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HomeMy WebLinkAboutUNDERGROUND TANK 2002-2004J -1989 \, CHEVRON STATION 91554 10 UNION AVENUE ~'l '~, -- 1~ ,1 1 L i r~ ~~ 1' i WESTERN PUMP 3235 "F" Street, San Diego CA 92102-3315 -Phone: 239-9988, Ext. 224 - Fax: 236-7406 email: dianasCalwesternpump.com Cover Sheet Date: Wednesday, January 11, 2006 To: BAKERSFIELD FIRE DEPARTMENT 900 Truxtun Ave Bakersfield CA 93301 Telephone: 661-326-3979 Fax Phone: 661-852-2171 From: Diana Duarte Subject: Message: xxx The following is a permit application for Jack in the Box station in Bakersfield for S6989 repairs. Please review and call me with any questions or when permit is approved. Thank you, Diana Duarte b 06/10/2006 20:16 17607214209 NiIT ENG AND CONST PAGE 02 tevro+9~'~ 8so'RapEun-iYuil~h. 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'~ ~L ~ III ~d~`~~J~JsS P~ ~'9 ~~fi7 ~P~~~a i~~Y.L~d~I3~,T~~~ L1I~~~S ~1Q.L~1I0~ ~UND~;R+~RpUNlt7 STORAGE 7CA1~Yl~,tlNY7'{QitiNC SYSTEIVIv CER'I'I~C4TION D. Results of TestittglServfcimg 3Pera~it Numl7er: Sallvvare Version Installed: ~a? . o e Com lete the t`gllowin checklist; 'YC9 ^ NO'~0 Yy fhG Rudlblc 31ti1111 erdixOnal'1 Yes ^ No* Is the visual alarm o crational? Yes ^ No's Were alI sensors visuall sins ectcd, func~t~jlally tested, and confirmed 4 eraiioual? ~Q Yes ^ Na'" Were a13 sensors installed at lowest poit.t of sacor,.cit~ry containrnemr and pobirioned so that other eyuipnlent wi11 not interfere rwith their r er o oration? Yes O No" If alaiTtts are relayed to a remote nitorissg station, is all comaluniCatipuS cgnSpment (c.g. modern) ^ NIA operational? 4~i Yes d ND* Fax pressurized piping systems, d4cs tha tur'binc autan~atacally shut dDwn it'tha piping secondary c4ntainmctzt ^ Iti'/A monitoring system detects a lcals~ fails to #rperate, or is elec,~trical3y disctmncctad? If yes: which su.~ors initiate positive slut-dorvu? (CHeCk al! that upp~~) ~Sump/Trcriclz Sensors; f,~Dispeuser Cantainrnent Sensors_ l~,d yDLE GDnf'irln ositAVC 517i1t-dDWII dll~' [ij ~+.':L1CR 811d S271SOr f8111tY~I(ll$COIJI]CCt20II~ Y~,p'; ^ 1`IO. l~ij Yes ^ No" For tank systems tha# utilize the tnon~tp~irl~ system as tEie primary tank overfill warning dc«ce (i.e. no ^ NIA mechanical overfill prevention valve is inslalled), is the overtlll warning alarrrt visible and audible at the tank till oint(s) and a ~r-3ti roped tf sq, at what +;rcent of tank ca achy does [be alarm tri er? ~ °1n © Yes* No Was any rn4nitAT'irlg equipment replaced if yes, identify specific sensors, probes, or other equiprneut r~cplaced and 1isC thr manufacturer Hartle and model der all r laeeraexlt parts in Section E, below. Yes* 4 No Was l;cluid found inside any secondary c~ntainmetlt aystculs designed as dry systems? (Check all rhul apply) ^ Product; ~ Water. Tf es, doscribe causes in Section E, below. Yes ^ Noy Was rnoniCD ' system set-tua reviewed to insure ro r aettin s? AtCach set u r~ orts, if" ap licabla YfS ^ IYp"° I5 Fill rrl0nit0Tt.II a u2 nienT eratl4nal zT manufacturer's C~1fICat18ri3? ~' In Section ]? below, descrit>r hu~r 8nd when these: deficicnCiK~ were or will be Corrected. ~, ~Ulrilx1Ql11'S. F' ~~~ a /a ~~1~ .. f<.a11 /w.1 F") ~IGL '~U~ ~~ 'rt1 ~ ~. h-A.S UEIi:FIM-9301 {Rev Oi-03) Yxge 2 ut4 County oi'S:u- l~ieg~-DN~I1-Huxrrduus Materials i7iviaion Eli 39Gd 1SN0~ QNb 9N3 ~I...W 60ZbLZt09LI 9L~6Z 900ZI0L/90 •3 iJNDERGROUnFD STURAGE TANK.'tY~t3N'Y'1"ORTz'ti[: SY5TElvF CEICtTIFiCATIdN r'. In-Tank Gauging !SIR 1~y;uipmenL: 'Permit Number: _ '~ Check this 'box if rani: gauging is usc$ only Fob jttvenzory control ^ Check this box if no tarsk gauging or S'1R eyuipni is installed This section must be completed if in-kax>rt gaug7ng ~q~~~~mettt is used to perform leak dc,tection monitoring. a..vu IC4c ;;I+i ;V kYP f;i; V;1C~nlW;F . C] Yes ©No'~ Has all input wiring been inspCC~ted far propQr entry and termination, iztcluding testing for b~round faults? ^ Yes ^ No* Were all tasilc gauging grobcs visually insp~cfed for damage and residue buildup? ^ Ycs D No* Was accuracy of system prodtu:t level rcadj~~;s tested? ~J Yes CJ No* 'UJas accuzacy of system water level readin~~ tested'? ^Ycs ^ No* 'Were atI probes reinstalled properly? ^ Yes ^ Nu* 11t'Gra all itatus on the equipment rnanufact~r's maintenance aheckiist corapictrtl? In Sect ion H beiovv. describe how 8nd when these cieficiencles were ac wiif 6e currecteti_ G. I.irte T,ea6 Detectais (~~Tl): d Check ibis box ~f'L'LDs are not utstalled. ~umolete the Yoituwias+ eltecklist: l'~I 'Yes ^ No* © N!A For cquigmcnt start-up or'annual equiprra~nt cctt~carlon, was a Leak simulated to verify LLA perfoi~nnce? (C'fteck all lhtet apply) Simulated lettle rate: I~(3 g.p.h.; ^ 0.1 g.p.l~. ; ^ 0.? g.p.lx. Yrs C] Noy' Were all LLDs conf"umed op~~.ozaal and a~~urate within regulatory reguirarrens,? Yes ^ No* Was rhG testing apparatus properly calibrat~~~> ~ 'Y'CS ^ N'o* ^ NIA For mechalucal LLT)s, dues the T..1.L7 restrict product flow if it C1~ectS a leak? . ^ YGs ^ 1Vo* ~ Ni.A, For electronic Li,Ds, does the turbine autorr~tically shut o~'iFthe LLD detects a leak? Q Yr's ^ No* ~J N/A For electronic Ll~bs, does the turbinC autgmtitically shuT aff' if any pomon of the munitorm,g sysirrtt is disabled or disoannocted'? ^ Yes C.] No" `~ hT/A For electronic LLDs, dons the turbine autonrvriieally shut off if any portion oftha rnnttitoring system malfunctions or fails a tcs~t? ^ 'Yas ^ N'rr* N/A For electronic LLDs, have all accessible wi~iIIg cornectious been visually inspected? YGS No* W ~ all items on the equipment rnanufactvre~'s ntaintzn~ince ehncklist comple~d7 __.. ~ n SfCt ,. _. 1Ot1 11 t)n1UYV. SYf.'SCl'1be hU'W slllat When thwVM dPti(:7Pnl~YWi wAr(+.~r will iw nns•.•.aa furl Y~. Cummenis~ 1lEH:F{N1-9301 (IteY Ol-U3) Yagr 3 u1' 4 Cuunry of 5vu iliaga.uEti.Pei:uarduur iViuteriats DiveS7on b0 39~d 1SN0~ QNt1 9N3 l:~W 60ZbTZL09L1: 9T~0Z 900ZI01:}90 ` . } .~ 1 r]N]R~R.G~tQUND 5T4R.~GE ~'Ai~TM P~OI~iITOlE~t1,1G $YSTEI4I GERTiFtCa.7YDN permit N um6er• UST Man~.>~ori~.ng -Site ~'lau Siee A~.dress: !a UN r4N ~ tl~. 7~A~' ~f~h .. _ . .. . ~ . .. ... . . . .... ~ ~ r ~.rn~~~- . - - - - -~ - ~ - - - .............. . Date map was d~~wn: ~...1.,~._IQtP ~, Ins~cdotis If you already taav~e a dia~arn that shows alI squired iamr~van, yc~u may ix-clude it, rather Haan this page, with your Monitoring System Gerdfical'ion. On your site plan, Sl#tfw the general layout of tanks and piping. Clearly icl~atify locations off' the following equipment, if installed- o~itorfng system control panels; sensors monitoring lank annular spaces, sumps, dispenser pa~zs, spill containers, ar okher peaandtuy oantainment area; mecharic~l or eleetronio line leak cietecturs; :and in-tank lie7uid lc~el Frob.:s (if used for 3eak~ 3~:tzCtictin). In rho SpdCc provided, note the dote This Sits Plan was prepared. llEH:kilYl-93D1 (Ruv OY-Q3) ~8g~ A qT~ Cvgetty OLS:w liege-DF..Ii-HazardUUS Materials i-ivisiua 50 3J'dd 1SN00 QNd JN3 lIIV 60ZbZZL09LT 9T~0Z 900Z/0Z190 SWRG$, January ?406 Sj7ir~ Bucket Testing deport Form Tleis form is l~ue,~tj~sd fvr use by contractors perforrrrdng Q~rt! testt-eg of UST spill containment straactures. The cutnpleted furr-z acrd printouts from tests (tf applicable), should be provided tv the faciliry ownertoperaror,for su6+nitral to the taco! regulatory agency. x. F~,ciz.rrY olz>vta,Tloiv Facility Name: ~, ek 5'tCiF'P ~ ~7J:-3 Date of Testing, ~ 5 o(e ................ Facility Address: p V~ t1>wy v~Na E d... I~SFr Ee~A CA o Facility Contact: „j a 4~~s- ~ S Phone: GoG [ - gG 1- b S 3 .......... bate Local Acency 1Nas Not'if'ied of Testing : 5 ~y ,y(,~ Name of Local A en ector r reser:r durin te~7in N (p g cY ~ ~fP S ~= 2. TESTING CONTRACTOR INFORMATION CompxnyName: t'T' i~.sGr~~~(t G. ~3'T~~e ra..~ 1ae. Technician Conducting Test: KiL~~ ~rti.T'r{ Crtdrntitrlsr: ~ CSLB Contractor x ICC Service Tt:ch, SWRGB Tank Tester Other (S r:cifvJ i,icense Numbex(s): A r 4l A Y~ 7t339fo 5 z. G'~ 3 a 2~ T - 3. SpYLY, BUCKET T~,~TING INFORIVIAT'ION Test Method Used: x Hydrostatic . 'vacuum Other Test Equipment Used: ~/. S u A- ~ .. . ~ Equipment Resolution: . Identify Spi118ucket {i3}, Tank Nurrcber, Stored product, erc.l . . 1 ~ 7 .~~,. 4 1 ~ ~ r ~ ~ ~4 4 Bucket Installation Type: Direct Bury Contained in Sum pirect Flury Contained in Sum bisect Bury Contained in Sum Direct Bury Contained in S Bucket Dirlmetcr: i ~ " '[ 2 " j 2 •~ Bucket Depth: ~ $ " t u ~ $ .r Wait time between g 1 rn PP Y g vacuutn/water and start of test: JO µ • ~+ 3 a ~ ~ ~+ 30 ~ ~,~ Test Start Time (TJ. [ ' e~ ~M- .............. 1:oc~ p.... 1 : ~o P.~- [nitial Reading (R~}: S.~ ~ ~ ~.T$ ~~ .~ •• Test End Time (TF): ~ -ob P+~ ~ : eao p,~ ~, ' oc, r P Fins! Reading (RF}~ S S 'r ~. 75 `~ X0.0" Test Duration (TF - T'r). Cp ~ µ ~ •~ ~ ~ ~ «s ~ U rt ~,- Change in Reading (RF - Rr}: L ~- .. .~ -~} Q~1Fa;i rhreghoit< or criteria: ~ ~ ~ Test ~,e~8>ult: ~ Pass 0 Fat! ~ Pass ^ Fail f~f Pa98 ^ ~`tlit Q Psis C7 Fs11• Comments - (inclazde in{ormation on repairs made prier {ra resting and recorrtinenufed follow-up for failed tests) CERT~ICATION OF TECHiVYC1AN RESFON'Sl'ST.F :FOR CoNDi]CTING TIiLS TEST]xIG I hereby certify that trll the ittformutlipn containea! ttt this report ~ true, accurate, and !n full car~pllance with le~rtl regrrireme~s. Technician's Signature: bate: G I S ~a G ~ State laws and regulations do not currently require testing to be Ferfortaed by a qualified contractor. However, local requirements may be more sttringznt. 90 39~d 1SN00 QNG 9N3 IIkJ 60ZbLZL09LT 91:~0Z 900Z10I%90 06/10f2006 20:16 17607214209 MIT ENG AND CONST PAGE 07 } ,. ~te~~ss~d ua~}issa~ yo1'ac zeal al sne;s so.}.aa;ap ~e~ ~ ~~ Ifns c~. 3iul; 1lJL(~ a1c,~ ~s ; ~ae9p~l~ a}e~ ~noy a$ suolf ~lnssa~ awno un~.,a ~ '~F~~d ~~~~~~ s w '~ O li0~i~'7. G ; . ac~~a::}uo~ _ .~: JOB CARD c POST CARD AT JOB SITE INSPECTION' RECORD-USTs BAKERSFIELD FIRE DEPT. Prevention Services ..900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 FACILITY NAM 04VNER ADDRESS ADDRESS CITY STATE ZIP 3 CITY STATE 21P BAKERSFIELD CA ©~ ~ BAKERSFIELD ~ CA Q Q PHONE NO. ~ PERMIT N0. INSTRUCTIONS: PLEASE CALL FOR AN INSPECTOR ONLY WHEN EACH GROUP OF INSPECTIONS WITH THE SAME NUMBER ARE READY. THEY WILL RUN IN CONSECUTIVE ORDER BEGINNING WITH NUMBER 1. DO NOT COVER WORK FOR ANY NUMBERED GROUP UNTIL ALL ITEMS IN THAT GROUP ARE SIGNED OFF BY THE PERMITTING AUTHORITY. FOLLOWING THESE INSTRUCTIONS WILL REDUCE THE NUMBER OF REQUIRED INSPECTION VISITS AND THEREFORE PREVENT ASSESSMENT OF ADDITIONAL FEES. INSPECTION DATE INSPECTOR TANKS AND BACKFILL BACKFILL OF TANK(S) SPARK TEST CERTIFICATION OR MANUFACTURES METHOD CATHODIC PROTECTION OF TANK(S) _,:. PIPING SYSTEM PIPING & RACEWAY W/COLLECTION SUMP CORROSION PROTECTION OF PIPING, JOINTS, FILL PIPE ELECTRICAL ISOLATION OF PIPING FROM TANK(S) CATHODIC PROTECTION SYSTEM-PIPING DISPENSER PAN SECONDARY CONTAINMENT, OVERFILL PROTECTION, LEAK DETECTION LINER INSTALLATION -TANK(S) LINER INSTALLATION -PIPING VAULT WITH PRODUCT COMPATIBLE SEALER _ - LEVEL GAUGES OR SENSORS, FLOAT VENT VALVES PRODUCT COMPATIBLE FILL BOX(ES) PRODUCT LINE LEAK DETECTOR(S) , LEAK DETECTOR(S) FOR ANNUAL SPACE-D.W. TANK(S) MONITORING WELL(S)/SUMP(S) - H2O TEST ~ ~~;~ ~ ~ F! ® ~ U LEAK DETECTION DEVICE(S) FOR VADOSE/GRO NDWATER SPILL PREVENTION BOXES FINAL MONITORING WELLS, CAPS & LOCKS FILL BOX LOCK MONITORING REQUIREMENTS TYPE ~ ~ ~ ~ AUTHORIZATION FOR FUEL DROP ` ~ CONTRACTOR ~~ ~~~(-ifhlpp (~LIG~,i~ ~C- CONTACT ~1ZC~ DdCt~' LICENSE NO~~o 7~J ~~.3 [a ' PHONE NO. ~DI'l c,~_~9 ~ l ~ g$ FD 2097 (Rev. 09!05) 8 H R 9 P I D ~iA~ ~Rr~r r UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELp / LfNE TESTING i SB989 SECONDARY CONTAINMENT TESTING (TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CirRTIFICATION B B R S P I A ~i~r ARTAI T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: {661) 326-3979 Fax: (661) 852-2171 Page 1 of t PEFWIIT NO. ~f 3 r ^^ ENHANCED LEAK DETECTION ^ LINE TESTI VG ^ SB-989 SECONDARY CONTAINMENT TESTING 1 1 TANK TI(_HTAIFCC TGCT ~ T/l VL~R F(1I 1M1~ CI IGI M1~7(1NITCIRIA!(: ('FRTIG If'..".Tlfl#I __ SITE INFO RMATION FACILITY F'~7123 vic TuF NAME 8 PHONE NUMBER pF GONTAC7 PERSON ~oA~nla H,aaritS G~~' 8'~of-OS~3 _ ADDRESS ~ p I~ (Jnl/onJ /Qv~^JJ~ ~AG~R.SFtEa-D 7 3307 OWNERS NAME .J sac N tsE ~o x, ! ~ c . ___ OPERATORS NAME PERMIT TO OPERATE N0. NUMBER OF TANKS TO BE TESTED IS PIPIN~~ GOING TO BE TESTED? ^ YES ^ NO 7ANK# VOLUME CONTENT _ } TANK TESTING COMPANY ~ NAME OF TESTING COMPANY p M/7 ENG /N~Ert rn/G dt Co NST2 vc Zonl, 1.~~. NAME & PHONE NUMBER OF CONTACT PERSON ~JESsE Kt ~~c 7100 - ? 2 i -¢/20 MAILING ADDRESS /a 5 4~io E.ea.oo~ !~/A y . Su. £ O GEA nlt -a f . C.4 Za 54~ N ME & PHONE NUMBER OF TESTER OR SPECIAL IN:;pECTOR r+tu P Sn.~t-rte 95~- 7~ -9r 3~ __ CERTIFICATION #: ~O -os- /¢ ve~ot:,~2nor DATE & TIME TEST TO BE CONDUCTED ~wc : t pnn _ ____ ICC #: 523352 -UT _ TEST METHOD SIGNATURE OF APPLIC r~ J ~4~ _ ~ DATE 5 ~ / f 0 6 orr aECOm. ~APPRO~IEQ.___ APPROVED BY ,,' DATE ~' ~' FD 2D95 (Rev. 09/05) .zanaa~ x~3 T00/100 ~9~'d 69 ~ TT 9002/9T/~ x'~3~u~i'N UNDERGROUND STORAGE TANKS `~ .. APPLICATION TO PERFORM ELD /LINE TESTING / S6989 SECONDARY CONTAINMENT TESTING /TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION BAKERSFIELD FIRE DEPT. H $ R ~ I D Prevention Services ~~Re AItfM T 900 Truxtun Ave., Ste. 210 .~. Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 PERMIT NO. 1 I `Y~ ~l',~ ^ ENHANCED LEAK DETECTION ^ LINE TESTING ~SB-989 SECONDARY CONTAINMENT TESTING TANK TIGHTNESS TEST ^ TO PERFORM FUEL MONITORING CERTIFICATION SITE INFORMATION FACILIT`~~- (`_ I" ~~ 1 NAM & PHONE NUMBER OF CONTACT Pi R ©N_ VC ~/ ~ DDRESS ~~~ WNf~RS N ME OPE AT RS NAME ~~~ ~~ PERMIT TO OPERATE NO. NUMBER OF TANKS TO BE TESTED IS PIPING GOING TO BE TESTED? __ ^ YES __^_ NO _ ___ TANK# VOLUME CONTENTS -- t - - ~ k _ ~v~ uN~`~~ Lo << -P~~v~ r~r~~,~rn~ TANK TESTING COMPANY . NA E OF TEST N~ OMP NY ~ N PNO N M EFJ OF CONT TpER~ON ~~ ~ `c~ M ILI GAD RESS%~"I~UU'i~.YC7 G.~ C v vt ,. ~tr GW (~~"~ NA & P ONE~U MB'R OF TESTER OR v v l/ ECIAL INSPECTOR ERT~oATION ~~ ~^ ~, G `J DATE & TI E T ST T ~ B E COND CTE V CC #; ~~l ~~ ~ - ~~ C~ EST METHOD VpG-~ IGNATURE OF APPLIC ~- ATE ~.~ ©~ __ _ ,~_ ~ ~ ~ ~I ~ .A N! B!E.O~OM~~S: ~ ~ M ~T' ~ , ~ ~~k P ; ~" ~V '--- PPROVED BY DATE O FD2106 RightFax .s 12/27/2005 4:23 PAGE 002/007 Fax Server .~ UNDERGROUND STORAGE TANK ;; ~. BAKLRSFIELD FIRE DEPT. ~~~.~ :>~ I Prevention Services PERMIT APPLICATION ~`~ ~;= 900 Truxtum Ave., Ste. 210 TO CONSTF~lCTaNSTALL NEW TANK (NEW FAgLIi'Y) ! ~ ~~ Bakersfield, CA 93301 NE1N TANK INSTALLATION (EXISTING FACILITY) / =y; Tel.: (661) 326-3979 MODIFICATION / 8 MINOR MODIFICATION - FaGUTY ~:% ~ Fax: (b61) 852-2171 PERMIT N0. ~n (~~ ~ ~ _ Paga i of t 1~'' I/l• TYPE OF APPLICATION: ~ NEVY TANK INSTALL J NE1N FACILITY O NEW TANK INSTALLATION /EXISTING fAC1UTY Check one Item onl D MODIFICATKIItI OF FACILITY MINOR MODIFICATION OF FACILITY ARTINCDATe osEO UATE AQ Ha ~ 2 0 X5'1 ~ ~ u I C1'C. V I ~ -1 ~ ~ ~ ~ ~~ T1t~3 FACRRY PEtiMlf NO. IUCllfllf gDOR~SS I u~lon ~uenue~ TTY a e+~~ielal IP CODE q3~©~~ ~c~s ~~ DRESS ~ ~, A1re~ RY ~ ~~~-e(d CDD~ . eS~ern `Qurnp,I,~c ~~. 1n~3853 ~. ~5fl?~q' U-:I 32;3.5 F ~S~'r~+ __~-: _ ~c~an ~~e o ~2rc~z NENR a3ta Grt1r eusxarss ucE.NSE NO. ~q~ 23q~ a a $ g COMP NO. ~0~ 4 0 ~4 ~ .~u0 ~ REn . Com iua:~h BRIEFLY OESCRalE THE WORK TO ~ OOa= e pe - 2., - rem'I u, ~ s WATER TO FAGILRI' PROVmED BY DEPTH TO GROUNO WATER SOdTYPE b(PECTED AT SITE N0. OF TAMCS TO BE WSTALLEA ARE THEY fOR MOTOR FUEL ^ YES ^ NO SPILL PREVENTION CONTROL AND OOUMI'ER MEASt1RES PLAN ON FILE C3 YES ^ NO The appltaant leas receivoec( wederstmlds, aotd will c»nlpty with tAez attached conditions of the per,nit arxt ae{V othe- state, laml rnxl federal ne~dations. Thisforsn has been we~leted wider petlafty oJAerl++rJ: and to the best of nQy beawkdgr. is trae aiad comec~ D~Gt~ta ~U(~,(~ APPROVE BY' ~~ APPLIGWT NAME (PRINT) PLICATION BECOMES A PERMIT WHEN APPROVED ~" %~( f ~~ FD2O86 It'ew. eerosl ~~ „RightFax 12!27/2005 4:23 FAGE 003!007 Fax Server BILLING & PERMIT STATEMENT sAx~atsFtELn FixE nE~r. Prevention Services '~+~ 900 Truxtun Avenue, Suite 210 PERMiF NO.: ~~r~ Bakersfield, CA 93301 L~ LOGTrON OF PROJECT ~ ^ Un l p ~l ~CU~ QTY owmr:R G ~Tl~ ~ 723 srnRr~ nnrE u COrnva.EnO-+ anrE r+naE PrtOJECr C~K ~ e~ ~QU ~~ ~+ n (1 E - I - 9~.3 p~wECT AL~iESS Cn'f n 5i TE Z1R CODE f,\ t 9 r~ I n ~ ./fit fP~ ~~ ~PI~~I E ~~ ('~- ~~~~~ OR NAi~AE CA LICgISE NO. ' ' TYPE OF LICENSE EWNATgN DATE tVt). CONTRACTOR COMPANY NAME ~ "Tl eG T Cm C~ 1~ ~ I ~ ~ Z!P CODfr} n C O~ ^ Alarans -New & Mal~Catians - (Minimum Char e) $262 50 84 g . 98 Over 20 000 S FL FL x 013125 = Penmit fee Sq ~ ~ , q. . . 98 ^ Sprinklers -New & Moc66cations - (NRnimum Char e) $210 00 ~ g . 98 ^ Over5 Ot10 Sq Ft 042 =Nermitfee 5q k x ~ , . . . . se ^ Minor Sprinkler Modifications (< 10 heads) 00 (Inspectio» On1yj $ 93 ~ _ . 98 ^ Commercial Hoods -New & Modifications $ 398 26 ~ . 98 ^ Additions! Hoods $ 36 00 ~ . 98 ^ i Spray Booths -New 8~ Modifications $458 (10 . ~ ^ Abovegr_ound Storage Tanks (UastalleGordlnsp.-~° 7ime) $165.00 82 ^ Additional Tanks $ 26.00 82 ^ Aboveground Storage Tanks (R~rrovaNlnspection) $109.00 82 ^ Underground Sbrage Tanks {~nstaltetiorr.llnspedlan) $878.00 (pertenk) 82 ^ Underground Storage Tanks (Modifiptar-) $878.00 (per site) ~ Underground Storage Tanks (Minor Mod~ication} $155.00 82 ^ Underground Storage Tanks (RBrrioveQ $675.00 (per tank) ~ ^ Qilw+elf (lnstalla6on) $ 72.00 84 ^ Mandated Leak Detection (Testing} ~ Fuel I~toniL Cert. $ 8].00 (persit8) ~ ^ Tents $93.00 (perter~' 84 ~ ^ i After hours inspection fee $1?2.00 ~ ^ i Pyrotechnic - (Per event, Plus Irrsp. Fee ~ $90 per hour) $ 60.00 + i5 hrs. rtrin: stand ~7yr 4ee Arlspedian} _ $510.00 84 ^ ~ RE-INSPECTION(S) ! FOl10W-UP INSPECTION(S) $ 93.00 (per hour) ~ ^ ~ Portable I.PG (Propane): NO.OF CAGES? $66.00 ~ ^ E~lasive Storage $249.00 ~ ^ `Copying & File Research (File Research Fee 333_t)0 p~ hr} 25¢ per page ~ ^ Miscellaneotts s4 FD 2021 {Rev. a9r05) 1 •OPIOINAL VYfin'E (to 7reasuryl (-YELLOW (to File) 1-PINK (to Customer) ~_ f MAIL TO: CITY OF BAKERSFIELD P.O. BOX 2057 HAKERSFIELD, CA 93303 CITY OF BAKERSFIELD CALIFORNLA PREMISES MUST CONFORM TO ZONING. HUILDIN(I, FIRE AND HEALTH CODES. CHANGE OF NEW OWNERSHIP ^ BUSINESS CHANGE OF ADDRESS O APPLICATION FOR BUSINESS TAX CERTIFICATE PURSUANT 7'O ORDINANCES OF THE CfIY OF BAKERSFIELD PLEASE TYPE OR PRINT LEGIBLY IN INK BUSINESS NAME ~ ~~ ~~~~ ~~ rtil ~' l NL ^ DATE l Z/Z `I /~ S BUSINESS LOCA17[3hi 3Z 3 S ~ `3. r'r2F..-sue ~ A-••~ ~/ ~ o C•/'t- _ ~f Z > D Z (SepQateCati6cneRequsr~fur£~;ktutmxw} STREET Ct1Y^,T 7.iF MAILRVG AI~DRES" STREET t'tTY ST ZIP KIND OF BUSINESS OR PROFESSION ~F~"O`~~`` ~ ~'"~~'~O~~Oi~ ~~~'`~"F'r TELEPHONE <0/9 239- Rgdt3 NAMES AND ADDRESSES OF ALL OWNERS/CORPORATIONS LIST OFFICERS • INCLUDE TITLES NnAME HOME ADDRESS TELEPHONE srRESr errY sr zIP ~A-N / ~ ~ 77 f t~.~ ~ f ~-+~, ~ Fc.r+-9.'n~~ y / T 2.~,a S~ ~-2 Y/4e~ ["per i7i1 w~ f ~ ~ 1J 1 ~z r i~s'S ~ '7 ~ wr- STREET CfrY ST Z1P TYPE OF ORGANIZATION: o S~ Z 7 d eS PARTNERSHIP ^ CORPORATION '~" FEDERAL EMPLOYER IDENTIFICATION NUMBER 33' INDMDUAL ^ Name SSN I claim exemption from the Business License Tax for the organization or individual named above since it is D Tax Exempt under Internal Revenue Code Section 501(Cx3) or under State of California Revenue & Taxation Cade Section 23701 or; D Considered a passive investment in the rental of Real Property under Internal Revenue Code Section 469. I understand I may be required to provide proof of continued exemption from the Business License Tax upon request. DATE COMMENCED BUSINESS IN BAKERSFIELD ' ~'~'"~ ~'A'~'Y Zoa So CALIFORNIA STATE CONTRACTOR'S LICENSE NUMBER, IF ANY ~ ~ ~ g s 3 SALES TAX PERMIT NO. ~ ~ _F 5 Z ~ ~ .S d 4 7 ~ _ ~~~ ALPHA NUMERIC ~ SUB Sales or use tax may apply to yow business activities. You may seek written advice regarding the application of tax to your particular business by writing to the nearest State Board of Equalization office. For general information, please call the Hoard of Equalization at 1-800-400-7115 Y ~ c~,~ 2S ESTIMATED ANNUAL GROSS RECEIPTS IN BAKERSFIELD - -~S, c7~o d~ I SWEAR UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. . ~ TITLE ~ ~T~~ DATE / Z 3 J ~oS Signature Owner. Partner, Agaq or Officer of Corporation liccnac C~eSxt. ONCE YOU HAVE COMPLETED THE APPLICATION AND STATEMENT OF COMPLIANCE, PLEASE CALL THE TREASURY DIVISION AT (661) 326-3762 TO DETERMINE THE AMOUNT OF TAX DUE. AT THAT TIME, THE CLERK WILL BE ABLE TO ADVISE YOU WHETHER OR NOT THE APPLICATION CAN BE MAILED IN. CITY OF B.AKERSFIELD No. STATEMENT OF COMPLIANCE FOR ~~~'~'¢"~ ~~ `"~ ~° /N~ Name of Business I understand that having a Business License/Tax Certificate Application from the City of Bakersfield does not authorize me to conduct a business and I must fulfill all obligations for obtaining. permits or approval to establish a business. The business premises: must conform to zoning, sign, building, fire and health codes. I will expeditiously comply with the requirements to obtain the permits that are applicable for the type of business covered by the Business License/ TaxCertificateApplication beforestarting business. t haveaccuratelydisclosed the kind of .business or profession and the location on the License/Certificate Application. The Business License Section must be notified in writing if there are changes in any of the following: Business: Location Mailing Address Ownership Mail to: City of Bakersfield P.O. Box 2057 Bakersfield, CA 93303 Wastewater Discharge: in accordance with Fedel~ai and State mandated regulations, the City of Bakersfield developed a Pretreatment) Program to regulate industrial wastewater discharges within the City's sewer service anea in order to protect the public health and the environment. Any wastewater that is disclharged to the City's sewer system shall.meet alFthe requiremen#s in the Bakersfield Municipal Code, Chapter 14.12. Contact City Wastewater at 835-0364. Prin# Name ~E~'^''s ~'~~~ ~ ~~ Title 1~i2+~s'~~T Signature Date. / Z ~° 1 os The following are agencies most commonly involved in reviewing new business in Bakersfield. They will be glad to review your plans with you. City Wastewater 326-349 County Environmental Health 861-3836 Utilities: City Envlronmentel3ervicss 326-31979 County Weights & wleasures 861-2418 So. Cal. Gas (800) 752-2820 Aboholk Bsveraps Control 396-21731 Franchise Tax Board 852-57.11 P.Ci.E. (800) 743-5000 Air Pollution Control Board 861-3882 State Board of Equilization 395-2880 Pac. Telephone (B00) 244-4515 California Water 3ervbe 396-2400 (Sales Tax) Original: 6/L File Yellow: Applicant JACK-IN-THE-BOX C-STORE #10 #9 ~ #5 #2 #1 #12 #11 #8 #7 #4 #3 m z -~ ® Reg STP I 20k N ® 17kSTP ® STP I ' E DSL Prem 7k 10k SCOPE OF WORK FOR: Jack In The Box 10 Union Ave Bakersfield, CA 93307 • Repair/replace test boot under UDC 11-12 • Re-glass premium fill sump or repair/replace necessary boots as needed Work Order: 3144045 Secondary ~outainiarent Testing Report .Form ~' ~~~ rJ,tetairu a bt.~..ddl f.. ,~.,s ay ~o„n,merv... ved~minx parf++~dbe t~t6+g rJ lls7'.serr~u~dary eourtal~n~+h,r ,}sAeeu~. u.+us rile app•~p- pages of this jorrrr ro npnv resaltr jot aii components rested 9i<ie crnrrplertd farrnl, -vrihen test proredar~.r. midpYhrrauts frax irsu fj'japplicrrbie), should Ge p~av{~ to tieC f~ity ow~riQpsrarar fa* n,3mmoJ ro ri're IneQf aegtl~ghDly ~R~ - 1. FA©[t[TY Luee ncy' Wes NotiFed ofTesUag Ayeacy InspectAi P[rsent 2_ T ~'L4TIIYG L"~NTR~tC1'[lR iNAnRMl7YnN Camp+myName~ ~„ - - - Teu6aician Comiettdng Test: ' .+.f .. -- G7ied~Salq: 'Lt3 laceased ~ SWACt3 Li~sed Tait Termer License Tme >md # ~ - ~ n $ 4p b~La ttursr Mennfachuar CQmponenS(s) D ~teTt'8itlin F.s fires _ Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 ~._ ~_ Techniclen'sSigoateue:- Dem:~~ _C~ti' .~ ~"- SwRCH December 2001 Work Order: 3144045 rant or ... _ 4. "PA?NK ~.1~hrU'LARTESTiNG _ _ Ie..t ~Yleth,~d l~evelope~ 73y: Tenk Martiufac~-e,- ~'Iiusm~ 4tmidard Prvfcssional ~nu:etr _ _ Clthcr (Specify) "fr>t Mttlmd ~L~sed: ~- -- --•--- t'resstuC C1ltt[t1 Iiydrostatic 'Test L•geiipmenl lr sc~3: ` ~~ Equipruent #tesolunam~~3 _~~, - '1'aNt # f 'A'auk. tl ~ Tank ~1 Tank t} Is Tank Exrrrrpe From Testit-~? Yca a~ Yes vAa Tun v~~y ~~, ~ "Tank Material: . a ~- ~. W , ~~~ . --- -------. _-~. ~ ----- Tank jv(apr,rai:L,rer~ } Y:+sd~s4t St4red~ ~, vJl. ~~ .w',s. ! ._. _ `~': act lime etwt,~sn agplyinb ,4g.! pressure~vaaunmfwalcx~ud Sr1~trr1~ [GSt: .. -- -- .. _'i.r"mil'/t ( f # ~ _.. f ~~rl%rl --' Tr;,~ fit,,,: 'r. nu. ~ S {d' o ~ -.. ~ .. ...... .... - ._.. Test Lad Titne~ .- c+Jf ~ - - -- - - -~30.,.._ _...... - . ---- ---- Firsx: Rc:~di rrg (Rr): ~/ "' ,- JO i 'CostLur3tion: ~ r / / r' l.}rarr~e in Fttading (T~•kr}. .... . -. ~ ---- . --- Paxr-.fFxil'TTues!><nld or t;`ri#eria: ~> ~fi .:. :. ~- W acsens~r recnaved for testing'? Yctr ~ ~ ?WA Ycs NA - - Yes No Nh Yes hu Itih_ W'as scnsor pratne~ly rr:plaecai and verifre.a hrncric,nal aficr resLiL~? ~e"} ''IU NA t~ hIu NA YtS 1V6 1`h Y:s lit, i`.? i:omments -,ri+-rchuLc infi~rncfYllan nri s~latrs made prdnr tole,stftSg, & reeemnt¢rSdedfol(ow-Itpf4t;JctilCd ttstsi ~ti Secondar;~ wnrainnoent systems where the coniinuwas monitoring automatically monitorx both the primacy end secondary ~ontain.~nert: such as systcmx ghat bee hyciro~tatieally hronirnred ar ruder conxrant vacuum, are taeempt fiom periodic containarent ttstiuit. ; f:alifa: r: is i:ode ot'Reguleriorrs,'1'ifta7.'i, tiertinn 2ti3T(a}(6}} Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 Test Me~thodDevelaped 13y: Piping ]1Aannfaettua ~ndu5by Staadaxd -Prefessi~al En Otlntr (,~ ~) 7estMethodUa~cl: ~ Vacuum Rydroctatic ~chei llyl - Test F.cytuptnen# Used: f-y r, debt Resolution ---J4 Pipiag Run A / Pipio~ Rung N ~ Piplttq llian # - Piping flan W PipmgMsterial' _.-_.' _-GV, ~~ - F.'~1tr N,"+~- . Piping dQAni,~gehiter- - - Niping Uigrneter: _ ~' ~ r ---- - Ixng#h of Piping Rtm: ~p ~ ~ ~ ! Q ,'._ ... __.. ....... -- Product Storod: - fq, -- . -- s«~•'~, ,o k~cadon of `Mel6ixl ~cl Ini7~-I91I1 IAO~HdOII: Tr..,,'.,w.+l:~~ -'j ~'n ~r~,Y-^i': ~~:~ ~, ~-}rn ,er"1-,-r%uiaAr'Kg r~'~>'r.~ apglYi>~ presauefvacut¢niwuter and atartiri test: ~ s...' - ~"'~'' _ ---C CJ'~e' f Pest Start 7'inte: ~ ~aG _ $b[~ taitial R.cadutg (Illy: _ -- _ , ,' -- ~3 ~ ~- , _ _ Test Firm Time: . - . _.. -e~ ~ - -.. - _ _ _.. Final Reading CitF}: . _ Test buradnm~ Change in Reading {1~,- r _ Pa~cxlFsil oId nr Crilate: ~Q s ~ ,t :OmmBlbt9 - {~nCaftfAtB iAfD-71~at10M v~~r~~p~uirv ode pfru~r are testJn~p' ar+r! r~mr~n~x/~dedtfoiiexLrep fryr j~eilea .._. !C lne... for RJ~fi~=~fllr~A,l:C, lJ'/a~; ~i:,~~'~.~F pan'T-: -- ~ot,_,~ . ~~ ees~J Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 ti. l'[P1NG SUMP TEST3NG ~Ss-__. or~ (;ottltitents - {trtcltede infdr»,atiott nn repairs rnadeirrir>r to tevJing, and ret:nntfr,ended nflnw• nr atfed tests n 'frst lbfethnd Tkvelcgted By: 5tttnp Ma~mfacluTer uatry Stud Yrofcan1cmal En>;inecr Other (Sprcifyj Test il±iethod Used: Presstue --- Vacuum . drostatic --- _ . . Other ~,tf~1 Ttst Ec{uiprtlent lJscd: If z T ------ -- )~tuipment Resolutiq~tl~ , ~, Sump # ~ SilnYlp # ~ Sump ~ Sump p Sump L}ianeetel- sump TSepth: _ _ ~ ~ - .~ •. Sln'rip IyIatC11IIT: _ - ~_ -- ~&!, '--- Ileight from Tank'I'op to'1'op ot` FTigh~t Piping Penetration: ~ ~~ ' '~ IIeight from Tank op to t~•est -' ._, . . . _. -- ~ .• " ~lecitioal Penetration: _ JQ_ ~ t'.ondition a a`t~tnp priar to tC$t1A~: Portion+d'SnsnpTi~T -_-.... 5~ _~ -'---'-' / . Does tuw 'ue shut t when sump sensar detects liquid (lwth cs i No NA _.. . ~ea7 No NA Yes ~ No NA xes No NA duct and water)?~ 'Iktrbiae shutdown responsrtin~e ____ _ _ Is system progtan~med or fai • ~ .e6 Na t'VA ~s ~3 Nd Nh es No c`IA Yns Flo NA safe shutdown? 4b as fail-safe verified to be operation4l?~ yi6 h'o NA Yes No Nh Yes itio ytt ..- -. .._. Yes ,lo ~tA 1~attiime hatweert ~yplying 1 .. - pt'eSSwuvactuuniwatGr and St3rhttg tCSt' ~ f ~.' ~ J / ~.,s ~~~ Test Start Tirnc: '~ ~j ~~ D _ Initial Reading (R,): uc+' ~ , owe,o' sC1Cnt1- . ,r~ripa" Test End Time: ~p~ ~-~' O~ ~i ~/ $" I•'inat heading (lt,): -; ~+• yt, ~.dvao! f,o Teri Dura4ion: I ~ t~ • ~ `] m 1r1. I ,al . rot " t~1. i ~ . ~ ! IL1. ~ r' t'-`~{ N • . ` f Change in ]tending TKr-K.~7: ~-.~ PasslFail TTueshold or Criteria: -,OOZ" +! .OV2~ +! ,00 ~" ~ _QU~" Wus aG.•nsur tY:moveii f'pr 1cstSty;? -~ No NA Na NA r Nt~ NA Yt.•s No NA Was seasa- properly repla:ed a-nd ~•trified functional after No NA No NA ca Ye9 No NA Yes Nu NA u sting? , Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 7. G1~IDLR-DY5pE~tSTR C:[1?~',~'.Al1Y;V1ENT {t~DC} TES'~IPIC 1 °s" - -- of ._ 'ica;t 19eilt+]r1 il[~~'r~l[.~txl Av- lil)C.' 1Nfuttii4L•turcx ~Chdustry Strtr3d3rd Prote:.siurml Cn~+inccr I other (sp~etfjr) - Tc~l ~Srtlru3 Uuc3: 1'ressuce ~'a1C:uut11 ~•H yClrnKttdis Uther (,5prc'ifyl _ }~ _ Test CgLl11i1]iErtt Used: VYt - ~~~ ~ I 1=;quil]enent Rcwtluliun: aA llu: # f ~~ UDC $ ~ LfiC # ,sc= UI1C H ~'... CTDG Menu ac;ttacr: o!lf a• -trs~.a~..I',.,,~~d! C,11C hiat rii " t ~1jr~ .~er ~fr6e~' , liciglht fiutu [;DC Battom to Top ,, ,, , t, of I li~lrrhr Piping Ytsnetrmou: - - - - ~ ~ I lrr~+ t tram l:Lx_: Liottoitf to ~ t F I i l P T t ti . ~ , , ~ ~ ~ . ~ ~ .rrwiw . crn ra ene ra on: - I - -• ...._ _.. C:onditiau of UDC prior to ~ [estirtQ: , e~ Ptrrtinn of f.1 H"t 1•csJed' __ f _ .. ~~~ Uurs turl,iix: shut ~lo~Yr, >k-h~,t • UDC. sensor de#er#s liquid • 'ca l~u NA Vo [vA Yes tiro VA Ktt ~',1 - ~' (both procL~-K arui water)? , I'utbirx shutdownrasyuuse tans _.. ._~ is systernprogramme for t~il• ti 1 ! 'ea, A=n Nq ~'pg _yo !\1L Yr No Nh cn trn '~A :9 w1s$pwa S3 __ r, , _ Gnu:; foil-safe sarifisd lit be ope><adonai?' }•es No IdA 4'C9 Nu NA I Yee Nn tilA Ycc 1\p wA ii~'sit tin,c hc;Eu•ccn app pink "._ _"° pr~arwc. r-aut~nrv~eater and skarlin~ Teri +....~ ~~a,,~,• ~ ,•,~ ,~,,n 'best Start Tirne. 1 ~.3 ~i >?.l ~ ' ~•~! . ...f-?3~ lnit,al }teadiug {R,): .v[xxx~` ,g~~a` .~ ' .o o r]c - c t oo' •cicyGt~r " 'l'est hod 'l'ime:. ~1___ Jn?~ t~ /J 51 _ _ _ ~ s Jt:st Ih,ralrOn: ~ ,'1''~;, !~] rYll•`1. i I. ~rY~ '. I jlrVlltu- 1 ~j,•]'~ rl;. I u1~41l,~,;,,1. `rr'1IrN• 1r~iliflk. r C;hangc in heading (fir-ft.)' f. I ~'.a .Qp~/ ,1•.oaa¢Q .Qenc~ )'asslTail 1hrt:shold or h t:rtl~afitA: }~ . ~~~ ~ r_ ,Od~_" }~ . f~O2 +i .OG 7_'r . ~. _.•., •..... gce ;y;'t;~' ~i:t~lt's i; •:;~;4.~. ~i•~.; ~.. ~: ~:~s:G'' ' . Q31,~. 1'l F81~,:; ,,, .~. 1~~68 ::,: Q: r'g1~``:.,: ~•.: ~... ...~: .. .., r ' },Vas sensor renx,ved Yoriestiuq' ~t~.._..Ao .,.,.,_VA __ e_No 1<e1 "e Vo tV1 'es TTu _ _ ~°a 41+as serlsea pcuPCrly replaced arrd ~;~ p,Iq es ti!a NA 'rs vo VA ~ ~ Itio Vrti r•~rilied Pwrcliurrs,l aC1cr trsliuk? C'rrrrnmenl, - 1'irrr:[eule anJi~rmutirrn on r-efucir•,+• mrcJN prior to trslirrg, crrrr! rec'tlrr:merxrl~dfullan•-v~+Tr]•fatled msfsl Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 7. UN1yFR-DTRPF.NSER CONTAINMEN'T' (UDt~ TESTING ~&e-nf` Cummrntts - (inrlurlr: enfirrmalinn un rrlwirc mrlrlw. prirx lu Ir!xtin[;, r~nrl rp:r:r-rmnsr:rulyd frllnw•u(r fort fadled sects) Test MethOdD¢velnper3 By: i3llC Mextufac nrlustry Standard Pmfivviunul Etiy;uiecr UtllQ {5pC'CF~'J __ __-- 'i•cRtNicthviU~a- pressure Vaeutun Jd~rdrostalic Othea (~be~Y1 _--_ _ _ _ Tsst EquipmattUsed: ~J ~~ hquiptmutltesolutiaa: Uuc~ ~fo u rmc~ Unc~ ~Ull{: a ,'n!raF.t' ;: UI}{: Mstt:rrsrel: . ~ ~' r .._.... - ..- LTi1CDepth. ------ ..~_ . Tics nom 'DC Bottomto Top ~ ,, ~ of_Higtrcst Piping Pcmctratrnn: ..