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Home My WebLink AboutUNDERGROUND TANK~' eceipt for '. ~ Certified Mail ~,. No Insurance Coverage Provided ,~ Do not use for International Mail (See Reverse) Street and Stat~and ZIP Code Postage Special Delivew Fee Res~icted ~livew ~e Re~rn. Receiot Showing to ~om & Date ~l~ered Return R~eipt Showing to Whom, Date, and Address~'s Address TOTAL Pos~ge Pos~ark or Date STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE, ANO CHARGES FOR ANY SELECTED OPTIONAL SERVICES (see front}. 1. if you want this receipt postmarked, stick the gummed stub to the right of the return address - leaving the receipt attac~d and present the article at a post office service window or hand it to your rural carrier (no extra charge). 2. If you do not want this receipt postmarked, stick the gummed stub to the right of the return address of the article, date, detach and retain tho receipt, and mail the mtic¼. 3. If you want a return receipt, write the certified mail number and your name and address on a return receipt card, Form 3811, and attach it to the front of the article by means of the Gummed ends if space permits. Otherwise, affix to back of article. Endorse front of an'ich RETURN RECEIPT REQUESTED adjacent to the number. ~l 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee, endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested, check the applicable blocks in item 1 of Form 3811. Save this receipt and present it if you make inquiry. 102595-93-z-o478 Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS .OF .PERMIT ON REVERSE SIDE This I~ermit is issued for the followinq: [] Hazardous Materials Plan FI Underground Storage of H~,.ardous Materials FI Risk Management Program [] Hazardous Waste On-Site Treatment PERMIT ID # 015-021-001808 CARNICERIA EL LOCATION 430 E 93307 TANK ~ZA~OU~SUBSTANCE ~C~A~!TY~ ~ ..... ~. ..... ~ ~:~ ;i: "~.'~,~:~ /.t DISPENSER PAN MONITORING 015-000-001808-0001 Premium Unlea&~-~ :x:(}~ '- ~:-~: None 015-000-001808-0002 Unlead~ Plus~.-,-:~ ....... % ~::<~:,~ .,~,~ ~ 10;0O0. ~N°ne~<~'~.~ ~ ,~,' ~':.,,. ~' IsSUed by: Bakersfield Fire Depa~ment~ ~ ~ OFFICE OF EN~RONMENTAL SER VICES· ' 1715 Chester Ave., 3rd Floor Approved by: C~IpgHu~'D~: Issue ~te Bakersfield, CA 93301 Voice (661) 326-3979 F~ ¢61) 326-0576 Exp~tion Date: Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF .PERMIT ON REVERSE' SIDE [] Hazardous MateriaIs I~ Underground Storage of HazardOus Materials [] Risk Management Program [] Hazardous Waste On-Site Treatment PERMIT ID # 015-021-001808 .: .~ ' ':. d~rt~ ,~',' ~ ~c i~ :~:.~....,~,. . LOCATION 430 E 93307' TANK PAN MONITORING 015-000-001808-0001 Premium "'~ ~ None 0154)00-0018084)002 Unleaded Plus 10,000 ', 015-000-001808-0003 Regular Unleaded Issued by: Bakersfield Fire Department.' .... ': · - . ':':.::;:: .... ~:':': '?":' ';' ~'"-: :' ..... -' OFFICE OF ENVIRONMENTAL SER VICES".: : · ':." ' ' "' r" ' 1715 Chester Ave., 3rd Floor Approved by: :: Bakersfield, CA 93301 .cnr~o~~S~ Voice (661) 326-3979 FAX (661) 326-0576 Expiration Date: 'June 30; 2003 City of Bakersfield Office of Environmental Services 1715 Chester Ave., Suite 300 Bakersfield, California 93301 (661) 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 inthe format of your choice: name of owner; name of operator; name of facility; street address, 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 3rd day of October, 2000 to: CARNICERIA EL RANCHERITO Permit #015-021-001808 430 E California Ave. Bakersfield, California 93307 December 27, 2000 Mr. Pablo Bugarin !221 Valorie Ave. FIRE CHIEF 3akersfield, CA 93304 CERTIFIED MAIL RON FRAZE 2)ear Mr. Bugarin: ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 ~ubject: Camiceria El Rancherito Mkt., VOICE (661) 326-3941 FAX (661) 395-1349 430 E. California Ave., Bhkersfield, CA SUPPRESSION SERVICES Nhile conducting a follow-up inspection on December 12, 2000, it was 2101 "H" Street Bakersfield, CA 93301 tiscovered that-you had closed your business. You had indicated that you had VOICE (661) 326-3941 FAX (661) 395-1349 :losed your business on or about December 2, 2000. PREVENTION SERVICES Fhis office is compelled to explain your options with regard to the underground 1715 Chester Ave. Bakersfield, CA 93301 ;torage tanks on your property. Section 7902.1.7.2.1, Temporarily Out Of VOICE (661) 326-3951 gervice: FAX (661) 326-0576 ENVIRONMENTAL SERVICES "Underground tanks temporarily out of service shall have the fill line, 1715 Chester Ave. Bakersfield, CA 93301 gage opening, vapor return and pump connection secure against VOICE (661)326-3970 tampering. Vent lines shall remain open and be maintained." FAX (661) 326-0576 TRAINING DIVISION ~rou must comply with the above-mentioned code for temporaryclosure. After 6642 wctor^ve. }0 days, you must either apply for a one-year temporary closure permit or put Bakersfield, CA 93308 VOICE (661)399-4697 he tanks back into service. Your 90 days will be up on March 2, 2001. FAX (061)309-5703 ;ailure to comply will result in your tanks being illegally abandoned, and further enforcement action will follow. Should you have any questions, please feel free to contact me at (661) 326-3190. Sincerel.ff, Steve Underwood Inspector Environmental Services SU/d A:\430 E. Califomia.wpd D December 27, 2000 vlr. Pablo Bugarin ).221 Valorie Ave. FIRE CHIEF 3akersfield, CA 93304 CERTIFIED MAIL RON FRAZE 2)ear Mr. Bugarin: ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 ;ubject: Carniceria E1 Rancherito Mkt., VOICE (661) 326-3941 FAX (661) 395-1349 430 E. California Ave., Bhkersfield, CA SUPPRESSION SERVICES Nhile conducting a follow-up inspection on December 12, 2000, it was 2101 "1-1" Street Bakersfield, CA 93301 iiscovered that-you had closed your business. You had indicated that you had vOiCE (661)326-3941 FAX (661) 395-1349 :losed your business on or about December 2, 2000. PREVENTION SERVICES Fhis office is Compelled to explain your options with regard to the underground 1715 Chester Ave. Bakersfield. CA 93301 ;torage tanks on your property. Section 7902.1.7.2.1, Temporarily Out Of VOICE (661) 326-3951 ;ervice: FAx (66~) ENVIRONMENTAL SERVICES "Underground tanks temporarily out of service shall have the fill line, 1715 Chester Ave. Bakersfield, CA 93301 gage opening, vapor return and pump connection secure against VOICE (661)326-3979 tampering. Vent lines shall remain open and be maintained." FAX (661) 326-0576 TRAINING DIVISION YOU must comply with the above':mentioned code for temporary closure. After ' 5642 Victor Ave. )0 days, you must either apply for a one-year temporary closurepermit or put Bakersfield, CA 93308 VOICE (661)399-4697 t~e tanks back into service. Your 90 days will be up on March 2, 2001. FAX (661) 399-5763 Failure to comply will result in your tanks being illegally abandoned, and further enforcement action will follow. Should you have any questions, please feel free to contact me at (661) 326-3190. Sincere~rv, Steve Underwood Inspector . Environmental Services SU/d A:\430 E. Califomia.wpd NOTE TO FILE While conducting a follow-up inspection at Camiceria Rancherito (formerly Jenny's Mini- Market) I discovered that business has closed. Pablo, the owner, was inside taking dOwn grocery items. He has indicated that he has been closed since Friday, December 9, 2000. He also states, the he is looking for a buyer. I explained proper closure requirements after ninety (90) days.' I have also informed Esther with regard to billing. Steve Underwood, Inspector 12-12-00 BAKERSFIELD FIRE DEPARTMENT N__. 1 0 2 0 Sub ~i~. ~30 You are hereby required to make the following cor~ctions at the above location: Cor. ~o Completion Date fo,' Correctiol~._. Date [~lq/1319 Inspector 326-3979 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301 FACILITY NAME ~o~Mtcrt~. ~.L ~ata~.~,"[o INSPECTION DATE itllq[t O ADDRESS q30 Ea~s{. ta~.{t~vtn~ ~q0c. PHONE NO. ,~q- f'!"