HomeMy WebLinkAbout4400 COFFEE ROAD (2)HAZARDOUS MATERIALS BUSINESS PLAN CERTIFICATION FORM
br Use by Unidocs Member Agencies or where approved byyour Local Jurisdiction
Authority Cited: Health andSafety Code §25503.3(c); 19 CCR §2729.5(c)
To: Agency Name: Bakersfield Fire Department, Fire Prevention Services
Agency Mailing Address: 1600 TRUXTUN AVENUE
Bakersfield, CA 93301
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: CVS Pharmacy # 9975
Facility Street Address: 4400 COFFEE RD
Date of Current HMBP: 03/01/2011
I certify that: (Check the appropriate box.)
City: Bakersfield
I have personally reviewed the Hazardous Materials Business Plan currently on file with your agency and
certify that the HMBP is complete and accurate. (See bottom ofpage 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
0 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 that, based upon my
inquiry of those individuals responsible for obtaining the information reported above, 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 IIMBP.
Name of Owner /Operator(Print): " cr-Wnba"'"' Agent forLonaorua Stores ceinomla ,LLc. Title: Regulatory Compliance Specialist, 3E Company
Phone: (760) 602 -8700 Signature, Date: 01/11/2012
By checking the upper box on this form, you are certifying that:
The information contained in the HMBP most recently submitted is complete, accurate, and up -to -date; and
There has been no change in the quantity of any hazardous material as reported in the most recently submitted Hazardous Materials
Inventory forms; and
The facility has not begun handling any hazardous material in a HMBP reportable quantity that is not currently listed in the
Hazardous Materials Inventory; and
The most recently submitted HNIBP contains the information required by Section 11022 of Title 42 of the United States Code; and
There have been no substantial changes in the facility's operations that would require revision of the current HMBP.
UN -039 - 1/1 www.unidoes.org Rev. 10/09/07
Facility Information Business Activities: CERS Business file: / //H:fbwilbanks/ Regulatory / CVS /HMBP /2012Bak isfield/124853.h(m k
Canfornla Environmental Reporting System: Business ?PCon R s'!atoly pnpa[miant :Arms^* $AQiat IMIS R=Cds Help
am 9ttb11tltJtslt F41:1011ltles Cou+110— 1bf Buskileea
LONGS DRUG STORE 417: Business Activities
Home » Facility (10024312) )) Fact* Information: Business ActitiiYes
We lidsform to Identify the acthfties occlrirg atyour facility that are regulated under CaGforrda's Lkified Hazardous Wasteand Hazardous Materials Management Regulatory Program
CERS will prods guidance on completing the reporting require ems for base business acd4fles.
Submittal Guidance
l AS (1) 10 RaWked (o) I A, Waning (1) I a Adyaay (0) I i'
Wenroa*Jw- * r= mo llore:.ue. mat probaWy .ppytoyou hm m nor repbedtorsdw bdom UbrWhV theFaoaity rnram.flM VubmIlral .I.me+t.
The Faulty Namehas dY rged. fromLONGS DRUG STORE 417 to CVS Pharmacy ft9975.
Caneei
Site identlflcatlo
FaWityNerthet .L;_-',-':rf';'f:?C 'i..V`,.l!°.A CVS Phamwcy # 9975 iJ L,.. ;r,,,.+a"s, 7;
BurineaaShaAddr A' '!
F
x :Mras
4400CCFFEE PD
BAKERSFIEW. CA93308 {'.`i7T,..tr
yyCOUiCemEJ'niC
i N f
P. CERS ID i3t10024312 t? #g1
aterdous -Mate
Does yourfacify has on site (for any purpose) at any one lime, hazardous materials at or above1 gaAonsfar
liquids, 500 pounds for solids, or 20Dcutdcfeet for compressed gases (Include liquids In ASTs and 115Ta); x the Ifyes. CERS WE prompt you to c-plawappicadaFederalthresholdquantityforanextremelyhazardoussubstancespedfiadh140CFRPart355, Append'oc Yes
A or B; orhandle rardobgical melerisls in quantifies for which an emergency plan is required pursuant to 10 CFR additionalfomreldocurentation.
Pmts 30, 40 or 707!1
Jnde,Mround-Petroteum -S+ore
If yes, CERS WIPrompt you to complete
Does you facility ovn or operate underground storage tanks? 1;, No additional formsldocunenfetion.
nazaragua-vvas -
Does your Fac'
Is youfacility a Hazardous Waste Generator'lw' Yes If yes, pro4de an EPA ID Number.
CALDDD356793
Doesyour facliy recycle more than 100 kg/mordn oftoduded orexampled recyclable materials (per HSC I #' No Ifyea, CERS will prompt you to amplete
25143.2)74t
II
addilonalforn-Wdocu eraabon.
Does you fadiy gnat hazardouswaste on -sile7 4 No Ifyes, CERS will promptyou te complete
eddltional forms/documanlason.
Is your facility's treatment sub)sOto financial assurance requinsu.. (for Permit by Rule and Conditional I No 11fyes, CERS will prompt you to complete
Authorization)? iP i Il additional formsIdoarnentedon.
Does you facility consoidate haazadouswaste generated at a remote site? iY ter No If yes, CERS WE promptyou to complete
addiQanelfomn.WdocurenfaQon.
Does you facility need to report the cbaue/rerto%al of a tank that was classffed as hazardous waste and cleaned No If yes. CERS wepromptyou W complete
on -site? 4 I additional forms/docwremBlon.
