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Home My WebLink AboutUNDERGROUND TANK-C-02/04/92 :~" SITE/FACILITY DI AGR~ NORTH SCALE: B_USINESS NAME FLOOR: OF + DATE:$ /8 /~) FACILITY N~ME: UNIT ~: 0r (CHECK ONE) SITE DIAGRAM FACILI~ DIAGR.%M ~ Inspector's Comments): -OFFICIAL USE ONLY- - SA - SITE DEAGRA?4 (Req itemS) ~'~ ?~ 1. Address: Identify'the 9. Lock (key) Box ~ principle buildings by the Street numbers. 10. MSD8 Storage Box = 2. Street(s), Alleys, Il. Railroad Tracks · Driveways, end Parking Areas adjacent to the 12. Fence or Barrier property. Include the a. Wire street names. b. Masonry 3. Storm Drains. Culverts. Yard Drains c. Mood 4. DraLnage Canals, Ditches. d. Gates Creeks, 13. Powariines S. Buildings a. Frame construction 14, Guard Station b. Masonry construction 15. Storage Tanks: Identify the c. Metal construction capacity In gal. a. Above ground d. Access Door b. Underground 6. Utility Controls a. Gas 16. Diking or Berm b. Electricity 17. Evacuation Route c. Mater 18. Evacuation Area: - Identify the /. 7. Fire Suppression Systems: location where a. Fire Hydrants employees will neet. b. Fire Sprinkler 19. Outeide Hazardous Connections MasSe Storage c. Fire Standpipe 20. Outside Hazardous Connections Ilatorial Storage d. Water Control Valves 21. Outside Hazardous for protection systems Material Use/Handling e. Fire Pu~p 22. Type of Hazardous Material/MasSe 3toted 8. Fire Department Access or Used (See · Below) TYPE O~ I~A~UU)OU$ N~,~TERiA~ F - Flasmable g - Explosive L - Liquid R - Radlologlcal C - Corrosive 0 - OZldlzer O - Oas P - Poison Mater Reactive T - Toxic S - Solid *H - Cryogenic O - Waste B - Etiological Example: Flannable Liquid - FL FACILITY DIAGRA~ (Required items in add/Sion to the. abo~e) l. Risers ~or Spr/nkloro 8. ~lro gacapea 2. Partitions 9. Air Conditioning Units 3. Stairways: Indicate tho 10. W/ndo~a levels served troa highest to lowest. Il. Inside Huardoue Masts Storage 4. Escalator: Indicate the levels served from 13. Inside Hazardous · highest to lowest. ~aterials 3Scrags S. Elevator 13. Inside Hazardous Materials Use/Handling 6. Attic Access 14, Se~er Drain Inlets 7. Skylights $ITE/~ACI LI TY DI AGR~ ~OR~ ~ BUSINESS, NAME; · FLOOR: OF (CHECK ONE) SITE DIAGRAm[ FACILI~ DIAGR.~ ~0~ Inspector's Comments): -OFFICIAL USE ONLY- - 5A - ~[TE DIAGRAM (Required irene) I. Address: Identify the 9. Lock {key) Box principle buildings by the Street numbers, lO. MSD$ Storage Box 2. Street(s), Alleys, Ii. Railroad Tracks Urivewaym, and Parking Areas adjacent to the 12. Fence or Barrier property. Include the a. Wire street n&aes. b. Masonry 3. Store Drains, Culverts, Yard Drains c. Wood 4. Drainage Canals. Ditches. d. Gates Creeks, 13. Powerlines $. Buildings a. Frame construction 14. Guard Station b. Masonry construction 15. Storage Tanks: Identify the c. Metal construction capacity in gal. a. Above ground d. Access Door b. Underground Utility Control, a. Gas 16. Dlkl~ or Berm b. Electricity l?. E~acuatl~n Route c. Mater 18. Evacuation Area: - Identify the 7. Fire Suppression Systems: location where a. Fire Hydrants employees will lost, b. Fire Sprinkler 19. Outside' Hazardous Connections Masts Storage c. Fire Standpipe 20. Outside Hazardous Connections Materiml Storage d. Water Control Valves 21, Outside Hazardous for protection systems Material Uae/seudling e. Fire Pump 22. Type oF Hazardous Material/Malta Stored 8. Fire Department Access or Used (See Seloe) TYPE OF HA~/~RDOUS I,~T~RiAL F - Fl---able E - Earploslve L - Liquid B - Radlologlcal C -Corrosiva 0 - Oxldlzer O - Oas P - Po/son Water Reactive T - Toxic g - Solid g - Cryogenic O - Waste' S · Etiological Example: Fla.mabie Liquid - FL ~AC~LITY DIAORA~ (Required items ia addition to the abo~a) l, Misers tar Sprinklers 8. Fire gacapee 2. Partitions 9. Air Conditioning Units 3. Stairways: Indicate the 10. Wind.s levels served from highest to lowest. 11. Inside Hunrdoua Waste $toraim 4. Escalator: Indicate.the levels ae~ved from 13. Inside Hazardous .highest to lowest. ~ateriaia Storage $. Elevator 13. Inside Bazardoua Wateriais Uae/Handling B. Attic Accels 14. SMr Drain Inlets T. ikyi/ghts SITE/FACILITY DIAGRAM FORM 5 NORTH SCALE: BUS INESS NAME: FLOOR: OF ~'- DATE:~./~ /4? FACILITY NAME: UNIT -~: OF (CHECK ONE) SITE DIAGRAM FACILI~ DIAGR.~ /' .~ [~Inspector's Comments): -OFFICIAL USE ONLY- - SA - ~T?~ DIAGRam4 {Required itemS) I. Address: Identify the 9. Lock (key) Box principle buildings by the Street numbers. 