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HomeMy WebLinkAboutBUSINESS PLAN 11/13/2006~ .ice _. ~~ ~ i ~ SNk~ r~r - ° ~i ~ i „- - ,~ ,; ~ ~~~ - l I - ,~~~~ ~a.~-9/ 1 ~,~ ~ ~~ ~. %~ -~: w a ~.. ~~~ ~~~~~~ UNDERGROUND STORAGE TANK MONITORING PROGRAM EMERGENCY RESPONSE PLAN (FORM) Page 1 of 1 B E R 5 F I D ~IRl ARTM f BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661)326-3979 Fax.: (661) 852-2171 This monitoring program must be kepi ai the UST location at al times. The information on this monitoring program are conditions of the operating permit. The permit holder must notify the Office o/ Prevention Services within 30 days of any changes to the monitoring procedures, unless required fo obtain approval before making the change. Required by Sections 2632(d) and 2641(h) CCR. FACILI//TYNAME ! ~ l~/~ ~ l7~CJ ~~,Ifi FACILITY ADDRESS IF AN UNAUTHORIZED RELEASE OCCURS, HOW WILL THE HAZARDOUS SUBSTANCE BE CLEANED UP? NOTE: IF RELEASED HAZARDOUS SUBSTANCES REACH THE ENVIRONMENT, INCREASE THE FIRE OR EXPLOSION HAZARD, ARE NOT CLEANED UP FROM THE SECONDARY CONTAINMENT WIT IN 8 HOURS, R DETERIO TE THE SECONDARY CONTAINMENT, THEN THE OFFICE OF PREVENTION SERVICES MUST BE NOTIFIED W ITHIN 24 HOURS. ~ ,N~l~ ~ ,^~ L P !~ C ~ ~r Q Q~°~Se~~a~~ ~~a-~crty~ ti ~G~f-~o~ ~4ut.. (e,rc~L t~©U °{-e ~aLfk/QI C L ~ ~~r ~ C~in1c~,~ S~~ ~ ~~~~ `(~ ~ Q~f ~~ufl ~ q~.l~~~r t~r.~,~~-c~.rs• c~ ro~~- c~ ~ a~ USc~'' ~4'or U~a.s~c. ~~crtcty~ • 1Dcp~c~-~ C~~O~al a ~ DESCRIBE THE PROPOSED METHODS AND EQ``~~PMENT TO BE USED FOR REMOVING AND PROPERLY DISPOSING OF ANY HAZARDOUS SUBSTANCE. ~~y ~L~~~ drS c~Sor~eri"~'. DESCRIBE THE LOCATION AND AVAILABILITY OF THE REQUIRED CLEANUP EQUIPMENT IN ITEM ABOVE. ~ ~ q ~ ~~©~,A DESCRIBE THE MAINTENANCE SCHEDULE FOR THE CLEANUP EQUIPMENT: ~~`'' ~C~lLl lk(lIL~ i ~~C~~~ rL ~ 1 i ` ;' LIST THE NAME(S) AND TITLE(S) OF THE PERSON(S) RESPONSIBLE FOR AUTHORIZING ANY WORK NECESSARY UNDER THE RESPONSE PLAN: NAME TITLE NAME TITLE L- , NAME TITLE NAME TITLE NAME TITLE FD2074b (Rev. ovosl UNDERGROUND STORAGE TANK MONITORING PROGRAM (FORM) a E R 5 F 1 D ElRt WRITTEN MONITORING PROCEDURES aRTAI T Page 7 of 1 BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax.: (661) 872-2171 This monitoring program must be kept at the UST location at a! times. The information on this monitoring program are conditions of the operating permit. The permit holder must notify the Office of Prevention Services within 30 days of any changes to the monitoring procedures, unless required to obtain approval before making the change. Required by Sections 2632(d) and 2641(h) CCR. FACILITY NAME CS~.S ~tl CTS llli~/i G,Y~7' FACILITY ADDRESS ~~ ~~~ ~! ~~~ ~ 93~3~P DESCRIBE THE FREQUENCY OF PERFORMING THE MONITORING: TANK PIPING ~~ WHAT METHODS AND EQUIPMENT, IDENTIFIED BY NAME AND MODEL, WILL BE USED FOR PERFORMING THE MONITORING: TANK !/-C`&D.E(~- 2ooj- j(ys- 16~ PIPING ~,+~ J^wt,o/. ~ T.'X,..~V ~c DESCRIBE THE LOCATION(S) WHERE THE MONIT RING W ILL BE PERFORMED (FACILITY PLOT PLAN SHOULD BE ATTACHED): LIST THE NAME(S) AND TITLE(S) OF THE PEOPLE RESPONSIBLE FOR PERFORMING THE MONITORING AND/OR MAINTAINING THE EQUIPMENT: Y NAME TITLE NAME TITLE r NAME TITLE NAME TITLE NAME TITLE REPORTING FORMAT FOR MONITORING: TANK Lw~ PIPING DESCRIBE THE PREVENTIVE MAINTENANCE SCHEDULE FOR THE MONITORING EQUIPMENT. NOTE: MAINTENANCE MUST BE IN ACCORDANCE WITH THE MANUF,AnCTURER'S MAINTENANCE SCHEDULE BUT NOT LESS THAN EVERY 72 MONTHS. ~~ 1 ~ ~ ~ t ~ i 9 ~®~- ~~ r~® ~MdI~~ ~' ~ ~IG 1 (~~ ~ (, t~/ DESCRIBE THE TRAINI G ECESSARY FOR THE OPERATION OF UST SYSTEM, INCLUDING PIPING, AND THE MONITORING EQUIPMENT: ~t5~4tt pPc~ u-k®r ar ~Ur ~~~.