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Delta Microlmaging Inc
9961 N Lower Sacramen-to Rd
Stockton, CA 95210, .
209-478-3600
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..p I . UWU U\WU G R 0 U P L L C
. ... ...' .. Innovation. Infrastructure. Results.
October 31, 2007
Bakersfield Fire Dept.
900 Truxtun Avenue
Room 200
Bakersfield, CA 93301
Attention:
CUPA Filing
Subject:
Correction to Form B
Quick Stuff #7723
10 Union Avenue
Bakersfield, CA 93307
Facility 10: 015-021-002367
To Whom It May Concern:
Page 1 of 1
G
S~
JMM Management Group, LLC, on behalf of Jack in the Box, Inc., recently submitted a packet of CUPA
forms for the above referenced facility, including the CUPA Form B. This submittal had incorrect data
pertaining to the tank installation date. Please accept the enclosed filing with the correct information.
Please feel free to contact the undersigned with any questions in this regard.
Sincerely,
JMM Management Group, LLC
D~ ~, c;:J-
Daniel A Erickson
Compliance Manager
Attachment
JMM .Management Group, LLC
2496 Technology Drive
Elgin, IL 6.0124
T: 847-888-0276
F: 847-888-0279
www.jmmmgt.com
1< ....
pi'
ID
D
R
TANKS
UNDERGROUND STORAGE TANKS - TANK PAGE 1
TYPE OF ACTION
D 1 NEW SITE PERMIT
D 4 AMENDED PERMIT lEI S CHANGE OF INFORMATION
430
(Check one item only)
D 3 RENEWAL PERMIT (Spedfy reason. lorlocal use only) (Specify reason. forlocal use only)
BUSINESS NAME (Same as FACILITY NAME or DBA. Doing Business As)
Quick Stuff #7723
(Optional)
(two pages per tank)
Page_of _
6 TEMPORARY SITE CLOSURE
7 PERMANENTLY CLOSED ON SITE
8 TANK REMOVED
431
#
434
Xerxes
L
20,000
(For local use only)
\
lEI 1. MOTOR VEHICLE FUEL
(II marked complete Petroleum Type)
D 2. NON.FUEL PETROLEUM
o 3. CHEMICAL PRODUCT
o 4. HAZARDOUS WASTE
(Includes Used Oil)
lEI 1 a. REGULAR UNLEADED 0 2. LEADED
o lb. PREMIUM UNLEADED D 3. DIESEL
D lc. MIDGRADE UNLEADED D 4. GASOHOL
COMMON NAME (from Hazardous Materials Inventory page)
o 95. UNKNOWN
(Check one item only)
EXTERIOR MEMBRANE LINER
D 4. SIGNLEWALLlN VAULT
[8] 2. DOUBLE WALL
TANK MATERIAL. primary tank
(Check one item only)
REINFORCED PLASTIC (FRP)
TANK MATERIAL. secondary tank X
ICheckoneitemonly) D 2. STAINLESS STEEL D 4. STEELCLADW/FIBERGLASS
REINFORCED PLASTIC (FRP)
o S. CONCRETE
D 2. STAINLESS STEEL D 4. STEEL CLAD W/FIBERGLASS
OR COATING
(Check one item only)
D 2 ALKYD LINING
lEI 6 UNLINED
o 4 PHENOLIC LINING
OTHER CORROSION 0 1 MANUFACTURED CATHODIC lEI 3 FIBERGLASS REINFORCED PLASTIC
PROTECTION IF APPLICABLE PROTECTION 0 4 IMPRESSED CURRENT
(Check one item only) . D 2 SACRIFICIAL ANODE (For local use only)
(local use only)
ICheckall that apply) lEI 1 SPILL CONTAINMENT
lEI 2 DROP TUBE
lEI 3 STRIKER PLATE
2002
2002
2002
II "Yes", complete one page lor each compartment.
S
437
438
440
D S. JETFUEL
o 6. AVIATION FUEL
D 99. OTHER
(from Hazardous Materials Inventory page)
o 95. UNKNOWN
D 99. OTHER
D 8. FRP COMPTIBLE W/lOO% METHANOLD 99. OTHER
o 8. FRP COMPTIBLE W/100% METHANOL
o 10. COATED STEEL
D 99. OTHER
D 99 OTHER
(For local use only)
D 95 UNKNOWN
D 99 OTHER
lEI 1 ALARM
lEI 2 BALL FLOAT
2002
2002
D 3FILL TUBE SHUTOFF VALVE
D 4 EXEMPT
(A description 01 the monitoring program shall be submitted to the local agency.)
