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Home My WebLink AboutUST REPT. 4/23/1982 ~:"" "' KERSFIELD FIRE DEPARTMENT BUREAU OF FIRE PREVENTION ?3 ,~,~.~1 ~%~'~2 × ~07 Date APPLICATION Application No. ~ conformity with provisions of pertinent ordinances, codes and/or regulations, application is In made " by: :~ ' t-lt~ndnr~ Rio Bravo Golt~ Couree lf, rv. 178 Name of Company Address ili to display, store, install, use, operate, sell or handle materials or processes involving or creating con- ditions deemed hazardous to life or property as follows: ~iissued~_. · ' ? '~ .... . ~ "~, .-z '. ............ Permit denied ..-c~_~....C..~..~.. ....... .~.'.~... By ....................... Date Fire Marsl~l -?:.. FILE CONTE.~]TS SUMMARY PERMIT #: ~%CbC>~_~ ENV. SENSITIVITY: ~--~ Activity Date # Of Tanks Comments 1700 Flower Street '~ERN COUNTY HEALTH DEPARTMEh, HEALTH OFFICER Bakersfield, California 93305 Leon M Hebertson, M.O. Telephone (805)861-3636 ENVIRONMENTAL HEALTH DIVISION DIRECTOR OF ENVIRONMENTAL HEALTH Vernon S. Reichard INTERIM PERMIT FERMI ~'~5~ 0 0 0 2 C TO OPERATE: ISSUED: JULY 1, 1986 EXPI RES: JULY 1, 1989 UNDERGROUND HAZARDOUS. SUBSTANCES STORAGE FACILITY NUMBER OF TANKS= 2 FAC ILITY: I OWNER: GOLF COURSE MAINTENANCE BUILDING I LA HACIENDA, INC. CASA CLUB & VISTA GRANDE I 6200 LAKE MING ROAD BAKERSFIELD, CA I BAKERSFIELD, CA 93306 TANK # AGE(IN YRS) SUBSTANCE CODE PRESSURIZED PIPING? 1,2 3 MVF 2 UNK NOTE: ALL INTERIM REQUIREMENTS ESTABLISHED BY THE PERMITTING AUTHORITY MUST BE MET DURING THE TERM OF THIS PERMIT NON--TRANSFERABLE '~ ~ ~ POST ON PREMISES DATE PERMIT MALT,~D: JUL 2 1 1986 PERMIT CHECKLIST Facility ..z.fj,~ ~i- /- ,~.~ - This checklist is provided to ensure that all necessary packet enclosures were received and that the Permittee has obtained all necessary equipment to implement the first phase of monitoring requirements. Please complete this form and return to KCHD in the self-addressed envelope provided within 30 days of receipt. Check: Yes No A. The packet I received contained: 1) Cover Letter, Permit Checklist, Interim Permit, Phase I Interim Permit Monitoring Requirements, Information Sheet (Agreement Between Owner and Operator), Chapter 15 (KCOC #G-3941), Explanation of Substance Codes, £quipmcnt Lizts and Raturn 2) Standard Inventory Control Monitoring Handbook ~UT-IO. 3) The Followin~ Forms: a) Inventory Recording Sheet b) Inventory Recording Sheet with summary on reverse c) Trend Analysis Worksheet 4) An Action Chart (to post at facility) B. I have examined the information on my Interim ,Permit, Phase I Monitoring Requirements. and Information Sheet (Agreement between Owner and Operator). and find owner's name and address, facility name and address, operator's name ant address, substance codes, and number of tanks to be accurately listed (if "no" is checked, note appropriate corrections on the back side of this sheet). C. I have the following required equipment (as described on page 6 of Handbook): ~ 1) Acceptable gauging instrument ~ 2) "Striker plate(s)" in tank(s) X 3) Water-finding paste D. I have read the information on the enclosed "Information Sheet" pertaining to Agreements between Owner and Operator and hereby state that the owner of this facility is the operator (if "no" is checked, attach a copy of agreement between owner and operator). E. I