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Home My WebLink About2004 ELD 6401 WHITE LANE ,~ .. f! 04/23/2004 17:21 6264447017 PAGE 01/02 City of 8Qkersfield Steve Underwood Phone: (661) 326-3979 Fax: (661) 326"()576 Email: EllvirOlllnemal Testing, LLb. 1,2BTylerAvmlle,S"ireK· Sou1hElMr1nte ~ d4 .91733-3622 CA OjJice80O-SJ340JD FIfL<t.626-417017 www.slûrleyenvirol.llllÐfItl.LCðlJ I I I '1 i I CUPA Notification 4/2312004 SET Job 020077 Dear Steve Shirley Environmental Testing scheduled compliance testing at: Facility: JACO #360 (Fastrip) 6401 White Lane Bakersfield Phone Time: 4128/04 at 0800 Test(s): Test Name Test Date ELD Inoculation ELD Sampling Cathodic Protection Lines Leak Detector Monitor Certifi<:ation 56-989 Tank Meter Calibration Olletfill Protectiol"1 Healy Vac Helium leak detection Construction start date 4/2812004 If you have questions about this schedule, please contact our office at 626444~7447 or by fax at 626-627-7017. Thank you. ShIrley e'1Vlronmenfal Testing c~ ~' 04/23/2004 17:21 6264447017 PAGE 02/02 Bnvlronmenr.al Testitlg, L.L C J926 TyltJr A_ue. SIIittJ K - $old" J!l MMtltl - CA - 91133-3622 CA OJJìœ8fJO-53fJ-40JO F(lJt 626-444-7017 WWW.IIt'rfsJ/ft)lÍJ')lIlntllWlLcØIII CUP A Notification 4/23/2004 City of Bakersfield ~eve UndenNOOd Phone: (661)326-3979 Fax: (661) 326-0576 Emall: Dear Steve SET Job 020118 Shirley Environmental Testing schedUled compliance testing at: Facility: Oswell Mobil 2524 Oswell St. Bakersfield Time: Test(s): 4126/04 at Test Name EW Inoculation ELD Sampling Cathodic Protection Lines Leak Detector Monitor Certification $8-989 Tank Meter Calibration Overfill Protection Healy Vac Helium leak detection ConstnJction start date Phone Test Date 4/26/04 4126104 If you have questions about this schedule, please contact our office at 626-444-7447 or by fax at 62~27-7017. Thank you. Shirley Environmental TestIng .. ,of' 134/23/213134 19:14 ,/ 62644471317 PAGE 131/131 E"vùonmentøl Testing, LL.C. 19:8 T)'lerA1IÐtue,SweK - Sø~rhBlMtmtc . C1 - 91733-3622 CA Off/N. 8(}().5JJ-4030 FdX 626-444-7017 www.,hirleye1l11lronmønltl/,(:ø.. CUPA Notification 412312004 City of Bakersfield Sreve Underwood Phone: (661) 326-3979 Fax: (661) 326-0576 EmeU: Dear Steve SET Job 020118 ~e: ;JOT1F1 Shirley Environmental Testing scheduled oompllance testing at: Facility: Oswell Mobil 2524 Oswell St. Bakersfield Phone Time: Test(s): '!1:!!()e~ ð góD Test Name ELD InQculation ELD Sampling Cathodic Protectio Lines L.eak Detector Monitor Certification 56·989 Tank Meter Calibration Overfill Protection Healy Vaç Helium leak detection Construction start date Test Date 41261 L1(Z. 7 (b4 104 'flb7/0 t.f If you have questions about this schedule, please contact our office at 626-444-7447 or by fax at 626-627-7017. Thank you. Shirtey Environmental Testing HAY-04-04 TUE 14:30 CITY OF BKSFLD COHHUN. FAX NO. 6613263313 P.Ol 05/a4/2aa4 12:43 6613920621 PAGE 01/01 ~CO~y RSQ~SSTED'PL&AS~ I"A.X( Gel) 39~-O&2,1 . CI'NOF Hi\. TaeQSJrTR.r .n OFFJCE.OF aNVIROl\lMENTAL SERVICES ~.112tl>crDn )1 Bakenf1ekI, CA (661) 326.3979 F~, : (.661) ; S, to .... '2../ 7"2. . APP£'IC4TIO~ TO PEBFOBM FUEL MONI~ CERTIFICATION F'ACIL1TY. (' ~l)®n - ' ~:: ADDRESS ov- f);5;dS ú)J-Hfi .i¡1n~- '1!iJk"EJ2~P l E-Lþ, (,q OPERATORS NAM'£ ,'. t OWNERS N:A'M'R J Tn , t ~ NAMSOFMONlfœMANtJP1CTtJ1l~ " ,r¡r;:'f¿nER...'R~T DOES FACILn"YHAVBI).JSP~,P~1:: YES:L.... NO_ t. ; VOL1;IMS"' I . r j(4 ~ ! I Q,fY)O· or r ' , ; to J txb I . Y f .~ .'~ -... CONTBNTS lJ/U-~'2 P~".9j VtE:'SFt TANK " I Q :6 " F1I - - . ; . . , NAMBOFTJ3S~GCQMPANY R!.ctJ' .-yIRnNMluITAL C~RS~~.' 9Q-I07¡:~' ;:; . : . . ." ~." " NÄ!¥Œ&;¡tHONB~OFCON'l'ACr~N JAMB.8 lU9B DATE" TDÆ -mSTm To 8B CONDuèœÞ.l . ..:s J t 1,( Ot.f,",< - '. ~'riaf~V ~'~ . ...um::llrnFl2hBY " . . ~~. ~~lltJI¡,I,,~ I, :'r'" [, " UiJ; 1.392-:--.8587 , t('):Q()~ h-) ~ ' ~jJJt/ tl.t.fl. .... " I'tJRB OP APPU'CÌi.NT ' r~ < I', il " ./ " " I' i .~i. - r ; " :;--. Jaco Oil Company P. O. 82515 Bakersfield, California 93380-2515 /" (~ t, (.., {('( December 12, 2003 c.o q () ( Wk \.~ C, L- ff- City of Bakersfield Fire Department 1715 Chester Ave. Bakersfield, California 93301 Attn: Steve Underwood RE: Underground Storage Tanks owned by Jaco H~ll and Jamieson Hillin the City of Bakersfield . Dear Steve, '.l '.- Pursuant to our meeting of December 10, this ,lettèr,out~ine~ what our plan of action is to:' '; .' " bring all of our City locations into compliance. I häveto prepare and bid each job and',., ' submit applications to your office. W¥are inthe prOcess of gathering the data for the pennits and I expect to be able to submit this for approval by :bècembèr28th due to the ' holidays it's possible this will be soone~. There wiÙ,be a partnership meeting the first " week of J ånuary, as this is a large capital expenditure and units will close. Those partners outside the company need notification and to be infomled of our direction. This is not considered to be any slow down of our efforts, only a fonnality. '-j 259 Harris Market: Due to economics this station will be closed and the tanks removed. Attached you will find the 60 day notice we have sent the operator. Weather pennitting on or about we will begin this job February 16,2004, we estimate about 3 weeks to complete. 355 Howard Market Stine and Belle Terrace: Economics dictate this station will be removed as well. We will start this on completion of Harris Market and estimate a start date of March 8, 2004. Again I have attached the 60 day notice. The above represents the two removals we will make. Re-tanking schedule: 3701 Ming Ave. We will replace the tanks and lines at this location. It is estimated we can begin this job on or about January 26, 2004. We estimate the time at 8 weeks. This can be cut to 6 weeks if an ELD test is not necessary. ;'r .' '! r-~ ',' I, '. I I I ,- 6401 South H: Based on the above job we will start on or about March 15 2004 and given the same condition will take 8 weeks to complete. 6401 White lane: Given the same schedule we will be in a position to start this job on or about May 3 and complete 8 weeks hence. ELD Testing: White and Gosford and 1200 Coffee Rd: We have 2 failed tests. In both cases these are very minor Vapor leaks I am confident we are not leaking product into our systems. I am waiting on results from a test that was competed on December 5th that had failed as well. We treated this site differently and closed it during the test to see if the results will come back positive on our part. We expect those results late this week. If that works we may take the same course of action. We will make arrangements to have this tested as soon as possible and as soon as I know that schedule I will advise you of same. I expect these no later than January 15 based on current information I have. Pending that these are acceptable to the department I will postpone these to Late this year but they will be finished by June of 2005. Air Pollution Issues . Þà' the saine time we do the abdve Ùpgt~de's ¡it l'sp~iof our ¡)làn to install new PhaséOOrie'<i I' , systems at all of the above station~: In 'severàl tases we Will be altering the phase one' , .~~. . ". '. , system in.stations that are currentlY-inComplian:ce. On those as We will qnly open up the:,,·. " , fill end of the tank do you want a permíi ~nthes~'or is irstri~tly a San Joáquin APCD ' " .: matter? In the below compliant list I will note whère this work will he done and you can., ;:'. í,: let me know. This has a mid 05 deadline as well at this point. This involves the seven sites identified in station that are currently in compliance Form Corrections I owe you corrected A and B forms on 805 34th Street. Omero has been handling these he is off sick and I will get to you by 12/16 on his return. Stations In complïance The below list is stations currently in compliance with the exceptions noted above. Where there is a "1" after the station address these are units where the Vapor recovery has to be upgraded to comply with APCD regulations. Please advise us if permits on these stage 1 modifications will be required by your department as well. '805 34th Street 1 2698 Oswell 1 3200 Panama Lane 2732 Brundage ;r 1640 South Chester 1 3501 Mt. Vernon 1 4901 South union 1 4013 South H. 1 If you have any comments or wish to discuss any specific station please call me at 633- 7536 my cell phone is 428-5761 I will be out of the office on Monday and Tuesday if you need me then please use my cell number. Generally it is better to leave a message at the office, as Verizon is not always reachable despite there brilliant commercial. I check my office voice mail frequently. Thank you for your continued assistance in this matter and I look forward to working with you on resolving these issues. Sincerely f/rð=; RoyF. Saunders V. P., Real Estate ¡;" . ';:. : ~ ~ .':, ,. '/ ¡, ," ...- i; ::. .i\.,. . " , ',> ~,,' . r : :' , ..1. , ; ~.: 'Jaco Hill Company 3101 State Road Bakersfield, California 93308 *U PO. Box 82515 Bakersfield, California 93380-2515 Phone: 661 393-7000 . Fax: 661 393-8738 December 12, 2003 Certified Return Receipt Mr, Mohammed H. Rahimi Howard~s Mini Mart 4201 Belle Terrace Bakersfield, CA 93309 RE: Cancellation of Agreement Dear Mr. Rahimi: The City of Bakersfield is requiring us to re-pipe and re..:tank our gasoline facility in order to continue selling gasoline on your property. After careful analysis of these costs and our return on our investment we have determined that it is economically unfeasible to make the investment to re-pipe and re-tank. Therefore Jaco Hill Company, formerly JTCompany, according to the Special Purpose Agreement, dated December 18,1984, and recorded on January 7, 1985, is giving you a 60- day notice that we will be canceling our Special Purpose Agreement, terminating all of our obligations, and removing all our petroleum equipment and signage located on your property. We will give you a schedule of the removal after we obtain permits. We have enjoyed doing business with you over the yèars. Please give me a call if you have any questions. ßelY, ~ R. crai~l~ GM Marketing Jaco Oil Company - P.O. Box 82515, Bakersfield, CA 93380-2515 - 805/393-7000 - Fax 805/393-8738 o Agent o Addressee C. Date of Delivery X B. Received by ( Printed Name) o Yes o No Is delivery address different from item 1? If YES, enter delivery address below: D. I ¡ · Complete items 1, 2, and 3. Also com pi 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: Merchandise v"" o Express Mail ~eturn Receipt for -0 t.Q,D. Restricted Delivery? (Extra Fee) 24100004 1390 3. Service Type ~ Certified Mai o Registered o Insured Mai Mr. Mohammed H. Rahimi Howard's Mini Mart 4201 Belle Terrace Bakersfield, CA 93309 o 4326 4. 