The URL can be used to link to this page

Home My WebLink AboutUNDERGROUND TANK (2) HAZARDOUS MATERIALS DIVI~ UNDERGROUND STORAGE TANK PROGRAM PERMIT No. ~-~~-~Lj-i PERMIT APPLICATION FOR. REMOVAL OF AN UNDERGROUND STORAGE TANK SITE INFORMATION SITE '~e~O~u~- ~:~_..~ (0t~tm"l~--Y-~\ ADDR.ESS Zt~S ~ ~.ZlPCODE ~APN FACILTW ~AME~~ ~~ ~bL CROSS STREET ~ ~ TANK OWNER/OPERATOR ~'~ ~'~% ' PHONE' No,. MAILING ADDRESS ~ ~ ~ ~%. Cl~~ ZIP CODE CONTRACTOR INFORMATION COMPAN~o~ ~ ~~.~. PHONE No~~-~ ~ 'LICENSE No. ADDRESS ~ ~k~ ~k~ ~ · ' ~.~ -,Cl~~oO INSURANCE C~RIE~~~'~ ~ ~ 'WORKMENS~_O_~p..Ng~.~~t~ COMPANY~~/ · · PHONE No. ~J~ ~ LICENSE No.~'~ ADDRESS '/~~ ~~ ~_ CI~/~~~ZIPCODE~)~.3 INSURANCE CARRIER · ~ ~ ~ WORKMENS COMP No. TANK ~L~ANIN~ INFORMATION · , ~ ~ z~P gODE ADDRESS 3~ ~ WASTE mANSPO~TER ~DENT~F~T~ON NUMBER ~~ ~O'~ ~ ~ Z NAME OF RINSTATE DISPOSAL~A~I~_~,;~- ~, ~ . . ADDRESS ~O ~~4~ /)~/~ 'CI~ ~/~~IPCODE FACILI~INDENTIFICATION NUMBER ~ ~~t~ · : - LICENSE No. ZIP CODE TANK TRANSPORTER INFORMATION CO Mp ANY,,,'~,/..~- PHONE No. ADDRESS CITY TAN K D ESTI NATION ~-.~,~4:~_..~ TANK INFORMATION TANK No. AGE 'VOLUME CHEMICAL DATES CHEMICAL STORED STORED PREVIOUSLY STORED THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATrACHED CONDITIONS OF THIS PERMIT AND ANY OTHER ' STATE, LOCAL AND FEDERAL REGUL~ATIONS. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. ,~PPRiDVED BY: // APPLICANT NAME (PRINT) ' AP-"'PI. ICAI:',IT SI'GNATURE / THIS APPLICATION BECOMES A PERMIT WHEN APPROVED Plot Plan must show the followin ~T 3. 4. 5. 6. 7. PLOT PLAN Roads and alleys buildings location of tanks, piping, and dispensers utilities SCALE water wells (if on site) any other relevent information September 26,1995 CITY OF BAKERSFIELD 1715 Chester ave. BAKERSFIELD CA .93312 Dear Mr. Huey In response to your letter of violation; Dewey pest control removed the underground tank over 5 years ago. To my knowledge all the appropriate permits were acquired and was removed by a contractor with the apporiate license and work experience. I hope this helps with your records. Sincerely Timothy Harris Branch Manager DEWEY PEST CONTROL, 2138 "Q" STREET, BAKERSFIELD, CALIFORNIA 93301-2990 o (805) 327-1433 · FAX (805) 323-9703 ENVIRONMENTAL SECURITY SINCE 1929 R.E. HUEY HAZ-MAT COORDINATOR (805) 326-3979 CITY of BAKERSFIELD FIRE DEPARTMENT FIRE SAFETY SERVICES & OFFICE OF ENVIRONMENTAL SERVICES 1715 CHESTER AVE. · BAKERSFIELD, CA . 93301 September 15, 1995 R.B. TOBIAS, FIRE MARSHAL (805) 326-3951 DEWEY PEST CONTROL 2138 Q ST BAKERSFIELD, CA 93312 Dear Business Owner: NOTICE OF VIOLATION STATE REGISTRATION REQUIREMENT Failure to renew your state registration is a violation of Section 25287, California Health and Safety Code, and will result in your Permit to Operate the underground tank(s) being revoked. Owners of underground storage tanks must register those underground storage tanks with the State of California Water Resources Control Board and renew that registration every five years. Our records indicate five years have passed since your last State registration pursuant to Section 25287 of the California Health and Safety Code. This means that for state registration renewal you must submit a state surcharge of $56.00 for each tank. Please make your check payable to the City of Bakersfield. You have 30 days from the date of this letter to return the state surcharge to 1715 Chester Ave., Bakersfield, Ca. 93301. If you have any questions or if we can be of any further assistance please don't hesitate to call 326-3979. Sincerely Yours, Ralph. E. Huey Hazardous Materials Coordinator REH/ed FIRE DEPARTMENT S.D. JOHNSON FIRE CHIEF CITY of BAKERSFIELD "WE CARE" May 19, 1992 2101H STREET BAKERSFIELD, 93301 326-3911 Dewey Pest Control 3711 Beverly Boulevard Los Angeles, CA 90004-0337 Attn: Ron Pelham CLOSURE OF 1 UNDERGROUND. HAZARDOUS SUBSTANCE STORAGE TANK LOCATED AT 2138 Q STREET, IN BAKERSFIELD, CALIFORNIA. PERMIT # BR0049 Dear Mr. Pelham, This is to inform you that. this department has reviewed the results for the preliminary assessment associated with the closure of the tank located