Loading...
HomeMy WebLinkAboutUNDERGROUND STORAGE TANK4 \~~~. ~~. ~~ (UNDERGROUND STORAGE TANKS) _~-_~; BROT-H__ER'S_MIl_VI-MART- . = -- ~~ ~ ! 801 E. CALIFOR1vIA~AVENUE ' Y J UNDERGROUND STORAGE TANKS UNIFIED PROGRAM CONSOLIDATED FORMS APPLICATION OPERATING PERMIT APPLICATION FAC/L/TY FORM - (STATE FORM A) One form per facility ~; ( ) Fax: (661) 852-2171 Page 1 of 2 TYPE OF ACTION: (Check one item only) ^ 1. NEW SITE PERMIT ^ 3. RENEWAL PERMIT 5. CHANGE OF INFORMATION (Speciy change local use Dory) ^ 8. TEMPORARY SITE CLOSURE ^ 7. PERMANENT SITE CLOSURE 5. TRANSFER PERMIT a00 I. FACILITY/SITE INFORMATIO N OTAL NUMBER OF USTs AT SITE ~~ 404 Ag IL~~ ~ Only) USINESS NA F (Same as FACJLITY NAME or DBA -Doing Business As) Ifr_` l S USINESS SITE ADDRESS ~ ~ ,_ ~~`~ ITY t04 s facility on Indian Reservation or Trust lands? ^ Yes o 405 I L PROPERTY OWNER INFORMATION ROPERTY OWNER NAME S QI'V~ f t ~ 407 0 PHONE 40 ~ (LING OR STREET ADDRESS G n "~c~~c.C.. tSC- 409 ITY Il~~ 1R~( 410. STATF~~ Ott ZIP CODE at 7~r I11. TANK OPERATOR INFORMATION ' PERATOR NAME ~ ~ \ 1 ~vJ HONE ~ ~ n~ T02 7 ILING OR STREET AD~REOSS r ~ G_ Itl_`'lL T03 ITY T04 TATE T05 ZI~,FQL~E TO Y ./•ClJ(''A~ ROPERTY OWNER TYPE ^ 1. CORPORATION ^ 2. INDIVIDUAL ^ 4. LOCAL AGENCY/ DISTRICT ^ 6. STATE AGENC ^ 3 .PARTNERSHIP ^ 5. COUNTY AGENCY ^ 7. FEDERAL AGENCY ata IV. TANK OWNER INFORMATION ANK OWNER NAME ~ ~'sw ~ of \ ata PHONE ~ ~ ~ 4t r ILING OR STREET ADDRESS ~ ~ 4ta ITY ~~~ 417 STATE ata Z1RG6pE at p7:JCJ(!U1 ANK OWNER TYPE ^ 1. CORPORATION/LCC ^ 2. INDIVIDUAL ^ 3. PARTNERSHIP ^ 4. LOCAL AGENCY/DISTRICT ^ 5. COUNTY AGENCY ^ 6. STATE AGENCY ^ 7. FEDERAL AGENCY az0 V: `BOARD OF EQUALIZATIQN UST STORAGE FEE ACCOUNT NUMBER (TK) HO 4 4 all (916) 322-9669 if there are any questions azt VI. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: .FACILITY OWNER ^ 3. TANK OWNER ^ 4. TANK OPERATOR ^ 5. FACILITY OPERTOR azz egal notifications and mailings will be sent to the tank owner unless box 4 or 5 is checked. UPERVISOR OF DIVISION, SECTION, OR OFFICE (Required for Public Agencies Only) 40a Cettiftcatlo~t; I cent VII. APPLICANT SIGNATURE that the Information _rovlded herein is true accurate and In full com Rance with l al r ulrements. IGNATURE OF APPLICANT r.~ ~ o~~ aza ATE a25 /~ /3 ~ ~ ~ , PHONE '~ O ~ 2 AME OF APPLICANT (print) a2T TREE 01=/A~PP'LI/CAyN~T/~ O(/(/~//.-C~~ USINESS NAME , 3 USINESS SITE ADDRESS 103 BAKERSFIELD FIRE DEPT. Prevention Services a S R s P l fl 900 Truxtun Ave., Ste. 210 I~IR/t Bakersfield, CA 93301 ANTM ~ Tel.: 661 326-3979 FD 2093 (Rev. 11/08/06 mPage 1 Steve Underwood Final hwfwrc b (Rev- 8-2006) doc _ , I f i i i 4 4 i I Y t i i i t f i t P i i I i 1 i I 1 1 e 3 i a t ( UPCF hwfwrc-b- 1/2 Rev. 8/2006 i r UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK FORM (One form per UST) TYPE OF ACTION ^ 1. NEW PERMIT ^ 3. RENEWAL PERMIT ^ 5. CHANGE OF INFORMATION ^ 6. TEMPORARY UST CLOSURE ^ 7. UST PERMANENTLY CLOSED ON SITE ^ 8. UST REMOVED Check one item onl . For a UST closure or removal, com lete onl this section and Sections I, II Itl, and IV below a3o Date UST Permanently Closed: +3on 1. FACILITY<INFORMATION FACILITY ID # (Agency Use Only) BUSINESS NAME ~ I 3. BUSINESS SITE ADD SS ~ /~~ CI ._ . 1 +-1- 1°4• .:. _ IL ;TANK.DES.CR RTIQN TANK ID # a32. TANK MANUFACTURER 433. number of tank units. This tank is: ^ 1. A STAND-ALONE TANK ^ 2.ONE OF TWO OR MORE COMPARTMENTS 434• DATE UST SYSTEM INSTALLED a35 DATE EXISTING UST 435b DISCOVERED: NUMBER OF COMPARTMENTS 437 TANK CAPACITY IN GALLONS 436 "' 1{I TANK USE and CONTENTS TANK USE ^ 1. MOTOR VEHICLE FUELING ^ 3. CHEMICAL PRODUCT STORAGE ^ 4. HAZARDOUS WASTE (Indudes Used Oil) ^ 5. EMERGENCY GENERATOR FUEL STORAGE ^ 6.OTHER GENERATOR FUEL STORAGE ^ 7, MARINA FUELING ^ 95. UNKNOWN ^ 99.OTHERS ec' a39. TANK CONTENTS PETROLEUM: ^ ta. REGULAR UNLEADED ^ 1b. PREMIUM UNLEADED ^ 1c. MIDGRADE UNLEADED ^ 3. DIESEL ^ 5. JET FUEL ^ 6. AVIATION GAS ^ 8. PETROLEUM BLEND FUEL ^ 9. BIO-DIESEL ^ 99. OTHER PETROLEUM S eci 440• NON-PETROLEUM: ^ 7. USED OIL ^ 10. ETHANOL ^ 99.OTHER (Specify): IV TANK C©NSTRUC_TION TYPE OF TANK : ^ t.SINGLE-WALLED ^ 2. DOUBLE-WALLED ^ 95. UNKNOWN 443 TANK PRIMARY CONTAINMENT ^ 1. STEEL ^ 3. FIBERGLASS ^ 6. INTERNAL BLADDER ^ 7. STEEL + INTERNAL LINING ^ 95. UNKNOWN ^ 99.OTHER (Specify): 444• TANK SECONDARY CONTAINMENT ^ 1. STEEL ^ 3. FIBERGLASS ^ 6. EXTERIOR MEMBRANE LINER ^ 7. JACKETED ^ 90. NONE ^ 95. UNKNOWN ^ 99. OTHER (Specify): 445• OVERFILL PREVENTION ^ 1. AUDIBLE 6 VISUAL ALARMS ^ 2. BALL FLOAT ^ 3. FILL TUBE SHUT-0FF VALVE ^ a. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT a52 1/ PRUDUCT / VIlA57E'PfPING CON57RlfC710N PIPING SYSTEM TYPE ^ 7. PRESSURE ^ 2. GRAVITY ^ 3. CONVENTIONAL SUCTION ^ 4. SAFE SUCTION (23 CCR §2636(a)(3)) ass. PIPING PRIMARY CONTAINMENT ^ 1. STEEL ^ 4. FIBERGLASS ^ 8. FLEXIBLE ^ 10. RIGID PLASTIC ^ 90. NONE ^ 95. UNKNOWN ^ 99.OTHER S eci a6aa PIPING SECONDARY CONTAINMENT ^ 7. STEEL ^ 4. FIBERGLASS ^ 8. FLEXIBLE ^ 10. RIGID PLASTIC ^ 90. NONE ^ 95. UNKNOWN ^ 99.OTHER S ec' a6an TURBINE CONTAINMENT SUMP: 001 SINGLE-WALLED ^ 02. DOUBLE-WALLED ^ 03 NONE 4~ `° 1/1' PENT AND:ifAP'ORF,tECOVERY ,'R PIPING,CQNSTRU~TION VENT PRIMARY CONTAINMENT ^ 1. STEEL ^ 4. FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify): aaaa VENT SECONDARY CONTAINMENT ^ 1. STEEL ^ 4. FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify): 4640 VR PRIMARY CONTAINMENT ^ 1. STEEL ^ 4. FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify): a6ar VR SECONDARY CONTAINMENT ^ 1. STEEL ^ 4. FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify): a6a VENT AND(OR VAPOR RECOVERY PIPING TRANSITION SUMP(S) : ^ t. DOUBLE-WALLED ^ 2.SINGLE-WALLED ^ 3. NONE a6an VII. -RISER /FILL PIPE CON.$TRUCTION , RISER PRIMARY CONTAINMENT ^ 1. STEEL ^ 4. FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify): 4641 RISER SECONDARY CONTAINMENT ^ 1. STEEL ^ 4. FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify): 4641 FILL COMPONENTS ^ SPILL BUCKET INSTALLED a51 ^ STRIKER PLATE)BOTTOM PROTECTOR INSTALLED asi b 1(111 UNDER,DI$PEIJ$ER CONTAINMENTS UDC UDC Construction TYPE ^ 1. SINGLE-WALLED o 2. DOUBLE-WALLED ^ 20. NO DISPENSERS a6sn UDC CONSTRUCTION MATERIAL ^ 1. STEEL ^ 4. FIBERGLASS ^ 70. RIGID PLASTIC ^ 99.OTHER (Specify) 468c IX. CORROSION PRO:I ECTIQN STEEL COMPONENT PROTECTION ^ ^_ SACRIFICIAL ANODE(S) ^ 4. IMPRESSED CURFEfvT r 6 ISOLATION aax• X APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in full com liance wit a al re uirements. APPLICANT SIGNATURE 'Om DATE /~ ago. FROM FAX NO. Jul. 25 2005 10:12PM P1 UNDERC3ROUND STORACRE TANKS • LfMIF1ED AROGRAM CONSOLIDATED FORMS APPLI.CATI~N OPERATING PERMIT APPL/CAT10N FACILITY FQRIN - (STATE FORM A) One form pet facilify PIRl n ARTUI f FYRE DEPT. Preveaatioa S~rviceg 900 "1`ruxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: {661) 326-3979 Fax: {661 552-2171 rage t of 2 TVpEOFA^-Tl0le (GradcmaRamnngd CB.Z9+PCRARYttOSURE O T.P~tW4NEdiSr7ET~06UnE 1~' AiapnreFErt~a7 TION(SpeClHU+xW9bWutsady} ~ ~~.~'~fY~~. ~~~" n.jC:^ / 4' y ~. ~ l4• '(2.ti'~~~. A" ~ ~! M • ~ V ' ~ ~,v /~~5~~.F ~c~h; i„1) • vj=~ ,~,y •' 21~:.y..^..'~.1••N s. .. . "..~ f d: »7°' .." h ~ Y y' ~ T , ~' . ~v q . ,x~. ..t : r. '~'@, .!W './•~ fdM ~P~" ~• "~; , . ~ ,4yam y W a.~ry v~• 7 '.J' l. ~y •a bTAI, NUMBER DF U&Ta AT SITE .W ;;y 404 ApUTr iD Na. • ~,. uaa only) USi[~f>=.4$ (Smn~ AS FA(SLGY NAA1E or D9A - Darg eu~neix As} ' h: SiME9.S SITE AODRE$S ,. /~ ~~~ ~ J-~ ITY to s faalib art irdian•Reaervation or Tfust lards? Q Yea 4aS .. ~ ~• . `~.! .u' 's ¢ ,r :: ~a, r. ~ ".Cr ~ i. ~'~: ,,,. .:e ~.: ...~ a '.~,w.. ~~ .: ny r _ ~. i b 4 a • y 5'~% ' ' l ~ y , _ , N.;A a . 4.. ~ I f p ' ~' ~ ~ ~'i~~. :v:~ • ' 'r ai ' .N~''' 7 ..,....:~~.Y, ..... '-:. /..i~u.w .. d1.,;;: . ,y ,~.. ~ F~. F. • +?i; . .... .;v, •~a, ..~... .. :.v F'.'l~;tiJ''ff!@h:si.t'<'k• .vY1~s~ ±$rk' -i t'' ..a' ROP~7Y OWNER NAIL ~ ~~~ ~ t ~ 48? PHONE. G OR 87REE'l' ADDRESS n ~~~~~ ~ 40a ITY . ~~ 47 D . 9TA 411 21P E 4 ~ ~' i .1 r~i!'i\, >'R;7j~'~~-~yn:4lS..~'fy'¢Ls~v; ~l•p. , a. ;n ~; rn 'i:1.O'.t. r'd,~1, :Y^.'r'Sf..X X',n'! •'w~Pi. •ES~hie~ ~"9~~.#f.~:`•:h'i..; 14Xl'Y(c:'~+vYV'W'',!. ~,.. ::~F 415'A~~"ra•CT~K 'a".'at :r~.; !?~~cy^~~~ o~ M1^ ~Y rt, IN .. ~ ~~aY ~,~~..~h,''4~.'~w~? 4 w'~~ v~ }u "~' ~ ~y" F~ ` `•7+.y° a~ ~ ° ' ~ •~ ~ ~` , ~ ~ ~ ,= f .. I~ % ~ a y, . R ~2 ,wy ie . .l~ x"ti {:~w;:!krfL2 ~,.'y.'~. ~'.. ~' ~ ~i~~. ~ci' s.~ i:r_~ oY..1..., . .. d: ~: Y ~i ~ Sr ~ d ~~r'~% ? : 5.9~.: C,.u ~~ ~ ` '~1~, tn_..T''"~(~•Q'~~+J.~~§,e~:! @'4" v PEFATOR NA~AE '~ ~ HONE ~ ~` W~ 702 l. r G OR SiREEf SS 703 ~~ • ITY TQ4, ATl: Y~ RQPERTY OWNER TYP£ q t. CORPCIRATKSN O 2. WDNIDUAL 13 4. LOCAL AGENCY! DISTRICF ©6. 6TATE AGENCY q 8 .PARTNERSHIP p 5, COUNTYAGENGY O 7. FEDERALAGENGY Ord .: ~ .' v • ..r. .~ ~~~ ~ s. ~~ o~.:.. 4..,.~ . y ~ + ANK AIIYNER NAbIS ~ . PHaN~ 47 4ia l r aRYI~ r G 4R STREET ADDRE53 ~ ~ 4t6 f (~ 1'fY ~+ 417 STATE 418 ~{:Q(~ 41 [f .~J[ {l!l ANK OWNER TYPE D t. CORPpRATIONA.CC D 2. INDIVIDtfAI d 5. CdUNTY AGENCY ~ 6. STATE AGENCY Q 3, PARTNERSHIP D 4. LOCAL AGENCYf DISTRICT Q 7, PEDE'RAL AGENCY •, T (710 Ho 4 4 O ~ I (9+~ a22-0669 if mare are any e~,eanans 42i x~ ~. ~ {~r, ~/ ~ yr. TN,.. ..,K.• Q;t NH .~ ~n + .~;~ k iK '.~ .~!• ,!'r. .p. rAS~~*. ~i~;x;~Gno i~b'? •~K : ~ .. r~ ~' ~'• ~ i • ' :rtV~ „ ~' ~, fi~. ~i':~ak~?4 '} : .,~+,r"~ r~ ~~'~,~~~ n. •~ ' ~~~~ '~ ~ r~Rf~ i &` " ~ e ~ ~ w a , . ., :..,_r; . :4 _ •a .'7f~ .,A ,[. ' , , . y : _ •'< ;y •:1 ~u ~' ,ry ': 1q5 b,.