7002 ..D..D ruru rnrn ;:T::r e,e Irlr rnrn r=!r=! ;:T::r ee e,e ee ee r=!r=! ::r;:T ruru ruru ee e,e ["'-["'- 102595-01-M-2509i I 2, Article Number (T fansfer from service label) PS Form 3811, August 2001 Domestic Return Receipt . , , $ .~ ó OFF Postage Certified Fee Postmark Here SentTo ._..___.___.._,._._-_.P_O....B.OX..82515..---~_. Street, '~r.. "l9' ' ?:_~:?~IRSElELD_.~_CA._9_33.8D.:2515_~..._._--_... City. State. ZIP+4 Return Reciept Fee (EndOrsement Required) Restricted Delivery Fee ~nt Required) c:::.. \., ,,"\. ~~', \f\. Total postage & FeE$ == - - - - - = = - - ~ - - - :\ "\ .., , . , .""I!J Jaco Hill Company ';'"' l 3101 State Road Bakersfield, California 93308 *u PO. Box 82515 Bakersfield, California 93380-2515 Phone: 661 393·7000 . Fax: 661 393-8738 December 12, 2003 Certified Return Receipt Hyon & Soon Kim Harris Market 1701 Union Ave. Bakersfield, CA 93301 RE: Cancellation of Agreement Dear Mr & Mrs Kim: The City of Bakersfield is requiring us to re-pipe and re-tank our gasoline facility in order to continue selling gasoline on your property. After careful analysis of these costs and our return on our invèstment we have determined that it is economically unfeasible to make the investment to re-pipe and re-tank. Therefore Jaco Hill Company, formerly JT Company, according to the Special Purpose Agreement, dated July 10, 1985, and recorded on February4, 1986, is giving you a 60-day notice that we will be canceling our Special Purpose Agreement, terminating all of our obligations, and removing all our petroleum equipment and signage located on your property. We will give you a schedule of the removatafter we obtain permits. We have enjoyed doing business with you over the years. Please give me a call if you have any questions. Sincerely, /? ë::2' \. C7--f1 R. Craig~i;;:¡ GM Marketing Jaco Oil Company - P.Q, Box 82515, Bakersfield, CA 93380-2515 - 805/393-7000 - Fax 805/393-8738 . f;~ ,.r .~, COMPLETE THIS SECTION ON DELIVERY SENDER: COMPLETE THIS SECTION A. Signature · 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: Hyon & Soon Kim 170 1 Union Avenue Bakersfield, CA 93301 ~----- o Agent o Addressee C. Date of Delivery x B. Received by ( Printed Name) D, Is delivery address different from item 1? 0 Yes If YES, enter delivery address below: 0 No -------_..-/' 3. Service Type ~ertified Mail o Registered o Insured Mail ~ Express Mail ' ~eturn Receipt for Merchandise ' o C.O.D. 4. Restricted Delivery? (Extra Fee) DYes 2, Article Number (Transfer from service label) PS Form 3811, August 2001 7002 2410 0004 1390 4197 Domestic Return Receipt 102595-01-M,2509, I"'- I"'- I]"" I]"" ,...:¡ ,...:¡ ::r ::r r:J r:J I]"" I]"" m m ,...:¡ ,...:¡ ::r ::r 0 r:J 0 r:J 0 r:J 0 0 ,...:¡ ,...:¡ ::r ::r ru ru 'U.S. Postal ServiceTM CERTIFIED MAILM RECEIPT' : . (Domestic Mall Only; No Insurance Coverage Provided) I ,. , : . . " ,. . , I o F W"" I C I A L U S E I r Postage $ Certified Fee , Return Reciept Fee Postmark (Endorsement Required) Here Restricted Delivery Fee (Endorsement Required) Total Postage & Fees $ ~, ru ru o 0 Sent To 00 I"'- I"'- -~:r~~::::;;--------P,-o-:-BOX·-SZ515·_------m__--__.._----"---_. ëitÿ;-Š¡ã¡~KfRSftftD;-eA--9j3'8Q:Z515"'---'-------'--' PS Form 3800, June 2002 " '. 'See Reverse for Instructions . I ,.'-, , ( . ,," '.<1,', iii' . LITY OF BAKERSFIELD OF.. .CE OF ENVIRONMENTAL S. ,.{VICES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 UNDERGROUND STORAGE TANKS CLOSURE CERTIFICATION s Page _ of _ .-----.-.---.- ¡ß - :¡"-;-:T-~1 I' ! , j I ;, ¡ f ' ~ ¡ : 3 ; PERMIT # 740 741 742 I STATE 743 ZIP C DE ' 744 1'- ~ .. -1- ~-3 - Tank ID # (Attach eddIIJonaI copJN oIlIIls ptge tot møt8 /ban """ I8n1cLJ .11. TANK CLOSURE INFORMATION I Concenballonòf Flammable Vapor Top Center Bottom , 746b 746c 7 TANK INTERIOR ATMOSPHERE : READINGS ì ' I i i I I r!~ 1 ~tc"'" UI....(uJJ tJt 6-' ~ &' 7498 74911 e-- é- : ",·,;mc ·l~·)&: "7 5.C{' ').':-"::. ".' 2 , ",.':..:" " ,." ';. <.' '''''.. ,')", - ,." ',.."iJ!'i"" ': ,':~ On examlnatl of the tank, I certify the lank Is visually free. from product. Sludge, sCale (thln,fI8ky residual of tank contents)~'riraSè'ahf and debris.,.' ',' certify that Informallonp dedherelnlstrueandaccuratetothebestofmyknowfedge.> ',,"',', ' "".,,' ";;'<¡:"" '}.S:A;;'<:,·,[+;1:/¡;'t!;!ii SIGNATU C FI STATUSORAFFILIATJONOFCERTIFYJNGPER~N,t "~ ... .,,;'>" ' Certifier Is a representatlve.of the CUPA, authorized agency,or:",IA: ;,760 II' YeS 0 No, -':' '. -~~_--"-'~<,;:'~;;":~~:.:.'." Name of CUPA, authorized agency, or LIA: ,"': :;:'761 754 755 City of. Balcersffeld Fire Department· OffIce of E~Ì'onnlèntal ~ìVléêS..:i~;;', ; ,'- - '_ ,- '. ~-;.'~ .'_,:.~,;j:;.:·--',:--:~-{·~->:,<t<·, ",,__-,,'-<:~;:,~_;.;-'.« ì If certifier Is'other than CUPA ILIA èheèk ap~tebÖ.iC'bèlo\y;·/;í)¡;jiÌG. '! . ,[J a. ,,~rtÌfied Iridustrf~1 Hy9Ienlàt(êiH)~.,;:~~':"Y;!~;~1::::;8:r,~~~~!i::-(;,;j~·':'t,i [Jb.. cèrtified Sar8ty ProfesslomJI (Cspf".·>: ,', ':, ", ":¡: ,: ,'::;:' o c. Certified Marine Chemist (CMC) ',...' '.' o d. Registered Environmental Health Speclalist (REHS) o e. Professional Engineer (PE) o f. Class II Registered Environmental Assessor o g. Conbactors' State Ucense Board licensed conbactor (with hazardous substance removal certification) 1715 ChesterA~~;;' 758 CITY Bakersfield, CA 93301 757 PHONE (661) 326-3979 759 CERTIFICATION TIME ( f '5 TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS (U yes, /he tenk Interior øtmosphef8 shaD be te-ehecked with a combustJble gas indicator prior to work being conducted on /he tenk.) ŒRllAER~~;;::Q~";¡~~RSCRAP;EAL~t!~,' ETC: L\v \'7J~a-\-, ~1-O.E..-.~~e Ln '. " 'del, (I~ ~'Wì ~¿JcHddðo5 " ,I U1Ju8fd J11.~ J A copy of this certificate shall accompany the tank to the recycling I disposal facility and be provided to the CUPA. If there Is no CUPA, ,,'>i;;~.§;..~:, ' ::oples shall be submitted to the LIA and authorized agency; owner I operator of the lank system: removal conbactor: and the recycling I disposal faCl!I!, ,..';,~' , 758 DATE r¡.. Yes o N9:c/iC.763', ¡ '-"':',','764 ' , , .. '.. . ;; .~,;'.". . , I 'CF (7/99) ._V:.:' S:\CUPAFOR~~,249~doc '. ~:' :.:,-~ -~.:.- -: , (:.. ~.¡. I r, CO./DRYICE _lIdco INVOICE FIRE EQUIPMENT -.-.."';'.j.- ~~.~ SAFETY EQUIPMENT 24 HR. PHONE: (661) 322-6001 HYDROSTATIC TESTING RETAIL STORE: 2301P STREET CALIF. WATTS: (800) 272-6326 LICENSES WAREHOUSE: 101 TRUXTUN AVENUE ORDER DESK FAX: (661) 322-0127 STATE # 546 BAKERSFIELD, CA 93301 OFFICE FAX: (661) 322-6000 O.O,T.A105 S \ 184799 CHP CA 7948 ----........ ............,.- , f" ' ; NAME w:=:' -.::;:.>--::>/ '¿>A/~ ADDRESS CITY STATE DATE { ,I" t " j i ì ! ¡ ¡ I ¡ i I I I ¡ 1 I ¡ , ì \ ¡ I I ! ¡ f I I I I I I I I I I ! CO BULK WEIGHT TICKET # CO. CYLINDERS . HELIUM CYLINDERS -NITROGEN CYLlÑDERS CYLS. DELIVERED Lbs. Lbs. Cu.Ft. - ~---- Cu.Ft. CYLS, RETURNED - " GOVERI'1MENT REGULA o CHARG L 0 DELIVER TAX TOTAL MATERIAL SAFETY DATA SHEET REMIT TO: P.O. BOX 1631 BAKERSFIELD, CA 93302 AVAILABLE ON REQUEST CORP. FED.I.D. NO. 95-2599411 TITlE TO All ABOVE ENUMERATED PERSONAL PROPERlY OR RENTAlS SHALl REMAIN WHOllY IN BRAND DRY ICE DBA BRANDCO UNTIL FUllY PAID FOR AND VENDEE SHAll BE RESPONSIBLE FOR SAME WHILE IN HIS POSSESSION AND WlllSURRENDER SAME UPON DEMAND IF IN DEFAULT. IT IS ALSDAGREED THAT, IF COLlECTION IS MADE BY SUIT OR OTHERWlSE.IIWE AGREE TO PAY A FINANCE CHARGE OF 1.5% PER MONTH, WHICH IS 18% PER ANNUM, AffiR 30 DAYS, ALSO COLLECTION COSTS AND INCWDING ATTORNEY'S FEES, AND WAIVE All RIGHTS TO ANY CLAIMS EXEMPTED UNDER STATE LAWS. MINIMUM INTEREST CHARGE $1.50, BASIS ON WHICH CYUNDERS ARE LOANED: PROVIDED THAT IF ANY LOANED CYlINDER NOT RETURNED WITHIN 30 DAYS FROM DATE OF SHIPMENT THE DISTflIBUTOR RESERVES THE RIGIiTTO MAKE A RENTAL CHARGE OF $8.00 PER CYLINDER PER MONTH FOR All TIME OVER 30 DAYS THAT SUCH CYlINDER IS AWAY FROM THE DlSTflIBUTOR, WHICH DEMURRAGE CHARGE THE CUSTOMER AGREES TO PAY ON DEMAND. THE CUSTOMER SHALl PAY PROMPTLY ON DEMAND TO THE DISTRIBUTOR ESTABUSHED CALCULATIONS AND RATES FOR LOSS OF OR DAMAGE TO ANY OF SAID CYlINDERS OR FlTIINGS RESULTING FROM ANY CAUSEAffiR DELIVERYTHEREDF TO THE CUSTOMER AND UNTIL RETURNED TO THE DISTRIBUTOR. REFILLING OF CYlINDERS IS PROHIBITED. ~ .- ..,,- _._--~:;- ._~".,-'~-""'-~.-------...,----------""'-- Received By Authorized Signature I I I I I ì I I I \ í ¡ 1 -'-""~-~i , ¡ I I I ¡ I I I I I i I I I I I I I 1 ¡ I j .--J i , ,/ \< . (/'\, L,,- '\ l;.f IINIFrF.O PROr.RAM CONSOf.lOATF:O FORM TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per sitel Page_of_ TYPE OF ACTION 0 l. NEW SITE PER~!lT (Check one item only) 03 RE'IEW\L PER~!lT JiT-",\IE:\i[)ED PERMIT o 5,CHA,-';GE OF I:-<FOR~-" TION :.;pecitÿ ch.lngt: locJ.1 use nnly o b,TEMPORARY SITE CLOSURE o 7,PER~f."':-;E'TL Y CLOSED SITE o 8, L\'K RE~IOVED .00 I. FACILITY I SITE INFOR1\IA nON .