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Home My WebLink AboutSLOUNIFLOW_FS1 Admin iRC3926i Color_0169_001Ca I ifornia Envi ro n menta I Re porting Syste m (CERS)Business Activities ldentification PS - San luis Obispo CERS ID Sacramento Dr 10416094 Luis Obispo, CA 93401 nty Luis Obispo EPA lD Number c4D981664022 Submittal Status Submitted on 8/t3/2OI3 by Alvin Solis of United Parcel Service, lnc. (Atlanta, GA) :omments by submitter: No change. lubmittal was Accepted; Processed on t2/29/2O75 by Kerry Boyle for San Luis Obispo County Environmental Health Hazardous Materials Does your facility have on site (for any purpose) at any one time, hazardous materials at or above 55 gallons for liquids, 500 pounds for solids, or 200 :ubic feet for compressed gases (include liquids in ASTs and USTS); or is regulated under more restrictive inventory local reporting requirements ishown below if present); or the applicable Federal threshold quantity for an extremely hazardous substance specified in 40 CFR Part 355, Appendix q or B; or handle radiological materials in quantities for which an emergencv plan is required pursuant to 10 CFR Parts 30, 40 ot 7O7 Yes Underground Storage Tank(sl (USTI Does your facility own or operate underground storage tanks?Yes Hazardous Waste s your facility a Hazardous Waste Generator?Yes )oes your facilitv treat hazardous waste on-site?No s your facility's treatment subject to financial assurance requirements (for Permit by Rule and Conditional Authorization)?No )oes your facility consolidate hazardous waste generated at a remote site?No )oes your facility need to report the closure/removal of a tank that was classified as hazardous waste and cleaned on-site?No )oes your facility generate in any single calendar month 1,000 kilograms (kg) (2,200 pounds) or more of federal RCRA hazardous waste, or generate n any single calendar month, or accumulate at any time, I kC Q.2 pounds) of RCRA acute hazardous waste; or generate or accumulate at any time Tore than 100 kg (220 pounds) of spill cleanup materials contaminated with RCRA acute hazardous waste. No s your facility a Household Hazardous Waste (HHW) Collection site?No Excluded and/or Exempted Materials )oes your facility recycle more than 100 kg/month of excluded or exempted recyclable materials (per HSC 25143.2].?No )oes your facility own or operate ASTS above these thresholds? Store greater than 1,320 gallons of petroleum products (new or used) in lboveground tanks or containers. No )oes your facility have Regulated Substances stored onsite in quantities greater than the threshold quantities established by the California Accidental lelease prevention Program (CalARP)? No lnformation additional comments Printed on L2/29/2075 8:58 AM Ca I ifornia Envi ronme nta I Reporti ng System (CERS)Underground Storage Tank - Facility lnformation Facility/Site UPS - San Luis Obispo J601 Sacramento Dr ian Luis Obispo, CA 93401 CERS ID 10415094 tubmittal Status iubmitted on8/I3/2OI5by AlvinSolis of United Parcel Service, lnc. (Atlanta, GA) :omments by submitter: Updated designated UST Operators' ICC certification expiration dates. iubmittal was Accepted; Processed on I2/29/2OI5 by Kerry Boyle for San Luis Obispo City Fire Department type of Action lonfi rmed/Updated lnformation Facility Information .JPS - San Luis Obispo 1601 Sacramento Dr ian Luis Obispo, CA 93401 :acility Type Board of Equalization Account Number Vlotor Vehicle Fueling 44032294 s the facility located on lndian Reservation/Trust lands? illo Property Owner 3T-OH, LLC "4041 828-7660 i5 Glenlake Parkway, NE qtlanta, GA 30328 lank Operator Jnited Parcel Service lnc., an Ohio Corporation ,s10) 453-2090 1400 Pardee Drive fakland, CA9462I lank Owner Jnited Parcel Service lnc., an Ohio Corporation s10) 4s3-2090 1400 Pardee Drive )akland, CA94627 Tank Owner Type !on-Government Permit Holder lnformation termit Holder Notifi cation lnformation fank Owner Supervisor of Division, Section, or Office (Required for Public Agencies Onlyl Financial Responsibility Mechanism(s) I80,107) or CCR, Title 23, Division 3, Chapter 18, Section 2808.1. ielf-lnsured Surety Bond State Fund and CFO Letter Yes State Fund and CD Other Mechanism Suarantee Letter of Credit nsura nce Exemption Local Government Mechanism Certification nt Name Lassiter Applicant Title Plant Engineering Area Applicant Phone (s10) 4s3-2090 Date Certified Ma Printed on 72/29/2015 8:58 AM Ca I ifornia Envi ron menta I Re porting System (CERS)Underground Storage Tank - Tank lnformation PS - San Luis Obispo CERS ID to4t6094Sacramento Dr n Luis cA 93401 Status on 8/I3/2OI5 by Alvin Solis of United Parcel Service, lnc. (Atlanta, GA) ments by submitter: Updated designated UST operators' ICC certification expiration dates. I was Acceptedi Processed on t2/29/2O15 by Kerry Boyle for San Luis Obispo City Fire Department of Action of Action (UsT Tank) I Permit lnformation PS - san Luis Obispo Sacramento Dr Luis cA 93401 Description nk lD#Date UST System lnstalled 8/ts/1989 Date Existing UST Discovered Tank Configuration A Stand-alone Tank Number of Compartments in the Unit 1 Additional Description Manufacturer s Corning Capacity ln Gallons Date UST Permanently Closed lank Construction lype of Tank )ouble Wall trimary Containment :iberglass 1 I I I Secondary Containment Fiberglass )verfill Protection Audible/Visual Alarms /es Ball Float Yes Fill Tube Shut-Off Valve Exempt Use and Contents Use Tank Contents Diesel Other Petroleum Contents otor Vehicle Fueling Other Non-Petroleum Contents / Waste Piping Construction Construction Primary Containment Fiberglass secondary containment Fiberglass Piping/Turbine Containment Sump Single-walleduble-walled ping System Type re Vapor Recovery URI and Riser / Fill Pipe Piping Construction Containment Vapor Recovery Primary Containment Fiberglass Riser Pipe Primary Containment Steel Vent Piping Transition Sumps None Fill Components lnstalled Yes Spill Bucket Yes StrikerPlate/BottomProtector rglass Containment Vapor Recovery Secondary Containment None Riser Pipe Secondary Containment None Containment Dispenser Containment (UDC) Type Construction Material Rigid Plastic Protection sacrificial Anode lmpressed Current nt Certification plicant Name Applicant Title Plant Engineering Area Date Cettified I Lassiter M r Printed on 12/29/2075 8:58 AM Ca I ifornia E nviro n me nta I Re porting Syste m (CERS)Underground Storage Tank - Monitoring Plan Monitoring is Performed Using the Following Method(sl Continuous Monitoring of Piping Secondary Containment Secondary Containment Panel Manufacturer Veeder Root Panel Model # TLS-350 Leak Alarm Triggers Automatic Pump Shutdown Failure/Disconnect Triggers Pump Shutdown Leak Sensor Manufacturer Veeder Root Leak Sensor Model # 20s Mechanical Line Leak Detector Performs 3 GPH l-eak Test Manufacturer MILD Model Root FXlDV Electronic Line Leak Detector Performs 3 GPH Leak Test LLD Manufacturer ELLD Programmed ln-Line Testing €LLD Triggers Automatic Pump Shutdown ELLD Failure/Disconnect Triggers Automatic ShutdownModel Pipeline lnte8rity Testing ne lntegrity Testing Frequency Visual Pipeline Monitoring Visual Pipeline Monitoring Frequency Suction Piping Meets Exemption Criteria No Regulated Piping Per Health and Safety Code, Division 20, Chapter 6,7 ls Connected To The Tank System Other Pipeline Monitoring - San Luis Obispo Sacramento Dr CERS ID to4L5094 Luis Obispo, CA 93401 UST Tank f 1 System Testing E[D Testing Secondary Containment Testing Dispenser Containment (UDC) Monitoring Monitoring Detection of Leak into UDC Triggers Audible and Visual Alarms UDC leak Alarm Triggers Automatic Pump Shutdown Failure/Disconnection of UDC Monitoring System Triggers Automatic Pump Shutdown Stand-alone Panel Manufacturer Panel Model f Leak Sensor Manufacturer Leak Sensor Model UDC Monitoring Stops Flow of Product at Dispenser Yes UDC Construction Single-walled UDC Secondary Containment Monitoring Leak Within Secondary Containment of UDC Causes Audible and Visual Alarms Printed on L2/29/2075 8:58 AM Ca I ifornia Environmenta I Reporti ng Syste m (CERS)Underground Storage Tank - Monitoring Plan :acility/Site UPS - San luis Obispo ]601 Sacramento Dr ian Luis Obispo, CA 93401 CERS ID 10416094 UST Tank # 1 Alarm Logs Visual lnspection Records Tank lntegrity Testing Results SIR Testing Results Tank Gauging Results ATG Testing Results Corrosion Protection Logs Maintenance and Calibration Records Personnel with UST Monitoring Responsibilities are Familiar with Training Oocuments Other Training Documents Designated Operator Training / Additional lnformation and Additional lnformation Responsibilities of First Person Having Responsibility Montgomery of First Person Having Responsibility nee rvtsor Certification Name Applicant Title Plant Engineering Area Signature Date Lassiter Ma s Name of Second Person Having Responsibility Jeanette Hopkins Title of Second Person Having Responsibility District Environmental Coordinator Signature Representation Authorized Representative of Owner Printed on t2/29/2015 8:58 AM Ca I ifornia Envi ro n menta I Repo rting Syste m (CERS)Underground Storage Tank - Monitoring Plan - San Luis Obispo Sacramento Dr CERS ID 10415094 Luis Obispo, CA 93401 UST Tank S 1 bmittal status bmitted on 8/t3/2O75 by Alvin Solis of United Parcel Service, lnc. (Atlanta, GA) by submitter: Updated designated UST Operators' ICC certification expiration dates. bmittal was Acceptedi Processed onL2/29/2Ot5by KerryBoyleforSanLuisObispoCityFireDepartment lnformation - San Luis Obispo Sacramento Dr n Luis cA 93401 Testing and Preventive Maintenance Equipment Serviced Locations Plot Plan Submitted Plan Previously Submitted Monitoring is Performed Using the Following Method(s) Continuous Electronic Tank Monitoring ry Containment System Monitor Panel Manufacturer Veeder Root Monitor Panel Model T6-350 Leak Sensor Manufacturer Veeder Root Leak Sensor Model # 302 uid-Filled Automatic Tank Gauging Panel Manufacturer ln-Tank Probe Manufacturer Veeder Root In-tank Probe Model Mag 1 Leak Test Frequency Weekly Programmed Tank Tests 0.2 GPHRoot Model fl Monthly Statistical lnventory Reconciliation Weekly Manual Tank Gauge Gauging Test Period Tank lntegrity Testing Tank lntegrity Testing Frequency Other Monitoring Printed on L2/2912Ot5 8:58 AM UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. I6 Califurnia Code of Regulations (CCR) FACILITYNAME UPS San Luis Obispo FACILITY PHONE (805) 544-7186 FACILITY SITE ADDRESS 3601 Sacramento Drive CITY San Luis Obispo REASoN FOR SUBMITTING THIS FOR:M (Check On"/, X Change of Designated Operator X Updat" of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATEDoPERAToRNAME: FlOfentinO RamifeZ RELATION TO UST FACILITY (Check One) ! o*ner ! operator ! Employee I Service Technician ! ttti.d-rurty BUSINESS N t+ME (tf dffirent from above): B&T SefViCe StatiOn COntfaCtOfS DESIGNATED OPERATOR PHONE:(805) 929-8944 ext. INTERNATIONAL coDE COUNCIL GERTIFICATIoN No.: 8009625 EXPIRATIONDATE: 1 l2Ol2O17 ALTERNA TE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATEDoPERAToRNAME: JameS WelCh BUSINESS N ltME (lf dffi re nt fro m above) : RELATION TO UST FACILITY (CheckOne) ! ow.ter f] operator I Employee [l Service Technician n rnira-pa.tyDESIGNATED OPERATOR PHONE:(805) 929-8944 ext. EXPIRATIoN DArE: 41 1612017INTERNATIONAL CODE couNCIL CERTIFICATION No.: 8201843 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optionol) DESIGNATEDOPERAToRNAME: Efland Caflsen BUSINESS NAME (lf dffirentfrom above)'. RELATION TO UST FACILITY (Check One) ! o*ner ! operator ! Employee I Service Technician ! ttrird-eartyDESIGNATED OPERATOR PHONE (805) 929-8944 ext. EXPIRATIoNDATE: 612812016INTERNATIoNAL CODE COUNCIL cERrIFICArloNNo.: 81557 52 DESIGNATEDoPERAToRNAME: NiChOlaS AdamitZ RELATION TO UST FACILITY (CheckOne) ! o*ne. ! operator ! Employee I Service Technician n ttird-patty BUSINESS NIIME (lf dfferentfrom above) DESIGNATED OPERATOR PHONE:(805) 929-8944 ext. INTERNATIONAL coDE couNCIL CERTIFICATIoN No.: 81 58837 EXPIRATToN DArE: 912612016 ALTERNATE 4 DESIGNATED UST OPERATOR FOR THIS FACILITY ALTERNATE s DESIGNATED UST OPERATOR FOR THIS FACILITY (Optionat) DESIGNATED OPERATOR NAME:Michael Conoway RELATION TO UST FACILITY (Check One) ! o*ne. ! operator I Employee X Service Technician ! rnirO-earty BUSINESS N.