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Home My WebLink About1407 COLUMBUS AVENUE10122f2008 10:04 6618718574 MAZARDOIIS MATE~tIAL MANAGEMENT PLAPI ~: . .. ~ . P~%~,'~i~~~ W.~ 'a ~~~ ,. APPLICATIQN BUSIN~SS OWIVER/OPERATOR ZDENTtFICATION FORM (NA~ARDOUS MAT~RIAL FACILITY INFORMATION) ~ PIP_PRINING_BKFD RAGE 04l17 BAKERSFI~LD FIR~ D~pARTMENT ~ PreventiG~ ServlCes ~ 7.501 7nixCUn Avenue, 1~ Floof D 8 B F Bakersfieitf, CA 93301 F/I~~f Phone: fi61-326-3979 . FeX: 661-852-27.71 ~~ r P~ge i of 2 .!y ~a •r~ .ry..w ~, , v .r .. ' i-• ~t•y,~` ~. : '~.',w...Y `yi'.. il:~. fy~ {~- :~~~~~i :,;~~ n, - ~i. ~j ^l,'~ 'M+ ' '~ `. ~t~4•' •Q .,'~ ~. J~S, th.., iP~' ~Ly~~,'.~i t ';'k . '~, '! . +;~ ,7... 1, , r1. "~:••~ " t." 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QWNER NAME ~ ^ I I 1.J ~ ~I ~I G' ~ (~J f ~ L~~ ~ (Q ~ ~ L ~ "3 QWN~R PHONB ~ O ~J S~ ~ ~ O y ~Z7 owNetnuiur+G ADORESS ~~/ /L I'I 1~ 1 ~~ ~~l~ `Il . ~~ 1 L V~IZ. 113 _~ S lsa cm ~~ ~~K-L- ~ ~~ ~(~ sra,E ~^ xxs nacop~ 02 ~ Z ssa ~<~t ~ , - ~.~~x,fiP" ~!( ~i.?;.,i .;:~ ^,~'•.;~j;,~i9~: YA~'r,~i' ,:My. r~},~•b'.~;i'.~,,"'1? ,.ay ' § . :3'~ :i '~C c' 1c. i•. 'i~rt i' .~~ it. 'S:;.ik .'J~"r. V r',g " $ •r. T`b i;.,S,`.C ~'~Cf'.` r~7:~Li,!~;~~~l.x";i ~t.~7iyt " `i~ ~+y; ".~~~~~' z~ ~ ~~4#' W' t~ ` k' ~~~'~ '~. ' ' ~ ~~ '~ , ~ , .~~a:.. ~. ~ti._ ~)t~' `y;:~ 1';..~y,.7yy":"gr~ • ~~~'Fb .,~'t . ~~':V 'r R.: Iy~y. .,rm :~~''.'"~" ; z • y r~1 ~?• .bN L' ~i~,~C S? t' i~gy ~~ wl ~+~" + .,~L'~:'~~`~. y, .. '~~'h~,~.. 'iA,;fy:~a:'+~+I~ rL~:1}~'~}`:. .'bV; ~:°,7~-~`~kt7;"~l~4~;h 'r~?;s~ ~ ~ ~ ' ' ~ ` ~ . , ! .. , J. % .r y ~ . , ,.?Y ~.,~ ^~' st:~~±,r{t:f~!~. ''~l~Y:~ i~Ga S`:~'A::[,+~'~ ~y $ii>,~. ti ~~1hr,J{:1•~n:' ~ ,:+~.. x v ~ J ~^ f, y KF;. 6'e ~,,.l~.,e~ °''4i~ ,~, ~y ~'f:~ ~.'~n.t. N~ . '.}' :'i~ 3,w~. . ~rs~r , '~., etii ~'~ y+ ~ ~ , . .2,.. ~r,~4 ..~„ .a' 6 l.F; 4• ~ ~'` : '~. o; <,V'~ f f. +~_ ~~~ o',•'y,w' ~.itiX" y,. ~~ 1~::~.~a::~"'+ ~: . `. ' ~5• 1 M ~~ ~ 74 ~.^iS' ,. ~ r ' a}~~ CONT PNON€ 116 GDroTAC~' Naa~ MAtl~ic~ ~oR-~S CZt~f 5Sb -13 2 - . . . . . - 119 CONTACr MAllddG ~RERS 7v' ~oio UJ' i.kl~~ CE-Jt~ D fL. ~ iT~ I3 i~o sra~ iu zm oooe s~ ~~Tr~ ~ra Cq - 4~~ o ~f ~:}: ~,Y%':i;. .~'k;~`i'•~ .rm~f~'"•~';~ ~~ i~~,{ ?y ' G;~;~;~yya'".d ' :".~' <. :w:t ~~.'..~ i~.ti •'ti4i.4i'sr°M',.., . ' ..bt~ ~ f,,~( ~ k~. 'y. t~~v 4J. ~,~}~: 11 ) ~• C• .~•~ ~.y`^xo a'i ` 'y~ y.f~~ ,~v I 'yZ" ~ ~~. " y.~ u;;#`,,yF `'+t(!q ~.4.~t.~S~,~~~. .~:~;r 1tky+~~ T:~~ ! ~Y.f~ ~•~~r~~•~.~~.',•+F•'.~,rl~.~^•V'.A . {.~~ ~: ~Y.~ .1.~ r,~ f:,r.+~y~,'{~ :Y,~~ a~' .y j' i~;~..~ .a•~;y„a k~~~,i~F~".,u .~,~r~~,;$~ ;~~~~' ~r.k.,.....d ,y ~,".k;c~.5,~;~~~+. 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J-• ~ <: i fi;,~ t~}i ~ ~5 n ~ > c i & rf.', , ^~~ t> ' L' Y.~'~ ~ i' ~.i.~ ~. F ' of law that I tt&vC pCrgpnalty IrlqUlrY Of Xhose fndividu8lS CCSpOflS~b~4 for obtaini~Q thg Infprmatlon, I certify und2r penalty CerLlflCadOn~ Based on my eXamined and ar++ f8miner wlCh the Info matiC~n SubmEtted m this inventocy an(J pgileve the infarmation is trY~e, aCCUrdte, and compleCO. SIGNAT I2 F DOCllMENT PREP a 1~ `~ ~~ DAlF 13b -Z -~'~ NAME OF ~OCUMENT pRePARL'R (PRIN'~ ~ 1gS M A~ v~ c~ FI.~ F.~s NAHE OF N4WOa~EU.47oa. (st~ Mi') 137 ' (~5 T.IYL~ pf DONMENT PREPARER 138 b~1~ECT~~2 oi- C'oM ~iR~J~E w ~z~4z (rtc.- ox~ae) 10/22/2008 10:04 6618718574 PIP_PRINING_BKFD PAGE 08~17 NAZAR~OUS MATERIAL MAWAGEMENT PI,.,A ~"~' . :a»,a~a~.,a~ ~ APPLICATIQN FOR S~GTION DISCOVERY & NOTIFICATION ` ~FORMS~ , BAKERSFIELD FIRE D~pAIZTMENT Prevention Servi~es I501 Truxtun Avenue, 1~ Fioor x $ Bakersfleld, CA 93301 !r/,~Q Phone: 661-326-3979 . Fax: 661-852-2171 w~ ~ Page i of 2 INSTRUCT~ONS 1. To avpid fLrther action, retum this Porm within 3Q days o~ r~eceipt. 2. Type/print a~swers In ENGLYSH. 3. Answer the questions below for the busines5 as a whole. 4. 6e as brief and concise as possible, ._:M . . ~a!'G~. _Y~. C~_ if~.r . ..~ ^x . ~y~. ~,+e ~ .at~• ;~ ,~ -~y..- ~r•. < ,.. •~` 'y;~ a~j ,»r~ • ~r .,. , : i; S,i~~ ~~ . lA•:,•' .~ .:yi.. . ~~ ma ' Sl:ty' 1Y;~ "7° ' 1 ,' '~1 ~{i` ~ . , , . ~ J! Bu5nu~55 NAME ~FACILfrY NAM~ Or P6A) _~ R~ 'lr 13b ~ U l._J- 1 S' . ~ .~ ~•p,~ •.~ ADDRE55 (Ior locei ~s~ o~ir~ ~ 40 '~ C.~~ v ~ i3us ~}-i~ ~,: -• FAC~-~Y xD # ;,"f • A ~~ ~,, . ,~t~ ~ ~ wr'~ ,y2 } ~• N ~ ~Ni ' r~ , .