~ ..'4M. ^ , , :• saue pqr~(~IlL erltl aentl Ie~~ 1 notlllcaavrre antl m~uGn9s Lo: FACI~y OWNFJi Q 3. TANK DWNFJt q 4, TANKOPERATOR O 5. FACaJTY OP6RTOR aa I rIOSmC8GOf1a and maiGnpa will tfe scnl yv qhe tarot owner wvesa box ~ ar 5 la alarJted. PERVfSOR OF DIVIgION, SECY'lpld, OR OFFICE (Raglbn:li for Plblic Apatttlea poly) ~ ~`t~':''h,~' ~ C ~' vf'.!•Fy'c' ~ 1a i$~., ht. '"r;vr~j, }~,11 !•~?.r 9!`1'+i!,Y^!` 1 :f: ~:hyvt ,y(~y , a. `'4 r ~ _..:7;~ ~.'•~~~~S a., .~,, ~; N. '~. ~.:~F~.~ i',~.' ,..~^ elf`-~~ ~ ~, ~ •i ,:vr... vr: = M1.r. Y ~ .~.j ~cr:. " ~v :~~ i l ..yr_o- ,: ~,. A• ! .,;v~i...., ,rl ~ ~ C. ~4 'a-y ,r ~~j~ ~E ~x~~~i~'1~1' i`~.ry.• '~R•..t' P. ~_ i~ 1 rL ~i 4`r ~' ,•i, l ~ v ;cy. ~~ y.+y;I: / ' ~ ' ~ ~ ~ ~ ~•L' . : ...T. : , .. . d~llhl •. ` _ } ~ f ,.I ) & anll;ki' ,,,,py by ~~ q;,' ~y,, S ` v iQa IGNATURE OF APPLK.A' NT 4Z1 ~r~ ~ ~ - ~~ ~' arf OF APPLICANT {pvin{i 427 TfILS OF APPLICANT U81NE$$ NAME . USINESS SRE ADDRESS - top FD 2119Ci (rmv. 7'uaBlOG FROM FAX N0. Jul. 25 2005 10:15PM P1 IIMDERGl~OUND 3TOFtAGE TANKS UNIFIED pROGRAIuQ CONSOLIDATED FORMS At~PLICATION OPERATING PERMIT APPLICATION FACILITY FORM ~ (STATE FORIU A) Qne farm der Yac-lify ^ >r ~'/~'~ w FIRk; DEPT. ~Y~,I1t101I< ~3'V'1C~S 9001YuxtLT.n Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Faa: (661) 852-21.71 Page 1 Of 2 Tva@ aPACriwe (f~teck Ana aaro aM'1 0 ~. mEwartE aErW n ^ 3. PFRIYII! ~ Rw s, ewwcg aFlr~r•~,~anoa fs~sumt~t~ ea+w~ a,!!q d a,>:-poRAay Brle eLOaur~. D ). PE7eeaelENT SRC uosul~ R't S. TR,~weFa w~wr - ,.4 ..ry„Y,. ViS~~y .\,s '~'r ~~' Ati 't:, .ii;f r t'- > •fc~ES • ~•lF",:• •:~ .'. N:~" w n., t ' \• a' ~L~ ia''r'T"' .mil ~~': ' 1 ~ -. r ~ y~ ,,JJ ~ ~ ~?'..:~{ ' ~y ~ ~v - ~ 5 ~1~ ::Y'' ti '0fl ~ ~~ ~ ~ '~ ~ , . . " •C~. • . 1^ t .. 'rt ° I15 .{e~i e a'N~.+4. OTAf, NUMBER OE USTi AT GRE , -~~ q0q ACILRY B) Np, 1^ Agersy Use On~~ SINESS {3amg as FACy.tIY NAME or DBA -Doing Business Aa) ' ~i USINE33SITEADDRES3 _ ~,, 1a r ~, fadtld m ficYen. Reservadon x Tn191 lanes! O Yes ~ •..' ~ ~ { '` fir... ."~'.q:, p. ~F P,.,. q~~ J "y", ' ~q ~ ~ ~i5.~.;;r', ~k : l~ ','r~ .,~ , . *~~^'C .• ,y r;s..:.rr~:a,. a~ ••. i- . •~{ a :•~~ r• .n~• '~i~,~ ,;~ .tf •.,~{ S ~iqS, ~ .t ^~n• ~ ~ .•',~ ~ S .a+, 4: d. ~~ 1~'.. ~- iS~ ;iv~ 'L 't it ~ ' n ,. sv.: ,f -~,.• .-la'' ~i" ° R4~iTY0NVNERNAME ~~~.. ~ 40T PHONE f, .. 49 uNG OR STREETADORBSg ~! eoe Crll 'TCFtiC.~i ~~r~..- ' ~ f ~, 410. 3TAT ~ a» ~P CODE 0 Xl 'Y^Yr w'•b~..~~ ~ ~~f ' y. tin ~ ~.~` t~ . !]. 1.. , i 4td ~Pi`.'ib'~ ~•.°hN.~ .1< \0~+ti „'i.°,.d'•FM: *N:ray~~d'Y. " t 4~.~ P.::~ '~:.(':'d, t:'.• ~1 ~~"~'• 'y~~"~.7!. -' .' a w~ {';bn _ ~' _ .v.~~. ett~`' .,y~.. rJ,~+1,~A'c<'Yrti•.. :•M,.~`•"a"^, { ~~s. ..W'.~'5... .~.~ F,i" ~ ~j ?`~'~',, 1 n r ~ t :~~IS'H. ~"~+~\' ~..y~ 3~ .ab- ~',~ `i. ~' Y:.+~y~'y.^'°.~ :n.~(. t~, ,~.~ 4Y', ,,, "kt -a'~~ ,sa ~ ..;~. ~;, ;'~~ ~ ~. ,. , . °~` : ~: ~ FY ,1 ^: ,.. ~ ~~ ~:"d~' ti~'~ '~°~ ~3`~'°~ ~ , , , , ; , : .. :.t ., : , t PFRATOR NAME 6 ' OHE Tpp 1 J r.` { ' R ~ ~- ~ LING OR STREET RCeC lam.! " l.~ ~ T04. TATS 7'0 ROPERTY-OWNER TYPE O t. CORPORATION ^ 2. INDIVBJUAL p 4. LpCAL AGENCY/ DfSTRICT Q 6. STATE AGENCY O 3. PARTNER3Fi~ a s CouNrrAG~ENCY O 7. FEUEftALAGENCY t7 ' ra*~ •A Y,t'<<'GI~Y '~,j tT n ". ~y - :f s~) ~ n- y"p~~~ ~Y ~, /~ ~ ~, .~,ye' ~f?~ ~ >,• ~*.,.. ,DMlf~ia~ Y ~-T, 's~t ~ ,1fs•'X'~ ,. ~'~R'aa'A~L'F:,~}~$Ni ~iq -i„L ~.o,'ur' ~l-'.[ ANK OWNER NAME 4i1 PHONE n e y~,~ ,~ - ~ ~. ` G OR STREET ADDRE$$ ate TY ~~ 41T srATe 41a ~~ ~ ANK OWNER TYPE Q ~. CORpORAT10N/LCC O z IND1vmUAl. O 3. PARTNERSHIP . p a, LOCAL AGENCY! DI$TRICr .. EN . ,. ~ .. . „ :, ~ , ,~-• ~ ~ s° , u. J_, Y. . , !~ .i~e: j .~ wrt• f+~~ai+t~ I~ FIp ~ p, (91 B) 322.8889 d tl1Br~ are erty questions 421 ~C~ - ~ y.~r~' ~ e ' ~* , i' ~ T .,..r,~ ~ . c . ~a ~`r ~ u~„ r 1 L 1' ~w(, k ; Lt,.,t 9},Jt... .t„ .~I •.. .,., "' .~x,~• ,:u w r 'i` 1~•\,-',ti"P3: ~>~ ~ ~7^ x~~ ,. .;nom. ~, 1, '~ • r ~Rt ~ ~~~ ~~ I,~.S,ti.4tY`:: ~ 5.~ V'H' ~ ~ ~ N~~~ •~!r'. ~' '• :: ' .'a't: L • ' ~ ' ' J ' ' ~ ~ ~ ~ - , „ : . :.r.u. . , . : . .I .tti, ~ +t:.+•; q• ;t YS. My •iNi~ ' 1 ~ :V^,~` ~~ "w'" "°`Xu R~ 119p~r mil alld Serltl nolifir~Olle and MOiGngS tC : FACBJT-Y QWNER 0 3. TANK OWNER d•4. TIWK OPERATOR epsl 11dItTtWllorle Ana rrl~ilings vvli) be aeM tp Um ip~k owner unbse bmt d pr 6 (a crleCkled. G•5. FACILITY OPERTOR \ 4?2 UPERVI$OR OP DIVISKIN, SECTION, OR OFF I C E {Regtale~ for Pubsc Apen~is5 Ordr1 ~ ' ~ 7 7,'yy,N'y~, ~*4. ~~' Vt~;rhntiz', ;i ~:~);~. t9~J. Y~~r/~M ~~ON. ~",'tY~,'~l.~i~'. ,y; i ~T! .t ~~.''. 50': b:' ?"'Ych '~:ti!s ~J :14,. ~p y.. ih. n'~ kIY '0~ir C~a'',. F' ~'~+ ,.v~ Yt'~•;±•w~~ .~,~i'~ ~Y.I ~t ~S ~ bq~~o ;..~Iwa~~~*t• ~~., ~;•'e~R't-''v'~ o'~, v~, "!s"',,:,: "~',Y'~ .~3 ae ;,.' :.; ~ `': ~ V~~ ~ •~ ad ~ ~,: ~ ' ` ~ , . o e r ' b'~eiti6 $' ~ '' ~~kio-. t!