HomeMy WebLinkAboutUNDERGROUND TANK
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'Í:
. STATEOFCAUFORNlA:.
STATE WATER RESOURCES CONTROL BOARD
UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM A
MARK ONLY
ONE ITEM
COMPLETE THIS FORM FOR EACH FACIUTYISITE
~
o 2 INTERIM PERMIT
o 3 RENEWAL PERMIT
o 4 AMENDED PERMIT
o 5 CHANGE OF INFORMATION' 0 7 PERMANENTLY CLOSED SITE
o 6 TEMPORARY SITE CLOSURE
I. FACILITY/SITE INFORMATION & ADDRESS· (MUST BE COMPLETED)
NAME OF OPERATOR
f-/...,'" f\, 4 I /" W;" ~,.-;:.f) , /1-"1...- \ .'
. . I NEAREST CRÇ)SS STREET PARCEL. (OPTIONAl)
!..A..,\'+ " G_ ..1\
ZIP CODe
A
q..~,¿ ~
,
. 0 FEDERAL-AG~NCY
o INDIVIDUAL
o PARTNERSHIP
. 0 LOCAL·AGENCY
DISTRICTS
O ,/ IF INDIAN 'OF TANKS AT SITE
RESERVATION '., ,
OR TRUST LANDS
o COUHTY..AGENCY
o STATE-AGENCY
. TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTOR .
'D 3 FARM D 4 PROCESSOR ~ OTHER
'.,., -\::
EMERGENCY CONTACT PERSON (PRIMARY)
DAYS: NAME (LAST, FIRST)
JJA /¡D J..J
NIGHTS: NAME (lAST, FIRST)
.G:4 :~'/ 6 S; r? -'.f~,=.!,
EMERGENCY CONTACT PERSON (SECONDARY). optional
DAYS: NAME (LAST, FIRST) PHONE' WITH AREA CODE
NI~HTS: NAME (LAST, FIRST)
PHONE' WITH AREA CODE
II. PROPERTY OWNER INFORMATION· MUST BE COMPLETED
CARE OF ADDRESS INFORMATION
,
--; ~C¡
,/ box I) indicale 0 INDIVIDUAL
o CORPORATION, 0 PARTNERSHIP
STATE ZIP CODE
c;A
I
~/,q9'
o LOCAL·AGENCY 0 STATE·AGENCY
/0 COUHTY-AGENCY 0 FEDERAL·AGENCY
PHONE ',WlTH AREA CODE
- ~C'(....,. QI 1- ÇÓ·.....'<
, III. TANK OWNER INFORMATION· (MUST BE COMPLETED)
NAME OF OWNER CARE OF ADDRESS INFORMATION
'c:!\ .- A". "\ ¡' ï::::
,.. ."Y1~_
MAILING OR STREEí1iDDRESS ,/ box I) ¡ndicale o INDIVIDUAL o LOCAl·AGENCY o STATE·AGENCY
!B"'éÓRPOR¡TlON o PARTNERSHIP o COUHTY-AGENCY o FEDERAL·AGENCY
CITY NAME STATE I ZIP CODE I PHONE. WITH AREA CODE
IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER· Call (916) 739-2582 if questions arise.
TY (TK) HQ GEJ-~
V. LEGAL NOTIFICATION AND BILUNG ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked.
CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING:
1·0
11·0 111·0
THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT
APPLlCANrs NAME (PRINTED & SIGNATURE)
APPUCANrs TITLE
DATE
MONTHlDAYiYEAR
LOCAL AGENCY USE ONLY
COUN7Y #
rn
JURISDICTION #
~
~
FACILITY #
~
LOCATION CODE· OPTIONAL
¡CENSUS ~:~ACH - OPTIONAL
I SUPVISOR . DISTRICT CODE . OPTIONAL
THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION· FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.
FORM A (9-90) FOR0033A·R2
-~- ----- --~ ~-_., ~ .
...-,,~
..
w)
\,.-
~
STATE OF CAUFORNlA
STATE WATER RESOURCES CONTROL BOARD
UNDERGROUND STORAGE TANK PERMIT APPLICATION· FORM 8
COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.
MARK ONLY
ONE ITEM
ø 1 NEW PERMIT
o 2 INTERIM PERMIT
o 3 RENEWAl PERMIT
D 4 AMENDED PERMIT
o 5 CHANGE OF,INFORMATION
o 6 TEMPORARY TANK CLOSURE
o 7 PERMANENTLY CLOSED ON SITE
D 8 TANK REMOVED
DBA OR FACILITY NAME WHERE TANK IS INSTALLED: C,"l/\ ,~.¡ E'~
L~¡'c·sl:::·~.:~ i
,
I. TANK DESCRIPTION
COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN
-,"- '- .
¡
I.. 'K
B. MANUFACTURED BY: ~CO'
D. TANK CAPACITY IN GAlLONS:
A. OWNER'S TANK I. D. #
C. DATE INSTALLED (MOIDAYiYEAR)
A.
IF A-liS MARKED. COMPLETE ITEM C.
1 MOTOR VEHICLE FUEL 0 4 OIL
D 2 PETROLEtJM 0 80 EMPTY
o 3 CHEMICAL PRODUCT D 95 UNKNOWN
D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED
B. ".,.
'~ PRODUCT
o 2 WASTE
O 1a REGULAR
C,. . UNLEADED
o 1b PREMIUM
UNLEADED
'0 2 LEADED
3 DIESEL 0 6 AVIATION GAS
o 4 GASAHOL 0 7 METHANOL
o 5 JET FUEL
o 99 OTHER (DESCRIBE IN ITEM D. BELOW)
C.A.S.':
III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D
A. TYPE OF o 1 DOUBLE WALL 0 3 SINGLE WALL .wITH EXTERIOR LINER 095 UNKNOWN
SYSTEM o ·2 SINGLE WALL 0 4 .SECONDARY CONTAINMENT (VAULTED TANK) 099 OTHER
0 1 BARE STEEL 0 2 STAINLESS STEEL 0 3 FIBERGLASS ~ 4 STEEL CLAD WI FIBERGLASS REINFORCE!;> PLASTIC
B. TANK
MATERIAL 0 5· CONCRETE 0 6 POLYVINYL CHLORIDE D 7 AlUMINUM 0 8 100"10 METHANOL COMPATIBLE W/FRP
(Primary Tank) 0 9 BRONZE 0 10 GALVANIZED STEEL 0 95 UNKNOWN 0 99 OTHER
0 1 RUBBER LINED o 2 AlKYD LINING 0 3 EPOXY LINING 0 4 PHENOLIC )..INING
C. INTERIOR 0 5 GLASS LINING %6 UNLINED 0 95 UNKNOWN 0 99 OTHER·
LINING ,
IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO_ i
,
D. CORROSION 0 1 POLYETHYLENE WRAP 0 2 COATING o 3 VINYL WRAP g 4 F~BERGLASS REINFORCED PLASTIC
PROTECTION 0 5 CATHODIC PROTECTION D 91 NONE o 95 UNKN9WN o 99· OTHER
IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUNpOR U IF UNDERGROUND. BOTH IF APPLICABLE
A. SYSTEM TYPE A tI) 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER
B. CONSTRUCTION A U 1 SINGLE WALL A<ÝÌ 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 .UNKNOWN A U 99 OTHER
I A U 1 BARE STEEL AU,2 STAINLESS STEEL A U 3 POLYVINYL CHLORIÓE (PVC)A(jþ4 FIBERGLASS PIPE
C. MATERIAL AND
CORROSION A U 5 AlUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP
PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC,PROTECTION A U 95 UNKNOW~/ A U 99 OTHER
-,
D. LEAK DETECTION o 1 AUTOMATIC LINE LEAK DETECTOR c¡¿r 2 LINE TIGHTNESS TESTING 0'3 INTERSTITIAL o 99 OTHER
MONITORING
V. TANK LEAK DETECTION /
g YVISUAL CHECK
lli 6 TANK TESTING
2 INVENTORY RECONCILIATION
o 7 INTERSTITIAL MONITORING
...//
@3 VAPOR MONITORING 0~ 4 AUTOMATIC TANK GAUGING 0 5 GROUND WATER MONITORING
o 91 NONE 0 95 UNKNOWN 0 99 OTHER
VI. TANK CLOSURE INFORMATION
,1. ESTIMATED DATE LAST USED (MO/DAYiYR)
2. ESTIMATED QUANTITY OF
SUBSTANCE REMAINING
3. WAS TANK FILLED WITH
GALLONS INERT MATERIAL?
YES 0 NO 0
THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT
APPLlCANrs NAME DATE
(PRINTED & SIGNATURE)
LOCAL AGENCY USE ONLY THE STATE J.D. NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW
STATE 1.0.#
COUNTY #
·OßJ
JURISDICTION #
~
FACILITY # TANK #
~ CI:EI:ill]
I PERMIT EXPIRATION DATE
PERMIT NUMBER .~
I PERMIT APPROVED BY/DATE
FORM B (9-90)
THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION· FORM At UNLESS A CURRENT FORM A HAS BEEN FILED.
FOR0034ß.R4
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,
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FILE CONTE~TS SUMMARY
FACILITY: C,Vl(ìY'..}e î ,t-kJs~
ADDRESS : 5 ¡:)û I \;\j h ì +e ko \It e
PERMIT '#: 3/(JÓ(~:2 ENV. SENS,ITIVITY:
Activ:i ty
Date
Comments
# Of Tanks
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~~~~~~~~~~~~~~~~~~~~~~A~
~ CERTIFICATE OF INTEGRITY ~
~ . .' ~
~ ~.
œ ~
~ ~
~ ,~
~ill THE UNDERGROUND STORAGE TANKS LOCATED AT' ~
-~ ~
I~ CHARTER HOSPITAL. 5201 WHITE LANE. BAKERSFIELD, CALIFORNIA . ~
~ ~
~ ~
~ HAVE BEEN CERTIFIED ENVIRONMENTALLY SAFE ,WITHIN ~
'~ ~HE GUIDELINES OF THSEySTATE OF CALIFORNIA ~
~ " , ,~
~ REDWINE - MANLEY TESTINGSERVICES, INC. ii.
~ ON THIS THE 28th, DAY OF, MARCH 19· 89 ~
~ ~
~ ~
,,_,t.~ j}~ Z ~
~. ATTESTED BYJkÍ.t~., (/~ ~
~ ~
~ .~
~ CERTIFICATION # CA 0183 ~
~ iji11
~ . ~
,~ MEMBER NATIONAL FIRE PROTECTION ASSOCIATION , ~
~~~~~~~~~~~~~~~~~~~~~~~
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INC. TESnNG METHOD: HORNER EZY-CHEK' REMARKS:
CALIBRATION':
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PllODUCt ~AC1'J:Y ),am ~¿.. CHAllr CAL ,0 { .
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rlE-MANLEY TESTING SERVICES t
BOX 1567
~FI!LDt CA't 93302
834;.6075
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KERN COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH DIVISION
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HEALTH OFFICER
Leon M Hebert.on, M,D.
DIRECTOR OF ENVIRONMENTAL HEALTH
Vernon S. Reichard
1700 Flower Street
Bakersfield, California 93305'
Telephone (805) 861-3636
"
Date'
Firm Name
Address
HAZA~DOUS MATERIALS MANAGEMENT PROGRAM
Underground Tank Facility # "3/ ()() 6 Z
EPA 1.0.#
Assessors Parcel # I /
Type Facility //jl.t!,c'YO}f//¡4r7 's1t1Vi)r;¡c MuK
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NOTICE OF VIOLATION AND ORDER TO COMPLY
The following conditions or practices observed this date areviolations of one or more sections of the California Health
and Safety Code, Oiv. 20, or the California Administrative Code, Title 22, Oiv. 4, Chap. 30, relating to the "storage,
handling, transportation, and disposal of hazardous waste" or Ordinance Code of Kern Co.ónty, Oiv. 8, "Underground
Storage of Hazardous Substances."
Conditions or practices must be corrected within the times ordered below:
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Your signature acknowledges receipt of a copy of this report and collection of any samples described above, and is
not an admission' of guilt.
Failure to fully comply with this "Notice and Order" may result in further legal action by County or State officials.
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Agent of the Kern Co~nty Health Officer
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Òwner or' uthorized Representative
White - Original
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KERN COUNTY HEALTH DEPAi:' . NT
ENVIRONMENTAL HEALTH DI IN
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HAZARDO~S SUBSTANCES SEC ON
.
1700 FLOWER STREET
BAKERSFIELD. CA 93305
PHONE (805) 861-3636
~'¡
INSPECTION RECORD
..
POST CARD AT J08SITE,
, '
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PERMI T #3/tJ(}{.¡2¡fl
INSTRUCTIONS: Please call for an inspector only when each group of inspections
with the same number are ready. They will run in consecutive order beginning
wi th number ,I. DO NOT cover work for any numbered group until all :ltems .in·
:that group.:,'are signed off by the Permitting Authority. ;Followlng.>;ithese
,,·instrÙt_~ons" wi}l reduce the number of required nspect on visrts~~:anß)thèref re
~preventfassessment of additional ,fees~' .