`- ~-Fo slna~3- FD 2074C (Rev. ozios~ State of Califomia For State Uso Only State of Water Resources Control Board Division of Financial Assistance P.O. Box 944212 Sacramento, CA 94244-2120 (Instructions on reverse side) CERTIFICATION OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. [ am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: ^ 500,000 dollars per occurrence ^ I million dollars annual aggregate or AND or ^ t million dollars per occurrence ^ 2 million dollars annual aggregate B. ('-f ~S/l,„7 ~. ~J/-1C9'is hereby certifies that it is in compliance with the requirements of Section 2807, (Name or Tank Owner or Operator) Article 3, Chapter 18, Division 3, Title 23, Califomia Code of Regulations. The mechanisms used to demonstrate financial responsibility as n3quired by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective Third Party T e Name and Address of Issuer Number Amount Period Action . Com Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this cert~cation also certifies that you are in compliance with all conditions for participation in the Fund. D. Facility Name Faality 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 Date Name of Witness or Notary i~ l3 0 6 (JEER (Revised 04!95) FILE: Original -Local Agency Copies - Facllity/Site(s) CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES ,~ . 1715 Chester Ave., Bakersfield, CA 93301 (661) _326-3979 UST Tank -1 Page , . of _ r" _ r ACTION ^ t NEW SITE PERMIT ^ 3 RENEWAL PERMIT YJ 5 CHANGE OF INFORMATJQ N (State type of change) ^ 7 PERMANENTLY CLOSED ON SITE Check ane item only /~/~ J QL[/,{,C-~( ^ 4 AMENDED PERMIT ^ 8 TEMPORARY SITE CLOSURE ^ 8 TANK REMOVED 429 i 1 BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 FACILITY tD # .. ~'',~ I I i ~ ~ ~ ~ /~l/ / /,~lL~ ~ E,;: .: j ' LOCATION (Option/en ,/ 1. TANK DESCRIPTION ' TANK ID # i 430 TANK MANUFACTURER 431 COMPARTMENTALIZED TANK ~ Yes ^ No 432 V v y~ G_w ~ It'Yes', complete one form for each compartment. DATE INSTALLED (YEAR/MO) 433 TANK CAPACITY IN GALLONS 434 NUMBER OF COMPARTMENTS 435 ~~, as a ~ ADDITIONAL DESCRIPTION (For klcal use only) 438 II. TANK CONTENTS TANK USE 437 VEHICLE FUEL TYPE 438 ~ (~ t MOTOR VEHICLE FUEL ~1a REGULAR UNLEADED ^ 2 LEADED ^ 5 JET FUEL ' (If marked, complete VehiGe Fuel Type) ^ 1b PREMIUM UNLEADED ^ 3 DIESEL ^ 8 AVIATION FUEL ^ 2 USED OIL i ^ 1c MIDGRADE UNLEADED ^ 4 GASOHOL ^ 99 OTHER ~ ' ^ 3 CHEMICAL PRODUCT ' ~ ^ 4 HAZARDOUS WASTE COMMON NAME (from Hazardous Materials Inventory page) 439 CAS # (from Hazardous Materials Inventory page) 440 ^ 95 UNKNOWN Ili. TANK CONSTRUCTION TYPE OF TANK ^ 1 SINGLE WALL ^ 3 SINGLE WALL WITH ^ 5 INTERNAL BLADDER SYSTEM 441 Check one item only ~ 2 DOUBLE WALL EXTERIOR MEMBRANE LINER ^ g5 UNKNOWN i ^ 4 SINGLE WALL IN A VAULT ] gg OTHER ' TANK MATERIAL (primary tank) ^ 1 BARE STEEL J~ 4 STEEL CLAD W/ FRP ^ 5 CONCRETE ^ 95 UNKNOWN 442 ~ Check one item ony ^ 2 STAINLESS STEEL ^ 3 FIBERGLASS ^ 8 FRP COMPATIBLE W/100% METHANOL ^ 99 OTHER TANK MATERIAL (secondary tank) ^ 1 B,q~ STEEL ^ 4 STEEL CLAD W/FRP ^ 8 FRP COMPATIBLE W/100% METHANOL ^ 95 UNKNOWN 443 Check one item onty ^ 2 STAINLESS STEEL ~, 3 FIBERGLASS ^ 9 FRP NON-CORRODIBLE JACKET ^ 99 OTHER ^ 5 CONCRETE ^ 10 COATED STEEL INTERIOR LINING OR COATING ^ 1 RUBBER LINED ^ 3 EPOXY LINING ^ 5 GLASS LINING ^ 95 UNKNOWN 444 Check one item only ^ 2 ALKYD LINING ^ 4 PHENOLIC LINING ^ 8 UNLINED ^ 99 OTHER OTHER CORROSION ^ 1 MANUFACTURED CP ^ 3 FIBERGLASS REINFORCED PLASTIC ^ 95 UNKNOWN 445 PROTECTION IF APPLICABLE Cheek one item only ^ 2 SACRIFICIAL. ANODE ^ 4 IMPRESSED CURRENT ^ 99 OTHER SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PROTECTION EQUIPMENT INSTALLED (YEAR) j 448 447 Check all that aDPly DROP TUBE Yes ^ No 448 ^ t ALARM STRIKER PLATE ~ Yes ^ No 449 ^ 2 BALL FLOAT ^ 3 FILL TUBE SHUT OFF VALVE IV. TANK LEAK DETECTION .