~mined end m~ f~miLier uith the infor~mtion submitted in this and eLL ettached documents, and that based on I my/4'~c~iry,p~ tl~ose JndivickmLs reepoos.JbLe for~obt~ining the information, ! believe thet the sut~itted information is true, eccurete, end complete. J~a~n~'elTtcl offlci~l'/ ~itLe of-~ner/olc~retor o~ o~l~e~r/opere~rr s authorized representative Signature ate Si~ned INVENTORY CODE SHEET Trans Code (Column 1) Use Codes (Column 10) A = Add This Item 01. Additive D = Delete This Item 02. Adhesive R = Revised Information " 03. Aerosol/Inflation 04. Anesthetic Type Code (Column 2) 05. Bactericide 06. Blasting P = Pure Material 07. Catalyst M = Mixture of Substances 08. Cleaning W = Waste (Must Also: Add Appropriate 09. Coolant/Antifreeze Waste Code from "Waste Code 10. Cooling Sheet") 11. Drilling 12. Drying Measure Units (Column 6) 13. Emulsifier/Demulsifier 14. Etching LBS = Pounds 15. Experimental/Analytical TON = Tons (2,000 lbs) 16. Fabrication GAL -- Gallons 17. Fertilizer BBL = Barrels (42 gals) 18. Formulation/Manufacturing Ft3 = Cubic Feet 19. Fuel CUR = Curies 20. Fungicide 21. Grinding Container Type (Column 7) 22. Heating 23. Herbicide 01. Underground Tank 24. Insecticide 02. Aboveground Tank 25. Instructional 03. Fixed Pressurized Cylinders 26. Lubricant 04. Portable Pressured Cylinders 27. Medical Aid or Process 05. Insulated Tank (Includes Cryogenics) 28. Neutralizer 06. Drums or Barrels - Metallic 29. Painting 07. Drums or Barrels - Non-Metallic 30. Pesticide 08. Carboy(s) 31. Plating 09. Glass Container(s) 32. Preservation 10. Plastic Container(s) 33. Refining 11. Box(es) 34. Sealer 12. Bag(s) 35. Spraying 13. Metal Containers (Not Drums) 36. Sterilizer 14. In Machinery or Processing Equipment 37. Storage/In Storage 15. Bin(s) 38. Stripper 16. Unlined Sumps 39. Washing 40. Waste Container Pressure (Column 8) 41. Water Treatment 42. Welding Soldering 1 = Ambient Pressure 43. Well Injection or Service 2 = Greater Than Ambient Press 44. Oil Treatment 3 = Less than Ambient Press 45. Resale 46. Aircraft Systems Container Temperature (Column 9) 47. Battery/Electrolyte 48. Breathing Air 4 = Ambient Temperature 49. Drafting Aid 5 = Greater than Ambient 50. Finished Product 6 = Less than Ambient Temp but not 51. Fire Protection Cryogenic 52. Hydraulic Equipment 7 = Cryogenic Conditions 53. Road/Hwy Maintenance 54. Testing 55. Wholesale Chemicals 99. OTHER - Specify on another page H O V~ A R D S M i N :1: M A R'I" ~ 8 01 .5 - 010 -- 002 .9 ? '7 02 - Fixed Containers at Site Hazmat Inventory Detail in Reference Numbe~ Order 02-...003 PREMIUM UNLEADED GASOLINE Liquid 12000 Moderate > Fire, Delay Hlth GAL (]:AS ~t: 886619 Trade Secret: No Form: I..i qui d 'l"ype: Pure Days: :365 Use: F:UEL ....... DaJqy Nax GAL - ...... ~ ....... DaJ]y Average GAL · ...... I ...... Annual Amount GAL · .... 12,000.00 I :), 500.00 I 91 , 000.00 ............... Storage .................. I Press I 'T'emp ..-I ............................. Location .................. UNDEI~ GROUND TANK IAmbJentlAmbJentl .... Conc '~! ...... * ...................................................... Components ................................... !- NCP .... lGuJde 100.0~ IGasoq Jne J NoderateI O0 .-. ()ve. rai'] .'.!~i.~.e < I)> Not i f,/l!.']vacuat i on/Meal i ca 1 <1> Agency Notification CALL 9-1-1 IF NEED CALL STATE EMERCENCY OFFICE 1-800-852-7550 or 1-619-262-1621 <2> Employee Notif./l!!vacuation ........ ALL EMPLOYEES ARE TRAINED AND AWARE THAT IN AN EVENT OF AN.EMERGENCY SITUATION THEY ARE TO FOLLOW THESE PROCEDURES' A. SHUT OFF (IF POSSIBLE) MAIN POWER BREAKER B. EVACUATE THEMSELVES AND ANYBODY IN OR AROUND THE PREMISES C. DIAL 9-'1-1 ~ " D. NOTIFY CLOSE NEIGHBORS TO EVACUATE IN NECESSARY <3> Public Iqotfif,/I.vacuatfi::: on NOTIFY NEARBY RESIDENTS AND SURROUNDING FACILITIES <4> Emergency Medical Plan j 05/'I..,/..:;~ J:k~ght-..t:.o....{now/f: List:/b.V Comn',Code and/on t:.e Il) Page O0 --- ()verall .Sflte <[:!> Prev./Iqinim'ization/C'leanup <'1> Release. P~ even,.~on ALL AREAS ARE KEPT CLEAR OF COMBUSTIBLE PRODUCTS PUMPS HAVE EMERGENCY SHUT-OFF SWITCH ABSORBENT MATERIALS STORED NEAR GAS ISLANDS <2> Re'lease Containment ..... IN EVENT OF SPILLAGE EMPLOYEE ON DUTY WOULD SHUT DOWN MAiN SWITCH IMMEDIATELY HOSE DOWN AREA IN EVENT OF A MAJOR SPILLAGE EMPLOYEE WOULD NOTIFY FIRE DEPARTMENT FOR BACK UP <3> C:te,.qn 'Up IF CUSTOMER OVERFILLS VEHICLE RESULTING IN SMALL SPILLAGE - HOSE DOWN AREA WITH WATER IF CUSTOMER DRIVES OFF WITH GAS NOZZLE IN CAR FILL TANK~ RESULTING IN A'SUBSTANTIAL FLOW OF GASOLINE - SHUT DOWN ENTIRE SYSTEM IF VEHICLE DAMAGE TO A PUMP RESULTS IN A LEAK-SHUT DOWN POWER TO THIS PUMP ONLY. HOSE DOWN AREA AND CALL YOUR DISTRICT MANAGER IF ADJACENT BUILDINGS IS ON FIRE, SHUT DOWN ENTIRE GAS ~ISLAND, EMERGENCY CONTROL SHUT-OFF, FIRE DEPARTMENT WILL ADVISE WHEN TO RESUME NORMAL OPERATIONS <4> ()t. her,,esc>u" rce Ac;'t.'iva't. ion NOTIFY DISTRICT (OPERATIONS) MANAGER TO CALL OUT RESPONSE EMERGENCY PERSONNEL HOWARDS MINI MART ~tf5 0'15.