Does your fadiy generate In arty single calendar morM 1,000 Idlograna (kg) (2.200 pounds) or mom offederal Ifyes, obtain afederal EPA ID Mme,
RCRA Iomdcuswaste, or generatein arty single calendar mini h, or eccu uiate atany Ome, 1 kg (2.2 pounds) of No
file Biennial Report (EPA Form
RCRA acute hazardous waste; or generate or aomm late atany time mme Ohms 10D kg (220 Ponds) of spill cleanup 8700.13XB), and satisfy requirements for
materials contaminated with RCRA acute hazardous waste. ; RCRA large Quantity Generator.
Isyour facility a Household HazardousWaste (H" Collection site ?4 I R;' No l If yes, see CLPAfor required fame.
h
i
1 oft 1/11/2012 7:06 AM
FacilityInformation Business Activities: CERS Business file: / //H- /bwilbanks/ Regulatory/ CVS/ HMBP /2012/Bakersfield/124853.btm
E
Aboveground Petroleum Storage
Doesyour faclity a-An or operate ASTe abrne ftleae rtrasholds? Store greatertram 1,320 gallons of Pave= If yes, coordfnata utih your local agency
products (newor used) In ebvAvvund tanks or containers. it '. No
Storage Ac
Abo)epround Petroleum
StoragePct (APSA) compliance.
Regulated Substance
Does your facility have Regulated Suhsiances stored onste in quantifies greaterthan Ole threshold quantities f. No if yes. coordinate Wth your local agency
established by the California Accidental Release prevention Program (CWARP)z t responsible for Cat4RP.
Additional 1nformatlon
Provide arty additional information as necessary andfor requhed by your local regulators} V
C—lad at•, 1ECompany Regulatory Department on 3n T201010:59 AM
Vrt Updated By3ECompany Regulatory Department on 1x10201210:05AM
Version 2.00.DDDB I EMancenents I CERS central Diagnostics I Ccndnons of use I Priyacy Policy I CorAad I HNP
California Environmental Reporting System: Busiress 102012 California Environments! ProtectionAgency
CERS TedricalAssfstace:leoe.caaw
Lkff ed ftgramGenerel Assistance: Canted your local rernlatorlsl
CERS Help CEPS Help 'ib Settings Settings My Business: LONGS DRUG STORE 417 jASelect Business i
2 of 1/11/2012 7:06 AM
Facility Information Business Owner /Operator Notification: CERS Bus... https : / /cersbusiness.calepa,ca.gov/ 28753 / Facility/]0024312 /Submittal...
California Environmental Reporting System: Business . Co oap ! RgulatDry DeoartmenCsAccairit_ Sign Out . -.,_I%k
x
Melling Addrepa —.--- -- rimary:Emergency Qpntac .
Melling Address 4' First 3 LastName G
CVS Caremark, Atln: Dianne E. Durand One CV.$ Drl%e- 23082A 3D,COfWANY
CHyv7a+ State ZIP/Postal Code in Tllle'l`_
Woonsocket N 02895 24HOUR EMERGENCY. CALL CENTER
Business Phone 24 -HourPhone a Pager NymD@r d
VNlltll :.
First3 Lest Name Phone
LongsDrug Stares California, L.L.C. (401)7.05-1500
MaHh1g Address.
CVS Caremark, One CVS Drhe- 230132A
City LPIPostalCode
Woonsocket 02895 ..
Country
United States
FhV & LastName Phone
CVS Caremark 4017851500
Emoil ik
Mailing Address •.
One CVS Drl%w23062A
City aPfPostal Code
Woonsocket 02895
Country
United Stalas
I Name of Slgner ? THb of Signer ( Date Signad/SubnOtted rR
Rebecca Wilbanks, Pgertfor Longs Drug Stores California, LLC. Regdatory. Corrpiange SPKWSL 3E Conperly 1/1112012
jName ofDocument Prepdrer ' AdditionalInformation
1 Rebecca Wlbanks, Agentfor Longs DrugStores Callforrda, L.L. C:,: -
l Locally-collected Fields
Some or all of the following fields may be required by your local regulator(s). .
First 8 LastName Phone
CVS Caremark, Attn: Dianne E. UArand 4017703315
Malting Address1OneCVSDrive-23062A
1 pity . Zip Code
Woonsocket 02895
Country
United States
f crnaled 9y: 9y4em.bminis foron 912 99:59AM
Lest Itpdat•d By: 3E Company Regulatory DepaMern on I W7012 1:51 PM
1 of2 1/19/20121:52 PM
Date: 01/11/12 Non -Waste Hazardous Materials Inventory Statement
For use by Unidocs Member.4gencies or where approved byyour LocalJurisdiction
Business Name-
Saaaeas FacilityName arDBA) CVS Pharmacy # 9975 Ty a ofReport on This Page: 9A4- Delete; Revise
Page 1 of 3
Ose papa perbudding
Chemical Location:
ei,;b;y,r,ge A,) Retail sales floor EPCRA Confidential Location? ® Yes; ® No
Trade Secret Information? ® Yes Ix7 No
Facility ED #
i "$° PC"o n/ 1 5 0 2 1 1 5 5 5 3
1.
Haz
Class
2.
Map and
Grid or
Location
Code
3.
Common Name
4.