~ ~: ~: IF SINGLE WALL TANK (Check all that apply): IF DOUBLE WALL TANK (Check one item only): 450 ^ 1 VISUAL (EXPOSED PORTION ONLY) ^ 5 MANUAL TANK GAUGING (MTG) ^ 8 VISUAL (SINGLE WALL IN VAULT ONLY) (~ 2 AUTOMATIC TANK GAUGING (ATG) ^ 8 VADOSE ZONE ^ 9 CONTINUOUS INTERSTITIAL MONITORING ~ ^ 3 CONTINUOUS ATG ^ 7 GROUNDWATER ^ 4 STATISTICAL INVENTORY RECONCILIATION (SIR) + ^ 99 OTHER j BIENNIAL TANK TESTING V. IAPIR IiLVJURC IIVtVKMA I IVIV / !'CRMARCIV 1 I~LVJURC IIY 1'LAI.C ESTIMATE4 DATE LAST USED (YR/MO/DAY) 451 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 452 GAS TANK FILLED WITH INERT MATERIALS 453 cal ^ Yes ^ No 2 B ~' D ~iR~ w/~TM T Fonn B a s: ~. ~ ~ CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 171 S Cheater Ave., Bakersfield, CA 93301 (805) 326-3979 UST • TANK PAGE 2 Pogo Of rl VI. PIPWG CONSTRUCTION fChark ail that annlvi S -- ABOVEGROUND PIPING INFORMATION UNDERGROUND PIPING INFORMATION SYSTEM TYPE-` ^ t SUCTION ^ V Y ~2 PRESSURE ^ 3 GRAVITY 454 - ^ 1 SUCTION ~2 PRESSURE ^ 3 GRAVITY 455 CONSTRUCTION ~ ^ 1 SINGLE WALL ^ 93 UNKNOWN ^ 1 SINGLE WALL ^ 3 LINED TRENCH ^ 99 OTHER 4 ~2 DOUBLE WALL ^ 99 OTHER 450 2 DOUBLE WALL ^ 95 UNKNOWN 454 _ _ MATERIALS AND ~ ^ 1 BARE STEEL ^ 8 FRP COMPATIBLE W/ 100% METHANOL ^ 1 BARE STEEL ^ B FRP COMPATIBLE W/ 100% METHANOL CORROSION PROTECTION ^ 2 STAINLESS STEEL ^ 7 GALVANIZED STEEL ^ 2 STAINLESS STEEL ^ 7 GALVANIZED STEEL ^ 3 PVC COMPATIBLE WITH CONTENTS ^ 93 UNKNOWN ^ 3 PVC COMPATIBLE WITH CONTENTS ^ 95 UNKNOWN 4 FIBERGLASS ^ 8 FLEXIBLE ^ 99 OTHER ~ 4 FIBERGLASS ^ 8 FLEXIBLE ^ 99 OTHER i ^ 5 STEEL W/COATING ^ 9 CATHODIC PROTECTION 455 ^ 5 STEEL W/COATING ^ 9 CATHODIC PROTECTION 456 i VII. PIPING LEAK f]ETECTION (Check all that aoDlvl ABOVEGROUND PIPING INFORMATION UNDERGROUND PIPING INFORMATION SINGLE WALL PIPING 457 SINGLE WALL PIPING 456 PRESSURIZED PIPING (Check all that appy): PRESSURIZED PIPING (Check all that apply): ^ 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, ^ 1 ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF SYSTEM FAILURE, ANO SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION +AUDIBLE AND ' ~ ^ 2 MONTHLY 0.2 GPH TEST VISUAL ALARMS ^ 3 ANNUAL INTEGRITY TEST (0. t GPH) ^ 2 MONTHLY 0.2 GPH TEST ^ 4 DAILY VISUAL CHECK ^ 3 ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS (Chock all that appy): CONVENTIONAL SUCTION SYSTEMS: ^ 4 DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY ^ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM ' TEST (0.1 GPH) ^ 6 TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS: SAFE SUCTION SYSTEMS: ^ 7 SELF MONITORING ^ 5 SELF MONTORING GRAVITY FLOW (Check all that apply): GRAVITY FLOW: ^ 8 DAILY VISUAL MONITORING ^ 6 BIENNIAL INTEGRITY TEST (0.1 GPH) ^ 9 BIENNIAL INTEGRITY TEST (0.1 GPH) j SECONha~RILY CONTAINED PIPING SECONDARILY CONTAINED P!^1NG PRESSURIZED PIPING (Ctteck a6 that appy): PRESSURIZED PIPING (Check all that appy): ~ (~ 10 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (check one) I~6I 7 CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE ANO VISUAL ALARMS AND I ^ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS (Check one) ~ ~ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ^ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ~ b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM ^ c NO AUTO PUMP SHUT OFF DISCONNECTION i '~I 11 AUTOMATIC LEAK DETECTOR ^ c NO AUTO PUMP SHUT OFF ~. 