HomeMy WebLinkAbout2222 F STREET (9)APPLICATION
BUSINESS OWNER/OPERATOR IDENTIFICATION FORM
HAZARDOUS MATERIAL FACILIYY INFORMATION)
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661.326 -3979 • Fax: 661 - 852 -2171
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HAZARDOUS MATERIAL MANAGEMENT PLAN II I .
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AMWI-R- - NT PLAN .4.-Jp
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BUSINESS ACTIVITIES PAGE
HAZARDOUS
0 FACILITY
BUSINESS
MATERIAL FACILrN INFORMATION)
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersirleid, CA 93301
Phone: 661-326-3979 • Fax: 661-852 -2171
5
VACII-17Y 10 A (for office use EPA 10 a
o _3q 5
SUSiNeSg E (FACILITY NAME or ORA)
DOES Your Facility— If Yes, Please Complete,., 219
A. HAZARDOUS MATfiRIAL 4* 0 No CHEMICAL DESCRIPTION FO 00
Have on site (for any purpose) hazardous material HAZARDOUS MATERIAL MANAGEMENT PLAN
at or above 55 gallons for liquids, 500 pounds for MinimUm required planainci elements;
or 200 ctt. ft, for compressed gases (Include Emergency Response Plan
liquids in AST and UST)? Maps
Training
Prevention
Certification
B, REQUILATED SUBSrA IRS 0 Yes CHEMICAL DESCRIPTION FORM 131
Have on site RS at greater than the threshold fdSk MANAGEMENT PLAN (RMP Submit to USEPA)
planning quantities established by the Callforrvii. tWDATED COMPLIANCE PLAN
Accidental Release Prevention program (CaLAPP)7 I 4,CaLARP Program Elements
UJST f 1324%CtLrTy FORM
1. Own or operate Underground Storage Tanks? R: FORM (one per tank
4:+VST ILM FORK 133
2. Intend to upgrade existing or install new UST?, one er tank) "A p
UST INStXk TION FORM (one per tank)
D. TANK CL SUREIREMOVAL. ST-TANKFORM (C *sure section one per tank)
I. Need to report closing an UST that held hazardous
material or waste?
1
2, Need to report the closure /removal of a tank that 13 Y. Itr< LIST TANK CLOSURE FORM
was classified as hazardous waste and cleaned
onsite7
E. OVWftO 2 PETF40LEUM STOJkAGE TANKS o Ye-i *Iqo HAZARDOUS MATERIAL MANAGEMENT PLAN
ANTI Incorporating Federal Spill Prevention Control and Countermeasure
1. Own or operate AST above these thresholds; any SPCC) Elements pursuant to 40 CFk Part 112.
tank capacity is greater than 660 gallons or the
total capacity for the facility is greater than 1,320
gallons?
F. I EPA 10 NUMBER - provide on this p 8Yes1, Generate hazardous waste? 0 To obtain EPA ID Number, please phone 916) 324 -1781
2. Recycle more than 100 kg/mo of recyclable 0 Y- e< • RECYCLING FORM
material at the same location It was aanarated7
3, Recycle more than 100 k9/mo of recyclable 0 Y- • RECYCLING FORM
material at an ofFsite location different from the
point of generation?