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')(~:~'7~' :~';":'¡~~;'~;':' ~.:.' .-~,~~:" ,. INSPECTION ,. , '. ,. DATE c' '. ~ ' "" ,'. INSPECTOR ~,~~j~rit~£'~~i~·1'¡" Ji,\.~~'~ ,- - -. ~
", Backf ill of Tank (s ) . ,': " " :.'-'." . .....", ;,. ,". ',~ ~,-:;:.;¡~:¡'i" . ",.,'",
SDark Test Certification .', :' .:." );''YÞff''..Y~;:;_~·~;;,~:::,,~~.~·<~" '.,..::.~.,
Cathodic Protection of Tank(s)
::;. \, . .
OVERFILL PROTECTION. LEAK DETECTION
Liner
Liner
Vault
- FINAL -
g~:~~~~TOR ~~f{~c 1ir:f:itetl1-
LICENSE # Z/4-074-
PH # ~ /I~()-
KERN COUNTY HEALTH DEP.~ENT
ENVIRONMENTAL HEALTHD' , ' ¡ON
HAZARD&US SUBSTANCES SECTION
-,
1700 FLOWER STREET
BAKERSFIELD. CA 93305
PHONE ,(805) 861-3636
~~).
INSPECTION RECORD
POST CARD AT JOBSITE
FACILITY
ADDRESS
CITY
PHONE NO.
-
. , '
INSTRUCTIONS: Please call for an inspector only when each group of inspection~
with the same number are ready. They will run in consecutive order beginnin:;
with number 1. DO NOT cover work for any numbered group until all items ir
that group are signed off by the Permitting Authority. Following thesE
instrutions will reduce the number of required inspection visits and therefore
prevent assessment of additional fees.'
-TANKS &
INSPECTOR
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CL'
OVERFILL PROTECTION. LEAK DETECTION -
Liner
Liner
Vault
Vent Valves
ace-D.W. Tank s
Vadose/Groundwater
Rog~. Phelps
" -Jirector of
Support Services
'::¡;Ir ¿1;J1(."(1i4
11/ Monitor!n£!' Wells. CaDS & Locks /l<'r ..?~~
Fill Box Lock ,
,
Monitorin£!' Reauirements
- FINAL -
WII\.
CHARTER HOSPITAL
OF BAKERSFIELD
!i1
5201 White Lane, Bakersfield, CA 93309 (805) 398-1800
A member of the Chaner Medical Corporation family of Qualíty health care 'acilities.
. CONTRACTOR fff1/ T1!~J1T
CONTACT ß /Jft:M ¡,
LICENSE # 2,'14074-
PH # 834--//00
2700 'M' Street. Ste. 300
'Bakersf;e1~, CA 9330\
(805) 861-3636
~)
PERMIT NUMBER 310062M
PERMIT TO CONSTRUCT
STORAGE FACILITY
'..j
FACILITY NAME/ADDRESS:
OWNER(S) NAME/ADDRESS:
CONTRACTOR:
Chàrter Hospital
5201 White Lane
Bakersfield, Cf\
Charter Medical
P. O. Box 209
Macon, GA 31298
Ph. # 800/841-9403
RLW Equipment
2080 So. Union Ave.
Bakersfield, CA ~3307
. Ph. # 805/å34-1100
License #294074
NEW BUSINESS
CHANGE OWNERSHIP
RENEWAL
XX MODIFICATION
OTHER
PERMIT EXPIRES
June 16, 1989
~PPROVAL DATE
APPROVED BY
March 16, 1989
&te0c/~-
Bill Sch~ide
. . . . . . . . . ; . . . . . . . . . . . . . . . . . . . . . . POST ON PREMI SES. . . . . . . ó . . . . . . . . . . . . . . . . . . .
CONDITIONS AS FOLLOWS:
Standard Instructions
1. This permit applies .Qnly to the modification of an existing facility
involving excavation of the diesel tank vent and product lines -for the
,repair or replacement of those lines, and soil sampling for possible
contamination.
2. It is the responsibility of the Permittee to obtain permits which may be
required by other regulatory agencies prior to beginning work.
3. Permittee must contact Permitting Authority for on-site inspection(s) with
48-hour advance notice.. .
4. If any contractors other than those listed on permi t and permi t application
are to be utilized, prior approval must be granted by the specialist listed
on the permi t . ,
r
2700 'M' Street. Ste. 300
B~kèrsf;eld. CA 9330\
(805) 861-3636
... KERN C.OUNT.
Environaental Health Services Depart2ent
PERMIT TO CONSTRUCT .
PERMIT NUMBER 310062M
UNDERGROUND STORAGE FACILITY
ADDENDUM
5. Preliminary assessment contractor must receive prior approval from the
specialist on this permit before any work begins.,
6. All samples must be analyzed for total petroleum hydrocarbons-diesel.
7~ All applicable state laws for hazardoùs waste'disposal transportation, or
treatment must be adhered to. Kern County Environmental Health must be
notified before moving and/or disposing of any contaminated soil.
8. Advise this office of,the time and date of. the proposed sampling with
48-hours advance notice.
,
9. Results must be submitted to this office within three days of analysis
c,?mpletion.
10. Copies of transportation manifests must be submitted to the Kern County
Environmental Health Department within five days of waste disposal.
11. Construction' inspection record card is included wi th permit given to
Permittee. This card must be posted at. jobsite prior to initial
inspection. Permittee must contact Permitting Authority and arrange for
each group of required inspections numbered as per in§truct~Qn en CâPS,
Generally, inspections will be made of: .
a. Product piping and backfill.
b. Any other inspection deemed necessary by Permitting Authority..
ACCEPTED BY
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Scheide\310062M
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:.J1!'IE-HANLEY 'l'ESTING SEKVICES,
. B~1567 .
ERS. LD. CA., 93302 .
5) 4-6075
INC. TESTING METHOD: HORNER EZY-CHEK' REMARKS:
CALIBRAnON:
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Construction ~ironmenta1 Services, ·Inc. (805)325-145,
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fIeld service manual
non-corrosive products division
. APPROVED SAFETY DEVICES
ITEM
Combust.ible Vapor
and O2 Alarm
Fresh Air Mask
Portable Light
Air l.fover -
Electric '
Air ¥.over -
Air Driven
Pipe Plugs
( Internal
Expanding)
Chest
Harness
Self Contained
Breathing
Apparatus
(Esca:ce Air)
PREFERRED
. EQJIFMENT
Bio-l-!a.rine No. 900R
· Calibration Kit P/N 160
· Batter ChargerP/N 140
· Calibration Cylinders
· Lead Filters PjN 137
.' Carr:r Case pIN 147
· Probe
MSA Constant Flow
Respirator 460863
· Ultra View Fa.ce
· A:..r Hose 455022
· Coupli.'1gs
Teledyne Explosion
mot Lantern 2B7EX
Coppus Vanco "C"
Explosion Proo£
Coppus Jectair Air
z,!over 3" Model Equipped
witt Grou"1di.'1g Device
Moeller Mfg. Co.
pj:ce I.D. Moeller No.
1" 44141-4
It'' 44050-4
lì" 44165-5
1-3/4" 440Z¡-2
2" 44098-3
~" 44402-2
2¡u 44052-2
3" 44117-4
3-7/8" 40246-2
Atlas Safety Equipment
Nylon No. 238
Surrivor Hippack System
Self Ccntai~ed 3io Ma:ine !~dustries
Bre~thi~g App8.:-at·.:.s Bi:) Pal<:
(¡(esc'.:.e Ai:-)
.
~ Safety
tIwIIeIin 1
1/4/84
oat.
5/17/76
..,IM<MCI.'
APPROVED
ALTERNATES
Gas Tech l.fode1 1214'
An1 eqdvalent with
NIOSH approval
}.:r.y :çarta,ole light ra.te c
tor use in explosive atr::
phere.
UL Gla.ss/Group D
Lamb .Air Mover
3" Hodel or Equal Per
Rated Capacity
An¡ Èquivalent-Must be
OSHA a.pproved
Any e~ui~ment vith NIOS~
a.~prova.l and min:.m1JID. 10
air supp:!..y
. ~
~
&
VoJ.t DC
540
~.
200
315
1ent
~;
e
9
APPBOVED
AI. TERNATES
Arr,¡ Ecp:L valent. - Mus t be
OSHA approvp.d·
Arr.l Eqjnvalent -!-1ust be
CSHA·' a.pproved
Del-Monox Model 150B
cartridge Type BA-5
Any equivalent air driven
diaphra.!!\. type pwnp
.
e
nual
roducts division
HCIIOft Safet.y
\. 2
_.lIft
1/4/ö4
d..,.
SW)etSIt, ~. _ 5/17/76
·1 u..,expected acute ha::ards may be encountered when
.el must enter a tar.k, mal'.hole, or pipe. For this
ning Fiberglas personnel havi."1g cause to enter a
~i t, :ii tch, or other co:Ü'i:l~d s!)ace ".Iill exercise ::
s as outlined in this proced~e and. others that app:
s.
ibil1ty of èach Owens-Co~.ir.g employee. Ult:iJnately
~sts with the Plant Mar.ager of each plant operating
l:::ation. In fullfilling th1! ~sponsibility, each
:' safety ecr.npment is available, in good working
1e operation and calibration of instruments is
( .d Technicians.
- ·e93 unde:- their control u.'1.Cier~and and comply with
. Policies, Procedures and Precautions as provided.
ncountered are:
atal concentrations - may result from known
ank, by gradual release from sludge or scale,
'y leakage from interconr.ected S"/stems due to
).rr or disconnect pipelines or ducts.
lusi.".g asphyxiation - may result from chemicals
lCing oxygen 1.'1 the tank air or from inert gas
.ude oxygen to reduce the possibility of explo-.
Ian tanks closed for an extended period may <:;;;.
n oxygen. Improper or inadequate ventilation
. :ay also result in a lack of oxygen.
m portable lights, tools, or associated
I'lt. .
Lcal equipment such as mixers, conveyors, etc.,
\fated".
-
direct contact with corrosives or dermatitis-
s.
.
# .
; ~
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~
Safety Bulletin #2
1/4/84
-- -- -- --.------.'.-
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e
r.J.
F. Physics.], hazards such as slip~ing. falling, and :f'alling oDjects.
G. 3urn ha.zards resulting t:-om accidental opening of a. steam valve in
a line vhic~ has no~ been blanked oft òr ignition ot flammable vapors.
H. Fire and explosion from cocbus~able liq,uid ~d vapors such as gasoline.
I
IV. SA:'"'E7f RE-~UIBE1·!E!rrS - GE~ŒRAL
Every attempt 'has been made to make the safety þrocedures es~abl1shed by these
instr~ctic~s 2S fool~root as ~ossible. Hove7er. there is no substitute fer
constant alertness and in~elligent plan:ing in every vessel or pipe entry
si~uation.
,,-
In add.! tion to rigid enforcement of the provisions of the esta.blished pro-
ced~es. it is essential that all persons involved in each job reco~ize
the extreme hazards involved and act accordingly'. Enforcement of these
mi~im~ sa.fe~~ards will under no circumstances be conside~d as relieving
those involved from responsibility tor any unforeseen development or circ~- .
stance.
If the co~ditions of the procedures cannot be s;eci~ical1y met or if questions
~ise from the interpretation of any part of these proce¿ures, they are to be
referrei to the·technicians immediate supervisor fer resolution.
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Safety
,
. ' field service manual
non-corrosive products division
Du...1íft
3
1/4/84
511/80
aa'e
SAFETY PROCEDURE - UNDERGROUND PETROLEUM TANK ENTRY
.o.øetSl<1..
The following procedure will be employed whenever an OCFField Technician has cause
to enter an underground petroleum storage tank, either for inspection or repair. Any
~dditional state, local, or federal regulations must. be observed. Additional customer
requir.ements should be cleared through FieldServ;ce in Toledo.
General Requirements'
. 1. Onl~ air-powered mechanical tools 'are to be employed.
2. The tank is to be mechanically ventilated at all times that a man is
inside the tank. .
3. Use of an air-supplied mask with Egress cylinder is required at all times
times unless,it can be absolutely ascertained that the tank has never
contained any product.
An approved safety harness with lifelines attached must be worn by the man
entering the tanK.
Tank~ h¿ving an atmosphere over 130°F are not to be entered.'
On ly an approved exp 10 sian proof 1; ght source is to be used.
A completed Confined Space Entry Permit is required to be posted prior to
each tank entry. .
A reliable safety observer, with no duties other than assisting and
monitoring the OCF technician, must be available at all times. The safety
observer is allowed to pass tools and similarly assist the man in the'tank
as long as voice and perferably visual contact is maintained. , If the
safety observer must leave the tank, the technician is to halt work and
exit the tank. ' ,
In addition to the primary safety observer, one (1) additional man must
be ','lithin' hearing distance and aware of the' air horn signal to help in
a physical rescue if required.
