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Home My WebLink AboutBUSINESS PLAN~/ ~:' ~~~~ ~~ ~~ ~.~ ~; ~i ~~ ~ ~ ~~ r i _ _, ~~ B ~~ BROOKSIDE MARKET AT THE OAKS .l ! 8803 CAMINO MEDIA Y. BROOKSIDE MARKET AT THE OAKS Manager DAN & VICKI THORPE Location: 8803 CAMINO MEDIA City BAKERSFIELD SiteID: 015-021-002197 BusPhone: (661) 654-0838 Map 123 CommHaz Moderate Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code:5541 DunnBrad:048479646 Emergency Contact / Title Emergency Contact / Title DAN & VIC KI THORPE / OWNERS DON JEFFRIES / OWNER Business Phone: (661) 654-0838x Business Phone: (661) 758-3072x 24-Hour Phone (661) 873-8297x 24-Hour Phone (661) 399-6712x Pager Phone (661) 706-6181x Pager Phone (661) 496-8359x Hazmat Hazards: Fire ImmHlth DelHlth Contact DON JEFFRIES Phone: (661) 758-3072x MailAddr: PO BOX 640 State: CA City WASCO Zip 93280 Owner JEFFRIES BROS INC Phone: (661) 758-3072x Address PO BOX 640 State: CA City WASCO Zip 93280 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG C - PROG U COMM HOOD UST ~~~~ ~ ~ f o A~! li., '9 2 ~~~ .!- - Based on my inquiry of those Individuals responsible for obtaining the in formation, I certify under penalty of law that I have personally examined and am familiar with the information submitted and b 'eve the in formation is true, urate, and c lete. ~ - 1~/7T~~J s 1 ~/ ~ ~~ D t Signature e a -1- 07/10/2007 5: F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ - STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: BROOKSIDE MARKET AT THE OAKS Cross Street Business Type: GAS STATION Org Type: CORPORATION Total Tanks 3 IndnRes/Trust: No PA Contact: Dsg Own/Oper RONALD ROGERS ICC Nbr: 5246218-UC PROPERTY OWNER INFORMATION Name DON JEFFRIES Phone: (661) 758-3072x Address: City Type CORPORATION State: Zip: TANK OWNER INFORMATION Name DON JEFFRIES Phone: (661) 758-3072x Address: City State: Zip: Type CORPORATION BOE UST Fee# 006130 Financ'1 Resp: INSURANCE Legal Notif Date:02/09/2001 Phone: (152) 6 - x Name:DON JEFFRIES Ttl:PRESIDENT State UST # TYMT 44-040810 1998 Upg Cert#: 00877 -2- 07/10/2007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP REGULAR UNLEADED GASOLINE F IH DH L 20000.00 GAL Mod PREMIUM UNLEADED GASOLINE F IH DH L 12000.00 GAL Mod DIESEL #2 F IH DH L 8000.00 GAL Low -3- 07/10/2007 -4- 07/10/2007 c ' F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME REGULAR UNLEADED GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 8006-61-9 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TMixtur~mbient ~ Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 20000.00 GAL 20000.00 GAL 20000.00 GAL n1iGKLCLVU.7 ~.v1~~rvlvaiviS gWt, RS CAS# 100.00 Gasoline No 8006619 I1HGL~iiCL HJ J~.7J1.1P~1V1J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Mod ~ Inventory Item 0002 COMMON NAME / CHEMICAL NAME PREMIUM UNLEADED GASOLINE Location within this Facility Unit Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8006-61-9 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid Mixture Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 12000.00 GAL 12000.00 GAL 12000.00 GAL tiHGbiKLVUJ 1:V1~lYV1V~1V7J oWt. RS CAS# 100.00 Gasoline No 8006619 ru~~tilcL ~laal,~aril;lvl5 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Mod -5- 07/10/2007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME DIESEL #2 Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 68476-34-6 STATE TYPE PRESSURE TEMPERATURE ~~ CONTAINER TYPE Liquid TMixture ~mbient ~ Ambient I UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 8000.00 GAL 8000.00 GAL 8000.00 GAL HAZARD OUS COMPONENTS oWt. RS CAS# 100.00 Diesel Fuel No. 2 No 68476302 L1tiLitiiCL Li. 7 AP~J.71`71S1V 1 ~7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low -6- 07/10/2007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 02/26/2001 ~ TLS 350 VEEDERROOT, CONTINUOUS MONITORING. Employee Notif./Evacuation 07/26/2006 ANY RELEASE OVER ONE GALLON: NOTIFICATION OF BAKERSFIELD FIRE DEPT, OFFICE OF ENVIRONMENTAL SERVICES, OR 911. Public Notif./Evacuation 05/26/2006 SMALL SPILLS, ABSORBENT KITTY LITTER; LARGER, CALL 911. Emergency Medical Plan 05/26/2006 EMPLOYEES WILL BE SENT TO THE NEAREST HOSPITAL. FIRST AID KIT, ZEE MEDICAL. -7- 07/10/2007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 05/26/2006 ~ ALL EMPLOYEES ARE TRAINED IN SAFE PREPRATION, EMC BUTTONS, FIRE EXTINGUISHER. Release Containment 05/26/2006 SMALL SPILLS, KITTY LITTER, AND PROPER DISPOSAL OF USED ABSORBENT. V 1 GGL11 VtJ Other Resource Activation 05/26/2006 KITTY LITTER USED AS ABSORBENT. -8- 07/10/2007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ .~L/c~.iai naaatu~ V1.1111.y .7111,11.-V11.7- Fire Protec./Avail. Water 07/26/2006 FIRE HYDRANT: N & E OF BLDG Building Occupancy Level 04/04/2006 25 EMPLOYEES -9- 07/10/2007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 05/26/2006 ~ MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: ALL EMPLOYEES HAVE BEEN TRAINED IN EMERGENCY PROCEDURES, MSDS SHEETS, AND MEDICAL NEEDS. rayv ~ nciu tvi r ul.UlC U.5'C nc.LU ivi rul.uiC UDC -10- 07/10/2007 • ~ ~. BROOKSIDE MARKET AT THE OAKS. Manager DAN & VICKI THORPE Location: 8803 CAMINO MEDIA City BAKERSFIELD SiteID: 015-021-002197 BusPhone: (661) 654-0838 Map 123 CommHaz Moderate Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code:5541 DunnBrad:048479646 Emergency Contact / Title ~ Emergency Contact / Title DAN & VICKI THORPE / OWNERS DON JEFFRIES / OWNER Business Phone: (661) 654-0838x Business Phone: (661) 758-3072x 24-Hour Phone (661).873-8297x. 24-Hour Phone (661) 399-6712x Pager Phone (661) 706-6181x Pager Phone (661) 496-8359x .............. Hazmat Hazards: Fire ImmHlth DelHltli ............... Contact DON JEFFRIES Phone: (661) 758-3072x MailAddr: PO BOX 640 State: CA City WASCO Zip 93280 ................ Owner JEFFRIES BROS INC Phone: (661) 758-3072x Address PO BOX 640' State: CA City WASCO Zip 93280 .............. Period to TotalASTs: = Coal Preparers TotalUSTs: = Qal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD PROG U - UST Based on my inquiry of those indivtda<oi;~ ENTD F E B 2 2 2007 responsible for obtaining the information, l certify under penalty of law that I have personally examined and am familiar with the information submitted and elieve the information is true, accurat , a mplete. _ f 9~l c° /- e Date -1- O1/26/~d07 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-00219'7 ~ STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: BROOKSIDE MARKET AT THE OAKS Cross Street Business Type: GAS STATION Org Type: CORPORATION Total Tanks 3 IndnRes/Trust: No PA Contact: Dsg Own/Oper RONALD ROGERS ICC Nbr: 5246218-UC PROPERTY OWNER INFORMATION Name DON JEFFRIES Phone: (661) 758-3072x Address: City Type CORPORATION Name DON JEFFRIES Address: City Type CORPORATION State: Zip: TANK OWNER INFORMATION Phone: (661) 758-3072x State: Zip: BOE UST Fee# 006130 Financ'1 Resp: INSURANCE Legal Notif Date:02/09/2001 Phone: (152) 6 - x Name:DON JEFFRIES Tt1:PRESIDENT State UST # TYMT 44-040810 1998 Upg Cert#: 00877 -2- O1/26/Z007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-00215'7 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Sites ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit NIP ............. REGULAR UNLEADED GASOLINE ~ F IH DH L 20000.00 GAL MOd PREMIUM UNLEADED GASOLINE F IH DH L 12000.00 GAL Mr~d DIESEL #2 F IH DH L 8000.00 GAL Lew -3- O1/26/Z007 -4- O1/26/Z007 F BROOKSIDE MARKET AT THE OAKS ~ Inventory Item 0001 COMMON NAME / CHEMICAL NAME REGULAR UNLEADED GASOLINE Location within this Facility Unit STATE - TYPE PRESSURE Liquid Mixture~Ambient SiteID: 015-021-002197 ~ Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8006-61-9 TEMPERATURE CONTAINER TYPE Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 20000.00 GAL 20000.00 GAL 20000.00 GAL tiAGHKLVUJ w1~1rV1vL"lv1J oWt. RS CAS# 100.00 Gasoline No 8006519 t1F~GHKL H551";~~P/11;1V 1"~J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCA No No No No/ Curies F IH DH / / / Mot3 ~ Inventory Item 0002 COMMON NAME/ CHEMICAL NAME PREMIUM UNLEADED GASOLINE Location within this Facility Unit STATE TYPE PRESSURE Liquid TMixtur~mbient Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8006-61-9 TEMPERATURE CONTAINER TYPE Ambient ~ UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 12000.00 GAL 12000.00 GAL 12000.00 GAL riAGLittLVU.7 LVl~lrV1VI;1V7.7 %Wt. RS CAS# 100.00 Gasoline No 8006519 t1HGE~tCL E~JJL"iJ51~11",1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MRCP, No No No No/ Curies F IH DH / / / Mi7t1 -5- O1/26/~007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-00219'7 ~ ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME DIESEL #2 Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 68476-34-6 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TMixture ~mbient ~ Ambient ~ UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container- Daily Maximum Daily Average - 8000.00 GAL 8000.00 GAL 8000.00 GAL - nric~rucLUU~ ~.t~i~lrulv~lvlJ °sWt. RS CAS# 100.00 Diesel Fuel No. 2 No 684763b2 I1tiGtiCtL H~ J~7L.~7J1~1r,1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MRCP No No No No/ Curies F IH DH / / / Low -6- O1/26/~007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-00219'7 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 02/26/2001 ~ TLS 350 VEEDERROOT, CONTINUOUS MONITORING. Employee Notif./Evacuation 07/26/2006 ANY RELEASE OVER ONE GALLON: NOTIFICATION OF BAKERSFIELD FIRE DEPT, OFFICE OF ENVIRONMENTAL SERVICES, OR 911. Public Notif./Evacuation 05/26/2006 SMALL SPILLS, ABSORBENT KITTY LITTER; LARGER, CALL 911. Emergency Medical Plan 05/26/2006 EMPLOYEES WILL BE SENT TO THE NEAREST HOSPITAL. FIRST AID KIT, ZEE MEDICAL: -7- Ol/26/~007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 05/26/20175 ~ ALL EMPLOYEES ARE TRAINED IN SAFE PREPRATION, EMC BUTTONS, FIRE EXTINGUISHER. Release Containment 05/26/20(75 SMALL SPILLS, KITTY LITTER, AND PROPER DISPOSAL OF USED ABSORBENT. lrlecln up Other Resource Activation 05/26/20(75 KITTY LITTER USED AS ABSORBENT. -8- Ol/26/~(70.7 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-00217 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~7jlC l.L1a1 ncl~aiu~ V1.1111.y ~711UL-V11~7 J Fire Protec./Avail. Water 07/26/2005 FIRE HYDRANT: N & E OF BLDG Building Occupancy Level 04/04/2005 25 EMPLOYEES -9- Ol/26/~007 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Fast Forme ~ ~ Training Overall Site ~ ~ Employee Training 05/26/20175 ~ MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: ALL EMPLOYEES HAVE BEEN TRAINED IN EMERGENCY PROCEDURES, MSDS SHEETS, AND MEDICAL NEEDS. rage Held for Future Use neiu iui ru~uie use -10- 01/26/2007 UNIFIED PROGRAM INSPECTiOIV CHECKLIST;` .SECTION 1: Business Plan and Inventory Program BAKERSFIELD FIRE DLPT Prevention Services EItI 900 Truxtun Ave., Suite 210 sRrr Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILI Y NAME NSPE TfON D TE INSPECTION TIME ~ ~. ADDR S ~- H ON NO. O OF EMPLOYEES pp ~~ FACILITY CONTACT USINESS ID NUMBER 15-021- Section 1: Business Plan and Inventory Program ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V (~=Compliances OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND m/ ^ BUSIf1eSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS , ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ~ ^ VERIFICATION OF LOCATION ^ ^ PROPER SEGREGATION OF MATERIAL VERIFICATION OF MSDS AVAILABILITY ^ VERIFICATION OF HAZ MAT TRAINING PR ^ VERIFICATION OF ABATEMENT SUPPLIES AND CEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION $S ^ SITE DIAGRAM ADEQUATE a ON HAND ANY HAZARDOUS WASTE ON SITES ^ YES EXPLAIN: - _~ IQNS REG D G THIS INSPECTION? PLEASE CALL US AT (881) 928-3979 ~/ ~/7 ////(/ _ --~ ~/1/K/~.~Fl ~ ../rl /C/_/ (Please Print) Fire Prevention / t°' In / Shrft of Site/Station k+ Business Site/School Site Responsible F White -Prevention Services Yellow - Station Copy Pink - Buaineas Copy FD2t>49 (Rev. OZIt15) :h. ~;,r. i~'4~t '"~ ~~ CITY OF BAKERSFIELD FIRE DEPARTMENT ~6 ~ b~ OFFICE OF ENVIRONMENTAL SERVIC:ES ~' ; '~~~~ ~ UNIFIED PROGRAM INSPECTION CHECKLIST Aw ~Rti,,!'~ 1715 Chester Ave., 3r`' Floor, Bakersfield, CA 93301 FACILITYrNAME~s ta~L A~~`(- (NSPECTION DATE Q~~7/~ Section 2: Underground Storage Tanks Program ^ Routine ~ombined ^ Joint Agency ^MultI-Agency ~ ^ Complaint ^ Re-inspection '-~ Type of Tank ~1fa)~g Number of Tanks Type of Monitoring I° ~ /fin Type of Piping ~.~~ OPERATION C V COMMENTS Proper tank data on tjle Proper owner/operator data on tale Permit.fees current Certification of Financial Responsibility f Monitoring record adequate and current Maintenance records adequate and_current Failure to correct prior UST violations ~. Has there been an unauthorized release? Yes NO l ,~ „1 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 witfi`OES Adequate secondary protection ' Proper tank placarding/labeling (s tank used to dispense MVF? If yes, Does tank have overtilUoverspill protection'? C=Compliance ~ '~ V=Violation Y=Yes N=NO ,,,." Inspector: , Office of Environmental Services (661) 326-3979 Whitc- 1'nv. Svcs. Business Site Responsib Party Pink -Business Copy + BROOKSIDE MARKET AT THE OAKS ________________________ SiteID: 015-021-002197 + Manager DAN & VICKI THORPE Location: 8803 CAMINO MEDIA City BAKERSFIELD BusPhone; (661) 654-0838 Map 123 CommHaz Moderate Grid: OSD FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code:5541 DunnBrad:048479646 Emergency Contact / Title Emergency Contact / Title DAN & VICKI THORPE /.OWNER DON JEFFRIES / OWNER Business Phone: (661) 654-0838x Business Phone:" "(661) 758-3072x 24-Hour Phone (661) 873-8297x 24-Hour Phone (661) 399-6712x Pager Phone (661) 706-6181x Pager Phone (661) 496-8359x Hazmat Hazards: Fire ImmHlth DelHlth Contact DON JEFFRIES Phone: (661) 758-3072x MailAddr: PO BOX 640 State: CA City : WASCO Zip 93280 Owner JEFFRIES BROS INC Phone: (661) 758-3072x Address PO BOX 640 State: CA City WASCO Zip 932$0 Period to Preparers Certif~d: ParcelNo: TotalASTs: - TotalUSTs: _ RSs: No Gal Gal Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD PROG U - UST '. eased on under ndividuats responsible for obtagning the information, i certi9~i penalty of law that I have examined and am familiar with the Info mna~iy acc anon submitted and believe the inform tion is true. nd complete signature ------_--_. ~~ Z~ m pa --~-_._._ ~/ o~ 55 ~~~ U~ E~ MA Y z 6 2006 -1- 04/04/2006 UNIFIED PROGRAM INSPECTION CHECKLIST=` &~+....,'..