~ .M d ' fi iP C• . ~ , , .~~ `. P ~ , , . . . ,f~ ,;~'f ~:?~i` T•',p~ ;~y ~ 'w JY . + ~ Y ' ' ~;',' r. t .~ ~~~>`h - ~ ~.J i"~i'.k;y'.1~s;' '~~ rR'~y „ a(~ ,~`/~~~',.~ ~Jt. .y~j,'<„~,b 'YS Y~.' ~!~?' '~ N~ vY~:f . .~ MM1i ~: . . A. ~EAp( p~~[OM ANO MbN]TpftlN~ pqp~DURFS: ~ :~l , ~~ ~7fFGE-F-v~~iv'7. ~F B- ~- ~, B. EMPlOYEE AND AGENGY NOTlFICA'1't01M: ~Toa.~E ~N,4 C~~2- rL~Spo n/s ~ BL~ -~oQ- cstw~;J[~ ~l' ll . G ENYIRONMENTAi RPSaONSE MANAGEMEPfi: S~°R~ A/IfM/A 6~C-~ f~~ 1a2. ilss ~ sT~4 N7 NVtN}1 G£-,Q_ D. ~MERG@NCY MEDICAL PIAN: U. S. l-{~~-~7~y l~rorL~s ~b I- 327- 9(017 I So~ v~r~srw ~,,r~ p,~~~~ ,~,~K~as~~r~, ~,~ . q33o J ~;~,~' ~ ` ~..t :x ~ ~ ~: ~- ~t~ ~ , :~ ~ ., ., .; , ~:. ~y- ,, .~ , ~.,; ;,2, ~,.w .~;,, ~,. ~ ~ •~Y~.~' 1r7 ~ al y ~ •'y y) 'S~ ` ,~~,~~,~ ~ `~ , ~' W . h1! , w _" 1 ~ ` r ~ A• HpZA.RD ASS~SMENT AND PREV~NTION raEa5URE5' E,~,~~,fly~s Af~ -'e~hN~ ~~/ pR~c~,~2~ES 7'0 2~hcr 7a ~- sp i ~~ oQ oTH~2 c~~c7, Evt~+•lT B. RELEASE CONTAINMENr AND/OA Ml7x~A7ZON: t~M/~S A~ ;N $AS~N-~r~ wHsr~ t~1L-a~ ~s No p~8~-« /~u~ss. r~r~s s~2~ c~os~ s.~s7t~n~s hN'~.~YL~ T!~'.~Q~ rS KO Mhri/V/jl~ F~'~'~~L~ q'2. G.~PTiNfa -'~}I.L DoNE' Vi~ l2-FM~~ PI~)/~Ib S~STE-NI• /Mhn'C~I~-T'E R-C-S~n(SE- C~N7/hn! tl~t~/IYt-O /hJD clfi,[- -~-~~ lJ~P4R.TM~NT jH~ M~~r~ S/t'FET • C. CLEAN-UP qroD R~qvERY PROCEdURES: G~ f.(~ S~ f~LS f}(L'E Go+~(T/1+'n(E1~ ~JS IIJ6 ~~~~B~I`T So~~cS. ~ ~~.~,~r up r's' A~N~ WiTft To-olE~S 'T~RT ~R~ ~T Fo2 n~sp~s•~ ~2 C~~~ U~ By ouR R€~Yc~~~v~ CaMp'7~J`'~- /~"C$~l2~ ~1po/~lM~n(TA-1~. Fp2169 (Rev 01/08} 10/22/2008 10:04 6618718574 PIP_PRINING_BKFD PAGE 09/17 Page 2 oT 2 1 ~ 4' y,.,~.r,q: i ' .!k. ~ ...'S. ~~ ,~ til:n'. 7p~+ 3~ "~~~, 'r c,~~ "t,; . ~.: ~ imuTV SHUT-0FfS (LOCATIpnt OF SNUT-OFFS pT YpUR FACILITY) 'rUW4L • ' `I ~I~I-L ~~ " ~j l. - . p~ ~~ ~.-l~ ~1~-~~ ~ I ~ ~-~(Z W. o~ 5~(~ o~ ~~~~~~ ~~vc.v+~l~~s ,4~~, ~: ` . N~t 5~ c~ r=~~tir c~~- ~r~iJ ~~ ~~~ E~~~ .~4 17 P ~b.s~ Iu ~;v~,l ~(75 wuvare r~ae wzo~crzoN~wnTeR nv,~u{s~~,r: A. PRIVA'TF FIRE PitO7ECTiON: 8. WATER AYAILABIUTY (F~RE MYDRAPIT): ~C~v-C~( !~C(~= G'~ f~(~-~(~~- J1~1 ~/~{~tK.~ Jr-~C~ ~(ZF-=/-~ ~j o f=(~L-'~i /-}~i,~,A R , f 1 4• / f 1. l ~ ~~' 4 , . > a ~R . ,. h, ~ NUMBER Of EMPLOYEES: 8 MATERtAL SaF~ETr DATA SM~S ON FILE: YES ^ Np IF Y~S, IOCATION: ~ BRIEF ~MMARY OF TRAINING PROGRAM: 1(1f~, r./ ~ Nl~ '~f~~S k~G~1-C'E /~T J~2 Co~~2~F-TE D~~ ~`~l SMV 1 A~-Nq _~Fg.S`~,o~3~lT Socf~S 6 c~~nl /p ~~r~~s ~~'spc.4~~c , v;orv ~.rn ovt-~~M~ pr~~~ S~~~- us~ 7a sHa.U Fb-^/ 7?7 uS~ 'rKfSE i i~+~lf, St~!?~ M~~/A~~S con/a~GT R~F2EStF~1L Lou2S~5 /}T T,~E S'~9F~ ~JQ.,~/C, ?ffFiR. MnMT~-`7 ST°2-E ME~n~v6..A" S~FG~Y iSS~~S i4(L.~ ~~IScvSS~ ~n/P /LEv~~Vd~- f. ~• ` ,~ '.~ ~~ i .: , r '' ~~i, • ~,,f, " ;~' ~ased on my inquiry of those Individual5 responsible for obtaining the information, i certify under penalty of law that I have personally examined and am familiar with the infnrmation submitted anQ belleve the Iriformatidn is true accurate and complete , , . SIGNqTURE OF 01aryCR/OPERATDR OR DESIGhIATE6 (ZQPR~SCroTATN[ ~ pq'{~ q -~f Z~/~8 wsntE qF I ~~p~ry~ a7e M~~ ~~ F~n~S T~r~E OF SIGNER a7g ; ~c~ pi2t-troR oF ~on~ p-.~ FD2169 (Rev 01/08) State law requires your business to complete all sections of the Emergency Response Plan Procedure listed below. "N/A" is not acceptable. Your business is required by State Law to provide immediate notification of any release or threatened release of a hazardous materials to 1) local fire emergency response personnel, 2) the Office of Emergency Services (OES), and 3) the Local Administering Agency. Businesses within Costa Mesa fulfill the Administering Agency notification requirement by calling 9-1-1. If you have a release or threatened release of hazardous materials, immediately call: Fire/Paramed ics/Police Phone: 9-1-1 Individual responsible for calling 9-1-1: Store Manager After the local emereencv resoonse oersonnel are notified, vou shall then notifv the Office of Emer¢encv Service (24 hours/dav): State Office of Emergency Services: (800) 852-7550 -or- (916) 262-1621 Individual responsible for calling State OES: Store Manager 2. List the local emergency medical facility that will be used by your business in the event of an accident or injury caused by a release