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Home My WebLink AboutBUSINESS PLANi r--?r- CHESTER LIQUOR & MARKET Manager BEND GULHATI BusPhone: Location: 3401 S CHESTER AVE Map 124 City BAKERSFIELD Grid: 18B CommCode: BFD STA 05 SIC Code: EPA Numb: DunnBrad: SiteID: 015-021-003511 (661) 337-0588 CommHaz Moderate FacUnits: 1 AOV: Emergency Contact / Title Emergency Contact / Title BEND GULHATI j PRESIDENT / Business Phone: (661) 337-0588x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire ImmHlth DelHlth Contact BENU GULHATI Phone: (661) 337-0588x MailAddr: 100 S OSWELL ST State: CA City BAKERSFIELD Zip 93307 Owner BEND GULHATI Phone: (661) 337-0588x Address 100 S OSWELL ST State: CA City BAKERSFIELD Zip 93307 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG U - UST Based on my inquiry of those individua's ~~sNUnsibie for obtairui~g the information, 1 Gertiry under penalty of law tha4 t have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. Signature Date r~ ~~ ~J / ,~ -1- 05/01/2007 .~ UNIFIED PROGRAM INSPECTION CHECKLIST? r~~~ wRf~ .SECTION 1: Business Plan and Inventory Program ~r BAKERSFIELD FIRE DEPT Prevention Services 900 TYuxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME N S P TIO DATE NSPECTION TIME ~~ r ^ V ADDRESS HO E N O OF EMPLOYEES 3 S sic - FACILITY CONTACT ~ USINESS ID NUMBER Section 1: Business Plsn and Inventory Program ^ ROUTINE OMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V (c=Compliance OPERATION V-Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND ^ BUSiness PLAN CONTACT INFORMATION ACCURATE ~I G~ ,,., / tsy ^ VISIBLE ADDRESS C~^ CORRECT OCCUPANCY , W/ ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES 1~^ VERIFICATION OF LOCATION ~ ^ i~/^ PROPER SEGREGATION OF MATERIAL VERIFICATION OF MSDS AVAILABILITY A~ ~( ~y pq, ~ q ~ ~^ VERIFICATION OF HAZ MAT TRAINING LSV ^ VERIFICATION OF ABATEMENT SUPPLIES AND P RO C EDURES ~ / ~ BY ^ EMERGENCY PROCEDURES ADEQUATE Crf,~^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ,~ / L5V ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? ^ YES '~/NO EXPLAIN: - - - - ---- ------ -----.--~..------ - DUE ~ NS REGA DI THIS INSPECTION? PLEASE CALL U8 AT (881) 928-3879 Inspector (Please Print) Fire revention / 1u In /Shift of Site/Station # Business Site/School Site Responsible PaAy (Please Prvtt) White -Prevention Services Yellow -Station Copy Pink -Business Copy FD2049 (Rnv. 02105) l INSPECTIONS BUSINESS PLAN & INVENTORY PROGRAM UNIFIED PROGRAM INSPECTION CHECKLIST B D E R S F I L D F/BE ARTM T Page 1 of 1 FACILITY NAME: ~~hr~r Vs!~~ ~~` Section 2: Underground Storage Tanks Program INSPECTION DATE: ~~f' ^ Routine L~ Combined ^ Joint A ncy ^ Multi-Agency ^~ Complaint ^ Re-Inspection Type of Tank Number of Tanks Type of Monitoring ~ t ,1y~ Type of Piping I~IfJE= OPERATION C V COMMENTS Proper tank data on file '~ Proper owner /operator data on file Permit fees current Certification of Financial Responsibility Monitoring record adequate and current Maintenance records adequate and current Failure to correct prior UST violations Has there been an unauthorized release? ^ Yes ^ No Section 3: Aboveground Storage Tanks Program Tank Size{s) Type of Tank OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MVF?) If yes, does tank have overfill I overspill protection? C =Compliance V =Violation Y =Yes N = No Inspector: Questions regarding this inspection? Please call us at (661) 326-3979 White -Prevention Services Aggregate Capacity Number of Tanks BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Business Site Responsible Party Pink -Business Copy KBF-7335 FD 2156 (Rev. 09/05) ~- -Prevention Services UNIFIED .PROGRAM INSPECTION CHECKLIST H A FRS,: , 9ooTruxtun Ave., Suite.2lo FIRE Bakersfield, CA 93301 SECTION 1: Business-Plan and Inventory Program ° aerM Tel.: (661) 326-3979 - ~ Fax: (661) 872-2171 FACILITY NAME ~ ~ ~ ~~~ INSP TION ATE lam INSPECTION TIME ~ S tr- ( ADDRESS ~~0 HO E N0. 3~2 "5~9ea O OF EMPLOYEES FACILITY CONTACT ~ . BUSINESS ID NUMBER 15-021- ~ /~~ Section 1: Business Plan_and Inventory Program - ^ ROUTINE LYI.OMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^.RE-INSPECTION C V ~ C=Compliance OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND ~ 1ti jj ~ C`t - LAY ^ BUSIneSS 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 ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? ^ YES ^ NO EXPLAIN: THIS INSPECTION? PLEASE CALL US AT (667) 326-3979 (Please Print) Fire~ention / 1s` In /Shift of Site/Station # White -Prevention Services Yellow -Station Copy ~.. ~ Business t esponsible Party (Please Print) Pink -Business Copy FD 2155 (Rev. 09/05 INSPECTIONS BUSINESS PLAN & INVENTORY PROGRAM UNIFIED PROGRAM INSPECTION CHECKLIST B E R S F I L D F/lit E Ali<TM T FACILITY NAME: ~~C' ~~~}nc- ~- Section 2: Underground Storage Tanks Program ^ Routine ~ombined ^ Jo'nt Agency ^ Multi-Agency Type of Tank 'tlJ t.. Number of Tanks Type of Monitoring {~T~ Type of Piping BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 INSPECTION DATE: _~Z~ ^ Complaint ^ Re-Inspection QW OPERATION C V COMMENTS Proper tank data on file Proper owner /operator data on file Permit fees current Certification of Financial Responsibility Monitoring record adequate and current Maintenance records adequate and current Failure to correct prior UST violations Has there been an unauthorized release? ^ Yes Section 3: Aboveground Storage Tanks Program Tank Size(s) Type of Tank OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placarding/labeling Is tank used to dispense MVF?) If yes, does tank have overfill /overspill protection? C =Compliance V =Violation Y =Yes N = No Inspector: Questions regarding this inspection? Please call us at (661) 326-3979 White -Prevention Services Aggregate Capacity Number of Tanks Business R ons'ible Party Pink -Business Copy KBF-7335 FD 2156 (Rev. 09/05) =~ _ y ~R,tVi,"' ~ ~ ~ MONITORING SYSTEM CERTIFICATION For Use By Al! Jurisdictions Within the State of California Authority Cite& Chapter b 7, Health and Safety Code; Chapter Ib, Division 3, Title 23, California Code ofRegulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepare for each monitorin s stem control anel by the technician who performs, the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: ~-1aF~.S~ E (~ ~ viz Bldg. No.: Site Address: ~~\o~.s• LNELSTE~- AVi~ City' ~Sh}1~-F~`~FsE•U'~ Zip: Facility Contact Person: 5 ~ ~,~ ~ Contact Phone No.: ~,~ ~(o`-l- 14 ~ a Make/Model. of Monitoring System: --7z1..~(L~~ EmL Date of Testing/Servicing: ?_/ 3 t / v7 B. inventory of Equipment Tested/Certified INSPECTOR ON-SITE. YES O NAME: ~j'C-Eyr:. yv,7E2t,.r>u r'h~r4 rl~r nnnrnnri afr hnvrc !n ;ndicnre cnecifiCenuinment insnecre dlserviced: `Tank 1D: U /~1 (/ 1~~ Tank ID,: fREtY? gt M ~ [n-Tank Gauging Probe. Model:, _._.t_~~RG~ ~ In-Tank Gauging Probe. Model: ~~}~~ Q Annular Space or Vault Sensor. Model: ^ Annular Space or Vault Sensor. Model: ~ Piping Sump /Trench Sensor(s). Model: ~) 3 ®Piping Sump /Trench Sensor(s). Model: ~ U z~i ^ Fill Sump Sensor(s). .Model: ^ Fill Sump Sensor(s). Model: ~ Mechanical Line Leak Detector. Model: ~-ED rJflC_ c~T ~ Mechanical Line Leak Detector. Model: f~ED dA G 1C~ l ^ Electronic Line Leak Detector. Model: Q Electronic Line Leak Detector. .Model: Q Tank Overfill !High-Level Sensor. Model: ^ Tank Overfill /Nigh-Level Sensor. Model: ^ Other (s ecif e ui ment t e and model in Section E on Pa e 2 . ^ Other (s eci a ui ment e and model in Section E on Pa ;e 2). Tack ID: Tank fA: ^ ]n-Tank Gauging Probe. Model: ^ !n-Tank Gauging Probe. Model: D Annular Space or Vault Sensor. Model: ^ Annular Space or Vault Sensor. Model: ^ Piping Sump /Trench Sensor(s). Model: ^Piping Sump /Trench Sensor{s). ModeE: D Fill Sump Sensor(s), Model: ^ Fill Stimp Sensor(s). Model: ^ Mechanical Line Leak Detector. Model: ^ Mechanical Line Leak Detector. Model: ^ Electronic Line Leak Detector, Model: ^ Electronic Line Leak Detector. Model: O Tank Overfill /High-Level Sensor. Model: ^ Tank Ove~A /High-Level Sensor. Model: ^ Other (specify e uipment type and model in Section E on Page 2). D Other (specify equipment type and model in Section E on Yage 2). Dispenser ID: ~- r~ Dispenser 1D: ~ ~') ~ Dispenser Containment Sensor(s). Model: OCR ( J~-Dispenser Containment Sensor(s). Model: ~_ ,~ Shear Valve(s). ~-$hear Valves}. ' ^ Dis eraser Containment Floats and Chain s). O Dis eraser Containment Ploat s and Chains . Dispenser ID: ~'~D Dispenser ID: 7- ~ >~ Dispenser Containment Sensor(s). Model: G'~7 ` ~ Dispenser Containment Sensor(s). Model: d ~~ 1 ®- Shear Valve(s). ~ Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). ^Dis eraser Containment Floats and Chains . Dispenser ID: Dispenser 1D: ^ llisper~ser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ^ Shear valve(s). O Shear Valve(s). ^Dispenser Containment Float(s) and Chain(s). D Dis eraser Containment Floats and Chain(s). -u the lacurry contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility: ~;. Cel"tl~lCiltlOll - (certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certificatlon is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (checlc all shat apply): ®"System set-up 1~Alarm history report "I'echnici<cn Name (print): ~~~gi.1,~y~J /1'1A~r~ Signature:~i~---'--~'"'r-- Certification iti'o.: _~~,~ [.J ~~S License. No,: __,~~8~t 93'U- y r Testing Company Natne: RICH ENVIRONMENTAL Phone No.:.