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Home My WebLink AboutBUSINESS PLAN (2),~-y ,, e~ ~- ~ _ --- -_____ STOCKDALE TEXACO ~ 5321 ST -~-, _ .. - - . - - OCKDALE HWY. _, -~~ ` .'~ 4. .3 ~\~. ( g ~ a~a _~ ~,~- ~~ i ~~~~~ -~ /', - - ~ - 00 - .Prvevention Services UNIFi~D PROGRAM-INSPECTION CHECKLIST,' A F ~ s F-, -_ n 90oTruxtunAve., suite.zlo _._~£~..~-_....;,a.a;. v. _:.- Free Bakersfield, CA 93301 SECTION 1: -Business Plan and Inventory Program ° aerM Tel.: (661) 326-3979. - ~ Fax: (661) 872-2171 FACILITY NAME - __(( f( tt /~ _t ~{-~- - ~ ®G%t LI.CL.~ clC~1 1 INSPE TIO ,(DATE V INSPECTION TIME ADDRESS ~~ ~ j . / - PHONE NO. NO OF EM LOYEES FACILI TY CONTACT _ - BUSINESS ID NUMBER 15-021- 1~ ~ ~-, ~- t -- - - _--- -- - - °Section 1:' Business Plan and Inventory Program ^ ROUTINE OMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ - __~ I RE-INSPECTION C V r C=Compliance OPERATION ' ` V=Violation COMME NTS ^ ~/ APPROPRIATE PERMIT ON HAND Q~tL.7~ hfe f It ~~ ,~ ~ ~~^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECTOCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS A U G ®~ 2007 VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ^ i~VERIFICATION OF MSDS AVAILABILITY ` MQ Z ' ~~ t l ^ VERIFICATION OF HAZ MAT TRAINING ` ~ (C ^ L~J' VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES L` ( ^ EMERGENCY PROCEDURES ADEQUATE l~ ~' ^ CONTAINERS PROPERLY LABELED HOUSEKEEPING ^ FIRE PROTECTION ` ^ ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? ^ YES ^ NO ~ ~ f no~ EXPLAIN: ~"11/~) ~r~o i . ~ ~~b QUESTION$.REGAeR[~ING~THIS INSPECTION? PLEASE CALL US AT (667) 326-3979 ~~~~~ (Please Print) Fire PrebER~on / 1~` In /Shift of Site/Station # ~ 'busin'ess Site _ ~ ~ -White -Prevention Services- ~ - _ Yellow -Station Copy Pink -Business Copy - FD 2155, (Rev. 09/05 .~ INSPECTIONS B I E R S F l L D BUSINESS PLAN & ~ rM r INVENTORY PROGRAM - ~- UNIFIED PROGRAM INSPECTION CHECKLIST FACILITY NAME: ,~ C r~~t/ ~mC1d ~Sf (~ Section 2: Underground Storage Tanks Program INSPECTION DATE: ~`Z ^ Routine ~ Combined ^ J int Agency ^ Multi-Agency ^ Complaint ^ Re-Inspection Type of Tank ~( ~ Number of Tanks 3 Type of Monitoring Type of Piping ~W(= OPERATION C V COMMENTS Proper tank data on file Proper owner /operator data on file Permit fees current Certification of Financial Responsibility Monitoring record adequate and current Maintenance records adequate and current ~ (- Failure to correct prior UST violations Has there been an unauthorized release? ^ Yes o Section 3: Aboveground Storage Tanks Program Tank Size(s) Type of Tank OPERATION Y N COMMENTS SPCC available SPCC on file with OES Adequate secondary protection Proper tank placardingllabeling 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 Pink -Business Copy 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 Page 1 of 1 KBF-7335 FD 2156 (Rev. 09/05) r_ _. -~- _ - - _ ~ CORRECTION NOTICE BAKERSFIELD FIRE DEPARTMENT p p Z 5 3 5 PREVENTION SERVICES DIVISION ~, 1600 TRUXTUN AVENUE, SUITE 401 - (661) 326-3979 Location: ~3~ j ~~~Yda~~L.. C~.tJ-~ Y~~ou~~are hereby required to take the following action at the above location; l1!/'CORRECT 8~ CALL FOR/`REINSPEC/TION /' ^ CORREECT & PROCEED 1~ ~ ~-tr~ ~~r-I-I t. ~ 01r ~iC~ r- In~~fl r ~ae.~1 ~ v -- ~ ~ ~~ ~ ~ ~"~ IQc Guae`t t~ t ~ CA r• ~ ~C' < < o~ _. ~ ((, Completion Date fo~orre~o~~ /~ /~ Received by: ~- Inspector: St@V@ Und@IWOOd Initial Date: ~ /~ /~ Desk Phone: (661) 326-3190 (from B:ODam to 8:30am) KBF-9229 STOCKDALE FOOD MART Manager FONG & MUNN CHAU Location: 5321 STOCKDALE HWY City BAKERSFIELD CommCode: BFD STA 11 EPA Numb: SiteID: 015-021-001242 BusPhone: (661) 832-1399 Map 102 CommHaz Moderate Grid: 34D FacUnits: 1 AOV: SIC Code:5541 DunnBrad: Emergency Contact / Title Emergency Contact / Title FONG CHAU / OWNER MUNN CHAU / OWNER Business Phone: (661) 832-1399x Business Phone: (661) 832-1399x 24-Hour Phone (661) 589-5982x 24-Hour Phone (661) 589-5982x Pager Phone (661) 301-6617x Pager Phone (661) 706-2611x Hazmat Hazards: Fire ImmHlth DelHlth Contact FONG & MUNN CHAU Phone: (661) 832-1399x MailAddr: 5321 STOCKDALE HWY State: CA City BAKERSFIELD Zip 93309 Owner FONG & MUNN CHAU Phone: (661) 832-1399x Address 5321 STOCKDALE HWY State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG U - UST ~N~® ~~ ~ ~ ~ ~~~~ F?ased on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that 1 have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. ~~~~~~~ ~~~5~~ Signatur Date -1- 08/08/2007 F STOCKDALE FOOD MART SiteID: 015-021-001242 ~ STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: STOCKDALE FOOD MART Cross Street Business Type: Org Type: PARTNERSHIP Total Tanks 3 IndnRes/Trust: No PA Contact: Dsg Own/Oper JAMES RICH ICC Nbr: PROPERTY OWNER INFORMATION Name MUNN CHAU Phone: (661) 832-1399x Address: City State: Zip: Type TANK OWNER INFORMATION Name MUNN CHAU Phone: (661) 832-1399x Address: City State: Zip: Type BOE UST Fee# Financ'1 Resp: SELF INSURED Legal Notif Business Mailing Address Date:l2/12/0200 Phone: (166) 183-2 13x99 Name:FONG & MUNN CHAU Ttl:OWENRS State UST # 1998 Upg Cert#: -2- 08/08/2007 F STOCKDA.LE FOOD MART SiteID: 015-021-001242 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers on Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP UNLEADED F IH DH L 15000.00 Mod PREMIUM F DH L 8000.00 Mod DIESEL L 7000.00 Low -3- 08j08/2007 -4- 08/08/2007 F STOCKDALE FOOD MART ~ Inventory Item 0003 COMMON NAME / CHEMICAL NAME UNLEADED Location within this Facility Unit STATE TYPE PRESSURE Liquid TMixtur~mbient SiteID: 015-021-001242 ~ Facility Unit: Fixed Containers on Site ~ Days On Site 365 Map: Grid: CAS# 8006-61-9 TEMPERATURE CONTAINER TYPE Ambient ~ER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 15000.00 15000.00 15000.00 riAGi~l[LVUJ 1,V1~lYV1V1;1V7a °sWt. RS CAS# 100.00 Gasoline No 8006619 tit~~tircL t~5a~a~ln~lvl~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Mod ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site ~ COMMON NAME / CHEMICAL NAME PREMIUM Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 8006-61-9 Liquid TMixtur~ AmbRient~E ~ AmbientT~E ~ UNDER GROUNDRTANKE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 8000.00 8000._00 8000.00 ri!-1GL-~tCLVU.7 1.V1~lYV1VL"1V1J oWt. RS CAS# 100.00 Gasoline No 8006619 tii-~GHtCL 1-~.~.7~JJ1~1~1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod -5- 08/08/2007 F STOCKDALE FOOD MART SiteID: 015-021-001242 ~ ~ Inventory Item 0002 Facility Unit: Fixed Containers on Site ~ lY/111 RT RlYLT 7.TTfRT ~ IYiTTfeT /Ywr ~tw ~~r AMOUNTS AT THIS LOCATION Largest C7000100r Daily7000100m I Daily7000r00e nr~L,rucl~v~a ~.vl~lrvlvnlvla %Wt. RS CAS# 100.00 Fuel Oil No. 1 No 70892103 Ilti[~L~itCL HA .71;.7 J1~1~1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Low -6- 08/08/2007 Liquid TMixture ~mbRent~E ~ AmbientT~E UNDER GROIINDRTANKE F STOCKDALE FOOD MART SitelD: 015-021-001242 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ Agency Notification 03/29/2006 FACILITY HAS LAMINATED EMERGENCY RESPONSE SHEET BY CASHIERS PHONE, LISTING 911, POLICE AND FIRE DEPT NUMBERS AND TEXACO PERSONNEL NUMBERS. Employee Notif./Evacuation 06/19/2006 THE MANAGER, ASSISTANT MANAGER OR CLERK/CASHIER WILL NOTIFY ALL OTHER EMPLOYEES AND/OR CUSTOMERS; EVACUATE TO PREDESIGNATED MEETING AREA SHOWN ON SITE MAP; CALL 911 FROM NEAREST, SAFEST PHONE. Public Notif./Evacuation 12/12/2000 EMPLOYEES HAVE BEEN INSTRUCTED TO ASSIST CUSTOMERS IN VACATING PREMISES TO PREDESIGNATED MEETING AREA. DIAL 911 FROM NEAREST, SAFEST PHONE. Emergency Medical Plan 12/12/2000 MERCY HOSPITAL, 2215 TRUXTUN AVE, 327-3371. -7- 08/08/2007 F STOCKDALE FOOD MART SiteID: 015-021-001242 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 06/19/2006 ~ GASOLINE PUMPS ARE EQUIPPED WITH AUTOMATIC SHUT-OFF NOZZLES. ABSORBENTS AVAILABLE TO CONTAIN SMALL SPILLS. EMERGENCY SHUT-OFF SWITCH, WITH SIGN SHOWING LOCATION KILL BUTTON, ON CASHIERS CONSOLE, PRODUCT DELIVERIES ARE CONTINUALLY MONITORED, CAMLOCK HOSE FITTINGS ON TANK FILLS. Release Containment 03/29/2006 LAMINATED EMERGENCY RESPONSE SHEET INSTRUCTS EMPLOYEES TO IMMEDIATELY COVER SMALL RELEASES WITH ABSORBENT MATERIALS. IF INCIDENT IS LARGE, CONTACT 911. Clean Up 06/19/2006 IF SMALL - WASTE IS PUT IN A LABELED, SEALABLE CONTAINER. ABSORBENT IS PROPERLY DISPOSED OF OR THE PRIMARY MAINTENANCE CONTRACTOR IS CONTACTED TO DISPOSE OF MATERIALS. IF LARGE - MAINTENANCE CONTRACTOR, RLW EQUIPMENT, IS CONTACTED. DIAL 911 AND NOTIFY AUTHORITIES OF EMERGENCY AND PROPER HANDLING. Other Resource Activation -8- 08/08/2007 a ~ ' b F STOCKDALE FOOD MART SiteID: 015-021-001242 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ .~t/c~,iai nac~aiuc = Utility Shut-Offs 04/03/2006 A) GAS - REAR OF MAIN BLDG OUTSIDE B) ELECTRICAL - CIRCUIT BREAKER PANEL INSIDE BLDG C) WATER - REAR OF BLDG OUTSIDE D) SPECIAL - EMER SHUT-OFF SWITCH LEFT OF FRONT DOOR E) LOCK BOX - NO Fire Protec./Avail. Water 03/29/2006 PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS IN LUBE BAYS AND IN CASHIERS AREA. FIRE HYDRANT - ACROSS STOCKDALE HWY, ACROSS NEW STINE RD. Building Occupancy Level 03/29/2006 = 4 EMPLOYEES -9- 08/08/2007 ', F STOCKDALE FOOD MART SiteID: 015-021-001242 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 06/19/2006 ~ MATERIAL SAFETY DATA SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: EMPLOYEES RECEIVE TRAINING UPON HIRING ON HAZARDOUS MATERIALS AND EMERGENCY RESPONSES. TRAINING IS REINFORCED EACH YEAR. rayc c Held for Future Use nc.LU ivi ru~.,utc vac -10- 08/08/2007 38293NC Bakersfield Final Summary .I[~R 1 A(~ Sl1MMARY TYPE OFTEST-(Pretest, Final, Leak locate, Retest] = Fir-aJ Probe Install? (YesiNo) WA Job Number: 38293NC SWO # 60003157 Client: DJN Construction Client Contach Jerry Hale Site Name: Stockdale Food Mart Phone: ss~-2o~s7o7 Site Address: 5321 Stockdale Hviry site CornacK: Jerty Hale City, State: Bakersfield, CA 93309 Site Phone: 661-201.3707 Crew: CA Cert: Ricardo Gonzalez LIC # 04-1695 Chemist: Ricardo Gonzalez Truck # 25 Trailer # 29 GC# 3800-15 Crew• Sergio Nunez a e rs Initial Approver Start Date: Day 2 Day 3 Day 4 Day 5 12H4J06 Start Time: 12H5/06 Start Time: 12115!06 Start Time: 12116/06 Start Time: 12/17/06 Start Time: 8:00 AM End Time: 7:30 PM 8:45 AM End Time: 12:00 PM 2:00 PM End Time: 7:30 PM End Time: End Time: Totals 11.5 71.5 3.25 3.25 5.5 5.5 20.25 20.25 MAKE NOTES IF YOU HAVE ANY UN-BILLABLE HOURS Total Billable Hours 2.25 Total Detected Leaks s TEST RESULTS (PASS /-FAIL) Pass If fail -Describe in summary -Failed Components COMMENTS: (Leaks, un-billable hours, site specific info) Needed to get off site for 2 hours to wait for Teak sim. Also possible teak in secondary in vent trench. This is still a passing site. LOG Completed Ricardo Gonzalez Date: 12/15/2006 Hours Approved B (Print Name): Gilbert Rodriguez Signature: Date: 12lt 5/2006 Compan of Approver. DNJ Construction Page 1 _~- - - `. ~ JOB CARD ~OST CARD AT JOB SITE INSPECTION RECORD-USTs B $IZBPI D ~~~a ~~rr~r r BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 FACILITY N E , OWIJER I ~ ~ ,w` ADDRESS ~~ ~ AbbRESS CITY STATE ZIP CItY STATE ZI BAKERSFIELD CA ~AKERSFIELD CA ~3 ~ PHONE NO. ~ ~ .. P~FtINR NO. ®~ r r INSTRUCTIONS: PLEASE CALL FOR AN INSPECTOR ONLY WHEN EACH GROUP OF INSPECTIt~i~S WITH THE SAME NUMBER ARE READY. THEY WILL RUN IN CONSECUTIVE ORDER BEGINNING WITH NUMBER 1. D N T COVER WORK FOR ANY NUMBERED GROUP UNTIL ALL ITEMS IN THAT GROUP ARE SIGNED OFF BY THE PERMITTING AUTHORITY. FOLLOWING THESE INStftUCTIONS WILL REDUCE THE NUMBER OF REQUIRED INSPECTION VISITS AND THEREFORE PREVENT ASSESSMENT OF ADDITIONAL FEES. INSPECTION ................ DATE INSPECTOR TANKS AN,D BAGKFILL ACC jz~£~Z~ -cJr BACKFILL OF TANK(S) t~~ ~ ~~ ,Inn,('-~y. O~ 9 !~ 6 ~ j~i,.~s SPARK TEST CERTIFICATION OR MANUFACTURES METHOD SAL 9 /~. 6 ~~~ ,~,~~ CATHODIC PROTECTION OF TANK(S) ~ (SC'LGt-psS O/ts~ S`~C~~-- c~ / 4 ~ ~-L~y,,~,~r- PIPING SYSTEM PIPING 8~ RACEWAY W/COLLECTION SUMP CORROSION PROTECTION OF PIPING, JOINTS, FILL PIPE ELECTRICAL ISOLATION OF PIPING FROM TANK(S) CATHODIC PROTECTION SYSTEM-PIPING ~ I DISPENSER PAN ',,, SECONDARY CQNTAINMENT OVERFILL PROTECTION, L AK DETECTI N _, ... LINER INSTALLATION -TANK(S) CS ~ LINER INSTALLATION -PIPING l l~ l1tC '' VAULT WITH PRODUCT COMPATIBLE SEALER LEVEL GAUGES OR SENSORS, FLOAT VENT VALVES ~`~ ~ ~ PRODUCT COMPATIBLE FILL BOX(ES) - PRODUCT LINE LEAK DETECTOR(S) ~ - ' LEAK DETECTOR(S) FOR ANNUAL SPACE-D.W. TANK(S) f a a © MONITORING WELL(S)/SUMP(S) - H2O TEST LEAK DETECTION DEVICE(S) FOR VADOSE/GROUNDWATER / SPILL PREVENTION BOXES ,:~ FINAL 7 , ,~ MONITORING WELLS; CAPS & LOCKS ~ ' FILL BOX LOCK MONITORING REQUIREMENTS TYPE AUTHORIZATION FOR FUEL DROP ZV CONTRACTOR ~ ~`` (`F` ~ ~ O(K.~i~C'T ~ ©M LICENSE NO. /11 ~I ~ ~"I DIY CONTACT V C C~-T_~~-t-~ C. ~ 0-0-~ G2UZ. LG ~ G/L~ Qao2S PHONE NO. rA O ('~ ~7 O 7 ~'/i-Ss~ / G~ l~imcc (~7 lS FD 2097 (Rev. 09/05) nignLrax resaic~~~ tv:~c YAIi~. Vu1iUV1 rax berv6r .;: ~`" ~~ ,. ~~ t1NDEAGRQUiVt? STORAGE TANK s ~. _ ..:- -:mss ~zc~`+'~-; ~~ ...... = ~~ ~ .. .. ~. a PE~tMIT ~~P'L~CAYO®!~ _ ~f~irra~ir v FOR REMOVAL f INSTAL:ATIdN OF AN UST P®rmit No:~~-.~~ 8 SITE ~rACILITY NPJ1+fE ~. _~e.~. i._. _ -- --~-- - __-- ----- ~ - ~TANKOWNERfOPERATpN M MAILiNGADDRESS /~'~ ~ iCR05SSTP.EET ' PHONE N0. ~22 ~ BB pp A~PN 1 --- -- i .._ ___-----.. ~._ _ __._..._L- ~ Q..._. __..._ L._.... _ .. -- --- -' CITY Q~~~ i ZIP CODE 9 ~~ ~ ~ CUMPANY ~ ~ -- TdtJE NO. -..~. ' ~. ---1.~~'~`~ -'___.. ~__._' -~ ----~.-.... ~ _ SLP~ ' ~1? 2 ~ ____ ADDRESS ~_~~ ~~CI~''Y IZ!PCODE ~ ~ ~~ 3~ - ~- -----°-~`'' a e~ - ~ ------ i ---~ ~'~} _--~-_--~__--i IN$URANCcCARRiER ~~1C / ~~/~ ijWORKMENS;7~ t~(f~~ ~ ~- i ~ C~PANY ~_ ~+. N.._.~' ~ PHONE NO. - - LICENSE NO. i RD~IESS GIT, Y ~` ' ~iP COOE J !NSUfiANCEvAFRIER _----- -- -_- WORKMENS COMP NO. ~-------+` ---------1 i COtJPAN~' PHONE NO: - ------------. -~ LICENSE NO. ----' ADDRESSS !-tY ; Z CODE ~ 3 ---- ~ ----~-----------------~-- - ._-_ _.. .. -' - -°-..... _. .. _ .. .. ....._..__ A iNSURANCECAFRIEA `WORKtu~NS COMP t+lc. FlTi9T?~A 1D£fl1Ft•CATICN t1(i1d6~R-~ -- - __ -- - - --F+4C~RY IOENTIFtCAT10N M7MBER - ... _ NAtAF CF R8+13ATE OtSPt1,4A1 FAC'~U]Y ._ __ ... ~ t------ - -------------- -'---~ _.... ~ ---•---- - - ... ......._ _ -1 ' ADDRESS j cITY i zip coD~ ~ ~ ~ 'd'am ~' ~'~IBA~'#E~NI COMPANY ---- ---- -_.-------- PHONE NO. ~--__ __ ~ LICENSE NO. -a.._ ~ADDREBS CITY ~21PCODE F ANK DE5TIiVa1'IC1N - '-~- ~ ~ i '- --------- ...-r-_...._._------------ --- ------- ' i ~ '~ . t~NEAAICAL UAFES CMEYIGA:. ` TANK NO. AGE VOLI>1NE STORED STORED PAEVK)L'SLY STORED S ~ ...... ;t7~ac- ~ ~~~ ~ `-~ MUOC2N G-C_A~~ - ___t)~c1S -.-~--.._ . _. ~ ~ i ~~ . ~~rc-s e 2 ~ ~~ f--------__ - -----~-- -, __ - r-~----- - - i For UfEiCiei lJeo Or41y ` TkEnvaLMJ~NTHABRb"„EryYD,UNDERSTA.HptS,gNON'ILLCQA9PLy6YJ7HTlfEA]TACHEDCDA;AtT101dSOF7N1a^PFfAl/7ANDANY07HF_RSTATE. ~-~ ~ [GCAL AND FED R£GiiLAZf~BIS. , TY1S FYJR+11IlA$SEe71-CJ~fPL7e~ tJ~tiOEA PHW1t7YOF?ER1llkY. ANO TO TN£BEST ~FdAY KNOIYIEGf~fS TRt1EAMDCORAEC7 ~ AaNticAN~ NaMe (PR~';~= -------- ~ AF'YUGAtJT SIGNRTUflE ; R flOVED BY -_ -~ --- l~~I, / , ! - ~ ~ JW __.- Tirfl5 APPLIC/~Tit~ MOLL BEC~11+9E A PERf~IfT WHEN APPR®VED Fib 2082 (R.v. ~2~0~} }3AR~RSFIL3.D P°~RE D~P'T. PiC'~eIIf.~O>Yi S~a'Yf~ 900 Truxtun Ave.. Ste. 210 Bakefield, CA 9:1:301 Tel: tfi61) 32.6-3979 Fax: (661) 852-2171 Paao 1 of t Healy Systems 9961 Clean Air Separator .- Page 1 of 1 ~~ ~~ .~ ~ Il€~~R4'lE t~k€11'~t~ .~ ~# ~~ ~ Af~~;~ ~ ~~"~` ~ ~~~? . l ,,,.. ' , 0 a ~ . ~ ~ PRODUCT INFORMATION ,Healy Stage 11 Vapor Recovery Systems ,,,;~~r,, .,~K~ ! . ' t; E ti ~ ~h. 1 t'/3 .~ t .. ~ ~ ~ Ce~tifie~l Stage II ~a~~nr Ric®s-eiv _ ~ _~ ~~® 9961 Clean Air Separator (C~ The Healy Systems Clean Air Separator prev' excess emissions and product loss by control gasoline storage tank pressure. The unit worF combination with Healy ORVR /EVR type no: part of a system that increases overall perforr and efficiency to meet EVR standards and specifications. . High reliability and very low maintenanc . No mechanical moving parts . No electrical connections needed . 10 year warranty r'~~~ . j ~ ~~. - _._~ 4~ .a CARB Certified for use with: Under CARB Executive O 9a aaau~~sb;Fe mw~e . Healy_900 ,EVR Nozzle VR-201.-A a0m~tsem, ~aaa R~03Y - -- ~3_~-~~~~ VR-202-A ro aam~ a~~ap ~ya4a~u, i~~ Sack Next ~, Mealy SystemsF fii~l6e ~~ 9~~~~~t~b~e I~~~/~~ ~t~~t~~e ~~ P~~p~rRe~avery~ ~e ,; VENT VALVE AS RED. 3" VENT PIPE SLOPE TOWARD VENT, AIR BREATHER ASSM. 100 FT. MAX. LENGTH, AIR (IN/OUT) 1 /8" PER FT. PITCH P/N 9948 1" BLADDER i" SYPHON VAPOR INLET ASSM. FLOAT CHECK VALVE P/N 9956 (REF.) P/N 9a66G OVERFILL PROTECTION 72' MINIMUM ABOVE GRADE 1" TEE WITH PLUG ON 6~ NIPPLE ~ SYPHON TUBE ADAPTER DALL VALVE P/N 996123 VAPOR P/N 9939 (REF.) LOCK P/N 996124 USE KEY P/N 996125 SYPHON TUBE AIR P/N 4186-6 (REf.) 104" REF. 400 GALLON BLADDER, P/N 9943 (REF.) CLEAN AIR SEPARATOR (36" O.D. X 93" LG.) P/N 9961 1" CONDENSATE DRAIN. PLUG S 89900 9945 FOR 0 AILS. 'I a •~.o NOTE: t-ALL BALL VALVES (B.V.T TO DE UL LISTED AND HAVE PADLOCK FEATURE. 2-PASSIVE TANK PRESSURE CONTROL-NO ELECTRICAL POWER REQUIRED. ~UND~'RGROUND STORAGE TANKS R UNIFIED PROGRAM CONSOLIDATED FORMS APPLICATION OPERATING PERMIT APPLICATION FACILITY FORM - (STATE FORM A) One form per facility TYPE OF ACTION: (Check one item only) ^ t. NEW SITE PERMR ^ 8. TEMPORARY SITE CLOSURE BAKERSFIELD FIRE DEPT. Page 1 of 2 ^ 3. RENEWAL PERMIT ^ 5. CHANGE OF INFORMATION (Specify change bcel use Doty) ^ 7. PERMANENT SITE CLOSURE ^ 8. TRANSFER PERMIT 400 1. FACILITYtSITE INFORMATIQ N TOTAL NUMBER OF USTs AT SITE ~ 404 AGILITY ID No. Agency Use Only) 1 BUSINESS NAME (Same as FACILITY ME r Fy~ Doing B ass A) r r• ` BUSINESS SITE ADDRESS g ~ ~ ~ f 103 CITY ~~ 104 Is facility on Indian Reservation or Trust lands? ^ Yes ~.A~ 405 II PROPERTY OWNER INFORMATION PROPERTY OWNER NAME '~ ~ ~ 407 PHO E ~ ~ 408 MAILING OR STREET ADDRESS ~ ~ 409 CITY I~U~ ~ ( 410 1 STATiE (~ ' 411 ~p ..lT ZIQ CODE 4 2 (~ ` IiL TANK OPERATOR INFORMATION OPERATOR NAME ~ ~ H0~ ~~ I 3g T02 MAILING OR STREET ADDRESS ~ t T03 d CITY T04 STAT T05 IP ODE 6 30 PROPERTY OWNER TYPE ^ 1. CORPORATION ^ 2. INDIVIDUAL ^ 4. LOCAL AGENCY/ DISTRICT ^ 6. STATE AGENCY ~ 3 ^ 5. COUNTY AGENCY ^ 7. FEDERAL AGENCY PA RTIJFRSHIP IV. TANK OWNER INFORMATION `' ANK OWNER NAME ~ ata PH Et~ ~ ,~ ~ at (LING OR STREET ADDRESS i ate Y ITY M _ /t I r ~ 417 ••~- 1` Lw STAT ~ at8 ZIP ~DE O Cy 4t 3 ANK OWNER TYPE ^ 1. CORPORATION/LCC ^ 2. INDIVIDUAL ^ 3. PARTNERSHIP ^ 4. LOCAL AGENCY/ DISTRICT 420 ^ 5. COUNTY AGENCY ^ 6. STATE AGENCY ^ 7. FEDERAL AGENCY V. BOARD OF EQUALIZATION UST STORAGE FEE,A000UNT NUMBER (TK) HO 4 4 all (916) 322-9669 if there are any questions 42t VI. PERMIT HOLDER INFORMATION ssue permit and send legal notifications and mailings to: .FACILITY OWNER ^ 3. TANK OWNER ^ 4. TANK OPERATOR ^ 5. FACILITY OPERTOR 422 egal notifications and mailings will be sent to the tank own unless box 4 or 5 is checked. UPERVISOR OF DIVISION, SECTION, OR OFFICE (Required for Public Agencies Only) 40a VtI. APPLICANT'SIGNATURE Certlficatloni I cerU that the Informatlcn ovtded herein is true .accurate and in full com Rance with l al uhements. IGNATURE OF APPLICANT a2a ATE azs PHO a AME OF APPLICANT (print) azT TITLE OF APPLICANT a2 USINESS NAME 3 USINESS SITE ADDRESS 103 Prevention Services $ B R 9 F 1 ~ 900 Truxtun Ave., Ste. 210 F1Rd Bakersfield, CA 93301 wr~fM r Tel.: (661) 326-3979 Fax: (661) 852-2171 FD 2093 (Rev. 11/06 UNDERGROUND STORAGE TANKS ~l3NIFIED PROGRAM CONSOLIDATED FORMS rt, APPLICATION (Continued) OPERATING PERMIT APPLICATION 1 FACILITY FORM - (STATE FORM A) One form per facility H B R S P I D P/R~ A~ ! BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave ,Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 2 of 2 `VIII. PRfMARY DESIGNATED OPERATOR INFORMATION RIMARY DESIGNATED OPERAT AM~~ •-, D01a Ic~1~ y' HONE D01b USINESS NAME DOtc ILING OR STREET ADDRESS D01d ITY D001e STATE DOtf IP CODE D01g CC CERT. # i D01h PIRATION DATE D01i RELATIONSHIP TO UST FACILITY (Check One): ^ 1. OWNER ^ 2. OPERATOR ^ 3. EMPLOYEE ^ 4. SERVICE TECHNICIAN ^ 5. THIRD PARTY D01j IX. ALTERNATE DESIGNATED OPERATOR INFORMATION ALTERNATEESIGNATED OPERATOR NAME D02a PHONE D02b BUSINESS NAME D02c MAILING OR STREET ADDRESS D02d CITY D002e STATE D02f ZIP CODE D02g ICC CERT. # D02h ~ EXPIRATION DATE D02i (RELATIONSHIP TO UST FACILITY (Check One): ^ 1. OWNER ^ 2. OPERATOR ^ 3. EMPLOYEE ^ 4. SERVICE TECHNICIAN ^ 5. THIRD PARTY D02jj (Attach an additional page if necessary.) I certify that; for this facility, the individual(s) listed above will serve as'Desigriated UST'Operatol'(s). The individual(s) will conduct and document month ;faci6 ins ections ahd,annual facif em to ee trainin ; in accordance,withCalifornia Code of RE ulatians Title 23, Sectiom2715©- NAME OFTANK OWNER (Please Print) D03a SIGNATURE OF TANK OWNER DATE )~D ~~ D03b FD 2093 (Rev.17/O6) HAZARDOUS MATERIALS MANAGEMENT PLAN BAKERSFIELD FIRE DEPT. Prevention Services INSTRUCTIONS "-- ~ R s °-' - n 900 Truxtun Ave., suite 210 P/RF Bakersfield, CA 93301 BUSNESSOWNER/pPpZATOR DBYTF1CATi0NFORM ARTN r (I1A7~4RDOUS MATERIALS FAC/LlTYINFORMATION) Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 I. FACILITY IDENTIFICATION: Enter the reporting period (year beginning and ending) for the facility information. Enter the business name and site address and phone number of your business. Do not use P.O. Box numbers. Enter the Dunn & Bradstreet or federal tax identification number for your business. Enter the Standard Industrial Classification (SIC) number for your business. Each type of business has a Standard Industrial Classification code number. Some common SIC codes are listed on the bottom of this page. Other SIC codes may be obtained from your worker's compensation insurance forms, the State of California Employment Development Department, or by calling our office at_(661) 326-3979. Enter the name and phone number of the person responsible for operating the business. II.OWNER INFORMATION: List the legal business owner or corporation name and provide the headquarter address or residential address if owned by an individual and phone number. III. ENVIRONMENTAt_ CONTACT: Identify the person who is primarily responsible for environmental compliance at the business. This person may be either the business owner, one of the emergency contacts, an environmental manager, or consultant. IV. EMERGENCY CONTACTS: List the name, title, and phone numbers of two people at the business who can respond if the Bakersfield Fire Department requires additional information or other assistance. These contact persons must have keys or access to all areas of the facility, be available for emergency call-outs, and have decision-making authority to call on other resources (such as hazardous waste clean-up companies) as necessary. V. CERTIFICATION: The business owner or operator must sign, date, and also identify the document preparer. COMMON STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODES 0111 Wheat production 0541 Grocery store 5821 Eating places 0115 Corn production 0724 Cotton ginning 5813 Drinking places (Alcohol service) 0131 Cotton production 1541 Dry cleaning 5983 Fuel oil dealers 0139 Field crops, except cash grains 2851 Paint manufacture 5984 LPG dealers 0161 Vegetables 8 melons 2911 Oil Refineries 7342 Pest control 0172 Grapes 3441 Welding Fabrication-structural 7532 Auto top, body, upholstery repair 0173 Tree nuts 3443 Welding Febrication-boiler Auto paint shops 0174 Citrus fruits 3569 Machine shop 7533 Auto exhaust repair 0175 Deciduous tree fruits 4222 Cold Storage 7536 Auto glass replacement 0179 Other tree fruits 8~ nuts 4925 Compressed gas supplier 7537 Auto transmission repair 0192 General farms, primarily crop 5093 Automobile salvage 7538 General auto repair 0241 Dairy Farms 5169 Chemical supply 7542 Car washes 0252 Chicken Eggs 5511 Motor vehicle dealers (new & used) 8071 Chemical laboratory 0253 Turkey eggs 5521 Motor vehicle (used only) 0291 General farm, primarily livestock & 5531 Auto & home supply stores Animal specialties 5541 Gasoline service stations FD 2141 (Rev. 09/05) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFIED PROGRAM CONSOLIDATED FORM) APPLICATION BraSNES.SC7V11NER/OPB'2ATORDENTFICATION FORM (HAZARDOUS MATERIALS FACILITY INFORMATION) e a x s r 7 . n --P/RF -- . ~; ~Rrr r BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661)852-2171 Page 1 of 2 I. F.AGILITY.IDENTIFICATION FACILITY ID NO. 1 Year Beginning too Year Ending tot BUSINESS NAME (Same as AGILITY M or DBA- Doi~Busin 4v s As) s BUSINES P~IQ ~ ~ J•( toz ~~ ~~ SITE ADDRESS ~ 103 CITY ^ ~~t P IN< l toa CA IP ^ Q Y toy DUNN & BRADSTREET t06 SIC CODE (4 Digit #) 107 COUNTY ~/~ _ ~ 1~ OPERATOR NAME ~ Q ~ ~ ~. `N M a ~~a ~ toe OPERA~O H~ "E13 ~ t10 IL OWNER,INFORMATION _ OWNER NAME rte.., t< ~ ttt ~~~ OWN R PH NE ~3~ ~ l 3 9 tt2 OWNER MAILING ADDRESS p d tt3 CITY tta STATE tts IP tte I IL ENVIRONMENJAL CONTACT' CONTACT NAN~rn ~ ~ ``~K tt7 CONTA~ ~ ~ E ~ ~ ttg CONTACT MAILING AD ESS ~~ ~ L tte CITY ~ t2o STAT 121 ~- ZIP X33 t71 .PRIMARY Iv: EMERGENCY coN TAers -S;ECONDARY- NAME ~ 123 NAME ~~A 728 TfrLE 124 TITLE r 129 BUSINESS PHONE pl r L 725 BUSINESS PHONE ~ 730 24-HOUR PHONE 1 r v ~ 126 24-HOUR PHONE ~ ~ 131 PAGER NO. `` ~O\r 127 PAGER N0. rr~ I ~~~o t ~~1 132 133 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 information submitted in this inventory and believe the information is true, accurate, and.complete. SIGNAT OF SIGNER 736 DATE 134 NAME OF DOCUMENT PREPARER 135 NAME F OWNER/OPERATOR (SDIGNATURE & PRINT) 737 TITLE OF OWNERIOPERATOR 138 FD 2142 (Rev. 09/05) (Hazardous Materials Facility Information -HMMP) Business Owner/Operator Identification Please submit the Business Activities page, the Hazardous Materials Faci/itylnformation (HMMP) Business OwnedOperator Identification Form, and Hazardo~ Materials Inventory Chemical Description Form for all hazardous materials inventory submissions. For the inventory to be considered, please complete this page, it must be signed by the appropriate individual. NOTE.• The numbering of the instructions follows the data element numbers that are on the Business Owner Operator Form page. These data element numbe. are used fore%ctronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary. Please number a!! pages of your submittal. This helps our CUPA or AA identify whether the submittal is complete and if any pages are separated. 1 FACILITY I.D. NUMBER -This number is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3 BUSINESS NAME -Enter the full legal name of the business. 100 BEGINNING DATE -Enter the beginning year and date of the report. (YYYYMMDD) 101 ENDING DATE -Enter the ending year and date of the report. (YYYYMMDD) 102 BUSINESS PHONE -Enter the phone number, area code first, and any extension 103 BUSINESS SITE ADDRESS -Enter the street address where the facility is located. No post office box numbers are allowed. This information must provide a means to geographically locate the facility. 104 CITY -Enter the city or unincorporated area in which business site is located. 105 ZIP CODE -Enter the zip code of business site. The extra 4 digit zip may also be added. 106 DUNN & BRADSTREET -Enter the Dunn & Bradstreet number for the facility. The Dunn & Bradstreet number may be obtained by calling (610) 882- , 7748 or by 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 on/y 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, if different from business phone, area code first, and any extension. 111 -OWNER NAME -Enter name of business owner, if different from business operator. 112 OWNER PHONE -Enter the business owner's phone number if different from business phone, area code first, and any extension. 113 OWNER MAILING ADDRESS -Enter the owner's mailing address if different from business site address. 114 OWNER CITY -Enter the name of the city for the owner's mailing address. 115 OWNER STATE -Enter the 2 character state abbreviation for the owner's mailing address. 116 OWNER ZIP CODE -Enter the zip code for the owner's address. The extra 4 digit zip may also be added. 117 ENVIRONMENTAL CONTACT NAME -Enter the name of the person, if different from the Business Owner or Operator, who receives all environmental correspondence and will respond to enforcement activity. 118 CONTACT PHONE -Enter the phone number, if different from the Owner or Operator, at which the environmental contact can be contacted, area code first, and any extension. 119 CONTACT MAILING ADDRESS -Enter the mailing address where all environmental contact correspondence should be sent, if different from the site address. 120 CITY -Enter the name of the city for the environmental contact's mailing address. 121 STATE -Enter the 2 character state abbreviation for the environmental contact's mailing address. 122 ZIP CODE -Enter the zip code of the environmental contact's mailing address. The extra 4 digit zip may also be added. 123 PRIMARY EMERGENCY CONTACT NAME -Enter the name of a representative that can be contacted in case of an emergency involving hazardou materials at the business site. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business 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's home phone number, then the service answering the phone must be able,to immediately contact the individu, stated above. i27 PAGER NUMBER -Enter the pager number for the primary emergency contact, if available. 128 SECONDARY EMERGENCY CONTACT NAME -Enter the name of a secondary representative that can be contacted in the event that the primary emergency contact is not available. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regarding incident mitigation. 129 TITLE -Enter the title of the secondary emergency contact. 130 BUSINESS PHONE -Enter the business telephone number for the secondary emergency contact, area code first, and any extension. 131 24-HOUR PHONE - Enter a 24-hour phone number for the secondary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individual stated above. 132 PAGER NUMBER -Enter the pager number for tfie secondary emergency contact, if available. 133 ADDITIONAL LOCALLY COLLECTED INFORMATION -This space may be used for CUPA's or AA's to collect any additional information necessan to meet the requirements of their individual programs. Contact your local agency for guidance. 134 DATE -Enter the date that the document was signed. (YYYYMMDD) 135 NAME OF THE DOCUMENT PREPARER (FULL PRINTED NAME) -Enter the full printed name of the person who prepared the inventory submittal information. 136 NAME OF DOCUMENT SIGNER (FULL PRINTED NAME) -Enter the full printed name of the person signing the page. The signer certifies to a familiarity with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information, ail the information submitted is true, accurate and complete. 137 SIGNATURE OF OWNERlOPERATOR/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 signer's belief that the submitted information is true, accurate and complete. 