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HomeMy WebLinkAboutUNDERGROUND TANK Permit tO Operate Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE ........... ,~,~,?i~,,~!???:??~,~?~;,, ..... This permit is issued for the following: ~:~: ,;..,. :~,~,~-. ~?~,=~? ?~::.~;..,~:..~. ~...,,. :~,%.~. ,,,,_,. ~:,~, ~,~,~ %~..,~:~.:...., Waste PE~IT ID ~ 015-021-001105 .....:_, ~,~....~ .... ..... ,. :, .......... ~..,.,~?~,~ ...... ~,.:.,,~,.,:,; ......... :~. LOCATION 3 1 0 1 ~i~~ ~-'"'?.:-:.-,=;::?::41,;' g'~SEt~D CA ~' ~i* ~...:'.-:?.~ ~-~........, .,::.:.':.:::::.::::,.? ~. ~ '.,., ,~.,~? .:' , ,' ,, /: .~ .... ,~ ? ~ ~'~ ~'. :, ~ ....'-~ D-....:'.~, ~'~,.:, ~i...~ ~: ..................... ~' , . ?',?~?j?~,~,t~'~'.d~d.,~¥'./.~'~g .~.i ~"....:~',~] TtNK ~tZI~BO~S SUBSTANCE CtPtCIIY GIL ~, ?' TiNK :~tlI(~' ~'~ ....... tl~ PIPING PIPING PIPING ~-....:':..:'-~. '%.:,~ ~~:. TYPE MATER~L MOniTOR TYPE METHOD MONITOR ~:',,,~ "a "~ "~' '=' -'="~- '":' '~ *:"d ~?, '., ....... ~,~..'*~. ~ ...-~ :',. '. ~ ~;~ ;..,~,.~":'~ .~i~,,. ',~ 0001 Re~lar Unleaded 20,~'::?~: G~I:'.~, 11/98/': :"" · DW F,.,.~"""? ~: A~ DWF P~SSU~ ALD ~2 Re~lar Unleaded 0,00ff~L '::?. ~=.'~Gal~'~...~, '~:.;'0.~1 ~i~l~ ~[:?~,. DW'~(;?'":~ ::;;~;'.'~;:~ .?D. '~TG DWF P~SSURE ALD 2 ~ ' :*~ ':h~ """r~=~¢:=~~* ~'-?~',',~ :"',,.. '": :~* ~:'*[. ? u *~. ,~ ~ '"'-.=, ;..=~,'::" '"~[~*~,-- '~:'~ ~ * ,? 0003 Premium Unleaded 20,000 ...... ...~a <. ~:~:;. ~,~98,~..~**~ ~,.D~,'~s~:~ E~:=~:. ?...~.< ~ h.=~, .... ATG DWF PRESSU~ ALD ........ ~:'*~:~:~4:} ./.~" ."~ /' .? .d 2.,:,*~,~~ Is~ by:  ~ O~CE OFE~R O~AL S~ ~CES ~ ~' 1715 Chewer Ave., ~rd Floor ~~ B~e~el~ CA 93301 Voice (805) ~2~3979 F~ (805)~S76 ExpkationDate: June 2000 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES 1715 CHESTER AVENUE BAKERSFIELD, CALIFORNIA 93301 RECOMMENDATIONS: Strongly recommend that float vent valve shut off be replaced with a positive shut off on the fill pipe. * · ~ 0CT-02-98 12:34 From: T-~48 P.02/04 Job-842 -- $" MIN. CL£'~-R~,N¢ BETWE£N CAP AND COVER ELECTRICAL SEAL-OFF (TYP.) //~ 10,/2 FILL~ SUMP SECTION I~li~;J'll~lll ~EFELOPME~T ~RflUP] DESCRmPTION, Or'REVISIONS; VALVE 3101 ~E A~NUE ~3R~, ~RN~ n~c~t I~U[ DATE: R/10/98 0CT-0Z-98 12:34 From: T-548 P.03/04 Job-842 TANK TAI FILL END 2" HIGH CRO~ 5 GALLON 18" MIN. CROWN AROUND 4" DIA. FRP OR CONTAINM£NT-- SLOPE LENGTH SCH 80 PVC RISER '1 ~X 3'-0" MIN. TO HYDROSTATIC RESERVOIR I 7'-0" MAX. COV£R IN-TANK GAL W/90~ OVERi J CALIBRATIOI PER MFR'S REOI~ 10/2/98 DOUBLE WALL UNDERGROUND STORAGE TANK, SEE  20" SQUt STRIKE BY TA . SLOPE 1/4" PER rOi GRAVEL BED &: BACKFILL (TYPICAL) --~ ADDENDUM ~)'IE~'B A~£'~rl°lif -l~l~V~*~oplJ, f.~lJl7· oRolj.l~ DESCRIPTION OF REVISIONS: ~ VI& N~, hllbml, g1~8 VALVE ~ : OCT-OZ-g8 1Z:34 From: T-548 P.04/04 Job-84Z ~ TANK: 20,000- GALLON FLUID CONTAINMENT DOUBLEWALL FIBERGLASS TANK, TWO 42" COLLARS, STEEL STRIKE PLATES, AND TIE DOWN GUIDES. TANK SHALL BE UL 58 APPROVED AND METHANOL COMPATIBL£. PIPING SUMP: FLUID CONTAINMENT 48" DIA. FIBERGLASS PIPING SUMP W/55" DIA. RISER AND LID. FIELD CUT TO BURIAL DEPTH. PROVIDE EXTENSIONS IF NECESSARY. POMECO 511C-1600 56" DUAL POINT FILL-SPILL MANHOLE W/l?" SPILL BOXES TO MATCH BUNG CONFIGURATION. FILL BOX SHALL BI[ 5 GALLON CONTAINMENT. OPM 634TT-7085 4" TIGHT FILL CAP AND OPM 655T-8076 FILL SET T 95 .. 8 ~P~OTM[[DC.O 110-$7WT 37" D,A. MANHOLE. WATER TIGHT AND TRAFFIC $/4" RIGID CONDUIT. POMECO 110-18WT 18" ROUND MANHOLE, WATER TIGHT AND TRAFFIC RATED, OPW 255VM 4x4x2x2 EXTRACTOR FITTING, OPM 1611-1620 5" x 4" VAPOR RECOVERY ADAPTER. OPM 1711T-7085 5" VAPOR RECOVERY CAP. ~ LEAK DETECTOR 8 VEEDER ROOT 794390-209 LIQUID SUMP SENSOR. .~t~k D, E.~.rI~,'V DEV££O~MENI' OROI. I,~ DESCRIPTION OF REVISIONS; ~E~- 1~ ~ ~ ?e~s Nm~a~ I~ 1~ REVISE NOTES 3~0~ ~ A~UE · ' Schmidt Envil onmental October 2, 1998 Mr. Ralph Huey " City of Bakersfield - Fire Department ..... 1715 Chester Avenue B~ersfield, CA 93301 Subject: Submittal of Addendum to Plans for Fire Permit for the Costco - Wholesale-Gas Station - Bakersfield, California Dear Mr. Huey: I am enclosing the addendum to the plans for the Bakersfield Costco site. If you have any questionts or concerns regarding this submittal please contact me at (818) 786-2373. Sincerely, .mdt Enviromnental Ii, es Cad~;id-P~'~ Project Manager 16509 Saticoy Street Van Nuys, California 91406 (818) 786-2373 (8 ! 8)786-5440 FAX $" MIN. CLEARANCE AND COVER ELECTRICAL SEAL-OFF (TYP.) FILL~ SUMP SECTION ADDENDUM SHEETA ~& OE$/GIV DEVELOPMENT GROUP DESCRIPTION OF REVISIONS: ISSUEDATE: 10/2/98 ~'~k'~ 7625 Hayvenhurst Avenue, Suite 12A ADDITION OF FLOAT VENT ~r'JL~, Van Nuys, California 91406 VALVE PROJECT NO. 3562 ~',~,~-'%"~ Phone: (elm 76a-6464 COSTCO ~32 ~ ~A::~ '~ Fax: (618) 792-844'; MP #94-113E REFERENCE SHEET T-2 oos,oo 3101 GILMORE AVENUE COSTCO ~ ~ ~ ~ BAKERSFIE~LD, CAUFORNIA 93308 ORIGINAL ISSUE DATE: 8/10/98 FILL END 2" HIGH CRO~ 5 GALLON 18" MIN. CROWN AROUND 4" DIA. FRP OR CONTAINMENT-- SLOPE LENGTH SCH 80 PVC RISER--~ '~ 3'-0" MIN. TO BRINE HYDROSTATIC 7'-0" MAX. COVER IN-TANK w/go% OVERI CALIBRATIO PER MFR'$ "' 10/2/98 STRIKE BY TA SLOPE 1/4" PER FOC - PEA (,;RAVEL BED &: BACKFILL (TYPICAL) ---%, ADDENDUM SHEETB & DE$16111 DEI/ELOPMEIIII' GROUP DESCRIPTION OF REVISIONS: I~UEDATE: 10/2/98 ~r-~-q~ 7625 H,awenhurst Avenue, Suite la& ADDITION OF FLOAT VENT ~1~ jL'q~ Van N.¥s, California 91406 PROJECTNO. 3562 ~l'/~%~J~ Photo,: (818! 782-6484 VALVE COSTCO ~32 f~/~..~ Fax: m~.] 782-6446 MP ~t)4-113E REFERENCE SHEET T-2 cc co __A OLiNE oo ,:o 3101 GILMORE AVENUE costco ~ ~ ~ ~ BAKERSFIE~.D, CALIFORNIA 93308 ORIGINAL ISSUE DATE: 8/10/98 >J< ~ TANK: 20,000- GALLON FLUID CONTAINMENT DOUBLEWALL FIBERGLASS TANK, TWO 42" COLLARS, STEEL STRIKE PLATES, AND TIE DOWN GUIDES. TANK SHALL BE UL 58 APPROVED AND METHANOL COMPATIBLE. >J< (~ PIPING SUMP: FLUID CONTAINMENT 48" DIA. FIBERGLASS PIPING SUMP W/`35" DIA. RISER AND LID. FIELD CUT TO BURIAL DEPTH. PROVIDE EXTENSIONS IF NECESSARY. )J< (~ POMECO 511C-1600 .36" DUAL POINT FILL-SPILL MANHOLE W/12" SPILL BOXES TO MATCH BUNG CONFIGURATION. FILL BOX SHALL BE 5 GALLON CONTAINMENT. >J< X/~ OPW 6.34TT-7085 4" TIGHT FILL CAP AND OPW 6.3.3T-8076 FILL >J< ~IA. MANHOLE, WATER TIGHT AND TRAFFIC 8 '---' RATED. 3/4" RIGID CONDUIT. >J< (~) POMECO 110-18WT 18" ROUND MANHOLE, WATER TIGHT AND TRAFFIC RATED. >J<(~ OPW 25.3VM 4x4x2x2 EXTI~'.ACTOR FITTING. >J<~ OPW 1611-1620 .3" x 4" VAPOR RECOVERY ADAPTER. ~< [~) OPW 1711T-7085 .3" VAPOR RECOVERY CAP. ~ ~ VEEDER ROOT 794`390-209 LIQUID SUMP SENSOR. ADDENDUM SHEETC ,~k DESIG~ DEVELOPMENT GROU,o~ DESCRIPTION OF REVISIONS: ISSUEDATE: 1012/98 ~r'~b"'~ 76;5 Hawenhurst Avenue, Suite 12A REVISE NOTES ~P'JL'Ik Van Nuys, California 91406 PROJECT NO. 3562 ,r,~"~ PhonE,: (818) 782-6484 COSTCO tli'32 ~'L'j~ 1~ Fox: (818) 782-8445 MP #94-113E REFERENCE SHEET T-2 3101 GILMORE AVENUE costco ~ ;~ ~ DR~ BAKERSFIELD, CAUFORNIA 93308 ORIGINAl. ISSUE DATE: 8/10/98  FAX T?ansm ittal B A K E R S F I E L D Cover Sheet CALIFORNIA Bakersfield Fire Dept. O~ce of Environmental Services 1715 Chester Ave. · Bakersfield, CA 93301 FAX No. (805) 326-0576 · Bus No. (805) 326-3979 Today's Date I (~ - I- q~ Time ~ ~ ,. ~c~_~ No. of Pages p1010052,jpg (12BOxg60x24b jpeg) p1010051 ,jpg (1280x960x24b jpeg) p1010050.jpg (1280x960x24b jpeg) p1010049.jpg (1280x960x24b jpeg) - BA](~F]~EIZI FI~ DEPARTMENT' 171~ Ches~e: Ave., Bakersfield, ~ 93301 -- (805) 326-3979 CO~ITIO~ OS T~r~s MRY 08 2003 13:18 BKSFLD FIRE PRE!VEHTIOH (661)852-2172 p.6 (<¥"" 0 O~iC~ O~ ~]~RO~NTAL S~RVIC~S ~~T ~LICA~ON ~OR ~OVAL O~ AN U~RGRO~D STOOGE T~K ~IT~ ~O~TIO~ SITE ~o~ ~D~S FACI~ N~ Co~ CR(~S S~ET T~ O~OPE~TOR ~ ~ PHO~ NO. M~L~G ~D~SS , co~c~oR ~O~T~ON ~S~ C~ ~S~ C~ER ~O~S CO~ NO, T~K ~~G ~Q~ON ' WAS~ ~S~R~R ~ICA~ON ~~ N~ OF ~SA~ DISPOS~ FA~ FAC~I~ ~E~ICA~ON T~K T~S~T~ ~~TION T~ D~ST~A~ON T~K m~~ON ~lC~ D~T~S CH~ T~ NO. AGE VOL~a TSE ~P~LIC~ ~ ~~, ~T~8, ~ WILL ~OMPLY WI~ ~ ~~ ~O~DITIO~8 OF T~I8 AND CO~. ~ APPROVED 8~- -- ~PLICA~ ~ms ~l~ON ~L B{COn~ A ~E~ ~ ~ROVED D September 10, 2002 Klm Stever Costco Wholesale F!RE CHIEF Real Estate Department RaN FRAZE 999 Lake Drive ADMINISTRATIVE SERVICES Issaquah, WA 98027 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 RE[ Request for Temporary Closure of Costco Fueling Center FAX (661) 395-1349 3101 Gilmore Avenue, Bakersfield, CA SUPPRESSION SERVICES 2101 "H' Street Dear Ms. Stever: Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661)395-1349 ~ Your request for temporaxy closure on the above mentioned Costco site PREVENTION SERVICES is hereby granted. I have received a third party certification letter from F~s~sE,~,.t,,~*xr,~,E,~, Bakersfield Service Station Repair verifying all temporary closure 1715 Chester Ave. ~ Bakersfield, CA 93301 , requirements are in effec~t. VOICE (661) 326-3979 FAX (661) 326-0576 i Please be advised that this temporary closure is good one year from the PUBLIC EDUCATION date that you stopped pumping, which according to our records is 1715 ChestorAvi~. I August 8, 2002. As per code, you must continue to have third party Bakersfield. CA 93301 VOICE (661) 326-3696 certifications sent to this ,office quarterly as a condition of your FAX (661) 326-0576 temporary closure. FIRE INVESI'IGAIION 1715 Chester Ave. Bakersfield, CA 93301 Should you have any questions, please feel free to call me at 661-326- vOICE (661) 326-3951 3190. FAX (661) 326-0576 TRAINING DIVISION Sincerely_, 5642 Victor Ave. ~ ~ Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Fire Prevention SBU/dc cc: Brett Tackett, BSSR SEP-- 9--82 MON i 5 : 46 FROM B i ~ I S i R i [ N C I P . 82 i .i Ba, kerdfield Servlee Station Repair Inc. 6630 Ros~lale H~ey #B Bakersfield, Ca 93308 ,. ': ;.,.': . Steve Und~o~ :..:..~.... Bakersfidd City Fire '~pt . ":'~ 1715 Chester Aw ... Bakorsfiel~ Ca 93301 Rff; Tempora~ cl~ur~ o[a UST, C~tco Oawline ~tafion : ,;. ,.',,: , 'l~is i~ is to ~flify'fiat all liquids have ~en remove, all flammabW va~rs have bc~n purge, mid VaSt lln~'have ~m ~pP~, ~w~ scxvlce to the pumps has ~ dis~nnected, at the Costco ..,.. G~ollne Station lo--ted al' 3101 Gillmore Ave, Bakersfield California, undc~ the Bakersfield Fire DU~'artmnet 'Environmcmtid $~a'vi~ "Requirements and Guidelin~ [bt Temporary Closure ora UST. '.. A~y fuaher r~uirem~ts, pk~se call u~ at 661-588-2777. . ...'.; :. ':": Thank you, Brcxt Tackett, ~esident BSSR lnc ...... ',, . ,,:. ','~ ,.., . .. :.: , '.~; SEP 05 '02 15:$2 FR COSTCO LEGAL 425 515 8114 TO 9166152605?6 P.01/02 / Real Estate Department ~ 999 Lake Drive ~ Issaqu?, WA 98027 Please immediately forward these copies cc:. Dennis Bock Company. ~~ ~ Phone: ~-3---~ Fax: 661-326-0576 II From: I Klm Stever J Company: Costco Wholesale Phone: (425) 42.7-7540 Fax: (425) 313-8105 Date: I 9/3/02 Number of Pages: 2 Comments: SEP 03 '02 15:52 FR COSTCO LEGAL 425 ]13 8114 TO 9166132605?6 P.02/02 September 3, 2002 Bakersfield Fire Department Environnemental Services 1715 Chester Avenue Bakersfield, CA 93301 RE: Temporary Closure of the Costco Gasoline Station Dear Sir or Madam, By this letter, Costco is requesting temporary closure of our service station located at 3101 Gilmore Avenue. Bakersfield Service Station Repair, will ready the station for closure trader the Bakersfield Fire Department Environmental Services "Requirements and Chaidelines for Temporary Closure of a UST". If you have any further questions, please contact me at (425) 427-7540 or Dennis Bock at (425) 427-7653. Sincerely, Costco Wholesale Corporation Real Estate Development Manager 999 Lake Drive * Issaquah, WA 98027 · 425/315-8100 · cosl'co.com - July 30, 2002 Costco 3101 Gilmore Bakersfield CA 93308 REMINDER NOTICE FraE CHIEF RE: Necessary Secondary Containment Testing Requirements by December RON FRAZE 31, 2002 of Underground ~' otorage Tank ts) Located at ADMINISTRATIVE SERVICES the Above Stated Address. 2101 "H' Street Bakersfield, CA 93301 VOICE 1661)326-3941 Dear Tank Owner/ Operator: FAX {661) 395-1349 SUPPRESSION SERVICES If you are receiving this letter, you have not yet completed the necessary 2101 "H" Street secondary containment testing required for all secondary containment Bakersfield, ca 03301 components for your underground storage tank ts). VOICE 1661) 326-3941 ' FAX 1661) 395-1349 Senate Bill 989 became effi~ctive January 1, 2002, section 25284.1 (California PREVENTION SERVICES Health & Safety Code) of the new law mandates testing of secondary FIRE SAFET~ SERVICES , EI'JVI~ONMENTAL SERVICES 1715 ChesterAvo. containment components upon installation and periodically thereafter, to insure Bakersfield, CA 93301 that the systems are capable: of containing releases from the primary VOICE 1661) 326-3979 FAX 1661)3260576 containment until they are detected and removed. PUBLIC EDUCATION Of great concern is the cument failure rate of these systems that have been 1715 ChesterAvi~. tested to date. Currently the average failure rate is 84%. These have been due Bakersfield, CA 93301 VOICE 1661) 326-3696 to the penetration boots leaking in the turbine sump area. FAX 1661) 326-0576 For the last four months, this office has continued to send you monthly FIRE INVESTIGATION 1715 ChesterAve. reminders of this necessary testing. This is a very specialized test and very few Bakersfield, CA 93301 VOICE 1661) 326-3951 contractors are licensed to perform this test. Contractors conducting this test FAX 1661)326-0576 are scheduling approximately 6-7 weeks out. TRAINING DIVISION The purpose of this letter is to advise you that under code, failure to perform 5642 Victor Ave. Bakersfield, CA 93308 this test, by the necessary deadline, December 31, 2002, will result in the VOICE 1661) 390.-4697 revocation of your permit to operate. FAX (661) 399-5763 This office does not want to be forced to take such action, which is why we continue to send monthly reminders. Should you have any questions, please feel free to call me at 1661) 326-3190. Steve Underwood Fire Inspector Environment~tl Code Enforcement Officer D July 23, 2002 Mr. Steve McArthur Costco Wholesale Northwest Atlantic Partners 17300 Red Hill, Suite :320 Irvine, CA 92614 FIRE CHIEF RE: Underground Storage Tanks Located at ~ON F~Z~ Costco, 3101 Gilmore Ave, Bakersfield, CA ADMINISTRATIVE SERVICES 2101 "H" Street Dear Mr. McArthur: Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 396-1349 This letter is intended I:o clarify the status of the underground fuel storage tanks located at your Costco facility, 3101 Gilmore Avenue, SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA. As the Unified Program Agency, responsible for the Bakersfield. CA 93301 regulation of underground storage tanks within the City of Bakersfield, VOICE (661) 326-3941 FAX (661) 395-1349 we issued a permit to remove these tanks to AESE Covey, Inc. on March 14, 2002. Mr. Jim Gonzales of A.ESE Covey, Inc. pulled the PREVENTION1715 ChosterSERVICESAvo.permit on behalf of Costco. There is no requirement to remove the Bakersfield, CA 93301 tanks at this site; they are double walled fiberglass tanks, and meet all VOICE (661) 326-3951 FAX (661) 326.0576 of the current code requirements. ENVIRONMENTAL SERVICES However, if the tanks are abandoned, which I believe is anticipated 1715 Chester Ave. Bakersfield, CA 93301 when you move to your new Rosedale Hwy facility in Bakersfield, the VOICE (661) 320-3979 FAX (661) 326.0576 tanks must either be removed or temporarily closed. A temporary closure for these tanks can be extended for up to twelve months. TRAINING DIVISION I do hope this clarifies any questions on the possible alternatives for 5642 Victor Ave. Bakersfield, CA93308 the underground storage tanks located at your Gilmore Ave facility. If VOICE (661) 399-4697 FAX (661) 399-5763 you have any questions, please contact me at 661-326-3979. Sincerely, Director of Prevention Services REH/dc cc: Kirk Blair, Deputy Fire Chief Don Anderson, Real Property Manager D June 30,2002 Costco 3101 Gilmore Bakersfield, CA 93308 REMINDER NOTICE RE: Necessary Secondary Containment Testing Requirement by December 31, 2002 of Underground Stc,rage Tank located at 3101 Gilmore. FIRE CHIEF RON FRAZE Dear Tank Owner / Operator: ADMINISTRATIVE SERVICES 2101 "H' Street Bakersfield, CA 93301 The purpose of this letter is to inform you about the new provisions in VOICE (661) 326-3941 FAX (661)395-1349 California Law requiring periodic testing of the secondary containment of underground storage tank: systems. SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 Senate Bill 989 became effective January l, 2002, section 25284.1 (Califomia VOICE (661) 326-3941 FAX (661) 395-1349 Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and periodically thereafter, to ensure PREVENTION SERVICES that the systems are capable of containing releases from thc primary 1715 Chester Ave. Bakersfield, CA 93301 containment until they are detected and removed. VOICE (661) 326-3951 FAX (661) 326-0576 Secondary containment systems installed on or after January 1, 2001 will be tested ENVIRONMENTAL SERVICES upon installation, six months after installation, and every 36 months thereafter. 1715 Chester Ave. Bakersfield, CA 93301 Secondary containment systems installed prior to January 1, 2001 will be tested by VOICE (661) 326-3079 FAX (661) 326-0576 January 1, 2003 and every 36 months thereafter. REMEMBER.* Any component that is "double-wall" in your tank system must be tested. TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 Secondary containment testing shall require a permit issued thru this office and VOICE (601) 399-4697 FAX (661) 399-5763 shall be performed by Bit]her a licensed tank tester or licensed tank installer. Please be advised that there are only a few contractors who specialize and have the proper certifications to perform this necessary testing. For your convenience, I mm enclosing a copy of the code for you to refer to. Once again, all testing must be done under a permit issued by this office. Should you have any questions, please feel free to contact me at (661)326-3190. Fire Inspector/Environmental. Code Enforcement Officer Environmental Services SU/kr D May 29, 2002 Costco 3101 Gilmore Bakersfield, CA,93308 RE: Necessary Secondary C, ontainment Testing Requirement by December 31, 2002 of Underground Storage Tank located at 3101 Gilmore FIRE CHIEF REMINDER NOTICE RON FRAZE Dear Tank Owner/Operator: ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 The purpose of this letter is t.o inform you about the new provisions in California VOICE (661) 326-3941 FAX (661) 395-1349 Law requiring periodic testing of the secondary containment of underground storage tank systems. SUPPRESSION SERVICES 2101 'H" Street Bakersfield, CA 93301 Senate Bill 989 became effective January 1, 2002. section 25284.1 (California VOICE (661) 326-3941 Health & Safety Code) of the: new law mandates testing of secondary containment FAX (661) 395-1349 components upon installation and periodically thereafter, to ensure that the systems PREVENTION SERVICES are capable of containing releases from the primary containment until they are 1715 Chester Ave. detected and removed. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 Secondary containment systems installed on or after January 1,2001 shall be tested upon installation, six months after installation, and every 36 months thereafter. ENVIRONMENTAL SERVICES Secondary containment systems installed prior to January 1,2001 shall be tested by 1715 Chester Ave. Bakersfield, CA 93301 January I, 2003 and every 36 months thereafter. REMEMBER!! Any component VOICE (661) 326-3979 FAX (661) 326-0576 that is "double-wall" in your tank system must be tested. TRAINING DIVISION Secondary containment testing shall require a permit issued thru this office, and 5642 Victor Ave. shall be performed by either a licensed tank tester or licensed tank installer. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 Please be advised that there are only a few contractors who specialize and have the proper certifications to perform this necessary testing. For your convenience, I am enclosing a copy of the code for you to refer to. Once again, 411 testing must be done under a permit issued by this office. Should you have any questions, please feel free to contact me at (661) 326-3190. Sincer~y, Steve Underwood Fire Inspector/Environmental Code Enforcement Officer SBU/kr enclosures 04/'24,/02 09:30 9661 326 0576 BFD HAZ MAT DI¥ ~r'~f6 ~]002 OFFICE OF E~RO~ENTAI~ SER~CES 1715 Chester Ave., B~ersfield, CA (~fil) 326-3979 PE~[T ~PLICATION FOR ~MOV~ OF AN ~ERGRO~ STOOGE T~K T~O~OP~TOR ~O~TCo ~06~,5~c~ ~O~NO. CON~C~OR ~~o~. co~ ,~ coo e~ ~o~ so. ~?~'~'~ u~s~ ~o, P~L~Y ASS~NT ~O~TION f~ , ,s co~~~ cva~ q .... ~HOm~ NO.[~ L~C~S~ ~O. ~S~CEC~ .~~e~_4 1~6~ WO~SCO~NO, T~ CLE~G~Q~ON ~C~ DA~ F~OI~U~ ~ TH['. &PPtI¢~NT ~ ~CE~D, ~ERST~D$, ~D W~L ~PLY W~H T~ A~AC~ED ¢ONDIY IONS OF PERMIT ~D A~ ~R STATE, L~ ~D F~E~L ~G~T I~$. TN['$ FO~ ~ BE~ GOMP L[~D ~DER P~YY OF PE~Y, AND TO THE ~EST OF ,e L D FIRE · April 17, 2002 Costco 3101 Gillmore FIRE CHIEF Bakersfield CA 93308 RON FRAZE ADMINISTRATIVE SERVICES ~: Necessary Secondary Containment Testing Required by December 31, 2002 2101 "H" Street Bakersfield, CA 93301 VOICE (661)326-3941 REMINDER NOTICE FAX (661) 395-1349 SUPPRESSION SERVICES Dear Tank Owner/Operator: 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 The purpose of this letter is to inform you about the new provisions in California law FAX (661) 395-1349 requiring periodic testing of the secondary containment of underground storage tank systems. PREVENTION SERVICES 1715 ChesterAve. Senate Bill 989 became effective January l, 2002. Section 25284.1 (California Health & Bakersfield, CA 93301 VOICE (661) 326-3951 Safety Code) of the new law' mandates testing of secondary containment components FAX (661) 326-0576 upon installation and periodically thereafter, to ensure that the systems are capable of containing releases from the primary containment until they are detected and removed. ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 Secondary containment systems installed on or after January 1,2001 shall be tested upon VOICE (661) 326-3979 installation, six months after installation, and every 36 months thereafter. Secondary FAX (661) 326-0576 containment systems installed prior to January 1, 2001 shall be tested by January 1, 2003 and every 36 months thereafter. TRAINING DIVISION 5642 Victor Ave. Bakersfield. CA 913308 Secondary containment testing shall require a permit issued thru this office, and shall be VOICE (661) 399-4697 performed by either a licensed tank tester or licensed tank installer. FAX (661) 399-5763 Please be advised that there are only a few contractors who specialize and have the proper certifications to perform this necessary testing. For your convenience, I am enclosing a copy of the code for you to refer to. Once again, all testing must be done unde, r a permit issued by this office. Should you have any questions, please feel free to contact me at 661-326-3190. Sincerelyw Steve Underwood Fire Inspector/Environmental Code Enforcement Officer SBU/dm enclosures f .SaKERSFIEI.D C~ 93:308 81051455705001 '2-3YSTEM ~T6~TUF:_; REPORT// aLL FUNC~TI,:3N~ I NVENTORV REPORT T 1 :Unleaded VOLUME = 9741 GaLS ULLAGE = 10210 OaI,S 90:?4 ULLAGE= 8214 GaLS TC VOLUME = 9664 GaLS HEIGHT = 58.62 l' 'HES ~ORTER VOL = 0 ~'~ ~ ,,laTER = O. O0 i~ES T 2:Unleaded VOLUM£ = 11138 ULLAGE = 8397 GaL~ 90% ULL~4GE = 6443 TC VOLUME = 1105:3 HEIGHT = ~7,35 I~E$ M~TER VOL = 0 ~4ATER = O. O0 I NCHE~ TEMP = 70.8 DEG F VOLUME = 99:36 ULLAGE = '3704 90% IJLL&GE = 7?40 TO VOLUME = 9858 HEIGHT = 56,.13 INOHES ~,J~"FER VOL = 0 GALS I,,,}&TER = 0. O0 [NCHE$ TEMP = 71.1 DEG F MaN I FOLDED TANKS 1 NVENTORY TOTALS T 1 :Unleaded T 2:Unleaded VOL I. JNE = '2 3 3 7 TC VOLUME 2071 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 Section 2: Underground Storage Tanks Program [] Routine ~ Combined [] Joint Agency ~ Multi-Agency ~ Complaint [~l Re-inspection Type of Tank Type of Monitoring 0/-. 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: Office of Environmental Services (805) 326-3979 Business Site Responsible Party White - Env. Svcs. Pink - Business Copy CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave. 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ~ 0~/~ 03ka legal INSPECTION DATE {i[l"l/o[ FACILITY CONTACT BUSINESS IDNO. 15-210- ~SPECTION TIME NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program [~ Routine ~ Combined [~ Joint Agency [~ Multi-Agency ~ Complaint {~ Re-inspection OPERATION C V COMMENTS Appropriate permit on hand ~. f Business plan contact information accurate ~, /' Visible address 1~ ~' Correct occupancy ~ /' Verification of inventory materials L~ ~' Verification of quantities L, ~' Verification of location Proper segregation of material %j /' Verification of MSDS availability L/ /' Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled ~e,/' Housekeeping ~,~'~ Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardous waste on site?: [~ Yes ~o Explain: Questions regarding this inspection? Please call us at (661) 326-3979 Business Site,,Respon~ible Party .43 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Inspector: _ _~ffZ,~ <78ks 6630 Rosedale Hwy., # B, Bakersfield, CA 93308 Phone (661) 7- ' MONITORING SYSTEM CERTIFICATION. This form must be used to document tearing and sorviclng of mohitOring equipment: /A $~Para~ 66~ficat~n or 'report, 'must b~. 0r~ared for each monitoring system control panel by the technician ~ho performs the work.' A copy of.fliis form must:be~rovidod to the tank system owner/operat6r.. The owner/operator must submit, a gopy of this form to ff~ local agency regulating UST systems within 30 days of test date. - : A. ' General Information : · Facility Name: CO~"r'cO CO~.~Ot-~fit. E~ .~ mdg:No.: ..G,t.~O~ZE O,v .... city: ~.E-ft~g'~,~t~ '.~zip:' q.~o~ Site Address; Facility Contact Pe~son: ~<l-{ ~ e/~" ~' ' Contact Phone No.: ( 66 l' :. ) ~- B. Inventory of EqUipment ~ested/Ce~e~ . Check the approorlate boxes to indicate Sl~flc equipment inspeCtedlserviced~ .~n-WankOaugingProbe. ' Model: ~t{a'3'qO- ~OCL {~n-TankOauglngProbe.' I~'Annular Space or Vault SenSor. Model: Cil~A~nula~ Space or Vault Sensor. Model: - ;g Sump / Trench Sensor(s). Model: ' [] Piping Sump / Trench SenSOr(s). Model: umpSensor(s). <~'I'P Model: ';]q~.~'~O-3 %:~__ Gld~lSump~s~s). 's'I9 Model: El Mechanical Line Leak Detector. Model: [] Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: [] Electronic Line Leak Detector. Model: ~ Tank Overfill / High-Level Sensor. Model: [] Tank Overfill / High-level' Sensor. MOdel: ..~er (sPeCify equipment type and model in. section E on Page 2). IgPO'~er.(SPecify equipment type and '~0~Iel in'$ectioWE on!lgage 2); TankID: '~ D~'~:¥V~I Orv'X ~ TanklD: "! C~n-~.n-Tank'~auging Probe. MOdel: ~-1:1 -"fi cio '- IOq'~ [] Ih-Tank Gauging Probe. Model: lil~Annular Space or Vault SenSOr. Model: :~. ! ~ ' :[] Annular Space or Vault Sensor. Model: C! Piping Sump / Trench SenSOr(s). Model: [] Piping Sump / Trench~Sensor(s). : Model: ~ Sump Sensor(s). ~'~t'P Model: ~qq~ ~O~ 7~e~;).~__ [] Fill Sump Sensor(s). Model: C! Mechanical Line Leak Detector. Model: .... "- [] Mechanical Line Leak Detector. Model: CI Electronic Line Leak Detector. Model: - [] Electronic Line Leak Detector. Model: C~thek Overfill / High-Level Sensor. Model: [] Tank Overfill I High-Level Sensor. Model: r (specify equipment type .~.d model in Section E on Page 2). ~ [] Oth~r (specify equipment .type and model in Sectio,n. I~ on p,a. ge 2). Dispenser ID: I "~ ~':{ ~ Dispenser ID: "af"q C3 Dispenser Containment Sensor(s). Model: [] Dispenser Containment Sensor(s). Model: O Shear Valve(s). [] Shear Valve(s). [] Dispense[ Containment Float(s) and Chain(s). fa Dispenser Con, tainment Float(s) and Ch.a!n(s). 6lap,set ID: ,~- 6 ~5 .... 0~pe~ m: .~/'.-?~ ,~'g CI Dispenser Containment Sensor(s), Model: " [] Dispenser Containment Sensor(s). Model: [] Shear Valve(s). [] Shear Valve(s). ...~ Dispens~ Containment Float(s) and Chain(s). [] Dispenser Con, tainment Fl,oat(s) and Chain(s). Dispenser ID: C~ -- I O ~"~-il:~ . Dispenser ID: . ~_| ,- I~o~. CI Dispenser Containment Sensor(s).- Model: ' ' ' [] Dispenser Contaihment Sensor(s). Model: CI Shear Valve(s). [] Shear Valve(s). ODispenser Containmc, nt Float(s) ~ Chain{s). . [] Dispenser Containment Pl, pat(s) and Cha!n~(s). , · .. · If the facility contains more tanks o? dispensers, COpy this form; Inalud~ information for every tank and dispenser at the facility. C. Certification - I certify that 'tile equipment idenfifl,~l in this document was inspected/serviced in accordance ~ the mannfaetnrers' guidelines. Attadmd to tl~ Certification is information (e.g. manufacturers' daeeklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating soeb reports, I have also attaeh.~ed a copy of the report; (e. Aee. A a//tiler api~ly): C~$'yst_e~n. set-up~ C! Adam history report Cerat~¢aao~ ~o.: .62 5- lO-' I -b ~'q L~,se. So.: ....... 6-q g- ~ i 2. · ~st~ngCompany~am~: 155~.ra ,cc.. ?~o~e.So.:( &g t ') '~9,fi- 2'~ :/-4 Site Address: ~O f'~O'~l~'bt~l L-'~ [q0~ ~/ Date of Testing/Servicing: Page I of 3 03/01 Monitoring System Certification O; Results of Testing/Servicing SoftWare Vorsion Installed: ~ } ~,.0 Complete the following checklist: ~yCs ~1 NO* Is ~e vis~I ~'~eraOonai? '- ~Y~ '~ N6*~ W~e aH scns0~s viSU~y ~p~ ~qc~o~ly t~ ~d cS~cd oPem~onal? ~es '~ No* Were all semors ~mlled at low~t po~t°f s~nd~ con~ent and posi~oned so ~at o~e'r equipment w~l e not ~tcrfere wi~ ~e~ proper ~cm~on? ~yes ~ No* ~ ~ ~e rc~y~ ~ a r~otc monito~ ~on, is aH'co~ca~ons' e~ment (c.g. modem) · ~ N/A op~fional? . : . ~ ~ No* For pr~ pip~g s~, d~ ~e ~b~e ~m~fio~y ~ut do~ ~o pip~g s~con~ con~ent ~ N/A ' mo~t~g ~a~ d~c~ a I~ f~s to op~te, or ~ el~lly ~scb~ected? If y~s: W~ch s~o~ ~a~ posiEve shutter? (C~ ~ll t~t app.) ]~~r~nch S~rs; ..~~ Con~ent.Se~ors. . ~ Did you c0~ positive sh~-do~ due m lJ~s Snd sensor f~il._~,~o~on? ~1 ~ No. ~ ~ No* For ~ syste~ ~at u~ ~e mo~m~g sys~ ~ ~e p~ ~ ~effiH w~g device (i.e: no ~ "Yes* ~ No W~ ~y ~~g ~Uipme~ r~h~d? ~ y~, iden~ ~cffic s~ors, ~b~. or o~er equipment r~laC6d ~ Y~* '~ No W~ ~d fo~d ~ido ~y s~ Con~:~t ~st~ d~ ~ ~ syste~ (~ect all that apply)  ~ No* W~ ~nito~g ~stem"S~t-up re~ :to er~ prop~ s~gs? A~ch set up ~p~, ffappli~ble ~ Sb~flon E below, d~i~e how and when ~e Page 2 ,mf3 03/01 E. In-Tank Gauging / SIR Equip t: E! Check this box if tank lng is used only for inventory control. El Check this box if no tank gauging or SIR equipment is installed. Th~ seeti~n must be completed if in-tank gauging eqnipment is used to perform leak detection monitoring. Corn )lete the follow~g checklist: * ' ';' ~¥es ' El "N~*' H~ all input'wir~ug been inspeCt~i for p;oper en~try and tem~tion' inClUd~g'testing for ground faults? ~/Yes El No* Were all tank gauging probes '~ually inspected for damage and'residue build~? ..... e s El 'No, Was accuracy of system product level readings tested7 es 'O N6* Was accuraCY of System ,water level read~gs tested? " ~r'~Yes 0 N~'* Wore ~a Probes reins~alle~.p~op~rly? .... ~Y'Yes El No* Were al! items on the equipment manufacmror's maint~muce checl~istcompleted? · In the Section l~ below, describe how and when these defl(~[encies were or will be~C0rrec~ed. G. LlneLeakDeteetors (LLD): 13 Check this box ff LLDs am not instaHed' !~ corn ~ete the r,o~o~viag,~e, em,~,St:~ , ,, ,, {ll'~es El'No* For '~l~n'pge, nt ~a~up '~r ,nnual equipm,,~nt certification, wa~ a leak ~ulated to' Verify LLD performance?' El N/A (Check all that apply) Simulated leak rate: 13 3 g.p.h.; ~ 0.1 g.p~h; 13 0.2 g.p.h. ~es El No* Wore all LLDs confn-med operational and accurate within regulatory requirements? I~F~Yes 13 No* For mechanical LLDs, does the LLD restrict pr6duct flow' if it det%tS a leak? 13 Y~s 13 No* For electronic LLDs,' does the turbine ~utonmtic~lly shut off if the LLD doteCts a leak? 13 ~ 13 No* For electronic LLDs, does the turbin~ automatically shut ~ff if any ~orfion of the monitoring sys~m is disabled ~ N/A or dizconnect~d? 13 Y~ ~ No* 'For el%~onic 'LLD~, does ~e turbine '~;u~on~tically shut off if ~ny por~,~ ~f the monitor~g ~ N/A malfunctions or fails a rq yes 13 No* F°r ele~t~ic LLDs, have 'all accessmle wir'mg connections beea viSUally inspected? "gl/~es 13 No* Were all items'io~ the equipment manufactm.or's main~ checldist cbmpleted? · In the SectiOn H, beloW, describe how and when these deflct~mcles were or will be corrected. H. Comments: Page 3 of 3 o~ot Monitottng System Certification UST Monitoring Site Plan Sitenddress: ~:~IO l t ~xq .............. .............. ~ .................... 2~-'.'~~. ............. ~ ~.~ ~ ~ ~ ~$a ~ ~ 2 ~ ~ ~ 2'~2 J-- 2~ ...... ..... ........... ....................... . .................. ~,¢ .... ...... : ....... .t · .......... - ~ ..... ~ ..... ~ :::::::: .:::: ================================== '~''~~ ....... ~ ...... ID~ ....... ~ ~2 ~ ~ ......... ' ~ ' ' . ..... 1~ ................. . ........ I~ffiOn~ w ~ r ~ ~f~mfion, you may ~olu~ E~t~; ~d m-~ hqmd lcveI prO~ [u u~u ,u, ,~ ~1_~_~) V~ prepped. 05100 Page . of L':OSTO,:) 32 BaKEt~:,S;F I ELD, C~. 661 -:324-0164 NO:,.,' 17.. 2000 '?:iS ~1"1 i:~l_[, t:'UN(27F [ ,;2;, N;-'_-; N,:_-:,P.I"I[iL I NVEI'.FI'OR'f REI::'OF:T T I :UIiLEa[~ED V( L JI"!E = 9234 ,.';aLE; IjLI..At-;E = 107' 1 ? 9F3::';;' iJLIJ':iL';'E=S721 (;;aLS TC ',,/OLLME = 9221 ,;J;a~ '-' HE I ,'2 HT ¢," . = _ t, ;2,0 ' t',l~hTE ~ VOL 0 I..,,I&TER = 0.00 INCHES TEI'"I~:' = 61,9 12)E{2~ F VOL LII'.'IE = 115'21 UL.L~GE = '84:30 Gai. fi; 90% ULLAGE= 6,434 ,:gALS TC VC,,LUHE = I I50E, GaLS i4EI,:i;HT = 66.76 II',~ S I,,.JA'I"ER V(4_ = 0 t,.J~'FER = O. 00 1NCHES TEMP = 61.9 DEG F T :3: I:'F!EI"I 1 UP1 'v'OLtJME = 7:320 GaLS LILLaE;}-] = 12631 C'*..,-,La,'-' \ 9"Jt~:. ULIJh(;E= l0F'3~J GaLS TC ",/OLLiHE = 7264 GIRLS HE[C;HT = 4?.46 IP,ICH£S t,.JaTER VOl.. = 0 ,'2;~LS t,./~:~TER = O. O0 INCHES TEf'IP = ,'7.'0.9 DEG F I"t~NIFOLDED TANKS T i: LII'.ILERE,ED ,"' TC VOLUI"}E = 20726 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ~0~eO OO~l~...4~.[t_. INSPECTION DATE Section 2: Underground Storage Tanks Program [] Routine [] Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection Type of Tank .13~ Number of Tanks Type of Monitoring d/. t~. Type of Piping EIC0/= OPERATION C V COMMENTS Proper tank data on lile Proper owner/operator data on file Permit fees current Certification of Financial Responsibility V/ Monitoring record adequate and current L,,/ Maintenance records adequate and current Failure to correct prior UST violations t~' 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 'BuSiness Site Responsibl~ P~ White - Env. Svcs. Pink - Business Copy ^pr-ZS-ZO00 OZ:38pm From-D~G. +81678Z8446 T-361 P.OOZ/O09 F-?90 FF~(~ : r.~T02 PHONE HO. ; 8~+~2481~  CITY OF BA~FIELD ~ OFFICE OF ENVIRONMENTAL SERVICES I~15 Ch~ter Ave., ~k,nfleid, CA 93301 (661) 32~3979 UNOEROROUND STOOGE T~KS - UST ~ACILI~ '" ~ ,'.:" ' , ~ ~' ~_! . ' ' ........... " ' : &~~~I~ .~'~ "-"' ':: ' ' ""' ' ' ...... .~~ .....= .... ..... ~,~,.r~ ' =~~ii~" ......... '" ~~~ ' , ~ '[ ~~ ......... ~.- · " ' ...... ~'l ! ~'"", ^p~ZS-ZOOO OZ:38pm From-DOG. +81678Z844B T-381 P.003/009 F-?90  CITY OF BA~RSFIELD OFFICE OF ENVIKONMENTAL SERVICES [ 7 l$ Chester Ave., Oakereflel~ CA ~330 [ (661) Apr-L'~-2OOO 0Z:40pm From-DDG. +8187626446 T-361 P.006/OO6 F-TO0 s?gl'C3~M$' Av~,, iMild. CJ& t3,1ol MI! ]3i,31TI ~ -'~ um',~ni~ ^pr-~OZ:4Opm From-DDG. +81878Z8445 T-381 P.OD?/O09 F-TgO OFFICE OF ENVIRONMENTAL SERVIC[$ ~ 171~ Chester Ave,, Bakersfield, CA 9330 [ (66 l) ~26-3979 UNDERGROUND ~qro~oE TANK~ - TANK ~AGE 1 STA'~E OF CALIFORNIA STATE WATER RE',SOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARKONLY 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE Of INFORMATION [] 7 PERMANENTLY CLOSED. SITE ONEITEM 2 INTERIM PERMIT ~ 4 AMENDED PERMIT [] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) ADDRESS NEARES~CROSS STREET PARCEL # (OPTIONAL) CITY NAME..-~ . I STATE ZIP CODE EiI~E PHONE # WITH AREA CODE v' BOX ~CORPORATION ~ INDIVIDUAL ~ PARTNERSHIP ~ LOCAL-AGENCY ~ COUNTY-AGENCY* ~ StATE-AGENCY TO iNDiCATE/ DISTRICTS * If o'ealer o! MST is a public agency, compiste the Jollowing: name of supervisor of division, section or office which operates the UST RESERVATION r--'-] 3 FARM ~ 4 PROCESSOR ~ 5 OTHER OR TRUST LANDS I I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) ~,' PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) ],PHCt~E # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 4/5-/ II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ~ bcx t~ i.~c3:~ ~ [NDNIDUAL F-] LOCAL-AGENCY ~ STATE.AGENCY q q' L bn'u YO OR"ORAT'ON = ,ARTN s.., r COO*-AG NCY CITY NAME ZIP CODE PHONE # WITH AREA CODE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME O~ .OWNER I CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS J ~ ~,to indicate [~ INDIVIDUAL J~] LOCAL-AGENCY [~] STATE-AGENCY L k-c 4)n / COR OR^TION = A TNE S., COU.'"-AGENCY EOERAL-AGE.CY CITY NAME J STATE ZIP CODE I PHONE # WITH AREA CODE IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) He ~- V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BI[ COMPLETED) -IDENTIFY THE METHOD(S) USED ¢' box to indioate [~ SELF-INSURED I'---] 2 GUARANTEE ~ 3 INSURANCE r~] 4 SURETYBOND I--"l 5 LETTER OF OREDIT ~ 6 EXEMPTION r--I 7 STATEFUND ~ 8 STATERJND&CHI£FFINANCIALOFFIOERLETfER ~ 9 STATE FUND & CERTIFICATE OF DEPOSIT ~ 10 LOOALGOV'T. MECHANISM r--'[ 99 OTHER VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. I CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. [] II. [~""~11. [] /i~HIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ~J TANJ/OVI~ER'S ~AME ~ (PRINTED & SIGNATURE) P4[,~ ~ ~ ,~,,,,~t~--/~' ~'3"~tJ-" ~' J ~'~J' [ TAN~ OWNER'S ~f~l J~.~ TITLE I~'~('' 1 J DATE f~'/ "-"'L~)CAL AGENCY USE ONLY -- / COUNTY it JURISDICTION # FACILITY it LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE . OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95) INSTRUCTIONS FOR COMPLETING FORM GENERAL INSTRUCTIONS: SECTION 27I 1 OF TITLE 23. CHAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286, 25287, AND 257B9 OF CHAPTER 6~7, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PEIIMIT. 1, One FORM "A" shall be completed for all NEW PER~4fT CHANGES or any FACILITY/SITE INFORMATION CHANGES, 2. SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the site. 3. This fi>tm should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK iNSPECTOR, 4. Please type or print clearly all requested information. ' 5. Use a hard point writing instrument, you are making 3 copiei, 6~ Tank owner must submit wfacility plot plan to the local agency ~ts pan~ of the application showing thc tocatio[! of th_~e U~Ts wilh.~spec[ to . _ buildings and landmarks [Section 2711 Ia)(8), CCR]. 7. Tank owner must submit docmnentation showing compliance with state financial responsibility requirements to the Iocat agency as part of the ' aplSlicatib'n'fdr pk;troleurri USTs [Secti'6n 27 t 1 '(a),(t l ), CCR]. _. TOP OF FORM: "MARK ONLY ONE ITEM" Mark an IX) in the box next to the item that best describes the reason the form is being completed. I, FACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETED) 1. Record name and address (physical location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state, m~d zip code, PD, BOX NUMBERS ARE NOT ACCEPTABLE. Include nearest cross street and name of the operator. 2, Phone number must have an area code. If the night number is th= same, write "SAME~' in p~>per_lqcation.. 3, Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex~ CORPORATION, INDIVIDUAL, 4, Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located within mn Indian reservation or other Ir~dian trust Iands,-ehe-ck the box Inarked' "YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID # or write "NONE" in the space provided. Il. PROPERTY OWNER iNFORMATION.& ADDRESS..(~{_UST BE COMPLiETEi3) Complete all items in this section, ~ntess ali items are ire same zs SECTION I; If {he s;~ue~ write "SAME AS SITE" across dss section7 to check PROPERTY OWNERSHIP TYPE box. itl TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) Comple~e~a. iLite!ns in t~is section, unless all items are the same ~.s SECTION t: If lhe same. write "SAME AS SITE" across this section~ Be sure to check TANK OWNERS TYPE box. IV~ BOARD OF EQUALIZATION UST STORAGE FFJ~ ACCOUNT NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CHAPTER 6,75, DIVISION 20. CALIFORNIA HEALTH AND SAFETY CODE.) Enter your Board of Equalization (BCE) UST storage fcc account number which is required before yot~r permit application can be processed,- Registration with the BCE will ensure that you will receive a quarterly storage fee ret~ir~ i~ reporting lhe per gallon fee due on the number of gallons placed in your USTs. The BCE will code persons exemp{ fi'om paying the stor:~ge fee so returns.will no~ be sent. if you.do not ha. ye.rm. account number with the BCE or ii'you lmve zany questions regm:ding the fcc or exemptions? please cult the BCE at 916~322~9~;fi9 or write to the BCE at the following address Bored of Ekqnallzation~ Fuel Taxes Dlvisiur~, P.O. Box %,o. 87% Sacramento, CA 9427%0001. V. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLETED FOR PETROLEUM USTs ONLY. SEE SECTIONS'2711 Ia)Il l) OF TITLE 23, CHAPTER I6, CALIFORNIA CODE OF REGULATIONS.) Identify the melhod(s) used by the ow~er and/or operator, iii meeting the Federal and State financial responsibility requipemen~s. USTs owned by any Federal or Slate agency as well as non-petroleum USTs are exempt from this requirement, VI. LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BUrial LEGAL AND BILLING NOTIFICATIONS, TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. [SEE SECTI(~NS 271 Ia)(13) OF TITLE 23 CHA][U'ER 16, CALIFORNIA CODE OF REGULATIONS.] INSTRUCTION FOR THE LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. The facility ~mmber may be assigue~ by the local agency; however, this number must be numerical and cannot contain any alphabetical characters, If the local agency prefers the State Board ~o assign the fimility number, please leave it blank. IT IS THE RESPONSIBILITY OF TIlE LOCAL AGENCY THAT iNSPECTS THE FACILITY 7'0 VERIFY THE ACCURACY OF T{qE. INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BCE ACCOUNT NUMBER IS NOT FILLED IN. THE LOC)~L A~G.EN~Y. I~.RESPONStBLE FOIl THE COMPLETION OF THE "LOCAL AGENCY USE ONLY'* INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE OR'IGINAL AND YELLOW 'COP'lES. THE PINK COPY SHOIILD BE RETAINED BY THE Ts'kNK OWNER. 6/95 STATE OF CALIFORNIA ~-~ ....... ' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ~ 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION [] 7 PERMANENTLY CLOSER SITE ONE ITEM[~ 2 INTERIM PERMIT r'-'-I 4 AMENDED PERMIT [] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME .."- ~. NAME OF OPERATOR ADDRESS'~'' ~ ~ ~ - ~' NEARES. S.S~CROSS STREET PARCEL # (OPTIONAL) CITY NAME..,,.. ' ~ J STATE ZIP CODE S]vTE PHONE # WITH AREA CODE v' BOX [~L~ORPORATION [~ INDIVIDUAL [~ PARTNERSHIP [~ LOCAL-AGENCY ~ COUNTY-AGENCY* [~] STATE-AGENCY * [~] FEDERAL-AGENCY TO INDICATE~' DISTRICTS · ~f owrar of UST is a public agency, complete the following: name of supervisor of dMsion, section or office which operates the UST TYPE OF BUSINESS 1 GASSTATION ~ 2 DISTRIBUTOR E~ v'IFINDIAN #OFTA ATSITE I.D.#(optional) RESERVATION · 3 FARM ~ 4 PROCESSOR E~ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) /. PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRS'T) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) __PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMATION MAILIRG OR STREET ADDRESS ~ bcx t3 i.nd~c~:e [~ INDIVIDUAL [~ LOCAL-AGENCY [---] STATE-AGENCY L ;a' ..ORAT,ON PA,TNE,S,IP COUN.-AG,NCY ,EOERAL-A ENC, CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE II!. ?ANK OWNER INFORMATION -(MUST BE COMPLETED) NAME OF OWNER J CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS J v' box, to indicate ~ INDIVIDUAL r-~ LOCAL-AGENCY [~ STATETAGENCY qqq /-r.~/~..4~).~ /[:~'¢&PO"AT'ON E'q~'AR~"ERS.,P ~COU.TY-^SENOY E3.EDERAL-ASENOY CITY NAME ' ~ STATE ZIP CODE PHC)NE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if quostions ariso. TY(TK) HO [~-~- V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED J v. boxto indicate ~'~ri~'SELF-INSURED r-] 2 GUARANTEE r--] 3 INSURANCE r--] 4 SURETY BOND r~) 5 LE'I-rER OFCREDIT ['---] 6 EXEMPTION ~--'1 7 STATE FUND - .~ J-'-q 8 STATE FUNO & CHIEF FINANCIAL OFFICER LETTER J---J 9 STATEFUND&CERTIFICATEOFDEPOSlT [---J 10 LOCALGOV'T. MECHANISM ~ 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notiJication and billing will be sent to the tank owner unless box I or II is checked.  THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ITANK'O~/NER'SNAME(PRINTED&SIGNATURE) ~ ~.,~j. ,~/ ~ ~ TANK OWNER'S TITLE I DATE MONTHIDAY/YEAR "-"~)CAL AGENCY USE ONLY " / / 'J COUNTY # . .. JURISDICTION It FACILITY # I THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95) INSTRUCTIONS FOR COMPLETING FORM "A" GENERAL INSTRUCTIONS: SECTION 27I 1 OF TITLE 23, CHAPTER 16, CALIFORNIA CODE (SF REGULATIONS AND SECTIONS 25286. 25287, Ar~ID 25289 OF CHAPTER 6.7, DtVISION 20, CALIFORNIA t:IEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1~ One FORM '~A" shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFOP, MATION CHANGES. 2. SUBMIT ONLY ONE (1) FORM "A* for a FacilityJSite, regardk:ss of the number of tanks located at the site, 3, This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR, 4, Plemse type or print clearly all requested information. - ....... 5. Use a hard point writing instalment, you are making 3 copies, 6 Tank owner mast submit a i£gcilitz plot plan to the }ocat agency as pad of the application showing lhe location of the U~Ts wi~h. mspect to buildings and landmarks [Section 2711 (a)(8), CCR]. 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the ' application for petroleum USTs [Section 271 l (a)(1 l), CCR]. TOP OF FORM: "MARK ONLY ONE ITEM" Mark an tX) in the box next to the item that best describes the reasort dm form is being completed, I, FACILITY/SITE INFORMATION & ADDRESS (MOST BE COMPLETED) 1. Record name and address (physical location) of the underground NOTE: Address MUST have a valid physical location including city, sta~e, aud zip P.O. BOX NUMBERS ARE NOT ACCEPTABLE. Include nearest cross street and name of the operator, 2, Phone number must have an area code. If the night ~mmber is the san,,{:, wale "SAME'~ in p(opes.location. 3, Check the appropriate box for TYPE OF BUSINESS OWNERSE:IP (ex. CORPORATION, INDIVII[)UAL, 4, Check the appropriate box for TYPE OF BUSINESS. 5, If Facility/Site is located within an Indium reservation or other Indian trust lands, check the box marked' 6. l~Micate the NUMBER of TANKS at this SITE. 7. Record the E.P,A. ID # or write "NONE" in the space provided. II, PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless ail items a~; lfie same a,s SECTION 1; tfthe same write "SAME AS SITE" across this seclion/ Be sim', to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless ail items are the same ;rs SECTI[ON 1: If the same. write "SAME A.S SITE" across this section. Be sure to check ~2kNK OWNERS TYPE box. tV, BOARD OF EQUALIZATION UST STORAGE t~E ACCOUNT NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CHAPTER 6,75, DIVISION 20. CALIFORNIA HEALTH AND SAI;~TY CODE.) Enter your Board of ~lualizadon (BEE) UST storage fee account number which is required before yom' permit application can be processed.- Registrmion with the BeE will ensure that you will receive a qumterly storage fee return i~ ~,sponing the, per gaIlo~ i~e due on the number of gallons placed in your USTs. The BeE will code persons exempt from paying the storage fr-e so returns will not be seal If you do not have account number with the BeE or if yon [,ave any quegtions rcgardit~g the tS:e or exempdo~ts, please call the BeE at 916~3220669 or writ~ 1o the BeE at the following address Boaxd of ~qualization, Fuel Taxes Division, P.O. Box 942879, Sacm~nento, CA 94279-.-009I~ V. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLE'~D FOR PETROLE!!M USTs ONLY. SEE SECTIONS 2711 (a)(I OF TITLE 23, CHAFI%R 16, CAL1EORNIA CODE OF REGULATIONS.) Identify the method(s) used by the owner and/or operator, in meeting the Federal and Sta~e financial responsibility requirements. USTs owt~ed by any Federal or Slate agency as well as non-petroleum USTs are exempt from this requirement, VI. LEGAL NOTIFICATION AND BILLtNG ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS, TANK OWNER OR AUTHORIZE[) REPRESENTATIVE MUST StGN AND DATE THE FORM AS INDICATED. [SEE SEcTIONs 2711 (a)(13) OF TITLE 23 CHAPTER t6, CALIFORNIA CODE OF P, EGULATIONS,I INSTRUCTION FOR THE LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can b: obtained by c~dling the State Board (916) 227-4303. The facility number may be assigned by the local agency; however, this number must be nnmefical and cannot contain any alphabetical charactem, if,he local agency pm}Ers the State Board to assign the fimitity nmnber, please leave it bNak. 1T IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT iNSPECTS THE FACtLtTY '~[O VERIFY 'Iktg ACCURACY OF THE INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BeE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" iNFORMATION BOX. THE LOCAL AC/ENCS" SHOULD RETAIN TIlE ORIGINAL AND YELLOW COPIES. THE PINK COPY SttOULD BE RETAINED BY THE TANK OWNER~ 6/95 STATE OF CALIFORNIA STATE WATER RE:SOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILrPflSITE I MARKONLY ~ 1 NEW PERMIT [~ 3 RENEWAL PERMIT [~ 5 CHANGE OF INFORMATION ~-~ 7 PERMANENTLY CLOSED, SiTE ONEITEM 2 INTERIM PERMIT r-'] 4 AMENDED PERMIT [] 6 TEMPORARY SITE CLOSURE I, FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERAT~R ADDRESS ~ - ~ PARCEL # (OPTIONAL) NEARES~CROSS STREET CITY NAME~ . STATE ZIP CODE S~TE PHONE # WITH AREA CODE V' BOX [~'~0RPORATION ~ INDIVIDUAL ~ PARTNERSHIP [] LOCAL-AGENCY [~ COUNTY-AGENCY* [~ STATE-AGENCY' ~ FEDERAL-AGENCY TO INDICATE~'' D~STR[CTS · ff owner of UST is a public agency, complete the following:, name of supen/isor of division, section or office whid~ operates the UST EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional I DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) ' ' -PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILI~'G OR STREET ADDRESS ¢' bcx t~ ind:ca:e{' r-'-I [~DIV]DUAL [--'] LOCAL-AGENCY [~} STATE-AGENCY L DChc < , ORATION ,ARTNER$.., CD -^GENCY ,EOER^L-AGENC . CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION OR STREET ADDRESS ~/ ~ox~toindicale ~ INDIVIDUAL ~ LOCAL-AGENCY ~ STATE-AGENCY MAILING< ;/ D. PARTNERS..P COUP-AGENCY ,EDERAL-AGENCY CITY NAME ~ STATE [ ZIP CODE PH,~NE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. (TK) HQ 1414-~- TY V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED) -IDENTIFY THE METHOD(S) USED I ¢. boxto indicate [~-'~SELF-INSURED I'~ 2 GUARANTEE (~] 3 INSURANCE r"'] 4 SURETY BOND r~] 5 LETTER OFCREDIT [~ 6 EXEMPTION r--I 7 STATE FUND r--'l s STATE~ND&CH~EFF~NANaALO~F~CERLE'rrER E~ ~ ST^TE~ND&CERT~F~CATEO. DEPOS~T r--I ~o LOCAL~OVT. MECHAN~$M i--I ~90TUER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. ?HIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUFIY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT "~'i.~)CAL AGENCY'USE ONLY COUNTY # JURISDICTION # FACILITY # LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION o FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95) 1INSTRUCTS©NS FOR C©M?LET[NG FORM GENERAL INSTR. UCTIONS: SECTION 2711 OF TITLE 23, CHAPTER 167 CALIFORNIA CODE OiF REGULATIONS AND SECTIONS !5286~ 252g?, AND 252{~9 OF CHAPTER 6~7~ DIVIStON 20, CALtPORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR Art UST OPERAT~N(3 ?ERMIT. 1~ One FORM "A' sha~I be completed for o~1 NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE (1) FORM 'A" for a Fac~li{y/Sim, regardless of the number of tanks located a{ the 3. This fom~ should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR, 4~ Ples, e type or print c~eady all ~quested ~nfo~madon. 5. Use a hsd point writing i~s~'ttment, you am m~ing 3 cop~es, & Tank owner must submit a facil~ty plot plan to the loc~ agency m; pan of the application show~ng lhe location of the USTs with respect to buildings and tandmsks {Section 2711 (a)(8), CCR]. 7. Tat~k owner must submk documemadon shoMng compI~ance with state finm~c~al msponsiNl~ty requiremeuts to the ~ocat agency as p:~ of the application for ~tmlenm U STs [Section 271 t (a)(1 I), CCR]. TOP OF FORM: *'MARK ONLY ONE ITEM~' Mm'k an (X) in the box next to the item that best describes the m~on ~h~ form is bei~tg completed l. FACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETED) I. Record nm'~c and address (physical location) of the underground P.O, BOX NUMBERS ARE NOT ACCEPTABLE. Include ~ea.rest cross stree~ and name of the opera[or 2, Phone number ~ntts~ have an area code. If the n~g{tt ~um~Jer is t}~ san-~e, wr~te "SA ~:~E' ~n pr?er 3, Check the appropriate box for TYPE OF BUS~NESS OWNERSHIP {ex. CORPORATION. ~ND~V~DUAL, 4, Check the appropfiam box for TYPE OF BUSINESS. 5, If Facilky/S~te is locnted within ~n Indian reservation or other tm~i~m trust lands, check the box marked "YES". 6. tnd~cate the NUMBER of TANKS at this SFD~. 7. Record the E.P.A. ID ~ or write '~NONE" i~ the space provided. Ii, PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED} to check PROPERTY OWNERSHfP TYPE box. lII. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) Complete ail items in this secdm~, unless all items ~ the same a~: SECTION i: If ~he same. write "SAME AS SFrE' across this section. Be sure to check TANK OWNERS TYPE box. IV. BOARD OF EQUALIZATION UST STORAGE ~ ACCOUNT NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CHAPTER 6.75, DIVISION 20~ CALIFORNIA HEALTH AND SA~TTY CODE.) Enter your Board of t:klUalization (BCE) UST storage fcc account: number which is required before your permit applicatio~ can be processed, Registration with the BCE will enst~m that you will receive a rNarterly storage fee rctm'r~ in repotting ihs per gr~llon igc due uu the i/umber of gallons placed i~ your USTs. The BCE will code persons exemp: i?om payiug the storuge fee so returns wilt accoun~ number with the BCE or if you i,ave *my questions regarding the ~e or exempdons~ please call ~hc BCE ar 9 ! 6 322~96/O or write to the BCE at the following address Bom'd of Equalization. Fuel Taxes i)~vision~ P}O, Box 942879, Saoeo.~nen~o, CA 9A2790-000~, V, PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLETED FOR PETROLEUM USTs ONLY. SEE SECFtONS 27t I (a)(11 ) OF TITLE 23, CHAP'I~R I6, CALIFORNIA CODE OF REGULATIONS.) Idcnd¢ the method(s) used by the ow[~cr and/or operator, i~ meeting lhe Federal aid Siam i2nallcial rcspons~bil~ly i~quim~cnts. USTs owned by any Federal or Sta~e age~cy as well as non-petroleum USTs a,~ exempt f'rom this requirement. VI. LEGAL NOTIFICATION AND B~LLING ADDRESS Check ONE BOX for the address that w~lI be u~ed for gOTH LEGAL AND BILLING NOTIFICATIONS, TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDKTATED. (a)(I3) OF TITLE 23 CHAFFER !6~ CALIFORNIA CODE OF REGUI.AT[ONS.1 INSTRUCTION FOR THE LOCAL AGENCIES The county andjufisd~cfio~ numbers am predetermined a[~d can be obtained by calI~ng the S~me Board (916) 227..4303. The fac~l~ty ~mm~r may be assigned by the lucai agency; however, this numN~r must b~ um~edcat ami canuot contain any alphabetical cN~nc~em~ If ibc tocal agency pmikrs the State Bo:u'd m assign the ~hci/ity hinter, please leave it bla~k~ IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY TItAT ~NSPECTS THE FACILFFY ~O VERtF¥ Tk{E ACC[.~}~.ACY OF THE [NFORMATK)N. THIS APPLiCATiON CANNOT BE PROCESSED IF TtiE BOE ACCOUNT NUMBER iS NDT FILLED IN. THE LOCAl. AGENCY IS RESPONSIBLE FOR THE COMPLETION OF Tt{E %~OCAL AGENCY USE ONLY" INFORMATION BOX, THE LOCAL AGENCY SHOULD RETA{N THE OR[GiNAL AND YELLOW COP1ES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER. 6/95 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ~ 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION [] 7 PERMANENTLY CLOSED ONSITEI ONE ITEM [] 2 INTERIM PERMIT [] 4 AMENDED PERMIT [] 6 TEMPORARY TANK CLOSURE [] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ~TEMS - SPECIFY ~F UNKNOWN A. OWNER'S TANK I. D. # B. MANUFACTURED BY: I C. DATE,NSTALLED MO/DAY. EAR D. TANK CAPAC, ,N GALLONS: II. TANK CONTENTS ~F A-1 IS MARKED. COMPLETE ITEM C. ~ [~. MOTOR VEH,CLE FUEL [] ~ O,L B. c. [] ,~ RE~U~R U.L~ © ~ D,ESEL [] ~ AVlATIONGAS [~ ]_._] lb PREMIUM UNLEADED [] 4 GASAHOL [] 7 METHANOL [] 2 PETROLEUM [] 80 EMPTY , - 1 PRODUCT [] lc MIDGRADE UNLEADED [] 5 JET FUEL [] 8 M85 [] 3 CHEMICAL PRODUCT [] 95 UNKNOWN [] 2 WASTE [] 2 LEADED [] 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A. 1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. #: III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, ANDC, ANDALLTHATAPPLIESINBOXDANDE A. WPE OF [~ I DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR LINER [] 5 INTERNAL BLADDER SYSTEM [] 95 UNKNOWN SYSTEM ~ 2 SINGLE WALL [] 4 SINGLE WALL IN A VAULT [] 99 OTHER B. TANK [] 1 BARE STEEL [] 2 STAINLESS STEEl., [~ 3 FIBERGLASS [] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM [] S 100% METHANOL COMPATIBLE W/FRP (Primary Tank) [] 9 BRONZE [] 10 GALVANIZED STF. EL [] 95 UNKNOWN [] 99 OTHER C. iNTERIOR [] 1 RUBBER UNED [] 2 ALKYD LINING [] 3 EPOXY UNING [] 4 PHENOLIC LINING LINING 0R [] 5 GLASS LINING [] 6 UNLINED [] ~5. UNKNOWN '~ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% Mi=THANOL? YES_j~r.¥ NO__ [] 1 POLYETHYLENE WRAP [] 2 COATING [] 3 VINYL WRAP ~/4 FIBERGLASS REINFORCED PLASTIC D. EXTERIOR .................. sP,LL CONTA, N E.T .STALLED OVERF, REVENT,O. EOUIPMENT INSTALLED I=. ~VlLL A~I, UVI:HI'II.L, etc. DROP TUBE YES ,~ NO §TRiKFR PLATE YES /~' NO DISPENSER CONTAINMENT ~E§ /I~,/ NO IV. PIPING INFORMATION~..P C~RCLE A IFABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEMTYPE A ~1 SUCTION A ~12 PRESSURE AU 3 GRAVITY A (~, FLEXIBLE PIPING AU 99 OTHER B. CONSTRUCTION A U I SINGLE WALL A ~ 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARES'rEEL A U 2 STAINLESS S3~EL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLF~W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CA~ODICPFIOTECTION A U 95 UNKNOWN A ~99 OTHER _~V~3.'1 ~1~ D~C3'OR I~l TESTING ~ MONITORING ~ LEAK OE~C~OR SHUTDOWN I I 99 OTHER V. TANK LEAK DETECTION = ~*.UAL ,.VE.~ORY '[] = W~OZE ~ ~ AUTOMATIC TA.K [] ~ GROUND WATER r--I~ A.NUALTANK VISUAL CHECK RECONCILIATION MONITORING GAUGING MONITORING TESTING ~ 7 CONTINUOUS INTERSTITIAL [] 8 SIR [] 9 WEEKLY MANUAL [] 10 MONTHLY TANK [] 95 UNKNOWN [] 99 OTHER ~ONITOR~NG TANK GAUGING TESTING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTIITY OF I 3. WAS TANK FILLED WITH YES [] NO [] SUBSTANCE REMAINING GALLONS INERT MATERIAL ? ~, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE LOCAL AGENCY NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # .FACILITY # TANK # PERMIT NUMBER PERMIT APPROVED BY/DATE DATE THIS FORM MUST BE ACCOMPANIEO BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A NAS BEEN RLED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REG~JLATIONS FORM B (6-95) INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Reg Jlations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners t,) apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all IX EW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. ' ' 2. This form should be completed by either the PERMIT AP PLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. '6. Tank owners must submit documentation showing comp;lance with state financial responsibility require- ments t..~ the local agency for petroleum USTs [2711 (a)(I 1) CCR] ...... TOP OF FORM: MARK ONLY ONE ITeM _. 1. Mark an (X) in the box next to--th'e item that best describes the reason the form is being completed. - 2. Indicate the DBA or Facility name where the tank-is installed. I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF LNKNOWN - SO SPECIFY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG). , C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex._ 25,000 or 10,000 etc.). II. TANK CONTENTS -- A. 1. tF MOTOR VEHICLE FUEL, check box 1 and complete items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box I is checked in A). D. Print the chemical nam~ of the hazardous substance sto'ed in the tank and the C,A.S.#. (Chemical Abstrac[ Service number), if box 1 is NOT checked in A. III. TANK CONSTRUCTION- ~ARK ONE ITEM ONLY IN BOX A, B, C & D -.-!.. :.. Check only one item in TYPE OF SYSTEM, T¢.N._K MATERIAL, INTERIOR LINING and CORROSION - - - PROTECTION. . ,. 27 If OTHER, print in the space provided. ,, 1V. PiPiNG INFORMATION -. ~. 1. Circle""A" if above ground circle "U" if underground, and circle,both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provided. - 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoridg requirement for the piping. _ ..V ..... TANK_LEAK DETECTION t. Indicate the-t~AK DETECTION system(s) used to ce'm~ly with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED Ih PLACE 1. ESTIMATED DATE LAST USED~,~MONTH/YEAR (Janu ~ry, 1988 or 01188) 2. ESTIMATED QUANTITY of HAZ~ARDOUS SUBSTANCE: remaining in the tank (in Gallons). -,/ 3. WAS TANK FILLED WITH INERT MATERIAL? Check "~'es" or "No". TANK OWNER OR AUTHORIZED REPRESENTATIVE! MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL' AGENCIES '- '~ The state underground storage tank identification number is co,mposed of the 6vo digit county numbei, the three digit jurisdiction number,-the six digit facility number and the six digit tank nu'~ber. The county.and.jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. The facility number~must be the same as shown in form "A". ' " ' The, tank number may be assigned by the local agenct, however, th~s number must 5e numer cai and cannot contain an alphabet. If the local agency prefers the State Board tc assign the tank number, please leave it blank. IT-tS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY` THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE .... LOCAL AGENCY US'-Z ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL ,AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAII~IED BY T-tE TANK OWNER.. . STATE OF CAUFORNIA STATE WATER F',ESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLE~ A SEPARATE FORM FOR EACH TANK SYS~M. MARK ONLY ~ 1 NEW PERMIT ~ 3 RENEWAL PERMIT ~ 5 CHANGE OF INFORMATION ~ 7 PERMANENCY CLOSED ONSITE~ ONE ~EM ~ 2 INTERIM PERMIT ' , ~ 4 AMENDED PERMIT ~. 6 TEMPORARY TANK CLOSURE ~ 8 TANK REMOVED :~ DBA OR FACIL~ NAME WHERE TANK IS INSTALLED: ~ ~ I. TANK DESCRIPTION COMPLETE ALL ~TEMS - SPEC[~ ~F UNKNOWN II. TANK CONTENTS ~F A-1 ~s MA.K~D, COMPL~E ~M C. ~ ~ ~o~o. v~.,c~ ~u~ ~ ~ o,~ ,. c. ,. ,~u~, u,~ ~ ~ °,~s~ ~ ~ ~v,~,oN ~s ~ 3 ,CHEMIC~PROOUCT ~ 95 UNKNO~ ~ 2 WASTE ~ 2 ~ADEO ~ 99 0$ER(OESCRIBEIN~MD, BEL0~ D. IF (A. 1)IS NOT M~KED, ENTER NAME OF SUBSTANCE STORED C. ~ S. ~: III. TANK CONSTRUCTION MARK ONE I~M ONLY IN BOXES A, B, ANDC,~DALL~ATAPPLIESINBOXDANDE A. WPE 0F ~ 1 DOUBLE WA~ ~ 3 SINGLE WA~ Wl~ E~ERIOR UNER ~ 5 I~RNAL B~DER ~M ~ 95 .UNKNO~ SYSTEM ~' 2 SING~ WA~ ~ 4 SINGLE WALL IN A VAULT ~ 99 oTHER B. TANK ~ 1 'BARES~E~ ~ 2 STAINLESS S~E[. ~ 3 FIBERG~SS ~ 4 S~ELC~D W/FIBERG~SSREINFORCEDP~STIC MA~HIAL ~ 5 CONCR~E ~ 6 POLW~NYL CHLO:a~DE ~ 7 ALUMINUM ~ e m0% METHANOL COMPAT~BLEW~RP (Prima~Tank)' ~ 9 BRONZE ~ ~0 GALVAN~ZEO STI~EL ~. DS UNKNOW~ ~ 99 OTHER C. i~ERIOR ~ ~ RUnnER UNED ~ 2 A~D u~ING ~ 3 EPOXY UNING ~ 4 PHENOUC. L~n ,s .o__ D. ~RIOR ~ ~ .OLY~YLENE WRAP ~ ~ COA~Na ~ ~ V~NYL WRAP ~ ~ F~S~RG~SS R~NFORC~D P~ST~C CORROSION PROTEC~ON ~ s CA~OO~CPRO~C~ON ~ 9~ NONE ~ ~ 95 UNKNOWN ~ 99 OTHER IV. PIPING INFORMATI~ C~RC[E A IF AnOVE GnOUNO On U $ UNDERGROUND. BOTH tF APPLICABLE ' A. SYSTEM~PE A.~i SUC~ON . A~2 PRESsuRE A U 3 GRAVI~ AO~ FL~IeLEPIP,NG A U ',90THE. B. C0NS~UC~0N A U 1. S!NG~ WALL A ~ 2 ~UBLE WAU. A U 3 LINED ~ENCH A U 95 UNKNOWN A U 99 OTHER C. MA~RIALAND A U 1 BARES~EL A U 2 STAINLESS S'~EL A'U 3 POLWINYL CHLORIDE(PVC)A U 4 FIBERG~SS PIPE CORROSION A U 5 ALUMINUM A U '6 CONCR~E A U 7 S~ELW/COA~NG A U 8 1~% M~HANOL C0MPATIBLEW~RP PROTEC~ON A U ' GALV~IZEO STEEL. A U 10 CA~ODICPRO~C~ON A U 95 UNKNOWN' A~99 OTHER O. LEAK D~C~ON ~ ~ ~,~ ~ ~ ~ 2 U,E ~ ~ 3 m,m,uous ,~ ~ 4 E~,C u,~ ~ 5 A~O~C ~ ~ ~OR ~ ~NG MO[~TORING L~ D~ SH~ ~ 99 O~ER V. TANK LEAK DETEC~ON I v,su VL TANK CLOSURE INFORMATION (PERMANENT CLOSURE ~N-P~C~) ~ 1. ES~D DA~ ~ST USED (MO~AY~R) ~ 2. E~MA~D QUANTI~ OF ~ 3. WAS TANK FILLED ~ . YES I ~ '~ ~ . ~ ~ SUBSTANCE RE~INING GALLONS ~ INERT MA~RIAL ? ~_ I TANK OWNER'S N~E, ~ ~ . ~ ' . I DATE -- I LOCAL J . / ~ ~ COUN~ ~ JURISDIC~ON ~ FACILITM ~ ' TANK" ' ' STAT I D ~ I PERMIT NUMBER ' PERMIT APPROVED BY. ATE PERMIT ~PIRATION ~ATE ~IS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCA~ON - FORM A, UNLESS A CtlRR~T FORM A HAS BE~ RLED. FORMC MUST BE cOMpLiED FOR INSTA~ONS. ~IS FORM SHOULD BE ACCOMP~IED BY A PLOT P~ R~ ~IS FORM W~ ~E LOCAL AGENCY IMP~NG ~E UNDERGROUND STORAGE T~K REGU~ONS FORM B (~95) INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Reg~Jlations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners to apply for an UST operating permit. 1. One FC,RM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please 'iype or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 cozies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. 6. Tank owners must submit documentation showing compliance with state financial responsibility require- ments te the local agency for petroleum USTs [2711 (a)(I 1) CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark ar, (X) in the box next to"-th'e item that best describcs the reason the form is being completed. 2. Indicate the DBA or Facility name where the tankqs installed. I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG). C. Indicate the year the tank was installed (ex. 1987). _ D. Indicate the tank capacity in gallons (ex: 25,000 or 10,00D etc.). II. TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and comple[e items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B. Check tiqe appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box I is checked in A). D. Print thE; chemical na[n~ of the hazardous substance sto 'ed in the tank and the C.A.S.#. (Chemical Abstrac'i Service number), if box 1 .is btOT checked in A. III. TANK CONSTRUCTION '~ARK ONE ITEM ONLY IN BOX A, B, C & D - ...... 1. Check only one item in TYPE OF SYSTEM, T_A.N._K MAT[:'RIAL, INTERIOR LINING and CORROSION PROTECTION. , .... 2:- If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle-~'A'' if above ground circle "U" if underground, and :ircle ~both if applicable. 2. If UNKhlOWN circle; or if OTHER, print in space provided. - 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. .V .... TANK.LEAK DETECTION 1. Indicate the-~':FAK DETECTION system(s) used to com~)ly with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED ih. PLACE 1. ESTIMATED DATE LAST USED_-_'MONTH/YEAR (Janu.