---... _. . e,Rht fi~oiu LJU(: Batmm to ~ v . Lowest Fdoctrical pt:zsttratlaa: / • ,. ' topdition of LTDC prior lu „ , _ testing; / Oa i a~ -- Piiltiou of [TDC Testtd- r..~ ~ --- --. -.. -- _ hoes ivtbine abut dawn when 1 IDC senscu dt•tecrs liquid e~ No CIA ~f es No :CIA Yea No 3IA YvR Nu !4A {both product end water)?` - ._. 7iurbina s tdown [t+spouse time -- - -• --. -_-- tR A~Rltan pnfgcalluned fOT Earl- • ~ NO NA Yee No Nh Yes No NA Y e.R Nn NA xafc Rhutdrrwn7 _ as il•eafc vcrificd to be -- _ _ YcR Ncr NA Yt~s Kv hiA Yes la0 NA Yes !Va h'R a ratioluil7 ._ Wait time 6etweem ~ly>n,? - - - pressurdvatuumlwnterand ~ ~ starting test , ~~~~ Tc~t Slant Time: ~r~ J f [nitial Readiu (Rr): .ocsgc~t~y •4OQQo' _ .o~ooo_' .n Test Irid'1'in~e: _ Final Reading (l~,): TCSI Drrrahon. ___.. ~~~rN t~. ,271ti. I;a ,'nit PSrrirtir_ 4.~ ( rY th1 1-`= Nr C gc: in Rcadin~ {Rp-Ri) __ _- ~'~' ~ . oae Pass/Fail 1'kucshoir3 or *~ 002 ° 002 ~~ OOap +r OQ Z° ~If Criteria: , . , • , °s•. ;`:: ~'` _ ~ _ _ ~_; ~ Pais 'A Earl _ ~•~.. • Was sensarc rctsmved for rearing? r No I:A No NA Yes No NA Ycs No VA Was sensor properly r2Frlaccd and Yr Vo PIA os No NA Yrs No NA Yc» No VA ueritieA fitne-iiona] aftertcR6ng~ Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 R. Tf[ d. RISER CON`Y`A>tNMENT SUArII' T'B.'4TiN is ~° - °f - Facility is Not Equipped rth Fil! lZiser tainrnant Sumps Fill Riser Containment SuraFs are Present, but wrre Nut Tratod ~ .--- Teat Mt~trod t)evel[med By_ Sump Manufacttue~ ~CYtttlttslry ~tttntYard rmfessiamal Engineer Othtr (SPeeify} _ ~ ---~~- - Test A~Icthcxl Uscxl: I're¢Stgp Vacuurp Tlydrostatie - t?thcr (~FecifYl -- --- ~--- Vest tfquipinestt Used: t/ ~~--- - lsguipmtnt RCS>7lulivrr7 amen lift Slump ~' } Fill S'nuhp # loll Sump # F01 Sump # Sump Diameter: ~ - -----~ $pmp Depth ~ - ... ~~Hcigbl from'Tank 'l'ap t~ "t'op oti Highcnt Piping Penetration: _ ..-. __ ~ ~ " !~ f ~~'-. - Height om Tank 1"up tv Lowest ElerxriealPeaetratzan• ~/ . `"._ ~.~ ~~ __ Cron "txon oi'sctmp tst'lOr to . .. -. testing: ~r . Portion of Sump T ~ ~~ , .... .. -- --- _ ... b'um M uteri _ .- - - -- -- -- sit lime bclwoczi applying / pn•~usrelracuumJwater and /,¢ " r JJ ~ SLVI[1Dg, test: / r /~!' ~ , w 1'rst start'1'ime: ~ r _ - .,o . - Tnitia] lteatling ~}:-- - `, .~,~~~' . - ., . _ Test End Tinge: _ _ / -~ ~/D -- Final Rtading C~)= . _- _. - - . Test 13ur3tion: ~ ~r~, ~, ~ ~r 4 " S:hau a in iteaduzg ~-Rt)• -. _ -. _ PacsfHail 'ilzres o d crc irtiteria: ~ _ .pot" } .002 I- . oQ2" }r .O a2 ° . ` .~., Is there a sec~or la the 9urutr? es NO a NIo c No , . -' Yes No Does IlSC GtlL.OY alarm wheII Ei1t1{r. nduct nr water is ~ietectecl? ~~y No NA L 3' ~c lrh~ 1VA _ _ ~ No 'VA Yes No 1~(t as sensor remove or testrgg No W a Na ~Nf1 ~ es Nfl tiA Y<Ca Nu NrL Was sensor property rzplaceci crrified fnnCtianal after besting? a No NA ~ loo NA -- ~S (va ~lA Yts I4a NA Comments - include u formation o/n repress made rirr to tesri-rp„ urrd recarnrnreaded.tto~~o/w-Hjp farfoilsd tesxs) i / , ~ ~. ~ f ~ - .+~CCl~vilWOwa '~S - GJ ~ 1~i.,,~~E4i C„~ ...~~,., Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 9- '+PlL~.1f3VL~RFII.L C4N'T~ttynzrtyT Bbx~S Pttge _ of I"acjljty je N4t 1,$quipped With SpjA~OVtrf>;11 Containment Bbxes Sp>:lll(herf U Conminment Tiaxts art I'rexegl7 Uut went 7Vbt Tested Test?vlethod DevcIupi:d 13y_ SpiliAucket Manufaaitmr yt4tducay Sts-ndard YrofeccTrtuti Engineer !3#her ~Sj~er:ify~ .. .. -- _.. _-. _. Y ..---- _ Test Method Used: Prc,x~ure Ve~cTT~RtI ~"~ T]rVatatjG C.)tbiy'lSP~'~l'~ _ _ __ 'l'est N,quipm~xd.I_I~xl: d ~ Ecluipmc~rit Rcsolul.ion: spill Bar #~f/ r Spil# Box rt ~SpSli flux ff qtr i* Spill Rn: {~ Bucitet I)iametcr. ~ ~ .• - 1~iTrkct Depth: --- ~ , - -- /~ ~ ~~ `-- ~ Y Zi%niLiSme hrtwuen -- -- - - - - + - :tgtslviuy IlT'CRtiI IIEr F'aGULUrL'wa14T _ -Pest Start Timc: a ~ S_. . ~~~ 5' J /~ o / Jxtitial Rtadjttlt (Rrl: Q } 'Test Gnd Time: ~ ~p~9 d . . ;/~7 ~ . _Jl,~. ~o JCb?~ Jt o _ Final Iteadirt~ 1Rr): - -- - .~~~ , ~ r ~. Pest (juraliou: / -...5. l ~ • k J~ ..,. ~ J S.N, ;. /S,n+k - i':hange in Rending (Rr- - `~',c~~-- =°~~~ ~ ' ~ ~~~ P• sai'1F`aiTThresholcl or -a- ~ ~ ~ tf l(~•rl'A' - ~^ Q ~ rQ • O Curamrnty - (include infurrnntiun c~ repairs made prior Io testrny nridrecafrxmended fn~low-rip forfaeied reslsJ 'R I __.. Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 r. Work Order: 3144045 9. SPILiJC~VEItF1L,LC(13~"f11INMFNTBQXCS t'aKG~of -_ Facility is hint l~:quq,pr:rl ~Vith Spi llit7~erftll Co„tximlrerq Foxes SpiliJ(3vt;rEi11 Containmtnt Haxcs aQe Present, btgwcacNnt'fcsa:d ' 'l'est Method I}evelolx:d Dy: Spi1113uclcet Manufacturer fadustry Standard 1'mfessiunal Engin4er Other(.Sf~r.•cify} rest Metl,cMl IJxd: I'reCaurt; ~ Vacuum N}~drns~atic - _ Other (,5becif}) ~.. Test 1uiiupmt~ Gsrtl• . ~- --~. F~uipment Resolution: ' ill Minx # F,'N Spill Box # Spill 13ox # Spill D8k # Ilucket T )iameter: ~ Iiuc~kot Depth; . ---- ~ _ _ i~4'aii time betlvcae ~~ -- - applying ~lll:.y.SRrC:V3CUll,]l~walcr ) 1 and alarti~ test J ' ~-- rest sl:~n Time: _ // JlS - - - - Initial Rcadin~q {R~): _ - - Test fund Tims: ~ / 51 l.20 ~ rival Flex{lhts{gr~: ~. S . ~. - .. . Test Duration: _ j ~,,,,, r / $ . ~.. C:hanlz: ia~teading [xr_ --- . }'asiFail shaid or ,~ - - -- C'rite:ria- _ _ ~3Q Cum~tits - (inrfudr: i~furrnptioit rrn repav~• merle prior ro tectir~;, rend recprrrt»Cnded follow-up fot•,fai2ed tesctiJ ~ _... ro Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 INTERNATIONAL CODE COUNCIL ROBERT WEIDENFELLER Qucce6dy~'u~ comj~e:CE~!%L~ f~jzs~aciv.~eu~G~s~ e~rui~al"iayo fiadP.t~an Gorr r~ 6tau~a~a• t~ ~ ey~'° ~ an~~sl~~.°~r~°~ ~1aue~~ua aa~• UST INSTALLATION/RETROFITTING given this duy of December 17, 2004 ..~~ w . . frank P. Hodge Jr. President, ICC Board of Directors ~~Vr James L. Witt ICC Chief Executive Officer 5250279-U1 Certificate Number INTERNATIONAL CODE COUNCIL ,l; f ; `%~ 1 // ! ` '"~2t ~5~~~+i f 4 ?; .` 5 { r RightFax 12127/2005 4:23 PAGE 002!007 Fax Server UNDERGROUND STORAGE TANK - ;; ~? PERMfT APPLiGAT10N TO t~ONST~JCT:INSTALL NEW TANK (NEW FAgLITY) ! ~ wt ~ NEW TANK INSTALLATION (EXISTING FAGRItY) ! :~, MODIFICATION! 8~ MINOR MODIFICATION - FACILITY PERMIT ND. 1 "tics U ` ~ l TYPE OF APPLICATION: O NEYY TANK INSTALL / NEIA! FACILITY ir•we..l...,.s I.s..~ ,,..~.., s-I aanrucu~ernal AF Gat•_u {T/ BAKERSFIELD FIRE DEPT. Preventaloa 8ervicea 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Paga t of 1 Q NE~M TANK INSTALLATION /EXISTING FACILITY '~a~r~nQ ul~nl~Ir~rlnN c~c Fsco Irv ARTING WITE 10N DATE ACgJ1Y Ni+l~ FACILlT'Y PERMIT NO. ' ~~,(f~~ls" ~11~ iZ ~ ~i In C~ ~ ti't"..~ "11 ~ I C~ ~ .~ ~'~7 E OF BUSQiESS -'i~15 ~- ~'i ~~r DRESS i ~, Avg fiY ~~?~ ~-e ~ d COD ~~~ RAC aR ~sE KO. P10.' e aa. GIY WSMI~SS LSCEtISE Nt3. 1~1~ 2?~3- ~i ~i 8 ~ C. N0. ` : ~O~ ~l ~ ~ ~ .:2~C~ ~{ RER . Cam ~~~~~h BRIEFLY DESCRIBE THE WORK TO BE ~ WATT TO FAZLLII'Y PROVa~ BY DEPTH TO GROUND WATER SO~YYPE EXPECTED AT SITE ~. OF TANKS TO BE A1.LED ARE THEY FOR MOTOR FLIB.. ^ YES ^ No SPILL PREVENTION CONTROL AND COUMER NHS PLAN ON FILE ^ YES ~ NO The has recieiwed, loaderslmlds, and will comply with the adached cowdidons of the permit and arty oRher stale, !ant arrd fedem( regulatTanc 77sisform leas been conopleted emderPe-la/ty' ofperjlrp, and m the best of mY IarowledSs. is ttxx axd Come ~ APPROV$) er. APPLICANT NAME (PRINT) THIS APPIJCATION BEGOMF..S A PERMIT WHEN APPROVED FC1Z086 mw. oval ~i nc~ RightFax 12/27/2005 4:23 PAGE 003/007 Fax Server BILLING &.PERMIT STATEMENT Bi9'x~~~Ln Fig nE~r' Preveat3on Services l•~lRt 900 TcvxWn Avenue, Suite 210 PERMff NO.: ~~rr~r Bakersfield, CA 93301 Loc~Taw of Paa,~cT ~ ~ ~~ ~ t ~ t1 ~ PROPERTY ov+rtrER ~~ ~ ~ 72.E STARTING OATS ~ COMPIkTfON DATE - ~ a•IAAIE PROJECT ~ AODRE O. C~ Ifs '~(=i~IV ~ / ~~( ~~~ '~1,4 ~(1 ~(-~.tr1 ~' ~.~ pROJECTAL+ORESS Cr7'Yi/P~T"I~'~~TE ~~ aPCODE ~~~C`)~ I tl b t .n I n .'1 .Ql rt') i 9~ - RA~rORNAME CAtJC9t5ENO. • ~. (' 1't~ irlZ - ~h~ TvPEaFUce+sE -~. E7W6:rlTgNDarE NO. c ~ `r •Z.~ t ~4 `S ~ ~ C~(G'I /.J~C.~ ~ ~ i fl~ 1 ~ ~~ ~ ~ ~, CONTRACTOR COI,~ANY NAME ~ r/(~ ~. ~ ~~ `" f ` t l ~"'1~1 C'~ ~ G~ C~i ~ ~ I CSC ~~ ZIP COD ~ ~ i ^ Alarms -New & Modifk~tians - {Rlfmimtxn Crrar e) $262 5Q ~ g . 98 _ __ Over 20 FL 000 Sq FL x 093125 = PemNt fee Sq ~ ~ , . . . 98 ^ Sprinklers -New & Modkfications - (AJ6nirnrun Char e) $210 00 ~ g . 98 ^ Over5 000 Sq FL 042=Pennitfee FL x S ~ . , . q. se ^ Minor Sprinkler Modifications (< 10 heads} 00 (Inspection OnJyJ $ 93 ~ . _- 98 ^ Commercial Hoods -New & Modifications 26 $ 3 ~ . 98 ^ Additional Hoods 00 3 36 ~ . se ^ Spray Booths -New 8 Modifications $458 00 ~ . 9s ^ _ AbovegrounrlStorageTanks(UlstalJatiordlnsp.-1°Time) $165.00 _ ~ ^ Additional Tanks S 26.00 s2 ^ Abovegn~und Storage Tanks (RenrovaLllnsQedion) $109.00 82 O Underground SbrErge Tanks (Mstelletlon.Anspaction) $878.00 (per tank). 82 ^ Underground Storage T~1ks (Modification} $878.00 (persite) s2 Underground Storage Tanks (Minor Mod~ication) $155.00 ~ ^ Underground Storagr' Tanks (Removal) .$675.00 (pertank} 84 ^ OilweB (installation) $ 72.00 84 ^ Mandated leak Detection (Testing} J Fuel Monit. Cert. $ 83:00 (persrte) s2 ^ Terris $ 93.00 (pertertQ.. 84 O After hours inspection fee $122.00 84 ^ !Pyrotechnic - {t?er event, Plus Insp. Fee ~ 390 per hour) $ 60.00 + (5 hrs. min: nand -0y ree Mspectlan) _ $510.00 ~ ^ ' t~INSPECTlQN(S) / FOilOW-UP INSPECTION(S) $ 93.00 (per hour) ~4 ^ Portable LPG (Propane}' NO.OF CAGES? $66.00. ~ O '. F~losive Storage $249.00 ~ ^ ` Copying & File Research (Fite Research Fee $33.00 p~ hr) 25¢ per page ~ ^ Miscellaneous 8a FD 2021 (Rev. 09105} 1 - ORlOINAL YYHITE (to 7rsaauryy 1-YELLOW (to FI7e) 1-PINK (to Customary CITY OF BAKERSFIELD MAIL TO: , CALIFORNIA PREMISES MUST CONFORM TO wxnvcl: CITY OF BAKERSFIELD Bun.Dnva. FIRE AND HEALTH CODES. P.O. BUX 2057 CHANOE OF NBW BAKERSFIELD, CA 93303 owNERS11~ ^ BUSINESS CHANGE OF ADDRESS ^ APPLICATION FOR BUSINESS TAX CERTIFICATE PURSUANT TO ORDINANCES OF THE CITY OF BAICERSFIELD PLEASE TYPE OR PRINT LEGIBLY IN INK BUSINESS NAME ~ ~s~.2.~ ~J rtit ~~ ~NL DATE / Z~Z 9 /c~ -Z" BUSINESS LOCAI7Q 3Z 3 S F ST2~S-B~ ~ i}'nl ~/ ~ ~ ~./-t r'/' Z > D (Se~eateCatiBeaeRe9uipnifurf~:7;L~sc~iostj S~ ~ MAILING ~tapRFS~' 's"l'REE'T C 5T XIF KWD OF BUSINESS OR PROFESSION ~~'To2'° `~~`'~ ~ L.~~ ~leq t'14.J ~~~ ~~~ "T TELEPHONE Co/9 239 - 9g 6t3 NAMES AND ADDRESSES OF ALL OWNERS/CORPORATIONS LIST OFFICERS -INCLUDE TITLES Nf~A-M-E a i s -~-kf.v~ E t L+2 HOME ADDRESS TELEPHONE /~.~ ~ ~ ~ Yr4a.~ ~i wr i / a..~ If I c~ ~,2.~'s . a a..ar STREET CfrY ST ZiP TYPE OF ORGANIZATION: ~3 , o ~ 2 7 d t5 PARTNERSHIP ^ ~ CORPORATION ~ FEDERAL EMPLOYER IDENTffICATION NUMBER INDMDUAL ^ Name SSN I claim exemption from the Business License Tax for the organization or individual named above since it is ^ Tax Exempt under Internal Revenue Code Section SOl(C}(3) or under State of California Revenue & Taxation Code Section 23701 or; O Considered a passive investment in the rental of Real Property under Internal Revenue Code Section 469. I understand I may be required to provide proof of continued exemption from the Business License Tax upon request. DATE COMMENCED BUSINESS 1N BAKERSFIELD ~'~"'j `!'A'2Y Zom So CALIFORNIA STATE CONTRACTOR'S LICENSE NUMBER, IF ANY ~ ~ ~ $ S 3 SALES TAX PERMIT NO. S Ie F }~. ?. ~ $ .S cd 4 7' $ - - (- - - - - > ~~~~r~a ALPHA NUMERIC SUB Sales or uae.tax may apply to your business activities. You may seek written advice regarding the application of tax to your particular business by writing m the nearest State Board of Equalization office. For general information; please call the Board of Equalization at 1-800.400-7115 V ~ C~,~ 2S ESTIMATED ANNUAL GROSS RECEIPTS IN BAKERSF[ELD ~S ~~~ I SWEAR UNDER PENALTY OF PERiURY THAT THE FOREGOING IS TRUE AND CORRECT. TITLE ~ .~ T~-o ~ DAT2r / Z~ /3 ~ / o.~ Signature Owner. Farmer, ASent or 09ker of Corpondoo ~~ Cade~~ ONCE YOU HAVE .COMPLETED THE APPLICATION AND STATEMENT OF COMPLIANCE, PLEASE CALL THE TREASURY DIVISION AT (661) 326-3762 TO DETERMINE THE AMOUNT. OF TA%-DUE. AT THAT TIME, THE CLERK WILL BE ABLE TO ADVISE YOU WHETHER OR NOT THE APPLICATION CAN BE MAILED IN. CITY OF B.AKERSFtELD No. STATEMENT OF COMPLIANCE FOR ~~~'~"~ !OJ `"' ~° /N~ Name of Business I understand that having a Business License/Tax Certificate Application from the City of Bakersfield does not authorize me to conduct a business and I must fulfill al! obligations for obtaining. permits or approval to establish a business. The business premises: must conform to zoning, sign, building, fire and health codes. I will expeditiously comply with the requirements to obtain the permits that are applicable for the type of business covered by the Business License/ TaxCertificateApplication beforestarting business. I haveaccuratelydisclosed the kind of .business or profession and the location on the License/Certificate Application. The Business License Section must be notified in writing if there are changes in any of the following:. Business Location Mailing Address Ownership Mail to:, City of Bakersfield P.O. Box 2D57 Bakersfield, CA 93303 Wastewater Discharge: In accordance with Fede~`al and State mandated regulations, the City of Bakersfield developed a Pretreatment) Program to regulate industrial wastewater discharges within the City's sewer service area in order to protect the public health and the. environment. Any westewaterthat is dischharged to tt~e City's sewer system shall meet all the requiremen#s in the Bakersfield Municipal Code; Chapter 14.12. Contact City Wastewater at 835-0364. -~--- Print Name ~E~'^"s ~'r7#wt~ r ~•c Title ~~'~~T Signature Date ~ Z ~° / ~ The following are agencies most commonly involved in reviewing new business in Bakersfield. They wilt be glad to review your plans with you. City Wastewater 32&3"49 County Environmental Mealth 881-3838 Utilities: City Environmental services ' 326-3i9T8 County Weights 8~ Measures 861-2418 So. Cal. Gas (800) 752.2820 Ak:ohollc eevsrape Control 39b-2731 Franchise Tax Board 652-b711 P.G.E: (800) T43-5000 Air Poltutlon t;ontrot Board. 881-3882 State Board of Equillzation 395-2880 Pac. Telephone (800) 244.4515 Catifornla Water Service 386-2A00 (Sales Tax) Original: B/L File Yellow: Applicant ACK-IN-THE-BOX C-STORE #10 #g #6 #5 #2 #1 #12 #11 #8 #7 #4 #3 m z --i cn Reg STP ~ - ~ ~ 20k -. N ® 17kSTP ® STP I ' E DSL Prem 7k 10k SCOPE OF WORK FOR: Jack In The Box 10 Union Ave Bakersfield, CA 93307 • Repair/replace test boot under UDC 11-12 • Re-glass premium fill sump or repair/replace necessary boots as needed Work Order: 3144045 Fage ~ of W Secondary ~outaiwnent T~sling Report .Form T3~ia faMSv n.t~..eldl fi,...as by ~o~h~ctors ~r~arusrngperYradle teartrrg ~f'ClS7's~condai}+ r. aurtgermap~rf a}tere~ras. U.te~ tNd opproprtot~ p~agey of rhislwa1 ~o ra~xrrt r~ssltr fiu ail coury~uorrenfs tested 91~ee crn~leled forth, xrit~ lest proreddrer~ andprttrtorers,fhom tests (rfttppficahfe), should bePTO°~to l/tefucijrfy utivRarlQpsratarforlv~imrtCaf -» rhefoecl vag~7atOry ag~n~ 1. FAC1ldTY Ih'FORMA'j'7~N FaeDlty I~tb. _ +' Lrate of Tatung; ~~ Fa~;tityA ~ [' FtCilitY Cons'a~~j~ ~~ ._ 1'hae~e• ~ /}~~ Date Local Agency VJttti Nati~ed of Testiag Al~r-c of Locei Agea,ey Inspector Ptaserrt 1. TI~S"III+TG CD1riTRAC1'OR AVFQRtl+IA7YOTT cotnpa~y~rratne-- ct., _ Teebndcian Cont3rmU~g Test.: .. .. -- ' .,.~~ GYedetttial~: L9 Lisenssid LTy~~a~~ ,~ - +~`~~ f] 5l?VRCB Licensed Taak Tester M®afasi~u'ac Tra rtgayb'Lat~isctursr ~P~m~s) l~f0 Tt631tin F.s ' cr,~ ~ _~Qs=~9 ~ '~ ~.~ -v _ ~ r~~-.. im ..--~,~ '~"~ 7~ _.. Tanlrnology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Tecltniclen'sSigoatrue:_ . SWRL'ii Work Order: 3144045 ~. 'Y'ANK ANhrLTLAR'I°ESTiNG __ 'feet ~Vleth~~d 1~veloprA liy: _ _ _____ 'I'ii 14l~tliti~ L~sed: 'TcstL•quipmeniL~acd:,~ ~ Tank Marlufac'aur~- $strv Sta7tdard Frofcssi~attal Bn.Bu:~er ~ _ ULher (Sper~J D'rsssurC .- ouurn IiydrLlst0.tic tDther (;5~ec fiJ Et~meatgtesolua~~~~-~~•, - ~ 'l'ook # / '~mlilr t~ ~ Tank ~! Tank p Is'1'anlc hattsnpt FrLmt Testier? Ycs ~~ Yts "'~ Yrg Nn Ycx Nn -- _. _ "1'~nk Material: _ -^ ~ ~ .- . Tiltllc l~li~TArFac:lllt2i-~ r_r ' ._. Y:US~~a4T ;yt4red' .r.~/G1~~ ~J an.:t 1 --- - •r `ait,iime etwc,t-n n~lilyinj; - pressure,''~scuatnfwalcr ~trd SLa~fl~ ICSt: _ ~{~~~r'i1 _ •~~Sa! i % __ _.. ~ ~~n~•r- J Ta:,L .. tru i 'ri IL1E~ .-.. , ._.. _ ..... _ .... ,. -•--- ln11181 ~i~~iJinl!, lu:}- ~ ~ ~~~ ~ i 'T-esLT'ndTirne' ~f S. - _ - _~.3!C?...._...... _-- -- Firsxl RCA[llttg {Kr): +J +`' - - --Jp _ i ' 1"est Lunation: ;` / r 'L ' / .. ~ C,}ia~tge in Eteading (I~:•ky1: . ... -- .. P~csrJFait'tTutslinld or L.,Yi#erlp: ~.; '3=k~:. .,~, ;}~ W ac sensor rernave for seRt~ng'l. ~~ : a ~. Y+.-a ~~ NA __ ~fi Ycs NA r _ :~ ;;~11'>;•~;~Efi;C~...tJlltirli 1 Yes No NA 'Ycs I;c hh ~45'as sensor pra4serly rrplaecel and vcrirind iirncrinnal afr+:r;csti>.t~? ~°"~ Nc NiA '~ hIu NA Yas No 1tiA Tres ~r~ i;.t Comments -,rir~clrule oaf i~rnc(Ytia~ do rr 1Qtrs madeprtnrtolentixg, &reCetnrrtendedfolfpw-tc~fo!'J`cttlcd tests` .s Secvudar;~ conrainment systems where tho caniinuwas manitoiigg antomaticz~lly monirorx both the prima~r and aecendary contai~ert. such assysfemsiharxrcltyelraatatieallymonitoredorrmderuronata~uroacmurr,areexemptfrornlxcmdiccaLtai~unemrsstiu~. ;f:alifit:cia i:ade oYRegulettons, ~l'itle 7'i, Section 2h37(s}(fi}} " Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 S. SECUNDAR~ PIPE TF.~TRVG ~ ~° ~. CAmffieatg - (tnduATe iTtfUYmatiPn vA r ,~sirv »f~d~ pri»t au tesun~ unrl rgmmrne_aaleid frllinw-sep~rxr fallerltg~/.yf _ 1c. ~,s d.>tn~ y~oCr_~Cd.' ~~Aa~C' ll f~ -*f~~ ~.•~~ ,~exi->~ ... ?est 14tcthod Ilcvelaped Hy: Piping Manufgeturer ~n~11u~y Stand~a8 -Prnfessi~al Enguneer Ottner ~~ JyJ Test MetltOd Ua~rcl: ~CSS[u~e fi/acuum Rya~p~j~ - -- 4ther fl ) Y Tsst F.gt>;pm~# Used: f Resolntian -- !~ F'ipiag Rsm IM / Piping Aua IV ~ Plplltg Rqu # ~ Piping Run A Ping MeteTisl_ ___.- . _--Gt]. ~~ F.'~ia~ W ~,^,~,r Piping ~uiEaG~ce~: - Piping Uisrneter: _ ~ .. ~ ---- - Length of Piping Rim, o c~"%O -_ ~~ e _... ~ ~? ,'.~ ... __.. ..., ... -- Product Stored: . ~ I ~" -- c ~~ _ "'k_b ~1$elbutl ~u1 1[x~lion of `~r..,,,'.,q+G: n~ ~r..-~. •afr. 3 ~rr,,.'ww~a'.~g un ix4ledan: PiPin~-r 'J_ ~"~~ ~- .n -.... _ ~ },~ ~''~f ~ .'., er 33t tII~ between spglying pressura(vacu~¢nlwater ~ ~ ' ` ~ sndstartin~tesi: +...~ !.~a.: +e, f} _ _ { lest Start'1'ime: ~ ~ p~ _. ~~ Tnitia'i Reading ~: _ - -- - ~ ' ~ - -. . _.. ~ '-- . ', Test Fund Timer - - - FiiLat Rending CfiF}, Test lduradom~ Change in Ring { - PauvJFaO nld nr Oriteria: ~4 s ~"" s Tanlozology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 6. YtY1NG SUMP TEaSTIATG ~4-_-. orT t;DtritlltDt3 - {lt[GhtdelR~drmatEoft Qtr rC~Q~!'S IxadCr7T'fOr tO tCP1fM~, tDttl re[xtmmended Rf~QW or atted tetts~- -_-- R TcstTt+fethnd Tlevelopod Bp: Sump Mattnfacttuer ustry S#a~dard ProFtnnicma) En~iuecr Cl,ther fSYe'e~+) Tt=st k+ittt-od l1i~d: Pressure Vacuum . drostatic [)then (1~r,'rify) - - Test Equipment Used: !~ ~ 7 ----- -- l~luiptnant Recaludgsf,~ , e~ Ramp # ~ $1JtYty ~# ~ Sump # 5nmp # Sump 13ianneteh .._.... .. _. . 7 $~ Sump ~h: _._ _ ~ ~ ~ _.. ~ -Sump Material: _ - _!____ ~&r. ----.. I~eight from Tank'i'op te'1'ap ot` FTighcst 1'ipiztg Penetration: ..... J _......f.~ ~ " IIeight fr~ Tank Top tc tees! ~eatrit~T Pette~eian: f Q . .._.-- ,~f ~~ ~ t:onditiun of a~unp prior to _ _ _ testing: ---- Portinnr~t'$u~gTCaiuiT ~ / . Uses tut uie a t dorm when SUIIIp SCi1SOi LlCtCGtS ltytud (b6th " cs l No NA No NA Yes ~ 1Vo NA Yes Nv NA product and water)? Tvrbitte shutdown responsttin~e _ __ Is aystent progrpntimt:d or ait• es No 1VA Nb IVA s es No ~(A Yes :Iu NA safe shutdown? ~ b"as as .safe verifie to a operational?* yes 1~'o NA Yes No NA Yes ho CIA -• •---...._ . Yes '~io CIA 1~att time hctweert apiel~i ng pYtSSwelvacuutr~watCr And St3t11tt tPSt' ,/ ' ~ ' g 1 f ~. / ... ~~ Test Stsirt. Ti~rie:: $" ~ fj D y2 tZ3 Initial Rtading (Rl: . we,o' .csclCCx~- .r~r~~~" Test Hnd Times ~p~ ._ . _. _ ~.~," _. _ `~`p~ ~i ~J g I~'irtal heading (itf): ~ ~ ~ f•. .moo I ,eo ' Test Duration: ~ lni. `j v+t tnl . ~ cj , M1! . pd ~ ~ ~ . ! ~1. t'~`~ n5 • . "` t . C:Mu~ge in Hestding (Kr-H.a): .aoc Passmail Tgtresh,old or Criteria: ,DOZ" 1.OU2_ ~'(, ~{7 ~-" ~ _C]U~" Wa8 at,7tsorn:movttxi For ttsiity;? -~ No ?~L4 Na NA r Ntt NA Ytiw No NA ti°V'as sectstn properly replarad and verified futtetional after No Nei Nn NA Yes Nc N,1 Yes Nu Nh Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 7. C1~DCYi-D)CSpENS1RR c:nltil'['.Al1~f~41E1rfT (1.~DC} TGSTINC ' as° - -- °f -. 'lest Mrtlluri )'k~~'r.14[tt:rl Ry- li1~i: MEtnt114t:turta ~ltdusttry 5taradard Profesaiuufll ~nL,rlnCCr 1 Other (S~iecifyj - - _ - . Tagil Vlrtiiod CJrnci: !'rissttre V,ticuulu kl~ yr-rn:rurtic TeStL~uiptnenlUstd: W~t - _._... ~uillent'n1.Rcxrt7uliun: _ +p !lH:: #J r~ TJD{.' # TTTIk: # ,g R!J1i: Bf~~..~. ~ ~I t)~~ 1b~8Ilt ac LLQCr: ~ ~ wT _ Oi~f a. ~ -~.a.It1~1'.a.~d~>{ tJ1?C_' 14'~3tC[rL111: .. ~ ~r r + , di tr , . ~lAer Height tiau tiDC Bottom to Tvp -' ~'"" of Ili~trssPipingYt~etranrn_i: _ ~• ~+ ~ ~ ~. I tete+ t irarn 4'LM_: NOttGrii to +~ ~ ~ ~ ~ ~ i.rtwrxt F.lermiral 1'enetratlotn: _ _.. C:otMitiou of UDC prior to I , testiaR:. i __.. _ erg Prtrtirtn of l'.1 ]f_: 3'cxtrtl' f - ' Ures turlritn: Sl:tutdotit-rr inlr~n UL?C. senstx de#ects liquid ca 1\v TdA No NA Yes `It- :N.A ~,+ f;rt A'.1 (lxtlll pl'lZdlll:t lil u~ WfltL'r)`~ 1'l1iUll1C Slfltrd0[YI1fQ5j1Ulr5~ tlt11C - - -- ~ -- lssystemprogrnmmcd orfail- SOfe slwtdawn' 'ce, Anti NA !'fS V6 !•A Ye i '•To N1l rra , Ttin '~A F>;~ frul-safe vcri(icii lu be _._ _.. i opet'ationalT Yes No N1L 4'eg Nu ?;IA I Yee Nv NA , ties Ito Vn. L§'x!L t][rll' }7L'EWLCrI appl}~irlg "" "`_"" pra;s:aurc.'r-aun+mrivatcr and y~ ~, /~ ] ata rain • ienl ~;,,,• ~ ,_ _ ~r„~f w.i .' ~ ~,~ i ~+ •'n ''+'r •%r "1-est S#art Tirrte: ~ f.3 (i ~?.[ ! ' / / ....~_.23~ Itritm! Hearliug {.R,): ,oC - 5r-+`_ ,oo~~a' .tyQ • .D r _ - c_t r ' ~. Test lnd '1'nne: ~~__- /ap ~ f J 5! _ ~ .; 1'ma l;tu ing {lit):. o '~.o~l f oao-~+.} ' % ~. t! 7i:stl~+rxtion: (~,1''lti;, Ir)+Ytfhl. r7r'Ylt '. ~f7rY~fN- I`=/l1 A;. ~`1I4'~j.6i..,(~}/l~~lA+,' 1r:~Aif+4. 4trdngc in JCeading t~--R.). ~ ~ ,~ Q, -. .4Ert+b/ ,~,se~o •~? Pass~'Pail lriresholt3 or t:t-~I~~r~A: }1-.t~o2 ~J_.ooz_° }l~.c~~z' +; .~,;.zn ,..., : .. .. ~'?x'.;t~sljlt'`s^'.i°~ :• ~ ~~ r=: .'•,~.:':~s:: ."s. ' Pa:~. Cl Fail:: i :• v ~ i , I'~zts. : Q: rslltl::. , ;:;~'1;; ... ., ,. - Vas stt>svr removed for #estui~' ~ Ro V /L a No 1~.1. 'e Vo N 7 'es Tu _ _ ~A 1~as~sensvr fnuYerlureplacet]and ~fi N4 ~~ .ya N~1. 'rs Flo till i t~ ~ ho Vr~ verified fuuclivtwl aRcr trsliu~? t:_:-a C`nrnmenl:s - i,'ifrr,tarde sn~i~rfrrutirr+t an. r-e:/+rci+-n mrrJrr print rv rrs'ttrtg, anr~t rtcanunerulet~juTlc+~v-t+Fr fc+~•-1'trr~er! r~ srsl Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 7. UNDTaIt-DTRPF,I~iSE1:tC4NTAlNML1'N'1<'(Ui~C'~'TI~STIN~ ~~-°f- t.`ummrnlet - (ine:lurlr: Pnfirrmulinn un rFfrrlir•a ntrlrlw. prirrr to fa.,~ting, rvtrl re:r:urnmr:ndrd frrlLr~w_ ufr for failed tavts) Test Methalil}e~ltrpeel By' tJDC: Manuf>iCrin~er t<ch+afi'y Standard Prafuxsiunul Eet}{inec~ 4 theC {5P~'~fj'J - ---- 'S•rntMctlswiLls~= ~ Peessvre r 1~aeutun Jd$ydrostalic Otter (S~ec:{fy1 ____ Test Equipment Used: •V>p.~ 7r-- ihquipimnt kesolution: UDC ~ -~![~ 1~ r - rmc # UDC # UL7{: Mstt±rt ,' r - . - .._.... Ficight mtn L C $ottonL to Top ~ ,, ~ of Highest Piping Pt~nottatmn: • •-_-... _. .. eight front [lDt: Beteata to v . Luwest. Electrical YtatErtetian: ~ .. _ . trotsdiiiun of UDC prior l~ ~ ~~~ ..... testing: Gee, ~ ;..-- --- __. Partioaof UDC Tested' ~..~ ~~" _-. ... _-- -- Uoes turtnrn shut down w4>~ I I17t: sensor detects lygwd ` No CIA `~.ti~' r No NA Yea No ;lA Y+rs Ne NA (both product and watts)? Turbines own tx+sponae timc: _- - - -.. _ ___ la gyslccn pnrgi~iuued far faII- ~ ~ No NA Yoe No PIA Yes No NA Yes Nn NA safc :tTtu9cinwwrc7 ar ; -Ra. c vcri u: to be -- l?• _ _ _ Ycs No- NA Yea l~U NA Yes No NA Yes Na h'A a atiana ._ Wait rime betwoero eppl7ia~ - - - - piessurdvatuttrrlwatar and ~ , ~f 5~[IIlig tE9t 7 , .~. . . Treat Slstri'l'ime: tta? ! t Initial Reading (R~): .o * ' .4p~4a' _ .o~boo' _ ,c~ Test End "l"ime: _ Final. Aeuding (l~r}: y _ Tesl Duix-tiun: ___ ~ ~2r~-!~ ~ .ilti. l ~ rV 1. P Firt'lrnl_ ~ rY fN 1-~ h ~ Clunlgc: m Rcarlin~{Rp-Ri}_--- ~$ .eaa PasslFat7 T'htcshold or 002' ~~ ' ff 4G1~ +r aa~R ~,/~ 4Q~~~ C:riberia: , -. . , , ~ e ~~..:.:; - Was seasaor removed for reeling? r No A:A No NA Yes Nv IWh Yts _ No VA Was sensoe prap~eriy t+eFlaccct and verified fimtdional aRcr tcxting'! Yr Vo NA os No NA Yrs I++o NA Ycx Ttin NA Tanlrnology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 9. FR,I.RISER(:al~`AIIlYMENT$UMP7"F.$'fiT"fC: p~°.-°~--. Faoi ty is blot mPP t °st~ ainmant Sumps Ftll I~lsec Cortlamment ~umFB 8rG Prenant, hllt vreaG NUt Teatod • ---- Teel €~lt±tt>Qd nevelcmedBy_ SttmpManufaGturer ,~Pttdu~lry 3lttntliird C'mfessinnal Engtnetr Otlttr ($~fYI . - _ 'Test A4ctturtl Uxcxl: i'ret:sure Vacuums '~tydra9totic - - -- Other (SFeeify) -'- --- - • - Test N.gttipmtbt Used: ~ ~~- Nqufpmtnt RcsMutivic;, aoe~, F5ll Sump !I Fill 4ufip ~ Fill Stunp {f FYIf Sarnp fi $utnp I7iametra': _ -----~ Sump Depth: . ~ -- - -~ ~~Ffi;ight from Tenk Tap to Tap oti i ~ "~ " ~ ~ ~-'•. on: I-Iighcnt Piping Penetrat ~ Het t om ank Top w Luwest El~rrerie al Peaet,'ativn: ~ . ~._ ~~ ~. _... - {:oti ih9n a stimli tst't~ to tcsti~: d ar .. -. .Portion of 5wttp Tos ~ .. --_ - Watt font hctwoc~ npplyirtg pns~ureJ+alcuum/water Head ~ ~~ star[i71 tESt: •"" l - r ~+Q - «~ ~ e 'Test Statt'1""nne: r ~ ,rd T~iitis] Reading lt~_)_: ~. ,~,~~ -_. _ - _ --- - Ftnal Reading {7t~): . ~- _.. 'I'estlku~on: f 1IJ. ~ fll}, f~ ~ ~ N C.'h0u ~ is I~et-dia RF-Rt): - - - - -- _ Pas: Nall ' tE.9 d ter aerie: t _ ,mpg!` _ ; .pp~' f/_ . t702" r , O O2 ~• • ~ , ~ .,,~ - Iu the sunµ+Z Is tL.ere a sec~x tse; No 13o c No , Y Na L~bt:a t , sensor a wlttn eitdar rnduct i~r water is de~ete[t?. ~,~ No NA ~'' ~ Na NA ~ No vA Yes ~Ia t`p assiattortmttov orteatntg. No Nw o Rlp NA es Nu tlA ~ Nu NA W3S SE9188T I1P6pt~ty rxplaC ctti$ed funCtlonal nfLSt tiesfigg? a No NA h'o NA No ~lA Yes Igo NA Commettts - (int~utte i~~formalion on repairs made rsr~r to !~s'lixg; and reeontrrae~+ded.{o11aw-i1 fotlett tests) Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 ~_ tiPLLL!#3V~.REII.L C~NT~iTNMCNT I30~CES Page _ of Facility is Not 1s4wPPed With SpilliOt+~f~l1 C:outair,ment Bones • 5psllJtJverfit] [:aut~inment ]iicsxes nrt Nre.4ent, but wers7V8t'Festrd TuSI IVleihod I,~evcIvpcd ap: SpiFi Bucket lvianufacttmr ~dusUy Stnndard F'rofe~.agt~tl En~iiteeT - -- Tee Method used: Prcasure _ -- Va+~u~ITR _. ; ~y~lrtrstxtic C3tl~a,• {Sp~cifj+} 'I~e.~t hquiprnCSd.1_lu:ri: ~ -~-- _ Ecluipanc'nt R;:sci]ut.iun: - _. b'plll P1or #~,~ a Spit! Bux it `upill I3ox ff ,rf a :ipill $r,x Basket 17ianictcr. f ~ •~ l3urk.~:l Depth: ~ ~ -- ~~ •' .. ~ .. -- Waiiteme brtw~cal tll)(]I~+1SL~ ~ ~~' ~ -- no,1 grarlia~ tl:yl: ~ . - I ~ ' ---4 ~,i~,. ~ti -iest Stait 7'i,nc: ~ ~ ~~, lJ' 'S / JG`,.? _ © _ / Xtlltla~ I~d1rtg (R,~: . Q t s 'Cost Grd'Fiore: f ~Oi9~. . ~`J~ . ~O._. ~ JGb~~ ~O Q_ Final YLeadirif~ l~_ r)~ . - -- .. ...r~,o ~ f, "Pest Duresiinu: .~.. .~ -...~. 1 S . k ~' ..,. ~ ./ s..,. - _/~`~Jk i~hange inR,ending fRr- R,}: ~ '~ o00 Pasa1`Fail T~~resholcl icrr ,~ ~ ~ ~ ~fkll'riil: - ~^ Q~ ~ r ~Q~ 'a~,tiS•' ?.. ljurnmrnty -('include infurmtllirltt cNr repairs rrutrf[!pr{or To testrn~ and recap:mended. fallow-,ipforfa~led r~rts~ ,~ ., __.. Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 Work Order: 3144045 ~. 3PILiJtaYE>lilrllrLC>tliti*'1't1IrFMFNTB07C1CS ~~.--~of -_ 1~ncility is i'vut I'iluq~ju:d N itb Spillrfill Ccx~ixianreril Doxes SpilU{}v,;rfa71 Contairimtnt Haxcs:ue Present, bt~wercNnt'I'estcd • ~ - `I'e~l Iwlethnd IbeveloFu:d lay: Spill Tiucket Mnnufachuer Industry ~5taudard f'rafe.5siunal Lngirt4er _ Otk~er (Sf~rcifyJ 7eSi i12etl~c~~! 11ac$: 1'resvuru -~ VaCUUm H)•drnslratic - .~.. _ Test Faj~ip~etlt UsetL ~ ~ • F~juipCttent Resolutio~i: iII box # ,~,~f~ Spill itox q 5pll1 Box # Spill 13~x p Bucket T)iameter. ~/~ ` ~3u~~kctDepth: - ~~ ~ . -- Vv'ai1 limo beriveere -- . applying In e: ys ure! uacu uinlw a t{: r and alxrting Lest: +r' Test StartTiril4: J/ ~ ff5 - - - Initial lic:adin~ {Rl}: ~~ - - Test kind Tirnc: ~ ~ 51 /.~o ~ - ~- - .. Pinml Rex{ling{R~): _ . ~. 5 4 Tc-a;t 17uration: f ~ r.. ! $ .'.~ f;:l~a~~gc i~~ eadtnk-g {Its --- R[~- _ '~1Oeas rO YassiFail haldor ,~ ~ ~ - Cri'[serL~: - - o:,. ' Cum~yepts - (tnrtudv.. i~t(urrntttio~t on repnira• ma~Ie prior to testing. unrf~~ecQ1rlf11C1ided follow-up fa+•faided rests) ro Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 INTERNATIONAL CODE COUNCIL _ ...~s..,~...-_.--- ROBERT ~EIDENFELLER ~~ ~ /r~~.!P.f~r~~zcr,C `cam ~o~uu..t~rc~i`e~/,d~ f~rzl,!` ~i~a~i~s~~%~.~zG~,zer~~ r~ cefa~~r~cct~eOi.~ ~if~zcft~y r/..~~ru~i~~~~~~e.~!~et~c~d'~e• a.~ f~r~.~'~ fi~~~ c"itf.~,A,1%©rta~ ~i~,e- ~~ ,L uccce.~s~~}` cnrr~~frir~ f~r,~,~z~~~cf~.Gra!e~.~.iz, e,~rrnriaatii~L G~tr~3ec~at2 ca~..d ezrzc~ <:/.rr~~~.r~z~d ~~ sir. e~,e.~ aicrz~i,~ /~.~e1~ rdd~ie2~ c~.r~ioz a~,,• UST INSTALLATION/RETROFITTING ~r riven this day ©f Dece~nbe~ I7, 2004 v ..: Frank 1'. Nodgr. Jr. President. ICC Board of L}irector, /~ ,r ~/ ~anles E.,. 1>ditt ~iC~ ~hiei" Exe~:.nt~vc: ~-Eiieer X250279-Lrl Certificate 1Vumber INTERNATIONAL CODE COUNCIL' - ~ ;~ r~ i~ ~, ::;~ °' 1 Y f ~ '.:l r1 1 T ~ v M r tat B O -a v~u C '{ C ~~ ~-. ~, &na~F'aubl~ +aer_ .i4~ ~~ -T. Namas '3ob Weid~t,feA@r' a - Corcipany, West~m Pump,-;; Cerfl~ecl"fPatt~ed toSCdltai? C~ar~ #.> , Cn 33u r! . '~cpit2tiuii data: January 19~;~20Q& ****** HP MFP Digital Sending: Delivery Confirmation ****** The following job has been successfully delivered to the specified recipient(s) and/or intermediate server. ---------------- Original message header ------------------ From: BFD HazMat 900 Truxtun - 10.1.17.55 Date: Tuesday, May 16, 2006 11:21:40 AM Subject: --------------------- Recipient List ---------------------- 16192367406 [successful transmission] :' Steve Underwood -~QSyBakersfielti.pdf ~ ,~,.,-..,~.~~~.._. _~.._,~...,, ~~~ ~~~ Page 2 G RigHtFax 12l27P2005 4:23 FAGF 0031007 Fax Seruer BILL.iNG B~.PEi2MIT STATEMENT BAKERSFtEI,D FIRE b~tYr: _ ,irr~r' Prevention ~exvices. RERMiT NO,' 900'7lvxhin Avenue, Suite 270 Bakecsfieid. CA 93301 w crr`r ~: zwcoa~ i ^ Alarms -New & Moderns - itdBnimum Cna~ $282:50 ~ . 98' Over20 0005q Ft 0f3?2S=Permitfae Sq Irtar ~ ^ _ ~O ^ , . _ _ _ SPrinkiers-•Mew&-ModAlcations--(I+rYnrmum GHargel - OyerS,000 Sq. Pi . . _ $21000 ~ Sa. Ft. x-.042 =Perm#fee 98 ~ _...~ 98 ^ NtinorSprinkler ModiflCaGans to 10 heads) § 93.08' (Inspection Oriyj ~ ~ - ~ 9$- . - ^ -New:& Modifications _._,._. . Commercial Noocls . - $-3~ ZB ._. ~ - ~ : . ... ~ ^ Additiarsa) Hoods _ E 3GtN1 - v-.. ~ . C] i Spray Fsoattis - New R Maotfiraitons ~ $458 (lti ~ . -- - ^ AhovegioundStangeTanks:tmstsnsEardmsp-1'Tirrie) $165.Ct() _ __ .___~._ _.~ _ __ --.. ~ 4 u.__ addiaonarre»~s s~sao _s~ • ^ llhovegiouna storage Tanks tR~nwellinwe~ksoi $tos,CM7 . ez ^ Underground Storage Tardt$ {hrstr~lionJinspeGbnj $87$.~ (Pa+'lmtk) 8Z . ^ tlndergraund -Tanks {Ma3~iwt,on). $87$.D0 (persitej I 62 Under~raund Stor~ge:Tanlcs tMmatutodficatioriY $195.7. ~ _ ... _ ~ 82 I ~- ^ ^ Under roundStora~e:Tanks{Renavaq Oi1w2N tlnstallahon) $675.«1 (pertankj $ x2D0 ~ i s4 84 ^ Mandated Leak Oetedion (Testing} 1 Tuat 6AOrrit. Celt. -._ $ $i.BQ' (per'silfj. __ . _-___ _ 82 fs. ,..._ Tents- r._ ...:.,__,~ $ 93,1)0 {parta(tf) I 8a - ^ I Afrerhours.lnsp¢edon fee _ §122IXY'. _. .~ ~ ^. ~.. lPyTOtCdVtIC - (RCf ewenL Plusirrsp. ~C0 ~.