HomeMy WebLinkAboutUST APPLICATION 6/25/2008UNnERGROUNDSTORAGETANKS
Y~ UNiFIED PROGRAM CONSOLIDATED FORMS
APPLICATION
OPERAT/NG PERMIT APP. LICATION
FACILITY FORM - (STATE FORM A)
One form per facllity
TVPE OF ACTION: (Check one ftem onty)
~i. NEW SRE PERMfi
O 8. TEMPORARY SITE CLOSURE
BAKERSFIELD FIRE DEPT.
Prevention Services
B E R 9 P I D 900 Truxtun Ave., Ste. 210
p~R~ Bakersfield, CA 93301
D ARTM T
Tel.: (661) 326-3979
Fax: (661) 852-2171
Page 1 of 2
D I~'= D ZI - v06- t~ I
^ 3. RENEWAL PERMIT ^ 5. CHANGE OF INFORMATION (Speciry change local use aVy)
O 7. PERMANENT SITE CLOSURE O 8. TRANSFER PFRMIT ypp
' ' I. FACILITI(/SITE INFORMATION `
.
_ _ .
TOTAL NUMBER OF USTS AT SITE ~ 404 ACILITY ID No.
AgenCy Use Only) ~,w
~~ ~~
~
~~ ~. ~
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
~C ~PC(~5 `~ ~1(1 1 ~~-l~~
BUSINESS SITEADDRESS 3.~~ (~ ~~~1,,.~~ ~ 103 CITY [3~~'~~l~"~{ E+~ 104
Is facility on Indian Reservation or Trust lands7 ^ Yes L~No 405
II. PROPERTY OWNER INFORMATI'ON
PROPERTY OWNER NAME q07
-` ~. PHONE 408
~ ^ ~oo ~~a ~~w
MAILING OR STREET ADDRESS 3~~, ~ ~ 409
,`
CITY ~ q~p STATE 411 ZIP CODE 412
~ ~3r
111. TA~JK OPERATOR INFORMATION
OPERATOR NAME '
~~ ~.~ ~ u~ c1 c li~a~~~ ~
We tE~ f"oo ~~ ~~~C- To2
MAILING OR STREET ADDRESS ^~^` ~~ ~1
~ i_ T03
',~ J. ~T {'1~1~'~
~~N T04 STA7~, TOS
C..~f ~CQD~ T06
,;l 1
PROPERTY OWNER TYPE ~. CORPORATION ~ 3• INDIVIDUAL ^ 4. LOCAL AGENCY/ DISTRICT ^ 6. STATE AGENCY
^ 5. COUNTY AGENCY ^ 7. FEDERAL AGENCY
IV. T;ANK OWNER INFORMATION , `
ANK OWNER NAME Qia
i ~ ~ '.b PHONE ai
ILING OR STREET ADDRESS ' aie
~TY ~ 417
13 a~~ ~ STA £ aie
;~- IF C a~
ANK OWNER TYPE ~ . CORPORATION/LCC ^ 2. INDIVIDUAL ^ 3. PARTNERSHIP p 4. LOCAL AGENCY/ DISTRICT azo
5. COUNTY AGENCY ^ 6. STATE AGENCY ^ 7. FEDERAL AGENCY
V: BOARD-OF EQUALIZ~4TION UST STORAGE FEE ACCOUNT NUMBER
(TK) HQ 4 4 all (916) 322•9669 if Nere are any questions a2~
~VF. PEIRMIT NOLDER INFORMATION
Issue permit and send legal nolifications and mailings to: ~ FACILITY OWNER O 3. TANK OWNER ^ 4. TANK OPERATOR ^ 5. FACILITY OPERTOR a2z
egal notificafions and mailings will be sent to the tank owner unless box 4 or 5 is checked. •
UPERVISOR OF DIVISION, SECTION, OR OFFICE (Required for Public Agencies Only) dpg
~ VII. AP,PLICANT SIGNATU'RE ~
Certiticatlori: 6coRf thaf the 9~rforrriaNOn vided heroio i, true. accunrto, and In tWf complianco with le al roaulroinonts. ,
IGNATURE OF PLICANT yZy
~-.:v~~-- - - - ATE a25
G-~~-~g PH a
6'6~-- 83--2~3 .
AME OF APPLICANT (prinf) a27
~(v~~ ~'Fl ~ v ~\~l'~ ~ TITLE OF APPUCANT ~ / y
~ W M Iz ~ ~ U~`~ ~Y
USINES NAME ~y~,p /1 ,~{--
0.V.. ~1r•G •,v1J~ 1 ~ l^O.S G~ Wl.l~~ 1(~O~~l ~ 3
USINESS SIT ADDRESS
2 ~a 1~ ~'~-~c '~\~ C`~~ °13~~ 3 ,os
FD 2093 (Rev. 11/06
UNDERGROUNDSTORAGETANKS ~~
UNIF~D PROGRAM CONSOLIDATED FORMS ~~
s:'~~~'{`^"~`~.."~"'-~.~.,.s,~"~..,.~:;w,v:.. ~ ~";:~~~. ~"~: ~z
APPLICATION (Continued) ~
OPERAT/NG PERM/T APPL/CAT/ON ~1
FACILITY FORM - (STATE FORM A)
One form per facllity
a s x s P I D
F1R~
DB~ARTM ~ T
BAKERSFIELD FIRE DEPT.
Prevention Serv~ices
900 Truxtun Ave , Suite 210
Bakersfield, CA 93301
Tel.: (661) 326-3979
Fax: (661) 852-2171
Page 2 of 2
. . . . . .., .. .,• ~. : ~ . y ~ : .... . ~ ~ ~ ~v ;a
~ . ~ ~,: . , VI.II „P ,R. IMA.RY„ DESIGNATED::"OPERATOR ,INFORMATION. , ~ ~
. . , .. .. .. . . . .... . ...
RIMARY DESIGNATED OPERATOR NAME \ D01a
~AYw~S ~ac~v~ ~u~v~w~.+~.~ HONE D01b
6'6 - o~- ~ "~
USINESSNAME ~U~~~~~ ~~~ ~~~ \, _ 1_\_. 1 /^~S ~ ,~;~ _ ..L- D01c
C~' ~'''U l.~ `l1/~ASV ~
ILING OR STREET ADDRESS } ~W D01d
~J22\ -`~
~TY ~\/ ,~ D001e
O``(_x'~ S STATE ~ D01f IPCOD~,~~~ 3 DOtg
CC CERT. # i ~ D01h PIR,4TION DATE D01i
RELAT~ONSHIP TO UST FACILITY (Check One): ^ 1. OWNER ^ 2. OPERATOR O 3. EMPLOYEE ^ 4. SERVICE TECHNICIAN ^ 5. THIRD PARTY D01j
„_ ;i'. y ' { ~ ? '::
~ ,, :. .,.,,. , : IX:;~ALTERNATE DES.IGNATED O,PE:RATOR.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
IRELATIONSHIP TO UST FAC~LITY (Check One): ^ 1. OWNER ^ 2. OPERATOR ~ 3. EMPLOYEE ^ 4. SERVICE TECHNICIAN ^ 5. THIRD PARTY D02jj
(Attach an additional page if necessary.)
I cert,ify;that fot;;this facility the inclividuai(s) hsted above will senre as Designated UST Operafor(s) Ttie indiVidual(s) will contluct and cJocument ; ~:;
~'montFil .facili rins ectioh's'~andrannual~facil' .~em'"lo ee:trainin"°•in~acco~dance.wdli;CatiforniaCode;of,Re ulations~TRIe~23~Sedio`n'27,150- .' ':~.,;. ~.
NAME OF TANK OWNER (Please Print) D03a
'~`(`~\-~~ F~U ~1y ~ H
SIGNATURE OF TANK OWNE - - - ~- - • - - -- ~- -.----_ _
~ __._~ ___~ _~-
DATE D03b
~~ r? ~`~~
FD 2093 (Rev.11106)
UNDERGROUND STORAGE TANK
MONITORING PROGRAM
EMERGENCY RESPONSE PLAN (FORM)
Page 1 of 1
B E R 5 P I D
IJRI
ARfAI T
~
BAKERSFIELD FIRE DEPT.
Prevention Services
900 Truxtun Ave., Suite 210
Bakersfield, CA 93301
Tel.: (661)326-3979
F~.: (661) 852-2171
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 notily the OSice of Prevention Services wirhin 30
days o1 any changes to the monitoring procedures, unless required to obtain approval be%re making the change. Required by Sections 2632(d) and
2641(h) CCR.
FACIUTY NAME
FACIUTY ADDRESS ~~~~~ ~ ~ V` C ~~,
1 c-~ f~-~ ~~Q ~' r f ~'~- q33~
IF AN UNAUTHORIZED RELEASE OCCURS, HOW WILL THE HAZARDOUS SUBSTANCE BE CLEANED UP? NOTE: IF RELEASED HAZARDOUS SUBSTANCES REACH THE
ENVIRONMENT, ~NCREASE THE FIRE OR EXPLOSION HAZARD. ARE NOT CLEANED UP FROM THE SECONDARY CONTAINMENT WITHIN 8 HOURS, OR DETERIORATE THE
SECONDARY CONTAINMENT, THEN THE OFFICE OF PREVENTION SERVICES MUST BE NOTIFIED WITHIN 24 HOURS.
