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Home My WebLink AboutBUSINESS PLAN ,-' ' ¡+~.' sm DIAGRAM rxr .. '- > BUIineu Name:~IV.E l~ 1) . T~ DIAGRAM f4] -.. '- . Business Address: .ç- 6 0 c¡ .s I :E /1/ IE JR.. .}) :t t~ ' - I 't ' I ~ <:: l/.) ') ~ . i ~ - , ..-..:::- ,> ~ " ~~~_()Ff LU ~ t E/lI/-: ..f# ~~~ W æ ~ V) ~ ~ J ~ u - G-- /i- ~ JIf? U 117 ¡:J Ji3n-¡ ,ER.G-EllleY ðHuT-o'¡:F (j/(J.lIÎ 5):- 'Ju)/Ý' d ~ s;tSYløH \t >t /'II-b!--t.. ~'11/-9 æ, tllýt(J 'tJ --i) )/lfj qj\fJ//l :ì~ ~G è:'~ ?ì~ (j) ,} Ii () ~ ~ \'t\ ~ '~ ~ ~ ]t.j \T\ ~ ~ b ~ 1 -". e It <-'" STINE ROAD TEXACO SiteID: 015-021-001916 Manager : Location: 5609 STINE RD City BAKERSFIELD CommCode: BAKERSFIELD STATION 13 EPA Numb: BusPhone: Map : 123 Grid: 23A (661) 665-2390 CommHaz : Low FacUnits: 1 AOV: SIC Code:5541 DunnBrad: Emergency Contact L0UNG K CHAO Business Phone: 24-Hour Phone : Pager Phone / Title / OWNER (661) 836 - 3766x (661) 393-8828x (661) 319 -8828x Emergency Contact MELISSA CHAO Business Phone: 24-Hour Phone Pager Phone / Title / OWNER (661) 836 -3 766x (661) 393-8828x (661) 319-8828x Hazmat Hazards: Contact : MailAddr: 5609 STINE RD City BAKERSFIELD Phone: State: Zip (661) 665 2~~9-K CA ~3~~37(ò.6 93313 Owner Address City LOUNG K CHAO 5609 STINE RD BAKERSFIELD Phone: (661) 393-8828x State: CA Zip 93313 Period Preparer: Certif'd: Parcel No: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: ~. .kteLtEkJ~ l/, GffA1jo h~~Sb1f C~G1i~ ~~~~ ~ ~~VS (Typa or p~e) rev¡e~ved the attached hazardous materials mai"iag~ ment plan forß1JI\Je tD T.éf/rljjnd tha~ it ~ong with (Name of Busin3ss) any corrections constitute a. rompi~s 2nd oorr®ct man. agement pian 10r my ~acilijy. '7~C(- oc( Daile -1- 07/08/2004 F STINE ROAD TEXACO f= Hazmat Inventory f== MCP+DailyMax Order e -- SiteID: 015-021-001916 By Facility Unit Fixed Containers at Site 9 9 9 DailyMax UnitMCP 12000.00 GAL Mod 8000.00 GAL Mod 4000.00 Low Hazmat Common Name... REGULAR UNLEADED PREMIUM UNLEADED DIESEL Ispec~azlEPA Hazards Frm I L L L -2- 07/08/2004 e e SiteID: 015-021-001916 9 Facili~y Unit: Fixed Containers at Site 9 F STINE ROAD TEXACO f= Inventory Item 0001 = COMMON NAME / CHEMI CAL NAME REGULAR UNLEADED Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 8006-61-9 S11ATE - TYPE Liquid Pure PRESSURE ---- TEMPERATURE Ambient Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 12000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 12000.00 GAL Daily Average 12000.00 GAL HAZARDOUS OMP NEN %Wt. RS CAS # 100.00 Gasoline No 8006619 C o TS HAZARD ASSESSMENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod Ag.Defined1: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag.Defined8: Ag.Defined9: Ag.Define10: ~ Ag .Define11 -3- 07/08/2004 e e SiteID: 015-021-001916 9 Facility Unit: Fixed Containers at Site 9 UST FORM B and AGENCY-DEFINED) Page 1 of 2 F STINE ROAD TEXACO f= Inventory Item 0001 STORAGE CONTAINER DATA Last Action Type: Location In Site: TANK DESCRIPTION Tank ID#: 3 Mfr: TRUSCO Installed: 10/1998 Capacity: 12000 Gals Additional Info: Compart Tank: N No. Of Comparts: Tank Use: MOTOR VEHICLE FUEL Matl Name:REGULAR UNLEADED TANK CONTENTS Petrol Type: REGULAR UNLEADED Cas #: 8006-61-9 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): BARE STEEL Material(s): BARE STEEL Lining : UNLINED Carr Prot: FIBERGLASS REINFORCED Spill Cnt : 1998 Drop Tube : 1998 Striker Plate: 1998 Sgl Wall: PLASTIC Alarm : Ball Float : Fill Tube S/O: 1998 LEAK DETECTION Dbl Wall: INTERSTITIAL MONITORING Installed: Installed: Exempt: No TANK Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -4- 07/08/2004 e -- F STINE ROAD TEXACO SiteID: 015-021-001916 9 f= Inventory Item 0001 Facility Unit: Fixed Containers at Site 9 STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping PRESSURE DOUBLE WALL AboveGround Piping Type : Const: Mfgr : Mtl : & : Corr : Prot : FIBERGLASS PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS Installed: 11/20/1998 Date: 06/21/1999 Name:LOUNG K CHAO Prmt Number: 1916 DISPENSER CONTAINMENT Type: FLOAT MECH. SHUTS OFF SHEAR VAL. OWNER/OPERATOR SIGNATURE Ttl:OWNER Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:04/22/2004 -5- 07/08/2004 e e SiteID: 015-021-001916 ì Facility Unit: Fixed Containers at Site ì F STINE ROAD TEXACO p= Inventory Item 0003 = COMMON NAME / CHEMICAL NAME PREMIUM UNLEADED Days On Site 365 Location within this Facility Unit Split Tank Map: Grid: CAS# 8006-61-9 STATE - TYPE Liquid Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 8000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 8000.00 GAL Daily Average 8000.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS ~ CAS # I 8006619 HAZARD ASSESSMENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod Ag.Defined1: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag.Defined8: Ag.Defined9: Ag.Define10: r- Ag. Define11 -6- 07/08/2004 e e SiteID: 015-021-001916 9 Facility Unit: Fixed Containers at Site ì UST FORM B and AGENCY-DEFINED) Page 1 of 2 F STINE ROAD TEXACO f= Inventory Item 0003 STORAGE CONTAINER DATA Last Action Type: Location In Site: Split Tank TANK DESCRIPTION Tank ID#: 2 Mfr: Trusco Installed: 9/1998 Capacity: 7000 Gals Additional Info: Compart Tank: N No. Of Comparts: Tank Use: MOTOR VEHICLE FUEL MatI Name:PREMIUM UNLEADED TANK CONTENTS Petrol Type: PREMIUM UNLEADED Cas #: 8006-61-9 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): BARE STEEL Material(s): BARE STEEL Lining : UNLINED Corr Prot: FIBERGLASS REINFORCED Spill Cnt : 1998 Drop Tube : 1998 Striker Plate: 1998 Sgl Wall: PLASTIC Alarm : Ball Float : Fill Tube S/O: 1998 TANK LEAK DETECTION Dbl Wall: INTERSTITIAL MONITORING Installed: Installed: Exempt: No Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -7- 07/08/2004 e e ,,' SiteID: 015-021-001916 ì Facility Unit: Fixed Containers at Site ì F STINE ROAD TEXACO f= Inventory Item 0004 == COMMON NAME / CHEMICAL NAME DIESEL SPLIT TANK Location within this Facility Unit Days On Site 365 Map: Grid: CAS# STATE - TYPE Liquid Pure PRESSURE ---- TEMPERATURE Ambient Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 4000.00 AMOUNTS AT THIS LOCATION Daily Maximum 4000.00 Daily Average 4000.00 %Wt. RS CAS# 1,00.00 Fuel Oil No. 1 No 70892103 HAZARDOUS COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Low HAZARD ASSESSMENTS Ag.Definedl: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag.Defined9: Ag.Definel0: Ag.Defined8: I- Ag .Define!1 -9- 07/08/2004 " e e . F STINE ROAD TEXACO SiteID: 015-021-001916 9 f= Inventory Item 0004 Facility Unit: Fixed Containers at Site ì STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: TANK DESCRIPTION Tank ID#: 1 Mfr: Trusco Installed: 10/1998 Capacity: 4000 Gals Additional Info: Compart Tank: N No. Of Comparts: Tank Use: MOTOR VEHICLE FUEL MatI Name:DIESEL TANK CONTENTS Petrol Type: DIESEL Cas #: TANK CONSTRUCTION Type : DOUBLE WALL Material{p): BARE STEEL Material{s): BARE STEEL Lining : UNLINED Corr Prot: FIBERGLASS REINFORCED Spill Cnt : 1998 Drop Tube : 1998 Striker Plate: 1998 S9l Wall: PLASTIC Alarm : Ball Float : Fill Tube S/O: 1998 LEAK DETECTION Dbl Wall: INTERSTITIAL MONITORING Installed: Installed: Exempt: No TANK Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -10- 07/08/2004 · .. e It F STINE ROAD TEXACO SiteID: 015-021-001916 9 f= Inventory Item 0004 Facility Unit: Fixed Containers at Site 9 STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION Piping Type : Const: Mfgr : Mtl : & : Corr : Prot : UnderGround PRESSURE DOUBLE WALL UNKN'OWN FIBERGLASS AboveGround Piping PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS Installed: 11/20/1998 Date: 06/21/1999 Name: LOUNG