HomeMy WebLinkAboutBUSINESS PLAN 9/18/2002 (COPY)Hazardous Materials/Hazardous Waste Unified Permit
CONDITIONS OF .PERMIT ON REVERSE SIDE
This oermit is Issued for the following:
OFFICE OF ENWR ONMENTAL SER WCES '
1715 Chester Ave., 3rd Floor Approved by: ,
Bakersfield, CA 93301 Omc~rEv~S~ic= -
Voice (661) 326-3979
Hazardous Materials/Hazardous Waste Unified Permit
CONDITIONS OF PERMIT ON REVERSE SIDE
................... ~.,~,:~:,~,~:~,,~, ................... This permit is issued for the following:
..... ,~:.~?:'i~'' i'., ?~:,?i'?'~'::::i }i ii:~ii;~:. ::~iii?iii!~. iii:~:~iiiiiiii::::'~::i il;}ii:~D:-:i~derground Storage of Hazardous Materials
LOCATION ' 1205 8TH ~"::,,',..~r~%~ .......... :.:~,' BAK~RS~!~LD CA '? ~" ,:~:~,'i~....'".,,~
::J:.':.. ' ..::F.:.. -":~'~::~ ~'2 '~::~'~ .... ~ i~L '~ ", '~ '.~!~ ~'~i'~?,~?" "~i' .. '"'.:~.
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:~,.'~-" -.~, 'Y'", .?~ ~:~[~ ~':~:~[~[~;~'::~:.[:~:....?. ........ ~LY ~' :.. "... '~;~:.'
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~-: ........... ~ : ~;~":~ ,::, ,:::, Z....:: -~..; -~ _ "', .~.'? .~ '~ ,,,
...... ' ..... ~ ............ ' .,,.. · -' · .., ,,- ~,.~ .:. I:~, I ~, .. ~
.................. ~ :, ~, ....................... ~H.'~"'~. ~..l~I' ',,~'~i~. .~ .:~.~i: ...... a ' ~ .l:~l
'?.~......'" .." ';:'~U;.,.. ::::::~ ':~::~......~{~:"~ i~ '~:.[~i' E~' ...::,~:~:,~'? ~ [ ~ ~--~:~''
[ssu~ by:
Bakersfield Fke Depa~ment Approved by:
OFFICE OF EN~R O~E~AL S~ ~CES
1715 Chewer Ave., ~rd Floor ~ ~ffice of ~en~l S~
B~e~fiel~ CA 9~01
Voice (805) ~26-3979
F~ (805)~6-0S76 Expiration Date: ~n~ ~0~ ~O00
.4? 1205 8th Street
Bakersfield, California 93304
Phone (661) 334-2200
"Our Business is People" ~ . th .~-
MAY ~ 1001
Ralph E. Huey, Director
Office of Environmental Services
1715 Chester Avenue
Bakersfield, CA 93301
Dear Mr. Huey:
Enclosed please find a revised site diagram of our facility
indicating the locations of the items requested.
Our oxygen is stored and chained directly next to the main
electrical panel. Our facility is equipped throughout with
automatic sprinklers with the main shut-off as indicated on
the site diagram.
Please note also that there are fire hose connectors located
at the main sprinkler valve.
If you have any questions or I can be of any assistance, please
contact me at (661) 334-2200.
Thank you,
Tom Harrison
Director of Maintenance
. . '.. ~.. .
· . ~ · . ..
~ .. . .
'
E
HOUSE ~ooSE
" SXTE/FACI LI TY DX A~R~
NORTH SCALE: BUS INESS N~g: FLOOR: 0F
~ DATE: / / FACILITY N~E: : UNIT ~: OF
;, (CHECK ONE) SITE DIAO~ FACILITY DKAG~
: 'l.nspec~or'8 Comments): -OFFICIAL USE ORLY2
{.
HMCU- 13
I,;, SITE/FACILITY D I A~ R~IVl
NORTH SCALE: BUS INESS N~g: FLOOR: OF
DATE: / / FACILITY N~E: UNIT
[CHECK ONE) SITE DIAG~ FACILITY DIAG~
peCtor's Comments}: -OFFICIAL USg ORL¥-
HMCU-13
CITY OF BAKERSFIELD FIRE DEPARTMENT
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave., 3r" Floor, Bakersfield, CA 93301
ADDRESS I~L.O~ ~71,~.-~'- PHONE NO.