12 ANNUAL INTEGRITY TEST (0.1 GPH) ~ 8 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) SUCTIOWGRAVITY SYSTEM: ~ 9 ANNUAL INTEGRITY TEST (0.1 GPH) ^ 13 CONTINUOUS SUMP SENSOR * AL:DIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check a6 that apply) ^ 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF * AUDIBLE ANO ^ 10 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND VISUAL ALARMS VISUAL ALARMS ^ t5 AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) I~ i t AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ^ 16 ANNUAL INTEGRITY TEST (0.1 GPH) ^ 12 ANNUAL INTEGRITY TEST (0.1 GPH) ^ 17 DAILY VISUAL CHECK ^ 13 DAILY VISUAL CHECK ;. .. :.. .,... .:; ., i VIII. DISPENSER CONTAINMENT . DISPENSER ^ t FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ^ 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER CONTAINMENT i ^ Yes ^ No ^ 2 CONTINUOUS ELECTRONIC SENSOR +AUDIBLE AND VISUAL ALARMS +AUDIBLE AND VISUAL ALARMS ^ 4 DAILY VISUAL CHECK IX. OWNE OPERATOR SIGNATURE __ I certiy that the informatbn provided herein is true 8 accurate to the best of my knowledge. SIGNATURE OF OWN R/OPERATOR DATE 482 ` NA F OWNER/OP ERATOR (pdnt) . 483 TITLE OF OWNER/OPERATOR 464 n ~ielJ f b R~ /~~ _ Permit Number (For local use only) Permit Approved Permit Explratlon Oale form B -~~ CITY' OF BAKERSFIELD ~: =~~ r~rr ;.~ O~~'FICE OF EYVIROIYMEIYTAL SERVICES ~~rr 1~iS Chester Ave., Bakersfield, CA 93301 (661) 326-3979 "~ "'"• UNDERGROUND STORAGE TANKS -TANK PAGE 1 Pte. _. a rvPE OF ACTION ^ I. NEW SITE PERMIT O ~. AMENDlD PERMIT O S. CHANGE OF INFORMATION) ^ d. TEMPORARY SITE CLOSURE i CnKA OM .lMn ONr! ^ >'. pERMANENTLr CLOSED ON SITE . ^ ]. RENEWAL PERAYT (~~, ~~ • ~ ~~ u» oM'1 (mod tlwpa • ~ beN use a+rY1 O 6. TANK REMOVED 9USINESS NAAE (Same a• RACIUTV NAME a DSA • Oarnq SurYlpr N- ] FACMY 10 r ~ L TANK OESCRIPTiON rAIVK ~ r A COMPARTMENTALIZED TANK ~ rp ^ No M'Ya', ~PWa ane pa9a fa sarJf oomparanarq• ^. TANK CCNTL~NTB ~ TANK USE 41lt PE TAOLELMATYPE - ~- i ^ 1. MOTOR VEHICLE iLlEl ^ t o REQUTAR UhLFJ1DED ^ 2 lFJ1DED ^ S. JET FUEL (NmaAaW, oOn~IrM PINeAwn 7yyy 10. PREMIUM UN.EADED ^ ]. DIESEL ^ 6. AVIATION FUEL NON-FUEL PETROLEUM ^ 2 . . ^ to MIDORAOE UKFADED ^ t. OASOHOI ^ 90. OTHER EANCAL PRODUCT j ^ 1 / 3. C N A4I a Ub * I ^ .. NAweDOw wABT>: (dawn COAw10N NAME (6We- I'4a~A7va AIaINWS MrM1WYD~D~1 7vr U 44t CAS r (Harr asar -~nrP+sa•~ ••. uaw oq j ^ es. uNKNOwN ^. TANK CCN9?RUCTiON rvPE of TANK Q t • srloLE wAIL ^ s. srKllg wAU wlnL ^ s. s1NG1.E WALL wrrH u~tTERNAL eLADOER SYSTEbL 44] (CMCR oM 4irrr oNYI ~2 DOUBLE WAIT DCTERK)R MEMBRANE LBazR ^ 96. UNIOrOWN ^ 4. $tNQLE WALL W A VAULT ^ ~• OTHER ' TANK MATERIAL • primary EuYC ^ 1. BARE STEEL wl, 7. FIBEROUISS /PLASTIC ^ s. CONCRETE ^ 95. Uf10~OWN 44t (CASek oM ifrar ally! ^ 2 STAINLESS STEEL ~ ^ 4. STEEL CIAO WIF61fROlAS3 REWFORCED PLASTK: (FRPy ^ 0. FAP COMPATIBLE W/100% MERiANOL ^ 9D. OTHER 'TANK MATERIAL • rrloonduy fault ^ 1. BAf1E STEEL Q, ]. FIBERGLASS /PLASTIC ^ 0. FRP COMPATIBLE WM00% METHANOL ^ 96. UNOrOWN 445 (CMut a+4 arnr aye ^ 2 STAM~tESS STEEL ^ 4. STEEL CLAD WIFIBfRf31ASS ^ 0. FRP NON•CORROOIBLE JACKET ^ fiD. OTHER AErsoACED PLASnc (FRP) ^ 10. ca-TEO STEEL O s. CONCRETE TANK INTERIOR LlMdLi ^ t. RUBBER LMl1'D ^ S. EPOXY LNMK3 ^ s. GLABS lJMlK; ^ 96. UMQfOV1M 146 DATE NSTALLED M7 OR COATMIO ^ 2 AIXYO LNlq O 4. PIENOLIC LINNJO O a UWLINED O ~. OTHER cn~ a» Oar A>ar ue» OTHER CORROSION ^ 1 MANUFACTURED CATHODIC ^ >. FIpEROLASS REY~ORCED PLASTIC ^ 96. UNIOrOVYN NS DATE INSTALLED 149 . PROTECTION IF APPLICABLE ~~~~ ^ 4• SSEO CURRENT ^ 9S. OTHER (CMetr ate Xaen oNYI ^ 2 SACRIFICIAL ANODE (Fa'bpl usa oM'1 SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (forbeal urn oNY) 45t OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 'MZ 4 (CAtack aI tlttaf ipplY) ~ 1. SPILL CONTAIHMlNf ^ 1. ALARM ~; 1. FILL TUBE SHUT OFF VALVE ~- 2 DROP TUBE ^ 2 BALL FLOAT ^ 4. E%EMPT 1. STRKER PLAT! .. . , r • .. •. • _'~ ~ Ali O'. p,~~.r. ~ .. s` ~~. :.~• i~NK 4d/Y~ ... ..~ ~ .. .. ....: ... ~~iAi~jr~N V -0Z ~.. :lY' •. Y~;'a C. S~~;.. IF SINOL/ WALL TANK (CAaelr M rMf aAolyF 461 a OOUBL! WALL TANK 011 TANK WITH BL/1D0lA (CArat orN Nam orllYl: ~ ^ f, VISUAL (EXPOSED PORTION OILY) ^ 6. MANUAL TANK GAIIGIN0lMT0) ^ 1. VISUAL (SMIOLE WALL IN VAULT ONLY) ^ 2. AUTOMATIC TAN( GAUOWO (ATO) ^ 0. VADOSE ZONE ^ 2 CONTINUOUS INTERSTTfIAL MONRORINO ^ ]. CONTINUOUS ATO ^ 7. OROUNOWATER ^ 1. MANUAL MONRORINO ^ ~. STATISTICAL INVlNTORY RECONCLIATK)N (SIR) • ^ 0. TAN(TESTWO BIENNIAL TANK TBBTINO ^ ~. OTHER ..._ ...