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Home My WebLink AboutUNDERGROUND STORAGE TANK #1/~ (UNDERGROUND STORAGE TANKS) FILE #1 ~ ~ ECONO-CUBE N_T_UNE -_ ~ ~\~~ .~-,_ ~~..-, 2901 BRUNDAGE-LANE -- ;~i - _ z~ooiic - -- _ _._ ,~ ~v J ~~ , ~, '~ ~. i;~ a ,, ~. t 1 ~ ~ ~ - .. ~ . ~ i ~ ~ /~~ t. MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California - Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or resort must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy.of this form to-the local agency.regulating UST systems within 30 days of test date. A. General'Information Facility Name: Econo Lube-N-Tune Bldg. No.: Site Address: 2901 Brundage Lane City: Bakersfield, CA Zip: 93304 Facility Contact Person: Vicky Contact Phone No.: (661) 322-7511 MakelModel of Monitoring System: Leak Alert Model # LA-04 Date of Testing/Servicing: 2R/2007 B. Inventory of Equipment Tested/Certified Check the annrnnriate hnYec to indirate .crwrifir enninment incnertedlcervirede Tank ID: Waste OII Tank ID: ~^ In=Tank Gauging Probe. Model: ^ In-Tank Gauging Probe. Model: ®Annulaz Space or Vault Sensor. Model: LAS-01 ^ Annular Space or Vault Sensor. Model: ^ Piping Sump /Trench Sensor(s). Model: ^ Piping Sump /Trench Sensor(s). Model: ^ Fill Sump Sensor(s). Model: ^ Fill Sump Sensor(s). Model: ^ Mechanical Line Leak Detector. Model: ^ Mechanical Line Leak llerector. Model: ^ Electronic Line Leak Detector. Model: ^ Electronic Line Leak Detector. Model: ^ Tank Overfill /High-Level Sensor. Model: ^ Tank Ove~ll /High-Level Sensor. Model: ^ Other (specify equipment type and model in Section E on Page 2). ^ Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ^ In-Tank Gauging Probe. Model: ^ In-Tank Gauging Probe. Model: ^ Annular Space or Vault Sensor. Model: ^ Annulaz Space or Vault Sensor. Model: ^ Pipirig Sump /Trench Sensor(s). Model: ^ Piping Sump /Trench Sensor(s). Model: ^. Fill Sump Sensor(s)., , Model: ^ Fill Sump Sensor(s). Model: ^ Mechanical Line Leak Detector. Model: - ^ Mechanical Line Leak Detector. Model: ^ Electronic Line Leak Detector. Model: ^ Electronic Line Leak Detector. Model: ^ 'l'ank Overfill !High-Level Sensor. Model:. ^ Tank Overfill /High-Level Sensor. Model: ^ Other (specify equipment type and model in Secfion E on Page 2). ^ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ^ Dispenser Containment Sensor(s). Model: ^ Dispenser Containment Sensor(s). Model: ^ Sheaz Valve(s). ^ Shear Valve(s). ^ Dispenser Containment Float(s) and Chain(s). ^ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ^ Dispenser Containment Sensor(s). Model:- ^-Dispenser Containm_ ent Sensor(s), Model: ^ Shear Valve(s). ^ Shear Valve(s). ^ Dispenser Containment Float(s) and Chain(s). ^ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ^ Dispenser Containment Sensor(s). Model: ^ Dispenser Containment Sensor(s). Model: ^ Sheaz Valve(s). ^ Shear Valve(s) ^ Dispenser Containment Float(s) and Chain(s). ^ Dispenser Containment Float(s) and Chain(s). °u uze racutry contains more tanxs or dispensers, copy tuts iorm. Include miormatton for every tank and dispenser at the facility. C. CertlfiCatlon - I certify that the equipment identified in this document was inspected serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ^ System set-up ^ Alar history report Technician Name (print): Jim Albitre Signature: Certification No.: 5248968-UT 06-0400 License. No.: 5 $ HAZ Testing Company Name: Redwine Testing Services, Inf. Phorie No.: (661) 834-6993 Site Address: 2901 Brundage Lane, Bakersfield, CA 93304 Date of Testing/Servicing: 2/7/2007 Page 1 of 3 Monitoring System Certification D. Results of Testing/Servicing Softwaze Version Installed: Complete the following checklist: ® Yes ^ No* Is the audible alarm operational? ® Yes ^ No* Is the visual alarm operational? ^ Yes ^ Nom Were all sensors visually inspected, functionally tested, and confirmed operational? ® Yes ^ No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? ^ Yes ^ No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem) ® N/A operational? ^ Yes ^ Noy` For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment - -- ®N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply) ^ Sump/Trench Sensors; ^ Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? ^Yes; ^ No. ^ Yes ^ No'~` For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no ® N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm trigger? % ^ Yes* ®No Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all replacement parts in Section E, below. ^ Yes* ®No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) ^ Product; ^ Water. If yes, describe causes in Section E, below. ® Yes ^ No's Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable ® Yes ^ No" Is all monitoring equipment operational per manufacturer's specifications? In Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: Page 2 of 3 Monitoring System Certification F. In-Tank Gauging /SIR Equipment: ^ Check this box if tank gauging is used only for inventory control. ® Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the following checklist: ^ Yes ^ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults'? ^ Yes ^ No* Were all tank gauging probes visually inspected for damage and residue buildup? ^ Yes ^ No* Was accuracy of system product level readings tested? ^ Yes ^ No* Was accuracy of system water level readings tested? ^ Yes ^ No* Were ail probes reinstalled properly? ^ Yes ^ No* Were all items on the equipment manufacturer's maintenance checklist completed? x In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): C.mm~letP the fnllnwin¢ chPrklict~ ® Check this box if LLDs are not installed. ^ Yes ^ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ^ N/A (Check all that apply) Simulated leak rate: ^ 3 g.p.h.; ^ 0.1 g.p.h ; ^ 0.2 g.p.h. ' ^ Yes ^ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ^ Yes ^ No* Was the testing apparatus properly calibrated? ^ Yes ^ No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ^ N/A ^ Yes ^ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ^ N/A ^ Yes ^ No* For electronic LLDs, does~the turbine automatically shut off if any portion of the monitoring system is disabled ^ N/A or disconnected? ^ Yes ^ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ^ N/A or fails a test? ^ Yes ^ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ^ N/A ^ Yes ^ No* Were all items on the equipment manufacturer's maintenance checklist completed? In the Section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: Page 3 of 3 , I o~iforeng Sys~~ Certifies#~on L1~T' ®n~t®ring Site ~~an to Address: _ v.-~,::~ ~~~ ~.~~ ~.:?;~~-~ ;F e~ _.~-~~-%l= `~ . . . . . B • . - -- ~-.-a w. .,~":. `~Pi~l ~J+ LJb i~`'.v...'.r- ~~ / .~...-- ~-~ --•-- •• -•-__ •_ _ __ ,_ /-~ __~~ . - E III -.._.r .. ~ • ~.. .._~._._~_.... ~. .._._.. ..._.. __ ................_.._........_....._......... e .._._... I • r . - i 'S ~ ~ ~ .- ( R } , I ~ ~,j ~ . f ' i \-~ .vim ~ ~_-~~ { i ['rte . ? ~. . a i\ ~ i ` ' C„ ~~~~ O./ . s ~ . . . . . '.-.___ ~ . . . _r~~;,l . . . . . . . , t~j. . . . . . . . . • E {~ . . . . . mate IIld1}? ws9S drawn. ~ _ _-.'~ Instr°ucte®~ f you already have a diagram that shows all required information, you may .include it, rather than this page, +~zth our tUlonitoring System Certification. On your site plan, shave the general layout of~ tanks and piping. Clearly jentify locations of the following equiprnent, if installed: monitoring sy5tern control panels; sensors n~an?torinS ank annular spaces, sumps; dispenser pans,. spill containers, or other secondary containment areas; mechanis:.al or ' lectronic line leak detectors; and in-tank liquid level probes (if used for leak detection). In the space prop-;ded, rote the date this Site Plan was prepared. r +, SWRCB, January 2006 Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory- agency. 1. FACILITY INFORMATION Facility Name: Econo Lube-N-Tune Date of Testing: 2!7/07 Facility Address: 2901 Brundage Lane, Bakersfield, CA 93304 Facility Contact: Vicky Phone: 661-322-7511 Date Local Agency Was Notified of Testing : 1/26/07 City of Bakersfield Fire Department Name of Local Agency Inspector (if present during testing): Inspector Steve Underwood 2. TESTING CONTRACTOR INFORMATION Company Name: Redwine Testing Services, Inc. Technician Conducting Test: Jim Albitre Credentialsl: CSLB Contractor X ICC Service Tech. SWRCB Tank Tester Other (Specify) License Number(s): 5248968-UT 3. SPILL BUCKET TESTING INFORMATION Test Method Used: Hydrostatic Vacuum Other Test Equipment Used: Equipment Resolution: - __ :__ - Identify Spill Bucket (By Tank Number, Stored Product, etc.) -- 1 2 _ 3 - _ _ _ 4 Bucket Installation Type: Direct Bury Contained in Sum Direct Bury Contained in Sum Direct Bury Contained in Sum Direct Bury Contained in Sum Bucket Diameter: 13" ' Bucket Depth: 3" Wait time between applying vacuum water and start of test: 30 Min Test Start Time (TI): 8:50 AM Initial Reading (RI): 1" Test End Time (TF): 9:50 AM Final Reading (RF): 1" Test Duration (TF - TI): 60 Min Change in Reading (RF - RI): 0 Pass/Fail Threshold or - Criteria: 0 - Test Result: X Pass Fail Pass Fail Pass Fail Pass Fail Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true, accurate, and in full compliance with Zegal requirements. Teclu Date: ~ ' ~ ~ of 7 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent. .,~ (.1a~I?ERG~3~t9i~I9 STf3~.4GE T A4~~OS ~~-~~ `~~.~ ,,~. ~ • ~~a~~ ~' ~~.~' ~~i . ' ' rZ~ ,~ B E~S ,~~~~~~~ ~' ~,~~~ B~kersfeld, C_A 9330? > °ERFORiVt ELD I LINE TESTi~lG ' "I'e?.: (651 326-3979 3s89SECONt?ARYCONT4{t`~MEhlT 1"ESTIi~G ' ~i3~: (~~~') grG2_~^7~ ~Nif TiG!-iTNESS TEST AN® T© PERFURi v~ 1=~EL N(T~41E'~€G C:ERT?F€C~T3~3Ni P2ge 1 Ci ? '~ ENH,`-\NCE4 i.E.aK DETECTION LI LiNE TESTING I~ S8-989 SEGGP:DAR'f CO~iTA.fN~ 1EN T TEST4N4 _I TANK TIGHTNESS TEST ,~ TO RERFORP~I FJEL tviONITORING CERTiFICAT!:iiV SITE ~NFCR[A.4 ~~Iuf. =ACiLITY ~ 1 iP:;:ni~= ~ ?RCyN= ,?iii~'.;8'=' ~F Cv:~ T ~,+' T !~'L~;%:!i? i iDDn^^ESc ~~~ ( ~ ~ ~~ `~ 3 3~ ~ k ev-sue ~~ ~ _ r~c ..ge.. - . ~. e ; _----------_____---- >NiPJERS NAME ~_.____.,___-_. _- :~Y=R;iTO'=y 'a`;Ii„!i'':~_ ~P..Y=:k'.. T u ;,p Jr~~~~fv'i; _ ..... iUlviBER O~ TANKS TO BE TESTED .___ .._. _.- _...TA~~4 ~,.-------_.. :OING T~ BE TESTED?---- - -.._r._O. ` ES__ _ _O. Cw -- --- I -- - - _....----V O ##_ li M E___. __... ._ .. _.. ...._ ~.___ _ _ -- ._ _-..... C ~ ~ T E N T S__. - _. -- ------ ~ nn ~~U~S 1-~_ d) ~ s _ i._ __ . ----- --- -- - ----------- ___ ...-_ ~ __.__~___.---_.... - .-... ._.-_._. I-- --- _ ---- _..__. ___ _ -_ ..------ I i -----. .. _.._..____._..-.....-_. _ _L_ .-_._~_.....---_--- . __..__ ..._ ___-_ _ ___....__.._ _.._ _ -- _ _..._._.-- ~i i I i --_- - - -- - - - - T4i`~< TESTING ~t~~U~t~AP~Y -- -- - - - -- - -- Atlfi OFT STfNG CO~~nPANY sSA.STc x t?U sF :! es~E~ `>F -.,Q ~ ..1.. ; _>;ci, i~! AIL! G ADDRESS ' 4AME & P;-;ONE NUMBER OF TESTER OR SPECIAL #NSPECTOR (CERTIFICATION =: aTE & TIME TEST TO BE CQNDUCTED ;IOC ~: TEST Pv7ETHOD GNATURE OF APPLICANT ~ ATE ~ ~~ ~ _Q ~ ---_ ------------ _---_-- ~.----.. _.__. ~F'~1,~~$~?I~~i>~~`~'~E~~11'SEC,~_~.~3_~_~~~&~~'`~~/h~~~1_~&~F?F$Q'5~~~'-- - flROVED 6Y !DATE t=D2i0n "- ~, Prevention Services UNIFIED PROGRAM INSPECTION CHECKLIST' _E R s_F , 0 900Truxtun Ave., suite 210 B _.- r ___ ~. __~__-___~ . ,~~ ~ ____ __ __ _ _ ~ F~R6 Bakersfield, CA 93301 SECTION 1: Business Plan and Inventory Program ~RrM r Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME / ~ ` ~ ~' ~ INSPECTION DATE f 2~ Z 6 ~ INSPEC TIME ~ ~ ~+ ~ O N o L. v~ 6 N it~ N~ z, 0 ii -- ADDRESS 2 ci D I b Q, rti h?