FA'CILITY CONTACT'~l,~ ~ ' 05'L. BUSINESS ID NO. 15-210- O~O~'_
INSPECTION TIME ~0 IIA.I~ NUMBER OF EMPLOYEES
SeCtion 1: Business Plan and Inventory Program
ne [21 Combined ~ Joint Agency I~ Multi-Agency 1~ Complaint I~ Re-inspection
OPERATION C V COMMENIS
Appropriate permit on hand
Business plan contact information accurate n,,/, ~c~vo ~t~,t~-"la'~ .c,r.rr~ .
Visible address
Correct occupancy
Verification of inventory materials !,//
Verification of quantities
Verification of location v/
ProPer segregation of material k/
Verification of MSDS availability
Verification of Haz Mat training ~'/
V~rification of abatement supplies and procedures ~/. ~irItk/6gl~ '~
Emergency proc'edures adequate t/r
Containers properly labeled ~"
Housekeeping
Fire Protection
Siie Diagram Adequate & On Hand
C=Compliance V=Violation
,I
on
AnY haz~rdo.qs~ waste site?: [~ Yes [21 No
Questions regarding this inspection? Please call us at (661) 326-3979 Business Site Responsible Party
:-VALLEY CONVALESCENT HOSPITAL SiteID: 015-021-000899
Manager : ~£0~,~ ~./~h/od< BusPhone: (805) 334-2200
Location 12058TH ST Map : 103 CommHaz : Low
City : BAKERSFIELD Grid: 3lA FacUnits: . 1 AOV:
CommCode: BAKERSFIELD STATION 06 SIC Code:8051
EPA Numb: DunnBrad:77-011-9162
Y~aro/v~ ~6n~c~Oc/~/ Title~4m,~/~rEmergency Contact / Title
Em~_~rger~cy
RQNALD OI~VER ~ ~W*~E*~ 3 3 ~ ~ gtco JIM DONOV~~ ~'~'~ ~ ~INTEN~CE SUP
Business Phone: (~) 334-2200x Business Phone: (~) 334-2200x
24-Hour Phone : (~) 5~-8443x 24-Hour. Phone : (~/ 83~ 4854xTX~-oFFo
~ Phone : (~/) ~/- 3~
~7/~P~o~g FO~-~ x Pa~er Phonc : (805) 335-421~x
Hazmat Hazards: Fire Press Im~lth
Contact : ~fw/y~ ~. ~5~/o~/~/ ~~ Phone: (~/)~g -~Oox
MailAddr: 1205 8TH ST State: CA
City : BAKERSFIELD Zip : 9330%
Address : /~5 F*'~+.-~..- · '- State: CAo
City .~ ~.~ ~ Zip :
Period : to TotalASTs: = Gal
Preparer: TotalUSTs: = Gal
Certif ' d: RSs: No
Emergency Directives:
~ Hazmat Inventory One Unified List
r---Alphabetical Order Ail Materials at Site
Hazmat Common Name... ISpooHazlEPA HazardsI Frm I DailyMax IUnitlMcP
OXYGEN F P IH G 1685.00 FT3 Low
~, (~r~/~ ~ ,,~,s,~/o~ Do hereby certify ~hm ~ have
~rype or print name)
~'eviewed the attached hazardous rnmer~als manage-
~ .
ment plan fo~/~/(~-~/,~/,~/'/-~/~/~nd ~ha~ it along wi~h
-- /(Name
any corrections constitute a complete and correc~ man-
agernem plan for my facility. .