_tl.~I'c. ~},~ *~~ IGNATURE F ~' O APPLICANT ,' ~., te/''. d a?~ ~~ ~ % - 1 ~ b~ ~ '~ ~ ~ , CF APP I L ~ CANT (prrrr0 42f TITLE OF APPLICANT ' ~ . ~ ~~~~~~~ 9USINE$S NANDE BUS9t1E33 $ITff A0DRE3g • • t08 FD 2093 {Rev.1UOBIEB Cd3 Century Surety Company 465 Cleveland Avenue Westerville, Ohio 43082 614-895-2000 www.centurysurerycom COMMERCIAL LINES POLICY COMMON POLICY DECLARATIONS POLICY NO.: CCP427568 NEW NAMED INSURED AND ADDRESS: CODE NO.: 5753H Sam's Liquor ~ Gas INSUREDS AGENT: 801 E. California Ave. Thomco Insurance Agency Bakersfield, CA 93307 4333 N. West Avenue Fresno, CA 93705 POLICY PERIOD: Fromp9/18/2006 To:o9J18/200'7 at 12:01 A.M. Standard time at your mailing address shown above. Business Description: CONVENIENCE STORE X Individual Joint Venture Partnership Limited Liability Company (LLC) Organization (Other than Partnership, LLC or Joint Venture) IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM COMMERCIAL GENERAL LIABILITY COVERAGE PART $ 859.00 COMMERCIAL PROPERTY COVERAGE PART 2,752.00 COMMERCIAL LIQUOR LIABILITY COVERAGE PART 650.00 TRIA PREMIUM 85.00 SURPLUS LINES TAX 130.38 SERVICE OFFICE FEE 7.61 25 % ofthe Policy Premium is fully earned as of the effective TOTAL ~ $ 4, 483.99 date of this policy and is not subject to return or refund. Service of Suit (if form CCP 20 10 is attached) may be made upon: BASS UNDERWRITERS, INC 6951 W. SUNRISE BLVD. PLANTATION, FL 33313 Form(s) and Endorsement(s) made a part of this policy at time of issue*: SEE ATTACHED SCHEDULE OF FORMS: CIL 15 OOb 02 02 *Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits„an applica deceptive statement is guilty of insurance fraud. ' COMPANY REPRESENTATIVE: :-~ - '~" :ox, BASS UNDERWRITERS, LLC Countersigned By 6951 W. SUNRISE BLVD. Authorized I PLANTATION, FL 33313 10/09/2006 LA fi., claim containing false or ~~,~~----jai ~ , resentative JD KOOGLER IN WITNESS WHEREOF, this Company has executed and attested these presents; but this policy shall not be valid unless countersigned by the duly Authorized Agent of this Company at the Agency hereinbefore mentioned. CSCP 10 01 03 06 Secretary President INSURED PREMIUM FINANCING SPECIALISTS of CA, INC. PO BOX 271389 CONCORD, CA 94527 PHONE: (800)473-1171 -FAX: (800)765-5355 NOTICE O~ ACCEPTANCE AN© OF ASSIGNiVIENT' REFER TO THIS IN ALL ACCOUNT N0 ACCOUNT NUMBER . CORRESPONDENCE CAC-91685 DEAR CUSTOMER, THANK YOU FOR THE OPPORTUNITY TO FINANCE YOUR INSURANCE. AS AGREED, WE HAVE PAID THE BALANCE DUE ON YOUR BEHALF. A PAYMENT SCHEDULE IS SHOWN BELOW. IF PAYMENT COUPONS ARE NOT ENCLOSED, YOU WILL BE BILLED FOR EACH INSTALLMENT. DETAILED PAYMENT INSTRUCTIONS ARE SHOWN BELOW. 1. YOUR PREMIUM FINANCE AGREEMENT HAS BEEN ASSIGNED TO PREMIUM FINANCING SPECIALISTS, INC. PAYMENT 2. TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, WRITE YOUR ACCOUNT NUMBER ON INSTRUCTIONS: YOUR CHECK AND RETURN THE PROPER COUPON WITH YOUR PAYMENT. 3. BE SURE YOUR PAYMENT IS MAILED IN TIME TO REACH OUR OFFICE BY YOUR DUE DATE. 4. MAIL YOUR PAYMENT TO THE ADDRESS ON THE COUPON. 5. IF YOU HAVE NOT RECEIVED YOUR PREMIUM FINANCE AGREEMENT NOTIFY US IMMEDIATELY. INSURED SAMS LIQUOR & GAS SAMRITH VONG 801 E. CALIFORNIA AVE. BAKERSFIELD, CA 93307-1147 AGENT THOMCO ASSOC INS INC 4333 N WEST AVE FRESNO, CA 93705 !! ff 00694^ I'1IIIIIIIIIIIIII'Ilt~ill'IIII~lillll'IIIIIII~I~IIIIII~~IIIIII DLSCLOSURE TOTAL PREMIUMS $ 4,689.86 DOWN PAYMENT $ 1,433.36 AMOUNT FINANCED $ 3,256.50 FINANCE CHARGE $ 238.47 ASSESSMENTS $ 0.00 TOTAL PAYMENTS $ 3,494.97 NUMBER OF PAYMENTS 9 PAYMENT AMOUNT $ 388.33 ANNUAL % RATE 17.250 ACCEPTANCE DATE 09/22/06 WE HAVE PAID THE BALANCE OF YOUR PREMIUM BELIEVING THE PREMIUM FINANCE AGREEMENT TO BE GENUINE AND IN FULL EFFECT AND THE SIGNATURE THEREON AUTHORIZED BY THE INSURED. IF FOR ANY REASON THIS 1S NOT TRUE, NOTIFY US IMMEDIATELY AT THE ADDRESS OR TELEPHONE NUMBER AS SHOWN ABOVE SCHEDULE O'F PAYMENTS PYMT NO. DUE DATE AMOUNT 1 10!18/06 $ 388.33 2 11 /18/06 $ 388.33 3 12i 18/06 $ 388.33 4 01 /18/07 $ 388.33 5 02.`18/07 $ 388.33 6 03/18/07 $ 388.33 7 04/18/07 $ 388.33 8 05/18/07 $ 388.33 9 ~ 06/18/07 $ 388.33 Go to www.premiumfinance.com to review your account and make online payments. SCHEDULE OF POLICIES P LILY N POLICY PR£FIX EFFE~TIVE Ft1LL NAME OF INSURER AND GENERAL AGENT07HER ObVEF3AGE FE~MBN PRENFIUM A D NUMBER DA E THAN SUBM1TTfNG PRODUC£P TO WHOM COPY bF THfS PTH~ATFFO MONTHS ETNA N(;ED NOTICE WAS SENT fWAR, I_M ,CAS '. COVERED ... :) .;_ BY-PREM PENDING 09/18/06 CENTURY SURETY COMPANY GL 12 $ 4,342.00 BASS UNDERWRITERS FEES $ 210.00 TAXES $ 137.86 i IIINf Niil IIIII ~~~~~ 11111 Ifll 1111 \ (05!98) Copyngh~ 1988 Premium Rnancing Specialists, Inc. P4 "40100" 09346 11.733696-7 Century Surety Company COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS .Cy No: CCP427568 Effective Date: 09/18/2006 ~* 12:01 A.M. Standard Time NAMED INSURED: same s Liauor & Gas LIMITS OF INSURANCE: General Aggregate Limit (Other than Product-Completed Operations) $ 2, 000, 000 Products-Completed Operations Aggregate Limit $ 1, ooo, 000 Personal and Advertising Injury Limit $ 1, 000, 000 Each Occurrence Limit $ 1, ooo, 000 X Fire Damage Limit Damage to Premises Rented to You $ 50, 000 Any one Fire/ Occurrence Medical Expense Limit $ 2, 000 Any one Person RETROACTIVE DATE: (CG 00 02, CGL 0002, CGL 1551 or CGL 1553) Coverage A and B of this insurance does not apply to "bodily injury", "property damage", "personal and advertising injury", or "advertising injury" which occurs before the retroactive date shown here: DEDUCTIBLE: Per Claim $ 500 Bodily Injury Liability & Property Damage Liability Combined (this deductible also applies to Personal and Advertising Injury Liability.) Deductible also applies to Supplementary Payments - Coverages A and B; Defense Expenses Coverages A and B (form CGL 0002 only) X Yes No LOCATION OF ALL PREMISES YOU OWN, RENT OR OCCUPY: 1 801 E. CALIFORNIA AVE. BAKERSFIELD CA 93307 PREMIUM RATE: ADVANCED PREMIUM St/Terr Code Classification Prem. Basis Prem. Ops. Pr/Co Pr/Co All Other CAj0513673Convenience GRSALES 360,000 2.127 (11.258 766.00 93.00 Food/Gasoline Stores - self and/or full service Audit period is Annual Unless Otherwise Stated Total Advance Premium $ 766.00 $ 93.00 Subtotal Coverage Premium 859.00 TRIA Coverage 17.00 Minimum Premium for This Coverage Pan $ - 876.00 FORMS AND ENDORSEMENTS (other than applicable Forms and Endorsements shown elsewhere in the policy: Forms and Endorsements applying to this Coverage Part and made part of this policy at time of issue: See Attached Schedule of Forms, CIL 15 OOB 02 02 *Inclusion of Date Optional THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THIS INSURED AND THE POLICY PERIOD 10/06/2006 LA CGL 1500 1204 From: Donnie Diaz At: ThomCo Insurance FaxID: To: Jay Diaz t; ~ r~ 1k~Z ~ S ~. i ~ °.'11~~ ~1~~` A ThomCo Insurance Affiliate Lic. #0691566 777 Minnewawa #15 Clovis, CA 93612 Date: 9/182006 04:47 PM Page: 2 of 3 NAMED INSURED: Samrith Vong DBA: Sam's Liquor & Gas MAILING ADDRESS: 801 E. California Ave., Bakersfield, CA 93307 PHONE #: (661) 861-1614 Renewal Quote Summary LIABILITY LIMIT ......................................................... $1,000,00(1 LIABILITY AGGREGATE .............................................. $2,000,000 LIQUOR LIABILITY ...................................................... $1,000,000 FIRE LEGAL ..:.............................................................. ..$100,000 BUILDING .................................................................... ...$400,000 PUMPS ........................................................................ ... $60,000 PERSONAL PROPERTY .....................................................$90,000 BUSINESS INCOME ... .....................................................$48,000 MONEY & SECURITIES ................................................. ....$10,000 PREMISES MED PAY ..........................................................$5,000 COMPANY COVERAGE TO BE PLACED WITH Colony Insurance Company- Liability Lloyds of London-Property PREMIUM .....................................................................$4,689.86 FEES & TAX .....................................................................$100.00 TOTAL ..........................................................................$4,789.86 Payment Option Minimum Down Payment .....................................................$1,533.36 Nine (9) Monthly Payments of ... $388.33 Finance Charge ...$238.47 Please make checks payable to Jay Diaz Insurance Service 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 acre conditions of the operating permit. The permit holder must noti/y 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. Bakersfield Fire Dept. Enviroamental Services ~/R~ 171 S Chester Ave r Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME ~ FACILITY ADDRESS /n ~ ~ r ~ y`~l ~ t~tm ~ ill lC(,,, DESCRIBE THE F{RE(Q^U~E^N~CY~OlF PER1FORMING THE MONITORING: TANK .1~ ~`y.+~ l ` ~^ ~ O O ~ t'7~Ul~lZ S PIPING WHAT METHODSI AND EOUIPMENi, ~ID7E^NTIFIED BYf` NAME AND MODEL. WILL BE USED FOR PERFORMING THE MONITORING: TANK ^I,U1.000~ S ~ ~ ` ©I~~ PIPING ICY ~ _©~ ~C] G ©CJl J DESCRIBE THE LOCCATION(S) WHERE THE M`ONIIT/ORING WILL BE PERFORMED (FACILITY PLOT PLAN SHOULD BE ATTACHED): ~ ,h ~ 1 . 