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Home My WebLink AboutUNDERGROUND TANKHazardous Materials/Hazardous Waste- CONDITIONS. OF Permit ID#:: 015-000-000428 ~'_ - ' MERCY SOUTHWEST He Unified' Permit ~PERMIT ON REVERSE SIDE This !~ermit is issued for the followin_.: [] Hazardous Materials Plan. [3 Underground Storage of H~_~=rdous Materials [3 Risk Management Program [3 Hazardous Waste On-Site Treatment LOCATION: 400 OLD RIVER RD TANK .... HAZARD O U S,,S ~,?BST,,~I~iCE 015-000-000428-0002 DIESEL Issued by: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES' 1715 Chester Ave., 3rd Floor - Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Approved by: 'C ~alffiPc~Ho~E~iro~ Issue IDate Expiration Date: 'June 30. 2003 · Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE .............. ,,,~,~,~?~?~,,~ ............... This permit is issued for the following: ,~,,¢i'~i'::'i: ~,!i '~i!/::~'~%i i ! ili;~; iii;:'ii?~ii~U~e[ground Storage of Hazardous Materials LOCATION 400 OLD RIVER~%.':,,¢,~::.._.';::¢ BAKERS[~LD CA . ~i, ".. ",ilE":~ .... :::=:..-.-.:;¢ ,'~:'¥'"':" ':'%¢;"¢i!~' ,' , ", ,' · ."" ': ,ii ~¢'~,,, i, ~ ~..""C~ HAZARDOUS SUBSTANCE DIESEL DIESEL PIPING PIPING METHOD ONITO ALD SUCTION CLM Issued by: Bakersfield Fire Department OFFICE OF ENVIR ONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (805) 326-3979 FA× (805) 326-0576 Approved by: Expiration Date: P~ph Hucy~ Office of ~a,ml~entai SewiCes June 30, 2000 B ~q~r E R $ P l'l~'~L D ICA Cert. No. 00737 City of Bakersfield Office of Environmental Services 1715 Chester Ave., Suite 300 Bakersfield, California 93301 (805) 326-3979 An upgrade compliance certificate has been issued in connection with the operating permit for the facility indicated below. The certificate number on this facsimile matches the number on the certificate displayed at the facility. Instructions to the issuing agency: Use the space below to enter the following information in the format of your choice: name of owner; name of operator; name of facility; street address, city, and zip code of facility; facility identification number (from Form A); name of issuing agency; and date of issue. Other identifying information may be added as deemed necessary by the local agency. This permit is issued on this 2na day of November, 1998 to: MERCY SOUTHWEST HOSPITAL Permit #015-021-000428 400 Old River Rd Bakersfield, California 93311 Permil t!o Operal:e Itazardou~ Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE . ~ - _.,=~ , This pe~it ts issued ~r the following: ~'.~~~¢~~rdous Materials Plan .~- :~ ~ ~ ~ ~~~round Storage of H~rdous Martials PERM~ ID~ 015~21e00428 ~ ~2~ ~~~~agement P~ram TAN H~OUS SUBSTANCE CAP~I~ ~ ~R~~ ~~~.~N~ ~ PIPING PIPING PIPING 0003 DIESEL 6.00~0~ ~; :: '~& F AT~z ~E~ OW IF ALD 0006 DIESEL 2,~O~:~AL _X~ ~ ~W F ~ ~ A~ DW ~F SUCTION CLM B~ersfield Fke D~m A~v~ by: ' 17~ ~ Aw, 3~ Floor B~s~ GA 93301 Vo~ k \ I \ ~, T / ? / FACILITY NAME i~tc~q 500'~k~(" ~05~,~ Section 2: Underground Storage Tanks Program CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301 INSPECTION DATE [] Routine [] Combined [] Joint Agency Type of Tank Type of Monitoring [] Multi-Agency Number of Tanks Type of Piping 0C0f- [] Complaint [] Re-inspection OPERATION C V COMMENTS Proper tank data on file ~, / Proper owner/operator data on file Permit fees 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 Office of Environmental Services (805) 326-3979 White- Env. Svcs. Pink - Business Copy ~usir~ess Site Re~~le P~y BSSR, Inc. .. 6630 Rosedale Hwy., it B, rsfield, CA 93308 Phone (661) 588-2777 Fax (661) 588-2786 MONITORING SYSTEM CERTIFICATION t This form must be used to document 'testing and servicing of mohitoring equipment. A separate certification or report must be, prepared for each monitoring system ~ontrol parlel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Inforraatio~ Facility Name: Site Address: ~, ~ff~,.~'~/~'"'~' , Bldg. No.: city: Facility Contact Person: Contact Phone No.: ~ Make/Model of Monitoring System: ~./~ ~"t~.l~ ,//'//~.~ ff~/~ Date of T~ffSe~ic~g: B. Invento~ of Eqmpment' ~~~ ff~ :/-~g' q~O ~0 ~. Char the appropriate boxes ~ indl~te specific e~uipment insp~t~l~: ' D In-T~k Gauging Pmbe,~ Model:~~/~ I ~ In-T~k Gauging ~be. M~el: D Annular Space or Vault Sensor. Model: ~~/~ ~~ Annul~ Space or Vault Sensor. Model: D Piping Stop / Tr~ch Sensor(s). Model:' ' ~/~ I 'D Piping Sump / Trench Sensor(s). Model: ~ Fdl Sump Sensors). ~ode~: ~~ ~ ~$~ ~ Fdl Sump Sensors). M~el: D Mechanical Line Le~ Detector. Model: ~ D Mech~ical Line Leak Detector. Model: [3 Electronic Line Leak Detector. Model: [21 Tank Overfill / High-Level Sensor. Model:. [3 Other (specify equipment type and model in Section E on Page 2). {3 In-Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: J, ff/Z) C3 Piping Sump / Trench Sensor(s). Model: FI Fill Sump S,ensor(s). Model: ~,E],~ O"~k:hanical Line Leak Detector. Model:~'iF~ [3 Electronic Line Leak Detector. Model: ,-~ El Tank Overfill / High-Level Sensor. Model: ~ . [3 Other(specify equipment type and model in gection E on Page 2). Dispenser ID:, .ff~}~ ,~/fJ~'° ~ [3 Dispenser Containment Sensor(s). Model: Fi Shear Valve(s). ~ Dispenser Containment Float{s) and Chain(s). Dispenser ID: 13 Dispenser Containment Sensor(s). Model: .. 121 Shear Valve(s). [3 Dispenser Containment Float(s) and Chain(s~. Dispenser ID: D Dispenser Containment Sensor(s). Model: [3 Shear Valve(s). El Electronic Line Leak Detector. Model: El Tank Overfill / High-Level Sensor. Model: ' 121 Other (specify equipment type and model in'Section E on Page 2). Tank ID: 121 In-Tank Gauging Probe. Model: [3 Annular Space or Vault Sensor. Model: El Piping Sump / Trench Sensor(s). Model: [3 Fill Sump Sensor(s). Model: 121 Mechanical Line Leak Detector. Model: [3. Electronic Line Leak Detector. Model: {21 Tank Overfill / High-Level Sensor. Model: [3 Other (sp, ecif}t equipment t~pe and model in Section E on Page 2). Dispenser ID: [3 Dispenser Containment Sensor(s). Model: [3 Shear Valve(s). ~ Dispenser Containment Float(sI and Chain(s). Dispenser ID: 121 Dispenser Containment Sensor(s). Model: [3 Shear Valve(s). I~ Dispenser Containment Float(s) and ChainqsI. Dispenser ID: El Dispenser Containment Sensor(s). Model: [3 Shear Valve(s). [3Dispenser Containment Float(s) and Chainls). [3 Dispenser Containment Float(s) and Chain(s/. *If the facility contains more tanks or dispensers, copy this form. Include information for eve~ tank and dispenser at the facility. C. Certification - I certify that the equipment identified In thiJ document w~s inspected/serviced in accordance with t.h.e~ manufacturers' guidelines. Attached to this Certification Is information (e.g, manufacturers' checldlsl~) necessary to verify that~J~ information is correct and a Plot Plan showing the layout of monitoring equi~pment. For any equipment capable of genera~fg such report~,'l have also attached .a cpp;x of t_he~.repo_~;~check all that apply): ~1 Syste/l~ set-~p ~!i A~la_rm. ~listory repm,f Teclmician Name (print): /~_J ,~//~J ~ff'"~" Signature'. ~je~/~,~' ~-~~_ . ,, .Certification No.: , License. No.: Testing Company Name: _'~ OC~J~ Phone No.:( ~'~'/ Site Address: ~,L~'~'o~'t0 ,~o~~~//~q'-~/,~_~ ~' Date of Testing/Servicing: Page I of 3 Monitoring System Certification 0.3/0 ! ~-D; Results of Testing/Servicing Software Version Installed: ,mplete the following checklist: alarm operational? ca Yes ca N°* Is'the visual alarm operational? " Yes ca No* Were all sensors visually inspected, func6onally tested~ and confirmed operational? ' Yes ca No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper .operation? Cl Yes ca No* If alarms are relayed to a rerhot~ monitdring station,'; !s~-all~ communications equipment (e.g. modem) . ~i~ N/A operational?....~....., .,' .... , E! Yes IZ! No* ,For pressurized piping systems, does the tarbine automatically shut down if the piping secondary containment N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply) El Sump/Trench'Sensors;, El Dispenser Containment Sensors. "'. .Did you confim~p0siti,~e shUt:doWn.due t~ leaks' and sensor failure/disconnection? El Yes; ca No. ca Yes ca No* For tank systems that utilize the rrionitoring system as the primary tank overfill warning device (i.e. no ~1 N/A mechanical overfill prevention valve is installed), is the overfill warning alarm vis~le and audible at the tank fill point(s) and operating prope, rly? If so, at what pcrcent"bf tank capacity does the alarm tri§get? ~ % El Yes* )~ No Was any monitoring equipment replaced? If yes, identify, spe6ifiC sensors, probesi"oFother equipment replaced and list the manufacturer name and mode! for all r~l~l~i~ment,~ iii'Section E, below. ~ Yes* ca No Was~liquid found inside any secondary containment.syst~msid~igned., as dry systems? (Check all that apply) I-I ProducB El Wat~.r. Ifyes~ descn'be causes in Section E~ below. ~ Yes El No* Was monitoring system set-up reviewed to ensure proper settingS? Attach set up reports, if applicable [~ Yes ca No* Is all mom,'toring e.q. uipment ope. rational.per manufacturer'.s sp.e.~.ifica.tions? . . * In Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: Page 2 of 3 03/01 . E. la-Tank Gauging / SIR Equip : Check this box if tank ga~ng is used only for inventory control. Check this box if no iank gauging or SIR equipme~nt is installed. This section must be completed if in-tank gauging equipment, !? u~sed [0 pe.rform leak detection monitoring. dete the following checklist: Yes U 'N~~. H'a'S all input wiring 'been inspected for proper e~t~y and termination, including t'esting for ground faults? , Yes El No* Were all tank gauging probes visually inspected for damage and residue buildup? '~ Yes El No* Was accuracy of system product level re~dings tested? Yes ri No* Was accuracy of system water level readings tested? Yes El No* Were all probes reinstalledlprop~rly? J~'~-',: ~'. ' * In the Section H, below, describe h~w and when the, se ,.deficiencies were or will be corredt~fl", ~'"~.~ El Yes El No* For ~quipment start-up or annual equipment '~eationi was'a leak simulated to'verify LLD PerfOrmance? El N/A (Checi all that apply) Simulatedleakrate: ,.~.,:~..gi~; El0. i'i~Zp:h~';~ri0.2ig.p.h. n Yes a No* Were, all LLDs c0~firmed operational and accurate with!,n regula~'~/~ ~'~-quirements? ri Yes- r-I No* Was the testing'apParatus properly cahl~rated? "'"""'"'~ El Yes .El No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak?i ri N/A El Yes ri No* For electronic LLDs, does the turbine automatically shut off if th~ LLD detecl~s a, le .~,?~.~ .... :, ;: ~, ,,~.~ ri N/A : ......................... 'i '- --.'~" '" '.,' ': ~,',. El 'Yes ri'No* 'For electronic LLDs, does the turbine automatically shut off if a~,~y portion of the monitoring system is disabled. ri N/A or disconnected? ri Yes El No* 'For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring .,system ri N/A malfunctions or fails a test? ri Yes ri No* For electronic LLDs, have all access~le wiring connections been' visually inspected? El Yes ri No* Were all items.on the equipment manufacturer's maintenance che~ldist completed? * In the Section H below, describe how and when these deficiencies were or will b~ corrected. · H. Comments: Page 3 of 3 03~01 Monitoring System Certification Site Address: 'Monitoring Site Plan m p. I~structions If you already have a diagram that. shows ~1! required information, you may include it, rather tl~an this page, with your Monitoring System Certification. On your site plan, show the general laYout"Of'tanks and piping. Clearly identify locations of the following equipmen~ if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, al!spenser pans, spill containers, or other secon .dary containment areas; mechanical or electronic line leak deteotors; and in-tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan was prepared. -~ ~'' Page ,~ of ~ 05100 CITY OF BAK~FIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 INSPECTION RECORD POST CARD AT JOB SITE Phone No. INSTRUCTIONS: Please call tbr an inspector only when each group of inspections with thc same number are ready. They will mn in consecutive order beginning with number I. DO NOT cover work for any numbered group until all items in that group are signed offby thc Permitting Authority. Following these instructions will reduce the number or' required inspection visits and theretbre prevent assessment o£additional fees. TANKS AND BACKFILL INSPECTION I DATE I INSPECTOR Backfill of Tank(s) Spark Test Certification or Manufactures Method Cathodic Protection of Tank(s) tl ~ PIPING SYSTEM Piping & Raceway w/Collection Sump ~OJ~,~ Corrosion Protection of Piping, Joints, Fill Pipe Electrical Isolation of Piping From Tank(s) Cathodic Protection System-Piping DiSpenser Pan SECONDARY CONTAINMENT, OVERFILL PROTECTION, LEAK DETECTION Liner Installation - Tank(s) Liner Installation - Piping Vault With Product Compatible Sealer Level Gauges or Sensors, Float Vent Valves Product Compatible Fill Box(es) Product Line Leak Detector(s) Leak Detector(s) for Annual Space-D.W. Tank(s) Monitoring Well(s)/Sump(s) - H20 Test Leak Detection Device(s) for Vadose/Groundwater Spill Prevention Boxes FINAL Monitoring Wells, Caps & Locks Fill Box Lock Monitoring Requirements Type Authorization for Fuel Drop CONTRACTOR ILrtl'~ dC~,.~.4~t,t~_4tO~ L,CENSE~ qff mc3 May ~0----~ Mike Wood Bakersfield Memorial Hospital 420 34th Street Bakersfield, CA 93301 CERTIFIED MAIL FiRE CHIEF P, 0 {'.1 FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 396-1349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAFETY SERVICES * ENVIRONm:NTJU. SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 PUBLIC EDUCATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 326-O576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 TRAINING DIVISION 5642 Vlctor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 Failure to Complete SB 989 Secondary Containment Repairs & Retest FINAL REMINDER NOTICE Dear Underground Storage Tank Owner & Operator: Since January 1, 2003, this office has sent you monthly reminders advising you of a failed SB 989 test. In that letter, this office also requested an update with regard to repairs of your system. This office further explained that repairs of your system are a condition of your permit to operate. Please be advised that you must have your system repaired and retested by June 15, 2003. Failure to comply may result in further enforcement action up to, and including revocation of your permit to operate. This office has extended every courtesy with regard to sending contractor information as well as one on one visit's Should you have any questions, please feel free to call me at 661-326- 3190. Sincerely, Ralph E. Huey Director of Prevention Services Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/dc m ~ Cerfiflsd Fee r--~ Ream R~pt F~ Po~ ~ (Endowment Require) Hem ~ Res~ed Del~e~ Fee ~ ~ (Endo~me~ Requi~) 'rom P MIKE woOeD_ ~ MEMORIAL HOSPITAL [~ghr~- BAKERSFILI~ ~vw [ 420 34vu STRE_ET~. aa301 [~.g3 DAKERSFIELD,~-'v~ ' ....... ' · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · · Print your name and address on the reverse so that we can return the card to you. by (PrintedNarne) C. Date of Delivery · Attach this card to the back of the mailpiece, or on the front if space permits. . { c~. Is deiivery address different from item.l? [] Yes 1. Article Addressed to: I if YES, enter delivery address below: [] No MIKE WOOD · MERCY SOUTHWEST '400 OLD RIVER RD [ a. Service Type ' 'BAKERSFIELD CA 93311 [ ~ [] Certified Mail [] Express Mail ~ ~ [] Registered [] Return Receipt for Merchandise .... - -- J [] Insured Mail [] C.O.D, Restricted Delivery? (Extra Fee) [] Yes 7002 3150 0004 9985 3929 _ PS Form 3811, August 2001 Domestic Return Receipt 2ACPRI-03-Z-0985 BSSR, Inc. , 6630Rosedale H . B, Bakersfield, CA 93308 Phone (661) 588-2777 Fax (661) 588-2786 MONITO NG sYSTEM CERTIFICATION Th. is form mtkst be used to document teSting and servicing of mohitoring e~lUiPment. A separate certifieati0n or ,report must be prepared for each monitoring system'control panel by the technician who performs' the wOrk~ A copy o£ this form must be provided to the tank system owner/oPerator. The, owner/operato? rlaust submit.a copy .of this', t'o~t° tike local agency regulating' UST systems :.. A. General Information .: - Facility Contact. PerSoni:.:~tC"Htq~3'' ~ILPIN 'contactPli°ncN°.:(g&t ) D tu q ,i Make/Model,of Monitoring ~ystcm: 1011JTO *~TI K :Tiqb'j I(~: · Date °fTcsting/SerVicing: ~{ /_;2 1/0'~ , 'B. InventorY6fEqUipmentTested/Cerfified 'i. .. ' ~' Check the appropriate boxes~to indicate specific equipment. insPected/Serviced: , ' · [it~nrTank Gauging Probe.: ;.: ModeiL D Cii~nnular Space Or Vault Sensor. "Model: .'.