HomeMy WebLinkAboutSLOUNIFLOW_FS1 Admin iRC3926i Color_3807_001Earth Sy stems Environmental, lnc.
A Member of The Earth Syslems Group
170-A Granada Drive . San Luis Obispo, CA 93401 (805) 541-5983 (805) 544-0531
November 5, 1990 Project No.: ES-05M-PGL
Document No.: 9010-E060.WP
City of San Luis Obispo Fire Department
748 Pismo Street
San Luis Obispo, California 93401
Attn: Mr. Mike Smith
SUBJECT:WORKPLAN FOR EI.WIRONMENTAL MOMTORING OF
HYDRAULIC ELEVATOR SUMP, 868 HIGUERA STREET,
SAN LUIS OBISPO, CALIFORMA
Ref eTence: SOILS ASSESSMENT AND BUILDING MATERIALS SURVEY, KLEINFELDER,
INC., SEPTEMBER 14, I99O
ENVIRONMENTAL ASSESSMENT REPORT ON TOTAL PETROLEUM
HYDROCARBONS IN SOIL AND GROUNDWATERUNDER ELEVATOR
PIT AT 868 HIGUERA STREET, SAN LUIS OBISPO, CALIFORNIA, RALPH
STONE AND COMPANY, INC., SEPTEMBER 28, I99O
Dear Mr. Smith:
Earth Systems Environmental, Inc. (ESE) is pleased to present this work plan
for environmental monitoring of the hydraulically operated elevator at the above
refcrenced property. The intent of this phase of investigation is to monitor the
previously identified contamination and dete rmine if groundwater carrying
hydraulic oil can be recovered from the sump located in the elevator pit. The scope
of services for this phase of work includes cleaning and inspection of the sump in
the elevator pit, weekly bailing of any oil and water that collects in the sump,
arranging for pressure-testing of the hydraulic elevator system, recommendations
for sump system modifications, and Iiaison with local regulatory agencies regarding
identified soil and groundwater contamination at the subject site.
B ackground
Previous reports, referenced above, indicate the presence of soil and
groundwater contamination at the site. During their investigation, Kleinfelder
collected one soil sample for each of two boreholes under the bottom of the elevator
pit. Total Petroleum Hydrocarbons (TPH) was detected in the sample from the
Elevator Sump November 5, 1990
borehole next to the sump at a level of 32 parts per million (ppm). TPH was detected
in the other sample from the boring in the southwest corner of the pit at a level of
39,000 ppm, which is above the action level of 100 ppm usod by the City of San Luis
Obispo Fire Department. Kleinfelder also reported 1.5 inches of free oil on several
inches of water aftet 24 hours in the southwest corner borehole. No free water was
observed in the borehole next to the sump.
The assessment performed by Ralph Stone and Company, Inc. included
inspections of the elevator pit and its drainage sump, and the elevator equipment
room, discussions with regulatory agencies, and recommendations concerning the
monitoring and remediation of the contamination at the subject site'
We do not propose to fully define the degree or extent of this contamination,
nor is any sampling of building material, soil or groundwater proposed at this time.
All methods employed are in compliance with regulations and guidelines set forth in
CCR Title 22, Chapter 30, Article 11, CCR Title 23, Chapter 3, as well as accepted
professional environmental and geotechnical engineering procedures' and
applicable local regulations.
Health & Safety Plan
The Health and Safety Plan is required under regulations set forth in Federal
osHA cFR 29 1910.120. The potential presence of hazardous materials and confined
space entry requirements at the site may exist. All our field personal have been
certified for hazardous materials work in accordance with osHA requirements' The
Health and Safety plan establishes personal protection standards, responsibilities of
supervisors and workers, and emergency response measures' All personnel working
on the site as part of this investigation will be required to read and sign the plan'
The Health and safety Plan can be found at the end of this document as an
attachment.
Cleaning and Periodic Bailing of Sump
The sump located in the elevator pit will be cleaned to remove all oil and dirt
with a steamcleaner and a tri-sodium phosphate (rsP) solution. Prior to cleaning the
sump, the sump pump along with the plate and associated piping will be disconnected
and removed. once the sump is cleaned, it will be inspected for cracks and the bottom
2
ES-0544-PGl 9010-8060.wP
Ii
)Elevator Sump November 5, 1990
will be observed to determine if it consists of bedrock or concrete. The liquid
generated from the cleaning activities will be collected and stored in a 55-gallon
drum onsite.
A weekly monitoring program will be implemented to observe if hydraulic oil
seeps into the sump from the ground under the pit floor. Any oil or oily water that is
present in the sump will be removed with a bailer. During the monitoring, the
volume of oil and oily water removed from the sump will be noted. It appears
possible, through previous investigations, that the sump can be used to remove oil
and oily groundwater.
Prior to removal of the sump pump, its' discharge location will be noted. If it is
discharging into the stonn drain or City sewer, then the system will have to be
modified to avoid contaminating storm water or receiving water. With the current
low rainfall, the pump can be disconnected and the sump can be manually bailed on a
weekly basis. However, during heavy rainfall, the sump will need to connected to a
system that can handle larger flows into the sump.
All oil and oily water collected during the cleaning and monitoring of the
sump will be transported to an appropriate oil recycling facility.
Report Preparation
A report documenting the cleaning of the sump and the sump monitoring
program will be prepared and submitted to the fire department after the one month
monitoring period. The report will include recorded quantities of oil and oily water
removed from the sump, recommendations for a liquid recovery system in the sump
and results of pressure-testing/leak testing the elevator hydraulic system. The
report will be signed by a California Registered Geologist.
S chedule
It is expected that work on the project could begin within 3 working days
following fire department approval with the report available within 10 working days
after the last monitoring period. If possible, we would like to arrange a site visit
with you.
3
ES-0544-PG I 9010-8060.wP
\Elevator Sump November 5, 1990
Thank you for your consideration of this work plan. If you have any
questions, or if we can be of service in any wol, please call this office at your
conveni enc e.
S incerely,
EARTH SYSTEMS ENVIRONMENTAL, INC.
Greg Little,
Environmental Engineer v President
4
Attachments:
Distribution:
Health and Safety Plan
1/AddresseellDr. Jorgensen
I/SLO File
No.4843
ry
U)**
OF
ES-0544-PGl 9010-8060.wP
I\
Earth Systems Environmental, lnc.
A Member of The Earth Systems GrouP
170-A Granada Drive . San Luis Obispo, CA 93401 (805) 541-5983 ' FAX (805) 544-0531
January 2, l99L Project No.: ES-0544-PGL
Document No.: 9101-E00I.RPT
City of San Luis Obispo Fire Department
748 Pismo Street
San Luis Obispo, California 93401
Attn: Mr- Mike Smith
SUBJECT:RESULTS OF CLOSURE INVESTIGATION,
HYDRAULIC AEVATOR SUMP, 868 HIGI.JERA STREET,
SAN LUIS OBISPO, CALIFORMA
Reference:RES{JLTS OF ENVIRONMENTAL MONITORING OF
HYDRAIJLIC ELEVATOR SUMP, 868 HIGUERA STREET,
SAN LUIS OBISPO, CALIFORNIA
Introduction
This brief report presents the results of additional investigation and
monitoring of the hydraulically operated elevator at the above referenced property.
The intqnt of this phase
,
of investigation was to further evaluate the presence of
leaked hydraulic oil beneaih the floor of the elevator pit and facilitate recovery of
accumulated oil, if possible. Based on the results of previous monitoring, presented
in the above referenced report, the existing sump located in the elevator pit does not
appear to . be capable of recovering leaked hydraulic oil at this time. The scope of
services for this phase of work included the installation of a shallow recovery well
within the elevator pit and initial monitoring of groundwater and/or oil within the
well.
Recovery Well Installation
A shallow well' was installed within the elevator pit at the location of a
borehole excavated previously by Kleinfelder Associates in which oil was first
encountered. The well was installed by coring through the approximately 10" thick
concrete floor and excavating to a total depth of 2.0-2.5 feet beneath the bottom of the
elevator pit. Cuttings retrieved from the bottom of the borehole appeared to be
)868 Higuera Street January 2, 1991
composed of highly weathered volcanic rock, which is consistent with the
interpretation of the geologic setting of the site. These rock fragments were
relatively dry and were not visibly stained by hydraulic oil.
The well was constructed of 4-inch diameter perforated PVC casing and
provided with a filter pack of commercially graded, washed sand. The uppermost
section of the casing was unperforated and the annular space above the filter pack
was sealed with bentonite clay and grouted to grade with concrete. A threaded PVC
cap was fitted to the top of the well.
Monitorine Results
During excavation of the borehole on December 20, 1990, liquid was observed
to be seeping from the coarse base layer beneath the concrete floor at a depth of
approximately 14 inches below floor level. At the time of well installation on the
following day, approximately 2 inches of water had accumulated in the borehole.
Following well installation, initial monitoring was conducted on December 28, 1990.
Water had stabilized within the well at a level of approximately 4 inches below the
base of the concrete slab. A trace of floating oil was noted on the surface of the water
and small globules of oil were visible in water bailed from the well,, $ total volume of
approximately 1.5 gallons of oily water was removed from the well and stored onsiie
in a sealed 55-gallon drum.
Concl usions
The shallow well installed within the elevator pit appears to be capable of
recovering additional hydraulic oil that may accumulate within the boring.
However, due to the low inferred volume of oil remaining in the subsurface, it
appears that accumulation of oil in the well will be limited. Based on the data
obtained to date, approximately 6.5 gallons of hydraulic oil may be present in ft
formation beneath the elevator pit. The release beneath the elevator pit can 'be
attributed to the old and faulty packing on the elevator lift jack. The packing was
recently replaced, effectively eliminating the source of the leaked hydraulic oil.
Based on the low estimated volume of hydraulic oil inferred to remain beneath
the elevator shaft, it is our opinion that the former release does not pose a significant
threat to water quality or the surrounding environment. Hydraulic oil would not
2
ES-0544-PG1 9101-E001.RPT
868 Higuera Street January 2, 1991
normally be considered as a hazardous material by California regulations. Due to the
low inferred toxicity, non-hazardous nature and limited pathways for exposure to
this material, it appears that the leaked hydraulic oil does not pose a threat to public
health.
