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HomeMy WebLinkAboutBUSINESS PLAN ITE DIAGRAM t i FACILITY DIAGRAM First In Stcticn: Area Mc~ ~ [ at Insoection Station: NORTH B A K E R S V [ E L'~ HazMatEmerg Complaint \ Haz Mat Incident / Spill Report / Complaint Follow Up Date "7/~/zT/ Time /- ReportingParty ~---J'fJ~ ~-~07~ Environmental Services Contact Address ~O~ Telephone No. ~'~- Location of the incident · Description of the incident ( Chemical name and Quantity ) Responding to Incident (~ N Observations Special Conditions and / or health risks Haz Mat Team Dispatched Y ~ Van Cellular No. 332-7865 OES Number Required Y ~ Number Poss Exposure Victims ~c_aD $~ ~ I 12C-~p~.~oa~ Medical Attention Required or Obtained Probable Hazardous Was[~Clean U~ll~2 Discussion and Disposition Referral ? FIRE ORDINANCE V ' ATION A 0 0~O'3 Bakersfield Fire Dept. FIRE PREVENTION SERVICES 1715 Chester Ave. OcCUPANCy )D,STRICT I BLOCK No. F DATE/ ~ 1 Bakersfield, CA 93301 CORRECT ALL ~ LOCATION OF VIOLATION CHECKED BELOW REQUIREMENTS V~O~TmON NO. r CO~US~[E WAaT~ I J Remove and safely dispose of aim hazardous refuse and d~ vegetation on the above premises (U.F.C.) DRY VEGETATION~- Provide noncombustible containers with tight tiffing lids for the storage of combustible waste and rubbish pending its ~fe disposal. (U.F.C.) COMBUSTIBLE STOOGE Relocate combustible storage to provide at least 3 feet clearance around motor fuse bonfire door (N.E.C.) (U.F.C.) Relo~te fire extinguisher(s) so that they will be in a conspicious I~ation, hanging on brackets with the top to the extinguisher not more than 5 feet above the floor. (N.F.P.A. NOml0) E~NGUISHER~ Provide and install (amount) __ app~ved (~ & size)' __ potable fire extinguisher to be immediately accessible for use in (area) (U.F.C.) Recharge ~me fire extinguishers. Fire extinguishers shall be se~iced at least once each year, a~d/or after each use, by a person having a valid license or ce~ifi~te. (U.F.C.) Provide and maintain "EXIT' sign(s) with meUers 5 or more inches in height over each r~uired exit (door/window) to fire escape. (U.F.C.) SIGNS Provide and maintain appropdate numbers on a contrasting background and visible f~m the street to indicate the correct address of the ~ . building. (B.MC.)(U.F.C.) FIRE ~OORB/ Repair am) (cracks/holes/openings) in pmaster in (location) . Plastering shall FiRE SEPARA~ONS return the su~ace to its original fire resistive condition. {U.B.C.) Remove/repair (item & location) . Self-closing doors shall be designed to close by gravity, or by the action of a mechanical device, or by an approved smoke and heat sensitive device. Self-closing doors shall have no affachments capable of preventing the operation of the closing device. (U.F.C.) Remove all obstruction from hallways. Uaintain all means of egress free of any storage. (U.F.C.) Provide a contrasting colored and permanently installed electric might over or near required exit (location) to clearly indicate it as an exit (U.F.C.) 8TO.GE Remove aim storage and/or other obstructions from fire escape landings and stai~ays stair shafts. (Fire escapes/stair shafts are to be maintain~ free from obstructions at aim times.) iD. F. C.) ELECTRICAL Extension colds shatl not ~ u~d in lieu of permanent approved wiring. InstaU additional approved electrical outlets where needed. APPLIANCES (N.E.C.) (U.F.C.) Remove mumitiple attachment cords from specified electrical convenience outlet (one plug per outmet). (N.EmC.) (UmFC.) /0 ~F VIOLATION; ON (DATE) 7 ~ ~ ~ AN INSPEC~ON WILL aE aADE, IF NO COaPLIANCE, ADDmONAL REGU~TORY AC~ON MAY BE INITIATED. SlG~TURE AFTER VIOLATIONS ARE CORRECTED, BY ORDER OF. tTHE FIRE CHIEF DATE COMPLETED ......................... RETURN THIS NOTICE BY BY MAIL OR IN PERSON TO: INSPECTOR INSPECTOR LEGEND FIRE PR~ENTION SERVICES C.F.C. CALIFORNIA FIRE CODE 1715 CHESTER AVE. U.aC. UNIFORM BUILDING CODE BAKERSFIELD, CA 93301 B.M.C. BAKERSFIELD MUNICIPAL CODE PHONE: 326-3979 NF.P.A. NATIONAL FIRE PROTECTION ASSOCIATION N. E.C. NATIONAL ELECTRIC CODE fd 1916 (rev Feb. 2003) Oul 11 O~ 12:09p Ron Ro:ers BGl-~BT-BS~ p. 1 Ace Petroleum Service; Invoice 15540 Strebot Drive r ......... r ' ' B~k~sfield, CA 93314 (661) 387-6522 811 TO JEFZ:RI~ I~IROTI~R=.~ mC P. O. ~OX 640 W/tJICO. C_~ 932801406 [-[USKY-0350 I Husky VI 3/4 X 3/4 Swivel 18.40 7/10/2004 Ig.40T DIF. SEU{O~F_.8 I g' DIF,%F.,L, HOSE $1.4~ 7/1~ 51.4~T LABOR I Ln,bo~ 45.00 per I~. 45.00 7110/2004 aS.ilO TRAVE[JMIt~.. I In Town Trnvel/Miloa~ C.~am.~,e 27.30 7110/2004 7.7.34} $142.35 $147.41 4700 Coffee Rd. Brookside Mkt. 07/08/04 Diesel Di Hose Leak BROOKSIDE MARKET & DELI SiteID: 015-021-001756 Manager : ~ ~ ~ BusPhone: (661) 588-1338 Location: 4700 COFFEE RD Map : 102 CommHaz : Low City : BAKERSFIELD Grid: 16C FacUnits: 1 AOV: CommCode: COUNTY STATION 65 SIC Code:5541 EPA Numb: DunnBrad:048479646 Emergency Contact / Title Emergency Contact / Title ~ ~',~, ~%~ / MANAGER D©~; JEFFP. I~Ct~L~ ~/ OWNER Business Phone: (661) 588-1338x Business Phone: (661) .