$g0 pet itOUr) S fit).tl() fi yffi,AfB.:~NtL BfarM-h/teennspei3.m) C $510.08~~ ._ I „ 84 I ^ ! REdNSPECTION(S) l FOLL:UW-UP.GYSPEC77ON(S) S 33A0 (pCr tour) I ~ ^ . I ?ortaWe LPG (Prune): MO. t3F CAGES? _._ _ §68.80 - .._ ~ . I ~ . 84 ~ ^ , _ F~losive Storage _ -r _. ____-___. $249.00 ,.__.~ ~ ~ i 1 ^ ~ t.o ytrtg & Fite Research {Fife ftesearai Fee.33300 per hr) . 25¢ p~ P f ~ ~~......i.Misceitariei~us ~ ° `84 i ~.OFioNaAL Yrt1t1E {to.Ynraewy) I:YElI(SW ha ENe?~ '1-PINK .(t0 Ctntsano~y r=o } oz1 {Rev. narU53 4 I ;Steve ~1'nderwood QS Bakersfield.pdf ~ ~ ~ ~~ ~ ~ ~ Page 1 RYghtFax 12/27.120175 4:23 PAGE 002140? FaX Server UNOERGROUNq 5TORAOETANK :' ~~ PERMIT APPLICATit?N ~~ ~ TOl7Q1~8TRUCT~N$TALL NEW TANK (t~YV FAgLITY) NEW TANK IN8TALI:ATN')ti (EXI$T~IG FACtGAY} 1 v; . NKmIFICATKNt l.S MNNOR MOOIFlCATKNt < FAGUTY saxERS~Ln nom. pi'B46IIt~01t. ~tV~B, 900 7tvatuii Ave., Ste. 210 HalcecsfieEd, CA -93301 Tel.: (861) 325-3979 Fax:. (b6lj X52-2171 PERIMR N0. ~tv \ ` ~ ~ 1_.S]..'! P~ga t M t TYPE .OF APPLtGATION: A NEw,TAHK INSTALL l NE1N FACILITY ~ Nk~M TANK INSTALLATION 1 EXISTING FACILITY :~ __ ~ .... _..~:.. n tanriteFrnnnn nc ~wr+n eTV ~cd'anuno unn~eu~annu ne renr tTv ~xr~wi~ ' ~ ~ DATE e.,~ .- ". , ~ no '_ ~ -" „- - .YlsT>tlci cA(YrtY VEte~Mr.RO. .. ~ ~ ~, ~ r~ (~ M1l . AC41IY h00flE5S 8Ufi9iES8. -~-- - fY ~.-~.~.,_._ ._.. _..,. __ - __ .~,., ,_ . ~ N - OYYRER.. - a r`l - iC @NO ''' - pp ^~~ cao i °R - iVC.~N5EriO - Nta ~ r~ Q CRY 8VS81 it~FJii ~ND. ~ 3 y~--'-~~ .. ~SI.Y t7ESl7tIBE TFIE iNOg1(TO BE ~ ~~i'~K~ ~c'~:c~:~~~?~~°~ ~r~ 3:t~~~'. i , -i 2. c.~,~~%1 ~>tS,n,~f~rZ -~~;~ S~.c,ns~ . ATt3iTCF RY 8Y .. .DFPTHT GROVNtI WATf.R - S9~T1t'E E%PEC•7ERAT377k'- N6: TMK6T 9E D "APE THEI'FOA1~T[%tT1~i ~. ~•~ 4Rq.1: CWEVEN't10N.CpMttRW:AN0O01MFERV~AF+F 11RE8P~lU1 Q+1Fi~ O YE$ ^ No C:r res ^ No ~~ FOR.OFftCIAI Ub O L _ - 77r c~pGmru hdi rminryai4 aaiofivraamrfr, and wiu ewrpty xdd+ et}r ~mAirl~ed c~wulirFiW oJNe rxnnit emd eu{y cYt+er ahte..?ocot med fedexll ragutcuiona 'Iiw fo*rn~as been coapleter! twdar o~iN ofD~+7p~, Y mid m the but uflap lamwdedy+r, is tme axd car*e~d. ^~_~_.:.. __~ ~.~...._. -_~ _ lll~~ E~1.f? ~E~~G 1~'1 rr' ____ l~l hPWti - - RE .AFWIOY~BY: a ~APPLM.AXT N~Mp(wRBRy TH9S APp ATIOM BEEOMES.A pER~T W-IEN AP~ROVEU Fp1088 ps.. pw1 t~j~ ,~ SteveUnderwood QS Bakersfield.pdf ~M ag~ r~~._~ ~~_. _~_ _~ . Page 3 a _,... .. CITY' OF. BAKERSk'IELD. MAIL TO: CALTFORNLA " CITY Of $AKERSPIEII? P.O. BOX 2037, BAKFR5IFIELD; CA 93303 PREM6fiS MUST CONFORM TO TANAIG. BUIIDM6, FtliH AND ttE+AL79{ [JDDBS. CHAHOEOP ~NESV OWNQRSF!{P O. BUSIEtESS ncoa>tess~ {~ APPLICATION FOR"BUSINESS TAX CERTIFICATE .PURSUANT TD ORDINANCES OF791E Gfil' OF BAKERSFlEED PLEA$E-'TYPE OR PItII+IT LEGIBLY AV IAIK W rEs:-j~`.z.~J ~/,..n: iA f r!~ 122 9 /<a :s^ BUSAtESS NA1ME - . " ~• ~ ~~ - .._ _. ----- (TATS Busn+esst:oeAtx~ ~z:3:S F. ~r.~.s-~~- 'S,lt~ !~~ Sao. ~'/~- °T 2~ c+ iSepeasCa~mRS9sbril~4n twca?.rcairsn} 'STH _ :f,ITY - - :,~ T.LL° _f _1. ,~. NtAlilNCa A77i7FiF:Sc :...... .. S REt-f ~ - ~ ~ "' - KnVDOF-BUSINkSSORPROFESSION - TT6T>~o~.6.!+-. ~..LJg.2icuAlln.J. '~R@.GS}i~a-~rT TELEPHtJNE.:Col9 23'9:-_rtR;B$-. .NAMES AND ADDRESSES C!F ALL OWNERSlCC+RPORATIONS LIST OF'F'ICER. S - INCLUDE 7'ITI:ES. NAh1E HDME.ADDRE5S TELEPHONE 1 s~xeb~r crrr sr zm ~<i-,~ra.~ K~ts+N, a:i c+e. rrF~~.e:~,a.z y ! "~"rz.ruas4+_ s9xe>?r CRY sr ~ s,~~ ~~ _ T'YPE:OF ORGANiZA9TC+N: PARTNERSHIP ^ t~ORPORATi(NV $~' FEDERAL EMPLOYER Il3ENTff[CATION.NUMBER 3~' ° ~ ~ 7 a f INDNIDUAL ^ Name 5SN I claim exemption from .the Business. License Tax fot the' oigauization or individual named above since it is D Tax Exempt under triternal Revenue-Code-Section 501(C)(3) or undex State of California Revenue & Taxation Code Setition2370I :or; L7 Considered a;passiye investment in the rentai of Real Property under Inte~•nal Revenue Code Section 469, I understand I may be required to provide proof of continued exeanprion iiom the Business Licensa Tax upon request: "DATE COMMENCED BUSINESS IN BAKBRSFIFt n "'_'T+"~'~`+u.s-~s-.Y_ Z-d~ CALIFORNIA STATE CCaNTRACTOR'S"LtCENSE NUMBER, ~, ANY ~ 7 ~' ~ ~ ~ SALES TA7C PERMTI' NO. S ~- ~F ~ -~'. '~ : ~ ~ ~ Q "I_' . ~ ..._. ~ (._. _ .... u.) ~f ~' ~fi AtPti11 NUMF.WC SUB Sates or use tax may apply:to your buninme acdvitles. Yoo'may ~dc writtan advitx regarding the appiiwtioa of tsa to yow pmtiailar Dtieuieae bi' writing to rho nearest State Board of Hgaalitation o@1oe For general infottnadon, please cast tkb 9oard;of Egualizat7on et 1.800.4e0~T115 .~:;., . C; O 2S ESTIMATED ANNUAL GROSS RECEIPT'S M BAKERSF[ECD ~~ e7o ~'~" I SWEAR UNDffit. PENALTY OR PERJURY THAT TSE POREG4ING I9 TRITE AND CORRECT. ~77 ~^ ~~ . , l.A_~ 'TPt1r,E ~ ~T~4~ .~.z:. -DATE / Z-~3,a f.nS ~-- Sigrmwre aAOe nxmer.+lp~ aaeiar4erapmtbn, uc~r ~~. ONCE YOU HAVE CaMPLETED THE APPLICATION :AND STATEMENT- dF CO23PLL4NCE, PLEASE, CALL TXE TREASURY DIVISION AT (661)- 326 3762 TO DETERMINE TlZE AMOUNT OF TAX.I)UE. AT THAT TIME, TAE"CI:ERK WILL BE ABLE TO ADVISE YOII WHETHER OR NC1T THE-APPI.ZCATIOtd CAN BE MAILED IN. Steve'Underwood - QS Bakersfield.pdf~ .~.~,.~~..,~Y...~~.~~..~.~.~...~~»~~~. ~~~ ~..R P.,.~~,~.~...v~._,~.~„w..~ µ~~i'~a~Page 4 _ .,.: p CITY QF BAKE~SFiELb` Nb.. STATEMENT fJF c4MPLIAtVCE; FAR ~a~s~ ~'^~ `" ~' /N~ Name.of Business I understand-that fiaving a Business LicenselTax Certificate Application #rom' the City of Bakersfield does na# authorize ~~ to condwct a business and I must fulfill ai! obligations for obtaining permits nr approval ta' establish. a :business:. The business premises:. must-conform t4 zoning,-sign., building;fire and health codes. `i vri(t exp®ditiously comply withi the: requiremenfs to obtain the permits that are applicable for the type of business covered by the Business License! Tax Certffica#eApplication'before starting business. i have accurately discle,sed the kind of ;business or pro#ession and the location on the t_icenselCertificate Application, Tne Business i_ieense Section must be. notified irl writing if there are changes in any of the following: `. Businesslocation ~,._ Maillrtg A~iciress .~ Ownership Mali to: City of Bakersfield P.tQ. Box 2057 Bakersfield, CA 93903 Wastewater Discharge:. in accordance with Federal and State tnandate~! regtjlations, the- Glty of Bakersfield developed a Pretreatmentl.Pcogram to regulate industrial: wastewater discharges within' the City's sewer service sties in order to pro#ec# the public health and the environment. Aray wastewater that is disciharged to-the City's st#wer system shall met3t:all the tequirements in`the Bakersfield Municipal Code; chapter 14.12: Contact City Wastewater at s3$-o364. Print Name: L ~'•aN,g ~'r~tut~ a ~'.c Title. 1~+^~s!~,a,tT- Signature, Date. ~~i ~~ ~o.s~ The fn0owing are agencies most commonly involved in reviewing new tauainasa in Bakersfield. They wilt. be glad to reytew your plans wtth.you, Gty Wastewater Gty Emrironrnentat Services Akohotb BA+reragq 0ontrot: Air Pollution Control Board Catifamk Water 9ereioe 326-3¢18 Gauniy Emtrorimental Mealth. '386.3979 Courtly Wetghts:& M8fl8ure8 `365-2fT31 franchlea Tex eoartl 861-3;882 State Board of EquilizatfO~a =39&2A00 (SaiBS Tax) 881-3636 Uttiitlea;. 86fi-2478 So. Cal. Gas (800) T52.252U 1352-571.1 P.Q.E. (a00)743-6000 395.2880 Pac. Telapharie 1800) 244=4615. Original. B%L Fiie Yellow. Applicant 'Steve'Underwood~- QS Bakersfeld.pdf~~'~F'~N~~'~~~ ~ ~~KK'~tr~~~%~~'"~'~~~"~'x't18~~'~+~' V~~-ry'~ Page 5~~~ JACK-ttV-TNE-BOX.. C-STARE #10,~ I #8 ~~#5 #2~ #1 #'12 #~1 #H ~ ~ #~ #4~#3 Rag. STP ;~ 2Qk 97k STP ~ STP E DSL "`-----~~~'"' Prem 7k 1Ak m cn `4 Steve Underwood - QS Bakersfield pdf a ..~~..:,...~'~ra..~.x ~ ~ ~~...~.~.. .~,.~.~r,~.~ya~,~.,..~ ~ ~.~~, Page~6 SC'QFE fJF WC.~;R.~ F'OR: Jack In The Box. l0 Union Awe Bakersfield, CA X3307 • Repar~replace test boot. urid~r UDC l 1-12 , • Re-glass premium fill sump or repair/replace. necessary boots as needed 'i~i ~ -.r ~~ _ ~ 4 - ~.- .. i n• i ~ S ~ , .r r ti ~~ 1 ~' ~ 7 . ~ _ ._. ~,,~ - ~ ~ _ ~ (, .#LJ ~' 7v S:i~ ~ ~'.l:,~j 9~'V .f~ C~ ~rr.~. ~::rr ,,lral~.rrrtc.!rverrf"e~"cif ~nrcr,.°.I iif~::.f~ r~rrfffr;~ si,rtrrrrrarrrit c, ~i~rrrtrs=i^t''v~. r~`Jr7:~ e;fr4rr,~rc. ' ~ - ~ Str~~uYrar"t%"~r-- <~rrrcyitirz/~cfl.`r~r_-t,~r!F~ <r,:.~~~f<rrrrrft"`~.J~ ,.:~rtturrrrfrtsrdirGr !~t~r~e `t~cerrz-trl , f ,': ~ ,~ie. cr~•:~'~r fr%.r~rt~.r~~:v.~<~r~p,!rs+l±~~rr~fr ~:~-ri`r;'v~s ~:i~+a~,r.,r~zr~r.~r ~~z<sa.!~/ra~r~er~,ri,3~,rx.%rlr/ ~, '-{ s#rrerF.i++Cr~!rr~'~;i- ~~<,r,!~ trt ~~~r`I; rr~,rrr~cu .+~:F.r'r'!~ cu~:Srl~r.~ ~~3 r"~Clts~i6~5+• rrs%-'. ~ ,. r xxff (\T 'f~~j ~:(j t~ i. ~ Ati ~1.i.1 .1 ~~ ~1~~\.+~1 ~11~~L 1~ ~i' 1 .1•~j l ~ 1 ~ J 3~+~~~.'\~ _ ~ j }~ / ~( j [ " ~~Jj / j{p ~~{~ZVfrZt Li~l:~ lt~~~'~~~ .t T6`f~l~~t'~U~f'~ ~s , ~LJ6lc~ ~j ' Twifi'FaQR+e4+ Y} qrj !/y /j~jj}}fR~.,.' ~"}.':4 ~)`~~°1:3:t ' f/`7`~ . ~\~"~ i ~ ~ ~ ~ ~' ~ . 7i. c, . 9d1i1 ,!;.53 !(:..l 4/ ~ .`: 6aar[iz,.[.C'~ $c~ar3 ~f'.I3irrcec.irs. ~~ 6~ V ~ ~ ~"1T31S fi ~P ~VST( ~N'4 Le14 T l~ S ~ 4.r ~~ _ / 77 7~~~ ~~^ v. 7 ~~j sC t,. te! k:xc ti tt+ .2f7iCr ~~~~ 4QiJ1'z41L , ,. j, t _ . L ;~. ~ ....,g_. __ _ S. _ ,~ ~-. _ 'rF '.~ ~ .,, __ 1 _ l _ '- ,' _ ~ - 4 f _ ~` °;; ', ,, :J ,~-;'.~~ _~~;. ~„ v„,~,„~..,,: ~~p ~ ~...~ ~..,,.~.,~~,>~.F~..~..~. .~,.~,~~ Page 9 j xi Steve Underwood - QS Bakersfield,pdf ~~~~~'' _ ~,. :,. ,, : _ , +wtutlific Y,Fnvi~Fk+i::~i ,t ("caxtputgr ~ '~rVE~firPi Flizrlji a~» C.~stiJi~(111~sia:eEttti+ta3Fe.rrC'a.;r.S N. -C: tt.;4:.t, s flxptn:.; oxi~ -n4aic4 ZI, 4L~,~i~ ~`~~~ B E R S F I F/ICE II RTM RONALD J. FRAZE FIRE CHIEF Gary Hutton, Senior Deputy Chief Administration 326-3650 Deputy Chief Dean Clason Operations/Training 326-3652 Deputy Chief Kirk Blair Fire Safety/Prevention Services 326-3653 2101 "H" Street Bakersfield, CA 93301 OFFICE: (661) 326-3941 FAX: (661) 852-2170 RALPH E. HLTEY, DIRECTOR PREVENTION SERVICES FlRE SAFETY SERVICES • ENVIRONMENTAL SERVICES 900 Truxtun Avenue, Suite 210 Bakersfield, CA 93301 OFFICE: (661) 326-3979 FAX: (661) 852-2171 David Weirather Fire Plans Examiner 326-3706 December 1, 2005 Jack-in-the-Box 10 Union Avenue Bakersfield, CA 93307 FINAL REMINDER NOTICE RE: Necessary Secondary Containment Testing Requirements by December 31, 2005 of Underground Storage Tank (s) Located at the Above Stated Address Dear Valued Customer, Over the last six months this office has continued to send reminder notices regarding secondary containment testing. Code requires that all secondary containment systems must be tested 6 months post construction and every 36 months there after. Senate Bilt 989 became effective January 1, 2002, section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and every 36 months, thereafter, to insure that the systems are capable of containing releases from the primary containment until they are detected and removed. Our records indicate that your facility is due prior to December 31, 2005. Those sites that have not been tested and have not pulled a permit prior to December 31, 2005, will have their permit to operate revoked. This office does not wish to take such action, which is why we will continue to send monthly reminders. Contractors are already booked several weeks in advance. I urge you to schedule your testing date as soon as possible to avoid possible revocation of your permit to operate. Should you have any questions, please feel free to call me at (661) 326-3190. Sincerely, Howard H. Wines, 111 RALPH E. HLTEY, Director of Prevention Services Hazardous Materials Specialist 326-3649 i C~~~ ~' Steve Underwood Fire Prevention Officer SU:db ~~Isf/~ LSbB 1%7011f~1JfNdl~6 ~ a,/I~ZPTB ~ cS~G%~t~~ •• F'' ... l :. ~ Tanla~aology 8501 N. MoPac Expressway, Suite 400 Austin, Texas 78759 Phone: (512) 451-6334 Fax: (512) 459-1459 Date Printed and Mailed: 01/10/2005 KERN CTY - ENVIROMENTAL HEALTH 2700 M STREET SUITE 300 BAKERSFIELD, CA. 93301 Test Date: 12/16/2004 Order Number: 3137840 Dear Regulator, Enclosed are the results of recent testing performed at the following facility: ' JACK IN THE BOX #7723 10 UNION AVENUE BAKERSFIELD, CA. 93307 Testing performed: Secondary Containment-Spill Container Stage II A/L tests Sincerely, Oar T~a~,~a-~ Dawn Kohlmeyer Manager, Field Reporting 5ooz s t N dr ~ ; -_ ~,; , SB-989 SECONDARY CONTAINMENT SUMMARY RESULTS r Tanknotogy TEST DATE:12/16/2004 CLIENT: JMM MANAGEMENT GROUP, LLC 820 TOLLGATE ROAD ELGIN IL 60123 MATTHEW J. THOMPSON 847-553-7185 Tank Interstital Tests TANK PRODUCT MANUFACTURER RESULTS - - REGULAR PREMIUM DIESEL WORK ORDER NO.: 3137840 SITE: JACK IN THE BOX #7723 10 UNION AVENUE BARERSFIELD CA 93307 Piping Interstital Tests LINE PRODUCT MANUFACTURER RESULTS Sump &Under-Dispenser Containment Tests Sump/ DISP.# MANUFACTURER P/F 87 FILL Phil-Tile Pass 91 FILL Phil-Tile Pass DIESEL Phil-Tile Pass 87VAPOR Phil-Tile Pass 91 VAPOR Phil-Tile Pass Tanknotogy representative: JERRY BELLOLI Services conducted by: ALEX ESKANDARIAN ~~~. UMP TESTS _ ~~~ SECONDARY CONTAINMENT TEST RESULTS Test Date: Work Order: 12/16/2004 3137840 Type Tank or Disp # Manufacturer ~ Model or Material Diam./WidthlLength (°) Depth. (°) Test Method Start Time Initial Level Level Change Finish Time Final Result Pass/ Fail Spill Container 87 FILL Phil-rite Plastic 12 10 .11:30 5.5 0 12:00 5.5 Pass Spill Container 91 FILL Phil-Tile Plastic 12 10 11:30 6.0 0 12:00 6.0 Pass Spill Container DIESEL Phil-Tile Plastic 12 10 11:30 6.0 0 12:00 6.0 Pass Spill Container 87VAPOR Phil-Tile Plastic 12 11 11:30 6.0 0 12:00 6.0 Pass Spill Container 91VAPOR Phif-Tile Plastic 12 11 11:30 6.0 0 12:00 6.0 Pass Comments: . . ~~ why 8501 N MOPAC EXPRESSWAY, SUITE 400 AUSTIN, TEXAS 78759 _ (512)451-6334 FAX (512) 459-1459 TEST DATE:12/16/04 WORK ORDER NUMBER3137840 CLIENT:JMM MANAGEMENT GROtTP, LLC SITE:JACK IN THE BOX #7723 COMMENTS Conf.#04-3187, all tests passed. On Dispensers 10 and 12 VacuSmart Equipment was used to test with. PARTS REPLACED QUANTITY DESCRIPTION HELIUM PINPOINT TEST RESULTS (IF APPLICABLE) ITEMS TESTED HELIUM PINPOINT LEAK TEST RESULTS Printed 01/10/2005 07:45 SBOWERS ITE DIAGRAM ~ Tan 8501 N MOPAC EXPRESSWAY, SUITE 400 AUSTIN, TEXAS 78759 (512) 451-6334 FAX (512) 459-1459 TEST DATE: 12/16/04 WORK ORDER NUMBER3137840 CLIENT:JMM MANAGEMENT GROIIP, LLC SITE: JACK IN THE BOX #7723 JACK-IN-THE-BOX C-STORE N #10 #9 #6 #5 #2 #1 E #12 #11 #8 #7 #4 #3 m z cn Reg STP I 20k 17k STP ~ ~ STP I DSL Prem 7k 10k Printed 01/10/2005 07:45 SBOWERS FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield. CA 93301 VOICE (661) 326-3911 FAX (661) 852-2170 SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661) 852-2170 PREVENTION SERVICES FIRE SAfETY SERVICES' ENVIRONMENTAl SERVICES 900 Truxtun Ave.. Suite 210 Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 852-2171 FIRE INVESTIGATION 1715 Chester Ave.. 3'd Floor Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 852-2172 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399·5763 December 10, 2004 Ms, Joanna Harris Jack in the Box 10 Union Avenue Bakersfield, CA 93307 REMINDER NOTICE Re: Necessary Compliance Deadlines for UST Owners/Operators Dear Ms. Harris: The purpose of this letter is to remind you about three compliance deadlines for UST Owners/Operators, These are as follows: 1) January 1,2005 deadline for submitting declaration statement designating: (a) Owner/Operator understands and is in compliance with all applicable UST requirements, and (b) Owner identifies the designated UST Operator for each facility owned, (c) Owner/Operator passes and submits proof of International Code Council Test. 2) EVR upgrade requirements on spill buckets are due April 1 , 2005. 3) Secondary Containment Testing on all secondary systems. Code requires re-testing 36 months from date of last test which was in 2002. Should you have questions regarding these compliance deadlines, please feel free to call me at 661 - 326-3190, s;n;! ct4J Steve Underwood Fire Prevention Officer SU:db II C' C):::' - /1 ~ /1 ~, JI Q/é/)f.11i-J~7 Ihø T(J(}///N/I,flllt~'l Q#().Ji: º 'I'lo-j((! c'dhall Qý'Í Yf;~)ltlit4;¡ · j / ár CA Cert. No. 28509 I City of Bakersfield Office of Environmental Services 1715 Chester Ave., Suite 300 Bakersfield, California 93301 (661) 326-3979 An upgrade compliance certificate has been issued in connection with the operating permit for the facility indicated below. The certificate number on this facsimile matches the number on the certificate displayed at the facility. Instructions to the issuing agency: Use the space below to enter the following infonnation inthe fonnat of your choice: name of owner; name of operator; name of facility; street address, city, and zip code of facility; facility identification number (from Fonn A); name of issuing agency; and date ofissue. Other identifying information may be added as deemed necessary by the local agency. This permit is issued on this 15th day of May 2002 to: JACK IN THE BOX Permit #015-021-002367 10 Union A venue Bakersfield, California 93307 .;; \,JES'STAR (559'77-0106 p.2 ..; 7 Jul 16 04 09:378 MONITORING SYSTEM CER'" 'FICATION "or Use By All Jurisdictions Within the State oJ California Authority Cite& Chapler 6 í, dealth and Safety Code; Chapler 16. Division 3, ritle 23, California Code of Regulations This fonn must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prcDareo for each monitoring system control {lane I by the technician who perfonns the work. A copy of this fonn must be provided to the tanI system owner/operator. Tbe owner/operator must submit a copy oftbis form to the local agency regulating UST systems wñthin3C days of test date. A. General InformatioD Facility Name: QUICK STUFF #7723 Site Address: 10 UNION A VB Facility Contact Person: MINTA MakeIModel of Monitoring System: TI..S-3S0 (VEEDER ROOT) B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to ludiea.e ¡pee/fie equipment Inspected/semced: Taøk lD- UNLEADED T8Øk JD- PREM amo In-Tank Gauging Probe. Model: VEEDER-ROOT BIn-Tank Gauging Probe. Model: VEEDER-ROOT 181 Annular. Spac:e or Vault Scasor. ModeL VEEDER-ROOT 181 Annular Space or Vault Sensor. Model: VEEDER-ROOT 181 Piping Sump I Trench Sensor(s). Model: VEEDER-ROOT 181 Piping Sump I Trench Sensor(s). ModeJ: VEEDER-ROOT 1m Fill Swnp Sensor(s}. Model: VIiliDER-ROOT 181 Fill Swnp Sen.sor(s). Model: VEEDER-Roo'J [] Mechanical Line Leak Detector. Model: [] Mechanical Line Leak Detector. Model: D EJedronic Line Leak Detector. Model: [] Electronic Line Leak Detector. Model: 181 Tank Overfill / High-Level Sensor. Model: VEEDER-ROOT 181 Tank Overfill I High-LeveJ Sensor. Model: VEEDER-ROOT o Other s' . ment and model in Section Eon 2 [] Other . i ment and model in Section E on P 2 . Tank JD: DIESEL Taut ID: 181 In-Tank Gauging Probe. Model: VEEDER-ROOT C In-Tank Gauging Probe. Model: 181 Annular Space or Vauh Sensor. Model: VIiliDER-ROOT 0 Annular Space or Vault Sensor. Model: 181 Piping Sump I Trench Sensor(s). Mode): VEEDER-ROOT 0 Piping Sump I Trench Seosor(s). Model: lEI FiII Sump Sensor(s). Model: VEEDER-ROOT [J Fill Sump Sensor(s). Model: a Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: a Electronic Line Leak Detector. Model: 0 EJec:tronic Line Leak Detector. Model: 181 Tank Overfil( I High-Level Sensor, Model: VEEDER-ROOT 0 Tank Over-filiI High-Level Sensor. Model: o Other (5 ifÿ uipment e and model in Section E on Pa 2). 0 Other ( 'fÿ e ui ment and model in Section E OD Page 2). DispeDSer ID: 1&2 Dispenser ID- 3&4 1m Dispenser Containment Sensor(s). Model: VEEDER-ROOT 181 Dispenser Containment Sensor(s). Model: VEEDER-ROOT ŒI Shear VaJve(s). ŒI Shear Valve(s). o Di ser Containment Float s and Chain s . 0 Di cnser Containment FI s and Chain s ¡ Dispenser 10- 5&6 Dispcoser ID- 7&8 lEI Dispenser Containment Sensor(s). Model: VEEDER-ROOT 121 Dispenser Containment Sensor(s). Model: VEEDER-ROOT 181 Shear VaJve(s). 181 Shear Valve(s). Dis Containment Floa s and Chain s . Di Containment Flo s and Chain s . Dispeaser ID- 9&10 Dispeaser ID- 1 ]&12 Dispenser Containment Sensor(s). Model: VEEDÉR-ROOT Dispenser Containment 8e08Or(s). Model: VEEDER~ROOT Shear VaIve(s). Shear Valve(s). i enser Containment Float s and Chain s . Di enset Containment Float(s and Chain(s . . If the façility QOn1aÌDs more tanks or dispensers, copy this form. Include information for every tank and dispenser at thc'facility, C. Certification - I certify tbat the eqllipmeot IdeÐtltied In this document was Inspected/serviced in accordance with tbe manuFacturers' guidelines. Attael1ed to this Certifieatioo is informatioo (e.g. manufacturers' checklists) necessary to verify that tlds information is corred and a Plot Plan showlDg the layout of momtoriog equipment, For aay equipment capable of gnerating such reports, I have also attached a copy of the report; (rJredtllllthllltlp[JI1): a System set-up 0 Alarm history report Technician Name (print): JASON ESQUEDA . Signature: Certification No.: 8922 License. No.: 605142 Testing Company Name: WEST STAR ENVIRONMENTAL Phone No.: ( 559 ) 277-9378 Site Address: 4688 W. ÆNN FRESNO,CA 93722 Date ofTestinglServicing: -2LJ 07 I 04 Bldg. No.: City: BAKERSFffiLD Zip: 93307 Contact Phone No.: ( 661 ) 861..0543 Date of Testing/Servicing: 07 I 07 ,'04 VIonitoring System Certification Page I of 4 03/01 . ..~-- .......---.... ~ ~ e \,JEST STAR e (559)277-0106 p.3 .~ Jul 16 04 09:378 .- - -----e·-w. ...---& Software Version Installed: _ DYes No· rm N/A 181 Yes 0 0 o N/A 181 Yes o No. o N/A o Yes* 181 No DYes· 181 0 0 0 E. Comments:TESTED ALL FILL BUCKETS UNLEADED FILL AND V APOR,PREM FILL AND VAPOR ,DIESEL FILL ALL PASSED. Page 2 of 4 03/0 I ----.- ... - .- ~ e \,JEST STAR e (559)277-0106 p.4 ~ Jul 16 04 09:378 F. In-Tank Gauging / SIR F,n1.Ípment: 181 Check this box i Ik gauging is used only for inventory control. D Check this box it no tank gauging or SIR equipment is instaJled. This section must be completed if in-tank. gauging equipment is used to perform leak detection monitoring. nIts? G. Line Leak Detectors (LLD): f8I Check this box ifLLDs are not installed. Com lete the followin check1ist: DYes 0 0 For equipment start-up or annual equipment certification, was a leak simulated to verify LLD perfonnance'1 o NI A (Check all that apply) Simulated leak: rate: [J 3 g.p.h.; 0 O. 1 g.p.h. 0 0.2 g.p.b. DYes DYes DYes DYes DYes etects a leak? e mODltoring system IS dlSa Ie DYes H. Comments: Page 3 of 4 03/01 '" e \,JEST STAR e (5591277-0106 p.5 -. Jul 16 04 09:388 Monitoring System Certification US T Monitoring Site Plan Site Address: 10 UNION AVE - ... ... ... ... ... ... ... ... ... ... ... . ... ... ... ... .. ... ... ... ... ... .. .. .. .. ... .. .. ... .. ... .. .. .---- : : : : a: : : ~(S'~~: ,~;O:)~: ~:OJÍSí ~ : - - - -(~~ . GJ Þ . - -.. . ~~~ - - : : - - : . . :: - - : . ~ . ... .. - .. .. ... ... .. .. ... .... .. .. .. .. ... .. .. .. .. ... ----- .. .. ... .. ... .. .. ... .. .. .. ... .. .. .. .. .. .. ... OIl ... .. .. .. .. ... .. ... .. .. .. .. .. .. ... .. .. .. .. .. .. .. ... ... - ... .. .. tQ~~(9 .. .. ... .. ~~~~ - - -- ... .. .. .. .. .. .. .. .. .. .. - - :-l £:j~ .. .. .. .. ----- ... .. ... .. .. ... ... .. ... ..---- - - : : ùO: tt - ~ . - .. .. ... .. ~ :~ g~~ ~ .. .. .. .. .. .. .. ... .. ... .. ... ... .. .. ... ... .. ... ... .. ... ... ... .. ... ... .. .. .. .. ... ... ... ... ... ... .. .. .. .. .. ... ... .. - : .,: :[J- :;: - - - - - - - - -(,..? --- -- - ~tj:¿ ~---~ ---- -- - :ä 0- : - : --r - - - \Þ: - ..... ....... ... ... ... ... ... .. .. .. .. ... ... .. ... ... ... ... .. .. ... .. ... .. .. .. .. .. .. .. .. .. ... .. ... ... ... .. ... - ... ... ... - ... .. ... ... - - .. ... ... .. ... ... .. ... ... ... ... ... .. ... ... .. ... ... ... ... ... ... .. ... ... . .. ... ... .. .. ... ... .. .. ... .. ... ... ... ... ... ... .. ... - ... .. .. ... .. .. ... ... .. .. ... ... ... ... ... ... ... ... .. .. .. ... .. .. .. .. ... .. ... ... .. .. .. ... .. ... .. .. ... .. .. .. ... .. ... ... ------ .. ... ... ... .. .. ... ... .. .. .. ... ... .. ... ... Date map was dmwn: I I~ 0 l¡ Instructions If you already bave a diagram tbat sbows aU required information, you may include it, rather d= this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identtify locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, splll containers, or other seeondary containment areas; mecbanical or electronic line leak detectors; and in-tank Uquid level probes (if used for leak detection). In the space provided, Dote tbe date this Site Plan was prepared. Page 4 of4 05/00 .'~.- .----.-.. "" \,JE"STAR (55~77-0106 p. 1 ., .,) Jul 16 04 09:36a ",H:~ 0 e:. "a'PEI~ . ~"I&I!~2HI'~h¿; . ~~.... WES·,r;:r: "·5,,' TAR ~;~~:.: ,,', . . EN'ffiaøNì.SNTAL"IN,C." SALES - ~~~~~~~";, SERVICE 46~8 W. JENN~~;,~~;t~~(fR~NOr CA. 93"7~2 (559l27!~¡l~f. ."9}.,~77-o106 ,~tIc. '#'A-H å~l.······· i~'''~~: ,f? .1EVOt;R ~PEJ~ ~Jn¡;J s-........nr 11f>'" . , FAX COVER LETTER DATE: 7/ìú./o~ TO.: '21J'i (Y\<},'1 () (Z.() 0 r leu e L.. . . . COMPANY~ h/'(:;- PdF . FAX NO: ÚJ(p{- 9,r2- '2-li 1 FROM: ¡?/ltl,tÁ~ Ae:-/1/J/2i'''Y , NUMBER OF PAGES (INCLUDES COVER SHEE)-: REfERJ;NCE: .1ft?/). ,nC4//¿,./Wlf ,J~ ...-~ '/ - ~' ... / "</ ' ,b7yLr~ ~ ., TIME SENT: )0-( Ltc) 1}/1 . SENDER: ~ , .. N~OFTBSTlNGCOMPANY W,¿J'( ) íf\L CONTRAcroRS UCENSE #. CoO ~ II..( L NAMBAPHONBNUMBEROFCONTACTPBRsoN .r-:-N- 277-c;J7r;J f'/flw,¿::' ~Aløw4~., DAm & 'I1ME'IBST 1S TO BB CONDUCtED ~lrl.f:;;L'1 C1 - .. [~ ?!?!Q'T !:~~ 7jJ(ö1- . ~Lf DAT.E Tt1RB OF APPLICANT Jul 07 04 08:28a ~~I U7 2002 15:21 \,JE. STAR B~~fLD FIRE PREVENTION \' (55'277-0106 (GG!J..B52-2172 .' ¡().~(. 11 ..."0' /N t'Yl. vll 0 (If rn \ f!-oO¡tl C;uc'Z . CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakerst1eld, CA (661) 326-3979 APPLICATION TO PERFORM ('A+ \ ~ FUEL MONITORING CERTIFICA TlON~.'L- tJ.,) , v "" (1 \ FACJLlTY QÙtC-lc.. ·,SroçF.¡J;, (72-:1' ADDRBSS lOt J ('\ 1<.>:I't A\J ~ OPERATORS NAMB_Q~tC.iC. S ru p¡G I ffirlC:... (ý) OW:NERS NAME \ \. \ , NAMEOFMONITORMANUFACTURÐR. \J~ DOES PACILlTY SA VB DISPENSER PANS? YEs?,- f5o'f... {l..cc)·r NO_ C' VOLUME . 2ú{ û(Ä~ t0lo(.,..0 (~, Oc....q CONTENTS (i A.j ,... ¿; 'ì ~1lS - '7 ,. (JIIEJ,¿L TANK # i 'Z. 1 t p. 1 p. 1 fiRE CHIEF ,'')1'1 cRA.ZE ADMINISTRATIVE SERVICES 2101 "H" street Bakersfield. CA 93301 VOICE (661) 326-3941 FAX (661) 852-2170 SUPPRESSION SERVICES 2101 "H" Street Bakersfield. CA 93301 VOICE (661) 326-3941 FAX (661) B52-2170 PREVENTION SERVICES fiRE SAfETY SERVICES' ENVIRONMENTAl SERVICES 900 Truxtun Ave.. Suite 210 Bakersfield. CA 93301 VOICE (661) 326-3979 FAX (661) 852-2171 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield. CA 93301 VOICE (661) 326-3951 FAX (661) 852-2172 TRAINING DIVISION 5642 Victor Ave. Bakersfield. CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 - - June 10, 2004 Jack- In-the-Box 10 Union A venue Bakersfield, CA 93307 REMINDER OF NOTICE OF VIOLATION & SCHEDULE FOR COMPLIANCE Dear Owner: Our records indicate that your annual maintenance certification on your leak detection system will be past due on 06-17-04. You will be in violation of Section 2641 (J) of the California Code of Regulations. "Equipment and devices used to monitor underground storage tanks shall be installed, calibrated, operated and maintained in accordance with manufacturer's instructions, including routine maintenance and service checks at least once per calendar year for operability and running condition." You are hereby notified that you have thirty (30) days to either perform or submit your annual certification to this office. Failure to comply will result in revocation of your permit to operate your underground storage system. Should you have any questions, please feel free to contact me at 661-326-3190. Sincerely, Ralph Huey Director of Prevention Services bYA t£iurJ(] Steve Underwood Fire Inspector/Environmental Code Enforcement Officer Office of Environmental Services SBU/db "rf};PI1Ù~r¡ ¡Iu) Y;;;J/lIIlIW/}lf.!;Y Qjf).,r (î 1/(lllf) d:lhrw OÇ(~/}uffl,rJ/» M8~ 24 04 11:188 \,JEST STAR OCT 07 2002 15:21 BKSFLD FIRE PREVENTION (559)277-0106 (661)852-2172 p.2 p. ¡ , CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakerstiel~ CA (661) 326-3979 APPUCATION TO PERFORM FUEL MONITORING CERTIFICATION FAcn.rrY. dUlC-1c.. ,'5tuÇF d:- '772-J ADDRESS 1 (..3 l) (\ l <J.^a A\J r:::: OPERATORS NAME Q'-.H Ck:: cc) ru ¡:;,c ¡ T"Ar JL.. I y') .ß 0]<... OWNERS NAMB. ' \. \ ' NAMEOPMONlTOR.MANUFA~~ fLc..,u', DOES FACILtrY HAVE DISPENSER PANS? YEs-?,- NO_ ( TANK # i 2- '1 VOLUME 2.0( DG<:.> l c..:, 0 c..- 0 L (....., o~ CONTENTS GI4,5 -S'ì ~A:S - '11 01 t.::J EL NAME OPTBSTING COMPANY W (63 r CONTRACfOItS UCSNSE t. C9Ú-r- (4 L NAMB&PHONENUMBBROFCONTACTPERSON rS""í- 2.77-9J7õ) Pllltu¡t? "AI~4¡"1 DATE & TJME TEST IS TO BE CONDUCTED Iß 11110"'" 6~;) 04,,</J <Jl£~r;{) J TfìL ( APPROVBDBY ~/ ~/f) V , I DATE ----- -....-.- JACK J N THE BO:>: 10 UN I ON f\\,/E. BAKER~3F 1 ELD. Cf~ . JAN 15, 2004 9:31 AM E;\'~3TÐ'1 E;T¡:"TUb REPORT - - - - - -. - - - - - - ALL FUNCT 1 CoNS NOHr"lAL I _'JTOR'/ ¡'::EPORT T 1 ~ L.Jt...tl ,r.:,..:;..r:;.¡;:J:~ V'O'LUMl: - 1 1 qOO r:1MLO ULLAGE 8235 GALS 9U~: ULLAGE= ¡:,:ë'64 GALE; TC VOLLlt"IE = j 149fJ '_;AU:; HEIGHT 65.81 INCHES sn: HE I GHT = 65.81 Ll'JI '1-iF~:; [.,JATH: \lOL 0 GfiL_: LJATER [j . DO i NCHD:; TEMP 56.2 DEG F T 2: PHEI"1 lUl"l \/OLUI"lE UUiiGE '30\: ULLAGE'" TC 'v'OLUHE '" HE IGHT sn: HEIGHT= l,JATEF: \lOL LJ~: T~ T 3: D I E~3EL \lOLUI"1E ULLAGE 9œ~ ULLAGE= Te \/OLUr"IE = HEIGHT sn: HEIC;HT= l..,.IATER \lOL l.JATER TEJ"lP r:,211 I~;ALS <1158 GALS :3121 GALE 6196 GALS 67.11 INCHE:3 t,7 . 1 1 I NC HEf:; (I GALB 0.00 INCHES 6:3 . 4 DEG F <1207 GAU3 2822 GALS 2]19 GALS 4198,:;ALS 68.0'3 I NCHE:3 68.09 I t~CHES o GAU3 0.00 INCHEf:; 54.8 DEG F ~ ~ ~ ~ ~ END ~ ~ ~ N ~ · eR UNIFIED PROGRAM IW'SPECT~ON CHECKLIST ~:'rE'~~~~~;:::;;:;:;:::,::::~~~~~·;:u1t:;:~~,;;-.:t.~,:S;;;¡C:Zg-'J:t,¡.:~z..;~~'%;;.~!;;:.á~~-::r.:Þ-~\R~~~~~V::;:^" SECTION 1 Business Plan and Inventory Program Bakersfield Fire Depft. Enironmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 F:~~~~_Lttl~__ßf)j,________u________________u______u_ __ __ _ __mnn ADDRESS l1L_1Jt110-tL_____AlL~__ _________________________ ____ ___m____ FACILITYCONTACT INSPECTION DATE INSPECTION TIME -- .--..-...---.--.-.--- I-'~I{ PHoNe No_-- ----- No_ õïi~~'OYãès----- ~i.l_____u_____u__m Business ID Number 15-021- ·_____.______u__~_ __ Section 1: Business Plan and inventory Program (j Routine ~Combined a Joint Agency LiI Multi-Agency LiI Complaint 01 Re-inspection c V ( C=Compliance ) V=Violation ~ ApPROPRIATE PERMIT ON HAND ~--~~~~~~-;;'::N ~~~~:~~-INF-~~~:~~~-:~~UR:~~- - ------------- --- - --- - - -- -- ~--~_~~IS;~~-~~~~~~~~~~~--~-~n-~-~--:=~-n ~~~~~~-nn-_~_:~:~~~ ---~~--_~~.-_- ~~~_~_~-._~----n - _n__ ro./D CORRECT OCCUPANCY t ~-~-~E~~~:~~~-~~--;~:~~~~Y :~~~~;:~:------m-------~--- n ___n______~______ ~-~-_._._-----'--------~--~-------------~---_._--~-..__. .----_... .----------.. -----.- --".-..-..---- - - -.-.-..-----...--- - - -.--- ..._...-.-._- ~D VERIFICATION OF QUANTITIES ?r;n--VE~~I~~~I~~~~~~~~~;~~-- ------ ._._~~~__n__________ .-.----------~---- n n__mn___u_~__~ __n ~--- PR~~~~-~-~~~~:T~~:-~~~~~~~:L---------- ------~ __nn__ ____n___n __~___nn .- -- __n_____mn__nn________ - ?~- --~~-~~~;~~IO~~~-~;~;~~~~~-~ILlrf~-~--u ~_______n_l-m- ___u. ·u__n__ --- - ------- __n_________ ~--VERI;~~~~~-OFHAT M~~-~~I~I~~-- . -------------- n--l--- _~__m_______ _ --------------------- 7Du-V~~~;I~~TION ~;~~~~~~~;~U~~~I;~~~~n;~~~~m~~RES-n------- -. ------ .