Recommend ations
We recommend that the San Luis Obispo Fire Department grant closure of the
case from a hazardous materials standpoint contingent upon the continued
monitoring of the recovery well as part of the operations and maintenance plan for
the building. Initially, the well should be monitored on a monthly basis for the
presence of floating oil. During periods of heavy rains, both the well and the
existing sump should be checked weekly. Recovered hydraulic oil should be recorded
as to the approximate volume and stored in a sealed drum onsite, pending proper
disposal or recycling.
Monitoring should continue until three successive monitoring events fail to
detect any accumulation of oil. During the monitoring program, interim reports
documenting the oil recovery efforts should be prepared on a quarterly basis. These
reports need not be submitted to regulatory agencies but should be retained by the
property owner along with maintenance records for the building. Upon completion
of the monitoring program, the well should be abandoned by removing the casing
and completely backfilling the borehole with a cement and bentonite grout.
Closure
This report has been prepared for the exclusive use of Dr. Jerry Jorgensen as
it pertains to the subject property located at the 868 Higuera Street in the City of San
Luis Obispo, California. The conclusions and recommendations rendered are opinions
based on readily available information obtained to date within the scope of the work
authorized by the client. All work has been performed in accordance with generally
accepted practices in environmental engineering, engineering geology and
hydrogeology. No other warranty, either expressed or implied, is made.
3
ES-0544-PG I 9101-E00l.RPT
"* 868 Higuera Street "l lanuary 2, 1991
It is hoped that this information will meet your needs at this time. If you have
any questions regarding this report or require additional information, please contact
this office at your conveniencc.
S incerely,
EARTH SYSTEMS ENVIRONMENTAL, INC.
G. #4843
Pro Geologist
Distribution:2/Dr. Jorgensen
1/ San Luis Obispo Fire Department
USLO File
4
/|
No.4843
w.
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G
ES-0544-PGl 9 10 1 -800 I .RPT
\l
Gtyo[sanluls oBtspo
FIRE DEPARTMENT
748 Pismo Street o San Luis Obispo, CA 93401 o 805/549'7380
January 2, l99L
Steve Little
Earth Systems Environmental, Inc.
170-A Granada
San Luis Obispo, CA 93401
cc:
Ffd.tr
RE: Environmental Monitoring of Iraking Hydraulic Oil
Site Closure - 868 Monterey St.
Dear Mr. Little:
I have reviewed your report dated January 2, l99L regarding the leaking hydraulic oil at 868 Higuera
Street. Assuming that this information is accurate and representative of existing conditions, it is the
position of this office that no additional sampling or cleanup of this site will be necessary.
This decision has been based on the following:
1. On-going maintenance records for the elevator indicate that the amount of hydraulic
oil released appears insignificant, less than 20 gallons-
2. The potential human exposure and health risks associated with this material are
extremelY low.
3. The proposed monitoring and maintenance plan for this site is not only a good idea,' but it should substantiate the facts above.'
Very truly
w"
Michael Smith
Hazardous Materials Inspector
Steve Little, Earth Systems Environmental, 1.70-4 Granada, SLO, CA 93401,
Bill Healey, Pacific Blue Group, 1,165 Coast Village Rd. Suite E, Santa Barbara, CA 93108
If you have any questions regarding this matter, please call me at 549-7380
() Recycled Paper
Earth Systems Environmental, lnc.
A Member ol The Earth Systems Group
170-A Granada Drive . San Luis Obispo, CA 93401 (805) 541-5983 FAX (805) 544-0531
Project No.: ES-0544-PGl
Document No.: 9012-E015.RPT
I
December 18, 1990
Dr. Jerry Jorgensen
628 California Boulevard, Suite E
San Luis Obispo, California 93401
STIBJECT:RESTJLTS OF ETWIRONMENTAL MONITORING OF
HYDRAULIC ELEVATOR SUMP, 868 HIGI'ERA STREET,
SAN LUIS OBISPO, CALIFORNIA
Reference: SOILS ASSESSMENT AND BUILDING MATERIALS SURVEY, KLEINFELDER,
INC., SEPTEMBER 14, I99O
ETWIRONMENTAL ASSESSMENT REPORT ON TOTAL PETROLEUM
FTYDROCARBONS IN SOIL AND GROUNDWATER {JNDER ELEVATOR
PIT AT 868 HIGUERA STREET, SAN LUIS OBISPO, CALIFORNIA, RALPH
STONE AND COMPANY, INC., SEPTEMBER 28, 1990
Dear Dr. Jorgensen:
This report presents the results of environmental monitoring of the
hydraulically operated elevator at the above referenced property. The intent of this
phase of investigation was to monitor the previously identified contamination and
determine if groundwater carrying hydraulic oil could be recovered from the sump
located in the elevator pit. The scope of services for this phase of work included
cleaning and inspection of the sump in the elevator pit, weekly bailing of any oil and
water that collected in the sump, liaison with local regulatory agencies regarding
identified soil and groundwater contamination at the subject site, and preparation of
this report.
Site Description
The subject site is located at 868 Higuera Street in San Luis Obispo, Califomia
(Figure 1). The elevator shaft is located in the south central portion of the building
at rhis location. The elevator pit is located at the bottom of the elevator shaft in the
basement of the building approximately sixteen feet below ground surface. The sump
is located in the northwest corner of the elevator pit and has a diameter of
approximately 16.5 inches and is approximately 28.5 inches deep (Figure 2).
868 Higuera Street 2 December 18, 1990
Backsround t
Previous reports, referenced above, indicate the presence of soil and possible
groundwater contamination at the site. During their investigation, Kleinfelder
collected one soil sample from each of two boreholes excavated beneath the bottom of
the elevator pit floor. Total Petroleum Hydrocarbons (TPH) were detected in the
sample from the borehole next to the sump at a level of 32 parts per million (ppm).
TPH was detected in the other sample from the boring in the southwest corner of the
pit at a level of 39,000 ppm, which is above the action level of 100 ppm used by the
City of San Luis Obispo Fire Department. Kleinfelder also reported 1.5 inches of free
oil floating on several inches of water in the southwest corner borehole after 24
hours. No free water was observed in the borehole next to the sump. The source of
this water is not known but could represent seepage from the drainage system of the
building, infiltration of runoff from the street level, or groundwater.
The assessment performed by Ralph Stone and Company, Inc. included
inspections of the elevator pit and its drainage surlpr and the elevator equipment
room, discussions with regulatory agencies, and reco(nmendations concerning the
monitoring and remediation of the contamination at the subject site.
Cleaning and Periodic Bailing of Sump
The sump located in the elevator pit was cleaned on November 14, 1990 by ESE
personnel with a hot water and tri-sodium phosphate (TSP) solution to remove all oil
and dirt. Prior to cleaning the sump, the sump pump along with the masonry support
blocks and associated piping was disconnected and removed. Approxi'mately one
gallon of oil, oily sludge and oily water present in the sump was removed with a shop
vacuum. Once the sump was cleaned, it was inspected for cracks. The bottom of the
sump appeared to be composed of a large aggregate concrete crudely placed over
bedrock. The bottom of the sump appeared to have liquids seeping in on all sides.
The liquid generated from the cleaning activities was collected and stored in a 55-
gallon drum on-site. The 55-gallon drum was stored in the elevator pump room
adjacent to the elevator shaft in the J.C. Penney building during the weekly
monitoring of the elevator sump. All oil and oily water collected during the cleaning
ES-0544-PGl 90r 2-E0l5.RPT
868 Higuera Street December 18, 1990
and monitoring of the sump will be transported to an appropriate oil recycling
facility.
A weekly monitoring program was implemented to observe if hydraulic oil and
water seep into the sump from the ground under the pit floor. After the initial
cleaning of the sump, no oil or oily water was observed in the sump. It appears
possible, through previous investigations, that the sump can be used to remove oil
and oily groundwater. However, with the current low rainfall, it appears that
groundwater level below the J.C. Penney building in not high enough for water or
oil to enter the sump from the formation below the building. The building is
inferred to rest upon bedrock of the Franciscan Formation which is characterized by
highly sheared and fractured volcanic and sedimentary rocks.
Elevator Service History
Mr. Bitl Healey of Pacific Blue Real Estate provided us with documentation
regarding the elevator hydraulic oil leak. A November 16, 1986 Otis Elevator
Supervisors Survey Report and a April 19, 1989 Otis Elevator Service Department
Report both recommended that the owner of the elevator re-pack the plunger, install
an emergency light and replace obsolete valves. The Otis Eleva[or r Company
documentation indicated that. previous reports did not recommend to re-pack the
plunger or replace any valves. The Otis Elevator Company has been servicing this
elevator since 1976.
Mr. Darryl Pyre of the Otis Elevator Company was contacted regarding the
subject elevator. In the phone conversation with Mr. Pyre, we were informed that
he has sirviced the elevator since 1983. He indicated that he services the elevator
once per month and logs his findings in a journal on the premises. He also indicated
that the packing around the lift jack is leaking hydraulic oil and replacement has
been recommended, as documented in the information provided by Mr. Healey of
Pacific Blue Real Estate. Mr. Pyre indicated that he recently replaced 5 gallons of
hydraulic oil during February of 1990, which is lOVo of the total volume of oil in the
elevator system. During the phone conversation with Mr. Pyre, we were informed
that, because the packing around the lift jack is old and brittle, excess hydraulic oil
from the reservoir collects on the elevator pit floor.
3
ES-0544-PG1 9012-E0l5.RPT
868 Higuera Street December 18, 1990
During the third monitoring visit, Otis Elevator Company servicemen were
observed to be present at the subject site replacing the packing on the elevator lift
jack. We believe that the replacement of the packing on the elevator lift jack should
eliminate the source of the hydraulic oil contamination.
Conclusions
The documentation provided to us and conversations with Mr. Pyre of Otis
Elevator Company indicate that the hydraulic oil release beneath the elevator pit can
be attributed to the old and faulty packing on the elevator lift jack. The packing was
recently replaced, effectively eliminating the source of the leaked hydraulic oil.
The Otis Elevator service records indicate that 10 gallons of hydraulii oil have
been added to the system since 1965. If all of this oil was discharged to the pit floor
because of the faulty packing on the elevator lift jack, it may have been lost through
a leak and entered the soil beneath the pit floor. This would suggest that a maximum
of l0 gallons of hydraulic oil could have seeped into the ground beneath the elevator
pit. Through previous investigations, approximately 2.5 gallons of oil and oily water
were recovered from the formation beneath the pit floor. In addition, approximately
1 gal[on of oil and oily water was removed from the sump during this investigation.