~?~?.=V .~R5kvY; ~4,.i. :..,.9P.ni <.+.F, '.a- -. ..~ .:~: .. w. .. ..,-, .. .SECTION 1: Business Plan and Inventory Program BAKERSFIE1f.D FIRE DEPT Prevention Services wlt~ 9001Yuxtun Ave., Suite 210 ~~~~ Bakersfield, CA 93301 Tel.: (661) 326-3979 - Fax: (661) 872-2171 FACILITY NAM NSPECTION DATE NS CTION TIME ~ ,_-• --~~ ~- Uo • ADDRESS H NE N O. O OF EMPLOYEES 8 f ~ / C ~ '1 ` / FACILITY CONTACT ~~~,~ g ~ ®t ~ ~ e~nn~+ USINESS ID NUM815~02~ ~ ~ I Section 1: Business Plan and Inventory Program UTINE MBINED ^ JOINT AGENCY ^ MULTI-AGENCY , ^ COMPLAINT ^ RE-INSPECTION C V (~-c«npl;an~) OPERATION V=Valation _____ COMMENTS ____ __ _ _ _ __ _ _ _ __ __ ~'-'^ APPROPRIATE PERMIT ON HAND _ ~_ ^ BUSInBSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ~. D VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ~~ ^ PROPER SEGREGATION OF MATERIAL ~- ^ VERIFICATION OF MSDS AVAILABILITY Q~ ~~ ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND R CEDURES ~^ EMERGENCY PROCEDURES ADEQUATE L~l. ^ CONTAINERS PROPERLY LABELED ~/ ~ ~ ^ HOUSEKEEPING ^ FIRE PROTECTION ~1~^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITET ^ YES NO EXPLAIN: _ __ QUESTIONS REGARDING THIS INSPECTION4 PLEA8E CALL U8 AT (881) 328-3979 l ,- t RAi»Bn ~'T~R2.4~-~ P ~ !~ CO Inspects (Please Print) Fire Prevention / 1" In / Shift of $ite/Stetion # Business Site/School Site Responsible Party (Pleaaeyy White - Prwention Sarvicea Yellow - Station Copy Pink - Business Copy FD2Q~9 (Rw.1PZ/0S) ~;~. - + BROOKSIDE MARKET AT THE OAKS ________________________ SiteID: 015-021-002197 + Manager DAN & VICKI THORPE Location: 8803 CAMINO MEDIA City BAKERSFIELD BusPhone: (661) 654-0838 Map 123 CommHaz Moderate Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code:5541 DunnBrad:048479646 Emergency Contact / Title Emergency Contact / Title DAN & VICKI THORPE / OWNER DON JEFFRIES / OWNER Business,Phone: (661) 654-0838x Business Phone: (661) 758-3072x 24-Hour Phone (661) 873-8297x 24-Hour Phone (661) 399-6712x Pager Phone (661) 706-6181x Pager Phone (661) 496-8359x Hazmat Hazards: Fire ImmHlth DelHlth Contact: DON JEFFRIES Phone: (661) 758-3072x MailAddr: PO BOX 640 State: CA City WASCO Zip 93280 Owner JEFFRIES BROS TNC Phone: (661) 758-3072x Address PO BOX 640 State: CA City WASCO Zip 93280 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif ~ d: RSs : No ParcelNo: Emergency Directives:~ ~~ ~~ PROG A - HAZMAT PROG C- COMM Hoop ~ ENT'D J U L 2 6 200 PROG U - UST Based on responsible for obta nin y °f those individuals under penalty of law9 the information, I cerfiiy examined and am familiaawith the nfo zonally submitted and believe the information is true, accurate at on n, and complete, ~~ ~ 6 Date ~~ ~ 5~`~"~ ~ ~j~p~ ~- -1- 04/04/2006 N.c.~.D ~ ~i~~' "~~~~ CITY OF BATZERSFTELD FIRE DEPAR'T'MENT ~~~~ ~ ~ M~ OFFICE OF ENVIRONI<~iENTAL SERVICES `~' y~`~ UNIFIED PROGRAM INSPECTION CHECKLIST \°w ~gti,,~'~~ 1715 Chester Ave., 3~`' Floor, Bakersfield,, CA 93301 ,.,~~ FACILITY NAME ~ S,,~4 r~~~f ~ INSPEC~'ION I)ATE~~O S~e^ct/ion 2: Underground Storage "Tanks Program ~" Routine 'C`ombined ^ Joint Agency ^Mufti-Agency ^ Complaint ^ Re-inspection iii/// Type of Tank d ~.1b1~ C.~AI( Number of Tanks ,, Type of Monitoring Type of Piping ~~Z.,~,all (,., ~: OPERATION C V COMMENTS Proper tank data on the Proper owner'operator data on the ~~~ 7 d~ ~~ Permit fees cun-ent ^Certification of Financial Responsibility ~~~ Monitoring record adequate and current ~z1,. q v? ? f!1 Maintenance records adequate and current ~ 7pGr,.t ~ ? p ~ Failure to correct prior UST violations Has there been an unauthorized release? Yes NU Section 3: Aboveground Storage Tanks Program TANK SIZE(S) Type of Tank AGGREGATE CAPAC[TY 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 overtill/overspill protection'? - C=Compliance V=Violation Y=Yes N=NO Inspector: ~ I~QI,-~A ~~ --~ Office of Environmental Services (661) 326-3979 Business Site Respon ~ e at'ty White - f-.nv. Svcs. Pink -Business Copy - r ~•. -~- .. - ,. Bkt:iC~}: ~ I L:~E f°1h F'I1:'T ~3>3U3 C'~;h9I f+JO - f"1EL? I H _ BH}'E!<'t~F I ELL? Cf; , y: ~3 0r _ •JhfV I I.}, 'QI Ir_ ~ 1 LI : 5u rif"1 Fk I P•JTEk Ek'kG~k -y II~J'~•:EhJTtik''' kEFtikT T I : ~ IPdLEHL:~ELi i '~Ji_iI_I_IP'1E = 14b4U i:_riLS yU``: ULL.Hi=~E= 34'33 ~i-iL:= Ti: r~_~LUP'lE = 1464'_ ~_i=iLh ~ HEIGHT = 8" . ?3 I fVi'HE~_ ' LJr-3TF.k = 0 . U~~ I PJi_ HE:_~ T ~' : P1=.'F1~'I I I_IP'J +rt?LIIf°lE _ `666 G~L~~ ~ ULLHGE = 4:`.'S GALE ' 90 ~ LILLr_";i E_ ,~ 1 ELI Grit ~- TC:-iSiLl_IP1E _ X665 i.;;;L~_ ' HEIi;H'I' _ ~?.54 IPdi~HE:=~ U,hTER ~'~'L = 1 7 GAL: I;JtiTEk = 1 . 1 ? I PJi='HE:. T := : Li 1 E:~F.L_ IJCiLUI°lE _ :.6111 NHL:=~ ' ULLiGF. = 441 .' i:;i-tL 'y U."•;. I_ILLriGE= 31.14 iyrL'.=~ 1 T~' tirr~L,UP9E = 3r:U9 i~HL:~ - HEIGHT = 50.'1 IP~J~HL:: 6JtiTEk `~r~'L = U GhL UJr~TEk = 0 . UO I P•J!.'HE ; ;~ TEf°iF' = 64.E DEG I' _ ~ ~: ~ *. EPJLi ~ ~ t.9 ~ ... UNIFIED PROGRAM INSPECTION CHECKLIST .SECTION 1: Business Plan and Inventory Program ~ ~ Tel.: (661) 326-3979 Fax: (661) 872-2171 FACIL Y NAME `/ ' ~I'(A/fl,'~ NSPE ION D TE INSPECTION TIME ADOR S e- HO NO. OOFEMPLOYEES 66 •- CI^Q a~ FACILITY CONTACT USINESS ID NUMBER ~~~ 15-021- Section 1: Business Plan and Inventory Program '- ~~~ ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V (C=Compliance OPERATION COMMENTS V=Violation ^ APPROPRIATE PERMIT ON HAND ~~~_;" _ $ [,®o~ . ^ BUSIf18SS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY O ^ VERIFICATION OF INVENTORY MATERIALS ~~ ^ VERIFICATION OF QUANTITIES ~l/" ~ ~ o VERIFICATION OF LOCATION 1 ~V C ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITY ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PRO EDURES ^ EMERGENCY PROCEDURES ADEQUATE _ ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING , ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND n j\ 1` ~ , ANY HAZARDOUS WASTE ON SITE? ^ YES O~IlP3 EXPLAIN: - _ --,.