~ 66t } 392_8687 Site Adclress: ~~ pt ~, Lt-}~TE,t2-. ~}J T~ ,~~S~-~E~~r~ Date of Testing/Servicing: '7 / ! /CJ7 --- Page 1 of 3 03101 Monitoring System Ce+-tifcation D. 1Zcsults of 'T'esting/Servicing Software Version Installed: /,~ • ~ ~ f'mm~lnfr tha fnllnwina oheoklict' •r ~ Yes _ ^ o - - Is the audible alarrn o erational? ~- Yes D o Is the visual alarm o erational? ~9 Yes O o Were all sensors visually ins ected, functional) tested, and confin•ned o erational? ~. Yes ^ o Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? ^ Yes O o If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) ~,N/A operational? Yes ^ o For pressurized piping systems, does the turbine automatically shut dawn if the piping secondary containment O N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? Ifyes: which sensors initiate positive shut-down? (Check all that apply) Sump/Trench Sensors; f?3,Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? ~=Yes; ^ No. ^ Yes O o For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no ~ N/A mechanical overfi I1 prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill point{s) and operating pro erly? If so, at what percent of tank capacity does the alarm trigger? ^ es ~ No Was any monitoring equipment replaced? Ifyes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all re lacement arts in Section E, below. ^ es No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) O Product; ^ Water. If es, describe causes in Section E below. . ~ Yes ^ o Was monitorin s stem set-u reviewed to ensure ro er settin s? Attach set u re orts, if a licable >~- Yes O o Is all monitoring equipment operational per manufacturer's specifications? * In Section G below, describe how end when these deficiencies were'or wily be corrected. E. Comments: Page 2 of 3 03101 F. In-Tank Ganging /SLR Equipment: ^ Check this box if tank gauging is used only for inventory control. ^ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tatilc gauging equipment is used to perform leak detection monitoring. LUI11 11611 ~. Yes : lllc IVIIV 7 ^ o T Ill 411 G~.nnua. Has all input wiring been inspected for proper entry and termination, including testing for ground faulis? ~ Yes ^ o Were all tank gauging probes visually inspected for damage and residue buildup? ® Yes O ° Was accuracy of system product level readings tested? ® Yes ^ o Was accuracy of system water level readings tested? 54 Yes ^ ° Were all probes reinstalled properly? ~- Yes ^ o Were all items on the equipment manufacturer's maintenance checklist completed? 1^ Ine JCCI+O [1 h, DBIp W, uescr+uc ,low ullu wilco tncnc ucuclcuclca yr cl c vi nlu ua. w. a a. ~.aw. G. Line Leal< Detectors (LLD): ^ Check this box if LLDs are not installed. C'mm~lnfn fhn fnflnwinrt nhnrlrlict• Yes ^ No` Fa' equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ^ N/A (Check al! that apply) Simulated leak rate: ~; g,p.h,, D 0. I g.p.h , O 0.2 g.p.h. ~ Yes O o Were all LLDs confirmed operational and accurate within regulatory requirements? ~ Yes ^ . o Was the testing apparatus properly calibrated? Yes ^ + o For mechanical LLDs, does the LLD restrict product flow if it detects a teak? ^ N/A ^ Yes ^ o For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? N/A ^ Yes ^ o For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ~ NIA or disconnected? ^ Yes ^ o For electronic LLDs, does the turbine automatically shut off if any pardon of the monitoring system malfifnctions ~ N/A or fails a test? ^ Yes ^ o For electronic LLDs, have all accessible aviring connections been visually inspected? ~- N/A ,~ Yes ^ o Were all items on the equipment manufacturer's maintenance checklist completed? ul luc .~ccuun n, ue+uw, uescr[ue uuw irnu W+ten u[eSe OeflCfenCteS WerC Of WlU DC COrreCiCQ. ~~. COnt1Il1Ct1tS; Aage 3 of 3 03101 LG 163-Y, Enc. II Monitoring System Certification Form: Addendum for Vacutim/Pressure Intersti6isl Sensors I. ,Results of Vacutun/Pressure Monitoring Equipment Testing • This page should be used to document testing and servicing of vacuum and ptessure interstitial sensors. A copy of this form must be included with the Monitoring System Certification Form, which must be••providcd to the tank system owner/optwzator. The owner/operator must,submit a copy of the, Monitoring System Certification Form to the local agency regulating UST systems within 30 days of test date. Mot1e1; System Type: Pressure; [~ Vacuum Manufacturer; Sensor ID Component(s) Monitored by this Senior: • Sensor Functionality Test Result: ^ Pass; ^ Fail Jnteratitia] Communication TostResult: ^ Pass; ^ Fail Component(c) Monitored by this Sensor:~ ~ ' Sensor Functionality Test Result: ^ Pass;' ~ ^ Fail Interstitial Communication Test Result: ^ Pecs; ^ Fail' Component(s)Monitared by this•Sensor: Sensor Functionality Test Result: j^ Pass; ^ Fail Interstitial Communication Test Result: ^ Pass; ^ Fail Component(s) Monitored by. this Sensor: StnsorFunctionalityTest 12esult: ^ Pass; ^ Fail Interstitial Commuiuration TestResult: ^ Pass; ^~ Fail ' 'Component(s) Monitored by that Sensor: SensorFunetionality Test Result: ^ Pass; •^ Fail Intestinal Cornn~unication Test Result: ^ Pass; ^ Fail ' Component(s) Monitored by t:hls.Sensor: ~ ' Sensor Functionality Test Result: Q Pass; ^ Fail Interstitial Communication Test Results ^ Pass; ^ Fail Component(s) Monitored by this Sensor: sensor Fuaciaonaiity Vest Result. ^ pass; ^ Fail I.nterstitial Communication Test Result: ^ Pass; [] Fail Components} Monitored by this Sensor: Sensor Furuidonality Test Result: ^ Pass; ^ .Fail ~ Interstitial Co~**»>n~eation~'est Result: ^ Pass; ^ Fail • Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ^ Pass; ^ Faa7 •' Interstitial Com*n»n~catiori Test Rcsalt; ^ Pass; ^ Fail Component(s) Monitored by this Sensor: ~ ' Sensor Functionality Test Result: ^ Pass; ^ Fai! Interstitial Communication Tess Result. ^ Pass; ^ Fail IIow war interstitial communication veriCed7 .^ 7 calc lut<-oduccd•atFar End ofIntcrstitia! Spacc;~ ^ Gauge; ^ Visual Inspection; ,^ Other (Describe In Sec. J, below) Vacuum was restored to operatfng levels in sIl interstitial spaces: Q Yes ^ No (~jno, describe in Sec. J, below) ' J. Comments: - /~~ ~~ ^-} ~ ~` /J~~ ~ ~ t_ ~.~ 7 Page ~____ of If the sensor successfully detects a simulated, vacuum/pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum~pressure has been demonstrated to be communicating throughout the interstice, onitoring System Certification UST Monitoring Site Plan Site Address: ,~ `\ o \ b -- -+---------------- _~r--- __..~----_ -__._ _ c -- ------------- ~ ---~~---- - -----3-------- ---- --------------------- ---------- --------------- ---- C Date map was drawn: Z/ ~) /~ ]Cnr'~nctions If you already have a diagram that shows all required information, you may include it, rather than this page, with your Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly identify Locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line leak detectors; and in-tank liquid Level probes (if used for Leak detection). In the space provided, note the date this Site Plan was prepared. Page ~ of~_ ostoo 863 B~tOO~S ~"~' ERSFt'~~I,D.~A.933Q$ f O~'~'TCE (fi61) 3928687 & k",A.x 1661.) ~$~~0627, " C71?K S~.~ET w/o#: k'aa:1.1.~~Xr Name , C~ES"rGfL ~-~-- 4v ~.~. Fac:i.~.~.~.~ Addx~e~s : ~Lk~- .5. c_11.~~`~T~ A~ , f~ ~ ~'.~_.~,~ c-~ I Frgc;(u~~ L~.zze T~a~ {T?ressuze, Suatia>u, ~drav~C~~r3,_Pt2E_bSJ~E. ~~2CIDT~CT LEAK pETECTOR `i'~,P~ ~ TEST T,Rx~' P,p.SS s~zAx, z~rnaa~z~ a~T~4W Pax aft ~./A T~~~ X1"7 Jf}CK~T ~ ,A. _ s~>~z~ # ~ ~- era )a, BA.zz.~ ~ L/I? Tit&~ ~~-7 ~AC~~r ~ A S q. r S,RZ2~T.~ #.,~EGHf~ ~- 2Q0 /2 ( BATS! L/L `TX'P~._ ~ YSS PA38 s~RTAL #~. BTU ~'A.TL L /7 Tit'P~ '!~S Pl#SS ~~~x~,x~ ~.~__._. - Ito x~.a.x~ I :;erti£y tZze aboue re3ts wexe corxduci;ed oxx this date aCCaxding ~o I Rad ,:faa.~at Pumps field test apFaxatua testing pxaaedux~e an limitat=~.4n~e. I Tli~:~ Mechanir.al Lea}c pete.ct.ar. Tact, past / fa~.~. is de~ex~tined by usizzg a lour flaw thxeshoJ.r.? trig rate of 3 gallon Fer hour ox' less a>r 1a Isl. l T .ackn.owledge tk;.at a]. 1. data ao7.leated ie true wind Clorr~a~ to tkie beet ~ of rr4~ knourledge . Tech : ~~~ ~ ..~~~~ ~, sigzL:~Cure. ~ Aare ~~1 "O~ _ Q'' •~ SWRCB, January 20( 5pill~Bucket'Tesfing Report Form . This form is fntended far use by contractors performing annual testing of (!ST'splll containment structures. •The completed form ari printouts fromlests (if applicable), should be provided to the facilily;oiuner/operatorforsubmittal to the local regulatory agency, 1 ~Af''TT,'TTV TNFhRMA7ZON .. ~ . Facility Name: ~ E tl t~ v ,lt_. ~ Date of Testing: -3 I b Facility Address: ~-to S - C~N E~sr~ ~ ~r2:s t-^s E-t--j Facility Contact ~ ,~ ~ Phone: (~(o ~ - ~~ - Datc Local Agcnoy was Notified of Testing :. ~ ~ ~ ~ . Name of Local Agency Inspcctut (efpreserit during te8tinp~: -r-~~ ~ ' .N ' ~ ~L1~?7 2. TESTING CONTRACTOR INFORMATION. Company Name: /Lz~,~ ~ ~s ~ .J~A` ~ ~ , .Technician Conducting Test: ~.l ~ A3a .J Credentials': CSLB Contractor CC Scrvtcc ec SWRCB Tank Tester, Other ( eci ) License Number(s): ~,-g 9 aU ' v ~ . 