Hazardous Components
For mixtures only)
Chemical %
Name Wt. EHS CAS No.
5.
Type
and
Physical
State
6.
Quantities
Max. Average Largest
Daily Daily Coat
7.
Units
S.
Storage Codes
Storage Storage
Pressure Temp.
9.
Hazard
Categories
3.00
MAP:
1
GRID:
Flammable
u ufdS.IJ -o.s. q 58.82 29.4132
a.fm
Inns
p <.mh. amb. pnG erdease
auoebeaMcbmoiehdthsolid
liquid
gas
Cnd-v
Or-6 —im)
DsysOn
Sitg
365
Sra ae
ig -'
C"Na -- EIIS
3.00
MAP:
GRID:
Flammable
I,ids,rl.o.s. a
i
p°C 58.63 29.131
x m
paaads
ambunt
amh
x amb,m
amb.
t
lzr- solid
hgrid pradva e)
P m On
365
stomas
Coate ser'
CAS No.: HAS
01
MAP:
GRID:-
miamao
asfeet
a iem
limb
aarb.
limb
amb.
Qyag
fue
eatve
pmemerelease
aanebeahh
daordchabh
ca&. ive
1:1 solid
liquid
gas
Curie
pr.••:"..,:"•)
Dart On
Olk:
Sarm
C0 .•
CAS ¢ El BAS 13
MAR.
GRID:
13 pme
mirmae
gahons
pounds
cufeet
sons
embitm
amh
eab.
am6iem
amh
emb.
fee
pressnrerelease
BMW brakh
c3maicbeahh
ad—cl—
solid
liquid
sW
Coda:
f¢nmh i)
Oxxv On
Slit:
Steraee
Contahrer.•
S.- 6HS
MAP:
GRID:
Pure
m
V&-
ponds
rufrar
Cl
amhiam
amb.
amb. Is
Qy,gma
rrJma
acnebeekh
cbrorkheahh
tsdioaoav
DI solid
liquid
gee
Shcdfa:
fnr.6o.m'z)
D.. On scot
Cootmer.'
CAS No•: Ws
MAP:
GRID:
r»R paa5dw- Rer
tons
ambiear
a rb
tmb.
ambomr
limb
amb.
e%yog—
fire
prcmae release
acts heeah
chromehmhh
mdroeaive
solid
mid
883
a. C=: Ofr.de.aire) 1
Situ=
to
fG is
ysyq arersm a rue
A AbovegroundTank
B B.1— groundTank
C TankInsideBuildinr
SI—_ amrsee arw -%I= o ydm arose erns 345-
D Stud Doan G Cmhny J Bab M Glass BoalearJg P TankWagon
B Plas[i</No ftRicDram H Sib N Bo N Plastic BottlealJag Q RAC.
F Can t Fiber Drum L Cylinder O ToteBm R Other
1f E RA, sign below:
UN -020EA - 12 bttp: / /www.unidoc&org Rev. 04/24/00
Date: 01/11/12 Non -Waste Hazardous Materials. Inventory Statement
For use by Unidocs Member Agencies or where approvedbyyour LocalJurisdiction
Samn
Fa
Name CVS Pharmacy # 9975SameuR.n3trNameor DBA) Y
Type ofReport on This
RaviAdd; [] Delete; Revise
Page of 3
0"F ? bwe' R°'
Chemical Location: PHOTO DEPARTMENT; RECEIVINGB.AdlinowraCe Arm)
EPCRA Confidential Location? ® Yes; No
Trade Secret Information? ® Yes; No
Facility ID #
AS—y' Um OnNl 1 5 0 2 1 1 5 5 5 3
1.
I1az
Class
2.
Map and
Grid or
Location
Code
3.
Common Name
4.
hazardous Components
For mixtures only)
Chemical %
Name Wt. ERS CAS No.
5.
Type
and
Physical
State
6.
Quantities
Max. Average Largest
Daily Daily Cont
7.
Units
8.
Storage Codes
Storage Storage
Pressure Temp.
9.
11azard
Categories
2.20
MAP:
1
GRID:
E -7; F -3
Helium 438 219 219
X ca. feet
tom
amh.
x ambient
anh
arogedc
fire
prmverek-
acute health
rhrotriebealth
mrltnadm
solid
liquid
gas
ptra&cu. =)
Dan On
Sits
365
S.tsaeE
7440-59-7
lip
MAP:
GRID:
pure
ntame
PR—
Pmmds
eLL feet
toss
a ebient
amt!
ftc E
amhiea
mb.
tb.
ayo8auic
6e
reactive
pressure reiea.e
chronichealth
radioactive
d
C9tti
ttrr.aio,ri.a)
D_ on
Silt•
Stone
Sartain -'
CAS No.: ffiIS
MAP:
GRID:
Pure
ttmmm
8a11nra
pow
uu fact
t+ffi
amh mt
rtfi
ambr
errbier
autb,
El ayogeme
fie
tearriw
pressmerelease
heaealtlt
rndmerays
solid
liq[nd
gas
Ste
tlrr.& °)
Daism.Qa
Sits
CAS No.: ENS
MAP:
GRID:
coo t. powds
uu far
trrs
ash
amb,
amb
a amb.