or threatened release of hazardous materials. Hospital/Clinic US Health Works Address City Zip Code Phone Number 1800 Wesfinrind Drive, Bakersfield, CA 93301 661-327-9617 3. Does your business have a private on-site emergency response team? ~?IYes rlNo If yes, describe what policies and procedures your business will follow to notify your on-site emergency response team in the event of a release or threatened release of hazardous materials. (Attach additional pages if necessary) All of the emplovees are trained in qrocedures to react to a spill or other emerqencv event notifv store manaqer or assistant. Use spill manaqement kit, absorbent socks to contain spill. Clean up with raqs/towels and dispose of the materials with Recvclinq Companv. 4. A business shall appoint an Emergency Coordinator and alternates to assist in initiating emergency response and evacuations in the event of a release. The Emergency Coordinator will be responsible for initiating actions of the business to respond to a release, or threatened release of a hazardous material to include mitigation, control, evacuation of all facility personnel, and meeting with emergency response personnel upon arrival. An example Emergency Coordinator Task Completion Sheet is attached to assist you. UPCF (1/99) HMP 3 Instructians OES Form 2731 List your facility's Emergency Coordinator and alternates. Emergency Coordinator's Name ' Title Maurice Flores Director of Comnliance Alternate #1 Name Title Chris Curley District Manager Alternate #2 Name Title Cesar Trelles Area Manager 1. Briefly describe your business's standard operating procedures in the event of a released or threatened release of hazardous materials: Describe the kinds of hazards associated with the materials present at your facility. Possible hazards include oil spill or antifreeze spill. All containers are closed svstems that are filed and emptied usinq remote connections. Spills are minimized. Spills are contained usinq absorbent socks or other materials.and then recvcled. 2. What preventative actions have been initiated by your business to abate or prevent hazards relating to hazardous materials handling, use, and storage (Place a"/" in the boxes below that aPP~Y)• Drum storaqe and/or aboveqround tank storaqe areas: I Isolation and separation of incompatible materials. I Berms or diked areas to contain spills. I Storage on non-combustible, concrete, or paved ground. Comaressed and/or crvoQenic qas storaqe areas: ^ Cylinders stored upright and secured. o Isolation and/or separation of incompatible gas cylinders (oxygen and flammable gases, etc.) General: o Hazardous Materials Data Storage Cabinet and/or lock box installed at a Fire Department approved location. ^ Information in Data Storage Cabinet is updated after each disclosure and/or as necessary. I Materials Safety Data Sheets (MSDS) are readily available for each hazardous material on the premises. I Labeling of all materials and storage areas with the product name and associated hazards I Separation between outside hazardous materials storage or tanks and combustible materials (wood, brush, etc). ^ Posting of "NO SMOKING" signs where appropriate. o Posting of NFPA 704 Placard in a Fire Department approved location. UPCF (1/99) HMP 3 Instructions OES Form 2731 3. Mitigation (reduce the hazard) ~Describe what is done to lessen the harm or the damage to person(s), property, or the environment, and prevent what has occurred from getting worse or spreading. What is your immediate response to a spill, fire, explosion, or airborne release from your business? Tanks are in the basement where there is no qublic access. Tanks are closed svstems where there is no manual fillinq or emptinq. All done via remote qipe svstem. Immediate response - contain hazard and call the Fire. Department then move to safetv. 4. Abatement (remove the hazard)~Describe what you would do to stop and remove the hazard. How would you handle the complete process of stopping a release, cleaning up, and disposing of released materials at your facility? What aspects of the response are beyond your ability and need to be handled by others? All spills are contained using absorbent socks. Clean up is done with towels that are sent for disposal or cleaned up bv our Recvcling Co Asburv Environmental. 