~ry, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check "Yes" or "No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR~ THE LOCAL AGENCIES The state underground storage tank identification number is composed of the tWo digit county numbe[, the three digit jurisdiction number, th(; six digit facility number and the six digit tank nu ~ber. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-,t303. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agenct, however, this number must be numerical and cannot contain an.alphabet. If the local agency prefers the State Board tc assign the tank number, please leave it blank. IT IS THE RESPONSI'BILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE AC:CU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USI=_ ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD -RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY T4E TANK OWNER. STA'rE OF CAUFORNIA ,,~'~.~"';" ? ~'~,~. STATE WATER RI:SOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE, FORM FOR EACH TANK SYSTEM. MARK ONLY ~ 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION [~ 7 PERMANENTLY CLOSED ON SITE ONE ITEM [] 2 INTERIM PERMIT [] 4 AMENDED PERMIT [] 6 TEMPORARY TANK CLOSURE [] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ~ ~. (..3 I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN OWNER'S TANK I.D., q--t [ B. MANUFACTURED BY: II. TANK CONTENTS ~F A-~ ~S MARKED, COMPL~ ~M C. ~~ lb PREMIUM UNL~ ~ 4 GASAHOL ~ 7 ME~ANOL ~ 2 P~ROLEUM ~ 80 EMP~¢ ' 1 PRoDucT ~ lc MI~E UNLADED ~ 5 JETFUEL ~ 8 M85 ~ 3 CHEMICAL PRODUCT ~ 95 UNKNOWN ~ 2 WASTE ~ 2 ~ADED ~ 99 0~ER(DESCRIBEINffEMD. BEL0~ D. IF (~1)IS NOT MARKED, EN~R NAME OF SUBSTANCE STORED C, A. S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B, ANDC. ANDALLTHATAPPLIESINBOXDANDE A. TYPE OF '~ 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR UNER [] 5 INTERNAL BLADDER SYSTEM [] 95 UNKNOWN SYSTEM ~ 2 SINGLE WALL [] 4 SINGLE WALL IN A VAULT [] 99 OTHER B. TANK [] I BARE STEEL [] 2 STAINLESS STEEL [~ 3 FIBERGLASS [] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM [] 8 100% METHANOL COMPATIBLEW/FRP (Primary Tank) [] 9 BRONZE [] 10 GALVANIZED STEFL [] 95 UNKNOWN [] 99 OTHER [] 1 RUBBER UNED [] 2 ALKYD LINING [] 3 EPOXY UNING [] 4 PHENOLIC LINING C. MNINGoR'NTERIOR r'--~ 5 GLAss LINING ['-~ 6 UNMNED [] ~, UNKNOWN 1~ OO OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES.~,.. NO__ D. EXTERIOR ~r'-'-] 1 POLYETHYLENE WRAP~r--'] 2 COATING [] 3 VINYL WRAP r~ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE ~ [] 95 UNKNOWN [] 99 OTHER SPILL CONTAINMENT~INSTALLED (YEAR)~i[,_/~L OVERFIL~ ~PREVENTION EQUIPMENT INSTALLED (YEAR) t E. SPILL AND OVERFILL, etc. DROP TUBE YES ,X NO ~TRiK~I~. PLATE YES ~ NO DISPENSER CONTAINMENT ~YE~ ~ NO IV, PIPING INFORMATIOI~? CIRCLE A I~ ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEMTYPE A ~)1 SUCTION A~'~)2 PRESSURE A U 3 GRAVITY A~'i~4 FLEXlBLE PIPING A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL A ~ 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARESTEEL A U 2 STAINLESS STEEL A~ U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 C~LVAN)ZED STEEL A U 10 CATHODICPROTECT~ON A U 9S UNKNOWN A~')99 OTHER D. LEAK DETECTION [~11 ~ ~ ~ [~12 U,E ~ I'~;~1 3 ~NU~S I~. ~ 4 ELE~ON~C UNE [] S A~C PU~ ~ L..._J DE3~CTOR ~ ~ESTiNG ~ MOI~'roRING ~ ~F.~K DE'r~CTOR ~WN I I 99 OTHER V. TANK LEAK DETECTION RECONCILIATION MONITORING GAUGING MONITORING TESTING 7 CONTINUOUS INTERSTITIAL [~ ~ 9 W~EKLY MANUAL [] 10 MONTHLY TANK [] 95 UNKNOWN [] 99 OTHER MONITORING TANK GAUGING TESTING VI, TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAY/YR) ~ 2, ESTIMATED QUANTI'I'Y OF 3. WAS TANK FILLED WITH THIS FORM HAS B~,EN. ~C]OMPLETED ~/N~2ER~.PENAL TY~ OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT I TANK OWNER'S N~MEj~ ~ ~,~'~ ~ _.-- I DATE / ( ~ COUNTY # JURISDICTION # 'FACILITY # · TANK # STATfi'I.D # FORM B (6-95) INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Rec. lulations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners ':o apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all r~EW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. 6. Tank owners must submit documentation showing compliance with state financial responsibility require- ments [o the local agency for petroleum USTs [2711 (a)11 I) CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describ ~s the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is inst~lled. I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. Indicate owners tank ID # - If there is a tank number thai is used by the owner to identify the tank (ex. AB70789). B. Indicat,9 the name of the company that manufactured th ~ tank (ex. ACME TANK MFG). C. Indicat,~= the year the tank was installed (ex. 1987). D. Indicat,~= the tank capacity in gallons (ex. 25,000 or 10,000 etc.). II. TANK CONTENTS A. 1. tF MOTOR VEHICLE FUEL, check box 1 and compl,~te items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box 1 is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1 is NOT checked in A III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A, B, C & D t. Check only one item in TYPE OF SYSTEM, 'i'ANK MA'f ERIAL INTERIOR LINING and CORROSION PROTECTION. 2. If OTHI=R, print in the space provided. IV. PIPING INFORMATION t. Circle~"A'' if above ground circle "U" if underground, anc circle both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provid~d. 3. Indicat~ the LEAK DETECTION system(s) used to coml)ly with the monitoring requirement for the piping. V. TANK LEAH; DETECTION 1. Indicate the LEAK DETECTION system(s) used to compl t with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED IIq PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check "Yes" or "No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county numbe[, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and ca~r~ be obtained by calling the State Board (916) 227-4303. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agen :y, however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board t~ assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSFECTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. q'HE PINK COPY SHOULD BE RETAINED BY 'r'HE TANK OWNER. STATE OF CAUFORNIA STATE WATER FIESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY [~ 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION [] 7 PERMANENTLY CLOSED ON SITEI ONE ITEM [~ 2 INTERIM PERMIT [] 4 AMENDED PERMll' [] 6 TEMPORARY TANK CLOSURE [] 8 TANK REMOVED t BBA OR FACILITY NAME WHERE TANK IS INSTALLED: {~),.~-'~_./.~ I, TANK BESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOW[q c. DATE ,NSTALLED(MO~AY~EAR) I t ,~ o. TANK GAPAC,~ ,N GALLONS: 020~ I1. TANK CONTENTS ~F A-1 ~S MARKED. COMPLETE ~TEM C. * ' lb PREMIUM UNLEADED [] 4 GASAHOL [] 7 METHANOL PETROLEUM [] 60 EMPTY 1 PRODUCT [] ,~ .,o~.~ u.L~oE~ [] ~ JET FUEL [] ~ M~ [] 3 CHEMICAL PRODUCT [] 95 UNKNOWN 2 WASTE [] 2 LEADED [] 99 OTHER (DESCRIBE IN ITEM D. BEL0W) D. IF (A. 1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. #: III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, ANrlC, ANDALLTHATAPPLIESINBOXDANDE A, TYPE OF '~ 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR UNER [] 5 INTERNAL BLADDER SYSTEM [] 95 UNKNOWN SYSTEM ~ 2 SINGLE WALL [] 4 SINGLE WALL IN A VAULT [] 99 OTHER 2 STAINLESS STEEl.. '~ 3 FIBERGLASS [] 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC 1 BARE STEEL B. TANK MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM [] 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) [] 9 BRONZE [] 10 GALVANIZED STI-'EL [] 95 UNKNOWN [] 99 OTHER C. iNTERIOR [] 1 RUBBER UNED [] 2 ALKYD LINING [] 3 EPOXY LINING [] 4 PHENOLIC~c.~LINI~N~ u.,.GOR [] ~ GLAss L,.'NG [] 6 UNL,NED []..~..UNKNOWN ~ ~ OTHER .r,,~ COATING is LINING MA~RIAL COUPA~SLE WITH 1~ METHANOL? YES_~. NO__ O. EXTERIOR [] 1 POLYETHYLENE WRAP [] 2 CoA'nNG [] 3 VINYL WI~P [] 4 F)BERGLASS RE)NFORCED PLAST)C CORROSION PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE [] 95 UNKNOWN [] 99 OTHER sP,LL CONTA,.ME";:,.~TA'LED ~R) I ~ ~ ,~L_ ' '~ '~ ¢/ OVERFIL~PREVENTION EQUIPMENT INSTALLED (YEAR) II - E. SPILL AND OVERFILL, etc. DROP TUBE YES ~ NO 'sTRIKER PLATE YES tl~ NO DISPENSER CONTAINMENT ;FRS ~ NO __ IV. PIPING INFORMATIO~N.~ CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A, SYSTEM TYPE A '~ SUCTION A (.~ 2 PRESSURE A U 3 GRAVITY A ~ FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A(~ 2 DOUBLE WALl. A U 3 ENED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARESTEEL A U 2 STAINLESS S;rEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING Al,[ 8 100% METHANOL COMPATIBLEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A('~) 99 OTHER ~'~II¥~A ~ [%) D. LEAK DETECTION r--11 MECHANICAL UNE IF. AK [~ 2 UNE TIGH'rk~SS [] 3 COI~NUO~S INTERSTIq3AI. [] 4 ELECTRONIC UNE [] 5 AUTOMATIC PUMP ~ DETECTOR ~ TESTING MONITORING LEAK 0;TECTOR SHUTDOWN [] 99 OTHER V. TANK LEAK DETECTION I[] . v,su~ C.ECK [] ~ ~.u~ I.VE.TOR~ [] ~ VADOZE [] ~ AUTOMAT,C TANK [] 5 ~ROUND WATER [] 6 ANNUALTANK RECO.C,~AT.ON MON,TOR,.G GAUG,N~ MON,TORING [] ~ CON..UOUS,.TERS.TIAL [] ~ S,R[] ~ .EEKLY ~NUAL [] 10 MONT.LY TANK [] ~5 UNK.OW.[] 9~ UT. ER MONITORING TANK GAUG,N~ TESnNG VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE mN-PLACE) I1. EsTI~TEo DATE ~ST USED (MO~AY~R) I ~.~MATEO OU~,~ OF I ~' WAS TANK.LLEO ~T. I /% //OBSTANCERE ,N,NG GAL'O.S ,NERTMATER,A. --- '' '---'' THIS FORM HAS BEEN C~)MP~ETED UNDE,~[.,~N~-.~ OF PER'JURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT I TANK OWNER'S NAME I [ ~- ~"~/'/ I DATE ~ i.D;/~ COUNTY # JURISDICTIOt4 # .FACILrI'Y # TANK # STATE I-W1 I] II I Illl THIS FORM MUST BE ACCOMPANIED BY l PERMIT APPLICATION - FORM A, UNLESS l CURRENT FORM l HAS BEEN RLED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Reg ]lations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners t,) apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all iN EW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENC'~ UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 co 2ies~ 5. Tank owners must submit a plot plan to the local agency showing the location of fiqe USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. ' '6. Tank ~)wner~ 'mt~§t submit documentation showing compliance with state financial responsibility require- ment-s to, the local agency for petroleum USTs [2711 (a)(I 1) CCR]. TOP OF FORM: M/IRK ONLY ONE ITEM 1. Mark an (X) in the box next to'he item that best describcs the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank-is,installed. I. TANK DESCRIPTION - COMPLETE ALL ITEMS - tF UNKNOWN - SO SPECIFY A. Indicate owners tank ID # - If there is a tank number that is used by ihe owner to identify the tank (ex. AB70789). B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG). ~.. C. Indicate the year the tank was installed (ex. 1987). --. D. Indicate the tank capacity in gallons (ex. 25,000 or 10,003 etc.). II. TANK CONTENTS -~- A. 1. IF M.DTOR VEHICLE FUEL, check box 1 and complele items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D.' B. Check t,~e appropriate box. C. Check the type of MQT,OR VEHICLE FUEL (if box 1 is checked in A). D. Print th~; chemical name of the hazardous substance sto 'ed in the tank and the C:A.S.#. (Chemical Abstracl Service number), if box1 is NOT checked in A. III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A, B, C & D. -.:1-:.-.__. Check only One item in TYPE OF SYSTEM, TA_.N..K..M. ATERIAL INTERIOR LINING an.d CORROSION - 7 - PROTECTION. , ?- - - - ~ ,, ~.~ 2. If OTHER, print in the space provided. ¢=. IV. PIPING INFORMATION u 1. Circle""A" if above ground circle "U" if underground, and :ircle-both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provided. - 3. Ir~dicate the LEAK DETECTION system(s) used to comp'y with the monitoring requirement for the piping. .... V ...... .TA~K. LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to cc;m~)ly with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CI..OSED Ih PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR (Janu,]ry, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3: WAS TANK FILLED WITH INERT MATERIAL? Check '"Yes" or "No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIG_N. AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES ....... The State underground storage tank identification number is composed of ~he two digit county number, the three digit jurisdi~:tion number, the six digit facility number and the.si.~ ~git tank nt~'nber. The county and. jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. The facili,ty number~must be the same as shown in form "A". The tank number may be assigned by the local agencl, however, thiS'number m'~st be numerical and cannot contain an alphabet. If the local agency prefers the State Board tc assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE ,FAClLITY TO VERIFY THE AC:CU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY US'--ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL ,AND YELLOW COPIES. TI4E PINK COPY SHOULD BE RETAINED BY T-tE TANK OWNER. STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM El · COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK oNLy ~ 1 NEW. I~ERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION ONE ITEM[] 2 iNTERIM PERMIT [] 4 AMENDED PERMIT [] 6 TEMPORARY TANK CLOSURE [~. 8 TANK REMOVED · DBA OR FACILITY NAME WHERE TANK IS INSTALI:ED:~ I, TANK DESCRIPTION COMI~LETE ALL ITEMS - SPECIFY IF UNKNOWN II, TANK CONTENT~ ~ ~-~ ~s U~R~ED, CO~.~ ~U C. , ~1 MOTORVEHIC~ FUEL ~ 4 OIL 'B' ~ C*' ~-laREGU~UNL~ ~ 3 DIESEL'' '~ 6 AVIATION GAS ' ''' ' ' lb PREMIUM. UNL~ ~ 4 GAS~0L ~ 7 METHANOL '~ ? CHEMICAL PRODUCT ~' ~5 uNKNOW~ 2 WASTE ~. 2 ~DED ' ' : ~ 99' O~ER (DESCRIBE IN ~ O. BEL0~ D. 'IF (A.i) IS NOT MARKED EN~R N~E 0F SUB~ANC'E STORED . III.' TANK coNsTRUCTION : a*RX ONS,~M 0NLr iN BOXES A. ~. ANt C. ~9 A~ ~AT APPL,~S ,N aOX O AND ~ A, ~PEOF~ 1 DOUBLE WA~ ~ 3 SINGLE WA~. Wl~ E~RIOR UNER ~ '5 IN,REAL B~DDER ~S~M ~' 95 UNKNO~ · SYSTEM . 2 SING~.WALL' ~ 4 SINGLE WALL-IN A VAULT ' ~ 99 OTHER a. TANK ~ 1 B~RE S~EL ~ 2 STAINLESS S~E~ ~ 3 FIBERG~SS ~ 4 S~ELC~D W/FIBERG~SS REINFORCED P~STIC. ~RIAL' ~ 5 CONCR~ ~ 6. POLWlNYL CHLORIDE~ 7 ALUMINUM ~ 8 100% M~ANOL COMPATIBLE W~RP C.I~ERIoR ~ 1 RUBBER UNED' ~ 2' AL~D LINING. ~ 3 EPO~ UNING ~ 4 PHENOLIC LINI~ COATING' IS LINING M~RIAL COMPATIB~ WI~ 1~ ME~ANOL? YES~ NO D,~RIO~ ' ~ 1 POLY~YLENE ~P ~ 2 COA~NG ~ 3 VINYL WRY. ~ 4 FIBERG~SS REINFORCED P~STIC C0RROSlON PROTEC~0N ~ 5 CA~0~IC'PRO~C~ON ~ 91 N~NE ', ~;~ ~ 95 UNKNOWN ' /~ 99 OTHER ~ ................. ' SPI~ CONTAINMEnt I~TAL~D ~R)-~L OVERFIhL~REVEN~ON EQUIPMENT INS~AL~D (Y~R) E, ~FILE A~U UVEH~ILL, eI¢. DROPTUBE YES~ NO ' STRIKERP~TE YES ~ . NO' ' . DISPENSER CONTAINMENT ~ES~ NO IV~'PIPING INFORMATIO~.~ . CIRCLE A IF ABOVE GROUND OR U 1F LINDERGROUND. BOTH IF APPLICABLE B, CONS~UC~ON A U '~ 'SING~ WALL .., t '~UBLE WA~. A U 3 UNEO mENCH ~ U 95 UNKNOWN A U 99 OTHER C, aA~RIALAND A U'~I. BARE~EE". . 'A U,,.2 STAINLESS ~EL A U 3 POLWlNYL CHLORIDE (PVC)A U 4 FIBERG~SS PIPE' PROTEC~ON A U '9 ~LV~IZ~D STEEL' A 'U 10 CA~ODIC. P~O~C~ON A U 95 UNKNO~ A V. TANK LEAK'D~ECTION ' " . . ' MONITORING · ~ ' . TANK GAUGING . TES~NG VI. TANK CLOSURE INFORMATION (P~RM~ENT cLOSu.E ~N-P~CE:~ INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 27t 1 of Title 23, Division 3, Chapter 16, California Code of Reg ~lations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners t) apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all Ik EW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT AF PLICANT or the LOCAL AGENCY; UNDER-. GROUND TANK INSPECTOR. 3. Please [ype or print clearly alt requested information. 4. Use a hard point writing instrument, you are making 3 copies~ 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. 6. Tank bwner~'mU§t submit documentation showing comp lance with state financial responsibility require~ merits t,:~ the local agency for petroleum USTs [2711 (a)(l 1) CCR]. TOP OF FORM: MARK ONLY ONE IT. EM 1. Mark an (X) in the box next to-(he item that best describe s the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank-is, installed. I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF L NKNOWN- SO SPECIFY A. Indicate. owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG).. ~ C. Indicate the year the tank was installed (ex. 1987). --_ D. Indicate the tank capacity in gallons (ex. 25,000 or 10,0C0 etc.). II. TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and complete items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate'box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MQTOR VEHICLE FUEL (if box 1 is checked in A). D. Print the chemical nam~ of the hazardous 'substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1 .is NOT checked in A. III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A, B, C & D · ....... t-. Check only one item in TYPE OF SYSTEM, TA.N.K.M_ATL:RIAL INTERIOR LINING and CORROSION - PROTECTION. , ....... .. '2-. If OTHER, print in the space provided. IV. PIPING INFORMATION ...... ' 1. Circle"W' if above'ground circle "U" if underground, and circle-both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provide, J. - 3. Indicate, the LEAK DETECTION system(s) used to comply with the monitoring requirement for the Piping. ...V ..... .TANK. LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to com~)I~ with the monitoring requirements'for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED Ihl PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check "Yes" or "No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, th,,= six digit facility number and the.si~ ~git tank number. The county and jurisdiction numbers are predetermined and car' be obtained by calling the State Board (916) 227. ¢303. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency, however, this-number must be numerical ~nd cannot contain an alphabet. If the local agency prefers the State Board to assign the tar)k number, ple,ase leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPI:CTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL A. GENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER. STATE OF CAUFORNIA ~~ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY [] 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION [] 7 PERMANENTLY CLOSED ON SITE ONE ITEM [] 2 INTERIM PERMIT [] 4 AMENDED PERMIT [] 6 TEMPORARY TANK CLOSURE [] 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL I~MS - SPECI~ IF UNKNOWN C. DATE INSTALLED (MO~AY~EAR) / I/ ~ D. TANK CAPACI~ IN GALLONS: II, TANK CONTENTS ~F A-~ ~S MARKED, COMPLAN ~M C. P~ROLEUM ~ SO EMP~ ~' 1 PRODUCT lb PREMIUM UNLmm ~ 4 GASAHOL ~ 7 MEmANOL ~ 3 CHEMICAL PRODUCT ~ 95 UNKNOWN 2 WASTE ~ 2 ~ADED ~ 99 O~ER(DESCRIBEINffEMD. BEL0~ D. IF (A. 1) IS NOT MARKED, EN~R NAME OF SUBSTANCE STORED C.A.S. ~: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, ANDC, ANDALLTHATAPPLIESINBOXDANDE A. TYPE OF ~ I DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR UNER [] 5 INTERNAL BLADDER SYSTEM [] 95 UNKNOWN SYSTEM [~' 2 SINGLE WALL [] 4 SINGLE WALL IN A VAULT [] 99 OTHER B, TANK [] 1 BARE STEEL [] 2 STAINLESS STEEL 1~ 3 FIBERGLASS [] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE[] 7 ALUMINUM [] e 100% METHANOL COMPATIBLE W/FRP (PrimaryTa~k) [] 9 BRONZE [] 10 GALVANIZED STEEL [] 95 UNKNOWN [] 99 OTHER ~ ~ 1 RUBBER UNED [] 2 ALKYD LINING [] 3 EPOXY LINING [] 4 PHENOLIC LINING c, LININGiNTERIOR0" [] 5 GLASS LINING [] S UNLINED []· ~95 UNKNOWN ~ 99 OTHER ~ ~ ~ COATING IS LINING MATERIAL COMPATIBLE WITH 10~ METHANOL? YES~ NO__ r D. EXTERIOR [] 1 POLYETHYLENE WRAP [] 2 COATING [] 3 VINYL WRAP [] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE [] 95 UNKNOWN [] 99 OTHER . sPiLL CONTA,NME~,,>TALLED ~R) ~ ~,~ 1~ OVERF'-U-J'REVENTION E~U~PMENT,NSTALLED {Y~R~ ~ ~a E. SPII. L AND OYERFILL, Bt¢. DROP TUBE YES ~ NO ~STR~<ER P~TE YES ,~. NO D~SPENSER CONTAINMENT ~ES ~ NO I¥. PIPIN~ INFORMATIO~_c~..~t~.~ C~RCLE A I~ ASOVE.~ROUND OR U ~F UNDERGROUNO, BOTH ~ APPUCABLE A, SYSTEMTYPE A "~1 SUCTION A U~2 PRESSURE AU 3 GRAVITY A~;1~)4 FLEXIBLE PIPING AU 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A[~U~ 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARESTEEL A U 2 STAINLESS S~EEL A U 3 POLYVlNYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE C0RR0Sl0N A U 5 ALUMINUM A U 6 CONCRE~ A U 7 STEEL W/ COA~NG AI~ 8 ~00% METHANOL COMPATIBLEW/FRP (u) [] 1 VISUAL CHECK [] 2 MANUAL INVENTORY ~ O VADOZE ~ 4 AUTOMATIC TANK [] 5 GROUND WATER [] 6 ANNUALTANK J RECONCILIATION MONITORING GAUGING MONITORING TESTING [] 7 CONTINUOUS INTERSTITIAL [] 8 SIR [] g WI--EKLY MANUAL [] 10 MONTHLY TANK [] 95 UNKNOWN [] 99 OTHER MONITORING TANK GAUGING TESTING VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE;~ I1' ESTIMATED DATE LAST USED (MO/DAY/YR) GALLONS I3' WAs TANK FILLED wlTHINERT MATERIAL ? YES[] NO[] THIS FORM HAS 3F PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT LOCAL AGENCY USE NUMBER IS COMPOSl-'D OF THE FOUR NUMBERS BELOW I COUNTY # JURISDICTION # FACILITY # TANK # STATE ' III I PERMIT EXPIRATION DATE PERMIT APPROVED BY/DATE I PERMIT NUMBER THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THiS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WTTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ~ FORM 8 (~95) .- - INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Reg ~lations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners t,) apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all IN EW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT AP PLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please [ype or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. 6. Tank owners must submit documentation showing comp iance with state financial responsibility require- ments to the local agency for petroleum USTs [2711 (a)(11) CCR]. TOP OF FORM: MARK ONLY ONE ITEM t. Mark an (X) in the box next to the item that best describ~ s the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF L NKNOWN - SO SPECIFY A. Indicate. owners tank ID # - tf there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate the name of the company that manufactured th~ tank (ex. ACME TANK MFG). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,0C0 etc.). II. TANK CONTENTS A. 1. tF MOTOR VEHICLE FUEL, check box 1 and complete items B & C. 2. If nol MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box 1 is ci~ecked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1 is NOT checked in A. III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A, B, C & D 1. Check only one item in TYPE OF SYSTEM, TANK MATI:RIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER, print in the space provided. IV. PIPING INFORMATION t. Circle 'W' if above ground circle "U" if underground, and circle both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provide'l. 3. Indicate, the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to compI~ with the monitoring requirements for the tank. VI. INFORMATK)N ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL.? Check "Yes" or "No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and car, be obtained by calling the State Board (916) 227-~303. The facility number must be the same as shown in form "A". '~'he tank number may be assigned by the local agency, however, this number must be numedcat ~nd cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT tNSPI=CTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ~ 1 NEW PERMIT [~ 3 RENEWAL PERMIT ~ 5 CHANGE OF INFORMATION ~ 7 PERMANENCY CLOSED ON SITE] ONE ~EM~ 2 INTERIM PERMIT ~ 4 AMENDED PERMIT ~ 6 TEMPORARY TANK CLOSURE ~ 8 TANK REMOVED I DBA OR FAClLI~ NAME WHERE TANK IS INSTALLED: ~ O I. TANK DESCRIPTION COMbL~ ALL ~MS - S.~C~ ~F UN~NOW~ C. DATE INSTALLED(M~AY~EAR) [ D. TANK CAPACI~ IN GALLONS: II, TANK CONTENTSIFA-1 ISMARKED, COMPL~EI~MC, lc MIDG~E U~DED ~ 5 JET FUEL ~ 8 M85 ~ ~ C"~M~C~PROOUCT ~ 9S UNKNOWN ~ ~ WAST~ ~ ~ mADE~ ~ 9~ O~R(~SCR~E~N~E~.~0~ O. ~F (~)~S NOT MA.KED, ~N~R NAM~ OF SUSSTANC~ STORE~ C.A.S. III. TANK CONSTRUCTION MARK ONS ~TSM ONLY ~N ~OX~S A. ~. AND C. AN~ ALL ~AT APPU~S ~N SOX O ANO ~ A. ~PE OF ~' 1 DOUBLE WA~ ~ 3 SINGLE WALL WIT E~ERIOR UNER ~ 5 I~RNAL B~DER ~M ~ 95 UN~O~ SYSTEM ~ 2 SING~ WALL ~ 4 SINGLE WALL IN A VAULT ~ 99 OTHER ~'3 B. TANK ~ 1 BARE S~EL ~ 2 STAINLESS S~EL. FIBERG~SS ~ 4 S~EL C~D W/FIBERG~SS REINFORCED P~STIC MA~RIAL ~ 5 CONCR~ ~ 6 POLWINYL CHLORIDE ~ 7 ALUMINUM ~ 8 100% ME~ANOL COMPATIBLE W/FRP (Prima~Tank) ~ 9 BRONZE ~ 10 GALVANIZED STEEL ~ 95 UNKNOWN ~ 99 OTHER C. I~ERIOR ~ ~ RUBSER UNED ~ 2 AL~D UN,Ne ~ 3 EPOXY UNPEG ~ 4 PHENOUC UNPEG LINING 0g ~ 5 G~SS LINING ~ S UNLINED ~ 95 UNKNOWN ~ 99 OTHER COATING IS LINING ~RIAL COMPA~BLE WI~ 10¢~ ME~ANOL? YES~ NO~ D. ~RIOR ~ ~ POLY~YLENE W~ ~ 2 COA~NG ~ 3 WNYL WRAP ~'4 F~BERG~SS RE~NFORCED P~ST~C CORROSION PROTEC~ON ~ 5 CA~ODIC PRO~C~ON ~ 91 NONE~' ~ ~ ~ 95 UNKNOWN ~ 99 OTHER ................. IV. PIPING INFORMATI~N~-~ C~RCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE B. CONS~UC~ON A U I SING~ WALL A ~2 ~UBLE WAU. A U 3 LINED ~ENCH A U 95 UNKNOWN A U 99 OTHER C. MA~RIALAND A U I BARES~EL A U 2 STAINLESS S'~EL A U 3 POL~INYL CHLORIDE(PVC)A U 4 FIBERG~SS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCR~E A U 7 S~EL W/ COATING A U 8 100% METHANO~ COMPATIBLEW~P PROTEC~ON A U 9 ~LV~IZED ~EEL A U 10 CA~ODIC PRO~C~ON A U 95 UNKNOWN A ~ 99 OTHER D. LEAK D~CTION ~ 1 ~ ~E ~ ~ 2 UNE ~ ~ ~NU~S I~ ~ 4 E~IC UNE ~ 5 A~O~C PU~ ~OR ~ ~S~NG MO~ L~ ~OR ~ ~ 99 O~ER V. TANK LEAK D~EC~ON MONITORING TANK GAUGING TES~NG VI. TANK CLOSURE INFORMATION (PS,MANSNT CLOSU"~ ~N-P~C~) ~ ~ 1. ES~MA~D DA~ ~T USED (MO~AY~R) ESTIMA~D QUANTI~ OF 3. WAS TANK FILLED WITH YES SUBSTANCE RE~INING G~LONS INERT MATERIAL ? THIS FORM HAS BEEN OF PE~'JURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT  TANK O~ER'S ~ ~ DATE LOCAL AGENCY USE I.D. NUMBER IS COMPOSED OF~E FOUR NUMBERS BELOW COUN~ ~ JURISDICTION ~ FAClLI~ ~ TANK STATE . ' I 13 I I I I I I I I I I I PERMIT NUMBER ~ PERMIT APPROVED BY~ATE PERMIT ~PIRATION DATE ~IS FORM MUST BE ACCOMPANIED BY A PERMIT APPMCA~ON - FORM A, UNLESS A CURR~T FORM A HAS BE~ FILED. FORM C MIJST BE COMPLIED FOR IN~AL~ONS. ~IS FORM SHOU~ BE ACCOMP~IED BY A PLOT P~. R~ ~IS FORM W~ ~E LOCAL AGENCY IMP~NG ~E UNDERGROUND STORAGE T~K REGU~ONS FORM B (6-95) INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Reg Jlations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners t) apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all I~ EW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. , 2. This form should be completed by either the PERMIT AF PLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly alt requested information. 4. Use a hard point writing instrument, you are making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. 6. Tank owners must submit documentation showing comp lance with'state financial responsibility require- ments t~ the local agency for petroleum USTs [2711 (a)(1 I) CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describ(s the reason the form is being completed. 2. Indicate the DBA or Facility n~tr~e where the tank' is installed. I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF UNKNOWN -SO SPECIFY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG): C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). II. TANK CONTENTS ; - A. 1. tF MOTOR VEHICLE FUEL, check box 1 and complete items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box t is checked in A). D. Print the chemical name of the hazardous substance sto 'ed in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1 .is NOT checked in A. III. TANK CONSTRUCTION' MARK ONE ITEM ONLY IN BOX A, B, C & D . -1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION ..... PROTECTION. .. ' ..... -2. tf OTHER, print in the space provided. " IV. PIPING INFORMATION u 1. Circle'-~'A'' if above ground circle "U" if underground, and :ircle~.both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provided. 3. Indicate the LEAK DETECTION system(s) used to comp y with the monitoring requirement for the piping. V. . TANK LEAK DETECTION 1. .Indicate the LEAK DETECTION system(s) used to cdr~ply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED I1~ PLACE t. ESTIMATED DATE LAST USED - MONTH/YEAR (Janu~zry, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check '"f'es" or "No". - TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) CCR] '~ ,. INSTRUCTION FOR THE LOCAL AGENCIES ' '~ ¢ ~ The state underground storage tank identification number is composed :f the two digit county numbe[, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county a/~d jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-,1303. The facility-8,umber r~ust be the same as shown in form "A". The tank number may be assigned by the local agenc'f, however, this number mu§t be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, pleas,e leave.it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONS BLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION-BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED. BY THE TANK OWNER. · STATE OF CALIFORNIA "' STATE WATER HESOURCES CONTROL BOAHD UNDERGROUND STORAGE TANK PER~IT APPLICATION - FORM B c0~.LE~ ~ SEP~.~T~ ~0.. ~O. E~C. T~.~ S~S~. ONE ELM ~ 2 ~NTenlU PERMIT ~ 4'AMENDED PERMIT ~. 6 TEMPORARY TANK CLOSURE ~. 8 TANK REMOVED ' DBA OR FAClLI~ NAME WHERE TA.K ~S ~.STALLED: ' ~ I. TANK DESORIPTION COMPL~ ALL ITEMS -~ SPeC~ ~F UNKNOWN C. DATE ,NSTALLED'(MO~AY~EAR).-. l~ ~ D. TANK CAPAC,~ ,N G~LLONS; I1. TANK CONTENTS ~F A-1 IS MARKED. OOMPL~E I~M C. ~ 1 .MOTOR VEHIC~ FUEL '~ 4 OIL B. C. ' ~ la REG"~ UN'Om ~ 3 DIESEL ~ 6 AVIATION GAS ' ~ lb PHYLUM UNL~ ~ 4 GASAHOL ~ 7 ME~ANOL · ~2 .P~ROLEUM' ~ 80 EMPW ~1 PRODUCT~. 1~ MIDGES U~DED ~ 5 JETFUEL ~ S MS5 ~ 3 CHEMICAL PRODucT ~ 9~ UN~OWN ~ 2 WASTE ~ 2 ~DED , . ~ 99 0~ER(DESCR1BEINITEMD. B~0~ D. IF (A?.) IS NOT M~KED, ENTER N~E OFSUBSTANCE STORED :' C.A.S.~: ' .. III, TANK CONSTRUCTION MARK ONE I~M ONLY IN BOXES A, B, ANDC,~DALL~ATAPPLIESINBOXDANDE A. ~PE OF ~ 1 DOUBLE WA~ ~ 3 SINGLE WALL Wl'm E~ERIOR UNER ~ 5 I~RNAL B~DER ~M' ~ 95 UN~0~ SYSTEM ~ 2 SING~ WALL ~ 4 SINGLE WALL IN A VAULT ~ 99 OTHER B, TANK ~ I BARE S~EL ~ 2 STAINLESS S~EL ~ 3 FIBERG~SS ~ 4 S~EL C~D W/FIBERG~SS REINFORCED P~STIC MA~RIAL ~ 5 CoNcR~E ~ 6. POLWlNYL CHLORIDE ~ 7 ALUMINUM ~ 8 100% METHANOL COMPATIBLE W~RP (prima~T~k) ~ 9' BRONZE ~ 10 GAWANIZED STEEEL ~ 95. UNKNOWN ~ 99 OTHER C. INTERIOR ~ 1 RUBBER UNED ~ 2 AL~D LINING ~ 3 EPO~.UNING ~ 4 PHENOLIC LINING LINING OR ; ~ 5 G~SS MNING ~ 6 UNUNED ~ 95 UNKNOWN ~ 99' OTHER ~ ~ COATING IS UNING MA~,IAL COUPATlaLE WI~ 1~ UE~ANOL? YES NO D. ~RIOR ,~ ~ POLY~YLENE W~P ~ 2 COA~NG ~ 3 VINYL WRAP . ~4 FIBERG~sS REINFORCED P~ST~C ' CORROSION PROTEC~ON ~ 5 CA~ODIC PRO~C~ON ~ 91 NONE ~ 95 UNKNOWN ~ 99 OTHER ' E. SPILL AND:OVERFILL, etc. DROP TUBE' YES ~ NO, STRIKER P~TE YES ~" NO ' - DISPENSER CONTAINMENT' YES · ~ NO IV. PIPING INFORMATI~N~ c~,c~E A IF ABOVE GROUND OR U IF LINDERGROUND. BOTH IF APPLICABLE A. SYS~B~PE :A ~ SUCTION A ~2 PRESSURE A U 3 GRAVI~ A~4 ~IBLEPIPING A U 9g OTHER . ' B. C0NS~UC~0N A U 1 SING~ WALL A 2 ~UBLE WA~. A U 3 UNED ~ENCH A U 95 UNKNOWN A U 99 OTHER C. MA~RIALAND A U I BARES~EL A U.. 2 sTAiNLESS S3~EL A U 3 POL~INYL CHLORIDE(PVC)A 'U 4 FIBERG~SS PIPE coRRosioN . u ~ *LU.,... ~ U ~ CO.O.~. ~ U ~ ~.~W, OO*...~ * U . ,00% ""~.~"O~ OO.~W~. PROTEC~0N A U 9 ~LV~IZED STEEL A U"10 CA~ODICPRO~C~ON A U 95 UNKNOWN A~g9 OTHER ~VJ~ ~. ~. L~K .~c~o. ~' .c~,~ u.. ~ ~ ~ ~..~..~ ~ ~.N.~S ~ ~..~o.,c.~ ~ ~ *.o~c .u. ~ ~. o~..~ ~OR ~S~ MO~T~ING ~ ~OR V. TANK LEAK D~ECTION ~ . v,s.~ c.~c. ~ 2 ~.U.L ,.vE~oR~ ~ ~ ~A~Z~ ~4 *.~O.*~C ~*.. ~ ~ G.OU.~ W*T~. ~ ~ *..U*LT*".I R~CO.C~,*T,O. ~ .O.~O.~.G G*UG,.G .O.~O.,.G ~S~.G , ~; CO~..O.S ~.~.S~ ~ . ~,. ~ ~ WE~.L~ .*..*L ~ ,0.0.~L~ ~*.. ~ .~ U...OW. ~ .. I MONITORING , T~NK GAUGING TES~NG ' VI. TANK CLOSURE INFORMA~ON [PERMANE.T CLOSURE ~N:P~CE: ~ ~. 1. ES~MA~D DA~ ~ST USED (MO~AY~R) .... I~ ESTIMA~D QUA~I~ OF ~ 3. WASTANK FILLED ~TH YER' ~ ' NO I · . . ' , . ~/~..~.*.C.R~.*,.,.~ ~o.~ I ' '"""~"*~"'*~?' ' ' - ~ ' ~ ~ .' '1 TANK OWNER'S N~E~ ,~ ' '~ ~ ' , ~ :' ," . . I DATE ' · LocAL AG~.CY usE.~LY/~s~ L~ .U~.E. ,S CO.POSE~ O~ T.E ~OUR.U'..E.S.ELOW · ' ',. ' / ~ / ~ couN~ ~ JURISDiCTION~ ~ FACIL~ ~ . . ' ' TANK ~ · " STATE I D:~ FORM B (&95) INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Tide 23, Division 3, Chapter 16, California Code of Reg Jlations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners t) apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all tk EW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT AF PLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. 6. Tank owners must submit documentation showing comp lance with state financial responsibility require- ments to tl~e local agency for petroleum USTs [2711 (a)(11) CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describ~.s the reason the form is being completed. 2. Indicate the DBA or Facility n~e where the tank is inststled. I. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF L NKNOWN - SO SPECIFY A. Indicate. owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate. the name of the company that manufactured th~ tank (ex. ACME TANK MFG). C. Indicate. the year the tank was installed (ex. 1987). , D. Indicate. the tank capacity in gallons (ex. 25,000 or 10,0C0 etc.). II. TANK CON'I"ENTS A. 1. IF MOTOR VEHICLE FUEL, check box I and complete items B & C. 2. If not MOTOR VEHICLE FUEL, checkthe appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box 1 is c ~ecked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box I is NOT checked in A. III. TANK CONSTRUCTION--MARK ONE ITEM ONLY IN BOX A, B, C & D .t .. Check only one item in TYPE OF SYSTEM, TANK MATI:RIAL, INTERIOR LINING'and CORROSION PROTECTION. - '2. If OTHER, print in the space provided. IV. PIPING INFORMATION -, 1. Circle"A'' if above ground circle "U" if underground, and circle both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provided. 3. Indicate the LEAK DETECTION system(s) used to coml: ly with the monitoring requirement for the piping. V. . TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to cer~pl~' with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED II'1 PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR (January, 1988 or 01/88) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS T,&NK FILLED WITH INERT MATERIAL? Check "Yes" or "No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN. AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) OCR] INSTRUCTION FOFi. THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank n~mber. The county a~d jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-¢303. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency, however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPI~CTS THE FACILITY TO VERIFY THE ACCU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AG~ENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY 'filE TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM COMPLETE A SEPARAT;E FORM FOR EACH TANK SYSTEM. MARK ONLY ~ 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION [] 7 PERMANENTLY CLOSED ON SITE ONE ITEM [] 2 INTERIM PERMIT [] 4 AMENDED PERMIT [] 6 TEMPORARY TANK CLOSURE [] S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0 ~ ~'J~ Y~' I. TANK DESCRIPTION COMI~LETE ALL ITEMS- SPECIFY IF UNKNOWH A. OWNER'S TANK I.D.' ~'3 B. MANUFACTURED BY: ~f ~{ (~,j'~ J I1. TANK CONTENTS ~F A-~ ~S MA.~., COM.~ ~U C. ~ g'; MOTORVEHIOLE FUEL ~ 4 OIL B. C. ~ laREGU~RUNL~ ~ 3 DIESEL ~6 AVIATIONGAS P~ROLEUM ~ 80 EMPW ~1 PRODUCT lb PREMIUM UNL~ ~ 4 GASAHOL ~ 7 ME~ANOL lc aI~EU~DED ~ 5 JET FUEL ~ 8 M85 ~ 3 CHEMICAL PRODUCT ~ 95 UNKNOWN ~ 2 WASTE ~ 2 ~ADED ~ 99 0~ER(DESCRIBEIN~MD. BEL0~ D. IF (A. 1) IS NOT MARKED, EN~R N~E OF SUB~ANCE STORED C.A.S. ~: -:" ' IlL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF r~ 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR UNER [] 5 INTERNAL BLADDER SYSTEM [] 95 UNKNOWN SYSTEM [] 2 SINGLE WALL [] 4 SINGLE WALL IN A VAULT [] 99 OTHER B. TANK [] 1 BARE STEEL [] 2 STAINLESS STEEL. [~ 3 FIBERGLASS [] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL [] 5 CONCRETE [] S POLYVINYL CHLORIDE [] 7 ALUMINUM [] e ~00°/o METHANOL COMPATIBLE W/FRP (PrJmaryTallk) [] 9 BRONZE [] 10 GALVANIZED STFEL [] 95 UNKNOWN [] 99 OTHER C. iNTERIOR [] I RUBBER UNDO [] 2 ALKYD LINING [] 3 EPOXY UNING [] 4 PHENOLIC LINING LINING OR [] 5 GLASS UNING [] 6 UNUNED [] 95 UNKNOWN [] 99 OTHER F 1~ COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES ~ NO__ D. EXTERIOR [] 1 POLYETHYLENE WRAP [] 2 COATING [] 3 VINYL WRAP J~4 FIBERGLASS REINFORCED PLASTIC CORR0Sl0N PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE [] 95 UNKNOWN [] 99 OTHER ..... ~ IV. PIPING INFOR~ATIONn ,~ cmcLE A ~F ABOVE ~ROUNO OR U ~F UNDERanOUNg, SOTH ~F APPUCABLE A. SYSTEM ~PE A~ SUC~ON A ~2 PRESSURE A U 3 GRAVI~ A~ 4 FL~IBLE PIPING A U 99 OTHER B, CONS~UC~ON A U 1 SING~ WALL A ~2 ~UBLE WALL A U 3 ENED ~ENCH A U 95 UNKNOWN A U 99 O~ER C. MA~RIALAND A U I BARE.EL A U 2 STAINLESS S~EL A U 3 POL~INYL CHLORIDE(PVC)A U 4 FIBERG~SS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCR~E A U 7 S~EL W/ COATING A U 8 100% METH~NO~ COMPATI~LEW~P PROTEC~ON A U 9 ~LV~IZED STEEL A U 10 CA~ODICPFIO~C~ON A U 95 UNKNOWN A~99 OTHER [~J~ ~ ~ D. LEAK D~ECTION ~ 1 MEC~ UNE ~ ~ 2 aNN ~ ~3 c~mNu~S I~A ~4 ~lC aNN ~ 5 A~O~C ~ ~ ~OR ~ MOI~T~ING ~ D~OR ~ ~ 99 O~ER - V. TANK LEAK D~ECTION J ~ 1 VlSU~ 6HECK ~ 2 BNUAL INVE~ORY ~ 3 Vi~ZE ~4 AUTO"A~C TANK ~ 5 GROUND WATER ~ 6 ANNUALTANK RECONClUATION ~ONITOHIN6 GAUGING MONITORING ~S~NG ~ONITORING TANK 6AUGIN6 ~S~NG VI. TANK CLOSURE INFORMATION (PERM~ENT CLOSURE IN-P~E) M ¢ LOCAL ~GENCY USE ~LY/-- ~STA~ I.~. NU~BE. IS CO~POS:ED OF~E FOU..U~eE.S aELOW / / Y COUN~ ~ JURISDICTIOH ¢ 'FAClLI~ ~ · TANK ~ STATE I g:¢ PERMIT NUMBER j PERMIT APPROVED BY. ATE ~ PERMIT EXPIRATION DATE I ~IS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICA~ON - FORM A. UNLESS A CURRENT FORM A HAS BE~ FILED. FORM C MUST BE COMPLIED FOR IN,ALl, OHS. ~lS FORM SHOULD BE ACCOMP~IED BY A PLOT P~N. RLE ~lS FORM ~ ~E LOCAL AG~CY IMP~M~NG ~E UNDERGROUND STORAGE T~K REGU~ONS FORM B (~95) INSTRUCTIONS FOR COMPLETING FORM "B" GENERAL INSTRUCTIONS Section 2711 of Title 23, Division 3, Chapter 16, California Code of Reg Jlations and sections 25286, 25287, and 25289 of Chapter 6.7, Division 20, Health and Safety Code require tank owners t :) apply for an UST operating permit. 1. One FORM "B" shall be completed for each tank for all lk EW PERMITS, PERMIT CHANGES, REMOV- ALS and/or any other TANK INFORMATION CHANGE. 2. This form should be completed by either the PERMIT AF PLICANT or the LOCAL AGENCY UNDER- GROUND TANK INSPECTOR. 3. Please [ype or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. 5. Tank owners must submit a plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [2711 (a)(8) CCR]. 6. Tank owners must submit documentation showing comp lance with state financial responsibility require- ments to the local agency for petroleum USTs [2711 (a)(11) CCR]. TOP OF FORM: MARK ONLY ONE ITEM 1. Mark an (X) in the box next to the item that best describ~ s the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. 1. TANK DESCRIPTION - COMPLETE ALL ITEMS - IF LNKNOWN - SO SPECIFY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. indicate the name of the company that manufactured the tank (ex. ACME TANK MFG). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). 11. TANK CONTENTS A. 1. IF MOTOR VEHICLE FUEL, check box 1 and comple[e items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL (if box 1 is checked in A). D. Print thE; chemical name of the hazardous substance Sto'ed in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1 is NOT checked in A. III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A, B, C & D 1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER, print in the space provided. IV. PIPING INFORMATION 1. Circle"A" if above ground circle "U" if underground, and :ircle both if applicable. 2. If UNKNOWN circle; or if OTHER, print in space provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENTLY CLOSED II', PLACE 1. ESTIMATED DATE LAST USED - MONTH/YEAR (Janu.~ry, 1988 or 01188) 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE: remaining in the tank (in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check "Yes" or "No". TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST ,SIGN AND DATE THE FORM AS INDI- CATED [see section 2711 (a)(13) OCR] INSTRUCTION FOR THE LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, 'the three digit jurisdiction number, the six digit facility number and the six digit tank nu ~nber. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agenct, however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board te assign the tank number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE AC:CU- RACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY US'E ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL ,AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY T-IE TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM II. INSTALLATION (mark all that apply): [~he installer has been cedified by the tank and piping manufacturers. [~he installation has been inspected and certified by a registered professional engineer. [~he installation has been inspected and approved by the implementing agency. ~AII work listed on the manufacturer's installation checklist has been completed. [~["'~he installation Contractor has been certified or licensed by the Contractors State License Board. [] Another method was used as allowed by the implementing agency. (Please specify.) III. OATH I certify.tha, t the,inf,orma, tion provided is true to the best of my belief and knowledge. Tank Owner/Age/aL.. ~_.~,~. ~),Ne.,..,~_~-" Date ~,'~ PrintName '.,~0~// '~J('~ Phone (<~1~ Address /~S'~'~' .~.r/) ~-.O~ LOCALAGENCYUSEONLY STATE COUNTY # JURISDICTION # FACILITY # TANK # FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 iNSTRUCTIONS FOR COMPLETING FORM "C": TANK INS'rALLATION CERTIFICATION GENERAL ~NSTR',UCTIONS Fach tank system must be in compliance witll the federal and state technica~ .~tar~dsrds, contained in law and regulations, tot tank and piping installation. 2. This certification shall be completed by either the UST owner or r~presentative. 3. One ceA~fication is required for each tank sy~;tem. This form shall be used to make the required cedification. 4. Please type or print clearly all requested information (for printing, please use a hard po~n~ writing instrument). 5. Su:bmit the completed cedificafion to the a~p?opriate Local Implementing ABency. i. INSTALLJ~TION: MARK ALL OF THE ITEMS THAT APPLY TO INDICATE THAT THE iNSTALLATION REQUIREMENTS ARE i~IET. OATH: THE TANK OWNER OR AGENT SHALL CERTIFY, BY SIGNING THE CERTIFICATION, THAT THE iNFORMATION PROVIDED IS TRUE AND CORREOT. THE PERSON'S NAiVtE SHOULD BE PRINTED UNDER THE ~IGNATURE. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL B CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I. SITE LOCATION STREET ' II. INSTALLATION (mark ali that apply): [~Th ' e installer has been certified by the tank and piping manufacturers. E~'~he installation has been inspected and certified by a registered professional engineer. E~The installation has been inspected and approved by implementing agency. the II work listed on the manufacturer's installallion checklist has been completed. [~he installation Contractor has been certified or licensed by the Contractors State License Board. Another method was used as allowed by the implementing agency. (Please specify.) III. OATH I certify that the,information provided is 'true to the best of my belief and knowledge. Tank Owner/AgehL.., '~..~¢,,,,, ~-,....,,c::~ Date Print Name ,,~0~// ~/3(.j~/~ Phone (~/~' Address /~---~ ~ -~//') ~; (./~ LOCAL AGENCY USE ONLY STATE COUNTY # JURISDICTION # FACILITY # TANK # FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMITAPPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003567 INSTRUCTIONS FOR COMPLETING FORIVI "C": TANK INS'rALLATtON CEF~T~F]C!~TION GENERAL iNSTRUCTIONS Each ~ank sysSern must be in compliance witl~ ~he federal and skate ~echnical s~a~dards, core,air, ed ir~ ~aw smd regulations, 1or ~ank and piping installation. 2. This certification shall be completed by either She UST owner or representative. 3. One certification is required for each Rank sy,'~tem. This form shall be used to make She required certification. 4. Please ~ype or prin~ clearly ali requesSed information (for printing, please use a hard poinS writing instrument). 5. Submit, She completed certificaSion to ~he ~3propria~e Local Implementing Agency. INSTALLATION: ~/tARK ALL OF THE ITEf~tS THAT APPLY TO INDICATE THAT THE iNSTALLATION REQUIREMENTS ARE IVIET, !1. OATH: 'THE TANK OWNER OR AGENT SHALL CEI:~TIFY, BY SIGNING THE ,CERTIF~CATiON, THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. THE PERSON'S NA~E SHOULD EiE PRINTED UNDER THE S~GNATURE. CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I. SITE LOCATION STREET CITY ~j~ ~4..,r'S ~..