A SC8A safety harness and an air horn must he ðvailahle for immediate use.
9. . ~o flash pictures are to be taken in the tank.
10. No air tests are to be performed on a tank containing product.
Reference NFPA 329.
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Safety Bulletin #3
1/4/84
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General Requirements - Continued
11. Backfill and/or slab must be pròperly shored to prevent collapse
or cave-in.
12. No product deliveries arc to be made to any tank on the site while
a man is in a tank.
Entry Procedure
1. Instruct Safety Observer
a. Monitoring the combustion and 02 meter.
b. Being alert for possible sources of ignition (cigarette smokers,
open flames, etc.)
c. Constantly watching for erratic movements of the technician
while he is in the tank.
d. Assisting in feeding and pulling lifelines and air l~nes.
e. Assisting the technician by passing tools, materials, etc.
f. Maintaining visual or voice contact with the man in the tank.
- g. Putting on the safety harness and use of lifelines.
h. Use of SCSA and air horn.
(
i. Emergency procedure and telephone numbers.
The safety observer is to tell the technician (yell loudly, ~ound air
horn) to exit tank if:
a. The alarms on the meter go off.
b. The compressor stops or something interrupts or restricts air
supply to the technician.
c. A source of ignition is close by. .
d. The movemènts of the technician indicate he is getting "drunk"
or otherwise unstable.
e. A fire breaks out in the tank~
The safety observer is not to enter the tank for rescue if the loan can
get out himself.
If physical rescue is required, the safety observer is to:
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Safety_ Bulletin 13
1/4/84
Entry Procedure - Contiñued
a. SU/r.mon the backup man' (sound air horn if necessary). ,
b. Attempt to pull the technician toward the entry hole by means
of the life 1; nee
c. Put on the safety harnesi and attach lif~line.
d. Put on the SC8A and test operation.
e. Enter th~ tank and assist the backup man tn the rescue and
removal of the man.
.
2. Remove ~11 Possible Product
Use a hand pump or approved flammable fluid pump to 'remove as much
product as possible. No more than 1" of product should b~ in the
tank prior ~o ventilation.
, ,
3.
Start Ventilation
Connect an approved air mover to exhaust air from 'the fill pipe or
other pipe or hose within 12" of tank bottom. The air movèr must ,be-
grounded when in use. Extend exit point of exhaust at least 61 above
gr-ade.
Continue to ventilate until test with thécombustible gas meter
indicate the LEL is less than 20% within 12" of tank bottom. Re~ove
fill pipe to .check. This can me between 2 and 24 hours depending
on the amount of product left in the tank.
- )
If tank lines are manifolded, the line of the tank to be entered might
have to be broken to isolate the tank and allowdefuming.
4. Cut Entry Hole
Cut entry hole 6n1y after tests confirm the vapor level.with 12" of
the tank bottom is less than 20% of the LEL. Use only an air powered
saw. The minimum hole size to facjlitate rescue if required is 18"
x 13".
5. Tests Before Entering
After the ~ntry hole is cut, check the vapor level and 02 level through
the entry hole.
fw1inimum entry requirements ar~:
'>
.
1-Vapar level less than 20% LEL
02 level greater than. 19.5~
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,Safety Bulletin #3
1/4/84
-4-
6. Confined Soace Entrv Permit
Complete the attached Confined Space Entry Permit a~d post near the
entry hole.
7. Initial Entrv
When the above entry requirements are met, entry may be made with the
Uge of an air supplied mask and an Egress air cylinder.
At the first entry of the day, take the meter into 'the tank and check
for hot spots. If the 0, is less than 19.5% or the vapor level exceeds
20% LELt exit the tank and continue ventilating.
Remove any residual product with an approved pumping system or by
manual means. Dry the area with rags or lIoil dry" material and dispose
of in a safe place.
Plug internal openings after the air check.
a. Manifolded vent lines may be plugged with an expandable
plug or by forcing the ball of a check valve arrangement
up tight against the fitting with wood.
. .
b. Submerged pumps, if not removed, are to be capped at the
bòttom. The return line is to be plugged with a cork.
c. Suction and siphon lines are to be- capped' or enclosed in
plastic to prevent drips.
8. Continuous Monitorina
"
Vapor level and 02 level must be monitored continuously, either through
the entry hole or down the exhauster with the probe (at least 12" below
the exhauster into the fill pipe). Readings above 40% LEL or less than
19.5% 0, require work to cease and an investigation as to the source
with suösequent correction. '
9. Insoection
Inspect the
10. Reoair
tank for damage; record all data on appropriate sheet.
If an agreement is reached and the tank is to be repaired, proceed
as follows:
a. The tãnk ~ust De mechanically ventilated at all times.'
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Saf2ty Bulletin 13
1/4/84
10. Reoair - Continued
b. Complete the Confined Space Entry Permi~ and post at tank entry
hole. (Note: A new Confined Space Entry Permit is required for
each day's entry.)
c. Instruct the safety observer of his duties and emergency
procedures.
.
d. A safety harness with lifelines is required for in-ground tank
entry.
e.Use of an air-supplied mask and Egress air cylinder required
unless absolutely certain tank never had product in it. If an
air fed mask is not used:
(1.) During grinding, goggles ~r a hood and an approved
organic respirator are to be worn.
(2.) During layup work, or at ~ time resin is in the.
tank, goggles and an approved organic respirator
or a fresh air mask must be worn.
11. Final Exit
Remove all equipment. Double check to ensure that all caps used to'
plug pipes are removed. Sign Entry Permit and include with the
field trip report documents~
Procedure for External Work
If the repair work involves cutting into a tank or grinding adjacent to a
crack or split that extends through the shell wall, prior to any work the
tank must be ventilated such that the vapor level is less than 20~ LEL
initially and remains lower than 40% of the LEL during work. Tanks that
have been in service are to be continuously monitored to ensure these
conditions are met.
The above requirements must be met for field installation of fittings.
For external work, no air-supplied mask is required.
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['tOY 82 '88· 09:35 O~S CORNING L.A.,
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"~=IE'''. .. Safety Bullet1n 13 1/4/84
j :~ confined apace entry permit
ì·.o . operating t_"lea _
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P,.·Eriuy (CheCk)' Yes)
Hu tank been emptied?
Hu the air mover been Installed, r:;)perly grounded and Is effectively exhausting aIr from the tank?
C ·1.
C 2-
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C 3-
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C - 5.
a 6..
Have all Internal openIngs Int~ the t~nk been blanked, capped, removed or disconnected?
Has the entry hole been adequately barricaded?
Has the safely observer been InstruC1ed on the use of safety harness and SCBA?
Hils the safety observer been Instructed as to his responsibilities?
T.echnlclan sIgnature·
C'
Coos he fully understand?
.
Safety Observer signature
c:::J 7. Emergency Procedures reviewed?
Rescue/Ufe Squad Phone Number
Police Phone Number.
.
Fire Cepanmant Phone Number
o 8. Pro-entry readings:
. Oxygen level·
Flammable Vapor level:
o 9. Alr'supplled mask and air capsule In good working order?
!
o 10. ~f~ty. h.arn~~~ ~nd Jlf.!!!~!.s-!!C~e.L
a 11. O~I~ air tools In the tank?
o 12. This ontry permit Is posted near the entlY hole?
Post· Entry
a 13. Have aU tools, safety equlpmont and repaIr materlafsbeen removed?
oc:.-I~
TechnIcIan signature:
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Safety
field service manual
non-corrosive products division
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SJBJECT: c-.lstomer Tar-1< Preparation Prior to Entry
FúLICY
It is· ~he responsibility of the customer or final owner to properly clean,
defume, and in general make conditions safe prior to an ocr Field Tec¡'.nician
enter:;ng ar¡ tank. This includes entry due to ocr ~alit.~ problems.
BACKGROUND
,./
Owens-Corning Field Technicians are not autr.orized to i.?tS"Cect or work on
.any chemical tank where conditions are not suitable to ensure their health
and. safety. Each tecr.nician has wr:itten t'ank entry requirements that are
not to be nolated.
(-
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The customer w:il.l be rec;:u:ired to properly prepare a tar.k for entr:r beca.use
the customer is in the bast position to efficiently do so i. e. :
· Cleaning freq:.¡ently i."lvol ves specialized equipnent
,arranged for at the local level. '
. ocr is not equipped, nor trained to clean tanks.,
· Cleaning tanks can be hazardous i:!' one is unfamiliar ·tlith the "
specific preca.utions that should be observed when worldng
with a particular chemical.
· Only a clean tank can be properly inspected. I
Ma.r.",¡ay must be unobstructed - tree from, pwnps, ~iping, ate.
PROCEDURE
,
The Field Service Supervisor will, at first telephone contact, Worm
the job contact. of the following requirements that must be met 'Drier
to entry of a chemical tank: .
A. Chemical or anks
1. The tank must be substantiall'" clean ancf fume free. This means that
r.o more than 1" of fiush out ~ater máy remain in the bottom of the
tank, and that, after flush:L"lg, the tank has been mechanical.ly
ventilat.ed to exhaust fumes. No sl~ge may remain at the bottom
of the tank.
The only tank. cleaning an ocr techr.ician is authorized to perform
is to assist the customer in removal of the final 1" or less of
flush out water and local cleaning ot the tank side wall' areas to
be repaired.
2. Ii' the tar.k has had material in it of any kind (except water), and
the techr.ic1ar.s truck cànnot be parked within ìoo ft. ot the tank, thé
cu.stomer must provide a source of clean compressed ,air to supply an air-
fed mask tor internal. work.
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~/4/84 ..
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3. . All pipe l:L"1es connected to the tank must be either blanked off,
broken at least 10' from the tank, or disconnected. and removed.
4.' Internal agitators or other power driven equipnent must be made
inoperable or locked out.
5. A staridby .safety observer must be provided to assist the technician
and serve as a rescurer 1£ required. This standby man can have no
duties other than asrlsting the ocr technician.
In addition, one additional man is required to be within hearing
distance, to assist in aresc:ue if required.
6. It the tank is aver 15 '6" high measured at the top knuckle entry
through a top manw~ .or over the' side' of an open top tank will not
be made. The alternatives for a tank over 15 t6tt high not equipped
with a side manway are:
i) OCF technician to field install a side man~
2) tip the tank over
3) C'..lstomer to rig up a mechanical chair lilt. Cranes are not
allowed.
7. If external work must be done at heights over 15'6", there must
be provided by the customer either scar.rolding, cherr,r picker, or
other means of access. Ladders, other than those ,attached to the (
t8r'_1.c, a:e not allowed at heights over 15 '6". .
B. Petroleum Tar~s
1. The tank must have had the product pumped out to within 1" or less
of the bottom. This requires the use of hand pump.
2. Fuel oil tæù<:s must not only be pumped nearly' dry' but also manually
cleaned out. .
3. After pumping out, the tank must be ventilated until it is vapor
free. The use of an exhausting eductor (venturi) on the till tube
is recoriunended. The tank w:iJ.l not be cut into until th.e vapor level
in the tank is less thaµ 2:>% LEL.
4. A standby sar*ety observer must be provided to assist the technic;an
and serve as a rescurer if required. This standby man can have no
duties other than assisting the ocr technician.
In addition, one additional man is required to be 1dthin hearing
distance, to assist in a rescue i£ required. '
5.
The hemi end of the tank must be eXDOsed do\o4'l to the haJ.! way point
to allow the technician sufficient room for the technician to cut
the entry hole.
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Safety Bulle'!::.
1/4/84
S'noril'1g ot at least a 6' square area to prevent bac.'d:ill from
talli:lg near the entr:r hole.
If the tan.Y( has been 1."1 serdce, a mini...-um S; CFM compressor must
be pro-or..ded to allow the techni=.an to conti."1UO~ ventilate the
tank du..-ing entrj.
7.
8.
The custcme~ 1s respons~ble tó ~sconnect and recon:ect all ~iping
L~d tL~ accesscr~es to facilitate repair work.
A. jcbvill not be scheduled tor a technician to visit until the customer has
ag:-eed to ma.ki~ the required tank preparaticns. Only the Field 'rechnician I s
Supe~r.Lsor can vaive customer responsibilic7 tor tank preparation.
~ the_event a technician encounters a Job where· the required preparations
ha.ve not been a.ccomplished, tank entry vill not 'be ma.~. The customer vill
èe subject to an::¡ extra. expense involved in rescheduling a visit or hclding
the !ield technician .hile the custo~r prepares the t~~ tor ent=7.
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Permits t
Fac111 ty NOllie
3ið062/J1-L.
r/J{/ vi?V 11C>5j'íl7tl
Inspector
Date
RSc)é',de.
7-~ - X:9
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PINAL INSPECTION CIIBCKLIST
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0= P;¡¡ I I
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ð := WellS (ffkllit) I I
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Plot Diagralll
Plot plan notes
Yes' No
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1. All new and existing tanks Jocated on plot plan?
2. Does tank product correspond to product labels on
plot plan?
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3. ~ there _ modifIcations Identified which were
not depicted on the plot pl~ns?