-010-0029';"7 O0 - Overall Site <F> Site E!me'Pgency <1> Special HazaPds <2> Utility Shut-.(:~ffs <3> Fine Pmotec,/Avail . Water F/CE <4> Earthquake Vulner'ability <tS> "Fratning <1> 'Training Record Location ALL EMPLOYEE TRAINING RECORDS AND HAZARD COMMUNICATION PROGRAM ARE KEPT IN THE OFFICE WITHIN THE STORE. <2> .Describe Training Program ALL EMPLOYEES ARE REQUIRED BY STATE' LAW AND TRA'I.NED IN THE FOLLOWING .AREAS:. HAZARD COMMUNICATION STANDARD (HAZCOM) LOCK/OUT,TAG OUT RULE EMERGENCY RESPONSE PROCEDURES · EMERGENCY CONTACT LIST · ' IF ASSISTANCE IS NEEDED IN MEETING ':THESE REQUIREMENTS' CONTACT OPERATIONS MANAGER, MR. JOHN KERLEY AT (805) 3§3-7000 ;. <3> Emer. Agency Coordination CALL 9.11 FIRE DEPARTMENT ACTI~rATE EMERGENCY PUMP SHUT OFF SWI.TCH EVACUATE ALL PERSONS TO A SAFE LOCAT>ION RENDER AID TO THE INJURED IF YOU CAN. DO S'O WITHOUT PLACING YOURSELF IN DANGER· ' BLOCK OFF'DRIVEWAYS AND STORE ENTRANCES'IF SAFE·TO DO SO ' :'. ,. ASSIST EMERGENCY PERSONNEL CONTACT STORE MANAGER CONTACT GASOLINE OPERATIONS MANAGER .' ... <4> .l':men. Response Equipment SMALL· SPILL OF PRODUCT' SUITABLE ABSORBENT LOCATED AT STORE ' .' ': DO NOT WASH DO'WN WITH WATER TO CURB OR ·STORM. DRA"I'N' PLACE ABSORBENT:IN SUITABLE CONTAINER' SE. CURE THE.""- COLLECTED MATERIAL .'IN OUTSIDE STORAGE AREAi: ·ADVISE"'.. MANAGER OF I'NCIDENT ~ .... CONTACT GASOLINE OPERATIONS MANAGER FOR'"DISPOSAL .." ASSISTANCE , .' , .i' ; ' ,.:" LARGE SPILL OF PRODUCT' ACTIVATE. EMERGEONY SHUT OFF SWITCH CALL 91.1 FIRE'DEPT ? HOWARDS MINI MARl" ~6 015.-010.-.0029'7'7 00 .... Overall Site <H> SOHOOL$ WITHIN 1/2 MILE <1> High Schools High Schools <:3> ElementaPy Schools Private & Poe Schools 03/24/94 HOWARDS MINI MARKET #6 215-000-000621 Page 1 Overall Site with 1 Fac. Unit General Information Location: 4201 BELLE TERRACE Map:123 Haz:2 Type: 1 Community: BAKERSFIELD STATION 07 Grid: 02C F/U: 1 AOV: 0.0 Contact Name Title Business Phone 24-Hour Phone- SKIP WILLIAMS OWNER 1(805) 397-7600 x 1(805) 845-~-~ ROBYN MOORE ASSISTANT MANAGER (805) 397-7600 x (805) 327-8109 Administrative Data Mail Addrs: 4201 'BELLE .TERRACE D&B Number: City: BAKERSFIELD State: CA Zip: 93309- Comm Code: 215-007 BAKERSFIELD STATION 07 SIC Code: 5541 Owner: SKIP WILLIAMS Phone: (805) 397-7600 Address: 8601 KAM AV State: CA City: BAKERSFIELD Zip: 93307- Summary "~P~ 0 5 1994 reviewed the attached hazardous malerials ma~'age- any ~rr~iofls ~nstitute a ~mpl~e and ~ue~ man- agement plan for my fadli~. 03/24/94 HOWARDS MINI MARKET #6 215-000-000621 Page 2 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site Pln-Ref Name/Hazards Form Max Qty MCP 02-001 UNLEADED GASOLINE Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL 02-003 UNLEADED PLUS Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL 02-004 UNLEADED REGULAR Liquid 12000 Moderate · Fire, Delay Hlth GAL 02-005 UNLEADED PREMIUM Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL 02-002 CARBON DIOXIDE Gas 1700 Minimal · Fire, Pressure, Immed Hlth FT3 03/24/94 HOWARDS MINI MARKET #6 215-000-000621 Page 3 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order 02'001 UNLEADED GASOLINE Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GALI Daily Average GAL I Annual Amount GAL 12,000 ~ 4,250.00 207,388.00 Storage '~~Press T Temp Location UNDER GROUND TANK Iambient~ambientlUNDERGROUND TANKS -- Conc Components MCP -~Guide 100.0% IGasoline IModeratel 27 · 02-003 UNLEADED PLUS Liquid 12000 Moderate · Fire, Immed Hlth, Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GALI Daily Average GAL I Annual Amount GAL -- 12,000 ~ 4,250.00 207,338.00 Storage Press T TempI Location UNDER GROUND TANK Ambient~AmbientlUNDERGROUND TANK -- Conc Components MCP -~Guide 100.0% I Gasoline I Moderate I 27 02-004 UNLEADED REGULAR Liquid 12000 Moderate · Fire, Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GALI Daily Average GAL I Annual Amount GAL 12,000 ~ 4,250.00 ° 207,338.00 StorageI~Press T Temp Location UNDER GROUND TANK I Ambient~AmbientlUNDERGROUND TANK -- Conc Components MCP ---~uide 100.0% IGasoline IModeratel 27 03/24/94 HOWARDS MINI MARKET #6 215-000-000621 Page 4 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order 