~f~Bq 24-Hour Phone : (661) ~~6%~%~z 24-Hour Phone : ~x~%.-~6~ Pager Phone : (661) ~~%~-~q~ Pager Phone : ~~-q~(~ Hazmat Hazards: Fire Im~lth DelHlth Contact : %~PC ~ =~--~..~ .... (~ul).~ ~,~"=~ ~a-"~=--'~, ~ MailAddr: ~ ~ ~n State: CA %~-~ Owner ~FF~S BRO~%~~a'[~' ~ Phone: ~6!) 75~x Address : ~ ~o~% ~ ~n State: CA ~n-~q~'% City : ~ ~5q%~:~ Zip : ~ 95~L Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: ~,~,~ "~~~.. Do hereby certify that I have ~ a+jached hazardous materials manage- rsv~w6d ~, · ~nr%v¢o%5;~_ ~ ~nd t~t it along with any cofre¢ions Cnsfitute aoomplete and oorre¢ man- agemem plan lof my fadl~Y. 1 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: BROOKSIDE MARKET & DELI Cross Street : Business Type: Org Type: Total Tanks : 4 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : DON JEFFRIES Phone: (661) 588-2290x Address: City : State: Zip: Type : CORPORATION TANK OWNER INFORMATION Name : DON JEFFRIES Phone: (661) 588-2290x Address: City : State: Zip: Type : CORPORATION BOE UST Fee# : UNKNOWN Financ'l Resp: INSURANCE Legal Notif : Property Owner Mailing Address Date:04/28/2000 Phone: (661) 496-8359x Name:DON JEFFRIES Ttl:PRESIDENT State UST # : TYMT 44-040810 1998 Upg Cert#: 00865 -2- 07/07/2004 BROOKSIDE MAR~T & DELI SiteID: 015-021-001756 ~ Hazmat Inventory By Facility Unit -- MCP+Dail~ax Order Fixed Containers at Site Hazmat Common Name... ISpeoHazlEPA Hazardsl Frm DailyMax IunitlMcP GASOLINE L 10000.00 GAL Mod GASOLINE L 10000.00 GAL Mod GASOLINE L 10000.00 GAL Mod DIESEL #2 F IH DH L 10000.00 GAL Low 3 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~iv~vl~ ~vl~ / ~± ~ ~vl~ GASOLINE Days On Site REGULAR UNLEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 8006619 Liquid {Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 10000.00 GALI 10000.00 GAL 4000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS TSecretl ~S[BioHaz Radioactive/Amount I EPA Hazards NFPA I USDOT# MCP No N No No/ Curies / / / Mod MISC. LOCAL AGENCY DATA Ag.Definedl: Ag. Defined2: Ag. Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag. Defined8: Ag. Definedg: Ag.Definel0: -- Ag. Definell 4 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: SW CORNER OF FACILITY TANK DESCRIPTION Tank ID#: 1 Mfr: Modern Weld Compart Tank: N Installed: 10/1996 Capacity: 100000 Gals No. Of Comparts: Additional Info: TANK CONTENTS Tank Use: MOTOR VEHICLE FUEL Petrol Type: REGULAR UNLEADED Matl Name:GASOLINE Cas #: 8006619 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 1996 Alarm : Exempt: No Drop Tube : 1996 Ball Float : Striker Plate: 1996 Fill Tube S/O: 1996 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No -5- 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONATINMENT Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 07/06/1996 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 04/28/2000 Name:DON JEFFRIES Ttl:PRESIDENT Prmt Number: 1756 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:01/05/2004 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: Yes Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State License Board: Yes Approved Alternate methods: Date: 04/28/2000 Name:DON JEFFRIES Ttl:PRESIDENT -6- 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~U~U~ ~Vl~ / ~£ ~ ~vl~ GASOLINE Days On Site PLUS UNLEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 8006619 F STATE -- TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid Pure AmbientIi AmbientIi UNDER GROUND TANK I AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 10000.00 GAL 10000.00 GAL 4000.00 GAL %Wt. S CAS# 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS [TSecretI ~slBioHazI Radioactive/Amount EPA HazardsI NFPA USDOT# I MCP No N No No/ Curies / / / Mod MISC. LOCAL AGENCY DATA Ag.Definedl: Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag. Defined7: Ag. Defined8: Ag. Definedg: Ag.Definel0: -- Ag.Definell 7 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: SW CORNER OF FACILITY TANK DESCRIPTION Tank ID#: 2 Mfr: Modern Weld Compart Tank: N Installed: 10/1996 Capacity: 10000 Gals No. Of Comparts: Additional Info: TANK CONTENTS Tank Use: MOTOR VEHICLE FUEL petrol Type: UNLEADED PLUS/MIDGRADE Marl Name:GASOLINE Cas #: 8006619 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 1996 Alarm : Exempt: No Drop Tube : 1996 Ball Float : Striker Plate: 1996 Fill Tube S/O: 1996 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No -8- 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 = Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONATINMENT Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 07/06/1996 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 