3. SP1LL BUCKET TESTING IIVFORMATION Tcst lvfcthod -Used: Vacuum Other ~ . . Test Equipment Used: ~/z~ ~ ~. •• Fquipmt~ Resolution: Identify Spill Bucket (ByTank~• Number, Stored Product, etc. 1 'gam 2 . , g"~ 3 4 Bucket Installation Type: ect ~~ Contained in Sum ~~ ~' Con ill Sum Direct, Bury Direct Bury Contained in Sum Contained in Sum BuckciDiamater. ~ ~+ ~a'. . Bucket Dcpth: / ~' ` /(y' Wait tinic bctwcca aPPl3'inY vacuum/water and start af~ast: /nZ~ ,~ m~,.l Test Start Time (T~: ~• M /;•~j p~,.~ Initial Reading (R~; ~. ~ ,< 9 ., . Test End Time {Tp): o~ ~,3()P o7: 1°t"t Filial Reading (Rn): g " 9 ~.' Tcst Diuation (Tp - T~: ! H'>< ~. ~ (L Chango in Reading (RF - R~: p ~ + ~ i + Pass/Fail Thccstwld or Ca mmen is - Cnclude information on repairs made prior to testln~, and recommended follow-up for ailed tests') CERTIFICATION OF TECHNXCIAN RESPOI!1SIBLE FOR CONDUCTIlVG TES TE5TIlVG I' hereby Certifylhat alt the information contained in this report fs true, aeciuate; and do full compliance with legal requirement Technician's Signature ~-,~ ""1---- • " ' Date• ~ 3l `c~ 7 . ~ StatC iaw8 tlnd raeulution$ do not currently require testing to be port'o;mod by a gllal%ficd contracttlr. I~3owever, local raquiremtatG AIRY hC LIIOIC EtI1IIgc~, ALARM HISTORY REPORT _..._._ `- ALARM HISTORY REPORT ---- IN-TANK ALARM ----- ----- SENSOR ALARM --~-~ T 1 : UNLEADED L 1 :UNLEADED SUt°!P STP SUMP OVERFILL ALARM FUEL ALARM JUL 7. 2007 9:19 PM JUL 31. 2007 2:46 PM MAR 30. 2007 5:31 PM t~1AR l9. 2006 10:20 AM FUEL HLHRM FEH 12. 2007 6:16 Pt°i LOW PRODUCT ALARM JUL 30. 2007 9:18 PM FUEL ALARM JUL 6. 2007 2:38 PM JUL 14. 2006 9:00 AI°1 JU(V 17. 2007 11:32 PM • HIGH PRODUCT ALARM APR 25. 2005 12:58 PM SEF 18. 2001 8:04 AM INVALID FUEL LEVEL JUL 7. 2007 3:35 PM JUN 4. 2007 2:06 PM JUL 14. 2006 1G:09 AM :€ x ~ x ~ EIVD ~ ~ ~ ~ PROBE OUT JUL 14. 2006 10:05 AM DELIVERY NEEDED JUL 30. 2007 9:18 PM JUL 6. 2007 2:31 PM JUN 17. 2007 11:19 Phl ALARM HISTORY REPORT _____ SENSOR ALARM ------ L 2:PREMIUM SUMP STF SUMP . FUEL ALARM JUL 31. 2007 2:47 PNI ~ * ~ ~ * END * * ~ ~ * FUEL ALARM JUL 31. 2007 2:47 PM FUEL ALARM JUL 14. 2006 9;00 Ahl ALARM HISTORY REFORT ---- IN-TANK ALARM ----- ~ ~ ~ ~ ~ END ~ ~i ~ * ~ T 2 : PRl~f°1 I UM LOW PRODUCT ALARM JUL 11. 2007 10:22 AM JUN 5. 2007 9:07 AM APR 14. 2007 9:52 AM INVALID FUEL LEVEL JUL 21. 2007 3:14 PM JUN 12. 2007 6:30 PM JUL 14. 2006 lO:IA AM PROBE OUT JUL 14. 2006 10:11 AM DELIVERY NEEDED JUL 10, 2007 10:23 PM. JUN 5. 2007 9:06 AM APR 14, 2007 a:52 AM T 2:PREMIUM PRODUCT CODE 2 THERMAL COEFF :.000700 TANK DIAMETER 9b.00 TANK PROFILE i PT FULL VOL : 10000 FLOAT SIZE.: 4.0 IN. 8496 WATER WARNING 2.0 HIGH WATER LINIIT: 3.G I~IAK OR LABEL VOL : 10000 OVERFILL LIMIT 90i 9000 NIGH PRODUCT 95i ~. 9500 DELIVERY LIMIT lOf . ~ 1000 LOW PRODUCT 1000 LEAK ALARM L I t°1 I T: 99 SUDDEIV LOSS LIMIT: 50 TANK TILT 1,50 MANIFOLDED TANKS Tq : hJONE LEAK MIN PERIODIC: 0% 0 LEAK MIN AfVNUAL 0% 0 PERIODIC TEST TYPE QUICK ANNUAL TEST FHIL ALARM DISABLED PERIODIC TEST FAIL ALARM D.I SAIaLED GROSS TEST FAIL ALARM DISABLED ANIV TEST AVERAGING: OFF PER TEST AVERAGING: OFF TANK TEST fVOT I FY : OFF TNK TST SIPHOIV HREAK:OFF DELIVERY DELAY : 15 MIN LEAK TEST IhETHOD TEST WEEKLY : ALL TAPJK MON START T I THE l 2:00 AM TEST RATE :0.20 GALiHR DURATION : 2 HOURS LIQUID SENSOR SETUP L 1:UNLEADED SUMP TRI-STATE (SINGLE FLOATi CATEGORY STP SUt°1P L 2 : PREM i Uf°i SUMP TRI-STATE (SINGLE FLOATi CATEGORY STP SUMP EXTERNAL-ItVPUT SETUP - - NOfVE 4UTAUT RELAY SETUP R 1:UNLEADED TYPE: STANDARD FORMALLY CL05EB LIQUID SENSOR ALMS ALL:FUEL ALARM R 2:PREMIUM TYPE: STANDARD NORMALLY CLOSED L I QU [ D SENSOR ALMS ALL:FUEL ALARM LEAK TEST REPORT FORMAT NORI`1AL SOFTWARE REVISION LEVEL VERS1dN 15.01 COI°1MUNICATIONS SETUP IN-TAlVK SETUP SOFTWARE 346015-100-8 - - - - - - - - - - - - - - - - - - - .. _ - CREATED - 97,10.23.08.56 T 1:UNLEADED S-MdDULEq 330161-001-A PORT SETTINGS: PRODUCT CODE 1 SYST;~M FEATURES: THERMAL COEFF :.000700 PERIODIC IN-TANK TESTS COMIy BOARD. 2 {RS-232) TANK DIAMETER 96.00 ANNUAL IN-TANK TESTS BAUD RATE : 1200 TANK PROFILE 1 FT 0.20 GALiHR PI_LII PARITY : ODD FULL VOL 100U0 PRECISION TEST SPECIAL STOP BIT 1 STOP DATA LENGTH: 7 DATA FLOAT SIZE: 4.0 I N. 8496 AUTO TRANSMIT SETTINGS: WATER WARNING 2.0 HIGH WATER LIMIT: 3.0 AUTO LEAK ALARM LIMIT DISABLED MAX OR LABEL VOL: 10000 AUTO HIGH WATER LIMIT OVERFILL LIMIT 90i DISABLED 9000 AUTO OVERFILL LIMIT HIGH PRODUCT 95 SYSTEM SETUP DISABLED 9500 AUTO LOW PRODUCT DELIVERY LIIyIT l0 JUL 31. 2007 4:02 PM DISABLED 1000 AUTO THEFT LIMIT DISABLED LOW PRODUCT 1000 AUTO DELIVERY START LEAK ALARM LIMIT: 99 SYSTEIy UNITS DISABLED SUDDEN LOSS LIMIT: 50 0•S• AUTO DELIVERY END TANK TILT , 0.50 S`,'STEM LANGUAGE DISABLED EPJGLISH AUTO EXTERNAL INPUT OIV MANIFOLDED TANKS SYSTEIy DATE.'TIME FORMAT DISABLED T#: NONE I°ld N DD YYYY HH : hihl : SS xly AUTO EXTERNAL I fVPUT OFF DISABLEA THIARA FOOD MART AUTO SENSOR FUEL ALARM LEAK MIN PERIODIC: Oi 3401 SO CHESTEk DISABLED 0 BAKERSFIELD CA.93304 AUTO SENSOR WATER ALARM 661 --832-5900 D iSAHLED LEAK h1I N ANNUAL pi AUTO SENSOR OUT ALARM 0 SHIFT TIME 1 12:00 AM DISABLED SHIFT TIIyE 2 DISABLED SHIFT TIME 3 : UISABLEB PERIODIC TEST TYPE SHIFT TII°lE 4 DISABLED QUICK TAPJK PERIODIC WARfJItVGS ANNUAL TEST FAIL DISABLED RS-232 SECURITY HLARhI DISABLED TAIV}: Af~1PdUAL WARNINGS CODE OQU000 D]SABLED PERIODIC TEST FAIL LINE F£RIGDIC' WARNINGS ALARM DIS ABLED ENABLED LINE PERIODIC WARNING GROSS TEST FAIL DAYS 25 ALARM DISABLED LINE PERIODIC ALARM RS-23'? END OF MESSAGE DAYS 30 DISABLED AlVN TEST AVERAGING: OFF LINE ANNUAL 6JARNINGS PER TPST AVERAGING: OFF DISABLED TANK TEST NOTIFY: OFF PRINT TC VOLUhIES ENABLED TIVK TST S I PHON I3REAr; :OFF TEMP COMPENSATION DELIVERY DELAY 15 hICN VALUE (DEG F ): 60.0 STICK HEIGHT OFFSET DISABLED N-PROTOCOL DATA FORMAT HEIGHT DAYLIGHT SAVING TIIyE ENABLED START DATE " APR WEEK ] SUN START T ] h1E 2:00 AM ENU DATE OCT WEEK 6 SUN END TIME 2:00 AM . RE-DIRECT LOCAL PRINTOUT DISABLED SYSTEM SECURITY Ct}DE ~ OGUUOU MONITOFZ CERT.- F. ~..E~'ORT SITE NAME C~ E.`~ ~~ ~t~ ~~ ~ DATE: 7 31_--0-7 -- ADDRESS ~ 3 yo 1 5 c N ~. ~~-¢ A ~! G.. TECHNI,CIAN~'J~'~ m ~ 4j'~ - CITY BA ~rc.,~~x~"a SIGNATURE• ~~~ ---~`'~~ THE~FOI,I,OWING COMPONENTS WERE.REPLACED/REPAiRED TO CONTPLETE TESTING. REPAII2S~ ~~ N~ LABOR: /~c~.-~ E- PARTSINTALLED: ,^Jc~ ~.I G ,- - - ~ -- NAME:. TITLE: SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSTBYLITY OF NOTIFYING THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIROrnVIANTAL FOR ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF ANY FINES OR PENAI;TTES OCCURING FROM NON-COMPLIANCE. A COPY~OF TBl'S DOCUMENT .HAS BEEN LEFT ON-SITE FOR YOUR C011fVIENENCE. ~ . uNpERGROUND STORAGE TANKS BAKERSFIELD FIRE DEPT`. . 1-1R~ Prevention Services a1r.r~1- T 900 Tnuctun Ave., Ste. 210 APPLICATION ~~ Bakersfield, CA 93301 TO PERFORM ELD !LINE TESTING Tei.: (661 j 326-3979 t SB988 SECONDARY CONTAINMENT TESTING Fax: (661) 852-2171 !'TANK TIGHTNESS TEST AND TO PERFORM FuEt MONITORING CERTIFICATION Page 1 of 1 rn'~ PERMIT NO. { ^ ENHANCED LEAK DETECTION ^ -TE8i1NG`-~--'~° ^ SB-989 SECONDARY CONTAINMENT TiESTING ^ TANK TIGHTNESS TEST TO PERFORM FUEL MONITORING CERTIFICATIO MA i N ,, ,.: FACILITY ~ 0 E NUMBE OF CONT~T IjER,SQ~N f ADDRESS ~ ~ OWNERS NAME ! /q~ ~ ~I ~~~n r °~-~~~~ -='~k~~ 11--L~1 OPERATORS NAME -PERMIT TO OPERATE N0. NUMBER OF TANKS TO BE TESTED I PIPIN IN T ? Y D A ~u~ • , „ TAAK;7ESTING COMPANY NAME 0 TES ING OMPANY NAME b PHONE NUMBER CONT CT P~SO~ r MAILING ADDRESS ~~ + ~ ~~~ O NAME HONE NU BER OFT R OR SPECIAL I r PECTOR CERTIFICATION #: DATE & TIME TEST TO /BE C/O~yND CTED r.~~rU t/~•~' ' 1 ICC #: ST METi100 SIGNATURE OF APPLICANT •• ~' DATE DATE FD 2085 (Rev. 09!05) EiI~LING & PERMlT STATEMENT PERMfi' NO.: r BAKERSFIELD FIRE DEPT, Preve~iox- Services !-~Rt 900 Trusthan Avenue, Suite 210 A1itll/ T Bakersfield, CA 93301 T .1.: 16611 326-3979 S F ~ LCzbsl] 8~,5~2. LOCATION OF PROJECT ~~ PROPERTY ONMER STARTWGDATE~~~y~ ~'e0~-gyp DATE ~ /~ V~~ l / NAME ~ O / U __ ~ L _.{ PROJECT NAME ~ ADDRESS O PHONE N . l PROJECT ADDRESS l ~ ( ~ (,,+~ . CfiY ~ STATE ~ ZIP CODE CONTRACTOR NAME CA i.ICENSE NO, TYPE OF LICENSE EXPIRATION DATE PHONE N CONTRACTOR COMP NAME FAX NQ ,.~ - ADDRESS CRY ZIP CODE i~ml~ ~ o ~~ ~ ;_ 4,~ ; ~ i .i. ~, difications -(Minim m Char e) $262 50 ^ Afarm N & M 0 g u ew s - o . ~ ~ Ft 000 S O r 20 013125 =Permit fee S Ft x & ^ q. ve , q. . 9E ^ rinkler w & Matifications - (Minim m Char e) S -N $210 00 & g p u s e . 9f ^ Over 5;000 Sq. Ft Sq. Ft x .042 =Permit fee & 9t _ ^ Minor S rinkler Modifications (< 10 heads) $ 93 00 [inspection Only) 8` p . 9f ^ Commeraal Hoods -New & Modifications $ 398 26 8<. . 9F ^ Additional Hoods $ 38 00 ~ . 9E ^ Spray Booths -New & Modifications $458 00 ~ . 9t? ^ Aboveground Storage Tanks (/nstallatioNlnsp.