10. MSD$ Storage Box 2. Street(s), Alleys, Ii. Railroad Tracks Drivewaya. and Perking Areas adjacent to the 12. Fence or Barrier property. Include the a. Wire b. Masonry 3. Storm Drains, Culverts. .Yard Drslns c. Wood 4. Drainage Canals, Ditches, d. Gates Creeks, 13. Po~erlines 5. Buildings a. Frame construction 14. Guard Station b. Masonry construction 15. Storage Teaks: Identify the c. Metal construction capacity In gal, &. Above ground d. Access Door b. Underground 6. Utility Controls a. Gas 16. Dlklng or Berm b. Electricity 17. E~ecuatioa Route c. Water 18. Evacuation ~ea: - Identify the 7. Fire Suppression Systems: 3ocetion Nhere a. Fire Hydrants employees will meet. b. Fire Sprinkler lO, Outside Hazardous Connectlone Waste Storage c. Fire Standpipe 20. Outside Hazardous Connections Ilatorisl Storage d. Water Control Valves 21. Outstde Hazardous for protection syateu Material Use/Handling e. Fire PuAp 22. Type of Hazardous Material/Mamma Stored 8. Fire Department Access or Used (See '~pE OF R~ARDOUS F - F/mabJe S - Explosive L - Liquid R - Radiologlcal C - Corrosive 0 - Oz/dlzer G - Gao P - Poison W - Namer Reactive T - Toxic S - Solid H - C~yogeflJc O - Masts B - 8t/oLogLcal Example: Fla~ble Liquid - PAC~LI~ OIAG~ (Requl~ed Jt~s la addition to the ~) 2. PartJtiofll 9. Air Conditioning Units 3. StaJrweyl: ZndJclte tho ~0. WJM~I levels served ~rom hJghelt to Jowelt. Ii. Xnllde H~n~doul 4. Ssca~a~oc: Indicate the leveJs 8e~ed ~oB ~3. Inside · h/ghost to ~o~est. ~terlaJl ~torage 5. ~Jeva&or ]3. ]n~Jde Bazardou~ 6. Attic Accea~ 14. S~r Drain InJets SITE/FACILITY DIAGRAM FORM 5 NORTH SCALE: BUSINESS NAME: ~m~er~'~ld /~6~;~tf~ ' FLL)OR: OF ~ DATE: ~,/~ /~) FACILITY NAME: UNIT -.': OF (CHECK ONE) SITE DIAGRAM t/ FACILITY DIAGR.%M ~ ' o ~6rllw. .. ..... ~ ~ ~ ~: -- ~ -, ~~_ ~~ ~ ................................... ~1~** I ~ . {Inspector's Comments): -OFFICIAL ~SE ONLY- ~ITE DIAGRAN (Requl~d itewS) ~ , I. Address: IdentiFy'the 9. Lock (key) Box principle buildings by the Street numbers. 10. MSD$ Storage Box 2. Street(s). Alleys. 11. Railroad Tracks Drive,aye. and Parking Areas adjacent to the 12. Fence or Barrier property. Include the a.' Wire street names, b. Masonry 3. Store Drains. Culverts. Yard Drains c. Wood 4. Drainage Canals. Ditches. d. Gates Creeks. 13. Powerllnes 5. Buildings a. Fraee construction ]4. Guard Station b. Masonry construction 15. Storage Tanks: Identify the c. Metal construction capacity In gal. &. Above ground d. Access Door b. Underground 6. Utility Controls a. Gas 16. Diking or Berm b. Electricity 17. E~scuatloa Route c. Water 18. Evacuation Area: - Identify the Fire Suppression Systems: location where a. Fire Hydrants employees will meet. b. Fire Sprinkler If. Outside Hazardous Connections Waste Storage c. Fire Standpipe gO. Outside Hazardous Connections #ateriml Storage d. Water Control Valves 21. Outside Hazardous for protection systems Materia! Uee/Hmndllng e. Fire Puap 22. Type oF HazardOUS Material/Waste Stored 8. Fire. Department Access' or Used (See Brine) TY~g oF ~AR~OU$ Fl---able g - Explosive L - L/quid R - Radlologlcal Corrosive 0 - Oxidizer O = Gas P - Poison Water Reactive T - Toxic g - Solid 'H - Cryogenic D - Waste B · St/oJogtcal Example: Fl&anable Liquid - FL FACILITY DIAGRA~ (Required Items ia addltlon to the abo~e) 2. Partitions 9. Air Conditioning Units 3. Stairways: Indicate the 10. Windows levels served from highest to lowest. 11. Inside Hazardous Waste Storage 4. £scalator: Indicate the levels served from lg. Inside Hazardous .highest to lowest. Materials Storage 5. Elevator 13. Inside Hazardous // Materials Use/Handling 6. Attic Access 14. Seu~e Drain Inlets 7. Skylights STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARKONLY [] 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF iNFORMATiON ~ 7 PERMANENTLY CLOSED SITE ONE iTEM [] 2 INTERIM PERMIT [~ 4 AMENDED PERMIT [] 6 TEMPORARY SiTE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) vx BOX TO INDICATE RATION ~ INDIVIDUAL [~ PARTNERSHIP [~ LOCAL-AGENCY [~ COUNTY-AGENCY [~ STATE-AGENCY [~ FEDERAL-AGENCY DISTRICTS RESERVATION ~--~ 3 FARM ~ 4 PROCESSOR ,.,..