04/28/2000 Name:DON JEFFRIES Ttl:PRESIDENT Prmt Number: 1756 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:01/05/2004 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: Yes Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State License Board: No Approved Alternate methods: Date: 04/28/2000 Name:DON JEFFRIES Ttl:PRESIDENT -9- 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site GASOLINE Days On Site PERMIUM UNLEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 8006619 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average 10000.00 GALI 10000.00 GALI 4000.00 GAL %Wt. S CAS# 100.00 Gasoline N 8006619 ITsecret RS BioHazI HAZARD ASSESSMENTSI Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No I No No/ Curies / / / Mod MISC. LOCAL AGENCY DATA Ag. Definedl: Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag. Defined8: Ag.Defined9: Ag.Definel0: -- Ag.Definell -10- o7/o7/2o04 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site STOP~AGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: SW CORNER OF FACILITY TANK DESCRIPTION Tank ID#: 3 Mfr: Modern Weld Compart Tank: N Installed: 10/1996 Capacity: 10000 Gals No. Of Comparts: Additional Info: TANK CONTENTS Tank Use: MOTOR VEHICLE FUEL Petrol Type: PREMIUM UNLEADED Marl Name:GASOLINE Cas #: 8006619 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 1996 Alarm : Exempt: No Drop Tube : 1996 Ball Float : Striker Plate: 1996 Fill Tube S/O: 1996 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No -11- 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONTAINMENT Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 07/07/1996 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 04/28/2000 Name:DON JEFFRIES Ttl:PRESIDENT Prmt Number: 1756 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:01/05/2004 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: Yes Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State License Board: Yes Approved Alternate methods: Date: 04/28/2000 Name:DON JEFFRIES Ttl:PRESIDENT -12- 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0004 Facility Unit: Fixed Containers at Site DIESEL #2 Days On Site 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 68476-34-6 F STATE ~ TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid /Pure ]Ambient I .Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 10000.00 GALI 10000.00 GAL 4000.00 GAL HAZARDOUS COMPONENTS 100.00 Diesel Fuel No. 2 N 68476302 HAZARD ASSESSMENTS TSecretl ~slBioHaz Radioactive/Amount I EPA Hazards NFPA I USDOT# MCp No N No No/ Curies F IH DH. / / / Low MISC. LOCAL AGENCY DATA Ag. Definedl: Ag.Defined2: Ag. Defined3: Ag. Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag. Defined8: Ag.Defined9: Ag.Definel0: -- Ag.Definell -13- 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 = Inventory Item 0004 Facility Unit: Fixed Containers at Site STORAGE CONTAINER.DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: SW CORNER OF FACILITY TANK DESCRIPTION Tank ID#: 4 Mfr: Modern Weld Compart Tank: N Installed: 10/1996 Capacity: 10000 Gals No. Of Comparts: Additional Info: TANK CONTENTS Tank Use: MOTOR VEHICLE FUEL Petrol Type: DIESEL Matl Name:DIESEL #2 Cas #: 68476-34-6 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 1996 Alarm : Exempt: No Drop Tube : 1996 Ball Float : Striker Plate: 1996 Fill Tube S/O: 1996 TANK LEAK DETECTION Sgl Wall: Dbl Wall: VISUAL CHECK TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No -14- 07/07/2004 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 = Inventory Item 0004 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONTAINMENT Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 07/07/1996 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 04/28/2000 Name:DON JEFFRIES Ttl:PRESIENT Prmt Number: 1756 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:01/05/2004 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: Yes Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State License Board: Yes Approved Alternate methods: Date: 04/28/2000 Name:DON JEFFRIES Ttl:PRESIENT -15- 07/07/2004 BROOKSIDE MARKET a DELI ~eID: 015-021-00i756 Manager : LOWELL DOW BusPhone: (661) 75~ 2072 Location: 4700 COFFEE RD ~%% Map : 102 CommHaz : Low City : BAKERSFIELD ~30~ .,%~ Grid: 16C FacUnits: 1 AOV: CommCode: COUNTY STATION 65 SIC Code:5541 ~/ EPA Numb: ~D~6e-- DunnBrad: 0~~~~ Emergency Contact / Title Emergency Conta~// Title ?aun ~EEnT ~0~e~umomO/ MANAGER DON JEFFRIES// / OWNER Business Phone: (661) 555-2290x~(B~ : (661 Busines/~Phone ) 588-2290~ 24-Hour Phone : (661) ~9-~--S~R-R~B-q~ 24-H®ur Phone : (661) 399-6712~ Pager Phone : (~)4~ -~x /~a~ger Phone : (~)~ -~5~ Hazmat Hazards: ~ Fire ImmHlth DelHlth Contact : D~ ~~5~ / Phone: (661) 758-3072x MailAddr: PO BOX 640 / State: CA 0~ ~[-4~-~ City : WASCO Zip : 93280 Owner JEFFRIES BROS INC Phone: (661)~. ~~ Address : PO BOX 640 State: CA ~O City : WASCO Zip : 93280 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: I, tPA~r~_/V~_e,u~ ~ Do hereby certify that I have I ~ype or print name], ----' ' reviewed the attnch6u h~ardous materials manage- merit plan ~or ~ ~ ~ ~ and ~hat it along with any ~rm~ions constitute a compile and ~rr~ man- ~ement plan for my fadlity.  ';" j.. 07/15/2003 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: BROOKSIDE MARKET & DELI Cross Street : ~/A~.~n~ ~_O-~-~D ~ Business T~e: ~- ~~ Org T~e: Total Tanks : 4 IndnRes/Trust: No PA ~~'~ ~~ROPERTY O~ER INF( Name : DON JEFFRIES Phone: (661) ~x Address: '~.0. ~0~ ~O City : ~~,~ ~¢0 : Zip: T~e : CORPO~TION ~~L ~~~K INFOR~TION Name : DON JEFFRIES Phone: (661) Address: ~.0, 6~ X~O q~'~-B07m City : ~~,~ q~O State: Zip: T~e : CORPO~TION BOE UST Fee~ : ~OWN Financ' 1 Resp: , Legal Notif : Pro' Mailing Address Date: ~ Phone: (~) Name: ~ ~~~ Ttl :~.SST. MGR~ ~ State UST ~ :'~ ~ ~-0~ ~0 1998 Upg Cert~: 00865 / -2- 07/15/2003 UST Monitoring Site Plan '?: .............. [ ~oo~,~ t ...... . . . ......... ....... ........ ......... ............ ................ . ~ ~· ,, I ~ ' .... ~o~ ~ ' ....................................... ~ ;,~t ...... . ' .I '.2 ............ 3 x~ ...... J ...... ~; ............. '~ ........ ~22~~2~.~ ................. ...... ~. ~ ~.~ ......... :::::X ~ .................. ~ ......................... W ...... [ ......................................... ~t, ~ w~ ~: ~ 2 / 5 / 0 i. If you ake~y ~ve a ~a~ ~at. shows all requked ~fomafion, you may ~clude it, ra~er ~ ~s page, wi~ yo~ Monitoring Sys~m C~fi~ation. On yo~ si~ pl~, show ~e general layout of ~ ~d pip~g. Cle~ly idenfi~ loeafion~ of the following equipment, if ~talled: monitohng system consol p~els; sen~ors monitomg ~ ~uI~ ~aees, smps,.d~spenser p~s, ~ill conm~s, or o~ se~on~ eonm~ment ~eas; mech~ical or olec~o~ line le~ det~to~; ~d in-tank liquid level prob~ (if used for le~ detecfi~). ~ ~e ~ace prodded, note ~e date ~is Site Plan was prepped. Page ~ ,,of ~,, os~oo BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONATINMENT Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 07/06/1996 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: Name: JG~N A. Ri'i'I~E Prmt Number: 1756 Approved: Yes Expiration Date: 06/30/2003 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP0 : UST MONIT. CERT:ll/20/2002 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engine ,r: Yes Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State License Boar¢ : Yes Approved Alternate methods: -6- 07/15/2003 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONATINMENT Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 07/06/1996 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: O Name:J Prmt Number: 1756 Approved: Yes Expiration Date: 06/30/2003 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:ll/20/2002 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: Yes Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State License Board: No Approved Alternate methods: Date: Name: JO~iiN A ~iTCiIIE Ttl -9- 07/15/2003 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONTAINMENT Mtl : "FLEX" & : Corr : !'FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 07/07/1996 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: Name:JOlIN A. RITC!IiE Prmt Number: 1756 Approved: Yes Expiration/Date: 06/30/2003 AGENCY DEFINED / / TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:ll/20/2002 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: Yes Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by' Contractors' State License Board: Yes Approved Alternate methods: -12- 07/15/2003 BROOKSIDE MARKET & SiteID: 015-021-001756 ~ Inventory Item 0004 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONTAINMENT Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 07/07/1996 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 0~ Name:JOHN A. Ki/CHiE ~~g~-~ Ttl:~R.~, Prmt Number: 1756 Approved: Yes Expiration Date: 06/30/2003 AGENCY DEFINED TANK/LINE TEST : / CP CERT. : MANWAY INSP. : UST MONIT. CERT:ll/20/2002 STORAGE CONTAINER DATA (UST ORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: Yes Installation Inspected by Unified Program Agency Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State Licens Board: Yes Approved Alternate methods: -15- o7/15/2oo F BROOKSIDE MARKET & DELI SiteID: 015-021-001756 ~ Fast Format ~ F Site Emergency Factors Overall Site 9 -, Special Hazards --Utility Shut-Offs 01/24/1997 A) GAS - SE CORNER OF STORE B) ELECTRICAL - UG VAULT S END BY HAGEMAN; MAIN IN OFFICE ~ C) WATER - NE CORNER OF STORE D) SPECIAL - EMERGENCY SHUT OFF TO GASOLINE OUTSIDE AND INSIDE/ E) LOCK BOX - NO Fire Protec./Avail. Water ,/ 01/24/1997 PRIVATE FIRE PROTECTION - CALL ACTIVATED ALARM INSIDE~TORE - KERN SECURITIES. NEAREST FIRE HYDRANT - SE CORNER OF PROPERTY~ COFFEE & HAGEMAN. . / Building Occupancy Level ,/ -18- 07/15/2003 BR00KSIDE MARKET & DELI SiteID: 015-021-001756 Manager :~,~ ~v~. - ~,~,.