~l ~,l COUNTY II. INSTALLATION (mark all that apply): [~The installer has been certified by the tank and piping manufacturers. [~he installation has been inspected and certified by a registered professional engineer. [~The installation has been inspected and approved by the implementing agency. E~AII work listed on the manufacturer's installati',on checklist has been completed. [~'i'he installation Contractor has been certified or licensed by the Contractors State License Board. [] Another method was used as allowed by the implementing agency. (Please specify.) III. OATH I certify that the,info, rma_tion provided is t~rue to the best of my belief and knowledge. Tank Owner/^ge Print Name Address LOCAL AGENCY USE ONLY STATE COUNTY # JURISDICTION If FACILITY # TANK # FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROO3SC7 INSTRUCTIONS FOR CO~v'~PLETING FORIVt "C": TANK INSYALLAT~ON CERT~FtC&TION GENERAL INSTRUCTIONS 1, leach tank system must be in compliarme with the federal arid state technica~ 2, This cedificsdon shatl be compleied by either the DST owner o~ represen~stive, 3. One ce~fication is required for each tank system. This form shall be used to m~Ee the required cedification. 4. Please type or pd~ clearly all requested information (for printing, please use a hard poi~ writing ~nstru~ent). 5. Submi~ the comp~e[ed ceAifica~ion to ~he appropriate Loca~ Imp~ementin9 Agency. INSTALLATION: MARK ALL OF THE ITEi~S THA'' APPLY TO INDICATE THAT THE INSTALLATION REQUIRE~/IENTS ARE IVIET. OATH: THE TANK OWNER OR AGENT SHALL CERTIFY, BY SIGNING THE CERTIFICATION, THAT THE ]NF£)R~'~AT]O]~ PROVIDED IS TRUE AND CORRECT. THE PERSON'S NAf~E SHOULD BE PRINTED UNDER THE S~GNATURE. STATE WATER RESOURCES CONTROL BOARD CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM ,. STREET ~ J ~ I ...~/')/O'3 ~ J~¢'~ C,T cOU,T II. INSTALLATION (mark all that apply): [~"'~e installer has been certified by the tank and piping manufacturers. [~"~he installation has been inspected and certiified by a registered professional engineer. ~""~e installation has been inspected and app~roved by the implementing agency. [~"~ll work listed on the manufacturer's installation checklist has been completed. E~"~The installation Contractor has been certified or licensed by the Contractors State License Board. [] Another method was used as allowed by the implementing agency. (Please specify.) III. OATH, I, ceJ'fCfy that the informCJm~p_r_ovided is Irue to the best of my belief and knowledge. Tank Owner/Agent(_, ~(~I,,,~ ~ .Date Print Name ,...~{.)~/'1 "/'~1(.//~ Phone ( ~ ) Address LOCAL AGENCY USE ONLY STATE COUNTY # JURISDICTION ct FACILITY # TANK # TANK,.D.# ~ I I I~ I---I I I I I I I I I I I I I FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORO035C7 iNSTRUCTIONS FOR COIViPLETING FORiVI "C": TANK INSTALLATION CERTIFIC?;~,TION GENERAL INSTFiUCT~ONS L=ach t~nk system must be in compliance with the federal and state technical st~ndards, contained in law and regulations, 'for tank and piping installation. 2. This cedification shalt be completed by either' the UST owner or representative. 3. Or~e certification is required for each tank sy~tem. This form sha~l be used to ~make the required cedification. 4. Pl~as~ type or print clearly ali requested information (for printing, please use a 5. Submit the completed cedificafion to the ap[:ropriate Local implementing Agency. L INSTALLATION: ~ARK ALL OF THE ITEi~S THAT APPLY TO INDICATE THAT THE iNSTALLATiON REQUIREt~ENTS ARE IViET, II. OATH: THE TAN~: OWNER OR AGENT SHALL CERTIFY, BY SIGNING THE CERTIFICATION, THAT THE INFOR~vIATIOH PROVIDED IS TRUE AND CORRECT. THE PERSON'S NA~flE SHOULD BE PRINTED UNDER THE S~GNATURE. STATE OF CALIFORNIA STATE WATER RESOURCES CONTR( CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I.' SITE LOCATION STREET CITY /~ ~ ~'~"<J ~'~// COUNTY' ~ v"/"'~ II. INSTALLATION (mark all that apply): E~e installer has been certified by the tank a;nd piping manufacturers. [~"'~he installation has been inspected and certified by a registered professional engineer. · E~'~e installation has been inspected and approved by the implementing agency. · [~11 work listed on the manufacturer's installation checklist has been completed, · nstallation Contractor has been certified or licensed by the Contractors State License Board, [] Another method was us'ed as,allowed by the implementing agency, (Please specify.) III. OA, TH, I, ce[~fy that the inform~vided is true to the best of my belief and·knowledge. Tank Owner/Agentr~ ~(~.~,~ ~),j,,~~ Date Address LOCAL AGENCY USE ONLY ~ COUNTY # JURISDICTION # FACILITY # TANK # STATE FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORO035C7 iNSTRUCTiONS FOR COA/~PLETiNG FORM "C": TANK INS'rALLATJON CERTIFiCATiON GENERAL INSTFIUCT~ONS I. P-ach tank system must be in compliance wit~ the federal and state technical standards, contained in law and regulations, 'Ior ~an~ and piping installation. 2. *This certification shall be completed by either' the UST owner or representative. 3. One certification is required for each tank sy:}tem. This form sha~ De used to make the required certification. 4. Please type or print clearly ali requested information (for printing, please use a hard poir~t writing instrument). Submit the completed certification to the ~.p¢,ropriate Local Implementing Agency. I. INSTA!LLAT~ON: ~ARK ALL OF THE ITEf~S THAT APPLY TO INDICATE THAT THE iNSTALLATiON REQUIR. E~ENTS ARE IVIET. II. OATH: THE TANK OWNER OR AGENT SHALL CERTIFY, BY SIGNING THE CERTiFiCATION, THAT THE INFOR[V]ATIO['~I PROVIDED IS TRUE AND CORRECT. THE PERSON'S NA~tE SHOULD BE PRINTED UNDER THE S~GNATURE. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I. SITE LOCATION ~/"~o'-~ J~'/~/,,~ _ ~q' ~'' STREET ~-~/0 j ,.~')~ r"Z2_ /~r~ CITY /~ '~/~)'~* ~/')'c./~/ COUNTY ~ CFC-- II. INSTALLATION (mark all that apply)' [~e installer has been certified by the tank and piping manufacturers. {~""~he installation has been inspected and certified by a registered professional engineer. ~'"'~e installation has been inspected and approved by the implementing agency, [~ll work listed on the manufacturer's installation checklist has been completed. ~' The installation Contractor has been certified or licensed by the Contractors State License Board. [~ Another method was used as allowed by the implementing agency. (Please specify.) III. OATH I. certify that the informa.t[o~13rovided is true to the best of my belief and knowledge. Tank Owner/AgentQ_~ /,A?.~,~,. ~,..r-.~,~.~4;;~ Date PrintName .,~0~,,1 ~'~1¢j//~ Phone (~.~) Address LOCALAGENCYUSEONLY STATE COUNTY # JURISDICTION # FACILITY # TANK # FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICA'TION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORO035C7 INSTRUCTIONS FOR CO~,flPLET~NG FORIV~ "C": TANK INSEALLAT~ON CERTfF~CATtON GENERAL INSTRUCTIONS Each tar~k system must be in compliance with the ~edera~ and s~a~e ~ech~ca~ ~a~ndards, co,tanned ~ ~aw a~d regulations, Imf ~a~ and p~p~ ~stallat~o~. This ce~Jfics~ion sha~i be completed by eithe' the UST owner or representative, 3. Orle ce~ifica~on ~s required for e~ch tank system. This form sha~l be used ~o m~ke ~he required ceAificaJion. 4. Please ~ype or pr~n~ clearly ali requested informaJion (~or prJn~ing, please use a hard po~ wr~g ~ns~rumen~). 5. Su~bmi~ ~he completed ceAificafio~ ~o ~he ~p~,roprJa~e Local ~mplememing Agency. I. iNSTALLATiON: ?v]ARK ALL OF THE ~TE.~JS THA'I' APPLY TO iNDiCATE THAT THE INSTALLATION REQU~RE~ENTS ARE MET, OATH: THE ::rANK OWNER OR AGENT SHALL CERTIFY, BY SIGNING THE CERTIFICAT~ON, THAT THE ~NFC)Rf~AT1ON PROVIDED iS TRUE AND CORRECT. THE PERSON'S NAME SHOULD BE PRINTED UNDER THE S~GNATURE. ST ~.TE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I. SITE LOCATION STREET II. INSTALLATION (mark all that apply): [~The installer has been certified by the tank and piping manufacturers. TThe installation has been inspected and certified by a registered professional engineer. e installation has been inspected and approved by the implementing agency. [~AII work listed on the manufacturer's installation checklist has been completed. ~""TTh'e installation Contractor has been certified or licensed by the Contractors State License Board. [] Another method was used as allowed by the implementing agency. (Please specify.) III. OATH I certify that the information pj:.a.v.~'ue to the best of my belief and knowledge. Tank Owner/Agent (--)~ ~%b,-~;~ Date I Z PrintName ,~Oh~'l ~h(,[~ ~ Phone (~_)~ Address ~ ~g~ ~~ LOCAL AGENCY USE ONLY STATE COUNTY # JURISDICTION # FACILITY # TANK # FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROm5C7 INSTRUCTIONS FOR COMPLETING FORM "C": TANK INSTALLATION CERTIFICATION GENEF~AL INST~{UCT~ONS 1. Each tar~k system must be in compliance with the federal and state technical st~ndards, contained in ~aw and regulations, ~or tank and pipin~ installation. 2. This ceAificafion shall be completed by either ~he UST owner or representative. 3. One ce~ificafion is required for each ~ank system. This form shall be used ~o m;~ke ~he required cedificafion. 4. Please ~ype or pr~ clearly ail requested information (~or printing, please use a h~rd po~n~ writing ~ns~rument). 5, Submit the co~p~s~ed ceAificaflon ~o the appropriate Local Implementing Agency. I. INSTALLATION: ~,~ARK ALL OF THE ITEMS THA'r APPLY TO INDICATE THAT THE INSTALLATION REQUiFtEI~ENTS ARE II. OATH: THE TANK O%~'NEF~ OR AGENT SHALL C~iF~TIFY, BY SIGNING THE CERTiFiCATION, THAT THE INFOR~ATION PROVIDED IS TRUE AND CORF~ECT. THE PEF~SON'S NAI~E SHOULD BE PIR~NTED UNDER THE S~GNATURE. STATE OF CALIFORNIA STATE WATER I~ESOURCES CONTROL BOAR£ CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM II. INSTALLATION (mark all that apply): {~The installer has been certified by the tank and piping manufacturers. ~"~he installation has been inspected and certified by a registered professional engineer. [~The installation has been inspected and approved by the implementing agency. ~"~AII work listed on the manufacturer's installation checklist has been completed. ~"~The installation Contractor has been certified or licensed by the Contractors State License Board. [] Another method was used as allowed bythe implementing agency. (Please specify.) III. OATH. I cert, ify th~at the information ~ru.~e to the best of my belief and knowledge. TankOwner/Agent ~ )~ ~~~ Date /~ Print Name"~Ok~ ~¢~' ~ Phone (%~)~6 LOCAL AGENCY USE ONLY STATE COUNTY # JURISDICTION # FACILITY # TANK # FORM C (7/9'~) THIS FORI~ MUST BE ACCOMPANIED BY PER~[T APPLICATION FORhlS A & B U'N~LESS THEY HAVE BEEN FILED PREVIOUSLY FORO035¢7 INSTRUCTIONS FOR COMPLETING FORM "C": TANK INSTALLATION CERTIFICATION GENERAL INSTFIUCTION$ 1. Each tank system must be in compliance with the federal and state ~echnica~ sta~ndards, contained in ~aw and regulations, for ~ank and piping installation. 2. This certification shall be completed by either' the UST owner or representative. 3. Or~e ce~ificafion ~s required for sach tank sy.~tem. This form shall be used to make the required cedification. 4. Phrase ~ype or print clearly ali requested information (for printing, p~ease use a hard poin~ ~r~t~n9 ~nstrument). 5. Su~bm~t tbs completed ceAification to the ~p[,ropriate Local Implementing Agency. i. iNSTALLATION: ~flARK ALL OF THE iTEMS THAI' APPLY TO iNDICATE THAT THE ~NSTALLAT~ON F~EQUIREMENTS ARE IVIET. ii. OATH: THE TANK O~NNER OR AGENT SHALL CERTIFY, BY SIGNING THE CERTIFICATION, THAT THE ~NFOR~ATIOH PROVIDED iS TRUE AND CORRECT. THE PERSON'S NAME SHOULD [BE PRINTED UNDER THE S~GNATURE. STATE OF CALIFORNIA STATE WATER I:iESOURCES CONTROL BOARD CERTIFICATION OF COMPLIANCE FOR UNDERGROUND STORAGE TANK INSTALLATION FORM C COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM I. SITE LOCATION ~0-..%'7(-. ~ ~..~U~.o//'~ ~.. Z) STREET ':~J ~ / ~'ty~ C),~. ~[N4 L, OZ--~ CITY ~-'~' }<"(~{')"¢"[' / COUNTY kr( i'7-- II. INSTALLATION (mark all that apply)' ~The installer has been certified by the tank a~nd piping manufacturers. E~'The installation has been inspected and certified by a registered professional engineer. [~The installation has been inspected and approved by the implementing agency. [~AII work listed on the manufacturer's installation checklist has been completed. I~The installation Contractor has been certified or licensed by the Contractors State License Board. F-~ Another method was used as allowed by the implementing agency. (Please specify.) III. OATH I certify that the information D~Js.true to the best of my belief and knowledge. TankOwner/Agen, '-- )(3.-~"~ ~-./"~.."..t~,¢ Date I'~ PrintUame ~0~}~ ~Q¢(~ Phone (%~b.)~G Address ~ ~ '/ L 41 ~ E~")~ LOCAL AGENCY USE ONLY STATE COUNTY # JURISDICTION # FACILITY Ct TANK # FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICA~rlON FORMS A & a UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORO035C7 INSTRUCTIONS FOR CO~ViPLETING FORM "C": TANK INSi"ALLAT~ON CERTIFiCATiON GENERAL ~NSTRUCT~ONS 1. Each tank system must be i~ compliance with the federa~ and state ~echnica~ 2. This ceAification sh~ll be completed by eithe? the UST owner or representative. 3. O~e cedff~ca~ion is required for each ~ank sy:stem. This form shall be used ~o ~ma~e ~he required ce~ification. 4. ~P~ease ~y'pe o~ pr~ clearly all requested information {for pdn~ing, please use ~ 5. S~b~J~ ~he completed cedJfica~io~ ~o ~;~e ~p~,ropr~a~e Loce~ ~mp~emen~in9 Agency. iNSTALLATiON: ~'v~ARK ALL OF THE ]TE~$S THA~' APPLY TO INDICATE THAT THE ~NSTALLAT]ON REQU~R.E~ENTS ARE ~ViET, OATH: THE TANI~ OWNER OR AGENT SHALL CERTIFY, BY SIGNING THE CERTIFiCATiON, THAT THE INFOR~JATION PROVIDED iS TRUE AND CORRECT. THE PERSON'S NA~v~E SHOULD ~3E PRINTED UNDER THE S~GNATURE. March 29, 2000 Costco 3101 Gilmore Bakersfield, CA 93308 Dear Underground Tamk Owner: Your permit to operate the above mentioned fueling facility will expire on June 30, 2000. However, in order for this office to renew your permit, updated forms A, B & C must be filled out and returned prior to the issuance of a new permit. Please make arrangements to have the new forms A, B & C completed and returned to this office by May 15, 2000. For your convenience, I am enclosing all three forms which you may make copies of. Remember, forms B & C need to be filled out for each tank at your facility. Should you have any questions, please feel free to contact me at (661) 326-3979. Sincerely, Steve Underwood, Inspector Office of Environmental Services SU/dlm Enclosure 06/11/99 ~9:2i -~661 326 0576 BFD HAZ ]IAT DIV ~]002 crrY BAKE FmLD 171 Chester Ave., Bakersfield, CA (80 PERMIT APPLICATION TO CONSTRUCT/MODIFY UNDERGROUND STORAGE TANK TYPE OF A~PLI. CATION (CHECk) [ ~NEW' FACUltY' [~ODIFICATION OF FACU. YI~ [ ]NEW TAN~ 12~ST, ALT-ATIOlq AT EX~TING FACILrrY STARTING DATE (.d/]'~,]qq tq~OPOSED COMPLETION DATE FACU. n~ ~ ~-~ol,~_s~'~ ~Ti~F^~rrY~rrNo. ~-~'i'~, FACIL1TYADDRESS ~lol .~fl~ofG CITY TYPE OF BUSINESS (~( ~'~. 5-~,~'~ APN.# TANKOWNER ~ C,,~l~al~ ,_~c , . PHONENO. [4'~ CONTRACTOR ~ .i - ~.a,~izlt- k~am~rv/ ' CA LIC][]~NSENO. ~O~NO. ~. q~%o~ ~.~ ~~-n~s~u~NO. w~ m ~~ ~o~ ~ ~/~ -NO. OF T~ TO BE ~ST~t.L~ ~ - - ~~FOR~OTOR~ ~ ~/~ NO ~ON ~R MOTOR ~L T~(NO. ~OL~ ~~ REG~ P~ D~ A~ON ~.~ ~o,~_._ X' S~CTiON FOR NOel MOTOR 1~51~ S~O~E TANJ~ ~ ~ TANK NO. VOLUME CHEMICAL STORED CAS NO. CHEMICAL PREVIOUSLY STORED 0~o s~.~,D ~ Os m,~ow~ FOR OFFICIAL U~E ONLY :'I T[~ APPLICANT ~ I~ECF. IVflD: UNDERSTANDS, AI~D WILL COMPLY WrflH THE ATTACHED CONDITIONS OF THIS PERMrr .aND ANY OTHER ~TA'I'E, LOCAL AND FEDF1.R~L REGULATIONS. THIS FORM HA~ BEEN COMPLETED UNDER PENALTY OF PERJURY, AND T~OVln I~'r'iGE, IS V ~C.~~ BY: APPLICAI~F NAME (PRnq~ (._.---~CANT SiGNATURe' THIS APPLICATION BECOI~F,S A PERMIT WHEN APPROVED JUN-30-1999 WED 09:02 (~M O0~INMENT SOLUTIONS FAX NO,4~._.567952 P, Containment Solutions, 5150 Jefferson Chemical Road Conroe, Texas 77301 SOLUTIONS A DENALI COMPANY Number of pages including cover sheet: RE: Containment Solutions, Inc. Fluid Products Group Hoover Products Group Company: , ,, Phone: 409/756-7731 28 June 1999 CONTAINMENT SOLUTIONS Mr. Bradd Cohen Costco Wholesale 999 Lake Drive Issaquah, WA 98027 Phone No. 425 313 6181 Fax. No. 425 313 6900 Re: Completion of Precision Tank Test Costco Wholesale, Gilmore Avenue, Bakersfield, ,CA Dear Mr. Cohen: Containment Solutions, Inc. began precision tank tests of a 20,000-gallon double-wall brine filled tank at this site on 18 June 1999, and successfully completed testing on 27 June 1999. The multiple testing was necessary to allow sufficient entrapped air to escape the annular space to validate the test results to EPA and State of California protocols. Throughout this time period, tank tightness was assured by the continuous liquid brine leak detection system. On 26 June 1999, CSI Field Technician Larry Lumpkin arrived at the above site and filled the reservoir and the riser pipe connected to the reservoir to within 9- ~" of the top of the riser pipe top. He performed a four- hour standpipe precision test of the tank using the annular space fluid as prescribed in the testing protocol. The test consists of maintaining constant head pressure on the annular space to test both the tank inner and outer walls, and is on the list of approved California precision tank tests. The test was completed on the morning of 27 June 1999. The level change in the rise pipe was [/2" in a four hour period (which equates to .01 gallons per hour). To pass the tightness test, the calculated change can not exceed .05 gallons per hour with a 95% probability of detection and a 5% probability of a false alarm. The tank passed the precision test. The test results follow this Ietter. Please let mc know what further information we can provide. My phone number is 409 756 7731. ext. 227, and my fax. number is 409 756 7952. Sincerely Yours, Steve Macy vice-president cc: Dave Luke - President, Frontier Sales (Fax. No. 503.281.9227) Randy Crownover - Field Service Supervisor, CSI, Mt. Union JUN-30-1999 NED 09:03 ~,M O01~T_~INMENT SOLUTIC)NS F~,X NO, 4097567952 P, 03 OIC TANKS HYDROSTATIC T.iJVK MONITOR {'RECISION 'IF. ST .,. FOR Dw'r.TYPE rt TANKS WITHOUT DISPENSING joe ~zo.~ Bzs~c Inror'm~fion: ~rd t~uk U.t. number (if kni,,n) p,~:ont the nomin~ capacit7 af tl~ tank ~o,,,.) Reco.-d daze and t~m¢ ~ wu ~ t~ll~I~/,z/,/~7~) " l~.~co~ -~? ~"i"t~,~)'~'~""~',"~ '~-- ~'1~" ' Prepa~tion: ..... ~. .... ~__~_~_s_~ ~o~o~g.fi~_pl~.f~ I~ ........................................................................... Use ~~cr s~ p~ to ~e ~. 4. Add b~a~ ~ace ~ S~e BI~ ~ ~e ~ ~ ~e ~ ~o ~ ~ ~e~~d ~ I~ ~~ ~ m~ ~e l~vcl ~~ ~~ ~ S~ 4. Be~ t~s: c~ not lit is ~ '~"'_ all level m..cyum~_ uts m.a&: in the riser ar~ ma~ ~ a tefeaeoce point ~bcrve the bn~'~ in cbc tlser. It ts ~-qo a-~mme~ "~' azJ ~~-r mezs'm"~ne~ z~ ma~ ~:m x ~ pc~nt &bore'k" JUN-30-1999 ~4ED 09;03 (~M CONThlNMENT SOLUTIONS F~X NO, 4097567952 P, 04 7. C.. lcaLuc,.ud ', I. W~ ~1~ 3 h~ ~~~ ~d~~~~~h~~ ~ //(/ .... 15. R~ ~ ~ ~ ~ 1~ m~~: ~t~ 14 ~ ho~ ~ ~;~ to ~ ~ 16. W~ ~ le~ 4 ho~ ~d ~< mom =.d ~oM ~e lev~ of ~ ~e~at~ ~ ~e ~ to 17. RecoM ~c ~e of~e I~ m~~: ~ St~ 16 ~ horn ~ ~m~ m ~ ~ .... ~t~,. ~.~ &~ ........... 18. ~~d rccoM ~e lcv~[ of ~e ~~~ mb~ to ~e ~ 1~ M~ 19. R~M ~e ~e,of ~e 1~ m~m~: ~ St~ 18 ~ h~ ~ ~~ to ~ ~ End t~t: (~~ ~) ~e Icv~ m~~ h 3~ 16 ~ ~+e levd m~~ h $t~ 1~ ~ ~ ne~e ~ ~c Iev~ M~ ~ ~e t~) ~/A '; , ., e m~~ ~ St~ 14 ~ ~e Icv~ m,~~~ 1[. ~e l~ ~e w~ ~ ucg~vc ~ ~e lcy~ h~ ~-g ~ t~) ~~ 24. ~u~c ~c c~gc ~ I~ p~c~ ~' ~ ~e ~ BI~ ~ ch-~ge ~ 1~ · c lcv~ ~ S~ 10. ~__. ~ge ~,~ ~ ~t~ 24.. ?. ~ ) ~ . JUI',I-30-1999 ,ED 09:04 ¢~M OONTP, II',II"IENT SOLUTIONS FA× NO, 4097567952 P, 05 ~cr m the ~ Ibove ~ boacxn ~d~ :eservoir m~'b ~ ~m th~ Is, vd Check on th~ Accur'ac~ of the He~¢/-lo..Volume Convu'sloa Factor: . This 1-bout ~ is ben d .oue. a thc c~nC~oa of a 4-boar Ic~ deeecti~ ~ but check does not need to. be don~ each ume t~ tank is tcsu~ 28. Rcco~ the t~n¢ of ~e Irvel ,',',~~e~ ~n $~'p 27 in houri ~ ,~,Trt~ to t~ 29.Unifo~nly ~Id bc~ccn 0.~ zod 1.0 ~o~ offer to t~ z~ser o~er · l-hoer pe~od ·nd mezsu.-c ~nd re:oral ~ ~ vol~ ~~ ~ to ~ ~ ~ ~ ~ ~~ 0.5 ~d 1~) .... · c vol~e ~gc ~ St~ 37 by ~e d~on of ~e ~ c~~ ~ S~ 20. I JIJN-30-1999 WED 09:05 f~I OONTf~INI~ENT SOLUTIONS Ff~× NO, 4097567952 P, 06 ~~t~_ T~k t~ b ~~ve~_ ~ me of ~!~ cf ~lme ~ ~e ~ ~e m of ~ ~ volme ~ ~e ~ TRAPPED VAPOR NOMOGRAM ~- Surge Block Volume.Vb,, = 1,476 mi, One 4.026-1n.-Diameler Riser Pipe i JUN 23 '99 15:12 FR CONTAINMENT SOLUTIONS661 399 3489 TO 166132605?6 P.01/01 J~e 22, 1959  FLUID %'ac co~li~ce CONTAINMENT ~.0. ~ox ~.~6 Ojai, CA. 93024 Attn: Ted M~eely Ref: Costco $32 - 3101 ~il~re - Bakersfiela, CA. Dear Mr. McNeely: T~is letter =erutfies t~t faCtO~ authorize~ Contai~ent Solut~o~'s Field Service Tec~icians re~nufacture~ 1-20,000 gallon ~o~le-wa11 ~der~round fiberglas storage ta~ at the above reference location. T~e t~k bottom ~a~ a =ir=~[er~tial break at the 6 o' clock position on bottom of t~e pri~:ry tank. The break was approx. S~ lon~ and slightly bul~e~, inwar~ towards center of tank. Tec~icfans re-inforce~ the Bul~ea a=ea wlt~ a 15 ply mat-resin l~y-up 3' x 4' wide. Tec~ic~ians applied a 1S ply ~t-resin la~p 24" ~de r~in~ circ~E~rential from 10 o'clock position uo the 2 o'clock position c~n=e:=ea on the circ~ferential break. Tec~icfans fill the ~ular space with .brine ~olution after work was =~leued on 06/18/9~. You'may be aseure~ the t~k will retain the remainaer of ori~inal warr~ty provi~ea ~,ith the purc~se of t~e t~k. Yo~ use of Contai~ent Solu~tion'e ~er~ro~ tanks is a~preciatea. If You have any furtBer ~estion~, please ~eel free uo contact me at 814-~2-8~20. Fiel~ Se~i~e Sups~isor Reference G-20921 cc: Steve Joe Wie;and - CSI TOTAL CITY OF BAKERSFIELD OFFICE OF iENVIRONMENTAL SERVICES UNDERGROUND STORAGE TANK PROGRAM 1715 Chester Ave., Bakersfield, CA (805) 326-3979 APPLICATION TO PERFOgLM A TANK TIGHTNESS TEST FACILITY ~ ADDRESS ~ 1o / ~ /'L m o .o ~ ~-. PERMIT TO OPERATE # OPERATORS NAME ~Og"t'cD OWNERS NAME ~,-u~. oF T.e,'KS TO TmK,~ VO,.,CM~ co~rr~s TANK TESTING COMPANY "~/~ ('__,~ NAME & PHONE NUMBER OF CONTACT PERSON TEST M~THOD CERTIFICATION # DATE & TIME TEST IS TO BE CONDUC~SD/~D ~"'{ ~P~,O~Y DATE SIGNATURE~F APPLICANT 06/11/99 09:21 '/~661 326 0576 BFD HAZ MAT DIV [~002 CI~ OF BA~~F~LD ~ ~ ~ 6 ~ OFFICE OF E~ONME~~ SER~CES 171~ Caester Ave., Bakersfield, CA (~0~ 326-3979 PERMIT APPLICATION TO CONSTRUCT/MODIFY UNDERGROUND STORAGE TANK ~ OF td~J. CATION (CHECK) [ ]NEW FACILITY [~ODIFICATIOlq OF FACILITY [ ]lqEW TANK 131STALLATION AT EXIS~G FACILrI'Y FACIL1TY NAME ~ ~3o1,'/~_54-~h'o~4 FJ(ISTING FACIL1TY PERM1T NO. FACIIJrYADDRE~ 2roi .'