-- -~ D G THIS INSPECTION? PLEASE CALL US AT (661) 528-3979 Fire Prevention / 1" In /Shift of SNe/Stetion q Business White -Prevention Services Yellow - Station Copy Pink -Bus niV ss Copy BAKERSFIELD FIRE DEPT a Prevention Services ~~~~ 900 Truxtun Ave., Suite 210 wR*M t Bakersfield, CA 93301 ,., v i a,\ p ~I FD2048 (Rw.02/OS) i~~4~` ~~ ~ CITY OF I3AIKEItSFIEI.D FIRE DEPAR'I'1VIENT d .~ ~ b~; OFFICE ®F ENVIRON1t~IEN'1'AL SERVICES ;~ '~e~, UNIFIE® PR®CiiAM INSPECrI'ION CI-IF,CKLIST ;~ ow ~g~;,,,°~ 1715 Chester ~Ove., 3r`` Floor, Rakerstield, CA 93301 FACILITY NAME/ ~ ~~L~ INSPECTION DATE ~~ ~~ _ Section 2: Underground Storage Tanks Program ^ Routine ~ombined ^ Joint Agency ^Multi-Agency ~ ^ Complaint ^ Re-inspection Type of Tank ~~?~g Number of "tanks Type of Monitoring ~ py` Type of Piping ~~~ OPERATION C V COMMENTS Proper tank data on the Proper owner/operator data on the Permit tees current Certification o[' Financial Responsibility Monitoring record adequate and current Maintenance records adequate and current Failure to con•ect prior UST violations Has there been an unauthorized release? YeS No 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 [s tank used to dispense MVF? If yes, Does tank have overtill/overspill protection'? C=Compliance V=Violation Y=Yes N-NO Inspector: Office of Environmental Services (661) 326-3979 White - inv. Svcs. Pink -Business Ci~ry c Business Site Responsib Party SITE DIAGRAM [-~-- <~£ ffffe~£~/e~ · ~ ] . g~ ~FACILITY DIAGRAM [-~ ] BusinessName: ~.('O0~<o~& l~t~r ~ ~~ 0~5 Business Address: ~ ~ 3 6~.,~. :.~* (~C~¢~,~ ~t2~. c~ 32~1~ ite Plan http://www.brooksidemarket.com/Locations/At the Oaks/Site_Plan/body_site_plan. html CAMINO MEDIA LIBERTY PARK DRVffi BROOKSIDE MARKET AT THE OAK/~ SiteID: 015-021-002197 Manager : MATT JEFF~J~S __ BusPhone: (661) 654-0838 Location: 8803~C.~INO MEDIA Map : 123 CommHaz : Low City .'~RSFIELD Grid: 05D FacUnits: 1 AOV: CommCodg,:: BAKERSFIELD STATION 09 SIC Code:5541 EPA Numb: DunnBrad:048479646 ~~ / Title Emergency Contact / Title / STORE ~ACER DON JEFFRIES / OWNER Business P~fone: (661) 654-0838x ."Business Phone: (661) 758-3072x 24-Hour~hone : (661) 327-3615x ' 24-Hour Phone : (661) 399-6712x Pager/Fhone : (661) 496-7006xCELL Pager Phone : (661) 496-8359xCELL Hazmat H~cal~d-s: ~ 'Fire ImmHlth DelHlth Contact DON JEFFRIES Phone: (661) 758-3072x MailAddr! PO BOX 640 ~., ~ / State: CA city WASCO J ~~+~X/_~ zip : 9328O Owner JEFFRIES BROS INC Phone: (661) 758-3072x Address : PO BOX 640 i State: CA City : Zip : 93280 I ASCO Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: Res: No ParcelNo: Emergency Directives: J I~ ~/l~/,'l '~.~/~ ~o hereby ceit:ify that ~ have reviewed ~he ~a~ed h~ous materials manag~ ment plan ~or~~ ~;~and t~t i~ along with {~ ~ ~) ~y ~r~ions ~n~e a ~ple~e and corre~ i 0710712004 BROOKSIDE MARKET AT THE OAKS SiteID:. 015-021-002197 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: BROOKSIDE MARKET AT THE OAKS Cross Street : Business Type: GAS STATION Org Type: CORPORATION Total Tanks : 3 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : DON JEFFRIES Phone: (661) 758-3072x Address: ~ City : State: Zip: 0 Type : CORPORATION TANK OWNER INFORMATION Name : DON JEFFRIES Phone: (661) 758-3072x Address: City : State: Zip: ~ Type : CORPORATION ~ BOE UST Fee# : 006130 Financ'l Resp: INSURANCE Legal Notif : Property Owner Mailing Address Date:02/09/2001 Phone: (661) 588-2290x Name:DON JEFFRIES Ttl:PRESIDENT State UST # : TYMT 44-040810 1998 Upg Cert#: 00877 -2- 07/07/2004 BROOKSIDE ~RKET AT THE OAKS SiteID: 015-021-002197 ~ Hazmat Inventory By Facility Unit -- MCP+DailyMax Order Fixed Containers at Site Hazmat Common Name... ISpooHazlEPA Hazards] Frm DailyMax lUnit[MCP REGULAR ~LE~ED F IH DH L 20000.00 GAL Mod PREMI~ ~LE~ED F IH DH L 12000.00 GAL Mod DIESEL #2 F IH DH L 8000.00 GAL Low 3 07/07/2004 BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 = Inventory Item 0001 Facility Unit: Fixed Containers at Site REGULAR UNLEADED Days On Site 365 Location within this Facility Unit Map: Grid: GIVE THE LOCATION??????????????? CAS# 8006-61-9 Liquid Mixture Ambient Ambient UNDER, GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 20000.00 GALI 20000.00 GAL 20000.00 GAL HAZARDOUS COMPONENTS 100.00 Gasoline N 8006619 HAZARD ASSESSMENTS [TSecretI ~SIBioHazI Radioactive/Amount EPA HazardsI NFPA USDOT# MCP No N No No/ Curies F IH DH / / / Mod MISC. LOCAL AGENCY DATA Ag.Definedl: Ag.Defined2: Ag.Defined3: Ag. Defined4: Ag. Defined5: Ag. Defined6: Ag.Defined7: Ag.Defined8: Ag. Defined9: Ag.Definel0: -- Ag. Definell 4 07/07/2004 BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 = Inventory Item 0001 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: .GIVE THE LOCATION??????????????? TANK DESCRIPTION Tank ID#: 1 Mfr: ITEQ Compart Tank: N Installed: 08/00 Capacity: 20000 Gals No. Of Comparts: 1 Additional Info: TANK CONTENTS Tank Use: MOTOR VEHICLE FUEL Petrol Type: REGULAR UNLEADED Matl Name:REGULAR UNLEADED Cas #: 8006-61-9 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): BARE STEEL Material(s): BARE STEEL Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 2000 Alarm : 2000 Exempt: No Drop Tube : 2000 Ball Float : Striker Plate: 2000 Fill Tube S/O: 2000 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No -5- 07/07/20.0~ BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 = Inventory Item 0001 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : A.O. SMITH Mtl : FIBERGLASS & : Corr : FIBERGLASS Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 09/08/2000 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 02/09/2001 Name:DON JEFFRIES Ttl:PRESIDENT Prmt Number: 2197 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : - CP CERT. : MANWAY INSP. : UST MONIT. CERT:03/23/2004 6 07/07/2004 BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~lVUVl~ ~Vl~ / ~ · ~ ~vi~ PREMIUM UNLEADED Days On Site 365 Location within this Facility Unit Map: Grid: GIVE THE LOCATION???????????????? CAS# 8006-61-9 Liquid Mixture Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 12000.00 GALI 12000.00 GAL 12000.00 GAL HAZARDOUS COMPONENTS %Wt. RNo~ CAS# 100.00 Gasoline 8006619 I TSecret RS BioHaz I HAZARD ASSESSMENTS I I Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Mod MISC. LOCAL AGENCY DATA Ag.Definedl: Ag.Defined2: Ag.Defined3: Ag. Defined4: Ag. Defined5: Ag.Defined6: Ag.Defined7: Ag. Defined8: Ag.Definedg: Ag. Definel0: -- Ag.Definell 7 07/07/2004 BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: GIVE THE LOCATION???????????????? TANK DESCRIPTION Tank ID#: 2 Mfr: ITEQ Compart Tank: Y Installed: 09/2000 Capacity: 12000 Gals No. Of Comparts: 2 Additional Info: SPLIT TANK TANK CONTENTS Tank Use: MOTOR