have enclosed a copy of Calibration Charts for ail tanks at this facility (if tanks are identical, one chart will suffice; label chart(s) with corresponding tank numbers listed on permit). F. As required on page 6 of Handbook #UT-10, all meters at this facility have had calibration checks within the last 30 days and were calibrated by a registered device repairman if out of tolerance (all meter calibrations must be recorded on "Meter Calibration Check Form" found in the Appendix of Handbook). G. Standard Inventory Control Monitoring was started at this facility in accordance with procedures described in Handbook #UT-lO. Date Started ~-,/'~-- Date: %' / ,~ERN COUNTY HEALTH DEPAR NT 1700 Flower Street AIR POLLUTION CONTROL DISTRICT LEON M HEBERTSON, M.D. Bakersfield, California 93305-4198 Director ol Public Health Telephone (805) 861-3621 ~~1~ '- ,~.'~ ~!i" Air Pollution Control Olficer January 26, 1988 George Nickel 11200 Lake Ming Road Bakersfield, CA 93306 Re: Tank Abandonments - Rio Bravo Golf Course Dear Mr. Nickel This department has reviewed the laboratory analyses for the two underground storage tank at 11200 Lake Ming Road, Permit #A507- 51. The samples indicated no significant soil contamination at the site. Based upon this information, the department considers this preliminary site assessment complete and no further assessment is required. Sincerely, 8111 Scheide Environmental Health Specialist I Hazardous Materials Management Program BS/gb cc: McNabb Construction LABORATORIES, Ir-lc. J. J. EGLIN, REG. CHEM. ENGR. 4100 PIERCE RD., BAKERSFIELD, CALIFORNIA 93308 PHONE 327-49] 1 Purgeable Aromatics (SOIL) RLW EQUIPMENT Date of 2080 SO. UNION AVENUE Report: 16-Oct-87 BAKERSFIELD, CALIF 93307 Attention: Lab No.: 20703-6 Sample Desc: RIO BRAVO GOLF COURSE GASOLINE @ 6' DATE SAMPLE DATE SAMPLE DATE ANALYSIS COLLECTED: RECEIVED @ LAB: COMPLETED: 06-Oct-87 07-Oct-87 13-Oct-87 Minimum Reporting Analysis Reporting Constituent Units Results Level Benzene ug/g None Detected 0.10 Toluene ug/g None Detected 0.10 Ethyl Benzene ug/g None Detected 0.10 p-Xylene ug/g None Detected 0.10 m-Xylene ug/g None Detected 0.10 o-Xylene ug/g None Detected 0.10 Isopropyl Benzene ug/g None Detected 0.10 Pet. Hydrocarbons ug/g None Detected 5.00 Total Petroleum Hydrocarbons ug/g None Detected 0.10 TEST METHOD: California D.O.H.S. T.P.H. for Gasoline Dry Matter Basis Comments: PETROLEUM HYDROCARBONS: Quantification of volatile hydrocarbons present (Cl to C20) utilizing a gasoline factor. As outlined by California D.OoH.S. These volatile hydrocarbons are in addition the constituents specifically defined on this report. TOTAL PETROLEUM HYDROCARBONS: The sum total of all [non-chlorin- ated] constituents on this report. ~gl~i'n Robert Plaisance Chemi s t LABORATORIES, IRC. J' J' EGLIN, REG. CHEM. ENGR. 4100 PIERCE RD., BAKERSFIELD, CALIFORNIA 93308 PHONE 327-4911 Purgeable Aromatics (SOIL,) RLW EQUIPMENT Date of 2080 SO. UNION AVENUE Report: 16-Oct-87 BAKERSFIELD, CALIF 93307 Attention: Lab No.: 20703-5 Sample Desc: RIO BRAVO GOLF COURSE GASOLINE @ 2' DATE SAMPLE DATE SAMPLE DATE ANALYSIS COLLECTED: RECEIVED @ LAB: COMPLETED: 06-Oct-87 07-Oct-87 13-Oct-87 Minimum Reporting Analysis Reporting Constituent Units Results, Level Benzene ug/g None Detected 0.10 Toluene ug/g None Detected 0.10 Ethyl Benzene ug/g None Detected 