~sr ~-~ k~k~y l~~-e~ c~5 Q~,~ ~(~Sc,r~~ai~~ -~ac- sct~~ll S~~IIS, <<tv~Yc.
yPcl(5 ~c~C( ~ I ~ ~ 1-i r~ IlJc~~~
DESCRIBE THE PROPOSED METHODS AND E~UIPMENT TO BE USED FOR REMOVING AND PROPERLY DISPOSING OF ANY HAZARDOUS SUBSTANCE.
t~~~ly ~~-~c~ is s~-oec~ cc. ~ ~a~, ~a~u. ~.~ti~~ ~, fl~ ~cc~v~c~
~ i ~~ t~~ccv ~c~N ~5 ~~ I~ ~n~U~. ~~~~~~rQ~~t.y~e~~fc~~ c`Gc~~~~y ~Gt~
d,~~ ~ ~~'o~~~ (~( ClcS~~U~,
DESCRIBE THE LOCATION AND AVAILABILITY OF THE REOUIRED CLEANUP EQUIPMENT IN ITEM ABOVE.
4C~ ~'I C 4N l 5 j 0~c~~Cc~ l ~~ (~~ G~`~ ~~ v° O G t~~ ~'o :~~~ s y~.c~ c~ Ss.
DESCRIBE THE MAINTENANCE SCHEDULE FOR THE CLEANUP EOUIPMENT:
~ ~~y f~~c.~ t5 c~cc~cc~ C[!A~ ~y ~-o ~~~a~'c 5v v~c ~~vJql-~ rS
o v~ I~c~ tid ~t.k Ct. ((-~~~~,y
LIST THE NAME(S) AND TITLE(S) OF THE PERSON(S) RESPONSIBLE FOR AUTHORIZING ANY WORK NECESSARY UNDER THE RESPONSE PLAN:
NAME ~~\~~ t , ~\ ~
~v ~~ TITLE OW r1~~
NAME ~n ~ I ~ ~~ ~ ~\ TITLE ~Q / O W A ' ~
! 'y ~
NAME
TITLE
-- NAME - - - ---- - - ----- ----- ------
TITLE
NAME ~
TITLE
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FI~URE ~ ~~Rimr9~ ,sann n 1
HAN3EN ENC~INEERINO '' ~'J"~ ~~~~~~'~~ PflOJECT;
B ~ 3012 Antonino Street; Bakersfieid, CA 93308 MARKET ~~~
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~~
UST MONITORING PROGRAM
EMERGENCY RESPONSE PLAN
Page 1 of t
This monitoring program must be kept at the UST /ocation at all times. The
in/ormation on this monitonng program are conditions of the operating permit.
The permit holder must notily the Olfice of Environmental Seivices within 30
days ol 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~
AIt 11M 1
~
Bakersfield Fire Dept.
Environmental Services
1715 Chester Ave
Bakersfield, CA 93301
Tel: (661)326-3979
FACIIITY NAME
~ '~- ~ I~,ilt ~
FACILITY AOORESS
~ ~ -~+ ~ k ~I ~ ~~. 31.3
IF AN UNAUTHORIZED RELEASE OCCURS. HOW W1LL THE HAZARDOUS S TANCE BE CIEANED UP9 NOTE: IF RELEASED MAZARDOUS SUBSTANCES REACH THE
ENVIRONMENT, INCREASE THE FIRE OR EXPLOSION HAZARD, ARE NOT CLEANED UP FROM THE SECONDARY CONTAINMENT WITHIN 8 HOURS. OR DETERIORATE THE
SECONOARY CONTAINMENT, THEN THE OFFICE OF ENVIRONMENTAL SERVICES MUST BE NOTIFIED WITHIN 24 HOURS.
~S ~. o~ I~ ~~~ ~ ~~ cc- ~5 C;c.~9 s o I' ~~ Q c-,~ G~.c~.~-c~ rc~ f;~na~r y c~~+ ~~s~
~~1,~ ~'t [ I r~ t~~ r~~., ~~,,~. ~
OESCRIBE THE PROPOSEO METHOOS AND E~UIPMENT TO BE USED FOR REMOVING AND PROPERLY DISPOSING OF ANY FiAZARDOUS SUBSTANCE.
k, ~ ~ t ~-E-c~ ~~ ~~l ~o~ s c~~t ( y ~ ~ (C5,
3.OESCRIBE THE IOCATION AND AVAIIABILITY OF THE REOUIRED CLEANUP EQUIPMENT IN ITEM ABOVE.
~L: r~~ ~~-~r~ i5 5~0 ~_ c~ l ~~~ ~J ~ f k i~~ oi~- `~t' ~~ c~s y G~ CC~' ,
DESCRIBE THE MAINTENANCE SCHEDULE FOR THE CLEANUP EQUIPMENT:
~~r~~~~~ cC~~ f Y .
LIST THE NAME(S) AND TITLE(S) OF THE PERSON(S) RESPONSIBIE FOR AUTHORI2ING ANY WORK NECESSARY UNOER THE RESPONSE PLAN:
NAME TITLE
~,l 'T'A~ 1~U ~ 1~~A- ti\ ~ t~~~ ~~ ~t PF~A~~
`~ c~i So l~v..k~ ~o _ c~~,~z~ ~~ ~~ ~ ~~ ~~ ~
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UNDERGROUND STORAGE TANKS ~'"~' BAKERSFIELD FIRE DEPT.
UNIFIED PROGRAM CONSOLIDATED FORMS fis~J
Prevention Services
.. ...~.. ~<....:i~~_..-~5..^~,r'c
-~~•:~~.~ ~a,~~„• ~::;.~;~~<~,~:~:Y:~..;.~,r.:-,>,...,~~ ,~~~.~ : ~uT•.r. . ~~,
B R 9 P
~. i n 900 Truxtun Ave., Suite 210
OPERATING PERMIT APPLICATION ~~a
~ ~~R~
ARlM T Bakersfield, CA 93301
TANK - (STATE FORM B)
i~ Tel.: (661) 326-3979
~~ Fax: (661) 852-2171
(One form per us7)
Page 1 of 2
TYPE OF ACTION (Check one dem onty): y~ 1. NEW PERMIT ^ 3. RENEWAL ERMIT ~ 5. CHANGE OF INFORMATION
~] 6. TEMPORARY CLOSURE ^ 7. UST PERMANENTLY CLOSED ON SITE ~ 8. UST REMOVED a3o
(Check one item only. Fa a UST Gosure or removal, complete only this sectlon and SecGons I, II, III, and IV below)
DATE UST PERMANENTLY CLOSED: 430
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TANK ID NO. 432 TANK MANUFACTURER 433 NUMBER OF TANK UNITS. THIS TANK IS: 4
1 „ 'p~t STAN0.ALONE TANK
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` ^ 2 ONE OF TWO OR MORE COMPARTMENTS
DATE UST ISTALLED (YEAR/MO) 435 DATE EXISTING UST DISCOVERED
435b NUMBER OF COMPARTMENTS 43
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TANK CAPACIN IN GALIONS 436 `r'4 '` ie~ i~r'~ '~ ~~ k r''A ~ : ~d '~.~'` t' b`~ ."^ ,r .. `1 t t ~)~,,~ ja .~~,~,?a 7 r~ s~v
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tYi. MOTOR VEHICLE FUELING ^ 3. CHEMICAL PRODUCT STORAGE ^ 4. HAZARDOUS WASTE (InGudes Used Od
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MARINA ~UELING O 95
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^ 99. OTHER (Specify)
TA~Nj( CONTENTS (PETROLEUM TYPE ) TANK CONTENTS NON PETROLEUM TYPE: q4
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4y~a. REGULAR UNLEADED O 3. DIESEL ^ 7. USEDOIL
^ 1b. PREMIUM UNLEADED ^ 5. JET FUEL O 10. ETHANOL
^ 1c. MIDGRADE UNLEADED ^ 6. AVIATION GAS ^ 99. OTHER (Specify)
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TYPF~OF TANK (Check one item only
44
yy~ SINGLE WALLED ~ 2. DOUBLE WALLED ^ 3. SINGLE WALL WITH EXTERIOR MEMBRANE LINER ^ 95. UNKNOWN
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AN/~,pRIAAARY CONTAINMENT (Check one item only) ~
_
~1. STEEL ^ INTERNALBLADDER ^ 95. UNKNOWN
^ 3. FIBERGLASS ~ STEEL+QJTF.RNIILIJNING ^ 99. OTMER(Specify)
TANK SECONDARY CONTAINMENT (Check one ifem only) 44
^ 1. STEEI ^ 6. EXTERIOR MEMBRANE LINER • ^ 90. NONE
O 3. FIBERGLASS ^ 7. JACKETED ^ 95. UNKNOWN ~ 99. OTHER(Spedfy)
OVERFILL PREVENTION (Check one item only) 45
^ 1. AUDIBLE 8 VISUAL ALARMS 3. FILL TUBE SHUT-OFF VALVE
O 2. BALLFLOAT ^ 4. TANKMEEfSREQUIREMEIYfSFOREXEMPiIONFROMOVERFILLPREVEMIONC-0UIPI~Ali
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PIP~ G SYSTEM TYPE (Check one item only) 45
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FD 2094 (Rev. 11/06)
ti
rJfVDERGROUND STORAGE TANKS -
TANK - APPLICATION (CONT.D) (STATE FORM B)
Page 2 of 2
Page 1 of 2
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CERTIFICATION: I ceAify that this UST system is compatible with Ihe hazardous substance stored
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requirements.
APPLICANT SIGNATURE ~ DATE
47
_ / ~~
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FD 2094 (Rev. 11/06)
UNDERGROUND STORAGE TANKS ' =''', • BAKERSFIELD FIRE DEPT.