Based on the above assumptions, approximately 6.5 gallons of hydraulic oil may be
present in the formation beneath the elevator pit.
Although the existing elevator sump does not allow recovery of a sufficient
volume . of oil due to the present low rainfall, it appears possible that additional
hydraulic oil may be recovered from the formation below the sump during the rainy
season. In addition, the installation of a shallow well within the elevator pit,
specifically designed to recover hydraulic oil, could further reduce the amount of
residual oil beneath the elevator shaft. The recovery well should be located adjacent
to the original borehole in which floating oil was previously detected. Both the
existing sump and'the recommended recovery well could be inspected and any
accumulated oil removed as part of routine maintenance operations at the site.
Based on the low estimated volume of hydraulic oil inferred to remain
benenath the elevator shaft, it is our opinion that the former release does not pose a
significant threat to water quality or the surrounding environment. Hydraulic oil
would not normally be considered as a hazardous material and probably does not meet
4
I
ES-0544-PG1 9012-E015.RPT
868 Higuera Street December 18, 1990
the regulatory criteria for classification as a hazardous waste as set forth in Title 22,
Article 11 of tthe Califomia Code of Regulations. Dus to the low inferred toxicity, non-
hazardous nature and limited pathways for exposure to this material, it appears that
the leaked hydraulic oil does not pose a threat to public health.
Recommendations
We recommend the installation of a shallow recovery well within the elevator
pit and the continued monitoring of the existing sump as part of the operations and
maintenance plan for the building. Recovered hydraulic oil should be recorded as to
the approximate volume and stored in a sealed drum onsite, pending proper disposal p .[
{..
5
or recycling. Furthermore, we recommend that the San Luis Obispo Fire Department,
as the lead regulatory agency, grant closure of the case from a hazardous materials
or public health risk standpoint contingent upon the continued monitoring and
maintenance program outlined above.
Additional recommedations as to the frequency and procedures for the sump
maintenance program will be presented in a subsequent report ducumenting the
implementation of the recovery well described above.
Closure
This report has been prepared for the exclusive use of Dr. Jerry Jorgensen as
it pertains to the subject property located at the 868 Higuera Street in the City of San
Luis Obispo, California. The conclusions and recommendations rendered are opinions
based on readily available information obtained to date within the scope of the work
authorized by the client. The client must understand however, that even the most
comprehensive scope of services may fail to detect potential environmental liability
on a particular site. This report should not be regarded as a guarantee that no
contamination, beyond that which could have been detected within the scope of this
investigation, is present beneath the property.
All work has been performed in accordance with generally accepted practices
in environmental engineering, engineering geology and hydrogeology. No other
warranty, either expressed or implied, is made.
lr\
ES-0544-PG1 9012-E015.RPT
)868 Higuera Street December 18, 1990
We appreciate the opportunity to be of service., If you have any questions, or
if we can be of service in any way, please call this office at your convenience.
Sincerely,
EARTH SYSTEMS ENVIRONMENTAL, INC.
6
Greg Vogelpoh
Environmental
R.G
ect GeologistEngineer
2lDr. Jorgensen
1/ San Luis Obispo Fire Department
I/SLO File
Distribution:
No.4O43
W
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ES-0544-PG1 9012-E0l5.RPT
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Base Map: California State Automobile Association,
San Luis Obispo and Vicinity, 1989
Earth Systems
Environmental, lnc.
A l\,4ember ol The Earth Systems Group
Elevator Sump
San Luis Obispo, California
FIG. NO:
1
DATE: 1A1U9O JOB NO: ES-0544-PG1
SITE MAP
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Sump
Hydraulic Lift/Elevator Shaft
Spring
Borlng
Boring
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Spring
Elevator Pit
APPROXIMATE
SCALE
(1 INCH=2FEET)
To Elevator Room Pump
FIG. NO:
Earth Systems
Environmental, lnc
A Member of The Earth Systems Group
Elevator Sump
San Luis Obispo, California 2
DATE: 12/13t9o JOB NO: ES-0544-PG1
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Dale:1O1412022 Requested by:
t 1 NEWFACILTTYRECORD
t I TNFORMATION CHANGE
t $l/tLosE FActLtryAS oF: Date: I I
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OwnerlD: OW0001280
Ownar Name: Ross Drcss For Less lnc.
Orvner DBr[
OwnerAddress: 5130 HACIENDA OR FLOOR
DUBLIN, CA 94568-7579
Home Phone: 925.965-4400
Work Phone: 925-965-4831
Mailing Addre$: 5130 Haclenda Dr
Dublin, CA 94568-7579
I IO\NERSHIPCHANGE: [ ]Business [ ]Property [ ]Tank
I I UPDATE BILLTNG TNFORMATTON
I I UPDATE UST INFO (sys, type, capacity, etc.)
New Owner lD:
New Name:
New DBA:
New Address:
New Home Phone:
New Work Phone:
New MailingAddress:
New Care of:Care of:
Dale aun:
Facili Page#: 1lnformation as ol 101412022
LUtS
ID:577
FACILITY FILE INFORMATION
Faclllty lD: F40011677
Facility Name: Ross Dress For Less #0228
868 Hlguera St
San Luis Obispo, CA 93401
Phone: 805-543-4008
Maillng Addr€ss 5'130 Haclenda Dr
Oublin, CA 94568-7579
Care of: Ross Dtess For Less lnc.
CERS lD: 10506187
AccountlD: AR0023044
Accounl Name: KATHY HATCII/LICENSING DEPT
MaillngAddress: 5130 Haclenda Dr
Dublin. CA 94568
New lD:
New Name:
New Slte Address:
New Phone:
New Malling Address:
New Care of:
N€ur CERS lO:
New Account lD:
N€wAccount Name:
New Mailing Address:
cls:35.28057 -120.88248 NewGlS:
Carcof: SEAN HEWfi
Accounl Balance as ot'lol4f2o22: $0.00
New Care of:
Mail lnvoices to: Account Discount Code: Discount lnvolces?: N
LINKED PROGRAMS
PR001691 1 8E0000517 - MATHESON ELISS
PR0016912 EE00005t7 . MATHESON ELISS
Transfcr (Gitcle One)
UST(S) Program io Adivate/Change
Llnked New Owner? /lnactvalgY N o"01 1 76 - SLO CFY- WASTE GENERATOR (1 -S waste streams)
LastAdivlty: 08/31/202't - REGULAR INSPECTION
0760 -SLO CITY- HAZMAT DISCLOSURE'HWG ONLY <TQ
Last Adivlty: No Previous AdMty
Acliv€
lnactlve YN A c
I I CREATENEWFTLE FOLDER
I I UPDATE EXISTING FILE FOLDER LAEEL
UPDATE NEXf INSPECTION DATE: Date: I ' I
Copy to: File Other:
HAZARDOUS MATERIALS SPECIFIC:
Number of Materials
Number of Waste Slreams
Number of Tanks (ist
PE
..-'N toOER9porlal
Comments:
CERS updated lO I 6 12022, pm
Dale:0 LEntered by:
Date run:111212015 3:31:52PM
Run by: kboyle
Record Selection Criteria: Facility lD: F4000
Home Phone: Not Specified
Work Phone: Not Specified
Mailing Address:
COUNTY OF SAN LUIS OBISPO
Facility lnformation as of 111212015
New Owner lD:
New Name:
New DBA:
New Address:
Report #: MFR1
Page#: "t
[ ] Tank
oat, ftf r H. r l€ Requestedby:
pZT tNronMATloN CHANGE
FACILITY RECORD
t I UPDATE UST INFO (sys, type, capacity, etc.)
t IOWNERSHIPCHANGE; [ ]Business [ ]Property
,{-T[JPDATE Bt LLt NG I NFORMATION
t 1 TEMPORARILYINACTIVATEASOF: Date: =J_t_ [ ]CLOSEFACILITYASOF: Date'. I t
OWNER FILE INFORMATION
Owner lD:
Owner Name:
Owner DBA:
Owner Address:
New Home Phone:
New Work Phone:
New Mailing Address:
Care of:
FACILITY FILE I N FORMATION
Facility lD:
Facility Name:
Phone:
Mailing Address:
Care of:
CERS ID:
Location Code:
BOS District:
New Care of:
New lD:
New Name:
New Site Address:
New Phone:
New Mailing Address:
New Care of:
APN:
SIC Code:
3 Eft ft
ACCOUNTS RECEIVABLE FILE INFORMATION
Account lD:
Mail lnvoices to:
Account Name:
Program/Element and Description
New
Record lD Employee lD and Name
Facility / Account
One)
Status
Transfer
Program to (Circle One)
Activate/lnactvat
UST(s)
Linked
lnvoices to: Owner
t 1 CREATE NEW F|LE FOLDER
t 1 UPDATE EXISTING FILE FOLDER LABEL
UPDATE NEXT INSPECTION DATE:Date: I I
Copy to: File Other:
HAZARDOUS MATERIALS SPECIFIC:
Number of Materials
Number of Waste Streams
Number of Tanks (list
ca pacity/com partment)
PE
7;{ W
Entered
Comme
Date: I I t
nts:L +
Yn\\il f
-+&\(,? I {
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ftwJ1
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allaYTz
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Environmentbi Healtll uervices
(805) 781-5544
P.O.Box 1489
2156 Sierra Wav Ste. B
San Luis Obisoo. CA 93406
'P.i\-ctty o[ san luls oBlspo
FIRE OEPARTIilE}IT
2160 garla Earbah Avdu6' S.n Lub Obbpo, CA 931015210' {81}5} 781-7X80
"Courtesy & Service"
Dale:4813112021
GERTTFTED UNTFTED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIAL INSPECTION FORM
Time:
COUNTY
b SAN LUIS
OBISPO
Facility Name: Ross Dress For Less #0228 Aoency lnsoection TyoeUEHS trRoutine
trClTY FIRE trReinspection
trChargeable Reinspection
trChange of Ownership
trComplaint
trSecondary Containment Testing
trChargeable Secondary Containment Testinl
Site Address: 868 Higuera St
San Luis Obispo, CA 93401
Phone: (805)543-4008
Facility lD: FA0011577
Serial Number: DAEZSTKUC
PROGRAMS INSPECTED:trHazmat EHWGenerator trUST trAGT trCalARP trTPE
REINSPECTION REQUIRED:trHazmat trHWGenerator trUST trAGT trCa|ARP trTPE
PERMTSSION TO INSPECT: lnspections may involve obtaining photographs, reviewing and copying records, and
determining compliance with adopted codes.