Yes it
reaeiw
pt morelease
sanehealth
duroaich_hh
radi.&i
solid
liquid
Bps
Ca
Vrad:m;,e)
Dan On SLiaY4
K'
rem: Kus
MAP:
GRID:
U pure
nirmno
galbas
pow
mfxt
ambient
mb.
amb-
nbieat
mb.
amb.
cwe
fire
r.a-
pressurercleae
muchealth
radiaediva
8 solid
liquid If - di...:._)
DEYLOn s+ent
container.•
CASNo.: Ens
MAP:
GRID:
ae Pow
at feet
amh
anb.
amb
amb,
eps -i.
reactive
pnssunerelease
aonehealth
cLrorithealth
ii..uive
solid
hquid
P.
o
of-ft-f-)
P_0,
Or:
slo* ^
CSN.: MS 11
t -Pat, 3tonte lree
A AbovegroundTuck
B Belo groundTads
C Took InsideBuilding
L" Dtmaee r7 yyg{ amr-M rsoe "x15 Ana rvx y osorxe rvoe Sda4 asmaee t.oe If EPCRA, sign below:
D Steel Dnmt G Carboy 7 Bag M GlmBor&DTNji P Tank wwo.
E PlatwNe—taBie D= H Sb K Boor N Plastic BouteorJug Q RailCa
R Can I PiIw Ilium L Cylinder O TaeBin R Other
UN -020EA -1/2 http: //www.ouidocLorg Rev. 0424100
Non -Waste Hazardous Materials Inventory Statement
Date: 01/11/12 For use by Unidocs Member Agencies or where approved byyour LocalJurisdiction
Business Name:
tSaroe aa FadfnyNameor DBA) CVS Pharmacy # 9975 Type ofReport on This Page:
Add; Delete; Revise
Page a of S
c0— PaP- b"Bdm[)
Chemical Location:
A,r,, Retaif Sales Floor EPCRA Confidential Location? ® Yes; No
El NoTradeSecretInformation. Yes;
Facility ID #
raroRrny, 1 s 0 2 s s s s
1.
Haz
Class
2.
Map and
Grid or
Location
Code
3.
Common Name
4.
Hazardous Components
For mixtures only)
Chemical %
Name Wt. ERS CAS No.
Type
and
Physical
State
6.
Quantities
Max. Average Largest
Daily Dail Cont.
7.
Units
8.
Storage Codes
Storage Storage
Pressure Temp.
9.
Hazard
Categories
5.10
MAP:
1
cR>D:
oxidizing Liquid, N.O.S. E nz 56.69 28.34 1.32 Fo d,
p<amb.
x
x
peswereleese
dwmclrcehh
solid
liquid
g.
Oh e:) SIt6
365
storied
ysaf'
CAS N°•: ms 1:1
MAP:°
GRID:
a>lXl1aC
P%-
amb. amh
away
teatbve
pessue dam
aW.heakb
da h..hh
redxpctise
solid
li*d
Cs
Pr-d u;m)
Oa On
Sec
StslBee
conumcr.•
CAS No. El eHS
MAP:
GRID:
Pure
mu¢nte
geaons
pruak
at feet
mm
mof>icot
eafi
amh fr=
11
iextiw
p—amrd-
afeheahb
dwiiichakh
DI solid
ligaid
P3
Colin:
vvdvai.o)
Danon Sasrate
coa d:•
CAS {o. EHS
El
MAP:
GRID:
Pure
mi h.
suBow
p m h
idea
1ms
anibirm
amb.
amb.
mbiem
amb.
emb.
li.e
Ere
reeaive
pcmaerelearn
irateheath
dmvchahb
rsdiaauive
0
solid
liquid
E19"
Cpl1H
Nvdamc)
P92Q_n 9 ee
Coohdaer•
cwsr7p: xHS
MAP
GRID:
C1 tae
I
pomrds
ar feat
amh.
erab. amb,
ractise
P r idea:
suobahh
damticheahh
sed'mecdve
maid
liquid
g-
c_ :e.
pfr.din.ctiw)
Danon
fig:
Storan
Coatdae[:•
CASNa. Has
MAP:
GRID:
pure
o¢i:
pions
P-As
ar fed
a nb as
emh
r h
ambientf[<=
jog. .
e
ractiw
p w=rekm
muebb
chm ishahh
r,dW.V.
solid
Ggaid
g.
Calris
Ir,ae;a.m o7
DanOn
it : SterazsGnfau.er^
CASN- 6HS
a.aae aroraxe a.oe
A Abovagtmmd7mk
B BelowpowdTmk
C TankInsideBuildiM
lim o omee i ra -Ndm oioraae . a.ci< erg, o<e a.R ---qm sa= IfEPCRA, sign below:
D Strsl Ilium G Carboy J Beg M Glass Botdeorhg P TankWagon
E - - --- -Diom H silo K Box N Plastic Botdeorfug Q Rail Car
F Can 1 FiberDrum L Cylinder O Tote Bin R Oder
UN-020EA - 1/2 http: / /www.unidocs.org Rev. 04124/00
Date; 01 /11 /12
Hazardous Waste Inventory Statement
For use by Unidocs Member Agencies or where approvedby your Local Jurisdiction
Business Name: ^l •
Same wFaeJatyName or DBA) `"VS Pharmacy # 9975 Type ofRe ort an This Page:
X Add; [Delete; Revise
Page 2 of 4
o•F•awb x•r rw
Chemical Location: R@CElVlflquid -VS- eAte) 9 EPCRA Confidential Location? [I Yes; [R No
Trade Secret Information? Yes; Q No
Facility ID Al
4°c'u-- 0-1y) 1 5 0 2 1 1 1 5 5 5 3
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Map and
Grid or
Hazardous Components Type
and
Quantities
Annual
Storage Codes
Haz Location Chemical % Physical Max. Average Largest Waste Storage Storage Hazard
Class Code Waste Stream Name Name Wt ERS CAS No. State Daily Daily Coat Amount Units Pressure Temp. Categories
2.1 0
MAP:
GRID:
G -2
Compressed as,
RammableN.O.S.