~,~ lo'~L ~0v~ BusPhone: (661) ~ Location:_4~nn. -v ~v.-^--i~ RD qTOO CO~6e~ E_o~0 Map : 102 CommHaz : Low City : ~D ~A4C~ILS~{8-~ Grid: 16C FacUnits: 1 AOV: CommCode: COUNTY STATION 65 SIC Code: 5541 EPA Numb: DUnnBrad: Emergency Contact / Title Emergency Contact / Title PAUL MEERT / MANAGER DON JEFFRIES / OWNER Business Phone: (661) ~5%~2~f Business Phone: (661) 588-2290x 24-Hour Phone : (661) 391-0229x 24-Hour Phone : (661) 399-6712x Pager Phone : (&~) - x Pager Phone : ( ) - x Hazmat Hazards: Fire ImmHlth DelHlth Contact : Phone: (661) 758-3072x MailAddr: PO BOX 640 State: CA City : WASCO Zip : 93280 Owner JEFFRIES BROS INC ~,,_ ~.~ Phone: (661) - 75x83072 Address : PO BOX 640 /~%;~~/~ State: CA City : WASCO ~.?~.~;~ ~.~,?~ ~ ~...~ Zip : 93280 Period : to ~ '"'~ ,.~. TotalASTs: = Gal Preparer: ~'~'; ~>%~ ~ TotalUSTs: = Gal Certif 'd: ~ RSs: No Emergency Directives: · I,, ~LO~ELC, ~A) Do hereby certify ~hm I have (Type or print name) reviewed the attached hazardous materials manage- ment plan ~or .Bg0o¢$1i~ and that i~ along with (Name of Business) any corrections constitute a complete and correc~ man- agement plan ~~ -1- 10/31/2000 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: BROOKSIDE MARKET & DELI Cross Street Business Type ~l /~K~'~/&~ Org Type: Total Tanks 4 IndnRes~Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : DON JEFFRIES Phone: (661) 588-2290x Address: City : State: Zip: Type : CORPORATION TANK OWNER INFORMATION Name : DON JEFFRIES Phone: (661) 588-2290x Address: City : State: Zip: Type : CORPORATION BOE UST Fee# : UNKNOWN Financ'l Reap: STATE FUND Legal Notif : Property Owner Mailing Address Date:04/28/2000 Phone: (661) 588-2290x Name:iC~? A. State UST # : 1998 Upg Cert#: 00865 = Hazmat Inventory One Unified List --As Designated Order Ail Materials at Site Hazmat Common Name... JSpooHazlEPA HazardsI Frm I DailyMax lunitlMcP GASOLINE L 10000.00 GAL Mod GASOLINE L 10000.00 GAL Mod GASOLINE L 10000.00 GAL Mod DIESEL #2 F IH DH L 10000.00 GAL Low 2 10/31/2000 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 = Inventory Item 0001 Facility Unit: Fixed Containers at Site ~VUVl~ ~Vl~ / ~ ~ ~Vl~ G~OLINE Days On Site REGULAR ~LEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 8006619 F STATE i TYPE PRESS~E ~ TEMPE~TURE CONTAINER TYPE Li~id Pure Ambient Ambient UNDER GROUND T~K I AMO~TS AT THIS LOCATION Largest Container Daily Maximum Daily Average 10000.00 GAL 10000.00 GAL 4000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 ITSecret RS,BioHaz[~ HAZARDAiSESSMENTS I Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No I No No/ Curies / / / Mod : Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ ~UlV~Vl~ ~Vl~ / ~1 ~.-q.L~ ~Vl~ GASOLINE Days On Site PLUS UNLEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 8006619  STATE ~ TYPE PRESSURE --r TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container ~ Daily Maximum Daily Average 10000.00 GALL 10000.00 GAL 4000.00 GAL HAZARDOUS COMPONENTS %Wt. R)NoRS) CAS# 100.00 Gasoline 8006619 HAZARD ASSESSMENTS TSecretI ~slBioHazI Radioactive/Amount I EPA HazardsI NFPA USDOT# MCP No N No No/ Curies / / / Mod -3- 10/31/2000 BROOKSIDE MARKET & DELI SiteID: 015-021-001756 = Inventory Item 0003 Facility Unit: Fixed Containers at Site ~FUVI~N ~Vl~ / ~l~Z-*~_b N~Vl~ GASOLINE Days On Site PERMIUM UNLEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 80066~9 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average 10000.00 GALI 10000.00 GALI 4000.00 GAL , HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 RS BioHaz HAZARD ASSESSMENTS TSecret Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod = Inventory Item 0004 Facility Unit: Fixed Containers at Site ~tvUVl~l~ ~Vl~ / ~ ~-~.l~ ~Vl~ DIESEL #2 Days On Site 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 68476-34-6 F STATE TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient UNDER GROD-ND TANK I AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 10000.00 GAL 10000.00 GAL 4000.00 GAL I HAZARDOUS COMPONENTS ~ 02 %Wt. S CAS# 100.00 Diesel Fuel No. 2 N 684763 RS BioHazI HAZARD AiSESSMENTS I TSecret Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low -4- 10/31/2000 F BROOKSIDEMARKET & DELI SiteID: 015-021-001756 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 01/24/1997 EMERGENCY PHONE NUMBERS LISTED. --Employee Notif./Evacuation 12/08/1999 MAP IN OFFICE AND EMPLOYEES NOTIFIED. Public Notif./Evacuation 01/24/1997 AS INSTRUCTED BY STORE OPERATORS. Emergency Medical Plan 12/08/1999 911. -5- 10/31/2000 ~ BROOKSIDE MARKET & DELI SiteID: 015-021-001756 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site --Release Prevention 12/08/1999 AUTO-SHUTOFFS AT PUMP AND TANKS, EMERGENCY BREAK AWAYS ON ALL HOSES AND OVERSPILL BOXES AT EACH TANK. --Release Containment 12/08/1999 DRIVER TRAINING IN PLACE NOW, TRAINING OF STORE EMPLOYEES AND SHUT OFF MECHANISM AT CONSOLE. -- Clean Up 01/24/1997 HAVE LIST OF EMERGENCY COMPANIES AND PHONE NUMBERS. Other Resource Activation -6- 10/31/2000 F BROOKSIDE MARKET & DELI SiteID: 015-021-001756 Fast Format ~ Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs 01/24/1997 A) GAS - SE CORNER OF STORE B) ELECTRICAL - UG VAULT S END BY HAGEMAN; MAIN IN OFFICE C) WATER - NE CORNER OF STORE D) SPECIAL - EMERGENCY SHUT OFF TO GASOLINE OUTSIDE AND INSIDE E) LOCK BOX - NO Fire Protec./Avail. Water 01/24/1997 PRIVATE FIRE PROTECTION - CALL ACTIVATED ALARM INSIDE STORE - KERN SECURITIES. NEAREST FIRE HYDRANT - SE CORNER OF PROPERTY ON COFFEE & HAGEMAN. Building Occupancy Level -7- 10/31/2000 BROOKSIDE MARKET & DELI ~~~~~ SitelD: 015-021-001756 Trai~ng ~~~~~~~~ Overall Site i~ Employee Trai~ng ~~~~~~~ 01/24/1997 O WE ~VE 12 EMPLOYEES AT THIS FACILITY. o o WE DO HAVE MSDS SHEETS ON FILE. O B~EF SUMMARY OF T~INING PROG~M: ON ~ING FOR NEW EMPLOYEES BY PE~Y o SCOTT USING MSDS SHEETS. o O O O i~ Held for Fumre Use o i~ Held for Fumre Use O BROOKSIDE ELI SiteID: 215-000-001756 | ~OV 2~9 1999 Manager : PERRY SCOTT - LEES~E --"' ) usPhone: (805) 758-3072 Location: 4700 COFFEE RD ~v.~-'~'~t~''- ~ap : 102 CommHaz Low : City : BAKERSFIELD -'~ '~' ~rid: 16C FacUnits: 1 AOV: CommCode: COUNTY STATION 65 SIC Code:5541 EPA Numb: DunnBrad: Emergency Co~tact / Title Emergency Contact / Title Business Phone: (~5) ~--1-3-~8x~_~ Business Phone: (805) 588-2290x 24-Hour Phone : (~) 3~9--4~{-7x~/~0~ 24-Hour Phone : (805) 399-6712x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire ImmHlth DelHlth Contact : Phone: (805) 758-3072x MailAddr: PO BOX 640 State: CA City : WASCO Zip : 93280 Owner JEFFRIES BROS INC Phone: (805) 758-3072x Address : PO BOX 640 State: CA City : WASCO Zip : 93280 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif' d: RSs: No Emergency Directives: ~ Hazmat Inventory One Unified Li~ -- MCP+DailyMax Order All Materials at Site Hazmat Common Name... IspecHazlEPA HazardsI Frm I DailyMax Unit MCP GASOLINE L 10000.00 GAL Mod GASOLINE L 10000.00 GAL Mod GASOLINE L 10000.00 GAL Mod DIESEL #2 F IH DH L 10000.00 GAL Low ~, ~h~5.~:} ~l~,~-J~ Do hereby ce~ify that l have (T~pa or p~int name) reviewed tim a~ached hazardous materials manage- for'~r0ok.gA~ I~r~,,~ and that it along with ment plan (Name of P~usinea~) -- any corrections constitut~ a complete and correc~ man- agern~n~ p~an for nay facility. BROOKSIDE MARKET & DELI SiteID: 215-000-001756 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site -- COMMON NAME / CHEMICAL NAME GASOLINE Days On Site REGULAR UNLEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 8006619 F STATE ~ TYPE PRESSURE TEMPERATURE CONTAINER TYPE /Pure I Ambient GROUND TANK /Liquid I Ambient I UNDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 10000.00 GAL 10000.00 GALI 4000.00 GAL HAZARDOUS COMPONENTS %wt. CAs# 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS ~Secret] ~S BioHaz Radioactive/Amount EPA.Hazards NFPA USDOT# I MOP JNo N No No/ Curies / / / Mod = Inventory Item 0002 Facility Unit: Fixed Containers at Site 9 -- COMMON NAME / CHEMICAL NAME GASOLINE Days On Site PLUS UNLEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 8006619 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 10000.00 GAL 10000.00 GAL 4000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS ITSecret NoRSlBioHazI Radioactive/Amount I EPA HazardsI NFPA USDOT# MCP No No No/ Curies / / / Mod 2 11/29/1999 BROOKSIDE MARKET & DELI SiteID: 215-000-001756 = Inventory Item 0003 Facility Unit: Fixed Containers at Site ~v~v~ ~vx~ / ~ ~.~j~ ~v~ GASOLINE Days On Site PERMILIM UNLEADED 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# 8006619 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 100oo. 00 GALI 10000.00 GAL 4000.00 GAL ~ HAZARDOUS COMPONENTS 1 0 Gasoline 8006619 TSecret S BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No N No No/ Curies / / / Mod ~ Inventory Item 0004 Facility Unit: Fixed Containers at Site ~t;lVUVl~2i'd i'dZ-~lVl~; / ~l"l~lVl.L ~.LJ l~4Z-UVlr'; DIESEL #2 Days On Site 365 Location within this Facility Unit Map: Grid: SW CORNER OF FACILITY CAS# - 68476-34-6 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 10000.00 GAL 10000.00 GAL[ 4000.00 GAL HAZARDOUS COMPONENTS I 100.00 Diesel Fuel No. 2 N 68476302 HAZARD ASSESSMENTSI TSecreto RS BioHaz Radioactive/Amount EPA Hazards NFPA I USDOT# MCP No N No No/ Curies F IH DH / / / Low F BROOKSIDE MARKET & DELI SiteID: 215-000-001756 Fast ~Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 01/24/1997 EMERGENCY PHONE