\ME (If dffi r e n t fro m a b ov e )'. DESTcNATED opERAroR pHoNE: (805) 929-8944 ext. INTERNATIONAL CODE COLJNCIL cERrIFICArloNNo.: 5250414 EXPIRATToN DArE: 212412017 DESIGNATED OPERATOR NAME:Shawn Byham RELATION TO UST FACILITY (Check One) ! o*n"r ! operator ! Employee I Service Technician D third-pa.ty BUSINESS N Al|l4E (If d iffe r e nt fr o m a b ov e)'. DESIGNATED OPERATOR PHONE:(805) 929-8944 ext. INTERNATIONAL CODE couNcIL CERTIFICATION No.: 8017004 EXPIRATToNDATE: 811312016 uN-062 - l/2 www.unidocs.org n9D2t05 ALTERNATE 6 DESIGNATED UST OPERATOR FORTHIS FACILTTY (Optionat) DESIGNATED OPERATOR NAME:RELATION TO UST FACILITY (Check One) n o*n". ! operator I Employee ! Service Technician fl rnira-earty BUSINESS NANIE (lf differentfrom above) DESIGNATED OPERATOR PHONE:()ext. INTERNATIONAL CODE COI.JNCIL CERTIFICATION NO.:EXPIRATIONDATE DESIGNATED OPERATOR NAME: BUSINESS NAIvIF (If diferentfrom above)'. DESIGNATED OPERATOR PHONE:()ext. RELATION TO UST FACILITY (CheckOne) ! Owrer ! Operator ! Employee n Service Technician ! ttrirA-rarty INTERNATIONAL CODE COTJNCIL CERTIFICATION NO,:EXPIRATION DATE: ALTERNATE 7 DESIGNATED UST OPERATOR FORTHIS FACILITY I certify thato for the facility indicated at the top of this pageo the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations, Title 23, Section 2715(c) through (I). Furthermore,I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicabte to underground storage tanks. TANK owNERNAME: Crystal Lassiter TANK OWNER TrTLE: Plant Enqineering Area Manager OWNER PHONE 10) 453-2090 rANK owNER SIGNATURE: (CERS HMBP Sumbmitta r)DATE: Auqust 13.2015 INSTRUCTIONS l. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (lCC). ICC certification information is available on-line at: wrvw.iccsafe.org/e/certsearch.html. Search for "California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.html. Contact information for other local agencies within California is available at: www.swrcb.ca.gov/cwphome/ust/contacts/docs/local-agency_listxls. 3. Z: CCn $2715(a) requires that you notify the local agency of any changes to this information within 30 days ofthe date of change. November 2004 MONITL^TING SYSTE,M CERTIFIC. ^.IION For Use By All Jarisdictions l{ithin the State of Cglifo1nia Authority Cited: Chapter 6.7, Health ond Sa|"ty Code; Chapter 16, Division 3, Titie 23, CaliJbrnia Code of Regulations This form rnust be used to document testing and servicing of rnonitoring equipment. A separate certification g..f .r,eport must be prepared for each monitoring system control panel by the technician who pcrforms the work, A copy ol'this form must be provided to the tank systcm owncr/opcrator. LLt" o*n"Toperator must submit a copy of this form to the local agency regulating US'l'systems within 30 days of tcst date. A. General Information Facility Name: Upg SLO Bldg. No.: Site Address: 3S0l $acramento Dr City:San Luie Obispo Zip: 93401 Facility Contact Person:Contact Phone No.: (559) 978-3592 Make/Model of Monitoring System:TLS-350 Dat€ of Testing/Servicing:r0-t-14 B. Inventory of Equipment Tested/Certified Tsnk lD: ! In-Tank Cauging Probe. f] Annulu Space or Vault Sensor. n Piping Sump / Trcnch Sensor(s). fl ritl sump Senso(s). I Mechanical Linc Lcak Detector. E Electronic Linc Lcak Detector. E Tatlk Overfill / High-Level Sensor Model: Model: Model: Model: Model: Modcl: Model: E Othe. (specify cquipment type and model in Section E on Page 2). I tn-Tank Gauging Probc. I Annular Space or Vault Scnsor, S eiping Sump / Trench Sensor(s). I Fill Surnp Sensor(s). El Mechanical Line Leak Detector. Modcl; f] Electronis Line Leak Detector. Modcl: E t"ant Overfill / High-Level Sensor. Modcl: E Other (speci$ equipment type and model in Section E on Page 2)' Tank ID: Diesel Model; 205 Model: ilaq I Model: 302 Modcl: FXlDV f] In-'t'ank Gauging Probe. Model: il Annular Space or Vault Sensor. Model: I eiping Surnp I Trench Sensor(s). Model: E P'ill Sump Sensor(s). Model: I Mcchanical Line kak Detector. Model: E Electronic Line Leak D€tector. Model: E Tank Ovcrfill / High-Level Sensor- Model: D Othcr (speoiff equipment type and modcl in Scction E on Page 2)' Tnnk lD: U ln-Tank Cauging Probc. Model: E Annular Space or Vault Scnsor. Model: fl riping Sump / Trench Sensor(s). Model: E fitt Sump.Sensor(s). Model: D Mechanical l,ine l,eak Detector. Model: il Electronic Line Leak Detector. Model: I Tank Overfill / High-Level Sensor. Model: f1 Other lspecify equipment type and model in Section E on Page 2)" Trnk ID I Dispenser Containment Sensor(s). Model: E 5t.ar Valve(si. I Dispenser Containmcnt Float(s] and Chain(s). Dispenser lD: E Sttear Valve(s). f] Dispenser Containment Float(s) and Chain(s). Dispenser lD: l-2 E Dispenser Containment Sensor(s).Model: 001 ! Dispenser Containment Sensor(s). Model E Sheat Valve(s). E Dispenser Containment Float(s) and Chain(s). Dispenser lDDispenser ID: I Dispenser Containmsnt Sensor(s). Model: I Shear Valve(s). E Dispenser Containmetrt Float(s) and Chain(s). E Dispenser Containment Sensor(s). Model E Shear valve(s). n Dispenser Containmcnt Float(s) and Chain(s)' Dispenser IDDisoenser ID: fl Dispenser Containment Sensor(s). Model: n shear valve(s). ! Dispenscr Containmcnt Float(s) and Chain(s). tlf the facility contains more tanks or dispensers, copy this forrn. Include information for every tank and dispcnscr at the facility C. CertifiCation - I certify thai the equipment identified in this document was inspected/serviced in accordence with thc manufacturers' guidclines. Attached to this Certification is information (e.g. manufacturers'checklists) neces$ary to verify thtt this informetion is correct aud a Plot Plan showing the layout of monitoring rttached a copy of the reporq (check all lhal spply)l equtr ipment. For any eq System set-up ul capeble ofgenerating such reports, I have also history report Technician Name (print):James Welsch Signature: Certification No.:8201843 UT License. No.: 902034 Testing Company Narne: B&T Service Station Contractots Phone No.: (805) 929{944 Frontaqe Road Nipomo, CA.93444 10t1t2014Testing Company Address 630 S. Page 1 of 3 Date of Testing/Servicing: Rev (2/08) Mon itoring System Certifi cation D. Resulfs of TestinglSeruicing Software Version Installed: 325.02 checklist: + ln Section E below, describe how and when these deliciencies wer€ or will be corrected. E. Comments: Small amount of water found in STP sump and removed. Disposed of in DOT drum. I Yes D Not Is the audible alarm operational? E Yes D No*Is the visual alarm operational? I Yes E No*Were all sensors visually inspected, functionally tested, and confirmed operational? ffi Yes D No*Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? fl Yes I No+ 8 N/A If alarms are relayed to a remote monitoring station, is all communications equipment (e.9., modem) operational? E Yes D No* D N/A For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply) 8 Sump/Trench Sensors; E Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failureldisconnection? E Yes; E No. ! Yes fl No* 8 NiA For tank systems that utilize the monitoring system as the primary tank overfill warning device (i,e., no mechanical overfill prevention valve is installed), is the overfill waming alarm visible and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm higger'| o/o fl Yes*8No Was any monitoring equipment replaced? If yes, identi$ specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all replacement parts in Section E, below. E Yes*DNo Was liquid found inside any secondary containment systems designed as dry systems? (Check all rhat apply) E Product; [l Water. lf yes, describe causes in Section E, below. E Yes D Not Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable I Yes D No*ls all monitoring equipment operational per manufacturer's specifications? Page 2 of 3 M on itoring System Certification F. In-rank Gauging / sIR Equipment: E 3l::[lii:i:] ll:Ti.:i"_-;1il1,;:i,T?#;ffli:ffi:i[T' This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the following checklist: fl Yes E No*Has all input wiring been inspected for proper entry and termination, incl uding testing for ground faults? ! Yes E Nor Were all tank gauging probes visuatly inspected for damage and residue buildup? E Yes E No*Was accuracy of system product level readings tested? I Yes E No*Was accuracy of system water level readings tested? ! Yes E No*Were all probes reinstalled properly? fl Yes E No*Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H' below, describe how and when these deficiencies were or will be corrected. G. LineLeakDetectors(LLD): E CheckthisboxifLLDsarenotinstalled Com the ehecklist: * ln the Section H, below, describe how and when these deficiencies were or will be corrected. I Yes B No* tr N/A For equipment start-up or annual equ ipment certification,was a eak simulated to veriff LLD performance? (Check all that applv)s imulated leak rate:3 c.p .h tr 0.I g.p.h tr 0 .2 ab'p.h. El Yes fJ No*Were all LLDs confirmed operational and accurate within regulatory requirements? El Yes E No*Was the testing appaxatus properly calibrated? E Yes I No* D N/A For meshanical LLDs, does the LLD restrict product flow if it detects a leak? E Yes D No* El N/A For electronic LLDs, does the turbine automatically shut offif the LLD detects a leak? fl Yes E No* EI N/A For electronic LLDs, does the turbine automatically shut off if any portion of the m onitoring system is disabled or disconnected? E Yes E No+ tr NIA For electronic LLDs, does the turbine automatically shut off if any portion of the rnon itoring system malfunctions or fails a test? I Yes E No+ 8 N/A For electronic LLDs, have all accessible wiring connections been visually inspected? B Yes E No*Were all iterns on the equipment manufacturer's maintenance checklist completed? H. Comments: Page 3 of 3 Facility Name:UPS SLO Date of Testing: l0-l-14 Facility Address:3601 Sacramento Dr Facility Contact:Maurice Barksdale Date Local Agency Was Notified of Testing : Name of Local Agency lnspector (if