YES
tr
tr
tr
tr
tr
tr
tr
NO
tr
tr
tr
tr
tr
tr
tr
tr
BUSINESS PLAN
Business plan complete, current, available during inspection and submitted electronically (HSC 25505,
25508(aXl); 19 ccR 2651)
lnventory of hazardous materials is complete and submitted electronically (HSC 25505(aX1), 25506,
25508(aXl), 19 CcR 2652,26541
Site layouU facility maps are accurate and submitted electronically (HSC 25505(a)(2), 25508(aXl), '19 CCR
26521
TRAINING PLAN
Facility has appropriate training program, submitted electronically (HSG 25505(a)(4), 25508(axl), 19CCR
2659, 22CCR66265.16)
Training documentation is maintained on site for current personnel (HSC 25505(aX4), 22CCR66265'16)
EMERGENCY RESPONSE PLAN
Emergency response/contingency plan complete, current, submitted electronically, maintained onsite
(HSC 25505(aX3), 25508(aXl), l9CCR 2658, 22CCR 66265.52-.54)
Secondary containment is installed and sufficiently impervious to discharges. ICHSC 25270.4.5;40 CFR
112.8(cX2)l
GENERAL EH VIOLATIONS
Environmental Health fees paid. ICBPC 17200, Local Ordinance]
GPS Goordinates: Latitude: 35.2805700000 GPS Coord inates : Lonqtitude
=
-120.6624800000
tr
tr
tr
a
B
B
N/A VIOL. #
B BPOI
BPO2
BPO3
TROl
TRO2
EROl
ERO3
tr FEO1
INSPECTOR: MATHESON BLISS FACILITY REP: Ubaldo Garcia
FACILITY NAME: Ross Dress F 'pss #0228 ADDRESS' )8 Higuera St
gan Luis Obispo, CA 93401
HAZARDOUS WASTE GENERATOR
YES NO N/Atrtrtr vtoL. #
GTOl
EPA ID NO/PERMITS
Generator has an EPA lD number to treat, store, dispose, transport or transfer hazardous waste (22
CCR 66262.12) lf not, Call (800) 618-6942 to obtain your CAL EPA lD number
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted (22 CCR 66262.111
Eown knowledge tranalysis trother
Hazardous waste analysis/test records are kept for at least 3 years(22 GCR 66262.40.(c))
D ISPOSAUTRA NS PORTATION
Hazardous wastes disposed of at an authorized location (HSC 25189.5, 25201(al,22 GCR 66262.121
Facility utilizes a registered hazardous waste transporter, and hazardous wastes shipped with a
manifest (HSC 25160. 25163(al: 22 CCR 66262.20.66263.41)
trmilkrun Eother Store Manaoer
Manifests and/or receipts are properly completed/retained by generator for 3 years (22 CCR 66262.23,
66262.40(a))
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows: ( HSC 25123.3 (bxly(dy(hxl); 22 CCR 66262.34(d))
tr90 days if waste generated per month is greater than or equal to 1000 kg. (2200 lbs.)
81 80 days if waste generated per month is less than t 000 kg (see note)
tr270 days if waste generated per month is less than 1000 kg and transported more than 200 miles (see
note)
Note: Applies only if hazardous waste accumulated on site never exceeds 6000k9(13,200 lbs) and no
acutely/extremely hazardous waste over 1kg (2.2 lbs) is held on site for over 90 days.
Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation timd55-gal
or 1-qt limit) (22 CCR 66262.34(e))
lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (22 CCR 66252.3a(a)(1),
66265.176)
Containers of hazardous waste are properly labeled (includes appropriate daIe,"HAZARDOUS WASTE,"
waste composition/physical state, hazardous properties, name/address of generator) (22 GCR 66262.31,
66262.34(fl)
Containers/tanks containing hazardous wastes are in good conditiory'handled to minimize the release
or reaction (22 CCR 66262.34; 22 CCR 66265.171-.179,66265.177(c))
Gontainers/tanks/liners are compatible with waste stored or transferred (22 CCR 66262.34, 66265.172)
Containers storing hazardous wastes are closed/sealed (22 CCR 66262.34,66265.173)
Weekly inspection of areas where hazardous waste containers are stored is conducted (22 CCR
66262.34,66265.174)
Daily inspection of al! tank systems is conducted and documented (22 CCR 66262.34,66265.195)
Empty containers or inner liners > 5 gal has date when emptied and are properly managed within one
year of date emptied (22 CCR 6626r.7(0)
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC
25250.41
Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closed
rainproof container, labeled "drained used oil filters," and transferred for metal reclamation) (Iitle 22
ccRs 66266.130)
Spent leadacid batteries are being properly stored and transferred offsite under manifest or bill of
lading for recycling, reuse, or reclamation (22 CCR 66266.81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled (22 CCR 66266.2)
SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction documents or is
able make them available to the inspector within (5) days. (HSC 25244.191.2'11.22;22 CCR 67100.7/.8)
Source Reduction Evaluation and Plan contains the following five elements:certification, amounts of
wastes generated, process description, block diagrams, and implementationschedule of selected
so u rce reduction meas ures. HSC 25244.1 9 I 2'1, 22 CCR 67 1 0 0.5/7/.8)
Haanvaste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (22CCR
66262.34(aX4), 66265.51 -.54)
Employees trained upon hire, annually; training records maintained at facility as required (22 CCR
66262.34(aX4), 66265.1 6)
Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (22 CCR 66265.31-37)
tr
tr
tr
tr
tr
tr
GTO3
GTO4
GTO5
GTO6
GTOT
GTOS
GTO9
GTlO
GTlI
GT12
GTt3
GTl4
GT15
GT16
Gf17
GTl8
GTl9
GT2O
GT21
GT22
GT23
GT24
GT25
ERO2
tr
tr
tr
tr
EI
tr
EI
tr
tr
tr
tr
tr
tr
tr
E
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
n
tr
tr
tr
tr
tr
EI
tr
tr
tr
tr
tr
tr
tr
tr
E
tr
tr
tr
tr
tr
tr
tr
SUMM,
.,IY
OF OBSERVATTON9VIO:
.ilONS
tr No violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations were discovered.
SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your facility.
tr Violations were observed/discovered as listed below. All violations must be corrected by implementing the corrective
action listed by each violation. lf you disagree with any of the violations or corrective actions required, please inform th
CUPA in writinq
ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED CUPA must be informed in writing with a
certification that compliance has been achieved. A false statement that compliance has been achieved is a violation of
the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility may be
reinspected any time during normal business hours.
You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed corrective
actions. The issuance of this Summary of Violations does not preclude the CUPA from taking administrative, civil, or
criminal action.
FACILITY NAME: Ross Dress For Less #0228 ADDRESS: 868 Higuera St
San Luis Obispo, CA 93401
VIOLATIONS
VIOL. NO CORRECTIVE ACTION REQUIRED
INSPECTION COMMENTS:
Hazardous waste storage area in well maintained condition. Thank you
INSPECTED BY: MATHESON BLISS
DATE: O8131t2021
NAME OF FACILITY REP: Ubaldo Garcia
SIGNATURE OF FACILITY REP:
STATEMENT OF COMPLIANCE
I certify under penalty of perjury that this facility has complied with the corrective actions listed on
inspection form.
nature of Owner/O Date:
Environmental Health Services
(805) 781-5544
P.O.Box 1489
2156 Sierra Way Ste. B
San Luis Obispo. CA 93406
/...\\
clty o[ san Luls oBlspo
FIRF OEPARIMEITT
2160 Santa BarbaE Avdua'San Luts Oblspo,CA 93,t01-5240'(805) 78i-7380
"Courtesy & Set"vice"
Date: 0112812019
GERTTFTED UNTFIED PROGRAM AGENCY (CUPA)
HMARDOUS MATERIAL INSPECTION FORM
Time:
COUNTY
b SAN LUIS
OBISPO
Facility Name: Ross Dress For Less #0228 Aoencv
DEHS
trCITY FIRE
lnsoection Type
trRoutine
trReinspection
trChargeable Reinspection
trChange of Ownership
tlComplaint
trSecondary Containment Testi ng
trChargeable Secondary Containment
Testing
SiteAddress: 868 Higuera St
San Luis Obispo, CA 93401
Phone: (805)543-4008
Facility lD: FA0011577
Serial Number: DAZVSDQEM
PROGRAMS INSPECTED:trHazmat trHW Generator trUST OAGT trCalARP trTPE
REINSPECTION REQUIRED:trHazmat trHW Generator trUST trAGT trCa|ARP trTPE
PERMISSION TO INSPEGT: Inspections may involve obtaining photographs, reviewing and copying records, and
determining compliance with adopted codes.