at the above stated address. Based upon laboratory data submitted, this office is satisfied with the assessment performed and requires no further action at this time. This letter does not relieve you of any liability for past, present, or future operations. In addition, any future changes in site use may require further assessment or mitigation. It is the property owners responsibility to notify this department of any changes in site usage. If you have any questions regarding this matter, please contact me at (805)-326-3~97. ~~acer ,e~y' ..... A. Dunwo~ rdous Material Specialist Underground Tank Program ~A~-~ Bakersfield Fire De ~E~MIT No. ~~- '~ UNDERGROUND STORAGE TANK PROGRAM ~)(~ PERMIT APPLICATION FOR. REMOVAL OF AN UNDERGROUND STORAGE TANK SITE INFORMATION SITE '~,etO~--~:~C..~ (0~.~. 5~ ADDR.ESS ~[~ ~ ~. ZIP CODE ~APN FACI~ NAME~%3 ~~~o[CROSS STREET ~ ~ TANK OWNER/O~E~TOR '~--~ ~',% ' PHONE NO.. · MAILING ADDRESS ~~~ ~. ~1~~ ZIP OODE ~~ CONTRACTOR INFORMATION COMPAN'Cb~o~r'~\c~ ~. ('"~-k-~m. 6_ll,t~.'~. PHONE No~I,O'~'E,~I'~-~) [~ LICENSE No. INSURANCE CARRIE~ ~~'~¢ ~ ~ ~ ~ ' WORKMENS~_O~ Ng~_~ ~ ........ : ' 5-t-~ - ~-~ ~ PRELIMANARY ASSEMENT INFORMATION ~//~ COMPANY ~ c~/ - PHONE No. ~/~ ~ LICENSE No. ADDRESS /~~ ~~co ~ INSURANCE CARRIER · ~ ~) ~ WORKMENS COMP No. TANK CLEANING INFORMATION COMPANY ~-~--~ ~ ~g g-~--~ g ~ _ 'pHONE"NE.~ ~~- ADDRESS ~bO ~, ~~( ~ CIW~zIpCODE WASTE TRANSPORTER IDENTIFICATION NUMBER ~ ~0~ ~ ~ Z ~/ ~ NAME OF RINSTATE DISPOSAL~A~I~_~,;~- ~t L ADDRESS ~0~~4~ /~~ 'CIW ~~~IPCODE FACILI~INDENTIFICATION NUMBER ~% ~~3~ · ~60~ TANK TRANSPORTER INFORMATION COMPANY,S/./~- PHONE N°. ADDRESS CITY TANK DESTINATION TANK INFORMATION LICENSE No. ZIP CODE TANK No. AGE VOLUME CHEMICAL DATES CHEMICAL ~ STORED STORED PREVIOUSLY STORED / w/c. THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATrACHED CONDITIONS OF THIS PERMIT AND ANY OTHER STATE, LOCAL AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. ~PPR~VED BY: // ~PPLICANT NAME (PRINT) - ' AP~EICA~T SIGNATURE / THIS APPLICATION BECOMES A PERMIT WHEN APPROVED PLOT PLAN Plot Plan must shOw the following: 2. 3. 4. 5. 6. 7. Roads and alleys ............. buildings location o~ tanks, piping, and dispensers utilities SCALE water wells (if on site) any other relevent information BAKERSFIELD FIRE DEPARTMENT HAZARDOUS MATERIAL DIVISION 2130 G Street, Bakersfield, CA 93301 (805) 326-3979 TANK REMOVAL INSPECTION FORM f'AClLITY j-~u.)~M"---~ ~~/ ADDRESS ,R.)~.~ ~ ~ OWNER <~ ~/~ PE~ITTOOPE~TE~ CO~CTOR ~~~ k/ , CONTACT PERSON~cN~/~ ~~ TE~T ~ETHODOLOGY PRELI~NARY ASS~CO. ~c~ / CON, CT PERSON/~~~~, CO~ RECIEPT ' LEL% O2% ~ ~ ~ g PLOT PLAN CONDITION OF TANKS CONDITION OF PIPING CONDITION OF SOIL -_ - -COMMENTS .- -// .-- / ECTORS ~AME- DATE BA RSFIELD FIRE DEPARTMENT ItAZARDOUS MATERIAL DIVISION PERMIT TO OPERATE · UNDERGROUND HAZARDOUS STORAGE FACILITY Permit No.: 150076 State ID No.: 150076 Issued to: DEWEY PEST CONTROL Location: Owner: Operator. 2138 Q STREET BAKERSFIELD, CA 93301 DEWEY SERVICES 939 EAST UNION ST PASADENA, CA 91106 DEWEY PEST CONTROL 2138 Q STREET BAKERSFIELD, CA 93301 Facility Profile: -Tank -No. -- Substance Capaci .ty 1 GASOLINE 750 GAL Year Is Piping Installed UNKNOWN YES This permit is granted subject to the conditions listed on the attached summary of conditions and may be revoked for failure to adhere to the stated conditions and/or violations of any other State or Federal regulations. Issued by: Ralph E. Huey Title: Hazardous Materials Coordinator Issue Date: JULY 1, 1991 Expiration Date: JULY 1, 1994 POST ON PREMISES NONTRANSFERABLE State of California---Health and Welfare Agency Ssi Instructions on Back age 6 Depadment of Health Services Fca'm App~dved~OMB No. 2050---0039 (Expires 9-30.91) Toxic Substances ConTrol Division · Please print or"type, Form designed for uae on elite (1 and Front of Pa, Sacramento, California UNIFORM HAZARDOUS ~D.o..--, --~1 DocumentManifeStNo. r .=--~:. ru.uu ~I Information in the shaded areas 3, Generator's Name and Mailing Address ' I ~ v~ A; State M~if%t DocUment Number 5. Transpo.er 1 Company Name 6. US EPA ID Number " C:':,8tate Tranapmer'. !o ~ m~ 7. Tranapoder 2 Company Name 8. US EPA ID Number E~: State TFa~aP0der'a 16 '.: . : ." 