present during testing);Kerry Boyle SWRCB, January 2006 Spill Bucket Testing Report Form Thisform is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and printoutsfrom lesls (if applicable), should be provided to thefacility owner/operatorfor submittal to the loca! regulatory agency, I. FACILITY INT'ORMATION 2. TESTING CONTRACTOR II\Itr'ORMATION Company Name: B&T Service Station Contractor Technician Conducting Test: James Welsch Credentialsr: X CSLB Contractor X ICC Service Tech. ! SWRCB Tank Tester E Other (Specify) License Number(s): 90203 4 3. SPLL BUCKET TESTING INFORMATION Comments - (include information on repairs made prior la t es I i n g, q nd r e com me nde d fo I I ow -up fo r fa i I e d te s t s ) Test failed first-run due to bad drain valve. Replaced drain valve and tested ok. CERTTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTINC I hereby cerlft that all the tnformation contuined in lhis report is lrue, accatole, and ln full compliance with legal requiremenls, Technician's Signature:Date: l0-l-14 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements Test Method Used:i Hydrostatic I Vacuum X Other Test Equipment Used ldentifi Spill Bucket (By Tank I Diesel Fill ., Stored Product, Resolution: 3 4 Bucket lnstallation Typel x Direct Bury tr Contained in Sump I Direct Bury flContained in Sump ! Direct Bury ! Contained in Sump ! Direct Bury ! Contained in Sumn Bucket Diameter:ll" Bucket Depth 12" Wait time between applying vacuum./water and start of test:l5 min Test Start Time (T):See lnitial Reading (Ry): Test End Time (Tp)Incon Final Reading (Rr): Test Duration (Tr - Tr)Results Change in Reading (Rp - R1): Pass/FailThreshold or Criteria: Test Result:x Prss E Fail I Pass O Feil O Pats, I Fail tr Pess tr tr'eil may be more stringent. jTARTED A:2t P]'l ', .]TARTED 10/01/2014 ..., LEVEL ll,695? lN { iltr ilJ'lE 2i43 Pll :,,; i;,{TE 10/01/2014 , trir : EVEL 4.6964 IN . : THRESHOLI) O. OO2 IN :,I RE$JLT PAS$ED liLti ul'S 1 SACRI\IIENTI] DR Luls 0bispo, Ca 20't4 2244 Pfl - LEAK TEST REPBRT t)SL FIL SLI] UPS iol SACRAI'IENTt] DR r.r Luis 0blspo, ca 'IZAM 3:00 Pl'l .'' LEAK TEST REPORT OSL FIL STAR]ED 2:45 PII STARTED 1o/01/2014 .I LEVEL 4.6964 lN 'r:r. Ill'lE 3100 Pt'l ',; JATE 10/01/2014 . '.i, LEVEL 4,6959 IN THRESHOLO O. OO2 IN IJI RE$ULT PASSED lLealt< Deteat@:r]FXT ]EVA]LIUAT"TON C]HIA]RT Site Location: UPS SLO 3601 Sacramento Dr San Luis Obispo CA 93401 Service Company: B&T Service Station Contractors Date: l0lll20l4 Technician: James Welsch Tech Number: 8201843 UT TYPES OF LEAK DETECTORS TESTEI) TEST INFORMATION ! xLD fl i6-036-5)J FX1D fl t6-054-5 t] FX2BFLD n DLD fl16-017-5 n FX2 (116-046-s r_r FXlv fi 16-056-5) il BFLD (XL Model I l6-039-5 ! FX2D fl 16-048-s)t_t FX2V (116-057-s) : BFLD fi l6-012-5)x FXI Dv (116-055-5)t.t FXtDV (1r6-058-5) ;i xLP fl r6-035-5 I I FXzDV (l r 6-0s3-s)Lt FX2DV (il6-059-5 I PLD (l l6-030-s U FXIBFLD l_l FXIV fl l6-051-5 ! FXI (116-047-s LD 2000 X FE Petro Product Serial Number Opening Time Metering PSI/kPe Funclioml Elcflent Holding PSAPT Approrimrtc Tcst Lcrk Rrtc ML/Min GPH PrsCTril Test Lcrk Rrtc Ml,rllln GPH Pump PSI/kFa Ptcssurc Diesel 5 sec 10 l2 3gph Pass 28 'ri','Ii'fEl'l-SETUP il'"l' I. S0l4 I 2: 34 Pt.l r-'i.ilJl{ul J,l r'jr'l' I i"tFl5 i:;L'f I I I}OR'T SETT I NGS I)OMI"I BOARD : B {FXIYOD} EAUD RATE : 24NOPARITY : ODDSTOPBIT :lSTOP DATA LENGTH: ? DATARS-238 SECURITY,)ODE : DISABLED DIAL TYPE : TONEANSI^IERON:IRING I"IODEI.{ SETUP STRING : DIAL T+NE INTEEVAL: 32 IiIECE I UER SETLIP : I1 8:VEEDER EOOT (FI'1S) l-866-743-S:3?9 HCVR TYPE: CO'"IPUTER I-.ORT NO: 3 FJETRY NO: 5 I;JETRY DELAV: 5...ONFIR].1ATION REPORT : OFF rlUTO DIAL TIl"lE SETUP: IJ B:VEEDER RO.ST (FI'IS) FIAL I,IIEEKLV F'RIt,IAL TII"IE ; 4:47 PM RECEIVER REPORTB: Rl-j 'i::j:' El'lli OF llEl:';!.iHi.;Fl DISAELHD AUTO DIAL ALARI'4 SETUP ALL:ANNUAL TEST FAI ALL:PER TST NEEDED D 8:VEEDER FOOT {Ff'IS} I N_TANK ALAR]'1S ALL:LEAK ALARI4 ALL :HIGH I^IATER ALARI'I ALL:OVERFILL ALAR]'I ALL:SUDDEN LOSS ALARI"I ALL: HIGH PRODUCT ALAI;JI I ALLI I NVALID FUEL LE\iI-.I. ALL:FROBE OUT ALL : HIGH I^JATER I'{ARNI I..It.; ALL:]"IAX PRODUCT ALARI,I ALL:GROSS TEST FAIL ALL :PERIODIC TEST FAl I. ;';.,.5.[EF1 LINITSU.:i. i:l'r'ili'[EFl LANGUAGE l:l'ltil.JBH :'','1.':'fEH DATE,/TIl'lE FORIVIAT t1'ltFl DD VYYY HH:Fll'l:SS xl.'l :j'-r1.,!$f lJPg:lr.r-rl sAcRAl'4El{To i-;rrl{ LUIS 0EISPOrjil,:; 544 7184 L l^lli I'l r :li I t.;l I I i:i11 I:;lll 'l'iit,lK PER TST t-l'h+ELED'liit'llt FER TST I tr il'S = 30-li il"lK PER TST [,tir'i'S = 3u'lriI.lK ANltl TST I ' I r:IAELED ALL:ANN TST NEEDED l,illll'l ALL:PER TST NEEDED AI,.I'I ALL:ANN TST NEEDED AI..I1 ALL:NO CSLD IDLE TII"1E: ALL:CSLD INCR EATE liJARl*l ALL :ACCU-CHART CAL hJARI..I ALL:RECON I,^JARNI NG ALL:RECON ALARI"I ALL :LO[^J TEl"lP I{ARNI NG ALL:GROSS FAIL LINE T'I'II: LIAUID SENFOR ALMS ALL:FUEL ALARI"I ALL:SENSOR OUT ALARI'I ALL:SHORT ALARM ALL:I,iATER ALARM ALL:I^IATER OUT ALARl"l ALL:HIGH LI6UID ALARM ALL :L0l^J LISUID ALARI'I ALL:LIQUID I^JARNI NG Al'l SAELED SAELED SAELED 00 D D D r.tE l,lE tlE l,lE T T T T FT FT FT FT 1 2 3 4 I'IEHDED I,dRN NEEDED I^JRN NEEDED AL]-l NEEDED I,'JRN I. I I,IE RE-ENABLE I"IETHOD l'til':;S LINE TEST t".l htE FER TST NEEDED I^JFN [' t T.ABLED LINE ANN TST NEEDED I.'JRNf'f ';AELED I-'F.: I NT TC VOLUI.IES t-.lliiBLED 'II-:I.,IP COMFENSAT I ONt./gLUE (DEG F }: 6D.O ;:i.I'ICK HEIGHT OFFSET T.IiIAELED II I,ROTOQOL DATA FOFI"IAT I-IIj IGHT Itrr iL I GHT SAV I NG T I l"lE LiI..IitFLED iil'HRT DATEr1ali I^IEEX E SUN $TART TII"IEi :00 Atl FIN[, DATEI'li'r\J IAIEEK I SUN Fit'ltl T I l*lE!: ll0 Al"l F]F: D I RECT LOCAL PR I NTOUT r' I 5AELED F:IIF]O PHOTOCOL PEEFIX (l '.'Llr:iTol-1 ALARl"l LAEELS l'r l:-.;AELED IIECET SERV VER ALARI'IS ICE REPORT I,ilARN ALARM CLEAR I,^JAENING I N-TANK SETUP 1" I :DIESEL I RODUCT CODE.i HERI'IAL COEFF rANX DIAT"IETER I'ANK trROFILE FULL VOL O INCH VOL VSL VOL I'IAX QF LABEL VOL OVERFILL LII"IIT HIGH PRODUCT I,i'1.Ii.jl,.l..,i' Lllll l 0 0 69 46 ?3 NCH NCH I Ull07t-tit 92 , ttt-t4 P'fil I 15i 'j' 96Lr'l 60.: I 23b, t 1t587 95% I 0950 90% 103?'jl I Ll'i I I rj'.:' FLOAT SIZE:4.0 Il,l L{ATER lilARNI NG : HIGH lilATER LIt'lIT: I . t.t i.' a:l l.i:il.tl Fl.iillrr l':"1' : l.lliili r-i[.nFil4 I ll''ll f : I:iIJIjUEI{ LUSF LIT,II T: 'l .rl.ll: TILT : t.k'r!t.iE 0FFSET : I Lro I fru0 5 0.00 0.00 ::iII IION I.IANIFOLNED TANKS.I'il: NONE I, I I..IIJ I-IANIFOLDED TANKS 1'rr: NONE l.L.ali MIN PERIODIC: t-Enti l"lIN ANNUAL : I.[I-]IODIC TEST TVPE 6UICK iiI'II'IIJAL TEST FAIL ALARM DISAELED I'EI.:IODIC TEST FAIL ALARI"I DISABLED Ll.;\K TEST l"lETH0D 'ltllT I,^JEEKLY : TANH I $ultl i;'l'gP1 TII'IE : lE;0n API.TEIJT RATE :0. IO GAKHR LTURATION : 6 HOURS l'il EARLY STOP:DISAELED I L:AK TEST REPORT FOR]'IAT NORI'IAL LIOUID SENSOR SETUP L 1:ANNULAR SPACE DUAL POINT HYDROSTATIC CATEGORY : ANNULAR SPA'.} L 2:TUREINE SUMP TRI -STATE {SI NGLE FLLIA.I.' CATEGC}RY : STP SUI'4P OUTPUT RELAY SETUP R I:TUFFINE SHUTDOI,ilN TYPE: STANNARD NORMALLV CLOSED LIAUID SENSOR ALMSL I :FUEL ALARI"IL E:FUEL ALARNL I :SENSOR OUT ALARI'IL z:SENSOR OUT ALARI"IL I:HISH LIAUID ALAR].1L 2:HIGH LIQUID ALARF{L I:LOt{ LIAUIN ALARI"IL ?;LOl^.| LIAUID ALARI"I tl9d 0 0% 0 UROSS TEST FAIL ALARI'I DISAELED i-il.l],l TEST AVERAGING: OFF I'b.I.J TEST AVERAGING: OFF 't';it'lK TEST I'IOTIFV: OFF 'I'I'II: TST SIPHI]NI BREAH:OFF lrl.l.lVERY DELAY : 51'lIN r'L[,lP THRESH0LD : 1fl.0n% UNDERGROUND STORAGE TANK SYSTEM DESIGNATED OPERATOR F'ACILITY SMPLOYEE TRAIMNG RECORI) For use by unidocs Member Agencies or where approved hy yow l-ocal Jurisdiction rluthority Cited: Title 23, Div. 3, Ch. l6 California Code olRegulations (CCR) Facility Name: (t PS S Lr.t Facility Site Addrcsst loj {-fa-c. wtu-Cityr !.-n ? nb)ro o Section 2715 of Title 23, Califomia Code of Regulations, rcquircs that Designated Underground Storage Tank Operators 'rovide training to facility employecs who have responsibilities associated with the opcration and/or maintenance of undergrqurd srorago tank iUST) systerns. this taining must be providctl by July 1, 2005, and every I 2 months thereafter- For l-acility cmployeos hired after July l, 2005, the initial training must bc proviclerl within 30 days of the date of hire" At least one of tn" tn";tity emptoyees present during opcrating hours must have current training. This training must include, but is not limitccl to, the following iterns as specified in 23 ccR Se'ctions 271s(fxl) and (2): fr Operation of the UST systern in a marmcr corsistent with the faoility's Best ManagemenL Ractices;'E 1.t * ernployec's role with regard to UST monitoring equipment as sp*cihcd in the written UST Monitoring Plan; F The enrployee's role with regard to spills and ovcrtills as spocified in the written UST Response PIan; F Name(s) of contact person(s) tbr cmcrgencies and monitoring equipment alarms; S For facilities lhat arc not routincly staffed, facility employee responsibilities as spcri:ifiexl in the taining program approved by the local US'l'regulatory agency. 23 CCR $ 2?15(fX3) requires 0ut a list of employees who have boon trained by the Designated Underground Storage Tank Operato(s) be maintainJ on-site, or oft-site at a rcadily-available location if apnroved.b)' the local as.enov. and provided to the local agorrcy upon request. Completion of this fonn will satisfo UST training record kecping requirotuents. The followittg employees have been hainod as required by 23 CCR Scotions 271s(fxl) and (2): Facilitv Emnlovee Name Trainins Date Hire Itater Trainer Name2 ar {a4 lca Ia'-"r-, UJrotn Qw; o/4-a-*/ dlr / t+arl'ru)ffi {a'na A/Jtr/, Iilu"*g^ 6..*"d-\c"st-rq 9^:o-ft {a,*,+t A/./t.t (Conlinrcd on rctvtse) I Ifhired after luly l,2005. ' 'l'rainer must be a currcnt Dcsigneted usT opmtor for lhe ficility at the lime of training. UN-O6I . l/2 www'unidox.org al'/13fiJ5 UST System Designated Opcrator Feclltty Employee Training Record - Pagc 2 of 2 Faciti fv Em plo,yec Name Trainins Date Hirc Ilatc TrainerName uN-061 - ?2 wrw,unidoce.org o1i r3/o5 \) Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts t'rom tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. F'ACILITY INFORMATION Facilitv Address:3601 Sacramento St. San Luis Obispo, CA Facilitv Contact: Jason Schoon Phone: 818-947-4831 Date Local Asency Was Notified of Testing: 31612014 e TESTING CONTRACTOR INFORMA'TION SI]MMARY OF TEST RESULTS If hydrostatic testinc was describe what was done with the water after comDletion of tests: Station Contractors James WelschTest: Contractor Tank Tester Liccnse Tvoe:A. B. C-61. D-40 HazMat f,icense Number; 902034 Manufaclurcr Trainins Component(s)Datc Training ExpiresManufacturer Inoon TS.STS Pass Fall Not Testcd Repairs MadePassFeil Not Tested Repalrs Made ComponentComoonent tl L tl LJltL]LIDiesel Annular (Wet) U tJ LJ UUUDiesel Produot Pininc ljl LI ttltIUplItlUDiesel STP Sump tl I LI UlvlItlLuDc t-2 tt ltttttLILILIttttttllLL,l I l_l tl L L__l LJtltlLIttItiLItttttlttltttttL_lLI LIUt__.1 LUUttL LI L]lt I tl tl It L LI t_lttllUlltlLJllLI U tt L LI ltLItlttttllIItlUtttttttltttttlttIltllLIttttttIttttttttttLLIUttftnftltllll lrllltlrllrl Water in UDC spill bucket put in DOT drum on site. Water in STP sumn was r€tumed 9E9 trailer tank, CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in thls document are accurate and in lull compliance wlth legal requirements t)Technician's Signature: [- Date:3/2U2014 E tank Manufacturer I tndustry Standard I professionalMethod Developed By: Other Method Used:Pressure Vacuum Other esl Dicgel EI Yes I No fl Y"r n No nv". nuo Ev.t ENo lank Material; fank Manufacturer: Product Stored: Wait time between applying prcssure/vacuum/water and starting test: Iest Start Time: tnitial Reading (R1) Test End Time: Final Reading (Rp) Iest Duration: Change in Reading (Rp-R): Pass/Fail Threshold or Criteria: ;ii:nitiiiti: i:fi i*'lliili ii l.:::: Was sensor removed for testing?