-,}~, E LN PHONE NO. 2 L- 7S) I NO OF EMPLOYEES FACILITY CONTACT USINESS ID NUMBER 15-021- l a- a .Section 4: Business Pian and inven#aFy i'rt~gragt ~~~ ^ ROUTINE ~ COMBINED ^ .JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V ( C=Compliance} OPERAT{ON V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND ^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY 90®~ ,~ L ^ VERIFICATION OF INVENTORY MATERIALS p NI 1 ^ VERIFICATION OF QUANTITIES I ,/ l T ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITY ~^ VERIFICATION OF HAZ MAT TRAINING ee ~ O e ~ rt GO tOl S O ,.~ A ~ ~ fj rv YJ~ y yG 6 1 0 ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED 0 ^ HOUSEKEEPING ^ ^ FIRE PROTECTION ^ ^ SITE DIAGRAM ADEQUATE & ON HAND ti _~ nor-ouio ANY HAZARDOUS WASTE ON SITE? YES ^ NO EXPLAIN: ~ a S k' e a\ 1 s ~ ,~ ~ ~ '~ / s QUESTIONS REGARDING THIS INSPECT/I~ON? PLEASE CALL US AT (661) 326-3979 Inspector ( ease Print) Fire Prevention / 1~' In /Shift of Site/Station # White -Prevention Services Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 -~ - +~ ,~ /~~4y`. ~'~~_~ CITY OF BAICERSFIELD FIRE DEPARTMENT c ~~,,,v'~ FACILITY NAME ~C c~N o L ~,.Br` ~ 'i •+~, ~y ~ INSPECTION DATE 1~.,I ~- ~o ~ Section 4: Hazardous Waste Generator Program EPA ID # f~~ ^ Routine ~1 Combined ^ Joint Agency ^Muiti-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number Authorized for waste treatment an r storag Reported release, fire, or explosion within 15 days of occurrence Established or maintains a contingency plan and training Hazardous waste accumulation time frames 1112.1 a L s ~1- Containers in good condition and not leaking Containers are compatible with the hazardous waste Containers are kept closed when not in use - Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided Conducts daily inspection of tanks Used oil. not contaminated with other hazardous waste Proper management of lead acid batteries including labels /J ~ Proper management of used oil filters Transports hazardous waste with completed manifest Sends manifest copies to DTSC Retains manifests for 3 years Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal ~,=~,ompuance v=vroranon Inspector: C ~~~ ~ ~ 1 Office of Environmental Services (661) 326-39']9 White -Env. Svcs. ~ OFFICE OF ENVIRONMENTAL SERVICES b •y UNIFIED PROGRAM INSPECTION CHECKLIST ~ '" ti ~ 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 Pink -Business Copy tf ' Business Site Re onsible Party .~, . ~, INSPECTIONS BUSINESS PLAN & INVENTORY PROGRAM UNIFIED PROGRAM INSPECTION CHECKLIST B ~ E R S F I L D P/IitE ARTM T FACILITY NAME: C.GO~~ L:+-L~ ~ Tt,t.~ Section 2: Underground Storage Tanks Program ^ Routine -~. Combined ^ Joint Agency ^ Multi-Agency Type of Tank Number of Tanks Type of Monitoring ao, rc ~~r .~ Type of Piping ] f_ a L 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 INSPECTION DATE: ~~~=~. ^ Complaint ^ Re-Inspection OPERATION C V COMMENTS Proper tank data on file 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 o 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 Inspector: ~ ~""" ~/' ~ ~ `~ Questions regarding this inspection? Please call us at (661) 326-3979 White -Prevention Services ~- C usiness Site Responsible P Pink -Business Copy KBF-7335 FD 2156 (Rev. 09/05) F/RE ~ARTM T November 1, 2006 Ronald J. Froze Fire Chief Gary Hutton Mrs. Lopez Senior Deputy Chief Econo Lube-n-Tune Administration 326-3650 2901 Brundage Lane Bakersfield, CA 93304 Deputy Chief Dean Clason Operations/Training NOTICE OF VIOLATION AND 326-3652 SCHEDULE FOR COMPLIANCE Deputy Chief Kirk Blair Re: Failure to Submit Paaerwork for Transfer of Ownership Fire Safety/Prevention Services 326-3653 Dear Mrs. Lopez: Our records indicate that you have not completed the transfer of ownership PREVENTION SERVICES paperwork that was started last year. You have 30 days to complete the Ralph Huey, Director necessary paperwork. 900 Truxtun, Suite 210 Bakersfield, CA 93301 Please call me to schedule an appointment at your earliest convenience. My VOICE (661) 326-3979 direct number is 661 - 326-3190. FAX (661) 852-2171 Should you have any questions, please don't hesitate to call me. Sincerely, RALPH E. HUEY DIRECTOR OF PREVENTION SERVICES l-~~Q ~~~I'~-C~' By: Steve Underwood, Fire Prevention Officer REH/SU/db -._ ::..ii ~~55 ;'~3.2. 5', ~-t i?~ie'LF.9~' ~;e~i'5'c:L*_'v ... ~?; h~:~.i a'J"' -_.-N.,_ .,.. ..y yam. ;te 5-e' ~ '9~ _ as ~_ c 8.e'~ x~'"_: _=~~2 ~6~°~ a G=~~..' =J~~_ S ~'~~3`-~~. ;-;~~ =~.Ji ~ f.l~ LCj:jy~ ~~.. iUL _, -~%.V-J~ J e~"e'Ji_ ~ a -=~ i~~: °.-~J'~~`7~ :°`.'. v~41; mss-?E'S'A vLy~c' ~ _ J ~ _ -_ ~ i i1 ~'E?E T'C~i'?Fi'<1=~~ ~~i .~i?'~ 9~.3 Y.~--.i'sj^.-.. .`F,''__ ... t., .-__i ~ii~e:. v-n iii iEf :~;y(1A ~~ J - - - i ~v~~n~1j ~~'~- .. .. ._ -~~. ~~}} ~ b n ~ ~ ~'~ ~ J \ o~ ~ ~ CR.K.rt- ~- t J G --------------- ---. ~ -! r`,.. ., ~Tlt~~./~ ~"`.- S.- yr , ~NKa i O S -=L ' '_P4 -~' O 3. -. -_r.: _; ~ 4 •r '~ r U ... .I __ _ -- ~.~ -. ~-_ __ n__ .. _ _. _-_._ _._ .. .. ... t.l @~_~~s-~~,JV~~lZ~`~ tom. `v'i~~:~l i~`% ~ x/11., _ .- ,'. `; "4 :.. t .?~) > ~.."",`." „".~ 4. (~ti ,.~Pn eJ~(-,[~.FiJ L.a`if.-~ ~~~/ ~~ ~ ~D t4 f ' ~J'T'st+ ~ ~'~ . _.~?,i.`1` (1 ~.c~,C /S ~? ~ ,~tt-~.~c~. ~.~a~ ~ 3,.30- ~ --- r2 ~ ~v~±E titi€:4~~'ER 0=-'~Si~~ ~~ ca_ .3ii? '~iEt~rCiG C_ C=:: i:,.~ -- ~o~`. ~.Qrzerto (~(ol -..~~- ~(~~`~ ~ £~~ D3~ ~a ~ °--° U S 0~35,~, 13~- t7~'~ L C(-~~~ c7rvLU - C-~r~Si ~^~G 1~A~n Qc;2~~T~ -- _~% i C., ~-Et.J ~DNDERGROEJND STORAGE TAiVFCS ~` ;~ >~" ~- ~ - ~ ~~g''~' I.~ ~I$~' ~~' . _~ l~T , S~ H R S P 11= -L D gym,, ~a ~F ~w~ _~3'>~~ 900 Tnzxtun Ave., Ste. 210 ~~~~~~~~ _ _::~~ Bakersfield, CA 93301 To PERFORM EL®/ LINE TESTING Tel.: (6617 326-3979 / SB989 SECONDARY CONTAINMENT TESTWG Fax: (661) 852-2171 (PANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFlCATlON Page i of 1 PERMIT NO ~ O~G~ . ` ^ ENHANCED LEAK DETECTION ^ L1NE TESTING jE, I SB-989 SECONDARY CONTAINMENT TESTING ^ TANK TIGHTNESS TEST ^ TO PERFORM FUEL MONITOR4NG CERTIFiGAT10N SITE l!~1FORIviAT10Pa ~FAC!LI- ~NAPuSE & PHONE NUMB ER Ot'' CONTACT PERSON I - N - ! 1G ~u ~~o~ - 3a~- ~ s ~ ~ ~ ADDRESS i a g o 1 ~~p c~~. s ~ e e.~.a.~-Qd , CA 9 3 3d , (OWNERS NAtviE ~ i OPERATORS NAPv1E PEf?MIT TO OPERSATE NO. ~', !NUPABER OF TANKS TO BE TESTED I -- --- TANK # ____ _ j-- ----- - IS PIPfNG GOING TO BE TESTED? .~ YES ^ NO --__~_ 04., -._ VOLUME ___ i CONTENTS- --- -- - __ ----- _ ~ - -- ! --- - -- -- -- - ; i I ~ I ~ i I ~ I I i I i i ------------------ j ~, , L I - - -- - - II TANK TESTING COMPANY I NAM :~,.Jp~F~~T~E~~S~~~TIN~~G CO/MPAyNY l ~NARJIE P9-(ONE NR.~MB/~ER OF CONTACT" PERSO ~+ p ! I ~h-~ n Il~U/xAi 110 ~. i f C.LD/~ . L ~ ~ ~18.tii \ L[~/1/hP.Li ~n ~D ~ ' ~~ ~' ~0 f -l Po . ,&~r iSb?__ _~a.k~A~.v~ , C'.(~ 9 330 H~dAME & PHONE NU BER OF TESTER OR SPE~iAL 4N~PECTOR ERTIFICATION t: Geol..- ~Quco (Dl~l -.~- tQ(~~'~ ~ bSb3~ la R -- o S03S~ 13~ ATE & iM~T TO BE C NDUCTED iICC ~?: ES METHOD ~ ;a~Pin - 'a~19a4 - uT I~~~~ ~SlGNATURE OF APP ~ T ~ DATE , 2 ~~ _~'-' !APPROVED BY n rUi _ / //~~//~,,,,,~„ 1 (DATE / 7 / n / /1 i FD2f 06 ., _ ::~ ~ ~ I~S~I~LI~ ~I~2~ DES. UNDERGROUND STORAGE TANKS ~a ~,.. s r , r , . ~ n ~Y~~~~QIl ~~1'~'I~~S ~,~ r~~ ~~ ~ ~,i f_i'~ 900 Truxtun Ave., Ste. 210 APF~LICT9~tV ~ _:`; ~: ` B~xerS~ela, cA 933a~ TO PERFORM ELD /LINE TESTING Tel.: (661) 326-3979 / S6989 SECONDARY CONTAINMENT TESTING Fax: {661) 852-2171 (TANK TIGHTNESS TEST AND TO PERFORIIJI FUEL MONITORING CERTIFiCATiON Page 1 of 1 PERMIT NO. ~_ ~ ~~ ^ ENHANCED LEAK DETECTION ^ LINE TESTING ^ SB-989 SECONDARY CONTAINMENT TESTING ^ TANK TIGHTNESS TEST ~ TO PERFORM FUEL i~10NfTORING CERTIFICATION ;:: SITE INF_CRMP.T.VON FACILIT --- ---- ---- - --- NAIUIE & PHONE NUMBER OF CONTACT PERSON- - ADDRESS n GP b' ~Q~,O- , ~U l~t'1 9 3 30 OWNERS NAME I OPERATOfaS idAME .PERMIT TO OPERATE NO. (NUMBER OF TANKS TO BE TESTED IS PIPING GOING TO BE TESTED? ^_YES -i-_ ~ NO ____,.-` _ - __ TANK # ' ' i C O N T E N_TS. _._--J V d ~ U Nt E ( --.` -- ~ r--------- I I i -----_--- _., ,- ------ .._ ~ ~ I I ' ~ I ~ i ~ i I I ( ~ i I I TANK TcSTI~G' GOiL1PANY AME F TESTING COMPANY 'NAM & PHONE NUh9B R OF CONTACT PERSON IAILIN ADDR-SS .Q i -S(,~ 93 ~,2 ~G~.1rc,1,. .I. CA 3 AME & PHONE NUMBER OF TESTER OR SPECIAL SPECT R CERTIFICATION #: 'ATE R~Q'IME TEST TO BE CONDUCTED CC #: I EST METHOD i1.... J,.., /i~_ -. _. ,~ IAA/ n.._., n.,:n i ci7~/d nrl~ i~'T i eC-- Z ~~ ~A~PROVED BY ~ ~. / //Sn// uA.lo~ I (DATE i/C~/A l i FD2i06 _ _ _ __ ~~ MONITORING SYSTEM CERTIFICATION For Use By Aft Jurisdictions Within the State of Cal'rfomia .Authority Cited: Chapter 6, 7, Health and Safety Code; Chapter 16, Division 3, Tale 23, California Code of Regulations This form must be-used to document testing and servicing of monitoring equipment. A separate certfiigtiori or repoR roust be prepared for each monitorino system control panel by the technician who pertoims the work. -A copy of this form must be provided to the tank system o~dner/operator. The owner/operator must sut>mft a copy of this formto the ~oeal agency regulating UST systems within. 30 _ . days of test date. A. General Information Facility Name: Econo Luhe-N-Tune BId9• ~~ Sde Address: 2901 Brundage Lane City: Bakersfield, CA Zip: 93304-2429 Facility Contact Person: Alice Contact Phone No. (661) 322-7511 Make/Model of Monitoring System: Leak Alert LA-04 Date of TesGng/Servicirg: 1 / 10 / 06 B. Inventory of Equipment TestedtCertified Check the a m boxes to indicate uipmeM ins /serviced: TankiD: Waste Oil Tank - Tank ID: IrrTank Gauging Probe. ' Model: _ ^ IrrTank Gauging Probe. Model X Annular Space or Vault Sensor. Model: LALS-1 Annular Space or Vauk Sensor. Model: Piping Sumplfrench Sensor(s). Model: ^ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill !High-Level Sensor. Model: Tank Ove~lt !High-Level Sensor. Model: ^ Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: ^ Shear Valve(s). ^ Shear Valve{s}. ^ Dispenser Containment Float(s) and Chain(s). ^ Dispenser Containment Float(s) and Chain(s). Other (specfy uipment ty and model in Section E on Page 2 . ^ Other (s rtY equipment type and model in Section E on Pa a 2). Ta nklD: TanklD: ^ In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or VauR Sensor. Model: Annular Space or Vault Sensor. Model: Piping SumplTrench Sensor(s). Model: Piping SumplTrench Sensor(s)_ Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector: Model: Electronic Line Leak Detector.' Model: ^ Tank Overfill /High-Level Sensor. Model ^ Tank Overfill /High-Level Sensor. _ Model: ^ Dispenser Containment Sensor{s). Model: ^ Dispenser Containment Sensor(s). Model: ^ Shear Valve(s). ^ Shear Valve(s). ^ Dispenser Containment Float(s) and Chain(s). ^ Dispenser Containment Float(s) and Chain(s). ^ Other s ecify equipment type and model in Section E on Pa a 2). ^ Other (specify equipment type and model in Section E on Pa a 2). DispenserfD: DispenserlD: ^ Dispenser Containment Sensor(s). Model: ^ Dispenser Containment Sensor(s). Model: ^ Shear Valve(s). ^ Shear Valve(s). Dis nser Containment Floats and Chain s). Dis enser Containment Float(s) and Chain s). DispenserlD: DispenserlD: pispenser Containment Sensor(s}. Model: ^ Dispenser Containment Sensor(s). Model: ^ Shear Valve(s). ^ Shear Valve(s). Dispenser Containment Float(s) and Chain s). ^ Di enser Containment Float(s) and Chai s . DispenserlD: DispenserlD: ^ Dispenser Containmeht Sensor(s). Model: Dispenser Containment Sensor{s). Model: 8 Shear Valve(s). ^ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ^Dis user Containment Float{s and Chains . -n the raciiny cornains more tanks or dispensers, copy tms torn inaude imomtatwn ror every tank and mspenser at me taulrty. C. Certificatlon - I