1 I.,. ~S DOT De~oriptton (Including Proper Shipping Name, Hazard Class, and ID Number) Quantity Unit ~" Waate No.::: ' . No. Type WI / Vol :: ::~ a. State · NON EC~ ~OUS ~ASTE LIQUID EPA/~hor I I I I I I I 16. Special Handling Instructions and Additional information GENERATOR'S CE~IFICATION: I hereby declare ~hat the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transpo~ by highway according to applicable international and national government regulations. If I am a large quantity generator, I cedl~ that I have a program'in place to reduce'the volume and toxicity of waste generated to the ~egree I have determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have ~ade a good faith sired to minimize my waste generation and select the best waste management method that is av~lable to me and that I can afford. 17.'T~ah~po~e~ t~c~owledgement of Receipt of Materials "%. A ~T~a~ Signatur~ ~ Month Day Year Printed/Typed Name I Signature, Month Day Year I 19. Discrepancy Indication Space 20. Facility Owner or Operator Ce~lfication of receipt of hazardous materials covered by this manifest except as noted in Item 19. Printed/Typed Name ~ Signature Month Day Year I A ;EPA 8700--22 ',(Rev. 6-8g) Previous editions are obsolete. Do Not Write Below This Line Blue: GENERAI'OR SENDS IHIS COPY TO DOHS WIIHIN 30 DAYS To: P.O. Box 400, Sacramento, CA 95812-0400 INVOICE FIRE EQUIPMENT 24 HR. PHONE: (805) 322.~301 TY EQUIPMENT 101 TRUXTUH AVE.' ::.;~: ' ' CAUF. WATrS (am) 272-6326 HYDROSTATIC TESTINGs. "' '~ ~ BAKERSFIELD, CA 93301~:'" ORDER DESK FAX (805) 322~3127 lICENSES :. :" ' "~ ~ OFFICE FAX (~05) 322-6000 STATE # 646~ ,'A.;,CORP. FED. I.D. NO. 95-259941 !. ,_CONTRAC'FoR' LIC..C-16-B20'/8! ... ,, '"'~' ...... - .... /~'-'~ ' . ~ .... Price .N~ount ~'"" .... ' C0 BuLK WE'iGHT~TiCKET -' ' ' ', . ;' Cu. FI. ?-?::~ I:IELIUM CYLINOERS , ' ./ ~,::i.:,¥~ ...... CYLS. DELIVERED ".': .... '' CYLS. RETURNED ,~i~.~WILLC~,LL i'~:!'O DELIVER:. TOTAL ~ "'~. %', ~ ~ .r.. ~< ..~ ....... ' , MA~ERiAI~'$A~ETY DATA'SHEET · ~"~:~AVAILABLE ON REQUEST ,,, REMIT TO: P.O. BOX 1631 BAKERSFIELD, CA 93302-1631 ?TITLE T~'"~E'*B~E ENUMERATED PERSONAL P~PERTY OR RENTALS SHA~ ~E~L~ ~:ICE UNTIL FULLY PAID FOR AND VENDEE SHALL BE RES~NSlBLE FOR SAME WHILE IN ~WlLL SURRENDER SAME U~N DEMAND IF IN DEFAULT. IT IS ALSO AGREED THAT IF COLLECTION IS MADE BY ~SUIT, OR OTHERWISE, I~E AGREE TO PAY A FINANCE CHARGE OF 1.5% PER ~ONTH, WHICH IS 1~% PER ':ANHGM,.~ER ~ DAYS, ALSO COLLECTION COSTS AND INCLUDING ATTORNEY'S FEES, AND WAIVE ALL 'R GHT5 TO ~Y CLAIMS EXEMPTED UNDER STATE LAWS, MINIMUM INTEREST CHARGE $1 .~. "~&~l~ ~'~wHjCH'CYLINDERS ARE LOANED: ~OV DED THAT F ANY LOANED CYL NDER N~T RETURNED :~WITHIN,,~ DAYS FROM DATE OF SHIPMENT THE DISTRIBUTOR RESERVES~ .~I~H[.~..~_~.~E~.~ ~?CHARGE,OF 14.~ PER CYLINDER PER MONTH FOR ALL TIME OVER 30 DAYS ]HA1 SUCH ~.F~M THE DISTRIBUTOR,..WHICH DEMURRAGE CHARGE THE CUSTOMER AGREES TO PAY ON DEM~D. THE ~CUSTOMER ~HALL PAY ~OMPTLY ON DEMAND TO THE DISTRIBUTOR ESTABLISHED VALUATIONS AND RATES ~FOR L08~ OF OR DAMAGE TO ANY OF SAID CYLINDERS OR FITTINGS RE6ULTING FROM ANY CAUSE AFTER :JDELI~-THEREOF~/T.D. ~0 THE CUSTOMER AND UNTIL RETURNED TO TH~ DISTRIBUTOR, RE~ILLI~G.OE. CYLINDERS [!I~'.IVIt~C~'IFIJViL~F!'I[AI. AND (~I:NI::I~'AI. EI",ICGIhlEEI,,'II",IG J-.'('l 1 IC',:iJcll [ ~?DJ(. P'I J,~¢ ?'..:il. Ih August 29, 1990 To Whom it May Concern: Walter J. Wojak of Excel En~vironmental and General Engineering is working directly under my ~upervision in the collection of field samples as follows: lak. zng of field soil samples fro], tank excavations and site investigations for analytical sampling by a State Certified Laboratory. /akzng soil samples during the installation of groundwater wells and exploratory soil borings· Logging of soil borings and groundwater well installations. Should you require any' further clarification in tl~is matter, please call me at (213) 529-2511· Sincerely, Efren Ancheta STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARKONLY [] 1 NEW PERMIT [] 3 RENEWAL PERMIT [~. 