NUMBERS LISTED. -- Employee Notif./Evacuation 01/24/1997 MAP IN OFFICE EMPLOYEES NOTIFIED -- Public Notif./Evacuation 01/24/1997 AS INSTRUCTED BY STORE OPERATORS. Emergency Medical Plan 01/24/1997 911 -4- 11/29/1999 F BROOKSIDE MARKET' & DELI SiteID: 215-000-001756 Fast Format = Mitigation/Prevent/Abatemt Overall Site --Release Prevention 01/24/1997 AUTO-SHUTOFFS AT PUMP AND TANKS EMERGENCY BREAK AWAYS ON ALL HOSES OVERSPILL BOXES AT EACH TANK ~ Release Containment 01/24/1997 DRIVER TRAINING IN PLACE NOW TRAINING OF STORE EMPLOYEES SHUT OFF MECHANISM AT CONSOLE -- Clean Up 01/24/1997 HAVE LIST OF EMERGENCY COMPANIES AND PHONE NUMBERS. Other Resource Activation -5- 11/29/1999 F BROOKSIDE MARKET & DELI SiteID: 215-000-001756 f Fast Format F Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs 01/24/1997 A) GAS - SE CORNER OF STORE B) ELECTRICAL - UG VAULT S END BY HAGEMAN; MAIN IN OFFICE C) WATER - NE CORNER OF STORE D) SPECIAL - EMERGENCY SHUT OFF TO GASOLINE OUTSIDE AND INSIDE E) LOCK BOX - NO -- Fire Protec./Avail. Water 01/24/1997 PRIVATE FIRE PROTECTION - CALL ACTIVATED ALARM INSIDE STORE - KERN SECURITIES. NEAREST FIRE HYDRANT - SE CORNER OF PROPERTY ON COFFEE & HAGEMAN. Building Occupancy Level -6- 11/29/1999 BROOKSIDE MARKET & DELI SiteID: 215-000-001756 Fast .Format ~ Training Overall Site -- Employee Training 01/24/1997 WE HAVE 12 EMPLOYEES AT THIS FACILITY. WE DO HAVE MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: ON GOING FOR NEW EMPLOYEES BY PERRY SCOTT USING MSDS SHEETS. -- Page 2 -- Held for Future Use Held for Future Use -7- 11/29/1999 BAKERSFIELD CITY FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES 1715 CHESTER AVENUE, 3RD FLOOR = BAKERSFIELD, CA 93301 .... . (805) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN To cvoia tu[~ne~ action, return this to[m w~th~n 30 dcys of receiDt~ ~PE/PRINTANSWERS IN~N~dSn,' ~' " Answer :ne auestions D~lOW for me business cs ~ w~ol~, Be Dr',et ant concise cs Do. IDle, SECTION 1' BUSINE£S1DENTiFICATION DATA Broaks e' a, De/l' 5~JSiN=~ N.~ME'. x,~STREET NUMBER: SiC CODE: SECTION 2: EMERGENCY NOTIFICATION: CONTACT TITLE BUS, PHONE 24. HR. PHONE 2. OO~ ~~~ O~~ ~ ~-~0 ~. 3?? - ~azardous 1V~a~erials Division HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3: TRAINING: BRIEr SUMMARY Or I RAINING, RO. GRAM: SECTION 4: EXEMPTION REQUEST: CERTIFY UNDER ~CNALTY OF :':,o ~! Ir~v .B ..... x ..... .-HAT' MY USiNESSIS EXEMPT FROM THE RE?ORTING .2EGUIREMENTS CF ~"' ~'"- 6.95 -,,u~- ,. ,....,,~A;,-'t.=.ROF ~,,= "CALIFORNIA mE;'".,LTH & ~Ar_,Y COD: r'~,'R "'~ FOLLLC'WING REASONS: _ ~,,'q/.~RDOUS MAi c_.xlALS. ';i/E DO HANDLE ½AZARDCUS MATERIALS;' BUT THE ---QUANTITIES AT NO .,M,'-z,.xC~.zu Ir-:,'" MINIMUN! i<zrORTiNG GUANTI'ZIE~,. ..,'~, ,ER (S?cC~v ~'-'~ ..... ' SECTION 5: CERTIFICATION: · J/~,V~['~ CERTIFY THAT THE ABOVE INFOR- I~'ACCURATE. I UNDcRSTAND THAT THIS INFORMATION W~LL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDE;'i THE "CALIFORNIA HEALTH AND SAFE~ CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.),AND THAT iNACCURATE INF©R~2ON.CONSTfl'UTES ?ER JURY. 2. I-Iazardous ~ater~a~s Division HAZARDOUS ~ATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES: ~'A. AGENCY NOTIFICATION PRCCEz,"".UiRE~: /'C. PUBLIC EVACUATION: '~D. E.ME:RGENCY MEDICAL PLAN: Bakersfiel& Fb:e Dept. Hazardous Materials Dior[sion ...... :' '~'~ ~ HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7' MITIGATION, PREVENTION AND ABATEMENT PLAN: R~-,,.._A,..,,... PREVENTION STEPS: B. RELEASE. CONTAINMENT AND/OR MINIMIZATION' . ~:,~N-UP PRCCEDURER: SECTION 8: UTILITY SHUT-OFFS (LC~,-~, tON 0:- SHUT-OFFS AT YOUR FACILITY')' ,/~ATURAL GAS/PROPANE' LOC''~ ' Y~NO )iF'fO: ~:C,~ION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY: ,,/A. PRIVATE FIRE PBOTECT[ON' /B. WATER AVAILABILITY (FIR, F.. HYDRANT)j ~{, ~ ..~ BAKERSFIELD, CA 93301 ~~~ (805) 326-3979 H~ARDOUS MATERIALS INVENTORY F.,'.. ~-r'., DESCRIPTION 3, HECK IF-USINESS IS A FARM r ': ... --.',", '-', ~A,V~ ,~~ ~ ' · ,~,',,.,,/tl,,..i i ~ ._,'TY ' :, A i - - ZIP ::c scoa ~%'q/ :UN'& :FACSTREET NUMBER EMERGENC'f CCNTACTS HAZA US MATERIALS INVENTI FIY .siness Name Address ') INV-~J~ITORY STATUS: New { ( ] Re~Wn [ ] DeleUon { ] Cheet~ ~f~'~temm..~ i~ · NON ~E S~' H~D CA~GORIES 're ~ ~ee · ( ] Suaaen Rele~e of Pretsure [ ] Immeai~e He~ J) WAS~ C~$SIFICA~ON (3~ig~ code from DHS Fo~ 80221 USE CODE ') AMOUNT AND ~ME AT FACIUW UNITS CF M~SURE 8) STOOGE CODES M~mumOaNAmount: :~ [ ] ~a ~ ~3 [ ] ~)Con~ Annu~ Amoum: ~ ~ c) Temprite: ~est Size'Cont~nen ~ Oa~ On Site Circle~icn Monms: AIrYe~. 3. F. M. A. M. J. J. A. S. CHEMICAL DESCRI~ION ~ ~N~NTORY STA~S: Ne~ f~n [ ~"Re~mn ~ ] ~elet~o, i 1 Che~ ~ cnem~.