If "a" described
'Jó
4. Are ~onitoring wells securr and free of water and
product In sump?
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5. Is piplng system pressure. 'netion or gravi ty?
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. Yes No
6. Are Red Jacket subpur.lps a.nd all line 'lea det, tor· I_I I_I
accessible? ' I
Type of line leak detector if any ¡VI/I
7. Overf ill containllent'box as specified on : .lpl icatlon? LI I_I
If "No", what type and lIodel number:
a} Is fill box tightly sealed around fill tube? I_I I_I
b) Is access over water tight? I_I I_I
c) Is product present in fill box? LI I_I
8. Identify type of monitoring:
a) Are manual !!Ionitoring in9tr'lllents, product and
water finding paste on pre~ises?
I_I
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b} Is the fluid level In Owens-Corning liquid level
Monitoring reservoir and alarm panel in. proper
operating condition?
I~I
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c) Does the annular space or secondary containment
liner leak detection system have self diagnostic
capabilities?
If "Yes", lait functional
If "No", how is it tested for proper operating
conditIon?
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9. Notes on any abnormal conditions:
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_ COUNTY OF L l!.:R.
Environmental Health Sl- ¡ ,'ices : Jepartment
2700 "M" Street, Suitè 300
ßaker.;field, CA' 93301
(80S) 861·3636
(80S) 861·3.¿29 Fax Number
PERMIT NUMBER 310Qß2~-2
PERMIT TO CONSTRUCT UNDERGROUND
STORAGE FACILITY
FACILITY NAME/ADDRESS:
OWNER(S) NAME/ADDRESS:
CONTRACTOR:
Charter Hospital
5201 White Lane
Bakersfield, CA
Charter Medical
P. O. Box 209
Macon, GA 31298
Ph, # 800/841-9403
RLW Equipment
2080 So; Union Ave.
Bakersfield, CA 93307
Ph. # 805/834-1100
License #294014___
NEW BUSINESS
CHANGE OWNERSHIP
RENEWAL
XX MODIFICATION
OTH:ER
PERMIT EXPIRES
_?~J2!~mQêLl.5, 1989
APPROVAL DATE
June 15, 1989
--37 "
, ¡/I!·. I
1.:'(...( X/é0.ttX..::,- -
Bill Scheide
APPROVED BY
-1
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . POST ON PREMISES........... . . . . . . . . . . . . . ; . .
CONDITIONS AS FOLLOWS:
ª t and a ~9_II~s t rll £. t i on~
1. This permi t applies 9.!1-.lY to the modification of an existing tacili ty
involving excavation of the diesel tank vent and product lines. for the
replacement of those lines.
2. It is t~e responsibility of the Permittee to obtain permits which may be
required by other regulatory agencies prior to beginning work.
3. Permittee must ~ontact Permitting Authority for on-site inspection(s) with
48-hour advance notice.
4. I f any contractors other than those 1 j sted on permi t anci permi t appl ication
are to be utilized, prior approval must be granted by toe specialist listed
on the permit.
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PERMIT TO CONSTRUCT
PERMIT NUMBER -ª.10º62!::t~~
UNDERGROUND STORAGE FACILITY
ADDENDUM
5. All applicable .state laws for hazardous waste disposal transportation, or
treatment must be adhered to. Kern County Environmental Health must be
notified before moving and/or disposing ot any contaminated soil.
6. Copies of transportation manifests must be submitted to the Kern County
Environmental Health Department within five days of waste disposal.
7.. Construction inspection record card ,is included with permit given to
PeI'm.ittg~, 'l'hj,~ . card must be posted' at jobsite prior to initial
inspection. Permittee must contact Permitting Authority and arrange fo~
each group of required inspections numbered as per instruction on card.
Generally, inspections will be made of:
a. Product piping and backfill.
b. Secondary containment of piping.· ~
c. Any other inspection deemed necessary by Permitting Authority.
ACCEPTED BY DATE
BS:cas
Scheide\310062M-2
\(3-15-01
\~,
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Keh'ì- 'Coun ty Health Departmep.~
OrZrision of Environment.al ut ' th
1700 Flower street, Ba~ersfield, CA
(805) 861-3636
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Permit No. '1,/ t:7 0 {, ;Z M- -:z..
cation Date, ~- /-7I-f" 7
93305
APPLICATION FOR PERMIT TO OPERATE UNDERGROUND
HAZARDOUS SUBSTANCES STORAGE FACILITY
Type Of Application (check):
[]New Facility ~Modification Of Facility [JExisting Facility [JTransfer Of Ownership
A. Emergency 24-Hour Con tact (name, area code, phone): Days - :? ç.P- /f":J CJ 'I ~ J 3
.' ' J J ' - Nights -'..J (/1'-7 7.2.~.J
Faclllty Name éj.,-,.1;,.j...- H~~./,.f.- / o. Of Tanks .J
Type Of Business (check): [J'GasoJ 'ne Station ~Other (describe) ~..,.., â..·"¡"? J
Is Tank(s) Located 011; An Agricultural Farm? [JYes ~No ' J/
Is Tank (s) Used Primarily For Agricultural Purposes? DYes baNo ;/ I
Facility Address ~~Ol ¿,.¿t,. LN. B~V_,.'!>.t:_J-tJNearest Cross St. -#-<;'4'-
T R SEC (Rural Locations Only) , ' .
Owner ,....h~-! ~~~.I ';;'. ~ Contact Person ~.h", 7). U. oJ,)
Address " ,';" ~ ~ /~ j. Zip -$./2'77 Telephone /- f,.,ð- ?~)- 99t.1'3
Operator _6z-~__~+_~. Contact Person I?Ø9'Þ"Ph.../,.;7S
Address 7#q/ å/h. Á..u.' g;æ...J¿_.......LUZip '7!!r~~7 Telephone ~9r- /p'ðn I:i.¿¡;;.
B. Water To Facility Provided By ('Y..,./L/I.A)..¡_l_..
Soil Characteristics At Facility .I /.. /;4
Basis For Soll Type and Groundwater Depth determinations
Depth to Groundwater
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Contractor J? ). W £ '7'. "
Address ,/ -?~D --I". r.I I'll ! ,.A' 4· \þ .ø'
Proposed Starting Date ¿,- /¿/- po '9
Worker's Compensation Certification No.
CA Contractor's License¿No.
Zip 4' ~ ~ 0 7 Telephone
Proposed Completion Dáte
C .off à I.. I nsúrer
-2 7~ ð7-51
,?t7$'- ?~~J-//o~
¿ . / / _/ 9'
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D. If T.his Permit Is For Modification Of An Existing' Facility, Briefly Describ
M?difica~4ons Proposed .£í. ..:'.<-./h 1-- 0/ /?.- /n,.., '..Þ ~ ",,~. "".¡. I .If-'J ~ YI ð~J~..~j. t- lZ./.r.·
.L I;r, ~ - ¡¿. /"/~I'''' l.v'!..7" ¡::; b.-,- 7./.?~ ¡/"ilJ:?~ Þ ¡/,~d vc-.t.... ~ ¡".f-, J /.JV - ~,/ ~'"
E. Tan~(s) Store (check all that apply): h G...." '1 hH Coþf"''''''m''o- ¡. -I ,7Lj" A.t;..Þr,'Y-
Tank # Waste P~oduct Motor Vehicle Unleaded Re~ular P~emium Diesel Waste
Fuel Oil
I 0 0 ~ 0 0 0 Q(J 0
00 0 00000
00 0 00000
DO 0 00000
F.
Chemical Composition Of Materials Stored (not· necessary for motor vehicle fuels)
Tank # Chemical Stored (non-commercial name) CAS # (if known) Chemical Pr.eviously Stored
(if different)
/1' -
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G. Transfer Ofºwnership
Date Of Transfer
Previous Facility Name
I, accept fully all obligations of Permit No. issued t
I understand that, the Permitting Authority may review an
modify or terminate the transfer of the Permit to Operate this underground storaR'
facility upon receiving this completed form.
Previous Owner
- - - - - - - - - - - - - - - - - - - -
------
- - - - - - - - - - - - - -
~~~s c~~;:c~~s b7~~f:J,e~!:~c~~e!.R=.~al ty of per jury and to the best of my know~e-7f= ¿s.. ~r(;e
Facil i.t~~· Name
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H.
~ J.,?~ i-,· Jt.~I?' L /
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TANK I (FILL OUT SEPARATE FORM FO.. è:ACH TANK)
- FÕR ~ SEcTÏÕÑ, æEëK ALL APP"RõPRÏÄTE-šõXEŠ-
.
Permit No. 3/ð'O ~...:z //7-_
1. Tank is: OVaulted ONon-vaulted ~[buble-Wal1 DSiN;Jle-Wall
2. Tank Material
DCarbon Steel 0 Stainless Steel 0 Polyvinyl Chloride (2J Fiberglass-Clad Steel
o Fiberglass-Reinforced .~lastic '0 Concrete 0 AlLminum 0 Bronze OUnknown
o Other (describe) . , ~ c:c ~ '
3. primary Containment
Date Installed Thickness (Inches) Capacity (Gallons)
IV / fJ ~/ OOr>
4. Tank Sécondary Containment .
~Double-Wallu Synthetic Liner OLined Vault ONone OUnknown
[JOther (describe): . Manufacturer:
o Material Thickness (Inches) Capacity (Gals.) --:-'--
5. Tank Interior Lining
-rfRubber ÔÞJ.kyd OEpoxy DPhenolic OGlass Delay DU1lined mU1kno'-1'\.
Oather (describe):
6. Tank Corrosion 'Protection
-UGalvan1zed . ¡;¡gFiberglass-Clad O~lyethylene Wrap OVinyl Wrappi~
, [JTar or Þ.sphalt Ounknown ONOM Oather (describe): '
Cathodic protection: o None DImpressed CUrrent System D Sacrificial Mode System
Descrite System & Equipnent:
7. Leak Detection, Monitoring, and Interception '
~Tank: OVisual (vaulted tanks only) DGrouOOwater Monitorin:J' Well (s)
DVadose Zone MonitoriN;J Well(s) Du~ube Without tiner
o U-Tube with Canpatible Liner Dlrectio¡ Flow to Monitorirg Well (s) *
o Vapor t::etector* EJ Liquid Level Sensor 0 Cond~tivit¥ Sensor*
o Pressure Sensor in Annular, Space of Double Wall Tank
o Liquid Retrieval , Inspection' Fran U-Tµbe, Moni torin; Well or Annular Space
121 Daily Gal):]i~ , Inventory Reconcll iation .ß1 periodic Tightness Testirq ,
o None 0 Unknown 0 Other .
b. PipiN3: 0 Flow-RestrictlN3 Leak Detector (s) for pressurizedPipiN311'
ß1 Moni torin; Sump wi th Raceway 0 Sealed Concrete Raceoway
o Half-Cut Canpatible pipe Raceway D Synthetic Liner Raceway 0 None
o Unknown 0 Other
*Describe Make, Model: Ÿr.llule...Ir ~ pi(;? ~//AJ FI{)2..77..~-2. i)')0
8. ~nk4igh~n~SBe
S 1S a en Tightness Tested? ~Yes DNa' Ounknown '
Date of Last Tightness Test .:g -;.;:/tÇ-:..i"-2- Results of Teste &r' f,' ¡;:.,~ --r: ¿ h /.
Test Name JI.~/I/""" .5:2 v - eh....r. Test.i~ Canpany f?",..j'P/~'''''' - YJl>'<u/-7
9. Tank Repair '
Tank Repaired? .DYes ~No OUnknown
, Date(s) of Repalr(s)
Describe Repairs /Ylx//,' ~'/'c;-I;(,~_ ,7, (1,'Vlý
10. OVerfill Protection, . / ¡ I
6aoperator Fills, Controls, , Visually Monitors level
DTape Float Gal):]e ~Float Vent Valves 0 Auto Shut- aff Controls
DCapacitance Sensor ~Sealed Fill Box o None Ounknown
Dather: ' . List Make & Model For 1\bove Devices
F;\\'5 - RÇ>I.J "Ÿ'I
11. Pip ng "
a. underground Plpi~: ~Yes DNa OUnknoW1 Material rk-,. t;/,.:......
Thickness (inches) Diameter .z::. Manufacturer ..4 /)ç, þ,: i-It
OPressure 52JSuctionLlGravity Approximate Lerqth of Pipe RLn ' 4,tJ I
b. Underground Pipin:] Corrosion Protect ion : ' . '..
DGalvanized ~Flberglass-Clad OIrnpr.essed CUrrent .DSacrificlal Anode
DPolyethy1ene Wrap -DElectrica1 Isolation Ovinyl Wrap DTar. or Asphalt
DUnknown 'ONone OOther (describe): '
c. Underground Piping, Secondary Containment:
nf""\~-.,..h'.-"\_.t"...." f""'1........ __,t. . _.
Manufacturer
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Ker-n County Heal th DepaL' tmcLÙH-- ¡-
Division of Environmental~ ,th
1700\Flower Street, Baker..,eld, CA 93305
(8,O5...-}'''-· 861-3636
'!w~)
.