¢Iflv~o,'F_~ CITY [~,~a. rgbkJa~, ZIPCODE TYPE OF BUSINF~ 6-o~ol ~k Sd-~'en APN,# TANK OWNER [x~ac~ b,)n~)~salel_:YrOc. '-PHONE NO. {4~) ADDRF~S ~q~ I._r4t~_. Or,'wc. CITY ~'.~6aq. t4ak~ CONTRACTOR. 14 . ~ . %r. hrrW flF' &'-hv,~gl m~,,.'rr~ CA LICI/~SENO. Q / O T g ~ ADDRF__~ ILr'5'D~ 5,:*flZty-,} .~rr.~ {ill'Y_ _[,/,OO PHONE NO. ~td') t')g6 :~l'~Dg r_,cf. ,~-~ .... 1~~ n crp/' 8~ LICISNaE NO. .4"0 d&F&'~,'l/,~... (,o.},.y~__'~.4~ntc 1'5 }/_.,-~1<.[~.,, ..... - 0 wA'rmt TO F~mrry PROVIDED BY. DEFrH TO GRO~ WA~ }ol~ s;OIL TYPE EXPE~ ^T S~ ~NO. OF TANKS TO BE INST, taJ.h'rr) ~}~ -- ARE THEY FOR MOTOR FUEL : b/~rYES NO SPmL Pm~O~ co~rmOL ta~ COUNTm~ MEASUR~ PLAN ON FILE .y YF~~MO SECTION DDR MOTOR FUEL TA~_/No. ¥OLUME UNIY_ADED lIEGtmaR PKEMItrM DIF~P.L ^VlaTION 7~3 53o, rrV.. l~_.,t..i iON ii'OR NO]q' ]~lO~TOli lrL~l¢ STORAGE TA.I~ /~ J~ -TANK NO. ¥OLUM~ CHEMICAL STORED CA8 NO. CHEMICAL PREVIOUSLY 0qo aaa_m) ~,) 0v xa~ow~ FOR OFFICIAL USE ONLY TI~ APPLICAI4T HAS I~CFAVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIOI~ OF THIS PEILMrr AND ~ OTHER STAT~ LOCAL AND tEDERAL I~OLrLATION~. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AKD TO THE B~I'~ MY KNOWI I~GE, IS V~~BV: ~----C~ ~~ THIS APPLICATION BECOMES A PERMIT WHEN APPROVED 12/18_/_9.8___13:33 ~'~805 326 0576 BFD HAZ i~AT DIV ~002 WRITTEN MONITORING PROCEDURES UNDERGROUND STORAG1=~. TANK MONITORING PROGRAM This monitoring program must b~ kept at thc UST location at s/! times. The infonnatinn on thi~ monitoF~g pm~m arc eonditiofls of the operating permit. The pen'nit holder must notif), (~e !o~l aeency) whhin 30 days of any changes to the monitoring procc, du~, unh~s required to obtain approval before making the change. /~ Requir~ by Se~tioAs 2632(d) nnd 2641(h) CCR. Facility Address ~[0~ A. Describe the frequency of performing the monitoring: What methods and equipmen't, identified by name and model, will be used for performing the monitoring: ?an~ I/J.6JJ./ ~ TLS, ~S'O,e. ~1 ~a.~ ~s ~~t~ Piping ~_~/ ~ ~t'.~ ~ ~ ... I~~'~.~a~,, ~ o~g ~na~ C. Describe the location(s) where the monitoring will be performed (facility plot plan should be attached): D. List the name(s) and title(s) of the people responsible for performing the monitoring and/or maintaining the equipment Reporting Format for monitoring: F. Describe the preventive maintenance schedule for the monitoring equipment. Note: Maintenanoe must be ~n accordance w~th the manufacturers, maintenance sohedule but G. Describe ~he training nece:~sary for the operation of UST system, including piping, and the monitoring equipment:__ 12/18/98 13:34 ~805 326 0576 BFD HAZ YlAT DIV [~003 i EMERGENCY RESPONSE PLAN UNDt/RGROUND STORAGE TANK MONITORING PROG~M ~ moni~g pm~m mu~ ~ kept at ~c UST lo~ion at aU ~. Th~ ~fo~a~n on ~is monitoring pmgnm a~ ~ndicions o~ ~c o~mt~g ~. Th~ ~ holder must ~ti~ (~c 1o~1 ae~cv) ~thin 30 days of any ~hanges to ~o ~n~to~g p~u~, un~s ~ui~ to ob~in ~mval bcfo~ ~k~ ~e c~ngc. R~u~ by S~tio~,s ~2(d) and 2~l(h) CCR. 1. If an unauthorized releas,~ occurs, how will the hazardous substance be cleaned up? Note: If release~ hazardous substances reach the environment, increase the fire or explosion hazard, are not cleaned up from the secondary containment within 8 hours, or deteriorate the secondary containment, then Crime looal a~encv) must be removing and properly disposing of any hazardous substances. ~ieanup e~uip~en~ in iten Z above. 4. Describe the maintenance ~chedule for the cleanup equipment. ATTACHMENT A Costco S]pill Procedures Safety, Fires, and Spills Gasoline is a highly flammable product,, and must be treated with respect and caution. Also, working around moving vehicles can be dangerous if you don't pay attention to traffic at all times. In the event of a large fuel spill ,ar fire: · Hit the emergency shut-off switch on the data hut or on the center island. · Warn people to get away from the station. · Call 911 All gas station attendants must be trained in these safety procedures. They must also read and sign the Job Hazard Analysis form 'with a Supervisor before beginning work at the gas station. Prevention: 1. No smoking around the gas stations. If a member is smoking, pleasantly inform them that it's against federal law to smoke near a gas station. 2. Pursuant to federal law and the National Fire Protection Code, car engines must be turned off while fueling, regardless of how hot or cold it may be outside. 3. Replace any nozzle that is persistently causing significant "spitback" spills. Pay particular attention to sticky or malfm~ctioning trigger locks. 4. When changing hoses, nozzles or filters, always wear eye goggles and gloves located in the data hut. De-activate the dispenser by turning the circuit to OFF on the fuse panel, then service the unit. Defective hoses and nozzles awaiting exchange from the vendor should be dried out in the sun for a day before placing inside for pick up. 5. All portable gasoline containers must be UL approved and must be placed on the ground while being filled. Containers can pick up static electricity when riding in the bed of a truck and trunk of a car; this is especially true if the truck is equipped with a plastic bedliner. The static electricity can create a spark when the nozzle is brought close to the container, creating the potential for an explosion and fire. Please refer to the detailed memo included in this manual. 6. Stay alert! Watch for moving cars When walking between fuel islands. Keep an eye out for smokers, running engines, and people filling portable containers improperly. 7. Have the station's fire extinguishers checked on a regular basis. Fires: Small car fires can be extinguished with the fire extinguisher AFTER hitting the emergency shut-off switch on the center island. Don't be a hero trying to fight a fire. Your first concern should be your own safety and the safety of the members. If a fire appears out of control or too big to fight with the extinguisher, immediately follow the three steps shown above. Do not attempt to fight a gasoline fire with the water. Gasoline floats so water may only serve to spread fire. Large Spills: A large fuel spill is a potential disaster because the gas could ignite. 1. Immediately hit one of the emergency shut-off switches and call 911. 2. If a large fuel spill spreads beneath members' cars, DO NOT let them start their cars and drive away. Starting the car may ignite the spill. If necessary, put the car in neutral and roll it clear of the spill. 3. Warn everyone to stay away from the spill in case it ignites. For example, don't walk through a spill to reach the emergency shut-off switch on the center island. Use the switch on the data hut instead. 4. Immediately put up cones or barriers to keep cars from entering the station and driving into the spill. 5. Try to protect storm drains by covering them with plastic and surrounding them with a boom from your spill kit. 6. Large spills may sometimes occur wlhile you are receiving a fuel delivery. The fuel truck driver may be trained in some aspects of spill response, so work with them if possible. Do not defer to their judgment if it conflicts with your common sense assessment of the situation. Small Spills: Clean up minor gasoline spills immediately to avoid a fire hazard and to minimize any possible slip hazard. Minor spills can be contained by the Spill Containment Kit located in the data hut. You may find it easier (and less expensive) to clean up small spills with kitty litter or with a commercial oil absorbent (such as Oil Sponge or Max Dry). Keep a quantity of this material handy, along with a broom and dustpan. Dispose of the gasoline-soaked materials in the spill kit drum or other suitable container, such as a metal drum or garbage can. Do not use water to flush spilled gasoline into the storm drains. This is both unsafe and a serious threat to the environment. Any gasoline-soaked materials, such as rags and towels, can be disposed of in the barrel with plastic bags provided in the spill kit. Call the service company located on the spill kit drum (or a local company) to haul off the hazardous material. Do not dispose of clean-up material in a standard trashcan. It could ignite. (5) ISLANDS;__ P~=Li - (2) DISPENSERS TYP.,~ ~ II CONTROLLER I (3) 20,000 GAL. :LOSURE us - i ~w w I I ~RSFIELD-COSTCO- GENE~ SITE P~N SC~ 1" = 3~ 0 15 ~0 60 90 120 GRAPHIC SCALE IN FEET PROJECT NO. ~ 1 COSTCO,32 ADE$1GIII DEVELOPMEIIIT GR~OU~ MP ~G4'1132 B ~' '~ 7625 Hayvenhursc A ...... Suite 12A COSTCO W~-~O~.E~_E A,'_L'qA v.. Nuv., Co,ifor. iu 94406 3101 GIL~OREAVENUE ,LIl~'~,~q~ Ph .... [818] 782-6484 - CO~CO~~__INE [iiiii~FI~ii'~Fex: '8'18' 782'8445 ~'-~F~SF'EL~.C~FOtc~NJA93308 COSTCO WHO~.ESA~ ~ L~E gm/E ORIGINAL ISSUE DATE: 8/10/98 L_ State Water Resources Control Board Sacramento, CA 94244-2120 (3ns'~ucfi~n~ on II CERTIFICATION OF FINANCIAL RESPONSIBILI " FOR'UNDERGROUND STOOGE TANKS CONTAINING p~oLEUM A. I ~ rcqui~cd m dcmom~t= Fin=ci~ Resm=ibili~ in ~= ~d ~o~u u s~=ificd ~ ~on ~g07, ~ 1~, Div. 3, T/fie ~, C~ ~00,000 dollm ~r ~encc ~ !. million dollm or ~ or 8. ~~ ~L~}ig ~~} ~/0~ he~br i:e~es ~at it is in compliance ~ ~e ~quirements of Section 2807, A~icle 3, Chapter 18, Division 3, ~e 23,California Code of Regula~on~ ~n' The mechanisms used to demons~ate financial responsibili~ as ~;quimd by Sec as follows: 2807 a~ C. Mechanism.' . Name and Address'°f Issuer ".;:." "~"~'~::?~;~?~?-~?.? ..... "?~:~1':'?:~'~'~ · "1' c~mo. Note: If you are using the State Fund as any part of your demonstration of Snancial res ~onsibility, your execution and submission of this certification also certifies that you are in coml)liance with all ccu?~tions for participation in the Fund. I F~i~w N~e F~ ~ ,- ' I ~R~.~) FILE: Original - Lo~l Agen~ Copies - Facile/Site(s) LETTER FROM CHIEF FINANCIAL OFFICER I am the chief financial officer for Costco Wholesale, 999 Lake Drive, Issaquah, WA 98027. This letter is in support of the use of the Underground Storage Tank. Cleanup Fund to demonstrate financial responsibility for taking corrective action and/or compensating third parties for bodily injury and property damage caused by an unauthorized release of petroleum in the amount of at least $1 million per occurrence and $1 million annual aggregate coverage. ' Underground storage tanks at the following facilities are assured by this letter: Costco Wholesale Costco Wholesale 1601 Coleman Avenue ' 2001 E. Ventura Blvd. Santa Clara, CA 95050 Oxnard, CA 93030 Costco Wholesale Costco Wholesale 72 - 800 Dinah Shore Dr. 7981 E. Stockton Blvd. Palm Desert, CA 92211 Sacramento, CA 95823 Costco Wholesale Costco Wholesale 895 E. "H" Street 1900 Santa Rosa Ave. Chula Vista, CA 9.1910 Santa Rosa, CA 95407 Costco Wholesale Costco Wholesale 13111 Peyton Drive 6100 Sepulveda Blvd. Chino Hills, CA 91709 Van Nuys, CA 91411 Costco Wholes:de Costco Wholesale 951 Palomar Airport Rd. 1220 FoOthill Blvd. Carlsbad, CA 92009 Azusa, CA 91702 Costco Wholesale Costco Wholesale 4605 Morena Blvd. 11260 White Rock Rd. San Diego, CA 92117 Rancho Cordova, CA 95742 Costc° Wholesale Costco Wholesale 150 LaWrence Station Rd. 2030 N. Imperial Ave.. surmY~ale~ CA 94086 E1 Centro, CA 92243 CoStco Wholesale Costco Wholesale 1600 Expo Parkway 115 Technology West Dr. Sacramemo, CA. 95815 Irvine, CA 92618 999 Lake'Drive, Issaquah, Washington 98027 · '425/313-8100 LETTER FROM CHIEF FINANCIAL OFFICER (continued) Costco Wholesale Costco Wholesale 10950 Sherman Way 1099 E. Hospitality Lane Burbank, CA 91505 San Bemardi~o, CA 92408 2~TC7oOSrranStCO Wholesale COstco Wholesale 1 Skypark Drive '.,?~ 3101 Gilmore Ave.- ce, CA 90509 Bakersfield, CA 93308 Costco Whole~ale Costco Wholesale 1445 "R', Street 1755 Hacienda Drive Merced, CA 95340 Vista, CA 92083 1. Amount of anntlal aggregate coverage being assured by this letter ........... ; .................. 2..~ ....................... ' ............................... $ 1,000,000 *2. Total tangible assets ..................................... i ................. : ...... : ....... $ 5,873,705,000 *3. Total liabilities," .............................................. ; ............................ $ 3,174,191,000 *4. Tangible net worth ....................................... ~ ...... ~.~ ........................ $ 2,699,514,000 I hereby certify that the wording of this letter is :identical to the wording specified ia subsection 2808.1 (d) (1), Chapter 18, Division 3, Title 23 of the California Code of Regulations. I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge and belief. Executed at Issaquah, WA on: Signature Name: Richard A. Galanti Title: 'Chief Financ'ial Officer · *Note: Balances are as of 3-12-98 (2nd Qtr, FY 19911), the last reported financial data for Costco Wholesale.. A. E Schmidt Env onmental · :! .- December 21, 1998 ~. ' - Mr. Howard Wines ,: ~ .,. '~,.~. · -: City of Bakersfield - Fire Department · .. ' i,. t 715 Chester Avenue · ~ ' :'... .. '". .' - Bakersfield, CA 93301 ' ': 'i:'~ ~"- Subject: Submittal of Forms for Tank Certification Bakersfield, .... California ,, . .~ · Dear Mr. Wines: · " .. I am enclosing the follo~ving documentation Bakersfield Costco site located .-- .' at 3101 Gilmore Avenue. · [] Forms A, B and C ca Certificate of Financial Responsibility n Hazardous Materials llnventory ~. ., ca Written Monitoring Procedures for Underground Storage Tank ... Monitoring Program ., ca Costco Spill Procedures '~' ' ~" ~ ' I'f you have any question!; or concerns regarding this submittal please contact me at (818) 786-2373. Sincerely, .. -..~ ?~vir°nmental ' ~" Ines Cadavid-Parr Project Manager Cc: Tim Hurlocker, Costco 16509.Saticoy St}eet J.R. Gonzales, Costco Van Nuys, California '91406 (818) 786:2373 - . (818). 786-'5440 FAX. ..... ~SEI'.ISOR ALARM ...... -L 8:PREPIlUM FILL " OTHER SENSORS : -" ' HIGH LIOUID ALARM SENSOR ALARM ..... -._. -~- !' DEC:. 9. 1 ':998 9:49 Al'"1 L 1: LINLEADEI':: 87A ANNHT~":-:'  ' ANNULAR SPACE ~ "~ LOKI LI[:~UID ALARM COSTCO 02 DEC 9. 1998 9:54 AM :3101 GILMORE AVE ...... ;-3EN~,'.:)R ~LARI'.'I ~AKERSFI ELD. C:~. ~' . x._12 L11 :DIS]::'EI'.ISER t::'AN 3.4 r) ISPENSER PAN HIGH LIgUII') ~L~RI'.'I r)EC ':9.° 1998 ':9:44 ~l"l DEC ~.. l':~gE: 9:58 ...... SENSOR SYSTEM STF~TUS REPORT ' L 9:PREMITM ~TP SUMP .............. SENSOR ALARM ALL FUNCT l C>N~; N©RMAL H I GH L I (:=~LI I D ~LARI"I L 2: UNLEADED 87A F ILL - - [)Et:; 9, 1998 9:51:1 AM OTHER SEN~ORS INVENTOR'Y REPORT HIOH LI(-iUID ALARM DEC 9.. 1998 9:54 AM ........ S E 1'.~5;,.:-:.R ~L~R'M T 1: UNLE~I-)ED 87~ L 1 ~:,: D I SI:'EI'.~F_;ER PAN 1 ..2:.. 1. VOLUME = 15270 GALS ULLF~GE = 4681 GALS DISPENSER PAN - H ] ~:3H L IGLI 1D 90% ULLAC;E= 2~85 GAL'S:: I-:~EC 9 1 ')98 '-~: 5':J TC VOLUME = 15184 CiAJ : ~ ' - -- HEIGHT = 84.76 IN~ "II IJATER VOL = 0 GALS ..... SENF_JOR ALARM ...... ~,IATER = 0.00 INCHES L ?:PREMIUM ANNULAR TEMP. = 68 0 DEG F ANNULAR SPACE i~' ..... SEN~OR ALARM ..... · LOIJ LIOUID ~LARI"I j L :3:UNLEADED 87A ~TP DEC 9...1998 9:51 ........ STP .~UMP T' 2:UNLEADED 87~ HIGH LlgUlD ALARM VOLUME = 149'95 GALS DEC'. ':9, 1998 S~: 55 ULLAGE -- - 495i:, GALS · 90~-;; ULLAGE= 2960 [:;ALS -- - '.SENS:,::;,R F:~LAF:T.'I .... TC VOLUME = 14922 GALS L] 2;£:~iSPENF_;ER t:'~l~ 5. HEIGHT = 8~..36 INCHES OTHER SEI'.~'E:C, RS t,,IATER VOL = 0 c-;ALS , HIGH LIGUID ~LARI"I ~ATER = 0.00 INCHE~ DEC 9. 1':99G; ':9;5'_~ TEMP = 66,.cJ DEC; F ..... FSENSOR ALARM L 4 ;UNLEADED 87~, ANNULAR T :3; PREM I LIM ANNULF~R SPACE · x,._.,/ . VOLUME -- 14174 J::;A,.~./ LOI,,J LIGUID ALARM ..... E;ENS£:,R ALARM ..... LILL~C;E = 57?? GALS DEC; ~3 lq~8 9'5':' AM L14;DIEi_'PEI'.ISER PAN 9 i0 .... DISI::'EN~ER PAN 90% ULLAGE= :3781 'GALS , HIGH LIC-~UID ALARM TC VOLUP1E = 1410:3 GALS ~ DEC 9, 1.cJ98 9;56, AM HEIGHT= ,~cj~ _ .28 INCHES ..... ;:-;E NSOR ALARM t4ATER VOL = 0 t:iAL~ L 1:3; D I ;:_i]::'ENSEF.' PAN 7. t4ATER = O. O0 INCHES I')l SP:'Er,~E;ER t::'.~l,,~ TEMP = g7 1 DEC; F · FIJEL ~LARI'-'I DEC '9, 1 ':9'3EI 10 ;I.-JCI AP1 MAN I FOLDED TANKS INVENTORY TOTALS ..... SEN~;OR ALARI'.'I .... T 1;UNLEADED 87A L 5;IJNLEADED 87B FILL T '2; UI',ILEADE[:~ 87B OTHER SENSORS VOLUP1E = 302F_,5 GALS HIGH LIC4UID ALARM ..... SENSOR ALARM TC VOLUME :30108 l"." o DEC L:9 199B ~:5;:i'AP1 LIO;DI~PEi".ISER PAN 1..'2 = _,~L,,., " - D I SP'EI'.I?SER PAN HIGH LI(-IUID ALARM ~ ~ ~ ~ ~ END ~ ~ ~ ~ ~ DEC ':9, 1_~8 _':9;57 ....... ~;E NE;OR ALAF. T'I ~ , ..~,,~. Li 7:r:~ISI:'ENSER t:"~N I5. D [ SF'EN~ER HIC;H Ll(:il_ll[J ~L~RI'.'I DEC: '3. l':9.qE; 10;00 AM ..... SENSOR ALARM -- .... - L E, : UNLEADED 87B ,STP ~ : .... ! STP SUMP ..... SENSOR ALARM ...... HICiH LIgUID ALARI'.I LIS:DISPEi..iE;ER :-~1'.1~11 i'-' DE(:: 9, 1998 9: 5;3 AI"I HIGH LIGUID F~LAF~r...1 DEC; c_q., 1 -q'98 '9: 57 AM 0EC-09-98 08:07 From: T-490 P.OI/D3 Job-220 F'~X A.E. Schmidt Environmenta!. 16509 Saticoy Street Van Nuys, California 94406 (818) 786-2373 FAX (818) 786-5440 Number of pages including cover sheet To: From: Phone: Phone: (818) 786-2373 Fax: ~oC') L~?---~ - D~"~ ~ Fax: _(s,te) 786..,q440 cc: Urgent For your review [~ Reply ASAP ['-J Please comment T-490 P.OZ/03 Jo~-220 ~EC-Og-gB 08:07 From: ~ DEC R9 '98 zu:23 FR FI I¢~[NMENT I~: 4~ 756 ?~65 TO ~. 865440 P.02/0~ CONTAINMENT SOLUTIONS Oec~mber 9, 1998 Mr, Josh Nardtni Mr. John Tha~ _ A. E. $chmldt Environmental t65oe Saticoy Van Nuye, Celia=mia 91400 Phone: 618-.~12-3919 FAX: 818~766-5440 Reference: Deadman Anchor Sections ¢O8TC, O Bakersfmld Job Gentleman, We currently call ourselves Containment Solutions. V~en Owens-Coming sold their underground tank division to a group of investors in December, 1994, we became a separate company called Fluid Containment on January 1, 1695. T~he investors have purchased other companies since this original purchase, including Hoover who produces above ground steel tanlm end lube cubes, Ershigs, Fibercest, Beta Tank, and Plastifab, the name was changed to Containment Solutions to include the expense of all of there compslnies. Our portion of tho company still manufactures the same model fiberglass underground stem,ge tanks that worn manufactured by Owens-Coming in 1094. The Owens. Coming tank employlms went with the new oompany, so the exper'dss and quality of tank manufacture was never lost. I have been with the underground tank part of the business since 1973. The Containment Solutions Install~on Irmkructions show Ute use o! deadman anchors as an ap§on for holding down our underground ltanks. This is an approved method according to these printed Ins~lletien InstructJon~, The dead!men anthem Gan Oe =oAstrueted in one ieflgf:h, or in settler, s to match the length of the tank, The weight of the overburden on top of the deadman and tank~ provides the actual hold dwn force mr the tank. Our Installation Instructions also show the recommended width and height of deadman anohors. For a 10 foot 6 inch outside diameter tank, the deadman enchain should be 18 inches wide by 12 inches thick. Those 18 inoh wide by 12 inch thick cieadman anchors am provided by the contractor and eeo be eormfructod in 4~ecf/On~ ~ ma~h the Mnk length. The ~ecflor~ should be leg enouglt for connection of · mlnlmilm gl' [we strap locations. Containment Solutions provides deadmen anchors that are 12 inches wide by 12 inches thick, and these deadmafl enchain will work on 10 foot disrupter tanks provided the burial depth and ta~lk spacing are adequate. Our deadman anthem ara manufactured irt 12 foot, 16 foot, fO foot and 20 foot sections. The soctlorm are mateh(~i to provide · length thai equals ~he tank length. DEC-09-88 08:08 From: T-490 P.03/03 Job-Z2O DEC 09 '98 10:2~ FR FLU ~INMENT TX .4~9 756 76~ TO 1~7~65.440 P,0~0~ We can provide buoyancy calculations ~o show the factor of safety against floatout with tile 12 inch square deadman anchor~, Thank you Mr your inquiry, end for usir,g Containment Solutions tanks on your project. If you have questions abo~t the infom,,ation in ~is letter, or our installation lnst~u~ions, please contact me at 409-756-7731 extension 213. Sincerely yours, DEC'O? '98 11:~? FR FLUID CONTAINMENT TX 409 ?56 ?665 TO 18187865440 P.0~×02 ~ ~' CONTAINMENT SOLUTIONS December 7, 1998 Mr. John Tharp A. E. Schmidt Environmental 16509 Saticoy Van Nuys, California 91406 FAX: 818-786-5440 Reference: Deadman Anchor Sections COSTCO Bakersfield Job Dear Mr. Tharp, The Containment Solutions Installation [Instructions show the use of deadman anchors as an option for holding down our underground tanks. This is an approved method according to these printed installation instructions. The deadman anchors can be constructed in one length, or in sections to match the length of t~e tank. The weight of the overburden on top of the deadman and tanks provides the actual hold down force for the tank. Our Installation Instructions also show the recommended width and height of deadrnan anchors. For a 10 foot diameter tank, the deadman anchors should be 18 inches wide by 12 inches thick. These 18 inch wide by 12 inch thick deadman anchors are provided by the contractor and can be constructed in sections to match the tank length. The sections should be long enough for connection of a minimum of two strap locations. Containment Solutions provides deadman anchors that are 12 inches wide by 12 inches thick, and these deadman anchors will work on 10 foot diameter tanks provided the burial depth and tank spacing are adequate. Our deadman anchors are manufactured in 12 foot, 16 foot, 18 foot and 20 foot sect~'ons. The sections are matched to provide a length that equals the tank length. We can provide buoyancy calculations to show the factor of safety against floatout with the 12 inch square deadman anchors. Thank you for your inquiry, and for using Containment Solutions tanks on your project. If you have questions about the information in this letter, or our installation instructions, please contact me at 409-756-773'1 extension 213. Sincerely yours, Robert D. Upton ~ Product Technical Support Specialist CORPORATE OFFICE ~* 5!50 ,~EFFER$ON CHEMICAL ROAD · C()NROE~ TEXAS 77301-6834 * TELEPHON~': 409/756-7731 · FAX: 40~/756-776 '~ I]EC--01--98 i0'-29 ~M I~ESI~H I]EVELOPIHEHT ~ROUP $15 ?