R CHAO Prmt Number: 1916 TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:04/22/2004 DISPENSER CONTAINMENT Type: DISP. PAN SENSOR w/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Ttl:OWNER Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED -11- 07/08/2004 FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 oH" Street Bakersfield, CA 93301 VOICE (661) 326·3941 FAJ( (661) 395,1349 SUPPRESSION SERVICES 2101 'H" Street Bakersfield, CA 93301 VOICE (661) 326·3941 FAJ( (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 It . May 3, 2001 Mr. Lonng Chao Stine Road Texaco 5609 Stine Road Bakersfield, CA 93313 Dear Mr. Chao: Enclosed, please find the Site and Facility Diagram Instructions packet. When your Hazardous Materials Management Plan and Inventory were submitted it was lacking the diagram portion. Please draw and submit the diagram( s) of your facility by June 8, 2001. The diagram should include the following: 1) 2) 3) 4) 5) 6) 7) 8) name of your business; business address; indicate which direction is North; the cross streets neighboring business addresses (within 300 feet) entrances and exits location of utility shut-off's; location of the nearest fire hydrant; portions of the building protected by automatic sprinkler system; and most importantly the location of the hazardous material(s). 9) If you have any questions, please feel tree to call me at (661) 326-3658. Thank you for your assistance. Sincerely, RALPH E. HUEY, DIRECTOR OFFICE OF ENVIRONMENT AL SERVICES Æ Esther Duran, Accounting Clerk II Office of Environmental Services ED\db Enclosures ~~ C/./ .u~'J (/., - /h7 ()""nl /) <7./ .,., JéPuú~ uie (:/ónl./nu/u?~ ~:¥OP J~(:Jope .%.O/b .JCJ (je./lÚu,'"P' 1" ¡ , --. n"".. "l _ (/ þ'~ l( 'Þ'., '\ e TEXACO FOOD MART SiteID: 015-021-001916 Manager : Location: 5609 STINE RD City BAKERSFIELD BusPhone: Map : 123 Grid: 23A (661) 665-2390 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 13 EPA Numb: SIC Code:5541 DunnBrad: Emergency Contact / Title Emergency Contact / Title LOUNG K CHAO / OWNER MELISSA CHAO / OWNER Business Phone: (661) 836-3766x Business Phone: (661) 836-3766x 24-Hour Phone : (661) 393-8828x 24-Hour Phone : (661) 393-8828x Pager Phone : (661) 319-8828x Pager Phone : (661) 319-8828x . Hazmat Hazards: Contact : Phone: (661) 665-2390x MailAddr: 5609 STINE RD State: CA City : BAKERSFIELD Zip : 93313 Owner LOUNG K CHAO Phone: (661) 393-8828x Address : 5609 STINE RD State: CA City : BAKERSFIELD Zip : 93313 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: One Unified List ì All Materials at Site ì f= Hazmat Inventory p== As Designated Order Hazmat Common Name... SpecHaz EPA Hazards DailyMax MCP GASOLINE GASOLINE DIESEL L L L 12000.00 GAL 8000.00 GAL 4000.00 Mod Mod Low 1,'T-'U"\()~erU~~A~DO hereby certify that I have (Type or print narnø) reviewed the attached hazardous materials manage- ment plan for l e.xACO and that it along with (Namo of Business) any corrections constitute a complete and correct man- agement plan for my facility. ~=~ J - 2. I' 00 Date 10/31/2000 ;- e e F TEXACO FOOD MART p= Inventory Item 0001 = COMMON NAME / CHEMI CAL NAME GASOLINE REGULAR UNLEADED Location within this Facility Unit SiteID: 015-021-001916 ì Facility Uni~: Fixed Containers at Site ì Days On Site 365 Map: Grid: CAS # 8006619 [ ~TA~E I TYPE ~ P~ESSURE ~ TEM~ERATURE I CONTAINER TYPE =Llquld __pure ~mblent ---1 Amblent ~ UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 12000.00 GAL 12000.00 GAL 12000.00 GAL %wt. I 100.00 Gasoline HAZARDOUS COMPONENTS ~ CAS#a006619 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod HAZARD ASSESSMENTS p= Inventory Item 0003 = COMMON NAME / CHEMI CAL NAME GASOLINE PREMIUM UNLEADED Location within this Facility Unit Split Tank Facility Unit: Fixed Containers at Site ì Days On Site 365 Map: Grid: CAS # 8006619 [ ~TA~E I TYPE ~ P~ESSURE ~ TEM~ERATURE -I =Llquld __pure ~mblent ---1 Amblent ~ AMOUNTS AT THIS LOCATION Daily Maximum 8000.00 GAL CONTAINER TYPE UNDER GROUND TANK Largest Container 8000.00 GAL Daily Average 8000.00 GAL %wt. I 100.00 Gasoline HAZARDOUS COMPONENTS CAS # I 8006619 ~ No TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod HAZARD ASSESSMENTS -2- 10/31/2000 e e F TEXACO FOOD MART f= Inventory Item 0004 ¡:::= COMMON NAME / CHEMI CAL NAME DIESEL SPLIT TANK Location within this Facility Unit SiteID: 015-021-001916 1 Facility Unit: Fixed Containers at Site 1 Days On Site 365 Map: Grid: CAS # r ~TA~E T TYPE ~ P~ESSURE I TEM~ERATURE -, Llquld Pure Amblent Amblent AMOUNTS AT THIS LOCATION Daily Maximum 4000.00 CONTAINER TYPE UNDER GROUND TANK Largest Container 4000.00 Daily Average 4000.00 U %Wt. RS CAS # 100.00 Fuel Oil No. 1 No 70892103 HAZARDO S COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Low HAZARD ASSESSMENTS -3- 10/31/2000 e e Employee Notif./Evacuation SiteID: 015-021-001916 ì Fast Format ì Overall Site ì I I I I F TEXACO FOOD MART I p= Notif./Evacuation/Medical ~ Agency Notification I I I Public Notif./Evacuation Emergency Medical Plan -4- 10/31/2000 e e Other Resource Activation SiteID: 015-021-001916 ì Fast Format ì Overall Site ì I I I I F TEXACO FOOD MART I p= Mitigation/Prevent/Abatemt [:: Release Prevention Release Containment I I I Clean Up -5- 10/31/2000 e e F TEXACO FOOD MART I p= Site Emergency Factors r== Special Hazards Utility Shut-Offs SiteID: 015-021-001916 ì Fast Format ì Overall Site ì I 01/14/1999 A) GAS - B) ELECTRICAL - C) WATER - D) SPECIAL - E) LOCK BOX - Fire Protec./Avail. Water 01/14/1999 PRIVATE FIRE PROTECTION - NEAREST FIRE HYDRANT - Building Occupancy Level -6- 10/31/2000 ,."... '^".. e e SiteID: 015-021-001916 ì Fast Format ì Overall Site ì 01/14/1999 F TEXACO FOOD MART I F Training Employee Training HOW MANY EMPLOYEES DO YOU HAVE AT THIS FACILITY???????? DO YOU HAVE YOUR MSDS SHEETS ON FILE????????? GIVE A BRIEF SUMMARY OF YOUR TRAINING PROGRAM: Page 2 I I I Held for Future Use Held for Future Use -7- 10/31/2000 ~6/18/99 .... 13:48 '0'661 326 05i6 BFJ> HAZ-MAT DIV 141 002 ~_40:, e e " CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 CÀe.s,teLA.v.~ - 93301 (661) 326-3979 IREÇ~IVED 1- - Jý{:'~/ 2 ~. 1999 FACILITY INfORMATION / / P¡¡ge _ Of , , '. .:n:~";< ~:.'~ 'J'PÝ.·/"I·-:"~A~C"I~"'~'·'·':"">;""~' 'C"'ATIO' ·N' i:··:' ",' ~.,;.': ",~,:",,;\:.-,,'i;{.~-:';¡:;.~:,;::~··'¡' ',~ ,'.<:<. <',:,....~..<./.,: ~~<.;/.::. ..~-:-~...,...,'~tY.µ~~l... ~ .,~' .....,\-.::.:;.~~::I~,~~;~::?~~(:.~>_\:,I·. ~., , Year Beginning 'cr;J Year Ending FAClLliY JD ¡¡ !O' 3 ''-??2cP sIre ADDRESS 3& 5'"60 CITY _~_ {){53 rJ3' DUN & 106 SIC CODE BRADstReET (4 Digit #) COUNTY 109 OPERATOR PHONE .58'01-~"I 0 10:/ 10:; 105 107 1011 ,c' ';..:'. :," \:'::' ,':,:.:,~:: !;:: \:':~ ,{.~ ';¡ ,. ':>,:, :'~ '¡?t;~~{::i!f~~h:~t;~::~;~:::~!';:/:,-'::)~}~ø~~~\iN'F~~~~t.i~~;€;~:\\~:i{ ~N~;~~'::/}f;;'~j"i::.:~:::·::' ::::'. .::' . .,..,'~ i:-,iF~\:~~;:;1t~{:~~1kg OWNER NAME "1 OWNER PHONE 5. q -:l~07 112 113 STATE C,/h'5 ZIP 03' 'if J 3 116 , ::: '.);,: 'J:~ :i:;~:·{!":;:·:~::::iÞ:T,';:r(i':~:~~<}'.,\i~~;3~~;~*tg~~f{sf}tf:ì~~:\i~~~:~~t9\~~f.Ç"~~to/';i::~;;P~~1!f;~;¡~:;~ï~:~r~t{;i;~~;·?;t¡":>:;i~~},'·;~~i;::t:;J.,i;~!t~t,:~~~~ i;:,;~~, CONTACTNAME Loul\/G- K L,¡':¡-I/-O SI-ÞN&' X -E Áè/ '17 CONTACT PHONE ,'8 I1S !<ORP ZIP þ)33J3 1~ NAME mLE PA.GER 1:z3 125 TITlE ,25 ,21 24·HOUR PHONE 128 PAGER # . 29 '30 13' ,~ 133 , . ":, ':'; ",~ i;'\:,~:,:,>·:~. ::~'::t(';;~;?ij:f~~;j'~~i:::,;·~;r: I~~t;~ti:~~~~~;~", ,}¡~~t~lj~}g~~çS~!i~~'!'t~~~?;~{~~~~ni~~J~;~$iìt::!¡~tf$: ,j¡;~~t~i,i:2::' :'~ ;:~}: ;??: r,~):?:, 6f.