\0\ FAClLITY UWNER TYPE o t. CORPORATION o 2, INDIVIDUAL ~PARTNERSHIP 40: FACILITY fOil . FARM 05, COMMERCIAL o 4, PROCESSOR 0 6. OTHER .03 Is faci lity on Indian Reservation or . If owner of UST is a public agency: name of supervisor of division. section or office which trustlands? operates the UST (This is the contact person for the tank record>,1 404 0 Yes ~ ~O; ~06 II. PROPERTY OWNER INFORMA nON -107 PHONE ~08 -I()<) ~IO ~12 02. INDIVIDUAL ~PARTNERSIIIP -IIJ III. TANK OWNER INFORMA nON TANK OWNER NAME ~I~ 415 ~16 ~17 -119 02. INDIVIDUAL ~PARTNERSHIP ~10 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Call 916) 322-9669 if uestions arise V. PETROLEUM UST FINANCIAL RESPONSIBILITY ~21 INDICA TE METHOD(s) 1J'î.SELF-INSURED 02. GUARANTEE 0), INSURANCE 04. SURETY BOND 07, STATE FUND 05. LETTER OF CREDIT LfB."'STATE FUND & CFO LETTER 06. EXEMPTION 09. STATE FUND & CD o 10. LOCAL GOVT MECHANISM o 99. OTHER: ~12 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which addre" should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank Q\\"ner unless bo." I or 2 ís checkeu, o 1. FACILITY 0 2. PROPERTY OWNER ~'JK OWNER ~23 VII. APPLICANT SIGNATURE Certification -] certify that the ìnformatìon provîdeJ h\:rein is true and accurate: to the best of my knowledge. 426 (ì. _ "/'+í/"-, 42:i DATE ~~ /?-CJ7 TITLE OF APPLICANT 424 ...... -", SIGNATURE OF APPLlÇ , T , . ,,4 . 1998 UPGRADE CERTIFICATE NUMBER IFor 10",1 u,c unly) 429 UPCF (1/99 revised) 8 Formerly SWRCB Form A UST . Facility Formerly SWRCB Form A. Complete the UST· Facility page for all new permits. permit changes or any facility information changes. This page must be submitted within 30 days of penn it or facility information changes, unless approval is required before making any changes, Submit one UST - Facility page per facility. regardless of the number of tanks located at the site. This form is completed by either the permit applicant or the local agency underground tank inspector, As part of the application, the tank owner must submit a scaled facility plot plan to the local agency showing the location of the USTs with respect to buildings and landmarks [23 CCR [,J2711 (a)(8)]. a description of the tank and piping leak detection monitoring program [23 CCR 02711 (a)(9)], and. for tanks containing petroleum. documentation showing compliance with state financial responsibility requirements [23 CCR 02711 (a)(11 )]. Refer to 23 CCR 02711 for state UST information and permit application requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER - Leave this blank, This number is assigned by the CUPA. This is the unique number which identifies your facility. 3. BUSINESS NAME - Enter the full legal name of the business. ~. 400. TYPE OF ACTION - Check the reason the page is being completed. CHECK ONE ITEM ONLY. 401. NEAREST CROSS STREET - Enter the name of the cross street nearest to the site of the tank. 402. FACILITY OWNER TYPE - Check the type of business ownership. 403. BUSINESS TYPE - Check the type of business, 404. TOTAL NUMBER OF TANKS REMAINING AT SITE -Indicate the number of tanks remaining onthe site after the requested action. 405. INDIAN OR TRUST LAND - Check whether or not the facility is located on an Indian reservation òr other trust lands, 406, PUBLIC AGENCY SUPERVISOR NAME -If the facility owner is a public agency, enter'the name of the supervisor for the division, section or office which operates the UST, This person must have access to the tank records. 407, PROPERTY OWNER NAME - Complete items 407- 412 for the property owner, unless all items are 408, PROPERTY OWNER PHONE the same as the Owner Information (items 111-116) on the Business 409, PROPERTY OWNER MAILING OR STREET ADDRESS Owner/Operator Identification page (OES Form 2730). If the same, 410. PROPERTY OWNER CITY write "SAME AS SITE" in this section. 411. PROPERTY OWNER STATE 412. PROPERTY OWNER ZIP CODE 413. PROPERTY OWNER TYPE - Check the type of property ownership, 414. TANK OWNER NAME - Complete items 414- 419 for the tank owner.. unless all items are the . 415. TANK OWNER PHONE same as the Owner Information (items 111-116) on the Business 416. TANK OWNE;R MAILING OR STREET ADDRESS Owner/Operator Identification page (OES Form 2730). If the same" 417, TANK OWNER CITY write "SAME AS SITE': in'this section. 418. TANK OWNER STATE 419, TANK OWNER ZIP CODE 420. TANK OWNER TYPE - Check the type of tank ownership. 421, BOE NUMBER - Enter your Board of Equalization (BOE) UST storage fee account number, This fee applies to regulated USTs storing petroleum products. This is required befqre your permit application can be processed. If you do not have an account number with the BOE or, if you have any questions regarding the fee or exemptions, please càll the BOE at (916) 322-9669 or write to the BOE at: Board of Equalization. Fuel Taxes Division. P.O. Box 942879. Sacramento. CA 94279-0030, 422. PETROLEUM UST FINANCIAL RESPONSIBILITY CODE - Check the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements, CHECK ALL THAT APPLY. If the method is not listed, check "otherOand enter the method(s). USTs owned by any Federal or State agency and non-petroleum USTs are exempt from this requirement. 423. LEGAL NOTIFICATION AND MAILING ADDRESS -Indicate the address to which legal notifications ar:1d mailings should be sent.. The legal notifications and mailings will be sent to the tank owner unless the facility (box 1) or the property owner (box 2) is checked. ' SIGNATURE OF APPLICANT - The business owner/operator of the tank facility, or officially designated representative of the owner/operator, shall sign in the space provided, This signature certifies that the signer believes that all the information submitted is accurate and complete, 424, DATE CERTIFIED - Enter the date that the page was signed. 425. APPLICANT PHONE - Enter the phone number of the applicant (person certifying). 426. APPLICANT NAME - Enter the full printed name of the person signing the page, 427. APPLICANT TITLE - Enter the title of the person signing the page. 428. STATE UST FACILITY NUMBER - Leave this blank, This number is assigned by the CUPA as follows: the number is composed of the two digit county number, the three digit jurisdiction number, and a six digit facility number. The facility number must be the same as shown in item 1, 429.1998 UPGRADE CERTIFICATE NUMBER - Leave this blank, This number is assigned by the CUPA. UPCF (1/99 revised) 9 Formerly SWRCB Form A L:\IFIED PROGR.UI CO:\SOLlDA TED FOR.\I 1.\:\1\:5 C~DERGROr~D STORAGE T,-\,:\'KS - TA:\'K PAGE I I two ?Jg~s pè'~ tank ¡ (C*k one Item vnly, ... P!:R\ ,'.E\7L\ \.'~CS:;J¡j\ SITE "~'_Dl_1 J)O I TYPE Of ACTICS o ! ,\EW SiTE PER\W C".\IE.\OEJ'::'<.\:IT C: C,i,,\CE OF ::--'~;)R.\I\ ~:C" o 6 TE.\!PC~\RY SI r~ ('c05:' RS C j RESE'.",\'- rER.\!~T I S,:.:;.!·~ ~::Jj.'" - -.. ','~.l .~ ür.:·, I Sr~:'~·:. r:Jh~n . f,;" "J.:,J 'JS: ~lIh'r S TA:--'K R::\IO\ED HCIL!T':" ID J)I ~.'J Ifuycs". complc!c one p.1ge (0( (oJeh ¡:ompanmcnl T.-\:\K CAP.>.CITY I~ GC)i'<S '36 NL'MBER OF COMPARTMENTS 43' 4JI .' 11. TA:'I'K CO:\'TE:'\TS TANK USE œrf.'" MOTOR VEHICLE FUEL (Jfnwtcd ,ompl.., PelrolO\lm Typel o 2. NON·FUEL PETROLEUM 03. CHEMICAL PRODUCT C 4. HAZARDOUS WASTE Oaclud.. Used Oil) 095. UNKNOWN 439 PETROlEl'M TYPE ~ REGULAR L1IôLEADED o Ib, PRß!IUM L::"LEADED Ole. MJDGRADE L:--¡LEADED 440 o 2. LEADED 0), DIESEL o 4. GASOHOL OS. JET FUEL 06, A VIA TION FUEL 099. OTHER COMMON NAME ((romHazordous M...rial,lnvcn,orypas.) 441 CAS# ¡from Hazardous M~(l:'riallln..~nlof}' page) 442 TYPE OF T ANI< e...- III. TA:'<K CO~STRUCTIO:'l' 3. SINGLE WALL WITH 5, SI:'>'GLE WALL WITH INTERNAL BLADDER SYSTEM EXTER10R MEMBRASE LINER Ð 95, lJNK:--¡O~ 04, SIGI\LE W ALL IN VAULT 099, OTHER 3. FIBERGLASS i PLASTIC 5, CONCRETE 95. Li~K:-10WN 04. STEEL CLAD WiFIBERGLASS 08. FRP COMPTlBLE Wi I 00'10 METHANOL 099, OTHER REI:--¡fORCED PLASTIC (fRP) 3, FIBERGLASS.' PLASTIC 04. STEEL CLAD WFIBERGLASS RE/:-;FORCED PLASTIC (FRP) o 5. COSCRETE 3. EPOXY LINING Boo(o - {Q J - or I. SINGLE WALL 443 (Oeck.... ilem only) ¡¡(2. DOUBLE WALL I. BARE STEEL 02. STAINLESS STEEL oU4 TANK MATERIAL -primary tank (Cllcc:k 00' it.m only) TANK MATERIAL -",condary tank (Ckck one il<m only I I. BARE STEEL 02. STAI:--¡LESS STEEL 5. CONCRETE 95, UNKNOWN 08, FRP COMPTlBLE W, 100% METHANOL 099. OTHER o 10. COATED STEEL .¡os 04 PHE:--¡OLlC LINING S. GLASS LINI:"G lYI6L"NLINED 95. UNKNOWN 446 DATE INSTALLED .¡o7 TANKfNTERlOR LINING 01 COATING (Clleck _ i..... onlYI I. RLiBBER LINED o 2 ALKYD LlNJ:"G o 99 OTHER (for local ',Ie onlYI OTHEJl CORROSION 01 MANUFACTLiRED CATHODIC PROTECTION IF APPLICABLE PROTECTION (Occk.... i..... only) 0 ! SACRIFICIAL ANODE SPILL AND OVERfiLL YEAR INSTALLED (Oock alllhallpply) œfÍSPILL CONTAINME:--¡T O-<¡ Ø20ROP n;BE 0 -Y æf3šTRIKER PLATE C}.y o 3 FIBERGLASS REINFORCED PLASTIC o 4 IMPRESSED CLiRRENT o 9S L'NK.NOINN 099 OTHER 44S DATE I~STALLED ....9 IF SINGLE W ALL TANK. IChecbll<h1l opplyl IF DOUBLE WALL TAI\'K OR TANK WITH BLADDER 4H ¡Check Jnc item only' 01 VISUAL (EXPOSED PORTION ONL YI 0 S M-'lNUAL TA:'IIK GAL"GI:-;G (MTG) 0 I VISL:AL (SINGLE W.-\LL IN V,-\L'LTONLYI 02 AUTOMATIC TA:"K GALGI:--¡G (ArGI 06 VADOSE ZONE 0 ! CO:-;TINL'OUS I:--¡TERSTlTIAL ~IOI\ITORING 03 CONTJNl:OUS A TG 07 GROL:NDWA TER 0 j MANL'AL MO:>;ITOR.I:'o:G 04 STATISTICAL I)<VE:-OTORY RECO:"CILI·\ TIO~ 0 ~ T.\:'oiK TESTI:-':G (SIR) BIENNIAL TA:-.;K TEST!I'G 09" OTIIER IV. T,\:\K CLOS tRE I:\FOR:\I.-\ TlO' I PER.\I.·\'iE:\T ClOSlRE 1:\ PLACE (For loc3.1 we only) 451 OVERFILL PROTECTION EQLlP~IE:'>iT:YEAR INSTALLED 4!2 Ø1:ALAR~ cYY' 03 fiLL TUBE SHLT OFF VALVE j2r2 BALL FLOAT M 0 4 EXEMPT ESTIMATED DATE LAST LSEDI VR.~IO, D,·\ VI ':; I ESTI~I.,\TED QL.-\~TITY OF' 5U!ST.ASCE R!::~;l~I~G gallons '" ~h T·\:->K FILLED \\ITH \:-:E!'.T ~\."TER\.\L' 'F o Y~s 0 .