/O FACILITY CONTACT BUSINESS ID NO. 15-210- INSPECTION TIME NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program [~l Routine [~Combined [21 Joint Agency [21 Multi-Agency [21 Complaint [21 Re-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact information accurate ~' {~OC~O[ on.e, Visible address Correct occupancy Verification of inventory materials V' Verification of quantities Verification of location Proper segregation of material Verification of MSDS availability ~J LO~.-¢ ~O q~[' '~ 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 C=Compliance V=Violation Explain:Any hazardous waste on site?: ~lYes [21No~/°'//) ~ Questions regarding this inspection? Please call us at (661) 326-3979 Busi~es~ Site_R~'~nsible Party white-~n~. Svcs. Yenow - Station Copy ~'ink - ausiness Copy Inspector: CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME e0Xt~ ~r. cr{~t ~/__ 0.t~c,ktt~'lr~ INSPECTION DATE Section 2: Underground Storage Tanks Program [] Routine [~ombined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection Type of Tank ,5t.O 1~ Number of Tanks 3 Type of Monitoring hTO, Type of Piping ~,~ I=' OPERATION C V COMMENTS Proper tank data on file 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 UST violations Has there been an unauthorized release? Yes No Section 3: Aboveground Storage Tanks Program TANK SIZE(S). AGGREGATE CAPACITY Type of Tank 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: Omce of Environmental Services (805) 326-3979 ~us-in~ss ~ t~sponsible Party V,/hite - Env. Svcs. Pink - Business Copy .~~ CITY OF BAKERSFIELD OFf OF ENVIRONMENTAL [VICES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 "-'" ~--'" "'* UNDERGROUND STORAGE TANKS - TANK PAGE 1 Page -- el -- TYPE OF ACTION [] 1. NEW SITE PERMIT [] 4. AMENDED PERMIT [] 5. CHANGE OF INFORMATION) [] 6. TEMPORARY SITE CLOSURE (Check one item only) [] 7. PERMANENTLY CLOSED ON SITE [] 3. RENE~VAL PERMIT (S~oecify meson, for local use only) (Soec/fy change, for local use only) [] 8. TANK REMOVED 430 ~, LOCATIoN~wlT(-III~ ~lTETOpOonel) 4.11 I. TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK [] Yes ~ NO 434 1 d ~/.~ ~: h.~)~,j ~/,~ , , if -Yes-, c~mplete ~'~e page foz eac~ compartment. DATE INSTALLE (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 -ADDITIONAL DESCRIPTION (For local use only) 438 [~1. MO TANK USE 439 PETROLEUM TYPE 440 TOR VEHICLE FUEL [] la. REGULAR UNLEADED [] 2. LEADED [] 5. JET FUEL (If marked, complete Petloleum Type) ~ [] I~/J~IREMIUM UNLEADED [] 3. DIESEL [] 6. AVIATION FUEL [] 2. NON-FUEL PETROLEUM I.J.[vfc. MIDGRADE UNLEADED [] 4. GASOHOL [] 99. OTHER [] 3. CHEMICAL PRODUCT COMMON NAME (from Hase~dou~ Mate/fal~ Inven~o/y page) 441 CAS # (f~om Haza/~ous Matezial~ Inventozy page) 442 [] 4. HAZARDOUS WASTE (l~c/udes Used Oil) [] 95. UNKNOWN TYPE OF TANK ~ SINGLE WALL [] 3. SINGLE WAIL WITH [] 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one/tern on/y) [] 2. DOUBLE WALL EX'FERIOR MEMBRANE UNER [] DS. UNKNOWN [] 4. SINC-.-.-.-.-.-.-.-.~E WALL IN A VAULT [] 99. OTHER TANK MATERIAL - pdmary la~k [] 1. BARE STEEL [:~3. FIBERCW,.ASS / PLASTIC n 5. CONCRETE [] 95. UNKNOWN 444 (Check one item only) n 2. STAINLESS STEEL [] 4. STEELCt. ADW/FIBERGLAS~ [] 8. FRPCOMPATIBLEWI100% METHANOL F'199. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL ' sec°m'~a~ tank [] 1. BARE STEEL [] 3. FIBERGLA~SlPLASTIC [] 8. FRPCOMPATIBLEWI100% METHANOL []95. UNKNOWN 445 (Check one item only) n 2. STAINLESS STEEL [] 4. STEEL CLAD W/FIBERGLASS [] 9. FRPNON-CORRODIBLE JACKET []99. OTHER REINFORCED PLASTIC (FRP) [] 10. COATED STEEL [] 5. CONCRETE TANK INTERIOR LINING [] 1. RUBBER MNEO [] 3. EPOXY LINING [] 5.~d.A~ LINING [] 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING [] g. ALKYD LINING [] 4, PHENOLIC UNING [::~. UNLINED [] 99. OTHER ('Check one item only) ~ (~-ot I0~1 use DATE INSTALLED 449 OTHER CORROSION [] 1. MANUFACTURED CATHODIC [] 3. FIBERGLASS REINFORCED PLASTIC [] 95. UNKNOWN 448 PROTECTION IF APPLICABLE PROTECTION [] 4. IMPRESSED CURRENT [] 99. OTHER (Check one/tern on/y) : [] 2. SACRIFICIAL ANODE (Forlocal use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (Forlocal use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (Check,/lthetspply) [~//'1. SPILL CONTAINMENT ~;~ [:~/.. ~LARM ~f ~ 3. F,LL TUBE SHU'r OFF VALVE ~ [~. DROP TUBE ? ~ [] 2. BALL FLOAT__ [] 4. EXEMPT IF ~INGLE WALL TANK (C~k all that epp/y): 453 IF DOUBLE WALL TANK OR TANK WtTH BLADDER (Check one/tem o~/y): 454 [] 1, VISUAL (EXPOSED PORTION ONLY) [] 5. MANUAL TANK GAUGING (MTG) [] 1. VISUAL (SINGLE WALL IN VAULT ONLY) [] 2. AUTOMATIC TANK GAUGING (ATG) [] 6. VADOSE ZONE [] 2. CONTINUOUB INTERSTITIAL MONITORING [] 3. CONTINUOUS ATG [] 7. GROUNDWATER [] 3. MANUAL MONITORING [] 4. STATISTICAL INVEI~rroRY RECONCILIATION (SIR) + [] 8. TANK TESTING BIENNIAL TANK TESTING [] 99. OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTrrY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallo~s [] Yes [] No UPCF (7/99) S:\CUPAFORMS\SWRCB-B.WPD UST - Tank Page I ~ '-'-~ Complete the UST - Tank pages for each tank for all new permits, permit changes, closures and/or any other tank information change. This page must be submitted within 30 days of permit or facility information changes, unless approval is required before making any changes. For compartmentalized tanks, each compartment is considered a separate tank and requires completion of separate tank pages. Refer to 23 CCR )2711 for state UST information and permit application requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER - Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility. 3. BUSINESS NAME - Enter the full legal name of the business. 430. TYPE OF ACTION - Check the reason the page is being completed. For amended permits and change of information, include a short statement to direct the inspector to the amendment or changed information. 431. LOCATION WITHIN SITE - Enter the location of the tank within the site. 432. TANK ID NUMBER - Enter the owner~ tank ID number. This is a unique number used to identify the tank. It may be assigned by the owner or by the CUPA. 433. TANK MANUEACTURER - Enter the name of the company that manufactured the tank. 434. COMPARTMENTALIZED TANK - Check whether or not the tank is compartmentalized. Each compartment is considered a separate tank and requires the completion of separate tank pages. 435. DATE TANK INSTALLED - Enter the year and month the tank was installed. 436. TANK CAPACITY - Enter the tank capacity in gallons. 437. NUMBER OF TANK COMPARTMENTS - If the tank is compartmentalized, enter the number of compartments. 438. ADDITIONAL DESCRIPTION - Use this space for additional tank or location description. 439. TANK USE - Check the substance stored. If MOTOR VEHICLE FUEL, check box 1 and complete item 440, PETROLEUM TYPE. 440. PETROLEUM TYPE - If box I is checked in item 439, check the type of fuel. 441. COMMON NAME - For substances that are not motor vehicle fuels (box I is NOT checked in item 439), enter the common name of the substance stored in the tank. 442. CAS # - For substances that are not motor vehicle fuels (box I is NOT checked in item 439), enter the CAS (chemical Abstract Service) number. This is the same as the CAS # in item 209 on the Hazardous Materials Inventory - Chemical Description page. 443. TYPE OF TANK - Check the type of tank construction. If type of tank is not listed, check Aother== and enter type. ~.,!.~.. TANK MATERIAL (PRIMARY TANK) - Check the construction material of the tank that comes into immediate contact on its inner surface with the hazardous substance being contained. If the tank is lined do not reference the lining material in this item. Indicate the type of lining material in item 446. If type of tank material is not listed, check Aothers_- and enter material. 445. TANK MATERIAL (SECONDARY TANK) - Check the construction matedal of the tank that provides the level of containment external to, and separate from, the pdmary containment. If type of tank matedal is not listed, check ^othe~ and enter material. 