~151t;: Ceröfication: Based on my inquiry of those Indlvlèuals resþONiitlle for obtaining me information. I certify under penalty of law !hat I have p8l'Sonally examined and am famDiar with !he infonnalion submitted In rhl$ IWenlOry and beJ1eve me infonnatiOn is !rue. accul<lte. and complete_ SIGt{ATUR£ OF' OINNEI'IJOPERAT R DAlE'~ NAMe OF OOCUMEP« PRePARE 135 ,36 137 NA ~ Z7XI ~Ii!$) :.... 06~/18/99 \c- '6'661 326 e 13:50 05i6 BFD HAZ MAT DIV CITY OF BAKERSFIE~ OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326:..3979 iF UNDERGROUND STORAGE TANK FACILITY P!I... 1 New SIT!: o 5 CHANGE o~ N~ORMA TION 15me I)'Þe of ch~"ge I o :! RENEWAL PERMIT o . AMENDED PERMIT o 6 TEMPORARY sm; CLOSURe TyPIÕ OF ACTION (Check 0""" item onlYI PIÕRMIT I. FACILITY I srre INFOR~110N J FACILrrr ID II ß(I GAS STATION o ¡¡ DI~laVTOR I TOTAL NUM6ER OF- ;-"1'11<5 REMAINlNG,.T Smi 401 FACILIT"Y OWNER 1"11"£ , 0, CORPOAAT10N o ~ FARM 0 5 OTHER ..1)3 'I ~o ¡¡ INDIVIDUAL J PART~HIP D.1P"'OÇ~OR D_ü~E~":'" .. .._ Is f&..U¡y on IMIIII! R_rvellon O( l "n OWf>er or u$T 81>1'Dlc agency: n_ 01 itJØ...-i8Of 01 11U<II_? _on. secrløn orcrlllc$ which OP8rM18ll1e UST, , (Thi:; i:; !he «I"~ gonøn lor IN! tõonk _a,d.., 404 I(No -os OTN IL PROPERTY OWNER INFORMA T10N --.-.-..- ~ If I.tó _____ ~ð 8,¡f-XER SÞ::cG"Lo PROPERTY OWN!õR 'TYPE STA 1111 ZIP e¡:¡ ~...93g:IY .;1·12 o 1 CORPORATION ~;;. INDMDUJlL 0::; PARTNERSHIP o Q LOCAl. JlGENC:Y I DlSTfi ICT o S COUNT'/' AGENCY In_ TANK OWNER INFORMATION tANK OWNER NAME , LIJW1/G-. K. ~1:i:J4g__.. . MÃILIN!3 Ó¡:¡ STREET ADDRE:SS L-5~ oq S 7 f/ll ~_ ___ !S9/J-J) ¡I_CITY ß/Þk-GR$ Ff¿~ TANK OWNER TYPE o 1 CORPORATION I 141 OU4 o 7 PERM..NeNTLY CLOSED srTE o 8 T ANI< REMOVED 400 ...-..- ~-l 0.. LOCAL AGENCY/~l'PICT" o ,; COUNTY AGENCr o 6 5T...TE AGENCY- o 1 FEDERAL AG~CY'" .&()~ " .100 4071 PHONE g-~'$..7-66"rJj [G6¡) ~. "09 o ð STAll: AGENCY o 7 FEDGRJ\1. AGENCy ..11J 414 I PHONE ~3G-37 C:.6 ~15 ..,~ m I ST2A- 0.. LQC.o.L AGENCY I DI5TRICT o 5 COUNT'\" AGENCY .18;2 INDIVIDUAL o J P"RTNERSI1IP 1118 "19 ZIP OJ :5 3''13 06 ST"ll: AGENCY 07 FEOERAL AGENCY 420 --....--..-...--.. Call (916) 322-9669 if questions 8ri~e IV_ BOARD OF EQUAUZATlON UST STORAGE FEE ACCOUNT NUMI3¡;R .- -. ....-.....---.. . ,'.. ..---..---.---..---.-.. ..----. .. ..-..._-- I 4~' TV (TK) HQ V. PETROLEUM UST FINANCIAL RESPONSIBIUTY .-..-..-...... INDICAll: M!THO)(S) o .. ::OUR.,..,. SOND o ~ LETT'R OF CREDIT o 6 EX!õ:MPTJON o ? STATE ~UND o H STATE FUND & CFO LETTER __.._~9 STATE FUND & CD U , SEU'''¡N$uR60 o 2 GUAJ'\ANTES o 3 INtjURANCE VI. LEGAL NOTIFICATION AND MAIUNG ADDRESS o 10 LOCIII. OOVT MECHÞ.NISM 0\19 OTl1eïR. ;J.;z¿ M.____...__.... .....' ~ 1 FACILITY 423 o 2 PROPERTy OW"'!!!'! . ... .._. .. CMcl!: Qnc ~ 'SQ Indll:~IC' wtud\ ;add~ss sMud b. us.d rcÞr lev.al nolili"wF1$ "nd m.air1l11jl. Legi:ll noUrlQ:l!jon .,ncJ mdRi'1g1 ""ill be u.ðrJl tome Ian). u....."tII' ur'llees Þ()I 1 or21s ch~þ.e(J. VII. APPUCANT SIGNA. TURE .. -.-----....-.. CerlifocaUon: ",,";1. 111.[ 111.. Inro"""LJo~ pr0vt4..Q he..ln Ifo IN. . eCC\J'SI.. 10 m. 0.... or "" ~"OWI1.cge $IGNATu~E OF APPLICANT ~~.{~.,~¿¿f~ NAME OF APP\.ICAHT (Þ"",I ¿;:r ,- 426 DATE' -..</ TIT\.!;: ÓF APPlI(;AÑT -~O¡ -.. - --.--- ..- -..-- ---.-- - ---. -------.-. CATE NUlllllER (FCIr IOCSI LJli only) STATE UST F'ACIL NUMBE/i (For ICO:SI uN OI\1y) FDnT'I A o 3 TANK OWNER ..2.. PHONE 3q3 -~f1Z3' ..~ "27 06/18/99 13:49 '6'661 326 05i6 BFD HAZ MAT DIV I4J 003 .p' e e W' CITY OF BAKERSFIELD omCE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 I HAZARDOUS MATEJUALS INVENTORY Chemical DescrIption Form (oN Ibm> p., "'......, "., bUJJdiøl1 ør ""'.. DADO CI DELETE o REVISE 200 Page r; I ~ . J,/' I, 't,~"" ¡" ,.~. ~~~·~,""':·4~ ~,,!T,.:,~;:.:o-~,:~' :":" (:'r ~':: ., ~ \ ~t:'':}:'''7~7'::~'~~ .~..~.~.~..: ,~.~\~. !~".'ë.'~" ;,,; :'Ç4 ':"'::~J7J¡.'., It, ~õr:,:,:,~:'\~~~-:,~'~H:,,'" t.~ ~ ~,·l;"~t~·¿~. ,.,",.".':~ ,I>'.·~>'"·J·,'..·~.-:'~.,'~,·,>,~:, ..,,",-~..:,~.,;.