1 ~~ LIST THE NAME(S) AND TITLE(S) OF THE PEOPLE RESPONSIBLE FOR PERFORMING THE MONITORING AND/OR MAINTAINING THE EQUIPMENT: NAME TITLE ~'~~i~oYr ~~ ~~ REPORTING FOR/MA'T,^FOR MONITORING: TANK _~y,. ,LpY'YA, PIPING (" l~llf DESCRIBE THE PREVENTIVE MAINTENANCE SCHEDULE FOR THE MONITORING EQUIPMENT. NOTE: MAINTENANCE MUST BE IN ACCORDANCE VYITH THE MANUFACTURER'S MAINTENANCE SCHEDULE BUT NOT LESS THAN EVERY 12 MONTHS. ~ ~ ~ ~~~ )TJ-C..~ v ~~ OV~u.- t.` ~ C-fAU c e ~, ~ tdc~.c'~S DESCRIBE THE TRAINING NECESSARY FOR THE OPERATION OF UST SYSTEM, INCLUDING PIPING. AND THE MONITORING EQUIPMENT: ttAAww L` Yr~ s~e~s ~. UNDERGROUND STORAGE TANK MONITORING PROGRAM EMERGENCY RESPONSE PLAN (FORM) Page ~ of 1' B E R 5 F! D ~lRl ARtlll f BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661)326-3979 Fax.: (661) 852-2171 This monitoring program must be kepi at the UST location at al times. The information on this monitoring program are conditions of the operating permit. The permit holder must notify the Office of Prevention 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. FACILITY NAME a r ~ A ' _~ Q.{11, , h 1 CJVO r ~ CDC FACILITY ADDRESS Q ~y C~V 1 ~. IF AN UNAUTHORIZED RELEASE OCCURS, HOW WILL THE HAZARDOUS SUBSTANCE BE CLEANED UP? NOTE: IF RELEASED HAZARDOUS SUBSTANCES REACH THE ENVIRONMENT, INCREASE THE FIRE OR EXPLOSION HAZARD, ARE NOT CLEANED UP FROM THE SECONDARY CONTAINMENT W (THIN 8 HOURS, OR DET RIORATE T}~ ~~ tC~C ~ ~ 11 ~ ~ SECONDARY CONTAINMENT, THEN THE OFFICE OF PREVENTION SERVICES MUST BE NOTIFIED WITHIN 24 HOURS. 0 r e',A 7 ~71 a~ aG~so<G,~~t u~~ ~ f ( ~ P ~ ~ ~ r c~~ , o c Up~ c.a.~t ~ ~~~~~c . ~[Jui s~ ~ h V\I~~Lc ~c~~~.~ w ~( ~~ tt. DESCRIBE THE PROPOSED METHODS AND EQUIPMENT TO 8E USED FOR REMOVING AND PROPERLY DISPOSING OF ANY HAZARDOUS SUBSTANCE. \C ~ ~ ~ ` r o~ c~~So~~l, DESCRIBE THE LOCATION AND AVAILABILITY OF THE REQUIRED CLEANUP EQUIPMENT IN ITEM ABOVE. '~ C V L 11 Q ~ P 9 „ aCI` ~~ ~ ~~ .~` Q[ W l ~~~A~r DESCRIBE THE MAINTENANCE SCHEDULE FOR THE CLEANUP EQUIPMENT: C-e~Ctt.l,d ~K~ l~/ U LIST THE NAME(S) AND TITLE(S) OF THE PERSON(S) RESPONSIBLE FOR AUTHORIZING ANY WORK NECESSARY ND ER THE RESPONSE PLAN: NAME ~~~ ` O ~~ TITLE ~~ I' !~ NAME ~~ TITLE NAME - _ TITLE NAME --^ ~- TITLE --------- NAME TITLE FD2074b (Rev. 02/05) State of California For Stato Use Only State of Water Resources Contra{ 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 I8, Div. 3, Title 23, CCR: ^ 500,000 dollars per occtttrence ^ I million dollars annual aggregate or AND or million dollars er occurrence ^ 2 million dollars annual a re ate gg p g B. hereby certifies that it is in compliance with the requimments of Section 2807, (Name OI Tank Owner a Operator) Article 3, Chapter 18, Division 3, Title 23, California Code of Regulations. The mechanisms used to demonstrate Cnancial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective Third Party T e Name and Address of Issuer Number Amount Period Action Com jcl~ ~~~~ S~~` ~ ~tl(~oi~ ~S eot~ ~„t,s vttk. ®~~ ~3 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 N~me Faality Address sf~/7S ~-I Q~OJ~ ~ ~~ s Fatality Name Facility Address Facility Name Facility Address E. Signature of Tank Owner or Operator Dale Name and Title of Tank Owner or Operator ~~ ~~~ .~~1~~~~/ //t~~7'~ Q~~y Signature of Wi ass or Notary Date Name of Witness or Notary CFR(Revised 04/95) FILE: Original -Local Agency Coplcs - Faclllty/Slte(s) e D F/RE ARTM f RONALD J. FRAZE FIRE CHIEF Gary Hutton, Senior Deputy Chief Administration 326-3650 Deputy Chief Dean Clason Operations/Training 326-3652 Deputy Chief Kirk Blaix Fire Safety/Prevention Services 326-3653 2101 "H" Street Bakersfield, CA 93301 OFFICE: (661) 326-3941 FAX: (661) 852-2170 RALPH E. HUEY, DIRECTOR PREVENTION SERVICES flRE SAFETYSERVICES • 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, III Hazardous Materials Specialist 326-3649 April 10, 2006 Mr. Rawel Singh Brother's Market 801 E. California Avenue Bakersfield, CA 93304 REMINDER NOTICE Re: Guidelines for Unsupervised Dispensing Dear Mr. Singh: It has come to our attention that many convenience stores who sell gasoline, like yourselves, are cbsing late at night. If you are using card readers and leaving your fuel pumps on, this is defined in the California Fire Gode as: "Unsupervised Dispensing." Unsupervised dispensing is allowed when the owner or operator provides, and is accountable for daily site visits, regular equipment inspection and maintenance, including any unauthorized release or spills, posted instructions for safe operation of dispensing equipment, and posted telephone numbers for the owner or operator. Signs prohibiting smoking, prohibiting dispensing into unapproved containers and requiring vehicle engines to be stopped during fueling shall be conspicuously posted within site of each dispenser. In addition, a sign shall be posted in a conspicuous location reading: Incase of spill or release: 