446. TANK INTERIOR LINING OR COATING - If applicable, check the construction material of the interior lining or coating of the tank. ff type of interior lining or coating is not listed, check Aothers_- and enter type. 447. DATE TANK INTERIOR LINING INSTALLED - If applicable, enter the date the tank interior lining was installed. This is to assist the CUPA to develop an inspection schedule. 448. OTHER TANK CORROSION PROTECTION ~ ff applicable, check the other tank corrosion protection method used. ff other corrosion protection method is not listed, check Aothem and enter method. 449. DATE TANK CORROSION PROTECTION INSTALLED - ff applicable, enter the date the tank corrosion protection method was installed. This is to assist the CUPA to develop an inspection schedule. 450. YEAR SPILL AND OVERFILL INSTALLED - Check the appropriate box and enter the year in which spill containment, drop tube, and/or striker plate was installed. CHECK ALL THAT APPLY. 451.' TYPE OF SPILL PROTECTION - Enter the type of spill containment, drop tube, and/or striker plate. FOR CUPA USE O~,ILY. 452. YEAR OVERFILL PROTECTION EQUIPMENT INSTALLED - Check the appropriate box and enter the year in which overfill protection was installed or whether there is an exemption from overfill protection. CHECK ALL THAT APPLY, unless tank is exempt. 453. TANK LEAK DETECTION (SINGLE WALL) - For single walled tanks, check the leak detection system(s) used to comply with the monitoring requirements for the tank. CHECK ALL THAT APPLY. If leak detection system is not listed, check ^others= and enter system. 454. TANK LEAK DETECTION (DOUBLE WALL) ~ For double walled tanks or tanks with bladder, check the leak detection system(s) used to comply with the monitoring requirements for the tank. CHECK ONE ITEM ONLY. 455. ESTIMATED DATE LAST USED - For closure in place, enter the date the tank was last used. 456. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN TANK - For closure in place, enter the estimated quantity of hazardous substance remaining in the tank (in gallons). 457. TANK FILLED WITH INERT MATERIAL - For closure in place, check whether or not the tank was filled with an inert matedal pdor to closure. ATTACHMENTS - 1. Provide a scaled plot plan with the location of the UST system, including buildings and landmarks. 2. Provide a description of the monitoring program. I CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES ,.~'~'- ~ '~ Chelter Ave.. Bakersfield. CA 93301 (661) 3Z~r/'9 I I I I I UST - TANK PAGE 2 Page of "=: :',:".':, ".~=:,"F .:~.:..~:'r:.."Vl. ~IPING.C ,O~,~8TRU ,.CTI,ON, ,(,C~teC/ra~,~taA~/. , .' · ,:. ",,: ..' ..................... ~ ..... _:..U~N_D_.E. RGR_O_.U. ND P~IPING :. ABOVEGROUND PIPING SYSTEM TY E I~ REASSURE J"] 2. SUCTIONP ~ [] 3. GRAVITY 458 [] I. PRESSURE [] 2. SUCTION [] 3. GRAVITY 459 CONSTRUCTiON/iL~,I~INGLEWALL [] 3. LINED TRENCH []99. OTHER 460 [] 1. SINGLEWALL ~'-] 95. UNKNOWN 462 MANUFACTURERI[] 2. DOUBLE WALL [] 95. UNKNOWN [] 2. DOUBLE WALL [] 99. OTHER I MANUFACTURER 461 MANUFACTURER 463 [] I. BARE STEEL [] 6 FRPCOMPATBLEWI100% METHANOL [] 1. 8ARESTEEL [] 6. FRPCOMPATIBLEW/I00% METHANOL MATERIALS AND [] 2. STAINLESS STEEL [] 7. GALVANIZED STEEL CORROSION 1,-.~ / J-] 2. STAINLESS STEEL [] 7. GALVANIZED STEEL PROTECTION it 3./J~ASTIC COMPATIBLE WITH CONTENTS [] 95. UNKNOWN [] 3. PLASTIC COMPATIBLE WITH CONTENTS [] 8. FLEXIBLE (HDPE) F'"I 99. OTHER I ~'~. FIBERGLASS [] 8, FLEXIBLE (HDPE) [] 99. OTHER [] 4. FIBERGLASS [] 9. CATHODIC PROTECTION I[] 5: STEEL W/ COATING [] 9. CATHODIC PROTECTION 464 [] 5. STEEL WI COATING []95. UNKNOWN 465 ~ '. . :.;'..-.-', ....... ~;. ,.~..'.'. ~· .': ,""'~'. ,,. :, '.~?::?~':i:~'::, .,~,, ,~. ..,.~,.~ ~I,.?~iN~-b~-AK'O~ ~C~o,~(~:~'~op~) :~"~..,, , ,..~,,,~.~, ..,, ,~ ..-.: , , , .,,,. ,, UNDERGROUND PiPiNG ABOVEGROUND PiPiNG / SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): ' ~..~I~RI_ZED PiPiNG (Check all that apply): !.~v' 1, ELECTRONIC LiNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR [] 1. ELECTRONIC LiNE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK. SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL SYSTEM FAILURE. AND SYSTEM DiSCONNECTiON* AUDIBLE AND VISUAL ALARMS ALARMS [] 2. MONTHLY 0.2 GPH TEST [] 2. MONTHLY 0.2 GPH TEST [] 3. ANNUAL INTEGRITY TEST (0.1 C-:-:-:-:-:-:-:-:-:~H) [] 3, ANNUAL INTEGRITY TEST (0.1 GPH) [] 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS (Check all that apply): [] 5. DALLY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PiPING INTEGRITY [] 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST (0.1 Gl=ti) [] 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING):. SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [] 7. SELF MONITORING [] 7, SELF MONITORING GRAVITY FLOW: GRAV~ FLOW (Check [] 9. BIENNL4~. INTEGRITY TEST (0.1 GPH) r-} 8. DAILY VISUAL MONITORING [] 9. BIENNIAL INTEGRITY TEST (O.t GPH) SECONDARILY CONTAJNED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PiPiNG (Ct'leck 88 t/~t apply): PRESSURIZED PiPiNG (Check all b~at apply): I0. CONTINUOUS TURBINE SUMP SENSOR WiTH AUDIBLE AND VISUAL ALARMS AND (Check, o~e) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (c~ec~k o~e) [] a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ('~ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [] b. AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM [] b. AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [] c. NO AUTO PUMP SHUT OFF [] c. NO AUTO PUMP SHUT OFF [] 11. AUTOMATIC LiNE LEAK DETECTOR (3.0 GPH TEST} VV~'H FLOW SHUT OFF OR [] 11, AUTOMATIC LEAK DETECTOR RESTRICTION [] 12. ANNUAL INTEGRITY TEST (0.1 GPH) [] 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM: - SUCTION/GRAVITY SYSTEM: [] 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL Al. ARMS [] 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Checl; e# that apply) EMERGENCY GENERATORS ONLY (Check all that apply) [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ~- AUDIBLE AND [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL [] VISUAL ALARMS ALARMS [] 15.RESTRICTIoNAUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST} .WI.TI-I. OUT FLOW SHUT OFF OR [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) 16. ANNUAL iNTEGRITY TEST (0.1 GPH) [] 16. ANNUAL INTEGRITY TEST (0.1 Gl=H) [] t7. DAILY VISUAL CHECK , [] 17. DALLY VISUAL CHECK DISPENSER CONTAINMENT I"] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [] 4. DAILY VISUAL CHECK DATE IN~'~LLET D 468 [] 2. CONTINUOUS DISPENSER PAN SEN~OR + AUDIBLE AND VISUAL ALARMS [] 5. TRENCH LINER / MONITORING ~'~f (/~ I-Ii 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER' AUDIBLE AND VISUAL ALARMS [] 6. NONE 469 IX. OWNER/OPERATOR SIGNATURE I c4~lfy that the informatlo~ provlde<l heteln is tree and accurate to the t)est o~ my krtowte(lge. SIGN~A=t:/RE OF. OWNER/OPEEA'7OR I DATE 470 ~NAMEIOF OWNERIOPERAT~J:[T(p~fq.t~:~;;'''' ~ - / / 471I TITLE OF OWNER/OPERATOR 472 IPermitNumi~e~'(Forlecelueeonly) 473 I PermltA~l~m~(Forlocaluseonly) 474 PetmitExplrationDate(Forlocaluseonly) 475 UPCF (7/99) S:~CUPAFORMS~SWRCB-B.WPD UST -Tank Page 2 (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same'as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 458. PIPING SYSTEM TYPE (UNDERGROUND) - For items 458 and 459, check the tank=s piping system 459. PIPING SYSTEM TYPE (ABOVEGROUND) information. CHECK ALL THAT APPLY. 460. PIPING CONSTRUCTION (UNDERGROUND) - Check the tank=s piping construction information. CHECK ALL THAT APPLY. 461. PIPING MANUFACTURER (UNDERGROUND) - Enter the name of the piping manufacturer. 462. PIPING CONSTRUCTION (ABOVEGROUND) - Check the tank=s piping construction information. CHECK ALL THAT APPLY. 463. PIPING MANUFACTURER (ABOVEGROUND) - Enter the name of the piping manufacturer. 464. PIPING MATERIAL AND CORROSION PROTECTION (UNDERGROUND) - For items 464 and 465, check the 465. PIPING MATERIAL AND CORROSION PROTECTION (ABOVEGROUND) tank=s piping material and corrosion protection. 466. PIPING LEAK DETECTION (UNDERGROUND) - For items 466 and 467, check the leak detection system(s) used 467. PIPING LEAK DETECTION (ABOVEGROUND) to comply with the monitoring requirements for the piping. 