- n___________________ -C7~---~~~;~~~-C~ PROC~~~~~; AD~QUA~~--------·- ___n_ un ·___n________n_ - -- _______________mn___ ~---C;~~~I~~~S P-~~~~~~~-~~~~~~-u. ------------------------ n ________u___ ----- ___u_ Un _n___________ n___ -C7rJ-~H~~~~~~PI ~----------- ------~ --- _____u __un - _____nl__ .- ---- _n__.. -. . ..------- . u_ .___n_______nu_______ --7:.---n-------------------------------n------ ---------_ ~___n__ ___ ----t----------n- ð 0 FIRE PROTECTION ©~[ERA1~©N C©MMEIMTS - -.-.-. _..--._-------------_.~~._-_. -.- .---.- -- --------....-...-...--- "--'- ---.. .. ... __ ..._ _______.__" _.u·_.___ ____n"·______._._...___.._..__··· .- ---~--,...._.,---- .------.-... _._-.-- __._n____ ..______ .-..-.------.--.-----.----.---.--- -_.~~-----_. ------_._.~------ -- ._._~_._-- __._________.__n._~_..__ __.._.n_. _.__.. _._.___.__._._._ __.~_ _.______n_.___~.. Li/'6 SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE?: LI YES ~No EXPLAIN: aUZGARDIN THI I ~CTIDN? PŒASE : U~= (66~ :26~3979 Inspector (Please Print) Fire Prevention 1st-In/Shift of Site '0."""",,, "'~ * ~ White· Environmental Services Yellow - Station Copy Pink· Business Copy e CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd FHoor, Bakersfield, CA 93301 FACILITY NAME --..\ d.(lL (N ~() 't INSPECTION DATE 1-lq~(J1 Section 2: Underground Storage Tanks Program o Routine ¡:JCombined 0 Joint Agency Type of Tank nU)F Type of Monitoring c:' L tv\ o Multi-Agency 0 Complaint Number of Tanks -, - Type of Piping tQuJ F ORe-inspection OPERA nON C v COMMENTS Proper tank data on tile L / Proper owner/operator data on file '-' / / Permit fees current - / Certification of Financial Responsibility \...- / Monitoring record adequate and current ./ Maintenance records adequate and current ./ --- Failure to correct prior UST violations / Has there been an unauthorized release? Yes No f / \.J'" Section 3: AbovegB"ound Storage Tanks Program TANK SIZE(S) Type of Tank AGGREGATE CAPACITY Number of Tanks OPERA TION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MYF? If yes, Does tank have overfilI/overspill protection? C=Compliance Y=Yes N=NO Pink - Business Copy Inspector: Oftìce of Environmental Services (805) 326-3979 White - Env. Svcs. s Site Responsible Party ,;'- l~ \.......\; ...'./' - ---.e- . ~ l\'IONITORING SYSTEM CERTIFICATION For Use By All Juri:;dic!Ïor/$ Within dze State afCalifornia A¡!thority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, DiviY¡'on 3, Title 23, California Code of RegulatiolZS v';' Tnis form must be used to document testing and se:vicmg of mouitoTIDg equipment. A senarnte certification or report must be preoared for each motri~rine svstem control pane! by the te:::hrJcian who peñorms the work. A copy of this form must be provided to the tank system owner/operator. The owne:/opc:ator mwt submit a copy of this form to the loeil! agency regulating UST systc.:ns within 30 days of test date. A. General Infonnation Facility Name: Qv,'cl£:..- S.. .-..J r-¡; Sire Address: if) u ni' åû1 /Â/e. , F acHity Contact Person: Evvl'" '::j MakeIMode! of Monitoring Syste:n: \J ~'('!Å~ 'l 1/.-0<:\ i- B. Inventory of Equipment Tested/Certified Check tIIe:1 :£~~~~~I'?te s ec:ifie ui ment iM cctedlscryiced: Tank ID: €r '7 Tank ID: tt I œ'-lo.-T;mk Gauging Probe:. Mode!: V' ~·"t'c;I·a f2~ T. --c : 121 In-Tank. Gauging Probe. ModeJ; Ii ~:~d"r (loo I- ~ ~ AIUJUlar.Spacc or Vault Sensor. ModeL:;" " Qi Annular Space or VauJt Sensor. Model:" '" ~ Piping Sump I Trench Sensor(s). Model: \, " ts Piping Sump I Tre."1cb Sensor(s). Model: \I /" a Fill Sump Seosor(s). Mode!: 0 Fill Sump Sc:nsor(s). Mode!: o Mecl1anic:1l Line Leak Detector. Model: 0 Mec.J¡¡¡nical Line Le:ùc DeTector, Model: o E!ec:ronic tjne Leak Detector. Model: 0 ElectrQnic Line Leak. Detector. Model: o T:mk Overlm I High-LeveJ S<!%Isor. Model: Is (.j, JI ;::::-1 a'ì r 0 Tank Overfill/ Rigb-LeveJ Sensor. Mode!: t1 A. /I ~ J O<~ .J- o Othe:- ed eoui ent e and mode! in Section E on pa,ge 2). 0 Other sce~" e ui ment and model in Section E on Pa c 2). TllukID: rJ~.I'~ll'£..-l - T:JDkID: a¡¡ ill-Tank Gauging Probe. Mode!: \/ -e.>C!.~>G.(' (LM-t Q In-Tank Gauging Probe. Mode!: ~ Annular Space or VauJt Sensor. Model: '-\ I' 0 AnDular Space or Vault Sensor. Model: Q9 Piping Sump I Trench Sensor(s): Model: \' " 0 Piping Sump I Trench Sensor(s). Model: o· pm Sump Sensor(s). Model: . 0 Fill Sump Sensor(s). Model: o Mec!lanic.a1 Line Le:lk Detector. Mode!: 0 Mechanical Line Le:llcDetector. Model: o Elccttonic Line Le:Ù<: Detector. Model: 0 EiectrOnic Line Leak Detectct'. Mode!: r) Ta.nk Overfill/ High-Level Sensor. Modc:l: ß... JI fltJ",,/ 0 Ttlnk Overtil1/ High-Level Sensor. Mode!: CJ Other (st)e~i mc:nt t c and model in Section E on P;u¡-c 2), Q Ot,;er s eei e ui t ,:md model in Section E on !'~~ 2):-- I Dispenser ID: '/2- DlspeDSa'ID: "311J , ~ Dispenser Containment Sensor(s). Mode!: \) ~.t'ë'-e.," r2c:;o ¡- I Ø!J Dispenser Cont1!inment Se:¡sor(s). Model: ~f.f:-.ß..Gi:Ú::..- Q!I Shcar Valve(s). ø Shear Valve(s). Opisoenser_Çonrainme::t Ftoar(s) and Chain 5). 0 Disuc:¡¡¡e:- Conmipment Float s) and Chain(s . Dispenser ill: :r I ¿ Dispe~ ID: .., 1ft t5!I Dispe:lserCuntainmentSensor(s).. Moàel: Vf.~¡J..-e.( ¢.o~ ~ Dispenser Conwnment Sensor(s). Mode!; L'~.-rJ·u (2ré1r ':' ~ Shear Yalve(s). Iji Shear Valve(s). o Di enser ContJrinroc:nt FJoat(s) and Chain(s . 0 Di enser Containment Float 5) :md Chain(s). Dispenser ill: '7 //t:' D:speDsc:r ID: I' /, 2- fiZI Dispenser ContaiDrrÍe.:1t Sensor(s). Model: \I-e.~Il-e.( f.l!:Ot \ß Dispenser Coorainment Sensor(s). ModeJ: V ~<.,4-t( (l C'e)~ i Çi ShearValve(s). . a Shear Yalve(s). ODiscenser Contaimnent Float 5 and Chain(s). 0 DisPenser Containment F!oat(s and Chllin s). ·If the facility contains more tanks or dispensers, copy this form. Include infonnation for ,every tmk and dispenser at ~e ·facility. C. Certification - I ca:rtify that the equipment identified In this document W~ inspected/serviced In accordance with the m:t.Qu(acturers' guiddjnes. Attached to this Certifkatio» is information (e.g. manufactµren' checklists) neasSary to verify that this ÎÞ(ormanoD. is eorœct :Iud a Plot PIAn showing the Jayol1t of mouitoring equipment. For:my equipment caPable of geD.er:ltiDg such repom, I have also 1I~~bed 21..'UPY o~the report; (cJ¡~dc ail tJlatapply): a System set-ùp Q Alarm history rep~ TechnicumName(pnnt):¡rtY;hú.:!.I Á/t u,r/J/~ Signa~: /1--t---;:P" #~- Certification No.: Iic~. No.: T ..:sting Company Name: t..J't?sf sk, r Site Ac;iàress: ¡ C IM:r brJ IJ.ve #= '771< Bldg. No.: City: 8ø." t·"~ I~ ''E /çII e/l Zip: Cantle: Phone No.: ( ~ 6 I ) S'r:' I ~ C'.S'LI 1 Date ofTestinglServicing: V..1.l..!..Ql. .t3L.\. b~tS {,Ill'''' , CA. Phone No.:')" 5- ~) '2- ì 7 - ~5 7.g- Date of Testing/Servicing: -'-1-.1.2/...123 Page 1 00 03/01 Monitoring System Certification Z"d 90To-¿¿Z(6SS) èllHS 1.S 31'1 t'èll::I is ',1::1 eBS=BO £0 60 tnt .. e - ':"'" D. Results of Testing/Servicing '-:;. Software Version Installed: ¡ , I 0 Ye:¡ Complete thefol1owiD~ dtec!dist: ø Yes 0 No'· Is the audibLe ala.rm 0 ~tiona1? Yes 0 No* Is the Visual alaxm 0 erational? \!1 Ye:¡ 0 No" Were ail sensors visually ÏI1specteå, :functionall tested. and confumed 0 era.tional? ~ Yes 0 No* Were aU sensors mstal1ed at lowest point of õecondary containment and positioned so that other equiplD.I:n1 will not interfere with their pro er' et'ôltion? o No* If alar.n15 are relayed to a remote monitoring station, is ail communiC~l1:ioDS equipment (e.g. modem) ~ NI A operational? o No'" For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment o N/A monitoring system detects a leak, faj1s to operate, or is electrically disCoDIlected? If yes: which sensors initiate I positive shut-down? (Check all that apply) I) Sumpffrench Sensors; ~ Dispenser Containment Sensors. Did au confum ositive shut-down due to Jew and sensor fail~disconnection? Yes; 0 No. . o No" For tank systems that utilize the monitoring system as the primary tank overfill warning deviœ (i.e. no ~ N/A mec.!1anical overlilI prevention valve is iDsta.Ued), is the overfill warning alarm visih!e and audible at the tank ' fill omt(s) and ° e¡:a . ed ? Ifso, at what ercent oftmk ad does the alarm tri er? % 9Q Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced . and list the manufactl.1rer name and model for all renlacement s in Section E, below. Was liquid found inside any secondary contaimnent systems designed as dry systems? (Check all that apply) 0 Product; a WatJ:r, If es, describe causes in Section E, below. , 181 Yes 0 No* W-as monitorin stc:h set-u reviewed to ensure r c:r settin s? Attach set "Yes I:J No" I Is all monitoriDo e ui meX1t 0 erational per manufacturer's cifica:tioDS? '" In Section E below, describe how and when these deficiencies were or will be cOlTeded. , r I , I CJ Yes I ~ Yes DYes'" No :J Yes'" ~ No E. Comments: Page 2 oC3 03/01 £·d 90tO-l.l.2(SSS) ~~iSLS3M/~~LS'ì~ e8S=80 £0 SO tnL .. e e ~. , ..-----.. .-- ,{ F. In-Tank G~ãlg1ng / SIR Equipment: ~ Check this box if tank: gauging is used only fer inventory control. D Check this box if no tank ga.uging or SIR equipment is in£uJIed. This section must be cornpieted if in-tank gauging equipment is used to perform leak detection monitoring. c h cldi om'Ølete the fÐllowjn~ c e st: ~ Yes o No" Has all input wiring been inspected for pr:oper entry and termination. inclllding testing for ground fuults? 9D- Yes o No" Were aU tank gauging probes visually i:nspected for danmge and residue buildup? ~ Yes o No'" Was accuracy of sy~¡tem product level readings tested? : !D Yes o No" Was accuracy of system water level readings tested? I ~ Yes o No" Were all probes refustaJled properly? . ~ Yes o No* Were all itc1ns on the equipment manufucturer' s mamteDance checklist completed? ! * In the Section H, below. describe haw and wben these deficiencies were or will be corred:ed. G. Lme Leak Detector.:; (LLD): Js Check this box iflLDs are not installed. Comnlete the foUowme: checklist: CJ Yes a No" For equipment start-up or annual equipment certiñcation, was a leak simulateå to ver.J'y LID performance'! o N/A (Check all that apply) S:imul:lt¿ leak rate: Q 3 g.p.h.; Q O. I g.p.b.; [J 0.2 g.p.h.. o Yes o No* Were all LLDs cODfirmeri operational aDd accurate w:it1ùn regulatory requircmeIlÍ3? -- I o Yes o No· Was the testing :lppamtus properly calibrated? ¡ i q Yes o No· For roecblUÙcal LWs, does the liD restrict product flow ±fit detects a leak? Q N/A a Yes o No" For electronic LLDs, does the turbine automatically shut off if the liD detects a leak? o N/A o Yes o No· For electronic LLDs, does ilie turbine aUI0IIJ¡lticaily shut off if ¡my portion of the monitoring system is disabled o N/A or discoDIlected? o ¥<:s 0 No· For elecÍl'onic LLDs, doc:! the OIrbine automatically shut off if any portion of the monitoring system. :m1functions o N/A or fails a test? o y <:5 o No· For electronic LLDs, have all accessible wiring cDDDecrions been visually inspecteå? o N/A . DYes o No" Wr:re all items on the equipment manufacturer's mainte:nanœ checklist completed? . i ... In the Sectioø R, below, describe how and when these deficiencies were or will be corrected. B. Comments: .Page 3 of 3 OJJO 1 'Þ·d SOYO-¿l.Z(SSSJ èll:llS1S31'1I'èlIHS"1:I e6s:ao EO SO tnL ~ e e '___u__ ).1'- . :; l\'Ioo.itod:tig System. Certification Sire Aàdress: 10 v~c '\ UST lVlonitoring Site Plan A\J~. ß&1.It'~,-.;I"I'Ek(. CA. , o ?/r. C) \I-e1'qS' . }: é~: ETI . . . . . 'w,'!~' . . . . . €?) . J : 3: ~I ï: ~ I I. f . B [ill B . ., , , · · · · · · " . ST 0 ~ t:: · ". · . . · ~ /J-( I?: .r :A1 . · . . · . r f+~-;; : ~:dj . . . E8 B Date map was dnwn: ---..-! _/ _. Instructions If you already have a àiagram that shows all required inÏormation, you may include i¿ rather than this page, with your Monitoring System ,Certifica.tion. On your site plan, show the general layout of tanks and piping. Clearly identifY locaiions of the í01l0w1Dg ~uipment, if instalIeà: moDitaTing system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or ather secondary containment areas; mechanical or electronic line leak derectors; and in-tank liquid level probes (if used for leak detection). In the space provided, note the date this Site Plan was prepared. Page _of_ 051110 Sod 90TO-¿¿Z£SSS) ~~~S~S3M/~~~S"~ ess:ao EO SO Tnt ~:t ~ 11]:t :~'MI:1.:t.::8".1 E-...."'f =ct).C'I~ . Complete items 1_nd 3. Also complete item 4 if Restricte~iivery 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 mailpiÉite, or on the front if space permits. 1. Article Addressed to: A. S AttfIN TH X lBOAAVE. B. Rß'ANcQt6GØv~þ¡a,Q2 o Agent o Addressee C. Date ~ff3elivery ~ . D. Is delivery address different from item 1? 0 Yes If YES, enter delivery address below: 0 No PAUL DENEKA JACK IN THE BOX 9330 BALBOA AVE SAN DIEGO CA 92024 3. Service Type IX] Certified Mail o Registered o Insured Mail o Express Mail o Return Receipt for Merchandise o C.O.D. 4. Restricted Delivery? (Extra Fee) DYes 7002 3150 0004 9985 3059 PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-154C UNITED STATES POS"SERVICE . st-Class Mail tage & Fees Paid PS Permit No. G-10 .- · Sender: Please print your name', address, and ZIP+4 in this box · Bakersfield Fire Department Prevention Services 1715 Chester Avenue, Suite 300 Bakersfield, CA 93301 \~ \\1\ III 1\1." 1\, 1\ IIIIIIHI\ I \1' 1\1 \ 111\\ \\11\1111\1\ \\ \1\ 111\ a- Ll') a m Ll') t:Q a- a- Me®" ~O ~ [?[]~[Q) [M]B10~ ~~©~OlPiJ GfM/]~{j[J:i)~~~ ~1'fuíIl€!m~@ß OFFleiAl USE .:t' a a a Postage $ Certified Fee PosImlllk Retum Reclept Fee Here (Endorsement Required) Restricted Deßvery Fee (Endorsement Required) Total Postage & Fees $ a Ll') M m ru a To c:J PAUL DENEKA I"- 1%8ëf.'APCiVO:¡·············..·····························_···...................... or PO BøxNo. 9330 BALBOA AVE ëï6;..štätë;'z¡¡:¡;¡............._.............-.........................--......... Certified Mall Provides: e II! A mailing receipt (9SJ9A9/:J) ¡¡OO¡¡ 9Unr WJ0:l Sd I!j A unique id.entifier for your mailpiece Ii A record of delivery kept by the Postal Service for two years Iml'ortBnt Reminders: . I!'I Certified Mail may ONLY be co~ined YiìUT First-Class Mail® or Priority Mail@. I!iJ Certified Maills not available for any class of International mail. I!i NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. I!! For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Retum Receipt service, please complete and attach a Retum Receipt (PS Form 3811~ to the article and add applicable postage to cover the fee. Endorse mailpiece 'Retum Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USP5O:Þ postmark on your Certified Mail receipt is required. BI For an additional fee, delivery may be restricted to the addressee or addressee's authorized ag.ent. Advise the clerk or mark the mailplece with the endorsement "RestrictedTJelívery". ¡;¡¡ If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt Is not needed, detach and affix label with postage and mail. IMPORTANT: Save Ihls receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. - . FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "HO Street Bakersfield, CA 93301 VOICE (661) 326·3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H· Slreet Bakersfield. CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAFETY SERVICES· ENVIRONIlENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326.{J576 PUBLIC EDUCATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 32&-3696 FAX (661) 326.{J576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 32&-3951 FAX (661) 326'()s76 TRAINING DIVISION 5642 VIctor Ave. Bakersfield, CA 93308 VOICE (661) 3994697 FAX (661) 399-5763 '. e jò .."-' '" ';' March 19, 2003 Paul Deneka Jack in the Box 9330 Balboa A venue San Diego, CA 92024 CERTIFIED MAIL NOTICE OF VIOLATION & SCHEDULE FOR COMPLIANCE RE: Failure to File a Business Plan Dear Mr. Deneka: Enclosed, please find a Business Plan and Chemical Inventory. This office has never received a Business Plan associated with your underground facility at 10 Union A venue in Bakersfield California. You are in violation of Section 25505 of the California Health and Safety Code for failure to file a Business Plan. To avoid further enforcement action, you must submit the enclosed packet within 30 days, April 19, 2003. Should you have any questions, please feel free to call me at 661-326- 3190. Sincerely, Ralph E. Huey Director of Prevention Services bJ¡ (~ Steve Underwood Fire InspectorÆnvironmental Code Enforcement Officer Office of Environmental Services SBU/dc enclosure "" SC~ &fe W~ S7eve .A~ ~bt, ..Æ W~" I<~ ~ , - e CERTIFICATE OF UNDERGROUND STORAGE TANK SYSTEM TESTING 1-. 'DInIcnoIogy 8900 SHOAL CREEK. BUILDING 200 AUSTIN, TEXAS 78757 (512) 451-6334 FAX. (512) 459-1459 TEST RESULT SITE SUMMARY REPORT TESTDAi6; 12/18/02 TEST TYPE: p'fK-88 CUSTOMER Þo: PURPOSE; eOMPL~CE WORK ORDER NUMBER: 3126762 Cl.IENT: JACK IN THE BOX :me. 9,g30 :eN:.BOA AVE. SAN DXEGO, CA 92123 S~E;JACK IN TQE BOX #7723 10 'UNION AVENUE BAKERSFIELD, CA 93307 RICK PEPPER (858) 571~2463 JOANNA MAnIS (661)861-0543 The following test(s) were; conducted at tbe site above in accord31'lce with all applicable portions of Federal. 'NFPA and local regulations o Line and Leak Detector Tests ,0' -w:;;-"--,,.., I .,-, '''' "," '" I' "]:.!í'Y:,,,\,, I' ".;-,-- ,- ,,'. "'<;¡¡l='" ,,','1"," ~r;;;ST'" """"--'1'''' ," I'-~""" Ir~;¡;iµr=' ''''Ji!i1I'' ""''''''''''''''',' :i,:· \?",~\:.hi?:,::,: . ,!' "¡',!,:~ i:;I~~;>: ~'::: )':¡,\:, : ',:',:,..:,:''::',: ~::: ;,,:,,:~~:,\: i:\,:';ff,·f~f:::::';.!::;/:),K::'·:: l:i\IYI!::~;:;~:!~~i:?A:J{' ,!,:,/Wi~;:': .:i:::~,~,!I, ~q,·~~:t~:~::~¡¡I¡:i:'::!;;¡:"'i:~~fl~ ;1~jT ;'" "':"1')=1"."", ' ,"':- "', ,.',.i,. I: ,,:...", :':: .'" ',;," ,:,AI';(..l.;, '",,:,k¡;!': .,,1 ,L \I, :":,I;.....;¡h,too."~:,, ,.A"!=-,,." \ :r,~;,:":,:·",.'\,'rie~I:\mll",:,.-,, ':1 II¡', I, "":.,~";.,:,~,,,:,, :' 1,1"" ": ,,':1.1.:, ¡',', ..:: ~':.;" ':,\,:~:' ,:~ "",,,:..:II~-,..,;'.:,:, '\.;';':-.' ":"~' ","~'<' ',;~\:.:, '! ¡'}f¡ ':':,:'~:~1~1\t:"I~gy~ .it :20k 1 m:GULAR 10k 2 PREMIUM 7k 3 DIESEL TankDology appreciates the opportunity to serve you. and look, forward to working with yOu in the future. Please call My time. day or night, when )'Ou need us, Tanknology representative: KEN MINTON Test conducted by: WESI.EY COULi'ER /L +r ~ Ø?Ø Reviewed: Technician Certification Number: Printed 03113/2003 07:58 KMINTON ~OO~ lsao~ J1n5-~o1o~U8L 991L09~61~ XVd to:11 aKL ~O/~t/CO ", e e ~. 'IIInIcnc*Jgy 8900 SHOAL CREEK. BUILDING 200 AUSTIN. TEXAS 7ß757 (512) 451-6334 rAX (512) 459-1459 TEST DATE:12/18/02 CLlI;NT;JACK IN TIlE BOX mc, WORK ORDER NUMee:RJ126762 SITE.:JACK IN THE BOX 17723· COMMENTS Arri'Ved. on .:Lte at 8:00 A.M. £o~ CA 1:e9 SB-989 secQnd.iI:y contai.DIQ8Di: i:eating-" Two tank e.nftl.!lal:8 - both paaaed. Thl:88 pip.:l.ng i~teZ'8ti~ala - all passed. Th%'oe S'l'P I!n.DDP" - all passed. '1'hrèe fill vamps - all paSBeQ, Six ~apan$eZ' pans - all p~""ed. One fu11 drum left Dn site. PARTS REPLACED 1 ' - 85 Cl\LLaIf D1W)II HELIUM PINPOINT TEST RESUL T8 (IF APPLICABLE) ,!~i' Printed 0311312003 07:58 KMINTON 1:00 III lsa03 ¡Tn~-~oTo~uaL 99TL091:ZT~ XVd ~O:JT fiHl I:O/l:T/I:O e e SITE DIAGRAM ~. 'DInIcnøIøgy 8900 SHOAL CRE:EK, eUILOING 200 AUSTIN, T~XAS 78767 (512) 451-6334 FAX (512) 459-1469 TEST DATe: 12/18/02 ClIENT:JACK IN THE SOX me. WORK ORDER NUMBER3126762 SITE: .mCK IN !l!HE BOX 1772:3 lð JACK-IN-THE-BOX ~ C-STORE N #1 if fi i[#5 tI2 ff #1 T " #12Jt11 #8 JJ:1 #4:IT#3 § < m Z <ri Reg @ 17k@ ~ @ STP DSL Prem 7k 10k Prlntéd 0311312003 07:58 KMINTON tOO III ¡SBOJ Jln~-~olo~ua~ 99TL09CZTg XVd gO:TT ilHl CO/CT/CO '. e e Summary of Site Data Critical Data Survey done by: WESLEY COUl TER Site Name & ID # JACK IN THE BOX #7723 Address: 10 UNION AVENUE City, State. Zip: BAKERSFIELD. CA 93307 Phone # (661) 861-0543 I verify that the information and diagram are correct. rn Yes D No Site Information wO# 3126762 Tank# 1 Tank# 2 Tank# 3 Tank# 4 Tank# 5 Tank# 6 T ank# 7 Tank# 8 Product REGULAR PA,EMIUM DIESEL Tank Size 19703 10369 7029 Tank Diameter 118 118 118 Tank Materilll DW FIBE:RG OW FIBERG DW FIBERG Manifolded (ll< #) Overfill (Type) Ovel'$piU (Type) L.ine Material DW FIBERG DW FIBERG DW FIBERG line Secondary Containmen Y y y Mechanical Leak Detection Stage I (Type) Stage II (Type) ATG CP Site Diagram JACK-IN.THE.BOX C-STORE J N #1if#9 #6lf#5 #2 Jf #1 wte 012 ~1 #~7 ..R.. § ;¡;¡ ~ Reg @11k§ DSL 7k !l00~ 1S80J JTn~-~solo~ua~ 03/1312003 991L09CG111 XVd 110:11 ilHl CO/C1/CO e e Work Order: 3126762 Tanknology-NDE 8900 Shoa] Creek, Building 200 Austin, Texas 78757 900~ 1S80~ ¡Tn~-~otO~U8~ 991L09CZ1~ XVd 90:11 ßRl CO/C1/CO e e Work Order; 3126762 1"ankno1QGY-NDE 8900 Shoal Creek, Building 200 A\Min, Texas 78757 LOO~ 19aO~ Jtn~-~oto~L 9STL09CZTÇ XVd 90:TT ßHl CO/CT/CO e e Work Order: 3126762 Tanknology-NDE 8900 Shoal Creek, Building 200 Austin, Texas 78757 gOO IlJ 19S0J Jln~-~olo~uaL gg1LOg£~1~ XVd 11:11 fiHL £0/£1/£0 e SB..s89 SECONDARY CONTAINMENT SUMMARY RESULTS ~. 7JInIcnoIøgy TEST DA'rl$; 12/18/2002 CUENT: JACK DI ~ 90X me. 9330 BALBOA AVE. WORK 01IDER NO.: 3126762 SITE: ~ ~N ~HZ sax 17723 10 UNION A.VENUE SAN D:J:ECO R~CK PBPPBR 859-571-2463 a.. 92123 BAlŒRSF~ELn CA 93307 Tank Intal'8tital Tests :;....;,! [1'~1'1,:1¡;I'rI\~~r"è·::'fn;¡í~J'!í·,·-"(: ,1- 111'r.MI~r.,~- LI~Wfo-'FIJ'T,.,ln'·lrm1-nl\ 11\~\~'j~ .I,¡IIII), II" ìIT'!1~1',:~1I"I(I, ,\;I~'~" "'Ij~~ ~....t\I..~.,r,1 ,.11\ ¡¡fl~\~:V'¡""" ' ~j¡l".¡~L~¡ " ,,' II"~ / *'\b!\',t! "f"I.j I,,¡I,':,I[I,' ¡, ,"¡;,jl';I'~"', II, \ ,l,,\~.\ "" . ~; ï:~~~: '," ,'.' :I'C' jl('~~I~¡1 j: ':'1"1'\ j; " ~'~~~t:\~1 7 :"1"" I , . ~¡1~ -~.. \'~;.: ,I,t,' ¡ -;"7- '1 , .~: I I; , \;,;~ 1'"1 '~~'l ~ II :;:llr '~ UI ~ ~-;, ¡ t' \~ ~ I '.;, ~,' l~l~ 1,1 \ Ii] " -, 'III _" , ,_ v,;, 'I, l ''''~,~ 1",\' 1', L II I ¡ ~,-'r--" ' ~ IJI,r\I,:, ,I, ,ol II '1',195'1I~_"/ 1"'1':'1111' '1/ I' ¡~1W¡t'! ,r~"'1 ,~) II ""'PI'" ~"I I "11 ¡¡ "(I):' 1,1)1 V'~I'( ",I'~/: ;'I,:'fl" I'· 1,1 ¡: ,-: l"¡ '",' 1rl I" '~I~'~I< :,' j~~'\q .1."'0:'" I' ": (': '/1 I" ';1.. RBGULAR PREMIUM OIESEL XerxBs Xerxes Xer3CGS PASS PASS Piping Interstital Tests ,_~__, 1\,-.""" - -~-1F·~I,·'·-"'I~---:-..,r- '(1)-" "" "~'~ ","'; "' "","."'''' ·'.I:"':-r;nl",,', i 1 \" , ;!~i j, " " :o.)("'\}~>i~ ','., .., d, ",', 1'-, '\1 I ' : '~':,': "" " ' '~¡-!f')~;;~-;';<,' , ',,: :,'" :': ':::"':", :',:":,,;.. :,:'1.' !<':. ~f;~j·;.,.; :,:>::~;:{. ':',', ";,:, , ',:i,< ',.:; ': ':};~:';;:~ï';:-";:' /.: ':,' '::,' REct7LAR PREMIUM tlIESEL Smi th Sm:i th Smith PASS PASS PASS Sump & Under-Dispenser Containment Tests -~_. II' ---~ ,,' ," '''T'i7'-~~'"'' f - ,,-~- ,,' ~""~-,......,~_._-- ,'" . '~r'1'1 ""-~~.n--"",,, .' '-"""-f' "'~""""I ~\ ~'!~;~H";!' ,>,,\\';,\ "I' hl:rot,· I,",,, ")\W'''W I' """'~:1FI \ 1\'1""':";<I'¡¡)I~·j.1 1'\':,\'11' I I"~'", ¡,I',', ''' ':~II'',''', ,~,,~ ",,,~'~f.:I::-:- I J ,~:;,,/ ~:::~.;;I:I!,,~~/i ,II;:, , ,',;ß'~,f?\. :,' " '~':", ,',': ::::::';::, .;, ~L ,:.. ,~" .~,": :,':/ :,: ',:",::, 'i:;,~: <",'. '".:'::;HF ,',:: ,:':, > " '., ::..~>~W~.::':..:':· ','\: ~:'f,',:' .:",~4:';,',::\:'" , ,j~~¡.'I" ~;~:~. "'. 'il-,o· 1.< "" l/"'IUI"' I' 1·,-,·,,1, .,' ',' ". , - ,', '",I" ,\ :r.. ".IJ.I:!. ' '. .d· ,"'-1>" IUJ'I. '.-'>",1 ,n ';;:¡.,,' . 'I'''' L,,'.' 1 >,_.-<::-'~" f,' ,_,_1__~" ' 1'7"'~' , '" I ;' '~:"" "", '.' ': ,,:~',r:, '¡;,;~ ~~<, '''''~)1~~ ',,,\:,,::' '1'>,(" '''",'"" -~': "'I~,,',{r ~:'~" "~~~<~\:¡~, '\:~:i.~I,,' REGUL Xar&as Pass 3/4 !otal (:onb~nt Pass PMMI xa:_ø Pass 5/6 !rota! C~~nment Paas DIllS! XE!IJ:2.. Pasa 7/8 Tð~e~ ContaiDmaat PaBs 1U:GUI. x..ÞI;es Pass 9/10 Tota.l Cont:M.NÞI8nt Pase PREMI Xe~s Pass 11/12 Total CCl"1taiJmlent Pass DIESE xenra!l Pass 1/2 '.fot.aJ. ContaimMmt SlaBs Tanknology representative: KEN MINTON /L -11 ~ Services c;:onduc;:tcd by: WESLEY COULTER ~ 600 III ~9aOJ JTn~-~olo~~ 99tL09&Ztg XVd tt:tt l1Rl tOlttltO SITE NAME: JACK IN THE BOX #7723 JITB 7723 ¡DATE: 11211812002 IWORK ORDER¡ 3126762 SITE ADDRESS: 10 UNION AVENUE BAKERSFIELD CA 93307 REASON FOR TEST: SB-989 Compliance IGroundwater Level(" from aradel: '':f' $jfJi... 4f1P Tånknology SECONDARY CONTAINMENT TEST RESULTS Q c.> " I-' c.> " Q c.> ;! ~ I-' I-' e TANK INFORMATIDN AND INTERSTITIAL TESTS Tank Product Dia. MaRlifacturar Deplh Test Melllod Start Initial Finish FtnaJ Paw raJIk S1ze (.) MsJar1a1 (" } Time lfl81 TIme RBSult Fail 1 REGUlAR IWOG 116 DW FIBERG xerxes SB Vawum 1008 -10 "Hg 1108 -9.7 "Hg PASS 2 PREMIUM 10889 116 DW FIÐERG xerxes 57 Vacuum 1008 -10 "Hg 11(16 ·9.7 ''Hg PASS 3 DIES a 7~29 118 OW FIBERG X8nœ6 4 . S 6 7 8 Commen1S: Tt1!! premi~m and diesellankB eN )Brt of the 53me split 1an\. Ollly one annular amang$l1hem. I-' QI .., ~ QI I-' t.) c.> 00 Q ~ I-' 00 00 LINE INFnllMATION AND INTERSTITIAL TE~ Tank PmdIJC1 Dial. Len. Malerial ManufacluRJr Volume Test Metllod Slart Inlllal Finish Finlll Paw i'" rrtëii (.geIlonB) Time Leve:I Time Resull Fail 1 REGUlAR 3.00 230 DW FIBER Smith 68 Plessure t011 Ii psi 1111 II pti PASS 2 PREMIUM 3.00 250 DW FIBER Smith 61 pœssure 1004 5 psi 1104 5 psi PASS 3 DIESEL 3.00 120 DW FIBER Smith 29 Pressure 0959 5 psi 1059 S psi PASS 4 5 6 7 . 6 Comments: 0-'1 ~ ë o I-' o ~ I @ I-' Ho n o $I) en M '. I!§;I Q I-' Q " t-. .. Tanknology SECONDARY CONTAINMENT TEST RESUL T8 Test Date: 12118f2002 o ~ .... ¡... ~ .... o ~ WDIk Order: 3126762 SUMp TESTS T)pe Tank Dr 0Isp Manufacll.irar Modal Dr ÐIam.JW1dIhlLeng\l1 Daplh Tes! Me4hDd Start IniUaI level FiniSh FII!al Pusl , Maløñal (00) (" } ¡¡me Level Chanae Time Result fail S1P SLimp REGULAR XSOOIB Rberglll!l9 42 51 VPLT fOIiB 17 - -.00091 1110 +.035 gp l Pass SiP Sump PREMWM Xerxes fibe!glass 42 ~ \/PLT 1103 1B.5 n -.00009 1115 -.101 gph Pass SIP Sump OIESa Xerxe¡ Aberglasa 42 57 VPLT 1112 18.75 · -.00051 1125 -.1109 gpl! PII!I9 FBI Sump REGUlAR XeDœS F:ibergraBII 42 59 \/PlT 1136 19 - +.00055 114B -.008 gpll p- FBI Sum¡¡ PREMIUM XI!lxe9 Fiberglas!> 42 57 VPLT 1120 19.75 · +.00104 1132 -.022 gpl! Pass Fill Sump D1E5EL Xerxes Fiberglass 42 58 VPlT 1252 18.5 · ·.00111 1304 +.014 gpll Pass e DIspenser Sump 112 Total COIIIaißment fiberglass 36 x44 38 VPlT 1254 11.2.5 · +.00124 13Ð8 -.053 gpl! Pass Dispenser Sump 314 Total Containment Fiberglass $6x44 36 VPLT 1311 f1 · -.00036 1324 +,006 gph Pass Dispenser SUmp :5IS To1aI Canlainment FitIBglBss 361[44 36 VPLT 13\6 11.5 · -.00070 1329 +.028 gph Pass DiBpelUer Sump 11B To1al ConP.alnment Flb8I!Jlass 381[44 36 \/PLT 1323 11.1i · +.00011 13a5 ·.019 gpt! Pass Dispeflser Sump 11110 Talal Containment Flbarg 19116 36 I[ 44 36 \/PLT 1356 12 " ".00047 1409 -.014 gpl! Pass Dispenser Sump 11(12 ToP.a1 Con1ainmenl Fiberglass 36x44 36 \/PLY 1354 11.5 " ·.00136 14œ +.020 gph Pass Cammanl8: Due 10 tile po$illDn D'llhe J.bo;q¡s in each S1P & fill sump. \\III were unable to filllham ro above the highest efeG1ñca1 peøelr8tion. In 1ha SiP sumps. we were able 10 cover Ihe piping penetJatlon by X'. In tile lid s\IIm )&, the rowœz ~ing was entirely CIOvered by our waterline. Ula higher piping had approodmalÐIy 2" - 3" of tile top of 1I1e penelnllion ring unanrered. ;1 c::: ¡... ¡... ¡... C/I "!j ~ C/I ¡... N ~ OD o .... ¡... c» OD ~ ~ Š o ...... o ~ I C':! = ...... to+, C') o g, en C't .~ r!§iI o ¡... ¡... , ......- - -, FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 "H· Street Bakersfield. CA 93301 VOICE (661) 326·3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield. CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES FIRE SAFm SERVICES' ENYIROHIlEHTAI. SERVICES 1715 Chester Ave. Bakersfield. CA 93301 VOICE (661) 326-3979 FAJ< (661) 32S-0576 PUBLIC EDUCATION 1715 Chester Avè. Bakersfield, CA 93301 VOICE (661) 326·3696 FAJ< (661) 32S-0576 FIRE INVESTIGATION 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 32&3951 FAJ«661)326~76 TRAINING DIVISION 5642 VIctor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAJ< (661) 39g.5763 .. -- January 22, 2003 Jack In the Box 10 Union Ave Bakersfield CA 93307 RE: Upgrade Certificate & Fill Tags Dear Owner/Operator: Effective January 1,2003 Assembly Bill 2481 went into effect. This Bill deletes the requirement for an upgrade certificate of compliance (the blue sticker in your window) and the blue fill tag on your fill. You may, if you wish, have them posted or remove them. Fuel vendors have been notified of this change and will not deny fuel delivery for missing tags or certificates. Should you have any questions, please feel free to call me at 661- 326-3190. Steve Underwood Fire InspectorÆnvironmental Code Enforcement Officer Office of Environmental Services SBU/dc ~~ y~ de Y?~ ~ ~0Pe .rkt, .A ~enáu:?" {~ - - ~T -61tq ~ '-Fey^--, CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-397~ APPLICATION TO PERFORM A TANK TIGHTNESS TEST/ SECONDARY CONTAINMENT TESTING FACILITY J'l\ú'~ - ì 1'\ ~ .T\-k. - 8D)c -$: i? 2."1 ADDRESS I,,') V¡.Jì J~ PrvT. ) rsi't~sf-; 0l D PERMIT TO OPERATE # OPERATORS NAME ~\L- \ ~ - ~~ - çs ~x Lof'P. OWNERS·NAME ç~~ NUMBER OF TANKS TO BE TESTED 3 TANK # VOLUME \ 2,0} oOú Z \0) oo¡J 5 '1) 000 IS PIPING GOING TO BE TESTED ~. CONTENTS gr¡ ~.JJ LfA-Of ,.0 OJ \ v~H.xADE D D)' t- SEt- I - TANK TESTING COMPANY--! I'I-N'<'~ðl"ó~ MAiliNG ADDRESS 2151(0 CoMMfèILc..Æ:. Ú:.~ D~.) -#101 ) ~'iMíì-wut NAME & PHONE NUMBER OF CONTACT PERSON \?~O G5A11R.~;,..4) qOC1-~oe-d210 TEST METHOD \I (> IT ) , V\ ~hJ f-At- \1J~~ f~ GO I S NAME OF TESTER OR SPECIAL INSPECTOR ,\101 '1'~1 ~i)hlíì'" r-;~<;) CERTIFICA nON # '1 ~ '3, (p 0 ) bf. N:La/'rt --r:r p~ A DATE & TIME TEST IS TO BE CONDUCTED rl.A1r /02 \ 01lV ~, dtJLJIå() APPROVED BY (:1 'r?v ÐL DATE ~~ SIGNATURE OF APPUCANT JAC~I: I N THE EO>: 10 UNION AVE. BAKEF:SF I ELI! , CA . - NOV 15, 2002 9:10 AM -------- SY~3TEf"1 ST!ìTU8 REPORT ------- ALL fUNCTI ONS NORr"lAL 1 N\lENTGR'i RH'OFtr T 1: UNLEADED VOLUnE 1070::': GALS ULLAGE 9000 GALS gœ~; ULLAGE- '7029 GI-\." ,-. TC VOLUME = 10640 G' HEIGHT 62.28 INC S STK HEIGHT- 62.28 INCHES WATER VOL 0 GALS LJATER 0.00 INCHES TEf"IP 68.:3 DEG F T 2: PREf"1 IUI"I 'JOLUr·'!E ULLAGE 90~;; ULLAGE== TC \/OLUnE == HEIGHT STK HEIGHT- II,JATER \.101. WATER TEf'-'1P T 3:DIESEL VOLUt"IE ULLAGE 90% ULLAGE'" TC \I'OLUt"IE '" HEIGHT STK HEIGHT- I,..!ATER I'/OL WATER TEf"IF' 6246 GALS 4123 GALS 3086 GALS 61 90 CI';Ar'\ ~' , 67.40 67.40 IN~ S o GALS 0.00 INCHES '72.E. DEG F 2344 G!~LS 4685 GALS 3982 GALS 2328 GALS 43.21 I Nl:;HEE:~ 4::;. :"21 INCHES o GALS 0.00 INCHES 74.3 DEG F ~ ~ ~ ~ ~ END ~ ~ * ~ ~ e </ .J - ,JACK ! N THE BO>< liJ UNIC'N (i\/E. BF;)ŒRßF I E1.[' . CA . NOV 15. 2002 9:10 AM Er'/:3TH'1 STATU:::; REPORT - - - -- .- - ALL FUNCT ION:; NCH'lAL I f',JVENTC,R"! REP(:,RT T I: UNLEMIED VOLUME 10702 ULLAGE 9001 90% ULLAGE= 7030 TC VOLUME = 10640 HEIGHT 62.28 STr: HEIGHT= 62.28 WATER VOL 0 I.,JATER O. OiJ TEMP 68.3 T 2: PREf"l I ur··, \/OLUr"lE ULLAGE '30% ULLAGE> TC \/0 L LJr'lE = HEIGHT sn: HEIGHT= kiF; TER \/OL WATER TEr"IP T 3: DIESEL \/OLur"lE ULLAGE '90% UUAGE= TC VO L U~' E = HEIGHT STr: HEIGHT= I.",JATER VOL ,'JATER TEf"IP GALS GALS ll~:~ -~;.- If'JCHES INCHES GALS INCHES [lEG F 624G GALS 41 2:3 GAL:::; :]U8E. GALS b*~~f' (fas 67.41 IBs [I GALS 0.00 INCHES 72.6 DEe; F 2~:44 GALE~ 4685 GALS :::982 (;ALS 2:328 GALS 4J.21 I filCHES 43 . 2 1 I NC HES o C;ALS 0.00 INCHES 74.3 DEG F M M M ~ ~ END ~ ~ ~ M M e e e e CITY OF BAKIERSFJŒlLllJJ fiRE DEPARTMENT OFFICE OF ENVHRONMJENT AL SERVICES UNIFIED PROGRAM INSPECTION CHECKLHST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME \~{i('t l~ -\k &'!