UNIFIEL'~ROGRAM CONSOLIDATED FORMS E~~' Prevention Services
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R.~~~~,,r~~,~.....~ ~.... .,~:;4,_~,. .,~~:~.~,h w,~~~~..:_,.w.; .. ~,~ :~9:u...,.<._a.~ ~.. ~.: ,, a „~ x a r ~ „n 900 Truxtun Ave., Suite 210
OPERATING PERMIT APPLICATION '~~~? AR ~ r Bakersfield, CA 93301
TANK -~srnrE FoRM e~ _ ;~~~; Tel.: (661) 326-3979
(One form per usT) ~,'; Fax: (661) 852-2171
Page 1 of 2
TYPE OF ACTION (Check one ~Tem onfy): ~ NEW PERMIT ^ 3. RENEWAL ERMIT ~ ^ 5. CHANGE OF INFORMATION
^ 6. TEMPORARY CLOSURE ^ 7. UST PERMANENTLY CLOSED ON SITE ^ 8. UST REMOVED 430
(Check one ilem only. For a UST Wosure or removal, complete only lhis section and Sections I, II, III, and IV below)
DATE UST PERMANENTLY CLOSED: 430
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DATE UST ISTALLED (YEAR/MO) 435 DATE EXISTING UST DISCOVERED 435b NUMBER OF COMPARTMENTS 43
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OVERFILL PREVENTION (Check one item only)
45
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O 1. AUDIBIE S VISUAL ALARMS [L/~. FILL TUBE SHUT-OFF VALVE
^ 2. BALL FLOAT Cf 4. TANK MEETS REQUIREMENTS FOR EXEMPf10N FROM OVERFILL PREVENTION E~UIPI~NT
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FD 2094 (Rev. 11/06)
~ UNDERGROUND STORAGE TANKS -
TANK - APPLICATION (CONT.D) (STATE FORM B)
Page 2 of 2
Page 1 of 2
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APPLICANT SIGNATURE ~ _ __ DATE ' ~ ~/ 0 ~ 47
FD 2094 (Rev. 11/06)
UNDERGROUND STORAGE TANKS ~„; BAKERSFIELD FIRE DEPT.
UNIFI~D PROGRAM CONSOLIDATED FORMS a~''
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OVERFILI PREVENTION (Checkone itemonly) / 45
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TUF~INE CONTAINMENT SUMP (Check one item only) 464
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FD 2094 (Rev. 11/06)
P UNDERGROUND STORAGE TANKS -
TANK - APPLICATION (CONT.D) (STATE FORM B)
Page 2 of 2
Page 1 of 2
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CERTIFICATION: I certify that lhis UST system is wmpatible with the hazardous substance stored and that the irdortna6on provided herein is We, accurate, and in full compliance with legal
requirements.
APPLICANT SIGNATURE ~ DATE ~~ p%Q 47
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FD 2094 (Rev. 11/06)
UNDERGROUND STORAGE TANKS s:ff BAKERSFIELD FIRE DEPT.
UNIFIEC PROGRAM CONSOLIDATED FORMS '~'s Prevention Services
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~`'~~ rlRe Bakersfield, CA 93301
OPERATING PERMIT APPLICATION =~ti~ AIPTM ~
TANK -(STATE FORM B) ~ Tel.: (661) 326-3979
(One form per UST) ~:~:~ Fax: (661) 852-2171
Page 1 of 2
TYPE OF ACTION (Check one i7em onlyJ: D 1. NEW PERMIT ^ 3. RENEWAL ERMR ^ 5. CHANGE OF INFORMATION
0 6. TEMPORARY CLOSURE ^ 7. UST PERMANENTLY CLOSED ON SITE O 8. UST REMOVED e 30
(Check one item only. For a UST Gosure or removal, complete only this secUon and Sec6ons I, II, III, and IV below)
DATE UST PERMANENTLY CLOSED: 430
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TURBI E CONTAINMENT SUMP (Check one ifem only) 464
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FD 2094 (Rev. 11/06)
UNDERGROUND STORAGE TANKS -
TANK - APPLICATION (CONT.D) (STATE FORM B)
Page 2 of 2
Page 1 of 2
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CERTIFICATION: I cerUy that this UST system is compatible with the hazardaus substance stared and that the
informalion provided herein is true, accurate, and in full compliance with legal
requirements.
APPUCANT SIGNATURE DATE ' ~ ~~ (~ 47
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FD 2094 (Rev. 11/06)
~ 4yc ~ v~ ~
acoRO CERTIFICATE OF LIABILITY INSURANCE OPID DD DATE(MM1DOlYWY-
HAPPY-2 OS/29/OS
PRODUCER THIS CERTIFICATE IS 13SUED AS A MATTER OF INFORMATION
ThomCo Insurance Assoc. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE
License ~i0791289 HOLOER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
4333 N West Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Fresno CA 93705
Fhone:559-226-1000 Fax:559-226-1800 INSURERSAFFORDINGCOVERAGE NAIC#
INSURED INSURERA Markel Insurance Com an
INSURER 8:
Happy vas ~ Mini Mart
Vickram 6 Amita Budiyan i"s~RC:
3221 Taft Hig hway
Bakersfield CA 93313 ~n~raeao:
INSURER E:
COVERAGES
THE POLICIES OF INSURAfJCE USTED BEIOW FWVE BEEN ISSUED TO THE INSURED NPMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITtiSTANDING
ANY REOUIREMENT, TERM OR CONDIT~ON Of fWY CONIR,4CT OR OTHER DOCUMEM WITH RESPECT TO WHICH THIS CERTIFiCAiE MAY BE ISSUED OR
MAY PERTAIN, T}fE INSURANCE AfFORDEO 6Y THE POLICIES OESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POIICIES. AGGREGATE IIMITS SHOWN M4Y HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF WSURANCE POLICY NUMBER DATE (MMlDDM() DATE (MM1DDlYYj ~~M~
GENERAL LIAB0.fTY EACH OCCURRENCE E S~ OOO ~ OOO
A X COMMERCIALGENERPLLIABIIITY MSp610745 SL~OL~O~I ZL~OZ~OS pREMISES(Eaxcurence f SOO~OOO
CIAIMS MADE X~ OCCUR MED EXP (My one person} ; 5~ 0 0 0
aERSOwu anDV inknrav i 1, 000 , 000
A X Liquor Liability MSP610745 12/01/07 12/O1/08 GENER.4L 0.GGREGATE 5 2, 000 , 000
GENL AGGREGATE LIMIT PPPIIES PER: PRODUCTS - COMPIOP AGG S N/A
aaicY ~cr ~~ S,iq. Liab $1, 000 , 000
' AUTOMOBILE LIABILRV COMBINED SINGIE LIMIT S
ANY AAlfO (Ea acci0ert)
ALL OWNEDAUTOS
BOOILY INJIA2Y
SCFIEOULED All70S
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A X a~van'o MSP610745 12/01/07 12/01/08 oTMERnvw EAACC s1,000,000
A X OTNER THAN AUTO MSP610745 12/01/07 12/01/08 ~OOI~AY: q~,~ s3,000,000
EXCESSNMBRELIA LIABILI7Y EACH OCCURRENCE S
OCCUR ~ CIAIMS MADE AGGREGATE 5
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RETEMION y S
WORKERS COMPENSATION AND TORY LIMITS ER ~
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A Property Section MSPb10745 12/01/07 12/01/08 Property See Below
DESCRIPTION OF OPERATIONS / LOCATONS ! VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT! SDECIAL PROVISIONS
Buildinq/RC/Special Form $416,000; Pumps/RC/Special Form $120,000;
Canopy/RC/Special Form $130,000; Personal Property/RC/Special Form $301,600;
Hoses and Nozzles/RC/Special Form $5,000; Business Income/Special
Form/Actual Loss Sustained
CERTIFICATE HOLDER CANCELLATION
FORIN02
F'oz insurance Purposes only***
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SHOUID ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E%PIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 O DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 30 SHAIL
IMPOSE NO OBLIGATION OR LIABILRY Of ANY KIND UPON THE INSURER, RS AGENTS OR
REPRESENTATIVES.
~~12E~ SE ~IVE~
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B + E R S F I ~~ D
F/I~E
ARTM T
RONALD ]. FRAZE,
FIRE CHIEF
GARY HUTTON,
SENIOR DEPUTY CHIEF
ADMINI57RA7SON
TYLER HARTLEY,
DEPUTY CHIEF
OVEMT10N5/TNAINING
DOUG GREENER,
DEPUTY CHIEF
F[RE SAFETY/PREVEMION SERVICPS
HOWARD H. WINES, III,
DIRECTOR
PREVENTION SERVICES
PIR[ BMBTY SlRVICHS ~ ENViRONMENTAL SERKCF3
1501 Truxtun Avenue
Bakersfield, CA 93301
OFFICE: 661-326-3979
FAX: 661-852-2171
Dear Business Owner:
This packet contains important information regarding your business and the
requirements of Hazardous Material Inventory Regulations. Both State and Federal
laws may require that your business complete a Hazardous Material Management Ptan
(HMMP). Please read all the enclosed information carefully. Failure to comply
with any portion of the Business Plan requirements may result in Civil Liabilities of up
to $2,000 for each day in which violation occurs.
WHAT BUSINESSES MUST COMPLY
If you handle, use, store, or dispose of hazardous substances at any time during the
year in excess of the minimum reporting quantities you must submit a plan.
Typical everyday hazardous material you may find in your facility may include, but are
not limited to: compressed gasses; fuels - all types, including propane; solvents - most
solvents would be hazardous material; oils - new and waste; thinners; caustic or corrosive
material; poisonous or toxic material, and radioactive material.
Minimum State reporting quantities for hazardous material are:
• 55 gallons for liquids
• 500 pounds for solids
• 200 cubic feet (at standard temperature and pressure, for gasses)
For all acutely hazardous material the minimum reporting quantities are found on the
list of Extremely Hazardous Substances on the current EPA list (Vol. 52 No. 77 of the
Federal Register.) This list is available at the Office of Prevention Services of the
Bakersfield Fire Department, 1501 Truxtun Avenue, Bakersfield, California 93301. For
explosives and hazardous waste, any quantity is reportable. ~
Your reporting requirements are either the State quantities or the Federal (threshold
planning quantity). WHICHEVER IS LOWER!