468. DATE DISPENSER CONTAINMENT INSTALLED - If applicable, enter the date that dispenser containment was installed. 469. DISPENSER CONTAINMENT TYPE - Check the type of dispenser containment monitoring system. SIGNATURE OF OWNER/OPERATOR - The owner or agent of the owner shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is true and accurate. 470. DATE CERTIFIED - Enter the date the page was signed. 471. OWNER/OPERATOR NAME - Pdnt the name of signatory. 472. OWNER/OPERATOR TITLE - Enter the title of the person signing the page. 473. PERMIT NUMBER - Leave this blank, this number is assigned by the CUPA. 474. PERMIT APPROVED BY - Leave this blank, this is the name of the person approving the permit.' 475. PERMIT EXPIRATION DATE - Leave this blank, this is completed by the CUPA. ~f~ CITY OF BAKERSFIELD ~ ~' OFI~E OF ENVIRONMENTAL Bi'VICES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 ~''~"'~" UNDERGROUND STORAGE TANK~ - TANK PAGE 1 Page ~ ~PE OF ACTION ~ l. NEW SITE PERMIT ~NDED PERM~ ~ 5, C~NGE OF INFOR~TION) ~ 6. TEM~RY SITE CLOSURE Check one imm only) ~ 7. PER~NE~Y CLOSED ON SITE ~ 3. RENTAL ~RMIT (~ma~n.~r~luseo~) (~c~a~.~r~aluseonly) ~ 8. TANKRE~VED ~0 I. TANK DESCRIPTION TANK IO ft 432 TANK MANUFACTURER 433 I COMPARTMENTALIZED TANK [] Ye~ [] No 434 DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 ADOITIONAL DESCRIPTION (For local use only) 438 [~,/,, MO TANK USE 439 PETROLEUM TYPE 440 TOR VEHICLE FUEL [] la. REGULAR UNLEADED r'] 2. LEADED [] 5. JET FUEL (~ma~ed. Co//lD/0t~ PeUoleum Type) [~. PREMlUM UNLEADED [] 3. DIESEL [] 6. AVIATION FUEL [] 2. NON-FUELPETROLEUM [] lc. MIDGRADE UNLEADED [] 4. GASOHOL [~99. OTHER [] 3. CHEMICAL PRODUCT COMMON NAIV~. (fmm Hazardous Materials lnvenloo/ page) 441 GAS # (fmm Hazardous Matetfals lnven~oty page) 442 [] 4. HAZARDOUS WASTE (Includes Used Oil) [] ~. UNKNOWN · · ~:,,~ ~'~: ,,,,,/, ,,i:~:;: ',,~i;,,~?,:,,,,i;i:, i"~i,:T~ ~s'mu~o",~:;':' :~. ~,;',i,~il;,,~: ~,',,,ii'i ~:":??!':'?~'i;';.~,.. :"'""~ . ~', - ,; :~ :;'. ',:?.'? ~,~iiiiiii!ii!i?..,.' TYPE OF TANK [~. SINGLE WALL [] 3. SINGLE WALL WITH [~] 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one ~em only) [] 2. DOUBLE WALL ~R MEMBRANE MNER [] 95. UNKNOWN [] 4. S~NGI~ WALL ~N A VAULT [] 99. OTHER TANK MATERIAL - prlma~ tank [] 1. BARE STEEL [~. FIBERGLASS I PLASTIC [] 5. CONCRETE [] 95. UNKNOWN 444 (Check one item only) [] 2. STAINLESS STEEL [] 4. STEEL CLAD W/FIBERC-d,~,SS [] 8. FRPCOMPATIBLEW/100%METHANOL ~-J99. OTHER REINFORCED PI, ASTIC {FRP) TANK MATERIAL ' sec°oda~/ tank i'-I 1. BARE STEEL [] 3. FIBERGLASS/PLASTIC [] 8. FRPCOMPATIBLEWI100% METHANOL i--]95. UNKNOWN 445 (Check one item only) [] 2. STAINLESS STEEL [] 4. STEEL CLAD W/FIBERGLASS [] 9. FRP NON-CORRODIBLE JACKET [] 99. OTHER REINFORCED PLASTIC (FRP) [] 10. COATED STEEL [] s. CONC~'TE TANK INTERIOR LINING [] 1. RUBBER MNED [] 3. EPOXY MNING [] $. GLASS MNING [] 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING [] 2. ALKYD LINING I"] 4. PHENOLIC UNING [~. UNLINED [-] 99. OTHER Check one item on~v) (For local use only) OTHER CORROSION [] 1, MANUFACTURED CATHODIC [] 3. FIBERGLASS REINFORCED PLASTIC [] 95, UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APF~ICABLE PROTECTION [] 4. IMPRESSED CURRENT [] 99. OTHER (Check one/tern only) * [] 2. SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL / YEAR INSTALLED 450 TYPE (For lute/use only) 451 OVEJ~FILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 I:~. oRo. TUBE ~ ? [] 2. ~LL ~O^T ~ [] 4. ~EMPT IF SINGLE WALL TANK (Check sit that apply): 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one item only): 454 [] 1. VISUAL (EXPOSED PORTION ONLY) [] 5. MANUAL TANK GAUGING (IvrrG) [] 1. VISUAL (SINGLE WALL IN VAULTONLY) [--] 2. AUTOMATIC TANK GAUGING (ATG) [] 6, VADOSE ZONE [] 2. CONTINUOUS INTERSTITIAL MONITORING [] 3. CONTINUOUS AT(] [] ?. GROUNDWATER [] 3. MANUAL MONITORING i[]4. STATISTICAL INVENTORY RECONCILIATION (SIR) * 8. TANK TESTING 81ENNIAL TANK TESTING [] 99. OTHER ~ ·, . ~ V. TANK CLO,SURE INFORMATION I PERMANENT CLOSURE IN PLACE ~'~~ 45~ ~ ~ ~ '~ TANK FILLED ~ INERT MATERIAL? 457 UPCF (7/gg) $:~.CUPAFORM$\$WRCB-B.VVP D UST - Tank Page 1 Complete the UST - Tank pages for each tank for all new permits, permit changes, Closures and/or any other tank information change. This page must be submitted within 30 days of permit or facility information changes, unless approval is required before making any changes. For compartmentalized tanks, each compartment is considered a separate tank and requires completion of separate tank pages. Refer to 23 CCR )2711 for state UST information and permit application requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages.. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER - Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility. 3. BUSINESS NAME - Enter the full legal name of the business. 430. TYPE OF ACTION - Check the reason the page is being completed. For amended permits and Change of information, include a short statement to direct the inspector to the amendment or Changed information. 431. LOCATION WITHIN SITE - Enter the location of the tank within the site. 432. TANK ID NUMBER - Enter the owner~ tank ID number. This is a unique number used to identify the tank. It may be assigned by the owner or by the CUPA. 433. TANK MANUFACTURER - Enter the name of the company that manufactured the tank. 434. COMPARTMENTALIZED TANK - Check whether or not the tank is compartmentalized. Each compartment is considered a separate tank and requires the completion of separate tank pages. 435. DATE TANK INSTALLED - Enter the year and month the tank was installed. 436. TANK CAPACITY - Enter the tank capacity in gallons. 437. NUMBER OF TANK COMPARTMENTS - If the tank is compartmentalized, enter ihe number of compartments. 438. ADDITIONAL DESCRIPTION - Use this space for additional tank or location description. 439. TANK USE - Check the substance stored. If MOTOR VEHICLE FUEL, check box 1 and complete item 440, PETROLEUM TYPE. 440. PETROLEUM TYPE - If box 1 is checked in item 439, check the type of fuel. 441.'COMMON NAME - For substances that are not motor vehicle fuels (box 1 is NOT checked in item 439), enter the common name of the substance stored in the tank. 442. CAS # - For substances that are not motor vehicle fuels (box I is NOT checked in item 439), enter the CAS (Chemical Abstract Service) number. This is the same as the CAS # in item 209 on the Hazardous Materials Inventory - Chemical Description page. 443. TYPE OF TANK - Check the type of tank construction. If type of tank is not listed, Check Aothem and enter type. 444. TANK MATERIAL (PRIMARY TANK) - Check the construction matedal of the tank that comes into immediate contact on its inner surface with the hazardous substance being contained. If the tank is lined do not reference the lining matedal in this item. Indicate the type of lining matedal in item 446. If type of tank matedal is not listed, check Aothe~ and enter material. 445. TANK MATERIAL (SECONDARY TANK) - Check the construction matedal of the tank that provides the level of containment external to, and separate from, the pdmary containment. If type of tank matedal is not listed, check Aothe~ and enter material. 446. TANK INTERIOR LINING OR COATING - If applicable, check the construction matedal of the intedor lining or coating of the tank. If type of intedor lining or coating is not listed, check Aothe~ and enter type. 447. DATE TANK INTERIOR LINING INSTALLED - If applicable, enter the date the tank intedor lining was installed. This is to assist the CUPA to develop an inspection schedule. 448. OTHER TANK CORROSION PROTECTION - If applicable, check the other tank com3sion protection method used. If other corrosion protection method is not listed, check Aothe~ and enter method. 449. DATE TANK CORROSION PROTECTION INSTALLED - If applicable, enter the date the tank corrosion protection method was installed. This is to assist the CUPA to develop an inspection schedule. 450. YEAR SPILL AND OVERFILL INSTALLED - Check the appropriate box and enter the year in which spill containment, drop tube, and/or stdker plate was installed. CHECK ALL THAT APPLY. 