0.10 p-Xylene ug/g None Detected 0.10 m-Xylene ug/g None Detected 0.10 o-Xylene ug/g None Detected 0.10 Isopropyl Benzene ug/g None Detected 0.10 Pet. Hydrocarbons ug/g None Detected 5.00 Total Petroleum Hydrocarbons ug/g None Detected 0.10 TEST METHOD: California D.O.H.S. T.P.H. for Gasoline Dry Matter Basis Comments: PETROLEUM HYDROCARBONS: Quantification of volatile hydrocarbons present (C1 to C20) utilizing a gasoline factor. As outlined by . California D.O.H.S. These volatile hydrocarbons are in addition the constituents specifically defined on this report. TOTAL PETROLEUM HYDROCARBONS: The sum total of all [non-chlorin- ated] constituents on this report. 4~' ~....-J~Eg~n Robert P~aisance Chemist LABORATORIES. If-lC. PE~ilOL~UM J' J' EGLIN, REG. CHEM. ENGIt. 4100 PIERCE RD., BAKERSFIELD, CALIFORNIA 93308 PHONE 327-4911 Purgeable Aromatics (SOIL) RLW EQUIPMENT Date of 2080 SO. UNION AVE. Report: 20-Oct-87 BAKERSFIELD, CA. 93307 Attention: ~ Lab No.: 20703-4 Sample Desc.: RIO BRAVO GOLF COURSE DIESEL (WEST) 6' DATE SAMPLE DATE SAMPLE DATE ANALYSIS COLLECTED: RECEIVED @ LAB: COMPLETED: 06-Oct-87 07-Oct-87 15-Oct-87 Minimum Reporting Analysis Reporting Constituent Units' Results Level Benzene ug/g None Detected 0 10 Toluene ug/g None Detected 0 10 Ethyl Benzene ug/g None Detected 0 10 p-Xylene ug/g None Detected 0 10 m-Xylene ug/g None Detected 0 10 o-Xylene ug/g None Detected 0 10 Isopropyl Benzene ug/g None Detected 0.10 Petroleum Hydrocarbons ug/g None Detected 10.00 Total Pet. Hydrocarbons ug/g None Detected 0.10 TEST METHOD: California State D.O.H.S. T.P.H. for Diesel Dry Matter Basis Comments: PETROLEUM HYDROCARBONS: Quantification of Volatile hydrocarbons present (Cl to C30) utilizing a diesel factor. As outlined by the CalifOrnia D.O.H.S. These petroleum hydrocarbons are in addition to the constituents specifically defined on this report. TOTAL PETROLEUM HYDROCARBONS: The sum total of all [non-chlorin- ated] constituents on this report. ~J.~/J. ~li-~- Robert Plaisance Chemist AGJlI~UL ABORATORIES. Inc. ~OL[~ 4100 PIERCE RD., BAKEISFIELD, CALIFORNIA 93308 PHONE 327-4911 . Purgeable Aromatics (SOIL) RLW EQUIPMENT Date of 2080 SO. UNION AVE. Report: 20-Oct-87 BAKERSFIELD, CA. 93307 Attention: Lab No.: 20703-3 Sample Desc.: RIO BRAVO GOLF COURSE DIESEL (WEST) 2' DATE SAMPLE DATE SAMPLE DATE ANALYSIS . COLLECTED: RECEIVED @ LAB: COMPLETED: 06-Oct-87 07-Oct-87 15-Oct-87 Minimum Reporting Analysis Reporting Constituent Units Results Level Benzene ug/g None Detected 0.10 Toluene ug/g None Detected 0.10 Ethyl Benzene ug/g None Detected 0.10 p-Xylene ug/g None Detected 0.10 m-Xylene ug/g None Detected 0.10 o-Xylene ug/g None Detected 0.10 Isopropyl Benzene ug/g None Detected 0.10 Petroleum Hydrocarbons ug/g None Detected 10.00 Total Pet. Hydrocarbons ug/g None Detected 0.10 TEST METHOD: California State D.O.H.S. T.P.H. for Diesel Dry Matter Basis Comments: PETROLEUM HYDROCARBONS: Quantification of volatile hydrocarbons present (C1 to C30) utilizing a diesel factor. As outlined by the California D.O.H.S. These petroleum hydrocarbons are in addition to the constituents specifically defined on this report. TOTAL PETROLEUM HYDROCARBONS: The sum total of all [non-chlorin- ated] constituents on this report. Robert Plaisance Chemist LABORATORIES, IrqL:. J' J' EGLIN, ~EG. CHEM. ENGR. 41~ PIERCE