5. Facility Notification and Evacuation -~Describe how you will immediately notify and evacuate your facility. What communications or alarms are used? How will you operate this equipment during power failures? Specify emergency exits, alternatives, and staging areas you have identified. I Our Business has open pits to the basements. Emerqencv notification is done verballv from I emplovees in basement to upstairs. 6. Your business is required to keep a copy of this Business Plan, including your site maps, and your Hazardous Materials Inventory Disclosure. Describe where copies will be located at your business and where other copies will be maintained. Office file cabinets. EZ Lube Corporate office for Spills and Emerqencies. UPCF (1/99) HMP 3 Ins~tructions OES Form 2731 7. Records ~Describe where you keep other records required by this plan, such as employee training records (including drills), release report records, maintenance/safety records, and emergency phone lists. (Please note: records of drills shall be maintained for a period of three (3) years and shall be available for review by Fire Department personnel. The records shall include the facilitators name, title, facility location, date of drill and signature of the facilitator). File cabinet in manaqers office. Describe the training your business conducts for all employees in safety procedures in the event of a release or threatened release of hazardous materials. By law, this training shall include, but not be limited to, the following: new employee training, annual training, periodic refresher courses, and familiarization with Section B(Emergency Plans and Procedures) of this Business Emergency Plan. An example "Chemical Training Record" is attached to assist you in employee training (you may use this example or an alternative if you prefer). Traininq takes place at our corporate office in Santa Ana absorbent socks & clean up are materials displaved. Video & overhead photos are used to show how to use these items. Store manaaers conduct refresher courses at the store durina their monthlv store meetinq. All safetv issues are discussed and reviewed. OFFICIAL USE ONLY: Insp. # Issued: Reviewed By: Date Received: Correction Required: UPCF (1/99) HMP 3 Instructions OES Form 2731 Emerqencv Coordinator Responsibilities: A business shall appoint an Emergency Coordinator and alternates to assist in initiating emergency response and evacuations in the event of a release. The Emergency Coordinator will be responsible for initiating actions of the business to respond to a release, or threatened release of a hazardous material to include mitigation, control, evacuation of all facility personnel, and meeting with emergency response personnel upon arrival. Data incident reported: Time incident reported: Identify the nature and extent of the incident: I Place a"/" in the adiacent box as each task is comaleted: ^ Activate internal facility alarms or communication systems ^ Notify the Fire Department: Call 9-1-1 Including: Location of the incident (address, etc.) Nature of the incident (what it is) Scope of the incident (how big it is, what its impacting) Material involved (if known) Extraordinary circumstances (fire, explosion, injuries/deaths, airborne releases) Best route of entry into large facilities or to avoid airborne releases (gate, street) 0 Designate an employee to direct emergency response units to the incident scene and to the location of the Emergency Coordinator ^ Initiate prearranged mitigation and evacuation plans ^ Secure all emergency shut off valves (as required) ^ Initiate internal company personnel notification ^ Account for all evacuated personnel ^ Have resource material available for use by responding agencies (maps, drawings, MSDS's, etc.) I Identify actions taken by the business to control the incident: Identify actions taken to secure the incident scene to include clean up, treatment, storage, or disposal_of hazardous materials or waste involved: Other: (specify This form, completed as much as possible/practical, shall be given to the emergency response personnel (fire or police) upon their arrival at the facility. The business shall maintain blank copies of this, or