- INSPECTION DATE Il ~ lS-· (91- Section 2: Underground Storage Tanks Program o Routine [Sì;é'ombined 0 Joint Agency Type of Tank On}(; Type of Monitoring ~ L-IJA.. o Multi-Agency 0 Complaint Number of Tanks g.. Type of Piping UJlQ 9F ORe-inspection OPERA TION C V COMMENTS Proper tank data on tile l / Proper owner/operator data on tile V / V / Permit fees current Certification of Financial Responsibility ./ " Monitoring record adequate and current ,/ Maintenance records adequate and current / Failure to correct prior UST violations I' Has there been an unauthorized release? Yes No V Section 3: Aboveground Storage Tanks Program TANK SIZE(S) Type of Tank AGGREGATE CAPACITY Number of Tanks OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MVF? If yes, Does tank have overfill/overspill protection? C=Compliance V=Violation Y=Yes N=NO In,pecto,J1;, ritt:JJrIf) Office of Environmental Services (805) 326-3979 White - Env. Svcs. Pink - Business Copy e e CITY OF BAKERSfiEi..D FIRE DIEP ARTMIENT OFFICE OF IENVBRONMENT AJL SIEIRVRCES UNIFIED PROGRAM UNSJPIEC1!'llON CHECKLIST 1715 Chester Â''1fe.~ 3rd K'noor~ RalkersfnœRd, CA 93301 FACILITY NAME Òc1<.~ (\\..(.(.u ßO~ ADDRESS--10 ÜlAl{)v-... A\tL FACILITY CONTACT INSPECTION TIME INSPECTION DA TIE 1(- as-' <0 è PHONE NO. (.,(n( - <6cÞl' 0 S 4 3 BUSINESS ID NO. 15-210- NUMBER Of EMPLOYEES SediOlll1 I: BIIB§ñDU~§§ Plan mnd HlJllvœntory Pft"ogii"am o Routine [3tombined o Joint Agency OJ Multi-Agency o Complaint ORe-inspection OPERA nON c v COMMENTS Appropriate peonit on hand l V Business plan contact infoonation accurate ~ V , l / Visible address Correct occupancy '- ,/ Verification of inventory materials t:..o / Verification of quantities t / .~ I' Verification of location Proper segregation of material .,,/ Verification of MSDS availability v / Verification of Haz Mat training I....... Verification of abatement supplies and procedures (,..V Emergency procedures adequate v Containers properly labeled '" Housekeeping J Fire Protection ./ Site Diagram Adequate & On Hand / C=Compliance V=Violation Any !J¡¡S1æanrrdollis waste on site?: Explain: DYes QNt!) Pink - Business Copy Questions regarding this inspection? Please call us at (661) 326-3979 While - Env. Svcs. Yellow· Slation Copy Inspector: ----¡:- ~.,/ ,t, \ - ~@~~©w _ o/s-- ():J../- Oðd3Þ7 /0.3 -3) 0 b Jack In The Box #3576/Quick Stuff #7723 Hazardous Materials Business Plan ~ YEAR 2002 t) 10 Union Avenue (Facility Address) Bakersfield (Facility City) Kern (Facility County) POST TIDS DOCUMENT ON SITE SO IT WILL BE AVAILABLE IN THE EVENT OF A GOVERNMENT AGENCY INSPECTION, SITE ASSESSMENT OR AUDIT. ---;,- '/ ,3576 u D PROGRAM CONSOLIDATED FORM e FACILITY INFORMATION BUSINESS ACTIVITIES Page I of '1 I. FACILITY IDENTIFICATION FACILlTV 10# I I I I I I I I I I I I I I I 1 I EPA 10# (Hazardous Waste Only) 2 BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business AS) 3 Jack In The Box #3576/Quick Stuff #7723 I. ACTIVITIES DECLARATION NOTE: If you check YES to any part of this list, please submit the Business Owner/Operator Identification page (OES Form 2730). Does your facility... If Yes, please complete these pages of the UPCF... A. HAZARDOUS MATERIALS Have on site (for any purpose) hazardous materials at or above 55 gallons for liquids, 500 pounds for solids, or 200 cubic feet for compressed gases (include liquids in ASTs and USTs); or the [jVESD NO 4 J HAZARDOUS MATERIALS INVENTORV - applicable Federal threshold quantity for an extremely hazardous CHEMICAL DESCRIPTION(OES 2731) substance specified in 40 CFR Part 355, Aappendix A or B; or handle radiological materials in quantities for which an emergency plan is required pursuant to 10 CFR Parts 30, 40 or 70? B. UNDERGRotJND STORAGE TANKS lUSTs) [KJVEsD NO 5 J UST FACILITY (Formerly SWRCB Form A) 1. Own or operate underground storage tanks? J UST TANK (One page per tank) (Formerly Form B) 2. Intend to upgrade existing or install new USTs? DVESKJ NO 6 J UST FACILITY J UST TANK (One per tank J UST INSTALLATION - CERTIFICATE OF COMPLlANCE(one page per tank)(Fo~erly Form C) 3. Need to report closing a UST? DVEsKJ NO 7 J UST TANK (closure portion-one page per tank) C. ABOVE GROUND PETROLEUM STORAGE TANKS (ASTs) Own or operate ASTs above these thresholds: DVES[] NO 8 -any tank capacity is greater than 660 gallons, or J NO FORM REQUIRED TO CUPAS -the total capacity for the facility is greater than 1,320 gallons? D. HAZARDOUS WASTE 1. Generate hazardous waste? DVEsŒ] NO 9 J EPA 10 NUMBER-provide at the top of this page 2. Recycle more than 100 kg/month of excluded or exempted DVEslK] N010 J RECVCLABLE MATERIALS REPORT recyclable materials (per HSC 925143.2)? (one per recycler) 3. Treat hazardous waste on site? DVESllJ N011 J ONSITE HAZARDOUS WASTE TREATMENT - FACILITY (Formerly OTSC Form 1772) J ONSITE HAZARDOUS WASTE TREATMENT -UNI1(one page per unit) (Formerly DTSC Form 1772A,B,C,D, and L) 4. Treatment subject to financial assurance requirements (for Permit DVEsŒJ N012 J CERTIFICATION OF FINANCIAL by Rule and Conditional authorizaton)? ASSURANCE (Formerly DTSC Form 1232) 5. Consolidate hazardous waste generated at a remote site? DVESlX] N013 J REMOTE WASTE/CONSOLIDATION SITE ANNUAL NOTIFICATION (Formerly DTSC Form 1232) 6. Need to report the closure/removal of a tank that was classified as o YES c25J N014 J HAZARDOUS WASTE TANK CLOSURE hazardous waste and cleaned onsite? CERTI FI CATION (Formerly DTSC Form 1249) E. LOCAL REQUIREMENTS 15 (Vou may also be required to provide additional information by yourCUPA or local agency.) UPCF (1/99) 2 -~ , / .. 1.- CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 661 326-3979 FACILITY INFORMATION Business Avtivities Addendum FACILITY 10 # BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) Jack In The Box #3576/Quick Stuff #7723 Page 1-- of ~ 1 EPA 10 # (Hazardous Waste Only) 2 3 III Is your Facility Compliance Plan subject to review by... for satisfying the conditions of these permits? H. DEPARTMENT OF TOXICS SUBSTANCES CONTROL DYES ŒJNO vi' STANDARDIZED PERMIT . All Modifications DYES ŒJNO vi' Non·RCRA HAZARDOUS WASTE FACILITY DYES ŒJNO vi' RCRA HAZARDOUS WASTE FACILITY I. SAN JOAQUIN VALLEY UNIFIED AIR POLLUTION ŒJYES DNO vi' AUTHORITY TO CONSTRUCT CONTROL DISTRICT ŒJYES DNO vi' PERMIT TO OPERATE J. STATE WATER RESOURCES CONTROL BAORD CENTRAL VALLEY REGIONAL WATER QUALITY CONTROL DYES ŒJN04 vi' WASTE DISCHARGE REQUIREMENT (WDR) BOARD .., DYES ŒJNO vi' GENERAL PERMITS DYES ŒJNO vi' SPECIFIC PERMITS DYES ŒJNO vi' NATIONAL POLLUTION DISCHARGE ELIMINATION SYSTEM (NPDES) K. CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD DYES ŒJNO vi' REGISTRATION PERMIT L. KERN COUNTY RESOURCES MANAGEMENT AGENCY ENVIRONMENTAL HEALTH SERVICES PERMITS DYES ŒJNO vi' Domestic Water Well Permit DYES ŒJNO vi' Haz Mat Monitoring Well Permit DYES ŒJNO vi' Septic System Permit DYES ŒJNO vi' Public Swimming Pool Permit DYES ŒJNO vi' Food Facility Construction Permit DYES ŒJNO vi' Solid Waste Local Enforcement Agency (LEA) Related Permits DYES ŒJNO vi' Medical Waste Related Permits M. CITY OF BAKERSFIELD WASTE WATER DIVISION ŒJYES DNOs vi' INDUSTRIAL WASTE WATER DISCHARGE PERMIT NOTE: vi' If you checked YES to any part of Sections III-H to III-M above, then please address all applicable permit requirements in the Facility Compliance Plan. UPCF (1/99) 2 ------..;-- . - .. D PROGRAM CONSOLIDATED FO " FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION FACILITY ID# 100 ENDING DATE 12/31/2002 3 BUSINESS PHONE 661-861-0543 Page of 101 102 103 105 107 108 110 BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) Jack In The Box #3576/Quick Stuff #7723 BUSINESS SITE ADDRESS 10 Union Avenue CITY Bakersfield DUN & BRADSTREET 04-211-7200 COUNTY Kern BUSINESS OPERATOR NAME Jack In The Box, Inc. 104 106 ZIP CODE 93307-1549 SIC CODE (4 digit #) 5541 CA 109 BUSINESS OPERATOR PHONE (858) 571-2689 n. BUSINESS OWNER OWNER NAME Jack in the Box, Inc. OWNER MAILING ADDRESS 9330 Balboa A venue CITY I San Die 0 III OWNER PHONE (858) 571-2689 112 113 CONTACT NAME Paul Deneka CONTACT MAILING ADDRESS 9330 Balboa A venue CITY San Die 0 114 STATE CA Ill. ENVIRONMENTAL CONTACT 117 115 ZIP CODE 92123-1516 116 CONTACT PHONE (858) 571 ~2689 118 119 -PRIMARY - 120 STATE 121 ZIP CODE 122 CA 92123-1516 IV. EMERGENCY CONTACTS -SECONDARY - 123 NAME 128 Robert Fakinos 124 TITLE 129 Area Mana er 125 BUSINESS PHONE 130 661-394-7017 126 24-HOUR PHONE 131 661-394-7017 127 PAGER # 132 661-394-7017 NAME Joanna Harris TITLE Mana er BUSINESS PHONE 661-861-0543 24-HOUR PHONE 661-588-4511 PAGER # ADDITIONAL LOCALLY COLLECTED INFORMATION: Certification: Based on my inquiry of those individuals responsible for obtaining the infonnation, I certify under penalty of law that I have personally examined and am familiar with the info t' u . and believe the information is true. accurate, and complete. 136 135 Inc. NAME OF 51 ER (print) P,d-U t..- t? ¿Nt[ I::-"A- 137 MA'w UPCF ( 1/99 revised) 167 OES FORM 2730 (1/99) ~ .: '; CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHE~CALDESC~ON (one o..e oer material oer buildin. or area) ~ADD DDELETE DREVISE 200 I Page ~ of ~ I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 Jack In The Box #3576/Quick Stuff #7723 CHEMICAL LOCATION 201 CHEMICAL LOCATION 202 South side of Site CONFIDENTIAL - o YES ~ NO EPCRA FACILITY ID # I I 1~~jJ I I I~~~I I I I I I I I I MAP; (optional) 203 I GRI~4(OPtiOnal) 204 II. CHE~CAL INFORMATION CHEMICAL NAME 205 TRADE SECRET DYes ~ No 206 PETROLEUM HYDROCARBON If Subject to EPCRA. refer to instlUctions COMMON NAME 2(J1 208 REGULAR UNLEADED EHS* DYes ~ No CASH 209 8006-61-9 *If EHS is "Yes". all amounts below must be in Ibs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210 I-B FL HAZARDOUS ~TERIAL 212 I 213 TYPE (Check one item only) D a. PURE I8'J b, MIXTURE Dc. WASTE 211 RADIOACTIVE DYes I8'J No CURIES PHYSICAL STATE 215 (Check one item only) D a, SOLID I8'J b. LIQUID D c. GAS 214 LARGEST CONTAINER 20,000 FED HAZARD CATEGORIES 216 (Check all chat apply) ~ a. FIRE D b. REACTIVE D c. PRESSURE RELEASE 12 d. ACUTE HEALTH ~ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT m I MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 2191 STATE WASTE CODE: 220 15.000' 20 000 221 I DAYS ON SITE: 222 UNITS· I8'J a. GALLONS D b. CUBIC FEET D c. POUNDS D d. TONS 365 (Check one item only) · If EHS. amount must be in pounds. STORAGE CONTAINER D a. ABOVE GROUND TANK De. PLASTIC/NONMETALLIC DRUM D i. FIBER DRUM D m. GLASS B01iLE D q. RAIL CAR !XI b. UNDERGROUND TANK o f. CAN D j. BAG D n. PLASTIC BOTTLE 0 r. OTHER Dc. TANK INSIDE BUILDING o g. CARBOY D k. BOX D o. TOTE BIN D d. STEEL DRUM o h. SILO D 1. CYLINDER D p. TANK WAGON 223 STORAGE PRESSURE I8'J a. AMBIENT o b. ABOVE AMBIENT D c. BELOW AMBIENT 224 STORAGE TEMPERATURE I8'J a. AMBIENT D b. ABOVE AMBIENT D c. BELOW AMBIENT D d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 1 15% 226 METHYL TERT BUTYL ETHER 227 o Yes ~ No 228 1634-04-4 229 2 15% 230 TOLUENE 231 o Yes ~ No 232 108-88-3 233 3 21 % 234 XYLENE 235 o Yes ~ No 236 1330-20-7 237 4 5% 238 BENZENE 239 o Yes ~ No 240 71-43-2 241 5 5% 242 1,2,4- TRIMETHYL BENZENE 243 o Yes ~ No 244 95-63-6 245 III. SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE _ DATE 246 y?~ Oé,vé~~- "^'4 IL_ e- "."..1_ ¿........ Ý r?- \m ----- y /2-7/ ()7..- - , UPCF (1/99) 169 OES Fonn 2731 ~ -, CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION ~ADD DDELETE 200 DREVISE 1. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) Jack In The Box #3576/Quick Stuff #7723 CHEMICAL LOCATION South side of Site FACILITY ID U 201 CHEMICAL LOCATION CONFIDENTIAL - EPCRA MAPU (optional) 202 D YES ~ NO 203 G RIDU (optional) 204 CHEMICAL NAME PETROLEUM HYDROCARBON COMMON NAME PREMIUM UNLEADED CASU 8006-61-9 FIRE CODE HAZARD CLASSES (Complete if required by CUP A) 1 ll. CHEMICAL INFORMATION 20S TRADE SECRET 4 D Yes ~ No 206 If Subject to EPCRA, refer to instructions 2m 208 EHS* DYes 181 No 209 *If EHS is "Yes", all amounts below must be in lbs. 210 1-B FL HAZARDOUS ¥^ TERIAL TYPE (Check one item only) PHYSICAL STATE (Check one item only) FED HAZARDCA TEGORIES (Check all that apply) A VERAGE DAILY AMOUNT 213 o a. PURE 181 b. MIXTURE 0 c. WASTE 211 RADIOACTNE 0 Yes 181 No 212 CURIES 21S o a. SOLID 181 b. LIQUID o c. GAS 214 LARGEST CONTAINER 10,000 216 Qg' a. FIRE 0 b. REACTNE 0 c. PRESSURE RELEASE I!I d. ACUTE HEALTH [ÏI e. CHRONIC HEALTH 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 70 221 222 UNITS' (Check one item onl ) STORAGE CONTAINER 181 a. GALLONS 0 b. CUBIC FEET 0 c. POUNDS 0 d. TONS · If EHS, amount must be in ounds. o a. ABOVE GROUND TANK g b. UNDERGROUND TANK Dc. TANK INSIDE BUILDING o d. STEEL DRUM STORAGE PRESSURE 181 a. AMBIENT De. PLASTIC/NONMETALLIC DRUM o f. CAN o g. CARBOY o h. SILO o b. ABOVE AMBIENT o i. FIBER DRUM o j. BAG o k. BOX o 1. CYLINDER o m. GLASS BOTTLE 0 q. RAIL CAR o n. PLASTIC BOTTLE 0 r. OTHER o o. TOTE BIN o p. TANK WAGON 223 o c. BELOW AMBIENT 224 STORAGE TEMPERATURE 181 a. AMBIENT o b. ABOVE AMBIENT o c. BELOW AMBIENT o d. CRYOGENIC :us %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CASH 10% 226 METHYL TERT BUTYL ETHER 227 DYes 181 No 228 1634-04-4 229 2 9% 230 TOLUENE 231 DYes 181 No 232 108-88-3 233 3 14% 234 XYLENE 23S DYes 181 No 236 1330-20-7 237 45% 238 1,2,4- TRIMETHYL BENZENE 239 DYes 181 No 240 95-63-6 241 5 5% 242 BENZENE 243 DYes 181 No 244 71-43-2 24S III. SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE DATE 246 f1~L- t:?€NfE~ - M-4 n_ tf /1-')/0 L UPCF (1/99) 169 OES Form 2731 ,4 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION I8IADD DDELETE 200 DREVISE I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) Jack In The Box #3576/Quick Stuff #7723 CHEMICAL LOCATION South side of Site FACILITY ID # 201 CHEMICAL LOCATION CONFIDENTIAL - EPCRA MAP# (optional) 202 o YES 181 NO 203 GRID# (optional) 204 CHEMICAL NAME PETROLEUM HYDROCARBON COMMON NAME DIESEL FUEL #2 CASU 68476-34-6 FIRE CODE HAZARD CLASSES (Complete if required by CUPA) II-CL 1 II. CHEMICAL INFORMATION 205 TRADE SECRET 4 DYes 181 No 206 If Subject 10 EPCRA. refer 10 insINctions 2rJ7 208 EHS· DYes !81 No 209 ·If EHS is "Yes". all amounts below must be in Ibs, 210 HAZARDOUS MA TERrAL TYPE (Check OIfe item only) PHYSICAL STATE (Check one item only) FED HAZARD CATEGORIES (Check all that apply) AVERAGE DAILY AMOUNT 213 o a, PURE 181 b, MIXTURE 0 c, WASTE 211 RADIOACTIVE 0 Yes 181 No 212 CURIES 215 o a, SOLID 181 b, LIQUID o c. GAS 214 LARGEST CONTAINER 7,000 216 Ii] a. FIRE 0 b. REACTIVE 0 c. PRESSURE RELEASE o d. ACUTE HEALTH lit! e. CHRONIC HEALTH 217 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 221 222 UNITS· Check one item onl ) STORAGE CONTAINER 181 a. GALLONS 0 b. CUBIC FEET 0 c. POUNDS 0 d. TONS · If EHS. amount must be in ounds. o a. ABOVE GROUND TANK ~ b. UNDERGROUND TANK DC. TANK INSIDE BUILDING o d. STEEL DRUM De. PLASTICfNONMETALLIC DRUM o f. CAN o g. CARBOY o h. SILO o i. FIBER DRUM o j.BAG o k. BOX o 1. CYLINDER o m. GLASS BOTTLE 0 q. RAIL CAR o n. PLASTIC BOTTLE 0 r. OTHER o o. TOTE BIN o p. TANK WAGON 223 STORAGE PRESSURE 181 a. AMBIENT o b. ABOVE AMBIENT o c. BELOW AMBIENT 224 STORAGE TEMPERATURE 181 a. AMBIENT o b. ABOVE AMBIENT o c. BELOW AMBIENT o d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CASU 99.5% 226- DIESEL FUEL NO.2 227 DYes 181 No 228 68476-34-6 229 20.5% 230 NAPHTHALENE 231 DYes 181 No 232 91-20-3 233 3 234 PETROLEUM DISTILLATES 235 DYes 181 No 236 NONE 237 4 238 239 DYes 181 No 240 241 5 242 243 DYes 181 No 244 245 III. SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE DATE 246 ~t?'Lt..L ~ é,..re- fit..+. A.. 'v1L c..v()- t!:r'I..,R '-f / Z-J / ð L UPCF (1/99) 169 OES Form 2731 ^ CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMUCALDESC~ON (one P3Re per material per buìldin~ or area) g ADD DDELETE DREVISE 200 I Page -+ of ~ I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 Jack In The Box #3576/Quick Stuff #7723 CHEMICAL LOCATION 201 CHEMICAL LOCATION 202 Storage area of Kitchen CONFIDENTIAL - D YES g NO EPCRA FACILITY ID # I I If~~tl I I l¡f~:Þ~1 I I I I I I 1 I MA~ (optional) 203 I GRID# (optional) 204 F7 n. CHEMUCAL INFORMATION CHEMICAL NAME 205 TRADE SECRET DYes I8J No 206 CARBON DIOXIDE If Subject 10 EPCRA. refer 10 instructions COMMON NAME 2fJ7 208 CO2 EHS" DYes I8J No CASU 209 124-38-9 *If EHS is "Yes". all amounts below must be in Ibs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210 INRT-G HAZARDOUS ~ TERIAL 212 I 213 TYPE (Check one item only) 181 a. PURE D b. MIXTURE Dc. WASTE 211 RADIOACTIVE DYes 181 No CURIES PHYSICAL STATE 215 (Check one item only) D a. SOLID D b. LIQUID 181 c. GAS 214 LARGEST CONTAINER 2,600 FED HAZARD CATEGORIES 216 (Check all that apply) D a. FIRE D b. REACTIVE 181 c. PRESSURE RELEASE 181 d. ACUTE HEALTH D e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 2171 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 2191 STATE WASTE CODE. 220 2000 2600 221 I DAYS ON SITE: 222 UNITS' o a. GALLONS IX! b. CUBIC FEET D c. POUNDS D d. TONS 365 (Check one item only) · If EHS. amount must be in Dounds. STORAGE CONTAINER D a. ABOVE GROUND TANK De. PLASTIC/NONMETALLIC DRUM D i. FIBER DRUM D m. GLASS BOTfLE D q. RAIL CAR Db. UNDERGROUND TANK D f. CAN D j. BAG D n. PLASTIC BOTTLE D r. OTHER !J c. TANK INSIDE BUILDING D g. CARBOY D k. BOX D D. TOTE BIN D d. STEEL DRUM D h. SILO D I. CYLINDER D p. TANK WAGON 223 STORAGE PRESSURE D a. AMBIENT 181 b. ABOVE AMBIENT D c. BELOW AMBIENT 224 STORAGE TEMPERATURE D a. AMBIENT D b. ABOVE AMBIENT D c. BELOW AMBIENT 181 d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CASH 1 100% 226 CARBON DIOXIDE 227 DYes I8J No 228 124-38-9 229 2 230 231 DYes I8J No 232 233 3 234 235 DYes 181 No 236 237 4 238 239 DYes I8J No 240 241 5 242 243 DYes 181 No 244 245 III. SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE {):£ ~ DATE 246 {l tØ"t-<. '- Pe,....,ê~ t\.A.. CcM- r£,.Jc/ e:-.N~ 'f / 2- J (0 ""L -- - , UPCF (1/99) 169 OES Form 2731 - ------,-- ~ e e SECTION I BUSINESS EMERGENCY PLAN: EMERGENCY PROCEDURES Emergency response plans and procedures are an integral part of the Business Emergency Plan. By taking the time to review these procedures for your establishment, you will avoid complications resulting from inaction or misguided action during an emergency. Once these plans and procedures are implemented, your employees will have an informative guide to follow in the event of an emergency. 1. EMERGENCY RESPONSE PLANS AND PROCEDURES A. If you have a release or threatened release of hazardous material, your business is required by State Law to provide immediate notification of the following agencies Immediately call: LOCAL FIRE EMERGENCY RESPONSE PERSONNEL (Fire, paramedics, police, or sheriff) 9-1-1 STATE OFFICE OF EMERGENCY SERVICES: or (800) 852-7550 (916) 262-1621 'I Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SERVICES: 805-326-3979 PERSON(S) WITHIN THE FACILITY WHO ARE NECESSARY TO RESPOND TO A HAZARDOUS MATERIALS INCIDENT: Name: Joanna Harris / Store Manager Telephone: 661-861-0543 Name: Robert Fakinos / Area Manager Telephone: 661-394-7017 B. IDENTIFICATION OF THE LOCAL EMERGENCY MEDICAL FACILITY OR MEDICAL ASSISTANCE AVAILABLE TO YOUR BUSINESS APPROPRIATE FOR POTENTIAL ACCIDENT SCENARIOS: NAME: ADDRESS: CITY: PHONE: MERCY SOUTHWEST HOSPITAL 2215 TRUXTON A VB BAKERSFIELD 661-632-5281 1 -~- .. e e 2. PREVENTION Describe the kinds of hazards associated with the materials present at your business. Provide information on the steps taken at your business, or the policies or procedures now in place, to help prevent an aècidental release of a hazardous material. Issues for discussion may include safety, storage, and containment procedures. Be specific for each type of hazardous material at your business. The hazardous at this business are fire and spills associated with gasoline dispensing. Gasoline dispensing is supervised by trained personnel. Additional hazardous materials are stored in minimum quantities and stored in small, unbreakable containers. All underground storage tanks are monitored using an approved monitoring method. 3. MITIGATION .~ Describe the procedures to be followed to reduce the severity of a release or threatened release of a hazardous material at your business. The procedures should detail the actions to be taken by employees to stop a release, contain a release, or to reduce the problems associated with a release. What is your immediate response to a spill, fire, explosion or airborne release at your facility? Small incidents: For leaks and spills less than 5 gallons, isolate the area and contain with absorbent material. Clean up the spill immediately to prevent spreading. For fires, turn off pumps, use fire extinguisher if it can be done safely. Larger incidents: Turn off pumps using emergency pump shut-off, call 9-1-1, evacuate to -- emergency assembly area, wait for emergency personnel to respond. Immediately contact Paul Deneka, Jack in the Box Environmental Manager at 858-571-2686. 4. ABATEMENT Describe what you would do to stop and remove each hazard. How do you handle the complete process of stopping a release, cleaning up, and disposing of released materials at your business? What aspects of the response are beyond your ability and need to be handled by others? Who would you call to handle the release? Small incidents will be handled with the on-site clean-up equipment, (i.e., brooms, shovel, absorbent material, mops, etc.). For larger incidents, the on-site manager will turn off the pumps, call 9-1-1, and the Environmental Manager. For suspected leaks the Environmental Manager will contact an authorized contractor to assist in the investigation of the incident. If a UST leak is confirmed, then reporting will be done by the Jack in the Box, which complies with UST regulations. Jack in the Box will coordinate with any contractors required to stop a release, clean up a release and/or dispose of materials. All materials will be disposed of in accordance with state, federal and local laws and regulations. 2 5. e EVACUATION and RE-ENTRY e ~ Describe the procedures to be followed for immediate notification and evacuation of your facility and the re-entry procedures after evacuation has occurred. If warranted, evacuate to the designated assembly located at: At the driveway along Union Avenue The manager or lead employee will take a head count to verify all employees have evacuated safely. The manager or employee will confer the responding agencies to indicate the magnitude of the emergency. Re-Entry into the facility will only take place after the manager verifies with the responding agency personnel to ensure it is safe. 6. EARTHQUAKES Identify the areas and equipment in your business that would require immediate inspection or isolation due to their vulnerability to earthquake related ground motion. Check for equipment such as gas cylinders, piping, drums, etc., that may need to be secured or spillage that may require mitigation or abatement. Key areas to inspect are the UST tank monitor alann panel, dispenser islands, and any additional hazardous materials storage areas. .'j 7.· HAZARDOUS WASTE CONTINGENCY Specific procedures for prevention, mitigation and abatement of a release of hazardous waste generated at your business. This section only applies to hazardous waste generators. This business does not generally generate waste. If any waste is generated it would be water.. gasoline mixture removed from the underground tanks. 8. UNAUTHORIZED RELEASE RESPONSE PLAN Specific procedures for mitigation, abatement and reporting of an unauthorized releases from an underground storage tank (UST). The plan must address a release from a single wall or double wall tank system as applicable. This plan should cover the entire UST system. This section only applies to UST owner/operators. Refer to the Underground Storaf?e Tank Monitorinf? and Response plan If a released hazardous substance reaches the environment, increases the fire or explosion hazard, is not cleaned up from the secondary containment within 8 hours, or deteriorates the secondary containment, then the local agency will be notified Th1MEDIA TEL Y 3 -' .' SECTION II e e BUSThŒSSEMERGENCYT~G Employers are required by State law to have a program providing employees with initial and reftesher training. The Business Emergency Plan shall include a training program that is reasonable and appropriate for the size of the business and the nature of the hazardous materials handled. The training program shall take into consideration the responsibilities of the employees to be trained. The training program shall, at a minimum, include: B. C. D. E. F. .') G. H. I. A. Methods for the safe handling of hazardous materials stored at your business, including familiarity with the characteristics and hazards of each material and measures employees can take to protect themselves ftom chemical hazards. Procedures for coordination with local emergency response organizations. Correct use of emergency response equipment and supplies under the control ofthe business. The Cal OSHA Hazardous Communication Standards. The prevention, abatement and mitigation procedures you have developed for your business and explained on the Business Emergency Plan. The emergency evacuation plans you have developed, the notification procedure used to alert people to evacuate, and the closest location to obtain appropriate emergency medical care. Procedures to coordinate with and assist the local emergency persånnel that may respond to your facility. Who and how to call for immediate assistance in the event of an accident involving hazardous materials; Procedure for ensuring the appropriate personnel receives initial and reftesher training. ALL EMPLOYEE TRAINING SHALL BE DOCUMENTED AND UPDATED ANNUALLY Use the attached employee training log or similar form for record keeping. 4 ! ~MERGENCY RESPONSE PROCEDURES e In the event of a fire, spill, or a leak or suspected leak in the tanks and/or piping, the following steps are to be taken as applicable: 1. TURN OFF PUMPS using the Emergency Pump Shut-Off Switch. 2. EVACUATION: If there is any immediate danger, verbally ANNOUNCE to all persons on the site: "There is an emergency. Please turn off your engines and leave the station on foot immediately." All employees are to meet at the emergency assembly area. 3. CALL FOR HELP in case of an emergency by dialing 9-1-1 and giving the following information: "THERE IS A FIRE / GASOLINE SPILL at the gas station at 10 Union Avenue." If anyone is trapped or needs medical attention, tell the answering dispatcher. Stay on the phone and be prepared to answer any questions concerning the situation. 4. LOOK AROUND to assure that all others have left the station if necessary, particularly those in vehicles who may need assistance or may not have heard the emergency announcement. Assist, or direct assistance to, anyone having difficulty leaving the station area and anyone who may be injured. 5. ATTEMPT TO EXTINGUISH any small or incipient fire if you can do so safely. Have the fire extinguisher ready to use in the event of any spill. Try to contain any large spill, or use absorbent on smaller spills. 6. REPORT to arriving emergency response personnel to provide them with any information or assistance they .~ might need. 7. CONTACT the following individuals if not already at the station: a) Primary Contact: Name: Joanna Harris Title: Manager Bus #/24 hour/Pager #: 661-861-0543 / 661-588-4511 / b) Secondary Contact: Name: Robert Fakinos Title: Area Manager Bus #/24 hour/Pager #: 661-394-7017/ 661-394-7017 / 661-394-7017 c) Alternate Contact: Paul Deneka Title: Manager, Environmental Engineering Address: 9330 Balboa Avenue, San Diego CA 92123-1516 Phone: 858-571-2689 8. NOTIFY Jack in the Box, Inc. or the Emergency Maintenance Contractor by phone IMMEDIATELY. Jack in the Box will notify the appropriate State and Local agencies. A. LOCAL AGENCY: Bakersfield Fire Department PHONE NUMBER: 661-326-3979 B. CALIFORNIA OFFICE OF EMERGENCY SERVICES, (800) 852-7550 (24 HOURS) C. LOCAL POLICE AND FIRE DEPARTMENTS, 911 9. On-Site Manager should attempt to isolate leak location by inspection. 10. Jack in the Box will coordinate whatever corrective actions need to be taken beyond the Manager's capabilities. Jack in the Box will file whatever reports need to be filed with local and state agencies. 11. EVACUATION: In the event evacuation is necessary, the attendant will announce for all customers and personnel to evacuate the building using the nearest exit door. All persons should go to the emergency meeting area as designated on the site map. 12. RE-ENTRY: If evacuation has occurred and emergency responders have been called, re-entering this facility should take place with extreme caution and only under the direction of the senior emergency responder on site. e EMPLOYEE TRAINING PLAN e Employees must be given this training before starting work, and refresher courses must be provided annually. Records must be kept to show when each station employee has been given his/her safety training. Use the following outline and make copies as needed. Have employee date and sign this document upon completion of training. Retain these records for a minimum of three years. I. FIRST THINGS TO KNOW: A. EMERGENCY PUMP SHUT-OFF: This turns off the turbine pumps that provide flow to the dispensers from the underground tanks. In case of a leak, shutting off the pumps will help to prevent spills. Employees are to be trained on the use and location of each shut-off switch. LOCATION: 2 on light poles Sw corner & N. of Islan B. ELECTRICAL PANEL: The panel allows you to selectively cut off power to lights, signs, pumps, etc. The main switch kills all power at the site. Employees are to be trained on the use and location of the panel. LOCATION: East side of building & irside C. WATER SHUT-OFF: The water shut-off may be necessary in some cases. Employees are to be trained on the use and location. LOCATION: .'; D. NATURAL GAS SHUT-OFF: If your station has natural gas, it may be necessary to shut-off the natural gas flow in an emergency. LOCATION: East side of building E. FIRST AID KIT: Employees are to be trained on the use and location. LOCATION: in the Cashier Area and JIB storage F. FIRE EXTINGUISHER: Use only on small fires that you can handle. Do not attempt to extinguish large fires on your own; call 9-1-1 for help. All employees are to be taught proper use and location of fire extinguishers. - LOCATION: 5 inside building, see map #2 G. ABSORBENT: In the form of kitty litter, absorbent can soak up small spills of gasoline, diesel fuel, or other petroleum products. Absorbent should be used rather than washing spills down a drain. In case of large spill, merely try to contain it; a vacuum truck should be used to clean up any large spill. Employees are to be trained on the use and location of spill kits. LOCATION: Store room of store H. Emergency Response Plans: Employees are to be trained on the location of this plan and its contents. They should also be familiar with MSDS's and the information contained in them. LOCATION: at the cashier area I. Safety Procedures: Employees are to be trained on the proper safety procedures and to notify customers when appropriate, i.e. customer smoking on the island, children pumping gasoline or playing near dispensers, etc. 2 II. NEAREST MEDICAL FACILlTY~EmPIOYeeS should know what facilities t available in case customers or other employees need medical attention. 