~l-I R_IT~_ ~l 0 ' ~ ~"Piping Sump / Trench sens0r(s). ::Model:- El' Fill Sump sensOr(s)[ , Model: ' Cl Mechanical Line Leak Detector. Model: El Electronic,Line Leak Detector. ' Model: .: ~1 Tank Overfill / High-Level Sensor. ModeI:· [21 Other (specify equipment ,type and:model in Sec.tion E on Page 2). Tank ID: 13 In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: El Piping Sump / Trench Sensor(s). Model: C! Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: ~ Electronic Line Leak Detector. Model: 121 Tank Overfill / High-Level Sensor. Model: ~ Other (sPecify equipment type and model in Section E on Page 2). Dispenser ID: D Dispenser Containment Sensor(s). Model: ~ Shear Valve(s). cl Dispenser Containment Float(s} and Chain(s). Dispenser ID: ~! Dispenser Containment Sensor(s). Model: 121 Shear Valve(s). ~ Dispenser Containment Float(s) and Chain(s). Dispenser ID: El Dispenser Containment Sensor(s). Model: U! Shear Valve(s). ClDispenscr Containment FIo~t(s) and Chain(s). Tank ID: Cl. In-Tank GaUging Probe; Model: F1 Annular space or Vault Sensor.· ' ~ Model: ~ Piping Sump/.Trench Sensor(s).:. MOdel: . I~ Fill Sump Sensor(s) .... . ..- ,..Model: i:~ Mechanical LincLeak De~ector.. Model: [] Electronic Line Leak Detector. Model:' . CI Tank Overfill'/High~LeVel Sensor. 'Model:' ' ' · 'O Other (§PeclfY:eq~!Pment type ~d mOdel in}S;ct'ign Eon P~ge 2}~'~-- TatikID: ': .... '" ' : ' '" ' CI In-Tank Ganging Probe. Model: [] Annular Space or Vault Sensor. Model: [] Piping Sump / Trench Sensor(s). Model: ' ' ~ ' .-' El Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector/ Model: [] Electronic Line Leak Detector. Model: El Tank Overfill / High-Level Sensor. Model: -- [] Other (specify equipment type and model in Dispenser ID: [] Dispenser Containment Sensor(s). Model: [] Shear Valve(s). [] Dispenser Containment Float(s} and Chain(s). Dispenser ID: [] Dispense[ Containment Sensor(s). Model: [] Shear Valve(s). · [] Dispenser Containment Float{s} and Chain{s}. Dispenser ID: [] Dispenser Containment Sensor(s), Model: D Shear Valve(s). 121 Dispenser Containment Float(s} and Chain(s}. Section E on Page 2). *If the facility'contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the .facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): n Syste~m set-up. D Alarm history report Technician Name (print): "~ITY~' L ~"~l'~'~f LL.-C) Signature:~.(~t_,~ ("'O ~t~q.~' ' Certification No.: t,.[l I O License. No.: resting Company Name: ~_'~I~. ~*d('o .' ~ ehoneNo.:( S6! )~3~_~:~C:]':'~W ...... Site Address: (36'~C5 ~O ~?-B iq I~ ~ Ht,,Ox-[ ,~ ~ Date of Testing/SerVicing: t_~ /'"),~l, /_.0_.~ Page 1 of 3 ,' 03/01 Monitoring System Certification D~ Results of Testing/Servicing Software Version Installed: ..Complete the following' ehi~eklist: ,, aud~le alarm operational? ............. iD'Yes ' El No* Is the visual alarm qperat!onal? [~/Yes 'El'No* Were all sensors 9i'siaally in. spected, ~netionally tested, and confirme'd operation, al?" [il/Y6s El No* Were all sensors installed at lowest point of secondary containment and positioned so that. other equipment Will . not interfere with their proper operation? -. - El Yes El No*' If' alarms are relayed to a remote m°nitonlng station', is. all communications, equipment (e.g. modem) ..... ~i' N/A operational?. ~.: .- · El Yes El No~ For pre~urized piping systems, does the turbine automatically shut down if the'piping secondary containment ~l N/A ' monito~g system detects a leak, fails to operate, or is electrically disconneCted?', If yes: which sensors initiate positive shut-down? (Check all that apply) El SumP/Tren,ch Sensors; ..El Dispenser Containment Sensors. - Did you eonfn'm positive .shut-down due to leaks and sensor failure/disC° ..nne.cfion? El Yes; El No. ~Yes El No* For tank systems that utilize the nionitoring system aS the primary· tank' overfill Warning devic, e (i.e. n0' El N/A. mechanical overfill prevention valve is installed), is the 'OVerfill warning alarm visible and audible·at the tank fill point(s) and operating ProPerly?: If.sO, at what percen.t of ~ capacity does the a!arm m..'gger? q (') % El Yes* I~l No Was any monitoring equipment replaced~ If yes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for .all replaeem, en~PaRs El yes* El'No Was Liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)' · El Product;, El Water.../fyes, desen'beea.use~. ',m Section E~ b.e, low. "Off' ,Yes' 'El No* Was' monitg .ring sYs.tem set-up reviewed to ens.ure proper sett'.mgs? Attac~ seiiu,p .rep0rt~., if apPliCable.. {2r~Yes. El ..N°* ,Is a.llmonito, ring e.quiPmen, t operational..per m..an.ufacturer's specifications? .. * In Section E below, describe hOw and when these deficiencies were or.will be corrected.' E. Comments: Page 2 of 3 · 03lOt E. In-Tank Gauging / SIR E~pment: Cl Check this box gauging is used only for inventory control. .. ,~ 12 Check this box if no tank gauging or SIR equipment.is install,ed. Thi~' section must be completed if in-~ gauging equipment. . is used., : to perform leak detection monitoring. Com' flete the following checklist: '[ii/Y~s [] '"'N0* H}'s all input wiring been inspeeted'f~r proper entry and termination, including t'esting for ground faults? (~/Yes [] No* Were all tank gauging probes visually inspected for damage and residue buildup? .... . [~'Yes [] No* Was accuracy'~f system product level readings tested? lit/Yes [] No* Was accuracy of system water level readings tested? .~ [~Yes [] No* Were all probes.reinstalled, properly? ~Yes 121 No* Were all items on'the equipment manufacturer's maintenance checklist completed? * In the Section. H, below, describe how and when these deficiencies were or will be corrected. G~ Line Leak Detectors (LLD): ~heck this box ifLLDs are not installed. Complete the following checklist: '. [] Yes Q No* For equiPmen~t start-up or annual ~quipment certification, was a leak simulated to. verify LLD peffo~mee? 121 N/A (Check all that apply) Simulatedleakrate: ~3g.p.h.; []0.1g.p.h; []0.2g.p.h.. [] Yes 13 No* Were'all LLDs c~nfirmed operational and accurate within regulatory requirements? i , ' ': [] :Yes- 13 No* Was the testing apparatus properly eah'bmted? [] ,Yes [] No* For mechanical LLDs, does the LLD restrict product 'flOW if it detects a leak? [] N/A Q Yes Q No~' For electronic LLDs, does the turbine autom~tically shut off if the LLD detects a l~'ak? [] N/A [] ~s [] No* For electronic LLDs, does the turbi~'e automati~ally shut off if any Portion of the monitoH_ng system is disabled [] N/A or dis¢o~mected? [3 Yes ~ No* For electronic LLDs, does the turb~e automatically shut off if any portion of the monito~ag system [] N/A malfunctions or fails a te~t? ~3 Yes [] No* For electronic LLDs, have all aCCessible wiring cormeetions been visually inspected? [] N/A El Yes [] No* Were all items.onthe equipment manufacturer's maintenance checklist completed? * In the Section H below, describe-how and .when these deficieni:ies were or will be corrected. H. Comments: ]Page 3 of 3 Monitoring System Certification. USW Monitoring Site Plan Site Address: WOO OC['~ l~{k)~.l~ ]~1~ . Date map was drawn: Instructions, If you already have a diagram that. shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other seconda~. ~ containment areas; mechanical or electronic line leak detectors; and in;tank liquid level probes (if used for leak detection). In the space provided, .note the date this Site Plan was prepared. Page __ of__ 05/00 BSSR, Inc. 6630 Rosedale Hwy., # B, Bakersfield, CA 93308 Phone (661) 588-2777 Fax (661) 588-2786 MONITORING SYSTEM CERTIFICATION. · within 30 days of test date.. A. General Information - Facility Name: ~ ~'~. 140 <J P t TA [.- Site Address: ~00 ~ ~.~ ~ B. lnvento~ 6f EquiPment Tested/Co.ffled Ch~k the appropriat~ boxes to indi~te specific e~uioment inspecte~se~iced: .... ' .,: ' i, H ~.r,., I ~" I ' r , ,..%,, This 'form must be used to document testing and servicing of mbiiit0ring equipment, A separate certification or .report must be prepared for e.aCh men!toting system con.~o! panel by the technician who performs the work.· A copy of this form must be provided to the tank 'system owner/operatOr..The owner/operator must submit a copy of this form to the local agency regulating UST systems Bldg. No.: City: ~_/'..~'~'~rl~L~ Zip: cl'%,'~a}. Date ofT~Se~icMg: ~ 1 21 /O~ Tank ID: ~ In-Tank Gauging Probe: Model: [~Annular Space or vault Sensor. [iV'Piping Sump / Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 12i Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: Q Tank Overfill ! High-Level Sensor. Model: E! Other (specify equipment ty~e.., md model in Tank ID: Model: "~ tO ~.. . ~c.5 .. Section E 0~,.!~2). .. Q In-Tank Gauging Probe. Model: 121 Annular Space or Vault Sensor. Model: FI. Piping Sump / Trench Sensor(s). Model: 121 Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: 121 Tank Overfill / High-Level Sensor. Model: Tank ID: -. 121 In-Tank Gauging Probe. Model: D Annular Space or Vault SenSor.. Model: 121 Piping Sump.l Trench Sensor(s). Model: ~ Fill Sump Sensor(s). Model: ii Mechanical Line Leak Detector. 'Model: El Electronic LinC'Leak Detector. Model: rl Tank Overfill /High-LeVel S~nsor. Model: ' O Other ~specif7 equipment type.and model in'Section· E on Page 2); _ Tank ID: :' Ci Ih-Tank Gauging Probe. Model: C! Annular Space or Vault Sensor. Model: E! Piping Sump / Trench Sensor(s). Model: ~1 Fill Sump Sensor(s). Model: 13 Mechanical Line Leak Detector. Model: 021 Electronic Line Leak Detector. Model: Tank Overfill / High-Level Sensor. Model: ~Ci Other (specify equipment typ.e,,~nd model in .Section Eon .P~e 2).. Dispenser ID: ., Fl DisPenser Containment Sensor(s). Model: D Shear Valve(s). ...D... D. ispenser Conta!nment Float(s) _and Chain(s).. .... Dispenser ID: D Dispenser containment Sensor(s). Model: CI Shear Valve(s). O Dispenser Contai.n. ment F!oat(s) and Chain(s).. ...... Dispenser ID: [1 Dispenser Containment Sensor(s). Model: O Shear Valve(s). CIDi.spenser Containm,.~nt Float(s) and Chai,n(s). , .. ~. Oger (specify equipment b/pc and model in Section E on Page Dispenser ID: Fl Dispenser Containment Sensor(s). Model: D Shear Valve(s). El Dispenser Containment .~!?t(.s) and Chain(s). Dispenser ID: ~ Dispenser Containment Sensor(s). Model: O Shear Valve(s). 12! Dispenser Containment Float(s) and Chain(s).. .... Dispenser ID: 121 Dispenser Containment Sensor(s). Model: D Shear Valve(s). ~, DisEenser Containment Float(s) and Cha!n<s). · .. *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and ·dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ~ S_~em~ ~ Alarm ,history report Technician Name (print): '~"'~/~o E L C"{q ~J~l L. LO Signature: ...-~(,u,_Qk.k~, Certification No.: License. No.:. Westing Company Name: ['~_ -~?'9~- II',,~(,.'- ' _ '~ PhoneNo.:(.6(~{ ). Site Address: _~,_a~C) i-~O~'~'[~)AI. ~' ~'qt~x-[ 'l~ ~ DateofTeating/Servicing: ,~[ /'~ Page I of 3 03/0l Monitoring System Certification D; Results of Testing/Servicing ..Software Version Installed: ', Co..replete the [ollowing checklist: . alarm operational? [~'~Yes [21 NO* Is the visual alarm operational? ~ ' ~ Yes 1~1 No* were all,'sens~)'rs v'i~uall¥ inspected, fur),ctio, nally testedl and confh-med operational? ~l"¥es rn No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation7 -- [21 Yes [21 No, If alarms are relayed to a remote monitoring station, is all communications" equipment (e.g. modem) ~ 'Yes '"[J No* For pr .,:esgmSzed piping systems,' does the turbine automaficallY'shUidoWn i£the piping ~e¢ondary containment ~tlN2A ' monito.r!g.., g system detects a leak, fails to operate, or is electricallY disconnected7 If yes: which sensors initiate positive shut-down? (Check all that apply) ~ Sump/TrenchSensors; [I Dispenser Containment Sensors. Did you confnm positive shut-down due to.leaks and sensor failure/dis~onnec, fion? ~ yes;. Q .No. Q" Yes [I No* For tank systems that utilize the nionitoring system as the primary tank" overfill ~waming devi~e (i.e. no ~ N/A mechanical oVerfill prevention valve is installed), is the overfill' wam/ng alarm visl'ole and audible at the tank fill point{s)and operating properly?° ,If so, at what percent of tank c. apacity does the a,larm trigger? - % 121 Yes* ~11 No Was any monitoring equipment replaced? If yes, identify specific senSors, probes, or other equipment replaced and list the manufacturer name and. model.. ~ for ail rep...,..,..laCement..parts in'Section E, below. ' [3 Yes* Iii No Was liquid found inside any secondary confainment systems deSigned as dry systems? (Check all. that apply) Q Produgt; '~'Water. If yes, descn~oe causes in Section E, below. 8~Yes ~ 'No* Was mon..ito .rinlg' system set-Up recdewed to ensure proper settings?. Atta~ set up repom., if applicable. [ii'Yes ~ No*. Is all mom~t0ring equiPment.operatio.nal.per manufacturer's .sp.eci. fi..cations? ....... * In Section E below describe how and'when these deficiencies were or Will be corrected. E. Comments: Page 2 of 3 03/01 F~.. In-Tank Gauging / SIR Equ~ment: Cl Check this box ir ta~gauging is used only for inventory control. · [~F~Check this box if no tank gauging or SIR equipment is installed. This section must be completed ifin-tank~uging equipment is used to perform leak detection monitoring. Complete the following checklist: · 'iq .Vis' "12 No* His ail' input wiring been inspected fc~ proper~ entry';nd terminationl inciudingtesting for ground faults? 13 Yes 121' No* Were'an tank gaUging, probe~:visually inSPected for damage'and residue buiidup? 13 Yes':' 121 No* was accuracy of system product level readings tested? '- 121 Yes 13 No* Was accuracy ofsystem water level readings ~ested? I21' Yes r'l No* Wer6 ailprobes reinstalled.properly? ' 12 Yes 12i'" No* Were all items on the equipment manufa'cturer's'maintenance checklist completed? * In the Section H, below, describe hoTM and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): l~Check this box if LLDs are not installed. ComPlete the following checklist: "1~Yes ' CI' No* 'For' equipment start-up or annual equipment certification, was a leak Simulaied to verify LLD perf~)rm/nce? 12 N/A (Check all that apply) S/mulated leak rate: ~ 3 g.p.h.; /2 0.1 g.p.h; 12 0.2 g.p.h. '0 Yes 121 No* Were'ail LLDs conftrmed'°P~rati~nal a~d acCUrate within regulatory reqUirements? 13 Y6s- I~1"' No* Was the t~ting apparatus properly cah'bratec~'? ' ' 'h Yes 13 No* For mechanical LI.~Ds, does'~e LLD"~estri~t'~roduct' flow if it detects a leak? 13 N/A 13 Yes ~ No* For electronic LLDs, does the turbine automatically Shut off if the LLD detects a leak'?... 13 N/A , 121 ;les l~! No* For electronic LLDs,"~loes the turbine a{~{omatically shut off if any portion of the monitoring sYStem is disabled 12 N/A or disconnected? El yeS E! No* For electronic LLDs, does 'the turbine automatically shht "~ff'if any portion of the monitoring system ~ N/A malfunctions or fails a test? t21 .Yes 13 No* For electrOnic LLDs, have all' access~ie ~g connections been visually i~spected? yd a W;re an item,.on the eq.ipme-t: u a t r', m t ce cheoklist completed? * In the Section H, below, describe hoTM and When these deficiencie~ were or will be corrected. H. Comments: Page 3 of 3 03/0! Monitoring System certification Monitoring Site Plan Date map was drawn: q /~. I / 05,. Instructions If you already have a diagram that. shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site p!an; ~show the general layout of tanks and piping: Clearly identify locations of the following equipment, if installed: m~nitoring system control panels; sensors monitoring tank annular spaces, sumps, d!spenser pans, spill containers, or other secondary~ containment areas; mechanical or electronic line leak detectors; and'in-tank liquid level probes (if used ~'or leak detection). In thc space provided, note the date this Site Plan was prepared. Page __ of __ o5/oo D April 11, 2003 Mercy Southwest 400 Old River Rd Bakersfield CA 93311 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1 349 PREVENTION SERVICF.~ 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 CERTIFIED MAIL Recent SB 989 Secondary Containment Testing FOURTH REMINDER NOTICE Dear Owner/Operator: Our records indicate that you completed your secondary containment testing on October 21, 2002. Our records further show a failed test. Therefore you are required to have your system repaired and re-tested as soon as possible. This office requests an update with regard to repairs of your system. Please be advised that repairs involving the replacing of components must be under permit from this office. The repairs of your system are a condition of your permit to operate. Failure to repair and re-test will result in the revocation of your permit to operate. Should you have any questions, please feel free to contact me at 661- 326-3190. Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/dc ITl 133 rtl r-I Postage Retum Reclept Fee (Endorsement Required) Rest~cted Delivery Fee (Endorsement Required) ITt £ ~ I ~ Postman~ ru ~ MERCY soUTI-IW~EST , o [~ 400 OLD RIVER Rio I ~ · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ' · Print your name and address on the reverse so that we can return the card to you. , · Attach this card to the back of the mailpiece, or on the front if space permits. i. Article Addressed to: [] Agent C..Date of Delivery D. Is delivery address different from item 17 [] Yes if YES, enter delivery address below: [] No MERCY SOUTHWEST 400 OLD RIVER RD ~ypo BAKERSFIELD CA 93311 ] E Gertified Mail ~--- I []~ Registered ............................. ~ L [] insured Mail ~ 7002 3150 PS Form 3811, August 2001 [] Express Mail [] Return Receipt for Merchandise [] C.O.D. L 4. Restricted Delivery?'(Extra Fee) ['71 Yes 0004 9965' 3233 -- Dora~ . 2ACPRI-03-Z.-0985 M~'~rch 12, 2003 Mike Wood Mercy Southwest 400 Old River Road Bakersfield, CA 93311 CERTIFIED MAIL FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 'H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAFETY SER~I1CES · ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 3260576 PUBUC EDUCATION 1715 Chester Av~). Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 3260576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3961 FAX (661) 326-O576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 NOTICE OF VIOLATION & SCHEDULE FOR COMPLIANCE Failure to Perform/Submit Annual Maintenance on Leak Detection at the Above Stated Address. Dear Business Owner: Our records indicate that your annual maintenance certification on your leak detection system was past due on February 28, 2003. You are currently in violation of Section 26410) of the California Code of Regulations. "Equipment and devices used to monitor underground storage tanks shall be installed, calibrated, operated and maintained in accordance with manufacturer's instructions, including routine maintenance and service checks at least once per calendar year for operability and running condition." You are hereby notified that you have thirty (30) days, April 12, 2003 to either perform or submit your annual certification to this office. Failure to comply will result in revocation of your permit to operate your underground storage system. Should you have any questions, please feel free to contact me at 661-326-3190. Sincerely, Ralph Huey Director of Prevention Services Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/dc Postage Certified Fee Postmark Return Reciept Fee Here (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Tot~ F MIKE WOOD ~ MERCY SOUTHWEST ~nr'° 400 OLD RIVER ROAD . ....... [!(~"~ BAKERSFIELD CA 93311 ........ Complete items 1 2, and 3. Aisc complete[ J [I A Sgnature ~. j item 4 if Restricte~l Delivery is desired. ~ ~ ~ /'/~T"n/'~ ,~ [] Agen"~ · Print your name and address on the reverse~--'~J//(~'[~/'/(7.,~I J []Addressee' so that we can return the card to you. ~ I1~ .e;e,v;'~ b',~ed ~amc, ~-,e-~ve- ' · Attach this card to the back of the mailpiece,~.~1.-' ,, -,,,,,~, v . ,, .' or on the front if space permits. _~ -- ~ ' D. Is delivery address different from item 17 LI Y~ 1. Amc~e Addressed to: If YES, enter delivery address below: [] MIKE WOOD MERCY SOUTHWEST 400 OLD RIVER ROAD BAKERSFIELD CA 93311 3. Service Type [] Certified Mail [] Express Mail [] Registered [] Return Receipt for Merchandise [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 7002 2410 0002 1974 9916 PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1540 D March 5, 2003 Mercy Southwest 400 Old River Rd Bakersfield CA 93311 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 AH" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAFE'W SEFNtCES · EN~RONMENTAI. SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 PUBUC EDUCATtON 1715 Chester Av~e, Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 328-0576 FIRE INVESTIGATION 1715 Chester Ave, Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-O576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 CERTIFIED MAIL RE: Recent SB 989 Secondary Containment Testing THIRD REMINDER NOTICE Dear Owner/Operator: Our records indicate that you completed your secondary containment testing on October 21, 2002. Our records further show a failed test. Therefore you are required to have your system repaired and re-tested as soon as possible. This office requests an update with regard to repairs of your system. Please be advised that repairs involving the replacing of components must be under permit from this office. The repairs of your system are a condition of your permit to operate. Failure to repair and re-test will result in the revocation of your permit to operate'. Should you have any questions, please feel free to contact me at 661- 326-3190. Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/dc m I'rl PostaGe CeflJf/ed Fee Return Reclept Fee Postmark (Endorsement Required) Hem Restricted Delivery Fei (Endorsement Required Total Pos~ m} c¥ sourmv s, 400 · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. 'l Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: /' MERCY SOUTHWEST 400 OLD RIVER RD BAKERSFIELD CA 93311 A. Signa~e ~ /il . ~ ¥ ~ / ,/ ,~/~.,'(//,t~ 't~ Agent ~ ( ~~~ ~~ ~ Addressee BI Receiv~ ~ri~ted Name) ~ C. Da~ of ~eliye~ D. Is deliveff addm~ d~t f~m item 1 ?' ~ ~es If YES, enter delive~ 5ddress below: ~ No ,3. Service Type [] Certified Mail [] Express Mail [] Registered [] Return Receipt for Merchandise [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 7002 3150 0004 9985 3035 PS Form 3811, Aug'ust 2001 Domestic Return Receipt 102595-02-M-1540 March 1, 2003 Mike Wood Mercy Southwest 400 Old River Rd Bakersfield, CA 93311 CERTIFIED MAlL FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SM:ETY ~.R1/ICES · ~MEHTAt. SER~ICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 PUBLIC EDUCATION 1715 Chester Avb. Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 326-0576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 NOTICE OF VIOLATION & SCHEDULE FOR COMPLIANCE Failure to Perform/Submit Annual Maintenance on Leak Detection System at the above stated address. Dear Business Owner: Our records indicate that your annual maintenance certification on your leak detection system was past due on February 28, 2003. You are currently in violation of Section 2641(J) of the California Code of Regulations. "Equipment and devices used to monitor underground storage tanks shall be installed, calibrated, operated and maintained in accordance with manufacturer's instructions, including routine maintenance and service checks at least once per calendar year for operability and running condition." You are hereby notified that you have thirty (30) days, April 1, 2003 to either perform or submit your annual certification to this office. Failure to comply will result in revocation of your permit to operate your underground storage system. Should you have any questions, please feel free to contact me at 661-326-3190. Sincerely, Ralph Huey Director of Prevention Services Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/dc , · Complete items 1; 2, and 3. Also complete item 4 if Restricted Delivery is desired. · .· Print your name and address on the rev~[~se so that we can return the card to you. ~' , · Attach this card to the back of the mailpiece, or on the front if space permits. · 1..Article Addressed to: MnCE wOoD MERCY SOUTHWEST 400 OLD RIVER ROAD BAKERSFIELD CA 933 ! ! ....... 7fin2 241n nnne ' PSForm 3811, August 2001 A. Signj~tl~re / , . __ ~ X Addressee B. Received by ( Printed Name) lC. Dateef Delivery I O. Is delivery address different from item 17 [] Yes t if YES, enter delivery address below: [] No , 3. Service Type [] Certified Mail [] Express Mail [] Registered [] Return Receipt for Merchandise [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 1974 9527 Domestic Return Receipt ~ ~'-2ACP RI-03-Z-0985 Postage $ r'-J Certified Fee I~ r"l Return Reclept Fee (Endorsement Required) ~ Restn'cted Delivery Fee i ~ (Endorsement Required) rU Total P~--'"----------- ~ ru _ _ MIKEWOOD I.~ro MERCY soUTHWEST [~t~-,,-~ 400 OLD RIVER RoAD --~ Postmark Here February 13, 2003 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES S~ETY SERWCES · £nvu~o~u~m~ SER~CES 1715 Chester Ave. Bakersfield, CA 93301 · VOICE (661) 326-3979 FAX (661) 326-0576 PUBLIC EDUCATION 1715 Chester Av~. Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 326-0576 FIRE INVESTIGATION I ? 15 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 Mercy Southwest 400 Old River Rd Bakersfield CA 93311 Certified Mail Recent SB 989 Secondary Containment Testing SECOND REMINDER NOTICE Dear Owner/Operator: Our records indicate that you completed your secondary containment testing on October 21, 2002. Our records further show a failed test. Therefore you are required to have your system repaired and re-tested as soon as possible. This office requests an update with regard to repairs of your system. Please be advised that repairs involving the replacing of components must be under permit from this office. The repairs of your system are a condition of your permit to operate. Failure to repair and re-test will result in the revocation of your permit to operate. Should you have any questions, please feel free to contact me at 661- 326-3190. Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/dc Postage Certified Fee ( E n d °Rr:teUmr ~ nRtEl~ie;~' rFeed~ Restricted Del_ivery. Fe.e. (Enderserne~~---.~--,~ Postmark Here 'rota~Po, MERCY S ' OUTHWEST --~ Sen, re 400 OLD RT'''-''-' -- ~ BA ~v~ RD "'""t t~c~'~,-~ KERSFIELD CA 93311 ....... · Complete items 1; 2, and 3. Also complete item 4 if Restricted Delivery is desired; .· Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: I D, Is delivery address different from item 17 [] Yes if YES, enter delivery address below: [] No MERCY SOUTHWEST 400 OLD RIVER RD ~. Service Type BAKERSFIELD CA 93311 [] Certified Mail [] Express Mail [] Registered [] Return Receipt for Merchandise .......... / [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 7002 2410 0002 1974 92fi2 m PS.Form 3811, August 2001 Domestic Return Receipt 2ACPRI-03-Z-0985 D January 22, 2003 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES s~zrY S~RVtCES · uevmoaur~T~ Se;mcrs 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 PUBLIC EDUCATION 1715 Chester Avb. Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 326-0576 FIRE INVESTIGATION 1715 Chester Ave. BakersfleM, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 Mercy Hospital Southwest 400 Old River Rd Bakersfield CA 93311 RE: Upgrade Certificate & Fill Tags Dear Owner/Operator: Effective January 1, 2003 Assembly Bill 2481 went into effect. This Bill deletes the requirement for an upgrade certificate of compliance (the blue sticker in your window) and the blue fill tag on your fill. You may, if you wish, have them posted or remove them. Fuel vendors have been notified of this change and will not deny fuel delivery for missing tags or certificates. Should you have any questions, please feel free to call me at 661- 326-3190. Sincerel~ ?' Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/dc D January 13, 2003 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAFEI~ SERVICES * ENVIRONMENTJIL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 PUBLIC EDUCATION 1715 Chester AvE. Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 326-O576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 Mercy Southwest 400 Old River Rd Bakersfield CA 93311 Certified Mail Recent SB 989 Secondary Containment Testing REMINDER NOTICE Dear Owner/Operator: Our records indicate that you completed your secondary containment testing on October 21, 2002. Our records further show a failed test. Therefore you are required to have your system repaired and re-tested as soon as possible. This office requests an update with regard to repairs of your system. Please be advised that repairs involving the replacing of components must be under permit from this office. The repairs of your system are a condition of your permit to operate. Should you have any questions, please feel free to contact me at 661- 326-3190. Sincerely, Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/dc Postage Certified Fee Return Receipt Fee (Endomement Required) (Endorse' p~k ru TO~I P [~;~i; B AKE~- i ',tpo~ ~ R~FIELD CA 93311 ........... · Complete items 1, 2, and 3. Also complete~ item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: ~ MERCY SOUTHWEST 400 OLD RIVER RD BAKERSFIELD CA 933 IX~tlre 6~,~ ~/~j~l~ia r-]Agent _ . . [] Addressee I B. Rfec'ei~/ed by ( Printed Name) C. JDate of Delivery D. Is delivery address different from item 1 ? [] Yes if YES, enter delivery address below: [] No 3. Service Yype [] Certified Mail [] Express Mail [] Registered [] Return Receipt for Merchandise [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] ~es 7002 0860 0000 1641 5875 PS Form 3811, August 2001 Domestic Return Receipt 102595~02-M-0835 ~D w October 3 l, 2002 Mercy Hospital Southwest 400 Old River Road Bakersfield CA 93311 REMINDER NOTICE CERTIFIED MA~ FIRE CHIEF P. ON FRAZE ADMINISTRATIVE SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA ~1 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAFE'I'f SERVICES · ENVIRONMENTAL SER"dlCE$ 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 PUBUC EDUCATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 326-0576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93,................301 VOICE (661) 326-3951 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 RE: Necessary secondary containment testing requirements by December 31, 2002 of underground storage tank (s) located at the above stated address. Dear Tank Owner / Operator, If you are receiving this letter, you have no.._~t yet completed the necessary secondary containment testing required for all secondary containment components for your underground storage tank (s). Senate Bill 989 became effective January 1, 2002, section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and periodically thereafter, to insure that the systems are capable of containing releases from the primary containment until they are detected and removed. Of great concern is the current failure rate of these systems that have been tested to date. Currently the average failure rate is 84%. These have been due to the penetration boots leaking in the turbine sump area. For the last six months, this office has continued to send you monthly reminders of this necessary testing. This is a very specialized test and very few contractors are licensed to perform this test. Contractors conducting this test are scheduling approximately 6-7 weeks out. The purpose of this letter is to advise you that under code, failure to perform this test~ by the necessa~ deadline~ December 31~ 2002~ will result in the revocation of your permit to operate. 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 (661) 326-3190. Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services Postage Ce~ifled Fee Return Receipt Fee (Endomement Required) Restricted Delivery Fee (Endorsement Required) Total POetage & Feea POstmark Here · Complete items :1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: lflER~ HOSPITAL SOUTltl~ST 400 OLD RIVER ~ BAKERSFIELD CA 93311 i ii X - [] Agent : .,,, [] Addressee B..-~Received by (Printed Name) C. Date of Delivery D. Is delivery address different from item 17 [] Yes If YES, enter delivery address below: [] No 3. Service Type ][3 Certified Mail [] Registered [] Insured Mail [] Express Mail [] Return Receipt for Merchandise [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes ,. 7002 0,460 0000 PS Form 3811, August 2001 164t'6803 Domestic Return Receipt 102595-02-M.0835 CITY OF BAKERSFIEI~ OFFICE OF ENVIRONMENTAL SERVIC~ 1715 Chester Av~, Bakersfield, CA (661) 326-3979 APPLICATION TO PERFORM'A TANK TIGHTNESS TEST/ SECONDARY CONTAINMENT TESTING TANK # VOLUME CONTENTS Hazardous Materials~azardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE Permit ID #:: 015-000-000428 MERCY SOUTHWEST LOCATLON: 400 OLD RIVER RD TANK I HAZAROOU: 015-000-00(~28~001 IDLES EL i 015~00-000428~002J DIESEL [_ ..~ ~ ~ ~-~- -.5 -~ ~ ~ .. This, ~isJssaed for the followlr~: !~ ~ous Materials Plan mi Uadergmund Storage of la--,~4oUs Materials 13 Risk Manageme~ P~am n I. lazard~us Waste On.SiteTreatment Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES' 1715 Chester Ave., 3rd Floor Bakersfield, CA 97301 Voice FAX (661) 326-0576 Am~o,e~ ~: ~ 2 8 2000 ~..o. D,~: June 30:2003 FACILITY NAME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 INSPECTION DATE lO ~lt'O..C Section 2: Underground Storage Tanks Program Routine ~ Combined [~l Joint Agency Type of Tank .