451. TYPE OF SPILL PROTECTION - Enter the type of spill containment, drop tube, and/or striker plate. FOR CUPA USE ONLY. 452. YEAR OVERFILL PROTECTION EQUIPMENT INSTALLED - Check the appropriate box and enter the year in which overfill protection was installed or whether there is an exemption from overfill protection. CHECK ALL THAT APPLY, unless tank is exempt. 453. TANK LEAK DETECTION (SINGLE WALL) - For single walled tanks, check the leak detection system(s) used to comply with the monitoring requirements for the tank. CHECK ALL THAT APPLY. If leak detection system is not listed, check Aothe~ and enter system. 454. TANK LEAK DETECTION (DOUBLE WALL) - For double walled tanks or tanks with bladder, check the leak detection system(s) used to comply with the monitoring requirements for the tank. CHECK ONE ITEM ONLY. 455. ESTIMATED DATE LAST USED - For closure in place, enter the date the tank was last used. 456. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN TANK - For closure in place, enter the estimated quantity of hazardous substance remaining in the tank (in gallons). 457. TANK FILLED WITH INERT MATERIAL - For closure in place, check whether or not the tank was filled with an inert matedai pdor to closure. ATTACHMENTS - 1. Provide a scaled plot plan with the location of the UST system, including buildings and landmarks. 2. Provide a description of the monitoring program. I CITY OF BAKERSFIELD ~ OFFICE OF ENVIRONMENTAL SERVICES ~ ~'- - ~$ Cheater Ave., Bakersfield, CA 93301 (661) 32~79 UST - TANK PAGE 2 Page __ UNDERGROUND PIPING - 1 ' "ABOVEGROUND PIPING " ' .~_YST_E_M__~.__P/ _i.[~__./_._/~__~E.S.S_URE [] 2. SUCTION [] 3. GRAVITY 458 ![] t. PRESSURE [] 2. SUCTION [] 3. GRAVITY 459.. : CONSTRUCTION/i'r"~/1~. SINGLE WALL [] 3. LINED TRENCH [] 99. OTHER 460 [] I. SINGLE WALL [] 95. UNKNOWN 462 ' MANUFACTURERI[] 2. DOUBLE WALL [] 95. UNKNOWN [] 2. DOUBLE WALL [] 99. OTHER MANUFACTURER 461 MANUFACTURER 463 [] 1. BARE STEEL [] 6. FRP COMPATIBLE WI 100% METHANOL [] 1. BARE STEEL [] 6. FRP COMPATIBLE WI 100% METHANOL MATERIALS AND [] 2. ST~LESS STEEL [] 7. GALVANIZED STEEL [] 2. STAINLESS STEEL [] 7. GALVANIZED STEEL CORROSION 3.~LASTIC COMPATIBLE WITH CONTENTS [-'1 95. UNKNOWN r-I 3. PLASTIC COMPATIBLE WITH CONTENTS [] 8. FLEXIBLE (HDPE) [] 99. OTHER PROTECTION []~. FIBERGLASS [] 8. FLEXIBLE (HOPE) [] 99. OTHER [] 4. FIBERGLASS [] 9. CATHODIC PROTECTION [] 5. STEEL W/ COATING [] 9. CATHO01C PROTECTION 464 [] 5. STEEL Wl COATING [] 95. UNKNOWN 465 UNDERGROUND PIPING ABOVEG~OUND PIPING /' SINGLE WALL PIPING . 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRE~JRIZED PIPING (Check all that apply): '*'~/~ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR [] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST'WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS ALARMS [] 2. MONTHLY 0.2 GPH TEST [] 2. MONTHLY 0.2 GPH TEST [] 3. ANNUAL INTEGRITY TEST (0.1 GPH) [] 3. ANNUAL INTEGRITY TEST (0.1 GPH) [] 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS (Check all that apply): [] 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY [] 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST (0.1 GPH) [] 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [] 7. SELF MONITORING [] 7. SELF MONITORING GRAVr'I'Y FLOW: GRAVITY FLOW (Check all that apply): [] 9. BIENNIAL INTEGRITY TEST (0.1 GPH) [] 8. DAILY VISUAL MONITORING [] 9. BIENNIAL INTEGRITY TEST (O.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check ane) , . 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (chect< o~e) [] a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [] a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [] h. AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM [] b. AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [] c. NO AUTO PUMP SHUT OFF [] c. NO AUTO PUMP SHUT OFF [] 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WiTH FLOW SHUT OFF OR [] 11. AUTOMATIC LEAK DETECTOR RESTRICTION [] 12. ANNUAL INTEGRITY TEST (0.1 GPH) [] 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: [] 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS [] 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that app/y) EMERGENCY GENERATORE ONLY (Check all that apply) [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL VISUAL ALARMS ALARMS [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) wI'rHOUT FLOW SHUT OFF OR [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) RESTRICTION r-'l 16. ANNUAL INTEGRITY TEST (0.1 GPH) [] 16. ANNUAL INTEGRITY TEST (0.1 GPH) [] 17. DAILY VISUAL CHECK [] 17. DAILY VISUAL CHECK OlSPENSERCONTAINMENT [] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [] 4. DAILY VISUAL CHECK DATE INST, i~L~D 488 [] 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS .i"1 5. TRENCH LINER / MONITORING [] 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS [] 6. NONE 469 IX. OWNER/OPERaTOR SIGNATURE I c,e~lil,/that the info~mallo~ provided herein le line and accurate to Ihe best of my knowledge. SIG ~OF/O ~R/OPE R DATE Permit Number (For local uae only) 473 Peimlt Apl)roved (For local use only) 474 Pemllt Expiration1 Date (FOr local use Only) 475 UPCF (7~99) S:\CUPAFORMS~SWRCB-B.WPD UST-Tank Page 2 ' ~ '\ (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 458. PIPING SYSTEM TYPE (UNDERGROUND) - For items 458 and 459, check the tank=s piping system 459. PIPING SYSTEM TYPE (ABOVEGROUND) information. CHECK ALL THAT APPLY. 460. PIPING CONSTRUCTION (UNDERGROUND) - Check the tank=s piping construction information. CHECK ALL THAT APPLY. 461. PIPING MANUFACTURER (UNDERGROUND) - Enter the name of the piping manufacturer. 462. PIPING CONSTRUCTION (ABOVEGROUND) - Check the tank=s piping construction information. CHECK ALL THAT APPLY. 463. PIPING MANUFACTURER (ABOVEGROUND) - Enter the name of the piping manufacturer. 464. PIPING MATERIAL AND CORROSION PROTECTION (UNDERGROUND) - For items 464 and 465, check the 465. PIPING MATERIAL AND CORROSION PROTECTION (ABOVEGROUND) tank=s piping material and corrosion protection. 466. PIPING LEAK DETECTION (UNDERGROUND) - For items 466 and 467, check the leak detection system(s) used 467. PIPING LEAK DETECTION (ABOVEGROUND) to comply with the monitoring requirements for the piping. 468, DATE DISPENSER CONTAINMENT INSTALLED - If applicable, enter the date that dispenser containment was installed. 469. DISPENSER CONTAINMENT TYPE - Check the type of dispenser containment monitoring system. .- SIGNATURE OF OWNER/OPERATOR - The owner or agent of the owner shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is true and accurate. 470. DATE CERTIFIED - Enter the date the page was signed. 471. OWNER/OPERATOR NAME - Print the name of signatory. 472. OWNER/OPERATOR TITLE - Enter the title of the person signing the page. 473. PERMIT NUMBER - Leave this blank, this number is assigned by the CUPA. 474. PERMIT APPROVED BY - Leave this blank, this is the name of the person approving the permit. 