I'I~ C au ~ i'H.J, .....:i..L-...;;~=-= ---. ,
cation Date ~6'- jç-- ? 9
APPLICATION FOR PERMIT TO OPERATE UNDERGROUND
HAZARDOUS SUBSTANCES STORAGE FACILITY
Type Of Apólication (check):
. [JNew Facility ~Modification Of Facility [JExisting Facility []Transfer Of Ownership
A.
x ...:;? i::J.
Emergency 24-Hour Contact (name, are~ code, phone): Days .-3 q 2- 1ft? /")
J / /1 Nights 3'7 7- 7~..::z "7'
Facility Name ~ /1 ;J-/"'- 'Nð~?,'¡.I No. Of Tanks. /
Type Of Business (check):' OGasoJ e Station OOther (describe) &~h?' 1-... L
Is Tank(s) Located On An Agricultural Farm? . DVes ~No v #
Is Tank(s) Used Primarily For Agricultural Purposes? []Ves ~No
Facility Address 5;0) wh;.J.- )..111, g]O!}". Nearest Cross St.
T R SEC (Rural~Locations Only)
Owner ' ....¿"~.. ~ ~t-'7f2 Contact Person ~hlÙ ' D.z/.J.#.AJ
Address . ~ ~ . ~'" n ~- ~.._ Zip ,f!, J.2 q ,f Telephone ~- ~ðO- §j,'i l. J: «
Operator Ch.,,.¡'~'þ> ¡';/'o"',":¡/_) , Cont~ct Person ß-"'- (¿'_..,-I" ...,
Address 5";2bl td},,'J.,AJ· ß.....J.r:.._,t';..·I.'f.Zip 0/3-;'7 Telephone :rlt:?P-}R'ðð
, .. .
Water To Facility Provided By ß )~/ ù.)~';""',. ,
Soil Characteristics At Facility
Basis For Soil Type and Groundwater Depth Determinations
Contrsctor ~ ~~.
Address --7ò -' 'n, If :-.. J4!J"
proposed Starting Date ~~A r
Worker's Compensation Certificátion No.
B.
Depth to Groundwater
C.
CA Contractor's License No.
Zip r;;...::l~ tJ7 Telephone
Proposed Completion Date
/7..../ ¡:::: )... Insurer
. .
J79.!J79
;J. ::;-;./ / tJ 0
ð ¿It) ¡::? J_
D. If This Permit Is For' Modification Of An Existing F.aci 1 ity , Briefly Describ
l Modifications proposedEt.t':2u,,~ ~ 7öp loP ~~"k - C¡,...~fc. <.. J (J p.; ~I! ¡p.,lun,
. , r
/Nes- C ¡"..~h- ð// ~"'>?OJ:7~""1' ';-.ub-~-
E. Tank(J;J) Store (check all that apply): ('
Tank , Waste Product Motor Vehicle Unleaded Regular Prem'ium .Qiese I Waste
Fuel Oil
I 0 0 0 0 0 0 ~ [)
0 0 0 0 0 0 B B
0 0 0 0 0 0
0 0 0 0 0 0 0 0
F.
Chemical Composition Of Materials Stored (not necessary¡ for motor vehicle fuels)
Tank' Chemical Stored (non-commercial name) CAS # (if known) Chemical Previously Stored
(if different)
G.
Transfer Of Ownership
Date ,Of Transfer
Previous Facility Name
I.
Previous Owner
accèpt fully all obligations of Permit No. issued tt
I understand that the Permitting Authority may review an
modify or terminate the transfer of the Permit to Operate this underground storag
facility upon receiving this completed form.
- - - - - - - - - - - - - - - -
- - - -
------
- - - - - - - - - - - - - -
This form has been completed under penalty of perjury ånd to the best of my knowledge is true
and'correct.
dC1 /' /ê
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Signature
Tlt 1 e· .L 1'0; ~ ·"rn;;1'·' n. to .ß - L 2.=':7
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" ,to
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-tl'-
~ h -,or' J______ ,4"¿i,P'" L/' '._ Permit
TANK '~' (FILL OUT SEPARATE FORM. ACH TANK)
, -FÕREAéHSECTION, CHEëK ALL APPRõP"RU\TEOOXEŠ--
-- ._-
No.
~ (O~ C:>"1-~.
F.3C il i ty Name
"
H. 1. Tank is: 0 Vaul too o Ncin-Vaul ted J8l{):)uble-Wall OSirgle-Wall
2. Tank Material
OCarbon Steel 0 Stainless' Steel 0 Polyvinyl Chloride ~ Fiberglass~l~ Steel
Cl Fiberglass-Reinforced plastic D Concrete 0 Ahmimm D Bronze DUnkoown
[]Other (describe) ,
3. Primary Containment .
Date Installed Thickness (Inches) Capacity (Gallons) Manufacturer
4. Tank Secondary Containment .
~ Double-Wall U Synthetic Liner
o Other (descr ibe):
DMaterial
5. Ta~k Interior Lining
---rfRubber DAlkyd DEpoxy DÞhenolic .DGlass DClay DU1lined DLnknown
DOther (describe): ' .
6. Tank Corrosion 'protection
-rrGalvanized . ~Fiberglass-Clad DPolyethylene Wrap DVinyl WrappiD3
DTar or Asphalt 'DUnknown DNone DOther (describe): .
Cathodic protection: o None OImpressed OJrrent System DSacrificial Anode System
Descriœ System & Equipnent:
7. Leak Detection, Monitoring, and Interception .
a. Tank: OVisual (vaulted tanks only) DGrouMwater Monitorir13 Well (s)
OVadose Zone Monit.oriD;} Well(s) DU-Tube Without Liner
o U-Tube with Canpatible Liner Directi~ Flow to Monitorir13 Well(s) *
~ Vapor Detector· ~ Liquid Level Sensor 0 Condu:tivi t¥ Sensor*
o Pressure Sensor in Annular Space of DoubJ.~ Wall Tank '
o Liquid Retrieval , Inspection Fran U-Tube, Moni to ri I):] ,'Well or Annular Space
rg} Daily GaUJir~ , Inventory Reconciliation 0 periodic. Tightness Test1r¥J '
o None 0 Unknown 0 Other
b. ~iping: DFlow-Restricting Leak Detector(s) for Pressurized Pipil):]K
o Moni to ri I):] SlJ'I\p wi th Raceway 0 Sealed Concrete Raceway
o Half-Cut Canpatible Pipe Raceway 0 Synthetic Liner Raceway 0 None
rg¡ Unknown 0 Other
*Describe Make & Model:
8. ;;:nk~igh~n~s Be
s 1S a en Tightness Tested? . DYes Dtb Eunknown
Date of Last Tightness Test -LJ/µ_,~ Results of Test
Test Name TesliD;} Canpany .
9. Tank Repair
Tank Repaired? DYes ElNo OUnk.nown
, Date(s) of Repair(s)
Describe Repair~
10. OVerfill Protection.
[]Operator Fills, Controls, , Visually Monitors Level
DTape Float GaUJe DFloat Vent Valves 0 Auto Shut- Off Controls
DCapacitance Sensor DSealed Fill Box DNene Rlunknown
DOther: . List Make ~'Model For Above Devices
o Lined Vaul t 0 None 0 Unknown ¡J
Manufacturer: ;Yt,(1'(/1 ¿' ,
Thickness (Inches) Capaci~ (Gals.) l.,i~
11. Pipi~
ð. underground PipiN]: J2:§Yes ONe Ounknown Material ß I JI
Thickness (iriches) Diameter Manufacturer /
DPressure OSuction OGravi ty Appiõ'Ximate Leogth of pipe Ru1
b. Underground Piping Corrosion Protection .
OGalvanized DFibe~glasS-Clad OImpressed CUrrent DSacrÙiclal Anode
DPolyethylene Wrap OElectrical Isolation OVinyl Wrap DTar or Asphalt
J;lunknown ONone OOther (describe): .
c. Underground P iplng, Secondary Conta i rrnent : . '
DDouble-Wall OSynthetlc Liner Syst~m ONone' J81unknown
[JOther (describe):
-------------._~ ________u_..___ _
e
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Utilities
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
PUTLS801
General Account Maintenance
===============================================================================
Acct Nbr: 751001
Cyc Stat: CL
rBill Stat: NO
Acct Cyc Stat: CL
Transfer-from:
Transfer-to:
Page 1 of 6
Due: 0.00
1. Customer Name: CHARTER HOSPITAL OF BAKERSFIELD
2. Social Sec Nbr: 3. Telephone:
4,. Service Address: 5201 WHITE LN
5. Service City: BAKERSFIELD 6. State: CA 7. Zip: 93309
8. Parcel ID:
9. Bill Cycle: 6 20. Water Svc Class:
10. Route Nbr: 1
11. Comments: UST ACCOUNT
12. Prev Acct: HM01229 23. Misc Services: 23.1 TOll UNDERGROUND TAN
13. Service Date: 08/12/92 23.2
14. Fund no: 24. Closing Date:
15. Bill-to Address1: 5201 WHITE LANE
16. Bill-to Address2:
17. Bill-to City: BAKERSFIELD 18. State: CA 19~ Zip: 93309
===============================================================================
Enter Save(S), Cancel(XX), Next Page(/), or Field # to Change
ALT-F10 HELP I ADDS VP I FDX I 9600 E71 I LOG CLOSED I PRT OFF I CR I CR
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CITY of BAKERSFIELD
"WE CARE'"
I
FIRE DEP¡'.RTivlE~JT
D. S ,\JEEDHAivI
FIRE CHIEF
2101 H STREET
BAKERSFIELD. 93301
326391 1
Dear Tank Owner/Operator,
On July I, 1991 the Hazardous Material Division of the Bakersfield City
Fire Department is assuming the responsibility, from the Kern County
Environmental Health Department, for administering the underground storage
tank program within the Bakersfield City limits. This includes all activities
pertaining to permits to operate, reporting of an unauthorized release, tank
removals, tank installations and modifications, inspection of facilities, and
enforcement of state and federal regulations.
In order to make the transition as transparent as possible no immediate
changes in the program are planned at this time. All tank moni.toring,
operating practices, and reporting responsibilities, etc. previously enforc~d
by the County will continue under the oversight of this office.
As it stands now, billing for annual operating permits will be done
based on the fiscal year (91-92, 92-93,...) and should begin l~te in 1991. or
early 1992.
In effort to familiarize our office with your operation we have· enclosed
a questionnaire we would like you to complete and return to our office
located at the following address:
Hazardous Material Division
2130 "G" Street
Bakersfield, CA 93301
The staff of the State Water Resources Board has been in the process of
revising the regulations I regarding underground tanks found in Title 23
Chapter 16 of the California Code of Regulations. The Board is expected to
adopt them sometime this year. So that all tank operators within the city
limits can p~epare for the future we have attached a list of what the Board
considers to be the most significant changes.
, If you h~ve any questions please f~el free to call me or Joe Dunwoody at
(805) 326-3979.
Sincerely Yours,
Ralph E. Huey
Hazardous Materials Coordinator
'I
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PENDING REVISIONS
TO
UNDERGROUND TANK REGULATIONS
NEW TANKS AND PIPING ARE REQUIRED TO HAVE CORROSION PROTECTION
AND BE EQUIPPED WITH SPILL CONTAINERS AND OVERFILL EQUIPMENT.
OWNERS ARE REQUIRED TO CERTIFY THAT TANK SYSTEMS ARE INSTALLED
BY TRAINED AND LICENSED CONTRACTORS.
THE EIGHT SPECIFIC MONITORING ALTERNATIVES FOR EXISTING TANKS
ARE REPLACED WITH PERFORMANCE STANDARDS GIVING MORE
FLEXIBILITY TO OWNERS AND PROMOTING DEVELOPMENT OF BETTER
MONITORING METHODS.
THE TANK INTEGRITY TEST PERFORMED AT TANK INSTALLATION IS NOT
REQUIRED IF THE TANK IS EQUIPPED WITH AN INTERSTITIAL MONITOR
CERTIFIED TO MEET THE PERFORMANCE STANDARDS OF A TANK
INTEGRITY TEST.
LEAK DETECTION EQUIPMENT IS TO RECEIVE INDEPENDENT THIRD PARTY
EVALUATIONS IN ACCORDANCE WITH EPA PROCEDURES.
AFTER JANUARY 1, 1993 INVENTORY RECONCILIATION THAT UTILIZES
MANUAL STICK READINGS CAN'T BE USED IF THE GROUND WATER LEVEL
IS WITHIN 20 FEET OF THE TANK BOTTOM, AND WILL BE DISALLOWED
IN ALL OTHER AREAS AFTER DECEMBER 22, 1998.
TANKS BETWEEN 1,000-2,000 GALLONS CAN'T BE MANUALLY GAUGED
AFTER 1998.