GRANTED BY (NAME/TITLE): Name: Ghristina Vega Title: Store Manager
YES NOtrEl
trtr
trtr
trtr
trtr
trtr
trtr
BUSINESS PLAN
Business plan complete, current, available during inspection and submitted electronically (HSC 25505, 25508(a)
(1); 19 cCR 2651)
lnventory of hazardous materials is complete and submitted electronically (HSC 25505(aX1), 25506, 25508(aXl),
19 CCR 2652,26541
Site layouU facility maps are accurate and submitted electronically (HSC 25505(a)(2), 25508(aX1), 19 CCR 2652)
TRAINING PLAN
Facility has appropriate training program, submitted electronically (HSC 25505(a)(4), 25508(aXl), 19CCR 2659,
22CCR66265.16)
Training documentation is maintained on site for current personnel (HSC 25505(a)(4), 22CCR66265.16)
EMERGENCY RESPONSE PLAN
Emergency response/contingency plan complete, current, submitted electronically, maintained onsite (HSC
25505(aX3), 25508(aXl), 19CCR 2658, 22CCR 66265.52-.54)
Secondary containment is installed and sufficiently impervious to discharges. ICHSC 25270.4.5;40 CFR 112.8(c)
(2)l
GENERAL EH VIOLATIONS
tr tr tr FE01 Environmental Health fees paid. ICBPC 17200, Local Ordinance]
GPS Goordinates: Latitude: 35.2805700000 G PS Coord i nates : Lon gtitude : -120.6624800000
N/A VIOL. #
El BP01
tr BPO2
tr BPO3
TROl
TRO2
EROl
ERO3
tr
tr
tr
tr
INSPECTOR: KERRY BOYLE FACILITY REP: Christina Vega
FACILITY NAME: Ross Dress p less #0228 ADDRESS \68 Higuera St
San Luis Obispo, CA 93401
HAZARDOUS WASTE GENERATOR
YES
tr
tr
tr
tr
tr
tr
tr
NO
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
N/A VIOL. #tr GT01
GTO3
GTO4
GTOS
GTO6
GTOS
GTO9
GTlO
GT11
GT12
GT13
GT14
GT15
GT16
GT17
GT18
GT19
GT2O
GT2'I
GT22
GT23
G't24
GT25
ERO2
EPA ID NO/PERMITS
Generator has an EPA lD number to treat, store, dispose, transport or transfer hazardous waste (22 CCR
66262.121 lf not, Gall (800) 618-6942 to obtain your CAL EPA lD number
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted (22 CCR 66262.1'll
trown knowledge tranalysis trother
Hazardous waste analysis/test records are kept for at least 3 yearc(22 CCR 66262.40.(c))
D ISPOSAUTRAN S PORTATION
Hazardous wastes disposed of at an authorized location (HSC 25189.5, 22 CCR 66262.121
Facility utilizes a registered hazardous waste transporter, and hazardous wastes shipped with a manifest (HSC
25160, 25163(a); 22 CCR 66262.20, 66263.41)
trmilkrun trother
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
n
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
GT07 Manifests and/or receipts are properly completed/retained by generator for 3 years (22 CCR 66262.23,
66262.40(a))
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows: ( HSC 25123.3 (hXl)/(b)(1); 22 CCR 66262.34)
tr90 days if waste generated per month is greater than or equal to 100 kg. (220 lbs.)
tr180 days if waste generated per month is less than 100 kg (see note)
tr270 days if waste generated per month is less than 100 kg and transported more than 200 miles (see note)
Note: Applies only if hazardous waste accumulated on site never exceeds 6000kg(13,200 lbs) and no
acutely/extremely hazardous waste over lkg(2.21bs.) is held on site for over 90 days.
Hazardous waste "satellite" collection is managed properly (complete labeling/accumulation time/S5-gal or 1-qt
limit) (22 CCR 66262.34(e))
lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (22 CCR 66262.34(axl),
66265.1 76)
Containers of hazardous waste are properly labeled (includes appropriate date,"HAZARDOUS WASTE," waste
composition/physical state, hazardous properties, name/address of generator) (22 CCR 66262.31, 66262.34(f))
Containers/tanks containing hazardous wastes are in good condition/handled to minimize the release or reaction
(22 CCR 66262.34;22 CCR 66265.171-.179, 66265.177(c))
Containers/tanks/liners are compatible with waste stored or transferred (22 CCR 66262.34,66265.172)
Containers storing hazardous wastes are closed/sealed(22 CCR 66262.34, 66265.173)
Weekly inspection of areas where hazardous waste containers are stored is conducted (22 CCR 66262.34,
66265.1 74)
Daily inspection of all tank systems is conducted and documented (22 CCR 66262.34,66265.195)
Empty containers or inner liners > 5 gal has date when emptied and are properly managed within one year of
date emptied (22 CCR 66261.7(0)
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc) (HSC 25250.41
Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in closed rainproof
container, labeled "drained used oil filters," and transferred for metal reclamation) (Tille22 CCRS 66266.130)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or bill of lading for
recycling, reuse, or reclamation (22 CCR 66266.81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled (22 CCR 66266.2)
SOURCE REDUCTION:For facilities generating >12,000 kg,/yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction documents or is able mak(
them available to the inspector within (5) days. (HSC 25244.19/.211.22;22 CCR 67100.7/.8)
Source Reduction Evaluation and Plan contains the following five elements:certification, amounts of wastes
generated, process description, block diagrams, and implementationschedule of selected source reduction
measures. (HSC 25244.1 9l .2'l , 22 CCR 67100.7/.8)
Hazwaste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (22CCR 66262.34(aX4),
66265.51-.54)
Employees trained upon hire, annually; training records maintained at facility as required (22 CCR 66262.34(a)(4)
66265.1 6)
Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of hazardous
materials/waste constituents to the environment. Maintains all required or appropriate equipment including an
alarm and communications system (22 CCR 66265.31-.37)
'\ \___
SUMIV, ,,I.Y OF OBSERVATIONSVIOI IIONS
tr No violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations were
discovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to your
facility.
tr Violations were observed/discovered as listed below. All violations must be corrected by implementing the
corrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,
please inform the CUPA in writing
ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writing with
a certification that compliance has been achieved. A false statement that compliance has been achieved is a violation
of the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility may
be reinspected any time during normal business hours.
You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed
corrective actions. The issuance of this Summary of Violations does not preclude the CUPA from taking
administrative, civil, or criminal action.
FACILITY NAME: Ross Dress For Less #0228 ADDRESS: B68 Higuera St
San Luis Obispo, CA 93401
VIOLATIONS
VIOL. NO CORRECTIVE ACTION REOUIRED
INSPECTION COMMENTS:
Totes storing hazardous waste are securely closed and properly labeled. Good record keeping for employee
training and hazwaste disposal.
INSPECTED BY: KERRY BOYLE
DATE: 0112812019
NAME OF FACILITY REP: Christina Veqa
SIGNATURE OF FACILITY REP:
STATEMENT OF COMPLIANCE
ertification: I certify under penalty of perjury that this facility has complied with the corrective actions listed on
inspection form.
nature of Title:- Date:-
Gounty of San Luis Obispo
-)
oi
lur
clty
san s oBrspo +Environmental Health Services
(805) 781-5544
P.O. Box 1489
2156 Sierra Way
San Luis Obispo, CA 93406
Fire Department (805) 781-7380
21 60 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIALS INSPECTION FORM
EFW data
entry b!:
FACILITY NAME tr{-(t Ir
I J/- " trr ." .-" r v'.1 !vt.-v.i
ADDRESS:
I
EHS
AG DEPT
CITY FIRE
Complaint n Otner
Result Code: _70 _80 _90
Action Gode: 32 37 33 31
Routine Reinspection
PHdNHi" ;/
E ecr !cnmnen Business Plan E "* Generator ! usrPROGRAMS INSPEGTED:
[] usr ! ecr ncnmnp! Business Plan lP'F'* GeneratorREINSPECTION REQUIRED:N YES
PERMISSION TO INSPECT: lnspections may involve obtaining photographs, reviewing and copying records, and
letermininq compliance with. adopted codes. GRANTED BY (NAME/TITLE):
YES NO COSnil nnn ntrtr tr
nln!
n
n
nnntr
N/A
BUSINESS PLAN
Business plan is complete, current, & available during inspection (HSC 25503.5, Title L9 CCR2729)
lnventory of hazardous materials is complete (HSC 25504' Title 19 CCR2729)
Site layout/facility maps are accurate (HSC 25504' Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Titte 19 CCR2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR
6626s.t6)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273I & 22
ccR s 66265.s3/54)
Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR 2731 & 22 CCR 66265.31-
.43)
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b)
SPCC Plan is maintained on site or nearest field office. (HSC 25270)
materials.htm, to to comply with BP01-BP03, TR01 and ER01Go to http
GPS
trnnn ATOl
ATO2
t4,{,I ti!*.- " .tt-\.,i
i. i;r l, {l'
decimal min mln
INSPECTOR:
: Latitude: _deg mrn
FACILITY REP:
t ft|,'*fi\/ .r- I,I
I
County of S Luis Obispoirr I
Environmental Health Services
(805) 781-5544
P.O. Box 1489
2156 Sierra Way
San Luis Obispo, CA 93406
cffy
$an oBtspo -T
Or
lrils
Fire Department (805) 781-7380
21 60 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HAZARDOUS MATERIALS INSPECTION FORM
EFW data
entry by:lir
FACILITY NAME:
ADDRESS:
PHO E:
INSPECTION TYPE
;EfEoutine E nei
! complaint n, otlrer
32 33 31
Result Code:
Action Code:
AGENCY
f] EHS
E nO DEPT
F".cirY FrRE
! usr ! ner !cnlnnnPRoGRAMS IruSpeCTEo:n Business Plan ,d "* Generator
d*o N YES n Business Plan : kl'HW Generatorr n usr fl ncr !cnlnnnREINSPECTION REQUIRED
PERMISSION TO INSPECT: tnspections may involve obtaining photographs, reviewing and copying records, and
determininq compliance with adopted codes. GRANTED BY (NAME/TITLE):
natez Lf
Timei,4
BUSINESS PLAN
Business plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)
Inventory of hazardous materials is complete (HSC 25504, Title 19 CCR2729)
Site layout/facility maps are accurate (HSC 25504, Title 19 CCR2729)
TRAINING PLAN i,
Facilify has appropriate trainin$ program (Title 19 CCR2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR
6626s.16)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273I & 22
ccR s 6626s.s3/s4)
Facilify is operated'and maintained to prevent/minimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR2731 &22 CCR66265.31-
.43)
ABOVEGROUND PETROLEUM STORAGE TANK ACT /
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))
SPCC Plan is maintained on site or nearest field office. (HSC 25270)
YES NO COStrn trtr! ntrn n
nnNE,
tr
n
N/A
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
ATOl
ATO2
COMMENTS Go to to obtain forms to comply with -8P03, TRO1 and ERO1
INSPECTOR:FACILITY REP:
GPS Coordinates: Latitude: _deg min Longitude:_deg _min_decimal min
rf a\
crty o[ dan Lurs ostspo
FIRE DEPARIIEIIT
2tm gal. Br.baE Avou6' 8a Lub Obbpo, CA 93,101-52,.0' (8lF) t8l-7380
"Courtesy & Service"
Date:0212812018
GERTTFTED UNTFTED PROGRAM AGENCY (CUPA)
HMARDOUS MATERIAL INSPEGTION FORM
Time:
COUNTY
b SAN LUIS
OBISPO
Facility Name: Ross Dress For Less #0228 Aoencv
trEHS
trCITY FIRE
lnsoection Tvoe
trRoutine
trReinspection
trChargeable Reinspection
trChange of Ownership
trComplaint
trSecondary Containment Testing
trChargeable Secondary Containment Testinl
Site Address: 868 Higuera St
San Luis Obispo, CA 93401
Phone: (805)543-4008
Facility lD: FA0011577
Serial Number: DAJOKKSTK
PROGRAMS INSPEGTED:trHazmat BHWGenerator trUST trAGT trGalARP trTPE
REINSPECTION REQUIRED trHazmat trHWGenerator EUST trAGT trCalARP trTPE
PERMISSION TO INSPECT: Inspections may involve obtaining photographs, reviewing and copying records, and
determining compliance with adopted codes.