475. PERMIT EXPIRATION DATE - Leave this blank, this is completed by the CUPA. /~n~ · CITY OF BAKERSFIELD OFI~E OF ENVIRONMENTAL Si~VICES i715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 · ' UNDERGROUND STORAGE TANKS - TANK PAGE 1 Page ~ o~ __ ~PE OF ACTION ~ 1. NEW SITE PERMIT ~A~NDED PERMIT ~ 5, CHANGE OF INFOR~TION) ~ 6. TEM~RY SITE CLOSURE (Check one item only) ~ 7. PER~NE~Y CLOSED ON SITE ~ 3. RENTAL PERMIT (~ec~ma~n-~r~luseo~) (~ec~cha~-~r~aluseon/y) ~ 8. T~KRE~VED 430 BUSINESS ~ME (~e ~ FACILI~ ~E ~ O~ - ~6uan~ ~) 3 FACI~ ID ~ LO~TION ~HIN SITE (~na0 L TANK DESCRIPTION ~ TANK ID ~ 432 T~K ~NUFAC~RER 43~ ~MPAR~E~AL~ED TANK ~ Y~ ~ ~ 4~ ~ATE INSTALLED ~) 435 T~K ~AC~ IN ~LLONS ~6 NU~ER OF COMPAR~E~S ~g~ I0 ~ ~ c, ADD.lOlL DESCRI~ION (~r ~1 ~ o~) TANK USE 439 PETROLEUM TYPE 440 [~. MOTOR VEHICLE FUEL [~l~a. REGULAR UNLEADED [] 2. LEADED [] S. JET FUEL (/fmarked, comp/ere Pem~leum Type) [] lb. PREMIUM UNt. EADED [] 3. DIESEL [] 6. AVIATION FUEL [] 2. NON-FUEL PETROLEUM [] lc. MIDGRADE UNLEADED [] 4. GASOHOL [] 99. OTHER [] 3. CHEMICAL PRODUCT COMMON NAME (f~om Hazardous Meteria/s /nvena3ry page) 441 CAS # (f~m Haza/~k~us Mate/fei3 Invento/7 page) 442 [] 4. HAZARDOUS WASTE (Includes Used Oil) [] 95. UNKNOWN TYPE OF TANK . ~SINGLE WA-- [] 3. S~.C~E WALLW~ [] 5. S,NGLEWA" W~ INTERNAL a~OER SYSTEM (Check one ~em on/y) ~R MEMBRANE LINER [] 95. UNKNOWN [] 2. DOUBLE WALL [] 4. SI~ WALL IN A VAULT [] 99. OTHER TANK MATER~. - pdmat7 ta~k [] l. BARE STEEL ~. FIBERGLASS / PLASTIC [] 5. CONCRETE [] 95, UNKNOV~t 444 l (Check one item on/y) [] 2. STAINLESS STEEL [] 4. STEEL CLAD W/FIBERGLASS [] 8. FRPCOMPAT1BLEWI100%METHANOL []99. OTHER REINFORCED Pt. ASTIC (FRP) , TANK MATERIAL - seCOm~a~/ tank [] 1. BARE STEEL [] 3. FIBERGLASS/PLASTIC [] 8. FRPCOMPATIBLEWlI00% METHANOL []95. UNKNOWN 445 (Check one item only) [] 2. STAINLESS STEEL [] 4. STEEL CLAD W/FIBERGLASS [] 9. FRP NON-CORRODIBLE JACKET [] 99. OTHER REINFORCED PLASTIC (FRP) [] 10. COATED STEEL [] 5. CONCRETE DATE INSTALLED 447 TANK INTERIOR LINING [] 1. RUBBER ENED [] 3. EPOXY MNING [] 5. GLASS LINING [] 95. uNKNOWN 446 OR COATING I'-] 2. ALKYD LINING I"] 4. PHENOLIC LINING [~NLINED [] 99. OTHER ~ (Check o~e ~em o~) (For local use o~ly) · DATE INSTALLED 449 OTHER CORROSION [] 1. MANUFACTURED CATHODIC [] 3. FIBERGLASS REINFORCED PLASTIC [] 95. UNKNOWN 448 PROTECTION IF APPLICABLE PROTECTION [] 4. IMPRESSED CURRENT [] 99. OTHER (Check one/fern On/y) · [] 2. SACRIFICIAL ANOOE (For/ocal use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (Forlocal use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 .check a,, .a, o..ly SP.LLCO A,NMENT q f ALARM I? [] F,LL BES"UTOFFVALVE ~2. DROP TUBE (~ ~ [] 2. BALL FLOAT ~ [] 4. EXEMPT IF SINGLE WALL TANK (Check a/I that apply): 453 IF DOUBLE WALL TANK OR TANK ~ BLADDER (Check one ~tern on/y): 454 ~2. AISUAL (EXPOSED PORTION ONLY) [] 5. MANUAL TANK GAUGING (MTG) [] 1. VISUAL (SINGLE WALL IN VAULT ONLY) UTOMATIC TANK GAUGING (ATG) [] 5. VADOSE ZONE [] 2. CONTINUOUS INTERSTITIAL MONITORING [] 3. CONTINUOUS ATG [] 7. GROUNDWATER [] 3. MANUAL MONITORING [] 4. STATISTICAL INVENTORY RECONCtLIAT~ON (SIR) + [] 8. TANK TESTING BIENNIAL TANK TESTING [] 99. OTHER V, TANK CLOSUI~E INFORMATION / PEI~MANENT CLOSUI~E IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTI~f OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallo~a [] Ye~ [] No UPCF (7/99) S:\CU PAFORMS\SWRCB-B.WP D UST -Tank Page I ~' Complete the UST - Tank pages for each tank for all new permits, permit changes, closures and/or any other tank information change. This page must be submitted within 30 days of permit or facility information changes, unless approval is required before making any changes. For compartmentalized tanks, each compartment is considered a separate tank and requires completion of separate tank pages. Refer to 23 CCR )2711 for state UST information and permit application requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submitta!. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER - Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility. 3. BUSINESS NAME - Enter the full legal name of the business. 430. TYPE OF ACTION - Check the reason the page is being completed. For amended permits and change of information, include a short statement to direct the inspector to the amendment or changed information. 431. LOCATION WITHIN'SITE - Enter the location of the tank within the site. 432. TANK ID NUMBER - Enter the owner=s tank ID number. This is a unique number used to identify the tank. It may be assigned by the owner or by the CUPA. 433. TANK MANUFACTURER - Enter the name of the company that manufactured the tank. 434. COMPARTMENTALIZED TANK - Check whether or not the tank is compartmentalized. Each compartment, is considered a separate tank and requires the completion of separate tank pages. 435. DATE TANK INSTALLED - Enter the year and month the tank was installed.. 436. TANK CAPACITY - Enter the tank capacity in gallons. 437. NUMBER OF TANK COMPARTMENTS - If the tank is compartmentalized, enter the number of compartments. 438. ADDITIONAL DESCRIPTION - Use this space for additional tank or location description. 439. TANK USE - Check the substance stored. If MOTOR VEHICLE FUEL, check box I and complete item 440, PETROLEUM TYPE. 440. PETROLEUM TYPE - If box I is checked in item 439, check the type of fuel. 441. COMMON NAME - For substances that are not motor vehicle fuels (box 1 is NOT checked in item 439), enter the common name of the substance stored in the tank. 442. CAS # - For substances that are not motor vehicle fuels (box I is NOT checked in item 439), enter the CAS (Chemical Abstract Service) number. This is the same as the CAS # in item 209 on the Hazardous Materials Inventory - Chemical Description page. . 443. TYPE OF TANK - Check the type of tank construction. If type of tank is not listed, check Aother~-_- and enter type. 444. TANK MATERIAL (PRIMARY TANK) - Check the construction material of the tank that comes into immediate contact on its inner surface. with the hazardous substance being contained, ff the tank is lined do not reference the lining material in this item. Indicate the type of lining material in item 446. If type of tank matedal is not listed, check Aothe~ and enter material. 445. TANK MATERIAL (SECONDARY TANK) - Check the construction matedal of the tank that provides the level of containment external to, and separate from, the pdmary containment. If type of tank matedal is not listed, check Aother= and enter material. 446. TANK INTERIOR LINING OR COATING - If applicable, check the construction matedal of the interior lining or coating of the tank. If type of interior lining or coating is not listed, check Aothem= and enter type. 447. DATE TANK INTERIOR LINING INSTALLED - If applicable, enter the date the tank interior lining was installed. This is to assist the CUPA to develop an inspection schedule. 448. OTHER TANK CORROSION PROTECTION - ff applicable, check the other tank corrosion protection method used. ff other corrosion protection method is not listed, check Aothem_- and enter method. 449. DATE TANK CORROSION PROTECTION INSTALLED - ff applicable, enter the date the tank corrosion protection method was installed, This is to assist the CUPA to develop an inspection schedule. 450. YEAR SPILL AND OVERFILL INSTALLED - Check the appropriate box and enter the year in which spill containment, drop tube, and/or stdker plate was installed. CHECK ALL THAT APPLY. 451. TYPE OF SPILL PROTECTION - Enter the type of spill containment, drop tube, and/or striker plate. FOR CUPA USE ONLY. 452. YEAR OVERFILL PROTECTION EQUIPMENT INSTALLED - Check the appropriate box and enter the year in which overfill protection was installed or whether there is an exemption from overfill protection. CHECK ALL THAT APPLY, unless tank is exempt. 453. TANK LEAK DETECTION (SINGLE WALL) - For single walled tanks, check the leak detection system(s) used to comp!y with the monitoring requirements for the tank. CHECK ALL THAT APPLY. If leak detection system is not listed, check Aothem_- and enter system. 454. TANK LEAK DETECTION (DOUBLE WALL) - For double walled tanks or tanks with bladder, check the leak detection system(s) used to comply with the monitoring requirements for the tank. CHECK ONE ITEM ONLY. 455. ESTIMATED DATE LAST USED - For closure in place, enter the date the tank was last used. 456. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN TANK - For closure in place, enter the estimated quantity of hazardous substance remaining in the tank (in gallons). 457. TANK FILLED WITH INERT MATERIAL - For closure in place, check whether or not the tank was filled with an inert matedal prior to closure. ATTACHMENTS - 1. Provide a scaled plot plan with the location of the UST system, including buildings and landmarks. 2. Provide a description of the monitoring program. L CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICESt~~ ~ Cheeter Ave., Bakersfield, CA 93301 (661) 32~79 . . . UST - TANK PAGE 2 Page __ of __ ! ................ :__._/:_. ......... .?Lo_E. RGRO_U.