RD., BAKERSFIELD, CALIFORNIA 93308 PHONE 327-4911 Purgeable Aromatics (SOIL) RLW EQUIPMENT Date of 2080 SO. UNION AVE. Report: 20-0ct-87 BAKERSFIELD, CA. 93307 Attention: ' Lab No.: 20703-2 Sample Desc.: RIO BRAVO GOLF COURSE DIESEL (CENTER) 6' DATE SAMPLE DATE SAMPLE DATE ANALYSIS COLLECTED: RECEIVED @ LAB: COMPLETED: 06-0ct-87 07-0ct-87 15-0ct-87 Minimum Reporting Analysis Reporting Constituent Units Results Level Benzene ug/g None Detected 0 10 Toluene ug/g None Detected 0 10 Ethyl Benzene ug/g None Detected 0 10 p-Xylene ug/g None Detected 0 10 m-Xylene ug/g None Detected 0 10 o-Xylene ug/g None Detected 0 10 Isopropyl Benzene ug/g None Detected O.lO Petroleum Hydrocarbons ug/g None Detected 10.00 Total Pet. Hydrocarbons ug/g None Detected 0.10 TEST METHOD: California State D.O.H.S. T.P.H. for Diesel Dry Matter Basis Comments: PETROLEUM HYDROCARBONS: Quantification of volatile hydrocarbons present (Cl to C30) utilizing a diesel factor. As outlined by the California D.O.H.S. These petroleum hydrocarbons are in addition to the constituents specifically defined on this report. TOTAL PETROLEUM HYDROCARBONS: The sum total of all [non-chlorin- ated] constituents on this report. ~JffJ~glf~ Robert Plaisance Chemist LABORATORIES. I r-ii .. J' J' ~LIN, REG. CHEM. ENG,. 41~ PIERCE RD., BAKE~FIELD, CALIFORNIA 93308 PHONE 327-4911 Purgeable Aromatics (SOIL) RLW EQUIPMENT Date of 2080 SO. UNION AVE. Report-: 20-Oct-87 BAKERSFIELD, CA. 93307 Attention: Lab No.: 20703-1 Sample Desc.: RIO BRAVO GOLF COURSE DIESEL (CENTER) 2' DATE SAMPLE DATE SAMPLE DATE ANALYSIS COLLECTED: RECEIVED @ LAB: COMPLETED: 06-Oct-87 07-Oct-87 15-Oct-87 Minimum Reporting Analysis Reporting Constituent Units Results Level Benzene ug/g None Detected 0 10 Toluene ug/g None Detected 0 10 Ethyl Benzene ug/g None Detected 0 10 p-Xylene ug/g None Detected 0 l0 m-Xylene ug/g None Detected 0 10 o-Xylene ug/g None Detected 0 10 Isopropyl Benzene ug/g None Detected 0.10 Petroleum Hydrocarbons ug/g None Detected 10.00 Total Pet. Hydrocarbons ug/g None Detected 0.10 TEST METHOD: California State D.O.H.S. T.P.H. for Diesel Dry Matter Basis Comments: PETROLEUM HYDROCARBONS: Quantification of volatile hydrocarbons present (C1 to C30) utilizing a diesel factor. As outlined by the California D.O.H.S. These petroleum hydrocarbons are in addition to the constituents specifically defined on this report. TOTAL PETROLEUM HYDROCARBONS: The sum total of all [non-chlorin- ated] constituents on this report. ~J~ J 6~Eglkn Robert Plaisance Chemist ~TCX)FkM~SU.d ~ ,~N COUNTY HEALTH DEPARTN HE~I.THOFFiCER T~ (~5) ~ 1-~ EN~RONM~TAL H~ DIVI~ ... ~ .. DIRECTOR OF EN~R~MENTAL ~~~ ~n~ [ R~hl;d Faclllt~ Na~e /~~l/~k Kera County Perslt * * UNDgRO~OUND T~K DISPOSITION T~CKZNG RECORD * * This form 18 to be returned to the Kern County Health Department within 14 days of acceptance of tank(s) by disposal or recycling facility. The holder of the permit with number noted above lo responsible for lnsu~lflg that this form t8 completed and returned. Section 1 - To be filled out b_j/ tank removal contractor: Date Ta~8 Removed / ' ' '-'T; ~.'~[ ~ ~ ..... [ ~ '; ';; '; ;.