\0 UPCF (12/99 revised) 10 Formerly S\VRCB Form B UST· Tank Page 1 Formerly SWRCB Form B Complete the usr - Tank pages fcr each tank fer all new permits, permit changes, closures andíor any other tark information charge. This page must be submlttecl'ilthn 3C days of permit or facility ¡dormat,on crançes, unless ap¡:roval is required befere ma~ln; any charges Fer compartmentalized tanks, each compartment is considered a separate tark and requires completicn of separate tank pages, Refer to 23 CCR =2ì 11 for state UST information and permit application requirements, (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages, These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR. Appendix C, the Bilsiness Section of the Unified Program Data Dictionary,) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. ,. FACILITY ID NUMBER - Leave this blank. This number is assigned by the CUPA This is the unique number which identifies your facility. 3. BUSINESS NAME· Enter the full legal name of the business, 430. TYPE OF ACTION· Check the reason the page is being completed. For amended permits and change of information. include a short statement to direct the inspector to the amendment or changed information, )' 431. LOCATION WITHIN SITE· Enter the location of the tank within the site. ~~, 432. TANK 10 NUMBER - Enter the ownerå tank ID number. This is a unique number used to identify the tank, II may be assigned by the :i' owner or by the CUPA. ?,-: 433. TANK MANUFACTURER.. Enter the name of the company that manufactured the tank. 434. COMPARTMENTALIZED TANK - Check whether or not the tank is compartmentalized, Each compartment is considered a separate tank and requires the completion of separate tank pages. 435. DATE TANK INSTALLED - Enter the year and month the tank was installed. 438. TANK CAPACITY - Enter the tank capacity in gallons, 437. NUMBER OF TANK COMPARTMENTS -Iflhe tank is compartmentalized, enter the number of compartments. ~i; 438. ADDITIONAL DESCRIPTION - Use this space for additional tank or location description. 439. TANK USE - Check the substance stored. If MOTOR VEHICLE FUEL, check box 1 and complete item 440. PETROLEUM TYPE. 440. PETROLEUM TYPE - If box 1 is checked in item 439. check the type of fuel. 441. COMMON NAME - For substances that are not molar vehicle fuels (box 1 is NOT checked in item 439), enter !he common nåme of the substance stored in the tank. 442. CAS # . For substances that are not motor vehicle fuels (box,1 is NOT checked in item 439). enter the CAS (Chemical Abstract Service) . number. This is the same as !he CAS # in item 209 on the friazardous Materials Inventory - Chemical Descriptiòn page. 443. TYPE OF TANK - Check the type of tank construction. If type of tank is not listed. check CbtherÐand enter type. 444.TANK MATERIAL (PRIMARY TANK) - Check the construction material of the tank that comes into immediate contact on its inner surface with the hazardous substance being contained. If the tank is lined do not reference the lining material in this item. Indicate the type of lining material in item 446. If type of tank material is not listed. check CotherÐand enter material. 445. TANK MATERIAL (SECONDARY TANK) - Check the construction material of the tank that provides the level of containment external to, and separate from. the primary containment. If type of tank material is not listed, check Cothel1J and enter material. 446. TANK INTERIOR LINING OR COATING - If applicable. check the construction material of the interior lining or coating of the tank. If type of interior lining or coating is not listed, check [blher] and enter type. 447. DATE TANK INTERIOR LINING INSTALLED -If applicable, enter the date the tank interior lining was installed. This is 10 assist the CUPA to develop an inspection schedule. 448. OTHER TANK CORROSION PROTECTION - If applicable, check the other tank corrosion protection method used. If other corrosion protection method is not listed, check Chther!] and enter method. 449. DATE TANK CORROSION PROTECTION INSTALLED - If applicable, enter the date the tank corrosion protection method was installed, This ;s 10 assist the CUPA 10 develop an inspection schedule. 450. YEAR SPILL AND OVERFILL INSTALLED - Check the appropriate box and enter the year in which spill containment, drop tube. and/or striker plate was installed. CHECK ALL THAT APPLY. 451. TYPE OF SPILL PROTECTION - Enter the type of spill containment. drop tube, and/or striker plate, FOR CUPA USE ONLY, 452. YEAR OVERFILL PROTECTION EQUIPMENT INSTALLED - Check the appropriate box and enter the year in which overfill protection was installed or whether there is an exemption from overlill protection. CHECK ALL THAT APPLY, unless tank is exempt. 453. TANK LEAK DETECTION (SINGLE WALL) - For single walled tanks. check the leak detection system(s) used to comply with the monitoring requirements for the tank. CHECK ALL THAT APPLY. If leak detection system is not listed, check CotherO and enter system, 454. TANK LEAK DETECTION (DOUBLE WALL) - For double walled tanks or tanks with bladder. check the leak detection system(s) used to comply with the monitoring requirements for the tank. CHECK ONE ITEM ONLY, 455. ESTIMATED DATE LAST USED - For closure in place. enter the date the tank was last used, 456. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN TANK - For closure in place. enter the estimated quantity of hazardous substance remaining in the tank (in gallons), 457. TANK FILLED WITH INERT MATERIAL - For closure in place. check whether or not the tank was filled with an inert material prior to closure. .', "-¡:" .$ .~~' ATTACHMENTS- 1. Provide a scaled plot plan with the location of the UST system, including buildings and landmarks. 2. Provide a description of the monitoring program. UPCF(12/99 revised) 11 Fonnerly SWRC 8 Fonn B U.'lflED PROGRUI COl'\SOLlD..HED fOR~1 T\\"KS l"~DERGROU~D STOR-\GE TA~KS - TA.\K PAGE ., VI, PIP¡"C CO'STR LCTIO\ ,':,"" ,¡¡ :nJ: "". l.~DERGROl.;';D ?!?I\G SYSTEM TYPE ?!<ESSlRE 0 : SLCT!O\ CONSTRUcnON 0 I SI"GL-" IHLL 0 ;. lI:\EO TRE\CH 0 '19 OTHER. MM1:FACTURfR tr2 DOl'BLE W....LL 0 'is. L'iK\OW'O MANUf....CTLRER 8;; 461 o I. BARE STEEL 06. FRP COI>I?-\ 7"IBLE wilOO~, METH.-\:-'OL 0 I. BARE STEEL 02. STAINLESS STEEL 07, G....L\'....:\;ZEO STEEL 0 lnlu10wn 02. STA!;\LESS STEEL 01 PLASTIC CO!\IP-\ TmLE W CO:"TE:-:TS 0 'N, O\her O}, ?USTIC CO!\IP,-\ TIßLE W COSTE:"TS S7, FIBERGLASS O~, FLEXIBlE (HDPE) O~. FIBERGLASS OS, STEfL W/COATI:-.IG 09. CATIiODlC PROTECTIO:\ 464 0 S. STEEL W.COAT!:'G \ill. PIPING LEAK DETECTIO:'oì ICh,,' ,II ,h.. I!!A desctioÜon o(:h, monilonn r m .h,11 b, .ubm¡",d to ,t>< local. ,ne> , L~DERGROL"1'D PIPING SI~GLE WALL PIPI:-;G O:.'jR-\'.¡TY PRESSURIZED PIPING (Check ,n th,l,!,ply): [J I. ELECTRONIC liNE LEAK DETECTOR 3.0 GPH TEST W1.TI:I AUTO Pt:MP SHt:T OFF FOR LEAK, SYSTEM FAIlURE. A:-'1) SYSTEM DlSCOJ\'NECTION + AUDIBLE AND VISUAL AlARMS. o 2. MONTHLY 0.2 GPH TEST [J 3. ANNUAL INTEGRJTY TEST (0,1 GPH) CONVENTIONAL SUCTION SYSTEMS [J S, CAlLY VISUAL MONITORING OF PUMP~G SYSTEM + TRJESl'lAL PIPI:-IG INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): [J 7. SELF MONITORING ORA VITY FLOW o 9, BIENNIAL INTEGRJTY TEST (0,1 GPH) SECONDARlL Y CONTAINED PIPING PRESSURIZED PIPING (Check ,!llh.. "I'pl)'): 10. CON1TNt.:OUS TURBINE SUMP SENSOR ~ AUDIBLE AND VISUAL ALARMS AND (Chcek one) II/JÍ. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS I5!rb. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION De. NO AUTO PUMP SHUT OFF D II. AlITOMATIC LINE LEAK DETECTOR (3,0 GPH TESn WITH FLOW SHUT OFF OR RESTRJCTION 012, ANNUAL INTEGRITY TEST (0,1 GPH) SUcnONlGRA VITY SYSTEM ~3. CONTINUOUS SL1I<IP SENSOR + AUDIBLE A.'I1D VISUAL ALARMS EMERGENCY GESERA TORS ONLY (Ch.ck ,lIlh.. ,pply) D 14. CONTINUOUS SL~IP SENSOR WITHOUT AUTO PUMP SHUT OFF· AUDIBLE AND VISUAL ALARMS o IS. AUTOMATIC LlJ\E LEAK DETECTOR (3.0 GPH TEST) illI!:!.Q.!.oI FLOW SHUT OFF OR RESTRJCTlON 016. ANNUAL INTEGRJTY TEST (0,1 GPH) o 17, CAlLY VISUAL CHECK PJ~e ~( 4Ö! ABO';EGRr.JLSD ?,?:,-,~ o I ?R.ESS'_RE 0" SLCT:O-.; 0 " CRA \ITY o I SISGLE W,-\LL 0.5 LS;':;';OW'< 0". DOL'8LE W,-\LL 0 N OTHER M,-\:-.ILF.....C11..:RER 46) .J:-; 400> 46: 06, FRP CaMP.>. fJBLE w, 100', \lETH,~OL o 7, GAL V.>.:\IZED STEEL o 3, F~EXIBLE IHD?E) 099, OTHER 09. C.....THODIC PROTECTION 095, C'IK.\10\>'":'I .a6~ 466 ABOVEGROUJ-;D PIPING SINGLE WALL PIPING PRESSURJZED PIPING (Check ¡II thal,!,ply); o I. ELECTRONIC LINE LEAK DETECTOR 3.0GPH TEST.'!ïIIlJ AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAIlURE, A."D SYSTEM DISCONNECTION + ALDIBLE ASD VISUAL ALARMS, o 2. MONTHLY 0.2 GPH r¡:;ST o 3. ASN1JAl INTEGRITY TEST (0.1 GPH) 04, DAILY VISUAL CHECK .67 CONVENTIONAL SUCTION SYSTEMS (Chec' ,!llh.. '!'Ply) o S. DAIlY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM o 6, TRIE~IAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VAL VES IN BELOW GROUND'PIPING); 07, SELF MONITOIilliG GRA VITY FLOW (Check .!llh.. ,p>ly: 08, DAILY VISUAL MONITORING o 9. BIENNIAL INTEGRJTY TEST (0.1 GPH) SECONDARlL Y COI\T AI:-iED PIPING PRESSURJZED PI PING (Ch,d ,II Ih.. 'Pply: 10, CONTINUOUS TURBINE SUMP SENSOR YL!I!:! AUDIBLE AND VISUAL ALARMS AND (Check on,) o a AUTO PliMP SHUT OFF WHEN A LEAK OCCURS Db AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DC NO AUTO PUMP SHUT OFF 011. AUTOMATIC LEAK DETECTOR o 12. ANNUAL INTEGRJTY TEST (0,1 GPH) SllCTION,GRAVITY SYSTEM o 13. CO,'H!NUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS E:\.IERGE:"CY GENERA TORS O"'L Y (Check ,II Ih.. ,pply) o 14. CO:-.lTINUOUS SUMP SE:-iSOR WITHOUT AUTO PUMP SHUT OFF· AL'DIBLE AND VISUAL ALARMS o 15. ALTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) o 16. A!'o."'-'üAl !:'TEGRJTY TEST (0,1 GPH) o 17. DAILY \lSUAL CHECK DISPENSER CONT AINt-IE;o.;T CATE¡NSTALLED 461 .dá')~ VIII. DISPE:\SER CONT AI"~1E:-;T o I, FLOAT MECHA:,>¡SM THA T SHUTS OFF SHE.-\R V-\LVE 02, CO:-;TI:'>COUS DISPE,'ISER P-\:\ SENSOR· AUDII!LE AND VISUAL ALAR.\IS ID, CONTr:'olCOUS DISPENSER P.>.:-; SE:-.ISOR ~ AUTO SHUT OFF FOR DISPE:\SER . At:DIBLE A:"D VISUAL ,-\LAR.