BY DECEMBER 22, 1998 EXISTING TANKS AND PIPING MUST BE EITHER
REPLACED OR UPGRADED BY ADDING CORROSION PROTECTION, SPILL
CONTAINERS AND OVERFILL DEVICES. CORROSION PROTECTION IS
PROVIDED BY BOTH INTERIOR LINING AND CATHODIC PROTECTION.
THE ALLOWABLE TEMPORARY CLOSURE PERIOD FOR TANKS IS CHANGED
FROM TWO YEARS TO ONE YEAR.
SMALL FARM TANKS, WHEN CLOSED, MUST COMPLY WITH THE CLOSURE
REQUIREMENTS IN THE REGULATIONS.
..c----=
.....-'
....
e Bakersfield Fire Dept. ..
HAZARDOUS MATERIALS DIVISTðN
2130 G Street, Bakersfield, CA 93301
(805) 326-3970
'þ ....
UNDERGROUND TANK QUESTIONNAIRE
j
/
/
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¡
I. FACILITY/SITE
No. OF TANKS
j
,[ .
PARCEL No,(OPTlONAL)
STA TE
e.
D9
o INDIVIDUAL 0 PARTNERSHIP 0 LOCAL AGENCY DISTRICTS 0 COUNTY AGENCY 0 STATE AGENCY 0 FEDERAL AGENCY
TYPE OF BUSINESS
01 GAS STATION
03 FARM
o 2 DISTRIBUTOR /
04 PROCESSOR, ~ OTHER
KERN COUNTY PERMIT
TO OPERATE No.
8a5 393-ð7g¡
..39 ¿>- /t:Y 00
PHONE No. WITH ",REA CODE
NIGHTS: NAME (LAST. FIRST)
PHONE No. WITH AREA CODE
~
ðr7n7
II. PROPERTY OWNER INFORMATION (MUST BE COMPLETED)
NAME
CARE OF ADDRESS INFORMATION
.I BOX 0 INDIVIDUAL 0 LOCAL AGENCY 0 STATE AGENCY
TO INDICATE 0 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL AGENCY
STA TE ZIP CODE
tJ4- 9~.:?CJ7
98-/.#0 ð
III. TANKOWNER INFORMATION (MUST BE COMPLETED)
NAME
CARE OF ADDRESS INFORMATION
.; BOX
TO INDICATE
o INDIVIDUAL
o PARTNERSHIP
o LOCAL AGENCY 0 STA TE AGENCY
o COUNTY AGENCY 0 FEDERAL AGENCY
STATE ZIP CODE
PHONE No. WITH AREA CODE
t'fl. (} a 1 c;:> 9
80S 3t?~-/ðoo
OWNER'S
TANK No. '
, DATE
INSTALLED
~7
VOLUME
PRODUCT
STORED
f)r.15AL '
IN
SERVICE
ð)N
Y/N
Y/N
Y/N
Y/N
Y/N
/(J()O atû...
DO YOU HAVE FINANCIAL RESPONSIBILITY? Y/N TYPE
~,
.:
Fill¡:óne segment ~ for each tank, unless alaanks and piping are
/ con,ptructed of U.same materials, style andWype, then only fill
o~e segment out. please identify tanks by owner ID #.
>' I. -Ti4.NK DÉSCRIPTION COMPLETE ALL ITEMS·· SPECIFY IF UNKNOWN '
." ,:;
A. O\'VI'JER'$ TANK J. D. #
------_._~--
c.. DA TE 1,'iSTALLED (MO/DAYiYEAR)
/111. TANK CONSTRUCTION
B. MANUFACTURED BY:
7
D. TANK CAPACITY IN GALLONS:
()
MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX 0
o 3 SINGLE WALL WITH EXTERIOR LINER
~ ,4 SECONDARY CONTAINMENT (V AUL TED TANK)
o 2 STAINLESS STEEL
o 6 POLyVINYL CHLORIDE
o 10 GALVANIZED STEEL
[J 1 RUBBER LINED 0 2 ALKYD LINING
o 5 GLASS LINING 0 6 UNLINED
IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO_
¡'-.. I DOUBLE WALL
A, TYPE OF I_I
SYSTEM ¡-1 2 SINGLE WALL
l !
._-~-------
1 BARE STEEL
B. TANK r--,
, MATERIAL ~ 5 CONCRETE
(Primary Tank) D 9 BRONZE
_._~-------~
C. INTERIOR
LINING
D 3 FIBERGLASS
D 7 ALUMINUM
D 95 UNKNOWN
D 3 EPOXY LINING'
D 95 UNKNOWN
D. CORROSION
PROTECTiON
1 POLYETHYLENE WRAP 0 2 COATING
D 5 CATHODIC PROTECTION 0 91 NONE
D 3 VINYL WRAP
D 95 UNKNOWN
IV. PIPING INFORMATION
A. SYSTEM TYPE A
B. CONSTRUCTION A U
o 95 UNKNOWN
o 99 OTHER
o 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC
o 8 100% METHANOL COMPATIBLE WIFRP
o 99 OTHER
o 4 PHENOLIC LINING
o 99 OTHER
. 0 4 FIBERGLASS REINFORCED PLASTIC
o 99 OTHER
CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF 'APPLICABLE
1 SUCTION A U 2 PRESSURE A U 3 GRAVITY
1 SINGLE WALL
.._~---_._-----~
A U 2 DOUBLE WALL
A U 3 LINED TRENCH
A U 99 OTHER
A U 95 UNKNOWN
99 OTHER
A U
C. MATERIAL AND A U 1 BARE STEEL A U 2 'STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE
CORROSION A u 5 ALUMINUM A U 6 CONCRET,E A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W¡FRP
PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U ,95 UNKNOWN A U 99 OTHER
D. LEAK DETECTION ~ 1 AUTOMATIC LINE LEAK DETECTOR o 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL íl99 OTHER
MONITORING L.--..;
V. TANK LEAK DETECTION
[-=.J 1 VISUAL CHECK D 2 INVENTORY RECONCILIATION ~ VAPOR MONITORING 0 4 AUTOMATIC TANK GAUGING ~5 GROUND WATER MONITORING
I : 6 TANK TESTING ~'7 INTERSTITIAL MONITORING 0 91 'NONE 0 95 UNKNOWN [J 99) OTHER
I. TANK DESCRIPTION
COMPLETE ALL ITEMS u SPECIFY IF UNKNOWN
A. OWNER'S ,TANK I. D, # I B. MANUFACTURED BY:
r DATE INSTALLED (MOrDAYiYEAR) I D. TANK CAPACITY IN GALLONS:
III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPLIES IN BOX D
A. TYPE OF
SYSTEM
D 1 DOUBLE WALL
l' 2 SINGLE WALL
-~~-~
6. TANK
MATERIAL
(Primary Tank)
D 1 BARE STEEL
D 5 CONCRETE
Cl 9 BRONZE
~---~--
C. INTERIOR
LINING
n 1 RUBBER LINED
5 GLASS LINING
o 3 SINGLE WALL WITH EXTERIOR LINER
o 4 SECONDARY CONTAINMENT (VAULTED TANK)
D 2 STAINLESS STEEL D 3 FIBERGLASS
D 6 POLYVINYL CHLORIDE D 7 ALUMINUM
n 10 GALVANIZED STEEL 0 95 UNKNOWN
D 2 ALKYD LINING D 3 EPOXY LINING
D 6 UNLINED D 95 UNKNOWN
IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL?
YES
NO
D 95 UNKNOWN
o 99 OTHER
o 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC,
D 8 100% METHANOL COMPATIBLE WIFRP
o 99 OTHER
D 4 PHENOLIC LINING
o 99 OTHER
-~----
D. CORROSION i._'
PROTECTION ! ':J 5
IV. PIP!NG INFORMATION
POLYETHYLENE WRAP D 2 COATING
CATHODIC PROTECTION D 91 NONE
D 3 VINYL WRAP
D 95 UNKNOWN
o
D
4 FIBERGLASS REINFORCED PLASTIC
99 OTHER
A. SYSTEM TYPE
_~.__._.___ _m__.__
B. CONSTRUCTION
A U
CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE
1 SUCTION A U 2 PRESSURE A U) 3 GRAVITY
A U 99 OTHER
C. MATERIAL AND
CORROSION
, PROTECTION
---~--------~-~-
D, LEAK DETECTION
A U 1 SINGLE WALL
A U 1 BARE STEEL
A U 5 ALUMINUM
A U 9 GALVANIZED STEEL
A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE
A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATiBLE wrFRP
A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER
o 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 0 3 ~6~~~g~~ U 99 OTHER
A U 2 DOUBLE WALL
A U 3 LINED TRENCH
A U 95 UNKNOWN
A U 99., OTHER
V. TANK LEAK DETECTION
11
:__i 1 VISUAL CHECK' L.J
[] 6 TANK TESTING D
2 INVENTORY RECONCILIATION 0 3 VAPOR MONITORING 0 4 AUTOMATIC TANK GAUGiNG 0 5 GROUND WATER MONITORING'
7 INTERSTITIAL MONITORING D 91 NONE D 95 UNKNOWN ' D 99 OTHER
V; .~'
.. /
4
;' I. TANK DESÇHIPTION
COMPLETE A_MS -- SPECIFY IF UNKNOWN
,
//
.~\ O\':ERi/~~ I. D. # .
C;:,ÛÁTE INSTALLED (MOIDAYiYEAR)
ì '
I'
III. TANK CONSTRUCTION
MARK ONE ITEM ONLY IN BOXES A. B. AND C AND ALL THAT ApPLIES IN BOX D
¿
/'
B, MANUFACTURED BY:
D. TANK CAPACITY IN GALLONS:
A/TYPE OF
~ SYSTEM
o 3 SINGLE WALL WITH EXTERIOR LINER
o 4 SECONDARY CONTAINMENT (VAULTED TANK)
o 2 STAINLESS STEEL 0 3 FIBERGLASS
o 6 POLYVINYL CHLORIDE 0 7 ALUMINUM
o 10 GALVANIZED STEEL 0 95 UNKNOWN
LJ 1 RUBBER LINED 0 2 ALKYD LINING 0 3 EPOXY LINING
o 5 GLASS LINING 0 6 UNLINED 0 95 UNKNOWN
IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL?
[_.I 1 DOUBLE WALL
2 SINGLE WALL
I
,I
I
/
If
¿
-
..-..--
---~~--
I·,
1 BARE STEEL
B. TMJK
MATERIAL
¡Primary Tank)
-
5 CONCRETE
[I 9 BRONZE
. .__ _ ___ _. ____n_n_
/
C, INTERIOR
LINING
YES_ NO_
D. CORROSION
PROTECTION
o 1 POLYETHYLENE WRAP 0 2 COATING
'0 5 CATHODIC PROTECTION 0 91 NONE
o 3 VINYL WRAP
o 95 UNKNOWN
IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE
A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY
B. CONSTRUCTION A U 2 DOUBLE WALL A U 3 LINED TAENCH
--..------
A U 1 SINGLE WALL
A U 1 BARE STEEL
A U 5 ALUMINUM
A U 9 GALVANIZED STEEL
A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE
A U 6 CONCRETE A U 7 STEEL WI COATING A U B 100% METHANOL COMPATIBLEWIFRP
A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER
1', 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 0 3 INTERSTITIAL 0 99 OTHER
MONITORING
C. MATERIAL AND
CORROSION
PROTECTION
____._'u
D. LEAK DETECTION
o 95 UNKNOWN
[J 99 OTHER
U 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC
[J B 100% METHANOL COMPATIBLE WIFRP
o 99 OTHER
o 4 PHENOLIC LINING
o 99 OTHER
o 4 FIBERGLASS REINFORCED PLASTIC
o 99 OTHER
A U 99 OTHER
A U 95 UNKNOWN
A U 99 OTHER
V. TANK LEAK DETECTION
L_J 1 VISUAL CHECK 0
:-l 6 TANK TESTING 0
2 INVENTORY RECONCILIATION 03 VAPOR MONITORING 0 4 AUTOMATIC TANK GAUGING 0 5 GROUNDWATER MONITORING
7 INTERSTITIAL MONITORING 0 91 NONE 0 95 UNKNOWN 0 99 OTHER
I. TANK DESCRIPTION
COMPLETE ALL ITEMS·· SPECIFY IF UNKNOWN
A, OWNER'S TANK I. D. # B, MANUFACTURED BY:
------
C, DATE INSTALLED (MOiOAYiYEAR) D, TANK CAPACITY IN GALLONS:
III. TANK CONSTRUCTION
MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D
U 1 DOUBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER , 95 UNKNOWN
Ä. TYPE OF L-i
SYSTEM 1--' 2 SINGLE WALL 0 4 SECONDARY CONTAINMENT (V AUL TED TANK) í! 99 OTHER
,
-~-~--~-----
-- BARE STEEL 0 2 STAINLESS STEEL 0 3 FIBERGLASS n 4 STEEL CLAD WI FIBEHGLASS REINFORCED PLASTIC
, 1
B. TANK
MATERIAL ~ 5 CONCRETE 0 6 POLYVINYL CHLORIDE 0 7 ALUMINUM L1 B 100% METHANOL COMPATIBLE W¡FRP
(Primarv Tank\ g BRONZE 0 10 GALVANIZED STEEL 0 95 UNKNOWN LJ 99 OTHER
!---¡ 1 RUBBER LINED 0 2 ALKYD LlN ING 0 3 EPOXY LINING II 4 PHENOLIC LINING
C. IIHERIOR , . 5 GLASS LINING 0 6 UNLINED 0 95 UNKNOWN n 99 OTHER
LINiNG '----,
is LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO -
._---~--_.