~;,' ~;: ........... ~;t~o~ ~ __ ~ ~ o~ ~ ~o. ~ ~to -d ~ .t~ ~ t (). Authorized ~epcesentative of contractor certifies by sl~nla~ belo~ that ta~(s) have been decont~lnated In accor~ce eith Eern Co~t~ Bealth Depa~ent requirements ~ctl~ $ -T~ ~ filled out and sl~ned ~ a~ authorized representative of the ~reat=ent, storage, ~ disvosal faclllt~ accevtin~ rankle): Faclllt2 ~e ~NERIC~N NET~L RECYCLING~ INC. Address 2202 S. NILLIKEN 2VE. Phone $(714)947-2888 ONT~RIO~ C2 . Z19 91761 Date Tanks Rece~~d ~T. 8~ 1987 ~o. of T~s 2 Signature. Title VIC~ PRESIDENT (Authorized Rep~eeentutlve) ' ' ' ~ILI~G INSTRUCTIONS~ Fold la h~l[ ~d et~ple, Poetage ~d ~lllag l~bel have al~e~dF beea a[[lxed to outelde [oe you~ coavealence. (Fo~ ~.-1~0) ni~ I.~I:'T':;I'':'~' ~' .. ' ' '''':'''':'' "" ' . '" :b '':''' "::' "' ~ ': ? ' ' " Date'. " '~"'"~'"'"~"~"' '"';" :' ~ ' Monl~ rl~ 2 ~~ ~ ~.l .... . .... ...,~.: I Data . . .l.; .... ......-,... ~,..::,. ,~ ......... , _ ~ :..l,. .~:: '8 ..l .... :' ' ...-z '-¥'.:~ -:' ~;' .'. "": Wh,fe=..~SD~. '- " ~ eo~ A ~4): ,:-"."-': .,.u...:: ........ ~.. · ~DS. TH~, COPY ~0 ~ . . :~ . .:, ....... ,.: . ........... N5 WITHIN ~0 DAYS A~oo~l~' ....... -':.:' :" -~ ".' .... ~ PO'~' , ' ' '"" .... ... '. "' 1700FIower Street KERN COUNTY HEALTH DEPARTMENT HEALTH OFFICER Bakersfield, California 93305 Leon M Hebartson, M.D. Telephone (805) 861-3636 ENVIRONMENTAL HEALTH DIVISION DIRECTOR OF ENVIRONMENTAL HEALTH Vernon S. Reichard PERMIT FOR PERNANBNT CLOSURE PERMIT NUMBER A507-51 OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY FACILITY NANE/ADDRESS: OMNER (S) NANE/ADDRESS: CONTRACTOR: Rio Bravo Golf Course George Nickel RLW Equipment 11200 Lake Ming Road 11200 Lake Ming Road 2080 So. Union Avenue Bakersfield, CA Bakersfield, CA 93306 Bakersfield, CA 93307 Taft, CA Phone #(805) 872-5000 Phone #(805) 834-1100 License No. 294074 PERMIT FOR CLOSURE OF PERMIT EXPIRES November 11, 1987 2 TANKS AT ABOVE APPROVAL DATE August 11, 1987 LOCATION. APPROVED BY "-" Bill Scheide ................... POST ON PREMISES ..................... CONDITIONS AS FOLLOW: 1. It is the responsibility of the Permittee to obtain permits which may be required by other regulatory agencies prior to beginning work. 2. A copy of this permit has been provided to the Kern County Fir.~ ~epartment. Permittee must notl.~y the County Fire Department at (805) 861- 2577 two ~orking days prlo.~ to tank (removal) or {Jnertlng and arrange for required inspection(s). 3. Tank closure activities must be per Kern County Healtil and Fire Department approved methods as described in Handout #UT-30. 4. Tanks must be properly inerted and hauled to approved disposal site no later than 12 hours after inertlng and removal. 5. A minimum of four samples must be retrieved one-third of the way in from the ends of each tank at depths of approximately two and six feet. 6. If any contractors other than those listed on permit and permit application are to be utilized, prior approval must be granted by the specialist listed on the permit. 7. A minimum of two samples must be retrieved at depths of approximately two and six feet for every 15 linear feet of pipe run and also near the dispenser area(s). 8. The gasoline tank samples must be analyzed for benzene, toluene, xylene, and total volatile hydrocarbons. 9. The diesel tank samples must be analyzed for total petroleum hydrocarbons and benzene. DISTRICT OFFICES PBRMIT FOR PERMANENT CLOSURE PERMIT NUMBER A507-§1 OF UNDERGROUND HAZARDOUS ADDENUM SUBSTANCES STORAGE FACILITY CONDITIONS AS FOLLOW: 10. Copies of transportation manifests must be submitted to the Health Department within five days of waste disposal. 