' ~.. '.i,.~ '" ,,.- "~'-,
~,'~gnature
-1- 09/06/2001
VALLEy CONVALESCENT HOSPITAL ~/~~/~/~ SitelD: 015-021-000899 i
i~ Notif:/Evacuation/Medical ~~/~/~/~/~~/~~/~/~ Overall Site i
~/~ Agency Notification ~/~/~~~/~/~~~ 12/19/1990 i
o
911 o
OFFICE OF EMERGENCY SERVICES 1/800/852-7550 o
o
i~ Employee Notif./Evacuation/~/~~/~6~6~/~/~/~6~6/~ 12/19/1990 i
o
CALL 911, REPORT SPILL, AND DETERMINE MATERIALS. LOCATE SPILL, DETERMINE o
CONTENTS AND AMOUNT THEN FOLLOW EVACUATION PROCEDURE. DETERMINE IF o
NEIGHBORHOOD IS IN DANGER. °
i~6~ Public Notif./Evacuation ~~~6~~~6~6 12/19/1990 i
INTERCOM °
ACTIVATE FIRE ALARM SYSTEM AND NOTIFY PLAN AND PROCEDURE o
o
i~¢~ Emergency Medical Plan ~~~~~~ 12/19/1990 i
SAN JOAQUIN COMMUNITY - 2615 EYE ST - 327-1711 °
TRANSFER AGREEMENT 8-1-86. o
o
-2- 09/06/2001
i VALLEY CONVALESCENT HOSPITAL eeeeeeeeeeeeeeeeeeeeeeee SitelD: 015-021-000899
~eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee Fast Format i
ie Mitigation/Prevent/Abatemt eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee Overall Site i
iee Release Prevention eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee 12/20/1990 i
o PRESSURIZED BYLINDERS PROPERLY CHAINED. ALL SUPPLY DOORS LOCKED AND
o SECURED. OXYGEN TANKS HAVE CAPS AND PROPER REGULATORS.
ieee Release Containment eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee 12/20/1990 i
o SHUT OFF VALVE, REMOVE LEAKING OXYGEN TANK, REPLACE TANK
ieeee Clean Up eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee 12/20/1990 i
O O
o EVACUATE PREMISES o
ieeeee Other Resource Activation eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeei
-3- 09/06/2001
VALLEY CONVALESCENT HOSPITAL/~/~/~/~/~ SiteID: 015-021-000899
i~ Site .Emergency Factors ~~~~~~ Overall Site i
i~ Spec'iai Hazards
o
o
i~ Utility Shut-Offs fi~~fifi~~~~6~fifi~ 10/08/1997
o
A) GAS - OUTSIDE SE SIDE OF BLDG & OUTSIDE RM 3 NW SIDE OF BLDG
B) ELECTRICAL - OUTSIDE DOOR TO LAUNDRY TO THE LEFT
C) WATER- SE SIDE NEAR M ST o
D) SPECIAL- SITE AND FACILITY MAPS ON INSIDE OF ELECT~CAL BOX
E) LOCK BOX -~~/~~'~ O~ ~O~ O~ ~1~ ~
i~ Fire Protec./Avail. Water ~~~~~ 10/08/1997
o
P~VATE FIRE PROTECTION - SP~N~ER SYSTEM THROUGHOUT FACILITY, SMO~
DETECTORS, PULL ALARM MINISCAN 424 ALARM SYSTEM. k~ ~[
o
FIRE HYD~NT - NE SECTION OF BLDG NEXT TO 8TH ST ENT~NCE GATE.
i~ Building Occupancy Level ~~~6~fi~6~~ 10/08/1997
87 RESIDENTS AND ~EMPLOYEES. o
MAXIMUM OCCUPANCY 250.
-4- 09/06/2001
VALLEY CONVALESCENT HOSPITAL e~e~~e~eeeeeee SitelD: 015-021-000899
ii5~i~i~i5i~i~i~i~i5i5i~i5i5i5i5i~i5i~~i5~e~e~e~e~~ Fast Format
o
WE HAVE 80 EMPLOYEES AT THIS FACILITY.
o
WE HAVE MATE~AL SAFETY DATA SHEETS ON FILE. o
o
BREIF SUMMARY OF T~INING: MONTHLY WITH FIRE D~LLS AND DU~NG O~ENTATION
OF ALL NEW EMPLOYEES (~OUTULy ~RI~
~ re c~o ~ o
o
O
i~ Held for Fumre Use
o
o
i~6 Held for Fu~re Use
o
o
1205 8th Street
Bakersfield, California 93304
Phone (661) 334-2200
"Our Business is People"
October 04, 2001
ESTER DURAN
OFFICE OF ENVIRONMENTAL SERVICES
1715 CHESTER AVENUE
BAKERSFIELD, CA 93301
Dear Ms. Duran:
Enclosed please find the revised business plan you requested.