1. NAME: MERCY SOUTHWEST HOSPITAL ADDRESS: 2215 TRUXTON AVE, BAKERSFIELD PHONE NUMBER: 661-632-5281 ~ III. All employees should review the Hazardous Material Plan, of which this training plan is a part. Specifically, each employee should understand the procedures to be used in responding to various kinds of emergencies, and know how to monitor for leaks of hazardous materials. As a supplement to this package, employees should also review the Emergency Response Plan filed by your business to the appropriate local agency. Thirdly, employees should review and have access to the Materials Safety Data Sheets you have on file for each of the hazardous materials stored at the station and must be drilled in all emergency response procedures contained herein. IV. FIRST AID PROCEDURES (For exposure to gasoline or diesel fuel): A. EYE CONTACT: Flush with water for 15 minutes while holding eyelids open. Get medical attention. B. SKIN CONTACT: Flush with water while removing contaminated clothing and shoes. Follow by washing with soap and water. Do not reuse clothing or shoes until cleaned. If irritation persists, get medical attention. C. INHALÀTION (Breathing): Remove victim to fresh air and provide oxygen if breathing is difficult. If not breathing, give artificial respiration. Get medical attention. .') D. INGESTION (Swallowing): DO NOT INDUCE VOMITING BECAUSE GASOLINE CAN ENTER LUNGS AND CAUSE SEVERE LUNG DAMAGE !If vomiting occurs spontaneously keep head below hips to prevent aspiration of liquid into lungs. Get medical attention. E: NOTE TO PHYSICIAN: If more than 2.0 ml per kg has been ingested and vomiting has not occurred, emesis should be induced with medical supervision. Keep victim's head below hips to prevent aspiration. If symptoms such as loss of gag reflex, convulsions or unconsciousness occur before emesis, gastric lavage using a cuffed endotracheal tube should be considered. F. For further information, consult the Materials Safety Data Sheets for these products and for other hazardous materials. FIRST AID FOR EXPOSURE TO OTHER MATERIALS: Consult the warning advice on container labels or refer to the MSDS for that product. Document prepared by: Environmental Staff, RHL DESIGN GROUP, INC., 707-765-1660 I:\HAZMA T\JackintheBox\ERP MERGE.doc 3 ~ e e HAZARDOUS MATERIALS TRAINING REQUIREMENTS As the owner/operator of a business that handles hazardous materials, you must have the following: · A Hazard Communication Plan (also known as an Employee Right-to-Know Plan) · A SARA Tier II Chemical Inventory Report (in California this report is included in the Hazardous Materials Management Plan, also known as the CA Business Emergency Plan) · An Emergency Response Plan · An Underground Storage Tank Monitoring and Leak Detection Plan · A Release Reporting Plan .~ Each of these plans requires employee training. Training must be documented by a written description of the topics covered and by a dated signature of the employees receiving the training. Annual refresher training is required and the introduction of new hazardous materials or changes in procedures require immediate retraining. Training requirements that are common to more than one of these plans only needs to be given once to satisfy all of the plans containing that requirement as long as the training addresses the concerns of each plan. Training for the Hazard Communication Plan must include the following elements: · An overview of the requirements contained in the Hazard Communication Regulation and the worker's rights under the Regulation. · Locations of any operations in their work area where hazardous substances are present. · Location where a copy of the written Hazard Communication program is made available to them. · How to read labels and Material Safety Data Sheets (MSDS) to obtain appropriate hazard information, including physical and health effects of hazardous substances in the work place. · How to detect the presence of or the release of hazardous substances in the work place. · How to minimize their exposure to these hazardous substances by proper use of engineering controls, work practices, and/or personal protective equipment (gloves, etc). · Emergency and first aid procedures to follow if employees are exposed to hazardous substances. --t .. e e Spill/Release Response Plan for Carbon Dioxide D.O.T. Guide Number 21 Fire or Explosion: Cannot catch fire, but container may explode in heat of fire. Health Hazards: Vapors may cause dizziness or suffocation. Contact with liquid may cause frostbite. Emergency Action: Keep unnecessary people away; isolate hazard area and deny entry. Inert gases displace oxygen. Stop leak if you can do it without risk while avoiding suffocation. Assure sufficient oxygen is available before attempting rescue. Do not touch or walk through spilled material. Avoid breathing gases. Stay upwind, out of low areas and open all doors to ventilate area before entering Contact the supplier for additional assistance to stop the release. 1 Fire: Move container from fire area if you can do it without risk. Apply cooling water to the sides of the container that are exposed to the flames until after the fire is extinguished. Stay away from tanks end. First Aid: Move victim to fresh air and call emergency medical care; if not breathing, give artificial respiration; if breathing is difficult, give oxygen. In case of frostbite, thaw frosted parts with water. Keep victim quite and maintain normal body temperature. Prevention Procedures: Store tank and/or cylinders with valve protection caps installed. Tank and cylinders should be stored upright and firmly secured to prevent falling or being knocked over. Containers should be stored in a cool, dry, well ventilated area away from sources of heat or ignition and direct sun light. If you suspect any problems with the tank notify the supplier immediately to have the system inspected. ~, :; Date: April 22, 2002 - e WRITTEN MONITORING PROCEDURES UNDERGROUND STORAGE TANK MONITORING PROGRAM This monitoring program must be kept at the UST location at all times. The information on this monitoring program is a condition ofthe operating permit. The permit holder must notify Bakersfield Fire Department within 30 days of any changes to the monitoring procedures, unless required to obtain approval before making the change. Required by Sections 2632(d) and 2641 (h) CCR. Facility Name Jack In The Box #3576/Quick Stuff #7723 Facility Address 10 Union Avenue, Bakersfield A. Describe the frequency of performing the monitoring: Tank Continuous Electronic Monitoring Secondary Containment testing will be performed every 36 months. Piping Continuous monitoring mechanical Line Leak Detector. Annually all monitoring equipment is inspected by a certified contractor. B. What methods and equipment, identified by name and model, will be used for performing the monitoring: Tank: Veeder Root TLS-350 system with CLSD. model # 848290-022 Mag probe Model #847390-109 (0.1 gph) .~ Interstitial sensor 794390-409 Piping Veeder Root TLS-350 system with the following sensors Turbine Sump Sensor model # 794380-208 Dispenser Sump model # 794380-208 Line Leak Detector: FE Petro STP-Mechanical C: Describe the location(s) where the monitoring will be performed (facility plot plan- should be attached): The monitor is located in the Inside Storage room of Store. D. List the name(s) and title(s) of the people responsible for performing the monitoring and/or maintaining the equipment. Joanna Harris / Manager Robert Fakinos / Area Manager Paul Deneka / Manager, Manager, Environmental Engineering E. Reporting Format for monitoring: Tank: A written monitoring log. Piping: A written monitoring log and annual certification F. Describe the preventative maintenance schedule for the monitoring equipment. Note: Maintenance must be in accordance with the manufacturers' maintenance schedule but not less than every 12 months. The monitoring systems shall be certified annually in accordance with manufacturer's recommendations G. Describe the training necessary for the operation of UST system, including piping, and the monitoring equipment: The operators receive initial and annual refresher training in accordance to the manufacturers recommendations. Refer to the stations environmental binder, located in the office for more detailed information. e ~ 'f e i~~~ ~ ; Date April 22, 2002 e e EMERGENCY RESPONSE PLAN UNDERGROUND STORAGE TANK MONITORING PROGRAM This monitoring program must be kept at the UST location at all times. The information on this monitoring program is a condition of the operating permit. The permit holder must notify Bakersfield Fire Department within 30 days of any changes to the monitoring procedures, unless required to obtain approval before making the change. Required by Sections 2632(d) and 2641 (h) CCR. Facility Name Jack In The Box #3576/Quick Stuff #7723 Facility Address 10 Union Avenue, Bakersfield 1. If an unauthorized release occurs, how will the hazardous substance be cleaned up? Note: If released hazardous substances reach the environment, increase the fire or explosion hazardl, are not cleaned up from the secondauy containment within 8 hours, or deteriorate the secondary containment, then Bakersfield Fire Department must be notified within 24 hours. For small spills the on site personnel will use absorbent material to clean up the released material. In the event of a larger spill, the on site manager will call 9-1-1 (if necessary), and the company representative to assist in the emergency. ." 2. Describe the proposed methods and equipment to be used for removing and properly disposing of any hazardous substances. Spent absorbent will be placed into ·an approved container and disposed of in accordance with all Local, State, and Federal laws and regulations. Any additional equipment will be provided be the responding contractor. 3. Describe the location and availability of the required cleanup equipment in item 2 above. Absorbent is maintained on site and restocked as needed. Any additional equipment is maintained by the contractor, and available on an as needed basis. 4. Describe the maintenance schedule for the cleanup equipment. Absorbent is inspected weekly and reordered as needed. 5. List the name(s) and title(s) of the person(s) responsible for authorizing any work necessary under the response plan: Joanna Harris / Manager Robert Fakinos / Area Manager Paul Deneka / Manager, Manager, Environmental Engineering -----, j ON-SITE TRAININGþt - NEW EMPLOYEE TRAlNINIJERIFICATION Name of Company: Street Address: City, Zip Code: Employee Name (print) I acknowledge that I have received and understand environmental compliance training in the followin areas lease initial or mark N/ A for not a licable: Date ement/Business Plan Employee Signature Training verified by Social Sec. Number· Date Instructor Date MAINTAIN TillS FORM THE ENTIRE TIME THE EMPLOYEE WORKS AT THE FACILITY -1 ~' - ON-SITE TRAINING FORM e .J " ANNUAL REFRESHER TRAINING VERIFICATION Name of Company: Street Address: City, Zip Code: Employee Name (Print) I acknowledge that I have received and understand environmental compliance training in the following areas (please initial or mark N/A for not applicable): Date Employee Signature Training verified by Social Sec. Number Date Instructor Date MAINTAIN TillS FORM THE ENTIRE TIME THE EMPLOYEE WORKS AT THE FACILITY MAP# BUSINESS NAME JACK IN THE BOX #3576/0UICK STUFF#7723 BUSINESS ADDRESS 10 UNION A VENUE BAKERSFIELD DATE 4/22/2002 ZIP CODE 93307-1549 CALIFORNIA AijNOTATED SITE MAP c ® FUEL f - -1 PIPIN~ !-T---------, I ,160 061 : I I , , , : I I , I I 7,000 GAL : I I D~L : Î"6-~-----~J, ¡ /-,' I I /-, r ~ I I /01,0;:: : '''"' II II, 1 1/""''::\.11 I' 1 I- ,,--- l-r---------, I 'ÓII 1160 061 '6)116)11 I I 0 II 0 I I ,_/ '_/ L_____ J ®® 10,000 GAL 20,000 GAL PREMIUM REGULAR D F G PREPARED BY: DRAWING SCALE 1"=40'± H MAP SYMBOLS CD ELECTRICAL PANEL SHUT-OfF ® NA lURAL GAS SHUT-OFF ® WATER SHUT-OFF ® EMERGENCY PUMP 1>6 SHUT-OFF ð TANK MONITORING ALARM CD TELEPHONE c{þ FIRST AID KIT ~ FIRE EXTINGUISHER _ §I STORM DRAIN * SANITARY SEWER STAGING AREJ EVACUATION ~ HI.tI.tP ~~:i10~0 MSDS IoISDS 6 FIRE HYDRANT "*-* FENCE (ERE) EMERGENCY RESPONSE EQUIPMENT/ABSORBENTS c=:=) ABOVEGROUND STORAGE TANK ~-~ UNDERGROUND I ) ~-~ STORAGE TANK ® GASOLINE (FlAMMABLE UQUIDS) ® DIESEL FUEl (COMBUSTIBLE UQUIDS) ® MOTOR OILS c!c LUBRICANTS (COMBUSTIBLE UQUIDS) @ CARBON DIOXIDE tit . (COMPRESSED GAS) ® PROPANE (FlAMMABLE UQUID) @ ANTIFREEZE/COOlANTS ® WASTE OIL (FLAMMABLE UQUIO) @ CAR WASH PRODUCTS A 18~ 2 3 w :z « ---I 4 5 w ø « o :z :::> 0::: OJ 8 I> E UNION AVENUE ø . * JACK IN THE BOX '" C-STORE SEE MAP #2 6 l ~I TANK VENTS 7 I A 8 c D E F G PREPARED BY: DRAWING SCALE 1"=40'± H MAP SYMBOLS ® ELEC1RICAL PANEL SHUT-OFF ® NATURAL GAS SHUT-OFF ® WATER SHUT-OFF ® EMERGENCY PUMP SHUT-OfF ~ TANK MONITORING ALARM CD TELEPHONE .:{f FIRST AID KIT ~ FIRE EXTlNGUISHER e § STORM DRAIN * SANITARY SEWER STAGING AREf EVACUATlON HUMP ~~~:i1oiND MSDS M50S Ò FIRE HYDRANT *""* FENCE (@ EMERGENCY RESPONSE EQUIPMENT/ABSORBENTS C) ABOVEGROUND STORAGE TANK ~-~ UNDERGROUND I I ~-~ STORAGE TANK ® GASOUNE (FlAMMABLE UQUIDS) ® DIESEL FUEL (COMBUSTlBLE UQUIDS) ® MOTOR OILS c!c LUBRICANTS (COMBUSTlBLE UQUIDS) @ CARBON DIOXIDE e (COMPRESSED GAS) ® PROPANE (FlAMMABLE UQUID) 0 ANTlFREEZE/COOLANTS @ WASTE OIL (FLAMMABLE UQUID) @ CAR WASH PRODUCTS MAP# 2 CALIFORNIA AJ~NOTATED SITE MAP BUSINESS NAME JACK IN THE BOX #3576/aUICK STUFF#7723 BUSINESS ADDRESS 10 UNION A VENUE BAKERSFIELD DATE 4/22/2002 ZIP CODE 93307-1549 1 e; ,. I ~ DINING AREA 2 4 D 3 I Æs' \ --~ ~ CASHIER ,. I 5 6 7 CD nl L JOHN W. JOHNSON Co-President Principal BRIAN F. ZITA Co-President Principal JOHN B. HICKS Vice President Principal CECIL R. SPENCER Vice President Principal Roy W. PEDRO Regional Manager JOHN W. STROBEL Regional Manager Associate JESSE E. MACIAS Regional Manager Associate ALAN K. SHIMABUKURO Regional Manager Associate BLYTHE R. WILSON Regional Manager Associate e . ARCHITECTURE ENGINEERING ENVIRONMENTAL SERVICES 1137 North McDowell Boulevard, Petaluma, CA 94954-1110 Telephone: (707) 765-1660 Facsimile: (707) 765-9908 John W. Johnso", Architect Established 1 9 6 6 April 24, 2002 Ralph Huey Bakersfield Fire Department 1715 Chester Avenue, 3rd Floor Bakersfield, CA 93301 RE: Hazardous Material Management Plan for Jack in the Box, Inc. To Ralph Huey: Enclosed please find the Hazardous Material Management Plans, HMMP(s), and related documents for the new Jack in the Box facility located at 10 Union Avenue, Bakersfield. This is a new facility that is in the process of opening. If you have any questions regarding this submission, please feel free to contact me at 800-765-1025. Sincerely, RIlL Design Group, Inc. ~ Steven A. Skanderson Project Manager Enclosure I: \HAZMA T\JackintheBox\Bakersfield\Agency Letter .doc BELLEVUE, WA LA HABRA, CA MARTINEZ, CA PETALUMA, CA SACRAMENTO, CA SCOTTSDALE, AZ VANCOUVER, WA FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 21 01 "W Street Bakersfield. CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield. CA 93301 VOICE (661) 326·3941 FAX (661) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield. CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield. CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield. CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 - . May 29,2002 Jack in the BoX! Quick Stuff 9330 Balboa Ave San Diego, CA ,92123 RE: Necessary Secondary Containment Testing Requirement by December 31, 2002 of Underground Storage Tank located at 10 Union Avenue, Bakersfield, CA REMINDER NOTICE Dear Tank Owner/ Operator: The purpose of this letter is to infonn you about the new provisions in California Law requiring periodic testing of the secondary containment of underground storage tank systems. Senate Bill 989 became effective January 1, 2002. section 25284.1 (California Health & Safety Code) of the new law mandates testing of secondary containment components upon installation and periodically thereafter, to ensure that the systems are capable of containing releases from the primary containment until they are detected and removed. Secondary containment systems installed on or after January 1,2001 shall be tested upon installation, six months after installation, and every 36 months thereafter. Secondary containment systems installed prior to January 1,2001 shall be tested by January 1,2003 and every 36 months thereafter. REMEMBER!! Any component that is "double-wall" in your tank system must be tested. Secondary containment testing shall require a pennit issued thru this office, and shall be perfonned by either a licensed tank tester or licensed tank installer. Please be advised that there are only a few contractors who specialize and have the proper certifications to perfonn this necessary testing. For your convenience, I am enclosing a copy of the code for you to refer to. Once again, all testing must be done under a pennit issued by this office. Should you have any questions, please feel free to contact me at (661) 326-3190. Si;l' {~ Steve UndelWood Fire Inspector/ Environmental Code Enforcement Officer SBUIkr enclosures \ ~~7~ ~ W~ ~ V#;0Pe ..rbt, .A ~~" " Nln9o&1(tøøt!e ... .. .'~'... .1 9272 Jeronimo Road, Irvine, California 92618 . Phone 949/472-5444 . Fax 949/472-5445. www.ninyoandmoore.com To: Paul Deneka Date: May 30, 2001 Firm: Jack in the Box Inc. Fax No: 858-694-1542 9330 Balboa Avenue Telephone 858-571- 2689 Address: San Diego, California 92123 No: From: Paul A. Roberts Total Pages: Subject: Underground Storage Tank Closure Report, Project No: 202469002 Proposed Jack in the Box No. 3576, Bakersfield o Urgent o For Approval o For Your Use o Please Reply o As Requested Original Document: o Will Not Follow o Will Follow o By U.s. Mail o By Other If there are any questions, please call me at 949-472-5444. Thank you. · Geotechnical Engineering · Engineering Geology Cc: Inspector Steve Underwood City of Bakersfield Fire Department Environmental Services 1715 Chester Avenue, 3rd Floor Bakersfield, California 93301 · Materials Testing and Inspection · Construction Management · Engineering Design · Environmental Engineering · Environmental Site Assessments · Regulatory Compliance and Permitting .' Water Quality and Resource Evaluations · Hazardous Waste Management · Soil and Groundwater Remediation · Asbestos and Lead-Based Paint Surveys · Geophysical Studies · Mineral Resource Evaluations · Value Engineering · Forensic Studies .111 Expert Witness Testimony Irvine - San Diego _ Los Angeles _ Ontario - Oakland _ Las Vegas _ Salt Lake City _ Phoenix ('\ J -. X& Travis Engineetng . A Division of Travis Companies. Inc. January 31, 2002 ., Mr. Steve Underwood Fire Department ::J~llv.ironmental·Serv·ÌßeS.--...._.._ City 3Î.BakêrifÍeld ----..--.- ..---....-.............__.___._ _. " /' -.~- ""- .;/ Bakersfield, California 93301 ~ { : Ch~::~: CONTRACTOR _ INSTALLATION OF FUEL SYSTEM \ IMPROVEMENTS - 10 UNION AVENUE, BAKERSFIELD, CALIFORNIA. \ / ""'., Dear Steve: ./ , / "'-''-.... .",/,-J As yo"ùre·qtlested..,Ql~~~e find attached a copy of the site specific health _~l).çL.safétý plan that MIT Engineering and Constñiëfiõñ'has-prepared..f.m:-the....J.I1LprojeGt-at··ftrUñion Avenue. As you may recall, MIT is the new fuel contractor for this project and as such you requested a safety plan from them prior to finalizing your approval of the new fuel permits. Please accept and process this safety plan as required. Please contact me once the plans and the permit have been approved and ready for pickup. Thank you in advance for your assistance and cooperation in this matter. Please do not hesitate to contact me should you have any questions. KH:en Bakersficld06· ctter.doc 12453 Lewis Street. Suite 201 . Garden Grove. California 92840 0 714/750-0991 e (Fax) 714/750-0990 :-:::iS1Ðl f::ETUf' MRY 15. 2002 4:54 ~1 t~lt~TEr"l UN 1 T;::'~ Lt.::;. :::~'/::nH1 Lf-',NI. ENGL 1 ~3H f;',;,'f.;THl ['¡·'ll:: Ilf'l[ FOF:I"!AT ("10N DI! '/\"('( HH: f"If'i: :38,("1 -- .JA,='K ¡ N THE fiCo:·, In LH'· 1 (iN ¡:OJ'.,/E. bMJ~ER:3F 1 ELD . ,=.{, SHIFT TII''IE I Hr"1 :3HIFT Tlr"lE 2 ..,LED :3HIfT T II"lE ,-, ],):'.:;-.;BLED '-.) SHIfT rII"1£ 4 [I I :'_;HBLED TANK PH: T::3T NEEDED L.JRN D I :3ABLED TANI·: ANN Tf~T NEEDED l.,.IRN D I ;:3ABLED LI NE RE-ENf~BLE "'lETHOfI PASS LINE TD,3T L 1 NE PER T8T I-,¡EE[,!::D I...JRI'· DISABLED LINE f~NN n:;,i' NEEDED t,). D I :3ABLEü . PR I NT TC \.IOLUI"IÐ:: ENABLED TEI1P COr'1PEN:::RTION VALUE (DEG F !. hU.U ~:n I Cì< HE] CHT OfF:3ET EI"JABLED H-PROTOCOL [lATR FORI"1AT HEIGHT DA'lL I CHT SA\." I NG T I f"l£ ENABLED :3TFiRT DATE APR WEEK SUN START TI r"l£ 2:00 AI"1 EN[I D(HE OCT v.!EEK b SUN END T H'lE 2:00 Hr'1 . RE -[I I REC~T L':)(:F\L FR INTo JT D 1 SABLEI, EURO PROT':)I:'ÜL f'REF 1 >: c.' ,..J SiSTEr'l SECUF: 1 'Pi CODE 000000 cm'U"lUN I Cr:;T IONf3 SETUP - - - - - - - - - - PORT SETTINGS: e CO~~ BOARD 1 (RS-232) BAUD RATE 1200 PARITY EVEN STOP BIT 1 STOP DATA LENGTH: ';' DATA RS-232 ~3ECUR IT..,' CODE : DISABLELi AUTO TF:ANSf"l I T E;ETT I NC;S : AUTO LEAK ALAF:r"'l L 11"11 T D I ~3ABLED AUTO HIGH WATER LIMIT DISABLED AUTO O',JERF I LL L lI"1 I T DISABLED AUTO LmJ PRODUCT DISABLED AUTO THEFT LIMIT DISABLED AUTO DEL I \lERV START DISABLED AUTO DELIVERY END DISABLED AUTO EXTERNAL I, NPUT ON DISABLED AUTO EXTERNAL INPUT OFF DISABLED AUTO SENSOR FUEL ALARr'1 DISABLED AUTO SENSOR DISABLED AUTO SENSOR DISABLED e ~,JAT£R AL_ OUT AU1F:r"1 RS-232 END OF r"lESB~\GE DISABLED -. ~.' IN-TANK SETUP -----~-~ T 1: UNLEADEIJ PRODUCT CODE THERt"IAL COEFF TANK D I ArvlETER TANK PROFILE FULL \lOL 88.3 INCH \lOL 58.9 INCH VOL 29.4 INCH \JOL FLOAT :3 I ZE : t..JATER klARNI NG HIGH WATER LIMIT: ¡"1A>: OR LABEL VOL: O\JERFILL LIf"1IT HIGH PRODUCT DELIVERY LIr"lIT LO¡'J PRODUCT LEAK ALARM LIMIT: SUDDEN LOSS LIMIT: TANK TILT PROBE OFFSET rvlhN I FOLDED TAI'JK:3 TIi: NONE ",' . -- _. - - 1 : .000700 1 7.75 4 PT:3 1 ~J7[13 o o [I 4.0 1 N. 1970:3 90% 17732 95::~, 18718 15% 2955 LEAK f''1I N PER Ií)[J! C : .% _¿5 LEAK MIN ANNUAL 50% 9851 PERIODIC TEST TYFE STANDARD -- 500 15 40 0.00 2.75 ANNUAL TE8T fAIL {~LARt"1 D I :::;ABLED PERIODIC TEST FAIL ..~ ALAf:r"1 Ii J ~j~D GRO~3:3 TEfH fA J L ALARr"l DISABLED A/'m TEST A\lERAG J NG : Off PER TEST A\/ERAG I NG : OFF TANK TEST NOT I Pi: OFF TNK TST SIPHON BREAK:OFF DEL I \,I£RY DELAY STICK OFfSET PUf"lP THRESHOLD :3 r"\I N 0.00 10.0m, T 2: PREr"lI U~'1 PRODUCT CODE THERt"1AL COEFF TANK D I Af"lETER TANK PROFILE FULL \lOL 88.3 INCH I/OL 58.9 INCH \lOL 2'3.4 INCH \lOL FLOAT SIZE: WATER WARNING HIGH WATER LIMIT: t"lAX OR LABEL \/OL: OIJERF I LL LI f"1 IT HIGH PRODUCT DEL I VERY L I r"l I T LOl¡J PRODUCT LEAK ALARf"l L I ["!] T : SUDDEN LOSS LIMIT: TANK TILT PROBE OFFSET t"lANIFOLDED TANKS Tit: NONE e : .000700 117.75 4 PTS 10369 8512 5244 1950 4.0 IN. 10369 ~O~<; ':J332 .'..,¡::;~'~ t ,' 7,~ 15155 500 15 40 0.00 0.00 LEAK r'11 N PER IODIC: 25% 2592 LEAK MIN ANNUAL 50% 5184 PERIODIC TEST riPE e STANDARD ANNUAL TEST FAIL ALARr"1 D [ ~3ABLED PERIODIC TEST FAIL ALARt"1 D I :::~ABLED GROSS TEST FAIL ALARf"l D I SAELED ANN TE-:3T A\/ERAG I NG : OFF PER TEST AVERAGING: OFF TANK TEST NOT 1 FY : OFF TNK TST SIPHON BREAKa DEL I VER'! DELAY STICK OFFSET PU["1P THF:ESHOLD 3 ["lIN 0.00 ]0.00% ~~ 1.5 2.0 T :3: DIESEL PRODUCT CODE THERt"lAL COEFF TANK D I AJvlETER TANK PROFILE FULL \.iCiL 88.5 INCH VOL 59.0 INCH \JOL 29.5 INCH \/(iL FLOfH S I :~E: l:,JATER "Iì-\RN I N(; HIGH WATER LIMIT: t"1A>< OR LABEL VOL: O\JERF I LL L IrvlI T HIGH PRODUCT DEL 1 VERY L I 1"11 T LOW PRODUCT LEAK ALARM LIMIT: SUDDEN LOBS LIMIT: TANK TILT PROBE OFFSET ["IAN I FOLDED TAN¡:;:'~ Trt: NONE :3 : .000450 J 18.00 '\. 565, :3524 1388 4.0 IN., 7029 90% 6:326 95~~, 6677 1 E.% 1054 500 15 40 0.00 0.00 LEAK ¡"lIN PERIODIC: 1_ LEAK ~1 IN ANNUAL 50% 3514 PERIODIC TEST T\'PE STANDARD 1 ~ 2. ANNUAL TEST FAIL AU1Rn DISf1BLED F'ERIODIC TEST Fi-ìIL ALAF:I"l D I :3ABLED GRO:3S TE:3T FA I L ALHRt"l D I SA_) ANN TEt,T AVERAG I !'IG: ~ PER TEST A\lH:AG I NG : OFF TANK TE:3T NOT I FY : OFF TNK TST SIPHON BREAK:OFF DEL I VERi [¡ELAY :3T I CK OFFSET PUt"IP THRÐ3HOLD :3 I'll N 0.00 1 o.om~ LEAK TEST 1"1ETHOD - - - - - - - - TEST ON DATE : ALL TANK JAN 1, 1 996 START TIME : DISABLED TE:3T RATE : 0.20 GAL/HR DURATION : 2 HOURS TST EARL V STOP:DISABLED LEAK TEST REPORT FORI"lAT NORI"IAL e :: j(~U ~D _S~N~OR _ S~T~P .__ L i: UNLEADED ANNULAR TRI-STATE (SINGLE FLGATi CATEGOR'l : ANNULAR S¡:'¡4CE L 2: UI'4LEiWED TURBI N SUr"ll) TR I -E~TATE (E; I NGLE FLOAT) CATEGOR'l : SIP SUI"lF' L 3: UNLEA[JED FILL S ur"1P TRI-STRTE <SINGLE FLOAT; CFlTEGOR\' : PIP I NG SU~1P L 4: SPLI T TANK ANNULAR TRI -STATE (~3I NGLE FLO¡~T;' CATEGORY : ANNULAR StltE L 5 :PREMI Uf"í TURSIN sur"IP TRI -STATE <SI NGLE FLC-ATi CATEGORY : STP :3Uf"lP L 6: PREm Uf"1 FILL SUt'lP TRI-STATE (SINGLE fLOAT) CPlTEGOR\' : PIP I NG Bur-'n:> L 7:DIESEL TURBIN SLa TRI -STATE \SI NGLE FLW> CATEGORY : STP sur"lP L 8:DIE5EL FILL STMP TRI -STATE <~3I NC;LE FLOAT> CATEGORy' : PIP I NG ~3Uf"lP L 9: D I SP. 1-2 TRI-STATE <SINGLE FLOAT) CATEGORY : DI:3PENE::ER PAN LlO:DISP. 3-4 TRI-STATE \SINGLE FLOAT) CATEGORV : DISHNSER PAN Ll1:DISP.5-6 ... TRI -STATE (51 NGLE FUW, CATEGORY : D I SPEN::::ER PAN L12:DISP. 7-8 , TRI-STATE (SINGLE_FLOAT; ._ __....... ...... j . ,.... T .-~r·.T""~.I. ..rrJ T).().ld L1 3: D I SP. 9- 0 TRI-STATE <SINGLE FLOAT) CATEGOR'/ : DISPENSER PAN L1 4 : D I SP. I - j 2 TRI -:3TATE <Sf NGLE FLOiW:' CATEGORV : D J::':PENf;ER PAN OUTPUT RELAY' SETUP ----_0_ - - - - R : UNLEADED P8D T'iPE : Err A NDARD NOR/vIALLV CLOSED IN-TANK ALARf"/S T :HIGH ("JATER ALARf"] T I :LO{.j PRODUCT ALAR!"I LIQUID SEN:30R AU'IS L :FUEL ALARf"1 L 2: FUEL ALAR~'I L 3: FUEL ALAR!"1 L 9: FUEL ALARI") L I 0 : FUEL ALARf"1 e L I : FUEL ALAR~1 L1 2 : FUEL ALARf"1 L 3: FUEL ALAR!'1 L 14: FUEL ALAR~'1 L :HIGH LIQUID ALARM L 2:HIGH LIQUID ALARM L 3:HIGH LIQUID ALARM L 9:HIGH LIG¡UfD f~LAR~'l LIO:HIGH LIQUID ALARM L1 ¡ :HIGH LIOUID ALAR"'1 L12:HIGH LIQUID ALAR"'! L1:3: HIGH LIQUID fìLARf'" LI4:HIGH LIQUID ALARM R 2: FREf"l I UN PSD TVPE: :~TANDARD NORr"IALL v CLOSED e e IN-TANK ALARI"I}':; T 2:HIGH WATER ALAE T 2: LO[".I PRODUCT AU\RI"l LIQUID SENSOR I-1U1S L 4 :FUEL ALARr"1 L 5: FUEL ALARI"1 L b: FUEL ALARI"1 L 9: FUEL ALARr"l L1 0: FUEL ALARf"l Lll : FUEL ALAR~'l L 1 2 : FUEL ALARI"1 L 1 :3 : FUEL ALARt"'1 L 1 4 : FUEL ALARt'l L 4:HIGH LIQUID ALARM L 5:HIGH LIQUID ALARM L 6:HIGH LIQUID ALARM L 9:HIGH LIQUID ALARM LIO:HIGH LIOUID ALARM" Lll : HIGH LIQUID ALARH L12:HIGH LIQUID ALARM L13:HIGH LIQUID ALARM L14:HIGH LIOUID ALARM R 3:DIESEL PSD TYPE: ~ STAN(JARD _ NORMALLY' CLOSED IN-TANK ALAF:r'lS T 3:HIGH WATER ALARM T 3: LOt,) PROOUCT ALARr"l L I OU I D SENSOR {.,U"lS L 4 :FUEL ALARr"1 L 7: FUEL ALAF:t'1 L 8: FUEL ALMRt"l L 1 0 : FUEL ALARr"1 L14:FUEL ALARn L 4:HIGH LIQUID ALARn L 7:HIGH LIQUID ALARM L 8:HIGH LIQUID ALARM LIO:HIGH LIOUID ALARM L14:HIGH LIQUID ALARM R 4:0\.lERFILL TYPE: _ STANDARD W NORt"IALLV OPEN IN-TANK ALr:lRr"IS ALL: OiJERF I LL AUÜ~I"l f'\LL: HIGH PRODUCT ALAm"! ALL: t"lA>< PRODUCT r:lLARr"l LI GU I 0 SENSOR AU'lS ALL: FUEL ALARr"! ALL : ~\JATER OUT ALAF:r"l ALL: HIGH L r GU I D {;LAF~r"1 . RECONC I LI AT ION SETUP - - - - - - - - - - AUTor"lATIC DAIL\' CLiX3! NC; TIr'1E: 2:üü Af"! PEF~IODIC RECC'NCIL!ATION 1"'lODE: r"10NT HL'l TH'lP cor"IPEN~3AT I ON STANDARD BUS SLOT fUEL t"lETER TANK ~ -e ------ TAI'W ["lAt' Er"lFT'i ---- IN~rANK ALARM T 1: UNLEADED LOl,) PRODuCT ALARr"l ~~y 15. 2002 4:50 PM -a IN-TANK ¡,:;UiJ,:f'1 1"'UNLEADED DELIVERY NEEDED MAY 15. 2002 ~:50 PM ----- IN-TANK riU,Rr"] T 1: UNLEADED . SETUP DATA f...JARN I NG MAY 15. 2002 4:50 PM ,JACK I N THE £:0:< 1 W~ I ON A\/E,' SWSF1ELD.CA. MAY 15. 2002 4:50 PM .......------~.- SYSTEr"l STATUS REPORT - - - - - - - - - - - - T 1 :8ETUP DATA I"JARNI NG - JT:-L-V¡:;¡YFRXiUC'f ÄLARt'l L 1: FUEL ALAR!"! T 1: DEL 1 \jERV NEEDED L 2: FUEL f~LARI"l L10:FUEL ALARI"1 I r_ TOR'\" REPORT T 1: UNLEADED \/OLUI"1E ULLAGE 90~;; ULLAGE= TC VOLU!"lE = HEIGHT STK HEIGHT= WATER VOL WATER TEMP T 2: PRE!"1 I uri VOLUr"lE ULLAGE 90% ULLAGE= TC \lOLUI"1E = HE I C;HT 8TK HE I C;HT= WATER \lOL L,jATER TE_ T 3:DIE8EL VOLUf"lE ULLAGE 90% ULLAGE= TC VOLUI"lE = HEIGHT STK HEIGHT= LJATER \lOL WATER TEr"lP o (:;{IL8 1970:] GALS 177:32 GALS o GALS 87.07 INCHES 87.07 INCHES [I GALS 0.00 INCHES 70.7 DEG F 7825 GALS 2543 GALS 1506 GALS 7765 GALS 81.55 I NCHE8 81.55 INCHES Ci I::;ALS 0.00 INCHES 71.0 DEG F 5951 GAU3 1078 GALS 375 GALS 59::;'0 GALS 93. 1 INCHES 93. 11 I NCHE3 o GALS 0.00 INCHÐ3 71 .c~ DEG F * * M ¥ MEND M M ~ M * e ----- f3ENSOR ALARt'! _____ L 1: UNLEADED ANNULAR ANNULAR SPACE FUEL ALARt1 t"¡A\' 15.. 2002 :3: 03 Pr"! ----- SENSOR i::¡LA¡;'~t',¡ _____ .. UNLEADED ANNULAR LAR SPACE Fe ALARfv¡ MAY 15. 2002 3:03 PM ----- SENSOR ALARM _____ L I : UNLEADED ANNULAR ANNULAR SPACE FUEL ALARt"! MAY 15. 2002 3:03 PM --a. SENSOR ALARt,! _____ L~INLEADED ANNULAR ANNULAR SPACE FUEL ALARt"¡ MAY 15. 2002 3:04 PM ----- SENSOR ALARM ----- L 1 : UNLEADED ANNULAR ANNULAR SPACE FUEL ALARr"! MAY 8. 2002 9:30 AM e ----- SENSOR ALARM ----- L l:UNLEADED ANNULAR ANNULAR SPAC:E --FUEL -ACARr'" - MAY 8. 2002 9:30 AM - ----- ~ _~ ,r ~- " -.....,. - ~--........ " ~:oENSÜR~- FiLARf"! /- :~.._- L 2: UNl:£ÄDED TURB I N SU~'1P ~3TP S Ut"1P ~---- FUEL ALARr~1 '.... fvWl 15, 2CJû2 4 : :;:~û Pt"1 -." ~ '-. "-'- ""-. -~ ,-' -e ~3ENSCiR L 2:UNLEADED STP ~3 Uf:"1P FUEL ALAR!"! ("lAY 15. 20£12 ~ fiLAR!'" ..- - -- TÜRB I I'·J sur"lr~ - A~: 2 ~~ pr"1 " "'\ ----- SENSOR ALARM L 9: D I SP. 1 _ 2 DISPENSER PAN FUEL ALAR"" ,"/in" 1 5, 2002 .'] : 56 H'¡ -A_ SEt-¡SOF: ALARi'1 _. __ _ __ ~ ~SPL I T TANk ANNULAR t'i1\JfVULAR SPACE F~~L ALARI"} t"It'i'r 1 5, 2002 <4: 00 PI"! --.--- SENSe'R ALARI"} ._____ ~ 1 :UNL~ADED ANNULAR ANNULAR SPACE FUEL ALAR"'¡ "1A\1 1 5, 20lJ2 <4 : 00 PN e e ----- °Et'r'oP . 2: UNLEAgËr; Tp SUt<'IP ~~L ALARI") i'y 15, 2002 ALAF.'I·'f _ ,,_ _ _ TURRI N SUI"IP 4:01 Pt"! ~ ( .f SEN~30¡;~ ~Li:;Hr"1 L 5: PREt''1I Ut"l TURB IN SUt"lF' STP SUMP FUEL ALAHt" t"I.15. 2002 4: 02 Pt"l ----- SENSOR ALARM ----- L 4:SPLIT TANK ANNULAR ANNULAR BPACE FUEL ALARr-'1 MAY 15. 2002 4:03 PM ----- SENSOR ALARM ----- L 7:DIESEL TURBIN SUMP ST.'Llt"IP fli AL_ ARI'-'l r"IA'~ 5. 2002 4: 03 Pt"l - ----- SENSOR ALARM ----- L g:DIESEL FILL STMP PIP I NG Sur'1f-' FUEL ALARt'" MAY 15. 2002 4:03 PM ~ ....."....... ,,,.....- ----- SENSOR ALARM L1 0 :DISP. :]-4 D I SPENSER PAI~ FUEL ALARrvl t"l* 5. 2002 4: 04 PI'1 ----- SENSOR ALARr"l L1 4 : D I SP. 1 1 -1 2 D I ~3PENSER PAN F \JEL AUjRr"¡ MAY 15. 2002 4:05 ~M ~I ~ RE'-':,\ ~:lI~~-::~ - - R 1 : UNLEADED PSD TYPE: STANDARD NORr'lALL Y CLOSED IN-TANK ALARr"IS T 1: HIGH ~,JATER ALAFJ'] T 1: LO!.,J PRODUCT (~LARr"l LIQUID SENSOR ALMS L 1 :FUEL ALARr"l L 2: FUEL ALARr'l L 3: F \JEL ALARr'· L 9: FUEL ALARr"! L 10: FUEL ALARr"! Lll :FUEL ALARI"1 L 1 2 : F /JEL ALARt1 Ll 3 : FUEL ALARr"\ .' : FUEL ALAR!'" HIGH LIQUID ALARM L ¿:HIGH LIQUID ALARM L 3:HIGH LIQUID ALARM L 9:HIGH LIQUID ALARM L 10: HIGH L Ié~UID ALARr'l Ll1:HIGH LIQUID ALARM LI2:HIGH LIQUID ALARM LI3:HIGH LIQUID ALARM LI4:HIGH LIQUID ALARM -----~- OUTPUT RELAY f:;ETUP ------ - - - - R 2 :PRH1I UN P:3D TiPE: ." NDI:;RD N( LLY CLOSED I .~- .'