Propane 100.00 749&8 waste 50 25 10 200 galbm
Mfiz
tom
embiva
amb.
vabirm
Iamb. t—y cbeehh
fire
uoreham
1M97-8
M care ethad:
Recycled po-site
El Treated On-cite
solid
liid
0 gas
Cork.
Or .e alvs)
Rim
365
stortae
c °ruiner ' warro cove:
141
1
GRID:
G-2
onsumer U
State Regulated
Nan Regulated UquM, 100.00 Mhchrre waste 150 75 10 600 a•mm
a>
5.1
10RL
ar6iemH-
h
grim X the
reuse
fthmhhx
clnojehmhh
ndoacure
Management Method:
Shipped Off -site
ReeledOn -site
El Treated Orraite
Cl solid8liquid
Colin:
ur'" re)
Dan On
Sbs:
365
S
tag
N •rte Code
135
MAP:
1
GRID: GRID:
Consumer r0 u ,
State Regulated
Non Regulated Solid, 100.00 ff Mbrhrre W85te 150 75 10 600 WileMN,... ea fat
t
e91
0 <emb, c amb.
v—
lasethmj $
a
preen— relate
amaelaeah6
r
ManagemeutMethod:
Shipped Off -site
RecycledOn -site
Treated On-cite
solid
liquid
gas 365
wasteCode:
181
MAP:
1
GRID:
G
Fluorescent amp
Bulbs, Universal Waste Mercury 1.00 7439 -97-6 waste 50 1 0 200L Vwreb
of lee
un
aah
p <,
aab.
Iamb.
genic
revive
primerelease1aaueboaih
h.
ndoacdve
lead OAde Zoo 1317-38 -8
Maagement Method:
Shipped Off -,ice
Recycled Onsite
Treated Oa -rite
Glass (soda lime) 75.00 solid
liquid
Cl
awl
D3[! On
sik
365
stoma
Coatei>t•
to
waste Coder
Fluorescent Phosphor 3-DU E]
El
2.10
MAP:
1
GRID:
G -2
Waste erns s, Consumer Aerosols 100.00 Mix " wasfz 50 25L 1 0 2200 P
mE.1
rw
emblem
mb
amble,,
am6
arae
x
x
Bas
reactive
pressure rename
aaeheahh
rhronieheahb
Re
Cleaning APP
Management Method:
Shipped Off -cite
Recycled On -site
Treated On-sdo
PersonalCareProducts solid
liquid
fair!,,:
N –' W)
Dow 0o
s=4'
365
slor•e•
Contain 1214slats
woo C•
Airfresheners
MAP:
GRID:
G -2
B a 9
Universal Waste
ARsc Consumer Batteries 1oo.0o Mbdure vASfe 50 25 10 200 aagoem
p01'
m ihet
em
gale.
p <am6 N<-k. >
unh
aroamic
rattive
prQmetelem
aaae brahh
chronichuhh
ra&.ti.
cp,AaAA ev a
gaga
Shipped off -site
RecycledOn -rite
Treated On-siro
e solid
liquid
r
C. Dan On
S!L'
365
st>tmt cy.tinSG' stet£
Cody.
s SSA ..mr>L!e. s.oe &M-A 3105 a
A AboregrormdTank D Steel Drum G Cnrbcy
H Belowgrermd Tack t Phetic/NonmdaDic Dann H silo
C Turk hordeBuilding F Can I Fiber Drum
UN -0208 - 1/2
SIyys H krLYA, sign below:
J Bag M GlassBottleerrJug P Tank Wagon
H Boa N Plastic Bottle or Jug Q Rag Cer
L Cylinder O ToroBia R Odra
hap: / /www. unidonsorg Rev. 05!18/00
Hazardous Waste Inventory Statement
Date: o? 1? 12 For use by Unidocs Member Agencies or where approved by your Local Jurisdiction
Business Name:
Smoe u Faculty Nameor DBA)CVS Pharmacy # 9975 Type of Report on This Page:
NAM; Delete; Revise
Page 3 of 4
Onspetaperhaadingorw)
Chemical Location: R@C81VI11B- Mnr/StoraleArta) 9 EPCRA Confidential Location? Yes; MNo
xTradeSecretInformation? El No
Facility ID #
AS-Y u- Only) 1 5 0 2 1 1 5 5 5 3
1.
Haz
Class
2.
Map and
Grid or
Location
Code
3.
Waste Stream Name
4.
Hazardous Components
Chemical %
Name Wt EHS CAS No.
s.
Type
and
Physical
State
6.
Quantities
Max. Average Largest
Daily Daily Cont.
7.
Annual
Waste
Amount
8.
Units
9.
Storage Codes
Storage Storage
Pressure Tern .
10.