~t..O ~- Type of Monitoring ~_~-[/4 [~l Multi-Agency ~[~l Complaint Number of Tanks Type of Piping ~IB~- Re-inspection OPERATION C V COMMENTS Proper tank data on file 1,.., ~/ 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 }Ct=Violation. Y=Yes N=NO Inspector: ~~ ~_~__~~. / Off'ice of Environmental Services (805) 3'26-3979 White- Env. Svcs. Pink - Business Copy "-'Busi~ss'Siie l~e~po~ble Party September 30, 2002 Mercy Hospital Southwest 400 Old River Road Bakersfield CA 93311 FIRE CHIEF RON F RA~. E ADMINISTRATIVE SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 3954349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAF E'~I SERVICES · ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield. CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 PUBLIC EDUCATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 326-0576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 TRAINING DIVISION 5642 Vlctor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 REMINDER NOTICE RE: Necessary secondary containment testing requirements by December 31, 2002 of underground storage tank (s) located at the above stated address. Dear Tank Owner / Operator, If you are receiving this letter, you have no__~t yet completed the necessary secondary containment testing required for all secondary containment components for your underground storage tank (s). Senate Bill 989 became effective January 1, 2002, section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and periodically thereafter, to insure that the systems are capable of containing releases from the primary containment until they are detected and removed. Of great concern is the current failure rate of these systems that have been tested to date. Currently the average failure rate is 84%. These have been due to the penetration boots leaking in the turbine sump area. For the last five months, this office has continued to send you monthly reminders of this necessary testing. This is a very specialized test and very few contractors are licensed to perform this test. Contractors conducting this test are scheduling approximately 6-7 weeks out. The purpose of this letter is to advise you that under code, failure to perform this test, by the necessary deadline, December 31, 2002, will result in the revocation of your permit to operate. 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 (661) 326-3190. Sincerel~ f ~ ~ Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services D August 30, 2002 Mercy Hospital Southwest 400 Old River Blvd Bakersfield, CA 93311 REMINDER NOTICE FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 ~H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661 ) 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX' (661 ) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 RE: Necessary secondary containment testing requirements by December 31, 2002 of underground storage tank (s) located at the above stated address. Dear Tank Owner / Operator, If you are receiving this letter, you have not yet completed the necessary secondary containment testing required for all secondary containment components for your underground storage tank (s). Senate Bill 989 became effective January 1, 2002, section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and periodically thereafter, to insure that the systems are capable of containing releases from the primary containment until they are detected and removed. Of great concern is the current failure rate of these systems that have been tested to date. Currently the average failure rate is 84%. These have been due to the penetration boots leaking in the turbine sump area. For the last four months, this office has continued to send you monthly reminders of this necessary testing. This is a very specialized test and very few contractors are licensed to perform this test. Contractors conducting this test are scheduling approximately 6-7 weeks out. The purpose of this letter is to advise you that under code, failure to perform this test, by the necessary deadline, December 31, 2002, will result in the revocation of your permit to operate. 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 (661) 326-3190. Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services July 30, 2002 Mercy Hosptial Southwest 400 Old River Rd Bakersfield CA 93311 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H' Street Bakersfield. CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H' Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAFETY SERVICES · ENYIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 PUBUC EDUCATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3696 FAX (661) 326-O576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399.,4697 FAX (661) 399-5763 REMINDER NOTICE RE: Necessary Secondary Containment Testing Requirements by December 31, 2002 of Underground Storage Tank (s) Located at the Above Stated Address. Dear Tank Owner / Operator: If you are receiving this letter, you have not yet completed the necessary secondary containment testing required for all secondary containment components for your underground storage tank (s). Senate Bill 989 became effective January 1, 2002, section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and periodically thereafter, to insure that the systems are capable of containing releases from the primary containment until they are detected and removed. Of great concern is the current failure rate of these systems that have been tested to date. Currently the average failure rate is 84%. These have been due to the penetration boots leaking in the turbine sump area. For the last four months, this office has continued to send you monthly reminders of this necessary testing. This is a very specialized test and very few contractors are licensed to perform this test. Contractors conducting this test are scheduling approximately 6-7 weeks out. The purpose of this letter is to advise you that under code, failure to perform this test, by the necessary deadline, December 31, 2002, will result in the revocation of your permit to operate. 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 (661) 326-3190. Steve Underwood Fire Inspector Environmental Code Enforcement Officer D June 30, 2002 Mercy Hospital Southwest 400 Old River Road Bakersfield, CA 93311 REMINDER NOTICE FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 RE: Necessary Secondary Containment Testing Requirement by December 31, 2002 of Underground Storage Tank located at 400 Old River Road. Dear Tank Owner / Operator: The purpose of this letter is to inform you about the new provisions in California Law requiring periodic testing of the secondary containment of underground storage tank systems. Senate Bill 989 became effective January 1, 2002, section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components 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. Secondary containment systems installed on or after January 1, 2001 will be tested upon installation, six months after installation, and every 36 months thereafter. Secondary containment systems installed prior to January 1, 2001 will be tested by January I, 2003 and every 36 months thereafter. REMEMBER! Any component that is "double-wall" in your tank system must be tested. Secondary containment testing shall require a permit issued thru this office and shall be performed by either 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 am 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. Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Environmental Services SU/kr D May 29, 2002 Mercy Hospital Southwest 400 Old River Road Bakersfield, CA,93311 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661 ) 395-1349 SUPPRESSION SERVICES 2101 ~H" Street Bakersfield, CA 93301 VOICE (661) 326.3941 FAX (661) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave, Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 RE: Necessary Secondary Containment Testing Requirement by December 31, 2002 of Underground Storage Tank located at 400 Old River Road REMINDER NOTICE Dear Tank Owner/Operator: The purpose of this letter is to inform you about the new provisions in California Law requiring periodic testing of the secondary containment of underground storage tank systems. Senate Bill 989 became effective January 1, 2002. section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and periodically thereafter, to ensure that the systems are capable of containing releases from the primary containment until they arff detected and removed. Secondary containment systems installed on or after January 1, 2001 shall be tested upon installation, six months after installation, and every 36 months thereafter. Secondary containment systems installed prior to January 1, 2001 shall be tested by January 1, 2003 and every 36 months thereafter. REMEMBER!! Any component that is "double-wall" in your tank system must be tested. Secondary containment testing Shall require a permit issued thru this office, and shall be performed by either 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 am 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. Sincere/~,y. Steve Underwood Fire Inspector/Environmental Code Enforcement Officer SBU/kr enclosures D April 17, 2002 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 Mercy Hospital Southwest 400 Old River Rd Bakersfield CA 93311 RE: Necessary Secondary Containment Testing Required by December 31, 2002 REMINDER NOTICE Dear Tank Owner/Operator: The purpose of this letter is to inform you about the new provisions in California law requiring periodic testing of the secondary containment of underground storage tank systems. Senate Bill 989 became effective January 1, 2002. Section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components 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. Secondary containment systems installed on or after January 1, 2001 shall be tested upon installation, six months after installation, and every 36 months thereafter. Secondary containment systems installed prior to January 1, 2001 shall be tested by January 1, 2003 and every 36 months thereafter. Secondary containment testing shall require a permit issued thru this office, and shall be performed by either a licensed tank tester or licensed tank installer. Please be advised that there are only a few contractors who specialize a'nd 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 under a permit issued by this office. Should you have any questions, please feel free to contact me at 661-326-3190. Sincere~ Steve Underwood Fire Inspector/Environmental Code Enforcement Officer SBU/dm enclosures M~RC 7--02 THU $ : 2? FROM B . 'S . S.R. I NC. '~' ';'"',7-". ...... i D~ llll& 66J0 Rosedal. HW.,~ B~ld, CA ~3308 Phot~ (661) 5~777 Fax (601, MONITORING SYSTEM CERTIFICATI()i form must be u~.ed to docUme.nt 'testing a~d..servicing of mohitor~g ~quipm~nt. ~~Ls~.~ ,. .~.~ ~Or each m~to~.~'sw~Oa~o!~nae! by the t~c~ician who perfo~ ~e work. A copy .iI~{~'~' ~ system o~/op~tor, ~e'0Waer/o~r must ~ub~t i copy of ~is fol~ to ~e local of Equtpm~nt ~,ie~Ce~ed . Probe, . .:,. Model: ;,: i'"" YaUIt Sensor, ' M0del: RS." IO5 --.-- . ' ModM:' '.'." Line ~ Detect6r~' ':. :," Model: ~, ":, ~_ _~ / Etgh-~ve!'S~sor. M~el: '.' ,' ' ' ':'. ~d model i't ........ - ", · ' 'v~li SSo~. ~' "~ ." '. . S,~¢.. ~i: ' ' ........... , ~1:'. '. '.' L~k D~c~r.. i.' M~el: '. ' ~ De't~tor...." :'Mo~i: ' '. :. ' Sens0r:' ' Model:'.. ' ' : Co'ntainment Sensor(s). Model: ' ':.." : .'.'. irlValV¢(s). ': .i..'.:. ' .. ':. P= 02 ,,. . I'..',, '.";Il'Ii'iS Tank ID: 0 ln-T~lnk Gauging Probe, 0 Annular Space or Vault Se~or. ri Piping Sump/Tree, ch Scnsor(s). ~ Fill Sump Sensor(s). O Mechanical Line Leak Detector, Q Electronic Line Le~ Dector, Q Tank Or.fill 1Elgh-Levd Sensor Ta~k O Ih-T~ Gauging Probe, 0 Annular ~pacc or Vault gcnsor, ~ Piping Sump / ~cnch Sensor(s). ~ Fill Sump 0 Mcchan~caI Line Leak Detector. 0 ~lectmnic Line Leak Detector. ~ %ak Overfill / High-Level Sensor 0 Oben~¢r Containment Float(s) and Chain(S)." . . . .'. a,~l ...... ' . ':: ........... : . ' ................. 'O' !}~:~,~,r d~i;in'ment"~S0~S):" M°dei;"~' ;. ". L--- .... O Dispensor Co.tainm~nt Scot. GrOsS:'"" 0 ~g~cni~ Containment Hoar(s) ~d'C~in{s), ': '. ; Q Disp~r Containment Float(s) m~d ~.'~; . . ~ ~ , , 7 , ,,,,,,,. ..... ,., ,,,~,,. :: ~ ....:~ ~:= ~::- =.:~ :=_.~-::::.:::: .~ ~ :.:-:: .... . ....... Dt$~Ji~r'lD:' ' ...... . ','= ~.=' .:'.. .' ' ' Dispenser .0 [~eaa Containment Sensor(s)..M~ei: = . .. . .... .--~ 0 D~penser Contatnmenl Sensor(s). M ...... O"S~;~'~r'Valve(s), ' ' ' .' ~ .:',: ...'; ~ Shear Valve(s). ,~:C,~!~se~ Contain~nt Float(s) ~4~a~n($)..' '. '" .................. O DisP.~.e~ c~nt~inmcn~ F1p.!~t(s). m~:~... ~lr t~racilit' "oOnaiaa mor~ t~ks er diapen.~, ~p this ~ InClUde informfid~n ~r' eVe~ ~tnk-and 8'{~n~er .... ..., y ........... y . . .. .... c, Cer~ca~oa - l ~fy ~at t~ ~alpI~t. ld~fied la this documeet was iaspee/eOse~wi¢,,I ' ~au'fa~tu~' guld~na. A~c~ to ab C~fiadon iS infb~matlon (e.g. manuractssre.' checklists) l~?O:~tl~ 'tS'turret and a P~t Plan i~lag ~e layout ~f ~0~ltorlng equlplneat, hr ax~y equlp~;~e,,, ,'..,~ ................ ,~.,'~ .... -~, rgo~='lhivenboa~'m~pyofthlmPo~(~lall'gAe~Pply): O System se~Tt~p . ~ AI;,'~, , Technician' Name ~Mt): ~l ~L ~ ~ee~ ~ ~::" ' Signature: ~ ~- P ~C~ e ,. , Cer.c~0.cation No,: License. No.: ...... ": Tes~g ~O~any. N~m~:. ' ~~~ 'i ~ ~..' ........... Phone No.: _ . .,~, : ': ' Page. t o ..., ~Io~!l~.rI~g System Certification '. ..... MI:IR~.--'- 7--02 T HU Results of Testing/Servicing $Oftv~:~'~ Version Installed: = _ 8 : 28 FROM ]B . $ . S = R . I NC . P = 03 ~~e the following checklist: i/' ,1~ No* Is the aumt~ie alarm operarional't ?: a No* We~ all sensom i~talled at !ow~st Po~t of~onda~ contai.nm~nt and posi~on~d ~ H/A For ~,~~ piping sys~, ~es ~e ~bme automatically shut down ~c posinve shulton? (ciec~ ~11 tA~I ~p~) ~ Sump~cnch Sensors; ~ DJsp~ Con~nt ~ No W~ ~y' ~ni~g ~ulpment r~l~ed~ IfYgs, ident~y specific s~so~, probes, ~ ~ducg ~ wasa .~(y~s, descn3c causes ~ 8c~gon B, below. ..~ No .: .Was~mtormg sy~m!et-upmvt~we~ ~.~pmp~rsa~g~?.Aflachs~tupt99~, ffa~licabla . ::*~'i.f.~,.~i!i'ii Il: beIOW, describe how and .when these deficiencies were or will be corrected. E;.. Co~tme. nts. Pag~ Z of~ o~/ol THU 8 .' 30 FROM B.S.S.R. I NC. System Certification P= 05 ¢ .. _. UST Monito.ri, ng Site already have a diagram that. shows all r~quircd information, you may inaludc it, rather than this page, w!th your M~'liO~;i~'System Cert/fication. On your site plan, show the g~:neral layout of tanks and piping. Clearly ~dentify IO$~iiil~':i:~ the following equipment', if installed: monitoring system control pancls; sensors momtoring tank annular s~i~ai'.~=~inp$, disP=ser pans, spill containers, or other sec. oridary core,lament ~rca,; m¢ch.a,~ical or ~lectronic line l~nk 't~:i:~ii~,~1' ~:r~i in'tank liquid l~v¢l orobes (if used for leak d~tection), h~ the space provided, not~ the dat~ this Site Plan MA R~-- ?--02 T H U 8 -' 29 FROM B . S . S . R . I NC . P . 04 In+Tank Gatlgi~ag / SIR Eq~t ~t~ ~ ~h~ck ~i~ box fits ~ i~ u~ on~y ~o~ i~vc~to~ co~ol. ' ~Chcck ~his box if no t~ gauging or SIR equipment is lnz~llcd, '~s s~etioa,must be ~mpleted if in-t~ gauging equipment is used to perfolm le~ detec6on mouitoring, ~~.fl~e following ehee~lst: ~ ~ !'~;.~!~?~g~o~ ~.~loW, d~be now aaa w~a tR~se ~el~cies were or will be ~rrecte¢. G. {L!~!a,Lea. k Detectors (LLD): .. ~il~eck this box ifLLDs are not installed. cheek, list: ~ For equipment star,up or atmtud equtpmc-at c~ificatioa, was a leak simulated to v~fy LID performance? (Check ail that apply) Simula~d kak rat~: E] 3 g.p,b.; [l 0.1 g.p,h; CI 0,2 g.p,h. Were all LLDs confumed opora~ional and accurate within regulatory requirexaerits? Wu tho t~sting appaxatas properly cah'l~'ated? For mechanical LLDs, do~ the LLD restrict' product flow if it detects a leak? For elecl~onic LLDs, doea the turbine automa6cally shut off if fine LLD detects a leak? For, electxonie LLDss ,does the turbiue automatically shut off if auy portion of flxe monitoring system is disabled o: disco~uect~d? 'Fo~ eledxonic LLD~, do~s the turl~ino automatically shut off if'~y Portion"of ~he monitoring sys,t3ma malfimcfio~s or fails a test? "j:,,~ ,Ng* Nor electronic LLDs, have all access~Ie wiring connections been visually i~spccted? icl N.o*, W~re all items,on the equii~m--eaimariufa~tm;et'$ raaintena~{¢e Ch;cklisi-c0mPleted? ~0.~ H, belows describe how anti when these deildencteS were or will be corrected. Page 3 of~.