GRANTED BY (NAME/TITLE): Name: Channith Sim Title: Assistant Manager
YES NO N/Atrtrtrtrtrtrtrtrtr
tr
tr
tr
tr
tr
tr
u
tr
BUSINESS PLAN
Business plan is complete, current, available during inspection (HSC 25503.5, Title 19 CCR 2729)
lnventory of hazardous materials is complete (HSC 25504, Title 19 CCR 2729)
Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR 2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732& 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 &22
ccR) 66265.16
EMERGENCY RESPONSE PLAN
Emergency response/contingency plan is complete, updated, and maintained on site (HSC
25504, Title 19 CCR 2731 & 22 CCR S 66265.53/54)
Facility is operated and maintained to prevenuminimize/mitigate fire, explosion, or release of
hazardous materials/raraste constituents to the environment. Maintains all required or
appropriate equipment including an alarm and communications system (Title 19 CCR 2731& 22
ccR 66265.31-.37,40CFR 1 265.31)
Secondary containment is installed and sufficiently impervious to discharges.
ICHSC 25270.4.5; 40 cFR r12.8(cX2)l
GENERAL EH VIOLATIONS
tr tl tr FE01 Environmental Health fees paid. ICBPC 17200, Local ordinancel
GPS Coordinates: Latitude: 35.2805700000 GPS Goordinates: Lonqtitude: -120.6624800000
BPOl
BP02
BPO3
TROl
TRO2
EROl
ERO2
ERO3
INSPECTOR: KERRY BOYLE FACILITY REP: ChANNith SiM
I
FACILITY NAME: Ross Dre -for Less #0228 nOOn'- lp:
HAZARDOUS WASTE GENERATOR
868 Higuera St
San Luis Obispo, CA 93401
EPA ID
NUMBER:
Total generated/month:
Waste Oi[
-
Antifreeze:
Lbs or gals (average)
Solvents:
Others:-
YES NO N/Atrtrtr vtoL. #
GTOl
GTO3
GTO4
GTO5
GTO6
GTOT
EPA ID NO/PERMITS
Generator has an EPA ID number to treat, store, dispose, transport or transfer hazardous
waste (Title 22CCRS66262.12) lf not, Call (800) 618-6942 to obtain your CAL EPA lD number
HMARDOUS WASTE DETERM INATION
Hazardous waste determination conducted (Title 22 CCR 566262.11)
trown knowledge tranalysis trother
Hazardous waste analysis/test records are kept for at least 3 years(Title 22 CCR S66262.40.(c))
D IS POSAL/TRAN S PO RTATI O N
Hazardous wastes disposed of atan authorized location (HSC525189.5,Tltle22 CCR566262.12)
Facility utilizes a registered hazardous waste transporter, and hazardous wastes
shioDed with a manifest ffitle 22 CCR S66262.20. HSC Q25160/25163(a)l
trmilkrun trother
Manifests and/or receipts are properly completed/retained by generator for 3 years
(Title 22 CCR $66262.23, 66262.40 (a))
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows (Tille 22 CCR 566262.34)
tr90 days if waste generated per month is greater than or equal to 100 kg. (220 lbs.)
tr180 days if waste generated per month is less than 100 kg (see note)
tr270 days if waste generated per month is less than 100 kg and transported more than 200
miles (see note)
Hazardous waste "satellite' collection is managed properly (complete
labeling/accumulation time/S5-gal or 1-qt limit) (Title 22 CCR 566262.34(c))
lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title
22 CCR 566265.176)
Containers of hazardous waste are properly labeled (includes appropriate date,"HMARDOUS
WASTE," waste composition/physical state, hazardous properties, name/address of
generator) (Title 22 CCR 566262.31, 66262.34)
Containers/tanks containing hazardous wastes are in good conditiorVhandled to
minimize the release or reaction (Title 22 CCR 566262.34 (dX2),
Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCR$
s66262.34 (dX2), 66265.172)
Containers storing hazardous wastes are closed/sealed (Title 22 CCR 5566262.34 (dX2), 66265.1
Weekly inspection of areas where hazardous waste containers are stored is conducted (Title
22 CCRSS66262.34 (dX2), 66265.174)
Daily inspection of all tank systems is conducted and documented (Title 22 CCR 5566262.34 (dX2),
66265.195)
Empty containers or inner liners greater than 5 gal has date when emptied and are managed
properly within one year of date emptied (Title 22 CCR 566261.7 (f))
RECYGLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc)
(Title 22 CCRS 66266.13, HSC 525250.4)
Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in
closed rainproof container, labeled "drained used oil filters," and transferred for metal
reclamation) (Title 22 CCRS 66266.13)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or
bill of lading for recycling, reuse, or reclamation (Title22 CCR S66266.81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22
ccR 866266.3)
SOURCE REDUCTION:For facilities generating >12,000 kg./yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction
documents or is able make them available to the inspector within (5) days. (67100.7, 671 00.8, HSC
Source Reduction Evaluation and Plan contains the following five elements:certification, amounts
of wastes generated, process description, block diagrams, and implementationschedule of
selected source reduction measures. (67{00.7. 671 00.8. HSC S25244.19)
Hazwaste Gontingency Plan prepared, current, submitted to the CUPA, maintained onsite. (Title
22 CCR 566265.51-.54)
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
GTOS
tr GTO9
tr GT1O
tr GT11
tr GT12
tr GT13
tr GT14
tr GT15
tr GT16
tr GT17
tr GT18
tr GT19
tr GT2O
tr GT21
tr Gf22
tr GT23
tr GT24
,1
suMM 'lv or oBSERVATToNs ru'rt( \norus
tr No violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations were
discovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to yot
facility.
tr Violations were observed/discovered as listed below. All violations must be corrected by implementing the
corrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,
olease inform the CUPA in writinq.
ALL VTOLATTONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writing w
certification that compliance has been achieved. A false statement that compliance has been achieved is a violatior
of the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility may
be reinspected any time during normal business hours.
You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed
corrective actions. The issuance of this Summary of Violations does not preclude the CUPA from taking
administrative, civil, or criminal action.
FACILITY NAME: Ross Dress For Less #0228 ADDRESS: 868 Higuera St
San Luis Obispo, CA 93401
VIOLATIONS
VIOL. NO CORRECTIVE ACTION REOUIRED
INSPECTION COMMENTS:
Hazardous waste is properly managed, no violations noted. Discussed accumulation time frame as being
every 180 days or twice a year for disposal of hazwaste.
Hazardous waste is properly managed, and good record keeping for disposal. Very small quantities of
hazwaste collected. Accumulation period is limited to 180 days before the need to properly dispose of it
arises.
INSPECTED BY: KERRY BOYLE
DATE:0228t2018
NAME OF FACILITY REP: Channith Sim
SIGNATURE OF FACILITY REP:
STATEMENT OF COMPLIANCE
Gertification: I certify under penalty of periury that this facility has complied with the corrective actions listed on
is inspection form.
Signature of Title: Date:-
\
Gounty of San Luis Obispo
)
cffy-ol
san Luls oBtspo
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
rl
EFW data
entry by:
Environmental Health Services
(805) 781-5544
P.O. Box 1489
2156 Sierra Way
San Luis Obispo, CA 93406
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HMARDOUS MATERIALS INSPECTION FORM
n^t",fll]{ l4:'
Time:-i
FACILITY NAME:
EHS
AG DEPT
CITY FIRE
TYPE
Routine Reinspection
Complaint n Otner
Result Code: _70 _80 _90
Action Code: _32 _37 _33 _31
)
ADDRESS: BlaX
i{ 't o/uw
PHONE
PROGRAMS INSPEGTED:n Business Plan Er* Generator E usr n ncr ncnmnp
REINSPECTION REQUIRED:F No trYEs n Business Plan Fr* cenerator n usr I ncr f]cnmnp
PERMISSION TO INSPECT: tnspections may involve obtaining photographs, reviewing and copying records, and
determinins compliance with adopted codes. GRANTED BY (NAME/TITLE)
YES NO COStrn tr!n !nn n
ntr
n
n
u
tr
nnntr
N/A
BUSINESS PLAN
Business plan is complete, current, & available during inspection (HSC 25503.5' Title 19 CCR2729)
Inventory of hazardous materials is complete (HSC 25504' Title 19 CCR2729)
Site layout/facility maps are accurate (HSC 25504' Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732 &22 CCR66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR
6626s.16)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504, Title 19 CCR273I &22
ccR $ 6626s.s3ts4)
Facilify is operated and maintained to prevent/minimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR 2731 &22 CCR66265.31-
.43)
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b))
SPCC Plan is maintained on site or nearest field office. (HSC 25270)
!n n!TN
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
ATOl
ATO2
COMMENTS Go to http://www.slopublichealth.org/environmentalhealth/trazardous
GPS Coordinates
to obtain forms to with BPO1-BPO3,and
min Longitude: deg
-min
INSPECTOR:-deg
mln
FACILITY REP:
decimal min
J\
\vi\Ji
$,\J
DEPAR
ffi Lu.g;gspo
You are hereby notified that an inspection of your premises located at:
following fire safety hazards and/or violations.
cA 93401 (805) Z8r-7380
to
lRemove Cut/Uncut Weeds/Grass/Vegetation
lStorm Water Polution Prevention
Ceiling if No Sprinklers
Self-Closing Lid for Oil Rags
Trash Containers ilLid if >40 gal.
between Combustibles and Ignition Sources
Gas Cylinders I
2160 AVE.,SANLUIS
6.
I.D. #
has disclosed the
w
\
1. Fire
a.
b.
c.
d.Only
e.
f.)
e,
f.
o.
h.
3. Fire
a.
b.
System
Clearance for Riser/Control Valves
Caps/Clearance for Fire Department Connection
S-Year Certification
and Lock Valves Open
System
Cover Plates
Sign for Electrical Room Door 1" Letters
Combustible Storage_
Dlmpster a Minimum of 5' from Walls/Eaves
a.
b.
c,
d.
e.
f.