certify that Ute equipment identified in this document was inspected/serviced in accordance with the manufacturers guidelines. ' Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check al! that apply): ~ System set-up ~ Alarm history report Technician Name (print): Jim Albitre Cert./Lic. No. 532878 A HAZ 'nature: Testing Company Name: ~ Redwine testing Services, inc. Phone tVo. (881) 834-8993 ~ Page 1 of 4 Monitoring System Certification D. Resul4s of TestinglSetvicing software version installed: Cmm~lete the fntlnwirm checklist X Yes No' is the audible alarm o ational? X Yes No' Is the visual alann o rational? X Yes No' Were all sensors visuals ins ed, fundionall tested, and confirmed o erafional? X Yes No' Were all sensors installed at lowest point of secondary cwrtairmment and positioned so that other equipment will cwt intertere with their ro er o eration? Yes No' If alarms are relayed to a remote monitoring station, is aH t~mmunications equipment (e.g. modem) operational? N!A Yes No' For pressurized piping systems, does the turbine automatically strut down ii the piping secondary containment X^ N/A montoring system detects a leak, fails to o rate, w is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check aft that apply) Q Sump/Trench Sensors; ^ Dispenser Containment Sensors. Did you confirm sitive shut-down due to leaks and sensor failuretdisconnection? ^ Yes; No. Yes No` For tank systems that utilize the mon'rtortrg system as the primary tank overfill roaming device {i.e. no mechanical N/A overtill prevention valve is installed), is the overfill roaming alarm visible and audible at the tank fill point(s) and o erafin o ff so, at what cent of tank ca ac' does the alarm tri er? %. Yes X No` Was any monitoring equipment replaced? tt yes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all re lacement rts in Section E, below. Yes X No' Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) Prtiduct: ^IVater. If es, describe causes in Section E, below. Yes No' Was monitorin s stem set reviewed to ensure ro er settin s? Attach set u re rts, 'rf a Iicable. X Yes No` is all monitoring equipment o ational per manufacturer's spermcations? r m secnon t uerow, descnoe now and when mere deficiencies were or roil! be corrected. E. Comments: Annuylar Leak Alert LALS-1 Page 2 of 4 03/01 F. Itt-Tank Gauging (SIR EQuipm@nt: ^ Check this box if tank gauging is used only for inventory control. Check this box if no tank gauging or SIR equipment is installed. This section must be completedd in-tank gauging equipmem is used to perform leak detection monRotirtg. Complete the followina checklist: Yes No* Has ail in ut wirt been ins ed for ro r e and termination, incudin testi for round fauks? Yes No` Were all lark au in robes visual ins ed for dama a and residue buildu ? Yes No* Was a of s stem rodud level readin s tested? Yes No' Was accurac of s stem water level readin s tested? Yes No` Were all bes reinstalled o Yes No` Were all Bems on the ui ment manufacturer's maintenance checklist com Ieted? In the Section M, nelow, descnbe how and when these detiuencies were or will t)e corrected. G. Line Leak D@teCtors (LLD): Check this box if LLOs are not installed. Complete the following checklist: Yes No* For equipment start-up or annua{ equipment certfication, was a leak simulated to verify LLD performance? ~ N/A Check all that a Simulated leak rate: 3 ..h.; ~t .h.; 00.2 ..h Yes No* Were all LLDs confirmed o Tonal and accurate within ulat r uirements? Yes No` Was the testing apparatus property calibrated? Yes No' For mechanical LLDs, does the LLD restrict product flow if it detects a leak? N/A Yes No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? N!A Yes No' For electronic LLDs, does the turbine automaticaly shut off if any portion of the monitoring system is disabled N/A or disconnected? Yes No' For electronic LLDs, does the turbine automatically shut offrf any portion of the monitoring system maffundions N/A or faits a test? Yes No` For electronic LLD, have all accessible wiring corrnedions been visually inspected? N!A Yes No* Were all items on the ui nt manufacturer's maintenance diedklist completed? m urc actiuvr n, Ue1vW, kreSGrpe now ana Wnen II1ese OetlClenCleS Were or wilt D@ Corrected. H. Comm@nts: Page 3 of 4 03/pt liae~ai#oring Systee~ Certifecati®® US7' IVlonit®rin~ Site Plan Site Address: <~` `~`~ ; ~~ ~~~~~ 3'.~~~,-~ . ~ . . .., . . ~ __ . . . . .emu-tea __~__ `~ ~uxt~~.._.r`,~-J:_.._-...__. . .z- -.-. .- .- . . . . . . _- . :~, . ~. . ~ ........ ...... ~ ... _ ~~ ~~ o~ .... .. ~~r......... . ~~~~ t~,~~=~ . .~. ~~. . ..~. . . .~.. . ~I . .~ ..i . ~.,. [?ate man wac drawn / /t~ ~N IDS$i'UC$I!0~,4~ If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: munitvnng system control panels; sensors manitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in-tank liquid level probes (if used for teak detection). In the space provided, note the date this Site Plan was prepared. { n.~ `7~~~i ['3as'•2 __~ ;' 3 Pj`~C `I"'S I Eby°v . ~~S''~~ S~'v is§`a =~3 `.~. `'~ ~~ 3 ale 77;3 ~`€r -=S ~'~s: ~'~., _ .'„g- .'JV -!.i `~Li, 3 C"., SAC'- .l=J ~~ J_~`"^-ate _ .._.. PVC _- :J.~ J 2-' ^i' ~'~~-l.i. ',r ~; -. ~. _ :?fir ..:V _ I :. ', _/~}~ n. t _ } y _ } •J _. ; fig ~'~li.t~ ~i e ~ A~ "`t V ` a.11.i~1t _4 _ ' d AY.C C.A~ ~a ttt t ° ~~~ °' ' 1 ~ ^~ ( _- o~~~~ ors :~-~.:;_ _ _ .___-_ - T u ~ _~. ..-_ __.. __ ~_. _.~-__ __~.~_ _ ._ ., __._ . , ..._..____ .......__ .. .. .._ u,5'~,t 'kC -' ..~a ;~:t7~~ E, P. CFTC. ... _.._ _ ~sy ~i `_ ~ ~•-%~~iz ~i ri - •~, 7= c~ v~ ~.~ -•,-jF ~ j;~~ t c --------'----~-----.._ -_ .''min `. '- 1`l~ tS_-3?=LC'iSJVC =? '~~'-~... =S! F?i=-yv ~'~~= _. ._x ~~ ~== -J= ~ `.i^ B E R S F I F/RE ~I R TM RONALD J. FRAZE FIRE CHIEF Gary Hutton, Senior Deputy Chief Administration 326-3650 D Deputy Chief Dean Clason Operations/Training 326-3652 Deputy Chief Kirk Blair Fire Safety/Prevention Services 326-3653 December 1, 2005 Econo Lube N Tune 2901 Brundage Lane Bakersfield, CA 93304 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. 2101 "H" Street Senate Bill 989 became effective January 1, 2002, section 25284.1 (California Bakersfield, CA 93301 Health & Safety Code) of the new law mandates testing of secondary containment OFFICE: (661) 326-3941 components upon installation and every 36 months, thereafter, to insure that the FAX: (661) 852-2170 ', systems are capable of containing releases from the primary containment until they are detected and removed. RALPH E. HUEY, 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 Howard H. Wines, 111 Hazardous Materials Specialist 326-3649 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, RALPH E. HUEY, Director of Prevention Services ~-__ /-- Steve Undervvood Fire Prevention Officer SU:db J~+iis~ ~ fett~ ~ ..~112~ ~~y ~~~~ Tl~'ess~`r~ •. 03/22/2006 11:20 661-3227171 _ E!~IDNO LUBE N TUNE PAGE 02 `,Y r A :f ~ '03!lU/~UOti ,t~::'r Fx\ I~On.I ~~ SCC7TTSD ZE LtI N r ~ ~ 2A A NS CE CC7MPANY GaMMERCIAL PRQpEq~"'~` COVERAGE PARfi SUPPLEMENTAL i7ECLARATIQNS Poky Na,: ~, Ot'SaQ~;67,54 _ --- - - ~if8ctivB Date: Qbf 10/2DU5 ` N-tm~d Insured: E^bNO T,CJgFs & TUBE 12.T~tl. tan ar~C 1 T me oa o 7 a Item t. Business Descrlptlbn. OATtAGS IteRt2. PremiSesDeSCribed~ 2901 BctUNUAGE ~ANR, B,AKE1~5rIELL, CA 93304 FRAME / P(; - 3 ^~w-- --- - ------ --- •-•^...W.--- Item 3. $500 f~edllctible Unless otherwise indicated. Item 4. Gvverages Provided: Prom. Bldg. Gvverdge Limit Cif Covered T^~Catns No. No. Insurance Causes of Loss . 1 1 $JILDIN~ 300, 4170 SP>;CIAL 90 1 1 eUS . PiJRS . PR(>_P, __ ~ ~ 50 , 400 S?EC,IA~, gU _ Other Prvvitalcths _ _ _ _ -- ~ Q Agreed Value. ~ __,__-__w~ Expires• -• _ d Repti~cement Cost ---~ O Business Income Indemnity: Monthly Llmtt Period 1iRaximum CI Inflation Guard: 96 ^ Reporting Extended ~~_ DeduCtible~ i, coo Earthquake Deductible: .__. _ .a6 Exceptions; __ Prem. Bldg. Coverage Limit of CaverecJ Cpins No. Na. Insurance Causes of Lass . 1 - - Dther ?rovislt3wl; ~ •- ~ Agreed Value: __ Expires: ~ ~ peplacement Cost ^ t3Utiinggg InCnme indemnity: Monthly Llmlt Period' IlAaxirnum p lr1#lation Guard: 96 Q Reporting Extended Qeductlble: ._ Earthtuake Deductible: qia Exceptions: Rrerrt. . Bldg. Gpverage Limit of Covered Coins. No. Np. insurance Causes vt Lass _ Other Prw+lslt~Its , W ~~ []'Agreed Value: _ Expires; ~;} 14eplacement Cost ^ Buslnet;s Income Irldemniky: Monthly Limit Period: I~+~aximum p Inflation Guard: L~ ;Reporting Extended • fD$Cluctibte: ..._ Earthquake beductiUle• 96 Exceptions' Itarrr S. Famrs and Endorsements: • ~. 1=orm(s} and Endorsement{s) made a part of this policy at limp at Isat-ei: Sep 8chedutn o~F Fc~mnt: And Endprsernente; , REDWINETESTING SERVICES, INC. February 17, 2006 P.O. BOX 1567 ~ BAKERSFIELD, CA 93302-1567 PH (661) 834-6993 Fax (661) 836-3177 Email: redwinetest~prodigy.net Tank and Pipeline Compliance Experts Testing • Installation • Removal • Closure Monitor and Cathodic Protection Testing Inspector Steve Underwood Bakersfield Fire Department 900 Truxtun Avenue Suite 210 Bakersfield, CA 93301 Ref: Econo Lube-N-Tune ~ 2901 Brundage Lane Bakersfield, CA 93304 Dear Inspector Underwood: We retested the bucket on Friday, February 17, 2006 and the bucket passed. Thank you. Sincerely, - -- -- --- 7~~_ Dugan Turner Vice President License No. A-532878HAZ HG No. 415 RG No. 5761 DT:kf ;; ~' :,; ~,., J~n~. ?_`.. ~b~i ~~s'~ .•• SEf~~i~'~'~~'~'ST~ C~RT~FiCAT~U~ FCi Iii }`:,{< ~4ri :. ~~"` I?ATR Q ~:~ ~ t .,• ~bR UN ~ 1.. FA('ti.ITX A~} ~~~Q._~.:.:t~.fl 1~ r n 1 f~A (1k~:.- / r ,,r . 4. c~ Y ~"~ / ^'K ,r; ~ ~ h~~~: .. --~---- - ~.,~. ,~t,. ~.:,: . ;t:. ti3~'.f ~; Ts~lk ~ "~'s+rtk 4 'I'a#i& - ~ ~. ~, Tic 2 ~t~t Titre ~ _ - _ F ~Y1R~ ~'~Sitl'e ~~~ Titer :.; . . ~~ ~ . ~ ' ~. ::~:: ~ertii~cat~or~ ~u 1 \NNu;~ P' . (~fglnaturel _ Y~~i 4.; '::: ~~s~~ .. . ~~+.`~' 1.76wiiV~ ~... ;. ~::~ ~:lk..:: :~ti~ :~_ . ~.. icr"'•E' ~,'~;:;~ s~~~~~ "~~, ~.~: ~• ;~;:. . ,~ . ,~. . ~~~ ;;.~.: . ~-=~~~~ ~ij:. ~;_;; ~ . ,.. r ~~ r. . ._ ~.. =~,~ue 1~ . ' (; ]C,ine 2 Line 3 &ine 4 . Mart't"ettte . ~nidal Pressure ~ N 0 5~- :(.. ~ ~ : - - i~ dime ,k..; irit~a~ trg N? ' . ~~ ~: Cextiff+cs~Eon ~ . ~Si~ature) - ~~ ;5 ~. ,.i. .f .. ,:1~;. •i l~... H(: '- =~' .. _ ~~ .}~)l. !(•:~ . }~i kY. ~. ~~S . . ... v~.'. . `~".. - ~;,~ ~' ii~~'~ ~' i.a' ~is~ss ~k Y° I ~ 4 M ti.. ~~;- tV~,, ~~~ .. ~^n J,: ::\: .~. 4 j.i -. x~. x ~. . S . ~<~:~ ~q ~ `~ SL~QND~"~:'~' SYSTEM CERTIFICAT~4N ~a3it~? DA'TE~ FAGII,ITY~D ~~-a.r.ue~¢7rjNi - ~'AC.tLT'1CY ADDR.P.SS ~DL~t t~(DA~C~! of ,..._ Turbine Sumps $Uritp.1WA " ~~, Suan Z P Sum ~ P Sum 4 ~ P Start Time Iadtisl Height bf Water ~ I '~')me Water Height ~~ _. : . 'Water Aeight Tiate Wa~ber Height CCCCrt~cation ~V~~~~ N D sv ,v~ P ; I tl7ierffl[ BuCiC+CtS ,~ 4v4z4ift a. ~:.. (D+verfiU 2 Qverfiii 3 ~(33'vertifl 4 start Time ,~UAr'~F1. ~ ~ XNtial Height of Water Si~v ~,. ~ Time ~?..~ ' i Waber He1ghL : ~ ~~ E Time ~:(~p1M .. i. 'Water Height `,J i CertffFcation !(Signature) ~~~' - ~ - N~D (~ k'age 2 of 3 ~~~ . ~.. { _ :.~ ,~:.,: ~ . :~ ~.: ,~ ~~~ :: s: Paga 3 of _ ~/~7$ N~ ,~ ._ _ _.. .v - ~ ~L ... ... .. .. ....., - ~J ( ~i ~.~ - ::lL.~.s ~~.z.~_~.l.r~.,~,-mil Sl~n.i. ~.i.c.? , i„ ~-'~i.--:._ 5-'-'y _`_1 ~' r _-~ i_~..`~'_... <'-" r _e - = ~ -- ----- :.: ~:i~i"-~ ~_-~~ ~ may- '. .. .- .-i i ~~~' ~- 7 i~:4; L L(-E+~:L ~ WLU CX~S~ ~>JL ~~i~> Qi~~cr~~T ~ +-Fc..i ~ _1 ~. , + ^~ I .- ~ ~~ -~ ~. _- --• r ~ .... _ ..... ........_. .~ ~ ~ ~ .. _. ,. _.. .~- y.. ic...-.;s-v--..--+.--~4~-.i.:>z c.,. ...aw..z...:v...-.+vo. -~-.^'"`,•-r,a. •:~•.n,.S'~-4-=:..,..-.~ r ..4. ..~.,~~4F,'~~r .;-~~~^'".f~y.i. "\.v ~~r-\.,,,rv'v.,,~,;,u ,.