[yes nNo lrvn nvesnuo Dte nvesnno ENe Ives D'{o f}{A Was sensor properly replaoed and verified functional after testing?EvesENo ll.tl Ives l-luo l-}.tR l-lvesl-lNo l-N.q flYes fl'lo l-'Ne TANK ANNU ls Tank Exernpt From Testing? Capacity: Comments - (include information on repairs made prior ta testing, and recommendedfollow-upforfailed tests) Wet annular [1J Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary containment, such as systems that are hydrostatically monitored or under conslant vacuum, are exempt from periodic containment testing. {california code of Regutations, Tifle 23, section 2637(ax6)i \ dfrdmrrl^ \) sncoxDARY PIPE TESTING l Comments - (inclade informotion on repairs made prior to tesling and recommendedfollow-upfor failed tests) E piping Manufacturer E lndustry Standard n ProfessionalMethod Developed By; Other VacuumMethod Used Pressure Other I5: 4.5" Dlesel Product ent FiberglassPiping Material; Piping Manufacturer:AiO Smith 3"/2"Piping Diameter: l0'Length of Piping Run: Diesel PrcductProduct Stored: lsolation boot in STP Sump Method and location of piping run isolalion: l5 min Wait time bctween applying pressure/vacuum/water and starting test: Iest Start Time:12:47p 5.51psiInitial Reading (R): t;47pTest End Time: 5.51psiFinal Reading (Rp): I hourfest Duration: 0.0Change in Reading (Rp-R1): ffi0 I Threshold or PIPING SUMP TESTING Porlion of Sump Tested[1] turbine shut down when sump detects liquid (both product water)?' Comments - (include informalion on repairs made prior to testing, and recommendedfottow-upforfaited tests) [] lf the entire depth of the sump is not tested, speciff how much was tested. If the answerto any ofthe questions indicated with an asterisk 1'r) is "NO" or "NA", the entire sump must be tested. (See SWRCB LC-I60) E Sump Manul'acturer Q lndustry Standard ! ProfessionalMethod Developed By Other I Pressure E Otter (Swctfv) Iest Method Used ! Vacuum I Hydrostatic l: [rIest Equioment l 0.0000" Sump Diametcr:42" Sump Depth:47" Sump Material:Fiberslass llcight from Tank Top to Top of Hiehost Piping Penetration:lg" Height ftom Tank Top to Lowest Elsctrical Penetration:26u Condirion of sump prior to tssting:Dirty 20" lves fltto EF.m,Eves nNo fla flves flNo Dln fYes [.{o f}{A Turbine shutdown response time l0 second ls system programmed for fail-safe shutdown?'Eves flr'ro ElNa flyes ENo flna nves nno Erle flYes $to [1ff.1A Was fail-safe verified to be operational?'nves [No Elr'q,q Eves flt'to f]rue nves Et{o nNn flYes [}.lo f[.lA Wait time between applying pressurelvacuum/water and starting lest:15 minutes Iest Start Time:SEE lnitial Reading (\)INCON Iest End Timc:1'8ST Final Reading (R6)RESULTS Iest Duration: Change in Reading (Rr-R) PasVFail Thnshold or Criteria: fsbi!Ai$riltii:ii i.t. :!i :!iii il v 1111p33, 1:1':it l:fliilii Was sensor removed for testing?l?lYes [-].to NA flves l-ltto lun nyes fFqo ENn lYes [,,1o [1A Was sensor properly rcplaced and verified functional after testing?fJlves []xo l-lna l-lves l-ltto l-lrua IYes l-ltto f7lNa l-lYes l-T.lo l-xv,q CONTAINMENT TESl'ING OfUDC Does turbine shut dov.'n when UDC sensor detects liquid (both product and watetPi time Comrnents - (include inlormatlon on repirs made prior to tesling,and recommended fo I low-up for falled tesls) [l] If the entire depth of the UDC is not tested, specify how nuch was tested. If the answer to any of the questions indicaied with an astcrisk 1*) is "NO" or'NA", the entire UDC must be tested. (See SWRCB LG-160) U E UnC Manuf'acturer E lndustry Standard ! PmfessionalMethod DeveloPed BY: Other Method Used:acuumPressure Other EnvironJDC Manufaoturer: PlasticIJDC Matcrial: 9ilUDC Depth; 0rFleight fromUDC Bottom to ToP rf Highest Piping Penetration: 0'Height from UDC Bottom to Lowest Elecfi ical Penetration Dir1yCondition of UDC prior to testing: 7" llves fNo ENAlves flNo Dlnnyes ilNo n{eElves fltto D.tn fJYes ${o f}'lAl-lyes l-lNo nun flves lNo fJNeEYes nNo lNe ls system programmed for fail.safe rhutdown?' flYes $.lo f}]AEYes ENo D.tellves nuo flxn nves flrqo fNn to be l5 minutesWait time between aPPlYing pressure/vacuum/water zurd starting lest SEETest Start Time: INCONInitial Reading (Rt): TESTIest End Time: RESULTSFinal Reading (Rp): fest Duration;l5min x 2 Change in Reading (Re-ft):0 nves Etto Eun Passffail Tkeshold or Criteria:ffi Was sensor rcmoved for testing?lYes $o [,{A ii.-ffiTffit.'ffifrlilii!::jj.jljlj.l.:l.,;JEry .002 E]ves fFqo NA l-lYes l-T.{o l-NAl-lves l-lno iltq.el?lycs l-lNo l-lNe llves ENo ENa Was sengor propedy replaced and verified functional after testing? Facility Name:UPS SLO Date of Testing; 3-21-14 Facility Address:3601 Sacramento Facility Contact:Jason Schoon Date Local Agency Was Notified of Testing :3-6-14 Name of Local Inspector (if present during testing): Kerry Boyle SWRCB, January 2006 Spill Bucket Testing Report Form This forn is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests (if applicable), shauld be provided to the facility owner/operator .for submittal to the local regulatory qgency. I. FACILITY INFORMA TESTING CONTRACTOR II{FORMATION SPILL BUCKET TESTING INT'ORMATION Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIF'ICATION OF' TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certfu lhut all lhe infarmation conlalned in this reporl is trae, ilccutate, and in futl compliance wlth legal requlrements. Company Name: B&T Service Station Contractor Technician Conducting Test: James Welsch Credentials': X CSLB Contractor X ICC Service Tech. tr SWRCB Tank Tester O Other (Speeifu) License Number(s): 8201 843 Test Method Used:x Hydrostatic ! Vacuum Other t Diesel Fill 2 Stored Test Equipment Used: Identifo Spill Bucket (By Tank Equipment Resolution: 43 Bucket lnstallation Type:x Direct Bury ! Contained in Sump D Direct Bury D Contained in Sump tr Direct Bury E Contained in Sump ! Direct Bury O Contained in Sump Bucket Diameter:12" Bucket Depth:73 Wait time between applying vacuum./water and start of test:10rnin Test Start Time (T1):SEE Initial Reading (&):INCON Test End Time (Tp):TEST Final Reading (Rr):RESULTS Test Duration (Tr -T):IsMINX2 Change in Reading (Rn- Rr)0 Pass/Fail Threshold or Criteria:.002 Test Reiult:X Pass E Fail CI Pass tr Fail El Pase tr Fail tr Pg$ FX'ail I State laws and regulations do not cunently require testing to be perfonned by a qualified contractor. However, local requirements may be more stringent, UPS -San Luis Obispo s8989 03tzv14 SLO llPS'r 3601 SACRAT'INTO SAN LUIS OBISPO 03/211201a 11;50 Al',l SUI,IP LEAK TEST REPORT DSL F8K IEST STARTED 1'I:34 AH TEST STARTED 03/21/2O1II BEGIN LEVEI- 5.0979 IN END TIHE 1il4g AI'I END DATE o3/2il2014 ENO LEVEL 5.09?6 IN LEAK THRESHOLO O, OO2 IN TEST RESULT PASSEO uDc TEST STARTED 11:34 AIl TEST STARTED 03/21/2014 BEGIN LEVEL 1.6T20 IN ENI) TII4E 1 1 :49 A1.| END 0ATE 03l?1/2014 END LEVEL 1.0?36 IN LEAK THRESHI)LO O. OO2 IN TEST RESULT PASSEO SLO UPS 3601 'SACRAI,INTil SAN LUI$ OBISPO 03/?'112014 12:08 Pll SUf'IP LEAK TEST REPORT I}SL FB( TEST SIARTEI] 11152 ATI TEST STARTED 03121/2AM BEGIN LEVEL 5.0978 IN END TIt'lE 12:08 Pll END DATE O3I21I2O1T ENO LEVEL 5. Og?4 ITI LEAK THRESHOLD O. OO2 IN TEST RESULT PASSEO UDC TEST STARTED 1 1 :52 AI'I TEST STARIED 03121/2014 EEGIN LEVEL I.6739 IN END Tll'lE 12:08 Pt',l ENo 0ATE 03/2112014 END LEVEL 1.6751 IN LEAK THRESHOLD O. OO2 IN TEST RESULT PASSED SLO UPS 360I SACRAHNTI] SAN LUIS OBISPO 03/21/2014 1:16 Pl'l SUI1P LEAK TEST REPORT OSL STP TESI STARTED "i:OO PII TEST STARTED 03/21/2014 BEGIN LEVEL 5. 4'I5] IN ENo TIilE t: t0 pt'l ENo DATE 0312112014 ENt) LEVEL '5,4'161 IN LEAK THRESHOLO O, OO2 IN TEST RESULT PASSEO SL(] UPS 3601 SACRAfiNTO SAN LUIS OEISPO 0?121/2010 I r33 Pt'l SUI,IP LEAK TEST REPORT DSL STP TEST STARTED 1:1E PI'I TEST STARTED 03/21/2014 BEGIN LEVEL 5,4163 IN ENo Tll.lE 1:33 Pl'l Et{0 DATE 03/21/2014 E}ID LEVEL 5, 4]64 IN LEAK THRESHOLI) O, OO2 IN TEST RESULT PASSEO United Parcel Service, lnc. UPS - San Luis Obispo 3601 Sacramento Dr, San Luis Obispo 93401 cERsrD 10415094 Facillty lD FA0004810 status Submitted on 2/2512015 4:41 PM Chemlcal lo"-'' r Name Business/Org. Annual Waste Amount Federal Hazard Categories EHS CAS No.Common NameCode/Fire Haz. Class Nam€DailyCont. Quantities Max.Unit Hazardous Components %wt mixture on Gallons -sl-a-!9.... Liquid -T-YP-e--.. Pure 8000 Pressue ffi fi ;;f--- ws!!e'-qeg-e' lejTp-eElqlg Ambient Sto.aEe Container Diesel Fuel3 - Flammable and 68334-30-s 10800 12000 CAS No bustible Liquid. Class ll Liquids - Fire - chronic health Belowground Tank Days on Site: 365 Hazardous Materials And Wastes lnventory Matrix Report Printed on 2/27/2OL5 3:26 PM Page 3 of 3 UPS - San Luis Obispo 3601 Sacramento Dr, San Luis cERs rD LO41:6O94 FacilityrD FA0004810 status Submitted on 4:41 PM l Area 93401 Name Chemical LocatlonBusiness/ors. United Parcel Service, lnc. Annual Waste Amount Hazardous Components Federal Hazard Common NameCode/Fire Haz. Class NameCont. Quantities Max-Unit %Wt EHS CAS No. Damaged Package Wastes - Flammable Gases (Waste Aerosols) CAS No Pounds Solid -r-yP.g-. Waste 25 105 !Ieig-r19....-...---...w-?:!F-9-o-d-9 Ambient Tempsature-- Ambient 2.1 - Flammable Gases Fire300300 919-I-?-c-e-.f gjl1lt'-9I-..-. Steel Drum Days on Site: 90 Damaged Package Wastes - Flammable Solids CAS No Steel Drum Days on Site: 90 )OT: 4.1 - Flammable Solids Fire200 Pressue 300Pounds 600 State StoraPeContainer 799 Waste Code Ambient IgllPrE_!-ql_e_- Ambient Solid I-Ys9-. Waste )OT: 5.1 - Oxidizing Substances Damaged paCkage WaSteS - Oxidizers _cA-s-..l,t_-o_*.. Pounds -sl9I9-... Solid I-YPg- - Waste Steel Drum Days on Site: 90 50 237 - Reactive 3rq:9 e .................. ! /$!e--c-qg-e Ambient -r-e.uPs-.I?!-'1.t9-... Ambient 300300 Storage Co.It€ins Damaged Package Wastes - Miscellaneous Hazardous Materials CAS No Pounds 9l?Is-_ Solid lv_Le_ Waste 819 Ambient Y?-s-te -qgi-e... 200 Pressue Ambient I-e!nP-9.n!!Ig- 300500 9lgl_qqgco.nHn-e-L.'. Steel Drum Days on Site: 90 9 - Misc. Hazardous rials Hazardous Materials And Wastes lnventory Matrix Report 3 - Flammable and bustible Liquids 5.1 - Toxic Substances 8 - Corrosives (Liquids and Damaged Package Wastes - Flammable Liquids (Solidifi ed) CAS No Damaged Package Wastes - Corrosives 9.A:-Ie* Pounds 300 State StoraseContainer Steel Drum Days on Site:90 300 Storase Container Steel Drum Days on Site: 90 Pounds 300 State StoraseContainer 25300 1.43 Waste Code Fire 353 - Acute Health waste code - Chronic health 424 - Reactive Solid ryPs-." Waste Damaged Package Wastes - Toxic Pounds Substances !!9!9- Solidc.4gN9_ ry-eg_ Waste Steel Drum Days on Site: 90 Pressue Ambient -r-9-r1P.