•..- ~ .. ~.:. ~ V. TANK CLOBURII INRORYATKkI / PRRMAN~NT d .OdURR ql PLACa I ESTIMATED OATS IABT UBlO (YRIMOIOAY) 666 lSTIMATEO WANTITY OF SUBBTANCB REANINNJO 466 TALK FLLEO WITH (NEAT MATERLAL9 edofw ^ YM ^ No r67 UPCF (7/89) 3:1CUPAFORM3ISWRC~'~~ CITY OF BAKERSFIELD ~~` OFFICQ Of ENVIRONMENTAL SERVICES .,.-, 1713 Ch9sN1• Aw., Bak9nANd, CA 9J901 (441) 324.1979 j UST .TANK PAG! . Papa d K'I/INO CONSTRUCTION (C/laea r dlat app~l)~ uNOEROROUNO aPINO ABpvEGROUNO aPtNG SrSTEM rvPE ~ t PRESSURE ^ 2. SUCTION ^ ] GRAVRV 450 ~ t PRESSURE SUCTION ^ 7. GRAVRy ^ 2 . . . a~ CONSTRUCTIOw~ ^ t. SINGLE WALL ^ ~. LINED TRENCH ^ ti0. OTHER s00 ^ t. SINGLE wALL ^ 93. UNKNOWN aE MANUFACTURERI (41 2. DOUBLE WALL ^ 90. UNKNOWM I~, 2. DOUBLE WALL ^ 99. OTHER ~ MANUFACTURER S ~'v ~a"Q`I- 401 MANUFACTURER s ~")) ~ ^ t. BARE STEEL ^ 0. FRP COMPATIBLE VVJ 100% METHANOL ^ t. BARE STEEL ^ 0. FRP COMPATIBLE W/ t0px AAET1{ANpI MATERIALS ANO ~^ j, gTA1NLE39 STEEL ^ 7. (3ALVANiZEO STEEL ^ 2. STAINLESS STEEL ^ 7. GALVANIZED STEEL CORROSION aiOTECT10N ~ ^ ]• PLASTIC COMPATBBU? WITH CONTENTS ^ 96. UNKNOWN ^ 3. PLASTIC COMPATIBLE WITH CONTENTS ^ 0. FLEXIBLE (HOPE) ^ 90. OTHER 4. FIBERGLASS ^ 0. FLEXIBLE (HOPE) ^ 9Y. OTHER ~ 4. FIBERGLASS ^ 9. CATHODIC PROTECTION ^ S. STEEL W! COATING ^ 4. CATHODIC PROTECTION Ibl ^ S. STEEL WI COATING ^ 9S. UNKNOWN 48, VM. PlMi1G IIAK DETECTION (CAapt d tlrt agog) i' %riT; j Ut~ERGROUNO PIPING ABOVEGROUND PIPING ~ WALL 460 SIINf WALL PIPING 4g; PRESSURIZED PIPING (CMek a/ MIf tI010lYJ: PRESSURIZED PIPING (CAadr ar Mat apply): ^ t . ELECTRONIC LINE LEAI(OETECTOR 3.0 GPN TEST ~ AUTO PUMP SFIIlT OFF FOR ^ t. ELECTRONK: LINE LEAK DETECTOR 3.0 GPN TEST I F ALRO PU11i+ SHUT OFF FOR LEAI( LEAK SYSTEM FAILURE. ANO SYSTEM DISDOlftECTION • AWaILB AND VISUAL SYSTEM FAKURE, AND SYSTEM WSCONNECTgN + AUDIBLE AND VISUAL ALARMS ~~ ^ 2 MONTHLY 0.2 GPH TEST ^ 2. MOHT}It.Y 03 QPN TEST ^ 3. ANNUAL OYTEGRITY TEST (O.t QPH) ^ 1. ANNUAL WTEOi1ITY TEST (0.1 QPN) ^ 4, PALLY VISUAL CHECK CONVENTIONAL SUCTKkI SYSTEMS: WNVENTiONAI SUCTION SYSTEMS (CASek aI Matappy): ^ S. DAILY VISUAL MOWTORMIG OF PUMPRq SYSTEM + TRIEPMAL PpWG NRE(3RITY ^ S. DAILY VISUAL MONRORING OF PIPOrG AND PUMPING SYSTEM TEST (o.t GPH) ^ 0. TRIENNLIL INTEGRITY Tt"cST (O.t GPH) ~ SAFE SUCTION SYSTEMS (NO VALVES IN BEL,OYY GROUND PIPOrf'X SELF MONRORING ^ 7 SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPINGk . ^ 7. SELF MONRORING GRAVm FLOVr. GRAVITY FLOW (C/wck ar Mat aAOPNk ^ 9. BtENNU1L INTEGRITY TEST (0.1 OPH) ^ 8. OA6.Y VISUAL AAONITORY4G ^ 9. 81ElOiLAt INTEGRITY TEST (O.1 GPH) S®GOlOARILY CONTAINED PIP4Ki SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (CAack of Mat+IOOyJ: PRESSURIZED PIPING (CAsat a/ Mat apply): ~ t 0. C -~NllOtlS TUR&NE SUMP SENSOR ~ AUDIBLE ~V~D VLStJAL ALARMS AND / 0. CANT1N000S TURBINE SUMP SENSOR V~ AUDIBLE AND VLSIJAL ALARMS AND Idled[ one) ^ a. AUTO PUMP SNOT OFF WHEN A LEAK OCCURS ^ a. AUTO PUMP SHUT OFF WHEN A LF/1K OCCURS ~ FOR LEAKS. SYSTEM FAlLt1RE AND SYSTEM j ~ b. ~ D. AUTO PUMP SHUT OFF FOR LEAKS. SYSTEM FAILURE ANO SYSTEM DISCONNECTKNI OtSCONNECTKN~t ^ a NO AUTO PUMP SNOT OFF ^ e NO AUTO PUMP SHUT OFF ~, t t. ~ R~ NNE LEJ11C DETECTOR (!.0 OPFI TEST) ~ FLOW SHUT OFF OR ~1 t. AUTOMATK: LEAK DETECTOR ST ^ t 2. ANNUAL INTEGRRY TEST (0.1 GPH) ^ 12 ANNUAL INTEGRITY TEST (0.1 GPH) SUCTIONKrTtAVTTY SYSTEM: SUCTgNK)RAVRY SYSTEtrM ^ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ^ 13. CONTIIVlI0l1S SUMP SENSOR +AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (CAaCk d ilat+tAd)~1 EMERGENCY GENERATORS OMLY (CMck a/ Matapipyg ^ 14. CONTIWlt0U8 SUMP SENSOR ALRO PUMP SllltT OFF +ALIDIBIE AND ^ 14. CONTtNIK)US SUMP SENSOR ~ AUTO PUMP SHAT OFF + AUDIBLE ANO VISUAL VISUAL ALARMS ALARMS ^ t S. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) FLOW SHUT OFF OR ^ 1S. AUTOMATK; LWE LEAK DETECTOR (3.0 GPH TEST) RESTRICTION ^ 18. ANNUAL INTEGRITY TEST (0.1 GPH) ^ 18. ANNUAL INTEGRITY TEST (0.1 GPH) ^ t 7. DAILY VISUAL CHECK ^ 17. DAILY VISUAL CHECK DISPENSER CONTAINMENT ^ t . FLOAT MECHANISM THAT SHUTS OFF 9FIEAR VALVE ^ 4. OAri.Y VISUAL CHECK GATE INSTALLED 466 ~ 2 CONTOiU0U9 DISPENSER PAN SENSOR +AUDIBLE AND VISUAL ALARMS ^ S. TRENCH LINER / MpNRORIN(i ^ 3. CONTOrl10U3 018PENSER PAN 9EPISOR ~ ALRO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS ^ e. NONE 489 OC OWNER/OPERATOR 91pNATURE i certlN Mal tM inlbrmadan plvdda0 haraln I! Irw and attlxlfala ro Ma east d Illy kJfOrNadM. SIGNATURE Of OWNER/OPERATOR PATE 470 ~~ 0 WNER/OPERA70R (pMq 471 TITL OF OWNER/OPERATOR 471 ~, UPCF (7/99) S:ICUPAFORMSIBWRCB-B.WP~ CITE' OF BAKERSFIELD ,OFFICE OF E~VIROIYMEiYTAt. SERVICES i~71S Chester Ave., BakersReld, CA 93301 (661) 3Z6-3979 UNDERGROUND STORAGE TANKS -TANK PAGE 1 F ACTION Cn~ca uni .a..r oi/y! O 1. NEW SITE PERMIT ^ .• AMENDED PEAMIT O 7. RENEWAL, PEAIwT ^ !. CHANGE OR INFORMATION) (Soeeay n.,on • ibr bc.i u:. wrYJ (soec/Y uwgr • br bi/ wr oNYI I. TANK OESCRIPTTON Pags _ ~ ^ tf. TEMPORARY SITE CLOSURE ^ 7. PERMANEHTLr CLOSED ON SITE ^ 4. TANK REMOVED i ntve~ w . wu ~ ~~nn wwKU~l.I VF(tH v,i I ~- , COMPARTMENTALIZED TANK Yes ^ Np ~ H'Yes'. oompdets ans page dor eeUi oompartme-q, Ip~ N. TANK 00ltTElfT~ ~ TANK U9E s,19 PETAOI.EUM TYPE t ^ 1. MOTOR VEHICLE FUEL ^ 1a REfIUTAR UltFJ10ED ^ L LEADED ^ S. JET FUEL (Y~~ ~~ ~~ TYn.1 O ,U. PRfJNUM UNLEADED O s. DIESEL ^ a. AVtATgN FuE1 ^ 2. NGN.r:vEL PETTaotFUA1 p to. MDCiRADE UKEAOEn ^ .. ciA90rgL ^ 99. OTHER ^ s. CHEMICAL PRODUCT CONdON NAME (bon- INalabw /Iaeerlete rmhnurypape) 411 crs K (nan Hazsrdow Ate4rids drtransxypsya) 4<: ^ a. HAL~RDOUS WASTE jr,duwa ! uaa orJ i ^ es. uNKNOwN ~ pl. TANK CLMIgTRtJCT TON ~ rYPE OF 7ANK ^ t. 91Nt31E WAIL ^ 3. SNCiIE WALL WRH ^ S. 3o1GLE WALL WTTN INTERNAL BLADDER SYSTESVt 113 ~ (C1Nek onr Atam o-Vy) ^ L DOUBLE YYALL EXTERIOR L1NEft ~ ^ 96. UMt710WN I ^ 4. $9JQl,E WALL ql A VAULT ^ ~ OTFlER ' TANK MATERIAL • pAmary taf.c ^ 1. BARE 9TE'EL ^ 1. F18EROLAS$ /PLASTIC ^ S. CONCRETE ^ 93. UNKNOWN 44a (CMdc one Arm otVy) ^ Z STAINLESS STEEL ^ 4. STEEL CLAD wdFrBERC~LA$s ^ B. FRP COMPATT8LE wtt00% METHANOL ^ 9'D. OTHER REWFORCED PL/15T1C (FRP) TANK MATERV.L - ssoaWerY tank ^ t. BARE STEEL ^ S. F18FROLA3$ /PLASTIC ^ S. FRP COMPATIBLE Yi0'100% I~ET}IAIIOI. ^ 93. UlMSagwN 145 (CMtk ons Arm o~ry) ^ 2. $TANi.ESS 9'TEE4 ^ 4. STEEL CLAD w1F1BERCLASS ^ 0. FRP NQN-OORROOIBLE JACKET ^ 90. OTHER RQIlFORCED Pt.AST1C (FRP) ^ 10. COATED STEEL ^ S. CON(~tETE TA/il( INTERIOR UNINO - ^ L. RUBBER UIEO ^ 3. EPOXY tJNYK3 ^ s. Ot.A68 LkBNLi ^ 96. UNlveowrl 11e DATE WsTAU.En IAT oR coATUro ^ t ALKYD LS~eFKJ ^ t. PMENpUC LxawO ^ a. t~r~a.INED ^ 9A. OTHER (Caacll on. ~hn- orlyL- _ fFar bii use oNr) OTHER CORROSgN ^ I. ~~ CATH00~ ^ ~ ~~~ REU~FORCED PLASTIC ^ ob. uwcNOw*I 1Aa DATE INSTALLED 149 PROTECTION 1F APPI.iCJ~IE PROTECTION ^ 1. IMPRESSED CURRENT ^ 90. OTHER (Cnrck ona.tam pdYl ^ 2. $ACRIFICI/1L ANODE (Forbil usr oNYI SPILL ANO OVERFILL YEAR INSTALLED 130 TYPE (forbid use orYy) 131 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 (CMck ae met apply) ^ 1. SPILL CONTAINMENT ^ 1. ALARM ^ ~, FILL TUBE SHUT OFF VALVE - ^ 2. DROP TUBE ^ 2. BALL FLOl1T^L 1. EXjEMPT{ ^ 3. STRIKER PLATE ~U ~, ..,,~... L'Q("'I ~{ 1 U{t'Y IF SINOLi tIYAL,L TARTS jCJNCk JI IMI reply} ^ I, VISUAL (EXPOSED PORTgN ONLY) ^ 3. MANUAL TANK GAUGING (MTO) ^ 2, AUTOMATIC TANK t7AlK31NO (ATO) ^ 6. VA00$E LANE ^ ]. CONTINUOUS ATO ^ 7. GROUNDWATER ^ •. STATI$TICAt. II~NENTORY RECONCILU1TgN (SIR) • ^ rt. TANK TESTING BIENNIAL TANK TESTWO ^ ~ oTHFR V OOLRiLE WALL TANK OR TANK WITH OIJ1o0lR jCd»dr orw Rsm ~ ^ 1. VISUAL (SWCIL.E WALL IN VAULT ONLY) ^ Z CONTINIX)US iNTERSTRIAL MONITORING ^ ~. MANUAL MONRORINO tom`( fo+~~4~n~o~S Seco„~..,P.iy hol~,~C(e~ Y. TANK CI.OSIlRQ INFORMATION ! PQRMANQNT CLOSURlt IN PLAd! OATS LJ-ST USlD (YRIAADdDAY) 168 ESTIMATED QUANTRY OR 9US8TANGI REtiWNMIO i86 TANK FM.LED WITH INERT MATERNL9 oabol4 ^ Yes ^ No - - - - _,~ (7/99) ~>• S:ICUPAFORMSI3 WRC~'~O CITY OF 9AKERSFIELO ~ OFFICQ Of ENVIRONMENTAL SERVICES t71S Ch„tK Aw., 8ak~nMld, CA 9JJ01 (Nt) ~2d-J979 WT • TANK FAQ! : "{' Papa at K FMNIO CONtiT1tUCT10N (pwdr v rnu iavA~ -:_~ UNDERGROUND PIPING ~ ABOVEGROUND PIPING SYSTEM n'vE ^ t PRESSURE ^ 2. SUCTION ^ ), GRAVITY 4S6 ~ ^ t. PRESSURE ^ 2. SUCTION ^ 7. GRAVITY << ', CONSTRUCTIOW'^ t SINGIf: WAIL ^ ]. UNEO TRENCH ^ 90. OTHER 400 ^ t. SINGLE WAIL ^ 93. UNKNOWN 4b MANUfACTURERI^ 2. DOUBLE WALL ^ 90. UNKNOWN ^ 2. DOUBLE WALL ^'99. OTHER ~' ' ' MANUFACTURER 461 MANUFACTURER ~ ^ t, BARE STEEL ^ 6. FRP COMPATIBL,J' W/ t001L METHANOL MATERULS AND ' ^ 2. STAINlE99 STEEL ^ 7. OAIVANLZEO STEEL i CORROSION PROTECTION , ^ 7. PLASTiC COMPATIBLE WITH CONTENTS ^ 90, UNKNOWN ! ^ 4. FIBERGLASS ^ 6. FLEXIBLE (F10PE) ^ 99. OTHER I ^ S. STEEL W/ COATING ^ 9. GTHOOIC PROTECTION 404 VII. P~NO IEAIC DETECTION (CMat al Mat apply) a...urc r...~r r,~u.., Leo PRESSURIZED PIPING (CAatk M Maf appyJ: ^ t. ELECTRONIC UNE LEAK DETECTOR J.0 GPN TEST ~ AUTO PUMP $HIIT OFF FOR LEAK SYSTEM FAJLURE. AND SYSTEM QIL'SCD~IECT1pN + AUDIBLE A!p V{$UAL AU1R1N$ ^ 2. AAOtYTFILY 02 GPN TEST ^ 1. ANNUAL OYTEGRITY TEST (0.t QPNI CONVENTIONAL SUCTION SYSTEMS: ^ 5. GAILY VISUAL MpNITORINO OF PUMPING SYSTEM + TRIENNIAL P~PJD RITEGRITY TES7(O.t GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUt~ PO'ING}; 1 ^ 7. SELF MONfTOR1NG GRAVITY FLOW: ^ 9. BIENNIAL INTEGRITY TEST (0.1 GPFQ SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (CAack aI Mat appy): I t 0. CONTINUOUS TLIRBMIE SUMP SENSOR ~ AUDIBLE AND VtSUA1 ALARMS AMID ~ (Check ana) ^ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ^ p. ALRO PUMP SHUT OFF FOR LEAKS, SYSTEM FAIUIRE AND SYSTEM DISCONNECTION ^ G NO AUTO PUMP SHUT OFF ^ ,,. AUTOMATIC UNE LEAK DETECTOR (J.0 GPN TEST') y~ROW SHUT oFf OR RESTRICTION ^ 12. ANNUAL INTEGRIIY TEST (0.1 GPH) SUCTIONlGRAVITY SYSTEM: ^ 17. CONTINUOUS SUMP SENSOR + AUOIBLI? ANO VISUAL ALARMS CMERtiENCY OENlRATORt! ONLY (CAaatarMatapiply) ^ , 4. CONTINUOUS SUMP SENSOR ~ AUTO PUMP SFdJT OFF • AUDIBLE AND VISUAL ALARMS ^ t S. AUTOMATIC LINE LEAK DETECTOR (J.0 GPH TEST) ~gg~('j FLOW SHtfT OFF OR RESTRICTION ~OV1~10\Qt7!(V i~1t71`.\ CpC~ ^ i8. ANNUAL INTEGRRY TEST (0.1 GPH) ^ 17. DAILY VISUAL CHECK 31 L WAIL PIPINfi 46; PRESSUR12E0 PIPING (CAack M ONII apply): ^ t. ELECTRONIC LINE IF.AI( DETECTOR J.0 GPH TEST V }AUTO PUMP SHUT OFF FOR LEU( i SYSTEM FAILURE. AND SYSTEM 013CONNECTION + AUDIBLE ANO VISUAL. ALARMS ^ 2 MONTHLY 02 GPH TEST ^ J. ANNUAL OTEGRITY TEST (0.1 GPH) ^ s. GAILY VISUAL CHECK CONVENTIONAL 3LJCTION SYSTEMS (CJfsek ar Mat apWY1~ ^ S. GAILY VISUAL MONRORN4G OF PIPING AND PUMPING SYSTEM ^ 0. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ^ T. SELF MONRORING GRAVITY FLOW (CASC1t al tllat spplyJ: ^ 6. DAILY VISUAL MONITORWO - . ^ 9. BIENNIAL OYTEGR(TY TEST (O.t GPH) SFCOflaARILY CONTAINED PIPING PRESSURIZED PIPING (CheKk al Mat apply): f 0. CONTINUOUS TURBINE SUMP SENSOR VI(jTF~ AUQIBLE AND VISUAL ALARAS$ AND (chetlc one) ^ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ^ D. AU70 PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ^ c NO AUTO PUMP SHUT OFF ^ 11. AUTOMATIC LEAK DETECTOR ^ 1 Z ANNUAL INTEGRITY TEST (0.1 GPH) $UCTLONK,RAYRY SYSTEM: ^ 1 J. CONTINUOUS SNAP SENSOR + AUDIBLE ANO VISUAL AlARM3 EMERGENCY OENERATORt! ONLY (CMdc a1 Mat appy) ^ 14. CONTINUOUS SUMP SENSOR j AUTO PUMP SHUT OFF + AUDIBLE AND VISUAL ALARMS ^ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ^ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ^ 17. GAILY VISUAL CHECK DISPENSER CONTAINMENT ^ t. FLOAT MEGUWISM THAT SHUTS OFF SFIEAR VALVE ^ 1. GAILY VISUAL CHECK OATEINSTALLEO 460 ^ Z. CONTINUOU901$PEN$ERPANSENSOR+AU018lEANOVISUALALARM$ ^ S. ': 2.4'J:++i_i"lr ':~;1.