POLYETHYLENE WRAP 0 2 COATING 0 3 VINYL WRAP II 4 FIBERGLASS REINFORCED PLASTIC
D. CORROSION ,-- L-J
PROTECTION ,-¡ 5 CATHODIC PROTECTION D 91 NONE D95 UNKNOWN 0 99 OTHER
, ,
IV. PIPING INFORMATION
Ä. SYSTEM TYPE A U
CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE
1 SUCTION A U 2 PRESSURE A U 3 GRAVITY
A U 99 OTHER
8. CONSTRUCTION
A U 2 DOUBLE WALL
A U 3 LINED TRENCH
A U 99 OTHER
______._______ .__n_
_ .____ ~n_____*
A U 1 SINGLE WALL
A U 1 BARE STEEL
A U 5 ALUMINUM
A U g GALVANIZED STEEL
A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE ¡PVC) A U 4 FIBERGLASS PIPE
A U I) CONCRETE A U 7 STEEL WI COATING A U 8 100"10 METHANOL cm'.p.I,TIBLEw:FCiP
A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER
1- ¡ 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 0 3 1:~~~W¿b;;:¿' i] gg OTHER
C. MATERIAL AND
CORROSION
PROTECTION
~---._--_.-
D. LEAK DETECTION
A U 95 UNKNOV/N
V. TANK LEAK DETECTION
,,--¡ 1 VISUAL CliECK U 2 INVENTORY RECONCILIATION 0 3 VAPOR MONITORING I 'I 4 AUTOMATIC TANK GAUGING C 5 G;;OUND WATER MONITORING
,--. 6 TANK ESTING 0 7 INTERSTITIAL MONITORING 0 91 NONE 0 95 UNKNOWN c: 99 OTHER
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JOH N J. BREWER '
OSHPD CONSTRUCTION INSPECTOR
REGISTRATION NO: A-10402
9016 Deer Trail
P.O. Box Star Route 8076
Frazier Park, CA 93225
(805) 245-3917
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PCU.ULSRT"
INSTALLATION OF OOUIIU-WAlL F.ERGLASS TAN', PROIIE
(See 1010_"9 ~Qt- 10' ..".0' P8C*.~ ~s'.""On dJ,aW~m.J
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ASP"AL T OR
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l' - 4 , // -' MAN
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TYPICAL GROUNDWATER PROBE
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MONITORING WELL
MANHOLES
.
dC' ~~~
~kf¿;.' ..... ;,. '·:~,.60I\JlW;J
~~~:~~ \l
Universal all metal monitoring well manholes clearly distinguish
wells from standard fills.
· Clearly marked, cast in monitoring well designation, in
accordance with API Recommended Practice 1615.
· Cast iron ring and cover.
· Galvanized steel.skirt.
I';:'/;"i':'::;
"'60MW"
_,.;{'i;. ':.:~?~,
~i',';)¡';~'·, . - ,. , ,,". _', :;~;~~...:
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MONITORING WELL MANHOLE - Universal
60MW is recommended for applications where
limited access is not required. Screwdriver slots
provided for cover removal.
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MODEL # SIZE
60MW-8075 8" x 7'/2"
60MW-1280 12" x 8"
WEIGHT (LBS.)
11.4
25.0 "
A
B
c
9'/4" 8'/4" 8"
7'/2" 137/8" 12"
/
;.;
KERN 'COUNTY HEALTH DEPA.NT
~NVI~ONMENTAL HEALTH DIVISION
HAZARDOUS SUBSTANCES SECTION
e
1700 FLOWER STREET
BAKERSFIELD. CA 93305
PHONE (805) 861-3636
INSPECTION RECORD
POST CARD AT JOBSITE
FACILI'TY
ADDRESS'
CITY
PHONE NO.
INSTRUCTIONS: Please call for an inspector only when each group of inspections
with the same number are ready. They will run in consecutive order beginning
with. number, 1. DO NOT.cover work for any numbered group until ,all/~ltems;,in
:.Itl\a t(group . .....are,.s i gned . .of f~::,þy.. :;:,the < 'Permi t t i ng .;Author~ty .~·,':;~~::Follôwin"g~~;ithe·s e
'~di n s t rù ti on s ~-w i 11 -¡f:red uce the "nùm be:r".ó f -:'re u.1 re.d . ins è ctioíl::~vi s'{is :~;'å~ild1f~t-hêr'é råre
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Liner Installation - Tank(s)
Liner Installation - PiDinQ"
Vault With Product ComDatible Sealer
Level GauQ"es or Sensors. Float Vent Valves
Product ComDatible Fill Box(es)
Product Line Leak Detector(s) /1 f)
I Leak DetectorCs) for Annular SDace D.W. Tank(s) P~3ð'5v/ ,f..:( vct...v.H n
, MonitorinQ" Well(s)/SumD(s) :?- :?hSC:r A .4-h",;'/n.
Leak Detection Device(s) For Vadose/Groundwater·
- SECONDARY CONTAINMENT OVERFILL PROTECTION LEAK DETECTION -
't- Moni torinQ" Wells CaDs & Locks /~/¡J4j
Fill Box Lock , 6
Monitorine- Reauirements
- FINAL -
(..',: :":,7:
CONTRACTOR . ffJ4t' 1i/fJ1lð'T
CONTACT B /HI':, A
LICENSE # . z'14() 74-
PH # 834--//00
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Fl:Æ CONTENTS INVEi'lT':¡¿:Y
Facility ~~ 1ftJ-d¡1¿.K ~ t:l~uþ!J
PTO # Date App. Date #of ~anks Plot Plan~
Construction Permit # Date App. Date ~/I9ï-f7 #of Tank -1-
Abandonment Permit # Date App. Date / #of Tanks
Modification Permit # Date Appl. Date
Amended Permit Conditions
Annual Report Forms
Copy of Written Contract Between Owner & Operator
Inspection Reports
¡ .
Correspondence - Received
\,
Date
Date
Date
Date
Correspondence-Mailed.
Date
Date
Date
Date
Unauthorized Release Reports
Abandonment/Closure Reports
Sampling/Lab Reports
MVF Compliance Check (New Construction Checklist)
STD Compliance Check (New Construction Checklits)
MVF Plan Check (New Construction)
STD Plan Check (New Construction}
MVF Plan Check (Existing Facility)
STD Plan Check (Existing Facility)
"Incomplete Application" Form
Permit Application Checklist
Permit Instructions
Tightness Test Results _____
Discarded
Date
Date
Date
---
Monitoring Well Constructi~r. Data/Permits
Environmental Sensitivity Data:
Groundwater Drilling,' Boring Logs
Loçation of Water Wells
. Statement of Underground Conduits
Plot Plan Featuring All Environmentally Sensitive Data-
Photos Construction Drawings Location:
Half sheet showing date received and tally of inspection time, etc
Miscellaneous
<i::i";."-,:",...~.~.or.."if.:::L;'~~~':--'··'····~··_Þ'·-~~· .. .. - ·"·I·~ ... .....
"fW'\'A~....::":~~~~"""-"'''~~'''''''~~''''''~,¡;¡:~"~.~:.-;..r~=,,,:.'.~:·.,;.:
&
· Permit No. (?¿/J)QJßt6
App. ~ation Date _____ _
, ~éI~ County Health Departmen~-
Division of Environmental Hei.. .;h·
1700 Flower Street, Bakersfield, CA 93305
. (805) 861-3636
A.
APPLICATION FOR PERMIT TO OPERATE UNDERGROUND
HAZARDOUS SUBSTANCES STORAGE FACILITY
Type Of Application (check):
QgNew Facility []Modification Of Facility [JExisting Facility [JTransfer Of Ownership
Emergency 24-Hour Contact (name, area code, phone): Days BjJfFreY{Sð.r:) &'35 O/4/fjð'r
. ' Nights Bill F~ey (fjOS) ?;.C¡7 <õQ47liff'
Facility Name CfiA12íE:\2. !-tôSPliA-L 01= ßA¡(EQSFIELD No. Of Tanks O'IV£
Type Of Business (check): DGasoline Station ~Other(describe) !-tQSPliAL
Is Tank(s) Located On An Agricultural Farm? []Yes ~No
Is Tank(s) Used Primarily For Agricultural Purposes? DYes' ~No
FacUity Address 4200 s. b~lS$ðM ~T~E.E¡- Nearest Cross ,St. wHliE t...AN E
T R SEC (Rural Locations Only) ,
Owner CI-tA~TE'g MED/c.AL c.oRPotZAîl DN Contact Person .J6HN ÞA L TbN
Address Sil 'vfULBE:2J2Y ~T12EET M~DN Zip 3/2qB Telephone (1/4) 250 /4'1 I
OperatorC/+At<î€lZ NED/tAL- Co~R?QAi1D?J Contact Person. JoHN !:>A,L-TDN .
Address '$ï"7 Y\1UL.ßèerZY (,TI2£ET f/I;1ArolJ Zip 312-C\'a Telephone (7/4) ¿S6 14q I
B.
t
Water To Facility Provided By C I"iY 01= 13A¡¿EI2.SF/EU) Depth to Groundwater 1::::'0
Soil Characteristics At Facility . <:;./ L TY ~AND
Basis For Soil Type and Groundwater Depth Determinations ENédN€ër2.cD So/LS REP612T
C.
Contractor Mc.PSJIíT AND ~71ZE'E:T Ck Contractor's License No. ~51 7~5
Address 17SCVeéDH/LL ::¡:ev/~c cA Zip 9'2./14- TeleplÍone~'2/4) zt-O'iJlbé{
Proposed Starting Date 1!'Z-O/'8í Proposed Completion Date 1_/z.r/Ø7
Worker's Compensation Certif.ication No. ìr2JUSlQ3 ï ~7~Insurer TRt:\VE:l.-ël2:..5
D. If T~is Permit Is For Modi! ication Of An Existing . Facility. Briefly DescribE
Modifications Proposed (v/A
E. Tank(s) Store (check all that apply):
Tank :: Waste Product Motor Vehicle Unleaded Regular Premium Diesel Waste
/ Fuel Oil
0 0 0 0 0 0 ~ IT
0 0 0 0 0 0 0
0 '0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
F: Chemical Composition Of Materials Stored (not necessary for motor vehicle fuels)
, Tank # Chemical Stored (non-commercial name) CAS # ( if known) Chemical Previously Stored
(if different)
G.
Transfer Of Ownership
Date Of Transf,er IV/A Previous Ówner IV/A
, Previous Facility Name . ,IV/A
I. J..I/A accept fully all obligations of Permit No. issued t
¡V/A r understand that the Permitting Authority may review an
modify or terminate the transfer of the Permit to Operate this underground storag·
~acility upon receiving this completed form.
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------
This form has been completed under p8nalty of ~erjury and to the best of my knowledge is true
,and correct. J c::?~~.r" .' ,_:..~ _ I / .... _".
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e t\.c.RN COUNTY HEALTH DEPA~TMI,
HEALTH OFFICER
Leon M Hebertson, M.D.
1700 Flower Street
Bakersfield, California 93305
Telephone (805) 861-3636
ENVIRONMENTAL HEALTH DIVISION
PERMIT TO CONSTRUCT
UNDERGROUND STORÀGE FACILITY
DIRECTOR OF ENVIRONMENTAL HEALTH
Vernon S. Reichard
PERMIT NUMBER 310062B
FACILITY NAME/ADDRESS:
OWNER(S) NAME/ADDRESS:
. . CONTRACTOR:
Charter Hospital of Bakersfield
4200 S. Grissom Street
Bakersfield,'CA
Charter Medical Corp.
577 Mulberry Street
Macon, CA 31298
McDevitt and Street
17500 Redhill
Irvine,CA 92714
License #B451785
!XXI
I_I
I_I
I_I
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NEW BUSINESS
CHANGE OWNERSHIP
RENEWAL
MODIFICATION
OTHER
PERMIT EXPIRES
August 13, 1988
APPROVAL DATE
APPROVED BY
A~st 13, 1987
íJ 7--
t/ ð.( tiM- CA-...;
. Joe Canas
,:/:.
. . . . . . . . . . . . . .
. . .POST ON PREMISES. . .
. . . . . . .
CONDITIONS AS FOLLOWS:
1. All construction to be as per facility plans approved by this
d e part men tan d ve r i f i·e d b y ins p e c t ion b y Per m i t tin g Aut h 0 r i t Y . ~
2. All equipment and materials in this construction must be installed in
accordance with all manufacturers' specifications.
3. Permittee must contact Permitting Authority for on-site inspection(.s)
with 48 hour advance notice.