-e-.relqI-e-... Ambient Pressue Ambient Tempera*!-uje-- Ambient 100 Pressue Ambient -r-9-ru9re!gr-.. Ambient 300 300 50 Solid I-YPF-.- Waste Printed on 2/27/2075 3:26 PM Page 2 of 3 l€RS Business/Org. :acility Name United Parcel Service, lnc. UPS - San Luis Obispo 3601 Sacramento Dr, San Luis Obispo 93401 cERsrD 10416094 Facility lD FA0004810 status Submltted on?l21l20t9 4:41 PM Chemlcal Location Annual Waste Max. Daily Largest Cont. Avg. Daily Amount Federal Hazard Categories Hazardous Components (For mixture onlv) Component NameCommon Name)oT code/Fire Haz. Class Unit o/"Wt EHS CAS No. Liquid Plastic/Non-metalicDrum I-YP-e..... Mixture Davs on Site: 365 - Acute Health Waste Code Antifreeze - New 55 Pressue 55Gallons 110 State StoraseContainer Ambient-cAS-.N-e-..... LO7-27-7 707-27-1 7732-18-5 95% 5% ETHYLENE GLYCOL WATER lombustible Liquid, Class lll-8, rritant I-enP--el-q!-,tI.e-... Ambient Liquid Aboveground Tank, Tank lnside I_y_p-e*. Building, Steel Drum Mixture Days on site: 365 Motor Oil - New CAS No Fire165 Pressue 110Gallons 275 state StoraPeContainer 6474X.XX-XVARIOUS LUBRICATING BASE OILS 85 % 3ombustible Liquid, Class lll-B Ambient y-?g!-e-goqe 227 r emperature Ar6;;i--- MIXTURE 68649-42-3 ADDITIVE PACKAGE, INCLUDING 75 % ZINCALKYLDITHIOPHOSPHATE 2% DOT:3 - Flammable and 3ombustible Liquids Gallons LzO LzO -slq-!-e-^-sl9p-g_e-._c._o-t_kin-9.t.........Liquid Aboveground Tank, Tank lnside r-YP-e-..' Building Waste Days on Site: 90 q?:l-e-gede 60 Ambient Ambient 360 - Fire I9rP9r?r-qr-e*. 221"3ombustible Liquid, Class lll-B Motor Oil - Waste ss.l--l!-o-.-.... VARIOUS LUBRICATING BASE OILS 85 % 6474X-XX-X MIXTURE 68649-42-3 ADDITIVE PACKAGE, INCLUDING 75% ZINCALKYLDITHIOPHOSPHATE 2% )OT:3-Flammableand :ombustible Liquids CAS No 792 2 Pressue 1 :orrosive 18 40% J 7664-93-9Lead Acid Batteries - Spent Gallons 6 State StoraseContainer waste Code - Acute Health Sulfuric Acid - Chronic health Ambient I*e-nP.s-:-qlgre Ambient Liquid Other I-YPg-.. Waste Days on Site: 90 )OT: 8 - Corrosives (Liquids and iolids) Hazardous Materials And Wastes lnventory Matrix Report Antifreeze - Spent c-41$-o- Gallons -slPl_e_.. Liquid -T-YP--e-.-. Waste 55 55 !l9r*-e-.-q9-n-k1!3r..... Plastic/Non-metalic Drum on Site:365 30 110 - Fire Pressue waste code - Acute Health erOi""l--- -*"i34- - Chronic health -r_9.np_e!?!_rlI_e_... Ambient Ethylene Glycol Water 60% 40% 707-27-r 7732-78-5 Printed on 2/27/2015 3:26 PM Page L of 3 California Environmental Reporting System (CERS)Underground Storage Tank - Facility lnformation Facility/site UPS - San Luis Obispo 1601 Sacramento Dr ;an Luis Obispo, CA 93401 CERS ID 10416094 Submittal Status Submitted on 2/2512075 by Alvin Solis of United Parcel Service, lnc. (Atlanta, GA) :omments by submitter: Annual submittal. Submittal was Accepted; Processed on 2/27 /2075 by Kerry Boyle for San Luis Obispo City Fire Department type of Action Renewal Permit :acility lnformation JPS - San Luis Obispo 1601 Sacramento Dr ;an Luis Obispo, CA 93401 :acility Type Board of Equalization Account Number vlotorvehicle Fueling 44032294 s the facility located on lndian Reservation/Trust lands? {o rroperty owner ]T-OH, LLC 4O4\ 828-7660 i5 Glenlake Parkway, NE \tlanta, GA 30328 lank Operator Jnited Parcel Service lnc., an Ohio Corporation ,s10) 4s3-2090 1400 Pardee Drive Jakland, CA94621 lank Owner Jnited Parcel Service lnc., an Ohio Corporation s10) 453-2090 1400 Pardee Drive )akland, CA94627 lank Owner Type \,lon-Govern ment termit Holder lnformation termit Holder Notifi cation lnformation lank Owner superuisor of Division, Section, or Office (Required for Public Agencies Only) :inancial Responsibility Mechanism(s) 180.107) or CCR, Title 23, Division 3, Chapter 18, Section 2808.1.. ;elf-lnsured Surety Bond State Fund and CFO Letter Other Mechanism yes Suarantee Letter of Credit State Fund and CD nSurance Exemption Local Government Mechanism \pplicant Certifi cation \pplicant Name :rystal Lassiter Applicant Title Plant Engineering Area Manager Applicant Phone (s10) 4s3-2090 Date Certified 2/L0/207s Printed on 2/27/2015 3:26 PM Underground Storage Tank - Tank lnformationCalifornia Environmental Reporting System (CERS) - San Luis Obispo CERS ID 601 Sacramento Dr 10416094 Luis O cA 93401 Status on 2/25/2075 by Alvin Solis of United Parcel Service, lnc. (Atlanta, GA) mments by submitter: Annual submittal. I was Accepted i Processed on 2/27 /2O75 by Kerry Boyle for San Luis obispo city Fire Department of Action of Action (UST Tank) I Permit lnformation - San Luis Obispo Sacramento Dr n Luis cA 93401 Description tD#Date UST System lnstalled e/$/7s8s Date Existing UST Discovered Tank Configuration A Stand-alone Tank Number of Compartments in the Unit 1 Additional Description Manufacturer ns Corning Capacity ln Gallons Date UST Permanently Closed Iank Construction rype ofTank )ouble Wall trimary Containment :iberglass Secondary Containment Fiberglass )verfill Protection Audible/visual Alarms fes Ball Float Yes Fill Tube Shut-Off valve Exempt lank Use and €ontents 'ank Use vlotor Vehicle Fueling Tank Contents Diesel Other Petroleum Contents Other Non-Petroleum contents Under Dispenser Containment {UDC} :onstruction Type iingle-walled Construction Material Rigid Plastic Certification Name Applicant Title Plant Engineering Area Date Certified I Lassiter 2hOl207s Sorrosion Protection Sacrificial Anode lmpressed Current lsolation ,roduct / waste Piping Construction tiping Construction )ouble-walled tiping System Type )ressure Primary Containment Fiberglass Secondary Containment Fi berglass Piping/Turbine Containment Sump Single-walled Vapor Recovery {VR} and Riser / Fill Pipe Piping Construction Containment Vapor Recovery Primary Containment Fiberglass Riser Pipe Primary Containment Steel Vent Piping Transition Sumps None Fill Components lnstalled Yes Spill Bucket Yes StrikerPlate/BottomProtector Containment Vapor Recovery Secondary Containment None Riser Pipe Secondary Containment Noneone Containment Printed on 2/27/20]-5 3:26 PM California Errvi ron menta I Reporti ng System (CERS)Underground Storage Tank - Monitoring Plan UPS - San Luis Obispo 1501 Sacramento Dr ;an Luis Obispo, CA 93401 CERS ID 10415094 UST Tank # 1 ;ubmitted on 2125/2075 by Alvin Solis of United Parcel Service, lnc. (Atlanta, cA) :omments by submitter: Annual submittal. ;ubmittal was Acceptedi Processed on 2/27 l2OI5 by Kerry Boyle lor San Luis Obispo City Fire Department PS - San Luis Obispo Sacramento Dr Luis cA 93401 \4onltoring Equipment Seruiced \nnually ;lte Plot Plan Submitted ;ite Plan Previously Submitted Monthly Statistical lnventory Reconciliation Other Monitoring Monitor Panel Manufacturer Veeder Root Monitor Panel Model TLS-350 Leak Sensor Manufacturer Veeder Root Leak Sensor Model # 302 ln-Tank Probe Manufaclurer Veeder Root ln-tank Probe Model Mag 1 Leak Test Frequencl Weekly Programmed Tank Tests 0.2 GPH Weekly Manual Tank Gauge fank Gauging Test Period Tank lntegrity Testing Tank lntegrity Testing Frequency fes ContinuousElectronicTankMonitoring Secondary Containment System -iquid-Filled tes Automatic Tank Gauging \TG Panel Manufuctur€r /eeder Root tTG Model$ tLs-350 Printed on 2/2712015 3:26 PM Underground Storage Tank - Monitoring PlanCa I iforni a Environmental Reporti ng System (CERS) - San luis Obispo CERS ID Sacramento Dr Luis Obispo, CA 93401 10416094 UST Tank * I No Regulated Piping Per He.lth and Safety Code, Division 20, Chapter 6,7 ls Connected To The Tank System Suction Piping Meets Exemption Criteria Other Pipellne Monitoring continuous Monitoring of Piping Secondary Containment Secondary Containment Pipeline Integrity Testing lntegrity T€sting Frequency Root FXlDV Leak sensor Manuracturer Veeder Root Leak sensor Model # 20s Leak Alarm Triggers Automatic Pump Shutdown Failure/Disconnect Triggers Pump shutdown Electronic Line Leak Det€ctor Performs 3 GPH Leak Test Manufacturer ELLD Programmed ln-Line Testing Model EILD Trigg€rs Automatic Pump Shutdown ELLD Failure/Disconn€ct Triggers Auiomatic Shutdown visual Pipeline Monitoring Visual Pipeline Monltoring Frequency Panel Manufacturer Veeder Root Panel Model # TLS-350 Mechanical Line Leak Detector Performs 3 GPH Leak Test Manufacturer MLLD Model Detection of Leak into UDC Triggers Audible and Visual Alarms UDC Leak Alarm Tritgers Automatic Pump Shutdown Failure/Disconnection of UDC Monitoring System Triggers Automatic Pump Shutdown Leak within Secondary Containment of UDC Causes Audible and visual Alatms Monitorlng Stand-alone UDC Monitoring Stops Flow of Product at Dispenser Yes UDC Construction Single-walled UDC Secondary Containment Monitoring Panel Manufacturer Panel Model f [eak sensor Manufacturer Leak Sensor Model ELD Testing Secondary Containment Testing Printed on 2/27/2015 3:26 PM California Environmental Reporting System (CERS)Underground Storage Tank - Monitoring Plan CERS ID 10416094 UST Tank *Luis Obispo, CA 93401 - San luis Oblspo Sairam€nto Dr les Alarm Logs les Visual lmpection R€cords fank htegrlty Testing Results Sln Testing Results Trnk Gauging Resulte ATG T€sting Results Corrosion Protection Logs /eS EdulDment Malnienanca 6nd Celibrailff Rrc6rds /es Personn€l with UST Monltoring ReSponslbllities are Famlllar wlth Tralning Documents les UST Monltoring Plrn /es operatlng Manuats CA UST Ra8ulatlons eA UST la!,e SwRcB Handbook for Tank owners - Manual and slR SWRCB Publl.atlon: Underianding Autofitatlc Tank Gauglng Systems Other Trainlng Dorun€nts /es DesisnatedOEeratorTnlnlng :omments and Additionel hformati6n 'lame of Rlst Per6on Having Responsibllity (asi Montgomery 'rtle of Flrst Person Having Respan$lblllty )lant Engineering supervisor Name ofSecond Person Havlng Responsibility Jeanette Hopkins Itle of Secgnd P€rson Having Responsibllity District Environrnental Coordinator qppficant Name :rystal Lassiter Appllcant Tltle Plant Engineering Area Manager Signature Date 2/70lza15 Slgnature nepresentation Authorized Representative of Owner Printed on 2/27/2015 3:26 PM UNDERGROUND STORAGE TANI( SYSTEM DISIGNATED OPERATOR X'ACILITY EMPLOYEE TRAII{ING RECORI) For use by Unidocs Member Agencies or where approved hy yow Local Jurisdiclion AurhuityCited:Tille23,Div.3,Ch.16CatifomiaCodeofRegulations(CCR) Facility Nsme: /',*QS S Lts Scction 2715 of Title 23, Califomia C,ode of Regulations, rcquircs lhat Designated Underground Storage Tank Operators provide training to facility cmployecs who have responsibiiities associateJ with thc opcration and/or maintenance of rurdcrpgouud storage tant iUS'f'j ,yrtonr. this taining must be provi<Icd by July l' 2005, and every 12 months thereafter' For t'acility cmployees hired after i rry r, 2005, the initiat tralning must bc providerl within 30 days of the date of hire' At leasr one of the facility employees present during opcrating hours must have cunent haining. This haining must include' but is not limitcd to, the f;llowing itefirs as specified in ?3 CCR Sections 271 5(fX1) and (2): E operatlon of tie UST system in a manncr consistont with the faoility's Best Managemcnt Praetices; F Th" ernploycc's role wiih regard to UST monitorfurg equipment as spccihcd in the written UST Monitoring Plan; .!l The u1nptoy""', role with relard to spills and ovortills as specified in the written UST Response PIan; E Name(s) of contact person(sj lbt **"rg"n"ies arrd monitoring equipment alanns; fi f'or faci'lities that are not *utirr*ty stafied, facility employee reqrcnsibilities as spc'r-ifioxl in the tainirg progmrn approved by the local US'l'regulatory agency. 23 CCR {i 2715(lX3) requires that a list of employees who have been trained by the Designated Underground Storagc l'ank Operato(s) be maintained on-site, or oft-site at a rcadily-available location if approved by the local agencv. and provided to the local ug*"y upon request. Completion of this fonn"will satisff UST training record kccping requirettrents' The followilrg etnployees have heen rained as required by 23 CCR Scctions 271 s(fxl) and (2): Fncility I Ifhired afler July l, 2005. '!'l'rainer must he a crurcnt Dcsignated UST Opmror for lhe facility at the lime of training. UN-061 - lf, www'unidos'org Site Addressz /Oi d la-c lrbn-,^-tlo City: (Conliwed on tetene) l^t !),ro o Narne Trainins Date Hire Deter trainer ffa-d ro/or/tq arlaqfa O/4-"-*/ alt 1t+orl'ru)ffi 6-,*"'S-\c"ot.tq I ^ :o-ft o7113^)5 California Environmental Reporting System (CERSI Business Owner Operator PS - San Luis Obispo CERS ID Sacramento Dr L04L6094 Luis Obi cA 93401 ;ubmittal Status iubmitted on 4/2/2013by Anthony Delgodillo of United Parcel Service, Inc. (Atlanta, cA) ;ubmittal was Accepted; Processed on 2/LU2O74 bv Kerry Boyle for San Luis Obispo County Environmental Health ldentification Jnited Parcel Service lnc. )peratcr Phone 1805) s44-7186 Business Phono Susiness Fax Seginning Date 3/L/2013 Dun & gradstreet 006991681 fndin6 Date 2/28/20L4 5lC code 4275 (80s) s44-7186 (80s) s43-49ss Primary NAICS 492770 Mailing Address Emergency Contact 201 W. Olympic Blvd.iel McClelland Angeles, CA 90015 Business Manager Phone 24-Hour Phooe Pager Nuilber 544-7786 Owner BT-OH, LLC [404) 828-7660 r5 Glenlake Parkway, NE qtlanta, GA 30328 Emergency Contact aurice Barksdale nt Engineering Supervisor Phone 24-Hour Phone Pager Number 442-2925 ing Contact nited Parcel Service lnc ) 612-1924 adelgadillo@ u ps.com 201 W. Olympic BIvd Angeles, CA 90015 Environmental Contact \nthony Delgadillo 626]| 814-6269 t100 Baldwin Park Blvd. laldwin Park, CA 91706 adelgadillo@ u ps.com 0t Signer Massie Sigrer litle President Document Preparer Anthony Delgadillo al lnlormation Locally-collected Fields Some or all of the following fields may be required by your local regulator(s) Owner -OH, LLC 4O4l 828-7660 Address Glenlake Parkway, NE GA 30328 Assessor Parcel Number {APN) 053-23 1-025 Number of Employees 125 Facility lD FA0004810 Printed on 10/3/201,4 8:24 AM United Parcel Service, lnc. UPS - San Luis Obispo 3601 Sacramento Dr, San Luis Obispo 93401 c€RsrD 10416094 Facirity ro FA000/1810 status Submitted on 9:56 AM ,OPName Business/Org.Chemicl Location Annual Quantities Waste Max. D:ilV N-argest Cont. Avg. Daily Amount fHS CAS No. Federel liazard Common NameHaz. Class NameU nit Hazardous Components %wr USED MOTOR OIL S*P-"rye . 6474-\8-84 360 - Fire y-*:lgsg{,e- - Acrte Health 22IAmbient 6474-18-8470 Pressue I"ifP-g*!-YIe, Ambient 720Gallons 72O State StoraseCont;iner Aboveground Tank on Site: 365 7s% 75% LUBRICATING BASIC OIL DETERGENT INHIBITORS Liquid Lv-P-e-... Waste Liquid IvPg* Waste Steel Drum Days on Site: 365 25 45 - Fire pressse Waste Code - Acute Health erUi""r-*" "" -il** chronic health I-e-f ?-gl-q,tY.tg... Ambient Ethylene GlycolSPENT ANTIFREEZE Water 55 foxic Gallons 55 State StoraeeContainerCAS Na 707-2!-7 7732-18-5 60% 40% )OT:3-Flammableand lombustible Liquids :ombustible Liquid, Class lll-B 200 - Fire pressue - Chronic health ilbi;;i-* Y-itJe-te-* I-9$P9i-e3Yr.9- Ambient 110Gallons 255 State Stora2eCantainer 6474X-XX.XVARIOUS LUBRICATING BASE OILS 85 %[ubricating Oils S*-s-l!-o-..MIXTURE 68649-42-3 ADDITIVE PACKAGE, INCLUDING 15% ZINCALKYLDITHIOPHOSPHATE 2% Llquid Aboveground Tank, Steel Drum Mixture Days on Site: 355 Hazardous Materials And Wastes lnventory Mailix Report ANTIFREEZE 707-21--t Gallons 110 55 30 State StoaaseContainer f |-:t.s"99........-......... w-itJ9't9C-e.. Plastic/Non-metalic Drum, Plastic Ambient Bottle or Jug Temperature on Site:365 Ambient Acute Health EIHYLENE GLYCOL WATER 95% 5% 707-27-1 7732-ta-5Liquid, Class lll-8, cAs No rritant Liquid IvPg . Mixture Printed on 10/3/20L4 8:2a AM Page 1 of 4 Annu:l ltlast" Max. Daily Largest Cont, Avg. Daily Amouni fed€ral llazard Categories Component NameCommon Name)OT CodelFire Haz. Class Unit '/cwt EHS CAS No. |lazardous Coffiponents ,Far mixtu.e oslvl Belowground Tank Days on Site: 355 DIESEL FUEL NO. 2 Waste Code DIESEL 64476-34-6 \oo% 6a476-34-6Gallons 12000 12000 State StoraeeContainerCAS No lombustible Liquid, Class ll Fire Chronic health 6000 Pre5sue Liquid I:/-P9"- Pure Ambient relfp--e_t-?!-y.*.- Ambient )oT:3 - Flammable and :ombustible Liquids gERs Business/org. Facility ilame United Parcel Service, lnc. UPS - San [uis Obispo 3601 Sacramento Dr, San Luis Obispo 93401 cERsrD 10416094 racility rD FA00Olt81O status Submitted on 4/2/2013 9:55 AM chemi*l Lftation Hazardous Materials And Wastes lnventory Matrix Report Printed on 10/3/2014 8:24AM Page 2 of 4 tAB PACK - PACKAGE GENERATEDGaI|ons WASTE T-!*: !*:-.lt-o-.... Liquid IJP-:,,,, Waste 50 - Chronic health w?:I_9 q99-e 343 Days on Site: 180 Storaee Ccntainer Steel Drum 30 Pressue 5550 fther Health Hazard Ambient lgnp.3r-!a.r-e-. Ambient )OT:9-Misc.Hazardous Vlaterials Chronic health Storase Container CAS No 352 100 Pressu€ 200200 fther Health Hazard 1300 Waste CodeSteel Drum Days on Site: 180 Solid I-YP-9-... Waste tAB PACK. PACKAGE GENERATED Pounds WASTE :1939" Ambient IsnP.9-f-?19.r9.... Ambient )OT:9 - Misc. Hazardous Vlaterials )OT: 6-1 - Toxic Substances loxlc tAB PACK - PACKAGE GENEMTEDGaIIonS wAsTE lli-ie- r3;..n-o-....... Liquid rype w;;i; Steel Drum Days on Site: 180 Storaee Contain€r 3s2 30 Pressue 5550 ZO -Acute Health Waste Code Ambient -r-9np-9I-ql.lt.|-t.... Ambient LAB PACK - PACKAGE GENERATEDPoundS wAsTE :li-1-e-.. cAs No solid lf -g:_:_,tg...--.........w-?:!_9-Q_9$_C-Storage Container Steel Drum 33\ 100 Ambient Ii.nr"9.ri$i9. Ambient 200200 IvPg . 25O - Acute Health Waste Days on Site: 180 )OT:6.1 - Toxic Substances l-oxic United Parcel Service, lnc. UPS - San Luis Obispo 3601 Sacramento Dr, San Luis Obispo 93401 c6RsrD 10416094 Facility lD FA0004810 starus Submitted on 4/2/2OL3 9:56 AM {ED ChemiGl LtrationBusiness/Org. Nam€ Annual lAlasle Amount Federai llazrrd Common l{amecode/Fire Haz. Class Nam€ qua ntitie5 Unit Max. Daily Largest Cont. Hazardous Components mixtuae % wt. EHS CAS No- LAB PACK - PACKAGE GENEMTEDPoundS WASTE ,sl?_le- Solidgl-l'-... Ivsg.... Waste tls ::9e........-........w-?:!9."q9{c 352 100200 250 - Fire Days on Site: 180 4.1 - Flammable Solids ble Solid Ambient -r-9r.p_g$.YI9.-... Ambient 200 :-!9n-c_99r.r1iir"e.r"........ Steel Drum tAB PACK - PACKAGE GENERATEDPounds wAsTE l-!3-!s... Solidq$Ie-..-.- I-Y.*-"-.. Waste Chronic health Storase Container 181 100 Pressue 200200 :orrosive 400 Waste CodeSteel Drum Days on Site: 180 Ambient I-"_?eg$lq.'.s..- Ambient DoT: 8 - corrosives (Liquids and Solids) Hazardous Materials And Wastes lnventory Matrix Report 8 - Corrosives (Llquids and 5-1 - Oxidizing Substances ng, class 1 LAB PACK - PACKAGE GENERATEDGaIIonS WASTE :I3:9.. CAS No Liquid IvP9..- Waste LAB PACK - PACKAGE GENERATEDPoUndS wAsTE _sl3-!g, cAs No solid IYPg... 50 Storase Cont3iner Steel Drum Days on Site: 180 200 Storage Container Steel Drum Waste Days on Site: 180 30 l|.gt-s-9s................- Ambient w-?::n.-q99"e... 1-ZZtemperature Ambient 100 75 .lr9t-i-q-e-.................Y:9J-9.-c-99-q..Ambient 181 -r-9-.nP-91*!i.19.. Ambient 20 - Chronic health - Reactive - Acute Health - Chronic health 55 200 Printed on !0/3/20La8:24 AM Page 3 of4 United Parcel Service, lnc. UPS - San Luis Obispo 3601 Sacramento Dr, San Luis Obispo 93401 cERsrD 10416094 Facility lD FA0004810 9:56 AM Chemicl Lration on Name Business/org. Annual Wast€ Amount Federal tlazard Common NameCodelFir€ Haz. Class NaseCont. 0uantities Max.unii n/6wt EHS CAS No. Hazardous Component: mixture tAB PACK- PACKAGE GENEMTEDGaIIonS 50 wAsTE ::!3-19-.. -s-!9r3.C9.9-o-.r!3139! ... .gi:--n-o-...... Liquid steel Drum Lv-Pg-..Waste Days on Site: 180 30 elg.s!--Yg.............-..- Ambient -r-9.npst"q:Y.t9-... Ambient 331 wqilg cgd9.. 55 G0 - Fire Liquid, Class l-A 3 - Flammable and stible Liquids Hazardous Materials And Wastes lnventory Matrix Report Printed on 70/3/2074 8:24 AM Page 4 of 4 California Environmental Reporting System (CERSI Underground Storage Tank - Facility lnformation P5 - San Luis Obispo CERS tO 1 Sacramento Dr 10416094 n Luis Obi cA 93401 Status on 4/z/20t3bv Anthony Delgodillo of lJnited Parcel Service, lnc. (Atlanta, GA) mments by submitter: Certification of Financial Responsibility updated lwas Accepted; Processed on2/ffl2o74by Kerry Boyle forSan Luis Obispo County Environmental Health Iype of Action lonfi rmed/U pdated Information Facility lnformation JPS - San Luis Obispo 3601 Sacramento Dr ;an Luis Obispo, CA 93401 :acility Type Board of Equalization Account Number Vlotorvehicle Fueling 44032294 s ihe facility located on lndian Reservation/Trust lards? \o lank Owner Jnited Parcel Service lnc. s59\ 442-292s 1601 W. McKinley Avenue =resno, CA 30328 iank Owner Type !on-Government Certification Name Appticaot Title President Applicant Phone Date Certified 3/28/2013I Massie 874-6269 Operator nited Parcel Service lnc. 442-2925 W. McKinley Avenue cA 93728 Property Owner BT-OH, LLC 1404) 828-7660 i5 Glenlake Parkway, NE Atlanta, GA 30328 Holder lnformation Holder Notifi cation lnformati0n Supervisor of Division, Section, or Office (Required for Public Agencies Only) Owner Responsibility Mechanism(s) or CCR, Titl€ 23, Division 3, Chapter lB, Section 2808.1. Surety Bond State Fund and CFO Lett€r State Fund and CD Local Government Mechanism Other Me.hanism Letter of Credit nsurance fxempliofr Printed on L0/3/20J.4 B:24 AM California Environmental Reporting System (CERSI Underground Storage Tank - Tank lnformation lity/Site PS - San Luis Obispo CERS rt) 1 Sacramento Dr L04L6094 n Luis Obi cA 93401 Status ilted on 412/2013 by Anthony Delgodillo of United Parcel Service, lnc. (Atlanta, GA) nts by submitter: Certification of Financial Responsibillty updated itta I was Ac&pted; Processed on 2/1U2074 by Kerry Boyle for San Luis Obispo County Environ menta I Health of Action of Action (UST Tank) nfirmed/U lnformation cility lnformation San Luis obispo Sacramento Dr n Luis Obi cA 93401 Use and Contents Use Tank Contents Diesel Other Petroleum Contents Vehicle Fueling Other Non-Petroleum C0rtents Vapor Recovery (VR) and Riser / Fill Pipe Piping Construction Conlainmert Vapor Recovery primary Containment Fi berglass Vapor Recovery Secondary Containm!nt None Riser Pipe Prinary Containment Steel Riser Pipe Secondary Containment None Vent Piping Trarsiti0n Sumps None Fill Components lrstdlled Yes Spill Bucket Yes StrikerPlate/gottomProtector berglass Containment ne Jnder Dispenser Containment (UDCI :onstruction Type Construction Material iingle-walled Rigid Plastic Certification nt Narne Applicant Title President Date Certified Massie 3 Protection Sacriticial Anode lmpressed Current lsolation Description tDlt Date UST System lfrstalled 8/L5/1989 Date fxisting UST Discovered Tank configuration A stand-alone Tank Number 0l Compartments in the Unit T Additional Description Manutacturer Corning Capacity ln Gallons Date UsT Permanenlly Closed fank Construction fype of Tank )ouble Wall trimarV Containment :i berglass Secondary Containrnent Fiberglass )verfill Pr0tec$on Audible/Visual Alarms fes Ball Float Yes Fitt Tube shut-offValve gxempt ct / Waste Piping Construction Construction Primary Containment Fi berglass Secondary Containment Fiberglass Piping/Turbine Containment Sqmp Single-walledble-walled System Type re Printed on I0/3/20L4 B:24 AM California Environmental Reporting System (CERS)Underground Storage Tank - Monitoring Plan cility/Site PS - San Luis Obispo 1 Sacramento Dr n Luis Obispo, CA 93401 I Status tted on 4/212013bv Anthony Delgadillo of United Parcel Service, lnc. (Atlanta, GA) mments by submitter: Certification of Financial Responsibility updated was Accepted) Processed on 2/fIl20I4 by Kerry Boyle for San Luis Obispo County Environmental Health Facility lnformation JPS - San Luis Obispo 1601 Sacramento Dr ian Luis Obispo, CA 93401 Equipment Testing and Preventive Maintenance \4onitoring Equipment Serviced An n ually ceRS t0 10416094 UST Tank t 1 Monitoring Locations ;ite Pl0t Plan Submitted ;ite Plan Previously Submitted Monitoring is Performed Using the Following Method(s) Continuous Eleaironic Tank Monitoring Containment 5yst€m Monitor Panel Manufacturer Veeder Root Moniior Panel Model TLS-350 Leak Sensor Manufactsrer Veeder Root Leak 5ensor Model $ 302 u id-Filled Automati. Tank Gaugiog TG Panel Manutacturer l$" fank Probg Manufacturer Veeder Root ln-tank Probe Model Mag 1 Leak Test Frequency Weekly Programmed Taok Tests 0.2 GPHRoot Model it 50 Monthly Statistical lnventory Recon€ilirtion Weekly Manual Tank Gauge Gauging Test Period Tank lntegrity Testing Tank lntegrity Testing Frequen€y Other Monitoring Printed on 1.013/20L4 8:24 AM ) California Environmental Reporting System (CERSI Underground Storage Tank - Monitoring Plan cility/Site PS - San Luis Obispo Sacramento Dr n Luis Obispo, CA 93401 CERS ID r0416094 UST Tanl( tt t Monitoring is Performed Using the Following Method(s) Coniinuous Monitoring of Piping Se€ondary Coniainment Secoodary Containment Panel Man!tacturer Veeder Root Panel Model t TLS-350 Leak Sensor Manufacturer Veeder Root Lenk Sensor Model t 205 Leak Alarm Triggers Automatic Pump Shutdown tailure/Disconnect Triggers Purnp shutdown Ms.hanical Line Leak Detector Perlorms 3 SPH Leal( T€st Manu{actsrer MLLD Model er Root FX1DV Electronic Line Leak Detectol Pertorms 3 GPH Leak Test Manuiacturer ELLD Programmed ln-Line Testing ELLD triggers Automrtic Pufip Shutdown ELLD Failur€lDisconnectTriggers Automatic ShuldownLLD Model Pip€lin€ lntegrity Testing ne lntegrity Testing Frequency Visual Pipeline Monitoting Visual Plpeline Monitoring Frequency Suction piping Meets Exemptioil Criteria No Regulated Piping Per Health and Safety Code, Division 20, Chapter 6.7 ls Connected To The Tank System Other Pipeliile M0nitoring Dispenser Containment (UDC) Monitoring Monitoring Stand-a lone Panel Man0facturer Detectioo of Leak into UDc lrigger$ Audible and Visual Alarms UDC Leak Alarn Triggers Automafic Pump Shutdown Fail!re/Oisconnection of UDC Monito{ing System TriSgers Automatic Pump Shutdown UDC Monitoring Siops Flow of Product at Dispenser Yes UDC Construction Single-walled UDC Secondary Containmenl Monitoring DC Panel Model 4 DC Leak Sensor Manufacturer DC Leal( sensor Mod€l Leak Within Secondary containment of UOc causes Audible and Visual Alarms System Testing ELD Testing sec0ndary Conlainilent Ttsting Bucket Printed on l0/3/20L4 8:24 AM California Environmental Reporting System {CERSI Underground Storage Tank - Monitoring Plan PS - San Luis Obispo CERS tO 10416094 UST Tanl( il 1 601 Sacramento Dr Luis Obispo, CA 93401 ng Personnel with UST Monitoring R€sponsibilities rre Familixr wilh Training Documents UST Monitoring Plan Operating Man!als CA UST Regrlations CA UST Law swRc8 Handbook for Tnnk owners " Manual and slR SWRCg Publicatton: Understanding Automatic Tank Gauging Syslems Other Training Doruments / Additional lnformation and Additional lnformation Responsibilities of First Person Having Responsibility Name of Second Person Having Responsibiliiv Anthony Delgadillo Title of Second Person Having Responsibility District Environmental Coordinator T Service Station ol First Person Having Responsibility ctor ng Alarm Logs Visual lnspection Rec0rds Tank lntegrity Testing Resulis SIR Testing Results Tank Gauging Results ATC Testing Results Corrosion Protectioil logs Maintenance and Calibration lcant Certification Nam€Applicaot Title President Signature Date Signature Fepresentation Massie Tank Printed on L0l3/201.4 8:24 AM )"i HAZARDOUS MATET{ALS BUSINESS PLAN CL^TTIF'ICATION FORM For Use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Health and Safety Code $25503.3(c); 19 CCR $2729.5(c) To: AgencyName:San Luis Obispo Cou nty Environmental Health Services Agency Mailing Address PO Box 1489 San Luis Obispo,943406 FAX 805-781-4211 Pursuant to Section 25503.3(c) of California Health and Safety Code (HSC), the Hazardous Materials Business Plan (HMBP) certification described below is hereby submitted for the following facility: Facility Name: United Parcel Service Facility Street Address: Date of Current HMBP 3601 Sacramento Dr.City: San Luis Obispo 21112010 I certiSu that: (Check the appropriate box.) I have personally reviewed the Hazardous Materials Business Plan currently on file with your agency and certiff that the HMBP is complete and accurate. (See bottom of page for details.) If this facility is subject to Federal Emergency Planning and Community Right to Know Act (EPCRA) reporting requirements, I have submitted the following documents with this Certification Form: Unified Program Consolidated Form (UPCF) Business Activities page; UPCF Business Owner/Operator Identification page with current signature and date; Hazardous Materials Inventory Statement page(s) with an original signature, photocopy of an original signature, or signature stamp on each page for all Extremely Hazardous Substances (EHS) handled at or above their Federal Threshold Planning Quantity (TPQ) or 500 pounds, whichever is less. or Revisions to the Hazardous Materials Business Plan are necessary. The HMBP as revised is complete and accurate and is being implemented. A copy of the revisions has been electronically submitted or is enclosed with this Certification along with a signed UPCF Business Owner/Operator Identification page and UPCF Business Activities page if the HMBP revision include changes to the Hazardous Materials Inventory Statement. OWNER/OPERATOR CERTIFICATION: I hereby certify under penalty of law thato based upon my inquiry of those individuals responsible for obtaining the information reported aboveo I believe that the submitted information is true, accurate, and complete. I understand that a revised HMBP must be submitted within 30 days of any change in this facility's storage or handling of hazardous materials that would require updating of the HMBP. Name of Owner/Operator (Print): Noel Massie Phone: (818) 947-4831 Signa Title: President Dateil' /a- / 0 . The information contained in the HMBP most recently submitted is complete, accurate, and. There has been no change in the quantity of any hazardous material as reported in the most . The facility has not begun handling any hazardous material in a HMBP reportable quantity Hazardous Materials Inventory; and. The most recently submitted HMBP contains the information required by Section 11022 of Title not currently listed in uilllld s1",3' &lS; t- 1s ot HMBP and By checking the upper box on this form, you are certifuing that: Inventory forms; and . There have been no substantial revision ofin the S that would uN-039 - 1/1 www.unidocs.org h.tt l?i+ti UNIFIED PROGRAM CONSOLIDATED FORM FACILITY INFORMATION BUSINESS ACTIYITIES Page 1 of_ I. FACILITY IDENTIFICATION A 0 0 0 4 8 1 0 FACILITY ID # F l 2.EPA ID # (Hazardous Waste Only) c4D98t664022 BUSINESS NAME (Same as Facility Name or DBA - Doing Business As)3. tr. ACTIVTNES DFCI.ARATION NOTE: If you check YES to any part of this list, please submit the Business Owner/Operator Identification page (OES Forrr 2730). Does vour facility If Yes. please complete these pases of the UPCF. A. HAZARDOUS MATERIALS Have on site (for any purpose) hazardous materials at or above 55 gallons for liquids, 500 pounds for solids, or 200 cubic feet for compressed gases (include liquids in ASTs and USTs); or the applicable Federal threshold quantity for an extremely hazardous substance specified in 40 CFR Part 355, Appendix A or B; or handle radiological materials in quantities for which en emersencv nlen is reorrired mrrsttanf to 1O CFR Perfs 3O 4O nr XYEs n No 4. HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION (OES 2731) frITUNDERGROUND STORAGE TANKS OSTs) 1. Own or operate underground storage tanks? 2. Intend to upgrade existing or install new USTs? 3. Need to report closing a UST? lNo 5. Xno 6. flves X No X YES I YES UST FACILITY (Fomerly SWRCB Fom A) UST TANK (one page per tmk) (Fomerly Fom B) UST FACILITY UST TANK (one per tmk) UST INSTALLATION - CERTIFICATE OF COMPLIANCE (one page per tilk) (Fomerly Fom UST TANK (closre portion - one page per tank) C. ABOVE GROUND PETROLEUM STORAGE TANKS (ASTs) Own or operate ASTs above these thresholds: --any tank capacity is greater than 660 gallons, or --the total capacity for the facility is greater than1,320 gallons? lYEs X No 8.NO FORM REQUIRED TO CUPAs Recycle more than 100 kg/month of excluded or exempted recyclable materials (per H&SC 525143.2)? Treat hazardous waste on site? Treatment subject to financial assurance requirements (for Permit by Rule and Conditional Authorization)? Consolidate hazardous waste generated at a remote site? Need to report the closure/removal of a tank that was classified as hazardous waste and cleaned onsite? 6 2. 4 5 D. HAZARDOUS WASTE 1. Generate hazardous waste?Xves n No XNo n. X No 13. ENo ru. 9. ! YEs [] YEs X No ro. ENo u. ! ves fl YEs E vss EPA ID NUMBER - provide at the top of this page RECYCLABLE MATERIALS REPORT lone per recycler) ONSITE HAZARDOUS WASTE TREATMENT - FACILITY Gomerly Drsc Foms 1772) ONSITE HAZARDOUS WASTE TREATMENT - UNIT (one pase per unit) (Fomerly DTSC Foms 1772 A,B,C,D ed L) CERTIFICATION OF FINANCIAL ASSURANCE (Fomerly DTsc Fom 1232) REMOTE WASTE / CONSOLIDATION SITE ANNUAL NOTIFICATION lFomerly DTSC Fom I 196) HAZARDOUS WASTE TANK CLOSURE CERTIFICATION lFomerly DTsc Fom 1249) l5 UPCF Hwfactiv (1199\ - ll2 www.unidocs.org Rev.02l16/00 l .