~.,.~."..;:' .;....:....,..,< '.: ....'."..4.:",,:.' ...... ~ .'N,;." 'l.r..,.........., INF~A""ON ~ ."".~ "'- tt:-~:t:- ....' l'" r....... "Jr , .. "I'" , .. Jo.:1_,\":.) ..."'i ,,-_...L.' , ~., ...~-<O ,t:"_" ~ ...., .~ .... ~.;:~r:'·:-~~1:~ ·r"'...,..........J VIVIU'ta..... :~..;.·,.F~~..~~~:~·...,...,·-.~~'~...!.'",~·~'I~...~/r:f.£;-:.it~/":~"»:t.~.~~~~.:.-:;-'..;:.:~.. ',~,:,:.. crD8A· Dl;ing ~ As) (J Yea ISi No 2D2 204 : '" :>h'..: ~..>::. :s.,.....;-= :.-.-:' .~.-v..~'\~J"~';,~~:~,~.-: ..: "';:.. . :,;. . .:.:;..~·~-.¿~~·~·;r~:~i~ ;:i!=::~:'~';'~~':," .' ,'~ ''"~. ': ~~,.I .': j .: '. '<. .' '..,' '" ", "'¡...~¢l:ièUlCALINFORMA~"·..:··_h.,.: ,,'." _...':!\.i.-."-?v"'\o,' "... . " ,. . ..·~·..f,\· ,r: ;¡-;.... '~ .'.:' I~ '" '.. :' ~ I..~~,:::.:,..-t" ....~.... '." .:': .;:~'::~\..:!r..~:~..;'... ':( ~.~.:.~.. , . ..:.:. ,;.:. '~':"~':'" ~ .·::·,I:)'~~ CHEMICAL HAME .eL LI æ5 TIW)E secRET 0 y.,. No 2Œ II' Subecz 10 EPCRA. ~ 10 iinslnM:lÎOn$ c;QWoICII'I /'lAME ÐfS" o Yes 0 No :!IIØ CA.!!' ~',i~~:~t,.:,<r'þ:.. :'I.~j;:¡:;' ',!lII.~~;;' ~':.!"")~~""':''-'''~'~'''' \~"ÌS"I'~·"~iìødWa\üiiÌìe .<::.~ ZDI \"'~-_- ..,,~~~ ....~.'..r'.1..1.'.~.~,.. ....,.,.,..........; :S:~j ....~ffIS;'":.,.·....~hf: ''''¡.t- :'r:.!~~'." JI':.;...... .' ......:: ':,:,,;' : ~:J.r~. FIRE cooe HAZARD ses if n:quaIcd by IGI:aI ....... CIIid) . ¡CL#1rI.4-ff J-Æ 'T"r'PE! p PURl; 0 m NŒTtJIŒ 210 o .. WASre 211 ftADlOACT1YE o Yes .5i(No 212 ES 213 PI1TSICAI. $TI'-rç (J s SOUÐ pJUQUIO OgGAS 214 LARGesT CO......AINER 2'5 FED HAZAIõCO CA-re~ (Ched< ~ 1haI_1y) AtOoUAL WAS'Tti AMOOItI' ,Ø.1FIAE o 2 N!ACT'M: 03 F"I'IESSUÆ: FœlEASE 0" ACI.Jre HEAL'TH 05 OiFtONlC HEAL".. 216 217 NA.XDoUoI DAILY MotOUMT ~!IIICIAL DdCUPT ~"EHS. _ntmuBI lie In IN. 211 A\I1iRAGE DAILY AMOUNT 219 STA/p~oe DAYS ON SITE 22D UNITS" o IÞ l.8S [J 111 TONS 221 2Z2 STORAGE o)NTAIl'ER DB ABOvEGROuND TANK DO) fLASTÖNcN.ETALIJC gR\Jþot o i AllEiR DfU.4 (J m GI.ASS eoT11.E (J q fWl CAR Z23 (CTkJrM ;¡/1 !liar awI)oJ ,S; Þ UNDEfIGROUND TAl'll< 01 CAN (J J Ø4G [J II ~ BOTTLE Or OTHER o c; TNoIKIt4SIDi BUILDING 09~ o k BOX o 0 TOlã BIN [J d STt:EL ORUM o h SILO 01 CTUÞŒR (J II TANK WAGON 5T~~Si~ ~ . AMBIENT o ... ASO\IE AtoIIBIENT o be Ba.OW AMBIerT 224 STORAGE~1U~ ø(.NetENT o .. 4OVI! AreEtll' o IIa IIELOW AMBIENT o c CRYOGENIC 22S 228 :z ~O J 2301 .. ~ 5 242 L 0 VI() "ZZ1 0,.811 Q NO 22B 231 DYe 0.... 232 ~ OVesON<> Z36 Z!9 Oy_ DNO 240 2"" [:J YII& CJ No :!404 2Z9 z» 2'37 2041 245 .. -'";': ;>~:~:)~;,.~., >.:~;e~3:~,\ "DATE 2.06 ? F"",,:zn1~) 06/18/99 1=.1: 49 '6'661 326 05i6 BFD HAZ MAT DIY 141 003 '. t" e e CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATEJUALS INVENTORY Chemical Ðeac:rtpt)on Form r- _,,,,, "'._ _ ÞU/Jding '" ""'''. OADO Q DELETE LI FæVISE 200 Page r;/ .' CHEMICAl. NAME PRE G- £liS" CQW.ION MAoMã , ,::..>.~t(/}~~~i;~:~·~~~~i;in) ~~:~·~~~:,~'~~~~·;~~;'~·1:)f;~~,t(~:i~~~~~~"':I0l:··:<t?~ . 'ng~Aa;1 [J Yes ,ß(HO 2D2 204 .:'~:;)b{:-:'Y: ~7;~~~:~~l€Ä~if.F.6~r,o~t~~~~~P?:~;P:>~~·i~t~~:;;··~1~'·::':i> \L:', ',':,:,;,:. ,":(': .<': '1':;\ :i!Ð5 ~ Sf: 0 Yes ßfNo 206 LIlli gl) If Subjea 10 EPCRA. rrh1: 10 ÌÌItSIIudon$ 7 2ØII o Yos Pi( No, 2De '.@:~,s.~rJr.;::).I"~;·~~~~;;:-"···::'i'~·.'H·"·~~, ~:-;g-EHli~~ "~lØciWaiull.lÌe'\Y1~ " l~\;.-"'- ..,'1"lo ?\~ 'l!J"..r "I '1"'" :-. .. " . "I' " ...... ....i'..,:s:~ '::';~~!-",l'-~ç 'J',t!- "'~!:.':.' ~/':~'." .' ~.-.i. '::,';' : t>!..."~_ CJ>S . TVÆ o if~ by I«aI 1ft cIIid) 6 o III MlXTUfIE o ..' WASTE (]ye D No 2'13 PlfTSICAlSTI'TE Os~ I, I I , FeD HAZAIiC) CA'ŒOOØtJES (0I0IdI ~ Iha( _1)') ~W~ III ~ Õ>Oðd ~FIRE UNITS" 5TQRAGé ro/llTA!NeR. (CtkJr;1r aD lIIar awlYJ o II ABOvEGROuND TANK )8(Þ ~TANt< [J c T.aNKII<ISIDti BUILDING D c STEEL OFWM $T~ PFESSLJ1õdi! ~. AM8I!!NT STbRAGE~1V~ 2211 2 no ¡ ;õI3oII .4 Z3II 5 242 LOU 1tIG- K Clflfú FomI 2n1(J199) 210 211 RADIOACT1YE 212 ~ LIQUID IAJ'lGIó5T COI'lTJIoIIoIEA 2'5 OgGA$ 21.4 02 IlEACI'M: 05 CHRONIC HeALTH 2111 03 I"RI:BSUÆ Æ!.EASE 0.. Aarn! HEAL 11i 217 WAXDCJN DAILY MoIOUNT .