The URL can be used to link to this page

Home My WebLink AboutBUSINESS PLAN7 ELEVEN #32376 SiteID: 015-021-001885 Manager : SHASHI VEENA KAMBOJ BusPhone: (661) 588-4059 Location: 9600 BRIMHALL RD Map : 102 CommHaz : Low City : BAKERSFIELD Grid: 29C FacUnits: 1 AOV: CommCode: COUNTY STATION 65 SIC Code:5541 EPA Numb: DunnBrad: Emergency Contact / Title..~ Emergency Contact / Title SHASHI KAMBOJ / FRANCHISEES7 DAVID LISUK / FIELD REP Business Phone: (661) 588-~3fr9~ Business Phone: (888) 711-3720x 24-Hour Phone : (661) 872-3238x 24-Hour Phone : (800) 828-0711x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Contact : Phone: (208) 429-8466x MailAddr: PO BOX 711 State: TX City : DALLAS Zip : 75221 Owner THE SOUTHLAND CORP Phone: (208) 429-8466x Address : 10220 SW GREENBURG RD 470 State: OR City : PORTLAND Zip : 97233 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: (Tyt~ or print name) reviewed the attached hazardous materials rnent plan for 7'-' [/ and that it along (Name of any ~rm~ions constituts ~ compists and ~rr~ m~- ¢ ~gn~ 1 05/10/2004 7 ELEVEN #32376 SiteID: 015-021-001885 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: 7 ELEVEN #32376 Cross Street : Business Type: Org Type: Total Tanks : 3 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : DAVID LISUK Phone: (888) 711-3720x Address: City : State: Zip: Type : TANK OWNER INFORMATION Name : DAVID LISUK Phone: (888) 711-3720x Address: City : State: Zip: Type : BOE UST Fee# : 002251 Financ'l Resp: INSURANCE Legal Notif : Tank Owner Mailing Address Date:04/ll/2000 Phone: (503) 977-7713x Name:BOB DENINNO Ttl:ENVIRON. MGR. State UST # : 1998 Upg Cert#: 00872 -2- 05/10/2004 7 ELEVEN #32376 SiteID: 015-021-001885 ~ Hazmat Inventory By Facility Unit -- MCP+DailyMax Order Fixed Containers at Site Hazmat Common Name... ISpooHazlEPA HazardsI Frm I DailyMax IUnitlMC~ GASOLINE L 15000.00 GAL Mo( GASOLINE L 15000.00 GAL Mod 3 05/10/2004 7 ELEVEN #32376 SiteID: 015-021-001885 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: SW OF BLDG IN STORE PARKING LOT CAS# 8006619 F STATE ~ TYPE PRESSURE --~ TEMPERATURE I CONTAINER TYPE Liquid/Pure I Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 15000.00 GALI 15000.00 GAL 15000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS TSecretl ~SlBi°HaZNo N No Radi°active/Am°unt I EPA HazardsNo/ Curies NFPA/// 'lUSDOT~ MCP MISC. LOCAL AGENCY DATA Ag.Definedl: Ag.Defined2: Ag. Defined3: Ag. Defined4: Ag.Defined5: Ag. Defined6: Ag.Defined7: Ag. Defined8: Ag. Defi~ed9: Ag.Definel0: -- Ag.Definell -4- 05/10/2004 7 ELEVEN #32376 SiteID: 015-021-001885 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: SW OF BLDG IN STORE PARKING LOT TANK DESCRIPTION Tank ID#: 2 Mfr: Total Containment Compart Tank: N Installed: 3/1998 Capacity: 10000 Gals No. Of Comparts: Additional Info: TANK CONTENTS Tank Use: MOTOR VEHICLE FUEL Petrol Type: UNLEADED PLUS/MIDGRADE Matl Name:GASOLINE Cas #: 8006619 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 1998 Alarm : Exempt: No Drop Tube : 1998 Ball Float : Striker Plate: 1998 Fill Tube S/O: 1998 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No -5- 05/10/2004 7 ELEVEN #32376 SiteID: 015-021-001885 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : TOTAL CONATINMENT Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 05/17/1998 Type: DISP. PAN LIQUID SENSOR & ALARM OWNER/OPERATOR SIGNATURE Date: 04/11/2000 Name:BOB DENINNO Ttl:ENVIRON. MGR. Prmt Number: 1885 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST :10/09/2003 PASS CP CERT. : MANWAY INSP. : UST MONIT. CERT:03/17/2003 -6- 05/z0/2004 7 ELEVEN #32376 SiteID: 015-021-001885 = Inventory Item 0003 Facility Unit: Fixed Containers at Site ~lVllVl~ ~vl~ / ~ £ ~ ~Vl~ GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: SW OF BLDG IN STORE PARKING LOT CAS# 8006619 Liquid ~Pure Ambient Ambient UNDER GROUND TAi~K AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 15000.00 GALI 15000.00 GAL 15000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS TSecretl ~slBi°HazNo N No Radi°active/Amount I EPA HazardsNo/ Curies NFPA/// IUsDOT# ModMCP MISC. LOCAL