02-005 UNLEADED PREMIUM Liquid 12000 Moderate ~ Fire, Immed Hlth, Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: .365 Use: FUEL Daily Max GAL I Daily Average GAL I Annual Amount GAL 12,000 ~ 4,250.00 207,338.00 Storage ~~Press T Temp Location UNDER GROUND TANK I AmbientlAmbientlUNDERGROUND TANK - Conc Components MCP ---~uide 100.0% IGasoline IModeratel 27 02-002 CARBON DIOXIDE Gas 1700 Minimal ~ Fire, Pressure, Immed Hlth FT3 CAS #: 124-'38-9 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: WATER TREATMENT Daily Max FT3I Daily Average FT3 I Annual Amount FT3 -- 1,700 ~ 1,275.00 10,200.00 Storage I Press I Temp I Location PORT. PRESS. CYLINDER .Above IAbove SW CORNER OF STRUCTURE -- Conc Components MCP ---TGuide 100.0% ICarbon Dioxide IMinimal I 21 03/24/94 HOWARDS MINI MARKET #6 215-000-00062i Page 5 00 - Overall Site <D> Notif./Evacuation/Medical <1 > Agency Notification CALL 911 <2> Employee Notif./Evacuation CALL FIRE DEPT 911. SHUT OFF' EMERGENCY GAS SWITCH AND EVACUTE IMMEDIATELY. <3> Public Notif./Evacuation CALL 911 "FIRE DEPARTMENT". EVACIATE AMD DENY ENTRY INTO IMMEDIATE AREA UNTIL NORMALITY IS RESTORED <4> Emergency Medical Plan BAKERSFIELD OCCUPATIONAL MEDICAL GROUP 4580 CALIFORNIA AVE (805) 327-4527 (805) 327-4535 03/24/94 HOWARDS MINI MARKET #6 215-000-000621 Page 6 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention NORMAL GAS STATION SAFETY EQUIPMENT. <2> Release Containment GAS SPILL - USE DRY ASBSORBENT, BAG SAME, CALL RECYCLING HOT LINE (800) R-E-C-Y-C-L-E. CO2 - RELEASES TO ATMOSPHERE <3> Clean Up GAS SPILL - USE DRY ABSORBENT, BAG SAME, CALL RECYCLING HOT LINE (800) R-E-C-Y-C-L-E. <4> Other Resource Activation 03/24/94 HOWARDS.MINI MARKET #6 215-000-000621 Page 7 00 - Overall Site <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - CONSOLE INSIDE STORE AT REGISTERS B) ELECTRICAL - DELI BACK ROOM C) WATER - BEHIND BUILDING D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - 1 FIRE EXTINGUISHER LOCATED AT WEST GAS ISLAND DOOR ON INSIDE WALL; 1 FIRE EXTINGUISHER LOCATED ON EAST END OF DELI PREPARATION COUNTER APPROXIMATELY 20 FEET FROM CO2 CYLINDERS IN STORAGE ROOM. FIRE HYDRANT - WEST OF NORTHEAST ENTRANCE RAMP, NEXT TO GAS ISLAND <4> Building Occupancy Level 03/24/94 HOWARDS MINI MARKET #6 215-000-000621 Page 8 00 - Overall Site <G> Training <1> Page 1 WE HAVE 9 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE ALL NEW EMPLOYEES GET ROUTINE TRAINING ON HAZARDOUS MATERIALS ON LOCATION. MANUALS ON MATERIALS SUCH AS OIL & GAS ARE LOCATED IN EMPLOYEE BREAK AREA. CO2 MANUAL LOCATED ON WALL BEHIND CO2 BOTTLES. <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use HAZARDOUS MATEI~.S INSPECTION ]~ersfield Fire Dept. ~ ' ~?: Haza-irdous Materials Division ~ Date Completed Business Name: '~-'~4...,~z~c~.b-' ~..-;z~/' ..,~,,~,,~..~ RECEIVED Location: ~-'~/ ~-//~--- /~'-~~ {WAR Business Identification No. 215-000 g)-do ~ / (Top of Business Plan) HAZ. iV/AT. DIV. StationNo. ~ Shift ~ Inspector ~--~-'~.~'~-'..,~:~~ Arrival Time: ..~.~'~ Departure Time: ~,5'-~'""- Inspection Time: ~ Adequate Inadequate Verification of Inventory Materials .,~ ["1 Verification of Quantities J~ Verification of Location %~ I-1 Proper Segregation of MaterialxJ~ [--[ (_Comments: ~ Verification o[ MSDS Availabili~ ~ Number of Employees: /4~ Verification of Haz Mat Training ... ,,~" '; ? '~' Comments: " Verification of Abatement Supplies & Procedures ~ I--[ Comments: Emergency Procedures Posted.~' I'1 containers Properly Labeled .~ . I'1 Comments: Verification of Facility Diagram Special HazafdsAssociated with this Facility: h Violations: ,,,~c:,...,,~._ ~-- ~ ~'~__~' ""'~'~'.'?P--'> :' I "All Items O.K ~ Business Owner/Manager PRINT' NAME.-.. Correction Needed White-Haz Mat Div Yellow-Station Copy Pink-Business Copy 07/29/92 HOWARDS MINI MARKET #6 215-000-1 6~G 11 1992 Page 1 Overall Site with 1 Fac. Uni'. General Information ,~-------: Location: 4201 BELLE TERRACE Map: 123 Hazard: Low Community: BAKERSFIELD STATION 0~ /~ Grid: 02C F/U: 1 AOV: 0.0 / cOntact Name Title /i Business Phone 24-Hour Phoneq ISKIP WILLI _AMS I ~C~,~D- \. /I(805)397,7600 x I (805) 84/5_~3968 (805) 397-7600 Administrative Data Mail Addrs: 4201 BELLE TERRACE D&B Number: CitY: BAKERSFIELD State: CA Zip: 93309- Comm Code: 215-007 BAKERSFIELD STATION 07 SIC Code: 5541 Owner: SKIP WILLIAMS Phone: (805) 397-7600 Address: 8601 KAM AV State: CA City: BAKERSFIELD Zip: 93307- Summary 07/29/92 HOWARDS MINI MARKET #6 215-000-000621 Page 2 02 - Fixed Containers on Site Hazmat Inventory Detail in Reference Number Order 02-001 GASOLINE Liquid 48000 Moderate ~ Fire, Immed Hlth,' Delay Hlth GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid. TYpe: Pure Days: 365 Use: FUEL Daily Max GAL Daily Average GAL I Annual Amount GAL 48,000 I 17,000.00 829,353.00 Storage Press T Temp Location UNDER GROUND TANK AmbientlBelow IUNDERGROUND TANKS -- Conc Components MCP List 100.0% IGasoline ModerateI 02-002 CARBON DIOXIDE Gas 1700 Minimal ~ Fire, Pressure, Immed Hlth FT3 CAS #: 124-38-9 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: WATER TREATMENT Daily Max FT3I Daily Average FT3 ] Annual Amount FT3 . 