WHAT BUSINESSES ARE EXEMPT
If you do not handle hazardous material or if the quantities of hazardous material are
below the minimum reporting quantities at all times during the year, you are exempt.
Hazardous material which are stored in transit or temporarily maintained in a fixed facility
for less than thirty (30) days during the course of transportation are exempt from the
inventory requirements of the law.
NOTE: Hazardous material contained solely in a consumer product for dired
distribution to, and use by, the general public are NOT exempt from the reporting
requirements of the law per this Administering Agency.)
HOW DO BUSINESSES COMPLY
Businesses that are required to comply with requirements of Chapter 6.95 of
California Health and Safety Code must submit a plan. This business plan consists of:
1. Emergency Response Plans and Procedures.
2. Inventory of Hazardous Material.
3. Training Program for Employees.
The forms for completing the Hazardous Material Management Plan are attached to
this letter. By correctly filling in this business plan, you satisfy both the Federal
Requirements (Tier I and Tier II Inventory Requirements of SARA Title III) as well as the
California Requirements of Chapter 6.95 of the California Health and Safety Code.
Business owners are urged to read and become familiar with Chapter 6.95 of the
California Health and Safety Code. Copies are available at the Office of Prevention
Services of the Bakersfield Fire Department, 1501 Truxtun Avenue Bakersfield, California
93301.
The completed business plan is required to be submitted within 30 days of
receipt of this letter. On-site inspections are required to ensure compliance with the
law. If you have any questions or need assistance with completing the Business Plan,
please call Manar Haddad at 326-3464.
J~tt~isa~ ~e ~~au~ai~~~L .,~%lote ~l~ia ~ ~~arr~~ •.
HAZARDOUS MATERIAL MANAGEMENT PLAN j
, . ,. , , . `~ .:°s ,.:::;,«t . ". ._, ..m~t"~:_
INSTRUCTIONS
BUSINESS OWNER/OPERATOR ID FORM
(HAZARDOUS MATERIAL FACILITY INFORMATION)
B H R S A I D
F/RE
O ARTr r
~
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1~ Floor
Bakersfield, CA 93301
Phone: 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 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. ENVIRONMENTAL 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 5531 Auto & home supply store
0115 Corn production 0724 Cotton ginning 5541 Gasoline service station
0131 Cotton production 1541 Dry cleaning 5821 Eating establishment
0139 Field crops, except cash grains 2851 Paint manufacture 5813 Drinking establishment (alcohol)
0161 Ve etables & melons 2911 Oil refinery 5983 Fuel oil dealer
0172 Grapes j3441 Welding fabrication-structural !5984 LPG dealer ~
0173 Tree nuts 3443 Welding fabncation-boiler ;7342 Pest control i
0174 Citrus fruits 3569 Machine shop _ ~7532 Auto body, upholstery repair, paint
0175 Deciduous tree fruits ; 4222 Cold storage ~7533 Auto exhaust repair
0179 Other tree fruits & nuts ! 4925 Compressed gas supplier 17536 Auto glass replacement
0192 General farms, rimarily crop ; 5093 Automobile salvage ` i7537 Auto transmission repair
0241 Dairy farms ; 5169 Chemical supply ~7538 General auto repair
0252 Chicken eggs 1 5511 Motor vehicle dealer (new & used) ;7542 Car wash I
0291 General farm, livestock & animals ~ 5521 Motor vehicle dealer (used only) ~8071 Chemical laboratory ~
FD2141 (REV O6/07)
HAZAtRDOUS MATERIAL MANAGEMENT PLAN ~ BAKERSFIELD FIRE DEPARTMENT
~-~~~ ~~:; e~,,~~~.,., r_,: ~ I~ Prevention Services
.. .-~ ~~~;
AP .~. ~~° ,.~~F~ .
~~ ; 1501 Truxtun Avenue, 1~` Floor
PLICATION ~~ 8~ B~ s p I D Bakersfield, CA 93301
BUSINESS OWNER/OPERATOR IDENTIFICATION FORM ':'' F~RB Phone: 661-326-3979 . Fax: 661-852-2171
(HAZARDOUS MATERIAL FACILITY INFORMATION) ARTAI T
~ Page 1 of 2
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Certification: Based on my inquiry of those individuals responsible for obtaining the informa[ion, I certify under penalty of law that I have personally
examined and am familiar with the information submitt d in this inventory and believe the information is true, accurate, and complete.
SIGNATURE OF DOCUMENT PREPARER ~ 136 DATE
134 NAME OF DOCUMENT PREPARER (PRINn 135
~~ D ~, lyA~
NAME OF OWNER/OPERATOR (SIGN 8i PRINn 137 TITLE OF DOCUMENT PREPARER
138
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FD2142(REV O6/07)
~ HAZARDOUS MATERIAL FACILITY INFORMATION
BUSINESS OWNER/OPERATOR IDENTIFICATION
Please submit the Business Activities page, the Hazardous Material Facility Information (HMMP) Business Owner/
Operator ldentification Form, and Hazardous Material Inventory Chemical Description Form for all hazardous material
inventory submissions. For the inventory to be considered, please complete this page; it must be signed by the
appropriate individual.
NOTE: The numbering of the instructions follows the data element numbers that are on the Business Owner/Operator
Form page. These data element numbers are used for electronic submission and are the same as the numbering used
in 27 CCR, Appendix C, Business Section of the Unified Program Data Dictionary. Please number all pages of your
submittal. This helps our CUPA or AA identify whether the submittal is complete and if any pages are separated.
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.
101 ENDING DATE - Enter the ending year and date of the report.
102 BUSINESS PHONE - Enter the phone number, area code first, and any extension.
103 BUSINESS SITE ADDRESS - Enter the street address where the facility is located. No post office box numbers are allowed. This
information must provide a means to geographically locate the facility.
104 CITY - Enter the city or unincorporated area in which business site is located.
105 ZIP CODE - Enter the zip code of business site. The extra 4-digit zip may also be added.
106 DUNN 8t BRADSTREET NUMBER - Enter the Dunn & Bradstreet number for the facility. The Dunn & Bradstreet number may be
obtained by calling 610-882-7748 or by Internet.
107 SIC CODE - Enter the primary Standard Industrial Classification Code number for primary business activity. NOTE: If code is more
than 4 digits, report only the first four.
108 COUNTY - Enter the county in which the business site is located.
109 BUSINESS OPERATOR NAME - Enter the name of the business operator.
110 BUSINESS OPERATOR PHONE - Enter business operetor phone number, area code first, and any extension.
111 OWNER NAME - Enter name of business owner.
112 OWNER PHONE - Enter the business owner phone number, area code first, and any extension.
113 OWNER MAILING ADDRESS - Enter the owner mailing address.
114 OWNER CITY - Enter the city for owner mailing address.
115 OWNER STATE - Enter the 2 character state abbreviation for the owner mailing address.
116 OWNER ZIP CODE - Enter the zip code for the owner address; extra 4-digit zip may also be added.
117 ENVIRONMENTAL CONTACT NAME - Enter the name of the person who receives all environmental correspondence and will respond
to enforcement activity.
118 CONTACT PHONE - Enter the phone number at which the environmental contact can be contacted, area code first, and any
extension.
119 CONTACT MAILING ADDRESS - Enter the mailing address where all environmental contact correspondence should be sent.
120 CITY - Enter the name of the city for the environmental contact mailing address.
121 STATE - Enter the 2 character state abbreviation for the environmental contact mailing address.
122 ZIP CODE - Enter the zip code of the environmental contact mailing address; extra 4-digit zip may also be added.
123 PRIMARY EMERGENCY CONTACT NAME - Enter the name of a representative that can be contacted in case of an emergency,
involving hazardous material, at the business site. The contact shall have FULL facility access, site familiarity, and authority to make
decisions for the business regarding incident mitigation.
124 TITLE - Enter the title of the primary emergency contact.
125 BUSINESS PHONE - Enter the business number for the primary emergency contact, area code first, and any extensions.
126 24-HOUR PHONE - Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one
which is answered 24-hours a day. If it is not the contact home phone number, then the service answering the phone must be able to
immediately contact the individual.
127 CELL NUMBER - Enter the cell number for the primary emergency contact.
128 SECONDARY EMERGENCY CONTACT NAME - Enter the name of a secondary representative that can be contacted in the event that
the primary emergency contact is not available. The contact shall have FULL facility access, site familiarity, and authority to make
decisions for the business regarding incident mitigation.
129 TITLE - Enter the title of the secondary emergency contact.
130 BUSINESS PHONE - Enter the business telephone number for the secondary emergency contad, area code first, and any extension.
131 24-HOUR PHONE - Enter a 24-hour phone number for the secondary emergency contad. The 24-hour phone number must be one
which is answered 24-hours a day. If it is not the contact home phone number, then the service answering the phone must be able to
immediately contact the individual.
132 CELL NUMBER - Enter the cell number for the secondary emergency contact.
133 ADDITIONAL LOCALLY-COLLECTED INFORMATION - This space may be used for CUPA or AA to collect any additional information
necessary to meet the requirements of their individual programs. Contact your local agency for guidance.
134 DATE - Enter the date that the document was signed.
135 NAME OF DOCUMENT PREPARER (FULL PRINTED NAME) - Enter the full printed name of the person who prepared the inventory
submittal information. ~
136 SIGNATURE OF DOCUMENT PREPARER (FULL SIGNATURE) - Enter the full signature of the person preparing the page. The signer
certifies to a familiarity with the information submitted and that based on the signer inquiry of those individuals responsible for
obtaining the information, all the information submitted is true, accurate, and complete.
