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HomeMy WebLinkAboutBUSINESS PLANHazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF ~PERMIT ON REVERSE SIDE Permit ID #:: 015-000-001903 ROSEDALE PLAZA GROUP LI This permit ia Issued for the following: , 171 Hazardous Materials Plan E] Underground Storage of Hazardous Materials · '. [] Risk Management Program [] Hazardous Waste On-Site Treatment LOCATION: 7851 ROSEDALE HWY TANK 015-000-001903-0001 GASOLINE GASOLINE 01015'000-001903-00025-000-001903-0003 GASOLINE Issuedby: Bakersfield Fire Department (SFFICE OF ENVIRONMENTAL SER VICES' 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Approved by: (.. ~lpff.,,~, . Office of Ev~Se~vices ~' :?qEkpimtionDate: .., June 30. 2003 Issue Date IGH LEVEL N:~PROACH UGHT O'¥P. OF 7) \ \ \ S Off 12' 16' W 271.11 ~E AREA 2TEL. BOO1HS TP~4SH ENCLUbU~C I I MONITORING WELL Q (TYP. 2 PLCS.) STAGE I VAPOR RETURN ANNULAR SPACE GAUCE (FUTURE 'r'~.)® FILL ,SHUTOFF~ SWITCH AND ~TI:IER-PROOF-OUTI~ PER UFC REQUIREMENTS ! FUTURE VENT &: STAGE II RECOVERY (1YP.) TURBINE (3) 2"' DIA. BLACK STEEL VENT RISERS WRAPPED TO GRADE. P&INT TO MATCH sITE CONDITIONS ~ISLAND BUMPER. POST 4 PLCS.) PIC BUMPER POS1 (TYP. 12 PLCS.) VEEDER ROOT ALARM MON~OR.-' SYSTEM :- NEW AM/PM FACILITY (999~. SINGLE HOSE PER SIDE BLENDING 5 PRODUCT MPD) RISE ACTIVE SIPHON NOTE: LOCATE TELEPHONE NR AND WATER AWAY FROM TANKER UNLOADING OPERATION PER. DISTRIBUTION I.ANO~E ARF_A LANDSCAPE AREA p~OposED EASE I I I I -`~ ROSEDALE PLAZA GROUP LLC Manager VICTOR J SUPERTINO Location: 7851 ROSEDALE HWY City BAKERSFIELD SiteID: 015-021-001903 BusPhone: (661) 588-0557 Map 102 CommHaz Moderate Grid: 28A FacUnits: 1 AOV: CommCode: KCFD STA 65 EPA Numb: SIC Code:5541 DunnBrad: Emergency Contact / Title Emergency Contact / Title VICTOR J SUPERTINO / OWNER/MANAGER VICTOR A SUPERTINO / ASST MANAGER Business Phone: (661) 588-0557x Business Phone: (661) 588-0557x 24-Hour Phone (661) 301-2132x 24-Hour Phone (661) 331-7963x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth Contact VICTOR J SUPERTINO Phone: (661) 588-0557x MailAddr: 78.51 ROSEDALE HWY State: CA City BAKERSFIELD Zip 93308 Owner ROSEDALE PLAZA GROUP LLC Phone: (661) 588-0557x Address 7851 ROSEDALE HWY State: CA City BAKERSFIELD Zip 93308 Period to TotalASTs: - Gal Preparers TotalUSTs: = Gal Certif ~ d: RSs : No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG U - UST Uused or my inquiry of those individuals respon:~- !e for etiaining the inforrr~ation, I cerfsfy ave personalh,~ h unt:per penalty of la~~~ that I t ~ exarr~ineci anJ am fa.rniliar ;niith the information sL,bmitted a.rd i?slie'de t!~,e information is true, accurate, a~~ ti~=.fh^'.3te, ~ ~ 0 7-~7r~7 8igna'.~r~ r -- - Date . . ENT°D J U ~ .~ $ 2007 -1- 07/13/2007 F ROSEDALE PLAZA GROUP LLC SiteID: 015-021-001903 ~ - STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: ROSEDALE PLAZA GROUP LLC Cross Street Business Type: Org Type: Total Tanks 3 IndnRes/Trust: No PA Contact: Dsg Own/Oper JIM RAYMOND ALBRITE ICC Nbr: PROPERTY OWNER INFORMATION Name VICTOR 'A 'SUPERTINO Phone: Address: City State: Zip: Type CORPORATION TANK OWNER INFORMATION Name VICTOR A~SUPERTINO Phone: Address: City State: Zip: Type CORPORATION (661) 588-0557x BOE UST Fee# Financ'1 Resp: STATE FUND Legal Notif Business Mailing Address Date:07/20/1999 Phone: (536) 657- x Name:VICTOR J SUPERTINO Tt1:OWNER/MANAGER State UST ## 1998 Upg Cert#: 00794 (661) 588-0557x -2- 07/13/2007 'L~ F ROSEDALE PLAZA GROUP LLC SiteID: 015-021-001903 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCPI UNLEADED GASOLINE L 20000.00 GAL Mod UNLEADED GASOLINE L 12000.00 GAL Mod PREMIUM UNLEADED GASOLINE L 10000.00 GAL Mod CARBON DIOXIDE F P IH G 300.00 FT3 Min -3- 07/13/2007 :,y -4- 07/13/2007 F ROSEDALE PLAZA GROUP LLC SiteID: 015-021-001903 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME UNLEADED GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: UST CAS# 8006-61-9 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TMixture T Ambient ~ Ambient ~ER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 20000.00 GAL 20000.00 GAL 9000.00 GAL t1F~G.'~tC1J V u 5 1, V1~lY V1V L" 1V 15 %Wt. RS CAS# 100.00 Gasoline No 8006619 tiHGF~KL F~J JL' J.