\IS IX. OW:"ERlOPER.ATOR SIG;Ii,ATL"RE 04, DAIL Y VISUAL CHECK o S, TRENCH LINER, MONITORJNG 06,:"'01\E 46Q I ccnify thallhc inform.J.tlon prr~ Id,,;j h.:n:ln J Ir,Jc ;]l1d ;,¡c;'Jr;;¡:c to :hc: best JÎ my k.no',~ Icd;= UPCF (12/99 revised) 470 ~~.. 475 12 Formerly SWRCB Form 8 UST - Tank Page 2 Formerly SWRC8 F::rm 9 (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages, These data element numbers are used fer electronic submission and are the same as the numbering used in 27 CCR, Appendix C. the Business Section of the Unified Program Data Dictionary,) Please number all pages of your submittal. This helps your CUP A or local agency identify whether the submittal is complete and if any pages are separated. 458. PIPING SYSTEM TYPE (UNDERGROUND) - For items 458 and 459, check the tank::.s piping system 459. PIPING SYSTEM TYPE (ABOVEGROUND) information, CHECK ALL THAT APPLY, 460. PIPING CONSTRUCTION (UNDERGROUND) - Check the tank]¡ piping construction information. CHECK ALL THAT APPLY. 461. PIPING MANUFACTURER (UNDERGROUND) . Enter the name of the piping manufacturer. 462. PIPING CONSTRUCTION (ABOVEGROUND) - Check the tank[]¡ piping construction information. CHECK ALL THAT APPLY. 463. PIPING MANUFACTURER (ABOVEGROUND) . Enter the name of the piping manufacturer. 464. PIPING MATERIAL AND CORROSION PROTECTION (UNDERGROUND) - For items 464 and 465, check the 465. PIPING MATERIAL AND CORROSION PROTECTION (ABOVEGROUND) tankl1 piping material and corrosion protection. 466. PIPING LEAK DETECTION (UNDERGRo.UND) - For items 466 and 467, check the leak detection system(s) used 467. PIPING LEAK DETECTION (ABOVEGROUND) to comply with the monitoring requirements for the piping. ' 468. DATE DISPENSER CONTAINMENT INSTALLED - If afJplicable, enter the date that dispenser containment was installed. 469. DISPENSER CONTAINMENT TYPE - Check the type of dispenser containment monitoring system, SIGNATURE OF OWNER/OPERATOR - The owner or agent of the owner shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is true and accurate. 470. DATE CERTIFIED - Enter the date the page was signed. 471. OWNER/ OPERATOR NAME - Print the name of signatory. 472. OWNER/ OPERATOR TITLE - Enter the title of the person signing the page. 473. PERMIT NUMBER - Leave this blank. this number is assigned by the CUPA. 474. PERMIT APPROVED BY - Leave this blank, this is the name of the person approving the permit. 475. PERMIT EXPIRATION DATE - Leave this blank. this is completed by the CUPA. UPCF (12/99 revised) 13 Formerly SWRCB Form B '1'". ,¡ L:\IFlED PROGR..\,\l CO:\SOLIDA TED FOR.\I TA:\KS L-'DERGROLi\"D STOR\GE T.\\KS - T.-\~K P.,\GE I ~~IE.\::::;~~~\I:~ 0 j(H-\:'CEOF:"F':R'.:\~:r_'\ o 6 fE\loC:{\RY 5irE (~O~~E i t'.\.\} ;¡Jg~s pè~ ta:".K \ ! " TYPE Of ACTle" (C1wck;)C'tc Item ..,nl~'1 o ':" P~;i\.) \,'.::....."7"~.~ C:"'()5.~,)I:'. o 3 f,-\\"~E.\IO\ Ea ,,__PJ~' _ >1 _/ " ,t I _'0 I C: \E',\ 5:,:: o'ER,I!, C 3 R5\E'.\"\'- rEiÜ:rT ~ ~;""..: ~; r \ .';.Jj." '" '.:.;~¡ .~ <Jr.:,' (S(c::i\ r:1J.:n ~ ~'m',';;~1 ':'i:.Jnt-.¡ " , If~Yc.J", c.Gmplctc 3M p;~c. (Of cxh i:ornpanmcnt ~J6 I;¡;¡"IBER DF COMPARTMENTS 't: ,-..- 11. T A~K CO:'íTE:'iTS TANK USE 4)9 ~MOTOR VEHICLE FUEL (JI.arbcI 'ampl... Petrol,um Tlpe' C 2. NON.FUEL PETROLEUM o 3. CHEMICAL PRDDUCT a c. HAZARDOUS WASTE PETROlEL'M TYPE o I~. REGULAR UNLEADED Øb. PRë~IIL'M UNLEADD Ole. MIDGRADE L"NLEADED o 2. LE,-\DED o J. DIESEL 04. GASOHOL o 5. JET Ft:EL 06, A VIA TION FUEL. o 99, OTHER ~I CAS~ (from Hazardous Mo..rial. I.,'.olory p.,.) COMMON NAME (from Hsurdous Morerialslo.eolorypa..) 8000 -(iJ 1- 0( (I..lud.. U..d Oil) 0". UNKNOWN G(J~@JJIJ~ m. TA;liK CO:'iSTRUCTIO~ ). SINGLE WAll WITH 5. SrN9LE WAL.L WITH TNTERN.-\L BLADDER SYSTEM EXTERJOR'MEMBRANE LII\ER Ð 95: L'NKNOw:-l 04, S!GSLE WAl.L IN VAULT 099. OTHER ). FIBERGLASS! PLASTIC S. CONCRETE 95. L"'K~Ow:-l 04. STEEl. CLAD W!FIBERGLASS 0 8. FRP COMPTlBLE WIIOOo/. METHA:-IOL 099. OTHER R.EI:-IFORCED PLASTIC (FRP) J. flARE STEEL J. FIBERGLASS.' PLASTIC o 1. STAISLESS STEEL 04, STEEL CLAD WflBERGl.ASS R.E¡:-:FORCED PLASTIC (FRP) o 5. CO:-:CRETE }, EPOXY LI:-':ING rYPE OF TANK t. SI1'>GLE WALL C\ock ...<1 ¡Inn only) ¡¡6' DOl:BLE WALL I. BARE STEEL. 02. STAIMESS STEEL rANK MATERIAL -prim.ry,.ok ::wc.k ODC i\c:m onl,) 'AN" MATERIAL - KCO/Iduy raok I :1aoc:1e...c ¡11m .oly) 5, CONCRETE 95. L"NK:'iOW:-I o a FRP COMPTlBLE W,IOO"lo METHA:-ÓOL 0 '19. OTHER DID. COATED STEEL ANK INTE.RJOR LI:-.ilNG I. Rl.:8BER LINED 5. GLASS LINING 1r16L'NLlNED o 99 OTHER 95. USKNOYlN 446 DA TE I)-IST ALLED 'R CO" TtNG :!lock... ÎIIm onlYI o 2 ALKYD L~ING o ~ PHE:-IOUC LlN!:>IG o 95 L'NKNOWN 099 ornER 448 DATE 11\ST A UED THEIl COIUl.OSION 0 I MANUFACTURED CA THOOIC 0 J FIBERGLASS REINFORCED PLASTIC ROTECTION IF APPLICABLE PROTECTION 04 IMPRESSED CURRENT _Ie... ÎIIm ..Iy) 0 ! SACRIFICIAL ,o,:>/ODE PILL AND OVERFILL YHR fNST ALLED kk allwllf'Ply) ¡¡(¡SPILL. CONTMNME:>IT o-<¡ Ø2DROP Tt:BE 0 ..y æfJšTRIKER PLATE t) Y IV. T A:'iK LE,-\.K DETECTIO~ ,\ duenpuooof,., mon;'onn~ ~ro~"m ,holt be ,.bm"',d.o 'iIe loe,1 '~'ney) 4JJ ,fOf loca111te only. 4J2 4" OVERFILL PROTECTlO:-< EQLiIP~IE\lT:YEAR I!liSTALLED Ø"C ALAR~ ~ 0 J FIL.l TUBE SHL'T OFF VAL \iE It2B,\lLFLOAT éY/ 04EXEMPT 'SINGLE WALL TANKiCh..bllrh".ppIYI IF DOCBLE WALL T.-\1'K OR TA:'<'K WITH BLADDER I Ote::k J"' tlem only' o I VISUAL (SINGLE WALL r,.¡ VAL'L T 01'l VI 01 CO;-;TJ:>:UOUS INTERSTITIAL MO:"ITORI:>:G OJ MA:-'<L'AL MOSITOR!NG I ) I VISUAL (EXPOSED PORTION ONl Y) 05 MA:-:L'AL T ~SK GAl:Gl:"G I MTG1 12 Al1TOMATICHSK GAL'GI:-.IGtAT'G) 06 VADOSE 20.\E I} CONTlNL'Ol,;S ATG 0 ~ GROC~DW,\.TER 14 STA TISTICAlINVE:-'TOR \' RECO~CILf..\ TrON 0 ~ T~"'K TESTI:>:G (SIR) BIENNIAL TA:\K TEST[t\G 0 QQ OTHER IV. T,\:\K CLOSt:RE 1:-; FOR:'>I.·\TIO:-; I PER,\I.-\:\E:'iT ClOSlRE I' PLACE ;TlMATED DA TE lAST UEOI YR,\'IO OA ~¡ J~" ! J,~" T\~K FILLED \\ITH r'lERT \'1-1 YEU~L' o Y,;s 0 .\0 E5TI~I..\ TED (¡LA" TIn' of SLiBST A~LE RE\LIL'I"G gallons PCF (12/99 rcvis~d) 10 Formerly S\I,:RCB Form B lFør local :.u.c only! JJJ J.1J 43' 4J' 440 441 44J ... ..J 441 0\49 ~J~ .¡-i7 UST . Tank Page 1 Formerly SWRCa Farm a Complete t/1e UST - Tar'< pa·;es fcr each tank for aU reN permits. perrr:lt changes. c:oswres anc/or ary other tark ¡dormatIC" cr,ar~e ThiS page must be sub~¡tted -.¡''':Itr:r, 3C days cf per:--:i: ç~r :a::::iity irfor~éi:i.:r c~a"'':çes, i..i;,jess a.::rJval is "e~u:re,j before ¡;"Ia~;~,g 3r':/ ,:ha!";;2s. Fcr compartmentalized :ar:ks. each ccmpartment is ccr,s;cered a 5e~a:a:e lark arc re""lres cC",",;:ieticr of se¡::ara:e lark paçes. Refer to 23 CCR =2711 fer state U ST information ard ;:ermit applicatior, requiremerts, (Note: the numberirg of t~e irs/ructions follows the data element n:.;mbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary,) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages .re separated. 1. FACilITY ID NUMBER - Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility, 3.' BUSINESS NAME· Enter the full legal name 01 the business, , 430. TYPE OF ACTION - Check the reason the page is being completed, For amended permits and change of information, include a short statement to direct the inspector to the amendment or changed information. ;431. LOCATION WITHIN SITE· Enter the location of the tank within the site. '.'432. TANK 10 NUMBER - Enter the ownerl1 tank ID number. This is a unique number used 10 identify the tank. It may be assigned by the , " owner or by the CUPA. 433. TANK MANUFACTURER - Enter the name of the company that manufactured the tank. 434. COMPARTMENTALIZED TANK - Check whether or not the tank is compartmentalized. Each compartment is considered a separale tank . and requires the completion of separate tank pages. , 435. DATE TANK INSTALLED - Enter the year and month the tank was installed. ,;438. TANK CAPACITY - Enter the tank capacity in gallons, 1437. NUMBER OF TANK COMPARTMENTS ·If the tank is compartmentalized, enter the number of compartments. '... ADDITIONAL DESCRIPTION - Use this space for additional tank or location description. , 438. TANK USE - Check the substance stored. If MOTOR VEHICLE FUEL, check box 1 and complete item 440, PETROLEUM TYPE, ',.' 440. PETROLEUM TYPE - If box 1 is checked in item 439, check the type of fuel. .... 1. COMMON NAME - For substances that are not motor vehicle fuels (box 1 is NOT checked in item 439). enter the common name of [he substance stored in the tank. ""2. CAS # . For substances that are nol motor vehicle fuels (bax 1 is NOT checked in item 439), enter the CAS (Chemical Abstract Service) number, This is the same as the CAS # in item 20~ on the lrIazardous Materials Invenlory - Chemical Descriptionpage. .u3. TYPE OF TANK - Check the type of tank construction. If type of tank is not listed. check LbtherO and enter type. 444. TANK MATERIAL (PRIMARY TANK) - Check the construction material of the tank that comes into immediate contact on its inner surface with the hazardous substance being contained, If Ihe tank is lined do not reference the lining malerial in this item, Indicate the type of lining material in item 446. If type of lank material is not listed, check CotherOand enter material. 445. TANK MATERIAL (SECONDARY TANK)· Check the construction material of the tank that provides the reve: of containment external to, and separate from, the primary containment. If type of tank material is not listed, check CbtherC and enter material. .uS. TANK INTERIOR LINING OR COATING - If applicable, check the construction material of the interior lining or coating of the tank, If type of interior lining or coating is not listed, check CDtherJ and enter type, 447. DATE TANK INTERIOR LINING INSTALLED -If applicable, enter the date the tank interior lining was installed. This is to assist the CUPA to develop an inspection schedule, 448. OTHER TANK CORROSION PROTECTION - If applicable, check the other tank corrosion protection method used. If other corrosion protection method is not listed, check ~lherÐand enter method, 449. DATE TANK CORROSION PROTECTION INSTALLED - If applicable, enter the date the tank corrosion protection method was installed. This is to assist the CUPA to develop an inspectíon schedule. 