Hazard
Categories
s.00
MAP:
GRID:
G-2
Waste Corrosive
Liquids, N.O.S. (Acidic)
Mtsc. Cmoslve (Acidic) Products 100.00 Mhd,ae waste 25 12.510 100 rs
1
mfd
t-
s
o <-6'
oyogenie
x
x
IdWo
e ae6eahh
e
Hydra flodcAdd 20.00 7647 -01-0
Mane
El shipped Off -site
Q Recycled
nAuoricAdd 20.00 76643&3 solid
liquid
t3:
w--W -)
Dsn Oa
365
StR.
fil,
sulc
wade Code:
791
SulturkAdd 20.00 x 766463 -B
Acetic Add 20.00 6419 -7
8.00
MAP:
1
GRID:
G-2
s 01rOS
Liquids, N.O.S. (Basic)
Misr- C000sive (Basic) Products 100.00 Mbthua waste 25 12.510 1 00 NPF'
XIS
m ft
1°"
ambmt
ML
Q <amb,
s x
x
x
i
fin
ursiv°
Pnsswe 'et.
c)uoruehem"
Ammordum Hydrwdde 20.00 1336.21 -6
en. ameat Met
ShippedOff4ite
RecycledOn-site
11 TreatedOn-sift
Cakhun Hydroxide 20.00 130582-0 solidBliquid
PS
S:adts:
B^10' -)
p()g
sill:
365
S191i1
CAelaiag'
staf
W mCodC
122
Potasslum HydroAde 20.00 E] 1310563
El
3.00 GRID:
G -2
Waste anima a
Liquids, N.O.s
NIIsc Flerttmel>fe Liquid Pfoduds 100.00 Mtxhire waste
150 75 10 600
o
emh
eab
Ws
aarelam
akhTX=-'=C hmLh
Alcohol 59.09 MbQue
Management Method:
Shipped Off -site
I RecycledOn-site
TreatedOn-site
Acetone 50.00 67 -64-1 solid
liquid n:.dmive)
Qn
Si
365
Storm
ru:•
s
Waste Code:
214UghterFluid50.00 El mwum
Petroleum Distillates 59.00 El 8002-05-9
5.10
MAP:
1
GRID:
G -2
Waste X D9 Liquid,
N.O.S. Mist, OtddWn9 Products 100.00 Mbdure waste
25 12.510 100 mom
ms
m>bient m:e;em
yO e
X ere
x
pressureretese
x eO0f6
x clnaNh
Peroxides C] M&Wre
Management Method:
Shipped Off- ite
Recycled On-sift
Treated O"ite
solidBliquid
sas
orr.eia -i.e)
DMOn
Snc:
sJ
Vic• 5!014WasreC*4
131
MAP:
GRiD:
waste
Prnads
fret
10°5
ambimn
arob.
comb.
smbieat
curb
smh
e
e
rnerlile
wa.b -ath
en;cbulth
rye
Mame®ent Method:
Shipped O1€eito
Recycled On -sift
Treated Orraite
solidHliquid
gas
C °rice
oTr.a;am.
DMOn
sus
Sto
contai4r'
sass
Wpm C.
MAP:
GRID:
waste V5E
a
smb rnt
scrub
smbnit
curb.
fug
reactive
nre:t
a'c hmkb
rsdmeiw
Manseement Method:
Shipped Off-sift
I Recycled On-site
solidHliquid u F)
non o
5>Jf
storage
Cantaiau'
s
Wwe Ca4e
s aluxu m
A Abovegrotmd Tank
B Bebwgrouod Tsok
C Tank Inside Building
y @ ororvxe. sine ,&dm a.onee tm S.M aceraee .toe saes& Oyy.am s.vo 5--My If EPCRA, S1g0 Ow:
D Steil lhum G Cuboy J Bag M (lawBordeorJug P Tank Wagon
C Pb,6,Vo -1 isDk H S9n K Box N PlankBottle or Jug Q Reis Car
F Can 1 FiberDrum L Cylinder O ToleBin R Other
UN -020B -1/2 http:/ /www.unidoc&org Rev. 05/18/00
Date: 01 / 11 / 12
Hazardous Waste Inventory Statement
For use by Undoes MemberAgencies or where approvedby your Local Jurisdiction
Business Name: CVS Phaft118C # 9975SamemFacilityNameorDBA) Y
Type ofReport on This Page:
0 Add; El Delete; Revise
Page 4 of 4
Onenave per bwae •r o+)
ChCD1iCal Lomb°° Pharmacy and ReceivingB.W A.` ) Y 9 EPCRA Confidential Location? Yes; 0 No
Trade Secret Information? E) Yes; x No
Facility ID #
Aaorcy UmOrtHJ 1 5 D 2 1 1 5 5 5 3
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Map and
Grid or
Hazardous Components Type
and
Quantities
Annual
Storage Codes
Huz. Location Chemical % Physical Max. Average Largest Waste Storage Storage Hazard
Class Code Waste Stream Name Name Wt. EHS CAS No. State Daily Daily Coat Amount Units Pressure TemP. Categories
6.10
MAP:
GRID:
G-2, E-4
o)ac S. rganlc,
N.O.S.