11. All applicable state laws for hazardous waste disposal, transportation, or treatment must be adhered to. The Kern County Health Department must be notified before moving and/or disposing of any contaminated soil. 12. Permittee is responsible for makin6 sure tliat "tank disposition tracking record" issued with this permit is properly filled out and returned within 14 days of tank removal. 13. Advise this office of the time and date of the proposed sampling w/th 24 hours advance notice. 14~ Results must be submitted to this office within three days of analysts completion. iNTeRNAL USE KERN COUNTY HEALTH DEPARTMBNT PTO DIVISIOW OF ENVIRO~NT~ ~TH ~PLI~IOM 1~00 ~LO~R STREET, 9~RS~IELD. CA 93306 ~ OP T~KS TO BK AB~NEO '~-'~ (U05) 86i-3636 LENGTH O~ PiPiNG TO A~NDON APPLICATZON FOR Pr-'-R~4'rT I~OR P~'-RWI~kN~--NT C L OS U RE / ABAN DO N Wl~-- NT OF UNDERGROUND HAZARDOUS SUBSTANCES STORAG~ FACILITY THiS APPLICATION IS FOR ~REMOVAL. OR ~ ~DONN~NT IN PLACE (~[LL OUT ~ APPLICATION PER ~ACI~ITY) P~O~CT CO~TACT · ~ I ~ ~ I NIGHTS- T~K R~VAL C~CTOR I~DRESS IPHON8 PRELIMIN~Y SITE ~.,~.T CONT~CTOR WORK~'8 C~gATi ON I~TORY T~T MILL ~YZ8 CH~IC~ ~81TIOM O~ ~TBRIAL8 STOR[D M, ATILR TO ~&~ILI~ P~OVIi}~} BY II~M ~0 ~ . N~BST ~ATER NELL - GiVE DIST~CE ~O DESCRIBE ~PE I{ MITHIN 500 FEKT ~IL TYPE AT FACILI~ ~ ~ ~SlS ~ ~IL TYPE ~D ~OUNOMAT~ D~ff DET~I~TION / ' J~SCRIBB H~ RgSIDU~ IN T~K(S) ~O PiPiNG IS TO BE R~OVED ~D DISUSED OF (INCLUDE ~8PORTATION ~D OlS~S~ C~lKS): J~SCRIflE ~TH TH~ DI6~AL METIiOD ~D DIiPO~ D~TIOM ' ;20.: s, //, & ¢ /o , , , , 'P,' " ' · · PLEBE PROVID~ {NFO~TION REQUESTED ~ R~VgRSE ~lU~ ~ T~l~ SHEET BE~OR8 SUBMITTING ~PLICATION ~ R~VtEW * · THIS FO~ ~S BE~ C~PLET~ UNDER PE~LTY OF P~RJURY ~ TO TflB BEST OP MY KNOMLB~ IS TRUE ~D CORRECT. (For~ ~-1~0~ Kern County Health Department Permit No. _~]Z;(90 ~-~_. Division o~ Environmental Heal Applicatio- ' !700 Flower Street, Bakers' CA )3305 APPLICATION FOR PERMIT TO OPERATE UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY Type of Application (check): [-]New Facility r~Mndification of Facility ~Existing Facility [~Transfer of Ownership Facility Name ~3-~¢/~ ~4~'~$~·//~~, ~x/l~. No. of T~,kS; Type of Business (check): FT~sollne station =['lOthe~' (describe) Is Tank(s) Used Pr~.m~arily..~_or/;~gricu~tuFal 3~urpose~.~ []Yes ~No T R SEC '(Rural Locations rely) /' / - Owner ~_.~. ~ci~,~ ~_ / ~.. Contact Person ~ddress ......,~ ~, ~ ~,, ~.' ~-'*',~. '~J.,., Zip gB~O ~. Telephone Operator - Contact Person Address Zip Telephone Soil Characteristics at [~acili~y ~,x/~/ Basis for Soil Type and Groundwater Depth' De~eminati~ns C. Contractor CA Contractor's License No. Address Zip - Telephone Proposed "Startir~j Date Proposed Ccmpletion Date Worker's Compensation Certificatior~ ! Insurer D. If This Permit Is For Modification Of An Existing Facility, Briefly Describe Modifications Proposed Tank(s) Store (check all that apply): Tank ! Waste Product Motor Vehicle Unleaded Regular Premium Diesel Waste ~ue-I ___ [] [] O Chemical C~posiCion of ~a~erials Stored (not necessary ~or mtoc ~ehicle fueZs> Tank ! Chemical Stored (non-co~aercial na~e) ~ ! (if known) Cl~em~cal t>reviousl~ Stored (if a"i'ffere~t) G. Transfer of Ownership Date of ~-~nsfer preVious