450. YEAR SPILL AND OVERFILL INSTALLED· Check the appropriate box and enter the year in which spill containment. drop tube, and/or striker plate was installed. CHECK ALL THAT APPLY. 451. TYPE OF SPILL PROTECTION - Enter the type of spill containment. drop tube, and/or striker plate. FOR CUPA USE ONLY. 452. YEAR OVERFILL PROTECTION EQUIPMENT INSTALLED - Check the appropriate box and enter the year in which overfill protection was installed or whether there is an exemption from overfill protection. CHECK ALL THAT APPLY, unless tank is exempt. 453. TANK LEAK DETECTION (SINGLE WALL) - For single walled tanks, check the leak deteclion system(s) used to comply with the' monitoring requirements for the tank, CHECK ALL THAT APPLY, If leak detection system is not listed, check [¡¡therG and enter system, 454. TANK LEAK DETECTION (DOUBLE WALL) - For double walled tanks or tanks with bladder, check the leak detection system(s) used 10 comply with the monitoring requirements for the tank, CHECK ONE ITEM ONLY. 455. ESTIMATED DATE LAST USED - For closure in place, enter the date the tank was last used. 456. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN TANK - For closure in place, enter the estimated Quantity of hazardous substance remaining in the tank (in gallons), 457. TANK FILLED WITH INERT MATERIAL· For closure in place. check whether or not the tank was filled with an inert material prior to closure, ATTACHMENTS· 1, Provide a scaled plot plan with the location of the UST system, including buildings and landmarks. 2, Provide a description of the monitoring program. UPCF (12/99 revised) [ [ Formerly S\VRCB Form B L~IFIED PROGRU{ CO~SOLIDA TED FOR.\{ T .-\~"l<5 L~DERGROL~DSTOR~GETA~KS-TÂ~KPÂGE2 \1. PIPI"C CO"STRL~Tl0\j ':'"" ,i"'''''C l"'\2::RCROl"-iC ?i?[\C ¡ SY:> ,,:.M TYPE PR.ESS'3::. 0 : SLC:-:O' C:;"S~\;CT10'l 0 I Sí'iGL:: W ,L~ 0 J. U:-'EJ n.E\CH MA.""'f~CTU.£R ~ DOLSLS w....ll. 0 ~5, C'iK:\O\\'\ MA.'l1..iFACTl RER 5. ~61 C ; BARE STEEL 0 ó. fR? COMP-,- nBLE w. 100"', METH.~\OL 0 I, BAiŒ STEEL I 0 2., ST A¡:-;LESS STEEL 0 ~,GAL \',....:-¡IZED STEEL 0 Lnknown 01. SBI:"LESS STEEL I 03 PLASTIC CO'1P.... nULE W COSTESTS O.¡q, Other O}, PUSTIC CO,IPHI8LE W CO'iTE.'HS I 111!4, FtBf.RGLASS 0 ~. FLEXIBLE (HOPE) O~. FIBERGLASS 05. STEEL Wlco^nSG 09, CAmODIC PROTECTION ~61 D S. STEEL W.COATr-;G \ill, PIPI:'o'G LEAK DETEC710N ¡Chock ,1I,n.. IIA <1<",; fion o{:he mon;lono r L~DERGROL'ND PIPING SI~GLE WALL PIPING 0:, CiK,··:n 0-19 UT<1E;{ PIl£SSUJUZED PIPING (Che<k ,/I 'h.c apply): IJ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MIJ:I ,.,UTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE. AND SYSTEM DISCONNECTION + AUDIBLE A.'D VISUAL ALARI\,jS. C 2. MONTHL Y 0.2 GPH TEST CJ J. ANNUAL I t-.TEGRlTY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS CJ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING (NTEG RlTY TEST (0,1 GPH) SAFE SUCTION SYSiCMS (NO VALUES IN BELOW GROUNDPIPING); 07. SELF MONITORING JRA VITY FLOW :J 9. BIENNIAl. rNTEGRlTY TEST (0.1 GPH) " SECONDARlL V CONTAINED PIPING 'RESSURlZED PIPING «(beck ,lllhal 'Pply): O. CONTINliOUS TURBINE Sl:MPSE:-ISOR1tlI/:I AUDIBLE AND VISUAL ALARMS AND (Chcct one) S!(.'. AL'TO PUMP SHUT OFF WHEN A LEA!( OCCURS !55'b. AUiO PUMP SHUTOFf fOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION Dc, NOAlJTOPUMPSHUTOFF J 11. AUTOMATIC LfNE LEAK DETECTOR (3.0 GPH TESn WITH FLOW SHUT OFf OR RESTRICTION J 12. ANNUAL INTEGRITY TEST (0.1 GPH) UCTlONlGIlAVITY SYSTEM (i]. CONTINUOUS SL'!\.IP SESSOR + AUDIBLE A..'D VISUAL ALAR."'1S EMERG E.'CV CESERA TORS ONL Y (Cheek ,II ,hal 'pply) ] 14. CONTINUOUS SL'!\.IP SE.'SOR WITHOI1T AUTO I'll-II' SHUT OFF . AUDIBLE ^:>;D VISC-'.L ALAR."1S ) IS. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ~ FLOW StruT OFF OR RESTRICTION 116. ANNUAL INTEGRITY TEST (0,1 GP!!) 117. DAILY VISLAL CHECK P:1¡, of .&!~ ..\,BCVEGR'.)L'\C ?,?::--,,3 SLCT'O'i 0 : C~A \'IT\' o ./; L~K:-;OW" C .;0 OTHER -I<>.: [j: ?R.::'S3:Ò '¡:-J ~. ~bJ o l. SI:-;GL¿ ''\"LL o 2, DOLS ~E: 'Á ....LL .\!.-\NLF.....C1l.:'<.ER 46J 06, fR? eo 1-1 ?..... TlHLE ""',100', ~ETH.~~OI. 07. GALV.....NIZED STEEL 03, fLE.'C!JLE ¡HOPE) D 9" OTHER o 9. CA THODlC PROTECTION o q$, L':'oIK:'oIOWN "6~ sh;¡/ be J\.Ibmlltcd :0 the loa! CtIC . ~ ABOVEGROLND P¡PrNG SINGLE WALL PIP~G PRESSURIZED PIPr.-iG (Check all lb. apply); o I. 'ELECTRO:-O;¡C LINE LEAK DETECTOR 3.0 GPH iCST m!:J AUTO Pt.'MP SHUT OFF FOR LEAK, SYSTEM FAILURE, A.'D SYSTEM DISCONNECTION + AUDIBLE A:"ID VISL:AL ALAR.MS. o 2. MO¡o.,1'HL Y 0,2 GPH iCST 03. A:\-:-IUAL INTEGRITY TEST (O,IGPH) 04, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check ,11th.. apply) o 5, DNL Y VISU^L MONITORING OF PIPING A:-ID PUMPING SYSTEM D 6, TRJE;o.INIAL INTIGRITV TEST (0,1 GPH) SAFE StJCTlON'SYSTEMS (NO VALVES IN BELOW GROUND:PIPING); o 7. SELF MONlTORJ1oõG 467 GRA VITY FLOW. (Cheek.1I ,h.. ~ply): 03. DAILY VISUAL MONITORING o 9. BIE~IAL INTEGRJTY TEST (0. I GPH) SECONDARILY CONTAINED PIPINC PRESSURIZED PIPI:--;G ,Check .11 :hal 'PPlyl: 10. CONTINUOUS rt:RSI:>IE SL'MP SENSOR ~ AUDIBLE A.'D VISUAL ALARMS AND (Check 00') o a AUTO peMP SHI.;T OFF WHEN A LEAK OCCURS D t> AUTO PLMP SHUT OFF FOR LEAKS. SYSTEM FAILURE A.'D SYSTEM DISCONNECTION Dc NO AuTO PUMP SHUT OFF o II. AUTOMATIC LE^K DETECTOR o 12. A:-INtJAL INTEGRITY TEST (0.1 GPH) SUCTION-GRAVITY SYSTEM o 13. CO:-lTINUOUS SUMP SENSOR + AliOlSLE A:\'D VISUAL ALARMS EMERGE."CY GENERATORS ONL V (Cheek.1I 'h.. ,pply) o 14. CON1'lNlJOlJS Sl:MP SE:-ISOR ~ AUTO P¡;MP SHlJT OFF' AL'DIBLE AND VlSL'AL AL^RMS o IS. ALTOMA TIC LlI'E LEAK DETECTOR (3,0 GPH TEST) o 16, A1'o~UAL f:'¡TEGRlTY TEST (0, I GPH) 017. DAlL Y VISUAL CHECK VIII. DlSPE~SER CO:-iT A[~\tE:"iT o 1. FLOAT MECHA:-;IS;\1 THA T SHUTS OFF SHEAR VALVE D 1, CO¡';TI~L'OlJS DISPE,-';SER PA:> SE:oiSOR . ALDJBLE A'iD VISL:AL ALAR,\tS rJ3, COS1'I:\'I..'OI1S DfSPE:'oiSER PA:"i SE:\'SOR WITH AUTO SHLT OFF FOR. DISPE:-<SER . AL;OISLE .....'iD VISI..'AL ALAR),IS IX. OW'iER:OPER.-\TOR SIG:"iATtJRE !SP~SER CONT r\I:;ME~T ,TE[NSTALLED ~ ~-cf£JO~ ,,¡fy !Mllhc inform,¡uon pr('!\ Ided: ~('f't:" J ~r".JC Jnd .1c::Jt;¡~e:o the b.;it:)f my "~\Ao\c:d:;e ?CF (12/99 revised) 04. DAfL Y VISL.'AL CHECK 05. TRE,-';CH USER. MO~ITORl'iG 06, \OI-oE 46q "Q ,n ,., Permn ~~pll'2:lon Da~ I Fur loc,¡J \4iC un)YJ .7} 12 Formerly SWRCB Fonn B UST - Tank Page 2 Formerly SWRCB Form B (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages, These data element numbers are used fer electronic submissicn ar.d are the same as the numbering used in 27 CCR. Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. Thjs helps your CUPA or lecal agency identify whether the submittal is complete and if any pages are separated. 458. PIPING SYSTEM rfPE (UNDERGROUND) - For items 458 and 459. check the tank1 piping system 459. PIPING SYSTEM rfPE (ABOVEGROUND) information. CHECK ALL THAT APPLY. 460. PIPING CONSTRUCTION (UNDERGROUND) - Check the tankCS piping construction information. CHECK ALL THA T APPLY. X::481. PIPING MANUFACTURER (UNDERGROUND) - Enter the name of the piping manufacturer. i~'·J~,,· ~:~ -- : - -. '. - $'<482.' PIPING CONSTRUCTION (ABOVEGROUND) - Check the tankCS piping construction information. CHECK ALL ., THAT APPLY. ~, ~~3. PIPING MANUFACTURER (ABOVEGROUND)· Enter the name of the piping manufacturer. :::,.c84. PIPING MATERIAL AND CORROSION PROTECTION (UNDERGROUND)· :t¿-i85. PIPING MATERIAL AND CORROSION PROTECTION (ABOVEGROUND) ~~¡;.,. - F;;-;": ~'/~; For items 464 and'465, check the tank[$ piping material and corrosion protection~ }" 466. PIPING LEAK DETECTION (UNDERGROUND) - For items 466 and 467, check the leak detection system{s) used ~" 467. PIPING LEAK DETECTION (ABOVEGROUND) to comply with the monitoring requirements for the piping,' ' 488. DATE DISPENSER CONTAINMENT INSTALLED ·If applicable, enter the date that dispel1Ser containment was installed, 469. DISPENSER CONTAINMENT TYPE - Check the type of dispenser containment monitoring system. SIGNATURE OF OWNER/OPERATOR - The owner or agent of the owner shall sign in the space provided, This signature certifies that the signer believes that all the information submitted is true and accurate. 470. DATE CERTIFIED· Enter the date the page was signed. 471. OWNER! OPERATOR NAME - Printthe name of signatory. 472. OWNER! OPERATOR TITLE - Enter the title of the person signing the page. 473. PERMIT NUMBER - Leave this blank, this number is assigned by the CUPA. 474. PERMIT APPROVED BY - Leave this blank, this is the name of the person approving the permit. 475. PERMIT EXPIRATION DATE - Leave this blank. this is completed by the CUPA. UPCF (12/99 revised) 13 Formerly SWRC8 Form B .. , , ...'1 l:\IflED PROGR.-\:\I CO:\SOL!O.-\ TED FOR.\I TA:\KS L'DERGROC'DSTORAGETA~KS-TA~KPAGEl 7':?E 0;: "'CT,C,>; [J ; 'E'·> S. ,: ?E~;'iiT ~" ""'~"-'\"- 1I1 .t. .\,..c. ¡,¡::..; :':-.,-{. d \ I !',\'-; .:'J~-:s p~;" :a~k i "J~: _:)f __ (~'d. YlC :Icm .;'nl:'1 ---- o ~ CHA"Cr:OF :'-f':?:'\\ ~.U" 0 6 ~~\"(:?,\:t, S:TE C:'0':3, E o .. -):: ~ ',I \ \, E.'\"7'L y C~C5,:::-J "_:, \ Si:-E C : R..:S E',\,' \~ r::K.\~~T I :!:-.:~ '. ";l)l.1n . _-..:..:.1 .S( ·..:ni~ I : S...c::f~ r:Ut;n - :'''f '\XJi Ji~ ::,nl:_! 1('·..l'"u-, çompJc:re ~nc ~gc (0( c~ch ¡:ompanmcnl JJ6 !