VEHICLE FUEL Petrol Type: PREMIUM UNLEADED Marl Name:PREMIUM UNLEADED Cas #: 8006-61-9 TANK CONSTRUCTION Type : DOUBLE WALL Material (p): BARE STEEL Material (s): BARE STEEL Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 2000 Alarm : 2000 Exempt: No Drop Tube : 2000 Ball Float : Striker Plate: 2000 Fill Tube S/O: 2000 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No -8- 07/07/2004 BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : A.O. SMITH Mtl : FIBERGLASS & : Corr : Prot : FIBERGLASS PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 09/08/2000 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 02/09/2001 Name:DON JEFFIRES Ttl:PRESEIDENT Prmt Number: 2197 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:03/23/2004 9 07/07/2004 F BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~UiVUVlUH ~vl~ / ~H~£ ~h H~vl~ DIESEL #2 Days On Site 365 Location within this Facility Unit Map: Grid: GIVE THE LOCATION?????????? CAS# 68476-34-6 Liquid Pure Ambient Ambient UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container { Daily Maximum Daily Average 8000.00 GALI 8000.00 GAL 8000.00 GAL HAZARDOUS COMPONENTS 100.00 Diesel Fuel No. 2 N 68476302 TSecret S BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP · No N No No/ Curies F IH DH / / / Low MISC. LOCAL AGENCY DATA Ag.Definedl: Ag.Defined2: Ag. Defined3: Ag. Defined4: Ag. Defined5: Ag. Defined6: Ag.Defined7: Ag. Defined8: Ag.Defined9: Ag.Definel0: -- Ag. Definell -10- 07/07/2004 BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 = Inventory Item 0003 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: GIVE THE LOCATION?????????? TANK DESCRIPTION Tank ID#: 3 Mfr: ITEQ Compart Tank: Y Installed: 09/2000 Capacity: 8000 Gals No. Of Comparts: 2 Additional Info: SPLIT TANK TANK cONTENTS Tank Use: MOTOR VEHICLE FUEL Petrol Type: DIESEL Matl Name:DIESEL #2 Cas #: 68476-34-6 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): BARE STEEL Material(s): BARE STEEL Lining : UNLINED Installed: Corr Prot: FIBERGLASS REINFORCED PLASTIC Installed: Spill Cnt : 2000 Alarm : 2000 Exempt: No Drop Tube : 2000 Ball Float : Striker Plate: 2000 Fill Tube S/O: 2000 TANK LEAK DETECTION Sgl Wall: Dbl Wall: INTERSTITIAL MONITORING TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Last Used: Qty Remaining: Was Filled: No -11~ 07/07/2004 BROOKSIDE MARKET AT THE OAKS SiteID: 015-021-002197 ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping AboveGround Piping Type : PRESSURE Const: DOUBLE WALL Mfgr : A.O. SMITH Mtl : FIBERGLASS & : Corr : FIBERGLASS Prot : PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS DISPENSER CONTAINMENT Installed: 09/08/2000 Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Date: 02/09/2001 Name:DON JEFFIRES Ttl:PRESIDENT Prmt Number: 2197 Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : UST MONIT. CERT:03/23/2004 -12- 07/07/2004 BROOKSIDE MARKET AT SiteID: 015-021-002197 Manager : ~ BusPhone: (661) 654-0838 Location: 8803 CAMINO MEDIA Map : 123 .CommHaz : Low City : BAKERSFIELD ~5~ (~ Grid: 05D FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 09 SIC Code: EPA Numb: ~3 D i 6J~m- , DunnBrad: -----------~--(E~ergen~C~~ / Title Emergency Contact / Title DEVEKLY EiLEKJ / STORE ~AGER ~~~~GENE~L ~AGER Business Phone: (661) 654-08~8x Business Phone: ~61) 758-3072x 24-Hour Phone : ~ ~q~.~uELL~'~ Pager Phone/: (~[)~ (~) ~-3~2 24-Hour Phone ~(~i) ~79-S360xL6~-~ Pager Phone : (~ [~: ~ Fire / Im~lth DelHlth Hazmat Hazards: Contact : DON JEFFRIES Phone: (661). ~ MailAddr: PO BOX 640 State: CA City : WASCO Zip : 93280 Owner JEFFRIES BROS INC / Phone: (661) Address : PO BOX 640 State: CA / City : WASCO ~ Zip : 93280 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: I, ~AM Nl-°C~o iFJ~ _ Do hereby csrti~ ~hm I have (Ty~ or l~int name) reviewed the attached h~ardOus mmerials manage- ment plan forAT~ ~ and ~ha~ i~ along with - (~e of Ousine~} any ~rm~ions constitute a complete and corr~t man- ~ement plan for my fadlEy, - Sight, re Date 1 07/15/2003 BROOKSIDE MARKET AT SiteID: 015-021-002197 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: BROOKSIDE MARKET AT THE OAKS Cross Street :. Business T~e: GAS STATION Org T~e: CORP~TION Total Tanks : 3 IndnRes/Trust: No PA Contac~ ...... PROPERTY OWNER INFOR~ION ..... Name : ~T ~ G~~~ ~ Phone: (661) 758-3072x Address: City : ~ ~,0, ~ ~.D /state: zip: T~K ~ER INFOR~TION Name : ~ ~ ~ff~ Phone: (661) 758-3072x Address: ~~~~,~. City : ~,0. ~ ~ State: Zip: BOE UST Fee~ : 006130 Financ' 1 Reap: INSU~CE / Legal Notif : Property Owner Mailing Address Date:02/09/2001 Phone: (661) 588-2290x Name: DON JEFFRIES Ttl: PRESIDENT State UST ~ :'~ ~ ~-0~6~ ~0 1998 Upg Cert~: 00877 -2- 07/15/2003 ?~nitori~g System Certification ' " .'" 'UST Monitoring Site Plan SiteAddre~s: c~O~ ~"~echt~O r~.E~l~ ~3' . , ...... -.q ....... .~-~ ............... { F--I ...... I-T3 .......... D,. ~ ...... e. ........ .... ~' ............................ ' ~ ~'~'E' ' Date map wa~ drawn: ~ /~0 / 0~. Instructions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System C, erl~¢afion. On your site plan, show flae .general layout of tanks and piping. Clearly identify locations of the following equipment, if installed: moniWring system .control panels; s~nsor~ m .onito.ring tank.....annular spaces, sumps', ~spenser pans, spill containers, or otlmr sCc. ondary containment areas; mechanical or electronic line leak : detectors; 'and in-tank liquid level probes (if used fo~ leak deteotion)~ In the space Provided, note the date this Si~e Plan was prepared: Page _~ of, ,~ os/oo F BROOKSIDE MARKET AT SiteID: 015-021-002197 Fast Format F Site Emergency Factors Overall Site iSpecial Hazards --Utility Shut-Offs 02/26/2001 GIVE THE LOCATION OF THE SHUTOFFS???????????? A) GAS - B) ELECTRICAL - C) WATER- D) SPECIAL - NONE E) LOCK BOX - NO -- Fire Protec./Avail. Water /,/ 02/26/2001 PRIVATE FIRE PROTECTION - (IE. FIRE EXTINGU~ERS OR SPRINKLER BLDG??????) / NEAREST FIRE HYDRANT - GIVE THE LOCATION?~???????? Building Occupancy Level / -15- 07/15/2003 ,: / .. CITY OF BAKERSFIELD ~ ~ OFFICE OF ENVIRONMENTAL SERVICES ( 1715 Chester Ave., Bakersfield, CA (661) 326-3979 1. To avoid further action, return this fo~m within 30 days of receipt. 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. 5. You may also attach Business Owner / Operator Form and Chemical Description Form(s) to the front of this plan instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II. 1' DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: B. EMPLOYEE AND AGENCY NOTIFICATION: ,C C. ENVIRONMENTAL RESPONSE MANAGEME~ ~ ;.