(Check one
D 1 VISUAL (EXPOSED PORTION ONLY)
o 2 AUTOMATIC TANK GAUGING (ATG)
D 3 CONTINUOUS ATG
o 4 STATISTICAL INVENTORY RECONCILIATION
(SIR) BIENNIAL TANK TESTING
o S MANUAL TANK GAUGING (MTG)
o 6 VADOSE ZONE
D 7 GROUNDWATER
o 8TANKTESTING
D 99 OTHER
ESTIMATED DATE LAST USED (YR/MO/DAY)
ESTIMATED QUANTITY OF SUBSTANCE REMAINING
gallons
UPCF (12/99 revised)
10
item only)
o 1 VISUAL (SINGLE WALL IN VAULT ONLY)
lEI 2 CONTINUOUS INTERSTITIAL MONITORING
o 3 MANUAL MONITORING
TANK FILLED WITH INERT MATERIAL?
DYes D No
Formerly SWRCB Form B
i' ~.
,:,'
- ... .--. ,-_.......
, __ I-UKM
UNDERGROUND STORAGE TANKS - TANK PAGE 2
TANKS
VI. PIPING CONSTRUCTION (Checkallthatapply) Page _ of _
\ UNDERGROUND PIPING ABOVEGROUND PIPING
SYSTEM TYPE ~ 1. PRESSURE o 2. SUCTION o 3.GRAVlTY 458 0 1. PRESSURE 0 2. SUCTION o 3. GRAVITY 459
CONSTRUCTION o 1.SINGLE WALL o 3. LINED TRENCH o 99. OTHER 460 0 1. SINGLE WALL 0 9S. UNKNOWN 462
MANUFACTURER ~ 2. DOUBLE WALL o 9S. UNKNOWN 0 2. DOUBLE WALL 0 99. OTHER
MANUFACTURER A.a. Smith 461 MANUFACTURER 463
o 1. BARE STEEL 0 6. FRP COMPATIBLE w/l00%
o 2. STAINLESS STEEL 0 7. GALVANIZED STEEL
o 3. PLASTIC COMPATIBLE W/ CONTENTS
~ 4. FIBERGLASS 0 8. FLEXIBLE (HDPE)
o S. STEEL W/COATING 0 9. CATHODIC PROTECTION
VII. PIPIN~ Lt:AK
METHANOL 0 1. BARE STEEL 0 6. FRP COMPATIBLE W/100% METHANOL
o Unknown 0 2. STAINLESS STEEL 0 7. GALVANIZED STEEL
o 99. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 8. FLEXIBLE (HDPE) 099. OTHER
o 4. FIBERGLASS 0 9. CATHODIC PROTECTION
464 0 S. STEEL W/COATING 0 95. UNKNOWN
(Cheek.1I th.t .pply) (A description of the monitoring progr.m sh.1I be submitted to the 10e.l.geney.)
o
o
o
o 16. ANNUALlNTEGRITY TEST (0.1 GPH)
o 17. DAILY VISUAL CHECK
VIII. DISPENSER CONTAINMENT
o 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE
468 0 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS
~ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR
DISPENSER + AUDIBLE AND VISUAL ALARMS
IX. OWNER/OPERATOR SIGNATURE
SINGLE WALL PIPING
PRESSURIZED PIPING (Cheek.1I th.t .pply):
o 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT
OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION +
AUDIBLE AND VISUAL ALARMS.
o 2. MONTHLY 0.2 GPH TEST
o 3. ANNUALlNTEGRITY TEST (0.1 GPH)
CONVENTIONAL SUCTION SYSTEMS
o 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING
INTEGRITY TEST (0.1 GPH)
SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING):
o 7. SELF MONITORING
GRAVITY FLOW
o 9. BIENNIAL INTEGRITY TEST (0.1 GPH)
SECONDARILY CONTAINED PIPING
PRESSURIZED PIPING (Check all that .pply):
10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL
-
ALARMS AND (Check one)
o a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS
~ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM
DISCONNECTION
o c. NO AUTO PUMP SHUT OFF
~ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT
OFF OR RESTRICTION
o 12. ANNUALlNTEGRITY TEST (0.1 GPH)
SUCTION/GRAVITY SYSTEM
o 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS
o
o
o
o
EMERGENCY GENERATORS ONLY (Check.1I th.tapply)
14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF'
AUDIBLE AND VISUAL ALARMS
15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW
SHUT OFF OR RESTRICTION
16. ANNUAL INTEGRITY TEST (0.1 GPH)
17. DAILY VISUAL CHECK
DISPENSER CONTAINMENT
DATE INSTALLED
2002
I certify that the information prOVided herein is true and accurate to the best of my knowledge.