5 CHANGE OF INFORMATION r---],.7 PERMANENTLY CLOSED ONSlTE ONE ITEM [~ 2 INTERIM PERMIT [] 4 AMENDED PERMIT [] 6 TEMPORARY TANK CLOSURE 7 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. # / C. DATE INSTALLED (MO/DAY/YEAR) '7 B. MANUFACTURED BY: ~ D. TANK CAPACITY IN GALLONS: /OOC II. TANKCQNTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. MOTOR VEHICLE FUEL [] 40It~ B. C',,~l~ UNLEADED [] 6 AVIATION GAS [] 2 PETROLEUM [] 80 EMP'P¢ .,~i PRODUCT r~ lbPREMIUM [] 4 GASAHOL [] 7 METHANOL ~ UNLEADED [] 5 JET FUEL [] 3 CHEMICAL PRODUCT [] 95 UNKNOWN [~ 2 WASTE ~] 2 LEADED [] 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOXES A, B,ANDC, ANDALLTHATAPPLIESINBOXD A. TYPE OF ~[] 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR LINER [] 95 UNKNOWN SYSTEM ~ SINGLE WALL [] 4 SECONDARY CONTAINMENT (VAULTED TANIO [] 99 OTHER B. TANK .Z~ BARE STEEL [] 2 STAINLESS STEEL [] 3 FIBERGLASS [] 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM [] 8 100% METHANOL COMPATIBLEW/FRP (PrimaryTank) [] 9 BRONZE [] 10 GALVANIZED STEEL [] 95 UNKNOWN [] 99 OTHER ~ 1 RUBBER LINED r-~ 2 ALKYD LINING ~ 3 EPOXY LINING ~ 4 PHENOLIC LINING C. INTERIORLiNiNG [] 5 GLASS LINING ~ UNLINED E~ 95 UNKNOWN ~] 90 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES__ NO__ D. CORROSION [] 1 POLYETHYLENE WRAP~-'-~/[] 2 COATING [] 3 VINYL WRAP [] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [] 5 CATHODIC PROTECTION~ 91 NONE [] 95 UNKNOWN [] 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A~,,)I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION Al~l SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C, MATERIAL AND CORROSION PROTECTION A U(~I BARE STEEL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PiPE A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLEW/FRP A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [] 1 AUTOMATIC LINE LEAK DETECTOR [] 2 LiNE TIGHTNESS TESTING V. TANK LEAK DETECTION ] 3 INTERSTITIAL MONITORING ~ OTHER [] 1 VISUAL CHECK ~2~'2 INVENTORY RECONCILIATION [] 3 VAPOR MONITORING [] 4 AUTOMATIC TANK GAUGING [] 5 GROUND WATER MONITORING JZ~6 TANK TESTING [] 7 INTERSTITIAL MONITORING [] 91 NONE [] 95 UNKNOWN [] 99 OTHER VI. TANK CLOSURE INFORMATION SUBSTANCE REMA,N,NG ALLONS ,NEBTMATER,AL: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT I APPLICANT'S NAME ,I '.'~ _, .,/ // IDATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMBE D OFTHE FOUR NUMBERS BELOW COUNTY ~ JURISDICTION ~ FACILITY ~ TANK ~ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MU~T BE AC~MP~IED BY A PERM~ ~PLICATION · FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED, FOROO34B-R4 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 CLOSED SITE ONE ITEM [] 2 INTERIM PERMIT E~ 4 AMENDED PERMIT [] 6 TEMPORARY SiTE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) · ADDRESS ~' NEAREST CROSS STREET £ PARCEL#(OPTIONAL) CITY.b~ME STA SITE PHONE # WITH AREA CODE ~ BOX TO INDICATE ORPORATiON ~ INDiViDUAL ~ PARTNERSHIP ~ LOCAL-AGENCY ~ COUNTY-AGENCY ~ STATE-AGENCY ~ FEDERAL-AGENCY DISTRICTS ~PE OF BUSINESS [~ 1GAS STATION ~ 2 DISTRIBUTOR r-~ ~ IF INDIAN ,# OF TAN~KS AT SITE [ E.P.A.I.D.#(optiona/) RESERVATION [~ 3 FARM [~ 4 PROCESSOR ~ OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) I DAYS~.NAME (LAST. FIRST) ~ PHONE # WITH AREA CODE NIGHTS: NAME (L~ST. FIRS~ PHONE · WITH AREA C~E II. PROPERTY OWNER INFORMATION- (MUST BE COMPLETED) INAME MAILING OR STRE;~ET A~D~ESS ICITY N.