~/f~.. ~/ D. EMERGENCY MEDICAL PLAN: 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 11.2: RELEASE RESPONSE PLAN A. . HAZARD ASSESSMENT AND PREVENTION MEASURES: B. RELEASE CONTAINMENT AND/OR MITIGATION: C. CLEAN-UP AND RECOVERY PROCEDURES: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: ELECTVaCA : WATER:' SPEClAL: Pi ' LOCK BOX: YE~9~ IF YES, LOCATION: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: b,.) j l~ ( B. WATER AVAILABILITY (FIRE HYDRANT): HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING mJM EP, OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: Ye ~ BRIEF SUMMARY OF TRAINING PROGRAM: CERTIFICATION I, "~ 0 ~ ~J~f'~.~ CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. TITLE HAZ MAT MNGMNT PLAN & INSTRUC 4 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 Business Activities Page __ of __ I. FACILITY IDENTIFICATION FACILITY ID # (For office use only - please leave blank) 1 EPA ID # 2 DBNFACILITY NAME 3 II. ACTIVITIES DECLARATION Does Your Facility... If Yes, Please Complete... A. HAZARDOUS MATERIALS ~YES ONe 4 V' OES FORM 2731 (ChemicaIDescription Form) 1. Have on site (for any purpose) hazardous materials at or ¢' CONSOLIDATED COMPLIANCE PLAN above 55 gallons for liquids, 500 pounds for solids, or 200 Minimum required p anning elements: cuft for compressed gases (include liquids in ASTs and · Emergency Response Plan USTs)? · Maps 2. Have any amount of an explosive material (other than OYES ~INO 5 · Training ammunition) on site? · Prevention · Certifications B. REGULATED SUBSTANCES (RS) ~YES ONe 6 v' OES FORM 2731 (Chemical Description Form) Have onsite RS at greater than the threshold planning ¢' RISK MANAGEMENT PLAN (RMP Submit to USEPA) quantities established by the California Accidental v' CONSOLIDATED COMPLIANCE PLAN Release Prevention program (CalARP)? · Incorporating CalARP Program Elements C. UNDERGROUND STORAGE TANKS (USTs) ~YES ONe 7 ~' UST FACILITY FORM .;..4. Own or operate Underground Storage Tanks? V' UST TANK FORM (one per tank) ~.. Intend to upgrade existing or install new USTs? OYES ~)NO UST FACILITY FORM UST TANK FORM , V' UST INSTALLATION FORM (one per tank) OYES ~)NO 9 i ~' USt TANK FORM (ctosure section-one per tank) D. TANK CLOSURE / REMOVAL 1. Need to report closing a UST that held hazardous materials or waste? 2. Need to report the closure/removal of a tank that was OYES mO lO ¢ TANK CLOSURE FORM classified as hazardous waste and cleaned onsite? E. ABOVE GROUND PETROLEUM STORAGE TANKS (ASTs) OYES ~NO 14 ~/ CONSOLIDATED COMPLIANCE PLAN Own or operate ASTs above these thresholds: any tank · Incorporating Federal Spill Prevention capacity is greater than 660 gallons or the total capacity Control and Countermeasure (SPCC) for the facility is greater than 1,320 gallons. Elements pursuant to 40 CFR Part 112 F. HAZARDOUS WASTE: v' EPA ID number--provide on this page 1. Generate hazardous waste? OYES ~NO 12 To obtain EPA ID#, please phone (916) 324-1781 2. 'Recycle mere than 100 kg/mo of recyclable materials at OYES ~NO 43 v' RECYCLING FORM the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable materials at OYES ~NO 44 v' RECYCLING FORM an offsite location different from the point of generation? 4. Treat Hazardous Waste On site? OYES ~I~NO 15 v' TP FACILITY FORM (DTSC Form i772) ~' TP UNIT FORM (one per unit) 5. Subject to Financial Assurance requirements? OYES ~INO 46 v' CERTIFICATION OF FINANCIAL ASSURANCE 6. Consolidate Hazardous Waste generated at a remote OYES ~NO 47 v' REMOTE WASTE / CONSOLIDATION SITE site? NOTIFICATION FORM G. PERMIT CONSOLIDATION ZONE: OYES {~NO 4a ¢ CONSOLIDATED COMPLIANCE PLAN Intend to consolidate other Cai/EPA agency permits? · Incorporating all other environmental (If yes, please complete Section III and attach) permit requirements per 27 CCR 10410 ~)TE: - ./If you checked YES to any part of Sections IIA-IIG above, ther{ in addition to the forms requested above, please Submit OES Form 2730 ........ UPCF (7/99) S:\CU PAFORMS~ACTIVITY.wpd OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 FACILITY INFORMATION Business Activities Addendum Page ~ of __ I. FACILITY IDENTIFICATION FACILITY ID # (For office use only - please leave blank) 1 / EPA ID # 2 -~ DBA/FACILITY NAME 3 III. CONSOLIDATED PERMIT ACTIVITIES Is your Facility Compliance Plan subject to review by... for satisfying the conditions of these permits? H, DEPARTMENT OF TOXIC SUBSTANCES'CONTROL OYES (~NO ~ STANDARDIZED PERMIT · All Modifications OYES ONO v' Non-RCRA HAZARDOUS WASTE FACILITY OYI~S ~)NO v' RCRA HAZARDOUS WASTE FACILITY I. SAN JOAQUIN VALLEY UNIFIED AIR POLLUTION ~IYES eNO ¢ AUTHORITY TO CONSTRUCT CONTROL DISTRICT ~IYES ONO ¢' PERMIT TO OPERATE ,,J. STATE WATER RESOURCES CONTROL BOARD OYES (~10 ¢' WASTE DISCHARGE REQUIREMENT (WDR) _:NTRAL VALLEY REGIONAL WATER QUALITY CONTROL OYES ~NO ¢' GENERAL PERMITS ~o-~'~-~ OYES ~NO ¢' SPECIFIC PERMITS OYES ~NO v' NATIONAL POLLUTION DISCHARGE ELIMINATION SYSTEM (NPDES) K. CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD OYES ~)NO ~/ REGISTRATION PERMIT L. KERN COUNTY RESOURCE MANAGEMENT AGENCY ENVIRONMENTAL HEALTH SERVICES PERMITS OYES ~NO ~/ Domestic Water Well Permit OYES ~NO ~' Haz Mat Monitoring Well Permit OYES ~NO v' Septic System Permit OYES ~t~NO ~ Public Swimming Pool Permit OYES ~NO ~/ Food Facility Construction Permit OYES ~NO ¢' Solid Waste Local Enforcement Agency (LEA) Related Permits I OYES ~NO ¢ Medical Waste'Related Permits M. CITY OF BAKERSFIELD WASTE WATER DIVISION OYES ~NO ¢' INDUSTRIAL WASTE WATER DISCHARGE PERMIT NOTE: ¢' If you checked YES to any part of Sections III-H to III-M above, then please address all applicable permit requirements in the Facility Compliance Plan. $:'~CUP AFORMSLa.-thaty adendum.v, qxl July 1, 1998 CITY OF BAKERSFIELI~ OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 BU$1NI=$$ OWNER / OPERATOR ID£NTIFICATION FACILITY INFORMATION Page Of I, FACILITY IDENTIFICATION' FACILITY ID # i~ i"~= I Year Beginning ~00 Year Ending ~0~ BUSINESS NAME (Same as FACILITY NAME or DBA- Doin~ Business As) 3 BUSINESS PHONE ~02 SITE ADDRESS · ~o3 B~DSTREET (4 Digit COUNTY ~&r ~ 108 OPE~TORNAME ~~ 0~1 ~ C ,o90PE~TORPHONE 66[ ~ ~0 1,o OWNER NAME OWNER MAILING CONTACT MAILINGADDRESS CITY ~6SO8 ,20 STATE C~12, J ZIP q~~ 122 .USINESSPHONE 6 ~/ ~~ 90 ,2, BUSINESS PHONE Cb/ ~gg3~qO ,3, Ce~ifi~on: Based on my inqui~ of those individuals responsible for obtaining the information, I cedi~ under penalty of law that I have personally examined and am familiar with the information submiE~ in this inventow and believe the info~ation is tree, accurate, and complete. N~ E~ R (print) ~3e TITLE OF OWNE~OPE~O~ ' '~ 137 UPCF (7/99) S:\CUPAFORMS\OES2730.TV4.wpd ~ O er/Op ~ ness wn erator Iden n "Please submit the Business Activities page, the Business Owner/Operator Identification page (OES Form 2730), and Hazardous Materials - Chemical Description pages (OES Form 2731) for all hazardous materials inventory submissions. For the inventory to be considered complete this page must be signed by the appropriate individual. Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbem are used ,~r electronic 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 fl~ll 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. DUN & BRADSTREET - Enter the Dun & Bradstreet number for the facility. The Dun & Bradstreet number may be obtained by calling (610) 882-7748 or by Internet. 107. SIC CODE - Enter the pdmary Standard Induslfial Classification Code number for primary business activity[ NOTE: If code is more than 4 digits, report only the first four. 108. COUNTY - Enter the county in which the business site is located. 109. BUSINESS OPERATOR NAME - Enter the name of the business operator. 110. BUSINESS OPERATOR PHONE - Enter business ope~tor 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~ 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 will respond to enforcement activity. 118. CONTACT PHONE - Enter the phone number, if different from 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, if different from the site address. 120. CITY - Enter the name of the city for the environmontal contact=s mailing address. 121. STATE - Enter the 2 character state abbreviation for ~ environmental contact~ mailing address. 122. ZIP CODE - Enter the zip code for 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 hazardous materials at the business site. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regarding incident mitigation. 124. TITLE - Enter the title of the primary emergency contact. 125. BUSINESS PHONE - Enter the business number for the pdmary 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 individual 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 lhat 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, a~ea code firsL 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 CUPAs or AAs to collect any additional information necessary 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 DOCUMENT PREPARER - Enter the full name of the person who prepared the inventory submittal information. 136. NAME OF SIGNER - En~r 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~ inquiry of those individuals responsible for obtaining the information, all the information submitted is true, accurate and complete. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE - The Business Owner/Operator, or officially designated representative of the Owner/Operator, shall sign in the space provided. This signature certifies that the signer is familiar with the information submitted and that based on the signer~ inquiry of those Individuals responsible for obtaining the Information it is the stgner=s belief that the submitted information is true, accurate and complete. 137. TITLE OF SIGNER - Enter the title of the person signing the page, ,~/;~'~ CITY OF BAKERSFIELD~ '" i'~r'T~'~-~-F ~t[~% OFFICE OF ENVIRONMENTAL SERVICES ~A~M~ 1715 Chester Ave., CA 93301 (661) 326-3979 HA~RDOU$ MATERIALS INVENTORY CHEMICAL DESCRIPTION (one ~o~ oar mato~at oor [~W ~ ~ ~ R~ISE 200 Pao~ ~ of ADD DELETE 3 BUSINESS ~ME (Same as FACILI~ NAME ~ DBA - Doing ~usin~s ~) [' CHEMICAL LOCATION ~ Y~ ~ No 202 CHEMICAL LOCATION 201 CONFIDENTIAL (EPC~) FACILI~ ID g r,~q~ [~{~ 1 ~P ~ (opt~naO 203 GRID g (optionaO II. CHEMICAL INFORMATION 205 T~DE SECRET ~ Y~ ~ No 206 CHEMICAL NAME If Subj~ to EPC~, refer to inst~ions CAS g 209 ' *If EHS is'Yes," ~1 ~ts ~low mu~t ~ ~ lbs.~ ' '. FIRE CODE H~RD C~SSES (C~plete if r~u~t~ by I~1 fire ~ieO 210 ] ~ CURIES 213 ~PE ~ p PURE ~ m MI~URE ~ w WASTE 211 ~DIOACTIVE ~ Y~ ~ No 212 ~ {~ all that apply) 2 R~CTIVE ~ 3 PRESSURE REL~SE ACUTE H~LTH 5 CHRONIC H~LTH 216 ~'( AL WASTE 217 ~IMUM 218 AVENGE 219 STATE WASTE CODE 2~ 'A,,,~U~ DAILY A~U~ DALLY AMOUNT UNITS* ~ ga ~L ~ d CU ~ ~ lb LBS ~ tn TONS 221 DAYS ON SITE. 222 * If EHS, amount must be in lbs. STOOGE CO~AINER ~ a ABOVEGROUND TANK ~ e P~STI~NONM~ALLIC DRUM ~ i FIBER DRUM ~ m G~SS BO~LE ~ q ~IL ~R 223 (Check all that apply) ~b UNDERGROUND TANK ~ f CAN ~ j BAG ~ n P~STIC BO~LE ~ r OTHER ~ c TANK INSIDE BUILDING ~ g ~R~Y ~ k BOX ~ o TOTE BIN ~ d STEEL DRUM ~ h SILO ~1 CYLINDER ~ p TANKWAGON STO~GEPRESSURE ~ a AMBIENT ~ aa ABOVE AMBIE~ ~ ba BELOWAMBIENT 224 STOOGE TEMPE~TURE ~ a AMBIENT ~ aa A~VE AMBIE~ ~ ba BELOW ~BIENT ~ c CRYOGENIC 225 226 227 ~ Y~ ~ No 228 229 230 231 ~ Y~ ~ No 232 233 234 235 ~ Y~ ~ No 236 237 238 239 ~ Y~ ~ No 240 241 242 243 ~ Y~ ~ No 2~ 245 Po~N~'N~E & TITLEOF AUTHORIZED COMPANY RE¢~ESENTATIVE SIGNATURE DATE 2~6 UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd CITY OF BAKERSFIELD o OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one form per mate~al per building or area) 200 Page __ of · ~i~'.N~W. ........ ~_.A_.D.~. ..... D DELETE D REVISE I. FACILI~ INFORMATION 201, CHEMICAL LOCATION CHEMI~L LOCATION ~ CONFIDE~IAL (EPC~) . ..... ~-.-~" '-r-'-~ 1 ~P" (opt~naO 203 T GRID. (opt. naO II. CHEMICAL INFORMATION ~5 T~DE SECR~ ~ Y~ ~ No ~6 CHEMI~L ~ME If Subj~ to EPC~ ref~ to instm~i~s ~7 : FIRE CODE H~RD C~ES (~plete if r~u~~fl~e ~ie0 210 ~ WASTE 211 ~ ~DIOACT~E ~Y~ No 212 CURIES 213 ~PE P 215 ~/[ AL W~TE ~1~ ~IMUM 218 A~GE 219 ~i STATEWASTE CODE '~,,~U~ .... DAILY ~U~ DALLY ~U~ ~ DAYS ON S~E 2~ UNITS' ~ ~ ~L ~ d CU ~ ~ lb LBS ~ m TONS 221 ; ' ff EHS, am~nt m~t be in lbs. STOOGE CO~AINER ~ a A~VEGROUND TANK ~ e ~STI~ONMETALLIC DRUM ~ i FIBER DRUM ~ m G~SS ~LE ~ q ~IL ~ 2~ (Check all ~at ap~y) ~ ~b UNDERGROUNO TANK ~ f ~ ~ J ~G ~ n P~TIC BO~LE ~ r O~ER ~ c TANK INSIDE BUILDING ~ g ~y ~ k ~X ~ o TOTE BIN ~ h SiLO ~ I CYLINDER ~ p T~K WAGON ~ d STEEL DRUM STOOGE PRESSURE ~ a AMBIENT ~ ~ A~VE ~BIE~' D ~ BELOWAMBIE~ 224 STOOGE TEMPE~TURE ~ a AMBIENT ~ ~ ~VE ~BIE~ ~ ba BELOW ~BIE~ ~ c CRYOGENIC 225 ,: ,' EHS CAs %~ ~RDOUS COMPONE~ " ~7 ~Y~ ~No 228 2~ : ~6 ..... ~1 ~Y~ ~No 232 233 23O .... , ~5 ~ Y~ ~ No 236 237 3 ~ 234 ......4 gl ................ 238 239 D Y~ ~ No 240 241 ~ ..... 243 ~ Y~ ~ No 244 245 5 i 242 III. SIGNATURE o, Y R~R NTATIVE UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd ' .~j~' ~.~'~'-~,"~i[,;:'6 OFFICE OF ENVIRONMENTAL SERVICES ~nnr~r 1715 Chester Ave., CA 93301 (661) 326-3979 ~~' H~RDOU$ MATERIALS INVENTORY (oho ~o~ Dot motoaot 'NEW ~ ADO ~ DELETE ~ REVISE 2~ Page I. FAClLI~ INFORMATION BUSINESS ~ME (Same ~ FACILI~ NAME ~ D~ - ~ng.