~1~1~1V 1J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod ~ Inventory Item 0002 COMMON NAME / CHEMICAL NAME UNLEADED GASOLINE Location within this Facility Unit UST SPLIT TANK STATE TYPE PRESSURE Liquid TMixture ~mbient Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8006-61-9 TEMPERATURE CONTAINER TYPE Ambient -~ UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average ;~, ~ 12000.00 GAL 12000.00. GAL ' 9000.00 GAL I1HGti[CLVUJ l.Vl"lYV1VP~1V15 %Wt. RS CAS# 100.00 Gasoline No 8006619 I31iGtiKL HD .71=+.7.71~1L~1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod -5- 07/13/2007 .. .~~; F ROSEDALE PLAZA GROUP LLC ~ Inventory Item 0003 COMMON NAME / CHEMICAL NAME PREMIUM UNLEADED GASOLINE Location within this Facility Unit UST SPLIT TANK STATE TYPE PRESSURE Liquid TMixture~ Ambient SiteID: 015-021-001903 ~ Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8006-61-9 TEMPERATURE CONTAINER TYPE Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average ~~ 10000.00 GAL' 10000.00 GAL 9000.00 GAL t1E1Gt~ttUV U 7 1:V1~lYV1V151V 1 7 %Wt. RS CAS# 100.00 Gasoline No 8006619 t1AGKKL 1~S S L' ~ ~1~1L' 1V'1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod ~ Inventory Item 0004 COMMON NAME / CHEMICAL NAME CARBON DIOXIDE Location within this Facility Unit STATE TYPE PRESSURE Gas _ TPure ~ Ambient Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 124-38-9 TEMPERATURE CONTAINER TYPE Ambient FIXED PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 300.00 FT3 300.00 FT3 300.00 FT3 HAZARDOUS COMPONENTS ~Wt. RS CAS# 100.00 Carbon Dioxide No 124389 IIHGHKL H JJ1;~51~1~1V-1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Min -6- 07/13/2007 a -. ~l~ ROSEDALE PLAZA GROUP LLC SiteID: 015-021-001903 Manager VICTOR J SUPERTINO Location: 7851 ROSEDALE HWY City BAKERSFIELD BusPhone: (661) 588-0557 Map 102 CommHaz Moderate Grid: 28A FacUnits: 1 AOV: CommCode: KCFD STA 65 EPA Numb: SIC Code:5541 DunnBrad: Emergency Contact j Title Emergency Contact / Title VICTOR J,SUPERTINO / OWNER/MANAGER VICTOR A SUPERTINO / ASST MANAGER Business Phone: (661) 588-0557x Business Phone: (661) 588-0557x 24-Hour Phone (661) 301-2132x 24-Hour Phone (661) 331-7963x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth Contact ~ ~~~~N~;' Phone: (661) 588-0557x MailAddr: 7851 ROSEDA E HWY State: CA City BAKERSFIELD Zip 93308 Owner ROSEDALE PLAZA GROUP LLC Phone: (661) 588-0557x Address 7851 ROSEDALE HWY State: CA City BAKERSFIELD Zip 93308 Period ~ TotalASTs: = Gal Preparers- _ ,, ~ TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG U - UST R ~~ ~ ~ 6 ~00~ ~P ~~ EN Based on my inquiry of th~is~ Ir;~ivir~uals he ir~ft~rr~ation, I certify respansibt~ fnr ~btn~na~~1 t w that I have personally . l a under ponrtlty o examined anti am f~ar,"Iliar with the information submitted and `:liev~ the information is true, ac ,~r te, any' corn a"ate. ,/~ /~li r9 _ ~-- Signatur , Date -1- 02/06/2007 --- r n ,~ F ROSEDALE PLAZA GROUP LLC SitelD: 015-021-001903 ~ STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: ROSEDALE PLAZA GROUP LLC Cross Street Business Type: Org Type: Total Tanks 3 IndnRes/Trust: No PA Contact: Dsg Own/Oper JIM RAYMOND ALBRITE ICC Nbr: PROPERTY OWNER INFORMATION Name VICTOR A SUPERTINO Phone: Address: City State: Zip: Type CORPORATION TANK OWNER INFORMATION Name VICTOR A SUPERTINO Phone: Address: City State r Zip: Type CORPORATION BOE UST Fee# Financ'1 Resp: STATE FUND Legal Notif Business Mailing Address (661) 588-0557x Date:07/20/1999 Phone: (536) 657- x Name:VICTOR J SUPERTINO Tt1:OWNER/MANAGER State UST # 1998 Upg Cert#: 00794 (661) 588-0557x -2- 02/06/2007 ?' F ROSEDALE PLAZA GROUP LLC SiteID: 015-021-001903 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP UNLEADED GASOLINE L 20000.00 GAL Mod UNLEADED GASOLINE L 12000.00 GAL Mod PREMIUM UNLEADED GASOLINE L 10000.00 GAL Mod CARBON DIOXIDE F P IH G 300.00 FT3 Min -3- 02/06/2007 -4- 02/06/2007 ~. ; F ROSEDALE PLAZA GROUP LLC SiteID: 015-021-001903 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME UNLEADED GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: UST CAS# 8006-61-9 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TMixtur~Ambient ~ Ambient ~ UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 20000.00 GAL 20000.00 GAL 9000.00 GAL - rLti~titcL~ua ~~Lnr~iv~lvl~ oWt. RS CAS# 100.00 Gasoline No 8006619 tiHGH.KIJ HJ a L' .7.71~LL" 