137 SIGNATURE OF OWNER/OPERATOR/DESIGNATED REPRESENTATIVE - The Business Owner/Operetor, or officially-designated
representative of the Owner/Operetor, shall sign and print in the space provided. This signature certifies that the signer is familiar
with the signer belief that the submitted information is true, accurate, and complete.
138 TITLE OF DOCUMENT PREPARER - Enter the title of the person preparing the page.
Page 2 of 2 FD2142 (Rev 06/07)
HAZARDOUS MATERIAL MANAGEMENT PLAN ~
INSTRUCTIONS "'~
FOR SECTION DISCOVERY & NOTIFICATION ~
(FORMS)
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1~ Floor
Bakersfield, CA 93301
Phone: 661-326-3979 • Fax:661-852-2171
Pa9e 1 of 2
The Business Owner/Operator ldentification Form FD2089, Chemical Description Form FD2086, and other forms
(underground storage tank information, hazardous waste treatment, etc.) may be submitted as the first section of
the Hazardous Material Management Plan in order to avoid duplication of information for initial submissions.
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 material spill or emergency - what
procedures are used to notify these parties? At a minimum, you must call 911 and the Office of Emergency Services
at 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 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 material used at your business.
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 material 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 waste
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.
H S R 9 P I D
P/R!
~ ARfl1 f
FD2169a (Rev 06/07)
HAZARDOUS MATERIAL MANAGEMENT PLAN
~ SECTION II.2 - RELEASE RESPONSE PLAN (CONT2
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 material, 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 site in a place where employees can access them.
Give a brief summary of your Hazardous Material 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 material used by your business.
2. The Cal-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 material.
CERTIFICATION
Please fill in your name, title, signature, 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 call us at 326-3464.
Thank you for helping to keep our All America City cleaner and safer.
CITY OF BAKERSFIELD
BAKERSFIELD FIRE DEPARTMENT
OFFICE OF PREVENTION SERVICES
1501 Truxtun Avenue, Bakersfield, CA 93301
Page 2 of 2 FD2169a (kev o6/0~)
HAZARDOUS MATERIAL MANAGEMENT PLAN:~
APPLICATION
FOR SECTION DISCOVERY & NOTIFICATION '~
(FORMS)
BAKERSFIELD FIRE DEPARTMENT
~ Prevention Services
1501 Truxtun Avenue, 1~ Floor
s s x s F I nBakersfield, CA 93301
P/RL Phone:661-326-3979 • Fax:661-852-2171
~ A/f 1M ~ T
~ Page 1 of 2
INSTRUCTIONS
1. To avoid further action, return this form within 30 days of receipt.
2. Type/print answers in ENGLISH.
3. Answer the questions below for the business as a whole.
4. Be as brief and concise as possible.
~. ~ Ar Z ~, z ~;` r '~'i s:,~ ~~ ~f.t~ M~~a'~ ~4~'«'~c3u7 ~ ?.~t o tr t -~wrr ~ '~ta~~ ,9~ ;~ r ~- ~~ ~5 ~,~ ~ ~a n '~ .
, ~ ,~_ i T , ,. ^
r ~ : SECTION` I `~~FACILI~T~Y IDENTIFICATION ~~ `"~~~'~ ~ ~~'~~` ~~~~'`~` ~' ~~~ t
~• ~ ~" ''~ ~~' ~' u.. ~.~ > t k.~ i- ~..As' "'b w, S ~.
Nv ~r.~ .~~~', rw,~,x. m'c.,.~ ..xk~sss,~'~.~`,~~ .~~,.~c.asl_iK.i;°~'~.a~,~,.an.fin '94+
BUSINE55 NAME (FACILTfY NAME or DBA)
U ~1 ~I ~ M ~-~^c- • ~(3'H ~ C~as ~ M-(i.~' ~'l~c~ ~
ADDRESS (~or locai use oniy)
~ 2 -~a. ,~-"_ Hw~, ~`jA. lCe- ~',~1~ ~ °13~ I 3
FAQLITY ID # i,°:[~; 1
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~,~ S R., t~~ ~ Yt { w °W?r Rsa k - ~ ~,s~ ~~ r"- ~v~a '~iF 2^^k~ . ~a~~ a N"^+~ ,~, "r,~~?k* f~ 'T .~~5 "W: ~~'° "~': '~#~~~,~ ~'~+f~~x"'~+.'~,~ e k~~r,~y~~ ~~.~s ~~i~'
E ~
~` . , , ~~,:SECTION.II:1 ;,~DISCOVERY AND,NOTIFICATIaONS~ ~ ~s~r~;~~~~~~`~,.~ ~;.Yry~ ,.?~
,
A. LEAK DEfEClION AND MONITORING PROCEDURES:
~e ~~~ ~oti~- -rLS 3 S~ Ce~l ~ ~crl; ~'c~--~ `av~
B. EMPLOYEE AND AGENGY NOTIFICATION:
~ ' , f„~ _'~ ~.Y-` ~~ O~ V.Q~ ~~~GL` ~.¢.~ ~~lJ~ (i...~
l/`'~/L~
C. ENVIRONMENTAL RESPONSE MANAGEMENT:
S~ ~)r// ~ w ~/ 1 ~~J ~~l,`~'PiY ~~/vW~ ~/ t.(, l`l. l ~~ l
~`' ~J/
D. EMERGENCY MEDICAL PLAN:
~~-~C~ ~OS~I ~-
~~i y~ ~ $~- r i y~ ~ c ~`"'ktf '~~l s r.~s". q ~.t~ h~'-'~ ez~r "n.y :~`h ""q ~, R'~',"~ ~ . ~'.y~': t .,.iy.~is ~,y, ,, ~ , ~ x, ,:1:.?s',. ~} ~~y t ~+*x ~sy~~+q~5~~g~ k'~w.'i ~ ~P.
, : ru„.~ . :~ ~ SECTIONzI~I.2M,~~RELEASE `RESPONSE° PLAN ; ,~~~£ ~~y~~~~ ~ t ~~a~G,~~~ ;,~ ~p».~ ~:
A. HAZARD ASSESMENT AND PREVENTION MEASURES:
~ c~-'lI ~~-~~ a~~ (~1~o~fi~.a,r--~co~ ~~aL--
B. RELEASE CONTAINMENT AND/OR MITIGATION:
t~v~.a-(~ Sb,' l/ Ca,~ C~'//.-~v , ahs~t~+.~ ~volu-~~ ~` ~
~ 0 ~
C. CLEAN-UP AND RECOVERY PROCEDURES: ,~ /
~?C~ !~\/' • ~Y~SD YV-v.~-~ ~9c~~Y-'~l.
. /
FD2169 (Rev 06/07)
Page 2 of 2
~~` « ~~,'r~ ~'~~ ~r x~"~ 'r ~ "~ SECTION~'II:2"`T RELEASEx RESPONSE~ P ~LAN (CONT~)~ ~~Y °~r'~~: ~ ~~ ~ ~ ~ ~
~'x~iW~ Q ~ ,`G°~ ~~t.. ~4~'..s~r•k:~ t ~Sµk,,~'e r s'~.44E^` ,r"~~ .f~ ~ 2 ;`S'~'~ "y + v"~da j fi 4 » "~ p "~5}~.e~ l
~ ~ r , C .-'a~ a .~ 4v"t , ~~a + `k°, ~a ~. iaa . . ws ~ a • 9 M v : .dF. ``v'S: v.: .,.Fq o. 1 M._ { ,•k~:i
UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)
~
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PRNATE FIRE PROTECTION/WATER AVAILABILITY:
A. PRIVATE FIRE PROTECfION: /J t /,'~~ D w~
C.~1 ~ lN
U
B. WATER AVAILABILiTY (FIRE HYDRAN"f): ~~/~
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NUMBER OF EMPLOYEES: ~
MATERIAL SAFETY DATA SHEETS ON FILE: ~ YES ^ NO IF YES, LOCATION:
BRIEF SUMMARY OF TRAINING PROGRAM:
GL~( ~- 2cu~(,u,eey ~o-..J ~~ ~t~~~~%+tic~ s~-~f' ~ .~w ~'~'~ c~,~o~
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W~e~ ~-Iv Cev~-~c~: -~Ya,~%%.~ ~ w~-~ ~vv~- ti.~--r~ ~ .
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Based on my inquiry of those individuals responsible,for obtaining the information, I certify under penalty of law that I have personally
examined and am familiar with the information submitted and believe the information is true, accurate, and complete.
~
SIGNATURE OF OWNER/OPERATOR R DESIGNATED REPRESENTATNE
~ -~~ - an
DATE
G--z s o g
NAME OF SIGNE (PRINT) 478
~~ ~~A 3un ~~1Fl r~ 717'~E OF SIGNER 479
aw~,e o ~
FD2169 (Rev 06/07)
BAKERSFIELD FIRE DEPARTMENT
' ~~ Prevention Services
HAZARDOUS MATERIAL MANAGEMENT PLAN :°~ ~~ 1501 Truxtun Avenue, 1~ Floor
a $ R s r~ n Bakersfield, CA 93301
INSTRUCTIONS i„'; FiRe
~~ ' A~ r Phone: 661-326-3979 • Fax: 661-852-2171
CHEMICAL DESCRIPTION FORM ,°
HAZARDOUS MATERIAL INVENTORY FORM ~ Page 1 of 3
Make as many copies of the chemical description form as necessary to report your entire inventory of hazardous material. 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 ~y 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 considered 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.
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.
II. CHEMICAL INFORMATION:
Each of the instructions below corresponds to the entry Feld with the same number on the chemical description form.
205 CHEMICAL NAME - Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the
hazardous material. This should be the International Union of Pure and Applied Chemistry (IUPAC) name found on the
Material Safety Data Sheet (MSDS). NOTE: If the chemical is a mixture or a hazardous waste, do not complete this field;
complete the "common name" field instead.