If there are any questions or if I may be of any assistance,
please feel free to contact me at 661-334-2200.
Thank you,
Tom Harrison
Director of Maintenance
B D
IMPORTANT
DO NOT DISCARD
FIRE CHIEF Dear Business Owner:
RON FRAZE
ADMINISTRATIVE SERVICES California Law requires that all Businesses, which at any time during the
2101 'H" Street year handle reportable quantities of hazardous materials, file a Hazardous
Bakersfield, CA 93301
VOICE (661)326-3941 Materials Business Plan, including inventory of hazardous materials with
FAX (661) 395-1349
the local administering agency. Your business has filed such a plan.
SUPPRESSION SERVICES
2101 "H" Street This same regulation requires businesses to review the business plan
Bakersfield, CA 93301
-VOICE (661)326-3941 submitted to determine if revisions are needed, and to certify to the
FAX (661) 395-1349
administering agencies that the review was made and that any necessary
PREVENTION SERVICES changes were made to the plan. As a reminder you are required to notify
1715 ChesterAve. your administering agency within 30 days of any changes including:
Bakersfield, CA 93301
VOICE (661) 326-3951 increase of a hazardous material, handling of a new hazardous material,
FAX (661)326-0576
',i change in business ownership, business address or business name.
ENVIRONMENTAL SERVICES
1715 Chesler Ave.
Bakersfield, CA 93301 Your business hasn't revised their plan since 199 7 To facilitate this
VOICE (661) 326-3979 review we have enclosed a computer print-out of the' plan you last
FAX (661) 326-0576
submitted. Please review this plan in its entirety and make any necessary
TRAINING DIVISION revisions on the print-out. When the review and revisions are completed
5642 Victor Ave.
Bakersfield, CA 93308 sign the first page of the plan in the appropriate space certifying that the
VOICE (661) 399-4697 plan is complete and correct. Return the business plan alorig with any
FAX (661) 399-5763
revisions to this office within 30 days of receiving these forms.
Please note that one of the conditibns of your Permit to Operate is that
you review your business plan annually. If you have any questions or if
we can be of any assistance please do not hesitate to call 326-3979.
Sincerely,
Esther Duran
Office of Environmental Services
L D
Dear Business Owner:
FIRE CHIEF
RON FRAZE
This notice is meant to act as a reminder that the California Health
ADMINIS?RATIVE SERVICES and Safety Code, Chapter 6.95, requires any handler of hazardous materials
2101 'H" Street
Bakersfield, CA 93301 to revise their hazardous materials business plan within 30 days of any one
VOICE (805) 326-3941
FAX (805) 395-1349 of the following events: '% (~3o--~-- iqt T'oCD \
SUPPRESSION SERVICES
2101 'H'Street (1) A 100 per cent or more increase in the quantity of a
Bakersfield, CA 93301 previously-disclosed material.
VOICE (805) 326-3941
FAX (805) 395-1349
(2) Any handling of a previously-undisclosed hazardous
PREVENTION SERVICES
1715 Chester Ave. material, subject to the inventory requirements of Chapter
Bakersfield, CA 93301
VOICE (805) 326-3951 6.95.
FAX (805) 326-0576
ENVIRONMENTAL SERVICES (3) Change in business ownership.
1715 Chester Ave.
Bakersfield, CA 93301
VOICE (805) 326-3979 (4) Change in business address.
FAX (805) 326-0576
T~N~NO OIVISION (5) Change of business name.
5642 Victor Ave.
Bakersfield, CA 93308
VOICE (805)399-4697 Any questions regarding these required revisions, please call the
FAX (805) 399-5763
Hazardous Materials Division at (805) 326-3979.