~ ?,NG AeOVEGROUNO PIP~NO : SYSTEM TYPE [~' 1. PRESSURE ['-] 2. SUCTION [] 3. GRAVITY 458 [] 1. PRESSURE [] 2. SUCTION [] 3. GRAVITY 459 [] 1. SINGLE WALL [] 3, LINED TRENCH [] 99. OTHER 460 [] I. SINGLE WALL [] 95. UNKNOWN 462 ~ CONSTRUCTION/ ]MANUFACTURER [] 2. DOUBLE WALL [] 95. UNKNOWN [] 2. DOUBLE WALL [] 99. OTHER ! MANUFACTURER 461 MANUFACTURER 463 ! [] 1. BARE STEEL [] 6. FRP COMPATIBLE WI 100% METHANOL [] 1. BARE STEEL [] 6. FRP COMPATIBLE WI 100% METHANOL MATERIALS AND [] 2. STAINLESS STEEL [] 7. GALVANIZED STEEL [] 2. STAINLESS STEEL [] 7. GALVANIZED STEEL CORROSION i PROTECTION--~.[] 3 PLASTIC COMPATIBLE WITH CONTENTS [] 95. UNKNOWN [] 3. PLASTIC COMPATIBLE WITH CONTENTS [] 8. FLEXIBLE (HDPE) [] 99. OTHER [~4. FIBERGLASS [] 8. FLEXIBLE (HDPE) [] 99. OTHER [] 4. FIBERGLASS [] 9. CATHODIC PROTECTION : [] 5. STEEL W/COATING [] 9. CATHODIC PROTECTION 464 [] 5. STEEL WI COATING [] 95. UNKNOWN 465 , :.,. :~:,,,-.~,:,,.=~.,,?VII,~,pIPINGLEAKDETECTION*(CI~eCke.metapply)~ ,,-, .. .... ,~...~,~.:., ! . . ~...;, ·: '.:~; .: · ,' . · ..... ,,. . ,, , , ~-~ ~ , . , , ,, ,,, . · [ UNDERGROUND PiPiNG ABOVEGROUND PIPING ! SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 I P?ES~RIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): ! [::~1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WTTH AUTO PUMP SHUT OFF FOR [] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAtC []ALARMsLEAK' SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL [] 2. MONTHLySYSTEM FAILURE,0.2 GPH ANDTEsTSYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS 2. MONTHLY 0.2 GPH TEST [] 3. ANNUAL INTEGRITY TEST (0.1 GPH) [] 3, ANNUAL INTEGRITY TEST (0.1 GPH) [] 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS (Check all that apply): [] 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY [] 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST (0.1 GPH) [] 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [] 7. SELF MONITORING [] 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW (Check all that apply): [] 9, BIENNIAL INTEGRITY TEST (0.1 GPH) [] 8. DAILY VISUAL MONITORING [] 9. BIENNIAL INTEGRITY TEST (O.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that al)ply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) - 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (cflec~ one) [] a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [] a, AUTO PUMP SHUT OFF WHEN A LEAK OCCURS [][][] c.l~' NoAUTODIsCONNECTIONAuToPUMPpuMPSHUTsHuTOFFoFFFOR LEAKS, SYSTEM FAILURE AND SYSTEM [--I[] c.t)' NOAUTOAUToPUMPpuMPSHUTsHuTOFFoFFFOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION 11. AuTOMATIC LINE LEAK DETECTOR (3,0 GPH TEST) WITH FLOW SHuT OFF OR [] 11. AUTOMATIC LEAK DETECTOR RESTRICTION [] 12. ANNUAL INTEGRFi~ TEST (0.1 GPH) [] 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM: SUCTION/GRAViTY SYSTEM: [] 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS [] 13, CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check ell that apply) EMERGENCY GENERATOR~ ONLY (Check all that apply) .... [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL VISUAL ALARMS ALARMs [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) : RESTRICTION [] 16. ANNUAL INTEGRITY TEST (0.1 GPH) [] 16. ANNUAL INTEGRITY TEST (0.1 GPH) [] 17. DAILY VISUAL CHECK [] 17. DAILY VISUAL CHECK DISPENSER CONTAINMENT [] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [] 4. DAILY VISUAL CHECK [-] 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS [] 6. NONE 469 IX. OWNER/OPERATOR SIGNATURE I ce~i~y that the infom~atlon provided herein is tree and accurate to the best of my knowledge. T- 61b , w --I~ME~OF OWNER/OPEI~t.-T,,OR (,q"~'~ ~ _ 471 TITLE OF OWNER/OPERATOR 472 UPCF (7/99) S:\CUPAFORMS~SWRCB-B.WPD UST - Tank Page 2 ~- ~ (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 458. PIPING SYSTEM TYPE (UNDERGROUND) - For items 458 and 459, check the tank=s piping system 459. PIPING SYSTEM TYPE (ABOVEGROUND) information. CHECK ALL THAT APPLY. 460. PIPING CONSTRUCTION (UNDERGROUND) - Check the tank=s piping construction information. CHECK ALL THAT APPLY. 461. PIPING MANUFACTURER (UNDERGROUND) - Enter the name of the piping manufacturer. 462. PIPING CONSTRUCTION (ABOVEGROUND) - Check the tank=s piping construction information. CHECK ALL THAT APPLY. 463. PIPING MANUFACTURER (ABOVEGROUND) - Enter the name of the piping manufacturer. 464. PIPING MATERIAL AND CORROSION PROTECTION (UNDERGROUND) - For items 464 and 465, check the 465. PIPING MATERIAL AND CORROSION PROTECTION (ABOVEGROUND) tank=s piping material and corrosion protection. 466. PIPING LEAK DETECTION (UNDERGROUND) - For items 466 and 467, check the leak detection system(s) used 467. PIPING LEAK DETECTION (ABOVEGROUND) to comply with the monitoring requirements for the piping. 468. DATE DISPENSER CONTAINMENT INSTALLED - If applicable, enter the date that dispenser containment was installed. 469. DISPENSER CONTAINMENT TYPE - Check the type of dispenser containment monitoring system. SIGNATURE OF OWNER/OPERATOR - The owner or agent of the owner shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is true and accurate. 470. DATE CERTIFIED - Enter the date the page was signed. 471. OWNER/OPERATOR NAME - Pdnt the name of signatory. 472. OWNER/OPERATOR TITLE - Enter the title of the person signing the page. 473. PERMIT NUMBER - L~ave this blank, this number is assigned by the CUPA. 474. PERMIT APPROVED BY - Leave this blank, this is the name of the person approving the permit. 475. PERMIT EXPIRATION DATE - Leave this blank, this is completed by the CUPA. CITY OF BAKERSFIELD · 171~ Chester Ave., Bakersfield, CA 93301 (661) 326 3979 UNDERGROUND 8TO~GE TANKS - UST FACILI~ (Ch~ ~ ~m ~) UPCF (71~) S:~CUPAFORMS~.~ Complete the UST - Facility page for all new permits, permit changes or any facility information changes. This page must be submitted within 30 days of permit or facility information changes, unless approval is required before making any changes. Submit one UST - Facility page per facility, regardless of the number of tanks located at the site. This form is completed by either the permit applicant or the local agency underground tank inspector. As part of the application, the tank owner must submit a scaled facility plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [23 CCR )2711 (aX8)], a description of the tank and piping leak detection monitoring program [23 CCR )2711 (a)(9)], and, for tanks containing petroleum, documentation showing compliance with. state financial responsibility requirements [23 CCR )2711 (aX11)]. Refer to 23 CCR )2711 for state UST information and permit application requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionan/.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER - Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility. 3. BUSINESS NAME - Enter the full legal name of the business. 400. TYPE OF ACTION - Check the reason the page is being completed. CHECK ONE ITEM ONLY. 401. NEAREST CROSS STREET - Enter the name of the cross street nearest to the site of the tank. 402. FACILITY OWNER TYPE - Check the type of business ownership. 403. BUSINESS TYPE - Check the type of business. 404. TOTAL NUMBER OF TANKS REMAINING AT SITE - Indicate the number of tanks remaining on the site after the requested action. 405. INDIAN OR TRUST LAND - Check whether or not the facility is located on an Indian reservation or other trust lands. 406. PUBLIC AGENCY SUPERVISOR NAME - If the facility owner is a public agency, enter the name of the supervisor for the division, section or office which operates the UST. This person must have acc, ess to the tank records. 407. PROPERTY OWNER NAME - Complete items 407- 412 for the property owner, unless all items are 408. PROPERTY OWNER PHONE the same as the Owner Information (items 111-116) on the Business 409. PROPERTY OWNER MAILING OR STREET ADDRESS Owner/Operator Identification page (OES Form 2730). If the same, 410. PROPERTY OWNER CITY write 'SAME AS SITE' in this section. 411. PROPERTY OWNER STATE 412. PROPERTY OWNER ZIP CODE 413. PROPERTY OWNER TYPE - Check the type of property ownership. 