206 TRADE SECRET - 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 Trede 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 "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
209 CAS - Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number
of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this
column blank and report the CAS numbers of the individual hazardous components in the section below.
210 FIRE CODE HAZARD CLASES (leave blank)
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 "Y" for yes if the hazardous material is radioactive or "N" for 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 the physical and health hazards associated with the hazardous material:
PHYSICAL HAZARDS:
1 Fire: Flammable liquids and solids, combustible liquids, pyrophorics, oxidizers
2 Reactive: Unstable reactive, organic peroxides, water reactive, radioactive
3 Pressure Release: Explosives, compressed gases, blasting agents
HEALTH HAZARDS:
4 Acute Health (Immediate): Highly toxic, toxic, irritants, sensitizers, corrosives, other hazardous chemicals with
an adverse effect with short-term exposure.
5 Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long-term
exposure.
217 ANNUAL WASTE AMOUNT - If the hazardous material being inventoried is a waste, provide an estimate of the annual
amount handled.
218 MAXIMUM DAILY AMOUNT - Enter the maximum amount of each hazardous material or mixture containing a hazardous
material, which is handled in a building or adjacent/outside area at any one time over the course of the year. This amount
must contain at a minimum last year's inventory of the material reported on this page, with the reflection of additions,
deletions, or revisions projected for the current year. This amount should be consistent with the units reported in Box 221.
219 AVERAGE DAILY AMOUNT - Calculate the average daily amount of the hazardous material or mixture containing a
hazardous material in each building or adjacent/outside area. Calculations shall be based on the previous year'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.
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. A list of common State Waste Codes is included on page 3
of these instructions.
FD2144a (Rev 06/07)
HAZARDOUS MATERIAL MANAGEMENT PLAN
INSTRUCTIONS
FOR HAZARDOUS MATERIAL INVENTORY
CHEMICAL DESCRIPTION FORM
Page 2 of 3
221 UNITS - Check the unit of ineasure that is most appropriate for the material being reported on this page: gallons, pounds,
cubic feet or tons. NOTE: If the material is a Federally-defined Extremely Hazardous Substance (EHS), all amounts must be
reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons,
pounds, cubic feet, or tons).
222 DAYS ON SITE - List the total number of days during the year that the material is on site.
223 STORAGE CONTAINER - Check 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.
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 COMPONENT i-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in
that range.
230 HA2ARDOUS COMPONENT i-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in
that range.
234 HAZARDOUS COMPONENT i-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in
that range.
238 HAZARDOUS COMPONENT 1-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in
that range.
242 HAZARDOUS COMPONENT 1-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in
that range.
227 HA2ARDOUG COMPONENT 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 i% 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.
231 HAZARDOUG COMPONENT 1-5 NAME - When reporting a hazardous material that is a mixture, list up to five chemical
names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to
manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-carcinogenic, or
0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these
percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste
mixtures, mineral and chemical composition should be listed.
235 HA2ARDOUG COMPONENT i-5 NAME - When reporting a hazardous material that is a mixture, list up to five chemical
names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to
manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-carcinogenic, or
0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these
percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste
mixtures, mineral and chemical composition should be listed.
239 HAZARDOUG COMPONENT i-5 NAME - When reporting a hazardous material that is a mixture, list up to five chemical
names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to
manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-carcinogenic, or
0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these
percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste
mixtures, mineral and chemical composition should be listed.
243 HA2ARDOUG COMPONENT 1-5 NAME - When reporting a hazardous material that is a mixture, list up to five chemical
names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to
manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-carcinogenic, or
0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these
percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste
mixtures, mineral and chemical composition should be listed.
228 HAZARDOUS COMPONENT 1-5 EHS - 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.
232 HA2ARDOUS COMPONENT 1-5 EHS - 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.
236 HAZARDOUS COMPONENT 1-5 EHS - 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.
240 HAZARDOUS COMPONENT i-5 EHS - 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.
244 HAZARDOUS COMPONENT 1-5 EHS - 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.
229 HAZARDOUS COMPONENT 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous
components in the mixture.
233 HA2ARDOUS COMPONENT 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous
components in the mixture.
237 HAZARDOUS COMPONENT 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous
components in the mixture.
241 HA2ARDOUS COMPONENT i-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous
components in the mixture.
245 HAZARDOUS COMPONENT 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hatardous
components in the mixture.
III. SIGNATURE
246 SIGNATURE - Print name, title, sign, and date each chemical description form.
CALIFORNIA WASTE CODES
Code Descrj~jQn
Inorganics
111 Acid solution 2< pH < 7 with metals (antimony,
arsenic, barium, beryllium, cadmium, chromium,
cobalt, copper, lead, mercury, molybdenum, nickel,
selenium, silver, thallium, vanadium, and zinc)
112 Acid solution without metals
113 Unspecified acid solution
121 Alkaline solution pH >12.5 with metals (see 111)
122 Alkaline solution without metals
123 Unspecified alkaline solution
131 Aqueous solution (2 < pH < 12.5) containing reactive
Anions. (azide, bromate, chlorate, cyanide, fluoride,
hypochlorite, nitrite, perchlorate and sulfide anions)
132 Aqueous solution with metals (see ili)
133 Aqueous solution with total organic residues 100% or
more
134 Aqueous solution with total organic residues < 10%
135 Unspecified aqueous solution
141 Off-spec, aged, or surplus inorganics
151 Asbestos containing waste
161 FCC Waste
162 Otherspentcatalyst
171 Metal sludge (see 111)
172 Metal dust and machining waste (see 111)
181 Other inorganic solid waste
Code Descri tn ion
Organics (cont)
261 PCB and material containing PCB
271 Organic monomer waste (includes unreacted resins)
272 Polymeric resin waste
281 Adhesives
291 Latex waste
311 Pharmaceutical waste
321 Sewage sludge
322 Biological waste other than sewage sludge
331 Off-spec, aged or surplus organics
341 Organic liquids (non-solvents) with halogens
343 Unspecified organic liquid mixture
351 Organic solids with halogens
Sludge
411 Alum and gypsum sludge
421 Lime sludge
431 Phosphate sludge
441 Sulfur sludge
451 Degreasing sludge
461 Paint sludge
471 Paper sludge/pulp
481 Tetraethyl lead sludge
491 Unspecified sludge waste
Organics
211 Halogenated solvents (methylene chloride, chloroform,
TCE, TCA)
212 Oxygenated solvents (acetone, butanol, MEK)
213 Hydrocarbon solvents (Stoddard solvent, xylene)
214 Unspecified solvent mixture
221 Waste oil and mixed oil
222 Oil/water separation sludge
223 Unspecified oil - containing waste
231 Pesticide rinse water
232 Pesticide and other waste associated with pesticide
production
241 Tank bottom waste
251 Still bottoms with halogenated organics
252 Other still bottom waste
Miscellaneous
511 Empty pesticide containers 30 gal or more
512 Other empty container 30 gal or more
513 Empty containers less than 30 gal
521 Drilling mud
531 Chemical toilet waste
541 Photo chemical/photo processing waste
551 Laboratory waste chemicals
561 Detergent and soap
571 Fly ash, bottom ash, and retort ash
581 Gas scrubber waste
591 Bag house waste
611 Contaminated soil from site clean-ups
612 Household wastes
Page 3 of 3 FD2144a (Rev 06/07)
HAZARDOUS MATERIAL MANAGEMENT PLAN r~
CHEMICAL DESCRIPTION FORM `~
HAZARDOUS MATERIAL INVENTORY ~~`
~ NEW ^ ADD ^ DELETE ^ REVISE zoa
B fl R S P 1 D
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A~ T
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1~ Floor
Bakersfield, CA 93301
Phone:661-326-3979 . Fax: 661-852-2171
Page 1 of 2
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If sub~ect to EPCRA, refer to instruttlons
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FIRE CODE HAZARD CLASSES (complete if requested by local fire chie~ 210
7YPE ~ 211
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~DIOACTIVE: ^ Yes OtiNo CURIES 213
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PHYSICAL STATE ^ SOLID 0
LIQUID ^ GAS 21a L
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FED HAZARD CATEGORIES q;~ FIRE REACTIVE PRESSURE RELEASE ^ ACUTE HEALT}i ^ CHRONIC HEALTN
(Check all that apply)
ANNUAL WASTE i
AMOUNT '( ~ Z17
~ MAXIMUM Zlg
DAILY AMOUNT r~ 7~ n ~' AVERAGE 219
DAILY AMOUNT STATE WASTE 220
CODE
l/ t \~ V 1,` (
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^ UNITS~ GAL ^ CU FT ~ LBS 0 TONS ~~ ~~~~ •
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STORAGE CONTAINER: ZZ
^ ABOVEGROUND TANK ^ CAN ^ BOX ^ TANK WAGON
~ UNDERGROUND TANK ^ CARBOY ^ CYLINDER 0 RAIL CAR
^ TANKINSIDE BUILDING 0 SIlO ^ GLASS BOTTLE ^ OTHER
^ STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ^ TOTE BIN
0 PLASTIC/NONMETALLIC DRUM ^ BAG
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STORAGE PRESSURE: AMBIENT ^ ABOVE AMBIENT 0 BEIOW AMBIENT
225
STORAGETEMPERA7URE: AMBIENT 0 ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC
%WT HAZARDOUS COMPONENT EHS CAS #
1 226 ~.2 K 227 ^ YES ^ NO 228 229
Z 230 231 ^ Yes ^ No 232 233
3 234 ( .2 235 ^ Yes ^ No 236 237
4 238 ' 239 ^ Yes ^ No 2a0 2a1
5 Z4Z 2a3 ^ Yes ^ No 244 2a5
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FD2144(Rev 06/07)
Hazardous Material Inventory - Chemical Description
You must complete a separate Hazardous Material Inventory - Chemical Description page for each hazardous mater~al (hazardous substances and
hazardous waste) that you handle at your facility tn 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 material at your facility, reported separately for each butlding or
outside adjacent area, with separate pages for unique occurrences of physical state, storage temperature and storage pressure. (NOTE: the numbering of
the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are
the same as the numbering used in 27 CCR, Appendix C, and Business Section of the Unified Program Data Dictionary. Please number all pages of your
submittal. This helps your CUPA or AA identtfy whether the submittal is complete and if any pages are separated.
i FACILITY ID NUMBER - This number Is assigned by the CUPA or AA. This is the unique number which identifies your facility.