~'~'OTHER OR TRUST LANDS I / I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PH~N~: # WITH ARIFA NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE ~ W~TH AREA CODE I1. PROPERTY OWNER INFORMATION- (MUST BE COMPLETED) N~M~ / ~ / ~ ~ / / ~ J I CARE OF ADDRESS INFORMATION I~AILli~G OR STREET~)DRESS '/~' / ~'~ I ~/ boxt~oir ' [~ INDIVIDUAL [~ LOCAL-AGENCY I'---I STATE-AGENCY 13 '~ '7~, ,,~x"~ 5~-- "' I ~'~R"ORAT'O" r~ PARTNERSH.P ~ COUNTY-AGE.CY r~ FEDERAL-AGE"OY CI'~-~E/ -- ~ ~ - I STATE ~ I Z P CODE PHONE # WITH AREA CODE Io ??I- III. TANK OWNER INFORMATION - (MUST BE COMPLETED) I NAME OF OWNER CARE OF ADDRESS INFORMATION MAILIN"-G OR-STREETAD'~"RESS ./ box to indicate ~ INDIVIDUAL [~ LOCAL-AGENCY I~ STATE-AGENCY ~ CORPORATION ~ PARTNERSHIP [~ COUNTY-AGENCY ~ FEDERAL-AGENCY CITY NAME STATE ZiP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. TY(TK) HQ V. PETROLEUM MST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED ./ box to indicate E~ 1 SELF-INSURED [~ 2 GUARANTEE [~ 3 INSURANCE [---] 4 SURETY BOND [~ 5 LET,'ER OF CREDIT [~ 6 EXEMPTION ,.,~'"~"~THER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ly III. [] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ' LOC/~ AGENCY USE ONLY~'''~ /~' v COUNTY # JURISDICTION # FACILITY # LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A (5-91) FOROO33A-5 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK. PERMIT APPLICATION - FORM 8 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY [~ 1 NEW PERMIT [~ 3 RENEWAL PERMIT [~ 5 CHANGE OF INFORMATION [~ 7 PERMANENTLY CLOSED ON SITE ONEITEM [] 2 INTERIM PERMIT [] 4 AMENDED PERMIT [] S TEMPORARY TANK CLOSURE .w,~8 TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# / B. MANUFACTURED BY: ? C. DATE INSTALLED (MO/DAY/YEAR) '") O. TANK CAPACITY IN GALLONS: ~{~ ~ ;11, TANK CONTENTS IFA-1 IS MARKED, COMPLETE ITEM C. f ~ J~;~,4a'REI3ULAR [] 3 DIESEL [] 6 AVIATION GAS A. MOTOR VEHICLE FUEL [] 4 OIL B. ' ~ UNLEADED [] 4 GASAHOL [] 2 PETROLEUM [] 80 EMPTY ~RODUCT r--"l lbPREMIUM [] 7 METHANOL UNLEADED [] 5 JET FUEL [] 3 CHEMICAL PRODUCT [] 95 UNKNOWN [] 2 WASTE [] 2 LEADED [] 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, ANDC, ANDALLTHATAPPLIESINBOXD A. TYPEOF [~ 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR LINER [] 95 UNKNOWN SYSTEM ~ SINGLE WALL [] 4 SECONDARY CONTAINMENT (VAULTED TANK) [] 99 OTHER ~m'~"~RE STEEL [] 2 STAINLESS STEEL [] 3 FIBERGLASS [] 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM [] 8 100% METHANOL COMPATIBLEW/FRP (PrimaryTank) [] 9 BRONZE [] 1(~ GALVANIZED STEEL [] 95 UNKNOWN [] 99 OTHER [] 1 RUBBER LINED [] 2 ALKYD LINING [] 3 EPOXY LINING [] 4 PHENOLIC LINING C. INTERIOR [] 5 GLASS LINING f UNLINED [] 95 UNKNOWN [] g9 OTHER LINING -- IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES__ NO__ D, CORROSION [] 1 POLYETHYLENE WRAP~[] 2 COATING [] 3 VINYL WRAP [] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [] 5 CATHODIC PROTECTIO~jj~J'~NONE [] B5 UNKNOWN [~ 99 OTHER IV, PIPING INFORMATION cIRcLE A IFABOVEGROUNDOR U IFUNDERGROUNO, BOTH IF APPLICABLE A. SYSTEMTYPE ~ SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION ~ SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND~ BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PiPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 10~'/o METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [~ 1 AUTOMATIC LINE LEAK DETECTOR [~ 2 LINE TIGHTNESS TESTING [] 3MONITOR[NGINTERSTITIAL ~ OTHERr.,~:;~,.,~::~ V, TANK LEAK DETECTION ~,,,[~6 TANK TESTING [] 7 INTERSTITIAL MONITORING [] 91 NONE [] 95 UNKNOWN [] 99 OTHER VI. TANK CLOSURE INFORMATION , L )/ 2. ESTIMATED GUANTITY OF 3. WAS TANK FILLED W,TH YES [] · SUBSTANCE REMAINING GALLONS INERT MATERIAL ? TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT I APPLICANT'S NAME ~ 1~ /1 J¢ .~Jf . I DATE ./ I (PRINTED & SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER~/COMC~SED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # PERMIT NUMBER PERMIT APPROVED BY/DATE I PERTvIIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORO~34B.R4 CITY of BAKERSFIELD "WE CARE" · FIRE DEPARTMENT 2101 H STREET S. D. JOHNSON February 4, 1 9 9 2 BAKERSFIELD. 