\L'MBER OF COMPARTMENTS ADDITIONAL DESCRIPTION ,For [DC>! "'c onlyl II, T A:-IK CO:'<TE~TS TANK USE m ~M01'OR VEHICLE FUEL (JI..n.d 'ampl... P.rrol,um Type) CJ 2. NON-FUEL PETROLEUM OJ. CHEMICAL PRODCCT 0... HAZARDOUS WASTE (IDCludu U..d Oil) 095. UNKN0:wN PETROLEUM TYPE o la. REGULAR L~LEADED o It>, PREMIUM C:';LEADED Ole, MIDGRADE lNLEADED o 2. LE....DED !E"3. DIESEL o 4. GASOHOL o 5. JET F\iEl 06. A VIA TIOII FUEL o 99. OTHER 441 CAS# (from Hazardous "'¡m·ri..lt In'Cn1Þr')' P¡&~) 442 COMMON NAME ¡rromHlurdo", MI..ri.II In.,n,oryp"') 5íeSe/ #2 TYPEOFTAN1<. I. SP.I<GLE WALL 1II. TANK CO~STRVCTIO," J. SINGLE WALL WITH S. SNGLE W~LL WITH fNTER1"AL BLADDER SYSTEM EXTERIOR MEMBRA~E U¡";ER Ð 9j: t;NK~O~ 04, SIG1'õLE WALL IN V AUtT 099. OTHER 3. FIBERGLASS! PLASTIC 5. CO:-¡CRETE 95. liSK:\OWN 04, STEEL CLAD WlfIBERGL....SS 0 g, fRP COMPTlBLE WilOO'f, METHA:-<OL 099. OTHER RE:'iFORCED PLASTIC (FRP) J. FIBERGLASS! PLASTIC 04, STEEL CLAD W.FIBERGLASS RE¡:-¡FORCED PLASTIC IFRJ') o 5, CO:-;CRETE 3. EPOXY L/:"II:'IiG ....7 443 :C1Iock one ¡Ian only) Œ!2. DOUBLE WALL I. BARE STEEL 02. STAI¡..;lESS STEEL ..... rANI( MA iERlAL - primary ..nk Ckck ODe' ncm only) i ANK MA TERIAL - ..co.dlry rank o.eck. one ¡\em onl)') I. BARE STEEL 02. STAI:-ILESS STEEL 5, CO:-;CRETE 08, fRP COMPTIBLE W./()iJn¡o ~ETHASOL 010, COATED STEEL 95, UNK:\O\l,'N 099, OTHER +15 'ANK INTERIOR LINING t. Rl:BI3ER LINED 02 ALKYD LNfSG 5. GLASS UNI:-<G !Yf6úNLINED o ~9 OTHER 95. UNKNOWN ..... DATE INSTALLED 04 PHE:-IOLlC UNJSG IR COATING ~k .... ium only) (For Jocal:JJ.e ollly) 'THER CORROSION 0 ¡ MANUFACT1..:RED CA THODlC ROTECTION IF APPLICABLE PROTECTION :1Icc:k .... il<m only! 0 ! SACRlFICIAL A:'>IODE PU..L AND OVERFILL YEAR rNSTALLED :1Icc:k all w.. apply) I2(ÎsPILLC01'õTAINMENT 0,,-/ Ø2VROP Tl;BE () 1" (I13šTRIKER PLATE ð 'Ý OJ FIBERGLASS REINFORCEOPLASTIC o ~ IMPRESSED CURRE:';T o 95liNK!'O\IIN 099 OTHER -148 .a.l9 DATE INSTALLED IFor loe..I UJC only) J~I OVERfILL PROTECTION EQCIP~IE,"'TYEAR I;\iSTALLED Øí: ALAR.'l.1 ø'1 03 FILL TüBE SHUT OFF VAL VE iã2 B,\LL FLOAT M 04 EXEMPT 412 IV. T "\~K LEAK DETECTIO~ (.... dcscrtp(iot\~f~hc rnot\itQnng ~ro,rJ.m \l'Lalt be \u.blTllu~d:Q ~bc toc,),1 J.,~nc:,! I '5J = SINGLE WALL TANK ¡Check ,Ii 'h>! >polyl IF DOL'BLE WALL TASK OR TA:"õK WITH BLADDER \Cr.~::k )nc Item en':;) 01 VISL:AL(SINGLE IqLL (~V,...L'lTO:-;Lyt o ~ CO"TI:-<COL:S I:-<TERSTITIAL MO'>ITORI:-;G 03 i'lA:-CAL MO:-;ITORJ\;G 414 ] I V1St:AL tEXPOSEDPORnON ONL Yi 0 S MA:-;U.\L T "'~K GAL:GI:-óG ¡!\.ITG) J 2 ALJTOMATlCn:-ÓK GAlGI:"G¡....TG1 0 6 VADOSE ZO:-;E ] J CONTINt:OtJS ,HG 0 ; GROL:~DWHE~ J 4 STA TtST!C.\L ¡SVES TOR Y RECO:-;ClLlA TlON 01 TA";; TESTJ:-;G (SIR) BIENNIAL TA:"K TESTI!\G 099 OTHER IV. T..\~ ( CLOSlRE I~FOR.".,\ TlO." / PER,\IA,'E.''iT ClOSLRE I.' PLACE >TIMATED D..HE lAST UFO' YR."IO DA Y I ~jj .¡5h T "'''K "ILLEO II ITf! !"F~ T \1.... TE?: ...t.' .F o Y':s 0 ,~ ESnq·\ TED QL·\" TlTY (Jf SLHSrASCE RE.'l.IA;"I:-;G !:ö!lûns PCF (12/99 revised) 10 Formerly SWRCB Form B J!O .)1 J.'J U1 431 440 UST - Tank Page 1 .:r1y SWRCB F Ci,-;¡ a ,nplele the UST - To3r< pages fcr each :ark fer all :-.ew p2r~lts, per:::lt ::1 a,-:<;;2s , closures ardior ary other tark irforrna'ì::;r c~a¡,;e ihls age must be sub~¡tt¿~ .·~'itrir. 3C '':ays ,=f ~er;'ii: or f~c:ijíY :r~':"'~êil:n C,"'2.-;e5, ~;e~s a:çtJvaì 's re,~uire': befcre (';.ai,:r.; ary ct":a"·g9:s Fcr compartmentalized tark5, each c:mpart~ent is :~nSide~=c: 3 5eçaía~e :an<. ar"c ,"eç'..J:r¿s ::í'"1pietIGr. :;f 5e~aí3~e rar.~ ;a,;-:s, Refer to 23 CCR :::271 1 for stale USï informaLcn and ;¡ermlt ap¡:ka::or reqUlref'":erts. (Note: the numberirg of the irstructions follows the data eI2me,-:t numbers tt',at are on the UPCF pages, These data element numbers are UMd for eledronic submission and are the same as the numbering used in 27 CCR. A~pendix C, the Business Section of the Unified ?rcgram Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or Iccal agercy ¡der.tify whether tt1e submittal is complete ard if any pages are separated. 1. FACILITY ID NUM8ER . Leave this blank, This number is assigned by the CUPA. This is the unique number which identifies your facility. 3. BUSINESS NAME - Enter the full legal name of the business. 430. TYPE OF ACTION· Check the reason !he page is being completed. For amended permits and change of information, include a short f statement to direct the inspector to the amendment or changed information. k~.a1. LOCATION WITHIN SITE· Enter the location of the tank within the site, r<~. TAN~ ID NUMBER· Enter the owner':$ tank ID number. This is a unique number used to identify the tank. II may be assigned by the r.'" -',' owner or by the CUPA, ' ~ " 433. TANK MANUFACTURER· Enter the name of the company that manufactured the tank, ~.: 434. COMPARTMENTALIZED TANK - Check whether or not the tank is compartmentalized. Each compartment is considered a separate lank ~:" and requires the completion of separate tank pages. f'"435. DATE TANK INSTALLED - Enter the year and month the tank was installed. f:;:43e. TANK CAPACITY - Enter the tank capacity in gallons. f:·¡437. NUMBER OF TANK COMPARTMEN~S - If the tank is ?ompartmentalize?, enter t~e.number of compartments. r',43Ø. ADDITIONAL DESCRIPTION - Use this space for additional tank or location descnptlon. 438. TANK USE - Check the substance stored. If MOTOR VEHICLE FUEL. check box 1 and complete item 440, PETROLEUM TYPE. . -..440. PETROLEUM TYPE - If box 1 is checked in ltem 439, check the Iype of fuel. ;' 441. COMMON NAME - For substances that are not motor vehicle fuels (box 1 is NOT checked in item 439), enter the common name afthe substance stored in the tank, 442. CAS ## - For substances that are not motor v~hicle fuels (box 1 is NOT checked in item 439). enter the CAS (Chemical Abstract Servi.ce) numbe·r. This is the same as tt1e CAS # in item 209 on the lriazardous Materials Inventory - Chemical Description page. 443. TYPE OF TANK· Check the type of tank construction, If type of tank is not listed, check CotherD and enter type. 44-4. TANK MATERIAL (PRIMARY TANK) - Check the construction material of the tank that comes into immediate contact on its inner surface with the hazardous substance being contained, If the tank is lined do not reference the lining material in this item. Indicate the type of lining material in item 446, If type of tank material is not lisled, check CbtherJand enter material. 445. TANK MATERIAL (SECONDARY TANK) - Check the construction material of the tank that provides the level 01 containment external to, and separate from, the primary containment. If type of tank material is not listed, check [bther= and enter malerial. 448. TANK INTERIOR LINING OR COATING - If applicable, check the construction material of the interior lining or coaling of lhe tank, If type of interior lining or coating is not listed, check [bther::) and enter type. 447. DATE TANK INTERIOR LINING INSTALLED -If applicable, enter the date the tank interior lining was installed, This is to assist the CUPA to develop an inspection schedule. . 448. OTHER TANK CORROSION PROTECTION - If applicable. check the other tank corrosion protection method used. If other corrosion protection method is not listed. check CbtherG and enter method, 449. DATE TANK CORROSION PROTECTION INSTALLED - If applicable, enter the date the tank corrosion protection method was installed. This is to assist the CUPA to develop an inspection schedule, 450. YEAR SPILL AND OVERFILL INSTALLED· Check the appropriate box and enter the year in which spill containment, drop tube, and/or striker plate was installed. CHECK ALL THAT APPLY. 451. TYPE OF SPILL PROTECTION - Enter the type of spill containment. drop tube, and/or striker plate. FOR CUPA USE ONLY. 452. YEAR OVERFILL PROTECTION EQUIPMENT INSTALLED - Check the appropriate box and enter the year in which overfill protection was installed or whether there is an exemption rrom overfill protection. CH~CK ALL THAT APPLY, unless tank is exempt. 453. TANK LEAK DETECTION (SINGLE WALL) - For single walled tanks, check the leak detection system(s) used to comply with the monitoring requirements for the tank, CHECK ALL THAT APPLY. If leak detection system is not listed, check CDthetC and enler system. 454. TANK LEAK DETECTION (DOUBLE WALL) . For double walled tanks or tanks with bladder, check the leak detection system(s) used to comply with the monitoring requirements for the tank. CHECK ONE ITEM ONLY. 455. ESTIMATED DATE LAST USED - For closure in place, enter the date the tank was last used. 456. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN TANK - For closure in place, enter the estimated Quantity or hazardous substance remaining in the tank (in gallons), 457. TANK FILLED WITH INERT MATERIAL - For closure in place. check ·...,hether or not the tank was filled with an inert material prior to closure, ATTACHMENTS· 1. Provide a scaled plot plan with the location of the UST system. inclL:dirg buildings and landmarks. 2. Provide a description of the monitoring program, UPCF (12/99 revis~t.!) 11 formerl:-- SWRCB Form B .J ,. '. l~lflEO PROGR-\:\( CO:\"SOLI0.-\ TED FOR\t T-\.'iKS C~DERGROC:\D STOR"GE T-\:\KS - T.-\:\K PAGE 2 VI. PIPI"óC CO"SIRLC110~ . :',":< ,I""". ,~- fI~~ ,1' r;-.:::-::RCROL'iC :>:?!':C ! ,-\3C',E,~ ;:<,JLSD ?I?: ~ ,J 5YSrEM reo: M"t PRESSLR.:: o : SL:.:rc' 0:. ~~ ...·,~·:TY "\ ' ~ ? :¡;' " :_ iE 0' SLCT'c" I I ; :: c~,"'''"[n· J5-ì COSSTRl:CTlO" o I S¡"GLE. W,...L.L o j. U:'-ED TRE,-(H 0'19, OiHER .óù 0; S'''Ci.E '...-ILL o~; LSK.'OW" 4~ MA.'it:FKn.;UR rrT DaLBLE W...lL o ~S. L"K~OW" 01. DOL3LE WALL o .9 OTHER MANlF.-\CTlRER A () 8"-,, 'd £6: ~1.~SCFACn.;RER 4I>¡ o I. BARE STEEL o 6, fR? CO,\IP-\ TrBLE ",,zOC", METH....,\Ol 0' SARE >TEE,- o ó FRP CO/'./?A Tmu, W,IOO", \fETHA~Ol .. o 2. ST ,>\iN LESS STEEL 0', G....l.\'....SIZED STEEL o Lnl<oo"'n 02. 5T A~LESS S7EEL o 7, GAL V,..."'ZED STEEL OJ. PLASTIC CO,\I?A TrOlE II', CO.\':E\TS 09<1, Other OJ PLASTIC CO~IP,~ 'ìBL.E W ceSTESTS o ~, FL"X ,SLE (HJi':i 099. OTHER 51r4. FIBERGLASS o ~. fLEXIBLE: (HOPE) o~. FIBERGLASS o 9. CA mODIC PROTECTION o 5. STEEL W.'COA rr~G 09, CATHODIC PROTECTION 4bJ 05. STEEL W.COAT!:'G o 9'. t::\'K.