•1~ Time) $165.00 82 ^ Additional Tanks $ 26.00 82 ^ Aboveground Storage Tanks (Remova//lnspection) $109.00 132 ^ Underground Storage Tanks (Instal/ation.llnspection) $878.00 (per tank) 82 d Underground Storage Tanks (Modification) $878.00 (per site} 82 ^ Underground Storage Tanks (Minor Modification) $155.00 ~ ~ ^ Underground Storage Tanks (Remove!) $675.00 (per tank} 84 ^ Oilwell (Installation) $ 72.00 ~ ~ _ Mandated Leak Detection {Testi /Fuel Monit. Cert. $ 81.00 (per site) 82 ^ Tents $ 93.00 {per tent} 84 ^ After hours inspeCfJorr fee $122.00 84 ^ Pyrotechnic - (Per event, Plus Insp. Fee ~ $90 per hour) S 60.00 + (3 hrs. min. stand -by tee 1lnspectlon) _ $57 0.40 84 ^ REdNSPECTJON(S) /FOLLOW-UP INSPECTION(S) ; 93.00 (per hour) 8a ^ Portable LPG (Propane}: NO.OF CAGES? $66.00 ~ ^ Explosive Storage $249.00 ~ ^ Copying $ Fife Researrt- (File Research Fee $33.00 per hr) 25¢ per page 84 ^ Miscellaneous ; 84 1=0 2021 (Rev: 09105) t -ORIGINAL WH1TE fto Tr88YUrvi !-YELLOW Ito FI191 1-PlNK !t0 CUStORl9t1 .,. ` .~. ~~ .. RICH ENVIRQNM ENTAL ,,. . ATIQN SERVlCE5 SERVICE ST 90-7162/3222 ' 17 g" "' . uc;#ao9s5o . 5643' BROOKS CT " '~ , ~ ~ ''(~') BAKERSFtELD, CA `93308 3708 DATE <~~~ 1661).392 8687 _-.~F~;,, . ~`~ ~~ ~' DAl'TOTHF - - l ~R[N?R QF ~ ~ e ~ ~ ~ ~ t „ 8' ~; K, FA ®washin ton MU~t1Ai~ WA 8 F ~L0 7CA 98~0 ~ ~ ~ ,t : KERS 8 , : ... , . :. , ~d .. . ~ ' r ~ - ~ ~ ~ -,. . :. ..: . ., . FOR .: ~'. ;_: _ , ~: :.: ~. .. ~ ..: - ; :_ ~ 7.: .. ' nUTH ORIZH IGNAT R6 ~v~ i v 1 : `. ~ ~ Q`~ l . ... ._ . ; ~tt'00 '>t-? 9 ~:~~`:. ~. 3,2~~ 2 7 ~ ~-.2 Vii.. . 0 $ 7 S 01~~,p 0 7 ~~~~ 3 _.: . _... _ . A ti. i o . k' p~y ~t'~ HAZARDOUS MATERIAL MANAGEMENT APPLICATION BUSINESS OWNER/OPERATOR IDENTIFICATION FORM (HAZARDOUS MATERIAL FACILITY INFORMATION) ~~ ~~ 8 R F l D PIRG ARTM F BAKERSFIELD FIRE DEPARTMENT Prevention Services 1600 Truxtun Avenue, Suite 401 Bakersfield, CA 93301 Phone:661-326-3979 . Fax:661-852-2171 Page 1 of 2 ~ i ~~ I ~„FACILITY IDENTIFICATION; FACILITY ID # 1 YEAR BEGINNING 100 YEAR ENDING 101 BUSINESS NAME me a5 FACILITY NAME or DBA) 3 BUSINESS PHONE 102 ~ 3~. • ©SO SITE ADDRESS ' ~~O ~ ~ ~ ` ~Y~J~r I . vt~ 103 CITY g.4K,~RS~I~LA 1U4 c.4 ZIP CODE 9 33o~f 105 DUNN & BRADSTREET # ~~s, ~ ~ 106 ! 11\71 SIC CODE 107 COUNTY r ~ 108 OPERATOR NAM 109 OPERATOR PHONE 110 ctn J _r ` ' II OWNER INFORMATION - " OWNER NA~~~~ ~-`~~~~~ V 111 OWNE~ ~~^ OJ ~ U 112 OWNER MAILING ADDRESS 9.90 O ~ (v~'~'rc ~ 113 CITY ~ Fc~~~-tc~ llq STATE 115 ~~- ZIP CODE 3 116 IIL;`_ .ENVIRONMENTAL_CONTACT - CONTACT NA rr ~~ /tom I^A r1V YJ ~~~ . \IJL~{ 11J CONTACT PHONE ~~r ~ 118 CONTACT MAILING ADDRESS ,r{..~n ~ \ Y ~ 119 ` / CITY _ `.-^f~Yl``YS~~~•~(y _ _.-..._.._._ - .,._. ,..___._ _.____-> ....r _ ._._ . _.-_,- _ .. _ 120 -ST~E~ _ _. _ _ -_. _ 121 Z~33o(/ _ l°._._. __ 122 __.. ._.__ _ - IV. ;EMERGENCY-CONTACTS: PRIMARY SECONDARY NAME 123 NAME ~A ^ l 1` 128 TITLE cr" 124 LE ~.O'- C~ctlNcr 129 BUSINESS PHONE * ~~~ 125 BUSINESS PHONE4 ~ ~ ' 50~~ (OJ 130 24-HOUR PHONE 126 24-HOUR PHONE 131 CELL PHONE (~ 127 CELL PHONE l/~,~ l/_ 132 133 ' ` V. CERTIFICATION Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the inform ation submitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF DOCUMENT PREPARER 136 DATE 134 6-~3- o? NAME OF DOCUMENT PREPARER (PRINT) 135 NAME OF OWNER/OPERATOR (SIGN & PRINT) /~ ~ 1 ~ ~~ 137 TITLE OF DOCUMENT PREPARER 138 -- FD2142 (Rev 06/07) b~ ~~~ HAZARDOUS MATERIAL FACILITY INFORMATION BUSINESS OWNER/OPERA'TOR~~DENTIFICATION Please submit the Business Activities page, the Hazardous Material Facility Information (HMMP) Business Owner/ Operator Identification Form, and Hazardous Material Inventory Chemical Description Form for all hazardous material inventory submissions. For the inventory to be considered, please complete this page; it must be signed by the appropriate individual. NOTE: The numbering of the instructions follows the data element numbers that are on the Business Owner/Operator Form page. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, Business Section of the Unified Program Data Dictionary. Please number all pages of your submittal. This helps our CUPA or AA identify whether the submittal is complete and if any pages are separated. i FACILITY I.D. NUMBER -This number is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3 BUSINESS NAME -Enter the full legal name of the business. 100 BEGINNING DATE -Enter the beginning year and date of the report. 101 ENDING DATE -Enter the ending year and date of the report. 102 BUSINESS PHONE -Enter the phone number, area code first, and any extension. 103 BUSINESS SITE ADDRESS -Enter the street address where the facility is located.. No post office box numbers are allowed. This information must provide a means to geographically locate the facility. 104 CITY -Enter the city or unincorporated area in which business site is located. 105 ZIP CODE -Enter the zip code of business site. The extra 4-digit zip may also be added. 106 DUNN & BRADSTREET NUMBER -Enter the Dunn & Bradstreet number for the facility. The Dunn & Bradstreet number may be obtained by calling 610-882-7748 or by Internet. 107 SIC CODE -Enter the primary Standard Industrial 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 operator phone number, area code first, and any extension. 111 OWNER NAME -Enter name of business owner. 112 OWNER PHONE -Enter the business owner phone number, area code first, and any extension. 113 OWNER MAILING ADDRESS -Enter the owner mailing address. 114 OWNER CITY -Enter the city for owner mailing address. ,. ~ 115 OWNER STATE -Enter the 2 character state abbreviation for the owner mailing address. 116 OWNER ZIP CODE -Enter the zip code for the owner address; extra 4-digit zip may also be added. 117 ENVIRONMENTAL CONTACT NAME -Enter the name of the person who receives all environmental correspondence and will respond to enforcement activity. 118 CONTACT•PHONE -Enter the phone number 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. 120 CITY -Enter the name of the city for the environmental contact mailing address. 121 STATE -Enter the 2 character state abbreviation for the environmental contact mailing address. 122 ZIP CODE -Enter the zip code of the. environmental contact mailing address; 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 material, 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 primary emergency contact, area code first, and any extensions. 126 24-HOUR PHONE - Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one which is answered 24-hours a day. If it is not the contact home phone number, then the service answering the phone must be able to immediately contact the individual. 127 CELL NUMBER -Enter the cell number for the primary emergency contact. 128 SECONDARY EMERGENCY CONTACT NAME - Enter'the name of a secondary representative that can be contacted in the event that the primary emergency contact is not available. The contact shall have FULL facility access, site familiarity, -and authority to make decisions for the business regarding incident mitigation. 129 TITLE -Enter the title of the secondary emergency contact. 130 BUSINESS PHONE -Enter the business telephone number for the secondary emergency contact, area code first, and any extension. 131 24-HOUR PHONE - Enter a 24-hour phone number for the secondary emergency contact. The 24 ;hour phone number must be one which is answered 24-hours a day. If it is not the contact home phone number, then the service answering the phone must be able to immediately contact the individual ,. , 132 CELL NUMBER -Enter the cell number for the secondary emergency contact. 133 ADDITIONAL LOCALLY-COLLECTED INFORMATION -This space may be used for CUPA or AA 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. 135 NAME OF DOCUMENT PREPARER (FULL PRINTED NAME) -Enter the full printed name of the person who prepared the inventory submittal information. 136 SIGNATURE OF DOCUMENT PREPARER (FULL SIGNATURE) -Enter the full signature of the person preparing 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. 137 SIGNATURE OF OWNER/OPERATOR/DESIGNATED REPRESENTATIVE -The Business Owner/Operator, or officially-designated representative of the Owner/Operator, shall sign and print in the space provided. This signature certifies that the signer is familiar with the signer belief that the submitted information is true, accurate, and complete. 138 TITLE OF DOCUMENT PREPARER -Enter the title of the person preparing the page. Page 2 of 2 Foziaz (Rev o5/0~) HAZARDOUS MATERIAL MANAGEMENT PLAN APPLICATION FOR SECTION DISCOVERY & NOTIFICATION (FORMS) BAKERSFIELD FIRE DEPARTMENT Prevention Services 1600 Truxtun Avenue, Suite 401 H H R 9 F I aBakersfield, CA 93301 P/RL Phone: 661-326-3979 • Fax: 661-852-2171 ARlAI ! Page 1 of 2 INSTRUCTIONS ' '" 1. To avoid further action, return this form within 30 days of receipt. 2. Type/print answers in ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. SECTION I: FACILITY IDENTIFICATION BUSINESS NAME (FACIL1lY NAME or DBA t ADDRESS (for local use only) 3 ~f 0 l t-- o ~ FACILITY ID # 1 SECTION IL1~:, DISCOVERY AND NOTIFICATIONS A. LEAK DETECTIOwN,~A~,ND MONpITO^RING PROCEDUrRES: /~ B. EMPLOYEE ANDrArGENCY NOTIFICATION: r ^ w~ r ` _ O ~ ~~~ \ S I ~ ~ ~Q-~ ~ ~ ~~~ C. ENVIRONMENTAL RESPONSE MANAGEMENT: i3 ~~.