$2 8445 P.O1 Design Development Group FAX 7625 Hayv. nhurst Ave. Van Nuys, California 91406 (818) 782.6484 FAX (818) 782-8445 Date: November 30, 1998 Number of pages Including cover sheet: 4 To: Howard Wines From: ED COLLINS Bakersfield Fire Dept. , Dept: Desitin Development Phone: 805/326.3979 ' Phone: (818) 782-6484 Fax: 8051326-0576 Fax: (8'18) 782-8445 CC: n-I Urgent I--I For your review [:::] Reply ASAP I-'] Please comment Re: CostcoGas, 3101 Gilmore Please find attached the manufacturer's Installation Instructions for the deadman anchors at the above site. I have indicated with arrows the sections which I believe will address your concerns. I will call you shortly to discuss. DEC-01--98 18:29 AM DESIGN ~EVELOPMEHT GROUP 818 T82 8445 P.02 What Topics Will l~'e Covered? · Tank lasutllation ......................................... 2-12 · Double-Wall Tank Monitoring Systems .......... · Hydrostatio Monitor .................................. 1446 · Electronic Control Panels .......................... 17-1 · Switch Panels ................................................ 19 · Collars and Turbine Enclosures ................. 20-24 ~ , · Field Installed Fittings ............................... 25-27 Introduction · Other Accessories .......................................... 28 Tho purpose of this manun/i~ to provide .sp~..ificrs, owners. · Troubleshooting C, uide-Electrordc Panels ....... 29 oc~ttr'agtors and their employe~s w~th detailed ii'~l:mcfiom ~or installing Sin~lo-Wall and Double-Wall Fiberglass Under- · Wirins Diagrmns ....................................... :~0-]1 sround Storage Tank~ and related aragessories. Note: Tank installation is a very s.p~ialized busin,~s. If you do not have the proper experience, please contact a Important Reminders contras:tot who does, or call Fluid Contafivnent Inc.. for a list of experienced contractors. · Fiberglazs tanks must be ins~lled according to thee structions and NFPA 30 and 31. The material presented has been developed and refi~ed in t~e installation of over 200,000 tanks. · Any variances to the published installation iastmetions WHY IS ~ INFORMATION IMPO~~ must be approved by Fluid Containment in wrifingprlor Proper ~on ofeach tank is essemial: to the ~n~tallatton, · To ensur~ tim safety of all the individuals involwd in gm· Local codes may apply. Please consult them. tank installation. · The presence of a Fluid Containment representative · To prevent tank damage and/or f~ure, which coul,d lead the jobsite does not relieve the contractor of respomibil- to product loss and environmental contamination., ity to follow th~ published installation instmefion~, · To validate the tank structural warranty for underground , ........ petroleum storage. To Activate The Tank's ;~0-Year Structural Warranty for Underground Petroleum Storage; Tank lnstaIl~tion - Warning · These instructions must be followed.  · Installation checklist (Pub. blo. $S94) must b, properly ~ompl~t~d, si~ned by the in_s,_tallins ~mtractor's repr~- · Do not enter thg tank excavation units necessary and in sentative and the tank owner s representative. compliance with OSHA regulations[ Follow OSHA · The installation checklist m~tst be re~iv~ by the tank guidelines for tank excavation, owner and/or installing ~ontra~tor to validat~ any filture · Collapsing excavation walls can cause injury or d~ath[ warranty claim. ~EC-01-95 10:$0 AM ~E$IGH ~EVELOPME~T ~ROUP 818 ?$2 8445 P.O~ ,Deadman Anchors (cont'd) Anchoring Hardware · At rain,hum burial depth from chart on page 6) mini- All steel components should be protected from corrosion. mum dcadman size is as follov~ (sec table)*: Rebar Anchor Point - ~ anchor point can be fabricated Tank MinimUm Width from rebar a~ follows: Diameter Height ,~d~h &mmd~,an may b~ ~, CMtovt 7link ~'~k~cal Support foe d~t~ls . Tank ~]l~]~e Rebir* ...... Diameter Spu - Installation L~y dcadmen along ~ 6' ~6 4'4" chorin~ Hardw. r, ~i:?] lxN. Ancho, points may '"' Section) or, ~)i!] { ~lso b, fabri~atod dgadman and through with bonom plates. anchor strap. Consult a structural -~.~-- Triple clamp wire eagin~rforotheran- ~ rope. d~or point m~hods, ofta,nk on e, ach side. Turnbuckle~ (drop-for~ed) -May be used in plar~ of all For taaks mquirin]~ ~ or a portion of wire mpc described in this section, or mom a~chor points per dcadman, two - llmk Minimum T~r~badde Dia~'e'{~r (by type)' dcadmen sections' of Diameter Hook Jaw .... equal ~nndgth mayb 4' 3/4' { 1/2" [ 1/2" .... butted to end. : 6' 3/4" 1/2;'"' 1/2" Make sure each deadman section has at least 2 anchor s' ' 1,1/4" . ' .... 314" ""314" · The ~ank must not overshadow tl~ dcadman anchor. IlI ". 1ol/4",, [ ........ :~/4" _ Wir~ Rope · use 6 x 19 (improved plow stol) wire rope. eadman Anchors - Multiple Tank Installation Mialmu-, Each tank requires two draflman or, T~k Wir~ Diameter Diameter If one ge, adman ia us~ for adjacent tanks, it must bc DO NOT ....... doubled in width. · Use wire ey~bolts ..~' 3/8" · Use b~t steel eyebolts, ii ...... 3/8" · A separate anchor point mus~ b~ provided for each strap. S' , Multiple tank installations require 24" minimum spac., lO' lng b~t~ve~n tanks (exception 10', 1:2' tanks), 1:1' )EC--01--98 10::~1 A.I :DESIGN :DEVELOPMENT GROUP 818 ?82 8445 P.84 N~I- ,-9~ ~0N ]6:28 N~LL LET'I'E:~ ~gP F~X N0, 32'fbi,0 I',02 .... ~:~",~A~.~;~,~..~ ( ~ '4;-~ 'c ,'"~d, :'~L~,,,.~,I~ I ~ ~ ' ' , ' .~ ,' ~'r.~' '~,,-~;~.:", .~,,,~ , . *' , ' , , ,: .... .:.. ,.~ *,',~. , ~ . , :.; ,. , ~.~ · .~. ~ ~ ~ ~'.~.~ , ~'- BAKERSFIELIDFIRE DEPARTMENT ~ - . , ';.'~'.' ~ C~T~ W~ .* .... ' "';. I- sub ~v ........ -- ..... --~ .... , ~...,.,. ~ · .,. , -'%.,~ / --~ ~ I - - ~ " ~ ' ~ ' ' . ~ ~ .... - ........... / · / / / ~. , ..... ----- , .... / ~ ~ , -) ..... I ,~.~ " ' ~'~..:~ , ' , ~,,~ r,,f"*" I I~,. / I . , · J :,:(,' ~:~,.:' . I ' /..':~": ..... ~mpl~ Date for ~~i ',~ J ~ ~,~ '. .... . ~J~[~ ' -- -- ~ ............ [./ ~ ~,,.'~" _ n ~.,' . .~ -;~ I" . ~'" ~ ~ ~ ,' . ~ Date: I authorize my company to pay $30.00 per hour for the off-hours worked by a City of Bakersfield Environmental Services Division employee for removing, installing, or upgrading an UST. T~ot~an~unt~ Company employee and title: Employee silage: Comply n~e: Enviro~ent~ Semites Division ' Ad.ess: Ci~, State, Zip C~de: ]Phone: a:\form\UGST 12-22-98 CORRECTION NOTICE BAKERSFIELD FIRE DEPARTMENT N° '-~ - 0 1 i 2 Location Sub Div. C~)~'['~) Blk ..... ~t. You are hereby required to make the fo]lowing cor~etions at the above l~ation: Co~. ~o [nspector 326-397g CORRECTION NOTICE BAKERSFIELD FI, RE DEPARTMENT i i~ Location ~l'O I ~ !C~O~ Sub Div. ~0~'~0 Blk. . ~t You are hereby required to make the following cor~ctions .~,: at the above l~ation: ~.:~.'~ Cor. No Ii it ':" ~Completion Date for Corrections ~RtO~ ~0 ~'i~&L' /~. ~.,..~ Inspector ~ BAK. ~I~FIELD CITY FIRE DEPAI~' ~IENT ~ HAZARDOUS MATERIALS DIVISION INSPECTION RECORD POST CARD AT JOBSITE INS~UCTIONS: Ple~e ~11 for an ins~r on~ when each group of ins~ons w~ ~e same numar are rea~. They will run in ~nsecu~e order ~ginning w~ numar 1. ~ NOT cover work for any num~red group until all Eems in ~hat group are signed off by ~e Perm~ng Aurora. Following ~ese ins~u~ons will reduce ~e numar of required ins~cfion vis~ and ~erefore prevent ~sess~ent of add~onal fees. S,rk Test Creation or Manufac~res Me,od Ca~odic Prote~on of Tank(s) ~~~ ~ Corrosion Prote~on of Piping. Join,. RII Pi, Il Liebig, Isolation of Piping From Tank(s) ~ Ca~odic Prote~on System-Piping SECONDARY CONTAINMENT, OVERFILL PROTE~ION, L~K DETE~ION ~ ~ner Ins~llafion - Piping I~/~ VauE Wi~ Product Com~fible Sealer ~ Level Gauges or Sensors, Roat Vent Valves ~ Produ~ Com~fible Fill Box(es) ~ Produ~ ~ne Leak ~te~or(s) Monitoring Well<s)/Sum.(.)- H,O Test Leak Dete~on Device(s) for Vadose/Groun~ater FINAL II~ ~ I Monitoring Wells. Caps & Locks q Monitoring Requirements ....... 08/06/98 10:29 '~805 326 0576 BFD ttAZ MAT DIV ~]002 Ormit N~. CITY OF BAKERSFIELD OFFICE OF E~ONMENTAL S~R~CES 171S Chester Ave., Bakersfield, CA (80S) 32~3979 PERblIT APPLICATION TO CONSTRUCr/MODIFY UNDERGROUND STORAGE TANK TYPE OF APPLICATION (CHECK) ~NEW FACILITY [ ]MODIFICATION OF FACILITY [ ]NEW TANK INSTALLATION AT EXISTING FACILrrY STARTING DATE. FAcrLITY NAME ADDRESS CONTRACTOR 4%, ~+-,,~,~,~-~ c~ Fl, t_, .~c~, !J~ CA LICENSE NO. 7'/o?~ ADDRESS [~xo?.~{--,co.,/ S-t- ' 'CITY V'cz~ '/0~.,¢ ,~ ZIPCODE ?'1~O.~; PHONE NO, rOI ~-' 7'X~"_ -~ -~ .7'_~ Bm~S~SLD crr~ B~usncEss LICENSE NO.. WORXMA~ COMP NO. BRIEFLY D£SCKIBE THE WORK TO BE DONE WATER TO FACILITY PROVIDED BY. DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE NO. OF TANKS TO BE INSTALLED . ~ AKE THEY FOR MOTOR FUEL ¥ YES NO SPILL PREVENTION CONTROL AND COIT;NTER MF. ASr0RES PLAN ON FILE YES ¥ NO taxx ~o. ~vo,.u~ P~:ou~ ~RE~ ~s~ ^~AT:O~ S~CTXOr~ t~On son MO~:OR nmL STOOGE T~S u) ff TANK NO. VOLUME CHEMICAL STORED CAS NO. CHEMICAL PREVIOUSLY STORED (NO BKAND Nm~) (~F KNOWN) FOR OFFICIAL USE ONLY ". :..;:/i'"' .: ,' :iiiiii::,iiii-':;;!ii!!',ii!!!i!: :'-:: I I C~,."~-'.:~oi, i~,'..~!ii~i!!!i!!i~!!~,~i~iiiii~ii!i!J~"~i'''~.' '":~"~ ~:~;::::1 ~ ~RO~D ~: ' -- ~'N~ (P~, ~~IC~ SIGNA~ ~IS APPLICATION BECOMLS A PE~IT WHEN APPRO~D i FICE OF ENVIRONMENT SERVICES 1715 Chester Ave., Bakersfield, CA 93301 (805) 326-3979 UST Tank Page ~ of TYPE OF ACTION .~1 NEW SITE PERMIT ~ 3 RENEWAL PERMIT ~ 5 CHANGE OF INFOR~TION (State type of ~ange) ~ 7 PER~NENTLY CLOSEO ON SITE Ch~k ~e item ~ly ~ 4 AMENDED PERMIT ~ 6 TEM~RY SITE CLOSURE ~ 8 TANK RE~VED 429 BUSINESS NAME (~me ~ FACILI~ ~ME ~ DBA - D~ng Busings ~) 3 FACILI~ ID ~ ~ ~ LOCATION (Opt~naO I. TANK DESCRIPTION TANK IO 8 430 TANK ~NUFACTURER 431 COMPARTMENTALIZED TANK ~ Y~ ~No 432 DATE INSTALLED (Y~MO) 433 TANK ~PACI~ IN ~LLONS 4~ NUMBER OF COMP~TMENTS 435 ADDITIO~L OESCRI~ION (F~ I~ use ~ly) 436 II. TANK CONTEN~ TANK USE 437 VEHICLE FUEL ~PE 438 ~I ~TOR VEHICLE FUEL ~ la REGU~ UNLADED ~ 2 ~DED ~ 5 J~ FUEL (If ma~. ~plete V~ide Fu~ T~e) ~1~ PR~IUM UNLADED E~ 3 DIESEL ~ 6 AVIATION FUEL ~ 2 USED OIL ~ lc MIDG~E UNLADED D ~ O~ER ~ 3 CHEMICAL PRODUCT E] 4 ~HOL ~ 4 H~RDOUS WASTE COM~N ~E (fr~ H~s ~t~als Inv~to~ ~age) 439 ~S ~ (fr~ H~rd~s ~t~s Inv~t~ page) 'fL TANK CONSmUcTiON . .. ," Ch~ ~e il~ ~ly ~ ~UBLE WA~ ~RIOR MEMB~E UNER ~ 95 UNKNO~ ~ 4 SINGLE WALL IN A VAULT ~ ~ OTHER TANK ~TER~L (pdmau tank) ~ 1 ~E STEEL ~ 4 STEEL C~D W/FRP ~ 5 ~NCR~E ~ ~ UN~O~ ~2 Ch~ ~e it~ ~ly ~ 2 STAINLESS STEEL ~3 FIBERG~SS ~ 8 FRP COMPATIBLE W/100% METHANOL ~ ~ OTHER TANK ~TERIAL (~da~ tank) ~ 1 B~E STEEL ~ 4 S~EL C~D W/FRP ~ 8 FRP COMPATIBLE W11~% METH~OL ~ 95 UN~O~ ~3 Ch~ ~e item ~ly ~ 2 STAINLESS STEEL ~ FIBERG~SS D 9 FRP NO~ORRODIBLE JACKET ~ ~ OTHER ~ 5 ~NCR~E ~ 10 ~ATED S~EL INTERIOR LINING OR COATING ~ 1 RUBBER LINED ~ 3 EPO~ LINING ~ 5 G~SS LINING ~ 95 UNKNO~ Ch~ ~e it~ ~ ~ 2 A~O LINING ~ 4 PHENOLIC LINING ~ 6 UNLINED ~ ~ O~ER OTHER ~RROSION ~ I ~NUFAC~D CP ~3 FIBERG~SS REINFORCED ~STIC ~ 95 UN~O~ ~5 PROTECTION IF APPLI~BLE Ch~ ~e il~ ~ly ~ 2 SACRIFICIAL ~ODE ~ 4 IMPRESSED CURRE~ ~ ~ O~ER SPILL AND OVERFILL SPILL CO~AINME~ INSTALLED (Y~}. OVERFILL PRO~CTION EQUIPMENT INSTALLED (Y~) 447 Ch~ all that apply DROP TUBE ~ Y~ ~ No 448 ~ 1 A~RM STRIKER ~TE ~ Y~ ~ No ~9 ~ 2 ~LL FLOAT ~ 3 FILL TUBE SHUT OFF VALVE =============================== IF SINGLE WALL TANK (Ch~ all that ap~ly): IF ~UBLE WALL TANK (~ ~e item ~ly): 450 ~ 1 VISUAL (EX~SED ~RTION ONLY) D 5 ~NUAL TANK ~UGING (~G) ~ 8 VISUAL (SINGLE WALL IN VAULT ONLY) ~ 2 AUTO~TIC TANK ~UGtNG (ATG) ~ 6 VALSE ZONE ~ 9 ~INUOUS INTERSTITIAL ~NITORING ~ 3 CONTINUOUS ATG ~ 7 GROUNDWATER ~ 4 STATISTICAL I~ENTORY RECONCILIATION (SIR) + ~ ~ OTHER 81ENNIAL TANK TESTING V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN P~CE ESTI~TED DATE ~ST USED (Y~/OAY) 451 ESTI~TED QUANTI~ OF SUBSTANCE RE~INING 452 ~S TANK FILLED WITH INERT ~TERIAL? 453 gal ~ Y~ ~ NO July 1. 1998 F~m~y SWRCB Form B P:%uSTTNK-B.CM3.wpd OF BAKERSFIELD l~]~'Chester Ave., Bakersfield, CA 93301 (805) 326-3~ll~ . UST - TANK PAGE Page ~ Of VI,, pIPING ~:~)NSTRUCTIQN (Check all that aoolv) · ABOVEGROUND PIPING INFORMATION UNDERGROUND PIPING INFORMATION -~S~ CYPE [] I SUCTION [] 2 PRESSURE [] 3 GRAVITY 454 [] I SUCTION [] 2 PRESSURE [] 3 GRAVITY 455 [] 1 SINGLE WALL [] 95 UNKNOWN [] 1 SINGLE WALL [] 3 LINED TRENCH [] 99 OTHER ONSTRUCTION [] 200UBLE WALL [] 99 OTHER 450 [] 200UBLE WALL [] 95 UNKNOWN 454 MATERIALSAND [] I 8ARE STEEL ~"]6FRPCOMPATIBLEWIIOO%METH,4~NOL [] 1 8ARE STEEL [] 6 FRP COMPATIBLE WI IOO% METHANOL CORROSION PROTECTION [] 2 STAINLESS STEEL [] 7 GALVANIZED STEEL [] 2 STAINLESS STEEL [] 7 GALVANIZED STEEL [] 3 PVC COMPATIBLE WITH CONTENTS [] 95 UNKNOWN [] 3 PVC COMPATIBLE WITH CONTENTS [] 95 UNKNOWN [] 4 FIBERGLASS [] 8 FLEXIBLE [] 99 OTHER [] 4 FIBERGLASS [] 8 FLEXIBLE [] 99 OTHER [] 5 STEEL WI COATING [] 9 CATHODIC PROTECTION 455 [] 5 STEEL WI COATING [] 9 CATHODIC PROTECTION 456 · ".' '".i: VIL PIPING LEAK:DEi~iECTIo~I (Check all that apply) ABOVEGROUND PIPING INFORMATION UNDERGROUND PIPING INFORMATION SINGLE WALL PIPING 457 SINGLE WALL PIPING 456 PRESSURIZED PIPING (Chect( all thal apply): PRESSURIZED PIPING (Chec~ all that apply): ['"1 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, [] 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL 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 (C~ec~ all ~at apply): [] 4 DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY [] 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM TEST (0.1 GPH) [] 6 TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS: SAFE SUCTION SYSTEMS: [] 7 SELF MONITORING [] 5 SELF MONITORING GRAVITY FLOW (Check all that apply): GRAVITY FLOW: [] 8 DALLY VISUAL MONITORING [] 6 BIENNIAL INTEGRITY TEST (0.1 GPH) [] 9 BIENNIAL INTEGRITY TEST (0.1 GPH) BECONDARJLY CONTAJNED PIPING SECONDARILY CONTAJNED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Chec~ all that apply): [] 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (chE<;k ofle) [] 7 CONTINUOUS TURBINE SUMP SENSOR VVtTH AUDIBLE AND VISUAl. ALARMS AND (Ched< 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 DISCONNECTION [] c NO AUTO PUMP SHUT OFF [] b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION [] 11 AUTOMATIC LEAK DETECTOR [] c NO AUTO PUMP SHUT OFF [] 12 ANNUAL INTEGRITY TEST (0.1GPH) [] 8 AUTOMATIC MNE LEAK DETECTOR (3.0 GPH TEST) SUCTION/GRAVITY SYSTEM: [] 9 ANNUAL INTEGRITY TEST (0.1 GPH) [] 13 CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Chec~ all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) [] 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND [] 10 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS VISUAL ALARMS [] 15 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) [] 11 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) [] 16 ANNUAL INTEGRITY TEST (0.1 GPH) [] 12 ANNUAL INTEGRITY TEST (0.1 GPH) [] t 7 DAILY VISUAL CHECK [] 13 DAILY VISUAL CHECK · ":': ' .::::". ?: :!.'.:i.::i"'i':"?:i!:i.':'i !;ii~iii!i;~:i:.!::i:::;i!?::~ii.?i~/~ii~?i~i~i~!-~'~6~TAiN'~i~' DISPENSER [] 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [] 3 CONTINUOUS DISPENSER PAN SENSOR VVlTH AUTO SHUT OFF FOR DISPENSER CONTAINMENT [] Yes [] No [] 2 CONTINUOUS ELECTRONIC SENSOR + AUDIBLE AND VISUAL ALARMS +AUOIBLE AND VISUAL ALARMS [] 4 DAILY VISUAL CHECK IX. OWNER/OPERATOR SIGNATURE I certify thai the information provided h~aln is true & accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE 462 NAME OF OWNER/OPERATOR (pdnl) 463 TITLE OF OWNER/OPERATOR 464 July 1, 1998 Formerly SWRCB Form B P:\USTTNK.B.CM3.wpd  CITY OF BAKERSFI~D ~FFICE OF ENVIRONMENTA~SERVICES 1715 Chester Ave., Bakersfield, CA 93301 (805) 326-3979 UST Tank - 1 .~ Page __ of __ TYPE OF ACTION [] I NEW SITE PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION (State type of change) [] 7 PERMANENTLY CLOSED ON SITE Check one item only [] 4 AMENDED PERMIT [] 6 TEMPORARY SITE CLOSURE [] 8 TANK REMOVED 429 LOCATION (Optional) I. TANK DESCRIPTION TANK ID # 430 TANK MANUFACTURER 431 COMPARTMENTALIZED TANK [] Yes [] No 432 If "Yes", complete one form for each compartment. DATE INSTALLED (YEAR/MO) 433 TANK CAPACITY IN GALLONS 434 NUMBER OF COMPARTMENTS 435 ADDITIONAL DESCRIPTION (For local use only) 436 II, CONTENTS ' · TANK USE 437 VEHICLE FUEL TYPE 438 [] 1 MOTOR VEHICLE FUEL [] la REGULAR UNLEADED J'=] 2 LEADED [] 5 JET FUEL (If marked, complete Vehicle Fuel Type) [] lb PREMIUM UNLEADED r"] 3 DIESEL [] 6 AVIATION FUEL [] 2 USED OIL [] lc MIDGRADE UNLEADED [] 99 OTHER [] 3 CHEMICAL PRODUCT F'] 4 GASOHOL [] 4 HAZARDOUS WASTE. COMMON NAME (from Hazardous Materials Invent¢~ry page) 439 CAS # (from Hazardous Materials Inventory page) 440 [] 95 UNKNOWN :.~ ' ::~ .111, TANKCONSTRUCTION ~ . ": ' TYPE OF TANK [] 1 SINGLE'WALL [] 3 SINGLE WALL WITH [] 5 INTERNAL BLADDER SYSTEM 441 Check one item only [] 2 DOUBLE WALL EXTERIOR MI=MBRANE LINER [] 95 UNKNOWN [] 4 SINGLE WALl.. IN A VAULT [] 99 OTHER TANK MATERIAL (pdmary tank) [] 1 BARE STEEL [] 4 STEEL CLAD W/FRP [] 5 CONCRETE [] 95 UNKNOWN 442 Check one item only [--~ 2 STAINLESS STEEL [] 3 FIBERGLASS [] 8 FRP COMPATIBLE W/100% METHANOL [] 99 OTHER TANK MATERIAL (secondary tank) [] 1 BARE STEEL [] 4 STEEL CLAD Wi FRP [] 8 FRP COMPATIBLE W/100% METHANOL [] 95 UNKNOWN 443 Check one item only [] 2 STAINLESS STEEL [] 3 FIBERGLASS [] 9 FRP NON-CORRODIBLE JACKET [] 99 OTHER [] 5 CONCRETE [] 10 COATED STEEL INTERIOR LINING OR COATING [] 1 RUBBER LINED [] 3 EPOXY LINING [] 5 GLASS LINING [] 95 UNKNOWN 444 Check one item o~ly [] 2 ALKYD LINING [] 4 PHENOLIC LINING [] 6 UNLINED [] 99 OTHER OTHER CORROSION [] I MANUFACTURED CP [] 3 FIBERGLASS REINFORCED PLASTIC [] 95 UNKNOWN 445 PROTECTION IF APPLICABLE Check one item only [] 2 SACRIFICIAL ANODE [] 4 IMPRESSED CURRENT [] 99 OTHER SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PROTECTION EQUIPMENT INSTALLED (YEAR) 446 447 Check all that apply DROP TUBE [] Yes [] No 448 [] 1 ALARM STRIKER PLATE [] Yes [] No 449 [] 2 BALL FLOAT [] 3 FILL TUBE SHUT OFF VALVE IF SINGLE WALL TANK (Check all that apply): IF DOUBLE WALL TANK (Check one item only): 450 [] I VISUAL (EXPOSED PORTION ONLY) [] 5 MANUAL TANK GAUGING (MrG) [] 8 VISUAL (SINGLE WALL IN VAULT ONLY) [] 2 AUTOMATIC TANK GAUGING (ATG) [] 6 VADOSE ZONE [] 9 CONTINUOUS INTERSTITIAL MONITORING [] 3 CONTINUOUSATG [] 7 GROUNDWATER [] 4 STATISTICAL INVENTORY RECONCILIATION (SIR) + [] 99 OTHER BIENNIAL TANK TESTING V, TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 451 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 452 GAS TANK FILLED WITH INERT MATERIAL? 453 qal [] Yes [] No July 1, 1998 Formerly SWRCB Form B P:~USTTNK-B.CM3.wpd t ~ CITY Or: BAKERSFIELD I~l OFFICE OF ENVIRONMENTAL SERVICES 1'PI'5 Chester Ave., Bakersfield, CA 93301 (805) 326-3~J"~ UST - TANK PAGE Page Of · ' ' ' ':;:' ':': ::ii!::i:i ~,:::.Vi~ Pi~lN~CO'~STRij~lON::':i~heck all that'~:~ply) ABOVEGROUND PIPING INFORMATION UNDERGROUND PIPING INFORMATION . SYSTEM TYPE [] 1 SUCTION [] 2 PRESSURE [] 3 GRAVITY 454 [] 1 SUCTION [] 2 PRESSURE [] 3 GRAVITY 455 [] 1 SINGLE WALL [] 95 UNKNOWN [] 1 SINGLE WALL [] 3 LINED TRENCH [] 99 OTHER 3ONSTRUCTION [] 2 DOUBLE WALL [] 99 OTHER 450 [] 2 DOUBLE WALL [] 95 UNKNOWN 454 MATERIALS AND [] I BARE STEEL [] 6 FRP COMPATIBLE W/100% METHANOL [] 1 BARE STEEL [] 6 FRP COMPATIBLE W/100% METHANOL CORROSION PROTECTION [] 2 STAINLESS STEEL [] 7 GALVANIZED STEEL [] 2 STAINLESS STEEL [] 7 GALVANIZED STEEL [] 3 PVC COMPATIBLE WITH CONTENTS [] 95 UNKNOWN [] 3 PVC COMPATIBLE WITH CONTENTS [-~ 95 UNKNOWN [] 4 FIBERGLASS [] 8 FLEXIBLE [] 99 OTHER [] 4 FIBERGLASS [] 8 FLEXIBLE [] 99 OTHER [] 5 STEEL W/COATING [] 9 CATHODIC PROTECTION 455 [] 5 STEEL W/COATING [] 9 CATHODIC PROTECTION 456 ABOVEGROUND PIPING INFORMATION UNDERGROUND PIPING INFORMATION SINGLE WALL PIPING 457 SINGLE WALL PIPING 456 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): [] 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, [] 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS FOR LEAK. SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND [] 2 MONTHLY 0.2 GPH TEST VISUAL ALARMS [] 2 MONTHLY 0.2 GPH TEST [] 3 ANNUAL INTEGRITY TEST (0.1 GPH) [] 4 DAILY VISUAL CHECK [] 3 ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS (Check all that apply): [] 4 DAILY VISUAL MONITORING OF PUMPING SYSTEM 4- TRIENNIAL PIPING INTEGRITY [] 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM TEST (0.1 GPH) [] 6 TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS: SAFE SUCTION SYSTEMS: [] 7 SELF MONITORING [] 5 SELF MONITORING GRAVITY FLOW (Check all that apply): GRAVITY FLOW: [] 8 DAILY VISUAL MONITORING [] 6 BIENNIAL INTEGRITY TEST (0.1 GPH) [] 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 (ch(.,~k one) [] 7 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) [] 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 DISCONNECTION [] b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM [] c NO AUTO PUMP SHUT OFF DISCONNECTION [] 11 AUTOMATIC LEAK DETECTOR [] c NO AUTO PUMP SHUT OFF [] 12 ANNUAL INTEGRITY TEST (0.1 GPH) [] 8 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) SUCTIONIGRAVITYSYSTEM: [] 9 ANNUAL INTEGRITY TEST (0.1GPH) [] 13 CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) [] 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND [] 10 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS VISUAL ALARMS [] 15 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) [] 11 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) [] 16 ANNUAL INTEGRITY TEST (0.1 GPH) [] 12 ANNUAL INTEGRITY TEST (0.1 GPH) [] 17 DAILY VISUAL CHECK [] 13 DAILY VISUAL CHECK · .'~" ~,~'.~ : !:. ~.i,.~;'::': ::~:~: :'!::$:.<: ':: :: , :':~;: ?;":':~::~ ":~:~'~ :~:::~':~ ~ ;~:~,~%~:~:~,??:~:;:%~;/;'~;';~g~:/~:"::¥~:~:!:~!:,¥~!~::: :,:',: :~; : ! ?,::!;:':~'~,~¥~;:/~:;~:.'?::::::': ::: ', '2:'' ':~;~,~: ~,,~- ?' · ;.:..~:i:? ~: DISPENSER [] 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [] 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER CONTAINMENT [] Yes [] No [] 2 CONTINUOUS ELECTRONIC SENSOR + AUDIBLE AND VISUAL ALARMS + AUDIBLE AND VISUAL ALARMS [] 4 DALLY VISUAL CHECK IX. OWNER/OPI:-'RATOR SIGNATURE I certify that the information provided herein is true & accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE 462 NAME OF OWNER/OPERATOR (print) 41~3 TITLE OF OWNER/OPERATOR 464 J Permit Number (For local use only) Permit Approved I Permit Expiration Date I July I. 1998 Formerly SWRCB Form B P:\USTTNK~B.CM3.wpd