93301 FIRE CHIEF 326-3911 Samir Berbawy ~ ~ ~ Bakersfield Adventist Academy ~ 3333 Bernard St. ~C ~ ! Bakersfield, C~ 93306 CLOSURE OF 1 UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK LOCATED AT 3333 BERNARD STREET, IN BAKERSFIELD, CALIFORNIA. PERMIT # BR0035 Dear Mr. Berbawy This is to inform you that this department has reviewed the results for the preliminary assessment associated with the closure of the tanks located at the above stated address. Based upon laboratory data submitted, this office is satisfied with the assessment performed and requires no further action a't this time. This letter does not relieve you of any liability for past, present, or future operations. In addition, any future changes in site use may require further assessment or mitigation. It is the property owners responsibility to notify this department of any changes in site usage. If you have any questions regardi'ng this matter, please contact me at (805)-326-3797. Hazardous Material Specialist Underground Tank Program January 24, 1992 ~Mr. Joe Dunwoody CITY OF BAKERSFIELD - FIRE DEPARTMENT 2130 "G" Street Bakersfield, California 93301 REGARDING: Underground Fuel Tank Removal Project at 3333 Bernard Street, Bakersfield, California, (Tank Removal Permit Number BR0035), KES Project Number 91E2504 Dear Mr. Dunwoody: Enclosed please find analytical results (BC Laboratory Sample Numbers 57-1 and 57- 2) and chain of custody record for the above referenced project. Also attached is a copy of Uniform Hazardous Waste Manifest Number 91634282, a copy of the Tank Destruction Form No. 10189 (the original is to be mailed to you by Golden State Metals, Inc., Bakersfield, California) and a copy of the Non Hazardous Waste Manifest No. 103082. Sincerely, CRAIG~ORNETT, Lead Technician DCC:bd Enclosures Post Office Box 5337, Bakersfield, California 93388 · (805) 589-5220_ In California · (800) 332-5376 ~ Bakersfield Fire Dept. PERMIT No. 1YAZARDOUS MATERIALS DIVR UNDERGROUND STORAGE TANK PROGRAM PERMIT APPLICATION FOR REMOVAL OF AN UNDERGROUND STORAGE TANK SITE INFORMATION SITE Bakersfield Adventist Acade~DRESS 3333 Bernard St21PCODE 93306 APN FACILITY NAMEBakersfield Adventist Aca~M~DSS STREET Oswell TANK OWNER/OPERATOR Samir Berbawy PHONE No. (805)871-1591 MAILING ADDRESS 3333 Bernard St'. ClTyBakersfield ZIP CODE 93306 CONTRACTOR INFORMATION .. COMPANYKern Environmental Service PHONE No. (805)589-5220 LICENSE No. 432372 ADDRESS P.O. Box 5337 CITY Bakersfield ZIP CODE 933~8 INSURANCE CARRIER Tolman & Wike~ WORKMENS COMP No. WC-582-2132 PRELIMANARY ASSEMENT INFORMATION . COMPANY Kern Environmental Service PHONE No. (805158g-5220 LICENSE NO. 4~2~77 ADDRESS · P.O, Box 5397 CIT~ B~r.~¢~,l~ ZIPCODE '93388 INSURANCE CARRIER Tolman & Wiker WORKMENS COMP No. WC-582'2132 TANK CLEANING INFORMATION COMPANY Kern'Environmental Service· PHONE No. (805~589-5220 ADDRESS P.O. Box 5337 CITY Bakersfield ZIP CODE 93388 WASTE TRANSPORTER IDENTIFICATION NUMBER CAD 982 495 608 NAME OF RINSTATE DISPOSAL FACILITY Gibson Oil & Refining ADDRESS End of Commercial Drive CITY Bakersfield ZIP CODE 93308 FACILITY INDENTIFICATION NUMBER CAD 980 883 177 TANK TRANSPORTER INFORMATION COMPANY KVS Transportation, T~C,' PHONE No. (805)589-5220 LICENSE No. 4.32372 ADDRESS P.O. Box 5295 CITY ~ ZIP CODE TANK DESTINATIC)N Golden State Hetals, 2000 g. Brundage Ln,~ Bakersfield~ CA TANK INFORMATION TANK No. AGE VOLUME CHEMICAL DATES CHEMICAL " STORED STORED' PREVIOUSLY STORED 1 "20 )'rs 500 gallon Gasoline 1970 to 1980 Gasoline 'i:: '.'.':': :::'.:::.7.:;,:!i:'::i'.. :.' :?. ;:::":.: ':."::'.:i:: !i:' '. · - .. ~ .... · .... :.. :... :...:.. ':. ::::::::::::::::::::::::::::::::::::i!~i:!:'.:::.:-.::i '!-!;]~:::... :...::. :.. ,:. ,:.......: I',... ::~!i: '.:! ~:..::~i".,:.'....':i'~:.:.'!,: ::?!:i ·'·/! :. I,· - ':·; .' ,; h:;:::Z~ ' THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS PERMIT AND ANY OTHER STATE. LOCAL ANDFEDERAL REGULATIONS. THIS FORM HASSEEN COMPLETED UNDER PENALTY OF PERJURY. AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. LABORATORIES, INC. P£TROI.£UM J' J' EGLIN, REG. CHEM. ENGR. 41~ AT~S CT., BAKERSFIELD, CALIFORNIA 93~8 PHONE (~ 327-4911 F~ (~ 327-1918 Petroleum Hydrocarbons KERN ENVIRONFIENTAL SERVICES Date of P O BOX 5337 Report: 01/07/92 BAKERSFIELD, CA 93388 Lab ~: 57-1 Attn.: CRAIG CORNETT 589-5220 Sample Description: ~91E2504 BAKERSFEILD ADVENTEST ACADEMY: BA-1, SOIL ® 2' TAKEN ON 01-03-92 ® 1345 COLLECTED BY PHILIP C. PAYNE TEST METHOD: TPH by D.O.H.S. / L.U.F.T. Manual Method - Modified EPA 8015 Individual constituents by EPA Method 5030/8020. Sample Matrix: Soil 'Date Sample Date Sample Date Analysis Collected: Received ® Lab: Completed: 01/03/92 01/03/92 01/06/91 Minimum Analysis Reporting Reporting Constituents Results Units Level Benzene None Detected mg/kg 0.005 Toluene None Detected mg/kg 0.005 Ethyl Benzene None Detected mg/kg 