~ ~~ I I~~-~- ~ . D. EMERGENCY tMEDICAL PLAN: /I rr __ ~6t1c~~t '~'O NcaV'C5~- (`~S Pc~~ SECTION II.2: RELEASE RESPONSE PLAN A. HAZARD ASSESMENT AND PREVENTION MEASURES: ' (Cc~`( ~~~c~ c~5cc~ as cam ~~S®t•(~a~~- P(c1.s Y~o ~ ~c~ctl'~ Ro~-~-'~.5~ 3.55 B. RELEASE CONTAINMENT AND/OR MITIGATION: 5ce ~~~ is ~gxx . c ~ a C. CLEAN-UP AND RECOVERY PROCEDURES: K- tthy C3'S ~.d C.f} t ~l ~C. ~~~C~Cd (l1 ~(~ ~c ~-ifnf ~ td `~ ~lGlfCc~ (~~ ~' ~ CS QS~ FD2169 (Rev 06/07) Page 7 of 2 SECTION IL2 RELEASE RESPONSE PLAN (CONY) UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS PROPANE: S r ELECTRICAL: WATER: SPECIAL: PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A. PRIVATE FIRE PROTECTION: ~~~ ~:1 :~i i ~ 3t _ B. ~ WATER AVAILABILITY (FIRE HYDRANT): ~~~ ._ . i ..C -~ 1.~ .'~ I SECTION III: TRAINING NUMBER OF EMPLOYEES: ~ ~ ' >: ~, r. ~ MATERIAL SAFETY DATA SHEETS ON FILE: ^ ^ NO IF YES, LOCATION: BRIEF SUMMARY OF TRAINING PROGRAM: e.~.cc(~, ll.~.c.f~ ~oc- s~tfLs ~ C#cL~ zcup(~cc.. ~N'oc~1S tucc~' .. ~~ .SG«~ ' cam. ~ w~,o ~-o ta(.( ,v - .. . _~ ._._ _, .. I ~ ~CERTIFICATION.~ ~~ Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is. true; accurate, and complete. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 477 6-~3-0 ~ NAME OF SIGNER (PRINT) a7s , ~- ~ ~ ~~ (~ TITLE OF SIGNER ~ ~l a79 ~ . ~ ~ . , ,erg a ~ zs n ' '~ FD2169 .(Rev 06/07) HAZARDOUS MATERIAL MANAGEMENT PLAN CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIAL INVENTORY ^ NEW ^ ADD ^ DELETE ^ REVISE zoo BAKERSFIELD FIRE DEPARTMENT . ~ ~' Prevention Services s a x s >a I n 1600 Truxtun Avenue, Suite 401 p/Re Bakersfield, CA 93301 AAl,<I t Phone: 661-326-3979 . Fax: 661-852-2171 Page 1 of 2 I(1nc fnrm nPr malarial nar huilriinn. nr area.l I: FACILITY INFORMATION BUSINESS N~A E (FACILITY NAME or DBA) q ~ ~ 3 ~1- ~ ,{, / / V ~ \ Y' ~iC~~ CHEMICAL LOCATION ~ 201 CHEMICAL LOCATION 202 ' O ~ F ,~~5 v CONFIDENTIAL (EPCRA) ^ Yes ^ No FACILITY ID # 1 MAP # (optional) 203 GRID # (optional) 204 r, i . II. CHEMICAL INFORMATION CHEMICAL NAME zos /1 ~ /' ~® /t ~ ~~~`~~ ~~~ ~~ , C~1lC_ Il tl 206 TRADE SECRET ^ Yes ~iNo If sub ect to EPCRA, refer [o Instructions 207 COMMON NAME[f r It, a r1/'~n,l(' ~e C IP 1nV ~ ~ ` ~ EHS* 4Xes ^ N o 2oa , `~~'' C (,~ 1 V 1~l `w~~s { Y ~ Ill ~sv~, uU ~ 1 CAS # 209 *If EHS is yes, all amounts below must be Ins pounds. FIRE CODE HAZARD CLASSES (complete if requested by local fire chief) 210 TYPE - / 211 RADIOACTIVE: ^ Yes ^~jl~ 212 CURIES 213 ^ PURE ~y MIXTURE ^ WASTE LARGEST CONTAINER 215 PHYSICAL STATE ^ SOLID LIQUID ^ GAS 214 h/~ IV ~• ~ FED HAZARD CATEGORIES I-l~FIRE ISV REACTIVE ^ J PRESSURE RELEASE L9~ACUTE HEALTH CjiCIiRONIC HEALTH 216 (Check all that apply) ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 STATE WASTE 220 AMOUNT DAILY AMOUNT DAILY AMOUNT CODE Cr 221 DAYS ON SITE 222 ^ UNITS'" f3IGAL ^ CU FT ^ LBS ^ TONS 'If EHS, amount must be in lbs. STORAGE CONTAINER: 223 ^ ABOVEGROUND TANK ^ CAN ^ BOX ^ TANK WAGON ~DERGROUND TANK ^ CARBOY ^ CYLINDER ^ RAIL CAR ^ TANK INSIDE BUILDING ^ SILO ^ GLASS BOTTLE ^ OTHER ^ STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ^ TOTE BIN ^ PLASTIC/NONMETALLIC DRUM ^ BAG STORAGE PRESSURE: AMBIENT tSV ABOVE AMBIENT ^ BELOW AMBIENT 224 STORAGE TEMPERATURE: AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC 225 %WT HAZARDOUS COMPONENT EHS CAS # 1 226 227 ^'Yes ^ No 22s 229 Z 230 231 ^ Yes ^ NO 232 233 3 234 235 ^ Yes ^ NO 236 237 4 238 239 ^ Yes ^ No 240 tai $ 242 243 ^ Yes ^ No 244 gas -.III. SIGNATURE PRINT NAME & T IT LE O F T AU H ORIZED C OM PANY EPRESENTAT I V E SIGNATU R E DATE za6 R '~ ++ ~~ / Q~ r G (( ~ / W / t , ~(V [ y ~ y~ r ~ ( G '- FD2144 (Rev 06/07) CALIFORNIA WASTE CODES Code Description Inorganics 111 Acid solution 2 < pH < 7 with metals (antimony, arsenic, barium, beryllium, cadmium, chromium, cobalt, copper, lead, mercury, molybdenum, nickel, selenium, silver, thallium, vanadium, and zinc) 112 Acid solution without metals 113 Unspecified acid solution 121 Alkaline solution pH >12.5 with metals (see 111) 122 Alkaline solution without metals 123 Unspecified alkaline solution 131 Aqueous solution (2 < pH < 12.5) containing reactive Anions. (azide, bromate; chlorate; cyanide, fluoride;: hypochlorite, nitrite, perchlorate and sulfide anions) 132 Aqueous solution with metals (see 111) 133 Aqueous solution with total organic residues 100% or more 134 Aqueous solution with total organic residues < 10% 135 Unspecified aqueous solution 141 Off-spec, aged, or surplus inorganics 151 Asbestos containing waste 161 FCC Waste r 162 Other spent catalyst 171 Metal sludge (see 111) 172 Metal dust and machining waste (see 111) 181 Other inorganic solid waste Code Description Organics (cont) 261 PCB and material containing PCB 271 Organic monomer waste (includes unreacted resins) 272 Polymeric resin waste .281 Adhesives - 291 Latex waste ~ ~ ~ ~ - 311 Pharmaceutical waste` 321 Sewage sludge 322 Biological waste other than sewage sludge 331 Off-spec, aged or surplus organics 341 Organic liquids (non-solvents) with halogens 343Unspecified organic liquid mixture,.: .,, 351 Organic solids, with halogens . Sludge 411 Alum and gypsum sludge 421 Lime sludge .. 431 Phosphate sludge 441 Sulfur sludge 451 Degreasing sludge 461 Paint sludge 471 Paper sludge/pulp 481 Tetraethyl lead sludge 491 Unspecified sludge waste Organics 211 Halogenated solvents (methylene chloride, chloroform, TCE, TCA) 212 Oxygenated solvents (acetone, butanol, MEK) 213 Hydrocarbon solvents (Stoddard solvent, xylene) 214 Unspecified solvent mixture 221 Waste oil and mixed oil 222 Oil/water separation sludge 223 Unspecified oil -containing waste 231 Pesticide rinse water 232 Pesticide and other waste associated with pesticide production 241 Tank bottom waste 251 Still bottoms with halogenated organics 252 Other still bottom waste Miscellaneous 511 Empty pesticide containers 30 gal or more 512 Other empty container 30 gal or more 513 Empty containers less than 30 gal 521 Drilling mud 531 Chemical toilet waste , 541 Photo chemical/photo processing waste 551 Laboratory waste chemicals - 561 Detergent and soap 571 Fly ash, bottom ash, and retort ash 581 Gas scrubber waste 591 Bag house waste 611 Contaminated soil from site clean-ups 612 Household wastes Page 3 of 3 FD2144a (Rev 06/07) HAZARDOUS MATERIAL MANAGEMENT PLAN BUSINESS ACTIVITIES PAGE (HAZARDOUS MATERIAL FACILITY INFORMATION) Page l of 1 I. FACILITY IDENTIFICATION FACILITY ID # (for office use only) 3 i EPA ID # BUSINESS NAM E ( F ACI LITY NAME or DBA) 103 {r, p ~ ~h f~ ~~/~~ ~ ` II. _ ACTIVITIES.DECLARATION DOES Your Facility... If Yes, Please Complete... lze A. HAZARDOUS MATERIAL ^ Yes ^ No • CHEMICAL DESCRIPTION FORM 130 1. Have on site (for any purpose) hazardous material • HAZARDOUS MATERIAL MANAGEMENT PLAN at or above 55 gallons for liquids, 500 pounds for Minimum required olannina elements: solids, or 200 cu. ft. for compressed gases (include • Emergency Response Plan liquids in AST and UST)? • Maps • Training • Prevention Certification B. REGULATED SUBSTANCES (RSl ^ Yes ^ No • CHEMICAL DESCRIPTION FORM 131 1. Have on site RS at greater than the threshold • RISK MANAGEMENT PLAN (RMP Submit to USEPA) planning quantities established by the California . CONSOLIDATED COMPLIANCE PLAN Accidental Release Prevention program (CaIARP)? • Incorporating CaIARP Program Elements C. UNDERGROUND STORAGE TANKS (UST) es ^ No • UST FACILITY FORM 132 1. Own or operate Underground Storage Tanks? • UST TANK FORM (one per tank) ~ Yes ^ No UST FACILITY FORM 133 2. Intend to u rade existin or install new UST? P9 9 • UST TANK FORM (one per tank) • UST INSTALLATION FORM (one per tank) D. TANK CLOSURE/REMOVAL ^ Yes ~o • UST TANK FORM (Closure section -one per tank) 1. Need to report closing an UST that held hazardous material or waste? 2. Need to report the closure/removal of a tank that D Yes I?,~f6 • UST TANK CLOSURE FORM was classified as hazardous waste and cleaned onsite? E. ABOVEGROUND PETROLEUM STORAGE TANKS ^ Yes ^ No • HAZARDOUS MATERIAL MANAGEMENT PLAN LAST) • Incorporating Federal Spill Prevention Control and Countermeasure 1. Own or operate AST above these thresholds; any (SPCC) Elements pursuant to 40 CFR Part 112. tank capacity is greater than 660 gallons or the total capacity for the facility is greater than 1,320 gallons? F. HAZARDOUS WASTE EPA ID NUMBER -provide on this page 1. Generate hazardous waste? ^ Yes ^ No . To obtain EPA ID Number, please phone (916) 324-1781 2. Recycle more than 100 kg/mo of recyclable ^ Yes ^ No . RECYCLING FORM material at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable ^ Yes ^ No . RECYCLING FORM material at an off-site location different from the point of generation? 