465
466
SINGLE WALL PIPING
467
PRESSURIZED PIPING (Cheek.1I th.t.pply):
o 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP
SHUT OFF FOR LEAK. SYSTEM FAILURE, AND SYSTEM DISCONNECTION +
AUDIBLE AND VISUAL ALARMS.
o 2. MONTHLY 0.2 GPH TEST
o 3. ANNUAL INTEGRITY TEST (0.1 GPH)
o 4. DAILYVISUALCHECK
CONVENTIONAL SUCTION SYSTEMS (Check .lIth.t.pply)
o 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM
o 6. TRIENNIALlNTEGRITY TEST (0.1 GPH)
SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING):
o 7. SELF MONITORING
GRAVITY FLOW (Check .lIth.t .pply):
o 8. DAILY VISUAL MONITORING
o 9. BIENNIAL INTEGRITY TEST (0.1 GPH)
SECONDARILY CONTAINED PIPING
PRESSURIZED PIPING (Check allthat.pply):
10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL
ALARMS AND (Check one)
o a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS
o b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEf'A
DISCONNECTION .
o c NO AUTO PUMP SHUT OFF
o 11. AUTOMATIC LEAK DETECTOR
o 12. ANNUALlNTEGRITY TEST (0.1 GPH)
SUCTION/GRAVITY SYSTEM
13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS
EMERGENCY GENERATORS ONLY (Check .lIth.t apply)
14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF'
AUDIBLE AND VISUAL ALARMS
1 S. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST)
o
o
o
4. DAILY VISUAL CHECK
S. TRENCH LINER / MONITORING
6. NONE
469
UAIt:
10/31/07
./U
41
4/L
errm! NumDer (~or oeal use onry)
473
IIILt: ~,
Compliance Manager
errnR "!'prov... \.O"Oca, use only) 474 perrm! eXpiration U.te (~or oea use on YI
."
NAME OF OWNERlOPRATOR (print)
Daniel A Erickson
UPCF (12/99 reVised)
12
Formerly SWRCB Form B
. ".: '.:~ ~
, ..
~~
TANKS
UNDERGROUND.STORAGE TANKS - TANK PAGE 1
TYPE OF AmON
o 1 NEW SITE PERMIT
o 4 AMENDED PERMIT IEJ SCHANGEOFINFORMATION
430
(Check one item only)
o 3 RENEWAL PERMIT (Specify reason. for local use only) (Specify reason. for local use only)
. BUSINESS NAME (Same as FACILITY NAME or DBA. Doing Business As)
Quick Stuff #7723
(Optional)
(two pages per tank)
Page~of ~
6 TEMPORARY SITE CLOSURE
7 PERMANENTLY CLOSED ON SITE
8 TANK REMOVED
431
#
434
2
Xerxes
3/2002
10,000
(For local use only)
IEJ 1. MOTOR VEHICLE FUEL
(If marked complete Petroleum Type)
o 2. NON.FUEL PETROLEUM
o 3. CHEMICAL PRODUCT
o 4. HAZARDOUS WASTE
(Includes Used Oil)
o 1 a. REGULAR UNLEADED 0 2. LEADED
IEJ 1 b. PREMIUM UNLEADED 0 3. DIESEL
Ole. MIDGRADE UNLEADED 0 4. GASOHOL
COMMON NAME (from Hazardous Materl~ls Inventory page)
o 9S. UNKNOWN
(Check one item only) EXTERIOR MEMBRANE LINER
[8] 2. DOUBLE WALL D 4. SIGNLE WALLIN VAULT
TANK MATERIAL.primarytank X
(Check one item only) D 2. STAINLESS STEEL D 4. STEELCLADWIFIBERGLASS
REINFORCED PLASTIC (FRP)
TANK MATERIAL. secondary tank
(Check one item only)
D 2. STAINLESS STEEL D 4. STEEL CLAD WIFIBERGLASS
REINFORCED PLASTIC (FRP)
o S. CONCRETE
OR COATING
(Check one item only)
o 2 ALKYD LINING
IEJ 6 UNLINED
o 4 PHENOLIC LINING
OTHER CORROSION 0 1 MANUFACTURED CATHODIC IEJ 3 FIBERGLASS REINFORCED PLASTIC
PROTECTION IF APPLICABLE PROTECTION 0 4 IMPRESSED CURRENT
(Check one item only) 0 2 SACRIFICIAL ANODE (For local use only)
(local use only)
(Check all that apply) IEJ 1 SPILL CONTAINMENT
IEJ 2 DROP TUBE
IEJ 3 STRIKER PLATE
2002
2002
2002
If "Yes", complete one page for each compartment.