1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards 'NFPA USDOT# MCP No No No No/ Curies / / / Mod ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME UNLEADED GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: UST SPLIT TANK CAS# 8006-61-9 Liquid TMixture Ambient~E ~ AmbientT~E UNDER GROIINDRTANKE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 12000.00 GAL 12000.00 GAL 9000.00 GAL HAZARDOUS COMPONENTS %Wt. RS CAS# .100.00 Gasoline No 8006619 riHGt1K1J EiJ~7~~JL~L~1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod -5- 02/06/2007 T i F ROSEDALE PLAZA GROUP LLC SiteID: 015-021-001903 ~ ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME PREMIUM UNLEADED GASOLINE Days On Site 365 Location within this Facility~Unit Map: Grid: UST SPLIT TANK CAS# 8006-61-9 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TMixture ~ Ambient ~ Ambient ~ UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 10000.00 GAL 10000.00 GAL I 9000.00 GAL HAZARDOUS COMPONENTS %Wt. RS CAS# 100.00 Gasoline No 8006619 IIHGHKL 1~.7 .725.7.71~1L' 1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod ~ Inventory Item 0004 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME CARBON DIOXIDE Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 124-38-9 ~GasATE TPureE -~mbRient~E ~ AmbientT~E FIXEDOPRESSERCYLINDER AMOUNTS P,T THIS LOCATION Largest Container Daily Maximum I Daily Average 300.00 FT3 300.00 FT3 300.00 FT3 •aszc~n.lc.uv~w~ ~.vl•lrvlv~ly 1.7 %Wt. RS CAS# 100.00 Carbon Dioxide No 124389 rlt'1[~CiRL tiw 7 JLiJ.71.1L' 1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Min -6- 02/06/2007 ROSEDALE PLAZA GROUP LLC AM/PM Manager : VICTOR SUPERTINO Location: 7851 ROSEDALE HWY City : BAKERSFIELD CommCode: COUNTY STATION 65 EPA Numb: SiteID: 015-021-001903 BusPhone: (661) 588-0557 Map : 102 CommHaz : Low Grid: 28A FacUnits: 1 AOV: SIC Code:5541 DunnBrad: Emergency Contact / Title VICTOR J SUPERTINO / OWNER/MANAGER Business Phone: (661) 588-0557x 24-Hour Phone : (661) 301-2132x Pager Phone : (661) 393-7598xHM Emergency Contact / Title VICTOR A SUPERTINO / ASSISTANT MGR Business Phone: (661) 588-0557x 24-Hour Phone : (661) 331-7963x Pager Phone : (661) 587-1457xHM Hazmat Hazards: Contact : ~ ~ ~/ ~0S£'~L~ MailAddr:'~4q~-l--PAR~E City : BAKERSFIELD Fire Press ImmHlth Phone: (661) 588-0557x State: CA Zip : 93304 Owner ROSEDALE PLAZA GROU~ LLC ~ Address : 4~&---PARK-CI-RC-LE~%~ ~D~L~ \'~. City : BAKERSFIELD Phone: (661) 588-0557x State: CA Zip : 93304 Period : Preparer: Certif'd: ParcelNo: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: ii,-~¢0q ~d~~'~' ^°-- Do hereby cer~i~ ~h~ mv~ewed the attached h~ardous ma~s merit plan fo (~~) .... any corrections constitute a ~mplete and agement plan ior my ~adl~y. -1- 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: ROSEDALE PLAZA GROUP LLC AM/PM Cross Street : Business Type: Org Type: Total Tanks : 2 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : VICTOR A SUPERTINO Phone: Address: City : State: Zip: Type : CORPORATION TANK OWNER INFORMATION Name : VICTOR A SUPERTINO Phone: Address: City : State: Zip: Type : CORPORATION SiteID: 015-021-001903 (661) 588-0557x (661) 588-0557x BOE UST Fee# : Financ'l Resp: STATE FUND Legal Notif : Business Mailing Address Date:07/20/1999 Phone: (661) 588-0557x Name:VICTOR J. SUPUTURO Ttl:OWNER/MGR. State UST # : 1998 Upg Cert#: 00794 -2- 05/21/2004 F'~RoSEDALE PLAZA GROUP LLC AM/PM ~ Hazmat Inventory -- MCP+DailyMax Order Hazmat Common Name... GASOLINE GASOLINE GASOLINE CARBON DIOXIDE SiteID: 015-021-001903 By Facility Unit Fixed Containers at Site I SpecHazlEPA Hazardsl Frm DailyMax IUnitlMCP F P IH L L L G 20000.00 GAL Mod 12000.00 GAL Mod 10000.00 GAL Mod 300.00 FT3 Min 3 05/21/2004 F~'ROSEDALE PLAZA GROUP LLC A34/PM ~ Inventory Item 0001 -- COMMON NAME / CHEMICAL NAME GASOLINE ARCO EC UNLEADED Location within this Facility Unit UST SiteID: 015-021-001903 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 8006619 F STATE ~ TYPE PRESSURE Liquid Pure Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 20000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum I 20000.00 GAL Daily Average I 9000.00 GAL %Wt. 100..00 Gasoline HAZARDOUS COMPONENTS IRSI CAS# No 8006619 TSecretNo N~SIBi°HaZNo HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA /// USDOT# IModMCP