Owner Previous Facility Name I, accept 'fully all obligations of Per~ft No. __ issued to · I understand that the Permitting Authority may review and mod'f'fy or terminate the transfer of the Permit to Operate this mdergromd storage facility upon receiving this c~mpleted, form. This fora has been cgl~le~ under pena~j{ ,~f perjury and to J~]~e bes. t of my knowledge is TANK ~ . .'ILL OUT SEPARATE FORM . J~'~ACh .ANK) FOR ~ACH SECTION, CHECK A~.r_ APPROPRIATE BOXES · 1. Tank is: ~-]Vaulted []Non-Vaulted ['~Double-Wall [']Single-Wall 2. ~ Material arbon Steel .' Stainless Steel []Polyvinyl Chloride [~Fiberglass-Clad Steel iberglass-Re~nforced Plastic [] Concrete [] Al~m~in~ [] Bronze []Unknown ther (describe) 3. Primary Containment Da t~,~l 1 ed Thic kn~/~/~ Inches) Capacity(Gallons)~/~/<? Manufacturer 4. Tan. k- ~cOndar¥ contairm{e6t []Double-Wall ~lSynthetic Liner []Lined Vault []None ~nknown []Other (describe): Manufacturer: [] Ma ter ial Thickness' (Inches) Capacity (Gals.) 5. Tank Interior Lining ---~Rubber [-~Alkyd []Epoxy [Phenolic []']Glass []Clay [-]U~lined []Other (describe): 6. Tank Corrosion Protection ---~Galva~fzed ~ass-Clad [Pol~thylene Wrap []Vinyl Wrapping []Tar or Asphalt ~4~nknown [']None [']Other (describe): Cathodic Protection: []None ~Impressed Current System ['~Sa~'rificial Anode System Describe System & Equilm~ent: 7. Leak Detection, M?nitoring, and Interception a. Tank: []Visual (vaulted tanks only) [~Ground~ater Monitorirg' Well(s) []Vadose Zone Monitoring Well(s) ~U-Tube Without Liner []U-Tube with Ccmpatible Liner Directin~ Flow to Monitorirg Well(s)* [~ Vapor Detector* [] Liquid Level Sensor ~ Conductivity Sensor* [] Pressure Sensor in Annular Space of Double Wall Tank- [] Liquid Retrieval & Inspection From U-Tube, Monitoring Well or Annular Space [~]Daily ;uging Reconciliation []Periodic Tightness Testing •None /~kno~ Inventory[] Other b. Piping: []Flow-Restricting Leak Detector(s) for Pressurized Piping' [] Monitoring St~p with Race~y [2] Sealed Concrete Race~ay []Half-Cut Compatible Pipe Raceway []Synthetic Liner Race~y []None J nknown []Other *6escribe Make & Model: 8. Tank Tightness l~is Tank Been Tightness Tested? [qYes []No ~known Date of Last Tightness Test Result~of Test Test Name Testing C~mpany 9. Tank ~ ~ Repaired? []Yes ~ []Unknown Date(s) of Repair(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 []None []Other: L~st Make & Model For Above Devices a. Underground Piping: []Yes [-1No ~Unknown Material Thickness (inches) ' Diameter Manufacturer [-]Pressure []Suctfon [~Gravity Approximate tength of Pipe b. Underground Pipirg Corrosion Protection : []Galvanized []Fiberglass-Clad [qImlxessed Current [-~Sacrificial Anode []Polyethylene Wrap []Electrical Isolation []Vinyl Wrap []Tar or Asphalt []Unknown []None []Other (describe): c. Underground Pipirg, Secondary Containment: [Double-Wall []Synthetic Liner System [qNone -~known Facility Name Permit No. TANK ~ ~ ~LL OUT SEPARATE FORM ~ .,~CH ~qK) FOR EACH-SECTION, CHECK 'ALL APPROPRIATE BOXES H. 1. Tank is: ['~Vaulted [~Non-Vault~ I-]Double-Wall []Sirlgle-~all 2. Ta~ Material ~Carbon Steel [] Stainless Stee~- [~Polyvinyl Chloride D Fiberglass-Clad Steel B Fiberglass-Reinforced Plastic Iq Concrete [~ Alumlin~n [] Bronze []Unknown Other (describe) 3. Pti .mary Containment Dat~~ led Thic?