~w..c.,.a r - Bakersfield Fire Dept. UNIFIED PROGRAM INSPECTION CHECKLIST Enironmental Services 1715 Chester Ave SECTION 1 Business Plan and Inventory Program Bakersfield, CA 93301 TPt• (~R11~7R_~Q7Q FACILITY NAME it ~ INSP CTI N DATE INSPECTION TIME -- ------- --- - -- ~ - ~~ ~ 1 t < <, .-- --- - - y,, 1 --- - -- --- --- -- PHONE o. No. of E ployees ADDRESS ~ ~ t ; FACILITYCONTACT .Business ID Number ~ ~t t~.. 15-021- Section 1: Business Plan and Inventory Pn~gram ^ Routine ombined ~ Joint Agency ^Mnlti-Agency ^ Complaint ^ Re-inspection C V \V=Vioatptonnce~ OPERATION ^ LY APPROPRIATE PERMIT ON HAND ------------/------------ ------------------------------------- ^ L~f BUSINESS PLAN CONTACT INFORMATION ACCURATE L`I" ^ VISIBLE ADDRESS LN ^ CORRECT OCCUPANCY ~^ VERIFICATION OF INVENTORY MATERIALS ~^ VERIFICATION OF QUANTITIES ~ ^ VERIFICATION OF LOCATION L~ ^ PROPER SEGREGATION OF MATERIAL ~^ VERIFICATION OF MSDS AVAILABILITYE ^ ~ VERIFICATION OF HAT MAT TRAINING ^ ~ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ ~ EMERGENCY PROCEDURES ADEQUATE L~J ^ CONTAINERS PROPERLY LABELED L`I ^ HOUSEKEEPING L! ^ FIRE PROTECTION ^ LW SITE DIAGRAM ADEQUATE St ON F'IAND ANY HAZARDOUS WASTE ON SITE~:L•~' 'L~1 YES ^ NO ~ ~(~ ~+ EXPLAIN: ~.l1ft 5~-t. ~ l' ~ J 1 ~ ~ ~~ _ NC~ ~ ( ~'1~t ~1`( ~-7 QUESTIONS ~ARDING T S I PECTION~ PLEASE CALL US AT ~66~~ 326-3979 --- ---Inspector ~ -- -- ---- - ----- ----Badge No., -------- White • Environmental Services Yellow - Stettin Copy Business Slte Responsible Party Pink -Business Copy ...- .~.. .-.._' • . y ,..~,F~ ../~-~._ .-.f - .,~...,."~. i.._ , ,,....r-~..~%t'^..'~ ..---..,...-.-.. _ -~.,..~,,,`.,.'.~-.~,,.v~,..-... _:r,r.: -' .~-~. ..-.-,.. --.r,.: : ~:.:`~~_"•~"-=:~_y4~,,,- "t"}*wt N~SRRTr°. N^ „ _ .._ ~+ 9 -~. . q ~'1 `~~' ~~ C[TY OF BAKERSFIELD FIRE DEPARTMENT 1 ~ ~ro OFFICE F ENVIRONMEN L SERVICES y'1 LJNIi~~~PROGRAM 1 ION CHECKLIST ~~ :W ~g~,~~i ~ 1715 Chester Ave., 3 `' r, akerst"ield, CA 93301 ~Hininii FACILITY NAME ~C.b,M b ~ NdC~- ~ ~ ZcJrtc INSPECTION DATE~2 ~(7C-~ Section 2: tinderground Storage Tanks Program ^ Routine Combined ^ Joint Agency ^Mu1ti-Agency ` ^ Complaint ^ Re-inspection Type of Tank (1t~1 5 Number of Tanks Type of Monitoring Type of Piping tQA)f-~ a: • M a '~ OPERATION C V COMMENTS Proper tank data on file C~ Proper owner/operator data on file ~ ,: ~ ~~ Permit tees current Certification of Financial Responsibility (~ u Monitoring record adequate and current ' Maintenance records adequate and current ~ ~ 1 ~. Failure to correct prior UST violations Has there been an unauthorized release? YeS NO (~ Section 3: Aboveground Storage Tanks Program TANK SIZE(S) ~a0 Sul. b~~ T~ -,~1~ Type of Tank 11 L ~ ~~ Vlt-I AGGREGATE CAPACITY` ~ Ofl 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 Inspector: a ~' U,(~ 1 ~,[~~ Office of Environmental Services (661) 326-3979 White - rnv. Svcs. . Business Site Resp sible Party Pink -Business Copy CITY OF BAKERSFIELD a OFFICE OF ENVIRONMENTAL SERVICES ~~Rt 17I5 Chester Ave., CA 93301 (661) 326-3979 ..~ • A/rTM f _ ,,,,,,,, ~ _ „~,,,,,~. UNDERGROUND STORAGE TANK FACILITY ^ 1 NEW SITE ~ 3 RENEWAL PERMIT ^ S CHANGE OF INFORMATION (grate type o/charge) ^ 7 PERMANENTLY CLOSED SITE TYPE OF ACTION PERMIT ^ 4 AMENDED PERMIT ^ 8 TANK REMOVED (Check one item ony) ^ 8 TEMPORARY SITE CLOSURE 400 1. FACILITY /SITE INFORMATION i BUSINESS NAME {Sams as FACILITY NAME or D BA • Ooinp aualnass As) 3 FACILITY ID k 1 ~~~ l ~ 1 NEAREST CROSS STRE 401 FACILITY OWNER TYPE ^ 4 LOCAL AGENCY/OISTRICT• ^ 1 CORPORATION ^ S COUNTY AGENCY' BUSINESS ^ 1 :.\S STATION ~/ ^ 3 FARM qs4 OTHER 403 ~.2 INDIVIDUAL ^ 8 STATE AGENCY' TYPE ' ^ 2 DISTRIBUTOR ^ 4 PROCESSOR ^ 8 COMMERCIAL ^ 3 PARTNERSHIP ^ 7 FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS la fadGty on Indian Reservation or •I/ owner of UST a public agency: name of supervbor of -` REMAINING AT SITE lrustlands7 d(vblon, sectlon or oRke whkh operates the UST. (This b the contact person for the tank records.) I 4l)4 ^ Yes µkNo 405 ~ II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 ~ ect ~ ~kc,~ 8m©~ ~~ ~ 3~g"" i mniun~a vn ~~~ . CITY ' ccv PROPERTY OWNER TY i ©x a~c~ 410 STA E ,~ ~ ^ 2 INDIVIDUAL ^ 4 LOCAL AGENCY /DISTRICT ICVI'CORPORATION ^ 3 PARTNERSHIP ^ 5 COUNTY ?GENCY III. TANK OWNER INFORMATION C ~ ~0 7 ^ 6 STATE AGENCY ^ 7 FEDERAL AGENCY 413 TANK OWNER NAME //~A ~. //~~ / 414 PHONE 415 MAILING OR STREET ADDRESS 416 ~ CITY I _ 477 -STATE 418 ZIP 419 TANK OWNER TYPE CORPORATION ^ 2 INDIVIDUAL ^ 4 LOCAL AGENCY /DISTRICT ^ 3 PARTNERSHIP ^ S COUNTY AGENCY ^ B STATE AGENCY ^ 7 FEDERAL AGENCY 420 N. BOARD OF EQUALt7ATION UST STORAGE FEE ACCOUNT NUMBER TY (TK) HD 4 4 - Call (916) 322-9669 if questions arise 4z1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(S) SELF-INSURED i ^ 2 GUARANTEE f ^ 3 INSURANCE ^ 4 SURETY BOND ^ 7 STATE FUND ^ S LETTER OF CREDIT ^ B S7A7E FUND b CFO LETTER ^ 8 EXEMPTION ^ 9 STATE FUND if CD ^ 10 LOCAL GOVT MECHANISM ^ 99 OTHER: 4?2 i VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one pox to Indicate whkh addrou should De used for kigal rati8eatbna and malnrg. 1 FACILITY ^ 2 PROPERTY OWNER ^ 3 TANK OWNER fl Legal notlflcatbn and malllrg will be sent fo the tank owner unbss box 1 or z is checked. 423 VII. APPLICANT SIGNATURE ~ CeNfkatbn: I ceNry that the Informatbn provided heroin la we a accurate to tla best of my knowledge ' SIG R F APPLI _ ~ DATE 4z4 PHONE 4~ NAME OF APPLICANT (prlnq 428 TITLE~APPLICANT 4 ~ fora ~~~~~~ ° ~ Form A i s C(Tlc' OF BAKERSF[ELD _ ~ OFFICE OF ELYVIROtYMEIYTAt. SERVKES " ~ 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 - ~ ~ UNDERGROUND STORAGE TANKS -TANK PAGE t P'°' or /~ F ACT10N ^ t. NAY SITQ PlRb11T ^ ~, AMENOlO PERMIT ^ ~. CMArIG! Of fNFORMATION) ^ 6. TEMPOitAAY SITE CLOSURE ~,,~~•!•CnacM una •am aW/ ^ 7. PERMANENTLv CLOSED ON SRI; ^ ]. RENEWAL, PLRMfT lS~paey ~aaon • •W bcN wa o.vyl (SUK/Y cnapa • •br bca/ wa orwY1 ~ ^ e• TANK REMOVED 9U SINESS •WAE 1 Seine N FAGIITY NM,Ig ar OeA • Oanq duaYfaaa NI ] FAC1LlTY 10 I I I I ~_ I. TANK DESCRIPTION TANK I • C A ( /~ COMPAR71NEN7AlIZ.ED TANK ^ Yss Q]~No 1P Rr0 I M'Ye~'. comdM~ one 0~9e for ead~ oompartrnarn. OA f IN ( ) IN t N NU I ADDITIONAL OESCRIP'T10N (FCiI k?Ca/ we oM'1 c R TANK CONTENT! _ rAr+t USE .J9 PETRDIEUM TYPE ^ 1. MOTOR VEFtlCLE FUEL ^ ta• REGULAR IMFi~DED ^ 2 LEADED ^ S. JET NEL (M marko0, oartloMM PINOIrIarn type) ^ f 0. PREMUN UlS.EAOEO ^ D• DIESEL ^ g. AVULSION FUEL ^ i. NoN-FVEL PETftoL.EUM ^ ,G ~eooRADE waFADeD O ~. QASOf10L ^'~ oTHFJt (1)t ~ 0 c ^ ). CHEMIGL PROOUC,`T . COAwrOIV NAME (hWn IwLlrtlbtri AUANIW lnhnkNYOaDd ^ .. HA1~RDOUS WASTE (r>,rrl,oe, sat CAS a (Awn HazsrAwa .14tariefa rnrenrory papa) s.. uaaa O~ i ^ 9s. urra~+owec I p1. TANK CX>ll.9TRUCT ION . TYPE OF rANK ^ ~. SrNOLE VYALL ^ s, SlNfilt? yy,~ 1NTTf1 ^ s. SINGLE WALL vYtTN IMERNAL txAOOE,R SYSTEIAI a.~. (cJ,.ck ona 4vn orvp '[~, 2" DOUBLE wAU DCTERgR MEMBRANE Ut'ER ^ 94. uMagwN ^ 1. $tNOLE WALL IN A VAULT ^ pp OTHER TANK MATF.RIAI • pnmary tank 1. BARE STtcEI ^ J. F18EROLASS / PL.ASTlC ^ S. CONCRETE ^ 4S. UAMOUOWN ss4 (Crecx orra Tan orvy) ^ 2, STAWIE$S STEEL ^ s. STEEL cIAO vvIFtBERCat.ASS ^ a. FRP COMPATISLE Wnoox METFWrOL ^ 99. OT}tEti • REIi~ORCEO PLASTIC !F~ TANK MATERIAL - NoOrWary tank ^ 1 • e~E STFA ^ 3. FISERt)uSS 1 PLASTIC ^ >!. FRP COMPATIBLE VY/100% METHANOL ^ 9S. UTOO~OVNt a45 (Crack ona Aam orry) ^ 2. STAIti.ESS STEEL ~. STEEL CIAO W/FIBERGLA.43 ^ 9. FRP NCNOOfeIE JACKET ^ 40. OTH>=R REINFORCED PiAS'TIC (FRF~ ^ 10. COATED STEEL ^ s. ooNCRErE TANK IMERIOR tJNU+O ^ ,. RUlOER Ltl~ ^ ~. EPOXY Ut~tlPq oR coATtNO DArE WSTALLED ~+~ ^ s. Luse ItTAIrC1 ^ 9a. urno+owri .se ^ >~ ALKYD LMlPIO ^ .. P-E=.NOLx Llf~INO ~ a. uNLnrED ^ 9a. OTHER a» ~ FOr R7ul uya OTHER CARROSXkI ^ T. MAt~I~ACTUREO CAT1gD~ ^ ~ F1eERL3LAS3 Rg>t+FOPoCED ~~ ^ 9tf. UNt4JOV4N sa8 PROTECTION 1F APPt.ICAEIP OATS INSTALLED w9 PROrECT10N ^ a• D CURRENT ^ 00. OTHER (CJlack OM Tart ordrl ^ 2. SACRlfICfAl ANODE (For kcal uta only) SPfIL AND OVERFILL YEAR INSTALLED aS0 TYPE (Folkxa! uaa oNy) s31 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED a52 ^ i CAaCk of Mat sppyJ SPILL COMAINI.EM ^ t. ALARM ^ 3. FILL TUBE SHUT OFF VALVE ~_ ,, ,, / L 1. d. DROP TUBE ^ 2. BALL FLOAT ^ s. EXEMPT ,~ ~~ n ty~9. 3'TRN2A PLATE •~ ~V ~. ~.~•~. t~G(.., ')~ Ill;:' 't`. .,,,.: .~:.%' :.fi' .:i~xs r, c!{krT/UNKtQAIC .... .•. ~:. .,At`;;;' ;,e.:: 'r~;' ..X¢;.~ <•:..• , Ita slNOLa tW-LL TAN1((CMclt aI enac apoyl: ~es tF oouer,E WALL TANK oR TANK WITH eLADOex (crock ona Ram ontyx ss< t, VISUAL (EXPOSED POR?ION OH117 ^ !. MANUAL TANK OAUOINO (MTO) ^ t. VISUAL (SINOI.E WALL IN VAULT ONLY) 2. AU70MAT1C TAIL( GAUGING (ATO) ^ d. VAOOSE ZONE ~ COMINWU9 IMlRSTRIAL MONRORINO ), CQNTINuoue ATO ^ 7. OROUNOWATER ^ ]. MANUAL MONRORINO s. STATISTICAL IMIEMORY RECONCILtAT10H ($!R) • ^ a TANK TESTiNO _ t L~, `~ ~O ~1'~ In J 0 ~ S S CC C„J.4 r ~ f y b~ 9 N ~ ~- G (t ellNNW. TANK TIIATINO ^ pp, OTHER _ -_`• V. TANK CL03URII INFORMATION / PITRIMANENT C L03URQ IN PLACE 71MATlO OAT! uST UeED (YWMO/OAY) 4A8 ESTIMATED QUANTITY OF SUBSTANCE RQA{AINNSO see TANK FKLEO WITH INERT MATlRIALt ~7 °~Of M ^ YN ^ No F (7199) 3:\CUPAFt7RAAS13WRC~'~0 ` Cf'TY OF BAKER3FIEL0 i ~ OffICQ Of ENVIRONMENTAL SERVICES 't t71~ CNtntslr Aw.. Bak~nMld, CA 9JJD1 (ddt) ~2d~1979 urn • rANK ~AOe . _ ~ ~ K fMN1O CON>!'T1tUCTION (C/wot w Inat aAp/y) uNDEROROUNO PtPINO I ABOVEGROUND PIPING S~SiEM rvPE ^ t PRESSURE ^ 2. SUCTION ~ORAV1Ty 4~ I ^ i, PRESSURE ^ 2. SUCTION ^ 3, ~yny +; ^ ~ 91NGLP. WALL ^ 1. LINED TRENCH ^ 90. OTHER 480 ^ I. SINGLE'NALL ^ 93. UNKNOWN CONS TRUC T~Oi'0' +d MANUF.aCTURERI~pOUBIE WALL ^ 96. UNKNOWN ^ 2. OOUBLE'NALL ^'99. OTHER ' MANUFACTURER 4et MANUFACTURER ~ ^ t. BARE STEEL ^ d. FRP C011~AT18LE VYl 100!1 6E'THANOI ^ t, BARE STEEL ^ d. FRP COMPATIBLE W/ 100% MET}IANOI MATERNLS ANO ^ 2. 9TAINLE3$ STEEL ^ 7. GALVANIZED STEEL ^ 2. STAINLESS STEEL ^ 1. GALVANIZED STEEL CORROSION PROTECTION ~,^,, ]PLASTIC COMPATiBL.E NrtTH CON'TEMS ^ 96• UWWONM ^ ]. PLASTIC COMPATIBLE WITH CONTENTS ^ 8. FLEXIBLE (HOPE) ^ 48. OTHER ' LIV4. FIBERGLASS ^ s, FIEXtBIP (HOPE) ^ yti, OTHER ^ 4. FIBERGLASS ^ 9. CATHODIC PROTECTON ! ^ S. STEEL W/ COATING ^ 9. CATHODIC PROTECTgN tE4 ^ S. STEEL W/COATING ^ 95, UNKNONM 4~ VM. PIMNO L!•/1K DETECTION (Chrdr a1 tttu at~Wy) UNDERGROUND PIPING I AtIOVEGROUND PIPING PRESSURIZED PIPING (CINek a/ Ulat apply): ^ t. ELECTRONIC l1NE LFAK DETECTOR 3.0 GPt4 TEST 1~ AUTO PUAP SHUT OFF FOR LEAK SYSTEM FAILURE, AfdO SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS ^ 2. MONTHLY 0.2 GPH TEST ^ 3. ANNUAL O~REGRITY TEST (0.1 CiPH) avnua.C watt. PIYNrtii 46; PRESSURIZED PIPING (CJwek a/ fltat apply): ^ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST~TI AUTO PUUP SMJT OFF FOR LEAK SYSTEM FAILURE. AND SYSTEM WSCOIAdECT10N +AUDIBLE AND VISUAL ALARMS ^ 2. MONTHLY 02 GPH TEST ^ 3. ANNUAL INTEGRITY TEST (Q t GP-fl ^ t. OA1LY VISUAL CHECK coNVErrraNU sucTIDN SYSTEMS: ^ S. ONLY VISUAL MONITORING OF PUMPING SYSTEM • TRIEJtrNAL PIPWG /~(TEGRJTY TEST(O.t GPH) SAFE SUCTION SYSTEAAS (NO VALVES IN BELOW GROUND PIP1NGk i ^ 7. SELF bIONRORING GRAVrn Ftow: ^ 9. BIENNI/11. INTEGRITY TEST (0.1 GPH) SECONDAWLY COPITNNED PlPtlq i PRESSURIZEp PWttJG (Cheek s/ tAat4pp/y): t 0. CONTINUOUS TURBINE SUMP SENSOR ~ AUDIBLE AND VLSUAL ALAtiMS ANO (Cnecic any) ^ a. AUTO PUMP SHUT OFF WHEN A L.F~11C OCCURS ^ b. AUTO PUMP SHUT OFF FOR tFAKS. SYSTEM FAILURE AND SYSTEM pISCONNECTION ^ c NO AUTO PUMP SHUT OFF ^ t t. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ~ FLOW SHUT OFF OR RESTRICTION ^ , 2. ANNUAL INTEGRRY TEST (0.1 t)PH) SUCTaNKaRAVITY SYSTEM: ^ 13. CONTIMlOU3 SUMP SENSOR +ALWIBLE ANO VISUALALARMB coNVENraNAL sucraN sYSTEMS (cn.al a en.r,Pwy): ^ S. ONLY VISUAL MONITORING OF PIPING ANO PUMPING SYSTEM ^ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ^ 7. SELF MONfTOR1NG GRAVtTr Flow (c/act a~ tn.t,~p/y): ^ & OAIIY VISUAL MONITORWG ^ 9. BIENNNL WTEGRRYTEST(O.t GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Gook d Btat apply): t 0. CONTINUOUS TURBINE SUMP SENSOR V~TF~ AUDIBLE AND VISUAL ALARMS AND (Chock one) ^ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ^ D. AUTO PUMP SIM OFF FOR LEAKS, SYSTEM FARURE AND SYSTEM DISCONNECTION ^ t NO AUTO PUMP SHUT OFF ^ t t. AUTOMATIC LEAK DETECTOR ^ 12 ANNUAL INTEGRITY TEST (0.1 GPH) $UCTaN/GRAVifY SYSTFJYk ^ 13. CONTINUOUS SUMP SENSOR * AUDIBLE ANO VISUAL ALARMS EMERGENCY OENlRATORt! ONLY (Check as Ititat apply) EMERfiENCY OENERATOR>s ONLY (CMck d dtat aPAll~ ^ t t. CONTINUOUS SUMP SENSOR mj~j AUTO PUMP SHUT OFF +AUDIBLE AND ^ 14. CONTINUOUS SUMP SENSOR 7~ AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL VISUAL ALARMS ~y3 ^ t5. AUTOMATA UNE LEAK DETECTOR (3.0 GPH TEST) }~jj FLOW SHAT OFF OR ^ t S. AUTOMATIC UNE LEAK DETECTOR (3.0 GPH TEST) RESTRICTION ^ t 8. ANNUAL INTEGRITY TEST (0.1 GPH) ^ 18. ANNUAL INTEGRITY TEST (OJ GPH) ^ 17. OAIIY ViSVAL CHECK ^ t 7. OAIIY VISUAL CHECK .u'S~.a, ''6(,~;> 'CQl1TA)NMEN~.~'~~`?~;: .~i. ~:"~~..t;^~,~ ,:,'~~'.rv Y.-.' ISPENSER CONTAINMENT ^ t. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ' ' ^ t. ONLY VISUAL CHECK OATEIN TALLEO 4EE ^ 2. CONTINUOU901$PEN$ERPANSEN80R+AUDIBLBANOVISUALALARM3 ^ S, '~.~•ra:~; 5~,:~~<f%I~ iel~ty. ^ 3. CONTIM10U9 DISPENSER PAN SENSOR ~~ AUTO SHUT OFF FOR DISPENSER • AUDIBLE ANO VISUAL ALARMS ~ 489 D(. OMVNERK)PERATOR 910NATURB ~ I candy tha~i ~nMrr>latlan proNd~d MnNt Is Uw and acanala to dN ONt at my krtotMWO~. 1 SIGNA ovz~` ~'~5~c~ 470 PCF (7/99) S:ICUPAFORMS13t+NRCB-B.~'C UST MONITORING PROGRAM WRITTEN MONITORING PROCEDURES Page 1 of 1 This monitoring program must be kept at the UST location at all times. The information on this monitoring program are conditions of the operating permit. The permit holder must notify the Office of Environmental Services 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. ~IRI ~R~r ~ Bakersfield Fire Dept. Environmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME t'~ FACILITY ADDRESS ~~ DESCRIBE THE FREOULENCY OF PERFORMING THE MONITORING: TANK ~~~Il~~`~~pri~Ci n' PIPING Q YQV I IY 'T(i9~ WHAT METHODS AND ffE,,OUIPME/N~T, IDENTIFIED 8Y NAME AND MODEL, WILL BE USED FOR PERFORMING THE MONITORING: TANK ~QCtill ~IC~~ PIPING gaw.~ DESCRIBE THE LOCATION(S) WHERE THE MONITORING VN~L BE PERFORMED (FACILITY PLOT PLAN SHOULD BE ATTACHED): LIST THE NAME(S) AND TITLE(S) OF THE PEOPLE RESPONSIBLE FOR PERFORMING THE MONITORING AND/OR MAINTAINING THE EQUIPMENT: NAME - TITLE ~~tC_(t7~- ~a~C~ ~Ct~r` REPORTING FORMAT FOR MONITORING: TANK C~S{1~41A~? di PIPING Q rCQC)~~`F ~j F DESCRIBE THE PREVENTIVE MAINTENANCE SCHEDULE FOR THE MONITORING EOUIPMENT. NOTE: MAINTENANCE MUST BE IN ACCORDANCE WITH THE MANUFACTURER'S MAINTENANCE SCHEDULE BUT NOT LESS THAN EVERY 12 MONTHS. DESCRIBE THE TRAINING NECESSARY FOR THE OPERATION OF UST SYSTEM, INCLUDING PIPING, AND THE MONITORING EOUIPMENT: t~~ ~k ` UST MONITORING PROGRAM EMERGENCY RESPONSE PLAN Page 1 of 1 This monitonng program must be kept at the UST location at all times. The information on this monitoring program are conditions of the operating permit. The permit holder must notify the Office of Environmental Services within 30 days of any Changes to the monitonng procedures, unless required to obtain approval before making the change. Required by Sections 2632(d) and 2641(h) CCR. Bakersfield Fire Dept. Environmental Services f~R~ 1715 Chester Ave ~R~r t Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY MME cAH ~ -- l;(~ v i FACILITY ADDRESS c IF AN UNAUTHORIZED RELEASE OCCURS, HOW LL THE HAZARDOUS SUBSTANCE BE CLEANED UP7 NOTE: IF RELEASED HAZARDOUS SUBSTANCES REACH THE ENVIRONMENT, INCREASE THE FIRE OR EXPLOSION HAZARD, ARE NOT CLEANED UP FROM THE SECONDARY CONTAINMENT WITHIN 8 HOURS, OR DETERIORATE THE SECONDARY CONTAINMENT. THEN THE OFFICE OF ENVIRONMENTAL SERVICES MUST BE NOTIFIED VNTHIN 24 HOURS. DESCRIBE THE PROPOSED METHODS AND EOUIPMENT TO BE USED FOR REMOVING AND PROPERLY DISPOSING OF ANY HAZARDOUS SUBSTANCE. 3.DESCRIBE THE LOCATION AND AVAILABILITY OF THE REQUIRED CLEANUP EQUIPMENT IN ITEM ABOVE. DESCRIBE THE MAINTENANCE SCHEDULE FOR THE CLEANUP EQUIPMENT: LIST THE NAME(S) AND TITLE(S) OF THE PERSON(S) RESPONSIBLE FOR AUTHORIZING ANY WORK NECESSARY UNDER THE RESPONSE PLAN: NAME(n TITLE -~1 ~ i G 1 G~ ~. Kl lac. C~ ~A ~ N State of California For State Use Only State of Water Resources Control Board Division of Financial Assistance P.O. Box 944212 Sacramento, CA 94244-2120 (Instructions on reverse side) CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. ! am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: ^ 500,000 dollars per occurrence ^ I million dollars annual aggregate or AND or million dollars per occurrence ^ 2 million dollars annual aggregate B. hereby cerUfres that it is in compliance with the requirements of Section 2807, (Name of Tank Awner or Operator) Article 3, Chapter 18, Division 3, Title 23, Calitomia Code of Regulations. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective Third Party T e Name and Address of Issuer Numt~er Amount Period Action Com l, ~,. `'J T~'~ ~r`~ Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certifies that you are in compliance with all conditions for participation in the Fund. D. Facility Name Facility Address Facility Name Facility Address Facility Name Facility Address E Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator ~~_~~~- v ~3~0~ l~~ ~o ~~. ~.. ~, ~.~. -a . Signature o ttness or Notary Date Name of Witness or Notary CFR (Revised 04/95) F[LE: Orlglnal -Local Agency Coples - Facility/Site(s) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFIED PROGRAM CONSOLIDATED FORM) 7 _ .. .. APPLtCAT10N BUSNESS O~IMER/OPERATOR DBVIfI(.A110N FORM (HAZARDOUS MATERIALS FACILITY INFORMATION) B P. R S i 7 D F/R8 ~Rrr r BAKERSFIELD FIRE 1?3EPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 I. FACILITY IDENTIFICATION ~ FACILITY Ip N0. , Year Beginning ,oo Year Ending ,o, BUSINESS NAME (Same a FACILITY NAM or OBA- Doing Business As) 3 BUSINESS PHON^^E 11 ~~~~ 102 ~ KL dam- SITE AD S ~~ ~ ~ r,~ L ,oa CITY 0. t ,~< CA IP ,~ DUNN & BRADSTREET ~~ SIC CODE (4 Digit #) ,07 COUNTY '~ OPERATOR NAME ~ ~ ,oe OPERATOR PHONEt j ~ ~~ R '1 ~ -,o II. OWNER INFORMATION OWNER NAME p~ © >» OWNER PHONE44 ~/~93~ ~ ' "~12 V, acc~ 00. ~ ( 1 i OWNER MAILING ADDRESS ~ I ~ ~ L ,:3 cITY ~t - ~ 1C ,,, sTA~ ~ „s IP ~3 3 l f '' IIL ENVIRONMENTAL. CONTACT CONTACT NAME „7 CONTACT PHONE ~ - ~t~(~ 9'3~S ~., CONTACT MAILING ADDRESS 5 ~ ~ „ ~i S CITY - ~,t 120 STATE ,21 ZIP q33 ,~ :-PRIMARY Iv. EMERGENCYCON TACrs -SECONDARY- _ NAME 123 NAME (~ 12A TITLE 124 TITLE ®cvN V 129 1 BUSINESS PHONE ~ 125 BUSINESS PHONE ~ ~ ~_1 ^~' `JC 130 I 24-HO U R PHONE 126 24-HOUR PHONE 131 r ^ qG Q ALL ~ L t ~ ~ 1 ~ ~~ r PAGER NO. 127 PAGER N0. 132 133 V. CERTIFICATION Cert~cation: Based on my inquiry of those indiv iduals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF SIG R ~ 136 DATE 134 NAME OF DOCUMENT ?RF.RARFR 135 d'u' ~ - NAME OF OWNER/OP TOR (SOIGNAriIRE ... RIN f ? 137 TITLE OF OWNER/OPERA70R 138 o ~ ~ O A~.~ R ~~ ~~^-- ~~ ~,~\ FD 2142 (Rev. 09/05) (Hazardous Materials f~'uci(it~ Information -HMMP) Business Owner/Operator Identification Please submit the Business Activities page, the Hazardous Materials Faci/ity Information (HMMP) Business Owner/Operator Identification Form, and Hazardo~ Materials Inventory Chemical Description Form for all hazardous materials inventory submissions. For the inventory to be considered, please complete this page, it must be signed by the appropriate individual. NOTE.• The numbering of the instructions fo1/ows the data a%ment numbers that are on the Business Owner Operator Form page. These data a%ment numbe. are used fore%ctronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary. P/ease number al/pages ofyour submittal. This helps our CUPA orAA identify whether the submitta/ is comp/ete and ifany pages are separated. 1 FACILITY I.D. NUMBER -This number is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3 BUSINESS NAME -Enter the full legal name of the business. 100 BEGINNING DATE -Enter the beginning year and date of the report. (YYYYMMDD) 101 ENDING DATE -Enter the ending year and date of the report. (YYYYMMDD) 102 BUSINESS PHONE -Enter the phone number, area code first, and any extension 103 BUSINESS SITE ADDRESS -Enter the street address where the facility is located. No post office box numbers are allowed. This information must provide a means to geographically locate the facility. 104 CITY -Enter the city or unincorporated area in which business site is located. 105 ZIP CODE -Enter the zip code of business site. The extra 4 digit zip may also be added. 106 DUNN & BRADSTREET -Enter the Dunn & Bradstreet number for the facility. The Dunn & Bradstreet number may be obtained by calling (610) 882- 7748 or by intemet. 107 SIC CODE -Enter the primary Standard Industrial Classification Code number for primary business activity. NOTE.' lfcode is more than 4 digits, report on/y the first four. 108 COUNTY -Enter the county in which the business site is located. 109 BUSINESS OPERATORNAME -Enter the name of the business operator. 110 BUSINESS OPERATOR PHONE -Enter business operator phone number, if different from business phone, area code first, and any extension. 111 OWNER NAME -Enter name of business owner, if different from business operator. 112 OWNER PHONE -Enter the business owner's phone number if different from business phone, area code first, and any extension. 113 OWNER MAILING ADDRESS -Enter the owner's mailing address if different from business site address. 114 OWNER CITY -Enter the name of the city for the owner's mailing address. 115 OWNER STATE -Enter the 2 character state abbreviation for the owner's mailing address. 116 OWNER ZIP CODE -Enter the zip code for the owner's address. The extra 4 digit zip may also be added. 117 ENVIRONMENTAL CONTACT NAME -Enter the name of the person, if different from the Business Owner or Operator, who receives all environmental correspondence and wiH respond to enforcement activity. 118 CONTACT PHONE -Enter the phone number, if different from the Owner or Operator, at which the environmental contact can be contacted, area code first, and any extension. 119 CONTACT MAILING ADDRESS -Enter the mailing address where all environmental contact correspondence should be sent, ff different from the site address. 120 CITY -Enter the name of the city for the environmental contact's mailing address. 121 STATE -Enter the 2 character state abbreviation for the environmental contact's mailing address. 122 ZIP CODE -Enter the zip code of the environmental contact's mailing address. The extra 4 digit zip may also be added. 123 PRIMARY EMERGENCY CONTACT NAME -Enter the name of a representative that can be contacted in case of an emergency involving hazardou materials at the business site. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regardinc incident mitigation. 124 TITLE -Enter the title of the primary emergency contact. 125 BUSINESS PHONE -Enter the business number for the primary emergency contact, area code first, and any extensions. 126 24-HOUR PHONE - Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individu, stated above. 127 PAGER NUMBER -Enter the pager number for the primary emergency contact, if available. 