\ Business Activities Page Instructions You must submit this Business Activities page with all submittals. fNote: Numbering of the following instructions follows the Unified Program Consolidated Form (UPCF) data element numbers on the form. These data element numbers are used for electronic submittal and are the same as the numbering used in27 CCR, Appendix C, the Unified Program Data Dictionary.] Please number all pages of your submittal. 1 FACILITY ID NUMBER - This number is for agency use only. Leave this space blank. 2. EPA ID NUMBER - If you generate, recycle, or treat hazardous waste, enter your facility's l2-character U.S. Environmental Protection Agency (U.S. EPA) or California Identification number. For facilities in California, the number usually starts with the letters "CA." If you do not have an ID number, contact the Department of Toxic Substances Control (DTSC) at l-800- 618-6942 to obtain one. 3. BUSINESS NAME - Enter the complete FacilityName. 4. HAZARDOUS MATERIALS ONSITE - Check the appropriate box to indicate whether you have any hazardous material on site in a quantity subject to Hazardous Materials Business Plan reporting requirements (please to the Hazardous Materials Business Plan Information Sheet available on the Internet at http://www.unidocs.org). 5. OWN OR OPERATE UNDERGROLIND 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 (H&SC) $25316. If "yES", and you do not already have on file with your local agency a UST Facility page, UST Tank page for each tank, written UST Monitoring Plan, and UST Response Plan, then you must submit those documents. (There are no UPCF pages for the monitoring and response plans.) 6. UST INSTALLATION/[IPGRADE - Check the appropriate box to indicate whether you have installed or upgraded USTs containing hazardous substances as defined in H&SC $253 16. If "YES," then you must submit to your local agency a UST Installation - Certificate of Compliance page for each tank in addition to the UST Facility and Tank pages. 7 . UST CLOSURE - Check the appropriate box if you are closing a UST and complete the closure portion of the UST Tank page for each tank. 8. OWN/OPERATE ABOVEGROUND PETROLEUM STORAGE TANK (AST) - Check the appropriate box to indicate whether your facility stores petroleum aboveground in any tank greater than 660 gallons capacity or has aggregate aboveground petroleum storage greater than 1,320 gallons. (There is no UPCF page for ASTs.) The following are exempt from this requirement: o Pressure vessels or boilers subject to Division 5 of the Labor Code; o Tanks containing hazardous waste if a hazardous waste facility permit has been issued by DTSC; " Aboveground oil production tanks regulated by the Division of Oil and Gas;o Certain oil-filled electrical equipment, including, but not limited to, transformers, circuit breakers, and capacitors.9. HAZARDOUS WASTE GENERATOR - Check the appropriate box to indicate whether your facility generates a waste that meets any of thehazardous waste criteria adopted pursuant to H&SC $25141. 10. RECYCLE - Check the appropriate box to indicate whether your facility recycles more than 100 kilograms (approximately 220 pounds or 27 gallons) per month of recyclable material under a claim that the material is excluded or exempt per H&SC 525143.2. If you check "YES," and you do not abeady have a current Recyclable Materials Report on file with your Certified Unified Program Agency (CUPA), then you must also submit that report to the CUPA. Check "NO" if you only send recyclable materials to an offsite recycler. 11. ONSITE HAZARDOUS WASTE TREATMENT - Check the appropriate box to indicate whether your facility engages in regulated onsite treatment of hazardous waste. If you check "YES," and you do not already have current Onsite Hazardous Waste Treatment Notification - Facility and Onsite Hazardous Waste Treatment Notification - Unit documents on file with your CUPA, then you must submit those forms to the CUPA. 12. FINANCIAL ASSURANCE - Check the appropriate box to indicate whether your facility has Permit by Rule (PBR) and/or Conditionally Authorized (CA) operations subject to financial assurance requirements for closure of an onsite treatment unit. If you check "YES," and you do not already have current "Certification of Financial Assurance" on file with your CUpA, then you must submit that form to the CUPA. 13. HAZARDOUS WASTE REMOTE CONSOLIDATION SITE - Check the appropriate box to indicate whether your facility consolidates hazardous waste generated at a remote site. By answering "YES," you are indicating that 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. If you check "YES," and you do not already have current "Remote Waste Consolidation Site Annual Notification" page on file with your CUPA, then you must submit that form to the CLIPA. 14. HAZARDOUS WASTE TANK CLEANING - Check the appropriate box if any tank has been cleaned onsite per TrtIe 22,Div. 4.5 , Ch, 32, CCR. If you check "YES," then you must submit a Hazardous Waste Tank Closure Certif,rcation to your local agency. 15. LOCAL REQUIREMENTS - Check with your local agency before submitting this document to determine if any supplemental information is required. UPCF Hwfactiv (l/99) -2/2 www.unidocs.org Rev.02l16/00 FORMS-SANLT COUNTY CERTIFIED UNIFIED AGENCY BUSINESS OWNER/OPERATOR IDENTIFICATION I. IDENTIFICATION A 0 0 o 4 8 1 0FACILITY ID#F 100BEGINNING DATE Julv 2010 101ENDING DATE July 2011 t02BUSINESS PHONE (805) 544-7184 BUSINESS NAME (sme as FACILITY NAME or DBA - Doing Business As) United Parcel Service 3 BUSINESS SITE ADDRESS 3601 Sacramento Drive 103 San Luis Obispo 104CITY CA 105ZIP CODE 9340r DUN & BRADSTREET oo-686-5927 106 t0'1SIC CODE (4 digit #) 4789 San Luis Obispo 108COUNTY BUSINESS OPERATOR NAME Richard Cortez 109 ll0BUSINESS OPERATOR PHONE (80s) s44-7184 II. BUSINESS OWNBR |2OWNER PHONE (2r3) 6t2-r924 OWNER NAME United Parcel Service 111 OWNER MAILING ADDRESS 1201 West Olympic Blvd 113 1t4 Los Angeles CITY 115STATE CA 116ZIP CODE 90015 IU. ENVIRONMENTAL CONTACT CONTACT NAME David Ayala tl'7 118CONTACT PHONE 626-814-6269 cell CONTACT MAILING ADDRESS 1100 Baldwin Park Blvd 119 Baldwin Park t20CITY 121STATE CA 122ZIP CODE 91706 ry. EMERGENCY CONTACTS -SECONDARy-PRIMARY Richard Cortez 123NAME Klotonya Hamilton t28NAME Center Manager t24TITLE 129TITLE Supervisor BUSINESS PHONE (818) 947-4831 130BUSINESS PHONE (805) s44-7184 125 24-HOUR PHONE 126 PAGER # I CELL PHONE # N/A 13124.HOUR PHONE 132 ;769 PAGER # I CELL PHONE # N/A l2'1 133ADDITIONAL LOCALLY COLLECTED INFORMATION under penalty of law that I have personally examined and the information is true, accurate, and complete. of those submitted Certification: Based on my am familiar with responsible for obtaining the I REPRESENTATIVEYED,1-tL-30t0 t34DATE NAME OF DOCUMENT PREPARER Klotonva Hamilton 135 NAME OF SIGKER (ftnD Noel Massie 136t-TITLE OF SIGNER t37 President f Pag e of D:\Docunrents and $elting:i\wle'1keh\Loc*l $ettings\Terrrporary lnlerri*t FilestOLKIC\fRM-S1 2010.dt:cQTi12!1A Form S - San Lu )bispo County CUPA - Business Owner/Op 'ior Identification Please submit the Business Activities page, the Bushrcss Owner/Operator Identification page (OES Form27301,..rrd Hazardous Materials - Chemical Description pages (OES Form 273 1) for all hazardous materials inventory submissions. For the inventory to be considered complete this page must be signed by the appropriate individual. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF (Unified Program Consolidated Form) pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps the Department of Toxic Substances Control (DTSC) identi$, whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER - Leave this blank. This number is assigned by DTSC. This is the unique number which identifies your facility. 3. BUSINESS NAME - Enter the full legal name of the business. 100. BEGINNING DATE - Enter the beginning year and date of the report. (YYYYMMDD) l0l. 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. 103. BUSINESS SITE ADDRESS - Enter the street address where the facility is located. No post office box numbers are allowed. This information must provide a means to geographically locate the facility. 104. CITY - Enter the city or unincorporated area in which business site is located. 105. Zrc CODE - Enter the zip code of business site. The extra 4-digit zip may also be added. 106. DUN & BRADSTREET - Enter the Dun & Bradstreet number for the facility. The Dun & Bradstreet number may be obtained by calling (610) 882-7748 or by Internet. 107. SIC CODE - Enter the primary Standard Industrial Classification Code number for primary business activity. NOTE: If code is more than 4 digits, report only the first four. 108. COUNTY - Enter the county in which the business site is located. 109. BUSINESS OPERATOR NAME - Enter the name of the business operator, 110. BUSINESS OPERATOR PHONE - Enter business operator phone number, if different from business phone, area code first, and any extension. 111. OWNER NAME - Enter name of business owner, if different from business operator. 112. OWNER PHONE - Enter the business owner's phone number if different from business phone, area code first, and any extension. 113. OWNER MAILING ADDRESS - Enter the owner's mailing address if different from business site address. 114. OWNER CITY - Enter the name of the city for the owner's mailing address. 115. OWNER STATE - Enter the 2-character state abbreviation for the owner's mailing address. 116. OWNER ZIP CODE - Enter the zip code for the owner's address. The extra 4-digit zip may also be added. I17. ENVIRONMENTAL CONTACT NAME - Enter the name of the person, if different from the Business Owner or Operator, who receives all environmental correspondence and will respond to enforcement activity. 118. CONTACT PHONE - Enter the phone number, if different from Owner or Operator, at which the environmental contact can be contacted, area code first, and any extension. 119. CONTACT MAILING ADDRESS - Enter the mailing address where all environmental contact correspondence should be sent, if different from the site address. 120. CITY - Enter the name of the city for the environmental contact's mailing address. 12l. 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. 123. PRIMARY EMERGENCY CONTACT NAME - Enter the name of a representative that can be contacted in case of 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 ofthe secondary emergency contact. 130. BUSINESS PHONE - Enter the business telephone number for the secondary emergency contact, area code first, and any extension. 13 1. 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. 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 DTSC to collect any additional information necessary to meet the requirements of their individual programs. Contact DTSC, or your local agency 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 REPRESENTATM - 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 ofthose individuals responsible for obtaining the information it is the signer's beliefthat the submitted information is true, accurate and complete. 137. TITLE OF SIGNER - Enter the title of the person signing the page. il D:\Docurnent* ancl $ettingsl..wl*1keh\,,aca! $ettings\Tern porary lnternet F i!es\OLKHC\FRM-5 1 20 i O.ri *c 1 2- Jt*-1 C