Sincerely yours,
Director, Office ofEnvironmentalSe ices
CITY OF BAKERSFIELD FIRE DEPARTMENT
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301
FACILITY NA.ME Xl lle, INSPECTION DATE ~ O -~ dt
ADDRESS i~05'<g~- ~ PHONE NO. ,'~c- Z ZOO
FACILITY CONTACT "~_0~ }~t.~'p/t BUSINESS ID NO. 15-210-
INSPECTION TIME /~Jt~ ~'g:?/gl,% NUMBER OF EMPLOYEES
Section 1: Business Plan and Inventory Program
i Routiqe _[21 Combined I~ Joint Agency ~ Multi-Agency [_~ Complaint [~ Re-inspection
OPERATION C V COMMENTS
APpropriate permit on hand
Business plan contact information accurate
Correct occupancy ~~--"~---~
Verification of inventory materials
Verification of quantities
Verification of location
Prpper segregation of material
Verification of MSDS availability
Verification of Haz Mat training
Verification of abatement supplies and procedures
h
Emergency procedures adequate
Containers properly labeled
HQusekeeping
Fire Protection
Site Diagram Adequate & On Hand
C=Compliance V=Violation
Any hazardous waste on site?: [~ Yes [~.No
Questions regarding this inspection? Please call us at (661) 326-39'/9 Business Site Responsible Party
White- Env. Svcs. Yellow - Station Copy Pink- Business Copy Inspector: '~/~
Overall Site with 1 Fac. Unit
General Information
Location: 1205 8TH ST Map:103~~~~:J 3
City : BAKERSFIELD Grid: 3lA F/U: 1 AOV: 0.0
Contact Name Title Contact Name Title
RONALD OHAVER / OWNER JIM DONOVAN / MAINTENANCE SUP
Business Phone: (805) 334-2200x Business Phone: (805) 334-2200x
24-Hour Phone : (805) 589-8443x 24-Hour Phone : (805) 834a4854
Pager Phone : ( ) - x Pager Phone : (805) 335-4215 x
Administrative Data
Mail Addrs: 1205 8TH ST D&B Number: 77-011-9162
City: BAKERSFIELD State: CA Zip: 93301-
Comm Code: 215-006 BAKERSFIELD STATION 06 SIC Code: 8051
Owner: RONALD D. O'HAVER Phone: (805) 589-8443
Address: 17052 ROSEDALE HWY State: CA
City: BAKERSFIELD Zip: 93312-
- Summary
HOSPITAL HAS 87 PATIENTS.
i, Ronald D. O'Have_r._ DO hereby cert,[~J th3~ '
~',/pe orp~m r~ame~. ...
reviewed the a~hed h~a~ous match,is n'~
ment plan for Valley Convalesc~ tha~ it atcr. · '
any corr~iOns constitute a complete and ~rrem
agement plan for my facili~.
08/08/9'6 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 2
Hazmat Inventory List in MCP Order
02 - Fixed Containers on Site
Pln-Ref Name/Hazards Form Max Qty MCP
02-001 OXYGEN Gas 1685 Low
~ Fire, Pressure, Immed Hlth FT3
08/08/96 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 3
02 - Fixed Containers on Site
Hazmat Inventory Detail in MCP Order
02-001 OXYGEN Gas 1685 Low
· Fire, Pressure, Immed Hlth FT3
CAS #: 7782-44-7 Trade Secret: No
Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS
Daily Max FT3 Daily Average FT3 Annual Amount FT3
1,685 I 1,348.00 I 6,024.00
Storage I Press T Temp I Location
PORT. PRESS. CYLINDER Above I Ambient 02 STORAGE ROOM
- Conc Components~ MCP ---~uide
100.0% Oxygen, Compressed ILow ! 14
08/08/96 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 4
00 - Overall Site
<D> Notif./Evacuation/Medical
<1> Agency Notification
911
OFFICE OF EMERGENCY SERVICES 1/800/852-7550
<2> Employee Notif./Evacuation
CALL 911, REPORT SPILL, AND DETERMINE MATERIALS. LOCATE SPILL, DETERMINE
CONTENTS AND AMOUNT THEN FOLLOW EVACUATION PROCEDURE. DETERMINE IF
NEIGHBORHOOD IS IN DANGER.