~!'~a i~~~ ^ 1. CONTIMIOU9 DISPENSER PAN SENSOR ~ AUTO SHUT OFF FOR DISPENSER • AUDIBLE ANp VISUAL ALARMS 489 I I certfN that tM Dw srM aoauala t0 tM Deal d my ^ 1. BARE STEEL ^ 0. FRP COMPATIBLE W/ 100X METHANOL ^ 2. STAINLESS STEEL ^ 7. GALVANIZED STEEL ^ J. PLASTIC COMPATIBLE WRH CONTENTS ^ 8. FLEXIBLE (MOPE) ^ 49. OTHER ^ s. FIBERGLASS ^ 9. GTHOOIC PROTECTION ^ S. STEEL WI COATING _ ^ 95. UNKNOWN 46„ •on,2r_on, gun o,dw_ IX. OWNER/OPERAtOR 910NATURE TOR 471 I TRLE OF uaa JPCF (7/99) UNDERGROUND PIPING S:tCUPAFORMSISWRCB-B •~ C :.~~ CITY OF BAKERSFIELD d' fl R ~ P ~ OFFICE OF ENVIRONMENTAL SERVICES ,iRir >r 1715 Chester Ave., Bakersfield, CA 93301(661) 326-3979 • UNDERGROUND STORAGE TANKS -UST FACILITY Page _ of _ TYPE OF ACTION ^ 1. NEW SITE PERMIT ^ 3. RENEWAL PERMIT ^ 5. CHANGE OF INFORMATION (Specify change - ^ 1. PERMANENTLY CLOSED SITE (Check one Rem only) ~ ~ local use and LSV4. AMENDED PERMIT yl ^ 8. TANK REMOVED 400. ^ 8. TEMPORARY SITE CLOSURE I. FACILITY /SITE INFORMATION j BUSINESS NAME (Same as FACILITY NAME or OBA -Doing Business As) 3 FACILITY ID p 1 ~-S ® l ~ NEAREST CROSS STREET 40t. FACILITY OWNER TYPE ^ 4. LOCAL AGENCY/DISTRICT' 1 ^ t. CORPORATION ~,/ INDIVIDUAL ^ 5. COUNTY AGENCY' BUSINESS ~ TYPE t. GAS STATION ^ 3. FARM ^ 5. COMMERCIAL Ot7 2. ^ 3. PARTNERSHIP ^ 6. STATE AGENCY' ^ 7 FEDERAL AGENCY' 402 ^ 2. DISTRIBUTOR ^ 4. PROCESSOR ^ B. OTHER 403. . . TOTAL NUMBER OF TANKS Ls fapliry on Indian Reservation ar 'If owner of UST a public agency: name d supervisor of REMAINING AT SITE ttusdands7 division, SeCflon a< office which operates the UST. (This is the eontad person far the tank records.) 404 ^ Yes No 405. 408. II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. '~ ~ ~~-~33-~5~3 MAILING O S REST ADORF~SS _ ~ 409. CI 410. STATE 4t t. ZIP CODE 412. ~~ ~~ Q /~~ D PROPERTY OWNER TYPE ~ INDNIDUAL ^ 4. LOCAL AGENCY /DISTRICT ^ 8. STATE AGENCY 413. ^ 1. CORPORATION ^ 3. PARTNERSHIP ^ 5. COUNTY AGENCY ^ 7. FEDERAL AGENCY {fl. TANK OWNER INFORMATION _ TANK OWNER NAME 414. PHONE 415. C9-h ss~/ (~ .~~ - /-~C~-~ - ,~3-~~S .MAILING OR STREET ADDRESS ~/~ rr~ 416. C 1 c~ (! 417. STATE 418. ZIP CODE 419. ~ 3 TANK OWNER TYPE ~' , INDVIDUAL ^ 4. LOCAL AGENCY /DISTRICT ^ 8. STATE AGENCY 420. ; ^ 1. CORPORATION ^ 3. PARTNERSHIP ^ 5. COUNTY AGENCY ^ 7. FEDERAL AGENCY .. .. ' N. BOARD OF EQUALIZATION,UST STDRAGE FEE ACCOUNT NUMBER - .. --~' ~ TY (TK) HQ 4 4 - Call (916) 322-9669 if questions arise ~ 421• ; V. PETROLEUM UST FINANCIAL RESPONSIBILITY . ~ INDICATE METHOD(S) ^ 1, SELF-INSURED ^ 4. SURETY BOND ^ 7. STATE FUND ^ 10. LOCAL GOVT MECHANISM ^ 2. GUARANTEE ^ 5. LETTER OF CREDIT ^ 8. STATE FUND & CFO LETTER ^ 99. OTHER: ^ 3. INSURANCE ^ 8. EXEMPTION ^ 9. STATE FUND & CD 422. VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indlpte which address should be used for legal rrotifleations and mailing. ~ FACILITY ^ 2. PROPERTY OWNER ^ 3. TANK OWNER Legal notifications and mailings will be sent to the tank owner unless box 1 of 2 is checked. 423. I VII. APPLICANT SIGNATURE CeRiflcatlon: I cattily that the irdomfadon provided herein is, true and accurate to the beat of my knowledge. SIGNATURE OF PLICANT DA/TE / 424. PHONE ~ 425. i !~ ! 0 ~~ y~E~/F~AP~P`LI~C, A'~NT (prtnf) ~ 428. TITL OF APPLICANT 427. UPCF (7/99) S:\CUPAFORMS\swrcb-a.wpd