similar, Task Com letion Sheet forms readil available for use in the event of an accident. UPCF (1/99) HMP 3 Ins~tructions OES Form 2731 CHEMICAL TRAINING RECORD I nstructor Training Date Chemical/Substance (Attach Material Safety Data Sheet (MSDS) to Training Record) Chemical Use Employee Training Provided: A. Employee responsibility to report any release or threatened release of a hazardous material to: ^ yes ^ no Costa Mesa Fire Department (9-1-1) ~ ^ yes ^ no State Office of Emergency Services (800) 852-7550 B. Name of persons within facility who are responsible to respond to an incident: ^ yes ^ no Last Name First Name Business Phone Home Phone ^ yes ^ no Last Name First Name Business Phone Home Phone C. ^ yes ^ no Information contained in Material Safety Data Sheets D. ^ yes ^ no Warning Labels E. ^ yes ^ no Safe work practices F. ^ yes ^ no Procedures to follow during a release or.threatened release. Discuss possible release scenarios, possible evacuation, emergency exits, where to meet (staging areas), where to meet Fire Department, medical treatment facilities. Use previous pages as a guideline for documenting emergency responsibilities, employee evacuations and emergency coordinator responsibilities. G. ^ yes ^ no Use of emergency equipment and supplies H. ^ yes ^ no Use, limitations and location of personal protective equipment. Emplovees Trained: Employee Name Work Assignment Employee Signature UPCF (1/99) HMP 3 Instructians OES Form Z731 BUSINESS A~'I1~ITIES ~n.v caomarsr ~ax~~ ~ ~a~vr Q~a r~m c~ ~ ~a~} rn~ ~ s~cr. soaE ~ FA~IIIIY n~DRMA~YAN Bd~I, G la3Q1 86ld7M Pa= SRt~'T~l 1 of L FACILrIY ID~iZ'1~C~1Tt01N FACQ.I[YID# ! RFAIDial~w`asCr~i~j ~ HU6~SSNAME(Sr~ asF~rs`1~r~o ~ Bn~1~a) s ~~ wg~ ~ !30 a Acnvrr~s n~~a~+rr ~o~: ~~ ~~ ~ ~ ~.~t ot ~ ~c, ~ s~t ~ s~~ ~~,~a~~ia~~~~~ ~~c F~2~3o~, no~ r~~. ~ ~~t~.... A H878AiY]I1C 1td17'PjtTAT+~ HaGe ~ ~ {~ ~f ~~ ~ IDL~1~,9 ffi ~ ~ 3~ ' ~S bR ~ ~ ~4 ~ Siih~c ~ ~ Q~t ~ ~ ~ ~ . ~ ~ m A~ ~d USTSx a~ t~e ,fES Q D~ 4 ~AZA~S ~AT~AIS ~lBi~f - ~~ ~1 ~ q~ly f~ ~ ~ ~ ~.x~sL~J~~..m~, ~~m~ac~r~c~ss,~~~~:~~ ~~~~~~~~~~~ re~ed ~ m 16 CI8 PA~6 3~. ~4 ~ 70~? ~. U1~IDERlCTRd38JI~ID S1C?RAC~ T~I~CS IUSTs) tPSP FAt~.t'IYtRS7+4,.A) 1. E-am ara~ s~oca~ ~~? ~ YF5 NO 3 t~T TAA~ oe.~y.p.+.qA~c wm mi ~ 2. It~ ~ v~!~e e~ a ro~Il ~ CRST~? p ~ r~o ~ t~T F~mC ~IST TA1+I~ ~pm.~s eeq qP~P ~TSTNtI.JITDf]~ - ~7E (~! rx~aE.r~tar~r p,.PP~~~ e~.c- 3. t~ed m iep~at clo~g a~FSI? ~ xFS 2~D 7 ~SI' TAl~ ~~ -~..~v~.e~ Oomaa apea~ ASTs ab~e a m~l ca~ai9 bo~t~:~tya~~E~1~~.31~0~aIlmsT ~3'FS ~NO 8 ?~BC~9~H~QI1~tFDiU~CF~ 1. G~dte ~d0~5 9Ya9tP? ~'YP.S ~ I30 9 FFAII32~1648P8-~ at I~o Dop oftlm ~ ~. Bec~cle mme @~ lU0 kgb~ af ~d~e~gted ~+rytlabT~ ~als (pa H5C 251~3.~? ~ YF5 ~ b~ t0 HPC7~'t~.~BLP M,17FRIAi.s BF~BT.~. ~ ~m- a~~a~-+~ 3. T~eat h~ ~~ stl~! ~'PFS ~ 23D 11 QIZ~i7P 8AZJI~DL~t~'~ifAS~P ~i'~N'~-FACQIPYUx ~, itn~J ~T~ ~1ZA~t~'~WASZP TPF.AtT~t!°-t'diitT wnP~r~~OtRCYao 4. IY~u~t su~jeot ~~l as~ce ~aq~ts (fi~ ~'YF.S ~ 2~0 12 t~ ~t by SuIe ~d~al AsSt7~tA2i~Ee~c -~~ 5. C~d~ ha~~~~e ~d at a~aoate ~? D YE5 ~ ND t3 HEb6t7TE WASalL'~74~QiIDA~2t 561E IyABd[A~tLffi~t~c rea~ rr+s- b. IJeed m~at ~e cB~mertemcQal flf a~k t~at vas c~as~ ~ ~ ' ' ha~+daln,~ast2 ~l ~ a~e? 0 YES 2~D t4 HAZA~s ~AS1E 4 AI~ i. ~,ostlSP. ~ ~~ 1~ ,: Acc~p~~c~ity's Respo~eP~aisw6e~de~~!a~t~a~~Bus~P9,~ g~Dismfie ~ed a~aa9 seai~ms tu ~ pl~ ~ cac~u fi~ at ~e ab~e ~a fi~ ~~e ~ oa~ @~ p9aa fd~'D3 eavr~ S~C.1;~271~ UPCF (1/99) HMP 3 Instructions OES Form 2731 UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY - cHEnniCa~ ~ESCRiPTioN one a e er material er buildin or area ^ADD ^DELETE ^REVISE 200 Page _ of _ ~~~~.~...,~F.F........ ~~~'.. ~'u~~.~ .... ' ~ ~ ~z y~.,~, 1 Fie1CIL1..'f~Y~.1NFORMATION ~~~E~ ~~~' ,. ~ -~=~~~ .`~~~E .~~~'~' `~~ . s...x... . ,.,,.,,. , , a k~' .E , ,..~ ti~. .. ~~~: BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 EZ Lube #130 CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202 Basement EPCRA ~ YES ^ NO FACIUTY ID # ~~% ~ MAP# (optionaq 203 GRID# (optionaq 20a '~~~~ ;x~; ~,. ~=M~ ~ r~~.:. .'. ~~~ ,~ E~ .; .~.. ~~~ ' ~II:~C.HEMICALMINFt)RMATION , ~ ~ F; . ..~~..~~.;~..~~„ : : ~,F ~~„~ ~ ~~____..:~...