4. Treat Hazardous Waste on site? 0 Y-5 I*< • TP FACILITY FORM
TP UNIT FORM (one per unit)
5. Subject to Financial Assurance requirements? Dyes &1K0 + CERTIFICATION OF FINANCIAL ASSURANCE
6, Consolidate Hazardous Waste generated at a 0 Yes + REMOTE WASTE/CONSOLIDATION SITE NOTIFICATION
remote site? FORM
HOTEL If you checked YES to any part of Sections TIA - IIF above, then in addition to the forms requested above, please submit
BUSINESS OWNER/OPERATOR IDENTIFICATION PORM,
FD2143 (P.&V 01J06)
BA"RSFIELD FIRE DEPARTMENTN,4ZARDUus MATERIAL MANAGEMENT PLAN Prevention Services
p ' a 2101 H Street
CHEMICAL DESCRIPTION FORM jgxjr ` Bakersfield; CA 93301
MARi.. Phone: 661 -326 -3979 Fax-. 661-852-2171HAZARDOUSMATERIALINVENTORY
0 NEW ADD 0 DELETE REVISE 200
BUSINESS NAME (FACILITY NAM6 or DEAA)) ^ 3
CHEMICAL L TION
w +
201 CHEMICAL IACATION 202
C / "- d
CONFIDENTIAL (EPCRA) 0 Yes No
FACILITY ID 1. ?'' ;': 1 MAP ? (ovuanal) 203 GRAD # (optional) 204
CHEMICAL NAME
0 AMBIENT C ABOVE AMBIENT 0 BELOW AMBIENT
20S 206
AMBIENT
d-'11WTS' Q -GAL
11 EMS, amount must be In lbe.
0 CU FT LB,S
TRADE SECR6T Yea No
0 CRYOGENIC
li IV1 ,y
DAYSONS17E 222
STORAGE CONTAINER:
If N to EPCRA, 1.1or to InAwedons
COMMON NAME
1 226
207
227
222
229
0 TANK 0 CAN
EHS• Yes No
TANK WAGON
255
A B!OVEGROUND
9- - tKQERGROUIVD TANK
208
CAS #I
CYLINDER 0
209 If EMS Is Yee, all amounts below must be in
0 SILO 0 GLASS BOTTLE
Pauotb.
OTHER
FIRE CODE HAZARD CLASSES (complete if mquested by local fire chief)
D STEEL DRUM D FIBER DRUM
210
TYPE c.,, RADIpAGTIVE: 0 Yes p No
212 CURIES 213
0 PURE MIXTURE 03,1; . A5TL.
PHYSICAL STATE 0 SOLID 6- QUID 4.1 . ,s ;;
L 1
ESL CONTAINER 115
nf70 1'1
SURE
JC7
FED HAZARD CATEGORIES FIRE 0 REA TM ' "T7 1. E5 A CEASE' ACUTE HEALTH 0 CHRONIC HEALTH
2
heck a0 that apply)
ANNUM WASTE 217 MAXIMUM '.' c,. 213:,' e ' 229 STATE WASTE 220
DtJLYAMOFj f't „tii!.,:- n"t'r+ DAICY'AMOUNT CODE
STORAGE PRESSURE: 0 AMBIENT C ABOVE AMBIENT 0 BELOW AMBIENT
AMBIENT
d-'11WTS' Q -GAL
11 EMS, amount must be In lbe.
0 CU FT LB,S T{}N ?-:'•' :':' i': <.:' ;;
BELOW AMBIENT 0 CRYOGENIC
221 DAYSONS17E 222
STORAGE CONTAINER:
EHS CAS #
1 226 227
222
229
0 TANK 0 CAN BOX TANK WAGON
255
A B!OVEGROUND
9- - tKQERGROUIVD TANK CARBOY CYLINDER 0 RAIL CAR
5
TANK INSIDE BUILDINGy 0 SILO 0 GLASS BOTTLE 0 OTHER
D STEEL DRUM D FIBER DRUM D PLASTIC BOTTLE TOTE BIN
0 PLASTIC/NONMETALLIG DRUM 0 BAG -
STORAGE PRESSURE: 0 AMBIENT C ABOVE AMBIENT 0 BELOW AMBIENT
AMBIENT
22s
STORAGE TEMPERATURE: I4, ABOVE AMBIENT 0 BELOW AMBIENT 0 CRYOGENIC
WT HAZARDOUS COMPONENT EHS CAS #
1 226 227 Yes 0 No 228 229
2 230 131 Yes 0 No 232 233
3 234 255 Yes 0 No 'La6 237
4 238 239 f1 Yas 0 No 240 241
5 2.2 243 0 Yes No 244 245
PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNAUIBE DATE 246
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TU2144 rRov 11/08)