/~/~ Inches) Ca~c~Gallons) Manufacturer 4. Tank' Secondar~ Contain~ht 'J~- - []Double-Wall []Synthetic Liner []Lined Vault []None ~nknown []Other (describe): Manufacturer: []Material Thickness (Inches) Capacity (Gals.) 5. Tank Interior Lining ---~Rubber DAlkyd []Epoxy [~henolic ~Glass []Clay [2]U~lined ~.~nknown [2]Other (describe): 6. Tank Corrosion Protection --~Gal-vanized ~ass-Clad [Polyethylene Wrap []Vinyl Wrappir~ ~]Tar or Asphalt ~nknown ['~None [~Other (describe): Cathodic Protection{ [2]None ~]Impressed Current Syste~ ~]saerificial Anode System Describe System & Egui~ent: 7. Leak Detection, Monitorir~, and Interception a. Tank: [2]Visual (vaulted tanks only) []Groundwater Monitorirg' Well(s) []Vadose Zone Monitoring Well(s) []U-Tube Without Liner [U-Tube with C~mpatible Liner Directing Flow to Monitoring We.ll(s) [] Vapor Detector* [] Liquid Level Sensor* [] Conductivit~ Sensor" [] Pressure Sensor in Annular Space of Double Wall Tank- [] Liquid Retrieval & Inspection Fr~m U-Tube, Monitoring Well or Annular Space [-]~_]Daily G__a,at~jing & Inventory Reconciliation {-]Periodic Tightness Testing None ~J~[q~laknown [~ Other b. Piping: ['lFlow-Restricting Leak Detector(s) for Pressurized Piping" [] Monitoring Stm~p with Raceway [] Sealed Concrete Raceway []Half-Cut Ccmlpatible Pipe Raceway [] Synthetic Liner Raceway [None ~nknown [] Other *l~escribe Make & Model: $' ~en Tightness Tested? ~Yes ['~No ~known Date of Last Tightness Test Results of Test Test Name Testirg Cempany 9. Tank Re~air Repa{red? []Yes ~ []Unknown Tank Date(s) of Repair(s) Describe Repairs 10. Overfill Protection '[]Operator 'Fill's, Controls, & Visually Monitors Level []Tape Float Gauge []Float Vent Valves [] Auto Shut- Off Controls [-]Capacitance Sensor []Sealed Fill Box []None .,~Unknown [Other: List Make & Model For Above Devices 11. Piping a. Underground Pipits: []Yes [No ~Unknown Material Thickness (inches) Diameter Manufacturer [2]Pressure f']SuctiOn' ~Gravity Approximate Length 6f Pi'pe b. Underground Piping Corrosion Protection : []-]Galvanized []Fiberglass-Clad []Imlxessed Current [Sacrificial Anode [Polyethylene Wrap ~Electrical Isolation [~Vinyl Wrap [~Tar or Asphalt [-]Unknown []None [-]Other (describe): c. Underground Piping, Secondary Containment: [~Double-Wall [~Synthetic Liner System []None J~f~Oknown - SOD?E OF .'.-~?.. Rravo Golf J:,~.:l B. ""'"=""~ G~n=~al EQ. UIP:,~?.~ FRL~ISH~) & INSTAL;.~ BY ,~?~/iORF 1 - 2000 G~llon U.G. %i.L. Tank 1 - 3000 Gallon U.G.U.L. Tank 2 - 5~.odel 10OW Gasboy Pumps, One complete ~.;i~'~ va~or rec-ove~"y beset. nozzles, one for diesel 2 - 4" Fill Caps & Adapters 1 - 3" V~.por Reccvery Connector 2 -.Fill Boxes for. above 2 - 4" Drop Tubes 1 - GUagestick PIPE & FITTIN~ TO CC~4]DCT ABOVE InstallatiOn work by MLqx~OP~ CONSTRUCTION 1. Dig & set tanks (Backfill sand to be piu.-.ked :]u c,~. $~te, of excess soil on site) 2. Labor to connect above equi.~ent and piping 3. Form and.~our 1-3'X6' concrete island an.'] tank Dads. for fill=_ vapor recovery fitting 4. .Extend electrical from panel to F~st end of b,.lil4, lng wit_h switch inside to control pumps. Connect from switch to ~:,[~,.ps on ~..'..'.]and. Install 2-4" Dia. X 3'6" high bumpe_r .~sts at island 5. Obtain ail necessary A.P.C.D., Fire Dc. rt.: ,% ~-,,~l,~Jn..".~_ ... '~-~"~..,::.,. to construct 6. Final cleanup and check for cDe. ration