414. TANK OWNER NAME - Complete items 414- 419 for the tank owner,, unless all items are the 415. TANK OWNER PHONE same as the Owner Information (items 111-116) on the Busihess 416. TANK OWNER MAILING OR STREET ADDRESS Owner/Operator Identification page (OES Form 2730). If the same, 417. TANK OWNER CITY write 'SAME AS SITE' in this section. 418. TANK OWNER STATE 419. TANK OWNER ZIP CODE 420. TANK OWNER TYPE - Check the type of tank ownership. 421. BOE NUMBER - Enter your Board of Equalization (BOE) UST storage fee account number. This fee applies to regulated USTs storing petroleum products. This is required before your permit application can be processed. If you do not have an account number with the BOE or if you have any questions regarding the fee or exemptions, please call the BOE at (916) 322-9669 or write to the BOE at: Board of Equalization, Fuel Taxes Division, P.O. Box 942879, Sacramento, CA 94279-0030. 422. PETROLEUM UST FINANCIAL RESPONSIBILITY CODE - Check the method(s) used by the owner end/or operator in meeting the Federal and State flnandal responsibility requirements, CHECK ALL THAT APPLY. If the method is not listed, check Aothers_- and enter the method(s). USTs owned by any Federal or State agency and non-petroleum USTs are exempt from this requirement. 423. LEGAL NOTIFICATION AND MAILING ADDRESS - Indicate the address to which legal notifications and mailings should be sent. The legal notifications and mailings will be sent to the tank owner unless the facility (box 1) or the property owner (box 2) is checked. SIGNATURE OF APPLICANT - The business owner/operator of the tank facility, or officially designated representative of the owner/operator, shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is accurate and complete. 424. DATE CERTIFIED - Enter the date that the page was signed. 425. APPLICANT PHONE - Enter the phone number of the applicant (person certifying). 426. APPLICANT NAME - Enter the full printed name of the person signing the page. 427. APPLICANT TITLE - Enter the tJfle of the person signing the page. 428. STATE UST FACILITY NUMBER - Leave this blank. This number is assigned by the CUPA as follows: the number is composed of the two digit county number, the three digit jurisdiction number, and a six digit facility number. The facility number must be the same as shown in item 1. 429. 1998 UPGRADE CERTIFICATE NUMBER - Leave this blank. This number is assigned by the CUPA. EMERGENCY RESPONSE PLAN UNDERGROUND STORAGE TANK MONITORING PROGRAM This monitoring program must be kept at the UST localion at all times. The information on this monitoring program are conditions of the operating permit. The permit holder must notify the Office of Environmental Services within 30 days of any changes to the momtormg procedures, unless required to obtain approval b~Ol'~ rnMdng the change. R~luired by. Sections 2632(d) and 2641(h) CC1L /_ 1. /gan 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 fi.om the secondary containment within 8 hours, or deteriorate the secondary containment, t~h~en the Office ofEnv~r.' onmental Services must be no '.ti~_ e~i~ within24hours, lOer)e~[/~ ,~_ ~r [,[~_~ ~- ~r~dct~ac ~ % 2. Describe the proposed methods and equipment to be used for removing and properly dispos, ingo.fany, hazardous substance, c].~ ~ ~¥ ~t~x~r ets rm 3. Describe the location and availability of the r~quired cleanup equip.mere in iter~, 2 above. 4. Describe the maintenance schedule for the cleanup equipment: 5. List the name(s) and title(s) of the person(s) r?~on~ible for authorizing any work necessary under the response plan: '~X.~ .~ ~~x Y'., ~q WR EN MONITORING PRO EDURES UNDERGROUND STORAGE TANK MONITORING PROGRAM This monitoring program must be kept at the UST location at all ~ Th~ information on thi, ~ program are conditiom of the ol~rating permit. Th~ permit holder must nmffy the Office of Envimnmen~l ~0~ wlithin 30 da~ of ally ~ to th~ Illonitomg prlx~hli~ u~ f~ired to o~min ~ ~ making tl~ change. Required by ,~x:tiom 2632(d) and 2641(h) CCR. A. Describe the frequency of performing the monitoring: B. What methods and equipment, identified by name and model, will be used for per~o~ the monitoring: Piping ~. '- ~ ' C. Describe the location(s) where the monitoring will be performed (facility plot plan should be attached): D. List the name(s) and tire(s) of the people responsible for performing the monitoring =d/or maintaining the equipment:?~.~ ~/ c~/~//&¥x~, c~ ~ E. Reporting Format for monitoring: Piping F. Describe the preventive maintenance schedule for the monitoring equipment. Note: Maintenance must be in accordance with the manufat'turer's maintennnee sehed~e but not less than every 12 months. G. Describe the training necessary for the operation ofUST sy.sterrt, including piping, and the monitoring equipment: · · :;., ........ :u.:~ ..,¥ .r:'~.. ~." ,':', :,,:~':: '~ · ~ ~'~,?.. ' " CERTIFICATION OF FINANCIAL RESPONSIBILI 8.. ~m~y ce~s ~t ~ ~ ~ ~m~ ~h ~ ~ ~ ~n 2807, A~e 3, C~r I~, D~n 3, ~le 23, ~l~m~ ~e of Regu~t~. ~e ~~ ~ ~ ~~~ S~t~n 2807are ~ ~ilo~: ?~ird P~ Num~rm::~;,-. Note: If you are using gte 8tare Fund as any part of your demonstration of financial re~ ~onsibility, you~ ~ of this ce~__ __t~_ n ~_~_ cerEtfes that you are in comp/lance with all conditior~ for partJc~Dation /n b~e Fund. Z'HS'I'RUt~2~C)NB - , · --... .... PLMie type or print clearly all ~formtfon on Certification of Finenciet IlmlbiLity for~' ALL L~T feclLitlee MIWol' attes W or o~tecl My b~ Listed on m~ fcr~ therefore · Sl~lrete clrtlflc~te ia not required for eech eite. DOOJHEMT I~IFOIMATSOM A. M IMqulred - Check the M~propriete boxes.. B. ~ of Tenl~ (kter - FuLL nine of either the tank okner or the operator. or (llXtltor C. Will Type - lndlclte tdtich State IRx'oved mcheni~(a) are being ,mad to shmt flnmx:feL responlibfLlcy either as contained itt tho federal regu(etfonl, &O CFR, Pert Sd:q~rt: H, Sections 280.90 through 280.103 CSoe Flnangtlt RIxnilblLIty G~Jlde, for more infor~ltio~), or Section 2802.1, Chapter fa, Division 3, TitLe 5, CC3~. kll of IMusr - List eLL nmml lad addresses of ccxnpanies lad/or fndivfcl~Ls Issuing coverage. Hedunlem ~ - List fclentl~n~ nunber for each aechanim used. Examote: fmurence po(icy or file numar aa indicated on ~ or docusent. (If using State CLeenup FLrd CState Fu~cI) Leav~ blank.) Ccnmll~e ~ - indicate MJQI~t Of coverlSe for each l:ype of IlmchMltBIKS). Zf more then oM mchinJs~ ia indicated, total must ec~L 1002 of fl~iflcJaL, respc~tbiti~ for each feci Li~y. CoverNe Pm'ted - Indicate the effective dateCs) of aLL financial mchenisaCs). CState F~d coverage ~Jtd be continu~s as Long aa you Mintain cc~Lience ~cI retain eLigibLe to CQflttnus parttctl~tion in the Fund.) Corr~l~m Ac~lon - Indicate yes or no. 0oas the specified financial mec~anlm provide coterie for corrective ecti~fl? C]f using State FLed, indicate Third Party - Indicate yes or no. Does the specified fi~nclat mch~nZs~ provide coverage for Caepamatton third party ccapensacion? Clf using State FL~I, indicate D. FKiilty - Provide aLL facility and/or site ~es and addresses. Informtion E. $1gn~re Ilec~ - Provide etgnotura ~cl cbte sigMcl 1~, t~ mr or operator; printed or typed nam ~ title of tar~ mr or operator; signature of within or notary ~ cl~te sfgMcI; wcI printed or typed name of wltna~a or notary (if notary signs u witM~, pLesae pLece notary seal next to nocary~s signature). ~here to lief[ Certfffcltlon: Pteue send orfgimL to your Local ~get~y (agency ~ho issues your ~T ~mlts). certlfi~tlm at ~ fKILIW or site tfst~ m the fora. ~f ~ hl~ ~t{~ ~ f{~iaL r~ibiLicy r~ir~cs or ~ the Certlficaci~ of R~ibi.iity Fom, please c~tacC the State UST Ciea~ F~ ac (91~) ~9-2~. Ngte: PenlLtlll for Faitur~ to C_~'~LY with Financial R~__~:~mi_~ ibILIcY Re;utrtmnts: FaiLure to campLy Miy rfluLc In: C1) ]~rdfzi~ ctaimnc eligibility for the S~ote UST CLe~ F~, ~ (Z) LI~ILIW for civil mLcifl of ~ to SlO,OOO ~Ltars ~r day, ~r ~rgr~ storage t~, for el~ ~y of v~o[Itf~ ii IClCK In Article 7, S~ci~ 252~.76Ca) of the CILJfo~tl ffelith ~ bfe~ C~.