3 BUSINESS NAME - Enter the full legal name of the business.
200 ADD/DELETE/REVISE - Indicate if the material is being added to the inventory, deleted from the inventory, or if the information previously
submitted Is being revlsed. NOTE: You may choose to leave this blank tf you resubmit your entire inventory annually.
201 CHEMiCAL LOCATION - Enter the bullding or outside/adjacent area where the hazardous material is handled. A chemtcal that is stored at the same
pressure and tempereture, in multiple locatlons within a building, can be reported on a single page. NOTE: This information is not sub~ect 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 locatlon Information
confldential 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
appllcable, multiple grid coordinates can be listed.
205 CNEMICAL NAME - Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous materlal. This
should be the Intematlonal Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: If the
chemical Is a mixture, do not complete this Fleld; complete the "COMMON NAME" fieid instead.
206 TRADE SECRET - Check yes if the Informatton in this section is declared a trade secret or no if it is not. State requirement: If yes, and business is
not sub~ect to EPCRA, disclosure of the designated trade secret information is bound by HSC §25511. Federal requirement: If yes, and business Is
sub~ect to EPCRA, disclosure of the designated Trade Secret information is bound by 40 CFR and the business must submit a Substantiation to
Accompany Claims of Trade Secrecy form (40 CFR 350.27) to USEPA.
207 COMMON NAME - Enter the common name or trade name of the hazardous material or mixture contatning a hazardous material.
208 EHS - Check yes if the hazardous material is an Extremely Hazardous Substance (EHS), as deflned in 40 CFR, Part 355, Appendix A. If the materlal
Is a mixture contalning an EHS, leave this section blank and complete the section on hazardous components below.
209 CAS #- Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has
been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of
the Individual hazardous components in the appropriate section below.
210 FIRE CODE HAZARD CLASSES - Describes to flrst responders the type and level of hazardous material which a business handles. This information
shall only be provided if the local fire chief deems it necessary and requests the CUPA or AA to collect it. A Iist of the hazard classes and instructions
on how to determine which class a material falls under are included in the appendices of Article 80 of the Uniform Fire Code. If a material has more
than one applicable hazard class, include all. Contad 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 thts area to report the activity in curies. You may use up to nine digits with a floating decimal
polnt to report acCivity 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 LARGES7 CONTAINER - Enter the total capacity of the largest container in which the material is stored.
216 FEDERAL HAZARD CATEGORIES - Check ali categories that describe the physical and health hazards associated with the hazardous material.
217 AVERAGE DAILY AMOUNT - Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each
building or adJacent/outside area. Calculations shall be based on the previous year inventory of material reported on this page. Total all daily
amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this locatlon, the
amount shall be the average daily amount you proJect to be on hand during the course of the year. This amount should be consistent with the units
reported In Box 221 and should not exceed that of maximum daily amount.
218 MAXIMUM DAILY AMOUNT - Enter the maximum amount of each hazardous material or mixture contatning a hazardous material, which is handled
in a building or adjacent/outside area at any one time over the course of the year. This amount must contain at a minimum last year's inventory of
the material reported on this page, with the reflection of additions, deletions, or revisions projected for the current year. This amount should be
consistent with the units reported in Box 221.
219 ANNUAL WASTE AMOUNT - If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled.
220 STATE WASTE CODE - If the hazardous material is a waste, enter the appropriate Califomia 3-digit hazardous waste code as listed on the back of
the Uniform Hazardous Waste Manifest.
221 UNITS - Check the unit of ineasure that is most appropriate for the material befng reported on this page: gallons, pounds, cubic feet, or tons.
NOTE: If the materlal is a federally deftned Extremely Hazardous Substance (EFiS), all amounts must be reported in pounds. If material is a mtxture
containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons).
222 DAYS ON SITE - List the total number of days during the year that the material is on site.
223 STORAGE CONTAINER - Check the one box that best describes the type of storage container in which the hazardous material is stored.
224 STORAGE PRESSURE - Check the one box that best describes the pressure at which the hazardous material is stored.
225 STORAGE TEMPERATURE - Check the one box that best describes the temperature at which the hazardous material is stored.
226 HAZARDOUS COMPONENTS i-5 (% BY WEIGHT) - Enter the percentage weight of the hazardous component in a mixture. If a range of
percentages is avallable, report the highest percentage in that range. (Report for components 2 through 5 in 230, 234, 238, and 242.)
227 HAZARDOUS COMPONENTS i-5 NAME - When reporting a hazardous material that is a mixture, list up to five chemtcal names of hazardous
components In that mixture by percent weight (refer to MSDS or, tn 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 Flve
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 Iisted. (Report for components 2 through 5 in 231, 235, 239, and 243.)
228 HAZARDOUS COMPONEN7'S 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 colled any additional information necessary to meet the
requirements of thelr Individual programs. Contact the CUPA or AA for guidance.
Page 2 of 2 FD2144 (rtev o6/0~)
HAZARDOUS MATERIAL MANAGEMENT PLAN ~
~ x .. a ;,,~ -----.~^^~
BUSINESS ACTIVITIES PAGE
(HAZARDOUS MATERIAL FACILITY INFORMATION) ~
Page 1 of 1
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DOES Your Facility... if Yes, Piease Complete... lz9
A. FIAZARDOUS MATERIAL ^ Yes ~No • CHEMICAL DESCRIPTION FORM i3o
1. Have on site (for any purpose) hazardous material • HAZARDOUS MATERIAL MANAGEMENT PLAN
dt or above 55 gallons for liquids, 500 pounds for Minimum renuired la~g elements:
solids, or 200 cu. ft. for compressed gases (include • Emergency Response Plan
Ilquids In AST and UST)? • Maps
• Training
• Prevention
• Certiflcation
B. REGl1LATED SUBSTANCES (RS) ^ Yes No . CHEMICAL DESCRIPTION FORM 131
1. Have on site RS at greater than the threshold • RISK MANAGEMENT PLAN (RMP Submit to USEPA)
planning quantities established by the California • CONSOLIDATED COMPLIANCE PLAN
Accidental Release Prevention program (CaIARP)? • Incorporating CaIARP Program Elements
C. llNDERGROUND STORAGE TANKS (USTI Yes ^ No • UST FACILITY FORM i32
1. Own or operate Underground Storage Tanks? • UST TANK FORM (one per tank)
Y~ No
~ ' UST FACILIIY FORM 133
2. Intend to u rade existin or install new UST?
P9 9 • UST TANK FORM (one per tank)
• UST INSTA~LATION FORM (one per tank)
D. TANK CLOSURE/REMAVAL ^ YeS~NO • UST TANK FORM (Closure sectlon - one per tank)
1. Need to report closing an UST that held hazardous
materlal or waste?
2. Need to report the closure/removal of a tank that ^ Yes ~NO • UST TANK CLOSURE FORM
was classifted as hazardous waste and cleaned
onsite?
E. ABOVEGR~UND PETROLEUM STORAGE TANKS ~ Yes ^ No • HAZARDOUS MATERIAL MANAGEMENT PLAN
[ASTI • Incorporeting Federal Spill Rrevention Control and Countermeasure
1. Own or operate AST above these thresholds; any (SPCC) Elements pursuant to 40 CFR Part 112.
tank capacity Is greater than 660 gallons or the
total capacity for the facility is greater than 1,320
gallons?
F. HA2ARDOUS WASTE EPA ID NUMBER - provide on this page
1. Generate hazardous waste7 ~ves ^ rvo . To obtain EPA ID Number, please phone (916) 324-1781
2. Recycle more than 100 kg/mo of recyclable ^ ves~rvo . RECYCLING FORM
material at the same location it was genereted?
3. Recycle more than 100 kg/mo of recyclable ^ Yes~PyNO . RECYCLING FORM
materlal at an off-site location different from the
polnt of generation?
4. Treat Hazardous Waste on site? ves ^ No . TP FACILITY FORM
• TP UNIT FORM (one per unit)
5. Sub]ect to Flnancial Assurance requirements? ~.ves ^ rvo . CERTIFICATION OF FINANCIAL ASSURANCE
6. Consolidate Hazardous Waste generated at a ^ ves ~jrvo . REMOTE WASTE/CONSOLIDATION SITE NOTIFICATION
remote site? FORM
NOTE: If you checked YES to any part of Sections IIA - IIF above, then in addition to the forms requested above, please submit
BUSINESS OWNER/OPERATOR IDENTIFICATION FORM.
~~ BAKERSFIELD FIRE DEPARTMENT
~~ Prevention Services
a a R s r t n 1501 Truxtun Avenue, 1~` Floor
FIRE Bakersfield, CA 93301
~ AR1M t Phone: 661-326-3979 • Fax: 661-852-2171
FD2143 (Rev 06/07)
t4
..,
HAZARDOUS MATERIAL MANAGEMENT PLAN :~
r. o ~~' U.
,"~
INSTRUCTIONS
SITE & FACILITY DIAGRAM
8 B R S F I D
F/R6
~~ r
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1~` Floor ~
Bakersfield, CA 93301
Phone:661-326-3979 • Fax: 661-852-2171
Page 1 of 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 an 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'/zxll-inch 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 HMMP, on the top of the diagram.