AGENCY DATA Ag.Definedl: Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag. Defined6: Ag.Defined7: Ag.Defined8: Ag.Defined9: Ag.Definel0: -- Ag.Definell -7- 05/10/2004 7 ELEVEN #32376 SiteID: 015-021-001885 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: SW OF BLDG IN STORE PARKING LOT TANK DESCRIPTION Tank ID#: 3 Mfr: Total Containment Compart Tank: N Installed: 3/1998 Capacity: 10000 Gals No. Of Comparts: Additional Info: TANK CONTENTS Tank Use: MOTOR VEHICLE FUEL Petrol Type: REGULAR UNLEADED Matl Name:GASOLINE Cas #: 8006619 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 1998 Alarm : Exempt: No Drop Tube : 1998 Ball Float : Striker Plate: 1998 Fill Tube S/O: 1998 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No 8 05/10/2004 7 ELEVEN #32376 SiteID: 015-021-001885 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : Total Containment Mtl : "FLEX" & : Corr : "FLEX" Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 03/23/1998 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 04/11/2000 Name:Bob Denino Ttl:Environ. Mgr. Prmt Number: 1885 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST :10/09/2003 PASS CP CERT. : MANWAY INSP. : UST MONIT. CERT:03/17/2003 -9- 05/10/2004 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 filE SAfETY SERVICES' fNVlRONMfNJAl SERVICES 900 Truxtun Ave., Suite 210 Bakersfield. CA 93301 VOICE (661) 326-3979 FAX (661) 852-2171 FIRE INVESTIGATION 1715 Chesler 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 Mr. Shashi Kamiboj 7-11 9600 Brimhall Road Bakersfield, CA 93312 REMINDER NOTICE Re: Necessary Compliance Deadlines for UST Owners/Operators Dear Mr. Kamiboj: 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. Sincerely, 01 0 t;,1 /) ["'\ ~ ~lttt~ Steve Underwood Fire Prevention Officer SU:db "P');:I(,IIÙI;7 (he Y;¡()/ml/IfNu~1 Qj1íoojt. Q ¡tÙte cWt(bll . QS;f ~Itâl/)~ II MIx'T/STORE #2237-32376 A STORAGE TANK AGREEMENT THIS AGKEEMENT is made and entered into as of this ~ day of ~, ~,,~' ,19 ~J- , by and between TIlE SOUTHLAND COKPORATION, 'a Texas corporation ("Southland"). 2711 North Haskell Avenue, Dallas, Texas 75204, and Shas~ KantKambo, i and Veena Kamboj ("Franchis&'). WHEREAS, Southland is the owner of and Franchisee is an operator of underground storage tanks at a retail motor fuels outlet located at 9600 Bfimhall Road, Bakersfield, CA 93312-2200 (the "outlet"); and WHEREAS, Franchisee sells gasoline at the outlet on consignment from Southland pursuant to a Consigned Gasoline Amendment dated ~ - --~ - ~ d" ; and ~tLEAS, Southland and Franchisee are subject to certain Federal, state and local require- ments governing the operation of underground storage tanks at the outlet including, but not limited to, those set forth in Chapter 6.7 of Division 20 oft. he California Health and Safety Code (the "Act") and regulations promulgated thereunder and codified in Subchapter 16 of Chapter 3, Title 23, California Administrative Code (the "l~gulations"); and WHEREAS, Section 25923 of the Act and Section 2610(b)of the Regulations provide that if there is an operator of underground tanks at a facility who is not the owner of said tanks, the owner shall enter into a written contract with that operator to perform certain responsibilities under the Act and the Regulations. NOW THEPd~FORE, in cormideration of the Pre,nises and of the mutual promises and covenants contained herein, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the panics agree as follows: 1. ThisAgreementshallcommenceon ~ - ~ ,19fi_~,andshallcontinueuntil expiration or termination of the Consigned Gasoline Addendum between the parties. 2. Franchisee shall monitor the underground storage tanks at the outlet in accordance with Section 2644 of the Regulations and any applicable permit, rule or order issued pursuant to the Regulations or any other applicable Federal, state or local authorities. 3. Franchisee shall maintain appropriate records in accordance with Section 2712 of the Regulations and any applicable permit, rule or order issued Pursuant to the l~egulations or any other applicable Federal, state and local authorities. 