0.005 o-Xylene None Detected mg/kg 0.005 m-Xylene None Detected mg/kg 0.005 p-Xylene None Detected mg/kg 0.005 Total Petroleum Hydrocarbons (gas) None Detected mg/kg 1.. Comments: California D.O.H.S. Cert. $1186 Department Supervisor Printed on Environment 25 containing 100% reclaimed fibers with 15% Post-Consumer Waste ENVIRON/~£NTAL J. J. EGLIN, REG, CHEM. ENGR. PETROLEUM 4100 ATLAS CT., BAKERSFIELD, CALIFORNIA 93308 PHONE (805) 327-4911 FAX (805) 327.1918 Petroleum Hydrocarbons KERN ENVIRONMENTAL SERVICES Date of P O BOX 5337 Report: 01/07/92 BAKERSFIELD, CA 93388 Lab ~: 57-2 Attn.: CRAIG CORNETT 589'-'5220 Sample Description: ~91E2504 BAKERSFEILD ADVENTEST.ACADEMY: BA-2, SOIL ® 6' TAKEN ON 01-03-92 ® 1350 COLLECTED BY PHILIP C. PAYNE TEST METHOD: TPH by D.O.H.S. / L.U.F.T. Manual Method - Modified EPA 8015 Individual constituents by EPA Method 5030/8020. Sample Matrix: Soil Date Sample Date Sample Date Analysis Collected: Received ® Lab: Completed: 01/03/92 01/03/92 01/06/92 Minimum Analysis Reporting Reporting Constituents Results Units Level Benzene None Detected mg/kg 0.005 Toluene None. Detected mg/kg 0.005 Ethyl Benzene None Detected mg/kg 0.005 o-Xylene None Detected mg/kg 0.005 m-Xylene None Detected mg/kg 0.005 p-Xylene 'None Detected mg/kg 0.005 Total Petroleum Hydrocarbons (gas) None Detected mg/kg 1. Comments: California D.O.H.S. Cert. ~1186 Department Supervisor Printed on Envirgnment 25 containing 100% reclaimed fibers with 15% Post-Consumer Waste CHAIN OF CUSTODY RECORD I ~ ~ ,~- I :. ......... ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: . ~i~ ~ Posl Office Box ~37 ~ke~field, ~li[omia 9~88 in ~lffomia (8~)332-~76 Well, Tank No. P.O. BOX 5295 · BAKERSFIELD, CALIFORNIA 93388 Field or Area (805) 589-522o N°. 1 0 3 0 8 2 NON-HAZARDOUS WASTE HAULER RECORD TO BE USED FOR NON-HAZARDOUS WASTES ONLY G,ENERATOR"".:~.i 'i' ~;'.i':.i~ [ (Generator Must Complete) WASTE TO BE DISPOSED Type ~'¢~"Z~' G,~ ~,~¢O 1 Name _~~/~cO ~D~r¢~r ~~ ~ Generating Location Field Address ~~ ~~ ~ Special Handling Instructions: City, State, Zip ~~PIE~I ~ ~~ ~ Gloves ~ Goggles ~ Other Phone ~¢~ 8~l;~~l Quantity / -- ~ Bbls. Order Placed By ~ f~ ~¢~ ~ ~ DESIGNATED FACILITY S ignat_~~~~ ~ Name ~0~ .~.. ~.~ Address ~OOO ~. ~~ G ~ Date (~/Z~ ~ City, State, Zip ~4~¢R~1~C~ (~ Title ..... ~~~~ Phoae IR~NSPORTER Complete) , ', ,,,' ' :::'~; :~:(;:~'[ (Hauler Must Ticket ¢ Unit No. ~ / Name ~ ~ ~ AM Address ~-¢. ~ ~ PickU~Date /-~-~ ' Time City, State, Zip ~~1~ ~ ¢ ~3~ NOTE: This form to be used in lieu of the California Department of Health Services - Hazardous Waste Manifest lot NON-HAZARDOUS wastes only. Phone ~¢~ ~' ~ REMARKS: ,¥Signature of Authorized Agent or Driver Date ~-.~- ~ DISRQSAEFAGiE!~Y';';,I ..(Facility Operator Must Complete) · ',,, , . Quantity Received Bbls. Date Name ~~ ~ ~~ ~AM Address ¢ 0 ~ '*~1~ Time ~ PM City, State, Zip ~/~'~'¢-~.4~: ¢_.A-- 5"~'7 ,$'n DISPOSAL METHOD: [] Surface Impoundment [] Injection Phone "'$~-'1-3 ~.~"~ / Disp. Ticket # I° ~,~ '! [] Landfill [] Other Return Copy To: GENERATOR UNLESS OTHERWISE SPECIFIED Signature of Authorized Ag~t~//,/ ~ Date NOTE: It is not necessary to send Copy to Dept. of Health Services. NO HAZARDOUS FEES SHOULD BE LEVIED GENERATOR COPY FORM KVS-T-20 .' ', ,, . ... N_o 1O189 GOLDEN STATE METALS, INC. TANK DISPOSAL FORM Bakersfield, California 93387 Phone (805) 327-3559 · Fax (805) 327-5749 Scrap Metals, Pro~ssing & Recycling Li~nse No. I Contractor's CONTRACTOR: &~ ~ DESTINA~ON: G.S.M. · 2000 E. BRUNDAGE LANE · BAKERSFIELD, CA 93387 250 .14 550 .24 1000 - 6 ff .61 ~ RESIDUALS PRESENT (REJECT) 3ooo 1.32 LEL READING 5000 2.42 OXYGEN CONTENT 7500 3.28 DISPOSAL FEE .................................................................... ' ................................................................ ~ 9000 3.82 12000 4.93 TOTAL not 30 days from rocoipt of tank. Gontractor's roprosonts accoptaneo of torres for paymonl, and confirms that tank removal complies with State laws. CONTRACTOR'S SIGNATURE ~ ~ CERTIFICATE OFTANK DISPOSAL/DESTRUCTION THIS DE~TRO~ ~OR SC~R~CyCLING PURPOSE~ ONLY. ~ / ~THORIZED REP. DAlE WHITE ~ Con.actor Copy · YELLOW ~ Rle Copy · PINK-- Perma~nt Copy HAZARDOUS MATERIALS DIVISION UNDERGROUND STORAGE TANK PROG~-M-- PERMIT APPLICATION FOR REMOVAL OF AN UNDERGROUND STORAGE TANK SITE INFORMATION ' SITE Bakersfield Adventist Acade~ORESS 3333 Bernard StRIP-CODE 93306 APN FACILITY NAMEBakersfield Adventist Acad~M~SS STREET Oswell TANK OWNER/OPERATOR Samir Berbawy PHONE No. (805)871-1591 MAILING ADDRESS 3333 Bernard St. CITYBakersfield ZIPCODE 93306 CONTRACTOR INFORMATION COMPANYKern Environmental Service PHONE No. (805)589-5220 LICENSE No. 432372 ADDRESS P,O, Box ~3~7 CITY 2~%s~J.