~ 03/O I D February 20, 2002 Kitty Ringer Mercy Southwest 400 Old River Rd Bakersfield, CA 93311 CERTIFIED MAIL FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 NOTICE OF VIOLATION & SCHEDULE FOR COMPLIANCE Failure to Submit/Perform Annual Maintenance on Leak Detection System at Mercy Southwest, 400 Old River Rd. Dear Ms. Ringer: Our records indicate that your annual maintenance certification on your leak detection system is past due. December 17, 2001. You are currently in violation of Section 2641(J) of the California Code of Regulations. "Equipment and devices used to monitor underground storage tanks shall be installed, calibrated, operated and maintained in accordance with manufacturer's instructions, including routine maintenance and service checks at least once per calendar year for operability and running condition." You are hereby notified that you have thirty (30) days, March 22, 2002, to either perform or submit your annual certification to this office. Failure to comply will result in revocation of your permit to operate your underground storage system. Should you have any questions, please feel free to contact me at 661-326-3190. Sincerely, Ralph Huey Director of Prevention Services Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services cc: Walter H. Porr Jr., Assistant City Attorney Certified Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) 3.94 Postmark Here RINGER r'~;~-~; ................................................. CA 3311 · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Articl~.ddressed to: KITT~ RINGER "Sou'rm sr 400~.j~D RIVER RD ' P'AEJ!~SFTET. CA 93311 A. Received by (Please Print Clearly) B. Date of Delivery I Agent Is ~teml? []Yes If YES, enter address below: [] No 2. Article Number (Copy from service label) ?000 1530 0006 3456 3300 Ps Form 3811, J~ Domestic Return Receipt 3. Service Type ~ Certified Mail' [] Express Mail [] Registered [] Return Receipt for Merchandise [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra lee) [] Yes I02595-99-M.1789 FACILITY NAME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave:, 3,d Floor, Bakersfield, CA 93301 INSPECTION DATE Section 2: Underground Storage Tanks Program [] Routine [] Combined Type of Tank bM f~ Type of Monitoring Joint Agency [] Multi-Agency [] Complaint Number of Tanks ~ Type of Piping ./ZO ~-- [] Re-inspection OPERATION C V COMMENTS Proper tank data on file '~,,, / Proper owner/operator data on file Permit fees current ~ / Certification of Financial Responsibility ~, Monitoring record adequate and current U Maintenance records adequate and current k"'/ 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 Office of Environmental Services (805) 326-3979 White- Env. Svcs. Pink - Business Copy '~'~in~ss Site Res~nsible Party CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME INSPECTION DATE Section 2: Underground Storage Tanks Program [] Routine [~ Combined Type of Tank ~(= Type of Monitoring [] Joint Agency [] Multi-Agency Number of Tanks ~q Type of Piping Otdl [] Complaint [] Re-inspection OPERATION C V COMMENTS Proper tank data on file Proper owner/operator data on file Permit fees 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: v_~ ~~~ Office of Environmental Services (805) 326-3979 White - Env. Svcs. Pink - Business Copy TYPE OF ACTION [] 1. NEW SITE PERMIT (Chock one item only) · " CITY OF BAKERSFIELl Gn ICE OF ENVIRONMENTAL ERvIcES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 UNDERGROUND STORAGE TANKS - UST FACILITY ~,~' 3. RENEWAL PERMIT [] 5. CHANGE OF INFORMATION (Specify change - [] 4. AMENDED PERMIT local use only). [] 6. TEMPORARY SITE CLOSURE Page __ of ~ [] 7. PERMANENTLY CLOSED SITE [] 8. TANK REMOVED 400· I. FACILITY I SITE INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 NEAREST CROSS STREET t 401. BTyUpS?ESS J-~l. GAS STATION E]~3. FARM [] 5. COMMERCIAL DISTRIBUTOR [] 4. PROCESSOR~-,.6. OTHER 403. 2. TOTAL NUMBER OF TANKS Is fadlity on Indian Reservation or REMAINING AT SITE tnJstlands? FACILITY ID # FACILITY OWNER TYPE 91. CORPORATION [] 2. INDIVIDUAL [] 3. PARTNERSHIP [] 4. LOCAL AGENCY/DISTRICT* [] 5. COUNTY AGENCY* [] 6. STATE AGENCY'* [] 7. FEDERAL AGENCY* 402. [] Yes .~-~N o 405. *If owner of UST a public agency: name of supei~ser of division, section or office which operatas the UST. (This is the contact person for the tank records.) PROPERTY' OWNER INFORMATION PROPERTY OWNER NAME MAILING__OR STREET ADDRESS 407. r PHONE 408. 409. ZIP CODE PROPERTY OVVNER TYPE~-~ [] 2. INDIVIDUAL [] 4. LOCAL AGENCY/DISTRICT [] 6. STATE AGENCY .~,.4. CORPORATION [] 3. PARTNERSHIP [] 5. COUNTY AGENCY [] 7. FEDERAL AGENCY 412. 413. :., :~, · .,, , , · .:: II1: TANK OWNER, INFORMATION MAILING OR STREET ADDRESS 416. CITY 417. STATE 418. [ ZIPCODE 419. [] 1. CORPORATION [] 2. INDIVIDUAL [] 3. PARTNERSHIP [] 4. LOCAL AGENCY / DISTRICT [] 5. COUNTY AGENCY [] 6. STATE AGENCY [] 7. FEDERAL AGENCY TANK OWNER TYPE 420. TY (TK) HQ ' ' ' ' IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 4"4 -' ' Call (916) 322-9669 if questions arise · :. "::i!;ii~'~;~:'~"i : '~,: ' V. PETROLEUM UST FINANCIAL RESPONSIBILITY ~:'~ ~ ,,' . 421. · INDICATE METHOD(S) ~ SELF-INSURED [] 4. SURETY BOND [] 7. STATE FUND [] 10. LOCAL GOV"T MECHANISM [] 2. GUARANTEE [] 5. LE"FI'ER OF CREDIT [] 8. STATE FUND & CFO LETTER [] 99. OTHER: [] 3. INSURANCE [] 6. EXEMPTION [] 9. STATE FUND & CD 422. VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which eddreas should be used for legal notifications and mailing. [] 1. FACILITY '"~ 2. PROPERTY OWNER [] 3. TANK OWNER 423. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. · VII. APPLICANT SIGNATURE ~ifil~¢iuOn: IRF~pt[hlat tjN~inf~:x'mation provided hereit.,.% n is true a|nd accurate to the best Of my knowledge. DATE NAME OF APPLICANT (print) ~,~ 426. ~,T,T~TL,,~E OF APPLICANT ~¢,~~ 425. 424. P.ON · %'9'7 ::2. 427. STATE UST FACILITY NUMBER (Forlocal use only) 428. 1998 UPGRADE CERTIFICATE NUMBER (Forlocal use only) UPCF (7/99) S:\CUPAFORMS\swrcb-a.wpd TYPE OF ACTION (Check one item only) CITY OF BAKERSFIELD OF OF ENVIRONMENTAL SE'I ICES [] 1. NEW SITE PERMIT [] 4. AMENDED PERMIT .,~,.3. RENEWAL PERMIT (Specify reason, for local use only) BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 UNDERGROUND STORAGE TANKS- TANK PAGE 1 [] 5. CHANGE OF INFORMATION) (Specify change - for local use only) 3 Page __ of __ [] 6. TEMPORARY SITE CLOSURE · [] 7. PERMANENTLY CLOSED ON SITE [] 8. TANK REMOVED 430 431 I. TANK DESCRIPTION 432 433 434 TANK ID # DATE INSTALLED (YEAR/MO) .%- q% AODITIONA-~'~ESCRIPTION (~-orT~cal use only) 435 TANK MANUFACTURER 436 COMPARTMENTALIZED TANK [] Yes 1~ No If 'Yes", complete one page for each compartment. NUMBER OF COMPARTMENTS 437 438 II. TANK CONTENTS · .". TANK USE 439 [] 1. MOTOR VEHICLE FUEL (If marked, complete Petroleum Type) [] 2. NON-FUEL PETROLEUM [] 3. CHEMICAL PRODUCT [] 4. HAZARDOUS WASTE (Includes Used Oil) [] 95. UNKNOWN PETROLEUM TYPE [] la. REGULAR UNLEADED [] lb. PREMIUM UNLEADED [] lc, MIDGRADE UNLEADED [] 2. LEADED "~3. DIESEL [] 4. GASOHOL COMMON NAME (from Hazardous Materials Inventory page) IlL TANK CONSTRUCTION" ' 441 [] 5. JET FUEL [] 6. AVIATION FUEL ]99. OTHER CAS # (from Hazardous Materials Inventoq/ page) 442 TYPE OF TANK 'Check one item only) [] 1. SINGLE WALL :~. DOUBLE WALL [] 3. SINGLE WALL WITH EXTERIOR MEMBRANE LINER [] 4. SINGLE WALL IN A VAULT [] 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM [] 95. UNKNOWN. [] 99. OTHER 443 TANK MATERIAL - pdmary tank rCheck one item only) [] 1. BARE STEEL [] 2. STAINLESS STEEL ~,-3. FIBERGLASS/PLASTIC [] 5. CONCRETE [] 95. UNKNOWN [] 4. STEEL CLAD W/FIBERGLASS [] 8. FRP COMPATIBLE W/100% METHANOL [] 99. OTHER REINFORCED PLASTIC (FRP) TANK MATERIAL - secondary tank [] 1. BARE STEEL Check one item only) [] 2. STAINLESS STEEL ,1~3. FIBERGLASS / PLASTIC [] 8. FRP COMPATIBLE W/100% METHANOL [] 95. UNKNOWN [] 4. STEEL CLAD W/FIBERGLASS [] 9. FRP NON-CORRODIBLE JACKET [] 99. OTHER REINFORCED PLASTIC (FRP) [] 10. COATED STEEL [] 5. CONCRETE 445 TANK INTERIOR LINING [] 1. RUBBER LINED [] 3. EPOXY LINING [] 5. GLASS LINING "~ US. UNKNOWN 446 OR COATING [] 2. ALKYD LINING [] 4. PHENOLIC LINING [] 6. UNLINED [] 99. OTHER DATE INSTALLED 447 Check one item only) (For local use only) OTHER CORROSION [] 1. MANUFACTURED CATHODIC [] 3. FIBERGLASS REINFORCED PLASTIC [] 95. UNKNOWN PROTECTION IF APPLICABLE PROTECTION [] 4. IMPRESSED CURRENT [] 99. OTHER Check one item only) [] 2. SACRIFICIAL ANODE 448 DATEINSTALLED 449 (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (Forlocal use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED (Check all thatapply) [] 1. SPILL CONTAINMENT [] 1. ALARM ~."~'--3. FILL TUBE SHUT OFF VALVE [] 2. DROP TUBE C~L~J ! [] 2. BALL FLOAT [] 4. EXEMPT [] 3. STRIKER PLATE IF SINGLE WALL TANK (Check all that apply): [] 1. VISUAL (EXPOSED PORTION ONLY) [] 2. AUTOMATIC TANK GAUGING (ATG) [] 3. CONTINUOUSATG [] 4. STATISTICAL INVENTORY RECONCILIATION (SIR) + BIENNIAL TANK TESTING [] 5. MANUAL TANK C,-~UGING (MTG) [] 6. VADOSE ZONE [] 7. GROUNDWATER [] 8. TANK TESTING [] 99. OTHER 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER (Check one item only): 454 [] 1. VISUAL (SINGLE WALL IN VAULT ONLY) "'1~. CONTINUOUS INTERSTITIAL MONITORING [] 3. MANUAL MONITORING . V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ; ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 qallons [] Yes [] No UPCF (7/99) S:\CUPAFORMS\SWRCB-B.WPD OFFICE OF ENVIRONMENTAL SERVICES 15 Chester Ave., Bakersfield, CA 9330'1 (66'1) 326':3~79 MST - TANK PAGE 2 Page __ of i UNDERGROUND PIPING ABOVEGROUND PIPING iSYSTEMTYPE [] 1. PRESSURE ~2. SUCTION [] 3, GRAVITY 458 [] 1. PRESSURE [] 2, SUCTION [] 3. GRAVITY 459 I [] 1. SINGLE WALL [] 3. LINED TRENCH [] 99. OTHER 460 [] 1. SINGLE WALL [] 95. UNKNOWN 462 CONSTRUCTION/ MANUFACTURE,~ ~2. DOUBLE WALL [] 95. UNKNOWN [] 2. DOUBLE WALL [] 99. OTHER MANUFACTURER 461 MANUFACTURER 463 [] I. BARESTEEL [] 6. FRP COMPATIBLE W/100% METHANOL [] 1. BARESTEEL [] 6. FRP COMPATIBLE W/100% METHANOL MATERIALS AND [] 2. STAINLESS STEEL [] ?. GALVANIZED STEEL [] 2. STAINLESS STEEL [] 7. GALVANIZED STEEL CORROSION PROTECTION [] 3. PLASTIC COMPATIBLE WITH CONTENTS [] 95. UNKNOWN [] 3. PLASTIC COMPATIBLE WITH CONTENTS [] 8. FLEXIBLE (HDPE) [] 99. OTHER ~"4. FIBERGLASS [] 8. FLEXIBLE (HDPE) [] 99. OTHER [] 4. FIBERGLASS [] 9. CATHODIC PROTECTION [] 5. STEEL W/COATING [] 9. CATHO01C PROTECTION 464 [] 5. STEEL W/COATING [] 95, UNKNOVVN 465 UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 PRESSURIZED PIPING (Check all that apply): [] 1, ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS [] 2. MONTHLY 0.2 GPH TEST [] 3. ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS: [] 5, DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [] 7. SELF MONITORING GRAVITY FLOW: [] 9, BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Chec~ one) [] 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 [] 11. AUTOMATIC LINE LEAK DETECTOR (3,0 GPH TEST) ,W.!TH FLOW SHUT OFF OR RESTRICTION [] 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM: [] 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) [] 14. CONTINUOUS SUMP SENSOR WlTHQyT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) W!THOUT FLOW SHUT OFF OR RESTRICTION ~1,6, ANNUAL [NTEGRITY TEST(0.1 GPH) ~17. DAILY VISUAL CHECK SINGLE WALL PIPING 467 PI~ESSURIZED PIPING (Check all that apply): [] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS [] 2. MONTHLY 0.2 GPH TEST [] 3. ANNUAL INTEGRITY TEST (0.1 GPH) [] 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply): [] 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM [] 6. TRIENNIAL INTEGRITY TEST (0.1 GPI~) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [] 7. SELF MONITORING GRAVITY FLOW (Check all that apply): [] 8. DAILY VISUAL MONITORING r-] 9. BIENNIAL INTEGRITY TEST (O.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR VVlTH AUDIBLE AND VISUAL ALARMS AND (check one) [] 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 [] 11. AUTOMATIC LEAK DETECTOR [] 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM: [] 13. CONTINUOUS SUMP SENSOR ~- AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH_TEST) [] 16. ANNUAL INTEGRITY TEST (0.1 GPH) [] 17. DAILY VISUAL CHECK DISPENSER CONTAINMENT [] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [] 4. DAILY VISUAL CHECK DATE INSTALLED 468 [] 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS [] 5. TRENCH LINER / MONITORING [] 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS [] 6. NONE 469 IX. OWNERJOPERATOR SIGNATURE certify that the information provided herein is true and accurate to the best of my knowledge. NAME OF OWNERJOPERATOR (print),_., . DATE 9 471 TITLE OF OWNE,~JOPERATOR ~ x 472 470 Permit Number (For local use only) 473 Pm'mit Approved (For local use only) 474 t Permit Expiration Date (For local use only) 475I UPCF (7/99) S:\CUPAFORMS\SWRCB-B.WPD CITY OF BAKERSFIELD d 'ICE OF ENVIRONMENTAIL RVICES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 UNDERGROUND STORAGE TANKS - UST FACILITY TYPE OF ACTION (Check one item only) [] 1. NEW SITE PERMIT ,~. RENEWAL PERMIT . [] 4. AMENDED PERMIT [] 5. CHANGE OF INFORMATION (Specify change. local use only). [] 6. TEMPORARY SITE CLOSURE Page __ of __ [] 7. PERMANENTLY CLOSED SITE [] 8. TANK REMOVED I. FACILITY I SITE INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 BUSINESS [] 1. GAS STATION [] 3. FARM [] 5. COMMERCIAL TYPE [] 2. DISTRIBUTOR [] 4. PROCESSOR..~L6. OTHER 403. TOTAL NUMBER OF TANKS REMAINING AT SITE FACILITY ID # FACILITY OWNER TYPE ;;~LL. CORPORATION [] 2. INDIVIDUAL [] 3. PARTNERSHIP 1'"~4. LOCALAGENCWDISTRICT* []5. COUNTY AGENCY* ~-"16. STATE AGENCY* [] 7. FEDERALAGENCY° Is facilily on Indian Reservation or tnJstlends? *If owner of UST a public agency: name of supervisor of division, section or office which Roerates the UST. (This is the contact person for Ihe lank records.) 402. 404. [] Yes ,J~o 405. 406. II. PROPERTY OWNER INFORMATION CITY PROPERTY OWNER TYPE ,~1. CORPORATION 410. STATE 411. ZIP CODE 412. [] 2. INDtVIDUAL [] 3. PARTNERSHIP [] 4. LOCAL AGENCY I DISTRICT [] 5, COUNTY AGENCY [] 6. STATEAGENCY [] 7, FEDERAL AGENCY 413. IlL TANK OWNER INFORMATION :. , TANK OWNERNAME '~A~-~ A'-'~ Ag~- 414.I PHONE 415. MAILING OR STREET ADDRESS 416, CITY 417. STATE 418. ZiP CODE 419. , TANK OWNER TYPE [] 2. INDIVIDUAL [] 4. LOCAL AGENCYID~STRICT [] 6. STATE AGENCY 420. [] 1. CORPORATION [] 3. PARTNERSHIP [] 5. COUNTY AGENCY [] 7. FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY (TK)HQ 1414[-[ I J Call (916) 322-9669 if questions arise 421, V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(S) [] 10. LOCAL GOV'T MECHANISM [] 99. OTHER: ~;~--1. SELF-INSURED [] 4. SURETY BOND [] 7. STATE FUND [] 2. GUARANTEE [] 5. LETTER OF CREDIT [] 8. STATE FUND& CFO LET[ER [] 3. INSURANCE [] 6. EXEMPTION [] 9. STATE FUND & CD 422. VI. LEGAL NOTIFICATION AND MAILING ADDRESS Chec~ one box to indicate which address should be used for legal notifications and mailing. [] 1. FACILITY ~ PROPERTY OWNER [] 3. TANK OWNER 423. Legal nolificetions and mailings will be sent lo the lank owner unless box I or 2 is checked. VII. APPLICANT SIGNATURE Cediflcation: I ca,lily that the information provided herein is true and accurate to the best of my knowledge. 425. 427. STATE UST FACILITY NUMBER (Forlocal use only) UPCF (7/9g) 428. I 1998 UPGRADE CERTIFICATE NUMBER (Forlocal usa only) 429. S:\CUPAFORMS\swrcb-a.wpd F~E CITY OF BAKERSFIELD ~, OF OF ENVIRONMENTAL SE'i~VICES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326,3979 UNDERGROUND STORAGE TANKS- TANK PAGE 1 TYPE OF ACTION (Check one item only) [] 1. NEW SITE PERMIT [] 4. AMENDED PERMIT g~"~. BENEWAL PERMIT (Specify mason- for local use only) [] 5. CHANGE OF INFORMATION) BUSINESS NAME (Same as FACILITY NAME or DBA - Oolng Business As) Page __ of [] 6. TEMPORARY SiTE CLOSURE [] 7. PERMANENTLY CLOSED ON SITE (Specify change - for local use only) [] 8. TANK REMOVED 430 , J , I. TANK DESCRIPTION 432 433 434 TANK ID # DATE INSTALLED (YEAR/MO) ADDI~'IONAL DESCRIPTION (For local use only) 435 TANK MANUFACTURER TANK)~'.APACiTY IN GALLONS 436 COMPARTMENTALIZED TANK [] Yes ~No If "Yes", complete one page tot each compartment, NUMBER OF COMPARTMENTS 437 438 TANK USE 439 [] I. MOTOR VEHICLE FUEL (If marked, complete Petroleum Type) [] 2. NON-FUEL PETROLEUM [] 3. CHEMICAL PRODUCT [] 4. HAZARDOUS WASTE (Includes Used Oil) [] 95. UNKNOWN II. TANK CONTENTS PETROLEUM TYPE 440 [] la, REGULAR UNLEADED [] 2. LEADED [] 5. JET FUEL [] lb. PREMIUM UNLEADED "~--,..3. DIESEL [] 6. AVIATION FUEL [] lc. MIDGRADE UNLEADED [] 4. GASOHOL [] 99. OTHER 'J~'~COMMONNAME(fr°rnHazard°usMate#alslovent°q/psge)~ ~LP'~-~2 ~'~"~--,~ L 441 I III. TANK CONSTRUCTION CAS ft (from Hazardous Materfafs Invenlory page) 442 TYPE OF TANK (Check one item only) [] 1. SINGLE WALL "~OOUBLE WALL [] 3. SINGLE WALL WITH EXTERIOR MEMBR.a~NE LINER [] 4. SINGLE WALL IN A VAULT ~ 5m SINGLE WALL WITH INTERNAL BLADDER SYSTEM [] 95. UNKNOWN [] 99. OTHER 443 TANK MATERIAL - primary tank [] 1. BARE STEEL [Check one item only) [] 2. STAINLESS STEEL TANK MATERIAL - secondary tank [] 1. BARE STEEL (Check one item only) [] 2. STAINLESS STEEL "~3, FIBERGLASS/PLASTIC [] 5. CONCRETE [] 95. UNKNOWN [] 4. STEEL CLAD W/FIBERGLASS [] 8. FRPCOMPATIBLEW/IOO%METHANOL []99. OTHER REINFORCED PLASTIC (FRP) '~. FIBERGLASS/PLASTIC [] 8. FRP COMPATIBLE WJlOO% METHANOL E]95. UNKNOWN [] 4. STEEL CLAD W/FIBERGLASS [] 9. FRP NON-CORRODIBLE JACKET [] 99. OTHER REINFORCED PLASTIC (FRP) [] 10. COATED STEEL [] 5, CONCRETE 445 TANK INTERIOR LINING OR COATING Check one item only) [] 1. RUBBER LINED [] 3, EPOXY LINING [] 5. GLASS LINING ~;JS. UNKNOWN 446 [] 2. ALKYD LINING [] 4, PHENOLIC LINING [] 6. UNLINED [] gg. OTHER DATE INSTALLED 447 (For local use only) OTHER CORROSION PROTECTION IF APPLICABLE l(Check one item only) ['"] 1. MANUFACTURED CATHODIC [] 3. FIBERGLASS REINFORCED PLASTIC [] 95. UNKNOWN PROTECTION [] 4. IMPRESSED CURRENT [] 99. OTHER [] 2. SACRIFICIAL ANODE 448 DATE INSTALLED 449 (For local use only) YEARINSTALLEO 450 TYPE (For local use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 ,-, ,. sP,.L CONTA,NMENT O ,. ALARM __ 0 3. F,LL TU 'E SHUT OFF VALVE q' ! D 2' DROP TU"E % ~ ~ D 2' BALL FLO~T D am EXEMPT [] 3. STRIKER PLATE · :' .