Ag.Definedl: Ag.Defined5: Ag.Defined8: -- Ag.Definell MISC. LOCAL ~GENCY DATA Ag. Defined2: Ag. Defined3: Ag. Defined6: Ag.Definedg: Ag.Defined4: Ag.Defined7: Ag. Definel0: 4 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM SiteID: 015-021-001903 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: UST TANK DESCRIPTION Tank ID#: 1 Mfr: Trusco Compart Tank: N Installed: 7/1998 Capacity: 20000 Gals No. Of Comparts: Additional Info: Tank Use: MOTOR VEHICLE FUEL Matl Name:GASOLINE TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Corr Prot: FIBERGLASS REINFORCED PLASTIC Spill Cnt : 1998 Alarm Drop Tube : 1998 Ball Float Striker Plate: 1998 Sgl Wall: TANK CONTENTS Petrol Type: REGULAR UNLEADED Cas #: Installed: Installed: : : Fill Tube S/O: 1998 TANK LEAK DETECTION 8006619 Exempt: No Dbl Wall: INTERSTITIAL MONITORING Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -5z 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM SiteID: 015-021-001903 Inventory Item 0001 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : A.O Smith Mtl : FIBERGLASS & : Corr : FIBERGLASS Prot : PIPING LEAK DETECTION UnderGround Piping INTERSTITIAL MONITORING AboveGround Piping AboveGround Piping Installed: 07/21/1998 Date: 07/20/1999 Name:Victor Supertino Prmt Number: 1903 TANK/LINE TEST :' CP CERT. : MANWAY INSP. : UST MONIT. CERT:ll/14/2003 DISPENSER CONTAINMENT Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Ttl:Owner Approved: Yes AGENCY DEFINED Expiration Date: 06/30/2003 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: No Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State License Board: Yes Approved Alternate methods: Date: 07/20/1999 Name:Victor Supertino Ttl:Owner -6- 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM ~ Inventory Item 0002 -- COMMON NAME / CHEMICAL NAME GASOLINE ARCO ED UNLEADED Location within this Facility Unit UST Split Tank SiteID: 015-021-001903 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 8006619 STATE ~ TYPE Liquid ~Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 12000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 12000.00 GAL Daily Average 9000.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS N 8006619 TSecret No HAZARD ASSESSMENTS IRS,BioHazI Radioactive/Amount EPA Hazards No ~ No No/ Curies NFPA /// USDOT# I MCP Mod Ag.Definedl: Ag.Defined5: Ag.Defined8: -- Ag.Definell MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined6: Ag.Definedg: Ag. Defined4: Ag. Defined7: Ag. Definel0: 7 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM SiteID: 015-021-001903 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: UST Split Tank TANK DESCRIPTION Tank ID#: 2 Mfr: Trusco Compart Tank: N Installed: 7/1998 Capacity: 12000 Gals No. Of Comparts: Additional Info: Tank Use: MOTOR VEHICLE FUEL Matl Name:GASOLINE TANK CONTENTS Petrol Type: REGULAR UNLEADED Cas #: TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Corr Prot: FIBERGLASS REINFORCED PLASTIC Spill Cnt : 1998 Alarm Drop Tube : 1998 Ball Float Striker Plate: 1998 Sgl Wall: Installed: Installed: : : Fill Tube S/O: 1998 TANK LEAK DETECTION 8006619 Exempt: No Dbl Wall: INTERSTITIAL MONITORING Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -8- 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM SiteID: 015-021-001903 Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : A.0. SMITH Mtl : FIBERGLASS & : Corr : FIBERGLASS Prot : PIPING LEAK DETECTION UnderGround Piping AUTOMATIC LEAK DETECTORS AboveGround Piping AboveGround Piping Installed: 07/16/1998 Date: 07/20/1999 Name:VICTOR SUPERTINO Prmt Number: 1903 TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:ll/14/2003 DISPENSER CONTAINMENT Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Ttl:OWNER Approved: Yes AGENCY DEFINED Expiration Date: 06/30/2003 STORAGE CONTAINER DATA (UST FORM C) Installer Certified by tank/piping manufacturer: Yes Installation Inspected & Certified by Registered Engineer: No Installation Inspected by Unified Program Agency: Yes Manufacturer's Checklist Completed: Yes Installer Certified by Contractors' State License Board: Yes Approved Alternate methods: Date: 07/20/1999 Name:VICTOR SUPERTINO Ttl:OWNER 9 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM ~ Inventory Item 0003 -- COMMON NAME / CHEMICAL NAME GASOLINE ARCO EC UNLEADED