~d~ ZIP CODE 93388 INSURANCE CARRIER Tolman & Wiker WORKMENS COMP No. 'WC-582-2132 PRELIMANARY ASSEMENT INFORMATION COMPANY Kern Environmental Service PHONE No. (805) 580-5220 LICENSE No. ADDRESS P,O. Box,5~37 CITY Bmk~r.q¢~ld ZIP CODE 93388 INSURANCE CARRIER Tolman & Wiker WORKMENS COMP No. 'WC-582-2132 TANK CLEANING' INFORMATION COMPANY Kern Environmental Service PHONE No. (805~589-5220 ADDRESS P.O. Box 5337 CITY Bakersfield ZIP CODE 93388 WASTE TRANSPORTER IDENTIFICATION NUMBER CAD 982 495 608 NAME OF RINSTATE DISPOSAL FACILITY Gibson Oil & Refining ADDRESS End of Commercial Drive CITY Bakersfield ZIP CODE 93308 FACILITYINDENTIFICATION NUMBER CAD 980 883 177 TANK TRANSPORTER INFORMATION COMPANY KVS Transportation, Inc.' PHONE No. (805)589-5220 LICENSE No. 437~77 ADDRESS P.O. Box 5295 CITY t~k,~.~[,i.~,~L ZiP CODE 0't't88 TANK DESTINATION Golden State Metals, 2000 E. Brundage Ln.~ Bakersfield, CA TANK INFORMATION TANK No. AGE VOLUME CHEMICAL DATES CHEMICAL "' STORED STORED ' PREVIOUSLY STORED 1 20 yrs 500' gallon Gasoline 1970 to 1980 Gasoline · file APPLICANT HAS RECEIVED; UNDERSTANDS. AND WILL COMPLY WITH THE ATTACHED CONOIflO'NS OF THIS PERMIT AND ANY Of HER 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. /PPROCE¢'Y: F APPLICANT NAME (PRINT) ~C~NT SIGNATURE THIS APPLICATION· BECOMES A PERMIT WHEN APPROVED m ZARnOUS TERIAL OIVISION 2130 G Street, Bakersfield, CA 93301 (805) 326-3979 TANK REMOVAL INSPECTION FORM OWNER ~' PERMIT TO oPERATE~ CONTRACTOR k'~ ~- CONTACT PERSON ~'/~ LABORATORY ~ ~ d_- # OF SAMPLES -A__- TEST METHODOLOGY /.~/~-~)~ PRELIMANARY ASSESSMENT CO. ~/-w-~_~. CONTACT PERSON COz RECIEPT. y./.~ LEL% PLOT PLAN CONDITION OF TANKS CONDITION OF PIPING CONDITION OF SOIL COMMENTS ' DA~fE INSPECTORS N~ME / SIGNA~U~~- HAZARDOUS MATERIAL DIVISION 2130 G Street, Bakersfield, CA 93301 CERTIFICATION STATEMENT OF TANK DECONTAMINATION . I, Cf/~ COf~7'7- an authorized agent of name .~~/~O~6~h~ i~~ here by 'attest under penalty of contracting co. perjury that the tank(s) located at .3~.~ ~,/t~~-- 'il.---- and address being removed'under permit~ ~'~0.O.t~ has been cleaned/decontaminated properly and a LEL (lower explosive limit) reading of no greater 'than 5% was measured, i~ediately following the cleaning/decontamination process. 3/ ~ 2~- C~/~(print) date ' name - ~g~at. ure TELEPHONE (805) 871-1591 ~: ,, RECEIVED '¥~ ,: ,~,;~ ,~', ~...., HAZ. MAT. DIV. February 11, 1992 Joe Dunwoody Hazardous Haterial Specialist Fire Department 2101H. Street Bakersfield, CA 93301 Dear Joe I am writing concerning your letter of February 4, 1992 regarding closure of one underground hazardous substance storage tank located on our property, permit number BR003§. In your letter you stated that "any future changes in site use may require further assessment or mitigation. It is the property owners responsibility to notify this department of any changes in site usage." Our long range plans (3 to 5 years) call for a parking lot in that section. Would that require any further special permits or arrangements? Thank you for your help in these matters. Sincerely Yours Principal SB/le "And all thy children shall be taught of the Lord..." Isaiah 54:13 t1700 Flower Street r~,~RN COUNTY HEALTH DEPARTME HEALTH OFFICER Bakersfield, California 93305 :":" Leon M Hebertson, M.D.. * ' Telephone (805) 861-3636 ..~' ENVIRONMENTAL HEALTH DIVISION. .. · ' · - " DIRECTOR OF ENVIRONMENTAL HEALTH i~,*~ .... ~.~~ ~ ~ "EXPI RmS' :-.JU~Y. 1,'"'1989 . UNDERGROUND HAZARDOUS SUBSTANCES ....... _~ ... ~, : _-'_" =~. ~'~-' ': :". - ','w ;,'-;' ,., , ,.. .. ' -~ ~ · ' · :...:'. '..,-.:, ' ...... .:,. :~':",:;'::,.::::":':z v -/'.:.: :~: ~': }, BAKERSFIELD ADVENTIST ACADEMY - :_3., ~.' ..:? ':-;..'/: BAKERSFIELD ADVENTIST ~'ACADE... ~' ....-;' .: ' :~ ' - .... '. '~ ' . -.-"~ :-~' .... -' ELD ".CA:."9330 ,..~,.~, , .-s .... ' "'- ..... :~:~{~W~:':* :B~ERSFIELD, CA . .,.:,:~ .: ,.: ~: ....... ;.,:: ~.: :~.:~,~J..~ ,~.w. ~...,? ....... .: ...:- .,..... _--, · .... ~.~.~_~'~:.~.:,. ..... ...,,;:..;:,':~:.-;'~:::~.;:::TANK ~ '.'Y:'r'"'AGE(IN YRS). : ,-'.::; _SUBSTANCE CODE ........ ;'?'"