. NK ALARI"lS HIGH L'JATER ALARt"1 T ~.LOW PRODUCT ALARM LIQUID SENSOR ALMS L 4: FUEL f~LARr"1 L 5 :FUEL ALARr"l L 6: FUEL ¡::,LARr"l L 9: FUEL (:;LAR!"l L 10: FUEL ALARr", L11 :FUEL AU:;RM L12:FUEL ALARM L 1 3 : FUEL ALARf'1 L 14: FUEL ALARr1 L 4:HIGH LIQUID ALARM L 5:HIGH LIQUID ALARM L 6:HIGH LIQUID ALARM L 9:HIGH LIQUID ALARM LI0:HIGH LIQUID ALARM Lll :HIGH LIQUID ALARM LI2:HIGH LIQUID ALARM L13: HIGH LIQUI D ALARM LI4:HIGH LIQUID ALARM OUTPUT RELAY SETUP - - - - - - - - - - - - .) I ESEL P:3D T' " , ' STANDARD NORr"IALL Y CLOSED IN-TANK ALARr"1S T. 3: HIGH I.JATER HLF,Rr"1 T 3:LOW PRODUCT ALARM L I QU I D SENSOR AU'lf:; L 4: FUEL ALARf"1 L 7: FUEL ALARr"1 L 8: FUEL ALARr1 L 'j: FUEL ALAR!"l L 1 4 : FUEL ALARr"l L 4:HIGH LIQUID ALARM L 7:HIGH LIQUID ALARM L 8:HIGH LIQUID ALARM L 9:HIGH LIQUID ALARM LI4:HIGH LIQUID ALARM e 4' ~'«i.." ._ - -:;.. , -~ e LI au I D SEI'~~=JI.'R ~:ŒTUP - - - - - - - - - - L 1: UNLEADED P,NNUUiR IF: I -STATE ';SI NGLE FLOAT) Ce';ORY : ANNUL.AF: BUiCE L 2:UNLEADED TURBIN SUMP TRI-STATE (SINGLE FLOAT) CATEGORY : STP SUMP L 3:UNLEADED FILL sur"lP TRI-STATE (SINGLE FLOAT) CATEGO¡;N : PIP I NG SU~'1P L 4 :SPLIT TANK ANNULAR TRI-STATE (SINGLE FLOAT) CATEGORY : ANNULAR SPACE L 5: PREf'll U~1 TURB IN sur'w TRI-STATE (SINGLE FLOAT) CATEGORY : STP SUI"1P LIS: PREr'1 I ur"1 FILL SUI"lP TR_TATE (SINGLE FLOAT) CA_)RY : PIP I NG sur1P ~- .~--~ - L 7:DIESEL TURBIN SUMP TR_TATEi::::n NGLE FLOAT) CA~RY : STP ~3Ut"lP L 8:DIESEL FILL STI"1P TRI-STATE (SINGLE FLOAT) CATEGORY : PIPING SUMP L 9: D I SP. 1-2 TRI-STATE (SINGLE FLOAT> CATEGORV : DISPENSER PAN LlO:DISP. :]-4 TRI-STATE (SINGLE FLOAT) CATEGORY' : DISPENSER FAN Lll :DISP. 5-6 TRI-STATE (SINGLE FLOAT) CATEGORY : DISPENSER PAN L4IDISP. 7-8 TR I -STATE .; SINGLE FLOAT) CATEGORi : D I SF'ENEìER PAN Ll 3 : D I SP. 9 -1 Ü TRI -STATE <Sl N':;LE FLOAT) CATEGOR',/ : n I E~PENSER PAN Ll 4 : D I SP. 11 - I 2 TRI-STATE (SINGLE FLOAT> CATEGORV : DISPENSER PAN -. TYPE OF ¡ACTION .. UNIFleo PROGRAM (Up, FOAM ___ UND!ftGROUND STORAGE TANK&WFACILITY (one page per site) Psge _ of _ (Check one Iu,m QI'IIYI tJ 2. I o 3. RENEwA¡' P£:~MIT 0 II.CI'tANGe 0'" INFgflMArlON Q 4. AMI!'-IO&Þ ÞERMtT d 6.-mAPORA~Y SITE (;LOSU~e C ".ÞE"'M~!ktLyct..osEO BITE CJ B. T.NII: FlEMOVEÞ - f:'ACIUTY oWNeR TYPE 3 1. CORPORATION o 2. INDIVIDUAL D 3. PARTNe:RSHIÞ 4. LOCAL AQENCYJDlmlCT' C S. COUNTY AGENCY- C e. STATEAGENCV· tJ 7. FeOEAAL ABSoIcV' fGf 'I! GWNt 01 UST Is Q public: QglIIF1ep: nltlN aI eUþ8NiSar IS' áMJ an. III£fiCIfI 01' oll1cø ~ lIþSl8tlll u,ø lJST rTt\li lithe CGIIt8aI 1'8'-' lor_ taI* rIIZftIIL) - NM - . 41¥1 PHONE BSð. '511. 2b8" .. 40D ,,:¡ 1. CORPORATION 413 ~G. vENuE 41. PONE 8$8.571. ZbfØ .,. .11 CITY .ie ZIP cooe "0 c:.A C1'Z.I1.$ 4. LOCAL AGENCY I DISTI'tIGT a. STATE AGENCY II2Ø 3. ÞAFlTN~RSHIP 5. COUNTY AGENCY T. ÆDERAl AGENCY IV. SOARD OF eaUALlZA TJON UST STORAGE FEE ACCOUNT NUMBER Call 916 322·9669 If uestions arise 4~1 V. PETROLEUM UST FINANCIAL RESPONSIBILity a 4. SUAETY aOND a 7. STATE FUND [] to. LOCAl GO""" MECHANISM o 5. LETT'ER OF t;AEDIT a 8. STA"tE FUND & ct=o LemA 0 99. OTHE~: Cle. eXEMPTION a 9. STATE FUNO & CO VI. llGAL NOT1FICA TlON AND MAILING ADDRESS CPlatl! 01\0 bolla ¡ndalS wn IddreU NlauId be !tIr nalfllcaUQl1l anr.t fNlllIn9. le "."ItIe8Uo", end ,"sJII _ wW bo S91'1 to the IEI"IC ow"", UfI'êllll bI:!~ ! o~ 2 III e),eelllMl. I. ~ACIU1'Y I:] 2. PROP£RTV OWNEFI a 3. TANI( OWNeR 423 I I. AP ICANT SIGNAtuRE INOICATE MEn-40C(I) go 1. Sri .INSURED a 2, GUA~A~Tee [j 3. INS RANCE 422 æ OFFICIAL USE ONLY o STRICTn~SPECTOR STATE IJST FAC1 .JTY N MSER 62JI UP FORM (1I2QOO Vets! I THe CUP" Of' LOS AN I aE$ COUNTY UPF JAC4: OB_USTA UNIFIED PROGRAM (UP) FORM UNDERGROUND STORAGE TANKS - TAN 1. New SiT ¡¡ ÞI:RMIT 03. ReNEwAL PERMIT 0 5.CMANGIi OF INFORMATION tI ~. AMENOED PERMIT 0 e.TEt.IIPOAAs::IY sin CLOSU~E ACI ITV D: 4.3D I DATE INSTAllED (YEARfMO) .2-001- ADDITIONAL. DESCRIPTION (J:olloall ~~ C I'Ily) No öI 438 d.37 439 TANI< use 1£1. MOTOR VEHIOll: FUl';l III -1IiOCI COIIIØID" PcIllallMJ'" T'¡Ip> o 2. NON.FUEL PETROLEUM [j 3. CÞæMICAL Þ ;¡ObUCi o d. HAZAFlDOUS WAStË (IndIiSGS U5IJ4 CU) C 95. UNKNOWN II. 4.39 PëTF!OLEVM "tYPE 11(111. ~eGUL.Al'lLJNl..ëAOeC;l CJ 1b. Þ~EMIUM UNLEADED tile. MIÞGAADE UNI..EAOED COMMON N.AME Ørom I-\az.al'doUa Malerlels I"Vlln\Qty þIIga TANK CONTENTS 440 o 2. L.EAtJED C 3. DIESEl.. [J 4. GASOHOL. tJ s. JET FUeL. tJ e. AVIAiloN FueL 099. OTHER: CAS. (',om H~lCIøoJ' IOIaIIltiala 111.......1<:1" pagel 442 4.41 III. TANK CONSTRUCTION 3. SINGU: WAU.. WITH EXTERIOR MeMBRANe I.INER [J 4. SIGNLE WALLIN VAULT 3. FIBERGLASS I PL.Þ.STIC o 4. STEEL CLAD W~16ERGLASS AEINI'ORCED PLASTIC IFRP TANK MATERIAl. -~." IBII~ 1, BARE STEEl.. S. FISeRGLASS I PLASTIC (~.....ilamCO'll"J 0 2. S"tAINlËSS stl;EL. C 4. STEEL OLAO W/FISEi=lGLASS FlelNI=ORceo PLASTIC (FFlPI t) 10. COAtED STEEL 3. epoxy L. WING 5. r,iLASS UNING QS. UNI<NOWN TYPE OF TANK I(ChOalo ..... "_11\ Øl\lrJ 1. SINGI.E;: WA.Ll. W TH INTE~NAL. 8LADOER 4oi3 95. UNKNOWN CI 99. OTHER 444 44S TAN ( INTEI'IIOI=t UNING 1. ~ueaE~ UI\iE:b OA TE NST ALLEO 447 o 2 ~Lt(YtJ LINING o 4 PHENOLIC LINING IJ B UNLlN!;O 3 FIBERGLASS ReiNFORCED F' a .. IMPReSSED CURFlENT o 99 otHER 446 (Fa, _I \In Q~YI YeAR INSTAL.LeD 4':;0 TY E (læalu'.0n!tl 451 14411 OATE; INSTAL.L.EO ("'" IccaI \lDO OlIly) 44e MENT VEAAINSTALlED 452 ~ 2 21 ALARM ~ '1 of r e: g. a;t at 2 BALL FlO AT n:". ¿,. f) ð c...- :3 Fill 1VBE SHUT OFF VAlVE D 4 eXEMPT IV . TANK L.EAK DETECTION A Qe!IC/IP Jg" of 1~9 rIX)rIllo~n þ1VØ18'" 811811 b9 "'b,"l~ed 11;1 ,II, lcale ¡tçy.' IF SINGLE WALL T.ANK (CIIoeIIal!t!l8t.allpiy¡ 4G3 IF DOueLe WALL TANK OR TANI< WITH BLAODEFI 494 (C!Iec1I l1li11 Hsm ghiJ C 1 VISUAl {ExÞCSEC PORTION O~LYJ [:J 5 MANUAL TANI< GAUQING (MTQ t! 1 VISUAl (SINCKE WAlL IN ....AUL.T ONLY) C 2 AIITOMATIC TANI< GAUQING (ATG) CJ e VADose ZONe 1t2 coNTINUOUS INT£I1STltIAL. MONITOP,ING [J j CONTINUOUS ATG r:::J 7 GROUNClWATeR C 3 MANUAl MONITORING a 4. STATISTICAl. INVENTORY RECONCII..IATlON 0 B TANI( tEstiNG (SIR) + SIENNlAL TANI< TESTI"IG CJ 99 OTHeR V, TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATEC CATË LAS! LJs£:c (YRlMOIOAY .$5 I::STIMAT'E:D QUANTITY 01= SLJSSTÞ\NCI!REMA,INING 458 TANk PILieo WIT . INEFlT MAiEFIIAL? 4$1 tI Yes C No OFFICiAl USE ONLY DATE RECEIVED CUÞA PA OIS"tRICTlIN$PECTOR UP FOAM (1/2000 Vetslon) THE CUPAs OF LOS ANGELES COUNTY UÞF_LAC4:07_UST8 UNIFIED PROGRAM (UP) FOAM UNDE GROUND STORAGE TANKS - T A PAGE 2 V" "'INeI CONSTRUCTlDN Oheçk 8,11 thslappl UNDEAGFtOUND PIPING SVSTEM TYPE 1. ÞRESSURE 0 2. SUCTION CJ3. GFlAVIT'I" 458 CO~ST"uctIQM a 1. SINGLE WAIJ. t:J 3. \.INEb T~ENCk t:J99.0rtiER 460 W\fIUFACTUR£R.Z. ÞOU8LE WALL 1:1 85. UN~OWN MANUMCTVAEA 11-0 ~ 1"'/1 461 ~~~~~~NANO C ,. SAAE. stEEL MJM::L COMPATIBLE ./1110% PROTECnON 0 C 95. UNKNOWN [J 2. STAINLESS ST£El 7. GALVANIZED S't/¡EL o 3. PlASTIC C:OMÞATIBLE WI CO~ENTs tJ 8. FlEJliIBLE (HOPE) kd. FISI:RGI.ASS 0 9. CAt~OOIC PROTECTION 05. STEEl W/COATING. 0 99. OTHER VII. PIPING LEAK DETECTION Cllllc~ 811 \IIe\ , UNDERGROUND PIPING 91"OL£ WALL PIPING PFlESSUFlI2EC PIPING IC/'IOG..f! tnm, "plYI: C 1. !l!CTROHIC LINE LI!AI< DEteCTOR 3.0 GP'" TEST JimèI AUTO PUMÞ SH\J1' opp I=CR LEAK. SYSTeM FAILUPlE. AND SYSTEM DISCONNECTIOtll.. AUOIBlE AAD VISUAL ALA~MS, t! 2. MONTHl..V 0.2 OPH tEst D 3. ANNUAL INTEGI=IllY TEST (0.1 GP...) CON\{ENTION~ SUCtiON $VSTIò:M8 (CI'IOd .U !II.I _;1 D 5, DAILY YISUAL MONITORING OF ÞUMPING SYSTEM + 'tRIENNIAL PIPING Itrt~GRITV iEST (0.1 GPÞ04) !am ,¡'¡¡U bo .~IIC/ Ie "" IœIú II ABOVEGROUND PIPING SINGLE WALL PIPING F'ReSSI)~ lEb PIPING /~1I\'J1r 81 ilia! sp,,!¡I : D 1. eLeCTRONIC UNE LeAl( OEtec;rQA 3.0 GPÞ04 TeST r£IIt1 AUTO PUMP SHUT OFF FOI:I LEAK. SYSTEM FAIL.URE. AND SYSTEM DISCONNIæCTION .. AUDIBlE AND VISUAl ALARMS. a 2. MONTHl V D.2 GÞH TEST o 3. ANNUAL INTEGRIT'I' TEST 10.1 GÞH 04. CAlLY VISUAl CHECK CONVENTr~AL SlIdTION syst£Ms (ChedI aO fI8 IIIPfr o S. DAilY VISIJAI. h10NrtOI:tING o~ ÞIÞINca AND PUMPING SVSTeM C e. TFlIENNIAL INTEGRITY TEST (0. 1 GPH) SAFE SUCTION SYSTIær.4S (NO VAL.UES IN aEl..OW GROUNOPIPING): SAFe suCtiON 9YSTEMS (NO VAlves IN BELOW GFlOUNO PIPING): a 1. 5EI.F II'!ONITOAINO C 7. seLF MONITORING GAAVITY ~lOW GFlAVI'tY "LOW (CJoDck .nltls' ."p y : CJ 9. BIENNIAL ItrteG ;t ty TEST (0.1 GPH) tie. DAilY VISUAl MONITOI=IIHG 09. SIENNIAI.INTeGAITY TEST 10, \ GPH} S!ÇQHDAR'LY CONTAlNEO PIPING seCONDARILY CONTAlNE" þ/ÞIHGI Þ1;IESSURIZED PIPING IC~ .ø that ~: F'AeSSLJPlIZEÞ PIÞING IC~8Ck .11 Ü'lel e.pp y): 10. CONTINUOUS TURBINE SUMF' SENSOR WW:I AUCISI.E ANI) VISUAL. 10. CONTINUOUS TLI~a IIIE SUMP SENSOR!ttIIt:I AUDIBLE AND VISUAl A'-AAMSIIHÞ IC'" _) AlARMS ANO (ChedI_ o A. Auto PUMP S~UT O~~ WHEN A lEAK OCCUAS tJ a ,AUTO PUMP SHUT OFF WHEN A LbI< OCCURS ,Itb. AUTO PUMP SHUT OFF FOR LeAKS, SYSTEM FAilURe AND 0 b AUTO PUMP S~U't OFF FOR LEAKS, SYStEM ~,AILU~E Mlb SYSTEM SYSTEM OISC~NeCt'ON DISCONNECtiON Ce. NO AUTO PUMP SHUT OFF CC NO AUTO ÞUMP SHUT OFF 1(11. AUTOMATIC LEAK DETECTOR (3.0 Gf'H TEST) WJ1I: I'L.OW SHUT OFF C 11. AUTOMATIC LEAl< OETEOTOA ... 12. ANNUAL,t(tEcaArTY TEst (D, t GPH CJ 12. ANNUAL INTEGRtt'f TEST 10.1 GP~) SUCTIOWGRAV1~ SYSTEM SUCTIOIWGAAVITY SYSTeM D 13. CONTINUOUS SUMP SENSOI't . AlJOISLI: AND VISUAL AtAAAts 0 13. CON11NUaus SUMP SENSOR... AlJO'BLE AND ViSUA.l.. Al.AF\MS EMERGENCY GENERATO"! ONLY (Ø-_ all lllal a¡:t tlt) EMEFlGISHC't GEHEAATORB ONL If I~ eJllhellIØPI)- C 14. OONT1NUOUS SUMP SENSOR WIT ' OUT AUTO PUMP s~ur OFF · a 14. CONt1NUO/JS SUMÞ SENSOFll&ltt;Q\J1' AUTO PUMÞ SHUT OFF· AUDIBLE ANþ VISUAL ALAAMS AIJÞ/BLE ANO VISIJ¡l.L. AI.AJ:1MS C 16. AUTCMAt1C L£A ( omctOA (3.0 caþ~) WltHOL11' ~ow SHUt 01"1= 016. AutOMATIC LINE LEAl< DETECTOR 13.0 GÞH"tEST a 1e. ANNUAL INTE.GAITV TEst fCU GPI-I tJ 11. DAU..Y VISUAL CHECK D 10. A~NUAL INTEGRITY tEst 10.1 GÞH} C 17. QAll Y VI6\JAl C...I:CK VIII. DISPENSER CONTAINMENt DISPENSER ceNT AlNMENT 111. FL.OAT MeCHANISM 'tHAT SHUTS OFF SHEAR VALve OATE INSTALlEC 468.. CONT'NUoµs CISPeNSEA PAN SENSOI=! -+- AUOIBlE ANb VISUAL A1ARMS }(3. CONTINUOUS blBPENSER PAN SENSOR ~ AUTO SHut OFF FOR DISJilENSE~ . AUOleu: AND VISUAl. Al.AAMS . IX. OWN~AIOPEAATOA SIGNATURE 488 2002... P8i a of Asovel3F10UNO ÞIPINCi t:J 2. SUCTION tI 3. GRAVITY OilS. UNI<NOWN 0911. t)tHER a ,. Þ~ESSURe CJ 1. SINGLe WAL.l. e 2. DauBI.!: WALL MANtJI"Actu~e~ dl. BAAe STEEL 4se 40~ 4f!3 CJ II. ~RÞ COMPATIBL.E W/1QO"11, ME'I'I\IINol 1:12. stAINLESS STI<EL as. PI.ASTIC COMPATIBLE W/COHTE~S tJ.4. FIBeRGLASS a 5. STEEL W/COA'tlNG 07. GALVANIZEO STI:EL e 8. FLEXIBLE (~DPE) 0 95. UNK.NQWN o t. CATIofOOIC ÞFlOTe:CTION t:I 99. OTHER ~8~ 461 CJ 4. DAILY VISUAl CHECK d S. TRENCH LINER J MONITORING [J e. NONE 4139 470 n Permit Number 73 Perm" ApþtQVBd .75 UP ¡:ORM (1/2000 Version) THE CUPAs OF LOS ANGELES COUNTY :3 47 Permll Expiration Date UÞF _LAC4: 07 _USTB TYPE Or ACTION , UNIFIED PROGRAM (UP) FORM UNDERGROUND STORAGE TANKS - TANK PAGE 1 two II illS œt unll. Pa.afl of [::J 1.f'ERMANENtL. T CL.OSED SITe: a 11. tANI( ~EMoveo 43D 1 tþ. RSNEWAL. ÞI;RMIT 1:1 5.Cl-tAI\j(3E OF INrOf'lMATION o 4. AMËNOED ÞE~Urt t:l8.1EMPORA~Y SITE CLOSURe ~"CIUTY IP: II "'I'I!!', camplete 11M paGe ~, GJle:iI ~Þ4~I'I~ ~8 NUMSER OF COMPARTMENTS 431 No 434 431 438 TANK USE 43D )!Ít. MOTC~ "SHICLS ¡::I.IEL (II ~ ~.ht þgUul.um Ty IIJ o 2. NON-FUEL PETROleUM [J:t ClieMlt:AL PFlOOUCT C 4. HAZARCOUS WASTe: Clto:2!ùdraa \lNd ell) C 95. UNKNOWN II. ÞlrrROLEUM TYPE o 1a. REGlJ1.AA UN~oeo þj(1b, P1=\EMIUI,! UNL.EACED tJ 1c. MIOGRAbE UNl~OËb GOMMON NAME (11't1"1 I1WIOIIUI "4IQtI~'- Il'IlIonlOlY PI\ØOI TANK CONTENTS a40 a 2. lEACEO a 3. OleSEl [J 4. GASO~Ol t:I S. JET FUEL [:1 6. ~WI¡\T CN FUEl.. C lilt ot~~R: CAS. (Ira", MeutdJIUg MQI'II.II/lIIt""lcry 118DB) 442 &111 "NP OF TANK ((o.lll::t _'\lm CrI~ 6043 Jt2. COUSLE WALL TANK ATEFlIAL -pMUIIY\aIIJc 1. BARE STEEL. ((CIIeo:k ON iIøn mIr) C 2. StAINLEss STEEL BS. UNKNOWN I:] 99. OT o ER <IOU ((C:~-"""'_00\I 0) 5. CONCI=IE1'E 95. UNKNOWN tI s. F~P coUþ"tISLE W/'OQ'Y. M~ANOL 0 99. OTHE~ &49 TA.NK.INTERICFI UNltoIG DATE INSTAl.. D ..7 Q 2. AU<'!'D UNING 1:1 4 PH!;NOLIC lINI~G [J e UNL.INI:D .. FIBERGLASS REINFORCED PLASTIC o 4 IMP !: ESSED CU¡:¡RENT 446 IF", IQCBlllae 01'1'1'1 95 UNÞ<NOWN o 99 OTHER !~ DÁTæ INSTÁl.lSD (Fat II:caI ..,It GIlly) &46 YEAR INSTALLED 50 TYPE (Iac.al..a& only) 451 OVEA¡:lll Pl'ioreCTION EOl.iIÞMENT YeAR INSTALLED 4~:: c:.... 2 «1 ALARM ~ ~ d '!I r t:::. 8. ()() Z. œ 2 BALI. FlO AT rr::. .,. ¿" 0 £- :3 Fill rUaE SHUT OFF VAL V!; a 4 exEMPT tv. TANK LEAK DETECTION rlld4~I~II~l;Ir(119"'Onl\"ri~g t~tu¡,..lIbo ,ul!",l~od 10 IhoII)Q1,lS Srq'.I IF SINGLE WALL TANK (CI-.r:k '" li'1alIlØP'1'I 4SJ IF DO ell:: WALL TANK 0 TANK WIT~ el..ACCeR 4$4 (C~.c~ I;In,lløtlt only! a 1 VISUAL (EXPOSED PORTION ONLY) 0 i5 MANUAL TANk GAUGING (M'TG) 0 , VISUAL (SINGLE WALL IN VAULT ONLY) D 2 AUTOMATIC TANI< GAUGING (ATG) D 6 \lACOSE ZONE S'2 CONTINUOUS INTERSTITIAL MONITORING' C 3 CONTINUOUS ATG 0 7 GAOUNOWAtEI=I 1:13 MANUAL MONJTOFIING I:] 4 $'T'ATlSTICAlINVeNToRv RECONCilIATION a ø T""'I( TESTING (SIR) ... BIENNIAL. "tANK tæSTJ/IIG 1:1 99 OTI-!EF! V. TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ~stIMATEO OATe lAST USED (vRlMO/DAY) 4!5 eS"TIMATeO QUANTITY OF SUIi!STANCef'leMAINlNQ 458 TANI( : liED WITH INERT MATëRIAL? 4sr o Yes I:] Nc OFFICIAL use ONLY OATE RECEIVED CUPA PA. OISTl=I.tCTIINSFECTOFl UP FOAM (112000 Version) TIofE CUPAs OF LOS ANGELES COUNTY UPF _LAC4: 07 _U5TB UNIFIED PROGRAM (UP) FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION Chm:k all that a.Þøl ) UNOERGROUND ÞIPING SYSTEM TYPE 1. ÞI1ESSUI=\G: C 2. SUCTION t):t GAAIJIT'( ~ tONstAUCTIQM 1:11. SINGLE WAll 0 a.lINËO TRENCH 099,OTH£A 4IJO MANU~ActLll\t~. 2. DOUBLE WALl. 0 g ;. UNKNOWN MANUFAC'tUPlE~ II S~/"";I 461 MATeRI~1.S ANti 0 t SAAE STEEL. D 8. Ff:!P COMÞArlt3LI: wllOC'lO CO~~OSION' METkANCL PFlO"tEC'!'ION a 96. UNKNOWN 02. STAINLESS STEEL C 7. GAL.VANIZeo STIE/. 03. ÞI.AS'tIC COMÞA11BL.E WI CONTENTS CJ B. f:LEJlCIBL.Ë (HOPE) 8'4. ~laeRGI.ASS 09. CAT"'ODIC PROTeCTION 0$. STtEl W/cOATlNG 0 99. OTHEFI 4(111 VII. PIPING LEAl( DETECTION ChÞ .'1 Ilia! u UNDERGROUNO PIPING SINGLE WA1.L PIPING PAI:S5URIZEÞ PIPING ICheck 811 1lla18þplyl: a I. tl.EcT1=lCNIC liNE LEAk OET£CTOR 3.0 QÞH TEST ~ AUTO PUMP SHUT OFF FOR LEAl<. SYSTEM ¡;AILURE, ANt> SYSTEM DISCONNEctION.,. AUOIBLI: ANb VISUAL AI.AÞ.MS. a 2. MONTHlY 0.2 GF'H TEST tJ 3. ANNUAL. INTEGAITT TEST (0.1 GÞM CONVENTIONAl. SUCTION SYSTEMS (CI\DI:k 1111 llIal IIDPI¥ o S. OAIL Y VISUAL MCNI'tC~NG OF PUMÞINQ SySTEM + TRIENNIAL PIPING 'NTEORtT"r TEST (0.1 GP~) Pa e 01 ASOVeGFlOUNO PIPING o 2. SUCTION a 3. OAAVITV C 95. UNKNowN C ;9. O' ' . E~ tJ ,. P~E;9SUAS C 1. sINGle WALl C 2. OOUl;1l~ WAll MANU¡:Acru¡:¡eR a,. BÀRE SrEEL. 4S9 462 41)' C 6. F~P COMPATU9L.£ W/ico% MIm1ANOL. 02. STAINI.ES6 Sf EEL 03. PLASTIC; CCMÞA'tISLE W/CONtENTS CJ 4. FIBeRGLASS a 5. STeeL W/COAtlNG C 7. GAlVANIZEO STEEl o 8. FLE ( SI.£ (MOPEI 0 liS. UNKNOWN o 9. CATHODIC PAOTECfiCN Q 99. OTHER .S5 r ram A~ol' bo I U~.Ø lO the QCB . AI30VEG :¡OUNO PipiNG SINGLE WALL PIPING PFleSSUlqlZED F'IÞING IChoCk all tllaI8ÞÞlr): o 1. ELECTRONIC liNe leAK DETECTOR 3.0 GÞH T~ST mII1 AUTO PUMP ,SHUT OFF FOR LeAl(, SyStEM f'P,/LURE. AND SYSTEM D SCONNECTIO~ . AUOleLE AND VISUAL A~M9. [J 2. MONfHl Y 0.2 GÞM feST o 3. AN/IIVAI. INTEGAfh' TeST (0.1 QPH) CJ 4. DAI~ Y VISUAl. CHECK CONVENTIONAL 5uèTICN SYSTEMS (Cl\~ 8lltllai 8 p(y [) S. OAIl Ý VISUAL MONITO~ING OF PIPING .ANe PUMF'INO SYS1'eM o e. r~IENNIAI.I~te:GRI'N TaS'!' (0.1 GP"') SAÞI; SUC1ICN SystEMS (/110 VAlUSS IN BelOw GROUNDþlþING}; SA~e SUCTION 9YSTEMS (NO V.I'L.VES IN selow GROUND PIÞING): 07. 5ELC:! MoNItORING 07. Sel.F MONrtORI""G GRAVITY FlOW GRAVITY FlOW (ClIock 1111 I~IIIPP Y): [J 9. 8JENHIAlINTEGRI'TY TeST (0.1 GPH) Oe. OAIl., Y VISUAL ÞIIONITo~I/IIG 09, ÐII5N/I II\L INTEGA 1-y TeST (0.1 GPH) S!CONCAAILY CONTAINED PIPING SECCNÞ.AFlIL'f CONTAINIæD iI/PING PR!SSUFlllEtI FIPING (CNICk nil that UlPIy); PRESSURJZl:O PlþlNG (CI'\ØI:~ 111\ thalllþþly): 10. COm-INlJOUS 'T\JRSINE SUMP SENSO~ Jrat!:J AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSCI :¡ ~ AVD 3I"E AND VISUAL. AlARMS ~o (CII8Ci _I Al.A.RMS AND I~ OM) C a.. AUTO PUMP SHIJT O¡;¡:: WHEN A L.EA)( OCCURS Q a AUTO PUMP SHU" O~Þ wHeN A lEAk OCCUR$ Ø"b" AUTO ÞUMP SI-IIJT O¡; :: I=OFllEAKs, SYS1ËM FAILURE AN ) Q ¡, AUTO PUMp SHU't OFF FO :¡ LEAI<S. SVS'I'EM FAJI.\JRE AND SYBr~M SYSTEM OISCONNECTION bISCONNe.CTrON Ct. NO AUTO PUMP SIo4UT OFF 01: NO AUTO PUMP SHUT OF¡:: "11. AUTOt.tATIC L.eAlC. DETeCTOR \3.0 GÞIHEST) ïtlIbFLOW SI-IUT OFF tJ 11. AUTOMAtIC LEAK OtlECto¡::¡ .12. ANNUAl INTEGRI'T'V TE8r ID.1 GÞH) 0 12. ANNUAl. INfEC¡ :¡ 1'Y f~Sf (0.1 GPH) SUCTlO~RA\lI'N SYSTEM SUC'1'IONlGRAIII'tY systEM o '3. CONTINUOUS SUMP SENSOR. AUDI8LE ANO VISUAL AI.AFlMS CU. CON1'INVOUS SUMP SENSOR + AUOIBLe .ANO \f1$UAL ALARMS EMERGENCY GeNe~TO"S ONL" ICtllge~ lib tIuIllIPPl i) EM~GENC" GENeRATOR~ OHL't ¡1:II8dr.1III1I'Ia11lPÞi¡l1 a 1.. CONTINUOUS SUMP SEN.SO~ Wlfto OUT AUTO PUMP S!;UT OFF' CJ 14. CONTINUOUS SUMÞ SENSO :( WITHOUT AUTO PUMP SI1UT OFF' AUDIBLE AND VISUAL. ALARMS AuoISL.E AND VISuAl. .ALARMS tI 15. AUToMATIC WK DETI!CTCA (3.Ø GÞH) WljHOUT "'LOW SHUT C¡;¡; D 15. A\JiOMATIC UNE lEAk DET£CTO~ (3.0 GPH 'tEST) C ,S. ANNUAl. INTEGRITY TEST (0.1 GPI'f) 017. OAIL.Y VISUAL CHECK D 16. ANNUAL INTeG~ITYTeST (0.1 GPH¡ a 17. DAIL.Y YISUALCHECI< VIII. DISPENSER CONtAINMENT t:lISP&:NS£R CON1'AINMENT JK 1. FLOAT MECHANISM fl.4A't S~ùT9 O~~ s~eAR VAl.. ve DATe INstAL.L.EO tee., CONTINUOUS OISPENS& ; ÞAN S~NsO ; + AUDIBLE ANO VISUAL ALARMS }if3. CONtiNUOUS DiSPENSER. PAN SENSOR ~ AUTO S~U't Of~ FQR bISP~NSER .. AUDIBLE AND VISUAL AL.A qMS IX, OWNERlOpeA4TOR SIGNAtURE 466 Zoot.. . PermIt Number 4.61 04. OAILY VISUAL C~ECK c:J S. t~ENCH L.INEAJ MONITQRING o 6. NONE 489 4tQ .72 474 Perlttlt e.Jlþlratlol\ Dale 413 PertTlII AÞþro...ed UP FOAM (1/2000 VersJon)TME CUÞAs OF LOS P.NGELES COUNTY 3 41$ UPF_LAC4:07_usrB .. UNIFIED PROGRAM (UP) FORM UNCERG OUND STORAGE TANKS - TAN 1'Y OF ActiON 03. FlENEWAl Þ~~Mlr 0 5.CHANGE Of!: INFOFlMAtlON t:J 4. AMENoec PERMIT 0 UE¡MPOFlAFlV sri'E CLOSuRE FACILITY ID: 11 "'tel', ~o",pIO\CI_ Ø1190 lor IIc/'I CÞ'IID8/'IINInl. 4:16 NUM6ER OF COMþARTMENTS 2. 4~' No 434 4'1 4~e TANK USE ;t(,. MOTOI=! Vel-tlct.~ FUEL. (1/ INlbd ~II P.1ro1eùln T~ a 2. NQN.FUEl PIiT~OLEUM o 3. CliEMfCAL. PROCUot a 4. HAZAAÞoUS WAstE (11'ICIUlleI U3Ød 00) a 95. lJNKNOWN II. 439 PETROLEUM TYpe a 111, REGULAR UNLEAOËl) a 1 Þ. PREMIUM UNlEADEO a 1c. MlbGFlAOE U~lI~Aor;D COMMON NAME (I~ ~ualdoo~ MA!D~aJJ 1~Y9~!CJy þBgøl TANK CONTENTS 440 o 2. lEADEC )(3. DIEseL [J 4. GASOI'IOL C 5. JET I=I.JEL. CJ a. AVIATfON FUEL. o 99. OTHER: CAS# (1/oI'PI HWtdQIJl ",..llltle!! 1".ln!ol'p 1'1911 44~ 441 III. TANK CONSiRUCTION 3. SINGLE WALL. WITH 5, SI OLE WALL WITH INtERNAL BLACOEFI !:xTERIOR MEMS/V.,/IIE liNER CJ 9S. UNKNOWN tJ 4. SIGNLE WAL.LIN \fAulT 099. OT¡. eR 3. FIBERGLASS / PLASTIC' 5. OONC E 95. UNf<.NOWN a À. S"tEëL CLAD W/FI6EI=IGLASS 0 8. FRP COMF"118LE W,'oo% MEtHANOL [J 99. OTHE~ 444 ~EINFO~CEO F'!..ASTIO ("~Þ) raNI'; MA1'EFlIAL - I-=anallry 1811~ 1. B.óJlE. S1'E;I;L 3. F ERG 95 I PLASTIC S. CONCI=IETE 9S. UNKNOWN I(Cllþ. .....l1li"' anIy) 02. STAfNLI:SS S"~kL I:] 4. stEEL cLAD WIFIBE~QLft,SS 0 8, F¡:¡P COMPTIBlE W/100% MIITHANOL [J 99. atHER 445 !:tEINFOFlCEO PLASTIC (FI:IÞ) 0 '0. COATED STEEL 3. EPOXY UNIIIIG 9. G SS LINING 1. SINGLE WALL. 443 TANK MAT IAL - p~,.,." \aI!~ I~ QIIIIIøm ortIy) TANI< INTEP.IOF\ II 1. RU88E~ LINED DATE INSTALLED 447 o 2 ALK'fD LINING C 4 PHENOl..fC LI/IIING o S UNLINED ,,/I (Fe,lgçotl "',' QIOiYI 3 FI EAGI..ASS AEINFORCEO F'lA$ C 95 UNI<.NOWN DATE INSTALleD 448 o 4 IhAÞJ:lESSED CU~FlEI\ T D gg OTHER ! +Ie (FOt IOI;~I uso onlV! Y R INSTAL.LED 4SC TYPE (local "'u I;JI1ly, 451 oveRFill Þr;OTe.CTION EOUIPMENT 'rEAR INSTALlED IIIS~ r:... 21 ALARM ~ ., ~ r~g. 2(J()Z- 182 a.L.LFLOAT n:'8. ¿,OQc"... 3 FILL TUBE SHUT Or-F VAI..VE Q 4 EXEMPT I V . TAN K LEAK C ErECTION (A dé8ètIÞtJo~ tJf tI1c manlterin rDC}fB1'1.haIJ þ, 'lIbltUrtcd ta tile 1cI;oI1, ./It'(.) IF SINGLE WAL.L TANK (CIIBdlellll'laiapplyt 4SJ IF DOUBL.e WAL.L rANK OR rANK WlrH BLADDER 45<1 (ClUlcII """ llerrI IIn y, tJ 1 VISUAL (EXPOSEC PORTIO \ ONLY) [J 5 MANUAL TANK GAUGING (MTG 01 VISUAL {SINGLE WAll IN VAULT ONL.Y) 02 AUTOMATIC TANI( GAUGING (ATG) CJ e VAOOSË ZONE JtZ CONTINUOIJS INTERSililAL MONlTOR/NQ t:l3 CONTINUOUS ATG 01 GROUNbWAtE~ 03 MANUAL MONITORING Q <I STAtistIcAl INVf;;NTORY RE;CONC/UATION CJ e TANI< tt:STING (SIA) .. BIENNiAl TAl'll< TI:ST(NG 1:1 SS OTHER V. TANK CLOSUFtE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED CATE LAsT usee (YRlMOIDAY) 41\' eSTIMAtED OUAN11t'Y OF sueST ANCEREI\I!AINING 45Ð TANI( FILLED WiTH INERT M.4TEI=!IAL? 4$~ tJ Yes Q I\It) O :FICIAI.. USE ONLY DATE RECEIVEb CUþA PA DISTRICT/INspeCTOR UP FORM (112000 V9r$Îon) ¡HE CUPAs OF LOS ANGELES COU/IrtY UF'F ~LAC4: 07 _USTa UNIFIED PROGRAM (UP) FORM UNDERGROUNDSTORAGETANKS-TA VI. PIPING CONSTRUC1'10N (Check all tMt eEl Iy) UNCERGROU I¡ D PIPING sys't~M TYPE 1. PRESSURE a 2. SUCTION 03. GFlAVI"TY ~B coNST~uCTION tJ 1. SINGLE WAll tJ 3. LINED TRENCH 0119. arM!: ;! 4110 MAltUFAtTUAeR;Ø'2. DOUBLE WALl. C 95. UN (Ngw~ MANU :þ.CTtJÞ.I!:R 1/. S,Mlf"H 49' MATE~IALS AND C 1 BARE STEI:L C) e. F~Þ COMPATIBLE ...../1~ CORROSION' Mn .W O~ PROTeC'tlON 1""1 .... . ~e [) 95. UNKNOWN u 2. stAINLess STEEL ~ 1. GAL ....ANI2ED ST... L CJ 3. PLASTIC COMPATIBLE WI CONTENTs 0 8. FLEXleLE (HOÞE) 8'4. FU3ERGl.ASS C] 9. CATIoiODIC Þ!:!OTECTION [J 5. STEEL W/COATING C 9Q. O'tHEFI 464 VII, PIPING LEAk DETECTION C;~ack 81111181 B \JNDIEFlGROUND PIÞING SINGLE WALL PIÞ ~G PRESSUFlIZEC PIPING (chatt aD hI 1Iþþ111; [J 1. E~CTRON c ll~e LEAl( OETËCTOR 3.0 GPH TEST tllII:1 AUTO PUMP S~IJT OFF FOR IJ!AI<, SYSTEM I=AllURE. AND SYSTEM DISCONNECTION + AUOIBLE ANti VISUAL ALA~MS. [J 2. MOtmu. Y 0.2 QÞH fEST [J 3. ANNUAl. INTEGFHiY TEST (0.1 GPH) CONIJEHTIONAL. SUCTION SYSTEMS (Ch8ck ad tIIatlØpl' 'J CJ S. OAlL Y VISUAl MONITORING OF PUMPINQ SYSTEM... TI':1IENNIAL PIPING INT~GAI"N TEST (0.1 GÞH) 02. STAINLESS STEEL t:J 7. GALVMlIZED steEL 03. PLASTIC COMPATIBLE tI 8. FI.£XIS.LE (HÞPE) a 95. UNt<NOWN W/CONT'ENTS a 4. FlaE~GLASS [J 9. CATHODIC PROTECTION o 15. STeEL WICOATING [J lg. OTiotER NUll ollall bs submiMod 10 "" lOCal ABOVEGROUND PIÞING SINGLE WALL PIPING PRESSURIZI;O PIPING IC:/IoIck8i1I11aI6þþl' '¡: o 1. ELECTRONIC LINe LEAk OeTeCTOR 3.0 GÞ'" TEST W1nI AUTO PUMÞ SHIJT O¡:F FOR LeAl(. SystlM FAILU/ljE. ,IND SYSTEM DISCONNECTION.. AUDIBLe ANO VISUAL ALAI:IMS. o 2. MOHTHL Y 0.2 GÞH TEST a 3. ANNUAL 'NTEGRlty TEST (O.1GPH tJ 4. CAlLY ViSUAL CHECK CONVENTIONAL SUCTION SYSTEM9 (t/tedt II.Ó \l'la.lIIIPJ¡11 o S. OAIL Y VISUAL MoNlTOl'tlNG 01= ÞIÞ/NG MO PUMPING SYSTeM CJ 6. TRIENNIAL INTEGFUTV TeST (11.1 GP¡'¡, SAFE SUCTION SystEMS ¡NO vALUES IN BELOW GROUNþþ þIHG): SAFe SUCTION SYSTEMS (NO VAlves IN BelOW GROUND PIPING): o 7. SELF MO~ITCAING 0 7. SE."" MONITORING GF\AVfty FLOW GRAVITY FLOW (Chøc:M ell !ha\ 8þÞl, : C 9. BIENNIAL INTEGRITY TEst (0.1 GÞH) Ce. DAilY "'SUAI. MOMTORING 09. BIENNIAL IN1'eGRI1Y tEST (0.1 GPH) SECONÞAFUL.T CoNTAINED PIPING seCONDARILY CONTAIH!" PlþlNQ P~ESSURIZEO PIPING [Q18cUlllllAlqpply): PFlESSUF!IZ!:O PIPING (Chøcll 011) Irvü i~,,; 10. CCNTINUOOS TURBINE SUMP S!NSOFl W/!!:j AUDISLE ANO VISUAL 10. CONtINUOUS Tu~eINE SUMP SENsoR ~ ALJorBLS AND VISUAL ALARMS AND fCIIØ. _) ALARMS ANQ (cnlCll ane, o e. AUTC PUMP SH\JT OF~ W~EN A LEAK OCCU~S 0 a AUTO PUMP SHUT Ol: : WH!N A LEAl< oCCU :I S Ø"b. AUTO PUMP SHUT OFF FCI:Il.!AkS. SYSTEM FAILURE ANb a 0 AUTO ÞUMP SHUT OF'F FOI1 LEA",S, SYSTEM FAJLUFlE ~D SYSTeM SYSTEM ÞISCONNECTION OISCONNEctlON tic. NO AUTO PUMP SHUt OFF [Je 1110 AUTO PUMP SHUT OFF 1(11. AUTOMATIC LEAl( OETECTOR (3.0 GPH TESn ~FlOW SHUT OFF 0 11. AUTOM"TIC LeAK OeTl:CTOA .'2. ANNUAL INTEGAI"N TEST (0.1 GPH) CJ 12. ANNuAL INiEGFUiY TEST (0.1 GPH) SUC11QNtGRAVITf SYSTEM SUÇTIONlG~AVITY SYSTEM a 13. CON11~UOUS SUMP SENSOR... AUDIBLE ANO viSUAL. ALARMS 0 13. CONTINUOUS SUMP SE I SOFl. AUOISl! ANO VlSIJAL ALARMS I!MERGENCY GEHESiATOAS ONLY (CII«II, an lIIal.ppjJI EMERGENCY GENERATORS ONL T (c~eck 11111I1a1&¡1þly/ C 14. COPmNUCUS SUMP SENSO~ WIT.HOUT AUTO PUMP SHUT OFF' [J 14. COI'(rINUOUS SUMÞ 9ENSOR WITHOUT AUTO ÞU~Þ SHUT OFF . AUDISL.E AIIID VISUAL ALARMS AUDIBLe AND VISUAL Al,.AIIIMS . tI , 5. AUTOMATIC LEAK OETECTCA (3.0 GÞH) WITI-!OUT FLOW SHUT OFF [J 15. AUTOMATIC UNE LeAl< DETECTOR (3.0 GPH TEST) [J 16. ANNUAL tNTEGAITYTESf (0.1 GPH t:J 11. DAILY VISUAlCHECI< [J 16. ANNUA1,INTEGRfT'f TE:ST (0.1 G~"') 0 11. tJAlLY VISUAL CHECK vIII, ÞISPENSER CONTAINMENT ÞISÞENSEI:1 CONTAINMENT II t. FLOAT MECHANISM THAT SI<IUTS OFF s...e~~ VALVE DATE INSTAU£Þ .sa.. coNTINUOUS DISPE \ Sa : PAN SENSOI=! + AUblSlE AND VISUAL AL.A~MS jf3. CONTINUOUS tlISf'E \ SER PAN SeNso~ mti AUto SMUT OFF FeR DISÞENSER + AUCItSU: AND VISUAL AWMS IX, OWNENOPERATOR SIONATURE ,~ l ;;; Pa 8 ot ABOVEGROuNO PIF'ING C 2. SVCTICN t:l3. GMvl't'r o 99. U~KNOWN [J all. OTHtR CJ 1. PRfSSUl'I1: C 1. Sll11GlE WALL C 2. ooueLe WALL MANUFACTURER 01. ÐAFlE. stEEL 4S9 462 118:1 a e. FRP COMPATIBLE WflOO'A METfoIANOI. 465 .08 2.ct)Z- NAME OF OFFICIAL USE ONLY 4at o 4. DAILY VISUAL CMECI<. C 5. TRENCH LJN£R I MONITORING a S. NONE 489 470 412 Per",;t Nu",bgt 413 Permit Aþþroved 415 UP FORM (112000 Vet8loli) THE CUÞA8 OF LOS ANGELES COUNTY 3 474 Permit E.plreticl'I Dale UP~_LAC4:07_USTa State of Cali omia State Water Resources Control Board Division of Clean Water Programs P.O. Box 944212 Sacramento, CA 94244-2120 (Instructions on reverse) CERTIFICATION OF FINANCIAL RESPONSIBiliTY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I am required to demonstrate Financial Responsibility in the required amounts as specified in Section 2807, Chapter 18, Div. 3, TItle 23, CCR: D 500,000 dollars per occurrence D 1 million dollars annual aggregate or IXXI 1 million dollars per occurrence AND or D 2 million dollars annual aggregate B. Jack in the Box Inc. (Name of Tank OWler or Operator) hereby certifies that it is in compliance 'Aith the requirements of Section 2807, Article 3, Chapter 18, Division 3, Title 23, Califomia Code of Regulations. ~~. _. _. . _ _ . The mechanisms use-drõ ëlemôñstrã'te-fiñanëitirresponiii6i1ity asr:ëquired by Section 2807 are as follows: State UST Clean-Up Fund N/ A for UST $990KJ State UST P.O. Box 944212 Clean-Up occur & Clean-Up Sacramento, CA Fund annual Fund 94244-2120 aggregate Continuou Chief Jack in the Box Inc. N/ A for this $10KJ Annual Yes Yes Financial 9330 Balboa Avenue mechanism occur & Officer San Diego, CA 92123 annual Letter aggregate Note: If you are using the State Fund as any part of your demonstraüon of financial responsibility, your execuüon and submission of this ceroficaüon also cerofies that you are in compliance wth all condiüons for parocipaüon in the Fund. D. FaciUty.Name See attached for list of sites . facility Address Facility Name Facility Address Facility Na me Facility Address Facility Name Facility Address E. Signature or Tank Owner or Operator Dale Name and Title of Tank Owner or Op at John Hoffner, VP/CFO Signature or Witness of Notary Dale Name of Witness or Notary ~~ÿ~x~~ LYN CFR (Revised 04/95) FILE: Original - Local Agency Copies - Facility/Site(s) . . CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT \~~ I, I, ------ . - ---- -- -. -. -. -. - - - -- ,- -=- - - . . State of California }ss I, I, I, County of SAN D I EGO I· On APRIL 24, 2002 Date LYNNE B. SMITH Name and Title of Officer (e.g., "Jane Doe, Notary Public") , before me, I' i' I, I' I· I' JOHN F.. HOFFNER personally appeared Name(s) of Signer(s) ] personally known to me o proved to me on the basis of satisfactory evidence I' I.... ~ ~ - ~ ~ - - - - - - - - J r: (i LYNNE B. SMITH -:' --- -f ~ --'~~n;,~~~ ~ ¿=~. -~. -- I:) Son Diego County f I: Wf.¡Canm.Expires Dec26.ZD2 \: - -- -- -- --- -- -- -- -- -- -- -.-.- to be the person(s) whose name(s) is/are subs_cribed. _to~tbe~within_ instrument ~and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I, I' I, I' I, Place Notary Seal Above I' OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document Title or Type of Document: CERTIFICATION OF FINANCIAL RESPONSIBIL ITY Document Date: Number of Pages: Signer(s) Other Than Named Above: I' I· I, I, Capacity(ies) Claimed by Signer Signer's Name: JOHN F. HOFFNER o Individual tJ Corporate Officer - Title(s): EXECUTIVE V. P., CFO o Partner - 0 Limited 0 General o Attorney in Fact o Trustee o Guardian or Conservator o Other: . Top of thumb here S' I R t JACK IN THE BOX INC. I ~=<z::~~:::::=~~=~~~-====~==~~~~=-=<z=~-====~~J © 1997 Nalional Notary Assoclalion . 9350 De Solo Ave.. P.O. Box 2402· Chalsworth, CA 91313-2402 Prod. No. 5907 Reorder: Call Toll-Free 1-800-876-6827 7;X-' 'I 'i , ~ ,I I I 'J 'I ·1 I ,I 'J I 'J 1 ,'i 'I ,I I ·1 I ,I I 'I . . - -Attachment to State of-Galifornia --.. Certification of Financial Responsibility for Underground Storage Tanks Containing Petroleum - --'.- -""--- - ~- -- --- Facility Name Facility Address Quick Stuff #7700 9680 Business Park Drive, Sacramento, CA 95827 Quick Stuff #7703 3085 E. Central Avenue, Fresno, CA 93725 Quick Stuff #7704 6001 Goodyear Road, Benicia, CA 94510 Quick Stuff #7707 1900 Ramada Drive, Paso Robles, CA 93446 Quick Stuff #7708 1101 North Magnolia, Anaheim, CA 92801 Quick Stuff #7709 2602 Newport Blvd., Costa Mesa, CA 92628 Quick Stuff #7710 10 Center Drive, Deer Park, TX 77536 Quick Stuff #7712 46-651 Dillon Road, Coachella, CA 92236 Quick Stuff #7717 5000 East Valencia, Tucson, ÄZ 85746 Quick Stuff #7723 10 Union Avenue, Bakersfield, CA 93307 Quick Stuff #7724' 3500 East Philadelphia, Ontario, CA 91761 Quick Stuff #7728 5960 North Dallas Parkway, Plano;TX 75093 Environmental/Manual/Attachment to State of California.doc - e e - The Chief Financial Officer or the owner or operator must sign, under the penalty of perjury,a letter worded EXACTLY as follows or you may complete this letter by filling in the blanks with appropriate information: LETTER FROM CHIEF FINANCIAL OFFICER I am the Chief Financial Officer for Jack In The Box, Inc., 9330 Balboa Avenue, San Diego, CA 92123-1516 This letter is in support of the use of the Underground Storage Tank Cleanup Fund to demonstrate financial responsibility for taking corrective action and/or compensating third parties for bodily injury and property damage caused by an unauthorized release of petroleum in the amount of at least $ 10.000 per occurence and $ 10,000 annual aggregate coverage. (Dollar Amount) (Dollar Amount) -- - - - - l:JndergreuAcl-storage-tanks-atthe-following-facilitieSCiTe-aS-sure-d-uy-thisletter:-=-- ----. See attached for list of sites (Name and address of each facility for which financial responsibility is being demonstrated.) 1. Amount of annual aggregate coverage being assured by this letter.......................................................................... $10,000.00 $1,111,837,000* 2. Total tangi ble assets....................... ..,............... .............. .... 