~!III GIlL 0 ð CUff -tats. _III_lie In"" 2111 A\J9Wã DAILY AhIOUNT STA"Œ/V~ cu\YS ON SITE 219 zæ 222 o .. lBS o III 'tONS 221 o II f'I.AST~ALLJÇ DR\JM Of CAN 09~ o h SlL.O o i FIBeR DRUM OJ 84G o It BOX OICYlJNDER o m GI.ASS ÐOTTUi [J II ~ BOTTlE o 0 TOTe BIN o II TANK WAGON o C AAIl CAR Or OTHER 223 o as ABOVE AMBIENT o 118 øa.ow AhBBfT 224 o III AIIO\I8 ~fiNT o w IIELOW AMBIENT o c CRTOGENIC 22S 'ZZT Dyes ON!> 22B 231 Dves D.... 232 ~ (J Yell [J.... 236 239 Dyes 0 HD 240 24:3 CJ Y86 CJ..... <!44 Z29 233 737 241 2045 ,.- <':'::'~'~:,;'~1:~"::'<:"r;::::\ .~ .' - DATE 2.oB ~ 6 2/ 9 HAZARDOUS MATEIWU.S INVENTORY Chemical DescrfptJon Form ron. Ibm! ptll' "'.18'181 P¥ ÞU/l4ing ør "..... Page r;J 06/18/99 '.' 'fS'661 326 05i6 e BFD HAZ MAT DIV 13: 49 e CITY OF BAKERSFIELD OmCE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 '" . / DADO 200 Q DELETE LI REVISE Ii1J 003 ,~~.~~.f,_".~... -, ,~. .~. ~.~I:'~.~":..1.~~::;:;..·j';~":.:o·t':;;." :,,:..~'::,,~ ~~~·:·Þ,::':'·I~~";:;;:t·~.'h' ..~..~':'O:":.~\.....·..:·,:'ot'..\·!.....'J.·....r.;"....i.4'....::..,~' ,11,~7'....r.:;!I~~...~H.c;.:"~~~:h':'.:!l:·'~' .":,',,,':~.:_~~~."'_~.·J~_'v..:~.·~{..!...-..'::_:,·."F~,,':.,;:.~.,.;....~..:':,"~,:,:...',:'........,:.._.~,..,.. ..., .. .'~ r ............,INF..............ON.a .- r; ~ :,,:r:'::i.-::¿¡¡~ø,,':> :---".. .., ,)rs.;~~"~I"" .~...~,_.,..,_.... ,,,,..f,'_.J'" ~ .. . ~... .-~. ,t".:. . ..' # .' . :,";:~r .I·~~,.·~...t:....:AW""'."'.· ~n '-::~~..:..':.\~ ..~ '!}~~oÖ;l..·,...,._:';!'f"'';..I¡;~:JI'I'' ~·};'\~,.·..:,tt~"':·i~-i'-·~""~ ~"I\"":' ,,-:.....:. crD6A.)giI1~.b)····· '., .' .., ,......, '''.,,''.' ,<,..,.,..',. ." ".' rE~ R..Q 1 Q\J$'" FACIUTY ID. [:hesKNo 2D2 204 :æs : :.,·:·.t,\:',;~:~:;t: '·i{~~t:f.{ ;'. :::)h~,:':" .:'~:::J~{:-:Y ~?;~¿~~~€~~~Õ~~~,~7j:i~l??:~li':~~;:+r;~·})~,;;',~w": '.",;,': )L:. :';'.:. .\', , '. :',\ .~'~;~:~;: ", . '....... 1iIADE geCJõIET 0 V....ßi(No _ II' Subecz 10 EPCRA. .me- 10 ÌÜIstN<:IioII$ CHEMICAl. H.....e ÐfS" 7 ~N JoIoIoME o v... No :!De fl~E cooe HAZARD CLASses o if~ by 1«aI...... dûd) f'!> ·....·/!"~..rJr· :~I'-';:¡:" -i«, ~rt¡" ....,., U ,,; "." >,~ 2DI ~~~~~~~~:~~~~1~~ CAS' p~ o III MIXT1JRE o .. WASJë Dve DNo 211 RADIOACI1\IE P>fTSI~$TI'~ UIoRGE$T CO..rTAIIEA Jl41 LIQUID o :5 SOUÐ OgGA$ 2\.£ FeD HAZAICI CA~ (~ .. 1hIII_1y A/'ÌMI.IAL. WASTe ~NT ~11'1Æ o Z flEACI'M: 03 F'RESSIJÆ Iœ.EASE 0.. Aa.m;: HEAI.:iH 05 CHRONIC HeALTH 211 A~ DAILY AMOUNJ" 217 WAJIDC.IIoI DAILY AMOUNT .J{!II GAL (] d CUFf ." at5, _111_118 In fils.. o II LBS o 1/1 TONS ~ø 4/000 UNITS- STOf!AGé roNTA!NeR (CtId"" all ilia! aw/)'J o 8 P\AST.ciNotIM(¡' A:.IJÇ DRUM 01 CAN 09~ o n SILO o i fIBER DRUM OJ SAG o It BOX o I CTUtoIDIiR Om QASS BOTTLE OI~BOTTlE 00 TOTe" 0" TANK WAGON o B AEIOvEGROuND TANK ~ UIC>~TANtI: OcT lINK IoISIÐi ItUII..DIHG o d STEEL. CRUM STQRAGJõ PfEIiiLßõU: . AhIIIENT o 88 ABO\IE AMBIENr o DB BB.OW AIIoIBIENT 22B 'ZZ1 Dves eND 22B 2 Z¡O 231 Dves 0.... 232 J 2:W ZI$ OV.ONo 236 4 æ Z!9 o v.,. 0 ND 24Q 5 242 2q Over. 0..... 244 i.ðWIl/6- k o FO'TII 2711(31911) 210 212 RlES 213 215 21ð 219 2Z2 22D 221 DO¡ FWlCAR Or OTHER Z23 224 22S Z29 233 737 241 245 ."~~' ;'. \J ,~.. . .': 1·....· .:. -:~. : ~ ~:: ~':. \: .' . DATE 246 5""~O'1 CITY DUN& BRADSTREET COUNTY OPERATOR NAME - ~ :;:l'3~~34 ~.~ .. T \~ lh~ CITYOF~mELD ~1~' r::t~ l;..---- . OFFICE OF ENVIRONMENTAL SERVIC~ yvv v 1715 Chester Ave., Bakersfield, CA 93301 (805) 3~()-~ç' ,L r¡\~OÍ, FA~ILlTYINFORMATION ø-v {/ 3 BUSINESS PHONE 102 : :> Tí I\J6' 103 i 104 CA ZIP I 105 ' 106 SIC CODE (4 Digit #) 107 108 ¡ I 110 ¡ I S}~~~;:'::i: \):":;~(ti ~~ :'~,:~{>;1:?-:,,:: /: >:-» \:i~::> :~:~:~?\<- ·\ii'N'ÉRINFORMÄtìõ vj,,:::,,~ -, '-":,,"',,,~,,):\, ~<;};:'<::Y:~~(.