=:'"'""!~:i.!:':::':.:?iil ~'i:::~:;!i:'::~:i?i!':::i;:!:! ~i?::': :'" ' :':':~;::IV; :TANKLi~AK!~I~':I.:;~!.,;::~::iI!'; ,i :i~':i~ ?:":::" ~'::: "!i!'~:::!i::!':;:::i :::i ' . "" '"'~i:: 453 IF DOUBLE WALL TANK OR TANK W1TH BLADDER (Ch~c~' ~ne/tern only): 454 IF SINGLE WALL TANK (Check all ~lat apply): [] ~. VISUAL (EXPOSED PORTION ONLY) [] 2. AUTOMATIC TANK GAUGING (ATG) [] 3, CONTINUOUS ATG [] 4. STATISTICAL INVENTORY RECONCILIATION (SIR) + BIENNIAL TANK TESTING [] 5. MANUAL TANK GAUGING (MTG) [] 6. VADOSE ZONE [] 7. GROUNDWATER [] 8. TANK TESTING [] 99, OTHER [] 1. VISUAL (SINGLE WALL IN VAULT ONLY) [] 2. CONTINUOUS INTERSTITIAL MONITORING [] 3. MANUAL MONITORING V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MOIOAY) 455 ESTIMATEO QUANTITY OF SUBSTANCE REMAINING .gallons 456 TANK FILLED WITH INERT MATERIAL? [] Y, [] NO 457 UPCF (7/99) S:\CUPAFORMS\SWRCB-B.WPD ~ CITY OF BAKERSFIELD {~1 OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326311J~9 / UST - TANK PAGE 2 i Page __ of ~ VI. PIPING CONSTRUCTION (Check a8 met app,) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE CONSTRUCTION/I MANUFACTURER, MATERIALS AND CORROSION PROTECTION [] 1. PRESSURE 1~. SUCTION I'"] 1. SINGLE WALL [] 3. LINED TRENCH l~2. DOUBLE WALL [] 95. UNKNOWN MANUFACTURER [] 1.8ARE STEEL [] 2. STAINLESS STEEL [] 3, GRAVITY 458 [] 99. OTHER 460 461 [] 6. FRP COMPATIBLE W/100% METHANOL [] 7. GALVANIZED STEEL [] 3. PLASTIC COMPATIBLE WITH CONTENTS [] 95. UNKNOWN ~4. FIBERGLASS [] 8. FLEXIBLE (HDPE) [] 99. OTHER [] 5. STEEL W/COATING [] 9. CATHODIC PROTECTION 464 [] 1. PRESSURE [] 2. SUCTION [] 3. GRAVITY 459 [] 1. SINGLE WALL [] 95. UNKNOWN [] 2. DOUBLE WALL [] 99. OTHER MANUFACTURER [] 1. BARE STEEL [] 2. STAINLESS STEEL [] 6. FRP COMPATIBLE W/100% METHANOL [] 7. GALVANIZED STEEL 462 463 [] 3. PLASTIC COMPATIBLE WITH CONTENTS [] 4. FIBERGLASS ' [] 5. STEEL W/COATING [] 8. FLEXIBLE (HDPE) [] 99. OTHER [] 9. CATHODIC PROTECTION [] 95. UNKNOWN 465 VII. PIPING LEAK DETECTION (CheCk a# eat apply) ~' . UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 PRESSURIZED PIPING (Check all that apply): [] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS [] 2. MONTHLY 0.2 GPH TEST [] 3. ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS: [] 5. DALLY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [] 7. SELF MONITORING GRAVITY FLOW: I r'-I 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Chec~ one) [] 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 [] 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION [] 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM: [] 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION .,~16. ANNUAL INTEGRITY TEST (0.1 GPH) SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): [] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS [] 2. MONTHLY 0.2 GPH TEST [] 3. ANNUAL INTEGRITY TEST (0.1 GPH) [] 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply): [] 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM [] 6. TRIENNIAL INTEGRITY TEST(0.1 SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): [] 7. SELF MONITORING GRAVITY FLOW (Check all that apply): [] 8. DAILY VISUAL MONITORING [] 9. BIENNIAL INTEGRITY TEST (O.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (check one) [] 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 [] 11. AUTOMATIC LEAK DETECTOR [] 12. ANNUAL INTEGRITY TEST (0,1 GPH) SUCTION/GRAVITY SYSTEM: [] 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) [] 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS [] 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) [] 16. ANNUAL INTEGRITY TEST (0.1 GPH) DISPENSER CONTAINMENT DATE INSTALLED 468 [] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [] 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS [] 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS [] 4. DAILY VISUAL CHECK [] 5. TRENCH LINER / MONITORING [] 6. NONE 469 IX. OWNER/OPERATOR SIGNATURE I ce~i~,lhal the information provided herein is true and accurate ID the best of my knowledge. /S~LN~T01~E OF (~WNER/OPE .R.a/.T~R ~ NAME OF_OWNER/OPERATOR (/~/f/~t) ~ i 47f ~_____~LE OF OW~ER/.OPERATOR 470 Permit Number (For local use only) 473 Permit Approved (For local use only) 474 Permit Expiralion Dale (For local use only) 475 I UPCF (7/99) S:\CUPAFORMS\SWRCB-B.WPD CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Cljcster Ave., 3ra Floor, Bakersfield. CA 93301 I ~ Section 2: Underground Storage Tanks Program {~ Routine ~ Combined [~oin( Agegcy [~ Multi-Agency Type of Tank __~f b"C3 , Number of Tanks Type of Monitoring __~,'- ~ .... ! Type of Piping ~_OV [~l Complaint Re-inspection OPERATION i C V COMMENTS Proper tank data on file ,, ~e ,, Proper owner/operator data on file Pemfit fees current i ~'~ Certification of Financial Respon,qbility I Monitoring record adequate and current i Maintenance records adequate and current Failure to correct prior UST violations : i Has ~here 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 COMMENT8 SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling I Is tank used to dispense MVF? I If yes, Does tank have ovcrfill/overspill prot~,,ction? ,,, C=Compliance V=Violation Y=Ycs N--l' tO Office of Environmental Services (805) 326-3979 White- Envl lyes. Plhk -Busincss Copy usines's Site ~gnsible Party E/E'd ¢6~'0N S33IA~3S ~NI~33NI~N3 WWZO:~ 666['Z 'D30 RLW ENTBRPRISES 2014 SO UNION AVB #107 BAKERSFIELD. CA 93307-4154 Voice Fax: (805) 834-110~ (8e5) 834-4~i6 Sold To~ MERCY HOSPITAL-ENGINEERIN P.O. BOX 119 BAKERSFIELD, CA 93302-01 USA Customer ID MERCY Sales Rep ID Quanti~y Item [9 cus%!omer PO KEN/CHARLIEi Shipping Method None , Description 1.00 WSC 4¢30 1.OO LABOR 2 1.OO ZONE i 1.OO LABOR 2 1.OO ZONE 2 1.00 INFO TEST ~OR PROPER OPERATION TANK ~ONITOR SYSTEM AT BOTH ~OSPITAL LOCATIONS TEST GOWN TOWN FACILITY FOR COMPLIANCE MILEAGe/TRAVEL TIME DRIVER/TRUCK TRAVEL TIME TO DO~N TOWN PACILTY TEST OF SYSTEM FOR COHPL~,ANCE MILEAGe/TRAVEL TIME DRIVER & TRUdK TRAVEL TO OLD RIVER fFACILTY NOTE BOTH SYSTEMS ARE OPPER~TING AS PER SPECII'ICATIONS Invoice Number: S2117 Invoice Date= Sep 13, 1999 Page, Payment Terms Ne~ 15 Days Ship Date Unit Price Due Date 9/28/99 Extension 60.00 25.00 60.00 25.00 60.00 30.00 60.00 30.00 THIS IS TO CERTIFY THAT THE WORK WAS SATISFACTORILY COMPLETED. ACCEPTED Check No: Sub~otal Sales Tax Total Invoice Payment TOTAL E/I 'd PaY FROM THIS INVOICE/ NO STATEMENT WILL BE SENT!!!! P6I 'ON S33I^~3S DNI~33NIDN3 N~ZO: I 1 175.OO 175.00 o.o0 175.00 666I ' Z ' 33(I ,0 L D February 9, 1999 FIRE CHIEF RCN FRAZE ADMINISTRATIVE 8ERVICE8 2101 'H' Street Bakersfield, CA 93301 VOICE (805) 326-3941 FAX (805) 395-1349 SUPPRESSION SERVICES 2101 'H" Street Bakersfield, CA 9.3301 VOICE (805) 326-3941 FAX (805) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (805) 326-3951 FAX (805) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (805) 326-3979 FAX (805) 326-0576 TRAJNING DMSION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (805) 399-4697 FAX (805) 399-5763 Mercy Southwest Hospital 400 Old River Rd Bakersfield, CA 93311 RE: Compliance Inspection Dear Underground Storage Tank Owner: The city will start compliance inspections on all fueling stations within the city limits. This inspection will include business plans, underground storage tanks and monitoring systems, and hazardous materials inspection. To assist you in preparing for this inspection, this office is enclosing a checklist for your convenience. Please take time to read this list, and verify that your facility has met all the necessary requirements to be in compliance. Should you have any questions, please feel free to contact me at 805-326-3979. Sincerely, Steve Underwood Underground Storage Tank Inspector Office of Environmental Services SBU/dm enclosure MOV.16.1998 11:12AM EMGIMEERIMG SERVICES M0.559 P.1/2 MERCY HOSPITAL- CHW ENGINEERING SERVICES 2215 TRUXTUN AVE, P.O. BOX I ! 9 BAKi~RSFIELD, CA. 9330.2 FAX Number of pa§es Including covet [=ax .CC:: REMARKS: [] I I I[ II iii '~ For you~ review · I I From: Phol~' phone: (805) 632-$144 _ (sos) I. · Ill I I . dllll [] Reply ASAP [] Plcaso comment EMGIMEER~NG SERVICES 2~14 SO U~ION AVE BAKERSFIELD, CA 933e7-4154 InvoiCe MO. 559 P. BAKERSFIELD, CA 933e2-e~l~ Ship Invoice Date~ Nov 11. 1998 invoice e~48 Page~ 1 MERCY SOUTHWEST HOSPITAL OLD RIVER BLVD. Customer ID Oust°me= .PO MERCY , C 993239-~ Sales Rep ID Shipping Hethod None 9uan~i=¥ I=em 1.ee INFO INFO 1,oe WC 3eel INSTALLATION OF 2 COMPLET~ ~ER AGR~EHENT/ FLAT RATE THE ABOVE PRICE INCLUDES ALL LABOR. ADDITIONAL PARTS ~0R INSTALLATION AND TRAVEL TZM~, TERHS NET 15 DAYS FROH INVOICB DATE PER AGREEmENT,ON THE COMP~TZON OF JOB.,. THANK YOU Net 15 Days Ship Date Due Da~e 11/15/$8 11/26/98 Uni~ Price Extension 2,176.5e 2,176.'$e Check Subtotal Sales To=al Invotae Paymen~ TOTAL 2,176.50 2,176 · 50 ' e.ee 2. 176.50 PAY FROM THIS INVOICE/ NO STATEM~I~T WI~.T. NOT F BAKERSFIELD FIRE DEPARTMENT / ~ Sub Div. ~ ¥ ~t~ ~e,~ ~ · ~1~ ~t You are hereby required to make the following eor~etions at ~e above l~ation: Cot. No I Completion Date fox' Corrections ,~,/:9--/~ c/ , Inspector 326-3979 FIRE DEPARTMENT M. R. KELLY FIRE CHIEF CITY of BAKERSFIELD "WE CARE" January 30, 1995 WARNING! 1715 CHESTER AVENUE BAKERSFIELD, 93301 326-3911 CERTIFICATION OF FINANCIAL RESPONSIBILITY REQUIRED Dear Underground Storage Tank Owner: 215-000-000428 MERCY SOUTHWEST HOSPITAL 400 OLD RIVER ROAD ~3AKERSFIELD, CA 93302 ~,:'-" A T JACOBS Our records indicate that your business does not have a Certification of Financial Responsibility on file with this office. Please forward either a copy of your existing State approved mechanism to show financial responsibility or else complete the attached Certification of Financial Responsibility form. An attached letter from the State Water Resources Control Board lists the approved financial responsibility mechanisms required to pay for corrective actions resulting from leaking underground fuel tanks. Remember, most tank owners only have to show financial responsibility for at least $10,000 of clean up liability. The Underground Storage Tank Clean Up Fund (USTCF) may be used as the mechanism to cover the remaining accidental, release liability. The total amounts of financial responsibility required (check boxes from section A of form) are as follows: If you don't sell product from you tanks, and you pump less than 10,000 gallons per month, check "$500,000 per occurrence". Else, or if you are in the business of selling from your tanks, check "1 million dollars per occurrence". For owners of 101 or more petroleum underground storage tanks, check the "2 million dollar annual aggregate" box. All others need only check the "1 million dollars annual aggregate" box. Please be aware that failure to provide the financial responsibility document to this office within 30 days will result in your Permit to Operate being revoked. (25285.1 (b) California Health & Safety Code). ' If you have any questions, or would like help in completing the Certification of Financial Responsibility, please contact Howard Wines, Hazardous Materials Technician, at 326-3979. Sincerely, Hazardous Materials Coordinator REH/dlm ate Underground Hazardous Materials Storage Facility CONDITIONS ~!!;p:~!!~?~!l~ii~!!;a,EVERSE SIDE Tank Hazardous G.~}i:~ ?!?:%:.;:::i;::};: ..... Ye.a~:??~ii: :;i! ?.~Tank" '"::;i;;i;~:i~:~I ;iii'::i:.?!!ii Piping Piping Number Substance c~:pa6.!{~'%.~;;?' in'~iaii~8:?.'::::.. ~:??Type Moh:,t~'ia:~:?:::~;~: Type Method Bakersfield Fire Dept. HAZARDOUS MATERIALS DIVISION 1715 Chester Ave., 3rd Floor Bakersfield, CA' 93301 (805) 326-3979 Approved by: Piping Monitoring Ralph E. Huey, Hazardous Materials Coordinator Valid from: CORREC ON NOTI CE BAKERSFIELD FIRE DEPARTMENT N° ~" 0021 Location Sub Div./-(~ O[c~ .~e,.~ ~ - Blk ..... Lot You are hereby required to make the following corrections at the above location: Cot. ~o Completion Date for Corrections ~-~.,/~-/'~ ~ Date ~/I~,/~/ ~/~_ _/~/~x~--~~'/ Inspector 326-3979 UNDERGROUND ;E TANK INSPECTION Operating Permit: Business Name: Location: d Fire Dept. Materials Division Date Completed Business Identification No. 215-000 /-( ~ (Top of Business Plan) Number of Tanks. [.T.~5~ype: Containment: ~,~\~ ~ CONTACT INFORMATION / Emergency Contacts: ~ ,, · , ~ Monitoring Program Ade~ Inadequate1=1 RECORDS Maintenance Testing Inventory Reconciliation RESPONSE PLAN Emergency Plan White - Haz Mat Div Pink - Business Copy All Items O.K. D ~ Correction Needed Er SUMMARY , ENV. SENSITIVITY: Activity Date # Of Tanks Comments ! .//~/?/ t t HPS PLUMBING SERVICES INC. CA. LIC. # 477948 P.O. BOX 6386 BAKERS~ 93386 (805) 324-2121 FAX 322-5648 January 4, 1991 Kern County Resource Management Agency Environmental Health Services Department 2700 M Street Bakersfield, CA 93301 Attn: Wesley Nicks RE: Fuel Permit Application 400 Old River Rd. - Mercy Hospital Dear Mr. Nicks, I have reviewed your comments for the review. Below are responses to them. 1. Tank #1 - Boiler Fuel Oil Tank - 6000 gallons 2. Tank #2 - Generator Fuel Oil Tank - 2600 gallons 3. Both tanks will be backfilled with pea gravel, and hold in place with tie-doWn straps and deadmen, see detail #4 P 3.3. 4. Product Storage ' DieSel 5. Fuel Oil Supply Line - suction ~.~ 6. Product piping - Red Thread by Smith We are ready to start installation, as soon as a permit is issued, so if you have any questions, please call me. Thank you very much for your help so far. Tim A'shlock cc: #459.E COUNTY HEALTH DEPARTMENT iRONMENTAL HEALTH DIV~IO~'- SUBSTANCES INSPECTION RECORD POST CARD AT JOBSITE FACILITY.~)~A:~ ./~,L~ S.~, PERMIT ADDRESS 400 ~/A ~,[3~ ~o*~ ' C I TY ~ ~ ~'~_~,'~_/A_ PHONE NO. 1700 FLOWER STREET 'BAKERSFIELD. CA 93305 PHONE (80'5) OWNER ADDRESS · INSTRUCTIONS: Please call for an inspector only when each group of inspections with the .same number are ready. They~ will run in consecutive order beginning with number 1. DO NOT cover work for any numbered group until all items in that group are signed off by the Permitting Authority~ Following these instrutions will reduce the number of required inspection visits and therefore prevent assessment of additional~fees. _. - TANKS & BACKFILL - INSPECT I ON DATE ~ INSPECTOR ,Backfill of Tank(s) 9'/1~/~! -"~'), '~,.~ Spark T~i Ce~-tlflc~--~ea C ' ' Tank~) - PIPING SYSTEM [Piping a Raceway w/Collection Sump ~/~/ /, ) ~'~-~/~ ICorrosion Protection of Piping, Joints, Fill Pipe q//(~[ ~ ~~ Electrical Isolation of Piping From Tank(s) V~!~/~/' ~, ~~ ~ ,- V. ~ ..... - SECONDARY CONTAINMENT, OVERFILL PROTECTION. LEAK DETECTION - r Level Gauges or Sensors, Float Vent Valves Product Compatible Fill Box(es) Leak Detector(s) for Annular Space-D.W. Tank(s) Monitoring Well (s)/Sump(s) ................ ~ ~ Fur Vadose/Grvu,,dwatur - FINAL - ;:onltorlng ;';cll~','~-Cap~ &Lockc Fill Box Lock ' $/~/~& .-;'.3. ~ Monitorin~ Requirements ~/~ .-~.e~. ~ CONTRACTOR LICENSE CONTACT PH # RANDALL L. ABB~)TT DIRECTOR DAVID PRICE I!I ASSISTANT DIRECTOR ENVIRONMENTAL HEALTH SERVICES DEPARTMENT December 19, 1990 TO: Permit Applicant This Department has reviewed the application and plans submitted for the underground storage facility located at 400 Old River Road, Bakersfield, California known as Mercy Hospital Southwest. Based on this review, your application as received cannot be accepted as complete for the reasons listed on the attached Permit Application Checklist. We are returning the original permit application and plans. After making required corrections and/or modifications, the application may be resUbmitted for review. If you have any questions regarding our requirements please call Wesley G. Nicks at (805) 861-3636 extension 571. Sincerely, WGN:cas Wesley'~. Nicks Hazardous Materials Specialist Hazardous Materials Management Program \hospital.ltr 2700 "M" STREET, SUITE 300 BAKERSFIELD, CALIFORNIA 93301 (8O5) 861-3636 FAX: (805) 861-3429 2700k"M" STREET, SUITE 300 .... BAKERSFIELD, CA 93301 PERI,,_. APN~Ii~IflBER APPLICATION DATE APPLICATION FOR PERMIT TO CONSTRUCT/MODIFY UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY Type Of Application (check): .