1) Use Emergency Pump shut-off 2) Report the accident 3) Fire Department Telephone 4) Facility address During the hours of operation, stations having unsupervised dispensing shall be provided with a fire alarm transmitting device. A telephone not requiring a coin to operate is acceptable.. The fuel leak detection system must have a remote or phone modem to insure off-site monitoring during hours of unsupervised dispensing. During hours of darkness, sufficient lighting must be maintained so that all signs associated with fueling operation are conspicuous and readable. A gallon container of an absorbent material used for spills must be made available to the public during hours of unsupervised dispensing. Afire extinguisher with a minimum 2A, 26, and 2C rating must be located on dispenser island during hours of unsupervised dispensing: ~~ To: Mailing List of Valued Customers Reminder Notice Re: Guidance for Unsupervised Dispensing April 10, 2006 Page 2 of 72 To: Mailing List of Valued Customers Reminder Notice Re: Guidance for Unsupervised Dispensing April 10, 2006 Page 2 if you are currently having hours of unsupervised dispensing, you must comply with the above-mentioned requirements. Starting April 15, 2006, this office will conduct rahdom checks of all fueling stations within the city limits for compliance. If you shut your station down after normal business hours and are not pumping fuel, please disregard this reminder notice. Should you have any questions, please feel free to call me at 661-326-3190. Sincerely, Ralph E. Huey, Director of Prevention Services n By: Steve Underwood, Fire Prevention Officer REH/db l ,~UGIID, RGROUND STORAGE TANK I " r~ 8 H R 9 P 1 D PERMIT APPLICATION TO p~Re CONSTRUCT /MODIFY / MINOR ~~ t ~ MODIFICATION OF AN UST PERMIT NO. I l! l~ V --. Q TYPE OF APPLICATION: (Check one item only) ^ NEW FACILITY ~~r IunnlFlrorlnN nF Foru Irv Bakersfield Fire Dept. Environmental Service 9001Yuxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel: (661)326-3979 Fax: (661) 852-2171 Page 1 of 1 ^ NEW TANK INSTALLATION AT EXISTING FACILITY n MINnR MnnIFIC4T1nN nF FACILITY ARTING DATE ~ ~ OPOSED COMPLETION DATE i S AGILITY NAME s L ~ cau0~2 U~ STING FACILITY PERMR NO. AGILITY ADDRESS G• ~,'~. ~v~' nY ~t~.~~ IP CODE 933x9 ~J OAF BUSINESS y~ ~t / ~ # ANK OWNER ~ ~ d Gr HQNE NO ^~~ ~PZ Y '' ~ ~ ~ ~G~ F- Y~ 1~ ~Si~i 9~ir~s0 ~ OR . NST. rN c, LICENSE NO. ?9z 4 CC NO. DRE ~~,,// ~~__ ~~ -JQ ~lL plc /~N~" nY ~.~~G~~ iP DE ~~~0~ HONE NO. RSFIELD CITY BUSINESS LICENSE NO. ~~- 023 g4 ORKMANS COMP NO. ~~~ t o NSURER ~ ~ BRIEFLY DESCRIBE THE WORK TO DO ~' vE t.~~ C~AMo i ~S~~Cs ~p ~/~ ~ i~ WATER TO FACILffY PROVIDED BY DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE ~ Ei4 ~./41/t~~~... NO.OF TAN TO BE INSTALLED ARE THEY FOR MOTOR FUEL OYES ^ NO SPILL PREVENTION CONTROL AND COUNTER MEASURES PLAN ON FILE ^ YES ^ NO T411S RFCTI(11J IS F(1R Ml1Tf1R FI IFI TANK NO. OLUME NLEADED GULAR IUM IESEL VIATION -. -- 2 K- ~ 'HIS SECTION IS FOR NON MOTOR FUEL STORAGE TANKS TANK NO. OI.UME NLEADED GULAR REMIUM tESEL VIATION Y The applicant luu received, understands, and wiU comply with the attached conditions of the permit and any other state, local and federal regulations. ?his form luu been completed under penalty of perjury, and to the best of my jcnowledge, is true and correct. APPROVED BY: APPLICANT NAM (PRINT) APPLICANT SIGNATURE THIS APPLICATION BECOMES A PERMIT WHEN APPROVED ~ 0 n w _ _ = °Ri~htFax _. - : _ 6'/I'5/2UOE 9:28 _ PAGE w1l 3vZ fax Server _ i ~, ~ .. ~ BAKER.SFIELD FIRE UEp'I'. i3aLLif11G & REt2NtC~' ~~~1'~A~EI~T' ~ s ~ ~~_ m ~~~~~~~ ~~~ -.~.--~-'- KY~. X13 Tt~rci~;ix'1 ~v~ertuG, Su1ix X10 P~~1V~I'f Id0 '~` ~ H8~eTBfiCi~, G°A X33` Ot 2c~,: 661,E 3~~r-3979 0 Fai"t:.(161-;':1352,2171 `~,~eF ~~/~r- ~~ Rte- _ ~ S7kRtINO M7Q ~/J .~~ PFIOJECTAOGR6S6 , CtiY ~. S'r 'iE ZIE'~~ - ~rnacrosw-u~ ~IS~~ , °~7 ~q ~5 ~U Q~ - ~2~ TRA,CT9RC011fFAtVY MAhtE _ ~ RAX{'{4. g~Y' r ~ ~~ /~ Q A4an~s • +~ c~ ~~ ~ ,~ ~. 88 ~ Ower:~d~d` Sq ~ , S~. f~ ~c :dY13726'= ~ 6~ 84 __.. - 5pror&k~sss - lfd ~ ~ ffi~ - ~ ~ 9~ ~ar:5;laflii Sag FS Sq. F~ x .pd~= JPsrart3~ 84 ~ ~ W 98 ~ RAi~or Sprla+kl~r t9o~ ~< 1 p ) ~ [! ~ ' ~ a4 , a8 Commerc~t-Hoods -New & Maiifications ~ 39526 ~ ~ 98 CI sld+t~-t~vnalffooaCa $ 9~EAG ~ , 98 ' ` ' 84 L Spray 8oc~ - ~^or Pa IWu~I tI~aYTiars 5~~5~ ss ~ Above round ~torepe Tanks {lnstef~as~€nsp~-4~ T~e~ ~'G6~. 82 D Addr+r~ra~9 Ta~frs $ ~.~0 82 o Abo9~ttd St~ia~ ~' ~ ~~ S~~:pYD 82 O Underground Stcc~}eTan~CS {hssietla#tc~.ilrrsps+,'~t~e~ - _ ___ - ~B7fs.i1Q (;~er~ 82 ilndsrgraund 5~reas Tanks ) ~878A0 ~r,~eJ 8~ [] Undarg~esrrd~~e7a ~ ~~ e2 Q Underground Storage Tanks (Reino~t~ ,$675.OU (per 84 L7 OuweJJ pnsrattat~.vey 6.72:€IfY &F O _ tl9andS~ L~1t ~ 1 ~ 51.E J ~ I ___ p Tents $ 93:(lA ~aert~t~ 84 '~ o After ~tvu~a lrrspec~a fee 317~x.0a a4 fl Pyno -~~ ~$~~.