PREMIUM Location within this Facility Unit UST Split Tank SiteID: 015-021-001903 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 8006619 F STATE TYPE PRESSURE Liquid I Pure I Ambient -- TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 10000.00 GAL AMOUNTS AT THIS LOCATION I Daily Maximum I 10000.00 GAL Daily Average 9000.00 GAL %Wt. 100.00 Gasoline HAZARDOUS COMPONENTS  S CAS# N 8006619 TSecretNo RN~oRSBi°HazNo HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA /// USDOT# MCP Mod Ag. Definedl: Ag.Defined5: Ag.Defined8: -- Ag.Definell MISC. LOCAL AGENCY DATA Ag.Defined2: Ag. Defined3: Ag.Defined4: Ag.Defined6: Ag. Defined7: Ag. Defined9: Ag.Definel0: -10- 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM SiteID: 015-021-001903 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: UST Split Tank TANK DESCRIPTION Tank ID#: 3 Mfr: Trusco Compart Tank: N Installed: 7/1998 Capacity: 10000 Gals No. Of Comparts: Additional Info: Tank Use: MOTOR VEHICLE FUEL Matl Name:GASOLINE TANK CONTENTS Petrol Type: PREMIUM UNLEADED Cas #: TANK CONSTRUCTION 8006619 Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Corr Prot: FIBERGLASS REINFORCED PLASTIC Spill Cnt : 1998 Alarm : Drop Tube : 1998 Ball Float : Striker Plate: 1998 Fill Tube S/O: 1998 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING AUTOMATIC TANK GAUGING Installed: Installed: Exempt: No Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -11- 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM SiteID: 015-021-001903 Inventory Item 0003 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : AO SMITH Mtl : FIBERGLASS Corr : FIBERGLASS Prot : PIPING LEAK DETECTION UnderGround Piping AUTOMATIC LEAK DETECTORS AboveGround Piping AboveGround Piping Installed: 07/16/1998 Date: 07/20/1999 Name:VICTOR SUPERTINO Prmt Number: 1903 TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:ll/14/2003 DISPENSER CONTAINMENT Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Ttl:OWNER Approved: Yes AGENCY DEFINED Expiration Date: 06/30/2003 -12- 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM SiteID: 015-021-001903 Inventory Item 0004 Facility Unit: Fixed Containers at Site CARBON DIOXIDE Days On Site CO2 365 Location within this Facility Unit Map: Grid: CAS# 124-38-9 F STATE ~ TYPE Gas {Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE FIXED PRESS. CYLINDER Largest Container I 300.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 300.00 FT3 Daily Average 300.00 FT3 %Wt. 100.00 Carbon Dioxide HAZARDOUS COMPONENTS 1~24389 HAZARD ASSESSMENTS Radioactive/Amount I EPA Hazards No/ CuriesI F P IH NFPA/// { USDOT# Min Ag. Definedl: Ag. Defined5: Ag.Defined8: -- Ag. Definell MISC. LOCAL AGENCY DATA Ag.Defined2: Ag. Defined3: Ag.Defined6: Ag. Defined9: Ag.Defined4: Ag.Defined7: Ag. Definel0: -13- 05/21/2004 ROSEDALE PLAZA GROUP LLC AM/PM Manager : VICTOR SUPERTINO Location: 7851 ROSEDALE HWY City : BAKERSFIELD CommCode: COUNTY STATION65 EPA Numb: BusPhone: Map : 102 CommHaz : Low Grid: 28A FacUnits: 1 AOV: SiteID: 015-02~-001903 (805) 588-0557 SIC Code:5541 DunnBrad: Emergency Contact / Title VICTOR J SUPERTINO / OWNER/MANAGER Business Phone: (805) 588-0557x 24-Hour Phone : (805) Pager Phone : .~05) 33C Hazmat Hazards: Emergency Contact / Title VICTOR A SUPERTINO / ASSISTANT MGR Business Phone: (805) 588-0557x 24'-Hour Phone : (805) ~-7~~7~ Pager Phone : (805) ~ Fire Press ImmHlth Contact : MailAddr: 4301 PARK CIRCLE. City : BAKERSFIELD Phone: (805) 588-0557x State: CA Zip : 93304 Owner ROSEDALE PLAZA GROUP LLC 'Address : 4301 PARK CIRCLE City : BAKERSFIELD Phone: (805) .588-0557x State: CA Zip : 93304 Period : Preparer: Certif'd: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: reviewed the attached hazardous materials manage- . merit plan for7F.,.