1,700 ~ 1,275.00 10,200.00 Storage Press I Temp~ Location~ PORT. PRESS. CYLINDER Above IAbove ISW CORNER OF STRUCTURE -- Conc I Components I MCP iList 100.0% Carbon Dioxide Minimal 07/29/92 HOWARDS MINI MARKET #6 215-000-000621 Page 3 00 - Overall Site <D> Notif./Evacuation/Medical <1> Agency Notification CALL 911 <2> Employee Notif./Evacuation CALL FIRE DEPT 911. SHUT OFF EMERGENCY GAS SWITCH AND EVACUTE IMMEDIATELY. <3> Public Notif./Evacuation CALL 911 "FIRE DEPARTMENT". EVACIATE AMD DENY ENTRY INTO IMMEDIATE AREA UNTIL NORMALITY IS RESTORED '<4> Emergency Medical Plan 07./29/~2 HOWARDS MINI MARKET #6 215-000-000621 Page 4 O0 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention NORMAL GAS STATION SAFETY EQUIPMENT. <3> Clean Up CO&--.- <4> Other Resource Activation 07/29/92 HOWARDS MINI MARKET #6 215-000-000621 Page 5 00 - Overall Site <F> Site Emergency Factors <1> special Hazards <2> Utility Shut-Offs A) GAS - CONSOLE INSIDE STORE AT REGISTERS .B) 'ELECTRICAL - DELI BACK ROOM C) WATER - BEHIND BUILDING D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water, PRIVATE FIRE PROTECTION - 1 FIRE EXTINGUISHER LOCATED AT WEST GAS ISLAND DOOR ON INSIDE WALL; 1 FIRE EXTINGUISHER LOCATED ON EAST END' OF DELI PREPARATION COUNTER APPROXIMATELY 20 FEET FROM CO2 CYLINDERS IN STORAGE ROOM. FIRE HYDRANT - WEST OF NORTHEAST ENTRANCE RAMP, NEXT TO GAS ISLAND <4> Building Occupancy Level A//~ ~ 07/29/92 HOWARDS MINI MARKET #6 215-000-000621 Page 6 0'0 - Overall Site <G> Training <1> Page 1 WE HAVE 9 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE ALL NEW EMPLOYEES GET ROUTINE TRAINING ON HAZARDOUS MATERIALS ON LOCATION. MANUALS ON MATERIALS SUCH AS OIL & GAS ARE LOCATED IN EMPLOYEE BREAK AREA. CO2 MANUAL LOCATED ON WALL BEHIND CO2 BOTTLES. <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use CITY OF BAKERSFIELD IIAZARDOUS MATERIALS INVENTORY . ' Page / ~.f,~ - ~ Farm and Agriculture'S' Stand~rd Business NON- TRADE SECRET ~, ,' LOCATION: ~/ ~~ ~~C~ ' ~D~SS: ~/ ~W/Y¢~I~' ~ ST~ I'ND. CLASS CODE: CITY, ZIP: ~f~, ~4~ CITY, ZIP:~/~_ e~'), : D~N ~D B~ST~ET~ER/FEDE~a_~ 1' 2 3 4 5 6 7 8 9 10 11 ~ 12 13 14 Tr~s ~e ~ Average ~nual Measure ~ Days CoLt CoLt CoLt Uss Location ~ere % by N~s of M~ture/Com~nents Code C~e ~t ~ ~t .. Units on Site ~ Press Temp Code Stored in. Facility ~ See Inst~ctions Ph~ical and ~lth ~azard C.A.S. Nu~er ~ ~--~/--~ , Co~onent ~ Name & C.A.S. N~er -- (Check all that apply) Comp~ 2 Na~ i C.A.S. N~er of Pressure ~ealth ~ealth Component 8 3 Na~ ~ C.A.S. N~er ',1 I,"',,., ' I I':: I* i , Physical and ~lth ~azard C.A.S. Nu~er Co~onent ~ 1 N~ A C.A.S. N~er (Check all that apply) Co, orient ~ 2 Na~ & C.A.S. N~er of Pressure ~ealth Health Component ~ 3'Na~ & C.A.S. Nu~er Ph~ical and ~lth ~azard C.A.S. Nu~er Component ~ 1 Na~ & C.A%S. N~er (Check all that apply) Co~onent 8 2 Na~ & C.A.S. N~er ~ Fire ~az~d ~ Sudden Release ~ R~ctivtty ~ I~edia~e ~ Delay~ __ of Pressure Health H~lth Component ~ 3 Na~ ~ C.A.S. Nu~er Ph~ical and ~lth ~azard C.A.S. Nu~er Component ~ ~ Na~ & C.A.S. N~er (Check all that apply) Component ~ 2 Na~ & C.A.S. N~er ~ Fi~a Hazed ~ Sudden Release ~ Reactivity ~ I~ediat. ~ Delayed o~ P~assu~a Haalth ~ealth Component ~ 3 Na~ ~ ~.~.S. Numar Na~ Title ' 24 ~. Phone N~e Title 24 ~ phone ~tification (~ ~D SIGN AFTER COMPLETING ~.L SECTIONS) I certlfy ~der p~nlty of law that I hayer ~rsonally ~in~ ~d ~ f~il~ar with the ~n.f0~atlon submitted in this and all attache~ d~ents ~d that ~sed on ~ tn~i~ of those ~ndivid~l, res~nstble for obtaining the info=tion. I believe ~hat the .ubmitt.d info~ation t. true, acc~at., a~d, com~le~.,~ / ' ~R OR'~OP~R S A~ORI~D ~P~S~TI~ ~ DA~ SIG~D C I T¥ OF BAKERSF I ELD ~AT. ARDOUS MATERIALS INVENTORY -~ Farm and Agriculture'~ Standard Business Page~ o..f NON - 'IqlADE SECRET ADDRESS: ~fo/ /f',~//d~t£~o' , ~ STANDARD IND. CLASS CODE: 1' 2 3 4 5 6 7 8 9 10 11 12 13 14 Tra~s Type Max Average. Annual Measure # Days Cont Cont Cont Use" Location Where % by Names of 'MiXture/Components Code Code Amt Amt Amt Units on Site Type Press Tamp Code Stored in Facility wt See Instructions · C 7 i Physical and' Health Hazard C.A.S. Number ' Component # i Name & C.A er (Check all that apply) Component # 2 Name & C.A.