437
438
440
o S. JET FUEL
o 6. AVIATION FUEL
o 99. OTHER
(from Hazardous Materials Inventory page)
o 9S. UNKNOWN
o 99. OTHER
o 8. FRP COMPTIBLE W/I 00% METHANOLD 99. OTHER
o 8. FRP COMPTIBLE W/1 00% METHANOL
o 10.COATEDSTEEL
o 99. OTHER
o 99 OTHER
(For local use only)
o 95 UNKNOWN
o 99 OTHER
IEJ 1 ALARM
IEJ 2 BALL FLOAT
2002
2002
o 3FILL TUBE5HUTOFFVALVE
o 4 EXEMPT
(A description of the monitoring program shall be submitted to the local agency.)
o 1 VISUAL (EXPOSED PORTION ONLY)
o 2 AUTOMATICTANKGAUGING (ATG)
o 3 CONTINUOUS ATG
o 4 5TATISTICALINVENTORY RECONCILIATION
(SIR) BIENNIAL TANK TESTING
o 5 MANUAL TANK GAUGING (MTG)
o 6VADO~Zf?NE
o ! GROUNDWA1E~. '.
o 8TANKTE5TING
o 99 OTHER
ESTIMATED DATE LAST USED (YR/MOIOA Y)
ESTIMATED QUANTITY OF SUBSTANCE REMAINING
gallons
UPCF (12/99 revised)
10
(Check one
item onl~)
o 1 VISUAL (SINGLE WALLIN VAULT ONLY)
IEJ 2 CONTINUOUS INTERSTITIAL MONITORING
o 3 MANUAL MONITORING
TANK FILLED WITH INERT MATERIAl?
DYes 0 No
Formerly SWRCB Form B
\ .
.,j"':"
IN'11l 'FORM
- ... .--.
TANKS
UNDERGROUNDSTORAGETANKS-TANKPAGE2
VI. PIPING CONSTRUCTION (Check all that apply) Page _ of -
UNDERGROUND PIPING ABOVEGROUND PIPING
SYSTEM TYPE ~ l.PRESSURE o 2. SUCTION o 3.GRAVITY 458 0 1. PRESSURE 0 2. SUCTION D 3. GRAVITY 459
CONSTRUCTION D 1. SINGLE WAll o 3. LINED TRENCH o 99. OTHER . 460 0 1. SINGLE WAll 0 95. UNKNOWN 462
MANUFAGURER ~ 2. DOUBLE WAll o 9S. UNKNOWN 0 2. DOUBLE WAll 0 99. OTHER
MANUFACTURER A.a. Smith 461 MANUFACTURER 463
0 1. BARE STEEL o 6. FRP COMPATIBLE W/100% METHANOL 0 1. BARE STEEL D 6. FRP COMPATIBLE W/100%METHANOL
D 2. STAINLESS STEel o 7. GALVANIZED STEel o Unknown 0 2. STAINLESS STEEL o 7. GALVANIZED STEEL
0 3. PLASTIC COMPATIBLE W/CONTENTS o 99. Other 0 3. PLASTIC COMPATIBLE W/ CONTENTS o 8. FLEXIBLE (HDPE) o 99. OTHER
[g] 4. FIBERGLASS o 8. flEXIBLE (HOPE) o 4. FIBERGLASS o 9. CATHODIC PROTECTION
D 5. STEel W/COATING o 9. CATHODIC PROTECTION 464 D 5. STEEL W/COATING o 95. UNKNOWN 465
VII. 1"1',1\1\:1 (Check all that apply) (A description ofthe monitorin9 program shall be submitted to the local agency.)
SINGLE WAll PIPING 466 SINGLE WAll PIPING 467
PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply):
o 1. elECTRONIC LINE lEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT o 1. elECTRONIC LINE lEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP
OFF FOR lEAK, SYSTEM FAilURE, AND SYSTEM DISCONNECTION + SHUT OFF FOR lEAK, SYSTEM FAilURE. AND SYSTEM DISCONNECTION +
AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS.