FPyrethrins 30.00 Mbct" waste 25 12.510 100 Np=
m eet
r.a
p <aab md
X
pffiaerxlam
anteheaEh
rbrui.heebh
t 20.0o Mbdure
May¢emeat Method:
Shipped Off -site
Recycled On -sue
fff TreatedOo-trite
Calt)onate 20.00 Mb.ttre 8 solid
liquid
gas
CM1
tttr.a mnd
PATI.l2H
elite:
365
srm_-a.P:a.,... nom••
LWIt
wo"Code:
131Copperandlimo2o.00 Mbdure
Over tha Comfier Pharrracedicars 50.00 Mbdura
6.10
MAP:
GRID:
G-2, E-4
Waste Toxic Solids,
Organic, N.O.S. (Acxlte
McolineC-utn 100.00 MWM 25 12.5 25 100
tan,
an*,
vyagm c
p—relane
Kate hahb
chrome b-Ith
El
rJic» tine Patches 100.00 Mbdure
et>>od:
Shipped Offsite
Yekd Owe
Treed On-site
w retn tematy corakm mw raddeal p1s) 100.00 Mbdwe solid
liquid
gas
rte:
Of—) Av
365
S S=
Wawa c.de
311
MAP:
GRID:
waste gdbm
pounds
amtdmr
amh
OK
embimt
lime.
e
mclive
relearn
byte
ra6oa re
Management Method:
Shipped Off -site
Recycled Orr -sac
Ttemd Oa-site
solideliquid
gas
Caries;
u —)
Am on gip
to
tSte
warn ceae
MAP: waste gaHore mbitat mbant rte
GRID:
pamrds
aoa
f
aolr.
ay
amh
amh
orwt
native
p roremieue
antebeaeh
o chabh
K
MameementMethod,
Shipped Off -aite
Recycled On-site
Treated On-site
solid
liquid
gas
urn- -)
PQ s
00e.•
t(
wrote Cod
MAP.
GRID:
waste ga0ors
pwds
a. @er
embcnr
amh
amb.
emh cot
amh
avb.
e
e
rmctive
p+erelease
daaoi,: babe
adwrbve
Manaeemeat Method:
Shipped Off -site
Treated On -site
solid
liquid
Saa[!!a: D*n.4.
2a:
Stones
Sd•nli :•
s
waste coda
MAP:
GRID:
waste galls
pamds
a>. leer
whcot
amb,
amt'
ameiem
wb.
amll.
c
fire
sectiw
panne rde
wmbcwffi
daoosba1th
e
Ma ear M
Secyc Off-site
Retycled Oa -site
Treated On sue
solid
liquid
El gas
Caris
i_)
Dars on
Slit:
Stores
Ste"
Info
wmtecede:
1p ygQt AIM rvoe
A AbovevmundTmrk
B Bebwyoand Tara:
C Tank }aide BmMmg
IJN -020B - 1/2
Idim Drornc SADY Aroraee lym
D StedDrum G Carboy
E FbmtcMameiswi D_ a Sao
F Can 1 FiberDram
I Beg M (Hasa BattleorIng P Taak Wagon
K B_ N PlaneBottle or hrg Q RailCar
L Cylinder O Tot. Bin R other
bttp://www.unidoeLorg
IfEPCRA, sign below:
Rev. 05/1810O
CVS Pharmacy
Page 1 of 1
Attachment
Employee Training Program
Employees are trained periodically on the proper handling and storage of
currently identified hazardous materials and hazardous wastes, as applicable.
This identification process is ongoing, and training modules are developed and
implemented on an ongoing basis. The training modules currently in place,
including the Hazardous Waste Training Program and the Health, Safety &
Environment Program and associated video provided by CVS's photo processing
vendor, Kodak, are available upon request.
HAZARDOUS MATERIAL MANAGEMENT PLAN- A]Eltapi n
APPLICATION Fllitd
nc z'
SECTION DISCOVERY & NOTIFICATION ARTX r
FORMS)
INSTRUCTIONS
1. To avoid further action, return this form within 30 days of receipt.
2. Type /print answers in ENGLISH.
3. Answer the questions below for the business as a whole.
4. Be as brief and concise as possible.
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1600 Truxtun Ave., Suite 401
Bakersfield, CA 93301
Phone: 661- 326 -3979 a Fax: 661- 852 -2171
Page 1 of 2
e. trioir .(.v— +4
NrtYr'_."
St}hH_+Z:, r.- j\?LL"h!.EN+Yl /1 i '' C..
BUSINESS NAME (FACILrrY NAME or DBA)
CVS Pharmacy #9978
ADDRESS (for local ua only)
4400 Coffee Rd
FACILITY ID.l;µ I
u = -
CA -
drr. . _
Oi .M
A. LEAK DETECTION AND MONITORING PROCEDURES:
All hazardous materials are kept In their original containers and are visually Inspected by store personnel periodically.
B. EMPLOYEE AND AGENCY NOTIFICATION:
Employee notification through verbal communication. Agency notification to be advised by 3E Company.
C. ENVIRONMENTAL RESPONSE MANAGEMENT:
3E Company will be contacted for spill clean up procedures through the CVS Safety Hotline: (877) CVS -2040 or (800) 85e -1885 for the hearing Impaired. In the
event of a spill, 3E will Instruct the callerto Immediately isolate the area. 3E will evaluate the situation and provide proper spill clean up instructions K applicable. If
the situation requires Emergency assistance, 3E will notify the CVS corporate contact and dispatch an Emergency contractor upon client approval. If the spill poses
immediate risk to human life or the environment, 3E will advise the railerto call 9 -1 -1. 3E will advise on the proper storage of spilled materials according to local,
state and federal regulations. In addition, 3E will evaluate If State or Federal reporting Is necessary.