4. Franchisee shall implement reporting procedures as required by any permit, rule or order issued pursuant to the Regulations or any other applicable Federal, state and local authorities. 5. At its expense, Southland agrees to train Franchisee in the monitoring of the underground storage tanks, the maintenance of appropriate records and the implementation of reporting proce- dures as set forth in paragraphs 2, 3 and 4 of this Agreement, and Franchisee agrees to attend such training. 6. Southland shall properly close the underground tanks at the outlet as required by any permit, rule or order issued pursuant to the Regulations. 7. Southland shall indemnify Franchisee against any liability for civil penalties assessed as a result of Franchisee's failure to comply with the Act or the Regulations or Southland's failure to Form 4400288 4/95 (California only) Page I ot'2 JAN-O1-2~O1 11:02 FROM THE SOUTHLAND CORP. 2191 TO S150~2453438 P.03 comply with the Act or Regulations, except that no indem, nif, cation shall be provided where the noncompliance is caused in whole or in part by Franchisee s negligence or willful misconduct. 8. This Agreement shall not bemodified, altered, amended or revoked except in writing duly executed by the parties. 9. A breach of this Agreement by Franchisee shall not constitute a ground for termination or nonreaewal of the 7-Eleven Store Franchisee Agreement by and between Franchisee and Southland, unless the breach is otherwise a breach of the 7-Eleven Store Franchise Agreement. 10. In the event of a dispute or controversy arising out of this Agreement or the breach thereof, the arbitration provisions of the 7-Eleven Store Franchise Agreement shall apply. IN WITNESS WI-IE_REOF, the parties hate ex~cu;ed th~s Agreement as of the day and year fa'st above written. 7-ELEVEN: THE SOUTHLAND CORPORATION Signature -" v. - David Wheeler Jerry A_ Hook l~ltarl~et Manager Assistaiit ~ecretarv Full Name ('~yped) Full Name (Typed) 7-.ELEVENOffice/StoreNo. 2237-32376 A 5151 N. Palm Avenue,. StYe 711 ~,ddresi oI uf/~ce ~itreet Fresno CA 93704-2208 city · :~tate /ap FRANCHISEE(S) ,, ~hgnamre ~gnature ' Shashi Kant Kamboj Veena Kamboj Full Name (1 ypea) i'Ull Name (1 ypecl) Viitness: C', ~- ~'~/~ W imess: t~. ~/- 6~~ Wimesa oI A0o~-~ b~gnature Witness Of ~Ooge 5~gnamre 96OO Brirnhall l~ad Store Actdress street Bakersfield CA 93312-2200 City blare zip Form 4a00288 4/95 {California only) Page 2 of 2 LOG OF INTERSTITIAL MONITORING CALLS0 Date Store MKT Store Called Contact Interstitial Probe Status as Reported by Store 2133 32376 12/20/00 veena rul, mul, pul -- normal. Mh 2133 32376 11/21/00 VEENA IM PROBES-RUL,MUL,PUL-NOMRAL. JH 2133 32376 10/31/00 SANG IM PROBES-RUL,MUL,PUL-NORMAL. JH 2133 32376 9/15/00 Joseph rul, mul, pul im probes are normal td 2133 32376 8/8/00 Vena rul, mul pul im probes are normal td rul, pul im probes are normal mul is showing 2133 32376 7/19/00 Shazie fuel WA07190954 td 2133 32376 6/20/00 rang (kid) rul, pul im probes are normal td 2133 32376 5/24/00 singh irul, mul, pul im probes are normal td 2133 32376 4/24/00 veena rul, mul, pul im probes read normal td 2133 32376 3/23/00 singh rul, mul, pul im probes read normal td 2133 32376 2/25/00 Vena rul, mul, pul im probes read normal td 2133 32376 1/28/00 vina rul, mul, pul im probes read normal td 32376 IMLOG.xls ELEVEn January 4, 2001 Mr. Steve Underwood Bakersfield Fire Department 1715 Chester Ave. Bakersfield, CA 93301 RE: Compliance Inspections 7-Eleven #32376, 9600 Brimhall Rd. 7-Eleven #32241, 4101 Calloway Rd. Dear Mr. Underwood: As per the referenced inspections, enclosed please find: · Updated Hazardous Materials Management Plan · Owner/Operator Agreement · Permits to Operate for each site In addition, both of these sites have double wall tank systems. Each month, corporate headquarters polls the sites to confirm that all probes are operational and not in alarm condition. I have included a recap of the log for each store for your review. 7-Eleven Field Consultants are delivering the documents to the stores and will counsel the operators on the information contained. Each operator will train employees in the emergency procedures. Lastly, the fire extinguishers at the Calloway site are being serviced and the emergencY exits have been cleared. And, the broken cover on the Emergency Shut-Off switch is being repaired. Please feel free to contact me should you have any questions. Sincerely, Bob DeNinno 7-Eleven, Inc. CC Mike Austin (Market Manager) Environmental Services Department / 10220 S. W. Greenburg Road / Suite 470 / Portland, Oregon 97223 Phone (503) 977-7713 / Fax (503) 245~3438 7 ELEVEN #32376 SiteID: 015-021-001885 Manager : ~_'~~/~e¢~l~ ~~OJ ~ BusPhone: (661) 588-4059 Location: 9600 BRIMHALL RD Map : 102 CommHaz : Low City : BAKERSFIELD Grid: 29C FacUnits: 1 AOV: CommCode: COUNTY STATION 65 SIC Code:5541 EPA Numb: DunnBrad: Emerqency Contact / Title Emergency Contact / Title ~RS~/~~J ~ STORE MANAGER DAVID LISUK / FIELD REP Business Phone: (66~) 588-4509x Business Phone: (888) 711-3720x 24-Hour Phone : (661) 872-3238x 24-Hour Phone : (~O)~ Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Contact : Phone: (214) 828-7668x MailAddr: PO BOX 711 State: TX City : DALLAS Zip : 75221 Owner THE SOUTHLAND CORP Phone: Address : 10220 SW GREENBURG RD 470 State: OR City : PORTLAND Zip : 97233 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: Environmental Manager I, Do hereby certify that I have (Type or.print name) reviewed the attached hazardous materials manage- ment plan for'~i ~ ~'~"~' $z~71 and that it along with (Name of Business) any corrections co~itute a complete and correct man- // agement plan~ z~ I'Z~°'t,~ Z~ Signalure Date -1- 10/31/2000 7 ELEVEN #32376 SiteID: 015-021-001885 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: 7 ELEVEN #32376 Cross Street : Business Type: Org Type: Total Tanks : 3 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : r 7-Eleven, Inc. ~ Phone: ~) ~ Address: __~ f~.~ ~_ %~z/~ ~ City : Gasoline Acctg. State: Dallas, TX 75221-0711 Type : P.O. Box 711 TANK OWNER INFORMATION Name -r 7-Eleven, Inc. ~ Phone: ~oo~)_ ~ Address: Gasoline Acctg. State: Dallas, TX 75221-0711 City : P.O. Box 711 Type : BOE UST Fee# :. 002251 Financ' 1 Reap: INSURANCE Legal Notif : Tank Owner Mailing Address Date: 04/11/2000 Phone: (~3_~S~-~-77~i=3x Name: BOB DENINNO Ttl: ENVIRON. MGR. ~- 5/~~ ~9~d~ State UST # : 1998 Upg Cert#: 00872 ~ Hazmat Inventory One Unified List --As Designated Order Ail Materials at Site Hazmat Common Name... ISpooHazlEPA HazardsI Frm DailyMax IUnitlMCP GASOLINE L 15000.00 GAL Mod GASOLINE L 15000.00 GAL Mod GASOLINE L 15000.00 GAL Mod -2- 10/31/2000 7 ELEVEN ~32376 SiteID: 015-021-001885 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site -- COMMON NAME / CHEMICAL NAME GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: SW OF BLDG IN STORE PARKING LOT CAS# 8006619 F STATE 1 TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 15000.00 GALI 15000.00 GAL 15000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline No 8006619 HAZARD ASSESSMENTS TSoorotI~SIBioHaz Radioactive/Amount EPAHazardsI NFPA USDOT# MCP No N No No/ Curies / / / Mod ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site 9 ~U~IU~ ~/--LlVl~ / ~±~/~JJ ~Vl~ GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: SW OF BLDG IN STORE PARKING LOT CAS# 8006619 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average 15000.00 GALI 15000.00 GALI 15000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline, N 8006619 TSecret S BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No N No No/ Curies / / / Mod -3- 10/31/2000 7 ELEVEN #32376 SiteID: 015-021-001885 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: SW OF BLDG IN STORE PARKING LOT CAS# 8006619 Liquid Pure Ambient Ambient UNDER GROI3-ND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average 15000.00 GAL 15000.00 GAL 15000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS TSecretl ~SIBioHaz Radioactive/Amount I EPA HazardsI NFPA USDOT# MCP No N No No/ Curies · / / / Mod -4- 10/31/2000 F 7 ELEVEN #32376 SiteID: 015-021-001885 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 07/17/1998 AFTER CALL 911, THE BAKERSFIELD CITY FIRE DEPT WILL BE NOTIFIED ALONG WITH THE CALIFORNIA STATE OFFICE OF EMERGENCY SERVICES (800) 852-7550. -- Employee Notif./Evacuation 07/17/1998 THE STORE ATTENDANT WILL NOTIFY OTHER EMPLOYEES AND CUSTOMERS BY A SHOUT THAT THE BLDG MUST BE EVACUATED. ALL PERSONS MUST EVACUATE THROUGH THE FRONT DOORS TO THE EVACUATION STAGING AREA SHOWN ON THE FACILITY DIAGRAM. Public Notif./Evacuation 07/17/1998 THE STORE ATTENDANT WILL NOTIFY OTHER EMPLOYEES AND CUSTOMERS BY A SHOUT THAT THE BLDG MUST BE EVACUATED. ALL PERSONS MUST EVACUATE THROUGH THE FRONT DOORS TO THE EVACUATION STAGING AREA SHOWN ON THE FACILITY DIAGRAM. Emergency Medical Plan 07/17/1998 MINOR INJURIES WILL BE TREATED USING THE FIRST AID KIT LOCATED INSIDE THE STORE. THE CLOSEST MECIAL FACILITY IS BAKERSFIELD MEMORIAL HOSPITAL LOCATED AT 420 34TH ST, 327-1792. -5- 10/31/2000 7 ELEVEN #32376 SiteID: 015-021-001885 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site -- Release Prevention 07/17/1998 EMERGENCY FUEL SHUT OFF SWITCHES ARE LCOATED IN THE FRONT OF THE STORE AND NEAR THE STORE COUNTER. THE UNDERGROUND STORAGE TANKS ARE EQUIPPED WITH OVERFILL/OVERSPILL PROTECTION. TANK FLUID LEVELS AND INTERSTITIAL SPACE ARE MONITORED BY A TIDEL EMS 3500 MONITORING SYSTEM. TANK TURBINES ARE EQUIPPED WITH LEAK DETECTORS WHICH RESTRICT FLOW IF A LEAK IS DETECTED BENEATH DISPENSERS OR ALONG PIPING RUNS. -- Release Containment 07/17/1998 KITTY LITTER, LCOATED INSIDE THE STORE AT THE LOCATION SHOWN ON THE FACILITY DIAGRAM IS TO BE USED FOR SMALL FUEL SPILLS (LESS THAN 5 GAL). THE BAKERSFIELD CITY FIRE DEPT WILL RESPOND TO LARGER FUEL RELEASES BY PLACING SAND OR ABSORBANT ON THE SPILL. -- Clean Up 07/17/1998 ONCE A SPILL HAS BEEN CONTAINED, THE SAND OR ABSORBANT WILL BE CHARACTERIZED AND DISPOSED OF AT A PROPER DISPOSAL FACILITY. Other Resource Activation 6 10/31/2000 ELEVEN #32376 SiteID: 015-021-001885 Fast Format Site Emergency Factors Overall Site Special Hazards ~ Utility Shut-Offs 07/17/1998 A) GAS - N/A B) ELECTRICAL - NE CORNER OF BLDG, OUTSIDE C) WATER - E SIDE OF BLDG (OUTSIDE) AND IN PLANTER NW CORNER OF PROPERTY D) SPECIAL - NONE E) LOCK BOX - NO -- Fire Protec./Avail. Water 07/17/1998 PRIVATE FIRE PROTECTION - N/A NEAREST FIRE HYDRANT - IN PLANTER ON NW CORNER OF PROPERTY. Building Occupancy Level -7- 10/31/2000 7 ELEVEN #32376 EEEEEEEEEEEtS/~/~EE/~EEEtSEtStSEEEEtSEEt~E/~EEt5 SitelD' 015-021-001885 i ia Training ~/~/~/~t~~/~/~/~/~~~ Overall Site i i/~ Employee Training ~~~~~~~ 07/17/1998 i o WE HAVE 8 EMPLOYEES AT THIS FACILITY. o O WE DO HAVE MSDS SHEETS ON FILE BEHIND STORE COUNTER. ° o BRIEF SUMMARY OF TRAINING PROGRAM: EMPLOYEES ARE TRAINED IN A HAZARDOUS o MATERIALS COMMUNICATION PROGRAM. EACH EMPLOYEE IS INSTRUCTED ON HOW TO USE ° AND UNDERSTAND THE MATERIAL SAFETY DATA SHEETS. THE EMPLOYEES ARE INFORMED ° OF THE HAZARDOUS MATERIALS STORED AT THE SITE AND THE PROPER RESPONSE o PROCEEDURES, INCLUDING WHO TO CALL, IF A SPILL SHOULD OCCUR. o O O O i/5t5~ Held for Future Use ~/~~t~atSt~tS/5/5~/~~~~i o o it~/~tS~ Held for Fumre Use/~t~/~tS/~/~tS~fi/~/~fi~~~fi~~i O o 7 ELEVEN #32376 SiteID: 015-021-001885 Manager : u~ .... ~ ~'~.-CK~-__,/. --/~ V~ BusPhone: (661) 588-4059 ~FY%~ Map : 102 CommHaz : Low Location: 9600 BRIMHALL RD City : BAKERSFIELD Grid: 29C FacUnits: 1 AOV: CommCode: COUNTY STATION 65 SIC Code:5541 EPA Numb: DunnBrad: Emer~encv,Contact--.~ / ~ Title ~ _ Emergency Contact / Title Business Phone: (661) 588-4509x Business Phone: (888) 711-3720x 24-Hour Phone : (661) 872-3238x 24-Hour Phone : ( ) - x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Contact : Phone: (214) 828-7668x MailAddr: PO BOX 711 State: TX City : DALLAS Zip : 75221 Owner THE SOUTHLAND CORP Phone: (503) 977-7713x Address : 10220 SW GREENBLTRG RD 470 State: OR City : PORTLAND Zip : 97233 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: I. ,5' c ~v.,¥,~ Do hereby certify tha~ ! have (Type or.print name) reviewed the attached hazardous rnatsfials manage- ment plan ~or 7-~~7 ~ and that it along with (Name of Business) any corrections constitute a complete and correct rnan- agernent plan for ~/.