~m.~umber ~ Fire Hazard ~ Sudden Release ~ Reactivity ~ I=ed~ate ~ Delayed of Pressure Health Health Component # 3 Name & C.A.S. Number .- I~'~1 I/'..-"1,., .... --~ I'..' I." '" I":' I I-- I ~ I- I' "' Physical and Health Hazard C.AoS. Number i Component § i Name & C.A.S. Number (Check all that apply) Component # 2 Name & C.A.S. Number 11 '~ Fire Hazard ~ Sudden Release [] ReaCtivity ~ I~ediat. [~ Delayed I i : of Pressure Health Health Component # 3'Name & C.A.S. Number I' I I I I I I I I I I ! Physical and Health Hazard C.A.S. Number Component # i Name & C.AiS. Number , (Check all that apply) Component # 2 Name & C.A.a. Number ~ Fire Hazard [] Sudden Release ~ Reactivity [] In~ediate ~ Delayed of pressure Health Health Component # 3 Name & C.A.S. Number Physical and Health Hazard C.A.S. Numbe~ Component # 1 Name & C.A.S. Number (Check all that apply) Component # 2 Name & C.A.S. Number of Pressure Health Health Component # 3 Name & C.A.S. Number Nam~ Title 24 Hr. Phone Name Title 24 Hr Phone lertification (READ AND SIGN AFTER COMPLETING ALL SECTIONS) I certify under peanlty of law that I haver personally examined and am familiar with the inform4tion submitted in this and all attache~ documents and that based on my inquiry of those individuals responsible for obtaining the information. I believe ~hat the submitted information is true, accurate, and complete. // ?,. ~ ~ / ~ .- t,/ f '-- -T ' / ' R'S AUTHORIZED REPRES~'L~TIVE '~' IGN ' ' DATE SIGNED CITY OF BAKERSFIELD Agriculture ~;~ Standard Business Page~o..f .~___~J Farm and NON - TRADE SECRET LOCATION: ~.~L~_/ ~/~ ~~ ' ~D~SS: ~o/ ~/I¢4/~- , ~ ST~ IND. C~SS CODE: ~ITY, ZIP: ~, ~q~ CITY, zIp:~C~- ~2 ~_ ~ D~ ~D ~ST~ET N~BER/FEDE~ ~~ ~'~ ~R ~ INS~U~IONS ~R PROPER ~DES 1' 2 3 4 5 6 7 8 9 10 11 ~ 12 1~ . 14 ~s ~e ~. Average ~nual Measure ~ Days Con~ Conk Cont Use Location ~ere~% ~ N~s of M~ture/C~nents C~e C~e ~t ~ ~t Units on Site ~ Press Temp Code Stored in Pacility See Insk~ctions (Chec~ ~ha~ of Pressure H~lth H~lth Component ~ 3 Na~ & C.A.S. N~er j Physical and H~lth Hazard C.A.S. N~er i Co~onent ~ 1 N~ & C.A.S. N~er (Cheek all tMt apply) Co~onent ~ 2 Na~ & C.A.S. N~er ~ Pit. Hazed ~ Sudden Release '~ R~ctivtty ~ I~iat. ~ Delay~ of Pressu~ H~lth H~lth . Co~onent ~ 3 N~ & C.A.S. N~er Ph~tcal and H~lth Hazard C.A.S. N~er Co~onent ~ 1 Na~ & C.A;S. N~er (Check all t~t apply) Co~onent ~ 2 Na~ & C.A.S. N~er of PreSsure H~lth H~lth Co~onent ~ 3 Na~ & C.A.S. N~er Ph~tcal and H~ith ~azard C.A.S. Nu~er component ~ i N~ & C.A.S. N~er (Check all t~t apply) Component ~ 2 N~ & C.A.S. N~er of Pressure Health H~lth Co~onent ~ 3 Na~ & C.A.S. N~er Na~ Title 24 ~. Phone N~e Title 24 ~ Phone l~t~ficat~on (~ ~D SIGN AFTER COMPLETING ~L SECTIONS) certify ~der p~nlty of law that I hayer ~rsonally ~in~ ~d ~ f~l~ with the ~nf0~ation submitted in this ~d all attache~ d~ents ~d that ~sed on ~ in~i~ of those I[ndivid~ls res~nsible for obtaining the lnfo~tion. I believe that the su~itted info~ation ~s t~e, aucurate, and c~plete. // CITY OF BAKERSFIELD HAZARDOUS MATERIALS INVENTORY Farm and Agriculture ~] Standard Business Page., NON - TRADE SECRET 1' 23~ 4 5 6 7 8 9 10 11 12 13 14 ~S ~e ~ Average. ~nual Measure ~ Days Cent Cent Cent Use Location ~ere :% by~ N~s of M~ture/C~nents Code C~e ~t ~ ~t~ Un,ts on Site ~ Press Temp Code Stored ~n Facility ~ See Inst~ct~ons (Check all t~at agP1y) ~ ~ ~ ~ ~ Componen~ 0 2 ~ C.A.S. N~er of Pressure H~lth H~lth Co, orient ~ 3 Na~ & C.A.S. N~er : Ph~tcal and H~lgh Hazard C.A.a. N~er i Co~onent ~ 1 N~ & C.A.a. N~er (Check all that apply) Co,orient ~ 2 Na~ & C.A.S. N~er ~ Fire Hazed ~ Sudden Release ~ R~cttvtty ~ Im~at. ~ Delay~ of Pressure H~lth H~lth Co,orient ~ 3'N~ & C.A.S. N~er ~ Ph~tcal and H~lth Hazard C.A.S. N~er Co~onsnt ~ 1 Na~ & C.AiS. N~er (Check all t~t apply) . Co~onent ~ 2 Na~ & C.A.S. N~er ~ Fire ~az=d ~ Sudden Release ~ R~ctivity ~ I~ia~e ~ Delay~ of PreSsure Health H~lth Co,orient ~ 3 Na~ & C.A.S. N~er .... Component ~ 2 Na~ a C.A.a. N~er of Pressure Health H~lth Co~'onent ~ 3 Na~ & C.A.S. N~er Na~ Title 24 ~. Phone N~e Title 24 ~ Phone c~t~ficat~o. (~ ~D SIGN AFTER COMPLETING ~L SECTIONS) certify ~der p~nlty of law that I hayer ~rsonally ~in~ ~d ~ f~li~ with the in.f0~tion submitted ~n this and all attache~ d~ents ~d that ~sed on ~ndivid~ls res~nsible for obtaining the tnfo~tiom. I believe that the submitted