3. Total Ii abilities...................................................................... $616,292,000* 4. Tangible net worth (subtract line 3 from line 2. Line 4 must be at least 10 times line 1 )........................... $495,545,000* *Reported for the fiscal year ending September 30,2001 I hereby certify that the wording of this letter is identical to the wording specified in subsection 2808.1 (d) (1), Chapter 18, Division 3, Title 23 of the California Code of Regulations. I declare under penalty of perjury that the foregoing is true and correct to the best of my knowl- edge and belief. Executed at San Diego. CA . (Place of Execution) On (Date) (Signature) John F. Hoffner 04/24/2002 14:34 FAX 9167841386 04/24/02 08:42 FAX 858 69~42 Date: April 22, 2002 JACK IN THE BOX JACK IN THE BOX INC e I4J 019/024 ~019 WRITTEN MONITORING PROCEDURES UNDERGROUND STORAGE TANK MONITORING PROGRAM This monitoring program must be kept at the UST location at all times. The infonnatíon on this monitoring program is Ii condition of the operating pennit. The permit holder must notify Bakersfield Fire Department within 30 days of any changes to the monitoring proçedures, unless required to ob~ approval before making the change. Required by Sections 2632( d) and 2641(11) CCR. Facility Name Jack In The Box #3576/Quick Stuff #7723 Facility Address 10 Union Avenue, Bakersfield A. Describe the frequency of performing the monitoring: Tank Continuous Electronic Monitoring Secondary Containment testing wUf be performed every 36 months. Piping Continuous monitoring mechanical line Leak Detector. Annually all monitoring equipment is inspected by a certified contractor. B. What methods and equipment, identified by name and model. will be used for performing the monitoring: Tank: Veeder Root TLS-350 system with CLSD. mode! # 848290-022 Mag probe Model #847390-109 (0.1 gph) ~ Interstitial sensor 794390-409 Piping Veeder Root TLS-350 system with the foliowing sensors Turbine Sump Sensor model # 794380-208 Dispenser Sump model # 794380-208 Line leak Detector: FE Petro STP-Mechanical C: Describe the location(s) where the monitoring will be performed (facility plot plan'· should be attached): The monitor is located in the Inside Storage room of Store. D. List the name(s) and title(s} of the people responsible for performing the monitoring and/or maintaining the equipment. Joanna Harris I Manager Robert Fakinos I Area Manager Paul Deneka I Manager, Manager, Environmental Engineering E, Reporting Format for monitoring: . Tank: A written monitoring log. Piping: A written monitoring log and annual certification F, Describe the preventative maintenance schedule for the monitoring eq¡uipment Note: Maintenance must be in aecor~~811lCe with the manufactulf'sl1's· maintenance schedule but not less than evs¡ry 12 months. The monitoring systems shaU be certified annually in accordance with manufacturer's recommendations G. Describe the training necessary for the operation of UST system, including piping, and the monitoring equipment: The operators li"eceiive initial and annual refresher training in accordance to the manufacturers recommendations. Refer to the stations environmental binder, located in the office for more detailed information. Date~rii22,2002 .- EMERGENCY RESPONSE pJ UNDERGROUND STORAGE TANK MONITORING PROGRAM This monitoring program must be kept at the UST locaüon at aU times. The information on this monitoring program is a condition of the operating permit. The permit holder must notify Bakersfield Fire Depamnent within 30 days of any changes to the monitoring procedures, unless required to obtain approval before making the change. Required by Sections 2632( d) and 2641(h) CCR. Facility Name Jack In The Box #3576/Quick Stuff #7723 Facìlìty Address 10 Union Avenue, Bakersfield 1. If an unauthorized release occurs, how will the hazardous substance be cleaned up? Note: If released hazardous subs~U1Jces reach the environment, increase the fire or explosion hazard, are not e~eaned up from the secondê!lry' containment within 8 hours. or deteriorate ~)he secondary containment, then Bakersfield Fire Department must be notified! wiihin 24 hours. For small spills the on site personnel will use absorbent material to clean up the released material. In the event of a larger spill, the on site manager will call 9-1-1 (if necessary), and the company representative to assist in the emergency. ;t 2. Describe the proposed methods and equipment to be used for removing and properly disposing of any hazardous substances. Spent absorbent will be placed into an approved container and disposed of in ' accordance with all Local, State, and Federal laws and regulations. Any additional equipment will be provided be the respondinQ contractor. 3. Describe the location and avaiJability of the required cleanup equipment in item 2 above. Absorbent is maintained on site and restocked as needed, Any additional equipment is maintained by the contractor, and available on an as needed! basis. 4. Describe the maintenance schedule for the cleanup equipment Absorbent is inspected weekly and reordered as needed. 5. List the' name(s} and title(s} of the person(s) responsible for authorizing any work necessary under the response plan: Joanna Harris I Manager Robert Fakinos I Area Manager Paul Deneka I Manager, Manager, Environmental Engineering e e I UNIFIED PROGRAM (UP) FORM UNDERGROUND STORAGE TANKS -INSTALLATION CERTIFICATE OF COMPLIANCE - 1 (one page per tank) Page 01 I, FACILITY IDENTIFICATION BUSINESS NAME (SaIne II FACILITY NANé or DBA - DoIng Bulilnesa As) JAG" (toa T..~ 130)( 3 ". ADD 476 ß AJU.tLSf'IEU>, LA q Zbl4 1 ÄN 471 :, ... '1 ""'. II,INSTALLATIQN 0' tf (Check all that apply) . . ì·· ' The installer has been trained and certified by the tank and piping manufacturers'. 478 479 The installation has been In8pected and certified by a registered professional engineer having education and experience with underground storage tank installations. .' . . ,:, ~ ; .~: "í!H·\'l\J\d:;! ¡nOd"!. ~ . ,j . t . ær· The installation has been inspected and approved by the Unified'Program Agency. lB"" All work listed on fhe manL!'~øurer's installation checklist has been completed. 4ØO 461 J. 'r 482 /9'" The installer has been certified or licensed by the Contractors' State License Board. l!:r The underground storage tank; any primary piping, and secondary containment was insìelled according to . applicable voluntary consensus standards and written manufacturer's installation procedures. 483 Description' of wofk being certified: I ",ç1"Þ.(,,(.A7(ON of Fv£L. SY~"Tc.""" 'i. . ' .. ..; " t:· .qZ. ;,y'jr,'lb/.·'j· \. .;¡. ".,' . 1 \ ;'., , , ¡I.' '. ;-"¡: ~ .~'~ \ ri: ).~""'¡';'I':I rl:; r~ \ 'I~I\\/,: I . ¡ , . ~.... ,;.,..."", . " ··.ì·· '. !. ,.' ",'_ 'I" . ':'"~ '. ,'.. "I, ·"t } ....r. i, .::! Pt·~ " "f' , ' \', .... .;.,", 'r" .'C·' '.¡, .... ...., . . 'r'!~}!t~t.·'1~(I.~'{.·1~·"" '"I f ~ ~ íft1.~:t1~.i¡L....~. lì,l. '. 'j' ... . '. ,~ l ( ¡ " ..'. " . ',. . III. TANK OWNER/AGENT SIGNATURE t Iht. ¥1~tþ1 ~~~ herein is tnIe and açcurate to the best of my knowledge. I NATU ~G NT DATE /l1A y f -Ir 'Z.Oo Z 485 TI~ OF TANK WNE ~ C t!Þ"'f'~C.!TolL I ~flÅ u.,(" ~ 484 466 CUPA PA UP Fonn (14OOQ>FuIJ Version) THE CUPAa Qf LOS MlG~~S COUNTY 35 ., " ,·ulr"':"~u ", .. /~~ 1;;f~<~~".t!\,1T:'-~~ . ¥ " .1,1' :trf·' ¡;. :.! ~t"."· " f . " ,·e e ., > :,,1 'Æ,. ~:. .~'_',' INSTRUCTIONS FOR THE UNIFIED PROGRAM (UP) FORM UST Installation· Certificate of Compliance Formerly SWRCB Form C .!. ·tfj'tt··..... ;' Complete this certification upon installation of an UST and piping. One certification is required for each tank system. This page may be completed by either the UST owner or representative. , Refer to 23CCR § 2635 for US!. i~tallation and testing requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UP Form 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 oft~e Uni~~9..P.r.ogram Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or PA 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. "';;;:. -... , " . ~ (,' j I '1;-.' ~·...i.,-. 3. BUSINESS NAME'· Enter the full legal name of the business. 47€ì. ADDRESS· Enter the street address where the tank is located. This is to assist the tank inspector in locating the tank. 477. TANK ID NUMBER· Enter the tank ID number assigned 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. 478. TRAINED AND C~RTIFIED BY TANK AND PIPING MANUFACTURER· Check if the tank installer provided e-.1dence of being trained and certified by the tank and piping manufacturer. 479. REGISTERE:D E:NGINEER INSPE:CTION - Check if the installation has been inspected and certified by a registered professional engi,neer, if necessary. 480. UNIFIED PROGRAM AGENCY APPROVAL - Check if the installation has been inspected and approved by the Unified Program agency. . '. :. i. ':,;.,. 1 481. COMPLETION OF MANUFACTURER'S CHECKLIST· Check if all work listed on the manufacturer's installation checklist wé!,scompleted. .. ," ;;,;,..", 482. CONTRACTORS' STATE LICENSE BOARD CERTIFICATION OR LICENSE - Check if the installer has provided proof of C~LB,certification or licensing. ~. .: -. " . -. , '.',. 483. INSTALLATION DESCRIPTION· Check if the UST system was installed according to applicable voluntary consensus standards and any manufacturer's written installation instructions. Describe the installation in the space provided. 'Clarify the type and the extent of work completed at the facility, such as installation 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 dé!t~ 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. ~', -t '.¡) ". ::," . .:, I I!,' ',;," . UP Fonn'(112OOo Fu/lVersion) THE CUP~ OF LO$ ANGEi.ES COUNTY 34 \ ""~~;".~: VPFORML3 , ,: ,~~;.¡~, \1-1, 1.) J. '.~.!~) ,~A, ',' , f '1: ~ .' I., "i, e e ~ UNIFIED PROGRAM (UP) FORM UNDERGROUND STORAGE TANKS -INSTALLATION CERTIFICATE OF COMPLIANCE - 1 (one page per tank) Page 01_ ) ;, ' I, FACILITY IDENTIFICATION BUSINESS NAME (Same.. FACILITY NAME Ct 08A - Daing Bualnesa As) JAGIC. t~ TH£ 'i3o)C 3 ADD 476 ßAlUtLSF'tEc.b, LA 9Zhl4 AN ID# 477 ,I :. ¡ '1,.i. II. INSTALLATION 0" tf (Check all that apply) ,! :, . '(. ;, , . , The installer has been trained and certified by the tank and piping manufacturers. " 478 479 The installation has been inspected and certified by a registered professional engineer having education and experience with underground storage tank installations. "', . ;;,.'.\ ..¡, ;'-~(\i~1.·fí~\t1~i!·'~ljH"(J) t·.I . '!' ' I' The installation has been inspected and approved by the Unified'Program Agency. 480 ¡¡r, IB"" 19" 481 All work listed on t!1e mam!f~cturer's installation checklist has been completed. .. 'I " .1 The installer has been certified or licensed by the Contractors' State License Board. 482 I!:r' The underground'storage tank,' any primary piping, and secondary containment was installed according to applicable voluntary consensus standards and written manufacturer's installation procedures, 483 Description' of work being œrtified: I ",ç1"Þ.t..LA7tON of FvE.t.. SYS""'e.~· ,., h:·!~:r:"'\·~"It¡tr',~)·:·;·~,, (. ',v r~ ' ..¡ lof' . ' f~ ,.~" ·.j!;:-~Ü,:: G~ \/1" ".', I"'" \ ,. " .J . ,.,,1 ': ~ ,¡ .,.. :'}\ :··~i."~ ~ ~.·:t.L.~'r,;·t¡~ '-:: ,'; ,',. ~ ..-. " , . ~u ',,', . :··;},;";·<~r:!,.~(.'Jl·~.'f('7';",,.~ ~-."; 1/_ ¡ .... ,: ~ . ~ " ' ( ',' '.' I . \ ·ì ." ~t~t~I!:,~>f~!'" l.~, '. 4~ , III. TANK OWNER/AGENT SIGNATURE Aa..ctST DATE /i"1Ay 14, 'WoZ- 485 TITLE OF TANK WNE 'A ' c..,.q /'lA. c.rof2/¡ NS'7à L(... £ A... 484 486 DATE RECEIVED CUPA PA UP Form (1I2OOQ,FuII Version) THE CUP~ Of, ~ ANGELES COUNTY 35 . '.;\id:Y~;·W~ .3 . -::; r :~!'~ .~-[;~. ~;:2) :~.;::; , .(;; Complete this certification upon installation of an U~T and piping. u¡¡~ CertlIicaiií.ií' í~ fijqUíígu ,...; ¡;¡dí.;¡ ¡...iif_ ;;I¡",,¡;Oiii. í ¡.... page may be completed by either the UST owner or representative. Refer to 23 CCR § 2635 for UST Ins.on and testing requirements. e '. (Note: the numbering of the in~U'uctions follows the data element numbers that are on the UP Form pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, th~ Business Section of!pe Unifi,~9.. p~ogram Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or PA 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. . .. .', !t'" 'j .,:,' '"";.,ó\" BUSINESS NAME';"Enter thÉdull legal name of the business. . .' 3. 476. ADDRESS· Enter the street address where the tank is located. This is to assist the tank inspector in locatin9 the . tank. ',.' t', L 477. TANK ID NUMBER· Enter the tank ID number assigned 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. 478. TRAINED AND CERTIFIED BY TANK AND PIPING MANUFACTURER· Check if the tank installer provided e"';dence of being trained and certified by the tank and piping manufacturer. 479. REGISTERED ENGINEER,JNSPI;CTION . Check if the installation has been inspected and certified by a registered professiona! engi.neer. if n~cessary. 480. UNIFIED PROGRAM AGENCY APPROVAL - Check if the installation has been inspected and approved by the Unified. Programagef\cy, J " . > ~- "'),1': ¡", . . 481. COMPLETION OF MANUFACTURER'S CHECKLIST - Check if all work listed on the manufacturer's installation checklist w~s completed. .' " :. '~,..", :';"',: 482. CONTRACTORS' STATE LICENSE BOARD CERTIFICATION OR LICENSE - Check if the installer has provided proof of CSLB. ~rtification or licensing. , '., ~ . . ,. I. . ·f '.;,' 483. INSTALLATION DESCRIPTION· Check if the UST system was installed according to applicable vOluntary consensus standards and any manufacturer's written installation instructions. Describe the installation in the space provided. Clarify the type and the extent of work completed at the facility, such as installation 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 Øate that the page was signed. 485. TANI<OWNER/AGENT NAME· Enter the full printed name of the person signing the page. 486. TANK OWNER/AGENT TITLE;· Enter the tiUe of the person signing the page. ',.'';. '{j~' , ..j' ' ',".> .. ". " ,r' 'I ':', ,:{ UP Form' (112000 Full Version) THE CUP.AI ,OF LO~ ANGELES COUNTY 34 . ',. ..··:~i" ~: IJPFORML3 . '.' . ;:··tl!'\;\!i;<r t' ,'(\ ) ~t~\ '. " i "': ¡ ., '; j. e - ~ - 1 UNIFIED PROGRAM (UP) FORM UNDERGROUND STORAGE TANKS -INSTALLATION CERTIFICATE OF COMPLIANCE (one page per tank) Page 01 I, FACILITY IDENTIFICATION ADD BUSINESS NAME (Same II FACILI'TY NAME 01 DBA - Doing Business As) JAGIt:. ctoa TIf£ i3o;c' 10 U vfo,.j·Av¡~y(' ,;~~ :ii~ 3 476 ßAIUt'LSf""ELb, LA QZh,4 1 AN D 4Tl II. INSTALLATION (Check all that apply) The installer has been trained' ~nd certified by the tank and piping manufacture'rs. .' ',c 11 ' '. 62r' Ô- 478 419 The installation has been inspected and certified by a registered professional engineer having education and experience with underground storage tank installations. : 'j: ~~:,f:{~'f~'i~";' ~J;irl~ ':' '. " The installation has been inspected and approved by the Unified'Program Agency. 480 Œr· IB' 19' 481 All work listed on the man~f¡icturer's installation checklist has been completed. The installer has been certified or licensed by the Contractors' State License Board. 482 I!::( The undergroÙnd storage tank; any primary piping, and secondary containment was ins~lIed according to' applicable voluntary consensus standards and written manufacturer's installation procedures. 483 Description'ofworkbeingeertified: '~Ç1'Ac..tA7to¡o.) of F¡,)£.L. SYS-re,,,,,-\ ., ! ¡~~. ":.(:~,1Ó~lf't' 0~~"·~~ ~~, 'd,1 ,';. " i ~ I . "'d :'.I. 'f~~!,(i. ..,¡.5 ;f~~~1'll""+ :1',,::' "¡~I~ P . '. I' '. ¡I,J .~ "...... '~\ :"' ¡ < (" _,f , . ,,. . ~} ';-; '-~'-. ¡'¡':.~·l;,j:'·¿:i ') ~, .', , ' !\'\1("¡ \ ;'1 \:~ i' ·:~.:'f0 ."~ /; ",' I, I -. " .f ". ',.. '. . , if ~\'t~~ '{¡i-' t '!, j" _ ~ ' " , III. TANK OWNER/AGENT SIGNATURE I certify that ~ ir!~1io!'I PfoV~eQ herein is true and accurate to the best of my knowledge. NA ÄEN 485 464 486 I OFFICIAL. USE 0f4. Y t DATE ReCEIVED f ORA J PA . , , DISTRlcrIlN$PECTOR , UP Fonn (1J2OOO,FuII Version) THE CUPAs OF LOS ANGELES COUNTY .35 ";'<i; 1:~~;.Mffi~~ - ~·~;":·~ì..\ ~."r:; > ~./ :~,,:.'/ . , . " . . ¡. e e 'I'·~i' 'J-X, !'," INSTRUCTIONS FOR THE UNIFIED PROGRAM (UP) FORM UST Installation· Certificate of Compliance Formerly SWRCB Form C .~~- ~f(~-._(.....'" ., Complete this certification upon installation of an UST and piping. One certification is required for each tank system. This page may be completed by either the UST owner or representative. Refer to 23 CCR § 2635 for UST.iostallation and testing requirements. t ~ , (Note: the numbering of the insÚ'1Jctions follows the data element numbers that are on the UP Form 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 t~,e Uni~~9 ProQram Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or PA 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. , ".0:. i I ,t'., '. ....:.1. BUSINESS NAME'· Enter ti1è full legal name of the business. 476. ADDRESS· Enter the street address where the tank is located. This is to assist the tank inspector in locating the . tank. . 477. TANK ID NUMBER· Enter the tank ID number assigned 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. 478. TRAINED AND CERTIFIED BY TANK AND PIPING MANUFACTURER - Check if the tank installer provided 8\'idenc8 of being trained and certified by the tank and piping manufacturer. 479. REGISTERED ENGINEERINSPECTION - Check if the installation has been inspecteçl 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 Unifi~d ~ro~ram .~geflcy. . i -~: . 'r ':.' , , . 481. COMPLETION OF MANUFACTURER'S CHECKLIST - Check if all work listed on the manufacturer's installation checklist, w~,s~pleted. . . 482. CONTRACTORS' STATE LICENSE BOARD CERTIFICATION OR LICENSE - Check if the installer has provided proof ~f9sLe ~rtification or licensing. . .'J .,' 483. INSTALLATION DESCRIPTION· Check if the UST system was installed according to applicable voluntary consensus standards and any manufacturer's written installation instructions. Describe the installation in the space provided. Clarify the type and the extent of work completed at the facility, such as installation 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. dat~ that the page was signed. 485.T ANt< OWNER/AGENT NAME· Enter the full printed name of the person signing the page. '486. TANKOWNERlAGENT TITLE· Enter the title of the person signing the page. , \~.l· . , ,.¡ . '. .1 ~ . ..' ; ; !~. '1( UP Form'(112000 FuUVersion) THE CUP~ OF LOS ANGaES COUNTY 34 , \ ,'::" ,~, ~~ UPFQRML.3 .' . '1',~,\,'bll:¡O ~A " , . i ~,. , . MONTIJOTANKTECJà rANK INTEGRITY TEST RÈPÖRT P.O. BOX 408 SAN MARCOS, CA 92069 (760)752-1989 F~760)7~2.1899 .,. TANK ADDRSSS 10 UNION AVE.. T,ocA TION CITY BAKERSFIELD, CA ZIP 92614 TANK OPERATOR JACK. IN 1HE BOX PHONE (661'\861-OS43 NAME JACK. IN THE BOX PIiO~(858)S71·2463 TANK nWNF.R ADDRESS 9330 BALBOA A VB. CITY SAN DIEOO, CA ZIP 92113 I Bcuoa (Ot Tuk SIItaD TadD,c: TrieDDial PJoduc:t SudioDl.Rcøtotc Fill LiDe AnnuaJ Test Retest Mer Repair ADnua1 Product Pressure Line s~ l.Qk; Otbcr NEW INSTALLATION Typo ofProduot LiAelFiU DdM;ry: Pæssurizcd X Remote Fill Suotiou Other NlA Typo of Spì1JIOw=nül PnMntiOÐ: Positive Shut Off BaD Floats X High Level Alazm. X T_ T_ T_ Pruåct o..rtIIW TM Teft U........ Tut T_ i.. No. c.,.d*7 CedNØ Uae Iad.._ Veld. Viper. <....... ........ ] )Me I'iII .......~ ~ PuaIJr.u GüftMlr ~IIN c.uJIotItr PutfII.... 1 20000 REG -.006 PASS NlA N/A -,044 PASS '/13/02 2 JOOOO SUIIER -.003 PASS N/A NlA +,043 PASS ,/U/œ 3 7000 DSL -.005 PASS NIA NlA +.029 PASS '/1)/02 . , .' 1'bne tat rauIÞ ban beea ~ .... perfo........ by. "'r certttled HeOnUag tv tbé requinm.- .,.... taak .. .......~. ................ Tbe tea.r" ~ ..y.... Water Raou..... Caaà'oI BoanI ()fIke ofTuk T."r L~.............. .............. of 511......'17. TJde 13, oItbe CA Code of~ (cfflldh'e JlIIIIUUY 1, I"'). The.... ."........... aøtIn.d 0' thac: I"CIUÞ., ímd .... ... advl.ted or &he reportlbg reqlli.remeB.. 'or Jmesriay __ Tb.U UBT ........ teat II ap,Nveci b)' .... State Water Retourea C...... Beud (SWRCB). ... reeelved Ib1rd pari)' verifi&:atiua, aad øacetJ iBlappJicabIe 1bøÞadœu. Toa_ C.ømpDUy ~ONTIJO T~ 'Œ£H N8IIIO afToet Equipn-t PETRO 'ftI'E LINR TESTER Name on ioaDNd Tott« Sipann ofTc.tcr Liøausø No 90-1090 Da~ 51] 3102 e' e ****.*. c U S TOM E R D A T A *****.** JOB NUMSIR ct1STOMER (COMPANY NAME) : CUSTOMER CONTACT (LAST, FIR.ST): ADDRESS - LIß 1 CITY, STATE ZIP CODE (XXXXX-XXXX) PHONE NUMBER (XXX) XXX-XXXX ******* COM MEN T 000195 Jack in The Box Pepper, Rick 9330 Balboa Ave. San Diego, CA 92123 (858)571-2463 L I N E S ******* ****.*. SIT E D A T A ******** SITE NAME (COMPANY NAME) SITE OONTACT(LAST, FIRST) ADDRKSS - LINE 1 CITY, STATB ZIP CODE (XXXXX-XXXX) PHONE NUMBER (XXX)XXX-XXXX GROUND WATER 1!EVBL (FT) NUMBER OF TANKS LENGTH OF PO-TEST CHIN) LENGTH OF TiST (NIH) Jack in The Box Pepper, Rick 10 Union Ave. Bakersfield, CA 92614 (661)861-0543 Below Tanks 3 30 240 '. . . e e .....*. TANK DATA ******** TANK NO. TANK NO, TANK NO. TANK NO. 1 2 3 4. TANK DIAMBTSR (IN) 111 111 111 LENGTH (FT) , 3!L 19 20.63 13.98 VOLUME (GAL) 19703 10369 7029 TYPE ST ST ST FUEL LEVEL (IN) 87.11 81.60 93.14 I FUEL TYPE REG UNLD SUP UNLD DIESEL 2 dVOL/dy (GAL/IN) 185.76 104.96 59.25 CALIBRATION ROD P;¡;STANCE 1 10.65625 2 26.95313 3 41.93750 " S6~93750 5 74.93750 . ' e e INVOICE #tt000195 TEST DATi: 05/13/02 MONTIJO TANK TECH P.O. BOX 408 SAN MARCOS, CA 92069 TANK STATU'S EVALUATION REPORT ----------------------------- ***** CUSTOMiR DATA ....* ***** SITE DATA ***** Jack in The Box 9330 Balboa Ave. San Diego, CA 92123 Jack in The Box 10 union Ave. Bakersfield. CA 92614 OO~ACT: Pepper, Rick PHONE #: (858)571-2463 CONTACT: Pepper, Rick PHONE #: (661)861-0543 ***** COMMENT LINES ****. CtJRR.ENT EPA STANDARDS DICTATE THAT FOR UNDERGROUND FUEL TANKS, THE MAXIMUM ALLOWABLE LEAK/GAIN RATE OVER THE PERIOD OF ONE HOUR IS .05 GALLONS. TANK #1: llEG UNLEADED TYPE: STEEL RATE: .04462 G,P.H. LOSS TANK IS TIGHT. ULLAGE IS TIGHT. TANK #2: SUPER t1NLEADBD TYPE: STEEL TANK IS TIGHT. ULLAGE IS TIGHT, RATE: .04364 G.P.H. GAIN '. . TANK #3: DIESEL FUEL 2 TYP:&:: STEEL RATE: .02975 G.P.H. GAIN TANK IS TIGHT. ULLAGE IS TIGHT. f~~~; ¡;~_~foIJO SIGNATURE: _?_~ DATB:~~:~~~:_ "'"' 1 0 ~ % (,) ~ t) .- o o . 'wJ ~ 0 :z - LLI -5 0- ~ o -10 e 15 -,' ..' .. ... " ' .... .Ø78 -...,," .1H462 GPH LOSS -15 o tt8Øll195.!S!,2 , 15 45 60 8511310Z 30 TIME (MINUTES) Cr: ...,'...... ,,: ' ,... 1Q ~ :I: o i: ~ .- -0 o ~ -' ~ z - w -5 "- ~ o -10 15 SIAR! !11Œ:III:12:38:øø CUHIIDt! ! lltE:89:12:38:øtJ o \ ", ~... ';' ".J '..... ,.__' "'" :Jt. it .~ i'· t...".. J~.... í l~ ". \ A . ~. >, I \.\ ,', ',. .. J ~ 1 ..... ~- ~ . . -.: ." .-". J " "" /. - .11122 ..149 BATE: .14364 GPH GlUM P!II, UDSIOft 1.21 -15 o tt8Ø819S.rsr,2 . 15 4-5 60 85113182 30 TIME (MINUTES) SOL 1 c..: -. 10 tn W :I: o a: õ .- o o . to.J ~ z ~ -5 ~- ~ J: u -10 15 e CI': o -15 o tt888195.'ISr,2 . 15 30 TIME (MINUTES) 60 85/13182 45 '. . . e e Montijo Tank Tech P.O. aox.w8 san Marcos, CA 92088 (700)752-1989 Jaçk in the Bax ' . Lines Tw It: Pt'8SSUf'18 Site: Address: 10 Union Ave. Bak8rlfleld, CA Date: 5113102 LINE TIME TE8TPROCEDURES PSI PSI VOLUME VOLUME VOLUME CUMMULATIVE ID COMMENTS BEFORE AFTER BEFORE AFTER CHANGE CHANGE .-t 815 ISOLATE LINE 50 0.033 RU 830 1ST READING 48 50 0.033 0.031 -0.002 -0.002 845 2ND READING 48 50 0.025 0.023 -0.002 ..0.004 GOO 3RD READING 49 50 0.023 0.022 -0.001 .0.005 915 4TH READING 49 50 0.02 0.019 ·0.001 -0.006 BLEEDBACK 0.036 tt2 815 ISOLATE LINE 50 0.033 su 830 18T READING 49 50 0.031 0.030 -0.001 -0.001 845 2ND READING 48 50 0.027 0.025 -0.002 -0.003 900 3RD ReADING 50 50 0.022 0.022 0.000 -0.003 915 4TH READING 50 50 0.02 0.020 0.000 -0.003 BLEEDBACK 0.041 13 815 ISOLATE LINE 50 0.033 OSL 830 1ST READING 48 SO 0.03 0.028 -0.002 -0.002 845 2NC READING 49 50 0.028 0.027 -0.001 -0.003 900 3RD READING 48 SO 0.022 0.021 -0.001 -0.004 915 4TH ReADING 48 50 0.021 0.020 ..(). 00 1 ..0 .005 BLEEDBACK 0.035 ~\\\\\lM /:~ ~, ~1~ Of ,~..:....',~' ,... ':'\,7'- '., ,,--- ,'" . 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':;01, .~ ~.;:(.."! .~ .......: -....:::...... . - -~.- ., · CITY OF BA~SFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 INSPECTION RECORD POST CARD AT JOB SITE Owner ~ Address Facility Address City, Zip Phone No. City, Zip Pennit # 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 I. 00 NOT cover work for any numbered group until all items in that group are signed off by the Pennitting Authority. Following these instructions will reduce the number of required inspection visits and therefore prevent assessment of additional fees. TANKS AND BACKFILL Backfill ofTank(s) INSPECTION DATE INSPECTOR Cathodic Protection System-Piping Electrical Isolation of Piping From Tank(s) Dispenser Pan Liner Installation - Tank(s) Liner Installation - Piping Vault With Product Compatible Sealer Product Compatible Fill Box(es) Level Gauges or Sensors, Float Vent Valves Product Line leak Detector(s) leak Detector(s) for Annual Space-D. W. Tank(s) Monitoring Well(s)lSump(s) - H20 Test 3 (.3 (0 c.. Spill Prevention Boxes leak Detection Device(s) for Vadose/Groundwater Monitoring Wells, Caps &.lo,cks Fill Box Lock Monitoring Requirements Áuthorization for Fuel Drop FINAL \ ç'-O~ - !;,~O L , Ç't)L - Ç-O "Z.- ~ M rT thf¡"ccrui.f ¡- COh..4-t LICENSE 1# 1;;), 33"~ CONTRACTOR CONTACT ~\f t;S, ~ tu:Jl PHONE # )fnO ~~q9 ~ JHS- 01/24/02 13: 19 'aI'Bel J2B 0578 e BFD HAZ MAT DIV flI 00.1 .._ -- e Permit No. ß'[ O.;ll J- - CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Cheste'r Ave., Bakersfield, CA (661) 326-3919 PERMIT APPLICATION TO CONSl1UICTIMODŒY UNDERGROUND STORAGE TANK - YES NO ns.... x NO s£crro~ FOR MOTO~ ruä iË I: trnL~En REGULAA m;~ ~ rM\~ # ~T~ò o""fA-2."'M~T.s S£CT10N' 'OR NON M DJOR Jõ"!1El STORAGE T ANteS ~ DIESEL A V1A TION" )(. TANK NO. VOLUM~ CIŒMJCAl STOUD CAS NO. CmMJCAL PREVfOVSl Y STORiD (NO BRAND NAME) (IF ÞlOWN) 4PPUCþ.TÞN DATe FOR. OFFICw" usa 0 LY F4CIUIYNO. IoIO.OFTJ.H1C5 ræss THe AP,PUCANr "AS R!CEIVED, UNDERST A1'lPS, AND WILL COMPLY WITH THE A"IT ACHED CONDITIONS OF nns peRMIT AND ANY OTHER 5T ATE. LOCA.L AND FEDERAL R,ECillLA T IONS. HAS BUN' COMP LETED UNDER PENALTY OF PERJURY. AND TO THE BEST Qf CO THIS APPLICATION BECOMES A ,¡RMlT WHEN APPROVED . Travis Engim'ring ~~~ A Division of Travis Companies, Inc. January 18, 2002 - Mr. Steve Underwood Fire Department - Environmental Services City of Bakersfield 1715 Chester Avenue Bakersfield, California 93301 RE: CHANGE IN CONTRACTOR - INSTALLATION OF FUEL SYSTEM IMPROVEMENTS - 10 UNION AVENUE, BAKERSFIELD, CALIFORNIA, Dear Steve: The purpose of this letter is to advise you that the general contractor who is constructing the Jack in the Box food and fuel facility at the above referenced address has decided to utilize the services of an alternative fuel contractor. The new fuel contractor is very qualified and has completed fuel related work in the Bakersfield area for years. I have attached a copy of the insurance certificate and contractor's license for your review and records. The new fuel contractor is MIT Engineering and Construction. Please revise your records as necessary. If needed, please do not hesitate to contact me should you have any questions. Thank you in advance for your assistance and cooperation in this matter. KH:cn Bakcrsficld04·1cttcr.doc 12453 Lewis Street. Suite 201 . Garden Grove. California 92840 ø 714/750-0991 G (Fax) 714/750-0990 ,- . ~:>;T'~:;" , . · ~.~:02. I..... l.. ".. ,..-: '.. " --:'. '~,' {-. . ~ t,' -' " ' +'.-' .,.-:' ~ . ", .. . . ~'. . . f' '-7 THU 14:38 FAX ï60tIÞ420~ , h~ ,'.. f >"1". .., . >,-1 - . ó.'·' , "'> -. . .' :~~':'<~",:}';.:,/.' ... .', >CAE-:_- . ~t'~~~~'; c~;;;~rnj~< . ":.:. ~ ," ConIruiñer CONTRACTORS STATE LICENSE BOARD . At1iùn ACTIVE LICENSE. . MIT ENGINEERING . '- ' . '.. '. . -, License Number 723396 Entitý CORP , Business Name M I T ENGINEERING & CONSTRUCTION INC Classj ication(s) A HAZ C10 Expiration Date 06/30/2002 . , '. I . " ,. . '.- . ":'.':¡' . ...'.:: ~. »:~".' '."~',-.--;..: . -. ".. . 't ._<~ '<.~.¡. -~. }~;:;~"$':~ ',....r.-....., .. ,. . '-.,. '.'.;.-~' ',' 'r; " : -) >, ".-.':. - ~' ".', ';';, ' "<' . "..',;' '. -:.,'.. .; @002 . ."t' ", -. ,'-~ . , , , :t , -...;. . '.~ -; ." I ~~L..· . ~ -11 ~ .' . . ,j" .:...: ¿....)..,'..,.. <: . .,'" ,- .:~., .' -' " ~ ,'~' ..t " . '¡ :.', " . . . "~ . . , . . .. ~,' '" ¡,' , :' :" ". "OJ ~ '.' THU 14: 38 FAX IaJ 003 .... .- .-' y r , , PRODUCER . . Michael Ehrenfeld Company' 2655 Camino Del Rio North. Suite 200 San Diego, CA 92108 ' (619) 683-9990 Fax (619) 683-9999 License #0537922 ate. . ~9I19/200.1 .'.,' ;'THIS CERT1FléATEIS ISSUED 'AS A MATTEROFINF.,ORMAT10N ONLY AND '. ... ", '; i,CONFER.S NORIGI:ITS UPON THE CERTIFICATE' HOLDER; 'THIS:CERT1F1CATE ':: :'.': i<:'~~~~~~:'~~;~N~ORALTER?,E ~~~GI:~ORDED BY'II'HE COMPANY COMP~ES AFFORDING COVERAGE '. A SAFECOINSURANCÈ 88 COMPANY B STATE COMPÈNSATION INSURANCE FUND COMPANY . . c GULF UNDERWRITERS INSURANCE CO (EIS) COMPANY D INSURED M.I.T. Engineering & Construction. Inc. 105 CoppelWood Way, Suite G Oceanside, CA 92054 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIRCATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. '. EXCttlS:eNS'ANe' CONDITIONS-SF-StleH POLICIES: - ; MITS SHOWN' M:iy-:-jAVe-BEEN-Ref)tIeIIDßY 'PA:D-Ct:AlMS;"-~ - -~---~~. --:-- -. CO L TR TYPe OF INSURANCE GENERAL LIABILITY POUCY EFFECTIVE POLICYEXPlRAOON .. DATEIMMlDDIVY) DATE IMMIDD/YY) UMITS GENERAl. A~RE~TE ' PRODUCTS ,'COMPIOP AGG . ' POUCY NUMBER . . '.<:: ~_~'1r -,- .'>é~~/~OÒ{ . c <" . .~ . . 2/6/2002 - GU0693274 '~ \.. '. PERSONAL & ADV INJURY' , ... '_" :.."",', EACH OCCURRENCE. < ' ':. ' FIRE DAMAGE' (Any one fire) MEO EXP (AFI}' one person) X POLLUTION LIABILITY ' AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT ÞNf AUTO ALL OWNED AUTOS A X SCHEDU.EDAl/T05 X HIRED "UTOS X NOtH)WIŒD '""os , " BA8157616C ".0210612001 BODILY INJURY 02l06ì2002 (Per PeIson) , , ., , .. BODILY INJURY (Per Accident) "'... . PROPERTY DAMAGE GARAGE UABILITY AUTO ONLY - EA ACCIDENT" OTHER THAN AUTO ONLY: .",. .. ANY AUTO .' , , , EACH ACCIDENT . AGGREGATE \".. .., EXCESS LIABIUTY , eX' UMBRELLÀ .FOIV& . OTHER TIiAN UM8RELIA . WORKERS COMPENSATION EMPLOYERS' LIABIUTY . ' B THE PROPRIETOR! PARTNERSlEXECUTlVE OFFICERS ARE: OTHER p CONTRACTORS EQUIPMENT' , ' LEASED OR RENTED ,,< , GU0693273 . ' EACH ACCIDENT 02Ì06/2001' .02106/2002' AGGRE~TE ~ -, ... ", '. ," ~ X .. . ": 06/03/2Q01 06/0312002 1554598-01 . ;- INCl' X EXCL' , $2 000 000 $1000000 .. , $1000000 1 000000 $50 000 $5,000 $1,000,000 .'''. d,: . ,- "-'. " v ',,~$1 000 ODD, ,.: 1 000 000, ~, ~02/06(.?0~1: , 02106/2002 . :,~~~Ò6/20'01' i:.::{)2ì0~i2002 ' EL DISEASE, POLICY LIMIT EL DISEASE-EA EMPLOYEE i· ,;;' '" ,,'$90,570 TOTAL LIMIT '. " : ,$1,000 DEDUCTIBLE $150,000 ANY ONE ITEM : "":,,:$1.00Ó'DEDUCTíáLE ,'~I;i.o,ÌJU):ANY"qF.THE ~'n.=DES~R!BED:~CIEi!>8E CANCEl.J;ED,:~BEFORE THe: ::' , '; .. > ,t· ',_.'" > -- ,'-,. ,- -t·, -. - , ,. ... " '.. ~. '. ,'- . .' - ~ . ., ,. - . :EXJ?IRAll0N'DATE.THEREOFi':THE'ìSSUING COMPÀNv WILL ENDEAVOR :.TO MAIl.', '" ,:" ""'0,1 f,3ÒJ'DÁY~~~o-ri6e~~'furCErmF;èATE~hwE~"t:JAMED'T¿THË~ì=T:: " ,_,,~.,r,;:-~I~~£d~~~:~œ:s,~iMr"ese:No,'~~I~~~-; , ,,; 'i!:! ~ . OF ÞÏN .¡(ìNi5"uP.oN ";:,;rHE ·COMPANY. n's: "AGENTS:OR . REPREsENTAllVe ",,::,,;~, ENTA~,'¡"""/l.:"'-" " .' ~. I . , -,' ~ ' . ~' . ." .:.:~. ~ .. ". ~ " " ~" . " ," . ."#. ' , ~.' . ~ , , ", " '; . .;:"'72ULJ~M IL8336: :', . . . ~'. -t", . '" - I ~' ',' .''"': , ,', 72UUM'IL8336 ,> " .. . ~ '. .".. _',' .~:,,·t~:~I,.:~'r·;;.. : SAMPLE' CERT'F'CATÉ",';Lr~ , 4." ",' ", ':.\-~'.:/ :\}_t¿ ',,~.~-;--'_'=------ " ." .... < " ~ ~. '\' r ~, I¿," ~ , :. : ;, '-"--'--. ..'\ ....". " " ". 'i ..:.<" .. , . . .. '. ~. ,,- '¡"", _ r'·· . " .1 " . .. , .;. ì', .'. , , " ~. :, ;~. -.' ,. . . .. ,', :. ~':'.. ,,; .', 1 01124/02 09:06 'B661 326 0576 TRANSMISSION OK TX/RX NO. CONNECTION TEL CONNECTION ID START TIME USAGE TIME PAGES RESULT BFD HAZ MAT DIV . *************************** *** ACTIVITY REPORT *** *************************** 2721 8324567 01/24 09:05 01'24 2 OK ~001 ~ BAKERSFIELD CALIPORNIA . er - FAX"ransmittal Cover Sheet Bakersfield Fire Dept. Office of Environmental Services -., 1715 Chester Ave. · Bakersfield, CA 93301 FAX No. (6(j~.) 326-0576 · Bus No. (:661) 326-3979 " ---- TO: p.()!:>~ COMPANY: élPV\·eð.~'h:ð FROM: ~{(.\J('" UrAJosW@t¡)/ ." FAX No. ~ j.l" i.f~fc '7 COMMENTS: e ø f '\( @ t . A·~~ \f01J (¡ F 6' o~ "t :...... I l .