o 2. MONTHLY 0.2 GPH TEST o 2. MONTHLY 0.2 GPH TEST
D 3. ANNUAlINTEGRITY TEST (0.1 GPH) o 3. ANNUAL INTEGRITY TEST (0.1 GPH)
o 4. DAilY VISUAL CHECK
CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply)
o S. DAilY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING o S. DAilY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM
INTEGRITY TEST(O.1 GPH) .. . .' ..
SAFE SUCTION SYSTEMS (NO VALUES IN BelOW GROUNDPlPING): . , ~ -. I ~ .'. .. .' o 6. TRIENNIAL INTEGRITY TEST (0.1 GPH)
..
o 7. SelF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN BelOW GROUND PIPING):
GRAVITY FLOW o 7. SelF MONITORING
o g. BIENNIALlNTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply):
o 8. DAilY VISUAL MONITORING
o 9. BIENNIAL INTEGRITY TEST (0.1 GPH)
SECONDARILY CONTAINED PIPING SECONDARilY CONTAINED PIPING
PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply):
10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL
ALARMS AND (Check one) - ALARMS AND (Check one) -
o a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o a AUTO PUMP SHUT OFF WHEN A lEAK OCCURS
~ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM o b AUTO PUMP SHUT OFF FOR lEAKS. SYSTEM FAILURE AND SYSTEM
DISCONNECTION DISCONNECTION
D c. NO AUTO PUMP SHUT OFF o c NO AUTO PUMP SHUT OFF
~ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT o 11. AUTOMATIC lEAK DETECTOR
OFF OR RESTRICTION
o 12. ANNUAlINTEGRITY TEST (0.1 GPH) o 12. ANNUAL INTEGRITY TEST (0.1 GPH)
SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM
0 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS
EMERGENCY GENERATORS ONLY (Check all thatapply) EMERGENCY GENERATORS ONLY (Check all that apply)
0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP sl:lUT OFF. .. .,- 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF *
AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS
0\15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 0 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST)
SHUT OFF OR RESTRICTION
0 16. ANNUAL INTEGRITY TEST (0.1 GPH) 0 16. ANNUAlINTEGRITY TEST (0.1 GPH)
0 17. DAILY VISUAL CHECK 0 17. DAilY VISUAL CHECK
VIII. DISPENSER CONTAINMENT
DISPENSER CONTAINMENT 0 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE D 4. DAilY VISUAL CHECK
DATE INSTALLED 468 o 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS 0 5. TRENCH LINER I MONITORING
2002 ~ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR D 6. NONE 469
DISPENSER + AUDIBLE AND VISUAL ALARMS
IX. OWNER/OPERATOR SIGNATURE
I certify that the information provided herein is true and accurate to the best of my knowledge.
UA't .,u
10/31/07
NAME OF OWNERlOPRATOR (print) 4/ IItLt 472
Daniel A Erickson Compliance Manager
errrllt Numoer V"Of ocal use on IYJ 4/' perm~ Approvea (~or 'ocal use on y) 4/4 ...erm t txplratlon uate lI-or oca use on YJ ."
UPCF (12/99 revised)
12
Formerly SWRCB Form B
... l
TANKS
;... l'
. .".......' ., ,".. .'C ".'