~)New Facility ( )Modification of Facility ( )New Tank Installation at Existing Facility Ae Be Number of Tanks To Be Installed ~ Existing Facility Permit Type of Business Facility Name /y)~/~' Ho~f?.,'¥~l- Address .~00.... ~id~[~ ~o~d . City T: R__ SEC (~ural ~ocacion~ Only) Nearest Cross Street S+ockJ~l~ Tank Owner ~E. le'C¥ J~Osp~ 7'~ ~- ,.. Phone #:.~.-7-~?1 City/State J~/~r~l~t ¢/~ ,m Zip e3Z~Ol Soil Characteristics At Facility .5~~oY Water To Facility Provided By Depth To Groundwater)~o' Contractor. H~-~ f>.J~..~l.~ --q¢~,'~, _B,~, CA Contractor's License No. ~-/7~' Address t~O rqox 6~ City ~Le,~J Zip, e3J~ Worker's COmpensation CertificatiOn ~ ~0-37l~- ~'~ InsurerS~ Co~.~.~;o. PropOsed Starting Date ~-=~-~0 Proposed Completion Dale E. If This Application Is For Modification Of An Existing Tank System, Briefly Describe Modifications Proposed (Excluding New Tank Installation at Existing Facilities)../V//~ Tank(s) Storage (Check All That Appl.v): (If* 2 Complete Section G) Other* Other* lank # Unleaded Regular Premium Diesel Other Fuel* Waste Oil Waste Product ~ () () () ~) () () ( Chemical Composition Of Materials Stored (For Products Or Waste Marked With *) Tank # Chemical Stored (non-commercial, name) CAS # (if known) Chemical Previously Stored (if different) ~~ ~ 805/324-2121 Tim Ashlock ' P.O. ~ox 6386 · Bakersfield, CA 93386 ler penalty of perjury and to the best of my knowledge is £qulpa~nt to be Installed: ~-- Tank(s), z~O Ft. of Standard Compliance Check \ Suctlon ~]Pressurized · ~Gravlty, Pipini Proof of Contractor's License - License ~ Type of License Proof of Contractor's Worker"s Compensation Insurance Primary Containment ~Flberglass (FRP) [~Fiberglass-clad steel [-]Uncoated steel ~]Other: Comment: Make & Model Make & Model Make & Model Additional: Inspection: Secondary Containment of Tank(s) _~j~Double-walled tank(s) {-]Synthetic liner i-]Lined concrete vault(s) ~]Other Type Comment: Make a Model ~u~- Make & Model Sealer used Make & Model Additional: Inspection: _/ Secondary Containment Volume at Least 100~ of Primary Tank Volume(s) Comment: ~ . t~_). T"F4~KS k"~ . Additional: Inspection: Secondary Containment Volume for More Than One Tank Contains 150~ of Volume of Largest Primary Containment or 10~ of Aggregate Primary Volume, Whichever is Greater Comment: Additional Inspection: Req'd Approved __~/~r_Secondary Containment flour Rainfall Total Open to Rainfall Must Accommodate Volume Comment: Additional: Inspection: Secondary Containment ts Product-Compatible Product ~s~/ / ~/~,'/ Comment: / ~ Additional: Inspection: Documentation Annular Space Liquid is Compatible with Product Product Annular liquid Comment: Additional Inspection Primary Containment of Piping Ftberglass piping Size & Make Coated steel piping Size & Make OUncoated steel piping Size OOther Comment: Additional: Inspection: Secondary Containment of Piping ,Oouble-walled pipe Size Synthetic liner in trench Size Dother & Make & Make Comment: Additional: Inspection: .Corrosion Protection I-]Ta.nl~ ( s ) ~]Plplng & fittings '. [-]Electrical Isolation · : Comment: Additional: ./ Inspection: ManUfactu~rer-Approve'd Backfill for Tanks & Piping Type 1/'~ ~°~0~ / Comment: ,Req'd Approved Additional: Inspection: nk(s) Located no Closer than .10 Feet to Building(s) Comment: Additional: /~C Inspection: omplete ~onltortng System Monitoring device within secondary containment: ~Llquld level indicator(s,) , ~]Llquld used [~Thermal conductivity ~]Pressure sensor(s) ~]Vacuum gauge [~$ump(s) sensor(s) Oas or vapor detector(s) Manual inspection & sampling [-]V//Ysual inspection []~'Other I,'Q~,'~ ~~ ~.~ A~N!~ Comment:, Additional: Inspection: '' Other Monitoring [-]Periodic tightness testing Method ~]Pressure-reduclng line leak detector(s) [-']Other Coeaent: Additional: Inspection: Overfill Protection ~]?ape float gauge(s) loat vent valve(s) Capacitance sensor(s) Bigh level alarm(s) utomatic shut-off control(s) 0111 box(es) with 1 ft. 3 volume perator controls with visual level monitoring Other Comment: - 3 - .Req'd Approved Additional: Inspection: Monitoring Requirements Additional Comments Inspection: InsPector Date Date: Extra Inspect !OhS/Re !nspect lons/Consul tat tons Purpose: ¢onnent: Date: Tine Utilized Purpose: Conment: Date: Time Utilized Purpose: comment: Date: Tine 'Utilized Purpose: Comment: Invoice Date: Inspector - 5 - Tine Total Date: Utilized Time: Permit Application Checklist Facility Name Facility Address Application/Category: !/Standard-Design (Secondary Containment) Motor Vehicle Fuel Exemption Design (Non-Secondary Containment) Approved Permit Application Form Properly Cqmpleted Deficiencies: Copies of Plot Plan Depi.~ting: Proper.ty lines Area encompassed 'bY min'imum 100 foot radius around tank(s) and piping Ail tank(s)~ identi'fied by a number and product to be stored Adequate scale (minimum 1"=16'0" in. detail) North arrow Ail structures within 50 foot radius of tank(s) and piping Location,and labeling of. all product piping and dispenser islands Environmental sensitivity data including: *Depth to first groundwater at site *Any domestic or agricultural water well within 100 feet of tank(s) and piping *Any surface water in unlined conveyance within 100- feet of tank(s) and piping *All utility lines within 25 feet of tank(s).and piping (telephone, electrical, water, sewage, gas, leach lines, seepage pits, drainage systems) '~Asterisked items: appropriate documentation if permittee seeks a motor vehicle fuel exemption ~rom secondary containment Comments: Approved 3 Copies of Construction Drawings Depicting: -- ~ide Vi~ 5~ ~-~ ~-~ail~ti0n'wi~h 'Ba6~ill, Raceway(s), Secondary Containment and/or Leak Monitoring System in Place Top view.of Tank InstallatiOn with Raceway(s), Secondary Containment and/or Leak Monitoring System in Place A Materials List (indicating those used in the construction): Backfi'll Tank(s) Product Piping Raceway(s) ~e~(s) Secondary Containment Le'a'k Detector ('s) Overfi.ll'Protection Gas or Vapor Detector(s) Sump(s) Monitoring we'll(s) Additi'onal: Documentation of Product PerfOrmance Additional Comments RevieWed By Date SITE INSPECTION: Comments: Approved Disapproved Date Inspector RANDALL L. ABBOTT DIRECTOR DAVID PRICE I11 ASSISTANT DIRECTOR Environmental Health Semices Department STEVE McC^I ! Fy, REHS, DIRECTOR Air Pollution Control District WILLIAM J. RODDY, APCO Planning & Development Sez~ices Department TED ,JAMES, AICP, DIRECTOR ENVIRONMENTAL HEALTH SERVICES DEPARTMENT PERMIT TO CONSTRUCT UNDERGROUND STORAGE FACILITY FACILITY Mercy Hospital. Southwest 400 Old River Road Bakersfield, CA OWNER(S) NAME/ADDRESS: . Mercy Hospital 2215 Truxtun Avenue Bakersfield, CA 93301 'Phone No. (805) 32%3371 PERMIT NUMBER 280039 CONTRACTOR: HPS Incorporated P. O. Box 6386 Bakersfield, CA 93386 License # 477948 Phone No. (805) 324-2121 X NEW BUSINESS CHANGE OWNERSHIP RENEWAL MODIFICATION OTHER PERMIT APPROVAL DATE APPROVED BY EXPIRES April 9, 1991 January 9, 1991 Haza~5'ous Materials Specialist .............................. POST ON PREMISES .............................. CONDITIONS AS FOLLOW: Standard 'Instructions o 3. 4. 5. 6. All construction to be as per facility plans approved by this department and verified by inspection by Permitting Authority. All equipment and materials in this construction must be installed in accordance with all manufacturers' specifications. Permittee must contact Permitting Authority for on-site inspection(s) with 48-hour advance notice. Backfill material for piping and tanks to be as per manufacturers' specifications. Float vent valves are required on ventP~apor lines of underground tanks to prevent overfilling. Construction inspection record card is included with permit given to Permittee. This card must b6 posted at job site prior to initial inspection. Permittee must contact Permitting Authority and arrange for each group of required inspections numbered as per instructions on card. Generally, inspections will be made of.' a. Tank and backfill b. Piping system with secondary containment leak interception/raceway c. Overfill protection and leak detection/monitoring d. Any other inspection deemed necessary by Permitting Authority. 2700 "M" STREET, SUITE 300 BAKERSFIELD, CALIFORNIA 93301 (805) 861-3636 FAX: (805) 861-3429 Standard Instructions permit No. 280039 11. 12... All underground metal connections (e.g. piping, fitting, fill pipes) to tank(s) must be electrically isolated and wrapped to a ~inimum 20 mil thickness with corrosion-preventive, gasoline-resistant tape or otherwise protected from corrosion. Primary and secondary containment of both tank(s) and underground piping .must not be subject to physical or chemical deterioration due to the substance(s) stored in them. Documentation from tank, piping, and seal manufacturers of compatibility with these substance(s) must be submitted to Permitting Authority prior to construction. No product shall be stored in tank(s) until approva. 1 is granted by the Permitting Authority. Contractor must be certified by tank manufacturer for installation of fiberglass tank(s), or tank manufacturer's representative must be present at site during installation. Monitoring requirements for this facility will be described on final "Permit to Operate." Monitoring wells on "Typical Drawings" are not allowed unless monitoring probes are installed and functioning. Construction must be in accordance with Hazardous Materials Management Program standards as per UT-50. WGN:cas ~280039.ptc '?ENVIRONMENTAL HEALTH DEPAOEN~' 2700 "M" STREET, SUITE 300 BAKERSFIELD, CA 93301 APN NUMBER APPLICATION DATE' APPLICATION FOR PERMIT TO CONSTRUCT/MODIFY UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY Type Of Application (check): ~)New Facility ( )Modification of Facility ( )New Tank Installation at Existing Facility A. Number of Tanks To Be Installed ~_ Existing Facility Permit # Type of Business I-Io_~t-~( Facility Name /Y)~/~' Ho~,'+~l- Address ~00 0~( 'J~l~J ~o~,d City ~~,'~ T~ R~ SEC~ (~ural Socations Only) Nearest Cross Street S~oc~A~l~ m m B. Tank Owner ~c~ ~O~pl~ Phone ~: ~7-~1 Address ~y ~,n City/State ~,~1~, d~ Zip m Water To Facility Provided By ~1 (xY~Jr¢,~-~ ~,~.~ cpm Depth To Groundwater I&O' Soil Characteristics At Facility Contractor Hfs ~'1~.,.~.,~ ~v,'~, _G,~, CA Contractor's License Address ~0 FqOX 6:~E~ City. Worker's Compensation Certification # ~0-~?1~- ~o Insurer~h~t~- Proposed Starting. Date ~-~-~) Proposed Completion Dat'e Ee If This Application Is For Modification Of An Existing Tank System, Briefly Describe Modifications Proposed (Excluding New lank Installation at Existing Facilities) /V~/~ , Tank(s) Tank ~ Storage (Check All That Apply): (If* - Complete Section G) Other* Other* Unleaded Regular Premium Diesel Other Fuel* Waste Oil Waste Product () () () (x) () () ( ( ) ( ) -( ) (w) ( ) ( ) ( () () () () ()~ () ( () () () () () () ( Chemical Composition Of Materials Stored (For Products Or Waste Marked With *) Tank # Chemical Stored (non-commercial name) CAS # (if known) Chemical Previously Stored (if different) This form has been completed under penalty of perjury and to the best of my knowledge is true and correct Signature~~-~~~ Title ~/~C~ ~¢$. Date HM23 Permit # H.- 1. Tank {s: 2. Tank Material . ( ) Carbon Steel ( ) Stainless Steel () Concrete () Unknown 3. Primary Containment Date Installed Thickness (Inches) 4. Tank Secondary Containment (~J Double-Wall ( ) Synthetic Liner () Other (describe): o 10. 11. HM21 Contents ,-,UT SEPARATE FORM FOR EAC} -ffEc-K XC£ APPRO nATE SOXES ( ) Vaulted ( ) Jackdted Tank # ] ( ) Double-Wall ( ) Single-Wall . .. ~) Fiberglass-Reinforced plastic ( ) .Fibergla.ss_-_Clad Steel ( ) Other (Describe) Capacity (Gallons) 6oo0 ( ) Lined Vault Manufacturer ( ) None ( ) Unknown Manufacturer: tg~,,.q,,s- 6o~,,'-s ( ) Material Thickness (Inches) Capacity (Gallons)- Tank Interior Lining (~ Unlined ( ) Unknown ( ) Lined (describe) Tank Corrosion Protection ( ) Galvanized ~ Fiberglass-Clad ( ) Polyethylene/Vinyl (Wrapped or Jacketed) () Tar or Asphalt () Unknown () None () Other (describe)~ Cathodic Protection: ( ) None ( ) Impressed Current System ( ) Sacrificial Anode System Describe System and Equipment: ,a 0 ~ ~ Leak Detection, Monitoring~ and Interception * (Must be described below) a. Tank: ( ) Vapor Detector * {~O Liquid Level Sensor * ( ) Conductivity Sensor * ( ) Vadose Zone Monitoring Well(s) ( ) U-Tube with Liner ( ) U-Tube without Liner ( ) Visual Inspection (Vaulted tanks only) ( ) Groundwater Monitoring ( ) Sensor in Annular Space ( ) Vapor 0q') Liquid ( ) Pressure ( ) Other * ( ) Regular Monitoring of U-Tube, Monitoring Well or Annular Space ( ) Daily Gauging & Inventory Reconciliation ( ) Periodic Tightness Testing ( ) None ( ) Unknown ( ) Other /'lvd~os½~rcc. aq~l~ $?ac~ ,.no.ffo~' -0..o~ Co-'d~ · Describe Make & Model: O~e~ ~o,,~','.~ f~ lC) .se.,~o,' ' b. Piping: ( ) Flow-Restricting Leak Detector(s) f6'r Pressurized Piping* ( ) Sealed Concrete Raceway ( ) Monitoring Sump with Raceway ~) Complete Containment Liner with Sumps ( ) Half-Cut Compatible Pipe Raceway ( ) Synthetic Liner Raceway ( ) None ( ) Unknown ( ) Other · Describe Make & Model: O.c,. s,~.,.~, ,-/ I:/~ ~-~.,~_.~, iix I~) ~*"$~'~ Tank Tightness Has This Tank Been Tightness Tested? Date of Last Tightness Test Test Name Tank Repair ( ) Yes Date(s) of Repair(s) ,~0~¢ - ( ) Yes ( ) No Results of Test Testing Company ( ) No ( ) Unknown ( ) Unknown Describe Repairs Overfill Protection (Must describe below) ( ) Operator Fills, Controls, & Visually Monitors Level ( ) Tape Float ~Gauge ( ) Float Vent Valves ( ) Auto Shut-Off Controls ( ) Capacitance Sensor ( ) Sealed Fill Box ( ) None () Unknown ( ) List Make & Model for all Devices OP~v Sq -tO~O '{~lt sys~'e.,n *Describe other Protection System Piping a. do ( )Other * Underground Piping: ~) Yes ( ) No ( ) Unknown Material Thickness (inches) Diameter Manufacturer Type of piping System ~, F~s Foe ~. F; Il L;.¢ l, qO ( ) Pressure 00 Suction ~) Gravity Approximate Length of this Pipe Run z Underground Piping Corrosion Protection: ( ) Galvanized ( ) Fiberglass-Clad ( ) Impressed Current( ) Sacrificial Anode ( ) Polyethylene Wrap ( ) Electrical Isolation ( ) Vinyl Wrap ( ) Tar or Asphalt ( ) Unknown ( ) None (~) Other (describe):. tva ;~,~/c · Underground Piping, Secondary Containment: LineSystem ( ) None ( ) Unknown 2., 09 Double-Wall () Synthetic . ( ) Make & Model (describe): <~,,, ~ /- Permit # ~"1. Tank is: 2. Tank Material ( ) Carbon Steel ( ) Concrete 3. Primary Containment Date Installed Thickness (Inches) 4. Tank Secondary Containment 0Q Double-Wall ( ) Synthetic Liner ( ) Other(describe): e 10. HM21 Contents OUT SEPARATE FORM FOR EA~' .,.~NK) FOR EACH SECTION, CHECK ALL APPROI:r~rlATE BOXES ( ) Vaulted ( ) Jacketed ( ) Double-Wall ( ) Single-Wall ( ) Stainless Steel ( ) Unknown Tank Fiberglass-Reinforced Plastic Other (Describe).' ..... ( ) Fiberglass-Clad S~el Capacity (Gallons) Manufacturer 25~000 0..~- ( ) Lined Vault ( ) None ( ) Unknown' Manufacturer: 0,.,o, ~.- ( ) Material Thickness (Inches) Capacity (Gallons) Tank Interior Lining (X) Unlined ( ) Unknown ( ) Lined (describe). Tank Corrosion Protection ( ) Galvanized {K) Fiberglass-Clad ( ) Polyethylene/Vinyl (Wrapped or Jacketed) ( ) Tar or Asphalt ( ) Unknown ( ) None ( ) Other (describe): Cathodic Protection:. ( ) None ( ) I~m~ressed Current System ( ) Sacrificial Anode System Describe System and Equ!pment: Leak Detection, Monitoring, and Interception * (Must be described below) a. Tank: ( ) Vapor Detector * 0q Liquid Level Sensor * ( ) Conductivity Sensor * ( ) Vadose Zone Monitoring Well(s) ( ) U-Tube with Liner ( ) U-Tube without Liner ( ) Visual Inspection (Vaulted tanks only) ( ) Groundwater Monitoring ( ) Sensor in Annular Space ( ) Vapor (X) Liquid ( ) Pressure ( ) other * ( ) Regular Monitoring of U-Tube, Monitoring Well or Annular Space ( ) Daily Gauging & Inventory Reconciliation . ( ) Periodic Tightness Testing ( ) None ( ) Unknown ( ) Other bl¥~,'os¥o.~c, f~,,,,ta..- .~f,,~.. ,,no,,,[~,; · Describe Make & Model: O,.,,t,,~ ~o,.,:.,~ /~,,~ [0 b. Piping: ( ) Flow-Restricting Leak Detector(s) for Pt~urized Piping* ( ) Sealed Concrete Raceway ( ) Monitoring Sump with Raceway (~g~/~:omplete Containment Liner with Sumps ( ) _Half-Cut Compatible Pipe Raceway ( ) Synthetic Liner Raceway ( ) None ( ) Unknown ( ) Other · Describe Make & Model: O,-.~,.s (~,,,,,;,,~/'~10 s~,,~,,...~ (),/... ~,,,,,~o.c~ ~_/ Tank Tightne~ -' P.~ ~ Has This Tank Been Tightness Tested? ( ) Yes ( ) No ( ) Unknown Date of Last Tightness Test CJpon ~Je Uoe,-~, Results of Test Test Name Testing Company Tank Repair ( ) Yes ( ) No ( ) Unknown Date(s) of Repair(s) Describe Repairs Overfill Protection (Must describe below) ( ) Operator Fills, Controls, & Visually Monitors Level ( ) Tape Float Gauge ( ) Float Vent Valves( ) Auto Shut-Off Controls ( ) Capacitance Sensor 0C) Sealed Fill Box ( ) None ( ) Unknown ( ) List Make. &_. Model for all Devices O[~w' ~ '~- t~OO *Describe other Protection System Piping a. Underground Piping: OO Yes ( ) No ( ) Unknown ' Material Thickness (inches) Diameter Manufacturer be ( ) Other * Type of piping System~. F0n~oS.