128 SECONDARY EMERGENCY CONTACT NAME -Enter the name of a secondary representative that can be contacted in the event that the primary emergency contact is not available. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regarding incident mitigation. 129 TITLE -Enter the title of the secondary emergency contact. 130 BUSINESS PHONE -Enter the business telephone number for the secondary emergency contact, area code first, and any extension. 131 24-HOUR PHONE - Enter a 24-hour phone number for the secondary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individual stated above. 132 PAGER NUMBER -Enter the pager number for the secondary emergency contact, if available. 133 ADDITIONAL LOCALLY COLLECTED INFORMATION -This space may be used for CUPA's or AA's to collect any additional information necessan to meet the requirements of their individual programs. Contact your local agency for guidance. 134 DATE -Enter the date that the document was signed. (YYYYMMDD) 135 NAME OF THE DOCUMENT PREPARER (FULL PRINTED NAME) -Enter the full printed name of the person who prepared the inventory submittal information. 136 NAME OF DOCUMENT SIGNER (FULL PRINTED NAME) -Enter the full printed name of the person signing the page. The signer certifies to a familiarity with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information, all the information submitted is true, accurate and complete. 137 SIGNATURE OF OWNER/OPERATOR/OR DESIGNATED REPRESENTATIVE -The Business Owner/Operator, or officially designated representative of the OwnedOperator, shall sign in the space provided. This signature certifies that the signer is familiar with the signer's belief that the submitted information is true, accurate and complete. 138 TITLE OF OwNER/OPERATOR/OR DESIGNATED REPRESENTATIVE (SIGNER) -Enter the title of the person signing the page. Page 2 of 2 FD 2142 (Rev. 09/05) (HMMP) BAKERSFIELD FIRE DEPT. HAZARDOUS MATERIALS MANAGEMENT PLAN B , _E x s r,_i . a prevention Services °~ /IRl 900 Truxtun Ave., Ste. 210 INSTRUCTIONS ~R rM r Bakersfield, CA 93301 FOR HMMP SECTION DISCOVERY ~ Tel.: (661) 326-3979 AND NOTIFICATION (FORMS) Fax: (661) 852-2171 Page 1 of 2 SECTION I. -BUSINESS IDENTIFICATION DATA: The Business Owner /Operator Identification Form FD2089, Chemical Description Form(s) FD2086, and other forms (e.g.; underground storage tank information, hazardous waste treatment, etc., as needed) may be submitted as the first section of the Hazardous Materials Management Plan in order to avoid duplication of information for initial submissions. HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 11.1 -DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: Describe the procedures and equipment used to detect any release or threatened release of a hazardous material from any storage container, tank, or vessel at your business. Please provide a written explanation that also includes the make and model number of any automated or electronic leak detection equipment in use at your facility. B. EMPLOYEE AND AGENCY NOTIFICATION: What agencies and or corporate officials are notified in case of a hazardous materials spill or emergency -What procedures are used to notify these parties? At a minimum, you must ca119-1-1 and the Office of Emergency Services at 1-800- 852-7550 to report any spills that are a threat to life, safety or the environment, or for other non~mergency spill reporting, please call our office at (661) 326979. C. ENVIRONMENTAL RESPONSE MANAGEMENT: Please describe who will be responsible for what activities (notifying authorities, clean-up companies, etc.), and what the chain-of-command is at your facility for making sure these activities are carried out. D. EMERGENCY MEDICAL PLAN: Summarize your plan for handling medical emergencies occurring at your business. List the local medical facility capable of handling an accident involving Hazardous Materials used at your business. HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 11.2 -RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: Explain the procedures that you have developed and implemented to help prevent an incident from occurring. These steps could include, but are not limited to, storage methods, container types, segregation, safety equipment, and/or procedures used. B. RELEASE CONTAINMENT AND/OR MITIGATION: Explain the procedures that you have developed and implemented to assist in keeping a hazardous materials incident at your business as small or confined as possible. C. CLEAN-UP AND RECOVERY PROCEDURES: Explain what clean up procedures will be implemented in case of a release at your business. This should address small spills, as well as a major release of material once the material is contained. Hazardous Waste: Please provide the name of the hazardous waste company that regularly removes the wastes from your business, and how often that waste is removed. Please keep all disposal receipts for the last three years available on site for inspection. FD 2169a (Rev. 09/05) HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 11.2 -RELEASE RESPONSE PLAN (CONT.) UTILITY SHUT-OFFS List locations of shut offs using compass points and known or obvious landmarks. If you have a lock box containing keys and maps of the facility for the Fire Department to use, please list its location also. PRIVATE FIRE PROTECTIONNVATER AVAILABILITY A. Private Fire Protection: Describe on-site fire protection for your business or facility unit, including sprinklers, fire extinguishers, alarm systems and private response teams. B. Water Availability (Fire Hydrant): Give the location of the closest water supply or fire hydrant to be used by the Fire Department in case of an emergency. SECTION III -TRAINING List the number of employees that are working in the area of the hazardous materials, use or storage. Include all employees who have any occasion to be in those areas. Give the location where Material Safety Data Sheets (MSDS) are kept on file. The MSDS must be readily available on sit in a place where employees can access them. Give a brief summary of your Hazardous Materials Training Program. Employees are required by State law to have a program which provides employees with initial and refresher training in the following areas: 1. Methods for safe handling of the hazardous materials used by your business. 2. The Cal OSHA Hazard Communication Standard. 3. Correct use of emergency response equipment and supplies available at your business. 4. The prevention, minimizing and clean up procedures you have developed for your business. 5. The emergency evacuation plans you have developed, as well as, your notification procedure and medical plan. 6. Procedure to coordinate with and assist the local emergency personnel that may respond to your business. 7. Who and how to call for immediate assistance in the event of an accident involving hazardous materials. CERTIFICATION Please fill in your name, title, and sign and date on the signature line. IMPORTANT You must return this pl~u3, im°cntorn~ fortis, and map ~~~ithin 30 days of receipt. If you have any questions please callus at (661) 326-3979 Thank you for helping to keep our All America City cleaner and safer. CITY OF BAKERSFIELD BAKERSFIELD FIRE DEPT., OFFICE OF PREVENTION SERVICES 900 Truxtun Avenue, Suite 210, Bakersfield, CA Page 2 of 2 FD 2169a (Rev. osio5) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN APPLICATION FOR SECTION DISCOVERY AND NOTIFICATION (FORMS) B,_. B_R _9 F,_I D ~/R% ARTM T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 INSTRUCTIONS Page 1 of 2 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 ossible. SECTION I: FACILITY IDENTIFICATION BUSINESS NAME (Same as FACILITrY NAME or DBA -Doing Business As) - ~l~ 1D t~ ADDRESS (For focal use only) ~~ FACILITY ID N0. ~ SECTION 11.1: DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: Co ~" s ~ ~o wt~r.~-~c.. ~tn,I ~. ~ 0.Jq C~ B. EMPLOYEE AND AGENCY NOTIFICATION: act <~~~~ ©~ ~~>~~~~~ C. ENVIRONMENTAL RESPONSE MANAGEMENT: ~~~ ~~~ ~1'SC~ ~o~ a.~n sal'~~~ D. EMERGENCY MEDICAL PL N: L `N.Cad~S 1 ~©Sa r ~E.~ SECTION 11.2: RELEASE RESPONSE PLAN A. HAZARD ASSESMENT AND PREVENTION MEASURES: ~_ ~~t r B. RELEASE~C1ONTAINMENT ANDfOR MITIGATION: rr V~~ O~ ~L~~ 1(.~~ G CLEAN-UP AND RECOVERY PROCEDURES: ~ ~ ~L 1 ~~ FD 2169 (Rev. 09/05) Page 2 of 2 SECTION 11.2: RELEASE RESPONSE PLAN--CONT. UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GASlPROPANE: C ' ~ ELECTRICAL: WATER: SPECIAL: n PRNATE FIRE PROTECTIONNVATER AVAILABILITY: A PRNATE FIRE PROTECTION: ``~ B. WATER AVAILABILITY (FIRE HYDRANT): ~CS . . - SECT,ION Iil: TRAINING ?'' NUMBER OF EMPL~EES: MATERIAL SAFETY DATA SHEETS ON FILE: s BRIEF SUMMARY 0 TRAINING PROGRAM: .~ (,C. 1`fc tJ ~ ih,~~ f ~ ~ ~t S QO ~~~1 ~01~~ ~.{ ~ncc i r cal CERTIFICATION ;: I Based on my inquiry of those individuals responsible for obtaining the information, 1 certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. SIGNATURE O ER (OPERATOR OR DESIGNATED REPRESENTATIVE DATE q77 NAME OF SIG (print) ~j r 478 Ems- ~ ~ 1 ~ V ~ ~ ~ TITLE OF SIGNER 479 , ~ ~/~ti I FD 2169 (Rey. ostos) (HMMP) BAKERSFIELD FIRE DEPT. HAZARDOUS MATERIALS MANAGEMENT PLAN Prevention Services :~ $. »_n_s,.r._t . p 900 Truxtun Ave., Ste. 210 FIRE Bakersfield, CA 93301 ~~~~~~~ w= ~ r Tel.: (661) 326-3979 FORCHEMICAI-DESCRIPTION FORM ~- Fax: (661) 852-2171 HAZARDOUS MATERIALS INVENTORY FORM Make as many copies of the chemical description form as necessary to report your entire inventory of hazardous materials. Report every hazardous material handled in quantities equal to or exceeding 55 gallons of a liquid, 500 pounds of a solid or 200 cubic feet of a gas. Report any amount of any hazardous waste being generated or handled on site. I. FACILITY INFORMATION: Check the appropriate box for a new inventory or for additions, revisions or deletions to an existing inventory. Enter the business name at the top of the form. Enter the page number in the right hand comer. Describe the exact location of the hazardous waste or material being reported. NOTE: Chemical location information is considered confidential unless you check "no." If a site map is being submitted, you may refer to the map number and grid coordinates for the approximate location of the material, as shown on the map. II. CHEMICAL INFORMATION: Each of the instructions below correspond to the entry field with the same number on the chemical description form. CHEMICAL NAME 205 Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the International Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: If the chemical is a mixture or a hazardous waste, do not complete this field; complete the "common name" field instead. TRADE SECRET 206 Check "Y" for yes if the information in this section is declared a trade secret, or "N" for no, if it is not. State requirement: If yes, and business is not subject to EPCRA, disclosure of the designated trade secret information is bound by Health and Safety Code, Section 25511. Federal Requirement: If yes, and business is subject to EPCRA, disclosure of the designated Trade Secret information is bound by Title 40 Code of Federal Regulations (CFR) and the business must submit a "Substantiation to Accompany Claims of Trade Secrecy" form (40 CFR 350.27) to USEPA. COMMON NAME 207 Enter the common name or trade name of the hazardous material or mixture containing a hazardous material. EHS 208 Check "Y" for yes if the hazardous material is an Extremely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section blank and complete the section on hazardous CAS 209 Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the section below. FIRE CODE HAZARD CLASSES (Please leave blank) 210 HAZARDOUS MATERIAL TYPE 211 Check the one box that best describes the type of hazardous material: pure, mixture or waste. If waste material, check only that box. If mixture or waste, complete hazardous components section. RADIOACTIVE 212 Check "Y" for yes if the hazardous material is radioactive or "N" for no, if it is not. CURIES 213 If the hazardous material is radioactive, use this area to report the activity in curies. You may use up to nine digits with a floating decimal point to report activity in curies. PHYSICAL STATE 214 Check the one box that best describes the state in which the hazardous material is handled: solid, liquid or gaseous (gas). LARGEST CONTAINER 215 Enter the total capacity of the largest container in which the material is stored. FEDERAL HAZARD CATEGORIES 216 Check all the physical and health hazards associated with the hazardous material: PHYSICAL HAZARDS: Fire: Flammable Liquids and Solids, Combustible Liquids, Pyrophorics, Oxidizers Reactive: Unstable Reactive, Organic Peroxides, Water Reactive, Radioactive Pressure Release: Explosives, Compressed Gases, Blasting Agents Page 1 of 3 FD 2145 (Rev. 09/05) HEALTH HAZARDS: Acute Health (Immediate): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, other hazardous chemicals with an adverse effect with short term exposure. Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long term exposure. ANNUAL WASTE AMOUNT 217 If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled. MAXIMUM DAILY AMOUNT 218 Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or adjacenUoutside area at any one time over the course of the year. This amount must contain at a minimum last year's inventory of the material reported on this page, with the reflection of additions, deletions, or revisions projected for the current year. This amount should be consistent with the units reported in box 221. - AVERAGE DAILY AMOUNT 219 Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each building or adjacent/outside area. Calculations shall be based on the previous year's inventory of material reported on this page. Total all daily amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this location, the amount shall be the average daily amount you project to be on hand during the course of the year. This amount should be consistent with the units reported in box 221 and should not exceed that of maximum daily amount. STATE WASTE CODE 220 If the hazardous material is a waste, enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. A list of common State Waste Codes are included on page 3 of these instructions. UNITS 221 Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet or tons. NOTE: If the material is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons). DAYS ON SITE 222 List the total number of days during the year that the material is on site. STORAGE CONTAINER 223 Check all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: tf appropriate, you may choose more than one. STORAGE PRESSURE 224 Check the one box that best describes the pressure at which the hazardous material is stored. STORAGE TEMPERATURE 225 Check the one box that best describes the temperature at which the hazardous material is stored. HAZARDOUS COMPONENT 1 - 5 (% by weight) 226, 230, 234, 238, 242 If a range of percentages is available, report the highest percentage in that range. HAZARDOUS COMPONENT 1 - 5 Name 227,231,235,239,243 When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures, mineral and chemical composition should be listed. HAZARDOUS COMPONENT 1 - 5 EHS 228,232,236,240,244 Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "N" for no, if it is not. HAZARDOUS COMPONENT 1 - 5 CAS 229, 2.33, 237, 2415 245 List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. III. SIGNATURE: 246 Please print name, title, sign and date each chemical description form. If you have any questions Please call us at (661 } 326-3979 FD 2145 (Rev. 09/05) CALIFORNIA WASTE CODES Code Description Inorganics III Acid solution 2 < pH < 7 with metals (antimony, arsenic, barium, beryllium, cadmium, chromium, cobalt, copper, lead, mercury, molybdenum, nickel, selenium, silver, thallium, vanadium and zinc) 112 Acid solution without metals 113 Unspecified acid solution 121 Alkaline solution pH >12.5 with metals (see 111) 122 Alkaline solution without metals 123 Unspecified alkaline solution 131 Aqueous solution (2 < pH < 12.5) contain- ing reactive anoins. (azide, bromate, nitrite, perchlorate and sulfide anions) 132 Aqueous solution with metals (see 111) 133 Aqueous solution with total organic residues 100% or more 134 Aqueous solution with total organic residues less than 10% 135 Unspecified aqueous solution 141 Off-spec, aged, or surplus inorganics 151 Asbestos containing waste 161 FCC Waste 162 Other spent catalyst 171 Metal sludge (see 111) 172 Metal dust and machining waste (see 111) 181 Other inorganic solid waste Organics 211 Halogenated solvents (methylene chloride, chloroform, TCE, TCA) 212 Oxygenated solvents (acetone, butanol, MEK) 213 Hydrocarbon solvents (stoddard solvent, xylene) 214 Unspecified solvent mixture 221 Waste oil and mixed oil 222 Oillwater separation sludge 223 Unspecified oil -containing waste 231 Pesticide rinse water 232 Pesticide and other waste associated with 241 Tank bottom waste 251 Still bottoms with halogenated organics 252 Other still bottom waste 261 PCB's and material containing PCB's 271 Organic monomer waste (includes Code Description Organics (con't) 272 Polymeric resin waste 281 Adhesives 291 Latex waste 311 Pharmaceutical waste 321 Sewage sludge 322 Biological waste other than sewage sludge 331 Off-spec, aged or surplus organics 341 Organic liquids (non-solvents) with halogens 343 Unspecified organic liquid mixture 351 Organic solids with halogens Sludges 411 Alum and gypsum sludge 421 Lime sludge 431 Phosphate sludge 441 Sulfur sludge 451 Degreasing sludge 461 Paint sludge 471 Paper sludge/pulp 481 Tetraethyl lead sludge 491 Unspecified sludge waste Miscellaneous 511 Empty pesticide containers 30 gal or more 512 Other empty container 30 gal or more 513 Empty containers less than 30 gal 521 Drilling mud 531 Chemical toilet waste 541 Photo chemical/photo processing waste 551 Laboratory waste chemicals 561 Detergent and soap 571 Fly ash, bottom ash, and retort ash 581 Gas scrubber waste 591 Bag house waste 611 Contaminated soil from site clean-ups 612 Household wastes Page 3 of 3 FD 2145 (Rev. 09/05} (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN UNIFIED PROGRAM CONSOLIDATED FORMS CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIALS INVENTORY ^ NEW ^ ADD ^ DELETE ^ REVISE 200 ».. 4xs.FI n F/IrL ARfN T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 (One form per material, per building, or area) Pana1 of ~ I. FACILITY INFORMATION - Doing Business As) BUSINESS NAME (Same as FACILITY NAME or~ w* ~ U i~L CHEMICA LOCA ION 201 CHEMICAL LOCATION 202 CONFIDENTIAL (EPCRA} ^ Yes ^ N FACILITY ID No. 1 MAP No. (optional) 203 GRID N0. (optional) 20 IL CHEMICAL INFORMATION CHEMICAL NAME 205 2 TRADE SECRET ^ Yes ^ No t' COMMON NAME , 207 ~ EHS' ^ Yes ^ No O 20 CAS No. 209 'If EHS is "Yes;' all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 21 TYPE ~ ~ 211 212 RADIOACTIVE: ^ Yes G t~ CURIES 21 ^ p PURE ISvtTi MIXTURE ^ w WASTE LARGEST CONTAINER 21 PHYSICAL STATE ^ s SOLID QUID ^ g GAS 214 ~ FED HAZARD CATEGORIES ZY'! FIRE ^ 2 REACTIVE ^ 3 PRESSURE RELEASE ^ 4 ACUTE HEALTH ^ 5 CHRONIC HEALTH 21 (Check all that apply) ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 STATE WASTE 22 AMOUNT DAILY AMOUNT DAILY AMOUNT CODE 221 222 ^ UNITS ^ ga GAL ^ cf CU FT ^ Ib LBS ^ to TONS DAYS ON SITE If EHS, amount must be in lbs. 22 STORAGE CONTAINER ^ k BOX ^ p TANK WAGON (Check all that apply) ^ a9BOVEGROUND TANK C f CAN ~/6 UNDERGROUND TANK ^ g CARBOY ^ I CYLINDER ^ q RAIL CAR ^ c TANK INSIDE BUILDING ^ h SILO ^ d STEEL DRUM ^ i FIBER DRUM ^ n PLASTIC BOTTLE ^ e PLASTIC/NONMETALLIC DRUM ^ j BAG ^ o TOTE BIN 22 STORAGE PRESSURE ^ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 22 STORAGE TEMPERATURE ^ a AMBIENT ^ as ABOVE AMBIENT u ba BELOW AMBIENT ^ c CRYOGENIC %WT HAZARDOUS COMPONENT EHS CAS # 1 226 227 ^ Yes ^ No 228 22 2 230 231 i~ Yes ^ No 232 23 3 234 235 ^ Yes ^ No 236 237 4 236 239 ^ Yes ^ No 240 241 5 242 243 ^ Yes ^ No 244 2q III. SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIG NATURE DATE 24 o ~'c• ~U u1' l~ L q a~ ~-~. 0 3 ~ b ~ ` o '~ FD 2144 (Rev. 09/05) Hazardous Materials Inventory -Chemical Description UNIFIED PROGRAM CONSOLIDATED FORMS You must complete a separate Hazardous Materials Inventory -Chemical Description page for each hazardous material (hazardous substances and hazardous waste) that you handle at your facility in aggregate quantities equal to or greater than 500 pounds, 55 gallons, 200 cubic feet of gas (calculated at standard temperature and pressure) or the federal threshold planning quantity for Extremely Hazardous Substances, whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory should reflect all reportable quantities of hazardous materials at yc~ ~r facility, reported separately for each building or outside adjacent area, with separate pages for unique occurrences of physical state, storage temperature and storage pressure. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for elecVonic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER -This number is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3. BUSINESS NAME -Enter the full legal name of the business. 200. ADDlDELETE/ REVISE -Indicate if the material is being added to the inventory, deleted from the inventory, or if the information previously submitted is being revised. NOTE: You may choose to leave this blank if you resubmit your entire inventory annually. 201. CHEMICAL LOCATION -Enter the building oroutside/ adjacent area where the hazardous material is handled. A chemical that is stored at the same pressure and temperature, in multiple locations within a building, can be reported on a single page. NOTE: This information is not subject to public disclosure pursuant to HSC §25506. 202. CHEMICAL LOCATION CONFIDENTIAL - EPCRA -All businesses which are subject to the Emergency Planning and Community Right to Know Ad (EPCRA) must check "Ye> to keep chemical location information confidential. If The business does not wish to keep chemical location information confidential check "No". 203. MAP NUMBER - If a map is included, enter the number of the map on which the location of the hazardous material is shown. 204. GRID NUMBER - If grid cAOrdinates are used, enter the grid coordinates of the map that correspond to the location of the hazardous material. If applicable, multiple grid coordinates can be listed. 205. CHEMICAL NAME -Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the Intemationsl Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: If the chemical is a mixture, do not complete this field; completF the "COMMON NAME" field instead. 206. TRADE SECRET -Check "Yes" if the information in this section is deGared a Vade secret, or "No" if it is not. State requirement: If yes, and business is not subject to EPCRA, discosure of the designated Vade secret information is bound by HSC §25511. Federal requirement: if yes, and business is subject to EPCRA, disclosure of the designated Trade Secret information is bound by 40 CFR and the business must submit a "Substantiation to Accompany Claims of Trade Secrecy' font (40 CFR 350.27) t0 USEPA. 207. COMMON NAME -Enter the common name or trade name of the hazardous material or mixture containing a hazardous material. 