138 TITLE OF OWNER/OPERATOR/OR DESIGNATED REPRESENTATIVE (SIGNER) -Enter the title of the person signing the page. Page 2 of 2 FD 2142 (Rev. 09/05) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS FOR HMMP SECTION DISCOVERY AND NOTIFICATION (FORMS) SECTION 1. -BUSINESS IDENTIFICATION DATA: ~ H R 9 F I D F/R~ wItTM T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 The Business Owner /Operator Identification Form FD2089, Chemical Description Form(s) FD208Ei, and other forms (e.g.; underground storage tank information, hazardous waste treatment, etc., as needed) may be submitted as the first section of the Hazardous Materials Management Plan in order to avoid duplication of information for initial submissions. HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 11.1 -DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: Describe the procedures and equipment used to detect any release or threatened release of a hazardous material from any storage container, tank, or vessel at your business. Please provide a written explanation that also includes the make and model number of any automated or electronic leak detection equipment in use at your facility. B. EMPLOYEE AND AGENCY NOTIFICATION: What agencies and or corporate officials are notified in case of a hazardous materials spill or emergency -What procedures are used to notify these parties? At a minimum, you must call 9-1-1 and the Office of Emergency Services at 1-800- 852-7550 to report any spills that are a threat to life, safety or the environment, or for other non-emergency spill reporting, please call our office at (661) 326.3979. C. ENVIRONMENTAL RESPONSE MANAGEMENT: Please describe who will be responsible for what activities (notifying authorities, clean-up companies, etc.), and what the chain-of-command is at your facility for making sure these activities are carried out. D. EMERGENCY MEDICAL PLAN: Summarize your plan for handling medical emergencies occurring at your business. List the local medical facility capable of handling an accident involving Hazardous Materials used at your business. HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 11.2 -RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: Explain the procedures that you have developed and implemented to help prevent an incident from occurring. These steps could include, but are not limited to, storage methods, container types, segregation, safety equipment, and/or procedures used. B. RELEASE CONTAINMENT AND/OR MITIGATION: Explain the procedures that you have developed and implemented to assist in keeping a hazardous materials incident at your business as small or confined as possible. C. CLEAN-UP AND RECOVERY PROCEDURES: Explain what clean up procedures will be implemented in case of a release at your business. This should address small spills, as well as a major release of material once the material is contained. Hazardous Waste: Please provide the name of the hazardous waste company that regularly removes the wastes from your business, and how often that waste is removed. Please keep all disposal receipts for the last three years available on site for inspection. FD 2169a (Rev. 09105) HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 11.2 -RELEASE RESPONSE PLAN (CONT.) UTILITY SHUT-OFFS List locations of shut offs using compass points and known or obvious landmarks. If you have a lock box containing keys and maps of the facility for the Fire Department to use, please list its location also. PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. Private Fire Protection: Describe on-site fire protection for your business or facility unit, including sprinklers, fire extinguishers, alarm systems and private response teams. B. Water Availability (Fire Hydrant): Give the location of the closest water supply or fire hydrant to be used by the Fire Department in case of an emergency. SECTION III -TRAINING List the number of employees that are working in the area of the hazardous materials, use or storage. Include all employees who have any occasion to be in those areas. Give the location where Material Safety Data Sheets (MSDS) are kept on file. The MSDS must be readily available on sit in a place where employees can access them. Give a brief summary of your Hazardous Materials Training Program. Employees are required by State law to have a program which provides employees with initial and refresher training in the following areas: 1. Methods for safe handling of the hazardous materials used by your business. 2. The Ca{ OSHA Hazard Communication Standard. 3. Correct use of emergency response equipment and supplies available at your business. 4. The prevention, minimizing and clean up procedures you have developed for your business. 5. The emergency evacuation plans you have developed, as well as, your notification procedure and medical plan. 6. Procedure to coordinate with and assist the local emergency personnel that may respond to your business. 7. Who and how to call for immediate assistance in the event of an accident involving hazardous materials. CERTIFICATION Please fill in your name, title, and sign and date on the signature line. IMPORTANT You must return this plan, inventory forms, and map within 30 days of receipt. If you have any questions please callus at (661) 326-3979 Thank you for helping to keep our All America City cleaner and safer. CITY OF BAKERSFIELD BAKERSFIELD FIItE DEPT., OFFICE OF PREVENTION SERVICES 900 Truxtun Avenue, Suite 210, Bakersfield, CA Page 2 of 2 FD 2169a (Rev. osio5) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN APPLICATION FOR SECTION DISCOVERY AND NOTIFICATION (FORMS) B S R 9 F I A P/R! A T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 INSTRUCTIONS Page 1 of 2 1. To avoid further action,. return this form within 30 days of receipt. 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4 Be as brief and concise as possible. ---- -- SECTION I: FACILITY IDENTIFICATION BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) ADDRESS (For local use only) FACILITY ID N0. ~ ~ _ _ __ __ SECTION 11.1: bISCOVERY AND NOTIFICATIONS ..: A. LEAK DETECTION AND MONITORING PROCEDURES: B. EMPLOYEE AND AGENCY NOTIFICATION: C. ENVIRONMENTAL RESPONSE MANAGEMENT: D. EMERGENCY MEDICAL PLAN: i SECTION IL2: RELEASE RESPONSE PLAN --- _ -- __ A. HAZARD ASSESMENT AND PREVENTION MEASURES: B. RELEASE CONTA{NMENT ANDIOR MITIGATION: C. CLEAN-UP AND RECOVERY PROCEDURES: FD 2169 (Rev. oslos) Page 2 of 2 SECTION 11.2: 'RELEASE RESPONSE PLAN--CONT. UTILITY SHUT-OFFS (LOCATION OF SHUT-0FFS AT YOUR FACILITY) NATURAL GAS/PROPANE: ELECTRICAL: WATER: SPECIAL: PRNATE FIRE PROTECTION/WATERRVAILABILITY: A. PRNATE FIRE PROTECTION: B. WATER AVAILABILITY (FIRE HYDRANT): i SECTION III: TRAINING NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: CERTIFICATION - -- Based on my inquiry of those individuals responsible for obtaining the information, /certify under penalty of law that I have personally exam' ed and am familiar with the information submitted and believe the info-mation is true, accurate, and complete. / ~ SI TURE OF OWNER /OPERATOR OR DESIGNATED REPRESENTATIVE DATE 477 NAME OF SIGNE (p int). 478 TITLE OF SIGNER 479 FD 2169 (Rev. os/os> (HMMP) ``~ BAKERSFIELD FIRE DEPT. HAZARDOUS MATERIALS MANAGEMENT PLAN Prevention Services :_, _..:. ~ ~..__ a _ a x s r~ n 900 Truxtun Ave., Ste. 210 F/RF Bakersfield, CA 93301 ~~~UC~~(~ ~' ARrY r Tel.: (661) 326-3979 FOR CHEMICAL DESCRIPrfION FORM ~ '''~' Fax: (661) 852-2171 HAZARDOUS MATERIALS INVENTORY FORM _ Make as many copies of the chemical description form as necessary to report your entire inventory of hazardous materials. Report every hazardous material handled in quantities equal to or exceeding 55 gallons of a liquid, 500 pounds of a solid or 200 cubic feet of a gas. Report any amount of any hazardous waste being generated or handled on site. I. FACILITY INFORMATION: Check the appropriate box for a new inventory or for additions, revisions or deletions to an existing inventory. Enter the business name at the top of the form. Enter the page number in the right hand comer. Describe the exact location of the hazardous waste or material being reported. NOTE: Chemical location information is wnsidered confidential unless you check "no." If a site map is being submitted, you may refer to the map number and grid coordinates for the approximate location of the material, as shown on the map. II. CHEMICAL INFORMATION: Each of the instructions below correspond to the entry field with the same number on the chemical description form. CHEMICAL NAME 205 Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the International Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: If the chemical is a mixture or a hazardous waste, do not complete this field; complete the "common name" field instead. TRADE SECRET 206 Check "Y" for yes if the information in this section is declared a trade secret, or "N" for no, if it is not. State requirement: If yes, and business is not subject to EPCRA, disclosure of the designated trade secret information is bound by Health and Safety Code, Section 25511. Federal Requirement: If yes, and business is subject to EPCRA, disclosure of the designated Trade Secret information is bound by Title 40 Code of Federal Regulations (CFR) and the business must submit a "Substantiation to Accompany Claims of Trade Secrecy" form (40 CFR 350.27) to USEPA. COMMON NAME 207 Enter the common name or trade name of the hazardous material or mixture containing a hazardous material. EHS 208 Check "Y" for yes if the hazardous material is an Extremely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section blank and complete the section on hazardous CAS 209 Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the section below. FIRE CODE HAZARD CLASSES (Please leave blank) 210 HAZARDOUS MATERIAL TYPE 211 Check the one box that best describes the type of hazardous material: pure, mixture or waste. If waste material, check only that box. If mixture or waste, complete hazardous components section. RADIOACTIVE 212 Check "Y" for yes if the hazardous material is radioactive or "N" for no, if it is not. CURIES 213 If the hazardous material is radioactive, use this area to report the activity in curies. You may use up to nine digits with a floating decimal point to report activity in curies. PHYSICAL STATE 214 Check the one box that best describes the state in which the hazardous material is handled: solid, liquid or gaseous (gas). _ LARGEST CONTAINER 215 Enter the total capacity of the largest container in which the material is stored. FEDERAL HAZARD CATEGORIES 216 Check all the physical and health hazards associated with the hazardous material: PHYSICAL HAZARDS: Fire: Flammable Liquids and Solids, Combustible Liquids, Pyrophorics, Oxidizers Reactive: Unstable Reactive, Organic Peroxides, Water Reactive, Radioactive Pressure Release: Explosives, Compressed Gases, Blasting Agents Page 1 of 3 FD 2145 (Rev. 09/05) FU~LUr3~'? CN~4+.:±+:^ik;Psi^~4d~:~~ITdi:-~.!':~itev;~? ~; '~w;3%: i-{~~AC:S1C)I)5 Stt7~;,'~FZ"s ~i_$ iFd'~ ~*1 T ~~; HEALTH HAZARDS: Acute Health (Immediate): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, other hazardous chemicals with an adverse effect with short term exposure. Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long term exposure. ANNUAL WASTE AMOUNT 217 If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled. MAXIMUM DAILY AMOUNT 218 Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or 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. AVERAGE DAILY AMOUNT 219 Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each building or adjacent/outside area. Calculations shall be based on the previous year's inventory of material reported on this page. Total all daily amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this location, the amount shall be the average daily amount you project to be on hand during the course of the year. This amount should be consistent with the units reported in box 221 and should not exceed that of maximum daily amount. STATE WASTE CODE 220 If the hazardous material is a waste, enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. A list of common State Waste Codes are included on page 3 of these instructions. UNITS 221 Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet or tons. NOTE: If the material is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons). DAYS ON SITE 222 List the total number of days during the year that the material is on site. STORAGE CONTAINER 223 Check all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: If appropriate, you may choose more than one. STORAGE PRESSURE 224 Check the one box that best describes the pressure at which the hazardous material is stored. STORAGE TEMPERATURE 225 Check the one box that best describes the temperature at which the hazardous material is stored. HAZARDOUS COMPONENT 1 - 5 (% by weight) 226, 230, 234, 238, 242 If a range of percentages is available, report the highest percentage in that range. HAZARDOUS COMPONENT 1 - 5 Name 227,231,235,239,243 When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures, mineral and chemical composition should be listed. HAZARDOUS COMPONENT 1 - 5 EHS 228,232,236,240,244 Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "N" for no, if it is not. HAZARDOUS COMPONENT 1 - 5 CAS 229, 2.33, 237, 2415 245 List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. III. SIGNATURE: 246 Please print name, title, sign and date each chemical description form. If you have any questions Please call us at (661) 326-3979 FD 2145 (Rev. 09105) CALIFORNIA WASTE CODES Code Description Code Description Inorganics III Acid solution 2 < pH < 7 with metals (antimony, arsenic, barium, beryllium, cadmium, chromium, cobalt, copper, lead, mercury, molybdenum, nickel, selenium, silver, thallium, vanadium and zinc) 112 Acid solution without metals 113 Unspecified acid solution 121 Alkaline solution pH >12.5 with metals (see 111) 122 Alkaline solution without metals 123 Unspecified alkaline solution 131 Aqueous solution (2 < pH < 12.5) contain- ing reactive anoins. (azide, bromate, nitrite, perchlorate and sulfide anions) 132 Aqueous solution with metals (see 111) 133 Aqueous solution with total organic residues 100% or more 134 Aqueous solution with total organic residues less than 10% 135 Unspecified aqueous solution 141 Off-spec, aged, or surplus inorganics 151 Asbestos containing waste 161 FCC Waste 162 Other spent catalyst 171 Metal sludge (see 111) 172 Metal dust and machining waste (see 111) 181 Other inorganic solid waste Organics 211 Halogenated sotvenfs (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 241 Tank bottom waste 251 Still bottoms with halogenated organics 252 Other still bottom waste 261 PCB's and material containing PCB's 271 Organic monomer waste (includes Organics (con't) 272 Polymeric resin waste 281 Adhesives 291 Latex waste 311 Pharmaceutical waste 321 Sewage sludge 322 Biological waste other than sewage sludge 331 Off-spec, aged or surplus organics 341 Organic liquids (non-solvents) with halogens 343 Unspecified organic liquid mixture 351 Organic solids with halogens Sludges 411 Alum and gypsum sludge 421 Lime sludge 431 Phosphate sludge 441 Sulfur sludge 451 Degreasing sludge 461 Paint sludge 471 Paper sludge/pulp 481 Tetraethyl lead sludge 491 Unspecified sludge waste Miscellaneous 511 Empty pesticide containers 30 gal or more 512 Other empty container 30 gal or more 513 Empty containers less than 30 gal 521 Drilling mud 531 Chemical toilet waste 541 Photo chemical/photo processing waste 551 Laboratory waste chemicals 561 Detergent and soap 571 Fly ash, bottom ash, and retort ash 581 Gas scrubber waste 591 Bag house waste 611 Contaminated soil from site clean-ups 612 Household wastes Page 3 of 3 FD 2145 (Rev. 09/05) (HMMP) ~~ HAZARDOUS MATERIALS MANAGEMENT PLAN UNIFIED PROGRAM CONSOLIDATED FORMS b _li R 8 A I A ,....-.., ~..~x.~..,,.,,v..:..,~.:.~.~.,...~,_~,.~,._,.~.~_..,.~~~.~~.~.~~..~x. ,~.. PIRG ~' CHEMICAL DESCRIPTION FORM ~RrN r HAZARDOUS MATERIALS INVENTORY ^ NEW ^ ADD ^ DELETE ^ REVISE 200 BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 (One form per material, per building, or area.) Paoe1 of 2 F CILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) CHEMICAL LOCATION 201 CHEMICAL LOCATION 202 CONFIDENTIAL (EPCRA) ^ Yes ^ No FACILITY ID No. 1 MAP No. (optional) 203 GRID N0. (optionaq 2 Il: CHEMICAL `INFORMATION CHEM{CAL NAME 205 2 TRADE SECRET ^ Yes ^ No ~ c ti COMMON NAME 207 EHS' ^ Yes ^ No 20 CAS No. 209 'If EHS is "Yes," all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 21 TYPE 211 212 CURIES 21 ^ p PURE ^ m MIXTURE ^ w WASTE RADIOACTIVE: ^ Yes ^ No LARGEST CONTAINER 21 PHYSICAL STATE ^ s SOLID ^ I LIOUID ^ g GAS 214 21 FED HAZARD CATEGORIES ^ 1 FIRE ^ 2 REACTIVE ^ 3 PRESSURE RELEASE ^ 4 ACUTE H EALTH ^ 5 CHRONIC HEALTH (Check all that apply) ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 STATE WASTE 22 AMOUNT DAILY AMOUNT DAILY AMOUNT CODE 221 222 ^ UNITS ^ ga GAL ~ ^ cf CU FT ^ Ib LBS ^ to TONS DAYS ON SITE If EHS, amount must be in lbs. 22 STORAGE CONTAINER ^ k 60X ^ p TANK WAGON (Check all that apply) ^ a ABOVEGROUND TANK ^ f CAN ^ b UNDERGROUND TANK ^ g CARBOY ^ I CYLINDER ^ q RAIL CAR ^ c TANK INSIDE BUILDING ^ h SILO ^ d STEEL DRUM ^ i FIBER DRUM ^ n PLASTIC BOTTLE ^ e PLASTIClNONMETALLIC DRUM ^ j BAG ^ o TOTE BIN 2 STORAGE PRESSURE ^ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 225 STORAGE TEMPERATURE ^ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT ^ c CRYOGENIC %WT HAZARDOUS'COMPONENT EHS > CAS # 1 226 227 ^ Yes ^ Na 228 22 2 230 231 ^ Yes ^ No 232 23 3 234 235 ^ Yes ^ No 236 237 4 238 239 ^ Yes ^ No 240 241 5 242 243 ^ Yes ^ No 244 24 . ` IIL SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE 24 C~. .~ 2 - 2 ~ - a ~ !~ FD 2144 (Rev. 09!05) Hazardous Materials Inventory -Chemical Description UNIFIED PROGRAM CONSOLIDATED FORMS You must Complete a separate Hazardous Materials Inventory -Chemical Description page for each hazardous material (hazardous substances and hazardous waste) that you handle at your facility in aggregate quantities equal to or greater than 500 pounds, 55 gallons, 200 cubic feet of gas (calculated at standard temperature and pressure) or the federal threshold planning quantity for Extremely Hazardous Substances, whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory should reflect all reportable quantities of hazardous materials at 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 orAA 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 fegaf name of the business. 200. ADD/DELETE/ REVISE - Indipte 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 appl"tcable, multiple grid coordinates pn 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: tf 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 trede 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, discosure of the designated Trade Secret information is bound by 40 CFR and the business must submit a "Substantiation to Arx:ompany 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 ftom 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 infomtatior 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 Gass, inGude all. Contact CUPA or AA for guidance. 211. HAZARDOUS MATERIAL TYPE -Check the one box that best describes the type of hazardous material: pure, mixture or waste. If waste material, check only that box. If mixture or waste, complete hazardous components section. 212. 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 ohvsical and health hazards associated with the hazardous material. PHYSICAL HAZARDS HEALTH HAZARDS Flre: Flammable Li uids and Solids Combustible Li uids P ro horics Oxidizers Acute Health (Immediate): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, Reactive: Unstable Reactive Or anic Peroxides Water Reactive Radioactive other hazardous chemipls with an adverse effect with short term ex osure Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with Ion term ex sure 217. AVERAGE DAILY AMOUNT =Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each building or adjacenU outside area. Calculations shall be based on the previous year's inventory of material reported on this page. Total all daily amounts and divide by the number of days the chemical wilt 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 wnsistent with the units reported in box 221 and should not exceed that of maximum daily amount. 