~sin~ ~) 3 ~HEMICAL LOOATION 20~j CHEMI~L kO~ATION ~ Y~ ~ No 202 ~ CONFIDEmlAL (Em~) ' FACILI~ ~ ~"' ~- '~ 1 ~P~(o~t~naO 203 ~ GRlO~(opt~naO 2~ ' CHEMI~L ~ME : ~ If Subj~ to EPC~, ref~ to instmcti~s CAS~ 209 'If EHS is'Yes." MI ~ts ~w mu~ ~ ~ lbs. ~RE ~DE H~D C~SSES (~plete if r~u~t~ by I~ fire ~i~ 210 , : CURIES 213 ~PE ~ p PURE ~'m MI~URE ~ w WASTE 211 ~ ~DIOACT~E ~Y~ No 212 i ALW~TE 217 ~IMUM 218 A~GE 219 [ STATE WASTE CODE '~,,~U~ DAILY ~U~ DAILY ~U~ UN~S' ~ ga ~L ~ ~ CU ~ ~ lb LBS ~ tn TONS ~1 ~ DAYS ON SffE 222 ' If EHS, am~nt m~t be in lbs. STOOGE ~AINER ~ a A~VEGROUND T~K ~ e ~NMETALLIC DRUM ~ i FIBER DRUM ~ m G~SS ~E ~ q ~IL ~ 2~ (Check all that ap~y) ~b UNDERGROUND TANK ~ f ~ ~ j ~G ~ n P~STIC BO~LE ~ r O~ER ~ C T~K INSIDE BUILDING ~ g ~Y ~ k SOX ~ o TOTE BIN ~ d STEEL DRUM ~ h SILO ~ I CYLINDER ~ p TANK WA~N STOOGE PRESSURE ~ a AMBIE~ ~ ~ ~VE ~BIE~' Dba BELOW AMBIE~ 224 STOOGE ~MPE~TURE ~ a AMBIENT ~ ~ ~VE ~IE~ ~ ba BELOW~BIE~ ~ c CRYOGENIC 225 %~ : H~RDous COMPONE~' . EHS ~ CAS 1 ~ 226 ~7 ~Y~ ~No 228 ~ 2 ; 230 ~Y~ ~ 232 ~ I ~5 237 3 i 234 ~Y~ No 236 242 2~ ~ Y~ ~ No 2~ 245 III. SIGNATURE -~~LE OF AUTHORIZED COMPAN~PRESE~ATIVE SIG~TURE 24~' DATE UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd Hazardous Materials Inventory - Chemical Description You must complete a separate Hazardous Materials Inventory - Chemical Description page for each hazardous material (hazardous substances and hazardous waste) that you handle al 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 quantltiee of hazardous materials at your 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 electronic 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. ADD/DELETE/REVISE - Indicate if the matadal 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 or outside/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 Act (EPCRA) must check "Yes" to k~ep 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 coordinates 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 Intamational 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; complete the 'COMMON NAME' field instead, 206. TRADE SECRET - Check "Yes" if the information in this section is declared a trade san.et, or "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 HSC §25511. Federal requirement: If yes, and business is ~ubject to EPCRA, disclosure of the designated Trade Secret informaUoo is bound by 40 CFR and the business must submit a 'Substantiatin to Accompany Claims of Trade Secrecy' form (40 CFR 350.27) to 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' 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 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 information 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 class a material falls under are included in the appendices of Article 80 of the Uniform Fire Code. If a material has more than one applicable hazard class, include 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 secUon. 212. RADIOACTIVE - 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 cudes. 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 fha largest container in which the material is stored. 216. FEDERAL HAZARD CATEGORIES - Check all cats~3oriss that describe the physical and health I~,:,ards associated with the hazardous material. PHYSICAL HAZARDS HEALTH HAZARDS I Fire: Flammable Liquids and Solids, Combustible Liquids, Pymphorics, Oxidizers Acute Health (Immedlete): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, I Reactive: Unstable Reactive, On:danic Peroxides, Water Reactive, Radioactive other hazardous chemicals with an adverse effect with short term exposure J Pressure Release: Explosives, compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an I adverse effect with long term exposure 217. AVERAGE DAILY AMOUNT - Calculate the average daily amount of the hazardous matedal or mixture cor~taining 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 [ocaUon, 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 adjacent/outside 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 esUmata 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 matedal is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If matarial is a mixture containing an EHS, report (he 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: If appropriate, you may choose more than one. 224. STORAGE PRESSURE - Check the one box that best describes the pressure at which the hazardous matedal 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. 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. (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. (Report 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, UPCF (1/99) 7 OES Form 2731 : UNLEA[SE[~ VC,[..UPiE ~= 131'7:3 ULL,::':~G E = 69i.3'0 ULLAGE= dg00 V,:[;,LUIflE = i 31 :-q? (,;ALS t4EI,i;HT = '79.5:3 INCHES t,,.!c:~TER 'v'OL = 0 C;F~I.S I....j,qT EFt = 0.00 TEMP = 63.8 DE,:--; F %' 2: i:.'EEl"{l [jl"l ',,.,','.]~LIJME = 5 { f.t':'i IJLL~GE = 6 C',57_' '_21 I? ;:. IJL[.~GE= .¢5 t:, .i' ' HEIGHT = %-.',B2 i¢,I~TEF: V,'.3L = 0 GnL. S i.,.,lei"l'ER = U. L!0 | TEMt:' = 6'5.5 PEG F T ;.3: D 1 ESEL VOLUME - 5 i 94 I IL.L~:~,:';F = 2833 5~Cp:, F= :-2 0'.3 F~ T(' \. = 51 :'41 IqEl(gr;, = '7;: 62. iIqCHE~ I.,,IA'fER :./':)[~ = 0 *')&LEi I.,,]¢kTER = ',0.00 I I']C:HES TEMP = 65.? PEG F \ .I ;,,: :.. ..; · .4 El'.l[.:t x .,:"~* 02/07/01 Wednesday~.__.~ DAILY SALES SHEET,: aks MO'F~01~r~L INVENTORY REPORT '~',~,.~,. ,'.*~ PURCHASE JOURNAL 'PI~MIUM UNLEADED Pt. US DESEL PURCHASE URCHA~ CASH ~ 9~161 16~322 404 6~601 VENDOR INVOICE · INVOICE DATE AT COST ~T RETAI PAID OUT ADD 0 0 0 0 TOTAL 9~161 15~$22 404 6~501 LEES~LES 486 2~097 404 120 BOOK INV. 8r675 13~225 0 6~8t CASH PAID O4JT (NON-PtJRCHA~E) GENE~J~L BANK DEPOSfl' $2,4~1.81 CREDrr CARDS ' $3~185.98 ~TOTAL-CASH PA~-OIJT (NON.~O~JRCHASE') $5,855.?0 ~ C~SH R£~:STER co~rrRo~ CR£OIT CARO ~ATC..UMB~ ? S~,S20.98 cR~rr CA.D BATCH .UMB~. 5 $~,98Z~ CREDIT CARD BATCH NUMBER CREDIT CARD BATCH NUMBER Unleaded $2,g65.98 CREDIT CARD BATCH NUMBES~ TOTAL SALES $7,098.55 Plus tlTOTAL CRF.~IT CARDS $3,383.8g ~ SALES TAX $34.23 Premium $682.28 CASH [S'rART C~: DAY $7,21~.42 Diesel $20~.04 CHARGE 8ALES CO;.LECT~ONS $8.00 JBI CHARGE ~LBZS $4.00 CRV ~.40 ~TOTA' CHARC~=-S S4.00 ~ ~A.U~. ~UE~ SO.00 SALES RECAPITULATION & CASH BALANCE TOTAL- MO~TH TOACCOU.TrO. Ii- $~4.a~.~ ]1 ~-o-t~ PRODUCT TOTAL FORWARD TO DATE 20.22 TOBACCO $1 ¶ 4.56 CASH PAID OUT CHEWING TOB. $11.22 (PURCHASE) $0.00 BEER $72.92 CASH PAD OUT Credit Cards Over/Short (MTD) COFFEE $67.65 (NON-PURCHASE) $5,835.?0 $0.00 FOUNTAIN $126.59 Bmokslde Charge $16.22 SODA $62.68 CASH (END OF DAY) $8,001.11 DRINK NON-TAX $60.41 J8i CHARGE SUPS $4.00 GROCENY NON-T $148.11 LOTTERY o W1NNERS $8.00 GROCERY TAX $6.11 GAS CARDS MANUAL $8.00 H.B.C. $1.29 PRE-PAY STUCK $8.00 DAIRY/~CE CREAM $37.87 CFN DOM.ARS $4.91.98 Register I $0.00 TOTAL ACCTED. FOR ~ Register 2 $0.00 DEU COLD $824.02 OEU HOT $219.62 C/Cd'$ $0,00 ~E CREAM FOUN' $6.00 OVER,~ORT ($0.$7) Less Change $0.00 W~NE $13.99 Beg. Count $0.00 FRESH MEAT $8.00 CFN $0.00 CATERING $6.00 Total $0.00 TOTAL- FIJEt. $4,4~.8~ Fuol $ Sum TOTAL 8ALES 87,098.63 YEAR TO DATE $32.26 Credit Cards YTD · $0.00