3. Label the location of the hazardous material and identify them by name and type of hazard (flammable
liquid, corrosive solid).
4. Label the location of utility shut-ofF 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 HMMP. 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 of the UST continuous leak monitoring
system and/or the location where the UST monitoring will be performed.
FD2170 (Rev 06/07)
, a
~,_
HAZARDOUS MATERIAL MANAGEMENT PLAN ~`
f ~T {
SITE & FACILITY DIAGRAM
B B R S A I D
PIR6
o ~Rrr ~
~
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1~ Floor
Bakersfield, CA 93301
Phone:661-326-3979 • Fax: 661-852-2171
Page 2 of 2
L ~ SITE DIAGRAM FACILITY DIAGRAM
Business Name:
Business Address:
NORTH
Please indicate direction of North
, State uf California For Ststa Usa Only
State uf Wate~ Resources Control k3oarci
Division uf Financial Assistance
P.O. E3or 9A4212
Sacramcntu, CA 942Jd-212Q
(Instructions un reverse side)
CERTIFICATION OF FINANCIAL RESPONSIBILITY
FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM
A. l am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807, Chapter 18, Div. 3, Tide 23, CCR:
~ 500,000 dollars per occurrence ~ I million dollars annual aggregate
or AND or
~ I million dollan per occurrence ~ 2 million dollars annual aggregate
s. R lJ D ly fl N ~-Yl~ hereby certifies that it is in compliance with the ~equirements of Section 2807,
~
(Neme ol Tenk Owner a Opereto~
ARicle 3, Chapter 18, Division 3, Tit/e 23, Califomia Code of Regulations.
The mechanisms used to demonstrate financial rosponsi6ility as iequired by Sec6on 2807 are as follows:
C. Mechanism
T Mechanism Coverage Coverage Corrective Third Party
e Name and Address of Issuer Number Amount Period Adion Com
S~-~e._.. U S-f 5~~ U S~ C~• ~
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Note: I/ you are using the State Fund as any paR o/ your demonstration of Tnancia! responsibility, your execution and submission of
this certification also certifies that you are in compliance with all conditions for participation in the Fund.
D. Facilily Name ~~~~ (~AS ~ h,.~~„~ ,~,~a~ Facility Address ~2~1 ~~ ~
~
~~-ks-`~~-~(~ ~-~' ~~\~
Facility Name Facility Address
Facility Name Facility Address
E. Signat re of Tank Owner or Operator Date
~ Name and Title of Tank Owner or Operator O~ N~,~ )
~=~' 6-2 S ~ ~ '~`M ~"~W ~ U ~\~~-1'r~ ~l
D ~-~
Signature of Witness or Notary Date Name of Wilness or Notary
~-~5- ~ 8
~rn ~ncvisca uqiy~~ N"lL~: Urlglnal - Local Agency " Coples - Facllity/Site(s)
. TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer ~ocation: 7-ELEVEN #17721, MKT 2368, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifier Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Location: Around Tanks
Rectffier Manufatctured by : universal Model: SSP Serial Number: 961891
Rectifier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectiffer DC Output: 50.0 volts 10.0 amps ~ Shunt: 50 mv 10.0 amps
Installation date:
Comments:
CP operating properly: Yes
F ~+,~e,
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4 •
5
8
7
8
•9
10
11
12
13'
14
15
W.O. 1305699 Technician: CPTECH
TANKNOLOGY .,
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Locatlon: 7-ELEVEN #17721, MKT 2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifler Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface ~ Location: Around Tanks
Rectifier Manufatctured by: universal Model: SSP Serial Number: 961891
Rectifier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifler DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amp~
Instailation date:
Comments:
W.O. 1304979 Technician: CPTECH
TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MKT 2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Locatlon of Rectifler Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface ~ocation: Around Tanks
Rectifier Manufatctured by : universal Model: SSP Serlal Number: 961891
Rectifier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifler DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments:
W.O. 1305333 Technician: CPTECH
TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MKT 2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifier Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Locatlon: Around Tanks
Rectifler Manufatctured by : universal Model: SSP Serial Number: 961891
Rectifler AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifler DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments:
CP operating properly: Yes
~
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~ I
~
; Settln
w~
p: a~ ,a
4~ 1'1.20: 2.64 .08/01/07 ARC I
2 11.20 2.67 07/01L07 ARC'
3
4
5
6
7
•B
9
10
11
12
13
14'
15 .
W.O. 1304222 Technician: CPTECH
TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MKT 2133. 3601 STOCKOALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifler Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit: •
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Location: Around Tanks
Rectifler Manufatctured by : universal Model: SSP Serial Number: 961891
Rectifler AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifler DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments: '
W.O. 1304632 Technician: CPTECH
TANKNOLOGY '
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MKT 2133, 3601 STOCKDALE HIGHWAY, BAKERSFfELD CA 93309
Location of Rectiffer Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Location: Around Tanks
Rectifler Manufatctured by : universal ' Model: SSP Serial Number: 961891
Rectifler AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifier DC Output: 50.0 volts • 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments:
CP operating properly: Yes
~, ~~ CC ~O" u~t ~DG~ ut ~ ~.`"
1 11.20 2.28 05J01l07 ARC
2 10.80' 2.40 OS/~1/07 ARG`
3
4
5
6
7
8
9
10
11
12
13
14
1S
W.O. 1303863 Technician: CPTECH
TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MKT 2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifier Unit: ABOVE DOOR IN STOREROOM
Type of Rectifler Unlt:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Locatlon: Around Tanks
Rectifier Manufatctured by: universal Model: SSP Serial Number: 961891
Rectlfier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifier DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments:
CP operating properly: Yes
~~ '~~, .°,~ ~~~ ~~CYO~utput'OCOutpul D~ Ra"coMid
': 3, 4: w Dy Romarks
1 11.20 2.24 04%01/07 ARC:
2
3
4
5
6
7
8
9
10
11
12'
13
14
15
W.O. 1303589 Technician: CPTECH
TANKNOLOGY ~ ~
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MARKET #2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Locatfon of Rectifler Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface ~ Location: Around Tanks
Rectifier Manufatctured by : universal Model: SSP Serial Number: 961891
Rectifler AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifier DC Output: 50.0 votts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments:
W.O. 3151384 Technician: TIMOTHY COULTER
TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Locatlon: 7-ELEVEN #17721, MARKET #2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifier Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Location: Around Tanks
Rectifier Manufatctured by : universal Model: SSP Serial Number: 961891
Rectifier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifler DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments:
CP operatfng properly: Yes
f_'~~ ~ . , ~J
~ 4 E1 ' R@ .
1 9.00 0.80 01104f07 TCOULTER
2 ,
3
4
5
6
7
8
9. .
10
11
12 _
1.3
14
15. .
W.O. 3150343 Technician: TIMOTHY COULTER
TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MARKET #2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
L'ocation of Rectifler Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode: •
Type of Ground Bed: Distributed Surface Location: Around Tanks
Rectifler Manufatctured by: universal Model: SSP Serial Number: 961891
Rectifier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectlfler DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments:
CP operating properly: Yes
' ~~ ",~,~~
~a ;
Satlin IDC Ou$i -
volts ~ Q - - ~ •~.~. .~
!~y
Rema~ics
1 8.27 1.00 11 /151~ SGALLARD
2
3
4
'5
8
7
8
•9
10
11 , . _ __
12
13
14
15
W.O. 3149572 Technician: STEVEN GALLARDO
TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MARKET #2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifier Unit: ABOVE DOOR IN STOREROOM
Type oi Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Locatlon: Around Tanks
Rectifier Manufatctured by: universal Model: SSP Serial Number: 961891
Rectifier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifler DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments:
CP operating properly: Yes
~ , ~~ , ~ +~^ ~~`~ ~:~~,,~ ~+ D~ Oiifput `OCYOtitpu'f -"~,5,?~~, "~ -° • , ~
~ ~'~ ~'_ 'Settlrepi' volq ~mps~' ~f~r Ramarlcs
~?~r~~ ~.;~ C~
1 8.30 1.26 07/26/06 sg
2
3
a
5
8
7 .
;8
~9
10
11
12
13 ~
14
15
W.O. 3147771 Technician: STEVEN GALLARDO
TANKNOLOGY
CATHODIC PROTECTION. RECTIFIER MAINTENANCE
Customer Locatfon: 7-ELEVEN #17721, MARKET #2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifier Unit: ABOVE DOOR IN STOREROOM
Type of Rectifier Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Location: Around Tanks
Rectifier Manufatctured by: universal Model: SSP Serial Number: 961891
Rectifier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifier DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installatlon date:
Comments:
CP operating properly: Yes
«"~ , ~ : ~D~i Q~ rQ~'~+~Y~ ~
' ~~ , S tbn~ ~a br ~
r s. ~ 0 1.2Q -08%09106'~ AE
2
3
4
5
6
7
8
9
10
11 .
i ~2
13
14 .
15
W.O. 3147064 Technician: ALEX ESKANDARIAN
TANKNOLOGY
CATHODIC PROTECTION RECTIFIER MAINTENANCE
Customer Location: 7-ELEVEN #17721, MARKET #2133, 3601 STOCKDALE HIGHWAY, BAKERSFIELD CA 93309
Location of Rectifier Unit: ABOVE DOOR IN STOREROOM
Type of Rectifler Unit:
Number of Anodes: Unknown Type of Anode:
Type of Ground Bed: Distributed Surface Location: Around Tanks
Rectifier Manufatctured by: universal Model: SSP Serial Number: 961891
Rectifier AC Input: 115 volts 6.2 amps 1 phase 60 Hz
Rectifier DC Output: 50.0 volts 10.0 amps Shunt: 50 mv 10.0 amps
Installation date:
Comments: