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Home My WebLink About6401 H ST (2) IIIIIII VIII III IIII 31 IE UNIFIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS ACTIVITIES Page 1 of 1. FACILITY IDENTIFICATION FACILITY ID I I I I I I I , I I EPA ID#(Hazardous Waste Only) z (Agency Use Only) BUSINESS NAME(Same as Facility Name of DBA-Doing Business As) -0,0602 3 BUSINESS SITE ADDRESS 103 BUSINESS SITE CITY , tat CA ZIP COD II.ACTIVITIES DECLARATION NOTE: If you check YES to any part of this list, lease submit the Business Owner/Operator Identification page. Does your facility... tf Yes,please corn lete these pages of the UPCF.... A. HAZARDOUS MATERIALS Have on site(for any purpose)at any one time,hazardous materials at or above HAZARDOUS MATERIALS 55 gallons for liquids,500 pounds for solids,or 200 cubic feet for compressed ®yES ❑ NO 4 INVENTORY—CHEMICAL gases(include liquids in ASTs and USTs);or the applicable Federal threshold DESCRIPTION quantity for an extremely hazardous substance specified in 40 CFR Part 355, Appendix A or B;or handle radiological materials in quantities for which an emergency lan is required pursuant to 10 CFR Parts 30,40 or 70? B. REGULATED SUBSTANCES Have Regulated Substances stored onsite in quantities greater than the threshold quantities established by the California Accidental Release ❑YES 9'NO as Coordinate with your local agency prevention Program(CalARP)? responsible for CalARP. C.UNDERGROUND STORAGE TANKS(USTs) UST FACILITY(Formerly SWRCB Form A) Own or operate underground storage tanks? NfYES ❑ NO 5 UST TANK(one page per tank)(Formerly Form B) D. ABOVE GROUND PETROLEUM STORAGE Own or operate ASTs above these thresholds: Store greater than 1,320 gallons of petroleum products(new or used)in ❑YES WINO a NO FORM REQUIRED TO CUPAs aboveground tanks or containers. E.HAZARDOUS WASTE Generate hazardous waste? ❑YES ( NO 9 EPA ID NUMBER—provide at the top of this page Recycle more than 100 kg/month of excluded or exempted recyclable M' NO(per HSC 25143.2)? E]YES MNO r0 RECYCLABLE MATERIALS REPORT (ore per recycler) Treat hazardous waste on-site? ❑YES NrNO I I ON-SITE HAZARDOUS WASTE TREATMENT—FACILITY ON-SITE HAZARDOUS WASTE TREATMENT—UNIT (one page per unit) Treatment subject to financial assurance requirements(for Permit by Rule and Conditional Authorization)? C3 N YES O ,Z CERTIFICATION OF FINANCIAL ASSURANCE Consolidate hazardous waste generated at a remote site? REMOTE WASTE/CONSOLIDATION [I YES (�NO 13 SITE ANNUAL NOTIFICATION Need to report the closure/removal of a tank that was classified as �/ hazardous waste and cleaned on-site? El YES m NO Ir HAZARDOUS WASTE TANK CLOSURE CERTIFICATION Generate in any single calendar month 1,000 kilograms(kg)(2,200 pounds)or � Obtain federal EPA ID Number,file R more of federal RCRA hazardous waste,or generate in any single calendar ❑YES NO Biennial Report(EPA Form 8700- month,or accumulate at any time, 1 kg(2.2 pounds)of RCRA acute hazardous 13A/B),and satisfy requirements for waste;or generate or accumulate at any time more than 100 kg(220 pounds)of RCRA Large Quantity Generator. spill cleanup materials contaminated with RCRA acute hazardous waste. Household Hazardous Waste(HHW)Collection site? �t1p/ ❑YES NO lab See CUPA for required forms. F. LOCAL REQUIREMENTS 's (You may also be required to provide additional information by your CUPA or local agency.) UPCF Rev,(1212007) IIIIIIIIIIIII III IIII 32 IE Business Activities Please submit the Business Activities page,the Business OwnerlOperator Identification page,and Hazardous Materials Inventory-Chemical Description pages for all submissions. (Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form(UPCF)pages. These data element numbers are used for electronic submission and are the same as the numbering used in Division 3,Electronic Submittal of Information). Please number all pages of your submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER-Leave this blank. This number is assigned by the Certified Unified Program Agency(CUPA)or Administering Agency(AA). This is the unique number which identifies your facility. 2. EPA ID NUMBER-If you generate,recycle,or treat hazardous waste,enter your facility's 12-character U.S.Environmental Protection Agency(U.S.EPA)or Califomia Identification number. For facilities in California,the number usually starts with the letters-I CAF-i. If you do not have a number,contact the Department of Toxic Substances Control(DTSC)Telephone Information Center at(916)324-1781,(800)-61-TOXIC or(800)61-86942,to obtain one. 3. BUSINESS NAME-Enter the full legal name of the business. This is the same as the terms rFacility Namen or-IDBA-Doing Business Asn that might have been used in the past. 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. BUSINESS SITE 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. 4. HAZARDOUS MATERIALS— Check the box to indicate whether you have a hazardous material onsite. You have a hazardous material onsite if: It is handled in quantities equal to or greater than 500 pounds,55 gallons,or 200 cubic feet of compressed gas (calculated at standard temperature and pressure), It is handled in quantities equal to or greater than the applicable federal threshold planning quantity for an extremely hazardous substance listed in 40 CFR Part 355,Appendix A, Radioactive materials are handled in quantities for which an emergency plan is required to be adopted pursuant to Part 30,Part 40,or Part 70 of Chapter 10 of 10 CFR,or pursuant to any regulations adopted by the state in accordance with these regulations. If you have a hazardous material onsite,then you must complete the Business Owner/Operator Identification page and the Hazardous Materials Inventory- Chemical Description page,as well as an Emergency Response Plan and Training Plan.. Do not answer DYES❑to this question if you exceed only a local threshold,but do not exceed the state threshold. 4a.REGULATED SUBSTANCES—Refer to 19 CCR 2770.5 for regulated substances. Check the box to indicate whether your facility has CaIARP regulated substances stored onsite. 5. OWN OR OPERATE UNDERGROUND STORAGE TANK(UST)-Check the appropriate box to indicate whether you own or operate USTs containing hazardous substances as defined in Health and Safety Code(HSC125316. If C YES 0,then you must complete one UST Facility page and UST Tank pages for each tank. You must also submit a plot plan and a monitoring program plan. 8. OWN OR OPERATE ABOVEGROUND PETROLEUM STORAGE TANK OR CONTAINER-Check the appropriate box to indicate whether there are ASTs onsite which exceed the regulatory thresholds. (There is no UPCF page for ASTs.) This program applies to all facilities storing petroleum in aboveground tanks. Petroleum means crude oil,or any fraction thereof,which is liquid at 60 degrees Fahrenheit temperature and 14.7 pounds per square inch absolute pressure (HSC 25270.2(g)). The facility must have a cumulative storage capacity greater than 1,320 gallons for all ASTs. NOT Subject to the Act (exemptions): An aboveground petroleum storage tank(AST)facility with one or more of the following(see HSC 25270.2(k))is not subject to this act and is exempt: A pressure vessel or boiler which is subject to Division 5 of the labor Code, A storage tank containing hazardous waste if a hazardous waste facility permit has been issued for the storage tank by DTSC, An aboveground oil production tank which is regulated by the Division of Oil and Gas, Certain oil-filled electrical equipment including but not limited to transformers,circuit breakers,or capacitors. 9. HAZARDOUS WASTE GENERATOR-Check the appropriate box to indicate whether your facility generates hazardous waste. A generator is the person or business whose acts or processes produce a hazardous waste or who causes a hazardous substance or waste to become subject to State hazardous waste law. If your facility generates hazardous waste,you must obtain and use an EPA Identification number(ID)in order to property transport and dispose of it. Report your EPA ID number in tf2. Hazardous waste means a waste that meets any of the criteria for the identification of a hazardous waste adopted by DTSC pursuant to HSC 25141. "Hazardous waste"includes,but is not limited to,federally regulated hazardous waste. Federal hazardous waste law is known as the Resource Conservation and Recovery Act(RCRA). Unless explicitly stated otherwise,the term"hazardous waste"also includes extremely hazardous waste and acutely hazardous waste. 10.RECYCLE-Check the appropriate box to indicate whether you recycle more then 100 kilograms per month of recyclable material under a claim that the material is excluded or exempt per HSC 25143.2. Check OYESO and complete the Recyclable Materials Report pages,if you either recycled onsite or recycled excluded recyclable materials which were generated onsite. Check ONO❑if you only send recyclable materials to an offsite recycler. You do not need to report. 11.ONSITE HAZARDOUS WASTE TREATMENT-Check the appropriate box to indicate whether your facility engages in onsite treatment of hazardous waste. 'Treatment"means any method,technique,or process which is designed to change the physical,chemical,or biological character or composition of any hazardous waste or any material contained therein,or removes or reduces its harmful properties or characteristics for any purpose. 'Treatment"does not include the removal of residues from manufacturing process equipment for the purposes of cleaning that equipment. Amendments(effective 111/99)add exemptions from the definition of Ctreatment7 for certain processes under specific,limited conditions. Refer to HSC 25123.5(b)for these specific exemptions. Treatment of certain laboratory hazardous wastes de not require authorization. Refer to HSC 25200.3.1 for specific information. Please contact your CUPA to determine if any exemptions apply to your facility. If your facility engages in onsite treatment of hazardous waste then complete the Onsite Hazardous Waste Treatment Notification-Facility page and one set of Onsite Hazardous Waste Treatment Notification-Unit pages with waste and treatment process information for each unit. 12.FINANCIAL ASSURANCE-Check the appropriate box to indicate whether your facility is subject to financial assurance requirements for closure of an onsite treatment unit. Unless they are exempt, Permit by Rule (PBR) and Conditionally Authorized (CA) operations are required to provide financial assurance for closure costs(per 22 CCR,67450.13(b) and HSC,25245.4). If your facility is subject to financial assurance requirements or claiming an exemption, then complete the Certification of Financial Assurance page. 13.REMOTE WASTE CONSOLIDATION SITE-Check the appropriate box to indicate whether your facility consolidates hazardous waste generated at a remote site. Answer CYESC if you are a hazardous waste generator that collects hazardous waste initially at remote sites and subsequently transports the hazardous waste to a consolidation site you also operate. You must be eligible pursuant to the conditions in HSC 25110.10. If your facility consolidates hazardous waste generated at a remote site,then complete the Remote Waste Consolidation Site Annual Notification page. 14.HAZARDOUS WASTE TANK CLOSURE-Check the appropriate box to indicate whether the tank being dosed would be classified as hazardous waste after its contents are removed. Classification could be based on: Your knowledge of the tank and its contents The mixture rule Testing of the tank The listed wastes in 40 CFR 261.31 or 40 CFR 261.32. Inability to remove hazardous materials stored in the tank If the tank being closed would be classified as hazardous waste after its contents are removed,then you must complete the Hazardous Waste Tank Closure Certification page. 14a.RCRA LOG-Check the appropriate box to indicate whether your facility is a Large Quantity Generator. If YES,you must have or obtain a US EPA ID Number. 14b.HOUSEHOLD HAZARDOUS WASTE COLLECTION-Check the appropriate box to indicate whether your facility is a HHW Collection site. 15.LOCAL REQUIREMENTS-Some CUPAs or AAs may require additional information. Check with your CUPA before submitting the UPCF to determine if any supplemental information is required. UPCF Rev.(1212007) UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY-CHEMICAL DESCRIPTION (one vaRe Per nmteriW Per building or area) ❑ADD ❑DELETE ❑REVISE 200 Page—of- I. FACILITY INFORMATION BUSINESS NAME(Same as FACILITY NA E or DBA-Doing Business As) 3 �w CHEMICAL LODCATION 201 CHEMICAL�gC ATION CONFIDENTIAL EPCRA 202 ❑ YES ff-NO 17-rAPI(upuorai) 203 GRID#(optional) 204 FACILITY ID# II. CHEMICAL INFORMATION MICAL NAME 205 TRADE SECRET Yes No 206 If Subject to EPCRA,refer to instructions COMMO AME 207 208 EHS* ❑ Yes ( No CAS# 209 *If EHS is"Yes",all amounts below must be in lbs. FIRE CODE HAZARD CLASSES(Complete if required b.CUPA) 210 2l3 HAZARDOUS MATERIAL _� 211 RADIOACTIVE ❑Yes No 212 CURIES TYPE(Check one item only) ❑a PURE b.MIXTURE ❑c.WASTE PHYSICAL STATE 214 LARGEST CONTAINER 215 (Check one item only) ❑ a SOLID LIQUID ❑ c.GAS FED HAZARD CATEGORIES �.,� 216 (Check all that apply) �FIRE ❑b. REACTIVE ❑ c.PRESSURE RELEASE ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT zn MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 J 221 DAYS ON SITE: 222 UNITS•ec a M GALLONS ❑b. CUBIC FEET ❑ c.POUNDS ❑d.TONS 315 Chk one item only) •If EHS,arnount must be in pounds. STORAGE CONTAINER �a.ABOVE GROUND TANK ❑e.PLASTIC/NONMETALLIC DRUM ❑ i.FIBER DRUM ❑m GLASS BOTTLE ❑ q.RAIL CAR 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 ❑It.SILO ❑ I. CYLINDER ❑p. TANK WAGON 223 STORAGE PRESSURE Va. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# 1 226 227 ❑Yes ❑ No 228 229 2 230 231 ❑Yes ❑ No 232 233 3 234 235 ❑Yes ❑ No 236 237 4 238 239 ❑Yes ❑ No 240 241 5 242 243 ❑Yes ❑ No 244 245 If more bacardous components are present st greater than 1%by weigbt if no-carcnogenic,or O.1%by weight if carcinogenic,attach additional sheets of paper capturing the required infornution. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA Please Sign Here UPCF(Rev.12/2007) Hazardous Materials Inventory - Chemical Description You must complete a separate Hazardous Materials Inventory-Chemical Description page for each hazardous material(hazardous substances and hazardos waste) that you handle at your facility in aggregate quantifies equal to or greater than 500 pounds,55 gallons,200 cubic feet of gas(calculated at standard temperature and pressure)or the federal threshold planning quantity for Extremely Hazardous Substances,whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40,or 70. The completed inventory should reflect all reportable quantities of hazardous materials at your facility,reported separately for each building or outside adjacent area,with separate pages for unique occurrences of physical state,storage temperature and storage pressure. (Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form(UPCF)pages. These data element numbers are used for electronic submission and are the same as the numbering used in Division 3,Electronic Submittal of Information.) Please number all pages of your submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER-This number is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3. BUSINESS NAME-Enter the full 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 revised. NOTE: You may choose to leave this blank if you resubmit your entire inventory annually. 201.CHEMICAL LOCATION-Enter the building or outside/adjacent area where the hazardous material is handled. A chemical that is stored at the same pressure and temperature,in multiple locations within a building,can be reported on a single page. NOTE:This information is not subject to public disclosure pursuant to HSC Section 25506. 202.CHEMICAL LOCATION CONFIDENTIAL-EPCRA-All businesses which are subject to the Emergency Planning and Community Right to Know Act(EPCRA) must check"Yes'to keep chemical location information confidential. If the business does not wish to keep chemical location information confidential check "No'. 203.MAP NUMBER-If a map is included,enter the number of the map on which the location of the hazardous material is shown. 204.GRID NUMBER-If grid coordinates are used,enter the grid coordinates of the map that correspond to the location of the hazardous material. If applicable, multiple grid coordinates can be listed. 205.CHEMICAL NAME-Enter the proper chemical name associated with the Chemical Abstract Service(CAS)number of the hazardous material. This should be the International Union of Pure and Applied Chemistry(IUPAC)name found on the Material Safety Data Sheet(MSDS). NOTE:If the chemical is a mixture,do not complete this field;complete the"COMMON NAME"field instead. 206.TRADE SECRET-Check'Yes*if the information in this section is dedared a trade secret,or'No'if it is not. State requirement: If yes,and business is not subject to EPCRA,disclosure of the designated trade secret information is bound by HSC Section 25511. Federal requirement: If yes,and business is subject 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 containing a hazardous material. 208.EHS-Check"Yes'if the hazardous material is an Extremely Hazardous Substance(EHS),as defined in 40 CFR,Part 355,Appendix A. If the material is a mixture containing an EHS,leave this section blank and complete the section on hazardous components below. 209.CAS#-Enter the Chemical Abstract Service(CAS)number for the hazardous material. For mixtures,enter the CAS number of the mixture if it has been assigned a number distinct 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-Fire Code Hazard Classes describe to first responders the type and level of hazardous materials 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 list of the hazard classes and instructions on how to determine which class a material falls under are included in the appendices of Article 80 of the Uniform Fire Code. If a material has more than one applicable hazard Gass,include all. Contact CUPA or AA for guidance. 211.HAZARDOUS MATERIAL TYPE-Check the one box that best describes the type of hazardous material:pure,mixture or waste. If waste material,check only that box. If mixture or waste,complete hazardous components section. 212.RADIOACTIVE-Check"Yes'if the hazardous material is radioactive or"No'if it is not. 213.CURIES-If the hazardous material is radioactive,use this area to report the activity In curies. You may use up to nine digits with a floating decimal point to report activity in curies. 214.PHYSICAL STATE-Check the one box that best describes the state in which the hazardous material is handled:solid,liquid or gas. 215.LARGEST CONTAINER-Enter the total capacity of the largest container in which the material is stored. 216.FEDERAL HAZARD CATEGORIES-Check all categories that describe the physical and health hazards associated with the hazardous material. PHYSICAL HAZARDS I HEALTH HAZARDS Fire:Flammable Liquids and Solids,Combustible Liquids,P ro horics,Oxidizers Acute Health(Immediate):Highly Toxic,Toxic,Irritants,Sensitizers,Corrosives, Reactive:Unstable Reactive Organic Peroxides Water Reactive Radioactive other hazardous chemicals with an adverse effect with short term exposure Pressure Release:Explosives,Compressed Gases,Blasting Agents Chronic Health(Delayed):Carcinogens,other hazardous chemicals with an adverse effect with long term exposure 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'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. 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 adjacentloutside area at any onetime over the course of,the year. This amount must contain at a minimum last year's inventory of the material reported on this page,with the reflection of additions,deletions,or revisions projected for the current year. This amount should be consistent with the units reported in box 221. 219.ANNUAL WASTE AMOUNT-If the hazardous material being inventoried is a waste,provide an estimate of the annual amount handled. 220.STATE WASTE CODE-If the hazardous material is a waste,enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. 221.UNITS-Check the unit of measure that is most appropriate for the material being reported on this page:gallons,pounds,cubic feet or tons. NOTE:If the material is a federally defined Extremely Hazardous Substance(EHS),all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in(gallons,pounds,cubic feel,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 COMPONENTS 1-5(%BY WEIGHT)-Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available,report the highest percentage in that range. (Report for components 2 through 5 in 230,234,238,and 242.) 227.HAZARDOUS COMPONENTS 1-5 NAME-When reporting a hazardous material that is a mixture,list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or,in the case of trade secrets,refer to manufacturer). All hazardous components in the mixture present at greater than 1%by weight if non-carcinogenic,or 0.1%by weight if carcinogenic,should be reported. If more than five hazardous components are present above these percentages,you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures,mineral and chemical composition should be listed. (Report for components 2 through 5 in 231,235,239,and 243.) 226.HAZARDOUS COMPONENTS 1-5 EHS-Check"Yes" if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355,or"No" it'd is not. (Report for components 2 through 5 in 232,236,240,and 244.) 229.HAZARDOUS COMPONENTS 1-5 CAS-List the Chemical Abstract Service(CAS)numbers as related to the hazardous components in the mixture. (Repeat for 2-5.) 246.LOCALLY COLLECTED INFORMATION-This space may be used by the CUPA or AA to collect any additional information necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance. UPCF(Rev.1212007) UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY-CHEMICAL DESCRIPTION (one p4e 00 material W b0dinst or areal ❑ADD ❑DELETE ❑REVISE 2110 Page_of_ I. FACILITY INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 s� CHEMICAL YUCATION I _ 2U1 CHEMICAL L ATION CONFIDENTIAL EPCRA 202 [I YES §ff NO MAP#(ovdonall 203 GRID#(opdonei> 204 FACILITY ID# „ II. CHEMICAL INFORMATION EMICAL NAME 205 TRADE SECRET Yes No 206 'J If Subject to EPCRA,refer to irutnMians COMMON NAME zu7 208 EHS* ❑ Yes frNo CAS# 209 *If EHS is"Yes",all amounts below must be in lbs. FIRE COUE HAZARD CLASSES(Complete if required by CUPA) 210 HAZARDOUS MATERIAL 213 _� 2u RADIOACTIVE ❑Yes No 212 CURIES TYPE(Check one item only) ❑a PURE b.MIXTURE Cl c.WASTE 215 PHYSICAL STATE 214 LARGEST CONTAINER (Check one item only) ❑ a.SOLID VrLIQUID ❑ ..GAS FED HAZARD CATEGORIES �,,/ 216 (Check all that apply) tih e• FIRE ❑b. REACTIVE ❑ c.PRESSURE RELEASE TdACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 2I9 ANNUAL WASTE AMOUNT 219 1 STATE WASTE CODE 220 6 aa!�q, 221 DAYS ON SITE: 222 UNITS' _��a.GALLONS C1 b. CUBIC FEET [I c.POUNDS El d.TONS Z Check one item only) •If EHS,amount must be in pounds. ✓(f/ STORAGE CONTAINER �a.ABOVE GROUND TANK ❑e.PLASTIC/NONMETALLIC DRUM (I i.FIBER DRUM [I m.GLASS BOTTLE ❑ q.RAIL CAR UNDERGROUND TANK ❑f.CAN ❑j.BAG [In. PLASTIC BOTTLE ❑ r.OTHER ❑c.TANK INSIDE BUILDING ❑g.CARBOY ❑ k.BOX ❑o. TOTE BIN ❑d STEEL DRUM ❑h.SILO ❑ I. CYLINDER Cl p. TANK WAGON 27 STORAGE PRESSURE Wa. AMBIENT [I b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# 1 226 227 ❑Yes ❑ No 229 229 2 230 271 ❑Yes ❑ No 232 233 3 274 233 ❑Yes ❑ No 236 277 4 238 239 ❑Yes ❑ No 240 241 5 242 243 ❑Yes ❑ No 244 243 1r mom hazardous components are present at greater thm 1%by weight if non-ardnogenic,or 0.1%by weight)rarcinegeaic,attach additional sheets of papa capturing the required inrorrmfian. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA Please Sin Here UPCF(Rev. 12/2007) Hazardous Materials Inventory - Chemical Description You must complete a separate Hazardous Materials Inventory-Chemical Description page for each hazardous material(hazardous substances and hazardous waste) that you handle at your facility in aggregate quantities equal to or greater than 500 pounds,55 gallons,200 cubic feet of gas(calculated at standard temperature and pressure)or the federal threshold planning quantity for Extremely Hazardous Substances,whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40,or 70. The completed inventory should reflect all reportable quantities of hazardous materials at your facility,reported separately for each building or outside adjacent area,with separate pages for unique occurrences of physical state,storage temperature and storage pressure. (Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form(UPCF)pages. These data element numbers are used for electronic submission and are the same as the numbering used in Division 3,Electronic Submittal of Information.) Please number all pages of your submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER-This number is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3. BUSINESS NAME-Enter the full 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 revised. NOTE: You may choose to leave this blank if you resubmit your entire inventory annually, 201.CHEMICAL LOCATION-Enter the building or outside/adjacent area where the hazardous material is handled. A chemical that is stored at the same pressure and temperature,in multiple locations within a building,can be reported on a single page. NOTE;This information is not subject to public disclosure pursuant to HSC Section 25506. 202.CHEMICAL LOCATION CONFIDENTIAL-EPCRA-All businesses which are subject to the Emergency Planning and Community Right to Know Ad(EPCRA) must check'Yes"to keep chemical location information confidential. If the business does not wish to keep chemical location information confidential check 'No'. 203.MAP NUMBER-If a map is included,enter the number of the map on which the location of the hazardous material is shown. 204.GRID NUMBER-If grid coordinates are used,enter the grid coordinates of the map that correspond to the location of the hazardous material. If applicable, multiple grid coordinates can be listed, 205.CHEMICAL NAME-Enter the proper chemical name associated with the Chemical Abstract Service(CAS)number of the hazardous material. This should be the Intemational Union of Pure and Applied Chemistry(IUPAC)name found on the Material Safely Data Sheet(MSDS). NOTE:If the chemical is a mixture,do not complete this field;complete the'COMMON NAME"field instead. 206.TRADE SECRET-Check*Yes if the information in this section is declared a trade secret,or'No'if it is rot. State requirement: If yes,and business is not subject to EPCRA,disclosure of the designated trade secret information is bound by HSC Section 25511. Federal requirement: If yes,and business is subject 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 containing a hazardous material. 208.EHS-Check'Yes'if the hazardous material is an Extremely Hazardous Substance(EHS),as defined in 40 CFR,Part 355,Appendix A. If the material is a mixture containing an EHS,leave this section blank and complete the section on hazardous components below. 209.CAS#-Enter the Chemical Abstract Service(CAS)number for the hazardous material. For mixtures,enter the CAS number of the mixture if it has been assigned a number distinct 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-Fire Code Hazard Classes describe to first responders the type and level of hazardous materials 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 list of the hazard classes and instructions on how to determine which class a material falls under are included in the appendices of Article 80 of the Uniform Fire Code. If a material has more than one applicable hazard Gass,include all. Contact CUPA or AA for guidance. 211.HAZARDOUS MATERIAL TYPE-Check the one box that best describes the type of hazardous material:pure,mixture or waste. If waste material,check only that box. if mixture or waste,complete hazardous components section. 212.RADIOACTIVE-Check'Yes'if the hazardous material is radioactive or'No'if it is not. 213.CURIES-If the hazardous material is radioactive,use this area to report the activity in curies. You may use up to nine digits with a floating decimal pant to report activity in curies. 214.PHYSICAL STATE-Check the one box that best describes the state in which the hazardous material is handled:solid,liquid or gas. 215.LARGEST CONTAINER-Enter the total capacity of the largest container in which the material is stored. 216.FEDERAL HAZARD CATEGORIES-Check all categories that describe the physical and health hazards associated with the hazardous material. PHYSICAL HAZARDS HEALTH HAZARDS Fire:Flammable Liquids and Solids,Combustible Liquids,Pyrophorics,Oxidizers Acute Health(Immediate):Highly Toxic,Toxic,Irritants,Sensitizers,Corrosives, Reactive:Unstable Reactive Organic Peroxides,Water Reactive Radioactive other hazardous chemicals with an adverse effed with short term exposure Pressure Release:Explosives,Compressed Gases,Blasting Agents Chronic Health(Delayed):Carcinogens,other hazardous chemicals with an adverse effect with long term exposure 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'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. 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 years inventory of the material reported on this page,with the reflection of additions,deletions,or revisions projected for the current year. This amount should be consistent with the units reported in box 221. 219.ANNUAL WASTE AMOUNT-If the hazardous material being inventoried is a waste,provide an estimate of the annual amount handled. 220.STATE WASTE CODE-If the hazardous material is a waste,enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. 221.UNITS-Check the unit of measure that is most appropriate for the material being reported on this page:gallons,pounds,cubic feet or tons. NOTE:If the material is a federally defined Extremely Hazardous Substance(EHS),all amounts must 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 COMPONENTS 1-5(%BY WEIGHT)-Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available,report the highest percentage in that range. (Report for components 2 through 5 in 230,234,238,and 242.) 227.HAZARDOUS COMPONENTS 1-5 NAME-When reporting a hazardous material that is a mixture,list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or,in the case of trade secrets,refer to manufacturer). All hazardous components in the mixture present at greater than 1%by weight if non-carcinogenic,or 0.1%by weight if carcinogenic,should be reported. If more than five hazardous components are present above these percentages,you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures,mineral and chemical composition should be listed. (Report for components 2 through 5 in 231,235,239,and 243.) 228,HAZARDOUS COMPONENTS 1-5 EHS-Check"Yes" if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355,or "No" if it is not. (Report for components 2 through 5 in 232,236,240,and 244.) 229.HAZARDOUS COMPONENTS 1-5 CAS-List the Chemical Abstract Service(CAS)numbers as related to the hazardous components in the mixture. (Repeat for 2-5.) 246.LOCALLY COLLECTED INFORMATION-This space may be used by the CUPA or AA to collect any additional information necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance. UPCF(Rev. 12/2007) UNIFIED PROGRAM CONSOLIDATED FORM HAZARDOUS MATERIALS HAZARDOUS MATERIALS INVENTORY-CHEMICAL DESCRIPTION lane me Per material per building or area) ❑ADD ❑DELETE ❑REVISE 200 Page_of_,,. I. FACILITY INFORMATION BUSINESS NAME(Same as FACIL TY NA or ABA—Doing Business As) 3 • -"00, CHEMICAL L ATION 2111 CHEMICAL LOCATION CONFIDENTIAL EPCRA zoz ❑ YES W NO FACILITY ID# t' MAP#(optionso 203 GRID#(optional) 2W II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET Yes Vo 206 If Subject to EPCRA,refer to instrucliau COMMON NAME 207 208 + EHS* ❑ Yes WNo CAS# 209 *If EHS is"Yes",all amounts below must be in lbs. FIRE CODE HAZARD CLASSES(Complete if required by CUPA) 210 2l3 HAZARDOUS MATERIAL /� 211 RADIOACTIVE ❑Yes No 212 CURIES TYPE(Check one item only) ❑a PURE N b.MIXTURE [I c.WASTE PHYSICAL STATE 215 (Check one item only) ❑ a.SOLID VrLIQUID El c.GAS 214 LARGEST CONTAINER FED HAZARD CATEGORIES 216 (Check all that apply) FIRE ❑b. REACTIVE ❑ c.PRESSURE RELEASE WACUfE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 2N MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 UNITS* Me.GALLONS ❑b. CUBIC FEET ❑ c.POUNDS ❑d.TONS 221 DAYS O/N SITE: 222 Check one item only) •If EHS,amount must be in pounds. 3L STORAGE CONTAINER s.ABOVE GROUND TANK ❑e.PLASTIC/NONMETALLIC DRUM ❑ i.FIBER DRUM ❑m GLASS BOTTLE ❑ q.RAIL CAR UNDERGROUND TANK ❑C CAN ❑j.BAG [In. 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 W.-AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT(For mixture or waste only) EHS CAS# 1 226 227 ❑Yes ❑ No 228 229 2 230 231 ❑Yes ❑ No 232 233 3 234 235 ❑Yes ❑ No 276 277 4 238 239 ❑Yes ❑ No 240 241 5 242 243 ❑Yes ❑ No 244 245 If mono hazardous components are present ai greater than 1%by weight if nomcascinotenlc,or 0.1%by weight if carcinogenic,attach additional sheets of paper capturing the required inrorrmtiaa ADDITIONAL LOCALLY COLLECTED fNFORMATION 246 If EPCRA Please Sign Here UPCF(Rev. 1:12007) Hazardous Materials Inventory - Chemical Description You must complete a separate Hazardous Materials Inventory-Chemical Description page for each hazardous material(hazardous substances and hazardous waste) that you handle at your facility in aggregate quantities equal to or greater than 500 pounds,55 gallons,200 cubic feet of gas(calculated at standard temperature and pressure)or the federal threshold planning quantity for Extremely Hazardous Substances,whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40,or 70. The completed inventory should reflect all reportable quantities of hazardous materials at your facility,reported separately for each building or outside adjacent area,with separate pages for unique occurrences of physical state,storage temperature and storage pressure. (Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form(UPC F)pages. These data element numbers are used for electronic submission and are the same as the numbering used in Division 3,Electronic Submittal of Information.) Please number all pages of your submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated. 1, FACILITY ID NUMBER-This number is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3. BUSINESS NAME-Enter the full legal name of the business. 200.ADDIDELETFJ REVISE-Indicate if the material is being added to the inventory,deleted from the inventory,or it the information previously submitted is being revised. NOTE: You may choose to leave this blank it you resubmit your entire inventory annually. 201.CHEMICAL LOCATION-Enter the building or outside/adjacent area where the hazardous material is handled. A chemical that is stored at the same pressure and temperature,in multiple locations within a building,can be reported on a single page. NOTE:This information is not subject to public disclosure pursuant to HSC Section 25506. 202.CHEMICAL LOCATION CONFIDENTIAL-EPCRA-All businesses which are subject to the Emergency Planning and Community Right to Know Ad(EPCRA) must check"Yes'to keep chemical location information confidential. If the business does not wish to keep chemical location information confidential check 'No". 203.MAP NUMBER-If a map is included,enter the number of the map on which the location of the hazardous material is shown. 204.GRID NUMBER-If grid coordinates are used,enter the grid coordinates of the map that correspond to the location of the hazardous material. If applicable, multiple grid coordinates can be listed. 205.CHEMICAL NAME-Enter the proper chemical name associated with_the Chemical Abstract Service(CAS)number of the hazardous material. This should be the International Union of Pure and Applied Chemistry(IUPAC)name found on the Material Safety Data Sheet(MSDS). NOTE:If the chemical is a mixture,do not complete this field;complete the"COMMON NAME"field instead. 206.TRADE SECRET-Check"Yes'if the information in this section is declared a trade secret,or"No'if it is Trot. State requirement: If yes,and business is not subject to EPCRA,disclosure of the designated trade secret information is bound by HSC Section 25511. Federal requirement: If yes,and business is subject 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 containing a hazardous material. 208.EHS-Check'Yee if the hazardous material is an Extremely Hazardous Substance(EHS),as defined in 40 CFR,Part 355,Appendix A. If the material is a mixture containing an EHS,leave this section blank and complete the section on hazardous components below. 209.CAS ft-Enter the Chemical Abstract Service(CAS)number for the hazardous material. For mixtures,enter the CAS number of the mixture Hit 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-Fire Code Hazard Classes describe to first responders the type and level of hazardous materials which a business handles. This information shall only be provided if the local fire chief deems id necessary and requests the CUPA or AA to collect it. A list of the hazard classes and instructions on how to determine which class a material falls under are included in the appendices of Article 80 of the Uniform Fire Code. If a material has more than one applicable hazard Gass,include all. Contact CUPA or AA for guidance. 211.HAZARDOUS MATERIAL TYPE-Check the one box that best describes the type of hazardous material:pure,mixture or waste. H waste material,check only that box. If mixture or waste,complete hazardous components section. 212.RADIOACTIVE-Check"Yes"H the hazardous material is radioactive or"No'H it is not. 213.CURIES-.If the hazardous material is radioactive,use this area to report the activity in curies. You may use up to nine digits with a floating decimal point to report activity in curies. 214.PHYSICAL STATE-Check the one box that best describes the state in which the hazardous material is handled:solid,liquid or gas. 215.LARGEST CONTAINER-Enter the total capacity of the largest container in which the material is stored. 216.FEDERAL HAZARD CATEGORIES-Check all categories that describe the physical and health hazards associated with the hazardous material. PHYSICAL HAZARDS HEALTH HAZARDS Fire:Flammable Liquids and Solids,Combustible liquids,Pyrophorics,Oxidizers Acute Health(immediate):Highly Toxic,Toxic,Irritants,Sensitizers,Corrosives, Reactive:Unstable Reactive.Organic Peroxides,Water Reactive Radioactive other hazardous chemicals with an adverse effect with short term exposure Pressure Release:Explosives,Compressed Gases,Blasting Agents Chronic Health(Delayed):Carcinogens,other hazardous chemicals with an adverse effect with long term exposure 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 shalt 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. 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.ANNUAL WASTE AMOUNT-If the hazardous material being inventoried is a waste,provide an estimate of the annual amount handled. 220.STATE WASTE CODE-It the hazardous material is a waste,enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. 221.UNITS-Check the unit of measure that is most appropriate for the material being reported on this page:gallons,pounds,cubic feet or tons. NOTE:if the material is a federally defined Extremely Hazardous Substance(EHS),all amounts must 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 appropriaie,you may choose more than one. 224.STORAGE PRESSURE-Check the one box that best describes the pressure at which the hazardous material is stored. 225.STORAGE TEMPERATURE-Check the one box that best describes the temperature at which the hazardous material is stored. 226.HAZARDOUS COMPONENTS 1-5(%BY WEIGHT)-Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available,report the highest percentage in that range. (Report for components 2 through 5 in 230,234,238,and 242.) 227,HAZARDOUS COMPONENTS 1-5 NAME-When reporting a hazardous material that is a mixture,list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or,in the case of trade secrets,refer to manufacturer). All hazardous components in the mixture present at greater than 1%by weight if non-carcinogenic,or 0.1%by weight if carcinogenic,should be reported. If more than five hazardous components are present above these Percentages,you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures,mineral and chemical composition should be listed. (Report for components 2 through 5 in 231,235,239,and 243.) 228.HAZARDOUS COMPONENTS 1-5 EHS-Check"Yes" if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355,or "No" if it is not. (Report for components 2 through 5 in 232,236,240,and 244.) 229.HAZARDOUS COMPONENTS 1-5 CAS-List the Chemical Abstract Service(CAS)numbers as related to the hazardous components in the mixture. (Repeat for 2-5.) 246.LOCALLY COLLECTED INFORMATION-This space may be used by the CUPA or AA to coiled any additional information necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance. UPCF(Rev, 12/2007) UNIFIED.PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9 TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY alu. FACILITY ID# (Agency Use Only) BUSINESS N ME(Same as FACILITY NAN r DBA- ng Bus ness As) ; BUSINESS SIT ADDRESS 103. CITY 104. FACILITY TYPE ,�.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. 3.FARM ❑ 4.PROCESSOR El 6.OTHER Trust lands? ❑Yes &no II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 4U7. PHONE 408. MAILING ADDRESS 4099, 1 CITY 490. STATE 411. Z[PCODE 412. III. TANK OPERATOR INFORMATION TANK O ERATOR NAME 42871. PPONONE / 428-2 MA LING ADDRESS / 428-3 -'box is / CITY 428-4 PTATE 428-1 ZIP CODE 428-6 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. //PH�ON 415. � (60 61 �L ADD SS 416. r CITY 4 q STAT aia. ZIP DE air. 3 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 55.COUNTY AGENCY ❑ 6.STATE AGENCY 420. E] � 7.FEDERAL AGENCY a.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 10 11 19 17 L2 L31 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' VI. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 423 pe g gs ❑ 4.TANK OPERATOR V-3 TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTFFICATION: 1 certifv that the inf rovided herein is true,accurate,and in full compliance with legal requirements. APPLICANTS DATE 424, PHONE 425. '�� APPLICANT NAME(print) 426. P LICAN ITLE 422 r D r UPCF UST-A Rev.(12/2007) UST Operating Permit Application-Facility Information Page 1 Instructions (Formerly SWRCB UST Permit Application Form A and UPCF Form hwfwrc-a) Complete this form for all new permits, permit changes,or facility information changes. This form must be submitted within 30 days of permit or facility information changes, unless your local agency requires approval prior to making the changes. For changes, submit only that form that contains the change. Submit one UST Operating Permit Application-Facility Information form per facility,regardless of the number of USTs located at the facility. If not already on file with the local agency,the tank owner must submit with this form,a current UST Operating Permit Application-Tank Information form for each UST;a UST Monitoring Plan and a UST Response Plan pursuant to 23 CCR 2632,2634 and 2641;and, for USTs containing petroleum,a certification of financial responsibility pursuant to 23 CCR 2807. The following documents,at a minimum,are also required,if applicable(check with your local agency to see if they require submittal or if there are other forms/information needed): O Written agreement between UST Owner and UST Operator per Health and Safety Code§25284(a)(3); ❑ Letter from the Chief Financial Officer(if using State Cleanup Fund,financial test of self-insurance,guarantee,local government financial test, or Local Government Fund as a financial responsibility mechanism). Please number all pages of your submittal. (Note: Numbering of these instructions matches the data element numbers on the form.) 400. TYPE OF ACTION-Check the reason this form is being submitted. CHECK ONE ITEM ONLY. 404. TOTAL NUMBER OF USTs AT SITE-Indicate the number of tanks that will remain on the site after the requested action. 1. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete Business Name.(Same as FACILITY NAME or DBA(Doing Business As)). 103. BUSINESS SITE ADDRESS-Enter the street address of the facility, including building number, if applicable.This address must be the physical location of the facility.Post office box numbers are not acceptable. 104. CITY-Enter the city or unincorporated area in which the facility is located. 403. FACILITY TYPE-Indicate the type of facility. 405. INDIAN RESERVATION OR TRUST LANDS-Check whether the facility is located on an Indian reservation or other trust lands. 407. PROPERTY OWNER NAME- Complete items 407-412 for the property owner. Include the area code and any 408. PROPERTY OWNER PHONE- extension number. 409. PROPERTY OWNER MAILING ADDRESS- 410. PROPERTY OWNER CITY- 411. PROPERTY OWNER STATE- 412. PROPERTY OWNER ZIP CODE- 428-1. TANK OPERATOR NAME- Complete items 428-1 to 428-6 for the UST operator. 428-2. TANK OPERATOR PHONE- Include the area code and any extension number. 428-3. TANK OPERATOR MAILING ADDRESS- 4284. TANK OPERATOR CITY- 428-5. TANK OPERATOR STATE- 428-6. TANK OPERATOR ZIP CODE- 414. TANK OWNER NAME- Complete items 414-419 for the UST owner. 415. TANK OWNER PHONE- Include the area code and any extension number. 416. TANK OWNER MAILING ADDRESS- 417. TANK OWNER CITY- 418. TANK OWNER STATE- 419. TANK OWNER ZIP CODE- 420. TANK OWNER TYPE-Check the type of tank ownership. 421. BOE NUMBER- Enter your State Board of Equalization (BOE) UST storage fee account number. This fee applies to regulated USTs storing petroleum products and is required before your permit application will be processed. If you do not have an account number with the BOE,or if you have any questions regarding the fee or exemptions,contact the BOE at(916)322-9669 or by mail at: Board of Equalization, Fuel Taxes Division,PO Box 942879,Sacramento,CA 94279-0030. 423. PERMIT HOLDER INFORMATION - Indicate the party to whom the UST operating permit is to be issued and legal notifications and mailings should be sent. 406. SUPERVISOR OF DIVISION SECTION OR OFFICE SUPERVISOR- If the facility owner is a public agency, enter the name of the supervisor of the division section or office that operates the UST. This person must have access to the UST records. APPLICANT SIGNATURE-The application form must be signed,in the space provided,by: • The UST owner or operator,facility owner or operator,or a duly authorized representative of the owner,or • If the UST(s)is/are owned by a corporation,partnership,or public agency: 1.) A principal executive officer at the level of vice-president or by an authorized representative responsible for the overall operation of the facility where the UST(s)is/are located;or 2.) A general partner or proprietor;or 3.) A principal executive officer,ranking elected official,or authorized representative of a public agency. 424. DATE-Enter the date the form was signed. 425. PHONE-Enter the phone number of the applicant(i.e.,person signing the form).Include the area code and any extension number. 426. APPLICANT NAME-Print or type the full name of the person signing the form. 427. APPLICANT TITLE-Enter the title of the person signing the form. UPCF UST-A Rev.(12/2007) UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one farm per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,I[,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430° I DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINES NAME(Same as FA ILITY AME or DBE-Doing Business As) 3 i BUSINESS SfrE A DRESN b I03 CITY 1 II.TANK DESCRIPTION d TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 T1 l{J t.A STAND-ALONE TANK ❑2.ONE M A COMPARTMENTED UNIT. Complete one paSe ror each cornpanment in the unn. DATE UST SYSTEM INSTALLED 435 TANK APACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE BrIa.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: 971a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL IFI FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7:JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION W1.AUDIBLE&VISUAL ALARMS .BALL FLOAT 6 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE WE PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(aX3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL W4_ ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 461a SECONDARY CONTAINMENT C1 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/rURBINE CONTAINMENT SUMP TYPE 711.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 44r4d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99..OTHER.(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ L STEEL VT FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ L STEEL MI.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464g) VR SECONDARY CONTAINMENT ❑ 1.STEEL 6r4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE V7 SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT El L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC .NONE 0 99.OTHER(Specify) 4641 464'I RISER SECONDARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4641 464k1 FILL COMPONENTS INSTALLED W7,SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance w' al uiremen APPLICANT SIGNATURE DATE 470. 6 � v APPLICANT NAME(print 471. APPLIC NT TITLE 472. UPCF UST-B-1/2 Rev.(12/2007) UST Operating Permit Application -Tank Information Instructions (Formerly SWRCB Permit Application Form B and UPCF Form hwfwrc-b) Complete a separate form for each UST for all new permits,permit changes,and any UST system information changes. This form must be submitted within 30 days of permit or UST system information changes,unless your local agency requires approval prior to making changes. For tanks that are part of a compartmentalized unit, each compartment is considered a separate tank and requires completion of a separate Tank Information form.For a UST permanent closure or removal,complete only TYPE OF ACTION and Sections 1,11,111,IV,and IX.(Note: Numbering of these instructions matches the data element numbers on the form.) 430. TYPE OF ACTION-Check the appropriate box to indicate why this form is being submitted. 430a. DATE UST PERMANENTLY CLOSED-For reporting closure only:enter the date the UST was removed or closed on site. 430b. DATE EXISTING UST DISCOVERED-Enter the date this UST was discovered.Leave blank if installation date is known. 1. FACILITY[D NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete facility name. 101 BUSINESS SITE ADDRESS-Enter the street address of the facility,including building number,if applicable. This address must be the physical location of the facility.Post office box numbers are not acceptable. 104. CITY-Enter the city or unincorporated area in which the facility is located. 432. TANK ID#-Applicant may enter the owner's tank identification number or leave this space blank.The Local Agency will assign the State tank identification number as the unique identifier for the tank. 433. TANK MANUFACTURER-Enter the name of the company that manufactured the tank. 434. TANK CONFIGURATION.Check the appropriate box to indicate if the tank is a stand-alone tank or one in a compartmented unit.A separate UST Operating Permit Application-Tank Information form must be submitted for each compartment. 435. DATE UST SYSTEM INSTALLED-Enter the date the local agency signed-off on installation of the UST system. This is the date of ini W tank system installation,and does not include upgrades or retrofits which may have been performed later.If this is for a new installation,leave blank. 436. TANK CAPACITY IN GALLONS:Enter the tank capacity. For compartmentalized tanks,enter data for the compartment covered by this tank form only. 437. NUMBER OF COMPARTMENTS IN THE UNIT:If the tank is a compartment,enter the total number of compartments in the unit. 439. TANK USE-Check the type of tank usage. 439x. If you checked"Other"specify the type of tank usage in the space provided. 440. TANK CONTENTS-Check the specific petroleum or non-petroleum substance stored. 440a. If you checked"Other Petroleum"specify the common name of the substance in the space provided[i.e.,the name used in the facility's Hazardous Materials Business Plan(HMBP)inventory]. 440b. If you checked"Other"under Non-petroleum,specify the common name of substance in the space provided(i.e.,the name used in the HMBP inventory). 443. TYPE OF TANK-Check the box that identifies the type of tank. 444. TANK PRIMARY CONTAINMENT-Check the construction material of the primary containment(i.e., inner tank wall nearest the hazardous substance stored). If the tank material is not listed,check"Other"and specify the material in the space provided. 444a. If you checked"Other"specify the type of primary containment in the space provided. 445. TANK SECONDARY CONTAINMENT-Check the construction material of the secondary containment that provides containment external to,and separate from,the primary containment described above.If the tank is a single-wall tank,check"None." If the material is not listed,check"Other"and specify the material in the space provided(e.g.,HDPE). 445a. If you checked"Other"specify the type of secondary containment in the space provided. 452 OVERFILL PREVENTION-Check the box(es)to describe the type(s)of overfill protection equipment installed. 458. PIPING SYSTEM TYPE - Check the type of product/waste piping installed in this tank system. "Safe suction" refers to piping systems meeting all requirements of 23 CCR§2636(a)(3)(also known as"European Suction"systems)(i.e.,sloped suction piping systems with no valves or pumps below grade and only one check valve,located below and as close as practical to the suction pump). Title 23,California Code of Regulations is available online at www.calreg5.com. 460. PIPING CONSTRUCTION-Indicate if the piping is single-walled or double-walled,or"other". 464. PIPING PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)underground product/waste piping. 464a. If you checked"Other"specify the type of primary containment in the space provided. 464b. PIPING SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(i.e., secondary piping,trench) provided for the product/waste piping.For single-wall piping systems,check"None." 464c. If you checked"Other"specify the type of secondary containment in the space provided. 464d. PIPING/fURBINE CONTAINMENT SUMP TYPE-Indicate the type of piping/turbine containment sump(s).Check"None"if not present. 464e-el VENT PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)vent piping. (Note:Address venting of the tank primary containment only.)Specify Other type of containment in the space provided. 464f-n VENT SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping,)provided for the vent piping. For single-wall piping systems, check "None." (Note: Address venting of the tank primary containment only.) Specify Other type of containment in the space provided. 4648-g1 V R PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)vapor recovery piping. For tanks without vapor recovery piping(e.g.,Diesel tanks),check"None." Specify Other type of containment in the space provided. 464h-h1 VR SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping)provided for the vapor recovery piping.For single-wall piping systems,check"None." Specify Other type of containment in the space provided. 4641. VENT PIPING TRANSITION SUMP TYPE-Indicate type of transition sump(s).Check"None"if not present. 464j-j 1 RISER PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)piping for all risers(not drop tubes)other than annular space risers(i.e.,risers for filling or gauging of the primary tank). Specify Other type of containment in the space provided. 464k-k I RISER SECONDARY CONTAINMENT-Check the material(s)used to construct secondary containment system(s)(i.e.,secondary piping,sumps)provided for the riser piping.For risers without secondary containment,check"None." Specify Other type of containment in the space provided. 451a-c. FILL COMPONENTS INSTALLED-Check the appropriate boxes to show that spill containment, tank bottom protection,and fill containment sumps(if applicable)are installed. 469a. UDC CONSTRUCTION TYPE-Check the box to describe the type of dispenser containment system(s)(i.e.,dispenser sumps or pans). If the system has no dispensers(e.g.,standby generator tank system),check"No Dispensers." If the system has a dispenser,but no UDC,check"None". 469b. UDC CONSTRUCTION MATERIAL-Check the box to describe the materials used to construct the UDC. 469c. If you checked"Other"specify the construction material in the space provided. 448. STEEL COMPONENT PROTECTION-All systems contain some steel components. Check the appropriate box(es)to describe all corrosion protection methods used. "Isolation" means electrical isolation from soil, backfrll,and groundwater. Examples include fiberglass cladding, non-metallic secondary containment systems which isolate steel components from the sub-surface environment,and insulating bushings. APPLICANT SIGNATURE-The same person who signs the UST Operating Permit Application-Facility Information Form shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true and accurate, and that the UST system is compatible with the hazardous substance stored. 470. DATE-Enter the date the form was signed. 471. APPLICANT NAME-Print or type the name of the person signing the form. 472. APPLICANT TITLE-Enter the title of the person signing the form. UPCF UST-B-2R Rev.(12/2007) UNIFIED PROGRAM CONSOLIDATED FORN9 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,II,HL IV,and IX below) 430 ❑ I.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST'PERMANENTLY CLOSED: 47i DATE EXISTING UST DISCOVERED: 430b 1. FACILITY INFORMATION FACILITY ID#(Agenev Use Only) I BUSINESS NAME(Same as F.A ILITY ANTE or DB' Doing Business As) 3 ow BUSINESS E ADDRESS 103 CITY 14 11.TANK DESCRIPTION TANK ID# 4J2 TANK MANUFACTURER 433 TANK CONFIGURATION: THISTANKIS 434 -r.2 M'1.A STAND-ALONE TANK [12.ONE IN A COMPARTWIENTED UNIT. Complete one page for each com atmem in the unit. DATE UST SYSTEM INSTALLED 435 TANK-CA ACITY IN GALLONS 431, NUMBER OF COMPARTMENTS IN THE UNIT 437 III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED Nrllb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S ci ): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S i : 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN . ❑ 99.OTHER (S ci ): 444a SECONDARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS .BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED .DOUBLE-WALLED ❑99 OTHER SYSTEM TYPE WT.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§263((a)(3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL VT FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL V1.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 461b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGTURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4&1d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE C3 99.OTHER(Specify) 464. 464.1 VENT SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL M4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL V14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 461h 464h1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0.NONE 0 99.OTHER(Specify) 4641 4(.r I RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE 0 99.OTHER(Specify) 464k 464L FILL COMPONENTS INSTALLED 07.SPILL BUCKET 3.STRIKER PLATE`BOTTOM PROTECTOR C1 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4693 CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S i ) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL.ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system Ls compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in cull compliance with legal requiremcfts, APPLICANT SIGNATURE DATE 470. 2c � APPLICANT NAME(print 471 APPLICANT TITLE. 4'` UPCF UST-B-112 Rev.(12/2007) UST Operating Permit Application -Tank Information Instructions (Formerly SWRCB Permit Application Form B and UPCF Form hwllvrc-b) Complete a separate form for each UST for all new,permits,permit changes,and any UST system information changes. This form must be submitted within 30 days of permit or UST system information changes,unless your local agency requires approval prior to making changes. For tanks that are part of a compartmentalized unit, each compartment is considered a separate tank and requires completion of a separate Tank Information form.For a UST permanent closure or removal,complete only TYPE OF ACTION and Sections 1,II.III,IV,and IX.(Note: Numbering of these instructions matches the data element numbers on the form.) 430. TYPE OF ACTION-Check the appropriate box to indicate why this farm is being submitted. 430a. DATE UST PER,LIANENTLY CLOSED-For reporting closure only:enter the date the UST was removed or closed on site. 430b. DATE EXISTING UST DISCOVERED-Enter the date this UST was discovered.Leave blank if installation date is known. I. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete tacility name. 103, BUSINESS SITE ADDRESS-Enter the street address of the tacility.including building number.if applicable. This address must be the physical location of the facility. Post office box numbers are not acceptable. 104. CITY-Enter the city or unincorporated area in which the facility is located. 432. TANK ID#-Applicant may enter the owner's tank identification number or leave this space blank.The Local Agency will assign the State tank identification number as the unique identifier for the tank. 433. TANK MANUFACTURER-Enter the name of the company that manufactured the tank. 434. TANK CONFIGURATION.Check the appropriate box to indicate if the tank is a stand-alone tank or one in a compartmented unit.A separate UST Operating Permit Application-Tank Information form must be submitted for each compartment. 435. DATE UST SYSTEM INSTALLED-Enter the date the local agency signed-off on installation of the UST system. This is the date of i i jd tank system installation,and does not include upgrades or retrofits which may have been performed later.If this is for a new installation,leave blank. 436. TANK CAPACITY IN GALLONS: Enter the tank capacity. For compartmentalized tanks,enter data for the compartment covered by this tank forth only. 437. NUMBER OF COMPARTMENTS IN THE UNIT:If the tank is a compartment,enter the total number of compartments in the unit. 439. TANK USE-Check the type of tank usage. 439a. If you checked"Other"specify the type of tank usage in the space provided. 440. TANK CONTENTS-Check the specific petroleum or non-petroleum substance stored_ 440a. If you checked"Other Petroleum"specify the common name of the substance in the space provided[i.e.,the name used in the facility's Hazardous Materials Business Plan(HMBP)inventory]. 440b. If you checked"Other"under Non-petroleum,specify the common name of substance in the space provided(i.e.,the name used in the HMBP inventory). 443. TYPE OF TANK-Check the box that identifies the type of tank. 444. TANK PRIMARY CONTAINMENT-Check the construction material of the primary containment (i.e., inner tank wall nearest the hazardous substance stored). If the tank material is not listed,check"Other'and specify the material in the space provided. 444a. If you checked"Other"specify the type of primary containment in the space provided. 445. TANK SECONDARY CONTAINMENT-Check the construction material of the secondary containment that provides containment external to,and separate from, the primary containment described above. If the tank is a single-wall tank check"None." If the material is not listed,check"Other"and specify the material in the space provided(e.g.,HDPE). 445a. 'If you checked"Other"specify the type of secondary containment in the space provided. 452 OVERFILL PREVENTION-Check the box(es)to describe the type(s)of overfill protection equipment installed. 458. PIPING SYSTEM TYPE - Check the type of product/waste piping installed in this tank system. "Safe suction" refers to piping systems meeting all requirements of 23 CCR§2636(x)(3)(also known as"European Suction"systems)(i.e.,sloped suction piping systems with no valves or pumps below grade and only one check valve, located below and as close as practical to the suction pump). Title 23,California Code of Regulations is available online at www.calregs.com. 460. PIPING CONSTRUCTION-Indicate if the piping is single-walled or double-walled,or"other'. 464. PIPING PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e_inner)underground product/waste piping. 464a. If you checked"Other"specify the type of primary containment in the space provided. 464b. PIPING SECONDARY CONTAINMENT-Check the material(s) used to construct the secondary containment system(s)(i.e., secondary piping, trench) provided for the product/waste piping.For single-wall piping systems,check"None." 464c. If you checked"Other"specify the type of secondary containment in the space provided. 464d. PIPING/TURBINE CONTAINMENT SUMP TYPE-Indicate the type of piping/turbine containment sump(s).Check"None"if not present. 464e-el VENT PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)vent piping. (Note:Address venting of the tank primary containment only.)Specify Other type of containment in the space provided. 464-171 VENT SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping,)provided for the vent piping. For single-wall piping systems, check "None." (Note: Address venting of the tank primary containment only.) Specify Other type of containment in the space provided. 464g-gl VR PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e..inner)vapor recovery piping. For tanks without vapor recovery piping(e.g..Diesel tanks),check"None." Specify Other type of containment in the space provided. 464h-hl VR SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping)provided for the vapor recovery piping.For single-wall piping systems,check"None." Specify Other type of containment in the space provided. 464i. VENT PIPING TRANSITION SUMP TYPE-Indicate type of transition sump(s).Check"None"if not present. 464j-j l RISER PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)piping for all risers(not drop tubes)other than annular space risers(i.e.,risers for filling or gauging of the primary tank). Specify Other type of containment in the space provided. 464k-kl RISER SECONDARY CONTAINMENT-Check the material(s)used to construct secondary containment system(s)(i e.,secondary piping,sumps)provided for the riser piping.For risers without secondary containment,check"None." Specify Other type of containment in the space provided. 451 a-c. FILL COMPONENTS INSTALLED-Check the appropriate boxes to show that spill containment, tank bottom protection,and fill containment sumps(if applicable)are installed. 469x. UDC CONSTRUCTION TYPE-Check the box to describe the type of dispenser containment system(s)(i.e.,dispenser sumps or pans). If the system has no dispensers(e.g.,standby generator tank system),check"No Dispensers." If the system has a dispenser,but no UDC,check"None". 469b. UDC CONSTRUCTION MATERIAL-Check the box to describe the materials used to construct the UDC. 469c. If you checked"Other"specify the construction material in the space provided. 448. STEEL COMPONENT PROTECTION -All systems contain some steel components. Check the appropriate box(es) to describe all corrosion protection methods used. "Isolation" means electrical isolation from soil, back-fill,and groundwater. Examples include fiberglass cladding. non-metallic secondary containment systems which isolate steel components from the sub-surface environment,and insulating bushings. APPLICANT SIGNATURE-The same person who signs the UST Operating Permit.Application-Facility Information Form shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true and accurate, and that the UST system is compatible with the hazardous substance stored. 470. DATE-Enter the date the form was signed. 471. APPLICANT NAME-Print or type the name of the person signing the form. 472. APPLICANT TITLE-Enter the title of the person signing the forth. UPCF UST-B-22 Rev.(12/2007) UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal.complete only this section and Sections I,[1,111.IV,and IX below) 431 ❑ I.NEW PERMIT ® 3. RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43 a DATE EXISTING UST DISCOVERED: 43Ob I. FACILITY INFORINIATION FACILITY[D.4(Agency Use Only) I BUSINESS NANIE(Same as F.A ILITY NAME or DBA_oing Business As) 3 BUSINESS SfrE A DRESS °; CITY 10.4 11.TANK DESCRIPTION TANK 10 9 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS Jar 9 TIA STAND-ALONE TANK El 2.ONE IN A COMPARTM1EM ED UNIT. Cum ete one p4,c for each com anment in the unit. DATE UST SYSTEM INSTALLED 435 TANK APACITY IN GALLONS 436 NUNIBER OF COMPARTMENTS IN THE UNIT 417 III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ W MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL IHSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.X11 DGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 $r.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 140b IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL .FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444& SECONDARY CONTAINMENT ❑ 1.STEEL WT.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [:199.OTHER(Specify): 445a OVERFILL PREVENTION .AUDIBLE&VISUAL ALARMS .BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED SrT DOUBLE-WALLED [199.OTHER 460 SYSTEM TYPE PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR§263QaN3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGfTURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 164d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 0 10,RIGID PLASTIC 90.NONE 99.OTHER(Specify) 461e 464e1 VENT SECONDARY CONTAINMENT ❑ I.STEEL F14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4618 461 l VR SECONDARY CONTAINMENT ❑ 1.STEEL Rr4.FIBERGLASS 0 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spccify) 44 467h I VENT PI PING TRANSITION SUMP TYPE Sri.SINGLE WALL 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL El 4.FIBERGLASS Ll 10,RIGID PLASTIC .NONE 99.OTHER(Specify) 4641 4611 RISER SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464L 46n1 FILL COMPONENTS INSTALLED V7.SPILL BUCKET 1 STRIKER PLATF.IBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a•c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE r7l.SINGLE WALL- E] 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC' ❑ 99.OTHER(Specify) 469b, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with 1 uirements. APPLICANT SIGNATURE DATE r.) 170 APPLICANT NAME(print / 471' APPLICANT TITLE 472. L' / �. UPCF UST-B-1/2 Rev.(12/2007) UST Operating Permit Application -Tank Information Instructions (Formerly SWRCB Permit Application Form B and UPCF Form hwvfivrc-b) Complete a separate form for each UST for all new permits,permit changes,and any UST system information changes. This form must be submitted within 30 days of permit or UST system information changes,unless your local agency requires approval prior to making changes. For tanks that are part of a compartmentalized unit, each compartment is considered a separate tank and requires completion of a separate Tank Information form. For a UST permanent closure or removal,complete only TYPE OF ACTION and Sections 1,IL 111,IV,and IX.(Note: Numbering of these instructions matches the data element numbers on the form.) 430. TYPE OF ACTION-Check the appropriate box to indicate why this form is being submitted. 430a. DATE UST PERMANENTLY CLOSED-For reporting closure only:enter the date the UST was removed or closed on site. 430b. DATE EXISTING UST DISCOVERED-Enter the date this UST was discovered.Leave blank if installation date is known. 1. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete facility name. 103. BUSINESS SITE ADDRESS-Enter the street address of the facility,including building number.if applicable. This address must be the physical location of the facility.Post office box numbers are not acceptable. 104. CITY-Enter the city or unincorporated area in which the facility is located. 432. TANK ID 0-Applicant may enter the owner's tank identification number or leave this space blank.The Local Agency will assign the State tank identification number as the unique identifier for the tank. 433. TANK MANUFACTURER-Enter the name of the company that manufactured the tank. 434. TANK CONFIGURATION.Check the appropriate box to indicate if the tank is a stand-alone tank or one in a compartmented unit.A separate UST Operating Permit Application-Tank Information form must be submitted for each compartment. 435. DATE UST SYSTEM INSTALLED-Enter the date the local agency signed-off on installation of the UST system. This is the date of initial tank system installation,and does not include upgrades or retrofits which may have been performed later.If this is for a new installation,leave blank. 436. TANK CAPACITY IN GALLONS:Enter the tank capacity. For compartmentalized tanks,enter data for the compartment covered by this tank form only. 437. NUMBER OF COMPARTMENTS IN THE UNIT:If the tank is a compartment,enter the total number of compartments in the unit. 439. TANK USE-Check the type of tank usage. 439a. If you checked"Other"specify the type of tank usage in the space provided. 440. TANK CONTENTS-Check the specific petroleum or non-petroleum substance stored, 440a. If you checked"Other Petroleum"specify the common name of the substance in the space provided[i.e.,the name used in the facility's Hazardous Materials Business Plan(HMBP)inventory]. 440b. If you checked"Other"under Non-petroleum,specify the common name of substance in the space provided(i.e.,the name used in the HMBP inventory). 443. TYPE OF TANK-Check the box that identifies the type of tank. 444. TANK PRIMARY CONTAINMENT-Check the construction material of the primary containment(i.e., inner tank wall nearest the hazardous substance stored). If the tank material is not listed,check"Other"and specify the material in the space provided. 444a. If you checked"Other"specify the type of primary containment in the space provided. 445. TANK SECONDARY CONTAINMENT-Check the construction material of the secondary containment that provides containment external to,and separate from, the primary containment described above. If the tank is a single-wall tank,check"None." If the material is not listed,check"Other"and specify the material in the space provided(e.g.,HDPE). 445a. If you checked"Other"specify the type of secondary containment in the space provided. 452 OVERFILL PREVENTION-Check the box(es)to describe the type(s)of overfill protection equipment installed. 458. PIPING SYSTEM TYPE - Check the type of product/waste piping installed in this tank system. "Safe suction" refers to piping systems meeting all requirements of 23 CCR§2636(ax3)(also known as"European Suction"systems)(i.e.,sloped suction piping systems with no valves or pumps below grade and only one check valve, located below and as close as practical to the suction pump). Title 23, California Code of Regulations is available online at www.calregs.com. 460. PIPING CONSTRUCTION-Indicate if the piping is single-walled or double-walled,or"other". 464. PIPING PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)underground product/waste piping. 464a. If you checked"Other"specify the type of primary containment in the space provided. 464b. PIPING SECONDARY CONTAINMENT-Check the material(s) used to construct the secondary containment system(s)(i.e., secondary piping, trench) provided for the product/waste piping.For single-wall piping systems,check"None." 464c. If you checked"Other"specify the type of secondary containment in the space provided. 464d. PIPING/TURBINE CONTAINMENT SUMP TYPE-Indicate the type of piping/turbine containment sump(s).Check"None"if not present. 464e-el VENT PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)vent piping. (Note:Address venting of the tank primary containment only.)Specify Other type of containment in the space provided. 464-171 VENT SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping,)provided for the vent piping. For single-wall piping systems, check "None." (Note: Address venting of the tank primary containment only.) Specify Other type of containment in the space provided. 4648-g1 VR PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e.,inner)vapor recovery piping. For tanks without vapor recovery piping(e.g.,Diesel tanks),check"None." Specify Other type of containment in the space provided. 464h-h I VR SECONDARY CONTAINMENT-Check the material(s)used to construct the secondary containment system(s)(e.g.,secondary piping)provided for the vapor recovery piping.For single-wall piping systems,check"None." Specify Other type of containment in the space provided. 4641. VENT PIPING TRANSITION SUMP TYPE-Indicate type of transition sump(s).Check"None"if not present. 464j-jI RISER PRIMARY CONTAINMENT-Check the material(s)used to construct the primary(i.e..inner)piping for all risers(not drop tubes)other than annular space risers(i.e.,risers For filling or gauging of the primary tank). Specify Other type of containment in the space provided. 464k-kl RISER SECONDARY CONTAINMENT-Check the material(s)used to construct secondary containment system(s)(i.e.,secondary piping,sumps)provided for the riser piping.For risers without secondary containment,check"None." Specify Other type of containment in the space provided. 451a-c. FILL COMPONENTS INSTALLED-Check the appropriate boxes to show that spill containment, tank bottom protection,and fill containment sumps(if applicable)are installed. 469a. UDC CONSTRUCTION TYPE-Check the box to describe the type of dispenser containment system(s)(i.e.,dispenser sumps or pans). If the system has no dispensers(e.g.,standby generator tank system),check"No Dispensers." If the system has a dispenser,but no UDC,check"None". 469b. UDC CONSTRUCTION MATERIAL-Check the box to describe the materials used to construct the UDC. 469c. If you checked"Other"specify the construction material in the space provided. 448. STEEL COMPONENT PROTECTION-All systems contain some steel components. Check the appropriate box(es)to describe all corrosion protection methods used. "Isolation" means electrical isolation from soil, backfill, and groundwater Examples include fiberglass cladding, non-metallic secondary containment systems which isolate steel components from the sub-surface environment,and insulating bushings. APPLICANT SIGNATURE-The same person who signs the UST Operating Permit Application-Facility Information Form shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true and accurate, and that the UST system is compatible with the hazardous substance stored. 470. DATE-Enter the date the form was signed. 471. APPLICANT NAME-Print or type the name of the person signing the form. 472. APPLICANTr TITLE-Enter the title of the person signing the form. UPCF UST-13-2!2 Rev.(120-007) UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN-(Page 1 of 2) TYPE OF ACTION ❑ 1.NEW PLAN ❑ 2.CHANGE OF INFORMATION 490.1 PLAN TYPE ❑ I.MONITORING IS IDENTICAL FOR ALL USTs AT THIS FACILITY. 490"2 (Check one item only) ❑ 2.THIS PLAN COVERS ONLY THE FOLLOWING UST SYSTEM(S) I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME) , 100 .2 3. BUSINESS SITE ADDRESS(��tJ/ q 103' CITY II.EQUIPMENT TESTING AND PREVENTIVE MAINTENANCE Testing,preventive maintenance,and calibration of monitoring equipment(e.g.,sensors,probes,line leak detectors,etc.)must be performed at the frequency specified by the equipment manufacturers'instructions,or annually,whichever is more frequent,and that such work must be performed by qualified personnel. _21 CCR§12632,2634,2638L2641L MONITORING EQUIPMENT IS SERVICED 1.ANNUALLY 99.OTHER a90-3 Q ---- ❑ (Specify):Y) 490-3b b III.MONITORING LOCATIONS Ll 1.NEW SITE PLOT PLAN/MAP SUBMITTED WITH THIS PLAN. 2.SITE PLOT PLAN/MAP PREVIOUSLY SUBMITTED. (23 CCR§2632, 2634)4'X04 IV.TANK MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S): W-1.CONTINUOUS ELECTRONIC TANK MONITORING OF ANNULAR(INTERSTITIAL)SPACE(S)OR SECONDARY CONTAINMENT 490-5 VAULT(S)WITH AUDIBLE AND VISUAL ALARMS. (23 CCR§2632,2634) SECONDARY CONTAINMENT IS: ®a.DRY ❑ b.LIQUID FILLED ❑ c.PRESSURIZED ❑d.UNDER VACUUM 490"6 ------------------------------------------------- ---------------- __ P_AN_E_LMAN_U_FACTURER: � i�Q -090"3'? MODEL# °948 -----"----- -- ----------------490--1--MODE •#-- -` LEAK SENSOR MANUFACTURER: p� 43U 9 MODEL#(S): 77 0 - 49o-10 ❑ 2.AUTOMATIC TANK GAUGING(ATG)SYSTEM USED TO MONITOR SINGLE WALL TANK(S).(23 CCR§2643) 490-11 PANEL MANUFACTURER: 490-12. MODEL#: 490"13 IN-TANK PROBE MANUFACTURER: 490"14' MODEL#(S): 490-15 LEAK TEST FREQUENCY: ❑ a.CONTINUOUS ❑ b.DAILY/NIGHTLY ❑ c.WEEKLY 490-16 ❑ d.MONTHLY ❑ e.OTHERS if 491117 PROGRAMMED TESTS: ❑ a.0.1 g.p.h. ❑ b.0.2 g P h. ❑ c.OTHER(S(Specify): 490-18 490"19 ❑ 3.MONTHLY STATISTICAL INVENTORY RECONCILIATION(23 CCR§2646.1): 490-20 E3 4.WEEKLY MANUAL TANK GAUGING(MTG)(23 CCR§2645). TESTING PERIOD: ❑ a.36 HOURS [:1 b.60 HOURS 490-21 a9u-zz ❑ 5.TANK INTEGRITY TESTING(23 CCR§2643.1): 490-z3 TEST FREQUENCY: ❑ a.ANNUALLY ❑ b.BIENNIALLY ❑ c.OTHER(Specify): 4W-25 a>t1-zs ❑99.OTHER (Specify): 490-26 490•n V.PIPE MONITORING IS PERFORMED USING THE FOLLOWING METHOD(S)(Check all that apply) 1.CONTINUOUS MONITORING OF PIPE/PIPING SUMPS)AND OTHER SECONDARY CONTAINMENT WITH AUDIBLE AND 490-28 VISUAL ALARMS. (23 CCR§2636) �,� SECONDARY CONTAINMENT IS:5a.DRY ❑b.LIQUID FILLED ❑c.PRESSURIZED ❑d.UNDER VACUUM 490.29 --------------------------- -------- - -- �7� e 490-30 ----- - - --- - -- - PANEL MANUFACTURER: MODEL 4'>D 31 ---------------- LEAK SENSOR MANUFACTURER:- 4911-32 MODEL#(S):��G��= 490-33 -------------------------------- - -- -- - --- ---------------- - - -- - PIPING LEAK ALARM TRIGGERS AUTOMATIC PUMP(i.e.,TURBINE)SHUTDOWN. ❑a YES ❑b.NO 490.34 FAILURE/DISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 490-35 2.MECHANICAL LINE LEAK DETECTOR(MLLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS AND RESTRICTS OR SHUTS OFF - _ PRODUCT FLOW WHEN A LEAK IS DETECTED 23 CCR§2636 490-30 MLLD MANUFACTURER(S): cxc 411"37 MODEL#(S): / 4938 ❑ 3. ELECTRONIC LINE LEAK DETECTOR(ELLD)THAT ROUTINELY PERFORMS 3.0 g.p.h.LEAK TESTS (23 CCR§2636) 490-39 49(1-011. I 490-41 ELLD MANUFACTURER(S)URER S ------ -- -- L MODEL#(S):--------•--------------------- -- -------------------------------------------------- - -- - -- - PROGRAMMED IN LINE LEAK TEST: ❑ 1.MINIMUM MONTHLY 0.2 g.p.h. ❑ 2.MINIMUM ANNUAL 0.1 g.p.h. 490-42 ELLD DETECTION OF A PIPING LEAK TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 49043 ELLD FAILURE/DISCONNECTION TRIGGERS AUTOMATIC PUMP SHUTDOWN. ❑a.YES ❑b.NO 4%-4 ❑ 4.PIPE INTEGRITY TESTING 490-45 TEST FREQUENCY ❑ a ANNUALLY ❑ b.EVERY 3 YEARS ❑ c.OTHER(Specify) 490-(6490-47 El 5.VISUAL PIPE MONITORING. 49148 FREQUENCY ❑ a.DAILY ❑ b.WEEKLY ❑c.MIN.MONTHLY&EACH TIME SYSTEM OPERATED- 491.49 Allm ed for monitoring of unburied emer mn enermor fuel piping only per HSC§2528 1.3(bX3) ❑ 6.SUCTION PIPING MEETS EXEMPTION CRITERIA 123 CCR§2636(ax3)1. 490-50 7.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM 4'x1-51 ❑ 99.OTHER(Specify) 491'-52 490-53 UPCF UST-D(12/2007)1/4 UST Monitoring Plan-Page 1 Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submitted with your initial UST Operating Permit Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to obtain approval prior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-1. TYPE OF ACTION-Check the appropriate box to indicate why this plan is being submitted. 490.2. PLAN TYPE-Check the appropriate box to indicate whether this plan covers all,or merely some,of the USTs at the facility. If the plan covers only some of the tanks, identify those tanks in the space provided[e.g.,by using the Tank ID#(s)in item 432 of the UST Operating Permit Application-Tank Information Form(s)J. 1. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete Facility Name. 103. BUSINESS SITE ADDRESS-Enter the street address where the facility is located,including building number,if applicable.Post office box numbers are not acceptable This information must provide a means to locate the facility geographically. 104. CITY-Enter the city or unincorporated area in which the facility is located. 490-3a MONITORING EQUIPMENT IS SERVICED-Check the appropriate box to specify the frequency of monitoring equipment test ing/certification. 490-3b Specify Other frequency for monitoring equipment servicing. 490-4 SITE PLAN-Indicate if a site plan/map is submitted with this monitoring plan or if it was submitted previously and is current for the facility.Monitoring plans must include a Site Plot Plan,Map showing the tank and piping layouts and the locations where monitoring is performed(i.e.,location of sensors,probes,line leak detectors,monitoring system control panel,etc.). 490-5 IV-1 CONTINUOUS ELECTRONIC MONITORING-Indicate ifthis monitoring method is being used to monitor the tanks. 490-6 SECONDARY CONTAINMENT-If I V-I is checked,check the appropriate box to describe the environment inside the tank secondary containment. 490-7 PANEL MANUFACTURER--If 1 V-1 is checked,enter the name of the manufacturer of the monitoring system control panel(console). 490-8 MODEL#-If IV-1 is checked,enter the model number for the monitoring system control panel. 490-9 LEAK SENSOR MANUFACTURER-If I V-1 is.checked,enter the name of the manufacturer of the sensor(s).If additional space is needed,use Section X. 490-10 MODEL#(S)--If IV-1 is checked,enter the model number for each type of sensor installed.If additional space is needed,use Section X. 490-11 IV-2 AUTOMATIC TANK GAUGING-Indicate ifthis method is used for monitoring the UST's. 490-12 PANEL MANUFACTURER-if I V-2 is checked,enter the name of the manufacturer of the monitoring system control panel(console). 490-13 MODEL#-If IV-2 is checked,enter the model number for the monitoring system control panel. 490-14 IN-TANK PROBE MANUFACTURER-If IV-2 is checked,enter the name of the manufacturer of the probe(s). 490-15 MODEL#(S)-If IV-2 is checked,enter the model number for each type of in-tank probe installed.If additional space is needed,use Section X. 490-16.LEAK TEST FREQUENCY-If I V-2 is checked,check the appropriate box to describe the in-tank leak test frequency. 490-17.SPECIFY-117490-16e is checked,enter the frequency of programmed leak tests. 490-18.PROGRAMMED TESTS-If IV-2 is checked,check the appropriate box to describe the tests programmed into the ATG system. 490-19.SPECIFY-If 490-18c is checked,enter the frequency of in-tank leak testing. 490-20.IV-3 INVENTORY RECONCILIATION-Check the box if statistical inventory reconciliation is performed. 490-21.1 V4 WEEKLY MANUAL TANK GAUGING.Indicate if this method is used to monitor the tanks. 490-22.TESTING PERIOD-If I V-4 is checked,check the appropriate box to describe the MTG testing period. 490-23.IV-5 TANK INTEGRITY TESTING:Indicate ifthis method is used to monitor the tanks. 490-24.TEST FREQUENCY-If IV-5 is checked,check the appropriate box to describe the frequency of tank integrity testing. 490-25.OTHER:If 490-24c is checked,specify other test frequency. 490-26.IV-99 OTHER:Indicate if monitoring of the tanks occurs that is not indicated in any other category. 490-27.If IV-99 is checked,enter a brief description of the other tank monitoring method(s)used(e.g.,vadose zone monitoring per 23 CCR§2647,groundwater monitoring per 23CCR§2648). Include the monitoring frequency(e.g.,Continuous,Weekly). If additional space is needed,use Section X. 490-28, V-1 CONTINUOUS MONITORING OF PIPE/PIPING SUMP(S)AND OTHER SECONDARY CONTAINMENT WITH AUDIB LE AND VISUAL ALARMS: Indicate if this is the monitoring method used for the piping. . 490-29.SECONDARY CONTAINMENT:If V-1 is checked,Check the appropriate box to describe the environment inside piping secondary containment 490-30.PANEL MANUFACTURER-If V-1 is checked,enter the name of the manufacturer of the monitoring system control panel(console). 490-31.MODEL#-If V-I is checked,enter the model number for the monitoring system control panel. 490-32.LEAK SENSOR MANUFACTURER-If V-I is checked,enter the name of the manufacturer of the sensor(s). 490-33.MODEL#(S)-If V-1 is checked,enter the model number for each type of sensor installed.If additional space is needed,use Section X. 490-34.PIPING LEAK ALARM T RIGGERS AUTOMATIC PUMP SHUTDOWN -If V-1 is checked,check Yes or No. 490-35.FAILUREMISCONNECTION OF THE MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-If V-1 is checked,check Yes or No. 490-36.V-2 PIPE MECHANICAL LINE LEAK DETECTORS PERFORM 3 GPH LEAK TESTS:Indicate ifthis monitoring method is used to monitor the pipelines. 490.37.MLLD MANUFACTURER(S)-if V-2 is checked,enter the name(s)of the manufacturer(s)of the mechanical line leak detector(s).If additional space is needed,use Section X. 490.38.MODEL#(s)-If V-2 is checked,Enter the model number for each type of mechanical line leak detector installed.If additional space is needed,use Section X. 490-39.V-3 PIPE ELECTRONIC LINE LEAK DETECTORS:Indicate ifthis monitoring method is used to monitor the pipelines. 49440.ELLD MANUFACTURER-If V-3 is checked,Enter the name of the manufacturer of the electronic line leak detector(s). 490-41.MODEL#(S)n- If V-3 is checked,enter the model number for each type of electronic line leak detector installed.If additional space is needed,use Section X. 49442.PROGRAMMED LINE INTEGRITY TESTS-If V-3 is checked,check the appropriate box to describe the type of tests programmed into the monitoring system. 490-43.ELLD DETECTION OF A PIPING LEAK ALARM TRIGGERS PUMP SHUTDOWN-If V-1 is checked,check Yes or No. 49444.ELLD DETECTION OF A PIPING LEAK FAILURE1DfSCONNECTION TRIGGERS PUMP SHUTDOWN.-If V-1 is checked,check Yes or No. 49445.V-4 PIPE INTEGRITY TESTING-Indicate if this monitoring method is used to monitor the pipelines- 490-46.TEST FREQUENCY-If V-4 is checked,check the appropriate box to describe the frequency of pipe integrity testing. 49447.SPECIFY-11749046-99 is checked,enter the frequency of pipe integrity testing. 490-48.V-5 VISUAL PIPE MONITORING- Indicate if this monitoring method is used to monitor the pipelines. 490-49.If V-5 is checked,check the appropriate box to describe the frequency of visual monitoring. 490-50.SUCTION PIPING MEETS EXEMPTION CRITERIA- Indicate ifthis monitoring method is used to monitor the pipelines. 490-51.NO REGULATED PIPING PER HEALTH AND SAFETY CODE,DIVISION 20,CHAPTER 6.7 IS CONNECTED TO THE TANK SYSTEM- Check this box if no piping in the tank system is regulated under the UST law,or there is no piping. 490-52.V-99 OTHER-Indicate if another method is used for pipeline monitoring. 490-53.SPECIFY-Enter a brief description of the other line monitoring method(s)used. If additional space is needed,see Section X. Be sure to clearly describe monitoring method(s)and frequency. This monitoring plan must include a Site Plan showing the general tank and piping layouts and the locations where monitoring is performed(i.e.,location of each sensor,line leak detector,monitoring system control panel,etc.). If you already have a diagram(e.g.,current UST Monitoring Site Plan from a Monitoring System Certification form,Hazardous Materials Business Plan map,etc.)that shows all required information,include it with this plan. UPCF UST-D(12/2007)2/4 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK MONITORING PLAN (Page 2 of 2) VI.UNDER DISPENSER CONTAINMENT(UDC)MONITORING 1. UDC MONITORING IS PERFORMED USING THE FOLLOWING METHOD 449U-SJb vo-s4a �� SCI 1.CONTINUOUS ELECTRONIC MONITORING ❑2.FLOAT AND CHAIN ASSEMBLY ❑ 3.ELECTRONIC STAND-ALONE ❑ 4.NO DISPENSERS ❑99.OTHER_(Specif,)_— _ _ _ __ _ _ _ _ _ __________ ---------------------- -- ---- ---- - PANEL MANUFACTURER: 490-55 I MODEL k:��-ry � 490.56. LEAK SENSOR MANUFACTU�� - L.r MODEL k(3): ago-s7 49 o-sa DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS Pla.YES ❑b.NO 490.59 UDC LEAK ALARM TRIGGERS AUTOMATIC PUMP SHUTDOWN Fla.YES ❑b.NO 490-60 FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN. 91a.YES ❑b.NO 49"1 UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER. ❑ a.YES ❑b.NO 4%_62 2.UDC CONSTRUCTION IS [11.SINGLE-WALLED [:12.DOUBLE-WALLED 49t"3 IF DOUBLE WALLED: 490a4o _— UDC INTERSTITIAL SPACE_IS MONITORED BY--El_l.LIQUID [:12.PRESSURE-[--]3_VACUUM A LEAK WITHIN THE SECONDARY CONTAINMENT OF THE UDC TRIGGERS AUDIBLE AND VISUAL ALARMS ❑a YES ❑b.NO 41.b VII.PERIODIC SYSTEM TESTING 1. ELD TESTING: THIS FACILITY HAS BEEN NOTIFIED BY THE STATE WATER RESOURCES CONTROL BOARD THAT ENHANCED 490-65. _LEAK DETECTION(ELD)MUST BE PERFORMED. PERIODIC ELD IS PERFORMED EVERY 36 MONTHS AS R_EQUIRED�(23 CCR§2644 _ M2.SECONDARY CONTAINMENT COMPONENTS ARE TESTED EVERY 36 MONTHS. 490-66 -- ------------------------------------------- -------------------- --------------------- �'3 SPILL BUCKETS ARE TESTED ANNUALLY, a9o�� VIII.RECORDKEEPING The following monitoring/ma*enance records are kept for this facility: Alarm logs 49G-68a Visual Inspection Records 490.68b ❑Tank integrity testing results 4xwee ❑SIR testing results(and supporting documentation records). 490-68d ❑ Tank gauging results(and supporting documentation records). 490-bae R ATG Testing results(and supporting documentation records).ivo-bar ❑ Corrosion Protection 60-day logs 49n-b8g Equipment maintenance and calibration records. 490-68h IX.TRAINING Personnel with UST monitoring responsibilities are familiar with all of the following documents relevant to their job duties. 4%-69a REFERENCE DOCUMENTS MAINTAINED AT FACILITY(Check all that apply) W frws UNDERGROUND STORAGE TANK MONITORING PLAN(Required)490(9b 910PERATING MANUALS FOR ELECTRONIC MONITORING EQUIPMENT(Required)490-61x ❑ CALIFORNIA UNDERGROUND STORAGE TANK REGULATIONS 4%-69d ❑ CALIFORNIA UNDERGROUND STORAGE TANK LAW 490-6% ❑ STATE WATER RESOURCES CONTROL BOARD (SWRCB) PUBLICATION: "HANDBOOK FOR TANK OWNERS - MANUAL AND STATISTICAL INVENTORY RECONCILIATION"49469f ❑ SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS"490-699 ❑ OTHER(Specify):M69h.W% This facility has a"Designated UST Operator"who has passed the California UST System Operator Exam administered by the International Code Council(ICC). The"Designated UST Operator"wilt train facility employees in the proper operation and maintenance of the UST systems annually,and within 30 days of hire.This training will include,but is not limited to,the following: • Operation of the UST systems in a manner consistent with the facility's best management practices • The facility employee's role with regard to the monitoring equipment as specified in this UST Monitoring Plan • The facility employee's role with regard to spills and overfills as specified in the UST Response Plan D Names of contact person(s)for emergencies and monitoring alarms.490-70 X. COMMENTS/ADDITIONAL INFORMATION Provide additional comments here or indicate how many pages with additional information on specific monitoring procedures are attached to this plan.490-71 XI.PERSONNEL RESPONSIBILITIES The UST Owner/Operator is responsible for ensuring that: 1)the daily/routine UST monitoring activities and maintenance of UST leak detection equipment covered by this plan occurs,2)all conditions that indicate a possible release are investigated,and 3)all monitoring records are maintained properly. The following person(s)are responsible for performing the monitoring and equipment maintenance: NAME GY db 490-72 TITLE 4%-73 NAME 490.74 TITLE 490-75 The Designated Operator shall perform a monthly visual inspection of the facility, provide a report to the owner/operator, and inform the owner/operator of any conditions that need follow-up action. XII.OWNER/OPERATOR SIGNATURE CERTIFICATION: 1 certify that the information provided is true and accurate to the best of my knowledge. APPLICANT SIGNAT 4'xi-76 DATE:/ 490.77 R T an r/ 0 3.F i rned0 0 3. 'zed Rgprnotkv c of Qw ver APPLICANT NAME(print): 490.78 APPLICANT TITLE: 490-79 PL-1. Lla=Aj r Aae B UPCF UST-D(122007)3/4 (Agency Use Only) This plan has been reviewed and: ❑Approved ❑Approved With Conditions Local Agency Signature: Date: Comments or Special Conditions: UST Monitoring Plan-Page 2 Instructions Complete a separate UST Monitoring Plan for each UST monitoring system at the facility. This form must be submitted with your initial UST Operating Permit Application and within 30 days of changes in the information it contains. Please note that your local agency may require you to obtain approval prior to installing or modifying monitoring equipment. (Note: Numbering of these instructions follows the data element numbers on the form.) 490-54a.MONITORING OF THE UNDER DISPENSER CONTAINMENT-Indicate the method used for UDC monitoring. 490-54b.SPECIFY-If 99"Other•is checked,describe other method used. If VI-I-1,VI-1-2 or VI-1-3 or VI-1-99 is checked,complete 490-55 to 490-64b. 490-55. PANEL MANUFACTURER-Enter the name of the manufacturer of the monitoring system control panel(console). If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490-56. MODEL#- Enter the model number for the monitoring system control panel(console).If there is no control panel(e.g.,only an electrical relay box is installed)leave this space blank. 490-57. LEAK SENSOR MANUFACTURER-Enter the name of the manufacturer of the sensor(s). 490-58. MODEL#(S)-Enter the model number of the sensor(s)installed.If additional space is needed,use Section X. 490-59. DETECTION OF A LEAK INTO THE UDC TRIGGERS AUDIBLE AND V1SUAt,ALARMS. Indicate Yes or No 490-60. UDC LEAK ALARM TRIGGERS PUMP SHUTDOWN- Indicate Yes or No 490-61. FAILURE/DISCONNECTION OF UDC MONITORING SYSTEM TRIGGERS AUTOMATIC PUMP SHUTDOWN-Indicate Yes or No 490-62. UDC MONITORING STOPS THE FLOW OF PRODUCT AT THE DISPENSER-Indicate Yes or No. 490-63. UDC CONSTRUCTION- Indicate if the construction of the UDC is single-walled,or double-walled. 490-64a.DOUBLE-WALLED INTERSTITIAL SPACE MONITORING- Indicate what is used to monitor the interstitial space. 490-64b.LEAK WITHIN THE SECONDARY CONTAIMENT OF UDC TRIGGERS AUDIBLE AND VISUAL ALARMS-Indicate Yes or No 490-65. VII-1 ELD TESTING-Check the box if you have been notified by the State Water Resources Control Board(SWRCB)that the UST(s)covered by this plan is/are subject to Enhanced Leak Detection Requirements(i.e.,UST-has any single-wall component and is located within 1,000 feet of a public drinking water well). 490-66. TESTING OF SECONDARY CONTAINMENT COMPONENTS EVERY 36 MONTHS-Check the box if you have secondary containment that requires testing. 490-67. SPILL BUCKET TESTING-Check the box if you have spill buckets. 490-68a-h.VIII RECORDKEEPING-indicate which monitoring and equipment maintenance records are maintained for this facility. 490-69a IX TRAINING STATEMENT-Check the box to verify that the statement is true. REFERENCE DOCUMENTS MAINTAINED AT FACILITY-Check the appropriate boxes to describe reference documents maintained at the facility. Note that the first two items on the list must be kept at the facility. 490-69b. MONITORING PLAN:Indicate that this plan is kept as a reference document. 490.69c. OPERATING MANUALS FOR ELECTRONIC EQUIPMENT:Indicate that this plan is kept as a reference document. 490-69d. CA UST REGULATIONS-Indicate that this is kept as a reference document. 490-69e. CA UST LAW-Indicate that this is kept as a reference document. 490-69f.STATE WATER RESOURCES CONTROL BOARD(SWRCB)PUBLICATION- "HANDBOOK FOR TANK OWNERS-MANUAL AND STATISTICAL INVENTORY RECONCILIATION-Indicate that this is kept as a reference document. 490-69g.SWRCB PUBLICATION:"UNDERSTANDING AUTOMATIC TANK GAUGING SYSTEMS":Indicate that this is kept as a reference document. 490-69h.OTHER-Indicate that other reference documents are kept. 490-69i. SPECIFY-If"OTHER'•is checked,enter a brief description of the other document(s)maintained at the facility.If additional space is needed,see Section X. 490-70. DESIGNATED OPERATOR TRAINING-Check this box to verify that this statement is true. 490-71. COMMENTS/ADDITIONAL INFORMATION-Make additional comments or you may attach and identify the number of additional pages of information to describe any additional UST system monitoring-related information(e.g.,additional information required by your local agency). Attach any monitoring logs that you will be using for the monitoring ofyour tank system. 490-72. NAME-Enter the name of the person who routinely conducts the monitoring and equipment maintenance under this plan. 490-73. TITLE- Enter the title of the person. 490-74. NAME-Enter the name of the second person,if applicable,who routinely conducts the monitoring and equipment maintenance under this plan. 490-75. TITLE- Enter the title of the second person OWNER/OPERATOR SIGNATURE-The tank owner/operator,facility owner/operator,or an authorized representative of the owner shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true,accurate,and complete,and that the training program specified in Section IX has been implemented. 490-76. REPRESENTING--Check the appropriate box to indicate whether the signer is the UST owner/operator,the UST facility owner/operator,or an authorized representative of the owner. 490-77, DATE-Enter the date the plan was signed. 490-78. APPLICANT NAME-Print or type the name of the person signing the plan. 490-79. APPLICANT TITLE-Enter the title of the person signing the plan. UPCF UST-D(12/2007)4/4 UNDERGROUND STORAGE TANK RESPONSE PLAN- PAGE 1 (One form per facility) TYPE OF ACTION ❑ 1.NEW PLAN ❑ 2.CHANGE OF INFORMATION Rol. L FACILITY INFORMATION FACILITY ID# (Agency Use Only) BUSINESS NAME(Same as FACIL TY NAME) Roe. re BUSINESS S110PE ADD SS R03. CITY R 04. Cn� s ' /,/ II. SPILL CONTROL AND CLEANUP METHODS This plan addresses unauthorized releases from UST systems and supplements the emergency response plans and procedures in the facility's Hazardous Materials Business Plan. If safe to do so,facility personnel will take immediate measures to control or stop any release(e.g.,activate pump shut-off,etc.)and,if necessary,safely remove remaining hazardous material from the UST system. ➢ Any release to secondary containment will be pumped or otherwise removed within a time consistent with the ability of the secondary containment system to contain the hazardous material,but not greater than 30 calendar days,or sooner if required by the local agency. Recovered hazardous materials,unless still suitable for their intended use,will be managed as hazardous waste. ➢ Absorbent material will be used to contain and clean up manageable spills of hazardous materials. Absorbent material which has become too saturated to be effective or which is no longer intended for use will be managed as hazardous waste unless a waste determination in accordance with 22 CCR§66262.11 finds that it is non-hazardous. Used absorbent material, reusable or waste, will be stored in a properly labeled and sealed container. Waste material shall be disposed appropriately. ➢ Facility personnel will determine whether any water removed from secondary containment systems, or from clean-up activity, has been in contact with any hazardous material.If the water is contaminated,it will be managed as hazardous waste unless a waste determination in accordance with 22 CCR§66262.11 finds that it is non-hazardous. If the water has a petroleum sheen(i.e.,rainbow colors),it is contaminated. A thick floating petroleum layer may not necessarily display rainbow colors. Water(hazardous or non-hazardous)from sumps,spill containers,etc.will not be disposed to storm water systems. ➢ We will review secondary containment systems for possible deterioration if any of the following conditions occur: I. Hazardous material in contact with secondary containment is not compatible with the material used for secondary containment; 2. Secondary containment is prone to damage from any equipment used to remove or clean up hazardous material collected in secondary containment; 3. Hazardous material, other than the product/waste stored in the primary containment system, is placed inside secondary containment to treat or neutralize released product/waste,and the added material or resulting material from such a combination is not compatible with secondary containment. III. SPILL CONTROL AND CLEAN-UP EQUIPMENT PERIODIC MAINTENANCE: Spill control and clean-up equipment,kept permanently on-site is listed in the facility's Hazardous Materials Business Plan. This equipment is inspected at least monthly,and after each use,supplies are replenished as needed. Defective equipment is repaired or replaced as necessary. EQUIPMENT NOT PERMANENTLY ON-SITE,BUT AVAILABLE FOR USE IF NEEDED: (Complete nly if applicable) EQUIPMENT LOCATION AVAILABILITY 10. R20. Rau. RI I. R21. R31. R12. R22. R32. R13. / � ��O R23. R33. RI4. R24. R34. R15. R25. j R35. IV. RESPONSIBLE PERSONS THE FOLLOWING PERSON(S)IS/ARE RESPONSIBLE FOR AUTHORIZING ANY WORK NECESSARY UNDER THIS RESPONSE PLAN: ME R40. TITLE Rya i v N ME R41, TITLE R51. �Lplg R42. TIT R52. h1E R43. T TIL Rs3. V. MONITORING INDICATORS IF MONITORING INDICATES A POSSIBLE UNAUTHORIZED RELEASE,STEPS TO VERIFY THE RELEASE WILL BE MADE AS FOLLOWS: ❑Additional system testing or data collection ❑Inspection by qualified persons ❑Recalibration of equipment Other: R60. UST Response Plan(3/2008)-U3 UST Response Plan—Instructions Complete one UST Response Plan for each UST facility. This form must be submitted with your initial UST Operating Permit Application and within 30 days of changes in the information it contains. It supplements the Emergency Response Plans and Procedures in the facility's Hazardous Materials Business Plan.(Note: Numbering of these instructions follows the data element numbers on the form.) RO 1. TYPE OF ACTION—Check the appropriate box to indicate why this plan is being submitted. FACILITY ID NUMBER—This space is for agency use only. R02. BUSINESS NAME—Enter the complete Facility Name. R03. BUSINESS SITE ADDRESS — Enter the street address where the facility is located, including building number,if applicable. Post office box numbers are not acceptable. This infonmation must provide a means to locate the facility geographically. R04. CITY—Enter the city or unincorporated area in which the facility is located. R10. EQUIPMENT—If you have spill control or clean-up equipment kept off-site, list that equipment in sections RIO through R15. If no equipment is kept off-site,leave this section blank. R20. LOCATION—If you have spill control or clean-up equipment kept off-site, list the equipment location(s)sections R20 through R25. If no equipment is kept off-site,leave this section blank. R30. AVAILABILITY—If you have spill control or clean-up equipment kept off-site, list the equipment availability in sections R30 through R35. If no equipment is kept off-site,leave this section blank. R40. NAME—At least one person responsible for authorizing any work necessary under this UST Response Plan must be identified. Use sections R40 through R43 to list the name(s)of the responsible person(s). R50. TITLE—At least one person responsible for authorizing any work necessary under this UST Response Plan must be identified. Use sections R50 through R53 to list the job title(s)of the responsible person(s). R60. MONITORING INDICATORS Briefly describe the steps that will be taken to verify the presence or absence of a release if the tank monitoring system indicates the possibility of a release. OWNER/OPERATOR SIGNATURE—The owner/operator shall sign in the space provided. This signature certifies that the signer believes that all information submitted is true,accurate,and complete. R70. DATE—Enter the date the plan was signed. R71. OWNER/OPERATOR NAME—Print or type the name of the person signing the plan. R72. OWNER/OPERATOR TITLE—Enter the title of the person signing the plan. UST Response Plan(312008)-2/3 UNDERGROUND STORAGE TANK RESPONSE PLAN - PAGE 2 VI. REPORTING AND RECORD KEEPING We will report/record any overfill,spill,or unauthorized release from a UST system as indicated in this plan. Recordable Releases: Any unauthorized release from primary containment which the UST operator is able to clean up within eight(8)hours after the release was detected or should reasonably have been detected,and which does not escape from secondary containment,does not increase the hazard of fire or explosion,and does not cause any deterioration of secondary containment,must be recorded in the facility's monitoring records. Monitoring records must include: The UST operator's name and telephone number; ➢ A list of the types,quantities,and concentrations of hazardous substances released; A description of the actions taken to control and clean up the release; The method and location of disposal of the released hazardous substances,and whether a hazardous waste manifest was or will be used; A description of actions taken to repair the UST and to prevent future releases; Y A description of the method used to reactivate interstitial monitoring after replacement or repair of primary containment. Reportable Releases: Any overfill,spill,or unauthorized release which escapes from secondary containment(or primary containment if no secondary containment exists),increases the hazard of fire or explosion,or causes any deterioration of secondary containment,is a reportable release. Reportable releases are also recordable. Within 24 hours after a reportable release has been detected,or should have been detected,we will notify the local agency administering the UST program of the release,investigate the release,and take immediate measures to stop the release. If necessary,or if required by the local agency,remaining stored product/waste will be removed from the UST to prevent further releases or facilitate corrective action. If an emergency exists,we will notify the State Office of Emergency Services. Within five(5)working days of a reportable release,we will submit to the local agency a full written report containing all of the following information to the extent that the information is known at the time of filing the report: • The UST owner's or operator's name and telephone number, • A list of the types,quantities,and concentrations of hazardous materials released; ➢ The approximate date of the release; ➢ The date on which the release was discovered; ➢ The date on which the release was stopped; Y A description of actions taken to control and/or stop the release; ➢ A description of corrective and remedial actions,including investigations which were undertaken and will be conducted to determine the nature and extent of soil,ground water or surface water contamination due to the release; ➢ The method(s)of cleanup implemented to date,proposed cleanup actions,and a schedule for implementing the proposed actions; ➢ The method(s)and location(s)of disposal of released hazardous materials and any contaminated soils,groundwater,or surface water. ➢ Copies of any hazardous waste manifests used for off-site transport of hazardous wastes associated with clean-up activity; ➢ A description of proposed methods for any repair or replacement of UST system primary/secondary containment systems; ➢ A description of additional actions taken to prevent future releases. We will follow the reporting procedures described above if any of the following conditions occur: D A recordable unauthorized release can not be cleaned up or is still under investigation within eight(8)hours of detection; D Released hazardous substances are discovered at the UST site or in the surrounding area; ➢ Unusual operating conditions are observed,including erratic behavior of product dispensing equipment,sudden loss of product,or the unexplained presence of water in the tank,unless system equipment is found to be defective and is immediately repaired or replaced,and no leak has occurred; Monitoring results from UST system monitoring equipment/methods indicate that a release may have occurred,unless the monitoring equipment is found to be defective and is immediately repaired,recalibrated,or replaced,and additional monitoring does not confirm the initial results. Record Retention: Monitoring records and written reports of unauthorized releases must be maintained on-site(or off-site at a readily available location,if approved by the local agency)for at least 3 years. Hazardous waste shipping/disposal records(e.g.,manifests)must be maintained for at least 3 years from the date of shipment. VII. OWNER/OPERATOR SIGNATURE CERTIFICATION: I certify that the information provi is true and accurate to the best of my knowledge. OWNER/OPERATOR SIG DATE p� aro O Z OWNER/OPERATOR NAME(print) R71. OWN ER/O ERATOR TITLE Rri' 7Q. r (Agency Use Only) This plan has been reviewed and: ❑Approved ❑Approved With Conditions ❑Disapproved Local Agency Signature: Date: UST Response Plan(3/2008)-3/3 Jaco Hill Company 3101 State Road, Bakersfield,California 93308. ***P O.;Mi-182515, Bakersfield Callfornia,93380-2515 P6ne:^661393-7000':7Faxc661-393-8738' October 1,,200,9 LETTER.FROM CHIEF;FINANCIAL.OFFICER I am the.Chief Financial Officer for Jaco Hill'Co'mpany. This letter is m support.of the Underground Storage Tank Cleanup'Fund to demonstrate�;financial.responsibility for-taking corrective',action'and/or compensating:third parties for°bodily injurq.arid property damage caused by an unauthorized release of petroleum in the amount ofat least ,$10;000 per occurrence; and $10000 annual aggregate coverage. Ondergr&ind;storage.tanks at th'e fo116WingfadiIitibs,are assuredyby this letter. .Fastrip#33, 640.1 S. "H" St., Bakersfield; CA 93304 1. Amount of annual aggregate-coverage,being assured.bythis,letter, $ 10;000 2. Total tangible assets: 7,954,400 r 3. Total liabilities: 1,236;000 4. Tangible net worth: 6,71$1000 I hereby certify that the>wording of%this letter is identical to the wording specified by subsection 2801:.1(4)(1), Chapter'18,,Division 3;'Title23 of the California Code of Regulations. I declare;under penalty of perjury that the foregoing.is'true an&correct'to!the best;of my knowledge antl belief. . . E3ixgpea c er l Octobe 1. 2009 ' ' Name: Brian Bu Title: Chief Financial`Officer i State.of6iifornia: �ForSt l7seOnlyt'r State of Water Resources Control Board;, - I)rvrsion of Financial Assistance Sacrmnertto CA ¢ P:O Box94421 9424.42120 (]nstrucuons:qrk revmc.iidc), CERTIFICATION OF :FINANCIAL RESPONSIBILITY FOR UNDO ' . RGROUND STORAGE TANKS G'ONTAIIVING PETRUIEUM' A: I'am required'to demonstrate Fir anc�al " ons�btL rri'the.Regwrcd;amoimts,as specified;in Sech6n_2807;Chapter�I&Piv:3,Title 23,CCR: gip. h 3001,000 dolliirs per occurrence• t millioirdollam;annual aggregate' of AND or M%( '].milliowdollars; er occurrence, �: 2:million:dollatsannual.aggregate g; Jaco Hill her0y:c s�6at it:is'in'comptioRca_wiPh the.requiremenfs of Sbdlon,2801, (Name blYrank-o o.oven3mrl Artrde 3-Chapter`18 Division 3 True''23 Caldomra Cotle ofRegulafrons: The" to deinonstrate frnancra/raspoasibrlrty as requireii:by Sectioh_2807 are as follows; L ,t'CMechanlsmQa t MechanrsmY Coverage M Govsrag o redlve} thirdtPartyb Nameantli �re�s�s;ofdlssue .. NUmbe � =F�m u Y ' ' PeR`o1 Act n_i 4 L;, rCoFri 1 r: State OST Cleanup.Fund NIA#or;UST $990,000 pe. -State UST P.O.'Box 944212 Cleanup Fund `Qccurence and Cleanup, State UST Fund Sacramento,CA 942442120, 'Annual Aggregate Fund YES YES Continuous Chieffinancial Jaco Hill N/A-.for this '$10,000 par Continuous 0McerLe'te'r P:0 Boil 82515 mechanism Occurence and Bakersfield,CA,93380 4515 'Annual Aggregate 'YES. YES Note.: If you aia it�iU the,StateTund as,'a`ny-pa>t'of�your demonstration of.rin`ancial iesponsr6{lity y.our:'execution and submission of this cecatron also:certiTtes_that;you aca,in corripl fence.with a7l,Ponditions forparttdpation rn:the-Fuird; D. Facility Name- Facility.Address' Fastrip#33 64Q7 S.'`H"�SEreeY. Bakersfield,..CA 93304 Facility.Namme Facility Address, 'Facility:'Name- Facility Address, E. Sin natu ' Feril¢'Owner or Operator Date and Tide of Tankbwner or operator, Thomas J Jpn`!epon,General Partner Cv Sign o do s' otary Date Name of Witness,orNoiary: Brian Busacca,Chieffinancial Officer C Revi d'04/.5) EILE:_original- acal Agency Gooies'-Facilky/Site(s) BiDRVP1/' FENCE 'GRA$5 AREA .WlTtt t1UMP AREA P! i '' _ .. . PT ACOVE GRPDC _ '�.. M.6 PMgMO •� '•�: LLREQl11RL 9CRlUING.{DRAINK.E <� - OVERFHARG-.6n..ASOVE GRADE V _ Q d Q. 5TMt BLDG. Lu FLOOD LIGHT 3 A:C PAVED PRKS LOT "6 A C OVER. r.; X,-GUA55 2 A.D. . LONC:BUAAP[Rt -.� - `VENT,LINES eiks'mr:) 6" CONC.WALK O' RE U bAi+l3Nus w OFD 6vr,�sk � 'ft�to►C z SYA@AtbA_ VW6 z J .H. 03 12 11 UNLEAOEO' RErsUTAR 'UNLM E _ M°, UNLGIOEO . LU Z. lJ) w J K4 PWL VWAL Y,�z"2 Z�J J " w °'GA5 15LAND5 "-5 x;_ w 4- O L.U: J 5.. RAGE ANKS � 516N oke ilsu�s ,. ., .6 a SCALE: , SPRINKL=ER LINE 111 ZO_FT QR CT OWIIR JACQ-HU=WMY 'sm' U1N 3-382 Q t2%is/oi WNVMUM AUIMV FOFb PANAMA LANE' o FASTRIP 'O!L COMPANY, L., BSfI4JQAI7FORlgA. �•O AKfR OF 1 UNIFIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION Page_of I.IDENTIFICATION FACILITY ID# BEGINNING DATE l00 ENDING DATE 101 BUSINESS NAME(Same as FACILrrY NAME or DBA-Doing Businm As) 3 BUSINESS PHONE 102 661)831-+70q BBUS`I,NESS SITE ADDRESS 103 BUSINESS FAX 102a BUSINESS SITE CITY 104 ZIP CODE 105 COUNTY 108 CA DUN&BRADSTREET 1116 PRIMARY SIC 107 PRIMARY NAICS lo7a BUSINESS MAILING ADDRESS Ioaa Wd BUSINESS MAILING CITY 108b STATE 108C 1.ZIP CODE load BU INESS OPERATOR NAME llwl USINE S OPERATOR PHON 110 e 4a ! 1- 09' II.BUSINESS OWNER OWNER NAME 111 1 O0 PHONE 112 {D�I OWNER MAILING ADDRESS 113 OWNER MAILING CITY 114 STATE 115 1 ZT CODE I I6 III.ENVIRONMENTAL CONTACT C NTACT AME 117 CONTA T PHONE 118 ((o' -7 COr4TVTMAILIN ADDRESS 119 CONTACT EMAIL 119a CONTACT MAILING CITY 120 STATE 121 ZIP CODE 122 0 -PRIMARY- IV.EMERGENCY CONTACTS -SECONDARY- NAME 123 NAME 128 TITLE 1.0 124 TITLE 129 BUSINESS PHONE 123 SINES PHONE 130 - 0e l U3 -7®o® 24-HOUR-PHONE 126 24-HOUR PHONE 131 PAGER# 127 PAGER# 132 ADDITIONAL LOCALLY COLLECTED INFORMATION: 133 Certification. Based on my inquiry of those individuals responsible for obtaining the information,I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true,accurate,and complete. SIGNATURE OF y TOR OR SIGN ESE ATIVE DATV 134 1 NAME OF DOCUMENT REPARER 135 NA WE OF SI NER(prim) 13.6 ;-ALE OF IGNER 137 ' UPCF(Rev.12/2007) Business Owner/Operator Identification Please submit the Business Activities page,the Business Owner/Operator Identification page,and Hazardous Materials Inventory-Chemical Description pages for all hazardous materials inventory submissions. For the inventory to be considered complete this page must be signed by the appropriate individual. (Note: the numbering of the instructions follows the data element numbers that are on the Unified Program Consolidated Form(UPCF)pages. These data element numbers are used for electronic submission and are the same as the numbering used in Division 3,Electronic Submittal of Information.) Please number all pages of your submittal. This helps Unified Program Agency(UPA)identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER-Leave this blank.This number is assigned by the UPA. This is the unique number which identifies your facility. 3. BUSINESS NAME-Enter the doing business as name. 100. BEGINNING DATE-Enter the beginning year and date of the report(YYYYMMDD) 101. ENDING DATE-Enter the ending year and date of the report.(YYYYMMDD) 102. BUSINESS PHONE-Enter the phone number,area code first,and any extension. 102a.BUSINESS FAX-Enter the business fax number,area code first. 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. BUSINESS SITE 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. DUN&BRADSTREET-If subject to EPCRA,enter the Dun&Bradstreet number for the facility. The Dun&Bradstreet number maybe obtained by calling(610)882-7748 or on the web at www.dnb.com. 107. SIC NUMBER-Enter the primary Standard Industrial Classification System Number.Required for EPCRA. 107a.NAICS NUMBER-Enter the primary North American Industrial Classification System Number. 108. COLJNTY-Enter the county in which the business site is located. 108a.BUSINESS MAILING ADDRESS-Enter the mailing address to be used for all official business correspondence.This mailing address must be filled in. 108b.BUSINESS MAILING CITY-Enter the name of the city for the business mailing address. 108c.STATE-Enter the two character abbreviation of the state for the business mailing address. 108d.ZIP CODE-Enter the zip code for the business mailing address. The extra 4 digit zip may also be added. 109. BUSINESS OPERATOR NAME-Enter the name of the business operator. 110. BUSINESS OPERATOR PHONE-Enter business operator phone number,if different from business phone,area code first,and any extension. 111. BUSINESS OWNER NAME-Enter name of business owner,if different from business operator. 112. BUSINESS OWNER PHONE-Enter the business owner's phone number if different from business phone,area code first,and any extension. 113. BUSINESS OWNER MAILING ADDRESS-Enter the owner's mailing address,if different from business mailing address. 114. BUSINESS OWNER CITY-Enter the name of the city for the owner's mailing address,if different from business mailing address. 115. BUSINESS OWNER STATE-Enter the 2 character state abbreviation for the owner's mailing address,if different from business mailing address. 116. BUSINESS OWNER ZIP CODE-Enter the zip code for the owner's address,if different from business mailing address. The extra 4 digit zip may also be added. 117. ENVIRONMENTAL CONTACT NAME-Enter the name of the person,who receives all environmental correspondence. 118. CONTACT PHONE-Enter the phone number,if different from Owner or Operator, for the environmental contact,area code first,and any extension. 119, CONTACT MAILING ADDRESS-Enter the mailing address where all environmental contact correspondence should be sent. l 19a CONTACT EMAIL-Enter the email address of the environmental contact in 117,if the contact has one. 120. CONTACT MAILING CITY-Enter the name ofthe city for the environmental contact's mailing address. 121, STATE-Enter the 2 character state abbreviation for the environmental contact's mailing address. 122, ZIP CODE-Enter the zip code for the environmental contact's mailing address. The extra 4 digit zip may also be added. 121 PRIMARY EMERGENCY CONTACT NAME-Enter the name of a representative to be contacted in case there is an emergency involving hazardous materials at the business site. The contact shall have FULL facility access,site familiarity,and authority to make decisions for the business regarding incident mitigation. 124. TITLE-Enter the title of the primary emergency contact. 125. BUSINESS PHONE-Enter the business number for the primary emergency contact,area code first,and any extensions. 126. 24-HOUR PHONE-Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number,then the service answering the phone must be able to immediately contact the individual stated above. 127. PAGER NUMBER-Enter the pager number for the primary emergency contact,if available. 128. SECONDARY EMERGENCY CONTACT NAME-Enter the name of a secondary representative that can be contacted in the event that the primary emergency contact is not available. The contact shall have FULL facility access,site familiarity,and authority to make decisions for the business regarding incident mitigation. 129. TITLE-Enter the title of the secondary emergency contact. 130. BUSINESS PHONE-Enter the business telephone number for the secondary emergency contact,area code first,and any extension. 131. 24-HOUR PHONE-Enter a 24-hour phone number for the secondary emergency contact. The 24 hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number,then the service answering the phone must be able to immediately contact the individual stated above. 132. PAGER NUMBER-Enter the pager number for the secondary emergency contact,if available. 133. ADDITIONAL LOCALLY COLLECTED INFORMATION-This space may be used for UPA to collect any additional information necessary to meet the requirements of their individual programs. Contact UPA for guidance. 134. DATE-Enter the date that the document was signed. (YYYYMMDD) 135. NAME OF DOCUMENT PREPARER-Enter the full name of the person who prepared the inventory submittal information. 136. NAME OF SIGNER-Enter the full printed name of the person signing the page. The signer certifies to a familiarity with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information,all the information submitted is true,accurate and complete. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE-The Business Owner/Operator,or officially designated representative of the Owner/Operator,shall sign in the space provided. This signature certifies that the signer is familiar with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information it is the signer's belief that the submitted information is true,accurate and complete. 137. TITLE OF SIGNER-Enter the title of the person signing the page. UPCF(Rev.12/2007)