-~~ =~ ~ D RE-lM5PEG370M{S} /Fd?L:LOki/-UP 1AtS~'LCT1A~f~ $: B3.p0I tPer Eeour) - a4 _. q Portt~ble €:RC; (^roga€-~~ !4~€3. D~ CA.~S~S~~ $ 6S.kIE3 84 . ^ t.~tpfasive S,ge ~2~~~ 84 i7 Co~yfig 8~ Fie. ResearcPi ~i Reseatcn'Fee :OD per 4r~} ~5+~ 'PaT Psi 84 _ ~ Misce~aneous _ 84 ~• i GLLv tc , .. '.f, ;: 5~~~~3~~''~YSTENi C~RT~F1~A'I'IUN FC~R1Vi ;} _ '~`~ ~ DATA o S S • f~ ' ,x FACIIC.I~` m l,l`~Quc~- r~~ , F~C`Ii.ITx ADDS ~x~~ii ~~ensia ~,~~E $a ~,.; s~,;~: `' €JST Arrnular Spsz~ .~, . • ~: ~~k ~`erik '1 ~~~ `T~,n~C 2 ~ Taa~k 3 ~ 'Wank 4 i,; S ~ ,~ ~ t8~ 'Time ~ .. .~ .~V ~~''' ~ r'=, ~~~... '~ Iyuti~i Pressure ~ :O . ~` .. d O `~ ~ ~nd: Time (~~ i : ~ © ) : ~ ~~ ~- i~~ arc ~ ,' , !~ o ; 44. ~ertifYcat€on ~., x'` ~~~;' ;.~ : ,., a;~ ; _ `~ ^`; S~ntigry Piping ~" ,~..., ;fir ~ . ~~. rs . ~ ~ ~ = ~~.itte~ ~! ~. ~:'lL;ine~ 2 ~~ Line 3 ~ ~ :. ;~.#ne .4 } ~:. ,~ Si~~c T-eme ~, S :.SZ>~~. l : SSA „~~;;~ ~, ~F`: ~eiit~si Pere • ~ ~ . "~ rf~ Egtd 9Ctme ~ '~ ~ ~'~' . ~,. ri . • ~ y ~ ~ Fi~~ Ptessure ~. ~ t ~ a ~f ~.r~a ii~Y~Vil ~' ~1 ~ ~ Ii ~~ti : . ~t,{ ;~, ~.> ' ~*' - ~ . p`. ~~'' ~ ~' .. ~ ~ ~ ~ ' Aiz , rj. i 1~ ~ ~~ • ~ ... _1~ f~} - 5 7 ~ ~ / F\ 1:^• a~'l~ ~ -' r SE~UI~t~'~ ~~STEM CIERTIFiCATI~Ibi ~'Q}RM ~~... k . MATE ! U ~~~ ~ ~~; ~ f .r G ~. t" T11Y'i~lAe ~ilsel~}S ' ~a~ si~eep; ~ seeea~p a Sump ~ ~ i • f.. ~_ ~ ~ ~~rr T~:~e : ~~ ~ ~ ; ~ ,~ a: ~.: , :. ]C~tia1 ~#etght ~ . ''=" -~. .,: . ~f Water ~ • $ ~~ i n~ ` ~~- ~~~~~ : ; - T~~~ a o o . . , tr ~ater~~~g~t ~ ~ ~. a_ ~.:~ ,~~~,. Time '~ r =, ~ - Water ~ieight ,l 0 -~l'©~1.~ :•~ ~~t '~`~~~ „j '~ieaee ~Q -~ ,. , r. '- !~Yater height 0 D >.-i 4~~ ~~~ s~\~ ~CLRLI~M~~ ~~ /~ ~;~=j ~~;:.. t~~~'e~ t < y; ,: ~~: ~. ~: ':~: avee~i! seeekets a .,~ ~~~;~~ . ;~ ~. . . . ~;.::: .~. - t tl ~;: ::. ; .. c~+ert~li a arerfiil 3 ~ ,,:.. >~~~ ~ . 'Mart Tree Q h ,<< ~. , ~ , teeitial i<Ielght Yr:: . ~ ~ bf Water DS~,.~ ,.. I. r : ~+ f," 'fiime ss'' ~~;; . ~' ~ ~ ,• Yater ~ieight , , ~ ...i i r ~ ~ ~` ~~:~~, Time .'/G' ~ ~ ~ `~ ~~~ °~~.: ~ . 'Water HE~i t ~ ` . ~ i../ U (r.J ~. "( Certlfica~tio~t ~ t,- . ~' :, - . ;~;~~ P8 C 2 of aaP~~.. ~, r ~"` Snap a ~-~ ~ A I >~ . S]~CD~E}A1t'~: ~~'~"1l"EM CERTiFICA"~'I~l~t F~-~tM ' '' DATE ~ ~=' ~ l ~ ~ 6 ~J + FA~ILiTY TD ) ~ , r ~, ~ l,L ~ ~~ ~ ~ ~ , ~ ~~ ~ ~ f l- FACTLiTX ADIDRFSR " ~, f y-. - ~t.. v' ~ -~~ ``-. :; IJDC TES'T`ING D~SF'E~I~?1~ ~ .~ISPENSEFt Z DISp`Ei~ISEIt. 3 I?L~~'ENSER 4 START TIME ~ ~~ y-!j" : -: / ; = .,' p 114i~TIAL ~I~I~tT OF WATER ~ F.-f . OJ . ~ ~ ,-- ~ „~ ~'~~ ~ ' WATER TIME ~;~? ; ~ ~~~ ~~ ~'VATER GAT ~ ~ ~ (; ~ ©13:,x ~ -9S"7, ~ ~/SS~ ,. , , CERTi~'ICAT~fldV t~~~i~5 5 ~, ~ . ~;:: ,~ ~, ~~.;" ~ '~~; DI~~ D~$PENSER 6 YIISPE1+15ER ? DYSPEi~iSER 8 ~:~~: ~~? ~: ~~: - : . START TIME O ~; ; . i;~- ;; .. . ~~~~~ INITIAI, ~ ~;~, . ~IEIGIiT GF ~,'°=`,. WATER ~~.,, , A, , TIME ~ ~7 ~ . ?~F4:: WATER ~ '. I~~ 1 ~~ ` ~~~~: ~1VATER k~j~~ ; _ N ~ ~ ~$EIGHT ' ~ ~ ~~~ i T i j ~'~' ~ CERTiFiCATLQt~ ,~"~' ~ `CSiGNATUREj ~SS~" r ~a: ~, :~ ;. Page 3 Af , ;fi;:. ~t:~,:.. ~rru,,i': L~1. r ~ v - ~- "9j ~ l ` 10/18f2005 13:27 6613920621 PAGE 01/02 i , UNDE}~GROUND ST{3RAG~ TaiJKS ~3,AKERSFIEL,D FIFt~ D~P7`. ~ ~- -~.~~ ..~' Preven~~oz~ Sex~vlces ' i ,r4 /t AI f Inlxt~ln /~~•c'., 5tr. 2It1 'lIJC1 ~,~~L~~'~~~~~ i ;:,I~~•rtillc{cl, ('~l S1:S:SU f fOP~RFa M1~LD~LINSTESTINQ -f't.•{,' I(ifiij ;32Ei~;i~?7~1 ' S8989 S ONt?ARY Q`ONTAINMENT TESTING f ~`,~ ~; {t,if~ 1 } ii51 ~ L 1 ~ 1 TANK TiGNTNE$S TEST AND TO PERFORM FUEL , MONITORING cEFiTIFICAT10N Fu,F , ,, , PERMIT Na. .Y» Q ~~ 5 r-1 LINE TE571NG © ENHANCED I AK DI~ECTIC7N L J ~ SF? ~'r.2 SFC~7NUARY Cr~NTAIPIMENT tESTltd(a ~ r ~ I TANK 11GHTN SS TEST C~ TO PE,RFOHM Fl,1Et. A4(:NlTOR161[J CER'I!l~r:;~TKrrl ~ --- - -- ~- -- ---_ SITE 1NFORMA710N ,...__._._ .. ~..--T.--.~...-- -....-.... P ' ,~--...~-_-.. -_~.,,-._.. - FACILITY ~~~ T NAME },PHONE Nu61BEFi ~Jr CONTACT PERSON _._ _......- -- AOOREBS ~ ~"'-- - _ - '-' bWNERS NAME - ,.~_ - .,~.-.-ter,. __ _..-. _. _ ._...__-_..,,.-. ... .... PERATQp9 NAMfx J ~ f RMIT TO OPt=RA76 NU NUMBER OF TANKS Tp BE T~STED~IS r'IPINQ G~)Ir•IC~ TO BE TES7Fp'~ ~ D rdr,;r,~ 4 ~i~,.s,. Cl . TANK ~_..--- voLUME caNT~N75 `7°-~ -- __ .--,-r- - ._ _ .....-... .._.-___- ___._..__ _ _... . TANK T'ESTIN©GOMPANY NAM F TESTSNG co PANY _ NAM pl•roNE I~uhta P uF CONTACT PERSON ;.,.~a.:_a~_,~.~rcco,o~r. ..~ ~ .-~ 4~b1- ~,3~,I-~R93 ~JIAlL1N AOD ESS i ~AME PHONE NUMBEp dF TESTER OA $P {AL INSPEC7QR CERTIFICA'T'ION Ir: .DATE IME TEST TD RE CGNDUCTEQ ~ ~ `ICC f+:~-~ _- TES METHdO f .. ,.. -., SIGNATURE OF PLICANT DAT£ t a ° I ~, A~ --. ~_y,.._ _.. _ __~ .,- .. . _ tS A~p~,IGA:t"I.QN ~~GOIkt~S A PERMI ~'l~l~N A~'PFtQ~EG APPROVED 81' f ~DATC g/