.' "'-;:~;"1- :;'.t::? :~~ );j:;/;{,;.:;~t't";i~~).~~t~':';;..,~.:.t":,;
UNDERGROUND STORAGE TANKS - TANK PAGE 1
TYPE OF ACTION
o I NEW SITE PERMIT
o 4 AMENDED PERMIT [EJ S CHANGE OF INFORMATION
430
(Check one item only)
o 3 RENEWAL PERMIT (Specify reason. for local use only) (Specify reason . for local use only)
BUSINESS NAME (Same as FACIUTY NAME or DBA. Doing Business As)
Quick Stuff #7723
(Optional)
(two pages per tank)
Page~of _
6 TEMPORARY SITE CLOSURE
7 PERMANENTLY CLOSED ON SITE
8 TANK REMOVED
431
#
434
3
Xerxes
3/2002
7,000
(For local use only)
[EJ 1. MOTOR VEHICLEFUEL
(If marked complete Petroleum Type)
o 2. NON.FUEL PETROLEUM
o 3. CHEMICAL PRODUCT
o 4. HAZARDOUS WASTE
(Includes Used Oil)
o I a. REGULAR UNLEADED 0 2. LEADED
o lb. PREMIUM UNLEADED [EJ 3. DIESEL
o lc. MIDGRADE UNLEADED 0 4. GASOHOL
COMMON NAME (from Hazardous Materials Inventory page)
o 9S. UNKNOWN
(Check one item only)
EXTERIOR MEMBRANE LINER
D 4. SIGNLEWALLlN VAULT
X
D 4. STEEL CLAD W/FIBERGLASS
~ 2. DOUBLE WALL
TANK MATERIAL. primary tank
(Check one item only) D 2. STAINLESS STEEL
REINFORCED PLASTIC (FRP)
TANK MATERIAL. secondary tank X
(Check one item only) 0 2. STAINLESS STEEL 0 4. STEELCLADW/FIBERGLASS
REINFORCED P.LAsnc (FRP)
o S. CONCRETE
OR COATING
(Check one item only)
o 2 ALKYD LINING
[EJ 6 UNLINED
o 4 PHENOLIC LINING
If "Yes", complete one page for each compartment.
437
438
440
o 5. JET FUEL
o 6. AVIATION FUEL
o 99. OTHER
(from Hazardous Materials Inventory page)
o 9S. UNKNOWN
o 99. OTHER
o 8. FRP COMPTIBLE W/lOO% METHANOLD 99. OTHER
o 8. FRP COMPTIBLE W/1 00% METHANOL
o IO.COATEDSTEEL
o 99. OTHER
o 99 OTHER
(For local use only)
OTHER CORROSION 0 1 MANUFACTURED CATHODIC [EJ 3 FIBERGLASS REINFORCED PLASTIC
PROTECTION IF APPLICABLE PROTECTION 0 4 IMPRESSED CURRENT
(Check one item only) 0 2 SACRIFICIAL ANODE (F", local use only)
(local use only)
(Check all that apply) [EJ I SPILL CONTAINMENT
[EJ 2 DROP TUBE
[EJ 3 STRIKER PLATE
2002
2002
2002
o 95 UNKNOWN
o 99 OTHER
[EJ I ALARM
[EJ 2 BALL FLOAT
2002
2002
o 3FILL TUBE SHUT OFF VALVE
o 4 EXEMPT
/
(A description of the monitoring program shall be submitted to the local agency.)
{Check one
o 1 VISUAL (EXPOSED PORTION ONLY)
o 2 AUTOMATIC TANK GAUGING (ATG)
o 3 CONTINUOUS ATG
o 4 STATISTICAL INVENTORY RECONCILIATION
(SIR) BIENNIAL TANK TESTING
o S MANUAL TANK GAUGING (MTG)
o 6 VADOSE ZONE
o 7 GROUNDWATER
o 8 TANK TESTING
o 99 OT!:I.ER. . ..
ESTIMATED DATE LAST USED (YA/MO/DAY)
, , "'~J ._ "-.
ESTIMATED QUANTITY OF SUBSTANCE REMAINING
gallons
UPCF (12/99 revised)
10
!"
~em only)
o I VISUAL (SINGLE WALLIN VAULT ONLY)
[EJ 2 CONTINUOUS INTERSTITIAL MONITORING
o 3 MANUAL MONITORING
TANK FILLED WITH INERT MATERIAL?
DYes 0 No
Formerly SWRCB Form B
/~
" :v
".~ ,-
, " ~' , :nDIIJI
j~ ':-~ -.i:;;~; ,- ':'.'. ;",;.,.'" -'....