~ME II1. TANK OWNER INFORMATION- (MUST BE COMPLETED) NAME OF OWNER MAILING OR STREET ADDRESS CITY NAME EMERGENCY CONTACT PERSON (SECONDARY). optional DAYS: NAME (LAST, FIRST) NIGHTS: NAME (LAST, FIRST) PHONE # WITH ARFA ~O~F PHONE # WITH AREA CODE CARE OF ADDRESS INFORMATION i~ box m indicate r-'-] INDIVIDUAL [~] LOCAL-AGENCY E~ STATE-AGENCY RPORATION F'-] PARTNERSHIP ~ ~ FEDERAL-AGENCY COUNTY-AGENCY i STATE I ZIP CODE I PHONE # WITH AREA CODE CARE OF ADDRESS INFORMATION box to indicate ~ INDIVIDUAL ~ LOCAL-AGENCY [~ STATE-AGENCY CORPORATION ~ PARTNERSHIP ~ COUNTY-AGENCY E~ FEDERAL-AGENCY STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION MST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. TYITK) HQ I- -I-I I I I ( I I V. PETROLEUM MST F,NA,C,AL RESPONS,B,L,TY-(MUST BE COMPLETED)-,DENT,FY T"E MET,OD(S) USED box ~indicale ~ 1 SELF-INSURED E~ 2 GUARANTEE ~ 3 INSURANCE ~ 4 SURETY BOND ~ 5 LETTER OF CREDIT ~ 6 EXEMPTION ,~;~THER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. AND BILLING: I. IlL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT A~PLICANT~ NAME (PRINTED & SIGNATURE) ~ ~ ] APPLICAN'PS TITLE LOCAL AGENCY USE O~Y ~ ' ~ ' COUN~ ~ JURISDICTION ~ I DATE MONTH/DAY/YEAR FACILITY # i LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY.AT LEAST (1) OR MORE PERMIT APPLICATION. FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A (5-91) FOR0033A-5 UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES 2FOR[OCAI~!AG ENC¥1 USE ONLY{:{::i:' ! !ii~:?ii:~:i:: ~i i::i ~?ii i i i i: i [] YES ~0 REPORT BEEN FILED ? ~ YES r~ NO ~AME~ ,--OF INDIVlDU~i~ FILING REPORT] '~ SlGNA~RE ~ REPRESENTING ~ X ~ OWNE~OPERATOR ~ REGIONAL BOARD COMPANY OR AGENC~ NA~E ~ ADDRESS NAME ~NT~T PERSON ' PHONE ADDRESS ' cou~ ~lP ~ CROSS STREET O L~AL AGENCY AGENCY N~E ~NTACT PERSON PHONE ~ ~ (1)'//t ~ NAME ,j QUANTI~LOST (~LLO~S) ~ ~ UNKNOWN ~ DATE DIS~VERED HOWDIS~VERED ~ INVENTORY~NTROL ~ SU~URFACE MONITORING ~ NUIS~CE CONDITIONS ~ DA~ DI~HARGE BE~N M~HOD USED TO STOP DISCHARGE (CHECK ~L ~AT APPLY) ~ HAS DISOHARGE SEEN STOPPED ? ~ REPAIR TANK ~ OLOSE TANK & FILL IN P~OE ~ OHANGE PR~EDURE SOURCE OF DIBHARGE CAUSE(S) ~m ~ TANK ~AK ~N KNOWN .~OV~ RE'EL ~ RUP~R~FA'LURE ~ SP'LL ~ O ~ PIPmNGL~K ~ OTHER ~ ~RROSION ~ UNKNOWN ~ OTHER a ~ ~NOAOT'ON TAKEN ~ PREL'M'NARY S'~ ASSESSMENT ~RK.~N SU.M,~EO ~ POLLUT'ON CHARACTER'~T,ON CHECK ONE ONLY ~ ~ ~ LE~ BEING ~NFIRMED ~ PRELIMINARY SITE ASSESSMENT UNDERWAY ~ POST CLE~UP MONITORING IN PROGRESS ~ REMEDIATION PLAN ' ~ CASE CLOSED(CLE~UP ~MPLE~DOR UNNECESSAR~ ~,, ,~ CLEANUP UNDERWAY CHECK APPROPRIATE ACTION(S) ~ EXCAVATE & DISPOSE (ED) ~ REMOVE FREE PRODUCT (FP) ~ ENH~CED BIO DEGRADATION (1~ ~ ~ P Sl~ (CD) ~ EXCAVATE & TREAT (E~ ~ PUMP & TREAT GROUNDWA~R (G~ ~ REP~CE SUPPLY (RS) ~ ~ CONTAINMENT BARRIER (CB) ~ NO ACTION REQUIRED (NA) ~ T~A~ENTATH~KUP(HU) ~ VENT SOIL (VS) ~ VACUUM ~XTRACT ¢~) ~ OTHER (O~ O HSC 05 (8/90) I. FACILITY/SITE DBA OR EACILITY NAME 'Bakersfield Fire Dept AZARDOUS MATERI..ALS DIVISION 2130 G Street, Bakersfmeld, CA 93301 (805) 326-3970 UNDERGROUND TANK QUESTIONNAIRI~JE[,' 2 19g! NO. OF TANKS ~ ~ ~1 ,.~ D( ~)1/_..~ AI]s'd ............ NAME OF OPERATOR ADDRESS N~REST CRO~ STRE~ ~ Clff NAME STATE ZIP CODE ~ BOX TO INDICATE ~ORPO~ON ~ INDIVIDUAL ~ PAR~ERSHIP ~ LOCAL AGENCY DISTRIC~ ~COUN~ AGENCY ~STATE AGENCY ~FEDE~L AGENCY PARCEL No.(OPTIONAL) TYPE OF BUSINESS GAS STATION ~13 FARM DISTRIBUTOR I KERN COUNTY PERMIT ~' ~ /~~.~ EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME (LAST, FIRST) PHONE No. WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE No. Wll~l AREA CODE EMERGENCY CONTACT PERSON (SECONDARY) optional DAYS: NAME (LAST, FIRST) PHONE No, WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE No. WITH AREA CODE I1. PROPERTY OWNER INFORMATION (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS CITY NAME II1. NAME ~ BOX [~ INDIVIDUAL ~ LOCAL AGENCY ~ STATE AGENCY TO INDICATE [~ PARTNERSHIP Q COUNTY AGENCY Q FEDERAL AGENCY STATE I ZIP CODE PHONE No, WITH AREA CODE TANKOWNER INFORMATION (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS CiTY NAME ~' BOX (~ [~INDIVIDUAL TO INDICA~ [~ PARTNERSHIP I~ COUNTY AGENCY ~ FEDERAL AGENCY LOCAL AGENCY [~ STATE AGENCY STATE I ZIPCODE PHONE No, WITH AREA CODE OWNER'S DATE VOLUME TANK No. INSTALLED DO YOU HAVE FINANCIAL RESPONSIBILITY? TYPE PRODUCT STORED IN SERVICE ~N. Y/N Y/N ¥/N Y/N Y/N · . Fill one segmentl for each tank, unless ~anks and piping are constructed of same materials, style ype, then only fill one segment out. pleaSe identify tanks by owner ID #. I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK ,. D.