(,~,o,~~and that ~t along with any corrections constitute a complete and correct man- agement plan for my facility. -1- 11/17/2000 F ROSEDALE PLAZA GROUP LLCAM/PM -- STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: ROSEDALE PLAZA GROUP LLC AM/PM Cross Street : ~ Business Type: 0rg Type: Total Tanks : 2 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : VICTOR A SUPERTINO Phone: Address: City : State: Zip: Type : CORPORATION TANK OWNER INFORMATION Name : VICTOR A SUPERTINO Phone: Address: City : State: Zip: Type : CORPORATION SiteID: 015-021-001903 (805) 588-0557x (805) 588-0557x BOE UST Fee# : Financ'l Resp: STATE FUND Legal Notif : Business Mailing Address Date:07~20~1999 Name:VICTOR J. SUPUTURO State UST # : Phone: (661) 588-0557x Ttl:OWNER/MGR. 1998 Upg Cert#: 00794 = Hazmat Inventory --As Designated Order Hazmat Common Name... ISpecHazl GASOLINE GASOLINE GASOLINE CARBON DIOXIDE One Unified List Ail Materials at Site EPA HazardsI Frm L L L F P IH G DailyMax I Unit I MCP 20000.00 GAL Mod 12000.00 GAL Mod 10000.00 GAL Mod 300.00 FT3 Min -2- 11/17/2000 ROSEDALE PLAZA GROUP LLC AM/PM ~ Inventory Item 0001 -- COMMON NAME / CHEMICAL NAME GASOLINE ARCO EC UNLEADED Location within this Facility Unit UST SiteID: 015-021-001903 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 8006619 F STATE ~ TYPE Liquid/Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 20000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 20000.00 GAL Daily Average 9000.00 GAL 100.00 Gasoline HAZARDOUS COMPONENTS CAS# 8006619 HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA/// I USDOT# MCP Mod ~ Inventory Item 0002 -- COMMON NAME / CHEMICAL NAME GASOLINE ARCO ED UNLEADED Location within this Facility Unit UST Split Tank Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 8006619 STATE TYPE PRESSURE Pure Liquid I Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 12000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 12000.00 GAL Daily Average 9000.00 GAL %Wt. 100.00 Gasoline HAzARDous COMPONENTS N 8006619 HAZARD ASSESSMENTS ITSecretI RS,BioHazl Radioactive/Amount I EPA Hazards No N© ~.No No/ Curies NFPA/// I USDOT# MCP Mod -3- 11/17/2000 ROSEDALE PLAZA GROUP LLC AM/PM ---- Inventory Item 0003 -- COMMON NAME / CHEMICAL NAME GASOLINE ARCO EC UNLEADED PREMIUM Location within this Facility Unit UST Split Tank SiteID: 015-021-001903 Facility Unit: Fixed Containers at Site Map: 'Grid: Days On Site' 365 CAS# 8006619 STATE -- TYPE PRESSURE Ambient Pure Liquid TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 10000.00 GAL AMOUNTS AT THIS LOCATION I Daily Maximum I 10000.00 GAL Daily Average 9000.00 GAL %Wt. I 100'.00 Gasoline HAZARDOUS COMPONENTS 8006619 TSecretINo NoRSIBi°HaZNo HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA I USDOT# MCP ' / / /I Mod ~ Inventory Item 0004 -- COMMON NAME / CHEMICAL NAME CARBON DIOXIDE CO2 Location within this Facility Unit Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 124-38-9 STATE ~ TYPE PRESSURE Ambient Pure Gas -- TEMPERATURE Ambient CONTAINER TYPE FIXED PRESS. CYLINDER Largest Container 300.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 300.00 FT3 Daily AVerage' 300.00 FT3 %Wt. I 100.00 Carbon Dioxide HAZARDOUS COMPONENTS 124389 HAZARD ASSESSMENTS Radioactive/Amount. EPA Hazards No/ Curies F P IH NFPA /// USDOT# Min -4- 11/17/2000 ROSEDALE PLAZA GROUP LLC AM/PM Manager : VICTOR SUPERTINO Location: 7851 ROSEDALE HWY City : BAKERSFIELD CommCode: COUNTY STATION 65 EPA Numb: SiteID: 015-021-001903 BusPhone: (805) 588-0557 Map : 102 CommHaz : Low Grid: 28A FacUnits: 1 AOV: SIC Code:5541 DunnBrad: Emergency Contact / Title VICTOR J SUPERTINO _ / OWNER/MANAGER Business Phone: <~;) 588-0557x 24-Hour Phone : (i~) -~ Phone : ( Emergency Contact / Title VICTOR A SUPERTINO / ASSISTANT MGR Business Phone: (~;~) 588-0557x 24-Hour Phone : (~/) -~.~Phone : (~) Hazmat Hazards: Fire Press ImmHlth Contact : MailAddr: 4301 PARK CIRCLE City : BAKERSFIELD Owner ROSEDALE PLAZA GROUP LLC Address : 4301 PARK CIRCLE City : BAKERSFIELD Phone: (805) 588-0557x State: CA Zip : 93304 Phone: (805) 588-0557x State: CA Zip : 93304 Period : Preparer: Certif'd: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: Do hereby certi~ [hat t have reviewed the attached hazardous ma~eriats manage- men~ plsn tor~nd ~,ha~. ii along any corrections conStitute a compie[e and correc[ man- agement plan for my ~acility. 1 10/31/2000 ROSEDALE PLAZA GROUP LLCAM/PM STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: ROSEDALE PLAZA GROUP LLC AM/PM Cross Street : Business Type: Org Type: Total Tanks : 2 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : '~ ~D~' ~' L~ ~ Phone: Address: City : State: Zip: Type : CORPORATION TANK OWNER INFORMATION Name : ~D~ '~ 6,~,f~ ~---d- Phone: Address: City : State: Zip: Type : CORPORATION SiteID: 015-021-001903 (805) 588-0557x (805) 588-0557x BOE UST Fee# : Financ'l Reap: STATE FUND Legal Notif : Business Mailing Address Date:07/20/1999S~35~o Phone: (661) 588-0557x Name:VICTOR J..