~:~"' ::':'""': ....... ' .' G THE TE~ OF-THIS P~I'~' -.....'.~:r..~,,..',.?- · ~_ .... ,.AUTHORITY MUST..BE MET DURIN .... .,: :... , : ..... :,.,..~:....-~.~,..::.r::<:,?.~.,.~x . -...' .. ~.. , , , . . - . : :-.' ... : ~...'/.'~-:~-c'3 '.."..' DA~ P~IT ~: ~UG 2 5 1986 . ' ' - .q.:.,//-',/5'.~:?:',,7/::..-/' . ..,.., % · . . ~ -....~..-,.¢:.'.,, . ~,'.'"" , ,. /TX.' . DA~ P~IT ~K LIST ~T~: .' ~..~.:.~':,~.'..,..~,:;:;_'..~::.:~,~.~:~; :.~ . ·. . . -*,.. . ,. ,- -. .... - .. ~: ,..p: ??- :. ,/" . .- _. '. '7" .-' ; ':{'-:,/:.:~'_::"~;:;;:.'F,:~F ', ..:. - · .' . ..' : 3'. ' . . -''. ' ~,*'.:-'-'E&.;,,~:*.' ~ :' '. . '~,* '*..-. ' /' '- ' ..--~ :'.:'- ';C'~*'" .:;'~;"' - -- Kern County Health Department P~.rmit No. Division o£ Environmental Hea]t]% Application Date 1700 Flower Street, Bakersf.i.eld, CA 93305 APPLICATION FOR PERMIT TO OPERATE UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY Type o__f Application (check): [-]New Facility [']Modification of Facility [~Existing Facility r']Transfer of Ownership A. Emergency 24-Hour Contact (name,' area cOde, phone): Days 7~,, //~,%/']~ Type of Business (check): rTGas01ine Station ~OO4~r (describe) Is Tank(s) Located on an Agricultural Farm? DYes DNo~ Is Tank(s) Used Primarily~or Agricultural Purposes? ~'Yes [2]No~--~//~-~L/C"~ { /~- Facility Address 33~.~ ~-~__~_ Nearest Cross St. T '~R SEC (Rural Ix)cations Operator ~ _-. Contact Person ~ ... Address -_ _- Zip Telephone B. Water to Facility Provided by Depth to' Groundwater Soil Characteristics at Facility Basis for Soil Type a~d Grour~water Depth Determinations C. Contractor CA Contractor's L~cense No. Addr ess Ztp Telephone Proposed Starting Date Proposed Ccmpletion Worker's Compensation Certifi6ati6n ! Insurer D. If This Permit Is For Modification Of An Existing Facility, Briefly Describe Modificatfon~ proposed E. ·Tank(s) Store (check all that apply): Tank ! Waste Product Motor Vehicle Unleaded Regular Premium Diesel Waste ! D [] O D D [] D [] [] D [] E) [] ~. Chemical O~positton o~ Materials Stored (not necessary for ~otor vehicle f~els) Tank ~ Chemical Stor~ (non-coe~ercial name) O~S ! (l~ known) Chemical ~reviousl~ Stored (if different) G. Transfer of Ownership Date of ~-~nsfer Previous Owner Previous Facility Name · .' I, accept fu'i"ly all qbl'igati~ of Permit No. issued to · I understand that 'the Pe~ttting Authority may review and modify or terminate the transfer of 'the Permit to Operate this t~dergro~d storage ..... faciI I ty -d~on-- r~c-~f'vt'~'--f_h't'.~--'~6~mple ~e-d -form ;- This form has been c~npleted under penalty of perjury and to the best of my knowledge is true and correct. Zig na tut e .~r~.? .~.x:~Z.~i Title / TANK ~ (FILL OUT SEPARATE FORM FO~{CH TANK) FOR EACH SECTIOn, CHECK ]gL APPROPRIATE BOXES H. 1. Tank is: []°vaulted []Non-Vaulted ~]Double-Wall ~ingle-Wall 2. ~ Material Carbon Steel ['] Stainless Steel [] Polyvinyl chloride [] Fiberglass-Clad Steel Fiberglass-Reinforced Plastic [] Co, ncrete [] Al~m~inum [] Bronze ~Unkr~own 3. Primary Containment 7' ' · Date Installed Thickness (Inches) Capacity (Gallons) Manufacturer A. ~ank Seeon~ar~ Containment ' I-1Double-Wa11 rTsynthetic Liner []Lined Vault E]None E~Unkno~n [] Other (~escr i be): Manufacturer: []Material Thickness (Inches) Capacity (Gals.) 5. Tank interior'Lining · ---~Rubber [[]Alkyd [[]Epoxy []Phenolic []Glass []clay []Unlined []Unkno~ .... ~6, .... Tank Corrosion Protection .................... --' ....... - ---~GalVanlZe~' ~ass-Clad E]polyethylene Wrap r~viny1 Wrai~in~ -:.t Ii,Tar or Asphalt E]Unkno~n []None E]Other (describe): -' ' Cathodic Protection: []None []Impressed Current System. ~lSacriflcial /~ode System : DeSCribe System & Equipment: 7. Leak Detection, Monitoring, and Interception a-~ 'Tank---~. E]---~isual (vaulted t~ ~Ground~ater Monttori~J' tlell(s) E]Vadose Zone Monitoring Well(s) [-IU-Tube Without Liner l~U-Tube with C~mpatible Liner Directirg Flow to Monitorirg We.Il(s)* Va~or Detector* E]Liquid Level Sensor* []Conductlvit~ Sensor" E] Pressure sensor in Annular Space of Double Wall Tank- [] Liguid Retrieval & Inspection Fr~ U-Tube, Monitoring llell or Annular Space [] Daily Gaugin~ & Inventory Reconciliation rTPeriodic Tightness Testirg [] None E] unkno [3 Other b. Piping: Flo~-Restrictirg Leak Detector(s) for Pressurized Pipt~j" [3Monitoring S~p with Race~y 'r T Sealed Concrete Race~¥ ~[~UnknHalf-Cut Cempattble Pipe Race~ay []Synthetic Liner Race,my rlNone