<3> Public Notif./Evacuation
INTERCOM
ACTIVATE FIRE ALARM SYSTEM AND NOTIFY PLAN AND PROCEDURE
<4> Emergency Medical Plan
SAN JOAQUIN COMMUNITY - 2615 EYE ST - 327-1711
TRANSFER AGREEMENT 8-1-86.
08/08/96 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 5
00 - Overall Site
<E> Mitigation/Prevent/Abatemt
<1> Release Prevention
PRESSURIZED BYLINDERS PROPERLY CHAINED. ALL SUPPLY DOORS LOCKED AND
SECURED. OXYGEN TANKS HAVE CAPS AND PROPER REGULATORS.
<2> Release Containment
SHUT OFF VALVE, REMOVE LEAKING OXYGEN TANK, REPLACE TANK
<3> Clean Up
EVACUATE PREMISES
<4> Other Resource Activation
08/08/96 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 6
00 - Overall Site
<F> Site Emergency Factors
<1> Special Hazards
<2> Utility Shut-Offs
A) GAS - OUTSIDE SOUTHEAST SIDE OF BUILDING & OUTSIDE ROOM 3 NORTHWEST SIDE
OF BUILDING
B) ELECTRICAL - OUTSIDE DOOR TO LAUNDRY TO THE LEFT
C) WATER - SOUTHEAST SIDE NEAR M ST
D) SPECIAL - SITE AND FACILITY MAPS ON INSIDE OF'ELECTRICAL BOX
E) LOCK BOX - NO
<3> Fire Protec./Avail. Water
PRIVATE FIRE PROTECTION - SPRINKLER SYSTEM THROUGHOUT FACILITY, SMOKE
DETECTORS, PULL ALARM MINISCAN 424 ALARM SYSTEM
FIRE HYDRANT - NORTHEAST SECTION OF BUILDING NEXT TO 8TH ST ENTRANCE GATE.
<4> Building Occupancy Level
250 OCCUPANCY MAXIMUM
08/08/96 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 7
O0 - Overall Site
<G> Training
<1> Employee Training
WE HAVE 86 EMPLOYEES AT THIS FACILITY
WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE
BREIF SUMMARY OF TRAINING: MONTHLY WITH FIRE DRILLS AND DURING ORIENTATION
OF ALL NEW EMPLOYEES
<2> Page 2
<3> Held for Future Use
<4> Held for Future Use
VALLEY.> CONVALESCENT HOSPITAL-~. ~'/~ ~ I~'! =~j SiteID: 215-000-000899
Manager : , B:sPhone: (805) 334-2200
Location: 1205 8TH ST By' M~p : 103 CommHaz : Low
City : BAKERSFIELD ........... ~id: 3lA FacUnits: 1AOV:
CommCode: BAKERSFIELD STATION 06 SIC Code:8051
EPA Numb: DunnBrad:77-011-9162
Emergency Contact / Title Emergency Contact / Title
RONALD OHAVER / OWNER JIM DONOVAN / MAINTENANCE SUP
Business Phone: (805) 334-2200x Business Phone: (805) 334-2200x
24-Hour Phone : (805) 589-8443x 24-Hour Phone : (805) 831-9606x
Pager Phone : ( ) - x Pager Phone : ( ) - x
Hazmat Hazards: Fire Press ImmHlth
Agency-Defined Topic Title
~ Hazmat Inventory One Unified List
~--- MCP+DailyMax Order Ail Materials at Site
Hazmat Common Name... ISpooHazlEPA HazardsI Frm DailyMax lunitlMCP
OXYGEN F P IH G 1685 FT3 Low
~y~ ~ p~nt ~)
rsvisw~d ~h~ a~ached h~erdous ma~i~ ~~-
men~ plan for ~/I~v ~o~u~z~d ~h~ ~ ~long ~h
(Na~ of Bus~e~) c,~
any corrosions
-1-
VALLEY CONVALESCENT HOSPITAL SiteID: 215-000-000899
~Inventory Item 0001 Facility Unit: Fixed Containers on Site
COMMON NAME / CHEMICAL NAME
OXYGEN Days On Site
365
Location within this Facility Unit
02 STORAGE ROOM CAS#
7782-44-7
F STATE TYPE PRESSURE ~ TEMPERATURE CONTAINER TYPE
Pure I Above Ambient I Ambient I PORT. PRESS CYLINDER
lGas .