218. MAXIMUM DAILY AMOUNT -Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or adjacenUoutside area at any onetime 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 he 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 alt 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 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 componehts 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 chemipl 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. Page 2 of 2 FD 2144 (Rev. 09105) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFlED PROGRAM CONSOLIDATED FORM) =;~ BUSINESS ACTIVITIES PAGE (HAZARDOUS MATERIALS FACILITY INFORMATION) 8 S R S F T D FIRE r BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210. Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 1 L"FACILITY IDENTIFICATION _ ... M... _ FACILITY ID # (For Office use only -please leave blank) 3 EPA ID # DBA /FACILITY NAME in IL ACTIVITIES DE CLARAT ION -- - DOES Your Facility ... If Yes, Please Complete ... 12 A. HAZARDOUS MATERIALS • CHEMICAL DESCRIPTION FORM 13 1. Have on site (for any purpose) hazardous ^ Yes ^ No HAZARDOUS MATERIALS MANAGEMENT PLAN materials at or above 55 gallons for liquids, Minim um re igu red planning_elements: 500 pounds for solids or 200 cu. ft. for • Emergency Response Plan , compressed gases (include liquids in ASTs and ^ Yes ^ No Maps Training USTs)? Prevention B. REGULATED SUBSTANCES (RSI 131 1. Have on site RS at greater than the threshold ^ Yes ^ No • CHEMICAL DESCRIPTION FORM planning quantities established by the California RISK MANAGEMENT PLAN (RMP Submit to USEPA) Accidental Release Prevention program • CONSOLIDATED COMPLIANCE PLAN (CaIARP)? Incorporating CaIARP Program Elements C. UNDERGROUND STORAGE TANKS (USTsI 13 1. Own or operate Underground Storage Tanks? ^ Yes ^ No • UST FACILITY FORM • UST TANK FORM (One Per Tank) 2. Intend to upgrade existing or install new USTs? ^ Yes ^ No • UST FACILITY FORM 13 • UST TANK FORM (One Per Tank) • UST INSTALLATI N FORM ne P r T nk D. TANK CLOSURE /REMOVAL 2. Need to report closing an UST that ~ hazardous ^ Yes ^ No UST TANK FORM (Closure section -one per tank) materials or 3. Need to report the closure !removal of a tank that ^ Yes ^ No • UST TANK CLOSURE FORM was classed as hazardous waste and cleaned on- site? E. ABOVEGROUND PETROLEUM STORAGE TANKS (ASTsI ^ Yes'^ No • HAZARDOUS MATERIALS MANAGEMENT PLAN 1. Own or operate ASTs above these thresholds; • Incorporating Federal Spill Prevention Control and any tank capacity is greater than 660 gallons or the Countermeasure (SPCC) Elements pursuant to 40 CFR Part 112. total capacity for the facility is greater than 1,320 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 kglmo of recyclable ^ Yes ^ No RECYCLING FORM materials at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable ^ Yes ^ No • RECYCLING FORM materials at an off-site location different from the point of generation? ` 4. Treat Hazardous Waste on site? ^ Yes ^ No TP 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 FORM `remote site? NOTE: If you checked YES to any part of Sections IIA - IIF above, then in addition to the forms requested above,. please Submit BUSINESS OWNERlOPERATOR IDENTIFICATION FORM (FD2089) FD 2143 (Rev. 09/05) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN SITE & FACILITY DIAGRAM Page 2 of 2 Tel.. (661) 32 39 9 Fax: (661) 852-2171 FD 2170 (Rev. 09/05) BAKERSFIELD FIRE DEPT. Prevention Services H ti R 5_P r _n 900 Truxtun Ave., Suite 210 P/BE Bakersfield, CA 93301 ~Rrwr r 6- 7 BAKERSFIELD FIRE DEPT. (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN PteV@ntiOn Sel'V1C@S - - --- s _ n R s r x. _n g00 Truxtun Ave., Ste. 210 INSTRUCTIONS wR M r Bakersfield, CA 93301 SITE & FACILITY DIAGRAM Tel.: (661) 326-3979 Fax: (661) 852-2171 Page lof 2 These instructions explain the use of the site diagram and the facility diagram. Normally, small and medium size . businesses will only have to submit a site diagram. If you have subdivided your business into smaller areas because of the complexity or size, then you will be completing and additional detail map, facility diagram, for each of these areas. Include instructions that show the route to your business if it is in a remote location. All diagrams must be on 8 '/2 x 11 paper and drawn using a straight edge tool. SITE DIAGRAM INSTRUCTIONS The site diagram is used to show your business and to indicate the businesses that immediately surround your property, usually within 300 feet. If you will be showing specific area detail on facility diagrams, use the site diagram to show an overall layout of the plant. If you will not be submitting facility diagrams, the site map must include all of the following information: 1. Check the box on the top left corner of the form provided that indicated "Site Diagram". 2. Print the name of your business, as shown in your 1-IlVIl~IP, on the top of the diagram. 3. Label the location of the hazardous materials and identify them by name and type of hazard (i.e., flammable liquid, corrosive solid). 4. Label the location of utility shutoff points for gas, electric and water services. 5. Label the location of fire hydrants. 6. Label portions of the building protected by automatic sprinkler systems. 7. Label the direction representing north on the diagram. (The diagram form provided includes a north arrow). 8. All labeling and identification on the diagram must be legible and easily understandable at the scale submitted. Diagrams must be sufficiently legible to produce a legible copy. Try to avoid the use of abbreviations or symbols. If you must use them, provide a legend explaining your system. Maps may be returned for correction if you fail to follow these instructions. FACILITY DIAGRAM INSTRUCTIONS Facility diagrams are supplements to the site diagram. Use them to show the subdivision details of a large business. 1. Check the box in the upper right hand corner of the form provided that indicated "Facility Diagram". 2. Print the name of your business as shown on your LIMP. Print the name of the area that this map .represents. This name should be the same name that you used on this area's inventory report. 3. Indicate which area the diagram represents and the total number of facility diagrams that you are including. If a map represented the first of four areas, it would be labeled # 1 of 4. 4. Follow instructions (3 -8)* for site diagrams regarding the specific details to be included on each facility diagram. UNDERGROUND STORAGE TANK FACILITIES PLEASE NOTE: * If you operate an Underground Storage Tank (UST) facility, the facility diagram shall also specify the location(s) of the UST continuous leak monitoring system and/or the location(s) where the UST monitoring will be performed. FD 2170 (Rev. 09/05) UI;DERGROUND STORAGE TANKS r BAKERSFIELD FIRE DEPT. raf UNIFIED PROGRAM CONSOLIDATED FORMS ~ Prevention Services OPERATING PERMIT APPLICATION ~ ~ B $ R 3 P I n 900 Truxtun Ave., suite 210 P/Ra Bakersfield, CA 93301 TANK - (STATE FORM B> ~#~~ ~RT® f Tel.: (661) 326-3979 (One form per USn Fax: (661) 852-2171 Page 1 of 2 TYPE OF ACTION (Check onedem ony): ^ 1. NEW PERMIT ^ 3. RENEWAL ERMIT ^ 5. CHANGE OF INFORMATION ^ 6. TEMPORARY CLOSURE ^ 7. UST PERMANENTLY CLOSED ON SITE ^ 8. UST REMOVED 430 (Check one item only. For a UST closure or removal, complete only this section and Sections I, II, III, and N below) DATE UST PERMANENTLY CLOSED: 430 ~,. ,; I: FACIUTY'INFORMATlON" _ - - FACILfTY ID N0. (Agency Use Only) ~ 1 BUSINESS NAME (Same as FACILITY N E or,D6 ing BusirrESS~As) BUSINESS SITE ADDRESS //~~ ~~ 1 ~ 103 1 _ _ _ _ _ _ __ _ _ _ II. TANK DESCRIPTION `` TANK ID N0. 432 TANK MANUFACTURER 433 NUMBER OF TANK UNITS. THIS TANK IS: ^ 1 STAND-ALONE TANK ^ 2 ONE OF TWO OR MORE COMPARTMENTS DATE UST (STALLED (YEAR/MO) 435 DATE EXISTING UST DISCOVERED 435b NUMBER OF COMPARTMENTS 43 TANK CAPACITY IN GALLONS `T _ ;III. TANKtUSE and`CONTENTS TAN K USE 43 - / D/ 1. MOTOR VEHICLE FUELING ^ 3. CHEMICAL PRODUCT STORAGE ^ 4. HAZARDOUS WASTE (Includes Used Oil (lf madced complete PetrWeum Type)) ^ 5. EMERGENCY GENERATOR FUEL STORAGE ^ 6. OTHER GENERATOR FUEL STORAGE ^ 7. MARINA f'UELI G ^ 95. UNKNOWN ^ 99. OTHER (Specify) TA NK CONTENTS (PETROLEUM TYPE) TANK CONTENTS NON PETROLEUM TYPE: ~ ~ 6Y 1a. REGULAR UNLEADED ^ 3. DIESEL ^ 7. USEDOIL ^ 1b. PREMIUM UNLEADED ^ 5. JET FUEL ^ 10. ETHANOL ^ 1c. MIDGRADE UNLEADED ^ 6. AVIATION GAS ^ 99. OTHER (Specify) ^ 8. PETROLEUM BLEND FUEL ^ 9. BIO DIESEL ^ 99. OTHER Specify) ,. _ _ - IV. TANK~CONSTRUC710N~ _ _ _____ TYPE OF TANK (Check one Rem only - / ^ 1. SINGLE WALLED ~/1. DOUBLE WALLED ^ 3. SINGLE WALL WITH EXTERIOR MEMBRANE LINER ^ 95. UNKNOWN TANK PRIMARY CONTAINMENT (Check one item onty) ^ 1. STEEL ^ 6. INTERNAL BLADDER ^ 95. UNKNOWN ^ 3. FIBERGLASS ^ 7. STEEL+R~ITERNALLTNING ^ 99. OTHER(Specrfy) TANK SECONDARY CONTAINMENT (Check one Rem only) ^ 1. STEEL ^ 6. EXTERIOR MEMBRANE LINER ^ 90. NONE ^ 3. FIBERGLASS ^ 7. JACIQ=fED ^ 95. UNKNOWN ^ 99. OTHER (Specify) OVERFILL PREVENTION (Check one item only) 45 ^ 1. AUDIBLE 8 VISUAL ALARMS FILL TUBE SHUT-OFF VALVE ^ 2. BALL FLOAT 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT .. ~ ,.; ,; V. PRODUCT L WASTE PfPING CONSTRUCTION' PIP ING SYSTEM TYPE (Check one Rem only) ~ 45 ~ / ~ • PRESSURE ^ 2. GRAVITY ^ 3. CONVENTIONAL SUCTION ^ 4. SAFE SUCTION (23 CCR §2636(a)(3) PIPING PRIMARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 4. FIBERGLASS ^ 8. FLEXIBLE ^ 10. RIGID PLASTIC ^ 90. NONE ^ 95. UNKNOWN ^ 99. OTHER (Specify) PIPING SECONDARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 8. FLEXIBLE ^ 10. RIGID PLASTIC ^ 4. FIBERGLASS ^ 95. UNIWOWN ^ 99. OTHER (Specify) ) TURBINE CONTAINMENT SUMP (Check one Rem only) ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE FD 2094 (Rev. 11/06) `~'~ Page 1 of 2 of UNDERGROUND STORAGE TANKS TANK -APPLICATION (CONT.D) (STATE FORM B) Page 2 of 2 -- ~ ~, ,< _ ~ .,, VI. VENT AND VAPOR~RECOVERY~(V.R) PIPING CONSTRUCTION -- VENT PRIMARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) VENT SECONDARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify) VR PRIMARY CONTAINMENT (Check one item only) 464 ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specfy) VR SECONDARY CONTAINMENT (Check one dem onty) ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) VENT AND/OR VAPOR RECOVERY PIPING TRANSITION SUMP(S) '~ ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE Vlt RI$ER I FILL;PIPE~,CONSTRUCTION i RISER PRIMARY CONTAINMENT (Check one ftem only) ~~ ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) RISER SECONDARY CONTAINMENT (Check one dem only) 464 ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) FILL COMPONENTS (Check one dem onty) ^ SPILL BUCI~T INSTALLED ^ STRIKER PLATE /BOTTOM PROTECTOR INSTALLED VR SECONDARY CONTAINMENT (Check one dem onty) 464 ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify) VENT AND/OR VAPOR RECOVERY PIPING TRANSITION SUMP(S) 464 ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE VIII: UNDER DISPENSER CONTAINMENT (UDC) UDC CONSTRUCTION TYPE 468 ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 20. NO DISPENSERS UDC CONSTRUCTION MATERIAL ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 99. OTHER (Specfy) IX. CORROSION PROTECTION STEEL COMPONENT PROTECTION ^ 2 SACRIFICIAL ANODE(S) ^ 4 IMPRESSED CURRENT ^ 6. ISOLATION X'. APPLICANT SIGNATURE - CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE ~ ~ _ ~ O ~ ~ 47 FD 2094 (Rev. 11/06) UN~`ERGROUND STORAGE TANKS ~l •"~UNIFIED PROGRAM CONSOLIDATED FORMS - ~~ .