own E] Other *Describe Make & Model: 8. ~en Tightness Tested? E]Yes E]No ~kno~n Date of Last Tightness Test Results of Test Test Name Testirg C~mpany 9. Tank ~ Repaired? nyes []NO known 'Date(s) of R~pair(s) Describe Repairs ~- 10. Overfill Protection " [-]Operator Fills, Controls,'& Visually Monitors Level []Tape Float Gauge []Float Vent Valves [] Auto Shut- Off Controls [_']CapacitanCe Sensor ['~Sealed Fill Box rTNone ~kno~ . BOther: List Make & ~kxiel For Above Devices 11. Piping [~tJn/kn a. Underground Piping: []Yes E]No own Material Thickness (inches) Diameter ManufactUrer ~Pressure []Suction ~Gravity Approximate Length of Pipe ~ ................. b. -.-Underground. Piping_Corrosion. Protection--: ........................................... []Galvanized []Fiberglass-Clad .[-]Impressed Current ~Sacrificial Anode []Polyethylene Wrap ~Electrical Isolation [2]Vinyl Wrap [-]Tar or Asphalt ~nknown []None [']Other (describe): c. Underground Pipirg, Secondary Containment: · [~Double-Wall []Synthetic Liner System E]None ~known E]Other (describe): F[L£ ,_'ONT ENTS ~Pe~mit to Op~ecace I ~~ Date / ~Const~uctton Pe~mtC t · Date ~Pe~m~C Co abandont N&. ~[ Tanks ,Date ~ended Permit Conditions ~PermiC Application Fo~m, . .( Tank She'ets, PIo~ ~l~' - ~Application to Abandon tanks(s) Date ~Copy og N~ttten Contract Between Owne~ & OpeE~o~ '' ~%napectton Repo~ts , ~ .- ~Cotre.poRdence - Received : : .. Date ~Co~es~ndence' - Nmi led ~ate ~te ~Unauthott~e~ Re,ease Reports . ~Saep~tng/~ab Reports ~ ' ~HVF C~p~ance Check (Ne'v 'Con~':'tuCt$on Che'dk'~at) ' ' ~S?O C~p~tanee Check (Ney Conat;uctton Check~$at) ~MVF PLan Cheek (Ney Constructton) ~STD e~an Check (Ney Conlttuct~on) ~MVF e~an Check (;xtattng Face,try) ~STD e~an Cheek (Extattng ~act~tty) ~ ~"Incomplete Application~ ~orm ~eermit Application Checklist ~ee~mit Instructions ~Discarded "' ~?ightnels Test Results D~te .' ' Da~e ~ofll~orl~ Mall Cons~ruC'~ion ~Enviro~enta~ Sensitivity Data= Ground~ater Drilling, Boring Logs Location of. Hater Hells ~Stateeent of Uncle;ground Conduits ~Plot Plan ~eaturing All Environmentally Sensitive Data ~Photos ~Cons~ruction Dra~ings Location ~Hal~ sheet sho~ing date teceived and tally cE inspection time, ~tc .' ~Mt scellaneous BAKERSFIELD . SAN LUIS OBISPO 3030 M STREET ' 313 SOUTH STREET P.O. BOX 1887. · 93303 P.O. BOX 89 · 93401 (805) 324-6716 (805) 543-1760 "May 8, 1985 ....... 3333 Bernard .................... Bakersfield, Ca. 93306 . ~... ,. Attn: Tom. Hardin Dear Sir: On October 20, 1969, one (1) 2000 Gallon Underground Tank was pur- chased by Bakersfield Adventist Academy from McCarthy Tank & Steel Co. The dimensions of the tank are as follows: The tank is 75.5 inches diameter, 104 inches long and is construct- ed of 3/16" thick mild steel. The exterior was coated with one coat of asphalt based utility coating. We are pleased to have been of service to you. Sincerely, Fred A. Butler Engineering FAB/jk ~IV[cc~zl~mI-~ ~-~ STEEL- FABRICATION · METAL BUILDINGS · INDUSTRIAL SUPPLIES KERN COUI'qT'~' HkALTH DEPAR1-MENI' ~ ~ 1700 FLOW£.~ STREET ~ Ii BILLING DATE BAKERSFIELD, CALIFORNIA 93305 J ......................... 505) 80t-2231 AMOUNT DUE AMOUNT ENCLOSED L ~ J DETACH HERE~._~ PL~SE RETURN THIS ~RTION TO INSURE CORRECT PAYMENT IDENTIFI~TION ~ DETACH HE~; :'"i~,*-" ' .'~- .. :~ ' '~ ':' ' " : ,' C ~.,.- ~;. 'i ~ ~ .' ' "~' ERN COUN~ HEALTH DEPA~MENT a*~ ~, ~,,~s~ ,~ .~. ,..~,.. ~ ,... ....................... 100 FLOWER STREET ..... "~" '~" ~ '~'" '~ "~ '* ...... ~"' ............. ~ ~,,.,,..o.~", TOTAL AMOUNT DUE · ~E~FIELD. CALIFORNIA 93305 x ~com~e~e ~o~ma~ion on fS~. page of ap~ca~ion "Application for Per~t to O~rate U~er~o~ Stor~e Fac~it~'. ~e i~orma~ion req~ed is noted in red on e~clos~ co~. ~-: .................... ~ ....... Other.: ; ......... ;.: ............. T ................. . -- ,. . - Permit Questionnaire Normally. permits are sent to facility Owners but since many sent~to the Operators of the facility where they are to be posted Please fill in Permit · and check, one of the followin~ before returning this form with payment: .................... ~ ~.~l-..-..-Send-.al. 1.-information_to Owner _at,.~the.addresa listed on invoice {if Owner is different than Operator, it will be Owner'~ responsibility 2. Send, all information to Owner at the following corrected address: 3. Send all information to Operator: Name: Address: {Operator can make copy of permit for owner).