~o..,~,,. i-'///~3/0/'~ ~'~L~. ¥'' 1 ~ 10/31/2000 7 ELEVEN #32376 SiteID: 015-021-001885 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: 7 ELEVEN #32376 Cross Street : Business Type: Org Type: Total Tanks : 3 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : DAVID LISUK Phone: (888) 711-3720x Address: City : State: Zip: Type : TANK OWNER INFORMATION Name : DAVID LISUK Phone: (888) 711-3720x Address: City : State: Zip: Type : BOE UST Fee# : 002251 Financ'l Resp: INSURANCE Legal Notif : Tank Owner Mailing Address Date:04/ll/2000 Phone: (503) 977-7713x Name:BOB DENINNO Ttl:ENVIRON. MGR. State UST # : 1998 Upg Cert#: 00872 ---- Hazmat Inventory One Unified List -- As Designated Order Ail Materials at Site Hazmat Common Name... IspecHazlEPA HazardsI Frm DailyMax lUnitlMcP GASOLINE L 15000.00 GAL Mod GASOLINE L 15000.00 GAL Mod GASOLINE L 15000.00 GAL Mod -2- i10/31/2000 7 ELEVEN #32376 SiteID: 015-021-001885 = Inventory Item 0001 Facility Unit: Fixed Containers at Site m COMMON NAME / CHEMICAL NAME GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: SW OF BLDG IN STORE PARKING LOT CAS# 8006619 rSTATE i TYPE i PRESSURE I TEMPERATURE I CONTAINER TYPE Liquid Pure Ambient Ambient %TNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average 15000.00 GAL I 15000.00 GAL I 15000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline No 8006619 HAZARD ASSESSMENTS I TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod = Inventory Item 0002 Facility Unit: Fixed Containers at Site 7 ~lv~vlu~ ~vl~ / ~ ~.~j.~ ~v~ GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: SW OF BLDG IN STORE PARKING LOT CAS# 8006619 STATE ~ TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Liquid /Pure Ambient Ambient %TNDER GROfTND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 15000.00 GAL[ 15000.00 GAL 15000.00 GAL HAZARDOUS COMPONENTS wt. CAS# 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS TSecret ~SIBioHazI Radioactive/Amount I EPA HazardsI NFPA USDOT# I MOP No N No No/ Curies / / / Mod -3- 10/31/2000 7 ELEVEN #32376 SiteID: 015-021-001885 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~UiV~VlU~ ~Vl~ / ~1~.1.~ GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: SW OF BLDG IN STORE PARKING LOT CAS# 8006619 Liquid Pure Ambient Ambient UNDER GROUND TANK , AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 15000.00 GALI 15000.00 GAL 15000.00 GAL ZARDOUS COMPONENTS %Wt. ~SI CAS# 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS TSecretl ~slBi°Haz Radi°active/Amount I EPA HazardsNo N No No/ Curies NFPA/// I USDOT~ IMCP -4- 10/31/2000 F 7 ELEVEN #32376 SiteID: 015-021-001885 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 07/17/1998 AFTER CALL 911, THE BAKERSFIELD CITY FIRE DEPT WILL BE NOTIFIED ALONG WITH THE CALIFORNIA STATE OFFICE OF EMERGENCY SERVICES (800) 852-7550. -- Employee Notif./Evacuation 07/17/1998 THE STORE ATTENDANT WILL NOTIFY OTHER EMPLOYEES AND CUSTOMERS BY A SHOUT THAT THE BLDG MUST BE EVACUATED. ALL PERSONS MUST EVACUATE THROUGH THE FRONT DOORS TO THE EVACUATION STAGING AREA SHOWN ON THE FACILITY DIAGRAM. -- Public Notif./Evacuation 07/17/1998 THE STORE ATTENDANT WILL NOTIFY OTHER EMPLOYEES AND CUSTOMERS BY A SHOUT THAT THE BLDG MUST BE EVACUATED. ALL PERSONS MUST EVACUATE THROUGH THE FRONT DOORS TO THE EVACUATION STAGING AREA SHOWN ON THE FACILITY DIAGRAM. Emergency Medical Plan 07/17/1998 MINOR INJURIES WILL BE TREATED USING THE FIRST AID KIT LOCATED INSIDE THE STORE. THE CLOSEST MECIAL FACILITY IS BAKERSFIELD MEMORIAL HOSPITAL LOCATED AT 420 34TH ST, 327-1792. -5- 10/31/2000 7 ELEVEN #32376 SiteID: 015-021-001885 Fast Format = Mitigation/Prevent/Abatemt Overall Site -- Release Prevention 07/17/1998 EMERGENCY FUEL SHUT OFF SWITCHES ARE LCOATED IN THE FRONT OF THE STORE AND NEAR THE STORE COUNTER. THE UNDERGROUND STORAGE TANKS ARE EQUIPPED WITH OVERFILL/OVERSPILL PROTECTION. TANK FLUID LEVELS AND INTERSTITIAL SPACE ARE MONITORED BY A TIDEL EMS 3500 MONITORING SYSTEM. TANK TURBINES ARE EQUIPPED WITH LEAK DETECTORS WHICH RESTRICT FLOW IF A LEAK IS DETECTED BENEATH DISPENSERS OR ALONG PIPING