~.~.,~e ~, ~ 0' ( ) Pressure 00 Suction (~) Gravity Approximate Length of this Pipe Run2.. 'tS" do Underground Piping Corrosion Protection: () Galvanized 2. ~ Fiberglass-Clad ( ) Polyethylene Wrap ( ) Electrical Isolation ( ) Unknown ( ) None Underground Piping, Secondary Containment: :2. ~) Double-Wall ~, (~ Synthetic Liner Sy. stem ( ) Make & Model (describe): 5,,~ Impressed Current( ) Sacrificial Anode Vinyl Wrap ( ) Tar or Asphalt Other (describe):. '( ) None ( ) Unknown ....... ~.; j~..., .......... . ....... . ........... CON~RfiC ~.B..S ~S~E~I~E~E. ~ ~ ............... , .......... ~ ,~ ..... . ,, ; ,,., ~ ~. ..... ., , ,, , .-, - ,,,,.l~ ..~ J,~,,~Eff~il~,;Jl:= ~ r', ~:~ ANX ..,.CHANGE., OF :,',BUSINESS.-~, I ~.~.~';~71~,"~"~:'~ ~ ,~ 't . · ~ ~j~ ! ~ , .. ~~ ~ ' 't -t~,..,~ ....... .~ ~,.'~v~.~ ~ ~ · · . ~ ,~'~.' .". ............. , ...... t ~' . . ~m .... ...~ · ,' A ~ ' '-~..' ,. ~': '.' '~,~ , ¢ ~ ~,~ '; - t~' ' .." ~ .",.- ~-.,~ '~ '~ .. , STATE OF CALIFORNIA DIVISION OF OCCUPATIONAL SAFEIq'AND HEALTH "~ ...... P~mit I~u~ To ~'.:. (InsO,.Employer's Name, Address ana Tolephono NOO...;..':~-: Ng'-Ub4Z4U No. · ':,:;.'.:.:~'~.i.-Pursuant to Labor Code ..,~ions 6500 and..6502,' ~is Permit is i.~ued to the above-named emPlOyer for ~e proje~ de~ribed below..'~ "-::-~'~.¢'::/' T:~ '~ . .' '..:' · ~'- · :~': Date Janu ,a~; 5, 1 990 - Region 2-No~C~o~ ''''' .' ' District 6-BakerSfield · Tel. (805~ -395.:2718 i..,... ~ of Pm~ ~ Add~ ~ ~ C~ Sm~ C~ ~S ~~S 1 2-31-90 e This Permit is issued upon the following conditions: 1. That the work is performed by the same employer. If this is an annual permit the appropriate District Office shall be notified, in ,writing, 'of dates and location of job site prior to commencement, That employer will comply with all occupational safety and health standards or orders :ap- plicable to the above projects, and any other lawful orders of the Division. That if any unforeSeen .condition causes deviation from the Plans, or statements contained in the Permit Application FOrm the employer"will r~otify the Division immediately. .:'." ' Any variation .from the specification and assertions of the Pei~mit Application Form or violation ..~:'-~ ?~i'i:" .~. of safety orders may be cause to revoke the'permit. " .. ' .:i~L. i,i:" ;',',.'-'-, '5..This permit shall be'posted at or near each place of employment as provided in 8 CAC 341.4~ ' _...;.;-. J. Ashlock I M. Troutman Investigated b~anu / ". -' ][] c~ [ $100.00 1-5-90 I Ewtom oex~,~-o~m ~smc~ co,-~w Approved by ary ~' A~ COFY---CANA~Y REGION :7,--,-.,: L .,, HARRY'S PLUMBING SERVICE P.O. BOX 6386 BAKERSFIELD, CALIFORNIA 93386 HP$ Inc. '~ Safe Practices and Operations Code (805) 324-2121 General 1. All' persons shall follow these safe practices rules, render every pos.sible aid to safe operations, and report all unsafe conditions or practices to the proper authority. 2. Foremen shall insist On employees observing and obeying every rule, regulation, and order as is'necessary to the safe conduct of the work, and shall take'such action as is necessary to obtain' observance. 3. All employees shall be given frequent accident prevention instructions. Instructions should be given at least once a month. 4. Anyone known to be under the influence of intoxicating liquor shall not be allowed on the job while in that condition. '5. Horseplay, scuffling, and other acts which tend to havean adverse influence on the safety or well-being of the employees are prohibited. 6. Work shall be Well planned and supervised to forestall injuries in the handling of heavy materials and in working together with equipment. 7. No one shall knoWingly be permitted or required to work while his ability or alertness is so impaired by fatique, illness, or other causes that it might unnecessarily expose him or others to injury. 8. Employees shall not enter manholes, underground vaults, chambers, tanks, Silos, or other similar places that receive little vmSlation, unless it has been determined that the air contains no flammable or toxic gases or vapors. Ventilate thoroughly, if no means of testing is available. 9. Employees should be alert to see that all guards and other protective devices are in proper .places and adjusted,' and Shall report deficiencies promptly to the foreman or superintendent. 10. Crowding or pushing when boarding or leaving any vehicle or other conveyance is prohibited. 11. Workers shall not handle or tamper with any electircal equipmen%, machinery, Or air, water, Or gas lines in a manner not within the scope of their duties, unless they have received instructions frOm their foreman. 12. All injuries shall be reported promptly to an authorized representative of the employer, so that arrangements can Be made for medical or first aid treatment. e HARRY'S PLUMBING SERVICE P.O. BOX 6386 BAKERSFIELD, CALIFORNIA 93386 . (805) 324-2121 13. When lifting heavy.objects, use the large muscles Of the leg instead of the smaller muscles of the back. · 14. Shoes with thin or badlY worn soles shall not be worn. 15. Do nOt throW material, tools, or other objects from build- ings or Structures until proper precautions are taken to protect others from the falling object hazard. 16. Wash thoroughly after handing injurious or poisOnous sUb- stances, and follow all special instructions from authorized sources regarding this matter. Hands should be thoroughly cleaned just Crior to eating, if they have been in contact with paint or.similar substances.' 17. Hod carriers should avoid t'he use of extension ladders when carrying loads..Such.ladders may provide adequate strength, but the rung position and rope arrangement make such climbing dufficult and hazardous for this trade. 18. Arrange work so that You are able to face ladder and use both hands while climbing. 19. Gasoline Shall not be used for cleaning purposes. 20. No burning, welding, or other source of ignition shall be applied to any enclosed tank or vessel, even if there are some openings, until it has firSt been determined that no possibility of explosion exists, and.authoritY for the work is obtained from the employer's represetative. 21. Any damage to scaffolds, falsework, or other s'uppOrting structures' must be repaired or reported promptly to the fOreman. 'Use of Tools and Equipment 22. Keep faces of hammers in good condition to avoid flying nails and brui.sed fingers. 23 HOld cold chisels in such a way that the knuckles will be protected if the hammer misses the head. Chisels struck bY others should be held by tongs or similar hol. ding devices. 24. Do not Use pipe or Stilson Wrenches as a substitute for other wrenches. 25. Wrenches should not be altered by the addition of handle- extensions or "cheaters." 26. Files sh~ll'be equipped with handles. Never use a file as a punch or pry. ' 27. Do nOt use a screwdriver as a chisel. 28. Keep handsaws sharp. HARRY'S PLUMBING SERVICE P.O. BOX 6386 BAKERSFIELD, CALIFORNIA 93386 (805) 324-2121 29. Do not push wheelbarrow with handles in an upright position. 30. Do not'lift or lower portable electric tools by means of the power cord. Use a r°pe. 31. Do not leave the cords of portable electric tools Where cars or trucks will run over them. 32. In locations where the handling of a portable power tool is a problem, try hanging it from some stable object, by means of a rope or similar s. upport of adequate strength. Machinery and Vehicles 33. Do not attempt to operate machinery or equipment without special permission, Unless that is one of your regular duties~ 34. Loose or frayed clothing, dangling ties, finger rings, etc.,. shall not be worn around moving machinery or other sources of entangle- ment. 35. Machinery shall not be repaired or adjusted while in operation, nor shall oiling of moving parts be attempted, except on equipment that is designed or fitted with safeguards to protect the person performing the work. 36' Do not work under vehicles supported by jacks or chain hoists, without protective blocking that will prevent injury if jacks or hoists should fail. 37. Air hoses should not be disconnected at compresSors until hose line has been bled. 38. Examine excavation befombackfilling, so as to be positive no one is in it~~ 39. Be sure no one is~below, before operating excavating equipment near tops of cut, banks, and cliffs. 40. OPerations of tractors, bulldozers, and carryalls~should be handled with care where there is possibility of overturning in dangerous areas like edges of deep fill, cut banks, and steep 'slopes. Trenching Operations 41~ Never start trenching without first calling USA, and giving them 48hrs. notice. 42. ~Never start trenching without a OSHA permit. 43. All trenchers shall be eXcavated in a safe manner. 44.' If trenches ~re dug that require shoring, shoring shall be installed in a manner where no employees are ever in an unsafe trench. 45. Special care shall be used in placing compactors in the bottom HARRY'S PLUMBING SERVICE P.O. BOX 6386 BAKERSFIELD, CALIFORNIA 93386 (805) 324-2121 of the trench. 46. The trench shall be kePt safe during the backfill operations. 47. A safe trench will be defined as per CAL-OSHA standards. 48. Limit man h'Ours in trenches where p°ss~ble. 49..Always 'assume 'that the trench might fail and have a~n emer- gency plan in'mind. 50. Always inform somebodY else prior to entering a trench~ · 51. Trenches are not the place to take breaks or eat lunches. 52. Avoid oVerhanging trenches. Tim Ashlock ~HANK YOU~ ' ' STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE RF~FIVED MARK ONLY '~ 1 NEW PERMIT [] 3 RENEWAL PERMIT [] 5 CHANGE OF INFORMATION [] 7 PERMANENTLY CLOSED SITE ONE ITEM 'E:3 2 INTER,M PERMIT ~ 4 ~E.DEO.ERM,T [] 6 TEM.O.ARY S,.~ CLOSURE {#AY~ 0 8 1992 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) H.,8,.Z E,'I~.T. DIV. DBA OR FACILITY NAME NAME OF oPERATOR AJ~DR'~SS / '' / ...... NEA'~EST CP~SS S'T'R~ET [ ' PARCEL # (OPTK)NAL) Cl'¢f NAME '-- ~ STATE - '-ZIP CODE ' - ~' SITE PHONE # WITH AREA CODE ~COR~RATION ~ INDIVIDUAL ~ P~TNERSHIP ~ L~AL-AGENCY ~ COU~Y-AGE~Y ~ STATE-AG~CY ~ FEDE~LAGE~Y TO INDICATE D~TRICTS ~PE OF BUSINESS~ 1GASSTATION3 FARM ~ ~ 42 DISTRIBUTORpR~ESSOR~ 5 OTHER I~ORRESERVATIONTRUSTV IF INDIAN I'O~KS AT SiTE]L~DS ' E.P,A. I.D.,(~ti~al) EMERGENCY CONTACT PERSON (PRIMARY) tDAYS:NAME ([:AST, FIRST) ~IGHTS: N~~ PHONE # WITH AREA CODE PHONE ~ WITH AREA CODE~' EMERGENCY CONTACT PERSON (SECONDARY) - optional IDA.Y~::~ NAME(LA?T, FIRST)T)~ ~- P~ONE # WITH AREA CODE ~IG~TS: NAME (L~T, FI~S - PHONE ~ WITH AREA CODE -- I1.-, PROPERTY OWNER INFORMATION - {MUST BE COMPLETED) INAM[ MAILING OR S~TREET ADDRESSr CARE OF ADDRESS INFORMATION · ,/' box to indicate I---] INDIVIDUAL E~ LOCAL-AGENCY E~] STATE-AGENCY ,~CORPORATION {----[ PARTNERSHIP [~ COUNTY-AGENCY ~ FEDERAL-AGENCY STATE ZIP CO.DE PHONE # V~ITH AREA CODE Ill. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER ~ M ~.l ~'l hJ'G*~'d~J"S~-F~ E T ADD',Ri[:s S ~' .... lCARE OF ADDRESS INFORMATION v" box to indicate ~ INDIVIDUAL ~ LOCAL-AGENCY ~ STATE-AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739-2582 if questions arise, TY (TK)HO V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to lhe lank owner unless box I or II is ch~cked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: T~a~~BEEN COMpliED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICA~S.J~~D ~GNAT~ I APPLICANT'S TITLE I DATE MONTI;I/DAY/YEAR I I LOCATION CODE - OPTIONAL C~S~T# - 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 (9-90) FORO033A-R2 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 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: ~/~F~_~(~ V' I, TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN C. DATE INSTALLED (MO/DAY/YEAR) II. TANK C,ON'TENTS IF A-1 IS MARKED, COMPLETE ITEM C, ~ [] 2 .EtROLEUM [] 90 EMPTY OUCT [] ,bPREM,UM [] 7 METH*.OL 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 CONS~T~N MARKONEITEMONLYINBOXESA, B, ANDC, ANDALLTHATAPPLIESINBOXD A. TYPEOF ~J 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 [~FIBERGLASS [] 6 POLYVlNYL CHLORIDE [] 7 ALUMINUM [] 10 GALVANIZED STEEL [] 95 UNKNOWN ] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ] 8 100=/o METHANOL COMPATIBLE W/FRP ] 99 OTHER ~ 2 ALKYD LINING [] 1 RUBBER LINED ~ I I 3 EPOXY LINING C, INTERIOR [] 5 GLASS LINING ~6 UNLINED [] 95 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES__ NO__ D. CORROSION [] 1 POLYETHYLENE WRAP [] 2 COATING [] 3 VINYL WRAP PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE [] 95 UNKNOWN ] 4 PHENOLIC LINING ] 99 OTHER [~ FIBERGL.~S REINFORCED PLASTIC [] 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE /~(~'~l SUCTION A U 2 PRESSURE A U 3 GRAVITY OTHER B. CONSTRUCTION C. MATERIAL AND CORROSION PROTECTION D. LEAK DETECTION SINGLE WALL /~2 DOUBLE WALL A IJ 3 LINED TRENCH A IJ 95 UNKNOWN A U 99 OTHER BARESTEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A~)4 FIBERGLASS PIPE ALUMINUM A I.I 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100=/o METHANOL COMPATIBLEW/FRP ALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN ~. A U 99 OTHER TOMATIC LINE LEAK DETECTOR {~ 2 LINE TIGHTNESS TESTING ~STITIALMoNrTORiNG [] 99 OTHER V. TANK LEAK DETECTION ...,,, [] 1 vISUAL CHECK ~ 2~.,[NVENTORY RECONCILIATION [] 3 VAPOR MONITORING ~AUTOMATIC TANK GAUGING [] 5 GROUNDWATER MONITORING [] 6 TANK TESTING[~7 INTERSTITIAL MONITORING [] 91 NONE [] 95 UNKNOWN [] 99 OTHER VI. TANK CLOSURE INFORMATION I 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES SUBSTANCE REMAINING GALLONS INERT MATERIAL ? I I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ) APPLICANT'S NAME I DATE I (PRINTED & SIGNATURE) LOCAL AG ENCY USE ONLY THE STATE I.D, NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # STATE I.D.# TANK # FORM B (9-9O) PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - 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 B MARK ONLY [~ NEW PERMIT COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ] 3 RENEWAL PERMIT ~] 5 CHANGE OF INFORMATION [] 7 PERMANENTLY CLOSED ONSITEI ] 8 TANK REMOVED I ONEITEM [] 2 INTERIM PERMIT [] 4 AMENDED PERMIT [] 6 TEMPORARY TANK CLOSURE I. TANK DESCRIPTION COUPLETE ALL ~TEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.~ ~ B. MANUFACTURED II. TANK CO~TE~S ~F A-1 ms MARKED. COMPLETE ITEM C. [~1 PRO UNLEADED [~] 4 GASAHOL [] 2 PETROLEUM [] 80 EMPTY DUCT [] lb PREMIUM [] 7 METHANOL UNLEADED [] 5 JET FUEL [] 3 CHEMICAL PRODUCT [] 95 UNKNOWN [] 2 WASTE [] 2 LEADED [~] 99 OTHER (DESCRIBE IN ITEM D. BELOW D. IF IA.l) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. #: III. TANK CONSTRUC,,T..~N MARKONEITEMONLYINBOXESA, B, ANDC, ANDALLTHATAPPLIESINBOXD A. TYPE OF ~"'~l DOUBLE WALL SYSTEM [] 2 SINGLE WALL B. TANK [] 1 BARE STEEL MATERIAL [] 5 CONCRETE (PrimaryTank) [] 9 BRONZE ] 3 SINGLE WALL WITH EXTERIOR LINER [] 4 SECONDARY CONTAINMENT (VAULTED TANK) [~ 2 STAINLESS STEEL ~*~'~'B~RGLASS ] 6 POLYVlNYL CHLORIDE [] 7 ALUMINUM [] 10 GALVANIZED STEEL [] 95 UNKNOWN ] 95 UNKNOWN ] 99 OTHER ] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ] 8 100% METHANOL COMPATIBLE W/FRP ] 99 OTHER [] 1 RUBBER LINED [~~ LINING [] 3 EPOXY LINING c. INTERIOR [] 5 GLASS LINING bj~'~6 UNLINED [] 95 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES_ NO__ D, CORROSION [] 1 POLYETHYLENE WRAP [] 2 COATING [] 3 VINYL WRAP PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE [] 95 UNKNOWN ] 4 PHENOLIC LINING [] gg OTHER [~'"~-IBERGLASS REINFORCED PLASTIC [] 99 OTHER A U 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEMTYPE A~)l SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALL .~ ~,~ DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN ,~ U 99 OTHER C. MATERIAL AND CORROSION PROTECTION D. LEAK DETECTION A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVlNYL CHLORIDE (PVC)A~)4 FIBERGLASS PIPE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLEW/FRP (VANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN ,----- A U 99 OTHER MATIC LINE LEAK DETECTOR [] 2 LINE TIGHTNESS TESTING~m'~'"~'"~'"~'"~'ERSTITIALMoNPFORiNG [] 99 OTHER V. TANK LEAK DETECTION [], v,suA. C.ECK ,.VENTOR RECONC,L,AT,ON [] 3 VAPOR MON,TOR,NG ' OMAT,O TANK AUG,N [] GROUND WA R MON,TOR,NG VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ~ NO ~ SUBSTANCE REMAINING GALLONS INERT MATERIAL ? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT I APPLICAN'PSNAME I DATE I (PRINTED & SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # FORM B (g-g0) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOROO34B-R4 Mercy Hospital 2215 Truxtun Avenue P.O. B~ 119 B ~ ake, r§field CA 93302 State.Board of Equalization 1020 N Street Sacramento, CA 9427~]> 'lhl,,,I,,h,i,ih,,ll,'h,l,i,,.I