4. Treat Hazardous Waste on site? ^ Yes ^ No . TP FACILITY FORM • TP UNIT FORM (one per unit) 5. Subject to Financial Assurance requirements? ^ Yes ^ No . CERTIFICATION OF FINANCIAL ASSURANCE 6. Consolidate Hazardous Waste generated at a ^ Yes ^ No • REMOTE WASTE/CONSOLIDATION SITE NOTIFICATION remote site? FORM NOTE: If you checked YES to any part of Sections IIA - IIF above, then in addition to the forms requested above, please submit BUSINESS OWNER/OPERATOR IDENTIFICATION FORM. BAKERSFIELD FIRE DEPARTMENT ~' Prevention Services B B ft S F I n 1600 Truxtun Avenue, Suite 401 FIRa Bakersfield, CA 93301 ABTM T Phone: 661-326=3979 • Fax: 661-852-2171 FD2143 (Rev 06/07) Hazardous Material Inventory -Chemical Description UNIFIED PROGRAM CONSOLIDATED FORMS You must complete a separate Hazardous Material Inventory -Chemical Description page for each hazardous material (hazardous substances and hazardous waste) that you handle at your facility in aggregate quantities equal to or greater than 500 pounds, 55 gallons, 200 cubic feet of gas (calculated at standard temperature and pressure) or the Federal threshold planning quantity for Extremely Hazardous Substances, whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to SO CFR Parts 30, 40, or 70. The completed inventory should reflect all reportable quantities of hazardous material 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, and 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 material is being added to the inventory, deleted from the inventory, or if the information previously submitted is being revised. NOTE: You may choose to leave this blank if you resubmit your entire inventory annually. 201 CHEMICAL LOCATION -Enter the building 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 keep chemical location information confidential. If the business does not wish to keep chemical location information confidential check no. 203 MAP NUMBER - If a map is included, enter the number of the map on which the location of the hazardous material is shown. 204 GRID NUMBER - If grid 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 International 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 secret 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 subject to EPCRA, disclosure of the designated Trade Secret information is bound by 40 CFR and the business must submit a Substantiation to Accompany Claims of Trade Secrecy 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 -Describes to first responders the type and level of hazardous material 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 section. 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 curies. 214 PHYSICAL STATE -Check the one box that best describes the state in which the hazardous material is handled: solid, liquid, or gas. 215 LARGEST CONTAINER -Enter. the total capacity of the largest container in which the material is stored. 216 FEDERAL HAZARD CATEGORIES -Check all categories that describe the physical and health hazards associated with the hazardous. material. 217 AVERAGE DAILY AMOUNT -Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each building or adjacent outside area. Calculations shall be based on the previous year inventory of material reported on this page. Total all daily amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this location, the amount shall be the average daily amount you project to be on hand during the course of the year. This amount should be consistent with the units reported in Box 221 and should not exceed that of maximum daily amount. 218 MAXIMUM DAILY AMOUNT -Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or 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 estimate of the annual amount handled. 220 STATE WASTE CODE - If the hazardous material is a waste, enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. 221 UNITS -Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet, or tons. NOTE: If the material is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons). 222 DAYS ON SITE -List the total number of days during the year that the material is on site. 223 STORAGE CONTAINER -Check the one box that best describes the type of storage container in which the hazardous material is stored. 224 STORAGE PRESSURE -Check the one box that best describes the pressure at which the hazardous material is stored. 225 STORAGE TEMPERATURE -Check the one box that best describes the temperature at which the hazardous material is stored. 226 HAZARDOUS COMPONENTS 1-5 (% BY WEIGHT) -Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available, report the highest percentage in that range. (Report for components 2 through S 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 S in 232, 236, 240, and 244.) 229 HAZARDOUS COMPONENTS 1-5 CAS -List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. (Repeat for 2-5.) 246 LOCALLY COLLECTED INFORMATION -This .space may be used by the CUPA or AA to collect any additional information necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance. Page 2 Of 2 FD2144 (Rev 06/07) CITY OF BAKERSFIELD B 6 R S P D OFFICE OF ENVIRONMENTAL SERVICES ~iR~ 1715 Chester Ave., CA 93301(661) 326-3979 `' ARTM t "'~ _ ,,;,_, w ~ . ,, ,s,,,~. UNDERGROUND STORAGE TANK FACILITY ^ 1 NEW SITE ^ 3 RENEWAL PERMIT ^ 5 CHANGE OF INFORMATION (State type of change) ^ 7 PERMANENTLY CLOSED SITE TYPE OF ACTION PERMIT MENDED PERMIT ^ 8 TANK REMOVED (Check one item ony) 400 ^ 8 TEMPORARY SITE CLOSURE i. FACILITY /SITE INFORMATION BUSINESS E (Same a~ACI~ 1 Q~~ r8A r mgt Cl~~~)~ 3 I FACILITY ID # I I ~, e ( I ~~ I I I I I I t NEAREST CROSS STREET 401 FACILITY OWNER TYPE i ~.~ ('(^~ t~CORPORATION I BnUPIENESS ~ S STATION ^ 3 FARM ^ 5 OTHER 403 'O" 'NDIVIDUAL ^ 2 DISTRIBUTOR ^ 4 PROCESSOR ^ 8 COMMERCIAL ^ 3 PARTNERSHIP I TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •It owner of UST a public agency: name of supervi I REMAINING AT SITE trus8ands7 divisbn, section or office which operates the UST. ' ~ (This Is the contact person for the tank records.) 404 ^ Yes ^ No 405 11. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME ~~~~ ~~l(^~ i I MAILING OR STREET ADDRESS ~ 9 d © ~ ~ t tn~1(`c ~ac . ~~(ch CITY n f n r _ ^ 4 LOCAL AGENCY/DISTRICT' ^ 5 COUNTY AGENCY' ^ 6 STATE AGENCY' ^ 7 FEDERAL AGENCY' 402 ..~~~,~ 408 ao'e iE 411 ~ ZIP a r i I C~ I `t.S~~b PROPERTY OWNER TYPE NDIVIDUAL ^ 4 LOCAL AGENCY /DISTRICT ^ 8 STATE AGENCY 413 ^ 1 CORPORATION ^ 3 PARTNERSHIP ^ 5 COUNTY AGENCY ^ 7 FEDERAL AGENCY III. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 ~co~~ C~oc~IG~a~t 3 MAILING OR STREET ADDRESS 418 ~ CITY a~ccs~(d 417 STATE 418 ~~ ZIP g33p;~ 419 TANK OWNER TYPE NDIVIDUAL ^ 4 LOCAL AGENCY / DISTRICT ^ 8 STATE AGENCY 420 ^ 1 CORPORATION ^ 3 PARTNERSHIP ^ 5 COUNTY AGENCY ^ 7 FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY (TK) HQ 4 4 - Call (916j 322-9669 if questions arise a21 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(S) 1SELF-INSURED ^ 4 SURETY BOND ^ 7 STATE FUND ^ 10 LOCAL GOVT MECHANISM ^ 2 GUARANTEE ^ 5 LETTER OF CREDIT ^ 8 STATE FUND 8 CFO LETTER ^ 99 OTHER: ^ 3 INSURANCE ^ 8 EXEMPTION ^ 9 STATE FUND & CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indkate which address should be used for legal notlfieatbns and mailing. ^ 1 FACILITY PROPERTY OWNER ^ 3 TANK OWNER 423 Legal noti8catbn and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII. APPLICANT SIGNATURE Certlflcatlon: I eeRlfy that the Information provided herein Is true 8 accurate to the best of my knowledge SIGNATURE OF APPLICANT DATE 424 PHONE 425 I __ _ /~ ~6^ ~3' 07 NAME OF APPLICANT (print) ^ 428 TITLE OF APPLICANT 427 'I ~ /~ G- N'y ~ V L N ft -! ! t ~U7 N ~ K I STATE UST FACILITY NUMBER (For ktcal use only) 1998 UPGRADE CERTIFICATE NUMBER (For bcal uee only) Farm A State of California For State Uso Onty State of Water Resources Control Board Division of Financial Assistance P.O. Box 944212 Sacramenw. CA 94244-2120 (instructions on reverse side) CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. [ am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: 500,000 dollars per occurrence ~ I million dollars annual aggregate or AND or ~l million dollars er occurrence ~ 2 million dollars annual a re ate gg g p B. hereby certifies that it is in compliance with the requirements of Section 2807, (Name o/ Tank Owner a Operator Article 3, Chapter 18, Division 3, Title 23, California Code of Regulations. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective Third Party T e Name and Address of Issuer Number Amount Period Action Com ~ef~ }~COrc~ (~, (tor( 5-30~0~ ~y~ Stlrcd- RIGm ~~~ ~"~. ~ ~-o -- , ~ ~s ~.~~ ~ r ~=3o-a~ 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 am in compliance with all conditions for participation in fhe Fund. D. Faaliry Name Facility Address ~o~~ ~ s . ~.~ ~~ Facility Name Facility Address Facility Name Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator 6-13-07 ~~N~ U~ ATI ~ot.