~ OPERATING PERMIT APPLICATION » 8 B 9 P I D j P/R! TANK - (STATE FORM B) i ARTM 1 (One form per US'r) TYPE OF ACTION (Check one item ony): ^ 1. NEW PERMIT ^ 3. RENEWAL ERMfT ^ 6. TEMPORARY CLOSURE ^ 7. UST PERMANENTLY CLOSED ON S4TE (Check one item only. For a UST dosure or removal, complete only this section and Sections I, II, III, and N below) BAKERSFIELD FIRE DEPT. Prevention Services 900 TrLixtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 ^ 5. CHANGE OF INFORMATION ^ 8. UST REMOVED aaa DATE UST PERMANENTLY CLOSED: _ _ _ , ,,.: _ _ I: FACILITY INFORMATION :. FACILITY ID N0. (Agency Use Only) ~ BUSINESS NAME (Same as FACILITY NAME or DBA-0oing Business As) BUSINESS SITE ADDRESS 103 1 - 11. TANK° DESCRIPTION - _ _ TANK ID NO. 432 TANK MANUFACTURER 433 NUMBER OF TANK UNITS. THIS TANK IS~ ^ 1 STAND-ALONE TANK ^ 2 ONE OF TWO OR MORE COMPARTMENTS DATE UST (STALLED (YEAR/MO) 435 DATE EXISTING UST DISCOVERED 435b NUMBER OF COMPARTMENTS 43 TANK CAPACffY IN GALLONS 436 ` IIL TANKa.USE and CONTENTS.: ~ .~-s _ _ TANK USE 43 ^ 1. MOTOR VEHICLE FUELING ^ 3. CHEMICAL PRODUCT STORAGE ^ 4. HAZARDOUS WASTE (Includes Used Oil (If marked comMete Petroleum Type)) ^ 5. EMERGENCY GENERATOR FUEL STORAGE ^ 6. OTHER GENERATOR FUEL STORAGE ^ 7. MARINA ~UELI G ^ 95. UNKNOWN ^ 99. OTHER (Specify) TANK CONTENTS (PETROLEUM TYPE) TANK CONTENTS NON PETROLEUM TYPE: ^ 1a. REGULAR UNLEADED ^ 3. DIESEL ^ 7. USEDOIL ^ 1b. PREMIUM UNLEADED ^ 5. JET FUEL ^ 70. ETHANOL ^ 1c. MIDGRADE UNLEADED ^ 6. AVIATION GAS ^ 99. OTHER (Specify) ^ 8. PETROLEUM BLEND FUEL ^ 9. BIO DIESEL ^ 99. OTHER Specfy) _ __ " ~~ ., ~ ~ ~, , IV. TANK;-CONSTRUCTION,,,. ~ _ _ ~' ~ ~~~ . TYPE OF TANK (Check one item only ^ 1. SINGLE WALLED ^ 2. DOUBLE WALLED ^ 3. SINGLE WALL WITH EXTERIOR MEMBRANE LINER ^ 95. UNKNOWN TANK PRIMARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 6. INTERNAL BLADDER ^ 95. UNKNOWN ^ 3. FIBERGLASS ^ 7. STEEL+INTERNALLWING ^ 99. OTHER (Specify) TANK SECONDARY CONTAINMENT (Check one item only) F O 3 ER MEMBRANE LINER ~ EXT 7 E . IB GLASS ^ ^ ~. UNKNOWN ^ 99. OTHER (Specify) JAC Kt ED OVERFILL PREVENTION (Check one item only) 45 ^ 1. AUDIBLE 8 VISUAL ALARMS ^ 3. FILL TUBE SHUT-OFF VALVE ^ 2. BALL FLOAT ^ 4. TANK MEETS REQUOZEMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPN~NT V. PRODUCT /WASTE PIPING CONSTRUCTION PIPING SYSTEM TYPE (Check one item onty) ^ 1. PRESSURE ^ 2. GRAVITY ^ 3. CONVENTIONAL SUCTION ^ 4. SAFE SUCTION (23 CCR §2636(a)(3) PIPING PRIMARY CONTAINMENT (Check one item only) ~ 9 NO EL 5~ QJO f 1SS ~ O N ~ OT ER ^ 10~ ~~ ~ 0. N 9 F (Specify) U 99 H PIPING SECONDARY CONTAINMENT (Check one r7em only) ^ 1. STEEL ^ 8. FLEXIBLE ^ 10. RIGID PLASTIC ^ 4. FIBERGLASS ^ 95. UNKNOWN ^ 99. OTHER (Specify) ) TURBINE CONTAINMENT SUMP (Check one item only) ^ 07. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE FD 2094 (Rev. 11/06} ~ `` UNDERGROUND STORAGE TANKS TANK -APPLICATION {CONT.D) {STATE FORM B) Page 2 of 2 Page 1 of 2 ~,. VL .VENT AND VAPOR RECOVERY {VR) P,IPING~~CONSTRUCTION VENT PRIMARY CONTAINMENT (Check one item only) J ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) VENT SECONDARY CONTAINMENT (Check one dem only) p 1. STEEL ~ ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Speciry) VR PRIMARY CONTAINMENT (Check one item only) 464 ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) VR SECONDARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify) VENT AND/OR VAPOR RECOVERY PIPING TRANSITION SUMP(S) 464 ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE ,.x/11. R,,ISER;/ FILL. PIPE,CONSTRUCTION __ _ __ _ _ RISER PRIMARY CONTAINMENT (Check one dem only) ~~ ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify) RISER SECONDARY CONTAINMENT (Check one dem only) 464 ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) FILL COMPONENTS (Check one dem onty) 464 ^ SPILL BUCIQ=T INSTALLED ^ STRII~R PLATE /BOTTOM PROTECTOR INSTALLED VR SECONDARY CONTAINMENT (Check one dem only) 464 ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify) VENT ANDlOR VAPOR RECOVERY PIPING TRANSITION SUMP(S) ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE - VIN. UNDER DISPENSER CONTAINMENT,(UDG) , UDC CONSTRUCTION TYPE 468 ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 20. NO DISPENSERS UDC CONSTRUCTION MATERIAL ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 99. OTHER (Specify) IX. CORROSION PROTECTION STEEL COMPONENT PROTECTION ^ 2 SACRIFICIAL ANODE(S) ^ 4 IMPRESSED CURRENT ^ 6. ISOLATION - X. APPL-ICANT_SIGNATURE. - CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE ~~©n 47 r.J FD 2094 (Rev. 11/06) _ UNDERGROUND STORAGE TANKS ~~' UNIFIED PROGRAM CONSOLIDATED FORMS ~~ ~~ OPERATING PERMIT APPLICATION § B $Piire i p TANK - (STATE FORM B) ~ ARTM 1 (One form per UST) ~ TYPE OF ACTION (Check one item onty): ^ 1. NEW PERMIT ^ 3. RENEWAL ERMIT ^ 6. TEMPORARY CLOSURE ^ 7. UST PERMANENTLY CLOSED ON SITE (Check one item only. For a UST Gosure or removal, complete only this sec5on and Sections I, II, III, and IV below) BAKERSFIELD FIRE DEPT. Prevention Services 900 TruxtLUi Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Pale 1 of 2 ^ 5. CHANGE OF INFORMATION ^ 8. UST REMOVED 430 DATE UST PERMANENTLY CLOSED: 43 {: FACILITY INFORMATION _ FACILITY ID NO. (Agency Use Only) 1 BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) BUSINESS SRE ADDRESS 103 1 - - ~_ - - ~ II. TANK DESCRIPTION..' _- ~-- TANK ID NO. 432 TANK MANUFACTURER 433 NUMBER OF TANK UNITS. THIS TANK IS: ^ 1 STAND-ALONE TANK ^ 2 ONE OF TWO OR MORE COMPARTMENTS DATE UST (STALLED (YEAR/MO) 435 DATE EXISTING UST DISCOVERED 435b NUMBER OF COMPARTMENTS 43 TANK CAPACITY IN GALLONS _ Ilt. TANK..USE and°-CONTENTS TANK USE 03 ^ 1. MOTOR VEHICLE FUELING ^ 3. CHEMICAL PRODUCT STORAGE ^ 4. HAZARDOUS WASTE (Includes Used Oil (If marked compplete Petroleum Type)) MARINA f'UELI ^ 7 G ^ 5. EMERGENCY GENERATOR FUEL STORAGE ^ 6. OTHER GENERATOR FUEL STORAGE ^ 95 . N . UNKNOWN ^ 99. OTHER (Specify) TANK CONTENTS (PETROLEUM TYPE) TANK CONTENTS NON PETROLEUM TYPE: ^ 1a. REGULAR UNLEADED ^ 3. DIESEL ^ 7. USEDOIL ^ 1b. PREMIUM UNLEADED ^ 5. JET FUEL ^ 10. ETHANOL ^ 1c. MIDGRADE UNLEADED ^ 6. AVIATION GAS ^ 99. OTHER (Specify) ^ 8. PETROLEUM BLEND FUEL ^ 9. BIO DIESEL ^ 99. OTHER Specify) -- ~ " iV..,TANK CONSTRUCTION __ _ TYPE OF TANK (Check one item onty _ ^ 1. SINGLE WALLED ^ 2. DOUBLE WALLED ^ 3. SINGLE WALL WITH EXTERIOR MEMBRANE LINER ^ 95. UNKNOWN TANK PRIMARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 6. INTERNAL BLADDER ^ 95. UNKNOWN ^ 3. FIBERGLASS ^ 7. STEEL+INTERNALLINING ^ 99. OTHER (Specify) TANK SECONDARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 6. EXTERIOR MEMBRANE LINER ^ 90. NONE ^ 3. FIBERGLASS ^ 7. JACKETED ^ 95. UNKNOWN ^ 99. OTHER (Specify) OVERFILL PREVENTION (Check one Rem only) 45 ^ 1. AUDIBLE & VISUAL ALARMS ^ 3. FILL TUBE SHUT-OFF VALVE ^ 2. BALL FLOAT - ^ 4. TANKMEETSREQUIREMENTSFOREXEMPTIONFROMOVERFILLPREVENi10NEQUIPMENi ~i '. V. RRODUCT /:WASTE RIPING'=CONSTRUCTION- PIPING SYSTEM TYPE (Check one item only) 45 ^ 1. PRESSURE ^ 2. GRAVITY ^ 3. CONVENTIONAL SUCTION ^ 4. SAFE SUCTION (23 CCR §2636(a)(3) PIPING PRIMARY CONTAINMENT (Check one Rem only) ^ 1. STEEL ^ 4. FIBERGLASS ^ 8. FLEXIBLE ^ 10. RIGID PLASTIC ^ 90. NONE ^ 95. UNIWOWN ^ 99. OTHER (Specify) PIPING SECONDARY CONTAINMENT (Check one Rem only) `~ ^ 1. STEEL ^ 8. FLEXIBLE ^ 10. RIGID PLASTIC ^ 4. FIBERGLASS ^ 95. UNKNOWN ^ 99. OTHER (Specify) ) TURBINE CONTAINMENT SUMP (Check one item only) ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE FD 2Q94 (Rev. 11/06) r* UNDERGROUND STORAGE TANKS TANK -APPLICATION (CONT.D) (STATE FORM B) Page 2 of 2 Page 1 of 2 VI DENT AND VAPOR RECOVERY (.VR) PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT (Check one dem only) ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specfy) VENT SECONDARY CONTAINMENT (Check one dem onty) ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) VR PRIMARY CONTAINMENT (Check one item only) 464 ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) VR SECONDARY CONTAINMENT (Check one item only) ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC d 90. NONE ^ 99. OTHER (Specify) VENT AND/OR VAPOR RECOVERY PIPING TRANSITION SUMP(S) ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE -- '- - - _. __ _ `V11.. RISER f FII.L~;PIPE CONSTRUCTION , RISER PRIMARY CONTAINMENT (Check one item onty) 4sar ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99. OTHER (Specify) RISER SECONDARY CONTAINMENT (Check one item only) ~ ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify) FILL COMPONENTS (Check one item only) 464 ^ SPILL BUCKET INSTALLED ^ STRIKER PLATE /BOTTOM PROTECTOR INSTALLED VR SECONDARY CONTAINMENT (Check one item only) 464 ^ 1. STEEL ^ 4 FIBERGIASS 17 10. RIGID PLASTIC ^ 90. NONE ^ 99.OTHER (Specify) VENT AND/OR VAPOR RECOVERY PIPING TRANSITION SUMP(S) 464 ^ 01. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 03. NONE VIIL, UNDER DISPENSER CONTAINMENT(UDC) UDC CONSTRUCTION TYPE 4~ ^ Ot. SINGLE WALLED ^ 02. DOUBLE WALLED ^ 20. NO DISPENSERS UDC CONSTRUCTION MATERIAL ^ 1. STEEL ^ 4 FIBERGLASS ^ 10. RIGID PLASTIC ^ 99. OTHER (Specify) , j tX. CORROSION PROTECTION ~. ; _ - -- , , , STEEL COMPONENT PROTECTION C 2 SACRIFICfAL ANODE(S) ^ 4 IMPRESSED CURRENT ^ 6. ISOLATION ! X. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE l 47 X' /~ j~ ~V (/ ~- v FD 2094 (Rev. 11/06) UST MONITORING PROGRAM EMERGENCY RESPONSE PLAN Page 1 of 1 This monitoring program must be kept al the UST location at alt limes. The information on this monitonng program are conditions of the operating permit. The permit holder must notify the Office of Environmental Services within 30 days of any changes to the monitoring procedures, unless required to obtain approval before making the change. Required by Sections 2632(d) and 2641(h) CCR. ~~R~ A1~1M T Bakersfield Fire Dept. Environmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)32b-3979 FACILITY NAME . ~ FACILITY ADDRESS l IF AN UNAUTHORIZED RELEASE OCCURS, HOW WILL THE HAZARDOUS SUBSTANCE BE CL NED UPT 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, THENGHE OFFICE OF ENVIRONM/~ENTAL S6ERVICES/MUGSTrBE N~OATIFIED WTHIN 24 HOURS. DESCRIBE THE PROPOSED METHODS AND EQUIPMENT TO BE USED FOR REMOVING AND PROPERLY DISPOSING OF ANY HAZARDOUS SUBSTANCE. k~~y l~~t~r ~5 aN a.loSor~Om~.~' 3.DESCRIBE THE LOCATION ANO AVAILABILITY OF THE REQUIRED CLEANUP EQUIPMENT IN ITEM ABOVE. 9~'~ ~a t e A A~ / ~ ~ ~ ~ ` C r ~ ~j l c I1 K ~NS~ DESCRIBE THE MAINTENANCE SCHEDULE FOR THE CLEANUP EQUIPMENT: ~~tG/(~ l I~a~ CY LIST THE NAME(S) AND TITLE(S) OF THE PERSON(S) RESPONSIBLE FOR AUTHORIZING ANY WORK NECESSARY UNDER THE RESPONSE PLAN: NAME '1 TITLE 1 >~ ~ I v~~ 4 UNDERGROUND STORAGE TANK BAKERSFIELD FIRE DEPT. MONITORING PROGRAM (FORM) a p x s p i D Prevention Services r/gt 900 Truxtun Ave., Suite 210 WRITTEN MONITORING PROCEDURES ARTAI T Bakersfield, CA 93301 Tel.: (661) 326-3979 Page 1 of 1 Fax.: (661) 872-2171 This monitoring program must be kept at the UST location ai al times. The information on this monitoring program are conditions of the operating permit. The permit holder must notify the Office of Prevention Services within 30 days of any changes to the monitoring procedures, unless required to obtain approval before making the change. Required by Sections 2632(d) and 2641(h) CCR. FACILITY NAME .~ d FACILITY ADDRESS ~ 3 s~~ ~ DESCRIBE THE FREQUENCY OF PERFORMING THE MONITORING: TANK PIPING ~~ l~ 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 PLOT PLAN SHOULD BE ATTACHED): tt -- Q E ~k t~t9 N~C.~ LIST THE NAME(S) AND TITLE(S) OF THE PEOPLE RESPONSIBLE FOR PERFORMING THE MONITORING AND/OR MAINTAINING THE EQUIPMENT: NAME r TITLE NAME TITLE h ~ t i.E GJ NAME TITLE NAME TITLE NAME TITLE REPORTING FORMAT FOR MONITORING: TANK PIPING 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 72 MONTHS. r ~ ` ~A DESCRIBE THE TR(A'ININGrN'EACESSARY FOR THE OPER_ATIION OF ULS~T SYSTEM, INCLUDING PIPING, AND THE MONITORING EQUIPMENT: ~~a VY"~~ ~~~~G~I~~,~,V FD 2074C (Rev. o2ios) State of Califomia For State Use Only State of Water Resources Control Board Division of Financial Assistance P.O. Box 944212 Sacramento, CA 94244-2120 (Instructions on reverse side) CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I 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 er occurrence ^ 2 million dollars annual a milli n dollar re at gg g o s p e B. hereby certifies that it is in cori-pliance with the requirements of Section 2807, (Name o! Tank Owner a Operator) Article 3, Chapter 18, Division 3, Title 23, Califomia Code of Regulations. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corredive Third Party T e Name and Address of Issuer Number Amount Period Adion Com Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certifies that you are in compliance wifh all conditions for participation in the Fund. D. Facility Name ~ Facility Address Facility Name Facility Address Facility Name Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator Signature of Witness or Notary D a t e Name of Witness or Notary y ~ / CFR (Revised /95) FILE: Original - ~cat'Agency ~ Copies - Facllity/Slte(s) _ _ _ l \ l .~, UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) /CONTAMINATION SITE REPORT EMERGENCY OES REPORT FILED <::~ ....3'Ikf:OG#tK~~~M1':Y;~~:~ii.'::?::~::?;~:>~ 5:~::.+:?::;:::':?:~?:~':?;~::':;;:~::?:::`: YES X NO X YES NO ::~&Y~~'Lai'f#fY:'Sk3Ac~`#:33i4ifS:#~fS37'ftBl33'S13:SH15c:1tPflS333ki::; :::::::::::::::::3::::::::::::'::::::':::::::::::::::::::: REPORT DATE CASE # #I1~"+.C~ARittNG~~k78?~~312w"FfifEft1.F10Y#IS[ION:QL=?3:lP.:E#~IC:.OT?~38lS:FORk~>~~i#r> ±''~'''':":`~:'~3: '': 0 9 0 2 0 5 05-5124 M M D D Y V NAME OF INDIVIDUAL FILLING REPORT SI Ian A. Ellis (336) 31 5-2831 C'Lr- C REPRESENTING COMPANY OR AGENCY NAME REPORTED Q LOCAL AGENCY ~ REGIONAL BOARD BY ~X OWNER/OPERATOR ~ OTHER Gilbarco Veeder-Root ADDRESS 7300 W. Friendly Avenue Greensboro, NC 27420 STREET CTTV ST ZIP NAME COMACT PERSON Safeway Vons Division Scott Miller 626-821-7781 RESPONSIBLE PARTY ADDRESS P.O. BOX 51338 Los Angeles CA 90051 STREET CITY Si ZIP ' FACILITY NAME OPERATOR PHONE 2512 Safeway Vons Cheryl Fry 661-396-0161 srtE LOCATION 2100 White Lane Bakersfield CA 93304 ADDRESS CITY ST ZIP CROSS STREET LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE AGENCIES City of Bakersfield CUPA Ralph E. Huey 661-326-3979 PHONE OES Chris Flure 800-852-7550 1 NAME QUANTITY LOST (GALLONS) Gasoline SUBSTANCE Less than 10 gallons _ ~x INVOLVED 2 QUANTITY LOST (GALLONS) a UNKNOWN DATE DISCOVERED HOW DISCOVERED O 9 O 2 () S ~ TANK TEST ^TANK REMOVAL NUISANCE CONDITIONS ^ M M D D V Y ~ INVENTORY CONTROL ~ SUBSURFACE MONITORING Seen Visually OTHER X~ ~ METHOD USED TO STOP DISCHARGE DATE DISCHARGE BEGAN ~ UNKNOWN ~ REMOVE CONTENTS CLOSE TANK 8 FILL IN PLACE a DISCOVERY D 9 D 2 0 S ~ REPAIR TANK REPAIR PIPING HAS DISCHARGE BEEN STOPPED X VES NO 8 ~ REPLACE TANK CHANGE PROCEDURE ABATEMENT O 9 O 2 O S ~ ~ CLOSURE TANK & REMOVAL Customer vehicle evacuated SOURCE OF DISCHARGE CAUSE(S) TANK TEST UNKNOWN ~ ~ OVERFILL UNKNOWN PIPING LEAK OTHER ~ ~ CORROSION SPILL Customer Vehicle ^X ^ REPTURE /FAILURE A hole in customer gas tank OTHER ^X CHECK ONE ONLY CASE TYPE aX OTHER Concrete Surface ^SOIL ONLY ~ GROUND WATER DRINKING WATER (WELLS AFFECTED) ^ CHECK ONE ONLY CURRENT ~ NO ACTION TAKEN ~ PRELIMINARY SITE ASSESSMENT SUBMITTED ~ POLLIfTION CHARACTERIZATION STATUS ~ LEAK BEING CONFIRMED ~ PRELIMINARY SITE ASSESSMENT UNDERWAY POST CLEANUP MONITORING IN PROGRESS REMEDIATION PLAN ®CASE CLOSED (COMPLETED /UNNECESSARY) CLEANUP UNDERWAY CHECKAPPROPRIATE ACTION(S) CAP SITE (CD) ^ EXCAVATE & DISPOSE(ED) REMOVE FREE PRODUCT(FP) REMEDWL CONTAINMENT BARRIER(CB) EXCAVATE BTREAT(ET) PUMP BTREAT GROUNDWATER(GT) a ACTION ~ VACUUM EXTRACT (VE) X~ NO ACTION REQUIRED(NA) TREATMENT AT HOOKUP(HU) VENT SOIL(VS) ~ ^ OTHER N/A ENHANCED BIO DEGRAOATION(IT) A hole in customer gas tank caused gasoline to reach concrete pavement. Station used absorbent material to clean the spill. coMMENrs Safeway has responded to this issue and all necessary action has been taken. No further actions are currently planned. snrzoos 1:38 PM ,. ; , ==~ '~ - Praxair Services, Inc. , 3755 N. Business Center Drive ? "~ ~ ~° }.~ ~~~~. ~ Tucson, AZ 85705... .. _ ..... .; I?raxai:r ~SerVices, It'1C.~ ~ ~ ~~ ~ _~ • ~~-Tel: (800) 394-9929 _.. _. ... __....._.. _,. .. .. ... ... _. ...._ Fax: (520) 293-1306 .,, ... NEW CONSTRUCTION ENHANCED LEAK DETECTION (NCELD) FINAL TEST RESULTS CUent Date. 12/15/2006 Site Info::. Job No'" 38293NC D N J Construction 3430 A Gilmore Ave Bakersfield,.~CA 93308 Stockdale Food Mart 5321 Stockdale Hwy Bakersfield, CA 93309 - - SYSTE M ~ -~ ~ ~ STATUS (~ Pass/ F ai!) Product / System Size Tank ' PRODUCT PIPING (Primary ") ':VENT PIPING (Primary,) 87 15,000 Pass Pass Pass 91 .8,000 Pass Pass Pass Diesel 7,000 Pass Pass- .-Pass Va or Recove Pass- Under Dispenser Containment (UDC) ~ Pass I declare under penalty of perjury that the information contained in this report is true and correct to the best of ` my knowledge Tester: Ricardo Gonzalez State Lic. #: 04-1695 Signature: Date: 12/15/2006 1 of 3 38293NC Bakersfield Final.xls ~` ___ _%~~~ '~ Praxair Services, Inc. 3755 N. Business Center Drive Tucson, AZ 85705 Praxair Services, Inc. Tel: (800) 394-9929 Fax: (520)293-1306 NEW CONSTRUCTION ENHANCED LEAK DETECTION (NCELD) FINAL TEST RESULTS TEST SUMMARY Testing was performed 12/14-15/2006 using hand-held detectors and on-site lab analysis. Leak simulation established a tracer soil migration time of 20 hours; backfill samples were collected via horizontal sampling probes a minimum of 20 hours from system inoculation. The multiple leaks detected in the 87 Tank and UDCs 2, 3, 4, and 5 were repaired by contractor and re-tested tight before end of testing event. No further detections were made after repairs completed. See the attached leak log for details. QA Summary: Test data and information has been reviewed and conforms to ELD procedure and protocol. All systems tested pass. Reviewed By: Drew Burk I 1/10/2007 Signature: y 1(~ 1 ~,/ _ :Attached Leak Log described issues encountered and repaired during test duration 3 of 3 38293NC QA Final DB LEAK LOG Job# 38293NC swo # 60003157 Site: Stockdale Food Mart Client: D N J Construction Client Contact Jerry Hale Site Address: 5321 Stockdale Hwy Bakersfield, CA 93309 Contact # 661-201-3707 Log Completed By: Ricardo Gonzalez Total Detected Leaks 6 Date: Leak/P,ass Time ITEM Test Testetl 'Sample ID Concentration: (ug/L - ppm - psig) Description (How collected, Volume CollectedComplete Notes) 12/14/06 1a 11:15 87TK BU 1 FVS Tracer Detected Bucket to faceshield adaptor leaking. 12/14/06 2a 11:45 87TK BU 1 FVS Note Bucket to faceshield adaptor repaired. 12/14/06 1b 13:30 87TK Final 2 FVS Tracer Detected Union on VR is leaking 12/14/06 2b 15:15 87TK Final 2 FVS Note Union on VR has been repaired. 12/14/06 1c 18:27 UDC Final 2 UDC #2 Tracer Detected Shear valve caps are leaking. 12/14/06 1d 18:28 UDC Final 2 UDC #3 Tracer Detected Shear valve caps are leaking. 12/14/06 1e 18:29 UDC Final 2 UDC #4 Tracer Detected Shear valve caps are leaking. 12/14/06 1f 18:30 UDC Final 2 UDC #5 Tracer Detected Shear valve caps are leaking. 12/15/06 2c 9:00 UDC Final 2 UDC #2 Note Shear valve caps have been repaired. 12/15/06 2d 9:01 UDC Final 2 UDC #3 Note Shear valve caps have been repaired. 12/15/06 2e 9:02 UDC Final 2 UDC #4 Note Shear valve caps have been repaired. 12/15/06 2f 9:03 UDC Final 2 UDC #5 Note Shear valve caps have been repaired.