~P~dK~ Ttl:OWNER/MGR. State UST # : 1998 Upg Cert#: 00794 = Hazmat Inventory --As Designated Order Hazmat Common Name... ISpecHazI EPA HazardsI Frm GASOLINE L GASOLINE L GASOLINE L CARBON DIOXIDE F P IH G One Unified List Ail Materials at Site I DailyMax IUnitlMCP 20000.00 GAL Mod 12000.00 GAL Mod 10000.00 GAL Mod 300.00 FT3 Min 2 10/31/2000 ROSEDALE PLAZA GROUP LLC AM/PM ---- Inventory Item 0001 -- COMMON NAME / CHEMICAL NAME GAS OL I NE ARCO EC UNLEADED Location within this Facility Unit UST SiteID: 015-021-001903 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 8006619 STATE I TYPE PRESSURE Pure Liquid Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 20000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 20000.00 GAL Daily Average 9000.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS 8006619 HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA I USDOT# I MCP / / / Mod ~ Inventory Item 0002 --= COMMON NAME / CHEMICAL NAME GASOLINE ARCO ED UNLEADED Location within this Facility Unit UST Split Tank Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 8006619 F STATE ~ TYPE Liquid ~Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 12000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 12000.00 GAL Daily Average 9000.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS CAS# 8006619 TSecretINO NoRSIBi°HaZNo HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA /// IUSDOT# I MCP Mod -3- 10/31/2000 ROSEDALE PLAZA GROUP LLC AM/PM ~ Inventory Item 0003 -- COMMON NAME / CHEMICAL NAME GASOLINE ARCO ECUNLEADED PREMIUM Location within this Facility Unit UST Split Tank SiteID: 015-021-001903 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 8006619 F STATE ~ TYPE Liquid /Pure PRESSURE Ambient TEMPERATURE · Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 10000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 10000.00 GAL Daily Average 9000.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS CAS# 8006619 HAZARD ASSESSMENTS I TSecret INo NoRS BioHazINo Radioact ive/Am°unt I EPANo/ Curies Hazards NFPA /// USDOT# MCP Mod ~ Inventory Item 0004 -- COMMON NAME / CHEMICAL NAME CARBON DIOXIDE CO2 Location within this Facility Unit Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 124-38-9 F STATE ~ TYPE Gas ~Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE FIXED PRESS. CYLINDER Largest Container 300.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 300.00 FT3 Daily Average 300.00 FT3 100.00 Carbon Dioxide HAZARDOUS COMPONENTS 124389 TSecretINo No RS I Bi°Haz No HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies F P IH NFPA/// I USDOT# MCP Min 4 10/31/2000 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 1. To avoid further action, return this form within 30 days of r~ei~ 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. SECTION 1: BUSINESS IDENTIFICATION DATA BUSINESS NAME: LOCATION: .7 ~'~ / MAILING ADDRESS: LT/.~ o / CITY: ~ ~O DUN & BRADSTREET NUMBER: PRIMARY ACTMTY: MAILING ADDRESS: {/,:~t9 ! ZIP: ~HONE: SIC CODE:__ ! SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE .,c-gg-a,,s-x- 7 24 tiR. PHONE / HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3: TRAINING NUMBER OF EMPLOYEES: /gQ MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: O,v/' .,v .,',", ?_ c/o,-,,,, SECTION ~4: EXEMPTION REQUEST I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH & SAFETY CODE" FOR THE FOLLOWING REASONS: 'NE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5.' CERTIFICATION I, ~/(c.~e_ ..77, .5~=~-~',,/o CERTIFY THAT THE ABOVE INFORMATION IS ~I~CURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER TI~ "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. '~I:i~,E / DATE ./ HAZARDOUS MATERIALS MANAGE1VEENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES AGENCY NOTIFICATION PROCEDURES: c/ll B. EMPLOYEE NOTIFICATION AND EVACUATION: Co PUBLIC EVACUATION: D. EMERGENCY MEDICAL PLAN: /, ~'~¢r/ ,o-vo ,o.