//:Ø-_)::~~';,<:nt:x·~-··; í 112 i I OWNER NAME ..) (1\1\ L GVG-r0O£cx..r¿r2- ~~~:ERS~AILlNG 1ll2...ò 62.cxJ.:::(L\<)~ CITY· i I 113 ¡ CONTACT NAME CONTACT MAILING ADDRESS CITY f~;;&;:0V::l'!: (,;:3l~~5~7~~~~~~,\< ~f\ÊNVïRÖNM :~'Ú:x-:,,<Ú:/-:,!~;:;~;~,,'{t.::<t74b~:_:/:'~'~0 119 I i 120 STATE ZIP I 122 ! I 121 : ;'; '~:::çs:;c;;;:;:~~~}~,:;'~~'/~?t:>::~::,:!:<i.'~:~~:,}~~-.<:>":: ->/,::;.;;,,,;:'. -:. '.,: ',,:-/\~;~,::;>: . " - ~;;'EMERGENCYCONJACTS';} ',,;,.',.,.,',.,...,.,'..,,.,..,,:..,.:;.~.^...',...,'.'...'.;.'~.';....'.;,'..',...,',',., "~,:·;::-~:-;i\;::~';t,'f:J'>;>;*-~-~-:<-."--::,;;..·.{::(::;'-'-::':::_,:;:;:,;;,::',~::/,~::»:-'~'(::':::)'â;':-:~::;::;: ~':'<::;:; ".", ^ --, ~ " ., .:<:,'.~, ·,-·':tH~;/ '>:- ,.. ... .-"'. < <""':~;ifKf§,~(:;'º~t)~~~·:· .~{':;:<¡;:; . '." :,.>:-.,~'." ", ">...,,.-:.... " -::' :.):')<; ':,::iJ; 123 NAME 129 I 130 I NAME ~ (JV'l c......EV (;;Nf) c:;c..I(¿}Z TITLE Ou-J NétL.. BUSINESS PHONE 24-H0UR PHONE PAGER # 125 TITLE 126 BUSINESS PHONE 131 127 24-HOUR PHONE 132 ! I (Ó6s--2..'3'Îð 128 PAGER # Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF OWNER/OPERATOR DATE 134 NAME OF DOCUMENT PREPARER 135 NAMES OF OWNER/OPERATOR (print) DES FORM 2730 (7/98) 136 TITLE OF OWNER/OPERATOR 137 I P:\OES2730,TV4.wpd -------- ", -----....- I . , ~ - CITY OF BAKERSFIf¿D .FICE OF ENVIRONMENT.SERVICES 1715 Chester Ave., CA 93301 (805) 326-3979 UNDERGROUND STORAGE TANK FACILITY Page of TYPE OF ACTION (Check one item only) DI 1 NEW SITE PERMIT o 3 RENEWAL PERMIT o 4 AMENDED PERMIT o 5 CHANGE OF INFORMATION (State type of change) o 7 PERMANENTLY CLOSED SITE o 8 TANK REMOVED 400 o 6 TEMPORARY SITE CLOSURE I. FACILITY I SITE INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) -ns-X ~ðD {lAtÄ¿'- NEAREST CROSS STREET l~'5 3 FACILITY 10 # tJG.J 401 FACILITY OWNER TYPE 01 CORPORATION :¡Þ2 INDIVIDUAL o 3 PARTNERSHIP 04 LOCAL AGENCY/DISTRICT' o 5 COUNTY AGENCY' 06 STATE AGENCY' o 7 FEDERAL AGENCY' 402 BUSINESS TYPE o 3 FARM o 4 PROCESSOR o 5 OTHER 403 o 6 COMMERCIAL 1 GAS STATION o 2 DISTRIBUTOR TOTAL NUMBER OF TANKS REMAINING AT SIT3 Is facility on Indian Reservation or trustlands? ·,f owner of UST a public agency: name of supervisor of division, section or office which operates the UST, (This is the contact person for the tank records,) 404 Dyes at No 405 406 PROPERTY OWNER NAME II. PROPERTY OWNER INFORMATION PHONE 408 MAILING OR STREET ADDRESS 409 CITY 410 STATE 411 ZIP 412 PROPERTY OWNER TYPE D 1 CORPORATION o 2 INDIVIDUAL o 3 PARTNERSHIP o 4 LOCAL AGENCY / DISTRICT o 5 COUNTY AGENCY o 6 STATE AGENCY o 7 FEDERAL AGENCY 413 TANK OWNER NAME ,,,;t' , .'" m,T~Nk 0WNERINFQRMATION':'''' PHONE 415 MAILING OR STREET ADDRESS 416 CITY 417 STATE 418 ZIP 419 TANK OWNER TYPE 01 CORPORATION o 2 INDIVIDUAL o 3 PARTNERSHIP o 4 LOCAL AGENCY / DISTRICT o 5 COUNTY AGENCY o 6 STATE AGENCY o 7 FEDERAL AGENCY 420 TY (TK) HQ IV. BOAFmÒF ÉcìÜALIZATION UST STORAGE ,FEE ACCOLlNTNUMB~R ~ .,~ Call (916) 322-9669 if questions arise 421 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(S) o 1 SELF-INSURED o 2 GUARANTEE o 3 INSURANCE o 4 SURETY BOND o 5 LETTER OF CREDIT o 6 EXEMPTION o 7 STATE FUND o 8 STATE FUND & CFO LETTER 09 STATEFUND&CD D 10 LOCAL GOV'T MECHANISM D 99 OTHER: 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notification and mailing will be sent to the tank owner unless box 1 or 2 is checked, o 1 FACILITY o 2 PROPERTY OWNER o 3 TANK OWNER 423 VII. APPLICANT SIGNATURE Certification: I certify that the information provided herein is true & accurate to the best of my knowfedge SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT (print) 426 TITLE OF APPLICANT 427 STATEUST FACILITY NUMBER (For local use only) 1998 UPGRADE CERTIFICATE NUMBER (For local use only) (Formerly SWRCB Form A) July 1. 1998 P:IUSTFAC,A.FM4,wpd