~N~-~' Signature of Witness or Notary Date Name of Witness or Notary CFR (Revised 04/95) FILE: Original -Local Agency Copies- Facility/Site(s) ACORD,~ CERTIFICATE OF LIABILITY INSURANCE °A 06 01 07~) PRODUCER 818-243-2651 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION RKM Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 251 N. Brand Blvd., #201 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glendale, CA 91203 INSURERS AFFORDING COVERAGE NAIC # INSURED wsuRERA: MARKEL INSURANCE CO. 13H113 CORP. INSURER B: DBA: CHESTER LIQUOR & MARKET INSURER C: 3401 S. CHESTER INSURER D: BAKERSFIELD, CA. 93304 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DD' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY ~ EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ PERSONALBADVINJURY $ GENERALAGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ POLICY PRO LOC AUT OMOBILE LIABILITY DSINGLELIMIT 1 000 000 A U MSP610841 05-30-07 05-30-08 (OaBade $ , , ANYA TO ALL OW NED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Per accident) X GARAGE LIABILITY PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EA ACC $ AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY ~ EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- O I EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACHACCIDENT $ OFFICER/MEMBEREXCLUDED? E.L. DISEASE-EA EMPLOYEE $ Ii es, describe under SPECIAL PROVISIONS below ~ E.L. DISEASE -POLICY LIMIT $ OTHER A BUILDING (SPECIAL FORM) MSP610841 05-30-07 05-30-08 $ 805,000 LIQUOR LIABILITY $1,000,000 DESCRIPTION OFOPERATIONS /LOCATIONS /VEHICLES /EXCLUSIONS ADDED BYENDORSEMENT/ SPECU\L PROVISIONS *10 DAYS CANCELLATION NOTICE WILL BE GIVEN FOR NON-PAYMENT OF PREMIUM CERTfFICATE HOLDER NAMED AS ADDITIONAL INSURED CERTIFICATE HOLDER rnNCFI ~ orioN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BHARAT & BEND GULHATI DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30* DAYS WRITTEN 3401 S. CHESTER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL BAKERSFIELD, CA. 93304 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. '~. AUTHORIZED REPRESENTATIVE ~~_.. ~/ ACORD 25 (2001/08) ©ACORD CORPORATION 1988 UNDERGROUND STORAGE TANK BAKERSFIELD FIRE DEPT. MONITORING PROGRAM (FORM) WRITTEN MONITORING PROCEDURES This monitoring program must be kept at the UST location at a! 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 fh) CCR. Page 1 of 1 FACILITY NAME p~- ~~ 1 FACILITY ADDRESS ~l0 So. sic ~ ~ ~Cc s~r~ ~ ~ . ~ 330 DESCRIBE THE FREQUENCY OF PERFORMING THE MONITORING: TANK ~ ~ No~9at~ PIPING WHAT METHODS AND EQUIPMENT, IDENTIFIED BY NAME AND MODEL, WILL BE USED FOR PERFORMING THE MONITORING: TANK ~~ PIPING ~~ (( DESCRIBE THE LOCATION(S) WHERE THE MONITORING W ILL BE PERFORMED (FACILITY P OT PLAN SHOULD BE ATTACHED): I~o~~~~- d~,~~~-c~ t~~~,~~ ~~~,daw~ . LIST•THE NAME(S) AND TITLE(S) OF THE PEOPLE RESPONSIBLE FOR PERFORMING THE MONITORING AND/OR MAINTAINING THE EQUIPMENT: NAME I ~ TITLE , NAME TITLE f''lc~ o~ r NAME ~ ~ TITLE NAME TITLE NAME TITLE REPORTING FORMAT FOR MONITORING: TANK ~~ PIPING ~ P ~,P DESCRIBE THE PREVENTIVE MAINTENANCE SCHEDULE FOR THE MONITORING EQUIPMENT. NOTE: MAINTENANCE MUST BE IN ACCORDANCE WITH THE MANUFACTURER'S MAINTENANCE SCHEDULE BUT NOT LESS THAN EVERY 12 MONTHS. A ~ ~ ~ ~C ~ ` r ~~ ~~ r~ l /\ ~ T~ r,G V\~ ~ ~ I/-Y/c a 3 c~c~ DESCRIBE THE TRAINING NECESSARY FOR THE OPERATION OF UST SYSTEM, INCLUDING PIPING, AND THE MONITORING EQUIPMENT: i~L~. I~Ccc~~ C-i~~3~ r~~u~cu.~ FD 2074C (Rev. 02105) B H R S P I n Prevention Services ~/Rt 900 Truxtun Ave., Suite 210 ARTM T Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax.: (661) 872-2171 UST MONITORING PROGRAM EMERGENCY RESPONSE PLAN Page 1 of 1 This monitoring program must be kept at the UST location at all times. The information on this monitoring progrem are conditions of the operating permit. The permit holder must notify the Office of Environments! 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. f/Rl AR1M T Bakersfield Fire Dept. Environmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME ,~ !~ 1 C~C3`1'C'C- ~( r ~ ~ FACILITY ADDRESS ~~~ ~ So , s~~ 933/' IF AN UNAUTHORIZED RELEASE OCCURS, HOW VNLL THE HAZARDOUS SUBSTANCE BE CLEANED UP7 NOTE: IF RELEASED HAZARDOUS SUBSTANCES REACH THE ENVIRONMENT, INCREASE THE FIRE OR EXPLOSION HAZARD. ARE NOT CLEANED UP FROM THE SECONDARY CONTAINMENT WITHIN 8 HOURS, OR DETERIORATE THE SECONDARY CONTAINMENT, THEN THE OFFICE OF ENVIRONMENTAL SERVICES MUST BE NOTIFIED WITHIN 24 HOURS. ~~ CaS~O~ n~y~~ (~ ' ^t~t~ [,/-,{~~ ~.~~cc' Vutf( ~c c~sc~ AS am c>,~oso~~Oav~~, G.ar~~ .~ s~c((5 ~a~f Rte e~ da~cr~c~C~. ~icc, (Q~lp~-~ DESCRIBE THE PROPOSED METHODS AND EQUIPMENT TO BE USED FOR REMOVING AND PROPERLY DISPOSING OF ANY HAZARDOUS SUBSTANCE. ~~~( ~~~~ s~o ~~ o v~s,~~ 5 pr lfs c~c (~ Gx ~ (c~vr~ c~ p dry ~~~P~ ~Y ~~s~es~~ e~ t r~ t~las~c. ~a~r c~,,~f-c• ~~~. 3.DESCRIBE THE LOCATION AND AVAILABILITY OF THE REQUIRED CLEANUP EQUIPMENT IN ITEM ABOVE. ~~~~ } .~c~ ~ ~ ~ ~_(_~ ~Sct~ ~G~E~y ~n~~-ct' ~O~N aV~ Sccfc O~f- ~o(`~ N ~p DESCRIBE THE MAINTENANCE SCHEDULE FOR THE CLEANUP EQUIPMENT: ^ C~`~V IS ~r ,~ ~ ~C `~ (t ~~~ ~t I f~ LIST THE NAME(S) AND TITLE(S) OF THE PERSON(S) RESPONSIBLE FOR AUTHORIZING ANY WORK NECESSARY UNDER THE RESPONSE PLAN: NAME ~~ ~~ ~,~ TITLE .'"~ - rwlRrt ARTM T TYPE OF ACTION Check ane dem any CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES ~, . 1715 Chester Ave., Bakersfield, CA 93301(661) 326-3979 UST Tank -1 Pege _ of ^ i NEW SITE PERMIT ^ J RENEWAL PERMIT ^ S CHANGE OF INFORMATION (Sole type of change) ^ 7 RERMANENTLY CLOSED ON SITE 4 AMENDED PERMIT ^ 8 TEMPORARY SITE CLOSURE J~ FACILITY IO M (- as FACILITY NAME or OBA - Oofnq Buelnsee As) ~ GtnrFnr ~- ~la~~~ 429 1 ^ 8 TANK REMOVED 3~f~ 1 S~, ~~es'~cr 1. TANK DESCRIPTION ~ nnn iu +r 4,tu rnnn mnnurgt, r untH a31 COMPARTMENTALIZED TANK ^ Yes ~.+~o a32 ' ~ C a t If'Yes', complete one loan for each compartment. DATE INSTALLED (Y WHO) 433 ANK CAPACITY IN GALLONS 434 NUMBER OF C MPARTMENTS 435 i~ ~ Ig?5 ~ ADOITIONF: DESCRIPTION (For bal uss ony) 438 ,,_, ~ TANK USE 437 L~J~(MOTOR VEHICLE FUEL (If marked. compbta Vehicle Fuel Type) ^ 2 USED OIL ^ J CHEI.::.:. L PRODUCT ^ 4 HALIRDOUS WASTE ^ 95 Ut•n~' 1V/N il. TANK CONTENTS ,,~, ~ VEHICLE FUEL TYPE L~1a REGULAR UNLEADED ^ 2 LEADED ^ 7D PREMIUM UNLEADED ^ 7 DIESEL ^ is MIOGRADE UNLEADED ^ 4 GASOHOL COMMON NAME (from Hazardous Materials Inventory page) 111. TANK CONSTRUCTION 438 ^ 5 JET FUEL ^ 8 AVIATION FUEL ^ 99 OTHER +39 I CAS p (from Hazardous Materials Inventory page) 440 TYPE OF TANK ~ SINGLE WALL ^ 3 SINGLE WALL WITH ^ 5 INTERNAL BLADDER SYSTEM 441 Check one ir.m only ^ 2 DOUBLE WALL EXTERIOR MEMBRANE LINER ^ 95 UNKNOWN ^ 4 SINGLE WALL IN A VAULT ^ 99 OTHER TANK MATERIAL (primery tank) BARE STEEL ^ 4 STEEL CLAD W/ FRP ^ 5 CONCRETE ^ 95 UNKNOWN 442 Check one item ony ^ 2 STAINLESS STEEL ^ 3 FIBERGLASS ^ 8 FRP COMPATIBLE Wl100% METHANOL ^ 99 OTHER TANK MATERULL (secondary tank) ^ 1 BARE STEEL ^ 4 STEEL CLAD W/ FRP ^ 8 FRP COMPATIBLE W/100% METHANOL ^ 95 UNKNOWN 443 heck one Rem only ^ 2 STAINLESS STEEL ^ 3 FIBERGWSS ^ 9 FRP NON-CORRODIBLE JACKET ^ 99 OTHER ^ 5 CONCRETE ^ 10 COATED STEEL NTERIOR LINING OR COATING ^ 1 RUBBER LINED EPOXY LINING ^ S GLASS LINING ^ 95 UNKNOWN 444 ;heck one !tem only ^ 2 ALKYD LINING ^ 4 PHENOLIC LINING ^ 8 UNLINED ^ 99 OTHER )THER CORROSION rROTECTION IF APPLICABLE ^ 1 MANVFACTUREO CP ^ 3 FI RGLASS REINFORCED PLASTIC ^ 95 UNKNOWN 445 :Hock ona Itsm ony ^ 2 SACRIFICIAL ANODE IMPRESSED CURRENT ^ 99 OTHER .PILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PROTECTION EQUIPMENT INSTALLED (YEAR) 44e 447 :heck all that apDN ,,,,~~ // PROP TUBE L~YYes ^ No 448 ^ 1 ALARM STRIKER PLATE ~s ^ No 449 ,, ., ~ LWl BALL FLOAT ^ 3 FILL TUBE SHUT OFF VALVE ' N. TANK LEAK DETECTION ~.: IF SINGLE WAl1 TANK (Cheek eA that eDDy): IF DOUBLE WALL TANK (Check one item only): 450 ] 11 VISUAL (EXPOSED PORTION ONLY) ^ 6 MANUAL TANK GAUGING (MTG) ^ 8 VISUAL (SINGLE WALL IN VAULT ONLY) ~~ 'S 2 AUTOMATIC TANK GAUGING (ATG) ^ 8 VAOOSE ZONE ^ 9 CONTINUOUS INTERSTITIAL MONITORING ~ 3 CONTINUOUS ATG ^ 7 GROUNDWATER ] 4 STATISTICAL INVENTORY RECONCILIATION (SIR) + ^ A9 OTHER f BIENNIAL TANK TESTING V. TANK CLOSURE INFORMATION /PERMANENT CLOSURE IN PLACE 971MATE0 DATE LAST USED (YR/MO/DAY) 451 ESTIMATED QUANTITY OP SUBSTANCE REMAINI NG 452 GA9 TANK FILLED WITH INERT MATERIALS 453 oel ^ Yee ^ No Form 8 CITY OF BAKER3FIEL0 OFFICE OF•ENVIRONMENTAL SERVICES 1T1S Ch~star Ava., Bakanfi~ld, CA 93301 (803) 328.3979 U>!T .TANK PAGE 2 ..- ----- - Pa00 -- O/ ~ ABOVEGROUND PIPING INFORMATION j UNDERGROUND PIPING INFORMATION SYSTEM 1`YPE ~ ^ t SUCTION _ PRESSURE ^ 7 GRAVITY a54 i ^ t SUCTION ^ 2 PRESSURE ^ J GRAVI 455 :ONSTRUCTION ^^ t SISINGLE WALL ^ 95 UNKNOWN i ^ I SINGLE WALL ^ J LINED TiYENCH ^ 99 OTHER ~(~J/l DOUBLE WALL ^ 4D OTHER 4S0 j ^ 2 DOUBLE WAIL ^ 9S UNKNOWN ~y MATERIALS ANO CORROSION ^ 1 BARE STEEL ^ 0 FRP COMPATIBLE Wf 100% METHANOL ^ t BARE STEEL ^ 6 FRP COMPATIBLE W/ t00% METHANOL PROTECTION ^ 2 STAINLESS STEEL ^ 7 GALVANIZED STEEL ^ 2 STAINLESS STEEL ^ 7 GALVANIZED STEEL ^ J PVC COMPATIBLE WITH NT CONT E S ^ 95 UNKNOWN ^ J PVC COMPATIBLE WITH CONTENTS ^ 93 UNKNOWN ^ 4 FIBERGLASS ~ , ~ 1.1Y8 FLEXIBLE ^ 99 OTHER ^ 4 FIBERGLASS ^ 8 FLEXIBLE ^ 99 OTHER ^ S STEEL WI COATING ^ 9 CATHODIC PROTECTION 455 ^ S STEEL W/ COATING ^ 9 CATHODIC PROTECTION ess VII. PIPING LEAK DETECTION (Check alI that aDDly) ABOVEGROUND PIPING INFORMATION ~ UNDERGROUND PIPING INFORMATION P._R,ES~'URIZEO PIPING (Chock all that appyr qyt ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST ~ AUTO PUMP SHUT OFF FOR LEAK. SYSTEM FAIL URE, AND SYSTEM DISCONNECTKN! +AUDIBLE ANO VISUAL ALARMS ^ 2 MONTHLY 0.2 GPH TEST ^ J ANNUAL INTEGRITY TEST (0.1 GPH) ^ 4 DAILY VISUAL CHECK CONVENTIONAL SUCT iON SYSTEMS (Check ad that apply): ^ 5 GAILY VISUAL MONITORING OF PUMPING SYSTEM ^ 8 TRIENNAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYS'~'~~:a: ^ 7 SELF MONITORING I GRAVITY FLOW (Ch..: •.oll that aDPN): It ^ 8 DAILY VISUAL MONITORING ^ 9 BIENNULL INTEGRITY TEST (O.1 GPH) SECONDARILY CONTAINED PU~INO PRESSURIZED PIPING (i.hack ad that apply): ^ 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (check one) ^ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ^ b AUTO SUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ^ e NO AUTO PUMP SHUT OFF ] t t AUTOMATIC LEAK DETECTOR ] 12 ANNUAL INTEGRITY TEST (0.1 GPH) I iUCTION/GRAVITY SYSTEM: ] 1J CONTINUOUS SUMP SENSOR +AUDIBLE ANO VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check at that apply) ] 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND VISUAL ALARMS t5 AUTOMATIC LINE LEAK DETECTOR (J.0 GPH TEST) t8 ANNUAL INTEGRITY TEST (0.1 GPH) 17 DAILY VISUAL CHECK PRESSURIZED PIPING (Cheek all that aDPN)~ ^ 1 ELECTRONIC LINE LEAK DETECTOR J.0 GPH TEST T AUTO PUMP SHUT OFF FOR LEAK. SYSTEM FAILURE, AND SYSTEM DISCONNECTION •AUDIBLE AND VISUAL ALARMS ^ 2 MONTHLY 0.2 GPH TEST ^ J ANNUAL INTEGRITY 7EST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS: ^ 4 DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS: ^ 5 SELF MONITORING GRAVITY FLOW: ^ 8 BIENNUIL INTEGRITY TEST (0.1 GPH) SECONDAiv':.Y CONTAINED PIPING PRESSURIZED PIPING (Check all that ap~~c ^ 7 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE ANO VISUAL ALARMS AND (Check one) ^ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ^ b AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE AND SYSTEM DISCONNECTION ^ e NO AUTO PUMP SHUT OFF ^ 8 AUTOMATIC LINE LEAK DETECTOR (J.0 GPH TEST) ^ 9 ANNUAL INTEGRITY 7EST (0.1 GPH) EMERGENCY GENERATORS ONLY (Check ad that apply) ^ 10 CONTINUOUS SUMP SENSOR WITH UT AUTO PUMP SHUT OFF + AUDIBLE ANO VISUAL ALARMS ^ 11 AUTOMATIC LINE LEAK DETECTOR (J.0 GPH TEST) ^ 12 ANNUAL INTEGRITY TEST (O.t GPH) ^ 1J DAILY VISUAL CHECK -• . • VIII. DISF SPENSER ^ 1 FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ^ 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER ]NT MENT ea ^ No ^ 2 CONTINUOUS ELECTRONIC SENSOR +AUDIBLE AND VISUAL ALARMS +AUDIBLE AND VISUAL ALARMS ^ 4 GAILY VISUAL CHECK _ I certiry that the h ,IGNATURE OF b herein la true b accurate to the beat of my 70R r-y` _ A ~ 48J 6-13 - 0 7 ~ /l1 T 4&/ ermd Number ( or kfcsl ute oroy) armlt Approved Permit xplrslbn ate Form 8 ~t ~~ ._ C[TY OF BAKERSFIELD ~iR~ OFFICE OF ENVIRONMENTAL SERVICES ~, AQTM f 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 UST Tank -1 Page _ of _ TYPE OF ACTION ^ 1 NEW SITE PERMIT ^ 3 RENEWAL PERMIT ^ S CHANGE OF INFORMATION (Stale type of change) ^ 7 PERMANENTLY CLOSED ON SITE Check ona ~ISm ony ^ • AMENDED PERMIT ^ 8 TEMPORARY SITE CLOSURE inp Buaheaa As) „ 3 FACILITY 10 K r ^ B TANK REMOVED 429 1 I. TANK DESCRIPTION TANK ID N 4J{7 LANK tYWNUFAG TURER 431 r COMPARTMENTALIZED TANK ^ Yes ~'Fio 432 F 111 V'L~ga,~ al If'Yes', complete one form for each compartment. (For kfeal use il. TANK CONTENTS TANK USE 437 tOTOR VEHICLE FUEL (If marked, compote Vehicle Fuel Type) ^ 2 USED OIL ^ 3 CHEf.~:.:. L PRODUCT ^ 4 HAZARDOUS WASTE ^ 95 Ut•n~''1WN VEHICLE FUEL TYPE ^ t a REGULAR UNLEADED ,~, ~ ^ 2 LEADED L~Lt6 PREMIUM UNLEADED ^ 1c MIDGRADE UNLEADED ^ 3 DIESEL ^ 4 GASOHOL COMMON NAME (from Hazardous Maleriala Inventory page) III. TANK CONSTRUCTION 438 ^ 5 JET FUEL ^ 8 AVIATION FUEL ^ 99 OTHER +39 I CAS p (from Hazardous Materials Inventory page) 440 TYPE OF TANK [SINGLE WALL ^ 3 SINGLE WALL WRH ^ S INTERNAL BLADDER SYSTEM 441 Check one il•m Orly ^ 2 DOUBLE WALL EXTERIOR MEMBRANE LIN ER ^ g5 UNKNOWN ^ 4 SINGLE WALL IN A VAULT ^ gg OTHER ~I TANK MATERIAL (primary lank) 1 BARE STEEL ^ 4 STEEL CLAD W! FRP ^ 5 CONCRETE ^ 95 UNKNOWN 442 Check ona item ony ^ 2 STAINLESS STEEL ^ 3 FIBERGLASS ^ 8 FRP COMPATIBLE W1100% METHANOL ^ 99 OTHER ' TANK MATERIAL (secondary tank) ^ 1 BARE STEEL ^ 4 STEEL CLAD W/ FRP ^ 8 FRP COMPATIBLE WH00% METHANOL ^ 95 UNKNOWN 443 heck ona Rem ony ^ y STAINLESS STEEL ^ 3 FIBERGLASS ^ 9 FRP NON-CORRODIBLE JACKET ^ 99 OTHER ^ 5 CONCRETE ^ 10 COATED STEEL NTERIOR LINING OR COATING ^ 1 RUBBER LINED t]~dEPOXY LINING ^ 5 GLASS LINING ^ 95 UNKNOWN 444 . ;heck one !rem ony ^ 2 ALKYD LINING ^ 4 PHENOLIC LINING ^ 8 UNLINED ^ 99 OTHER )THER CORROSION ^ 1 MANUFACTURED CP ^ 3 FIBERGLASS REINFORCED PLASTIC ^ 95 UNKNOWN 445 >ROTECTION IF APPLICABLE ;heck ona Itsm only ^ Z SACRIFICIAL ANODE IMPRESSED CURREM ^ 99 OTHER iPlll AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PROTECTION EQUIPMENT INSTALLED (YEAR) ;heck all that apDy ,,~~, //'' DROP TUBE ~ LV~Yes 448 447 ^ No 448 1 ALARM ^ STRIKER PLATE L9,ras ~ , ^ No 449 L'llz8"ALL FLOAT ^ 3 FILL TUBE SHl1T OFF VALVE N. TANK LEAK DETECTION ~.. IF SINGLE WALL TANK (Check aR that apply): IF DOUBLE WALL TANK (Check ona item only): 45o i t VISUAL (EXPOSED PORTION ONLY) ^ 6 MANUAL TANK GAUGING (MTO) ^ 8 VISUAL (SINGLE WALL IN VAULT ONLY) ~ AUTOMATIC TANK GAUGING (ATG) ^ 8 VAOOSE ZONE ^ 9 CONTINUOUS INTERSTITIAL MONITORING 3 CONTINUOU3 ATO ^ 7 GROUNDWATER j 4 STATISTICAL INVENTORY RECONCILIATION (SIR) + ^ 99 OTHER BIENNIAL TANK TESTING V. TANK CLOSURE INFORMATION /PERMANENT CLOSURE IN PLACE 4TIMATED DATE LAST USED (YR/MO/DAY) 4S1 ESTIMATED OUANTtTY OF SUBSTANCE REMAINING 4S2 GA3 TANK FILLED WITH INERT MATERUIL9 4S3 aal ^ Ysa ^ No , Porn B I iy. CITY OF BAKERSFIELD OFFICE OF ENVIR®NMENTAL SERVICES 171 S Chaatar Ava., Bakanflald, CA 93301 (80S) 328-3979 UOT • TANK PAGE 2 _. _ PWa ~ O/ $vSTEM TYPE ~ ^ I SUCTION ABOVEGROUND PIPING INFORMATION ^ J GRAVITY 434 I ^ 1 SUCTION ^ 2 PRESSURE ^ 3 GRAVITY ~5 ~ ^ t SINGLE WALL ^ 95 UNKNOWN i ^ 1 SINGLE WALL ^ ]LINED Ti7ENCH ^ 99 OTHER :ONSTRUCTION ~~UBLE WALL ^ 99 OTHER 450 ~ ^ 2 DOUBLE WALL ^ 93 UNKNOWN 454 MATERIALS AND ~ ^ t BARE STEEL ^ 6 FRP COMPATIBLE W! 100% METHANOL ^ 1 BARE STEEL ^ 6 FRP COMPATIBLE W! 100% METHANOL CORROSION PROTECTION ^ I STAINLESS STEEL ^ 7 GALVANIZED STEEL ^ 2 STAINLESS STEEL ^ 7 GALVANIZED STEEL ^ 3 PVC COMPATIBLE WITH CONTENTS ^ 9S UNKNOWN ^ J PVC COMPATIBLE WITH CONTENTS ^ 93 UNKNOWN ^ 4 FIBERGLASS / C~~B'F EXIBLE ^ 99 OTHER ^ 4 FIBERGLASS ^ 8 FLEXIBLE ^ 99 OTHER ^ S STEEL W! COATING ^ 9 CATHODIC PROTECTION 4S5 ^ S STEEL W/ COATING ^ 9 CATHODIC PROTECTION 456 ABOVEGROUND PIPING INFORMATION ~ UNDERGROUND PIPING INFORMATION PRESS IZED PIPING (Check all that appy): ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST y~11j AUTO PUMP SMUT OFF FOR LEAK SYSTEM FAIT URE, AND SYSTEM DISCONNECTION +AUDIBLE ANO VISUAL ALARMS ^ 2 MONTHLY 0.2 GPH TEST ^ 3 ANNUAL INTEGRITY TEST (0.1 GPH) ^ 4 GAILY VISUAL CHECK CONVENTIONAL SUCI iON SYSTEMS (Check a8 that appy): ^ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM ^ 8 TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYS''O.S.3: ^ 7 SELF MONITORING GRAVITY FLOW (Ch... •.~Il that appy): ^ 8 GAILY VISUAL MONTORING ^ 9 BIENNIAL INTEGRITY TEST (O.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (i.hedt a8 that appy): ^ 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (check one) ^ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ^ D AUTO SUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ^ e NO AUTO PUMP SHUT OFF 11 AUTOMATIC LEAK DETECTOR 12 ANNUAL INTEGRITY TEST (0.1 GPH) iUCTIOWGRAVITY SYSTEM: 13 CONTINUOUS SUMP SENSOR +AUDIBLE ANO VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check art that appy) 14 CONTINUOUS SUMP SENSOR vvlTHOtn AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS 15 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) t8 ANNUAL INTEGRITY TEST (O.t GPH) 17 OAiLY VISUAL CHECK PRESSURIZED PIPING (Cheek all that appy): ^ t ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WI_ jTl• AUTO PUMP SHUT OFF FOR LEAK SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE ANO VISUAL ALARMS ^ 2 MONTHLY 0.2 GPH TEST ^ 3 ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS: ^ 4 DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS: ^ 5 SELF MONITORING GRAVITY FLOW: ^ 8 BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDAiv'~Y CONTAJNED PIPING PRESSURIZED PIPING (Check all that ap~vc ^ 7 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE ANO VISUAL AtARAAS AND (Check one) ^ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ^ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ^ c NO AUTO PUMP SHUT OFF ^ 8 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ^ 9 ANNUAL INTEGRITY TEST (0.1 GPH) EMERGENCY GENERATORS ONLY (Chock a0 Mat appy) ^ 10 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND VISUAL ALARMS ^ 11 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ^ t2 ANNUAL INTEGRITY TEST (O.t GPH) ^ 13 DAILY VISUAL CHECK VIII DISPENSER CONTAINMENT SPENSER ^ t FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ^ 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER ~7NT//~NMENT 3.J/e~ ^ No ^ 2 CONTINUOUS ELECTRONIC SENSOR +AUDIBLE AND VISUAL ALARMS +AUDIBLE ANO VISUAL ALARMS ^ 4 DAILY VISUAL CHECK certlry that Me Intormatbn provided hareln Is true d accurate to Me Dest of my ,IGNATURE OF OWNER/OPERA7pR n" . /) _ , DATE 6-/~-0~ ermlt Number ( or kK:al use only) smgt Approved Parmll xplratbn ate UNDERGROUND PIPING INFORMATION form B _t._~: •~t ; :•~ ~GG_t ~ 1 ~ . ~._~ ~ 0'=Th,FT ~IE,1 _ ~ c . _ hvL _ _ Q f- I I .~-~..~.-- N ,~ u- .~ ~~ ~~~ ~~ r '~ ~ JJJ J _~ . _ ~. ~~- _ C~ U~"''S ~ ~ ~ , 1 f ~: i V ,j I~ l i I { t , ~I i ~I ~ I i j ,! , i ~. j •d ...-~_'- -- ~.. r:. ..... ~~ __ ._. ~ l ~ - _ ~ ~ ` `