4. Backfill material for piping and tanks to be as per manufacturers'
specification.
5. Construction inspection record card is included with permit given to
Permittee. This card must beposte~ at jobsite prior to initial
inspection. Permittee must contact Permitting Authority and arrange for
each group of required inspections numbered as per instructions on card.
Generally, inspections will be made of:
a. Tank and backfill
b. Piping system with secondary containment
c. Overfill protection and leak detection/monitoring.
d. Any other inspection deemed necessary by Permitting Authority
6,. All underground metal conn'ections (e.g. piping, fittings, fill pipes) to
tank(s) must be electrically isolated, and wrapped to a minimum 20' mil
thickness with corrosion-preventive, gasoline-resistant t~pe or otherwise
protected from corrosion.
DISTRICT OFFICES
Delano Lamont Lake Isabella
Moiave Ridqecrest Shatter Taft
~.
.
-
fÏ)
PERMIT TO CONSTRUCT
(J
UNDERGROUND STORAGE FACILITY
, PERMIT NUMBER 310062B
ADDENDUM
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CONDITIONS AS FOLLOWS:
7. Spark testing (35,000 volts) required at site prior to installation of
tank(s). Test(s) must be certified by the manufacturer, and a copy of
test certification 'supplied to the Permitting Authority.
8. No product shall be stored in tank(s) 'until approval is granted by the
Permitting Authority.
9. Liner shall be installed by a trained experience liner contractor and
installation at site approved by the Permitting Authority.
- 10. Monitor,ing requirements for this' facility will be described on final
"Permit to Operate."
ACCEPTED BY
~?-
DATE
cf- /~-J7.
, FaCi1~~ty Name
. __ Pel'mi t No:
TANK! ~ _ (FILL OUT SEPARATE FORM' ~AC;1 TANK)
FOI{ EACH SECTION, CHECK ill APPROPRIATE BOXES
H. 1. Tank is: 0 Vaulted aNon-Vaulted E1 Double-Wall 0 Single-Wall
2. Tank Material
-cr- Carbon Steel(] Stain]ess Steel '(] Polyvinyl Chloride 0 Fiberglass-Clad Steel
o Fiberglass-Reinforced Plastic 0 Concrete 0 Aluminum 0 Bronze 0 Unknown
~ Other (describe): tv! ILD STEeL PL.ATE'
3. Primary Còntainment
,Date Installed Thickness (Inches) Capacity (Gallons) Manufacturer
1000 .JOOR-
f~\
, r
Secondary Containment
Double-Wall D Synthetic Liner D Lined Vault
Other (describe):
Material
5. 'Tank Interior Linin~
DRubber 0 Alkyd [] Epoxy 0 Phenolic 0 Glass 0 Clay ¡g Unlined 0 Unknown
o Other (describe):
6. Tank Corrosion Protection
--.è 0 Galvanized ¡g Fiberglass-Clad 0 Polyethylene Wrap 0 Vinyl Wrapping
o Tar or Asphalt' [] Unknown (] None 0 Other (describe):
Cathodic Protection: ~ None (] Impressed Current System 0 ,Sacrificial Anode System
[] Describe System & Equipment:
. 7. Leak Detection, Monitorin~. and Interce,ption
a. Tank: tJ Visual (vaulted tanks only) Ó Groundwater Monitoring Well(s)
[] Vadose Zone MonHoring ~Ÿell (s) 0 U-Tube Without Liner
[] U-Tube with Compatible Liner Directing Flow To Monitoring Well(s)*
[] Vapor Detector * D Liquid Level Sensor * [] Conductivity 5ensor*
[] Pressure Sensor In Annular Space Of Double Wall Tank * /
[] Liquid Retrieval & Inspection From U-Tube, Monitoring Well Or Annulac Space
[] Oai~y Gauging & Inventory Reconciliation -P Periodic Tightness Testing
[] None [] Unknown g Other POLI..VLEJ2. vÞDeR6r!2ooÂlD PRoBE::
Piping: [] Flow-Res~ricting Leak Detector(s) For Pressurized Piping* .
- [] Monitoring Sump With Raceway 0 Sealed Concrete Raceway
[] Half-Cut Compatible Pipe Raceway 0 Synthetic Liner Raceway ~ None
o Unknown D Other
* Describe Make & Model:,
8. Tank Ti~htness
Has This Tank Been Tightness Tested? 0 Yes ~
Date Of Last Tightness Test tv/A
Test Name ~¡lA
9. Tank Repair
Tank Repaired? 0 Yes ,181' No
Date(s) Of Repair(s) ~A
Describe Repairs ~¿(A
10. Overfill Protection
o Operator Fills, Controls, & Visually Monitors
o Tape Float Gauge [] Float Vent Valves 0
[] Capacitance Sensor 0 Sealed Fill Box []
.!8I Other: rOM ECO lVOw$PfL.L P12.0-r-E:c...îl DJ\)
MA-tv Ito L éi
4. Tank
--w
0,
Thickness (Inches)
o None 0 Unknown
Manufacturer:
Capacity (Gals.)
b.
No 0 Unknown
Results Of Test
Testing Company
o Unknown
Level
Auto Shut-Off Controls
None 0 : Unknown
List Make & Model For
Above Devices
11. Pipinl'!
a. Underground Piping: FJ Yes 0 No 0 Unknown MateriaISCIt.4'6 $(E:€L
Thickness (inches) Diameter Manufacturer
o Pressure C8[ Suction 0 Gravity Approximate Length Of Pipe Run 0'
b. Underground Piping Corrosion Protection:
[] Galvanized 0 Fiberglass-Clad 0 Impressed Current 0 Sacrificial Anode
o Polyethylene Wrap 0 Electrical Isolation 0 V~nyl Wrap 0 Tar or Asphalt
o Unknown g' None. 0 Other (describe):
c. Underground Piping, Secondary Containment:
o Double-Wall 0 Synthetic Liner System ~ None 0 Unknown
o Other (describe):
Co'
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Standard Campliance Check
Facility: titJw ~JfA/ÚY5¡;e.1J CT ¿¡
Equipment to.he install'ed:
::.~--::- 'fnlll\.tS), /.5 ft. of 'E]sucti.on Dpressurizec1 piping
Reqle]
./
Approved
Sc.. J6~7Primary Containment'
'DFU)erglass (FRP)
œFiberglass-clad steel
DUncoa ted steel
DOther:
Comment:
Make & Morlel
Make & Model !O()D .::GDV
Make & Model
Make & Móôel
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Additional:
Ins p e c· t i on:
,/
~c....
Secondary Containment Qf Tank(s)
~Douhle-I,Jalled tank(s) Make &. Model Äoo/
DSynthetic liner Make & Model
Dtined concrete vault(s) Sealer used
DOtAer Type Ma ke & Morlel'
Comment:
Additional:
--
Inspection:
--
~C-,
,/
Secondary containment volume at least 100% of primary tank
- vo 1 ume ( s) ,
Comment:
Þ.d d i t ion a 1 :
Inspection:
Secondary containment volume for more than one tank
contains 150% of volume of largest primary contain~mnt or
10% of aggregate primary volume, whichever is greater
Commen t :
Add ií:ional:
Inspection:
Secondary containment open to rainfall must accomodate
24 hour rainfall Total Volume Comment:
1
.,
..
Req'd
Approved
~
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.
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Additional:
Inspection:
Secondary containment
'Prod uc t Dìp,,:> Q)
Comment:
Þ.cldi tional:
Inspection:
is product-compatible
Documentation
Annular space liquid is compatible with product
Product Annular liquid
Comment:
Additional:
Inspection:
primary Containment of Piping
DFiberglass piping
DCoated steel piping
~Uncoated steel pipin0
Do ther. '
Comment:
Additional:
Size & Make
Size &,Make
Size
Inspection:
Secondary Containment of Piping
, DDouble~walled pipe
DSynthetic liner in trench
DOther
Comment:
Size & Ma ke
S i z e & M'a k e
Additional:
Inspection:
Corrosion protection
&1Tank (s) ::s-~
Dpiping& fittings ~ hD
DElectrica1 i.solation
Comment:
/J
~¿ffd.
Additional:
,
\
Inspecti'on:
V :Çr'./~ManUfactureJroved Backfill for Tanks & pi ping
. Type 5>, ' Comment:
2
'~
~
r;}
Rèq'2
--
_L
/
.
.
Approved
!\nnitional:
Inspection:
'I'ank(s) Located No Closer 'I'han 10 Feet to Builcìing(s)
Comments:
Additional:
Inspection:
....-5C- '117/ Complete Monitoring System
1$7 Monitoring device within secondary containment:
. OLiquid level ind icator (s)
o Liquid used ' ,
O'I'hermal conductivity sensor(s)
DPressure sensor (s) ./
DVac uum gauge
OSump ( s)
øGas or vapor aetector (s) Pit JJIA...~
DManual inspèction & sampling
DVisual inspection
DOther
Comments:
Aaditional:
Inspection:
Other Monitoring
OPeriodic tightness testing
Methocl
DPressure-reducing line.leakdetector(s)
DOther'
-Commen t':
Aaditional:
Inspection:
g/
Overfill Protection
D'I'ape Elon!: gauge(s)
~Float 'lent valve(s) O:?/IJ ¡)7.,
DCapaci tance sensor (s)
OHigh level alarm(s)
DAutomatic shut-off control(s)
gFill hox(es) ,....itll 1 ft.1 volume .ßV'T.,J) -.e'"R""e,¡.t) 111
DOperator controls with visual level monitoring
Other
Comment:
/
3 I
?
..
Req'd
Approved
.
,~cl d i t ion a 1 :
Inspection:
--
Monitorin~ Requirements
Additional Comments
Inspection:
Inspector ~ee C:R~~
L\
Date
.J
~ -------..--. ~ ,..:::...
.!'
1i:~'
Da te :
Purpose:
Comment:
Da te :
Purpose:
Comment:
fìa t.e :
Pur po s e :
Comment:
Date:
purpose:
Comment:
.
.
Extra Inspections/Reinspe~tiDns/Consultations
Invoice Date:
Inspector
Time utilized
Time Utilized
Time Utilized
Ti me Ut il i zed
Total Time:
Date:
KERN ~OUNTY HEALTH DEPAR'ANT
EN. VIR' ON MENTAL HEALTH DIVI"!Irì'·-·
'OJ
HAZARDOUS SUBSTANCES SECTIO~
..
I
17UU fLUWt" ~lK~~l
BAKERSFIELD. CA 93305
PHONE (805) 861-3636
INSPECTION RECORD
POST CARD AT JOBSITE
FACIJ.ITYCkc,-,-_ cv ¡"~'r" t,·'..1
ADDRESS .
CITY'
PHONE NO.
PER r-rr T ;: ,? , (Y.":' ;': (.. ¡ 0 W N ERe k c--,- . ev
ADDRESS
CITY
~,( /1. . Ii
I '..r!Cf_<.J u_(
i co/T"
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___"._..____.___ _~._____...,,_.u__ ___"_ ..._.___...__ ',__ __ ..__ ""_'.
'INSTRUCTIONS: Please call )(11' an ittSPlêctO¡' onlj7 ~']he]1 ("If;;) r{"":'!!' ,.,r ;""~':"':,":":
with the same number are re::1C1Y, Thev ":-'-11 run in r(, 1~;<~('IIt:j\:n p,'d"\ ¡'·.:r';I!!':'I'
wit h n u m bel' 1. DON 0 T c 0 \' e r W 0 d~ for a II y n U IT! bel' ediT, r 0 U pUll t i 1 a. 1.1 i L 'co ~I S 'i'!
that group· are signed off by the Permitting, Authority. Following tJles0
. instrutions will r~duce the number of required inspection visits and therefore
prevent assessment of additional fees.
I 7-~ .0 .. .___u____.
Backfill of Tank(s) /,;)/{,.-ìJ7 ._._-..._.~_...
I Spark Test Certificatiün¡;'''7t-~ ~ 1'+0 ~~ ------.------.---.
Cathodic Protection of Tank(s) ,
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INSPECTION
TANKS & BACKFILL
DATE
INSPECT()J{
- PIPING SYSTEM -
j.;J-Ii.'J 7
Pi p'e /J/6ð 1
l.1~k n
~ ,
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-r
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_._-----
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Liner Installation - Tank(s)
Liner Installation - PÏPinll
Vault With Product Compatible Sealer
Level Gaug-es or Sensors Float Vent Valves
3 Product Compatible Fill Box(es) L').../(..-\1 T~
Product Line Leak Detector(s)
~ Leak Detectorls) for Annular Spacè-D.W. Tankls)
~~ Moni torinp' Well (s) /Sump( s)
Leak Detection Device(s) For Vadose/Groundwater
,
- SECONDARY CONTAINMENT. OVERFILL PROTECTION, LEAK DETECTION -
~ Monitorinp' We 11 s . Caps & Locks
~ Fill Box Lock
Monitorinp' Requirements ,
- FINAL -
CONTRACTOR
CONTACT
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LICENSE #
PH #