RUNS. --Release Containment 07/17/1998 KITTY LITTER, LCOATED INSIDE THE STORE AT THE LOCATION SHOWN ON THE FACILITY DIAGRAM IS TO BE USED FOR SMALL FUEL SPILLS (LESS THAN 5 GAL). THE BAKERSFIELD CITY FIRE DEPT WILL RESPOND TO LARGER FUEL RELEASES BY PLACING SAND OR ABSORBANT ON THE SPILL. -- Clean Up 07/17/1998 ONCE A SPILL HAS BEEN CONTAINED, THE SAND OR ABSORBANT WILL BE CHARACTERIZED AND DISPOSED OF AT A PROPER DISPOSAL FACILITY. Other Resource Activation -6- 10/31/2000 F 7 ELEVEN #32376 SiteID: 015-021-001885 Fast Format ~ Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs 07/17/1998 A) GAS - N/A B) ELECTRICAL - NE CORNER OF BLDG, OUTSIDE C) WATER - E SIDE OF BLDG (OUTSIDE) AND IN PLANTER NW CORNER OF PROPERTY D) SPECIAL - NONE E) LOCK BOX - NO Fire Protec./Avail. Water 07/17/1998 PRIVATE FIRE PROTECTION - N/A NEAREST FIRE HYDRANT - IN PLANTER ON NW CORNER OF PROPERTY. Building Occupancy Level -7- 10/31/2000 7 ELEVEN #32376 ~i5i5~/~6~/~/~/5~/~/~/~/~i5~~ SiteID: 015-021-001885 i~ Training/~~~~~~~/~ Overall Site i~ Employee Training ~~~~~~~ 07/17/1998 O WE HAVE 8 EMPLOYEES AT THIS FACILITY. ° O WE DO HAVE MSDS SHEETS ON FILE BEHIND STORE COUNTER. ° o BRIEF SUMMARY OF TRAINING PROGRAM: EMPLOYEES ARE TRAINED IN A HAZARDOUS o MATERIALS COMMUNICATION PROGRAM. EACH EMPLOYEE IS INSTRUCTED ON HOW TO USE ° AND UNDERSTAND THE MATERIAL SAFETY DATA SHEETS. THE EMPLOYEES ARE INFORMED o OF THE HAZARDOUS MATERIALS STORED AT THE SITE AND THE PROPER RESPONSE ° PROCEEDURES, INCLUDING WHO TO CALL, IF A SPILL SHOULD OCCUR. ° o 0 0 i~ Held for Fumre Use O o i~5/5i~ Held for Fumre Use O o .1./04/01_ TIAI .1.1:3,1. F/~[ 1,9.1.68582355 GR0tlNDWATER SITE DIAGRAM f I ,, ~' 'FA(~/,ITY DIAGRAM {~l ' . .j, /' ) ;~'~ _ ~ ,:~ ,-,,. , ....... · . ~ I / I ' 1/04/01 THU 11:211 FAX 19168582355 GROUNDWATER ~]004 STATEMENT OF ACCOUN~ ~ITY OF BAKERSFIELD BAKERSFIELD, CA Y'~03-2057 (661) 326-3979 ~ DATE: 6/01/00 TO: =,EVEN ELEVEN ~32376 - BRiMHALL P 0 BOX 711 ~ '' ~ TX CU~'TOHER NO' i9~32 CUSTOMER TYPE: ES/ 23234 CHARGE DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL AMOUNT 5/01/0o B~GINNI,~G BALANCE .00 HMO05 6/01/00 HAZ MAT HANDLiNg FEE E 110.00 HMO17 6/01/00 HAZ MAT ANNUAL INSPECTION 50.00 SSO01 6/01/00 CA STATE SURCHARGE 10.00 SSO0~ 6/01/00 UST STATE SURCHARGE 8.00 THIS FEE IS A STATE SURCHARGE OF $8.00 FOR EACH UNDERGROUND STORAGE TANK. UTO01 6/01/00 UNDERGROUND TANK ANNUAL 198.00 n=:~,~~.~,~,.,~ PERMIT FEE OF $66.00 FOR EACH TANK. THIS UNIFIED ~ILL REPLACES SEPERATE ~ILLS RECEIVED IN THE PAST ~F~R THESE PROGRAMS. FOR QUESTIONS OR CHAN~ES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER 90 PAYMENT DUE:' 37&. O0 DUE DATE: 7/02/00 JUN 0 8 ~000 TOTAL DUE: $37'6. O0 STATEMENT OF ACCOUN( CITY OF 8mK=nSr~E~u P 0 BOX 2057 BAKERSFIELD, CA 9'3303-~2057 ........... ~? ~ ~L~EN, INO. ^Ti'N: GASOUN~A~OUNTiNG 70 =nv 71~ DALLAS, TX 7~~ CUSTOMER NO' 3126 CUSTOMER TYPE' ES/ 3!26 CHARGE DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL. AMOUNT ~/0!/00 B~INN!N~ BALANCE 8.50- HMO05 ~/01/00 H~ MAT HANDLIN~ FEE E SSO0! ~.I/O!/O0 CA o~.,ATE ~u^o~= !O O0 ~=~n~ 6/Ol~r,~ U=~ =~i~= SURCHARGE 24 O0 THIS FEE IS A STATE SURCHARGE OF $8.00 FOR EACH UNDER~ROUND STORAGE TANK. UTO01 6/0!/00 UNDER~ROUND TANK ANNUAL 198.00 OPERATIN~ PERMIT FEE OPERATIN~ PERMIT FEE OF $66.00 FOR EACH TANK. THIS UNIFIED BILL REpLACEs SEPERATE BILLS RECEIVED IN THE PAST F~R THESE PRO'RAMS. FOR ~UESTION8 OR C'HAN~ES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER &O OVER 90 DUE DATE: 7/03/00 PAYMENT DUi::- 333. 50 JUN 0 8 TOTAL DUE' $333. 50 STATEMENT OF ACCOUNt CITY OF P O BOX 2057 BAKER~Fi~Lu, CA (661) 326-3979 DATE~ 6/01/00 · 'r'r",. ~EVEN ~' :'t~='~,i --~.'~ .~6.'