Info,trion ~s true, acc~ate, and c~plete. // ~ ~ 0FFICI~ TI~E OF ~OPE~R 0R ~R/OP~R'S A~0~D ~P~S~TI~ ~~ DA~ SIG~D CITY OF BAKERSFIELD HAZARDOUS MATERIALS INVENTORY ~ Farm and Agriculture ~ Standard Business Page ~--o..f~..' NON - TRADE SECRET USINESS O ER- Nm OF THIS' ACILITY: ~OCATION: ~/~D/ ~~ ~Arg ~D~SS: ~[~1 ~4/~(~,' . ~ ST~ IND. C~SS CODf: ~ITY, ZIP: ~'- ~/ CITY, ZIP:~/f~. ~O'~c ~ D~N ~D B~ST~ET N~BE~FE~E~ 1' 2 3 4 5 6 7 8 9 10 11 12 13 ~s ~e ~. Average. ~nual Measure ~ Days Cunt Cunt Conk Use" Location ~ere % by N~s of H~ture/C~nents Code C~e ~ ~ ~t Units on Sit~ ~ Press Temp Co~ Stored in Facility ~ See Inst~ctions Ph~tcal and ~lgh Haza~ C.A.S. N~er Co~onent ~ 1 N~ & C.A.S. ~ (Check all that, apply) Component ~ 2 N~ & C.A.S/~er ~ Fire Hazed ~ Sudden Release ~ R~ctivtty ~ I~iate ~ Delay~ ~N~ of Pressure H~lth H~lth Co~onent ~ 3 Na~ & C. er Ph~cal and H~lth Hazard C.A.S. N~er ' ~ Co~onent ~ 1 N~ & C.A.S. N~er (Check all that apply) Co~onent ~ 2 Na~ & C.A.S. N~er ~ Fire Saz~d ~ Sudden Release ~ R~Ctlvity ~ I~late ~ Delay~ ' of Pressure H~lth H~lth co~onent ~ 3'N~ & C.A.S. N~er Ph~ic.1 and ~l~h ~.zard C.A.S. N~er Co.orient ~ I Na~ & C.AlS. N~er (Check all t~t apply) Co~on~t ~ 2 Na~ & C.A.S. ~ Fire Hazed ~ Sudden Release O R~ctivtty ~ I~ia:e ~ Delay~ of Pressure Health H~lth Co~onent ~ 3 Na~ & C.A.S. N~er Ph~ical and H~lth ~zard C.A.S. Nu~er Component ~ i N~ & C.A.S. N~er (Check all t~t apply) Component ~ 2 Na~ & C.A.S. N~er of Pressure Health H~lth Co~onent ~ 3 Na~ & C.A.S. Nu~er E~RGENCY CONTACTS' ~/~,r~/glZ~/~ ~/~ ~~ ~'~~ ~2J~/~S ~/~~ Na~ Title '24 ~. Phone N~e- Title 24 ~ Phone :~tiftcation (~ ~D SIGN AFTER COMPLETING ~L SECTIONS) I certify ~der p~nlty of law that I hayer ~rsonally ~in~ ~d ~ f~tli~ with the info~tion submitted in this ~d all attache~ d~ents ~d that ~sed on ~ tn~i~ of those individ~ls res~nsible for obtaining the lnfo~tion. I believe ~hat the ~ubmitted info~tion is true, acc~ate, and c~plete. ~ ~ OFFICI~ TI~E OF ~OPE~ u~ ~nn/ .. .~12/15/91 H( DS MINI MART ~6 015'-010, 2977 Page 1 · = Genera] InformatSon ' Locatffon: 4201 BELLE TERRACE Map: 123 Hazard: Unrated Communffty: "BFD" RESPONSE AREA" Grid: 02C : 1 AOV: 0.0 --- Contact Name ---! Tfft]e I-- Busffness Phone -- 24-Hour Phone ELLIOT¥ WILLIAMS I 1(805) 39?-?600 × (805) 845-3988 MIKE MEADERS I 1(805) 39?-?600 x (805) 392-84?5 I I Admffnffs~atffve Data Mail ~ddrs: 3101 STATE RD D&B Number: Cffty: BAKERSFIELD State: CA Zffp: 93308- Comm Code: 015-901 "BFD" RESPONSE AREA" SIC Code: Owner: JACO OIL Phone: ( ) - Address: 3101 STATE RD State: CA City: BAKERSFIELB Zip: 93308- Summary CRNR MINI MART MITH GASOLINE PUMP ISLANDS LOCATED ON N SIDE OF STORE ISLAND. CARBON DIOXIDE CYLINDERS LOCATED IN BACK STORAGE ROOM, CHAINED TO H INTERIOR HALL. ,12/15/91 HC~RDS MINI MART ~6 015-010 12977 Page 2 Hazmat Inventory List in Reference ben Order ; 02 - Fixed Containers at Site Pln-Ref Name/Hazards Form Quantity MOP 02-001 REGULAR GASOLINE Liquid 12,000 Moderate > Fire, Delay Hlth GAL 02-002 UNLEADED GASOLINE Liquid 12,000 Moderate > Fire, Delay Hlth GAL 02-003 PREMIUM UNLEADED GASOLINE Liquid 12,000 Moderate > Fine, Delay Hlth GAL ,12/15/91 HCtTDS MINI MART ~6 015-010 2977 Page 3 - Fixed Containers at / Hazmat ~nventory Detail in Rererence Number Order 02-001 REGULAR GASOLINE Liquid 12000 Moderate > Fire, De]ay H]th GAL CAS ~: 886619 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daftly Max GAL .... [-- Daily Average GAL '--I-- Annual Amount GAL -- 12,000 I 5,500.00 I 200,000.00 Storage I Press I Temp -] Location UNDER GROUND TANK IAmbientlAmbfientlUNDERGROUND TANK E ISLAND' -Conc -I Components ~_ _~_0__.0~ IGasoline IModeratel 02-002 VUNLEADED GASOLINE Liquid 12000 Moderate > Fire, De]ay Hlth GAL CAS ~: 886619 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL .... I-- Daftly Average GAL I Annual Amount GAL -- 12,000 I 6,000.00 I 400,000.00 Storage I Press I Temp -I Location UNDER GROUND TANK IAmbientlAmbientlUNDERGROUND TANK E ISLAND -Conc -I Components I- Mcr --IList 100.0~ IGasoline IModeratel 02-003 PREMIUM UNLEADED GASO_IN_ Liquid 12000 Moderate > Fire, Delay Hlth GAL CAS ~: 886619 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL .... I-- Daily Average GAL I Annual Amount GAL -- 12,000 t 3,500.00 I 91,000.00 Storage I Press I Temp -I Loc~t~on UNDER GROUND TANK tAmbientlAmbientlUNDERGROUND TANK E ISLAND -Conc -I Components I- MOP --IList 100.04 IGaso]ine IModeratel ,12/15/91 DS MINI MART ~6 015-010-12977 Page 4 00 - Overall Site <D> Notif./Evacuation/Medical <1> Agency Notification <2> Employee Notif./Evacuation DIAL 911 FOR FIRE DEPT, IF NECESSARY EVACUATE EVERYONE S OF PR_MIoE,~ TO MOOSE LODGE PARKIN(~ LOT <3> Public Notif./Evacuation <4> Emengecmy Medical Plan GOLDEN EMPIRE AMBULANCE (805) 32?