~~ _'' CHEMICAL NAME 205 TRADE SECRET Yes No zos If Subjed to EPCRA, refer to instruclions COMMON NAME Z~~ EHS' ^ Yes ~ No 208 CAS# 209 'If EHS is "Yes", all amounts below must be in Ibs. FIRE CODE HAZARD CLASSES (comp~ete if required by CuPn) 210 HAZARDOUS MATERIAL 2tt RADIOACTIVE ^ Yes ~ No 21z CURIES N/A 2~3 TYPE (Check one item only) ~ a. PURE ^ b. MIXTURE ^ PHYSICAL STATE z~s (Check one item only) ^ a. SOLID ~ b. LIQUID ^ 2~4 LARGEST CONTAINER 960 FED HAZARD CATEGORIES 2~6 (Check all that apply) ~ a. FIRE ^ b. REACTIVE ^ c. PRESSURE RELEASE ~ d. ACUTE HEALTH ^ e. CHRONIC AVERAGE DAILY AMOUNT Z» MAXIMUM DAILY AMOUNT z18 ANNUAL WASTE AMOUNT 2~9 STATE WASTE CODE ZZo UNITS' ~ a. GALLONS ^ b. CUBIC FEET ^ c. POUNDS ^ d. TONS 221 DAYS ON SITE: ZZZ Check one item onl ' If EHS, amount must be in ounds. STORAGE CONTAINER ~ a. ABOVE GROUND TANK ^ e. PLASTIC/NONMETALLIC DRUM ^ i. FIBER DRUM ^ m. GLASS BOTTLE ^ q. RAIL CAR ^ b. UNDERGROUND TANK ^ f. CAN ^ j. BAG ^ n. PLASTIC BOTTLE ^ c OTHER ^ c. TANK INSIDE BUILDING ^ g. CARBOY ^ k. BOX ^ o. TOTE BIN ^ d. STEEL DRUM ^ h. SILO ^ I. CYLINDER ^ p. TANK WAGON 223 STORAGE PRESSURE ~ a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BELOW AMBIENT 22a STORAGE TEMPERATURE ~ a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BELOW AMBIENT ^ d. CRYOGENIC 225 ~'~ ~ %WT ~~ HAZARC)OUS COMPONENT Fore,mixture or aste o `y~ ~HS ~ ~~. ~~~CAS # ' ~~~~ ~; .~, ~F~e .~,x ~ ,~r..~. . . ..~_ ~____-_; - { ~ , E~,~~ ..:~;,~~ ~, ..~„ _~ . ,~ 1<.12 226 ZIC1C 22~ ^ Yes -~ No zza 7440-66-6 2z9 2 230 Motor Oil 231 ^ Yes ^ NO 232 233 3 234 235 ^ Yes Q NO 236 237 4 238 239 ^ Yes ^ No 2ao 2a~ 5 242 243 ^ Y8S ^ NO 244 245 N more hazardous components are present at greater than 1%~by weight H non-carcinogenic, or 0.1% by weigM N carcinogenic, attach additlonal sheets of paper capturing the required ADDITIONAL LOCALLY COLLECTED INFORMATION zas If EPCRA, Please Sign Here UPCF (1j99) OES Form UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY - cHEnnica~ ~ESCRiPrioN one a e er material er buildin or area ^ADD ^DELETE ^REVISE Z~~ Page _of_ . "..~ ~:` 4 ~ ` ~ ~~ ~ ~ ~ I ~~~FA~CILITY'INFORMATIO N ~' ~ ~`~' ~ `~~ ~~~~~ ' ~~ ~ ~ _ ~~ ~ . SF , , , . .:: ...~~Y ~+b'..,~br.,.§~..R~.a .n.~. ~~ p . I~iE~iaE'~Eia'.,.Ia~a`~J~,~~.. ~ n_~ . ~~~ r_i. .. . ~~ ~ ...___. . ~ ~.....,,,d4. . .._„ .. ~ . ,_ _T~ ~~ BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) s EZ Lube #130 CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL Zo2 BaS@I11211t EPCRA ~ YES o No FACILITY ID # o~ 'v % ~ ~ MAP# (op6ona~) 203 GRID# (optiona~) 2oa n ~ .- , , , ,.~ ~ ~ ~ ~`~~hy ~ CHEMiC/?-L~tNF O `~II ' RM ATiON ~ ~ ' ~ ~ 9 ~ ~ `°~~ ~ ~~~~~ ..... ~%s.~, .. : ~ . . ~ , ~.. . ~~ - ~ CHEMICAL NAME 205 TRADE SECRET Yes No 2os If Subjecl to EPCRA, refer to instrudions COMMON NAME 20~ zoa EHS' ^ Yes ~ No CAS# . zos 'If EHS is "Yes", all amounts below must be in Ibs. FIRE CODE H/~ZARD CLASSES (Comp~ete if required by CuPn) Z~o HAZARDOUS MATERIAL 2t3 TYPE (Check one item only) ^ a. PURE ^ b. MIXTURE ~ c. 2~ ~ RADIOACTIVE ^ Yes ~ No 212 CURIES N/A WASTE PHYSICAL STATE 2i5 (Check one item only) ^ a. SOLID ~ b. LIQUID ^ 21a LARGEST CONTAINER 970 c. GAS FED HAZARD CATEGORIES 2~6 (Check all that apply) ~ a. FIRE ^ b. REACTIVE ^ c. PRESSURE RELEASE ~ d. ACUTE HEALTH ^ e. CHRONIC AVERAGE DAILY AMOUNT 2» MAXIMUM DAILY AMOUNT Zi8 ANNUAL WASTE AMOUNT 2~9 STATE WASTE CODE 220 ZZ~ DAYS ON SITE: z22 UNITS' ~ a. GALLONS ^ b. CUBIC FEET ^ c. POUNDS ^ d. TONS ' 365 Check one item onl If EHS, amount must be in unds. STORAGE CONTAINER ~ a. ABOVE GROUND TANK ^ e. PLASTIC/NONMETALLIC DRUM ^ i. FIBER DRUM ^ m. GLASS BOTTLE ^ q. RAIL CAR ^ b. UNDERGROUND TANK ^ f. CAN ^ j. BAG ^ n. PLASTIC BOTTLE ^ r.OTHER ^ c. TANK INSIDE BUILDING ^ g. CARBOY ^ k. BOX ^ o. TOTE BIN ^ d. STEEL DRUM ^ h. SILO ^ I. CYLINDER ^ p. TANK WAGON 223 STORAGE PRESSURE ~ a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BELOW AMBIENT 22a STORAGE TEMPERATURE ~ a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BELOW AMBIENT ^ d. CRYOGENIC 225 %WT NAZARDOUS`COMPONENI' (For mizture or wa°ste only)~~ ~ EHS ~~~ ~ ~ CAS=#~<F~'~ ~ ~ - ' y,r~~a..: ..~~.;~r ...~.a~;.;. ~ :~i~,v ~, ,,;'~da, .:~5~.