-g ,~q.q_~ e~ 3 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMF~NT PLAN .A. RELEASE PREVENTION STEPS: RELEASE CONTAINMENT AND/OR MINIMIZATION: CLEAN-UP PROCEDURES: SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: ELECTRICAL: WATER: SPECIAL: LOCK BOX: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAIl.ABILITY Ao PRIVATE FIRE PROTECTION: 4 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 HAZARDOUS MATERIALS INVENTORY FACILITY DESCRIPTION CHECK IF BUSINESS IS A FARM [ ] BUSINESS NAME FACILITY NAME SITE ADDRESS '7 $8 CITY ~ ~/X'~-TE?S _~ t e. NATURE OF BUSINESS SIC CODE .q'_q"q/ STATE z~P DUN & BRADSTREET NUMBER PHONE tr~t~' ~ 6-~)~ -0 gg7 EMERGENCY CONTACTS BUSINESS PHONE BUSINESS PHONE ~ 3 I- O qOS'- H~RDOUS MATERIALS INVENTOY CHEMICAL DP. SCRIPTION /r.r.2;age of ~ 2) Common Name: Chemical Name: 4) Physical & Health Hazard Categories. 5) WASTE CLASSIFICATION 1) INVENTORY STATUS: New ~ Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ 3) DOT # (optional) ~vi[ ] c~s# ] Trade Secret [ ] PHYSICAL HEALTH: _ Fire [)C'] Reactive [)~] Sudd_~a Release of Pressure [~] Immediate Health (Acute) ,~] Delayed Health (Chronic) [ (3-digit code from DHS Form 8022) USE CODE /~ 6) PHYSICAL STATE Solid[ ] Liquid [.x/] Gas[ ] Pure[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amotmt Annual Amount Largest Size Container # Days on Site / Lbs[ ] G, al [.,~c'] fi3 [ Cm~ [ ] Circle Which Months: 8) STORAGE CODES a) Contain{u: b) Pressure: c) Temperature ~, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: List the three most hazardous chemical components or any AHM components COIvlPONENT 3) ~_~.l ~,,:~,-z~_.~,~_- CAS// % WT [ ] [ ] [ ] 10)LOCATION / 1) INVENTORY STATUS: New [~Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ 2) Common Name: ~/dd~ ~- L~.A~ /_,,,.,,a.-n ~"-t) ~a'~/,,,r~'" 3) DOT # (optional) Chem/cml Name: (_.,*4L<~ L//v~- t,~,~L'~_~,n~,o ~t~.~/ AHM [ ] CAS # ] Trade se~r~ ( ] 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire [ )ti Reactive [/~] Sudden Release of Pressure [ 3c] Immediate Health (Acute) [,Z] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE / ~ 6) PHYSICAL STATE Solid [ ] Liquid [x~] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container # Days on Site / UNITS OF MEASURE 8) STORAGE CODES Lbs [ ] Gal [ ] ft3 [ ] a) Contain~ Curies [ ] b) Pressure: c) Temperature Circle Which Months: AIl Year, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List the three most b~ardous chemical components or any AHM components COMPONENT l ) '/'~. ,,~ Z ~,~, E 3) L- r/4~l_ ~ ~ 2 ~_ CAS# % wr [ ] [ l [ Business Name I~RDOUS MATERIALS LNVENTI CI~.. ~C~ DESCRIFrION //~;age of__ ) INVENTORY STATUS: New ~],Addition [ ] Revision [ 2) Common Name: ,~0~e,O f_.-~ LOW/~,~/./9~o.o Physical & Health PHYSICAL H~ard Categorie~ Fire [ ~'] Reactive [ ~,] Sodd~ Release of Pres.~u-e [ ,~ WASTE CLASSIFICATION ] Deletion [ ] Cl~ck if chemical is a NON Trad~ S~cret [ ~'~.~,~,z ~. ~ 3) DOT # (optional) /~6A AH~[ ] CAS# ] Trad~ S~-t [ HEALTH Immediate Health (Acute) [J~] Delayed Health (Chronic) [ (3-digit cod~ from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [XS] Cr~ [ ] 7) AMOUNT AND TIME AT FACILrrY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Contain= # Days on Site 9) MIXTURE: List the thr=~ most hazardous chemical components or 10)LOCATION /~9 ~: Oo O Pure[ I Mixture[ ] W~,[ ] UNITS OF MEASURE 8) STORAGE CODES Lb~[ ]Gall ]fl3[ ] a)Containe~. Curi~ [ ] b) h'es.sm'e: c) Temperature Cimle Which Month~: All Year, J, F, M, A, M, J, J, A, S, O, N, D COIVIPONENT 2) 7-,') CAS// % WT AHM [ ] [ ] [ ] ] CheckifchemicalisaNONTradoSecr~[ ]Trad~Secr~[ ] 3) DOT # (optional) 1) INVENTORY STATUS: New [',/q Addition [ ] Revision [ 2) Common Name: /0~,~_) "~ t o ~c, O~ / ] Deletion [ Chemical Name: ama[ ] cAs# 4) Physical & Health Hazard Categori~ Fire [ ] Reactive [ 5) WASTE CLASSIFICATION PHYSICAL HEALTH ] Sudden Relea.m of Pressure [/,X] Immediate Health (Acute) [ . O-digit ~ from DHS Form 8022) USE CODE ] Delayed Health (Chwnic) [ 6) PHYSICAL STATE Solid [ ] Liquid [ ] C~ [~] Pure[ ] Mixt~[ ] 'was~[ ] ~Lioacdve[ ] 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Ann~ Amount . Largest Siz~ Container ~'o-~ e,~ ~4'. # Days on Site 3 UNITS OF MEAS~ 8) STORAGE CODES Lbs[ ]Gal[ ]II3[~Z] a)Containe~. 02 Curie~ [ ] b) Pressure: /. c) Temperature ~, F, M, A, M, J, J, A, S, O, N, D Ch-cie Which Months: 9) MIXTURE: List COMPONENT the three most hazardous 1) ~ ~ ~_, chemical components or 2) any AHM components 3) CAS# % WI' [ ] [ ] [ I