-9000 KCFD 911 HOLDS MINI MART ~6 015-010, 2977 Page 5 O0 - Overall Site <E> Prev./M~nimization/C]eanup <1> Re]ease Prevention DAILY MONITORING AND ANNUAL TANK TESTING <2> Release Containment GASOLINE SPILL - CLERKS ARE INSTRUCTED TO USE ABSORBANT POWDER, THEN SWEEP UP WHEN DRY. THERE ARE SHUT OFF VALVES. IN EACH PUMP TO STOP LEAKAGE IN CASE OF A HOSE RUPTURE. <3> Clean Up <4> Other Resource Activation .12/15/91 H~RDS MINI MART ~6 015-010 ;2977 Page 6 O0 - Overall Site <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS/PROPANE - SN CRNR OF STORE 8) ELECTRICAL - UNDER SERV COUNTER C) NATER - N~ CRNR OF STORE D) SPECIAL - NONE E) LOCK BOX - NONE <3> Fire Protec./Avail. Nater 2 FIRE EXTINGUISHERS - ~1 MOUNTED ON N NALL, ~ SIDE OF GAS ISLE DOORS. ~2 LOCATED IN DELI PREP AREA, E END OF COUNTER. FIRE HYDRANT N OF STORE AT N SIDE OF ENTRANCE, EXIT RAMP. <4> Held for Future use 12/15/91 HC~DS MINI MART ~8 015-010 2977 Page 7 O0 - Overall S~te <G> Traffnffng <1> Page 1 <2> Page 2 as needed <3> Heqd for Future Use Held for Future Use ,12/15/91 MINI MART ~6 015-010, 2977 Page 8 00 ~- Ovenall Site ? <M> Events Ledger "M" 11/17/88 RE-INSPECTION/OK 09/30/88 ANNUAL/VIOLATION ,12/15/91 MINI MART ~6 015-010 29?? Page 9 00 -- Overall Site <M> Inspections List 11/17/88 RE-INSPECTION/OK 09/30/88 ANNUAL/VIOLATION G2,H2) PLEASE OBTAIN MATERIAL SAFETY DATA SHEETS (MSDS) FROM FUEL DISTRIBUTOR FOR ALL GRAD_,a OF GASOLINE (VIOLATION OF UNIFORM CODE 80 103H) Do hereb5~ certif! that I have reviewed the attached Hazardous Materials business ~lan (name of business) and that. it along with the attached additions or corrections constitute a complete and correct Business 'Plan for mM facilit~-. s~na~ure ~ate CITY of BAKERSFIELD NO N-- T RAD E S E C RETS ' ~,g,.~_of/ leans T~ ~x A~i ~1 Msu~ I ~ Cmt ~t ~t ~ L~ttm ~ C~e C~e Mt Mt Est Un~ts m Site l~ ~ Im ~ .. St~ In F~tltty~ ~ I~t~t1~ Ic~k ~11 t~t e~ly) - ,.__~, - / ~ - / ~ , ~ ~ ~ ~ ,~,,, ~ ~,~ ..,.~ ~.,.s. ~/~-7~- 9 ~ ,, ~, c.,.s. ~ '~ ~_ c~~ ~lth of P~.~ ~lth ............. -'~--[ ...... L .......... 1 [ I L .... } ! 1., I, , . ' ...................... (C~k ill t~t e~ly) - -- r--~ -- . r--~ ~t12 ~ & C.A.S. ~ ~ Flee Hazeed ~ ~ RHctivity ~--J bla~ [ ~ ~ blme ~--J I~t~te . Halth of P~su~ ~lth "--1 '----~ .... L_ti ........ L ...... : ..... t .......... J.. ,__.t__J_ ] t'__h ' ' . . (C~k ill t~t C~t l~ ~ & C.A.S. -~ FteeHazaed ~--a ~tivity --d ~la~ ~--~ ~ ~elme ~--d I~tate Halth of Prasure ~alth . ............ . ~1~ ..................... H-~'~ ............................. Certtficatim (Read and sign after Completing all sections) 'L ~USINESS NAME HOWARDS MINI MARKE~/#~ ID NUMBER 215-000-000621 LOCATION 4201 BELLE TERRACE~.~ HIGH HAZARD RATING 2 1 . OVERVIEW LAST CHANGE 08/04/88 BY ESTER JURIS CODE 215-007 JURIS BAKERSFIELD STATION 07 MAP PAGE 123 GRID 02C FACILITY UNITS 1 HAZARD RATING 2 RESPONSE SUMMARY 2A SEC 4) NO PRIVATE RESPONSE TEAM Ans'd EMERGENCY CONTACTS 2A SEC 2) SKIP WILLIAMS - 397-7600 OR 845-3968 MIKE MEADERS - 397-7600 OR 393-1833 UTILITY SHUTOFFS 2A SEC 3) --~ A) GAS - CONSOLE' INSIDE STORE AT REGISTERS B) ELECTRICAL - DELI BACK ROOM C) WATER - BEHIND BLDG D) SPECIAL - NONE E) LOCK BOX - NO < NO INFORMATION RECORDED FOR THIS SECTION > PAGE 1 12/27/88 16:47 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME HOWARDS MINI MARKET #6 ID NUMBER 215-000-000621 LOCATION 4201 BELLE TERRACE HIGH HAZARD RATING 2 LAST CHANGE / BY < .NO INFORMATION RECORDED FOR THIS SECTION > ~, / 4 . LOCAL EMERGENCY MEDICAL ASSISTANCE LAST CHANGE 08/04/88 BY ESTER 2A SEC 5) MERCY HOSPITAL - 2215 TRUXTUN AVE - 327-3371 PAGE 2 12/27/88 16:47 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME HOWARDS MINI MARKET #6. ID NUMBER 215-000-000621 LOCATION 4201 BELLE TERRACE HIGH HAZARD RATING 2 FACILITY UNIT 01' a. OVERALL HAZARDOUS MATERIALS INVENTORY LAST CHANGE 08/04/88 BY ESTER ID TYPE NAME MAX AMT UNIT HAZARD LOCATION CONTAINMENT USE 1 PURE GASOLINE 48000 GAL HIGH UNDERGROUND TANKS FUEL ID PERCENT COMPONENTS HAZARD LISTS 1182.00 100.0 GASOLINE HIGH < NO INFORMATION RECORDED FOR THIS SECTION > PAGE 3 12/27/88 16:47 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME HOWARDS MINI MARKET #6 ID NUMBER 215-000-000621 LOCATION 4201 BELLE TERRACE HIGH HAZARD RATING 2 n . EMPLOYEE NOTIFICATION / EVACUATION LAST CHANGE 08/04/88 BY ESTER 3A SEC 2) CALL FIRE DEPT 911. SHUT OFF EMERGENCY GAS SWITCH AND EVACUTE IMMEDIATELY. E . MITIGATION / PREVENTION / ABATEMENT LAST CHANGE 08/04/88 BY ESTER 3A SEC 1) NORMAL GAS STATION SAFETY EQUIPMENT. PAGE 4 12/27/88 16:47 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 DATE~ ;ADDRESS . .