~.s NON ~DE ) PH~ICAL STA~ Solid ( ; uama ~ ( ] Pure [ ] M~ure ~te [ ] , ') AMQUNT AND ~ME AT FAC:U~ UNITS CF M~SURE 8) STOOGE Averse O~N Amoum: ~, 00~ tunes [ ', b) Pressure: ~nu~ Amount: ~ ~ ~ - ¢) Tempera: ~ Da~ On Site ~'~ Cir~e~icn Morons: ~1 Yeu. J. F. M. A. M. J. J. A. S. O. l~e t~ree most n~ous ~) cnem~ com~nenm~r ~ - O) ~n ' ., ' HAZ OUS MATERIALS INVEN I RY' Page_of_ Jsiness Name Address CHEMICAL DESCRIPTION 1 ) INVENTORY STATUS: New [~Addflion [ ] ReVmion [ ] ~letion [ ] Ch~k ~ ~emi~ = a NON ~DE SECR~ ~[~E SECR~ [ ] H~D CA~GORIES Fire [~Reamwe [ ] Sudden Relate of Pressure [ ~ Immed~e He~h (Acme) ~d He~ OhiO) [ ] , 5) WAS~ C~SSIFICA~ON .(~iga ~de ~om DHS Fora 8022} USE CODE 7) AMOUNT AND ~ME AT FACI~ UNITS OF M~SURE 8) STOOGE CODES M~imum Omly Amount: * I~ [ ] ga [~3 [ ] ~ Con~ne~ Average DaN A~unt: ~ cunes[ ] b) Pressure: Annu~ Amount: ~ c) Tem~um: ~gest Size Contaner: · Days On Site C~mle~ich Months: All Ye~. J. F. M. A. M. J. J. A. S. O. N. D 9) MITRE: ~st COMPONENT ~~ ~CAS ~ ~ AHM cneml~ com~nents or ~y AHM com~nents 2) [ ] [ ] ~ 0) Loceaon CHEMICAL DESCRI~ION ~ ~ IN~NTORY STA~S: New [~on [ ]Reviston [ ] Deletion ( ] / Chec, ~ chemi~ is a NON ~DE SECR~ [~~SECR~ [ ] =~,m,ca Name: 5~ AHM[] CAS, H~RD CA~GORIES Fire [~ Rea~ve { ] Sudden Reie~e of Pressure [ ] Immedi~e He~h (Acme) [ ]~ ~layed He~ic) [ ] 5) WASTE C~SSIFICA~ON .(~digit coee from OHS Fo~ 8022) USE CODE / ~ 5) PHYSICALSTA~ Solid [ ] ~Quid ~G~ [ ] Pure [ ] M~um [~te [ ] R~io~we [ ] 7) AMOUNT AND TIME AT FACIU~ UNITS OF M~SURE 8) STOOGE CODES M~mum Daily Amount: ['bs [ ] g~ [~3 [ ] a) Contaner: Average Oaly Amount: ~ cunes[ ] b) Pressure: Annual Amount: /~ c) Tem~r~ure: ~gest Size Contaner: [ ~ Days On Site ~ Circie ~icn MOnthS: NI Yeu. J. F. M. A. M. J. J. A. S. O. N. D the t~ree most h~ous 1) ~- ~ [ ] c~eml~ com~en~ or ~y AHM com~nems 2) [ ] ,:em~ u~er pen~W of law, ~t I nave pe~on~iy ex~in~ ~a'~ ~iii~ wire m~ intoma~ ~uDmi~ on ~J~ ~ ~l a~Gh~ documenm. Pa~e. 'of' -3usiness Narfle Address / : CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New Adcliflon{ ] Revision[ ] Deletion[ ] "' Check if cl~emicad is a NON TRAOE' sECRET [ ] TRADE SECRET [ 2) common Name: 3) DOT # (oI~i°n~) ChemicaJ Name: ., · . AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ]" 5) WASTE CLASSIFICATION (3-di~ DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ Gas [ ] Pure [ ] MLxture [ ] Waste [ ] Radioactive 7) AMOUNT AND TiME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES MaXimum Daffy Amount: lbs [ ] gaJ [ ] ~3 [ ] a) Contmner:. Average Daffy Amot~nt: cunes[ ] b) Pressure: Annum Amount: c) Temperature: Largest Size'ContaJner: # Days On Site Circie Whicn Months: All Year. J. F. M. A. M. J. J. A, S. O. N. D 9) MIXTURE: List CAS # % WT' AHM tl~e three most hazardous 1) [ ] cnemlcaJ components or any AHM comDonents 2) [ ] [ ] 1 0) Location CHEMICAL 'ION 1 ) INVENTORY STATUS: New [ ] Add,ion [ ] Revision [ ] Deletion [ ] Ckck if chemicaJ is a NON TRADE SECRET [ ] TRADE SECRET [ 2) Common Name: ~,, 3) [:X:)T # (opt]orlaJ) ChemicaJ Name: ~ AHM [ ] CAS #, 4) PHYSICAL & HEALTH PHYSICAL ~ HEALTH HAZARD CATEGORIES Fire [ ] Reactive[ ] Sudden Release of Pressure [ ] Im~mecli~Heatth {Acute) [ ] Delayed Health {Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid { ] Liquid [ ] Gars [ ] Pure [ J Mixture [ ] WasXt~ [ ] Radioa,ctrve [ 7) AMOUNT AND TIME AT FACIL;JTY UNITS OF MEASURE 8) STORA DES, Maximum DailvAmou_nt: lbs [ ] gaJ [] ~3 [ ] a) ContaJl~r:- , Average Dmly Amount: cunes[ ] b) Pressure.~ ' Annuat Amount: c) Temperat .die; Largest Size ContaJner: '\, # Days On Site CircteWhicn Months: All Year. J. F. M. A. M. J. J. A. S. O. N. D 9) MIXTURE: list COMPONENT CAS # % WT AHM the three most hazarctous 1) [ cnem~caJ components or ~ny AHM components 2) [ ] [ 1 10) Locmon. cern~ unoer pena/ly of/aw. ~hat I have personally exarnineO anct am familiar wiD~ me infoma~on suDmlrtec~ on Ulis ~ all alZacl]eci documents. / I~etieve ~ut~mittect informabon is Due, accurate, and complete. · .... CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND 8TORA~--~_ TANK8 CONTAINING PETROLEUM AND here~y ce~es ;ha~ # is/n comp#ante w~t~ the re~/~drements of ,.;e~'~on ~0~, Article $, Chapter ~, ~iv~s~on ;3, 7'#~e £3, Cai~omJa C~e o! The mechanisms ~ ~o demor~t~e #haneda! respons#~#~/ as re~red by Section £~0~ am as ~#ows: Note: If you are Ming ~ ~ate Fur~ as any part of your demonstration of financial responsibility, your execuOon and suDrniss~on of this cerffifcation also certifies that you are in coml~liance with al~ conditions for parlJcipation in the Fund. F~lit~N~me F~:~i~ Add~m "-'~ F~fli~Nm Fm~e/~,ddrem Fm:ilit'y Addrem Petroleum Distributors and Cardlock fuels - JEFFRIES BROS., INC. NCY ~ LOC~I... I:rlRE~ F'OLICE ~FID SHERIFF 9:1.:1. I::'0 [ SON CENTER 4 :L ;~:~....~,~ ]...-6669 H I G H W ~:.l Y I::' i:.~ T I:;: 0 L 911 VACUUI'I TF:UCI/, M. P Vr.~CI.JI. II~I ,:~f..'),~-..3 :-1,:1-"1151 (805) 758-3072 ' · FAX (805) 7.58-3077 P. O. Box 640 Wasc..o, Calif. 93280