~ ~ ~ ~ ~ ~" ~F~°~"'.:r,lu~`~`~'~~-,_; 1<.12 226 ZIC1C 22~ p Yes p No ZZa 7440-66-6 zz9 2 230 231 ^ Yes ^ NO 232 233 3 234 235 ^ Yes ^ No 236 237 q zsa zas ^ Yes ^ No zao zai 5 zaz 2as ^ Yes ^ No zaa zas H more haza~dous components are present at greater than 1% by weigM N non-carcinogenic, or 0.1% by weight H carcinogenic, attach additional sheets of paper capturing the required ADDITIONAL LOCALLY COLLECTED INFORMATION 2as If EPCRA, Please Sign Here UPCF (1/99) OES Form 2731 UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY - cHEMica~ ~ESCRiPTioN one a e er material er buildin or area ^ADD ^DELETE ^REVISE 200 Page _ of _ ~ _ , a . ..~. , _ .: ~ ~'. ° R.~ ... 1°~FACILITY~I,NF~ORMATION `~:. ~` ~~~~~~~g - -~~ ~~ : $.~~ ~~,~ - -- _ ___._._~_~_. BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 EZ Lube #130 CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202 Basement EPCRA ~ YES ^ NO FACILITY ID # ~, ~ MAP# (opuonap 203 GRID# (optionaq 2oa ~~ ~~ h ~ ~ .. . , -~ _ ~ N ~ ~ ~ ~.~~ ~. _ ~ N ~ ` ", ~ ~~~ INFOR ~~ MATIO II CHEMICAL ~ ~ ~ ;, E~~ `~ ~ ~ `' 3' , ~ ; .: , .. . . ...,,, ~:~.._R.~ - ~.,, . . .. , , . ... ;, ~. F~ ~~ . ~~.....~ CHEMICAL NAME 205 TRADE SECRET Yes No 2os ~e e G C~ If Subject to EPCRA, refer to insWCtions COMMON NAME Zo~ zoa EHS" ^ Yes ~ No CAS# 209 'If EHS is "Yes", all amounts below must be in Ibs. FIRE CODE HAZARD CLASSES (Comp~eteitrequiredbycuPn) z~o HAZARDOUS MATERIAL z~3 TYPE (Check one item only) ^ a. PURE ~ b. MIXTURE ^ c. 2» RADIOACTIVE ^ Yes ~ No 2i2 CURIES N/A WASTE PHYSICAL STATE 2~5' (Check one item only) ^ a. SOLID ~ b. LI~UID ^ 2~4 LARGEST CONTAINER 135 c. GAS FED HAZARD CATEGORIES Zis (Check all that apply) ~ a. FIRE ^ b. REACTIVE ^ c. PRESSURE RELEASE ~ d. ACUTE HEALTH ^ e. CHRONIC AVERAGE DAILY AMOUNT Z~~ MAXIMUM DAILY AMOUNT 2i8 ANNUAL WASTE AMOUNT Z~9 STATE WASTE CODE 2z~ 22~ DAYS ON SITE: 222 UNITS' ~ a. GALLONS ^ b. CUBIC FEET ^ c. POUNDS ^ d. TONS ' 365 If EHS, amount must be in unds. Check one item onl STORAGE CONTAINER ^ a. ABOVE GROUND TANK ~ e. PLASTIC/NONMETALLIC DRUM ^ i. FIBER DRUM ^ m: GLASS BOTTLE ^ q. RAIL CAR ^ b. UNDERGROUND TANK ^ f. CAN ^ j. BAG ^ n. PLASTIC BOTTLE ^ r.OTHER ^ c. TANK INSIDE BUILDING ^ g. CARBOY ^ k. BOX ^ o. TOTE BIN ^ d. STEEL DRUM ^ h. SILO ^ I. CYLINDER ^ p. TANK WAGON 223 STORAGE PRESSURE ~ a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BELOW AMBIENT 22a STORAGE TEMPERATURE ~ a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BELOW AMBIENT ^ d. CRYOGENIC 225 ,,.., %WT ,f ~'~HAZARDOl1S COMP~NENT~ For~mncture or waste on y)~ ~~` EHS,,s ' CAS:.#'~~ ~ ~ ~ ~ ~ . ~ ~~- L. ~~ ~~ ~. ...:~ , t....„e~ ..~_ ~~..~~~ ~.~h ~ .~.... ,.~ ,,... ~ u~. . ~ ~ t ~ ~<n ~ 55 226 Ethylene Glycol 22~ ^ Yes ^ rvo zz8 107211 zz9 2 7.5 230 Diethylene Glycol 23, ^ Yes ^ No Z3z 111464 Z~ s 7.5 Z~ Propylene Glycol 235 ^ Yes ^ rva 236 57556 Z3~ a<5 2~ Hydrated Inorganic Acid, Sodium Salt 239 ^ Yes ^ No 24o Propriety 24~ 5 50 242 Water 243 ^ Yes p n,o z~ 7732-18-5 z45 N more hazardous components are present at greater than 1% by welgM If noncarclnogenic, or 0.1% by welght N carcinogenlc, attach additlonal sheets of paper capturing the required ADDITIONAL LOCALLY COLLECTED INFORMATION ~ zas , If EPCRA, Please Sign Here ~ ~ ' _-- ,r,_._ _. r -v ~__ S~ ,sr / vy, ;r~ . UPCF (1/99) ~.w.~ ~~ L~ OES Form 2731 ~ ~M~ S UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION one a e er material er buildin or area ^ADD ^DEL.ETE ^REVISE 200 Page _ of _ ~"ra<&~~ ~ 3, ;, . ~ ::: ' .. ~ . .. ~.: ~ k~~ ~ ~~~ a. ::. . ~,~, ' ~ 1,;~~FACILITY; INFORMATION _~ ' ~ ~,.M ~ . ..E ~~ ~~ ~~~ . ` ~ ~ ~.~, s . ~~ ~m. : BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) s EZ Lube #130 CHEMICAL LOCATION Zo~ CHEMICAL LOCATION CONFIDENTIAL Zo2 BaSeCTl2Clt EPCRA ~ YES ^ NO ,,-,,, ~ ~~ ~ MAP# (opUonaq 203 GRID# (optional) zoa FACILITY ID # ;`~n rn"~; ;fy~y; e. g„f ~. `~ , .,. ~~u, ~ ..:.. ;~ ,~y~~~~~~ ~~3`~~ ,~~~y~. ....il ::CHEMICAL°:INFORMAT~I,ON~ „ ~~.' .E ~ ~E`~.... ~ ... . ... .~.:'.. ..,.,in ,.~, 3.~':~ a.