Adapter
a. [Annual Test Record Required
b. fiRepair/Replacec. flnrouiaeCi.*m.Vry
4. Kitchen Hood System/Spray Bootlr/Clean Agent System
a. flProvide 6 Month Service
b. lCleaniRepair
5. Fire Lanes/Ilydrants/Access
EPaint.Fire Lanes
Signage
' Clearance aro.pnd Hydrant
Access Ways
Key Box/I(eys
AddressAJnit Numbers _"
Clearance/Signage Roof Access
Private Fire Hydrant
J
Compressed
EProvide Seismic Strapping/Ivlaintain/Repair Water Heaters
8.
a,
b.
d.
e.
f.
o
h.
i.
j.
k,
l.
m.
n.
a.
b.
c.
d.
e.
f.
o
h.
it
COMMENTS:
This Inspection Record official OF VIOLATION and order to comply.
The above noted afe violations of City Fire and Building Codes. Therefore, you must corr€ct the noted conditions immediately
upon receipt ofthis notice. A reinspection ofyour business will be conducted in
PLEASE NOTE: If a third inspection is required due to non-compliance, a fire-inspection fee of $_ may be charged for
that inspection and every inspection thereafter until compliance is obtained. Failure to comply may result in a misdemeanor
citation and an appearance by you in court.
I Fire Code Permit required for tr eR*-qta
INSPECTION CLyAR INIThL
FIRST E tl)tt V Lffi'1
SECOND t!, g!' t 1f \.,
THIRD
Fees payable upon receipt
4
/,
rrt*H
e$b
FEE
\ --\
)
Environmental Health Services
(805) 781-5544
P.O.Box 1489
2156 Sierra Way Ste. B
San Luis Obisoo. CA 93406
/-\
crty o[ san luls oBlspo
FIRE DEPARTMENT
2160 Sota Barbad Avauo'Sa Luis Obkpo,CA 93401-5240'{81}5) t8t-7380
"Courtesy & Service"
GERTTFTED UNTFTED PROGRAM AGENCY (CUPA)
HMARDOUS MATERIAL INSPECTION FORM
Time:Date:0212812018
COUNTY
bSAN LUIS
OBISPO
Facility Name: Ross Dress For Less #0228 Aoencv
trEHS
ECITY FIRE
lnspection Tvpe
trRoutine
trReinspection
trChargeable Reinspection
trChange of Ownership
trComplaint
trSecondary Containment Testing
trChargeable Secondary Containment Testinr
Site Address: 868 Higuera St
San Luis Obispo, CA 93401
Phone: (805)543-4008
Facility lD: FA0011577
Serial Number: DABXKNTGM
PROGRAMS INSPECTED:trHazmat trHW Generator trUST trAGT trCalARP trTPE
REINSPECTION REQUIRED:DHazmat trHWGenerator trUST trAGT trCalARP trTPE
PERMISSION TO INSPEGT: lnspections may involve obtaining photographs, reviewing and copying records, and
determining compliance with adopted codes.
GRANTED BY (NAME/TITLE): Name: Channith Sey Title: Assistant Manager
YES NO N/Atrtrtrtrtrtrtrtrtr
BUSINESS PLAN
Business plan is complete, current, available during inspection (HSG 25503.5, Title 19 CCR 2729)
lnventory of hazardous materials is complete (HSC 25504, Title 19 CCR 2729)
Site layouufacility maps are accurate (HSC 25504, Title 19 CCR 2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 &22
ccR) 66265.16
EMERGENCY RESPONSE PLAN
Emergency response/contingency plan is complete, updated, and maintained on site (HSC
25504, Title'19 CCR 2731 & 22 CCR S 66265.53/54)
Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or
appropriate equipment including an alarm and communications system (Title 19 CCR 2731& 22
ccR 66265.31-.37,40CFR 1 265.31)
Secondary containment is installed and sufficiently impervious to discharges.
IGHSC 25270.4.5; 40 CFR 112.8(cX2)l
GENERAL EH VIOLATIONS
tr tr tr FE01 Environmental Health fees paid. ICBPC 17200, Local Ordinance]
GPS Coordinates: Latitude: 35.2805700000 GPS Coord i nates : Lonqtitude : -1 20.6624800000
BPOl
BPO2
BPO3
TROl
TRO2
EROl
ERO2
ERO3
tr
tr
tr
tr
tr
tr
tr
INSPECTOR: KERRY BOYLE FACILITY REP: Channith Sim
FACILITY NAME: Ross Dr")For Less #0228 ADDf )S
HAZARDOUS WASTE GENERATOR
868 Higuera St
San Luis Obispo, CA 93401
EPA ID
NUMBER:
Total generated/month: Lbs or gals (average)
Waste Oil:Solvents: _Others:-
YES NO N/Atrtrtr VIOL # EPA ID NO/PERMITS
GTOI Generator has an EPA lD number to treat, store, dispose, transport or transfer hazardous
waste (Title 22CCR966262.12) lf not, Call (800) 618-6942 to obtain your CAL EPA lD number
HAZARDOUS WASTE DETERMINATION
GTO3 Hazardous waste determination conducted (Tille 22 CCR 566262.11)
trown knowledge tranalysis trother
GT04 Hazardous waste analysis/test records are kept for at least 3 years(Title 22 CCR S66262'40.(c))
D I S POSAL/T RAN S P O RTATI O N
GTOs Hazardous wastes disposed of at an authorized location (HSC $25189.5,Tit\e 22 CCR 566262.12)
GT06 Facility utilizes a registered hazardous waste transporter, and hazardous wastes
shioped with a manifest fiitle 22 CCR S66262.20. HSC S25160/25163(a))
trmilkrun trother
GTOT Manifests and/or receipts are properly completed/retained by generator for 3 years
(Titte 22 cCR 566262.23, 66262.40 (a))
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows (Tille 22 CCR 566262.34)
tr90 days if waste generated per month is greater than or equal to {00 kg. (220 lbs.)
tr180 days if waste generated per month is less than 100 kg (see note)
tr270 days if waste generated per month is less than 100 kg and transported more than 200
miles (see note)
Hazardous waste "satellite" collection is managed properly (complete
labeling/accumulation time/5S-gal or 1-qt limit) (Title 22 CCR 566262.34(c))
lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title
22 CCR 566265.{76)
Containers of hazardous waste are properly labeled (includes appropriate date,"HMARDOUS
WASTE," waste composition/physical state, hazardous properties, name/address of
generator) (Title 22 CCR 566262.31, 66262.34)
Gontainers/tanks containing hazardous wastes are in good condition/handled to
minimize the release or reaction (Title 22 CCR 566262.34 (dX2),
Containers/tanks/liners are compatible with waste stored or transferred (Title 22 CCRS
$66262.34 (dX2), 66265.172)
Containers storing hazardous wastes are closed/sealed (Title 22 CCR 5$66262.34 (dX2)' 66265.1
Weekly inspection of areas where hazardous waste containers are stored is conducted (Title
22 CCRSS66262.34 (dl(21, 66265.1 74)
Daily inspection of all tank systems is conducted and documented (Title 22 CCR 5566262.34 (dX2),
66265.195)
Empty containers or inner liners greater than 5 gal has date when emptied and are managed
properly within one year of date emptied (Title 22 CCR S6626f .7 (0)
RECYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc)
(Title 22 CCRS 66266.13, HSC 525250.4)
Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in
closed rainproof container, labeled "drained used oil filters," and transferred for metal
reclamation) ffitle 22 CCRS 66266.13)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or
bill of lading for recycling, reuse, or reclamation (Title 22 CCR 566266.81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22
ccR s66266.3)
SOURCE REDUCTION:For facilities generating >12,OOO kg./yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction
documents or is able make them available to the inspector within (5) days. (67100.7, 67100.8, HSC
Source Reduction Evaluation and Plan contains the following five elements:certification, amounts
of wastes generated, process description, block diagrams, and implementationschedule of
selected source reduction measures. (67100.7. 67100.8. HSC 825244.19)
Hazwaste Contingency Plan prepared, current, submitted to the GUPA, maintained onsite. (Title
22 CCR S66265.51-.54)
GTOS
tr
tr
D
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr
tr GTO9
tr GT1O
tr GT11
tr GT12
tr GT13
tr GT14
tr GT15
tr GT16
tr Grfl
tr GT18
tr GT19
tr GT2O
tr GT21
tr GT22
tr GT23
tr GT24
suMM'-W or oBSERVATtoNsMo hotts
tr No violations of underground storage tank, hazardous materials, or hazardous waste laws/regulations were
discovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to yot
facility.
tr Violations were observed/discovered as listed below. All violations must be corrected by implementing the
corrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,
please inform the CUPA in writinq.
ALL VIOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writing w
certification that compliance has been achieved. A false statement that compliance has been achieved is a violatior
of the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility may
be reinspected any time during normal business hours.
You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed
corrective actions. The issuance of this Summary of Violations does not preclude the CUPA from taking
administrative, civil, or criminal action.
FACILITY NAME: Ross Dress For Less #0228 ADDRESS: 868 Higuera St
San Luis Obispo, CA 93401
VIOLATIONS
VIOL. NO CORRECTIVE ACTION REOUIRED
INSPECTION COMMENTS:
Very small quantities of hazardous waste collected due to damaged goods or customer returns. Totes are
securely closed, properly labeled, and good waste disposal documentation. No problems observed.
Hazardous waste is properly managed, no violations noted. Discussed accumulation time frame as being
every 180 days or twice a year for disposal of hazwaste.
Hazardous waste is properly managed, and good record keeping for disposal. Very small quantities of
hazwaste collected. Accumulation period is limited to 180 days before the need to properly dispose of it
arises.
INSPECTED BY: KERRY BOYLE
DATE: 0212812018
NAME OF FACILITY REP: ChANNith SiM
SIGNATURE OF FACILITY REP:
STATEMENT OF COMPLIANCE
I certify under penalty of periury that this facility has complied with the corrective actions listed on
inspection form.