~m. 41P CODE ~ FEE B LOC .K' NO: ~ - f ~ ~' \ {"'-~'~::e.._ ' "::'" ' BUSINESS LICENSE NO. PERMIT NO. BUSIN~ ~ RESPONSIBLE BUSINESS PHONE HOME PHONE VIOLATION N ....... OCCUPANT LOAD OTHER DATE OF REINSPECTION (1) (2) (3) B .RSF EL*, CA 0330 (805) 326-3979 OFFICIAL USE ONLY ID# BUSINESS NAME HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 2A INSTRUCTIONS: 0 0 1. To avoid further action, return this form by 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. SECTION 1: BUSINESS IDENTIFICATION DATA B. LOCATION / STREET ADDRESS:...~/ ~el~ 7e~VC,~ SECTION 2: EMERGENCY NOTIFICATIONS In case of an emergency involving the release or threatened release of a hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4841. This will notify your local fire department and the State Office of Emergency Services as required by law. EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY: NAME AND, TITLE DURING BUS. HRS. AFTER BUS. HRS..... C. JOHN KERLEY, JACO OIL CO. 805-393-7000 office 805-398-8298 home SECTION ~: LOCATION OF ~ILI~ S~-OFFS FOR BUSI~SS AS A ~OLE ' C. D. SPECIAL: E. LOCE BOX: YES~~F YES, LOCATION: IF YES, DOES IT CONTAIN SITE PLANS? YES / NO MSDSS? YES / NO FLOOR PLANS? YES / NO KEYS? YES / NO SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE SECTION 6: EMPLOYEE TRAINING~ EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH"PR~VIDES"EM~EO~EES WITH INITIAL AND REFRESHER TRAINING IN THE FOLLOWING AREAS. CIRCLE YES OR NO INITIAL REFRESHER A. METHODS FOR SAFE HANDLING OF HAZARDOUS~"" "'"~ "~" '" ~ " ' ~'"'.'~ MATERIALS:...' .................................... ~..~ NO ~ NO B. PROCEDURES FOR COORDINATING ACTIVITIES WITH RESPONSE AGENCIES: ....................... ',..~ NO E~NO C. PROPER USE OF SAFETY EQUIPMENT: .................. (~ NO (~ NO D. EMERGENCY EVACUATION PROCEDURES: ................. ~ES~~:NO " E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... ' ~'~ ~-'~ '"--'~ SECTION ?: HAZARDOUS ~ATERIAL CIRCLE YES OR NO DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL.IN QUANTITIES LESS THAN $00 POU~F A SOLID, SS GALLONS OF A LIQUID, OR ZOO C~BIC FEET:oF'A COMPR~SSEb°GkS:..')~'~.. Y~NO I,/~//~ /;~~ / , certify that the above, information is accurate. ~I understand that this ~nformation Will be used to fulfill my firm's obliMations under the new California Health and Safety.code on Hazardous Materials (Div. 20 Chapter 6.95 Sec. 25500 Et Al.) and that inaccurate information constitutes perjury. / - 2B - · ~. BAKERSFIELD CITY FIRE DEPARTMENT ~ - 2130 "G" STREET / BAKERSFIELD, CA 93301 o OFFICIAL USE ONLY · ID# BUSINESS NAME: , .BUSI NESS PLAN SINGLE FACILITY UNIT FORM 3A INSTRUCTIONS 1. To avoid further act'ion, th~.s form must:be returned 2. TYPE/PRINT YOUR ASSWERS' IS ENGLISH. 3. Answer the questions belo~ for THE FACILITY USIT LISTED BELO~ 4. Be as BRIEF and CONCISE as .possible: .SECTION 1: MITIGATION~~ PRE~NTION, ABATEME~ PROCEDb~ES . SECTIO~ 2: ~OTIFICATIO~ ~ EVAC~ATIO~ PR0CEDU~ES ~T THIS B~IT' SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY A. Does this Facility Unit contain Hazardous Materials? ...... YES NO If YES, see B. If NO, continue with SECTIO~ 4. B. Are any of the hazardous materials a bona fide Trade Secret YES NO If No,.complete a separate hazardous materials inventory form marked: NON-TRADE SECRETS~'0NLY (white form #4A-l) If Yes, complete a hazardous materials inventory form marked: TRADE'SECRETS ONLY (yellow form #4A-2) in addStion to the non-trade secret form. List only the trade secrets on form 4A-2. SECTION 4:.PRIVATE FIRE PROTECTION SECTION 5: LOCATION OF'WATER SUPPLY FOB USE BY EMERGENCY RESPONDERS SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS b~IT ONLY. A. NAT. GAS./PROPAN~'~ B. ELECTRICAL: C. WATER: D. SPECIAL: E. LOCK BOX: YES / NO IF YES, LOCATION: IF YES, SITE PLANS? YES / NO MSDSs? YES /' NO. FLOOR PLANS? YES / NO KEYS? YES .,'_NO - 3B - B^KERSFIELD CITY FIRE DEPARTMENT I.D. ~ FORM 4A-I Page NON--TRADE SECRETS HAZARDOUS MATERI ALS INVENTORY ADDRESS: q ~7 ~, -~- ':~C , _ FACILITY UNIT ~:. PHONE *: ~q21?~ P,ONE ~: .~'.~-~-'Jg~F IOFFICIAL USE CFIRS 'CODE 1 2 3 4 5 6 7 8 9 10" TYPE MAX ANNUAL CONT USE LOCATION IN THIS % BY HAZARD D.O.T CODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT WT. CHEMICAL OR COMMON NAME CODE GUIDE P 48,000 890,105 gal. 01 19 see plot: plan 100% gasoline //.~ FLGS . EMERGENCY CONTACT:~/~ ~//~ T~TLE: ~ (Y/ 0~. PHONE 9 BUS