# ~:~ ~ - OO4~ a. MANUFACTURED BY: ~' ~ ~ ~ ~ III. TANK CONSTRUCTION UARK ONE I~M ONLY IN BOXES ~ B, ANDC,~DALLTHATAP.LIESlNaOXD A. TYPE OF [] 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR LINER · [~ 95 UNKNOWN SYSTEM [] 2 SINGLE WALL [] 4 SECONDARY CONTAINMENT (VAULTED TANK)[~ 99 OTHER B. TANK [] 1 BARE STEEL MATERIAL [] 5 CONCRETE (PrimaryTank) [] 9 BRONZE [] 2 STAINLESS STEEL [] 3 FIBERGLASS [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM [] 1 RUBBER LINED [] 2 ALKYD LINING [] 3 EPOXY LINING C. INTERIOR LINING [---~/5 GLASS LINING [] 6 UNLINED [~95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES__ NO__ [] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ] 8 100% METHANOL COMPATIBLEW/FRP ~,~99 OTHER ] 4 PHENOLIC LINING ] 99 OTHER D. CORROSION []'1 POLYETHYLENE WRAP [] 2 COATING PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE ,'~'i:~, .r-1 ' ~L WRAP .... []., F,BERG~S REINFORCED ~ST,C ~.:r-~95 UNKNOWN : [] 99 OTHER IV. PIPING INFORMATION ' CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A~I SUCTION ' A U 2 PRESSURE .. A U 3 GRAVI'[Y A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A IJ 3 LINED TRENCH J~95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION D. LEAK DETECTION A IJ 1 BARESTEEL A U 2 STAINLESS.STEEL A IJ 3 POLYVlNYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE A IJ 5 ALUMINUM A IJ 6 CONCRETE A U 7 STEEL W/ COATING A IJ 8100% METHANOL COMPATIBLEW/FRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION /1~0"~5 UNKNOWN A tJ 99 OTHER [] 1 AUTOMATIC LINE LEAK DETECTOR [] 2 LINE TIGHTNESS TESTING ~ 3 INTERSTITIAL MONITORING [] 99 OTHER V. TANK LEAK DETECTION I [] 1 VISUAL CHECK ,,[~_~'2 INVENTORY'RECONCILIATION [] 3 VAPOR MONITORING [] 4 AUTOMATIC TANK GAUGING [] 5 GROUND WATER MONITORINGI E~ ~ TANK TEST,NG [] ~ ,NTERST,T,ALMON,TOR,NG [] ,, ,ONE [] ,~ UN~OWN [] ~ OTHER I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK L D. # B, MANUFACTURED BY: C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, ANDC, ANDALLTHATAPPLIESINBOXD A. TYPE OF [] 1 DOUBLE WALL SYSTEM [] 2 SINGLE WALL ] 3 SINGLE WALL WITH EXTERIOR LINER [] 95 UNKNOWN [] 4 SECONDARY CONTAINMENT (VAuLTED TANK) [] 99 OTHER B. TANK [] 1 SARESTEEL [] 2 STAINLESS STEEL [] 3 FISERGLASS MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM (PrimaryTank) [] 9 BRONZE [] 10 GALVANIZED STEEL [] 95 UNKNOWN []., STEEL CLAD W, F,BERGLASS REINFORCED PLASTIC [] , 1~o METHANOL COMPAT,BLEW,FRP [] ~ OTHE" ~ 1 RUBBER LINED [---'12 ALKYD LINING ~ 3 EPOXY LINING c. INTERIOR [] 5 GLASS LINING [] 6 UNLINED [] 95 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100"/o METHANOL ? YES__ NO__ ] 4 PHENOLIC LINING ] 99 OTHER D. CORROSION [] 1 POLYETHYLENE WRAP [] 2 COATING PROTECTION r--15 CATHODIC PROTECTION E~ 91 NONE [] -~ v,.~L w,AP []., F,BERGLASS RE,NFORCED PLASTIC [] ~ UNKNOWN[] ~ OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A ~ 99 OTHER C. MATERIAL AND A U I BARE STEEL CORROSION A U 5 ALUMINUM PROTECTION A U 9 GALVANIZED STEEL A IJ 2 STAINLESS STEEL A IJ 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS.PIPE A IJ 6 CONCRETE A U 7 STEELWICOATING A U 8100°/o METHANOL COMPATtSLEW/FRP A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A IJ 99 OTHER D. LEAK DETECTION [] I AUTOMATIC LINE LEAK DETECTOR [] 2 LINE TIGHTNESS TESTING [] 3 INTERSTITIAL MONITORING [~ 99 OTHER V. TANK LEAK DETECTION TANKVISUALTEsTINGCHECK~[] 27 INTERSTITIAL MONITORINGIN~ENTORY RECONCILIATION E~]~.] 391VAPORNoNEMONITORING~[] 495 AUTOMATICuNKNOWN TANK GAUGING~-~[] 995 GROUNDoTHER WATER MONITORING I. TANK DESCRIPTION COMPLETE -- SPECIFY IF UNKNOWN T IA. OWNER'S TANK I.D.# / B. MANUFACTURED BY! C. DATE INSTALLED (MO/DAY/YEAR) / D. TANK CAPACITY IN GALLONS: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B. ANDC, ANDALLTHATAPPLIESlNBOXO A. TYPE OF [] '1 DOUBLE WALL [] 3..sINGLE WALL WI'IH EXTERIOR LINER : SYSTEM [] 2 SINGLE WALL [] 4 SECONDARY CONTAINMENT (VAULTED TANK) ] 95 UNKNOWN ] 99 OTHER TANK [] 1 BARE STEEL [] 2 STAINLESS STEEL [] 3 FIBERGLASS MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM (PrirnaryTank) [] 9 BRONZE [] 10 GALVANIZED STEEL [] 95 UNKNOWN ] 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC ] 8 100% METHANOL COMPATIBLEW/FRP ] 99 OTHER [] 1~ RUBBER LINED []'2 ALKYD LINING [] 3 EPOXY LINING [] 4 PHENOLIC LINING C. INTERIOR [] 5 GLASS LINING [] 6 UNLINED [] 95 UNKNOWN [] 99 OTHER LINING ,.. IS LINING 'MATERIAL COMPATIBLE WITH 100% METHANOL ? YES_ NO__ D. CORROSION .