~.... . , t~.' .: CHEMICAL NAME 205 TRADE SECRET Yes No zos lene G I COI If Subjed to EPCRA, refer to instrudions COMMON NAME Zo~ 2os EHS* ^ Yes ~ No CAS# 209 *If EHS is "Yes", all amounts below must be in ibs. FIRE CODE HAZARD CLASSES (Comp~ete if required ty CuPn) Z~o HAZARDOUS MATERIAL 213 TYPE (Check o~e item only) ^ a. PURE ^ b. MIXTURE ~ c. Zi i RADiOACTIVE ^ Yes ~ No 2~2 CURIES. N/A WASTE PHYSICAL STATE z~5 (Check one item only) ^ a. SOLID ~ b. LIQUID ^ 2i4 LARGEST CONTAINER 200 c. GAS FED HAZARD CATEGORIES 2~6 (Check all that apply) ~ a. FIRE ^ b. REACTIVE ^ c. PRESSURE RELEASE ~ d. ACUTE HEALTH ^ e. CHRONIC AVERAGE DAILY AMOUNT Z~~ MAXIMUM DAILY AMOUNT 2~8 ANNUAL WASTE AMOUNT 2~9 STATE WASTE CODE 220 22~ DAYS ON SITE: 22z UNITS' ~ a. GALLONS ^ b. CUBIC FEET ^ c. POUNDS ^ d. TONS 365 Check one item onl ' If EHS, amount must be in ounds. STORAGE CONTAINER ^ a. ABOVE GROUND TANK ~ e. PLASTIC/NONMETALLIC DRUM ^ i. FIBER DRUM ^ m. GLASS BOTTLE ^ q. RAIL CAR ^ b. UNDERGROUND TANK ^ f. CAN ^ j. BAG ^ n. PLASTIC BOTTLE ^ r.OTHER ^ c. TANK INSIDE BUILDING ^ g. CARBOY ^ k. BOX ^ o. TOTE BIN ^ d. STEEL DRUM ^ h. SILO ^ I. CYLINDER ^ p. TANK WAGON z23 STORAGE PRESSURE ~ a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BELOW AMBIENT 22a STORAGE TEMPERATURE ~ a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BE~OW AMBIENT ^ d. CRYOGENIC 225 ' ~ "`~b ~. ~~ ~ s :~ /t : ~ r ' E ~~ -"^"~"_ x . ~, %WT ;',;, HAZARC~~US CC7MP(?IVENT Far m~~ure or was#e anl ~~ ~~HS ~ ...: E 1 __ ~~ y~ , ~~~~ ~, .,.~ C ~5.~ ~ ~~ ,a.. , ~~ ~ , ~.~ ~~..,, :. .. „~~~ ~ ~-_. ....~... ~~, ~. ...~~~. ~~.~E ~'~ ~~> ~ ~~~~~.. ~ 55 226 Ethylene Glycol z2~ ^ Yes ~ rvo 2z8 107211 z29 z 7.5 230 Diethylene Glycol 23, ^ Yes ~ rvo z3z 111464 233 s 7.5 2~ Propylene Glycol z35 ^ Yes ^ rvo 236 57556 23~ a<5 238 Hydrated Inorganic Acid, Sodium Salt 239 ^ Yes ^ rvo Z4o Propriety z4~ 5 50 24Z Water 243 ^ Yes ^ No 2~ 7732-18-5 Z45 If more hazardous componeMS are present at greater than 1% by weight if noncarcinogenic, or 0.1 % by weight H carcinogenic, attach additlonal sheets of paper capturing the required ADDITIONAL LOCALLY COLLECTED INFORMATION 2as If EPCRA, P~ease Sign Here UPCF (1/99) OES Form 2731 ~~I~~~~~~il~ # ~ ~~ i~i ~~I. ~~t~ ~c~~al;~r-rt ~ ~~ ~~I ~L~ ~~~ ~~I ~-~~ ~~`i~ ~~I ~~~~ ~il ~~~ ~~I ~-~~ ~~~ ~~I. ~ ~-~~ ~i~~ ~;~I ~TF ~~~ ~~I. ~-~~ ~~n ~-~~ ~;~I. ~~ ~~I ~c~al~ir~t ~ir~~d~~~i ~I~~r~~r . ~ 10/22/2008 10:04 6618718574 PIP_PRINING_BKFD PAGE 17/17 BAKERSFIELD FIRE CEPARTMEryT .....--- -----,_......-------•:-.,._._.__...______., ....._..~__...~.._._-.._.....__........._._.__.._ f•-------- - • --- ._._~_...---- I ~ SITE DIAGRAM FACILxT'Y hIAGRAM ~ ~ . ..-~-.~~ . I Business Name: GZ L, ~~j(_ . . ~ ; ----- ~---,.,..---------~.~...~.r j i Business Address: ~~ ~~~ ~ ; I _ Q ~„ 7 _._. ~~ C~~ ~,,~~~5 _~._.. Av.~;_ __.---- f _. ...~__._. ..__-.. ... _._ ~ ; ; ; ; ' CO~ ~UIIiIB(~S S~ TREE T ; l ~ >~ MAZARD~US MA7FRIAL MANAGEMENT pLAN ~ ~~ ' t, . ~"~~ . srr~ 8~ FACic.~nr aYaGR~-M ,. I ~ I ~ ~ I Preventio~ Servlcee ~~ 1501 Truxtun Avenue, lg Floor /~R~ Bakersfie(d, CA 93301 ABf~ Phane: 661-32b-3979 • Fax: 661-$52-2171 ~~. Page 2 of 2 ~--...,-..,~.w. _.._.._..----• ,.~.r_~.-•--°-----,....~.--• --•------r....,,,~------ FO2170 iRev.01lOB) ~~~~ ~~~ ~---_ BAKERSF 1 ELD F i RE DEPARTMENT ABOVEGROUND STORAGE TANK ~ Prevention Services ~~ ,~,..~„>.,,.,.'•„,.a.r,~,;.~:.~..;~..,r,y~;,:~,~~,;~.~.~~-nw.~~.~.~~.~'.a e $w/Re D 1501 Truxtun Ave 1ST FLR APPLICATION FORM ~ ~Rru~ ~ Bakersfield, CA 93301 I NSTALLATION/REMOVAL OF AN AST ~'~ Phone: 661-326-3979 ? Fax: 661-852-2171 ~~ c.~.( ~ ~ t~'- ~ ~h ,S/~ Page 1 of 2 .y ~"~~'~` 6 ~ ~Z' ~~d~M'1~.. I NSTALL ~ REM~~/E ' ` I % f ~ :~ ;,, . ~~ ~ ;~ ~' S I? ~ ~ d . S~ .~ . ~ r PERMIT # -r'I ,... ti~=y G .• (/"'Lr_ I~ r_•~L~.{ ~ ~ ""!i~ ~/'A~/~ ~_ ~ FACILITY NAME 1 ~ ~,. L~a,~pp.. ~ ~ ~ ~ ~~ \ •- ~ 1.~_;~J •-•) ~~Lt ; "~ F,~ , •.•~ ; ~ {f p ~ ADORESS t 5v~ c w~~~~ NA~-~`~, ~~kE~:~~~~~ ~'~,~ OPERATOR NAME ~ PERMIT TO,OPERATE # ~ L~ i t~- L ~ ~ _ ~,r~p~.. OWNER NAME ~ - ~ ~ ~~~ N OF TANKS TO BE INSTALLED ~_ / REMOVED (~ q ~~;.~ . l ~t_ . ~ C `-33~~ ,~rrt..- _3 :~.;,:. ~~,.~ ~ ~ ` ~~ ~ n /•.:~~. l ~J i i:~~ ~ ~I ~~- ~~`~ /1-c~ . 7 v~ ~V t.. T' ~ G. i~'l._..- ~ I C~ ~3 ~1- -•~1~ NAME OF COMPANY INSTALLING AND/OR REMOVING TANK . ~ ~~ L~~3~ , MAILING ADDRESS ~so~ w : ~~~ e~-,~`~'~.,- ~r~., s'~-~'~ ~-~v,a , c~ . ~ ~~oy NAME & PHONE # OF CONTACT PERSON ~-'1 R E S c KGT~' -1 i~-1 - Q~'3 ~~f 7 4 3 DATE & TIME TANK IS TO BE INSTALLED/REMOVED '~ ~~'~~ '-~ Q SIGNATUR APP IC ~ DATE •9-~in~~O ~/~ APPROVEO BV DATE j~ ~ ~/ _.-- ~~ t~ j".? .. 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