Signature of Owner/Operato Title:- Date:-
Environmental Heairr' oervices
(80$ 7815544
P.O.Box 1489
2156 Sierra Wav Ste. B
San Luis Obisoo. CA 93406
8*Y':fiso**rc
Fire Deoartment (80$ 7817380
2160 Santa Barbara Avenue
Date'. 0911412017
San Luis Obisoo CA 9340tr5240
GERTTFIED UNIFIED PROGRAM AGENCY (CUPA)
HMARDOUS MATERIAL INSPECTION FORM
Time:
Facility Name: Ross Dress For Less #0228 Aoencv
trEHS
trCITY FIRE
lnsoection Tvoe
trRoutine
trReinspection
trChargeable Reinspection
trChange of Ownership
trComplaint
trSecondary Containment Testing
trChargeable Secondary Containment Testinl
Site Address: 868 Higuera St
San Luis Obispo, CA 93401
Phone: (805)543-4008
Facility lD: FA001 1577
Serial Number: DAGOWRWS
PROGRAMS INSPECTED:trHazmat trHW Generator trUST trAGT trCalARP trTPE
REINSPECTION REQUIRED EHazmat flHW Generator trUST trAGT trCalARP trTPE
PERMISSION TO INSPECT: lnspections may involve obtaining photographs, reviewing and copying records, and
determining compliance with adopted codes.
GRANTED BY (NAME/TITLE): Name: William Harper Title: Store Manager
YES NO N/A
trtrtrtrtrtrtrtrtr
tr
tr
tr
tr
BUSINESS PLAN
Business plan is complete, current, available during inspection (HSC 25503.5, Title 19 CCR 2729)
lnventory of hazardous materials is complete (HSC 25504, Title 19 CCR 2729)
Site layouUfacility maps are accurate (HSC 25504, Title 19 CCR 2729)
TRAINING PLAN
Facility has appropriate training program (Title 19 CCR2732 & 22 CCR 66265'16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 &22
ccR) 66265.16
EMERGENCY RESPONSE PLAN
Emergency response/contingency plan is complete, updated, and maintained on site (HSG
25504, Title 19 CCR 2731 & 22 CCR S 66265.53/54)
Facility is operated and maintained to prevenUminimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or
appropriate equipment including an alarm and communications system (Title 19 CCR273'l& 22
ccR 6626s.31-37, 40CFR I 265.31)
Secondary containment is installed and sufficiently impervious to discharges.
ICHSC 2s270.4.5; 40 CFR 1 12.8(cX2)I
GENERAL EH VIOLATIONS
tr tr tr FE01 Environmental Health fees paid. ICBPC 17200, Local Ordinance]
GPS Goordinates: Latitude: 35.2805700000 GPS Coordinates: Longtitude: -120.6624800000
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INSPECTOR: KERRY BOYLE FACILITY REP: William HarPer
FACILITY NAME: Ross Dr 'ior, Less #0228 ADDF -'l:
HAZARDOUS WASTE GENERATOR
868 Higuera St
San Luis Obispo, CA 93401
EPA ID
NUMBER:
Total generated/month:Lbs or gals (average)
Waste Oi!:Solvents:
Antifreeze: Others:-
YES
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N9
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N/A
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vtol. #
GTOl
GTO3
GTO4
GTOS
GTO6
EPA ID NO/PERMITS
Generator has an EPA lD number to treat, store, dispose, transport or transfer hazardous
waste (Title 22CCRS66262.12) lf not, Call (800) 618-6942 to obtain your CAL EPA lD number
HAZARDOUS WASTE DETERMINATION
Hazardous waste determination conducted (Title 22 CCR 566262.11)
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Hazardous waste analysis/test records are kept for at least 3 years(Title 22 CCR $66262.40.(c))
D IS P OSAL/TRAN S P O RTATI O N
Hazardouswastes disposed of atan authorized location (HSC525189.5,lille22 CCR566262.12)
Facility utilizes a registered hazardous waste transporter, and hazardous wastes
shipoed with a manifest fiitle 22 CCR Q66262.20. HSC Q25160/25163(al)
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Manifests and/or receipts are properly completed/retained by generator for 3 years
(Title 22 CCR 566262.23, 66262.40 (a))
STORAGE AND MANAGEMENT OF CONTAINERS/TANKS
Hazardous wastes are accumulated on site as follows (Title 22 CCR 566262.34)
tr90 days if waste generated per month is greater than or equal to 100 kg. (220 lbs.)
tr180 days if waste generated per month is less than 100 kg (see note)
tr270 days if waste generated per month is less than 100 kg and transported more than 200
miles (see note)
Hazardous waste "satellite" collection is managed properly (complete
labeling/accumulation time/S5-gal or 1-qt limit) (fitle 22 CCR 566262.34(c))
lgnitable or reactive wastes are located 15 m (50 feet) from facility's property line (Title
22 CCR 566265.176)
Containers of hazardous waste are properly labeled (includes appropriate date,"HMARDOUS
WASTE," waste compositiorVphysical state, hazardous properties, name/address of
generator) (litle 22 CCR 566262.31, 66262.34)
Containers/tanks containing hazardous wastes are in good conditiory'handled to
minimize the release or reaction (Title 22 CCR S66262.34 (dX2),
Gontainers/tanks/liners are compatible with waste stored or transferred (Title 22 CCRS
s66262.34 (dX2), 66265.172)
Containers storing hazardous wastes are closed/sealed (Title 22 CCR 5S66262.34 (dX2), 66265.1
Weekly inspection of areas where hazardous waste containers are stored is conducted (Title
22 CCRSS66262.34 (dl(21, 66265.1 74)
Daily inspection of all tank systems is conducted and documented (Title 22 CCR 5566262.34 (dX2),
66265.1 95)
Empty containers or inner liners greater than 5 gal has date when emptied and are managed
properly within one year of date emptied fiitle 22 CCR 566261.7 (0)
REGYCLABLE WASTE
Used oil is managed as hazardous waste until recycled (includes proper labeling, storage, etc)
(Titte 22 CCRS 66266.13, HsC 525250.4)
Used oil filters for recycling are managed properly (drained of free flowing liquid, stored in
closed rainproof container, labeled "drained used oil filters," and transferred for metal
reclamation) (Title 22 CCRS 66266.13)
Spent lead-acid batteries are being properly stored and transferred offsite under manifest or
bill of lading for recycling, reuse, or reclamation (Title 22 CCR 566266.81)
Solvents/other recyclable materials are managed as hazardous wastes until recycled (Title 22
ccR s66266.3)
SOURCE REDUCTION:For facilities generating >12,000 kg,/yr. of hazardous waste on site.
Generator is subject to SB14 and has prepared and retained current source reduction
documents or is able make them available to the inspector within (5) days. (67100.7, 67100.8, HSC
Source Reduction Evaluation and Plan contains the following five elements:certification, amounts
of wastes generated, process description, block diagrams, and implementationschedule of
selected source reduction measures. (671 00.7. 671 00.8. HSC 825244.1 9)
Hazwaste Contingency Plan prepared, current, submitted to the CUPA, maintained onsite. (Title
22 CCR 566265.51-.54)
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tr GTO9
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tr GT11
tr GT12
tr GT13
tr GT14
tr GT15
tr GT16
tr GT17
tr GT18
tr GT19
tr GT2O
tr GT21
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\suMrf' lv or oBSERVATIoNS Ntc' rllorus
tr No violations of underground storage tank, hazardous materials, or haza, dous waste laws/regulations were
discovered. SLO CUPA greatly appreciates your efforts to comply with all the laws and regulations applicable to yol
facility.
tr Violations were observed/discovered as listed below. All violations must be corrected by implementing the
corrective action listed by each violation. lf you disagree with any of the violations or corrective actions required,
olease inform the CUPA in writinq.
ALL VTOLATIONS MUST BE CORRECTED WITHIN 30 DAYS OR AS SPECIFIED. CUPA must be informed in writing w
certification that compliance has been achieved. A false statement that compliance has been achieved is a violatior
of the law and punishable by a fine of not less than $2,000 or more than $25,000 for each violation. Your facility may
be reinspected any time during normal business hours.
You may request a meeting with the Program Manager to discuss the inspection findings and/or the proposed
corrective actions. The issuance of this Summary of Violations does not preclude the GUPA from taking
administrative, civil, or criminal action.
FACILITY NAME: Ross Dress For Less #0228 ADDRESS: 868 Higuera St
San Luis Obispo, CA 93401
VIOLATIONS
VIOL. NO CORRECTIVE ACTION REOUIRED
INSPECTION COMMENTS:
Annual inspection for hazardous waste generator program. All hazwaste totes properly labeled, securely
closed and good employee training program. Hazwaste is generated due to customer returns and/or
damaged goods. No violations noted during facility inspection.
INSPECTED BY: KERRY BOYLE
DATE:09t14t2017
NAME OF FACILITY REP: William Harper
SIGNATURE OF FACILITY REP:
STATEMENT OF COMPLIANCE
: I certify under penalty of perjury that this facility has complied with the corrective actions listed on
inspection form.
nature of Title:- Date;-
,Gounty of San Luis Obispo Sff-ffiwoEnvironmental Health Services
(805) 781-5544
P.O. Box 1489
2156 Sierra Way
San Luis Obispon CA 93406
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luis Obispo CA 93401-5240
CERTIFIED UNIFIED PROGRAM AGENCY (CUPA)
HMARDOUS MATERIALS INSPECTION F'ONruI
EFW data
entry by:q
Date: I
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Time:
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BUSINESS PLAN
Business plan is complete, current, & available during inspection (HSC 25503.5, Title 19 CCR2729)
Inventory of hazardous materials is complete (HSC 25504' Title 19 CCR2729\
Site tayout/facility maps are accurate (HSC 25504' Title 19 CCR2729)
TRAINING PLAN
Facility has appropriate training program (Titte 19 CCR2732 & 22 CCR66265.16)
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR
6626s.16)
EMERGENCY RESPONSE PLAN
Contingency plan is complete, updated, and maintained on site (HSC 25504' Title 19 CCR273I & 22
ccR $ 6626s.s31s4)
Facility is operated and maintained to prevent/minimize/mitigate fire, explosion, or release of
hazardous materials/waste constituents to the environment. Maintains all required or appropriate
equipment including an alarm and communications system (Title 19 CCR 2731 & 22 CCR 66265.31-
.43)
ABOVEGROUND PETROLEUM STORAGE TANK ACT
SPCC Plan is reviewed and certilied by a registered engineer within last 5 yrs. (40 CFR 112.5(b))
SPCC Plan is maintained on site or nearest field office. (HSC 25270)
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Result Gode: _70 -80 -90Action Gode: 32 37 33 31
Routine Reinspection
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*O N YESREINSPECTION REQUIRED:
involve obtaining photographs, reviewing and copying records, andISSION TO INSPECT lns pections may
codes. GRANTED BYiance with
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INSPECTOR:
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FACILITY REP:
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