\iOW~ "6~ . VII. PIPING LEAK DETECïION ICñt:k.1I :h&l ..,.Iv" " dncnorion >,<11, mo""o,m, orO<T:lrn ,h,1I b. .ubm''',d '0 ,110 loaJ ..,"'. ¡ L;o;DER.GR.OUND PIPCNG ABOVEGROLIND PIPING SI:'iGLE WALL PIPING .a66 SINGLE WALL PLPING 41\7 , RESSIJ1UZED PIPING (arck.1! Ih.. apply): PRESSURIZED PIPING (CMdr ¡J lis.. apply): " C I. ELECTRONIC UNE LEAK DETECTOR 3.0 GPH TEST ~ AUTO PliMP SHtiT o I. £LECTR01\"IC LINE LEAK DETECTOR 3.0 OPH TEST MII:f AUTO PUMP OFF FOR LEAK. SYSTEM fAILURE. AND SYSTEM DISCONNECTION + SHLT OFF fOR LEAK, SYSTEM FAILURE. A..\iD SYSTEM DISCONNECTION + AUDIBLE AJI/D VISUAL ALAR....iS, AUDIBLE A.'IO VISL'AL ALARMS, C 2. MONtHLY 0.2 GPH rEST 02. M01<THL Y 0.2 GPH rEST C 3. ANNUAL INTEGRITY TEST (O.IGPH) o 3. .~~-:-;1.:,"'L MEGRlTY TEST (O,IOPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Ch«k.11 Ib.1 apply) o ,. DAlL Y VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING OS. DAlLY VISUAL MONlTOR!NG OF PIPING AND PL'MPING SYSTI:M INTEGRITY TEST (0. f GPH) IAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROllNDPIPING): o 6: TRIE~-:-;IALINTIGR¡TY TEST (0.1 GPH) C7,SELF MONITORING SAFE SUCTION SYSTEMS r.-O VALVÉS IN BELOW GROUND,PIPING): ORAVrrYFLOW o 7. SELF MONITOIWo;G [J 9. BIENNIAL INTEGRITY TEST (0,1 GPH) GRA VITY FLOW (Ch«k.1I ,eu, a¡oply): OS. DAILY VISUAL MONITORING o 9. B!E"~IAL INTEGRITY TIST(O,¡ GPH) SECONDARILY CONTAINED PIPING SECONDARlL Y CaNT AIS ED PIPING ~R.ESSURlZED PIPING (a...\; .11 :hl< applyl: PRESSURIZED PIPI:-.'G ICI>,<I.II :hot 'l'pIYI: 10. CONTINUOUS TURBINE SUMP SENSOR ~ AUDIBLE AND VLSt:Al. 10. CONTINt:OUS TCRBINE SUMP SE:olSOR ~ AUDIBLE AND VISUAL - ALÞJlMS AND ¡a...k one) ALAR.\1S A:-.1D (Check one) 82Ía. AUTO Pl:MP SHUT OFF WHEN A LEAK. OCCURS o . AUTO Pt:MP SHUT OFF WHE~ A LEAK OCct:RS 15!b. AUTO PUMP SHUTOFF fOR LEAKS. SYSTEM FAIU'RE AND SYSTEM Db AUTO PI.:MP SHt:T OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISC O¡.,;-'¡ ECTION Dc, NO AUTO PUMP SHUT OFF Dc NO ALTO PUMP SHGT OFF J 11. AUTOMATIC LCNE LEAK DETECTOR (3.0 GPH TESTI ~ FLOW Sm;T D 11, AUTOM,>.. TIC LEAK DETECTOR OFF OR RESTRICTION I J 12. ANNUAL INTEGRITY TEST (0.1 GPH) D 12. A:-n;¡;AL INTEGRlll' TEST (0,1 GPH) ,\JC110NJORA VITY SYSTEM SUCTION:GRAVITY SYSTEM jl'Í3. CONTINUOUS SL~P SENSOR + AUDIBLE AND YISt:AL ALARMS D 13. CONTINUOUS SUMP SESSOR + A UDIBLE AND VISUAL ALAR.\1S EMERGE:'/CY GE:'/[RA TORS ONL Y (Check ,II th.. 'pplyJ £~ŒRGENCY GENERA TORS ONLY IC1\«k 111 'hot 11'1>1y) ] 14. CONT1N1JOUS SLMP SENSOR WITHOL:T AUTO PUMP SHUT OFF' o 14. CONTI:o-.'1.:0t..:S SCMP SENSOR WITHOL'T AUTO PUMP SHUT OFF . AUDIBLE A:-ID \,1SCAL ALARMS AUDIBLE AND VlSCAL ALARMS J 15. A l..'TOM A TIC UNE LEAK DETECTOR (3.0 GPH TEST) illI!:!Q!il: FLOW o IS. AtJTOMATiC UNE LEAK DETECTOR (J.OGPH TESn SHUT OFF OR RESTRICTION ] 16, ANNUAL INTEGRITY TEST 10,1 GPH) o 16. A:-'~Al r,\TEGRJTY TEST (0,1 GPH) I J 17. DAILY VISUAL CHECK 017, DAIlY\lSUALCHECK VIII. DISPE:\SER CONT AI:-<;\tE:\T ISPENSER CONTAr.;MEST o L FLOA T MECHA;,\¡S~ TH" T SHCTS OFF SHE~R VALVE 04. OAIL Y vlSt:AL CHECK ATE fNSTALLEO 461 01. COI'TISL'O¡;S DISPE:-.ISER P,...:O: SE:>:SOR' ALPlBlE ASP VISLAL ALAR.\IS D 5, TRESCH USER, MO~lroRlNG ':Jfi - dLJO'V f). COiloTr..tCOL'S DISPE:-.ISER. PA~ SENSOR !UI!:i ALTO SHLT OFF FOR o 6. :-<01\E 4ðq DISPE:>iSER . AL"OI8LE .~~O VISUAL ALAR.\IS IX.OW:"IER:OPERATOR SIG:'iATL'RE cni tIw the ~rorm,¡tIOI' rN Idc~ herein is Ir.¡ó: Jnd Joc:..,r,ltc::o :hc bt::H ~;my kno...lcd¡;e '-ME ~71 DAT5, TITLE Of .¡;: 4~O Perm. E-CplC1tlOn Dalc ¡fur IOCJI -lSC o"ly) 4;5 PCF (12/99 revised) I:! Formerly SWRCB Form B UST - Tank Page 2 Formerly SWRca Form 8 (Note: the numbering of thé instructions follows tre data element numbers that are on the UPCF pages, These da~a element numbers are used for eiectronic submission and are tre same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Da:a Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and jf any pages are separated. 458. PIPING SYSTEM TYPE (UNDERGROUND)· For items 458 and 459, check the tank::5 piping system 459. PIPING SYSTEM TYPE (ABOVEGROUND) informaticn. CHECK ALL THAT APPLY. 460. PIPING CONSTRUCTION (UNDERGROUND) - Check the tanlû piping construction information. CHECK ALL THAT APPLY. ~:t: 4161. PIPING MANUFACTURER (UNDERGROUND) - Enter the name of the piping manufacturer. ~j:i " ~4e2. PIPING CONSTRUCTION (ABOVEGROUND) - Check the tanklS piping construction information. CHECK ALL ~i THA r APPLY. .~ g;t463. PIPING MANUFACTURER (ABOVEGROUND) . Enter the name of the piping manufacturer. t":X £;]~484. PIPING MATERIAL AND CORROSION PROTECTION (UNDERGROUND) - For items 464 and 465, check the ~:~485. PIPING MATERIAL AND CORROSION PROTECTION (ABOVEGROUND) tankl1 piping material and corrosion ¥! protection. ,*,~~ ;"-' -~;'. ~>t 4166. PIPING LEAK DETECTION (UNDERG~OUND) - For items 466 and 467, check the leak detection system(s) used , 467. PIPING LEAK DETECTION (ABOVEGROUND) to comply with the monitoring requirem'ents for the piping, ' 468. DATE DISPENSER CONTAINMENT INSTALLED -If~plícable, enter the date that dispel1Ser containment'was installed. 469. DISPENSER CONTAINMENT TYPE - Check the type of dispenser containment monitoring system, SIGNATURE OF OWNER/OPERATOR - The owner or agent of the owner shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is true and accurate, 470. DATE CERTIFIED - Enter the date the page was signed. 471. OWNER! OPERATOR NAME· Print the name of signatory. 472. OWNER! OPERATOR TITLE - Enter the title of the person signing the page. 473. PERMIT NUMBER - Leave this blank, this number is assigned by the CUPA. 474. PERMIT APPROVED BY - Leave this blank, this is the name of the person approving the permit. 475. PERMIT EXPIRATION DATE - Leave this blank. this is completed by the CUPA. UPCF (12/99 revised) 13 Formerly SWRCB Form 8 " ~ The installer has been trained and certified by the tank and piping manufacturers, ø The installation has been inspected and certified by a registered professional engineer having education and experience with underground storage tank installations, ø The installation has been inspected and approved by the Unified Program Agency. ~1I work ~iste~ on the manufacturer's installation checklist has been completed,' ~The installer has been certified or licensed by the Contractors' State License Bo,!-rd. ~The undergrou'nd st;rage tank', any primary piping, and secondary containment was instal\~d ac~ording to applicable voluntary consensus standards and written manufacturer's installation procedures, Description of work being certified; L:\"IFIED PROr.R.UI CO\SOLlD.-\TED FOR\! V~·DERGROC:\·D STORAGE TA\h:S - I\STALL-\TIO:\" CERTIFICATE OF CO\\PU,I.\CE I. FACILITY IDE\TlFIC\ 1'10\ 9'3 II. INSTALLATIO~ (Check all that appl)) III. T.-\:\"K OW:'iERJ.-\GE\T SIG\.-\TURE : certify that the infonnation provided herein is true and accurate 10 th~ best of my knowledge '!5 DATE NAME OF TANK UPCF (1/99 revised) 14 TA:\íKS (0n~ ;Jgt: ?er ~Jr.k! rJ~C ù( ':b ,-- -.," 478 479 480 481 482 483 /' 4'" ..&Hó Fonncrly SWRCB Form C UST Installation· Certificate of Compliance Formerly SWRCB Form C Complete this certification upon installation of an UST and piping. One certification is required for each :ank system. This page may be completed by either the UST owner or representative, Refer to 23 CCR 2635 fer UST installation and testing requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary,) ,Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is , complete and if any pages are separated. 1. FACILITY ID NUMBER - Leave this blank. This number is assigned by the CUPA This is the unique number which identifies your facility. '.. 3. BUSINESS NAME - Enter the fu/llegal name of the business, 416. ADDRESS - Enter the street address where the tank is located, This is to assist the tank inspector in locating the tank. 417. TANK ID NUMBER - Enter the tank 10 number assignee;! by the owner. This is a unique number used to identify the tank. It may be assigned by the owner or by the CUPA. This is the same as item 432 as found on the UST Tank .Page 1. 47a. TRAINED AND CERTIFIED BY TANK AND PIPING MANUFACTURER - Check if the tank installer provided evidence of being trained and certified by the tank and piping manufacturer. 479. REGISTERED ENGINEER INSPECTION - Check if the installation has been inspected and certified by a registered professional engineer, if necessary. 480. UNIFIED PROGRAM AGENCY APPROVAL - Check if the installation has been inspected and approved by the Unified Program agency. 481. COMPLETION OF MANUFACTURER'S CHECKLIST - Check if aI/ work listed on the manufac!urer:5 installation checklist was completed. 482. CONTRACTORSOSTATE LICENSE BOARD CERTIFICATION OR LICENSE - Check if the installer has provided proof of CSLB certification or licensing. 483. INSTALLATION DESCRIPTION - Check if the UST system was installed according to applicable voluntary consensus standards and any manufacturerLS written installation instructions. Describe the installation in the space provided, Clarify the type and the extent of work completed at the facility, such as instal/ation of dispenser containment, replacement of piping, or installation of turbine sumps. SIGNATURE OF TANK OWNER/AGENT - The tank owner or agent of the owner shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is true and accurate. 484. DATE CERTIFIED - Enter the date that the page was signed. 485. TANK OWNER/AGENT NAME - Enter the full printed name of the person signing the page. 486. TANK OWNER/AGENT TITLE - Enter the title of the person signing the page. UPCF (lf99 revised) IS Formerly SWRCB Form C ~ '. e e p1 01 0264.jpg (1280x960x24b jpeg) f6.s\\ \~ ~~\\OVO-l ~ P'rL"'1 RùN ~q 0 { W~\.~L LN. e e p1010263.jpg (1280x960x24b jpeg) e e p1010262.jpg (1280x960x24b jpeg) e e p1 01 0260.jpg (1280x960x24b jpeg) e e p1010259,jpg (1280x960x24b jpeg) ,. e e p1 01 0276.jpg (1280x960x24b jpeg) ~ .. . ir e e p1010277.jpg (1280x960x24b jpeg) . ~' 1i, ,I. :,.