- [] ~ POLYETHYLENE WRAP [] 2 COATING ~... [] PROTECTION, [] ~.;.C. ATHODIC PROTECTION [] 91-~NONE ~:; .... ;;=~-~ 3 VINYL WRAP 95 UNKNOWN ] 4 FIBERGLASS REINFORCED PLASTIC [] 99 OTHER IV. PIPING INFORMATION C~RCLE .~ IFABOVEGROUNDOR U IF UNDERGROUNDoBOTH IFAPPLICASLE ~': ';': ':' ;"; ~ " A. SYSTEM TYPE A U..1 SUCTION ...... ,~, U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A,U 1 BARE.STEEL : ~ A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE .: A IJ 5 ALUMINUM ' ~ A' U 6,.CONCRETE ~..:"- '"A. U 7' STEEL WI COATING A U 8 100% METHANOL COMPATIBLEW/FRP A U 9 GALVANIZED STEEL A. U~ 10 CATHOblCPROTECTION 'A U 95 UNKNOWN ' 'A U 99 OTHER D. LEAK DETECTION [] 1 AUTOMATIC LINE LEAK DETECTOR [~] 2 LINE TIGHTNESS TESTING [] 3 INTERSTITIAL MONITORING [] 99 OTHER V. TANK LEAK DETECTION I[] ' VISUAL CHECK [] 2 INVENTORY RECONCILIATION [] 3 VAPOR MONITORING [] 4 AUTOMATIC TANK GAUGING [] 5 GROUND WATER MONITORING [] 6 TANK TESTING [] 7 INTERSTITIAL MONITORING [] 91 NONE [] 95 UNKNOWN [] 99 OTHER. I. TANK DESCRIPTION COMPLETE ALL ~TEMS - SPECIFY ~F UNKNOWN B. MANUFACTURED BY: A. OWNER'S TANK I. D. # C. DATE INSTALLED(MO/DAY/YEAR) D, TANK CAPACITY IN GALLONS: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, ANDC, ANDALLTHATAPPLIESINBOXD A. TYPE OF [] 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR LINER ~ SYSTEM [] 2 SINGLE WALL [] 4 SECONDARY CONTAINMENT (VAULTED TANK) ] 95 UNKNOWN ] 99 OTHER [] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK [] t BARE STEEL [] 2 STAINLESS STEEL [] 3 FIBERGLASS MATERIAL [] 5 CONCRETE [] 6 POLYVlNYL CHLORIDE [] 7 ALUMINUM (PrimaryTank) [] 9 BRONZE [] 10 GALVANIZED STEEL [] 95 UNKNOWN ] 8 100"/,, METHANOL COMPATIBLEW/FRP ] 99 OTHER ~ 1 RUBBER LINED ~ 2 ALKYD LINING [] 3 EPOXY LINING C. INTERIOR [] 5 GLASS LINING [] 6 UNLINED [] 95. UNKNOWN UNING iS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES__ NO__ ] 4 PHENOLIC LINING ] 99 OTHER D, CORROSION [] 1 POLYETHYLENE WRAP [] 2 COATING PROTECTION [] S CATHODIC PROTECTION [] 91 NONE ] 3 VINYL WRAP ]95 UNKNOWN ] 4 FIBERGLASS REINFORCED PLASTIC [] . 99 OTHER IV. PIPING INFORMATION C[RCL~ A IFABOVEGROUNDOR U IFUNDERGROUND BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE J[ U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND i U 1 BARE STEEL i U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE CORROSION PROTECTION A U 5 ALUMINUM A U 6 CONCRETE ~, U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLEW/FRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 9g OTHER D. LEAK DETECTION [] I AUTOMATIC LINE LEAK DETECTOR ~] 2 LINE TIGHTNESS TESTING [] 3 INTERSTITIALMoNITORiNG ~ 99 OTHER V. TANK LEAK DETECTION I [] 1 VISUAL CHECK [] 2 INVENTORY RECONCILIATION [] 3 VAPOR MONITORING [] 4 AUTOMATIC TANK GAUGING [] 5 GROUND WATER MONITORING · [] 6 TANK TESTING [] 7 INTERSTITIAL MONITORING [] 99 OTHER ] 91 NONE [] 95 UNKNOWN FILE CONTENTS SUMMARY t / Activi-ty Date # Of Tanks COlllmellt$ ~ / / / ENVIRONMENTAl' HEALTHI 2700 "M" STR. 1' , STE ~ARTMENT ~0 APPLICATION ~0a PEabilT TO OPERATE O~DER~~ ~New Facility aaodiflcation Of Facility ~Existing F;'~ii~t.;y ~Trans,~';".Of Ownership Saerzency a4-nour Contact (name, area code, phone): ~ays ' Nights (818) 359-4259 Facility Name Dewey Pest Control Company No. Of Tanks 1 Type Of Business (check): ~Gasollne Station ~Other (describe) Pest Control Service Is Tank(s) Located On An Agricultural Farm? ~Yes ~No Is Tank(s) Used Primarily For Agricultural Purposes? ~Yes ~No ~aci. liW aaa~.