AMOUNTS STORED AND IN USE
Lrgst Cent.this Loc FT3 DailyMax this Loc FT3 DailyAvg this Loc FT3
1685.00 1348.00
DailyMax Stored FT3 DailyMax Open Use FT3 DailyMax Closed Use FT3
HAZARDOUS COMPONENTS
%Wt. EHS CAS#
100.00 Oxygen, Compressed No 7782447
-2-
VALLEY CONVALESCENT HOSPITAL SiteID: 215-000-000899
. Fast Format
F Notif./Evacuation/Medical Overall Site
Agency Notification 12/19/1990
911
OFFICE OF EMERGENCY SERVICES 1/800/852-7550
Employee Notif./Evacuation 12/19/1990
CALL 911, REPORT SPILL, AND DETERMINE MATERIALS. LOCATE SPILL, DETERMINE
CONTENTS AND AMOUNT THEN FOLLOW EVACUATION PROCEDURE. DETERMINE IF
NEIGHBORHOOD IS IN DANGER.
Public Notif./Evacuation 12/19/1990
INTERCOM
ACTIVATE FIRE ALARM SYSTEM AND NOTIFY PLAN AND PROCEDURE
Emergency Medical Plan 12/19/1990
SAN JOAQUIN COMMUNITY - 2615 EYE ST - 327-1711
TRANSFER AGREEMENT 8-1-86.
-3-
VALLEY CONVALESCENT HOSPITAL SiteID: 215-000-000899
Fast Format
~Mitigation/Prevent/Abatemt Overall Site
Release Prevention 12/20/1990
PRESSURIZED'~YLINDERS PROPERLY CHAINED. ALL SUPPLY DOORS LOCKED AND
SECURED. OXYGEN TANKS HAVE CAPS AND PROPER REGULATORS.
Release Containment 12/20/1990
SHUT OFF VALVE, REMOVE LEAKING OXYGEN TANK, REPLACE TANK
Clean Up 12/20/1990
EVACUATE PREMISES
Other Resource Activation
-4-
VALLEY CONVALESCENT HOSPITAL SiteID: 215-000-000899
Fast Format
~ Site Emergency Factors Overall Site
Special Hazards
Utility Shut-Offs 12/20/1990
A) GAS - OUTSIDE SOUTHEAST SIDE OF BUILDING & OUTSIDE ROOM 3 NORTHWEST SIDE
OF BUILDING
B) ELECTRICAL - OUTSIDE DOOR TO LAUNDRY TO THE LEFT
C) WATER - SOUTHEAST SIDE NEAR M ST
D) SPECIAL - SITE AND FACILITY MAPS ON INSIDE OF ELECTRICAL BOX
E) LOCK BOX - NO
Fire Protec./Avail. Water 12/20/1990
PRIVATE FIRE PROTECTION - SPRINKLER SYSTEM THROUGHOUT FACILITY, SMOKE
DETECTORS, PULL ALARM MINISCAN 424 ALARM SYSTEM
FIRE HYDRANT - NORTHEAST SECTION OF BUILDING NEXT TO 8TH ST ENTRANCE GATE.
Building Occupancy Level
-5-
VALLEY CONVALESCENT HOSPITAL SiteID: 215-000-000899
Fast Format
~ Training Overall Site
Employee Training 12/20/1990
WE HAVE 30 EMPLOYEES AT THIS FACILITY
WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE
BREIF SUMMARY OF TRAINING: MONTHLY WITH FIRE DRILLS AND DURING ORIENTATION
OF ALL NEW EMPLOYEES
Page 2
Held for Future Use
Held for Future Use
-6-
03/17/92 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 1
Overall Site with 1 Fac. Unit
General Information
Location: 1205 8TH ST Map: 103 Hazard: Low
CommUnity: BAKERSFIELD STATION 06 Grid: 3lA F/U: 1AOV: 0.0
Contact Name Title Business Phone 24-Hour Phone-
RONALD OHAVER OWNER (805) 334-2200 x (805) 589-8443
JIM DONOVAN MAINTENANCE SUPER (805) 334-2200 x (805) 831-9606
I Administrative Data
Mail Addrs: 1205 8TH ST D&B Number: 77-011-9162
City: BAKERSFIELD State: CA Zip: 93301-
C~mm Code: 215-006 BAKERSFIELD STATION 06 SIC Code: 8051
Owner: RONALD D.' O'HAVER Phone: (805) 589-8443
Address: 17052 ROSEDALE HWY State: CA
City: BAKERSFIELD Zip: 93312-
Summary
RECEIVED
APR 2 9 1992
HAZ. MAT. DIV.