~ SOUTHLAND CORP ~{ BALDWIN PO BOX 7!! r'AL' AS TX -~--~o, CUSTOMER NO: 3127 CUSTOMER TYPE' ES/ 3127 CHARg.E DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL AMOUNT FOR QUESTIONS OR CHANGES 'TO YOUR ACCOUNT PLEASE CALL THE NUMBER AJ ~ 4u~ u~ THiS STATEMENT. CURRENT OVER 30 OVER 60 OVER 90 ~ O0 8.50- DUE DATE: 7/03/00 PAYMENT DUE: 383.50 TOTAL DUE: $383. ~0 THE SOUTHLAND CORPORATION CITY OF BAKERSFIELD 1501 TRUXTUN AVE BA~ERSFI~E_L_D ___ CA 93301 Dear Sirs: Enclosed is our check for invoices submitted to The Southland Corporation. Please submit any future invoices or financial correspondence related to gasoline equipment or underground storage tank permits or licenses to the following address: However, please continue to reference the store number and / or address on the invoice. The Southland Corporation P.O. Box 711 Dallas, TX 75221 Attention: Kathleen Baldwin Sincerely, L),nn wilson Lynn Wilson 214-828-7668 LW Cityplace Center East / 2711 North Haskell Avenue / Dallas, TX 75204-2906 Mailing Address: P.O. Box 711 / Dallas, TX 75221-0711 214-828-7011 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 1. To avoid further action, return this form within 30 days of receipt. 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. SECTION 1: BUSINESS IDENTIFICATION DATA mING ADD.SS: As DUN & BRADSTREET NUMBER: SIC CODE: SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 2_4HR. PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3' TRAINING NUMBER OF EMPLOYEES: ~ BRIEF SUMMARY OF TRAININ. G PROGRAM: r ;,, / // r - SECTION 4: EXEMPTION REQUEST I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH & SAFETY CODE" FOR THE FOLLOWING REASONS: WE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION I, CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT TI-US INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. SIGNATURE TITLE DATE 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES A. AGENCY NOTIFICATION PROCEDURES: C. PUBLIC EVACUATION: D. EMERGENCY MEDICAL PLAN: HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7; MITIOATION, PREVENTION AND ABATEMENT PLAN A. RELEASE PRE .VENTION STEPS: B. RELEASE CONTAINMENT AND/OR MINIMIZATION] -- ' ~, ", ' c. SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: _ SPECIAL: LOCK BOX: YES~ IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAIl.ABILITY A. PRIVATE FIRE PROTECTION: ,,t/'/~ .. B. WATER AVAILABII,ITY (FIRE HYDRANT): ~_i~ &~o~'- o~ ~,~r~"~,-,'-'~/ 4 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA ($05) 326-3979 HAZARDOUS MATERIALS INVENTORY FACII,ITY DESCRIPTION CHECK IF BUSINESS IS A FARM [ ] EMERGENCY CONTACTS [ · ~OUS MATERIALS INVENTC CI~EMICAL DESCRIPTION I ) INVENTORY STATUS: New~/~i Addition [ ] Revision [ ] Deletion [ ] Check ffchemical is a NON Trade Secret [ ] Trade Secret , 3) DOT # (optional) ,, Chemi Name: [ 4) Physical & Health PHYSICAL HFALTH H~z_a_rd Categories Fire [~)O Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] DeAayed Health (Chronic) D~ 5) WASTE CLASSIFICATION O-digit code firom DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid f~ Gas [ 7) AMOUNT AND TIME AT FACILITY . uNrrs OF M~pSURE 8) STORAGE CODES Average Daily Amount I ~} ~, v~..~ ~ ' [ ] b) Pressure: [ Annual ,4=notmt c) Teml~raatre Largest Size Container / ~, V~'~' ~ ~ # Days on Site ~ 6,,'~ q" ~' Cimle Which Months: ~ J, F, lvl, A, M, J, J, A, S, O, N, D 9) MIXTURE: List COMI~NENT CAS# % w'r AHM the three most b_~dous 1) [ chemical components or 2) [ any AHM components 3) [ 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Sec'et [ ] Trade Secret [ 2) Common Name: : 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire [ I Reactive [ ] Sudden Release of Pressure [ 5) WASTE CLASSWICATION (3-digit code from DFIS Form 8022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ I Gas[ I Pure[ ] Mixture[ ] Waste[ I Radioactive[ l 7) AMOUNT AND TIME AT FACILITY uNrrs OF MEAS~ 8) STORAGE CODEs Maximum Daily Amount Lbs [ ] Gal [ ] ft3 [ ] a) Container:. Average Daily Amount Curies [ ]. b) Pressure: Annual Amount c) Temperature Largest Size Container # Days on Site Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, lq, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the three most hazardous 1) [ chemical components or 2) [ any AI-tM components 3) [ )LOCATION I certify under penalty of law, that I have personally examined and am tkmiLiar with thejnformation on this and all attached documents. I believe the submitted, information is true, accurate a~d PRINT Name & Title or'Authorized Company Representative Signature Date