~s 2~38 Q S,r~, Sa~=~fi~a 9330~ Ne.rest Cross T R SEC (Rural Locations Only) Tank Owner Dewey Pest Control Company Contact Person Kon Pelham aadress 37~ Beverl~ Blvd. City/StateL.A. ~ Calif.9000~elephone213/660-6804 Operator Same as above Contact Person Address Zip Telephone Bo Water To Facility Provided By Soil Characteristics At Facility Basis For Soil Type and Groundwater Depth Determinations Depth to Groundwater Contractor Address Proposed Starting Date Worker's Compeqsatlon Certification No. CA Contractor's License No. Zip Telephone Proposed Completion Date Insurer D. If This Permit Is For Modification Of An Existing Facility, Briefly Descrtb Modifications Proposed Tank(s) Store (check all that apply): .Tank t Waste Product Motor Vehicle Unleaded Regular Premium Diesel Waste Fuel O11 [] [] [] [] [] [] [] [] [] [] [] 0 0 0 [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] Chemical Composition Of Materials Stored (not necessary for motor vehicle fuels) Tank # Chemical Stored (non-commercial name) CAS # (If known) Chemical Previously Stored (If different) Transfer Of Ownership Date Of Transfer Previous Owner Previous Facility Name I, accept fully all Obligations of Permit No. issued tr I understand that the Permitting Authority may review am( modify or terminate the transfer of the Permit to Operate this underground storag( facility upon receiving this completed form. This form has been completed'under penalty of perjury and to the best of my knowledge Is true and correct. Eacflity Name Dewey Pest H. 1. o bo o 10. mtrol Company - ~ Permit No. .(FILL OUT SEPAR= FORM ~ .CH TANK) EACH SECTION, CHECK Ail. APPROPI~ItTE BOXES Tank is: ( ) Vaulted ( ) Non-Vaulted ( ) Double-Wall fiX) Single-Wall Tank Material' (lq Carbon Steel ( ) Stainless Steel ( ) Polyvinyl Chloride ( ) Fiberglass-Clad Steel ( ) Fiberglass-Reirfforc, ed Plastic ( ) Concrete ( ) Aluminum ( ) Bronze ( ) Unknown ( ) Other (describe) Primary Containment Date Installed Thickness (Inches) Capacity (Gallons) Manufacturer 1 ~ 000 Tank Secondary Containment ( ) Double-Wall ( ) Synthetic Liner ( ) Lined Vault (X) None . ( ) Unknown () Other (describe): Manufacturer: ( ) Material Thickness (Inches) Capacity (Gallons) Tank Interior Lining ( ) Rubber , ( ) Alkyd ( ) Epoxy ( ) Phenolic ( ) Glass ( ) Clay (X) Unlined ( ) Unknown () Other (describe): Tank Corrosion Protection ( ) Galvanized ( ) Fiberglass-Clad ( ) Polyethylene Wrap ( ) Vinyl Wrapping (X) Tar or Asphalt ( ) Unknown ( ) None ( ) Other (describe): Cathodic Protection: (.) None ( ) Impressed Current System ( ) Sacrificial Anode System Describe System and Equipment: 'Leak Detection, Monitoring, and Interception a. Tank: ( ) Visual (vaulted tanks only) ( ) Groundwater Monitoring Well(s) ( ) Vadose Zone Monitoring Well(s) ( ) U-Tube Without Liner' ( ) U-Tube with Compatible Liner Directing Flow to Monitoring Well(s)* ( ) Vapor Detector* ( ) Liquid Level Sensor* ( ) Conductivity Sensor* ( ) Pressure Sensor in Annular Space of Double Wall Tank* ( ) Liquid Retrieval & Inspection From U-Tube, Monitoring Well or Annular Space (X) Daily Gauging & Inventory Reconciliation ( ) Periodic Tightness Testing () None () Unknown '() Other Piping: ( ) Flow-Restricting Leak Detector(s) for Pressurized Piping* ( ) Monitoring Sump with Raceway ( ) Sealed Concrete Raceway ( ) Half-Gut Compatible Pipe Raceway ( ) Synthetic Liner Raceway OX) None ( ) Unknown ( ) Other *Describe Make & Model: Tank Tighmess Has This Tank Been Tightness Tested? fy,) Date of Last Tightness Test 1989 Test Name Tank Repair Tank Repaired? ( ) Yes (X) No Date(s) of Repair(s) Yes ( ) No ( ) Unknown Results of Test Testing Company ( ) Unkhown Describe Repairs Overfill Protection ( ) Operator Fills, Conu'ols, & Visually Monitors Level ( ) Tape Float Gauge ( ) Float Vent Valves ( ) ( ) Capacitance Sensor ( ) Sealed Fill Box ( ) None ( ) Other: Auto Shut-Off Controls (X) Unknown List Make & Model 'for Above Devices 11. Piping' a. bo Underground Piping: (~ Yes (X) No Thickness (inches) Diameter ( ) Pressure ( ) Suction ( ) Gravity Underground Piping Corrosion Protection: ( ) .Galvanized ( ) Fiberglass-Clad ( ) Impressed Current ( ) Polyethylene Wrap ( ) Electrical Isolation ( ) Vinyl Wrap (~) Unknown ( ) None ( ) Other (describe): Underground Piping, Secondary Containment: ( ) Double-Wall ( ) Synthetic Liner System ( ) None () Other (describe): ( ) Unknown Material Manufacturer Approximate Lengrfi, of Pipe Run Sacrificial Anode Tar or Asphalt Unknown