D. EMERGENCY MEDICAL PLAN:
In the event of an emergency, the manager on duty will contact 911.
ELf?, SIS I pV k,4a YIS2 <E
A. HAZARD ASSESMENT AND PREVENTION MEASURES:
All hazardous materials are kept in their original containers and are visually inspected by store personnel periodically.
B. RELEASE CONTAINMENT AND /OR MITIGATION:
3E Company will be contacted for spill clean up procedures through the CVS Safety Hotline: (877) CVS -2040 or (800) 856 -1885 for the hearing Impaired.
In the event of a spill, 3E will instruct the caller to Immediately isolate the area. 3E will evaluate the situation and provide proper spill clean up instructions
if applicable. If the situation requires Emergency assistance, 3E will notify the CVS corporate contact and dispatch an Emergency contractor upon client
approval. Ifthe spill poses Immediate risk to human life or the environment, 3E will advise the caller to call 9-1 -1. 3E will advise on the proper storage of
spilled materials according to local, state and federal regulations. In addition, 3E will evaluate if State or Federal reporting is necessary.
C. CLEAN -UP AND RECOVERY PROCEDURES:
The spilled materials will be property disposed of according to local, state and federal regulations.
FD2169 (Rev 08/07)
Page 2 of 2
R31, 0011 '
UTILITY SHUT -OFFS (LOCATION OF SHUT -OFFS AT YOUR FACILITY)
Please see Map 1- Interior MapNATURALPRPAN
ELECTRICAL: Please see Map 1- Interior Map
WATER: Please see Map 1- Interior Map
SPECIAL: N/A
LOCK BOX: YES 27 NO IF YES, LOCATION:
N/A
PRIVATE FIRE PROTECTION /WATER AVAILABILITY:
A. PRIVATE FIRE PROTECTION:
N/A
B. WATER AVAILABILITY (FIRE HYDRANT):
Please see Map 2 - Exterior.
mlW—m-
NUMBER OF EMPLOYEES:
12
MATERIAL SAFETY DATA SHEETS ON FILE: F9 YES G
NOv
IF YES, LOCATION: MSDS records are maintained electronically by 3E Company and can be
accessed via fax or online.
BRIEF SUMMARY OF TRAINING PROGRAM:
Employees are trained periodically on the proper handling and storage of currently identified hazardous materials and
hazardous wastes, as applicable. This identification process is ongoing, and training modules are developed and
implemented on an ongoing basis. The training modules currently in place, including the Hazardous Waste Training
Program and the Health, Safety & Environment Program and associated video provided by CVS's photo processing
vendor, Kodak, are available upon request.
d`.
Based on my Inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally
examined a m f ift r vlth the information submitted and believe the Information Is true, accurate, and complete.
SIG_ RED R/OPE OR 5 NATED REPRESENTATIVE DATE 477
01/15/2012
F SIGNS Pjl T) 47E TITLE OF SIGNER 479
Rebecca Wilbanks, Agent for Longs Drug Stores California, L.L.C. Regulatory Compliance Specialist, 3E Company
F02169 (Rev 08107)
ANNOTATED SITE MAP BUSINESS NAME: SITE ADDRESS: 4400 COFFEE ROAD MAP #1 OF 2CVSPHARMACY #9975 BAKERSFIELD, CA 93308
0
A B C D E F G H I
SCALE: UNDEYIM
DATE: 01/11/2012
Z
i
2
3
4
5
6 `
7
i _ ! ^: I
I
I
p I
CALIFORNIA
I — FIRS SXTINGULSBSR
ANNOTATED SITE MAP BUSINESS NAME: SITE ADDRESS: 4400 COFFEE ROAD MAP #1 OF 2CVSPHARMACY #9975 BAKERSFIELD, CA 93308
0
A B C D E F G H I
SCALE: UNDEYIM
DATE: 01/11/2012
Z
i
2
3
4
5
6 `
7
i _ ! ^: I
I
I
p I
HAZARDOUS
MATERIAIS BUSUGM
PLAN
I — FIRS SXTINGULSBSR
FE FIRE MT
HAZARDOUS AASn
STORAGE
HASLl i COMPRESSED GAS
CYLINDER
f>n
RE A O GAS MAIN
IEIVING
A RATER MAW
O ELECTRIC MAIN
FE
FOOD & BEVERA E
I
I
4
PREPARED BY: O
i
FE COMPANY
I I 5207 Grey Bawk Court, Suite 200
Carlsbad, CA 82010
CALIFORNIA ANNOTATED SITE MAP BUSINESS NAME: SITE ADDRESS: 4400 COFFEE ROAD MAP #1 OF 2CVSPHARMACY #9975 BAKERSFIELD, CA 93308
2
3
4
5
7
A B C D E F G $ I
HAGEMAN RO I I
I }
Locus - RETAIL -
I
II I ( ( I I RESIDENTIAL
RETAIL OPS — —
I — F-1 —
CABLES I !
4 — — -1 -
I I I I
VONSI
MUL
SmHo
PAi TG I I I
I I I I (P:fs:m:ENTIAL
SCALE: UNDEPINID
DATE: 01/11/2012
LEGEND
SAn H WUGE ARRA
FIRE HYDRANT
SMEW DRAIN
PREPARED BY:
3E
COMPANY
3207 " Hawk Court, Sdte 200
Carlsbad. CA 92010