. . TANKS
UNDERGROUNDSTORAGETANKS-TANKPAGE2
VI. PIPING CONSTRUCTION (Check all that apply) Page _ of _
UNDERGROUND PIPING ABOVEGROUND PIPING
SYSTEM TYPE ~ 1. PRESSURE o 2. SUCTION o 3.GRAVITY 458 0 1. PRESSURE 0 2. SUCTION o 3. GRAVITY 459
CONSTRUCTION o 1,SINGLEWALL o 3. LINED TRENCH o 99. OTHER 460 0 1. SINGLE WALL 0 9S. UNKNOWN 462
MANUFACTURER ~ 2. DOUBLE WALL o 9S. UNKNOWN 0 2. DOUBLE WALL 0 99. OTHER
MANUFACTURER A.a. Smith 461 MANUFACTURER 463
0 1. BARE STEEL o 6. FRP COMPATIBLE W/l00% METHANOL 0 1. BARE STEEL o 6. FRP COMPATIBLE W1100% METHANOL
0 2. STillNLESS STEel o 7. GALVANIZED STEEL 0 Unknown 0 2. STAINLESS STEEL o 7. GALVANIZED STEEL
0 3. PLASTIC COMPATIBLE WI CONTENTS 0 99. Other 0 3. PLASTIC COMPATIBLE WI CONTENTS o 8. FLEXI8LE (HOPE) o gg. OTHER
~ 4. FIBERGLASS o 8. FLEXIBLE (HOPE) o 4. FIBERGLASS o 9. CATHODIC PROTECTION
0 S. STEEL W/COATING o 9. CATHODIC PROTECTION 464 o S, STEEL W/COATING 0 9S. UNKNOWN 46S
VII. I'll""'" (Check all that apply) (A description of the monitoring program shall be submitted to the local agency.)
SINGLE WALL PIPING 466 SINGLE WALL PIPING 467
PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply):
o 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT o 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP
OFF FOR LEAK. SYSTEM FAILURE, AND SYSTEM DISCONNECTION + SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION +
AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS.
o 2. MONTHLY 0.2 GPH TEST o 2. MONTHLY 0.2 GPH TEST
o 3. ANNUAL INTEGRITY TEST(O.l GPH) o 3, ANNUAL INTEGRITY TEST (0.1 GPH)
o 4. DAILY VISUAL CHECK
CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply)
o S. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING o S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM
INTEGRITY TEST (0.1 GPH)
SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): o 6. TRIENNIALlNTEGRITY TEST (0.1 GPH)
o 7. SelF MONITORING SAFE SUCTION SYSTEMS (NO VALVES IN 8ELOW GROUND PIPING):
GRAVITY FLOW o 7. SELF MONITORING
o 9. BIENNIAL INTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply):
o 8. DAILY VISUAL MONITORING
o 9. BIENNIAL INTEGRITY TEST(O.1 GPH)
SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING
PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply):
10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL
ALARMS AND (Check one) - ALARMS AND (Check one) -
o a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS o a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS
~ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM o b AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM
DISCONNECTION DISCONNECTION
o c. NO AUTO PUMP SHUT OFF o c NO AUTO PUMP SHUT OFF
~ 11. AUTOMATIC LINE LEAK DETECTOR (3,0 GPH TEm WITH FLOW SHUT o 11. AUTOMATIC LEAK DETECTOR
OFF OR RESTRICTION -
o 12. ANNUALlNTEGRITY TEST (0.1 GPH) o 12. ANNUAL INTEGRITY TEST (0.1 GPH)
SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM
0 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS
EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply)
0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF'
AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS
0 1 S. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 0 1 S. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST)
SHUT OFF OR RESTRICTION
0 16. ANNUALlNTEGRITYTEST (0,1 GPH) 0 16. ANNUAL INTEGRITY TEST (0.1 GPH)
0 17. DAILY VISUAL CHECK " ., 0 17. DAILY VISUAL CHECK
VIII. DISPENSER CONTAINMENT
DISPENSER CONTAINMENT 0 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE o 4. DAILY VISUAL CHECK
DATE INSTALLED 468 o 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS o S. TRENCH LINER I MONITORING
2002 , IBl 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6. NONE 469
DISPENSER + AUDIBLE AND VISUAL ALARMS
IX. OWNER/OPERATOR SIGNATURE
I certify that the information prOVided herein Is true and accurate to the best of my knowledge.
UAlt 4/U
10/31/07
NAME OF OWNERlOPRATOR (print) 4/ 4/<
Daniel A Erickson Compliance ManaCler
ee"ntt NumDe' \rO' local,use only) "" .e""" "'PP'O~e<1 It Of lOcal use on YI "'" .e,mlt <xplfatlon va.. \to' oca use only) 47S
UPCF (12/99 revised)
12
Formerly SWRCB Form B