208. EHS -Check "Yes" rf the hazardous material is an ExVemely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section blank and complete the section on hazardous components below. 209. CAS # -Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the appropriate section below. 210. FIRE CODE HAZARD CLASSES -Fire Code Hazard Classes describe to first responders the type and level of hazardous materials which a business handles. This infonnatici shall only be provided if the local fire chief deems it necessary and requests the CUPA or AA to collect it. A list of the hazard classes and instructions on how to determine which Gass a material falls under are incuded in the appendices of Article 80 of the Uniform Fire Code. If a material has more than one applicable hazard Gass, inGude all. Contact CUPA or AA for guidance. 211. HAZARDOUS MATERIAL TYPE -Check the one box that best describes the type of hazardous material: pure, mixture or waste. If waste material, check only that box. If mixture or waste, complete hazardous components section. 212. RADIOACTNE -Check "Yes" if the hazardous material is radioactive or "No" if it is not. 213. CURIES - If the hazardous material is radioactive, use this area to report the activity in curies. You may use up to nine digits with a floating decimal point to report activity in curies. 214. PHYSICAL STATE -Check the one box that best describes the state in which the hazardous material is handled: solid, liquid or gas. 215. LARGEST CONTAINER -Enter the total capacity of the largest container in which the material is stored. 216. FEDERAL HAZARD CATEGORIES -Check all categories that describe the ohvsical and health hazards associated with the hazardous material. PHYSICAL HAZARDS HEALTH HAZARDS Flre: Flammable Li uids and Solids Combustible Li uids P ro horics Oxidizers Acute Health (Immediate): Highly Tozic, Toxic, Irritants, Sensitizers, Corrosives, Reactive: Unstable Reactive, Or anic Peroxides Water Reactive Radioactive other hazardous chemicals with an adverse effect with short tens ex sure Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with ton term ex sure 217. AVERAGE DAILY AMOUNT -Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each building or adjacenU outside area. Calculations shall be based on the previous year's inventory of material reported on this page. Total all daily amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this location, the amount shall be the average daily amount you project to be on hand during the course of the year. This amount should be consistent with the units reported in box 221 and should not exceed that of maximum daily amount. 218. MAXIMUM DAILY AMOUNT -Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or adjacenUoutside area at any one time over the course of the year. This amount must contain at a minimum last year's inventory of the material reported on this page, with the reflection of additions, deletions, or revisions projected for the current year. This amount should be consistent with the units reported in box 221. 219. ANNUAL WASTE AMOUNT - If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled. 220. STATE WASTE CODE - If the hazardous material is a waste, enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. 221. UNITS -Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet or tons. NOTE: If the material is a federalt defined ExVemely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons). 222. DAYS ON SITE -List the total number of days during the year that the material is on site. 223. STORAGE CONTAINER -Check all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: ff appropriate, you may choose more than one. 224. STORAGE PRESSURE -Check the one box that best describes the pressure at which the hazardous material is stored. 225. STORAGE TEMPERATURE -Check the one box that best describes the temperature at which the hazardous material is stored. 226. HAZARDOUS COMPONENTS 1-5 (% BY WEIGHT) - Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available, report the highest percentage in that range. (Report for components 2 through 5 in 230, 234, 238, and 242.) 227. HAZARDOUS COMPONENTS 1-5 NAME -When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to manufacturer). All hazardous components in the mixture present at greater than 1 % by weight if non- carcinogenic, or 0.1 % by weight if carcinogenic, should be reported. ff more than five hazardous components are present above these percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures, mineral and chemical composition should be listed. (Report for components 2 through 5 in 231, 235, 239, and 243.) 228. HAZARDOUS COMPONENTS 1-5 EHS -Check "Yes" if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR,Part 355, or "No" if it is not. (Repoli for components 2 through 5 in 232, 236, 240, and 244.) 229. HAZARDOUS COMPONENTS 1-5 CAS -List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. (Repeat for 2-5.) 246. LOCALLY COLLECTED INFORMATION -This space may be used by the CUPA or AA to collect any additional information necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance. Page 2 of 2 FD 2144 (Rev. 09/05) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFlED PROGRAM CONSOLIDATED FORM) BUSINESS ACTIVITIES PAGE (HAZARDOUS MATERIALS FACILITY INFORMATION) B P. R S P I D FIIPF ~Rr~r r BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (66 i) 326-3979 Fax: (661) 852-2171 Page 1 of 1 t. FACILITY IDENTIFICATION FACILITY ID # (For Office use only -please leave blank) 3 EPA ID # DBA /FACILITY NAME ~o II. ACTIVITIES DECLARATION DOES Your Facility ... If Yes, Please Complete ... t2 A. HAZARDOUS MATERIALS CHEMICAL DESCRIPTION FORM 1g 1. Have on site (for any purpose) hazardous ^ Yes ^ No HAZARDOUS MATERIALS MANAGEMENT PLAN materials at or above 55 gallons for liquids, Mini mum regUjred planning elements: 500 pounds for solids or 200 cu. ft. for . Emergency Response Plan , compressed gases (include liquids in ASTs and ^ Yes ^ No Maps Training USTS)? Prevention B. REGULATED SUBSTANCES (RSl 131 1. Have on site RS at greater than the threshold ^ Yes ^ No • CHEMICAL DESCRIPTION FORM planning quantities established by the California • RISK MANAGEMENT PLAN (RMP Submit to USEPA) Accidental Release Prevention program • CONSOLIDATED COMPLIANCE PLAN (CatARP)? . Incorporating CaIARP Program Elements C. UNDERGROUND STORAGE TANKS (USTsI 13 1. Own or operate Underground Storage Tanks? ^ Yes ^ No UST FACILITY FORM • UST TANK FORM (One Per Tank) 2. Intend to upgrade existing or install new USTs? ~ Yes ^ No UST FACILITY FORM 13 • UST TANK FORM (One Per Tank) • UST INSTALLATI N F RM One P r Tank D. TANK CLOSURE /REMOVAL 2. Need to report closing an UST that ~ hazardous ^ Yes ^ No • UST TANK FORM (Closure section -one per tank) materials or 3. Need to report the closure !removal of a tank that ^ Yes ^ No • UST TANK CLOSURE FORM was classified as hazardous waste and cleaned on- site? E. ABOVEGROUND PETROLEUM STORAGE TANKS (ASTs) ^ Yes ^ No • HAZARDOUS MATERIALS MANAGEMENT PLAN 1. Own or operate ASTs above these thresholds; Incorporating Federal Spill Prevention Control and any tank capacity is greater than 660 gallons or the Countermeasure (SPCC) Elements pursuant to 40 CFR Part t 12. total capacity for the facility is greater than 1,320 7 F. HAZARDOUS WASTE EPA ID NUMBER -Provide on this page 1. Generate hazardous waste? ^ Yes ^ No To obtain EPA ID Number, please phone (916) 324-1761 2. Recycle more than 100 kg/mo of recyclable ^ Yes ^ No RECYCLING FORM materials at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable ^ Yes ^ No • RECYCLING FORM materials at an off-site location different from the point of generation? 4. Treat Hazardous Waste on site? ^ Yes ^ No TP FAC{LITY FORM • TP UNIT FORM (One per unit) 5. Subject to Financial Assurance requirements? ^ Yes ^ No • CERTIFICATION OF FINANCIAL ASSURANCE 6. Consolidate Hazardous Waste generated at a ^ Yes ^ No • REMOTE WASTE /CONSOLIDATION SITE NOTIFICATION FORM remote site? NOTE: If you checked YES to any part of Sections IIA - IIF above, then in addition to the forms requested above, please Submit BUSINESS OWNER/OPERATOR IDENTIFICATI ON FORM (FD2089) FD 2143 (Rev. 09/05) (FiMMP) BAKERSFIELD FIRE DEPT. HAZARDOUS MATERIALS MANAGEMENT PLAN Prevention Services e._. e R _5._ P t. n 900 TrUXtun Ave., Suite 210 SITE & FACILITY DIAGRAM ,;R r r Bakersfield, CA 93301 Tel.: (661) 326-3979 Page2of2 ~ Fax: (661) 852-2171 NORTH Please indicate direction of North Ffl 717(1 ire., nninG~ (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS SITE & FACILITY DIAGRAM R A R S~ i D P/R~ ~Rrr r BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 These instructions explain the use of the site diagram and the facility diagam. Normally, small and medium size businesses will only have to submit a site diagam. If you have subdivided your business into smaller areas because of the complexity or size, then you will be completing and additional detail map, facility diagram, for each of these areas. Include instructions that show the route to your business if it is in a remote location. All diagams must be on 8 'h x 11 paper and drawn using a straight edge tool. SITE DIAGRAM INSTRUCTIONS The site diagam is used to show your business and to indicate the businesses that immediately surround your property, usually within 300 feet. If you will be showing specific area detail on facility diagrams, use the site diagram to show an overall layout of the plant. If you will not be submitting facility diagams, the site map must include all of the following information: 1. Check the box on the top left corner of the form provided that indicated "Site Diagram". 2. Print the name of your business, as shown in your HMMP, on the top of the diagram. 3. Label the location of the hazardous materials and identify them by name and type of hazard (i.e., flammable liquid, corrosive solid). 4. Label the location of utility shutoff points for gas, electric and water services. 5. Label the location of fire hydrants. 6. Label portions of the building protected by automatic sprinkler systems. 7. Label the direction representing north on the diagam. (The diagram form provided includes a north arrow). 8. All labeling and identification on the diagam must be legible and easily understandable at the scale submitted. Diagrams must be sufficiently legible to produce a legible copy. Try to avoid the use of abbreviations or symbols. If you must use them, provide a legend explaining your system. Maps may be returned for correction if you fail to follow these instructions. FACILITY DIAGRAM INSTRUCTIONS Facility diagams are supplements to the site diagram. Use them to show the subdivision details of a large business. I . Check the box in the upper right hand corner of the form provided that indicated "Facility Diagam". 2. Print the name of your business as shown on your HMMP. Print the name of the area that this map represents. This name should be the same name that you used on this area's inventory report. 3. Indicate which area the diagam represents and the total number of facility diagams that you are including. If a map represented the first of four areas, it would be labeled # 1 of 4. 4. Follow instructions (3 -8)* for site diagams regarding the specific details to be included on each facility diagram. UNDERGROUND STORAGE TANK FACILITIES PLEASE NOTE: * If you operate an Underground Storage Tank (UST) facility, the facility diagam shall also specify the location(s) of the UST continuous leak monitoring system and/or the location(s) where the UST monitoring will be performed. FD 2170 (Rev. 09/05)