Jim Donovan [~ h®r®b¥ c~ify t~ ~ h~
ms~ p~an ?o~ley con~t and ~ha~ ~ a~on~ ~iih
- ~te
03/17/92 VA'LLEY CONVALESCENT HOSPITAL 215-000-000899 Page 2
02 - Fixed Containers on Site
Hazmat Inventory Detail in Reference Number Order
02-001 OXYGEN .Gas 1685 Low
· Fire, Pressure, Immed Hlth FT3
CAS #: 7782-44-7 Trade Secret: No
Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS
Daily Max FT3 Daily Average FT3 Annual Amount FT3
1,685 I 1,348.00 I 6,024.00
Storage Press ! Temp Location
PORT. PRESS.. CYLINDER IAbove /AmbientlO2 STORAGE ROOM
-- Conc Components MCP List
100.0% ]Oxygen, Compressed IL°w I
03/17/92 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 3
00 - Overall Site
<D> Notif./Evacuation/Medical
<1> Agency Notification
911
OFFICE OF EMERGENCY SERVICES 1/800/852-7550
<2> Employee Notif./Evacuation
CALL 911, REPORT SPILL, AND .DETERMINE MATERIALS. LOCATE SPILL, DETERMINE
CONTENTS AND AMOUNT THEN FOLLOW EVACUATION PROCEDURE. DETERMINE IF
NEIGHBORHOOD IS IN DANGER.
<3> Public Notif./Evacuation
INTERCOM
ACTIVATE FIRE ALARM SYSTEM AND NOTIFY PLAN AND PROCEDURE
<4> Emergency Medical Plan
SAN JOAQUIN COMMUNITY - 2615 EYE ST - 327-1711
TRANSFER AGREEMENT 8-1-86..
03/17/92 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page. 4
00 - Overall Site
<E> Mitigation/Prevent/Abatemt
<1> Release Prevention j
PRESSURIZED BYLINDERS PROPERLY CHAINED. ALL SUPPLY DOORS LOCKED AND
SECURED. OXYGEN TANKS HAVE CAPS AND PROPER REGULATORS.
<2> Release Containment
SHUT OFF VALVE, REMOVE LEAKING OXYGEN TANK, REPLACE TANK
<3> Clean Up
EVACUATE PREMISES
<4> Other Resource Activation
03/17/92 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 5
00 - Overall Site
<F> Site Emergency Factors
<1> Special Hazards
<2> Utility Shut-Offs
A) GAS - OUTSIDE SOUTHEAST SIDE OF BUILDING & OUTSIDE ROOM 3 NORTHWEST SIDE
OF BUILDING
B) ELECTRICAL - OUTSIDE DOOR TO LAUNDRY TO THE LEFT
C) WATER - SOUTHEAST SIDE NEAR M ST
D) SPECIAL - SITE AND FACILITY MAPS ON INSIDE OF ELECTRICAL BOX
E) LOCK BOX - NO
<3> Fire Protec./Avail. Water
PRIVATE FIRE PROTECTION - SPRINKLER SYSTEM THROUGHOUT FACILITY, SMOKE
DETECTORS, PULL ALARM MINISCAN 424 ALARM SYSTEM
FIREHYDRANT - NORTHEAST SECTION OF BUILDING NEXT TO 8TH ST ENTRANCE GATE.
<4> Building Occupancy Level
03/17/92 VALLEY CONVALESCENT HOSPITAL 215-000-000899. Page 6
00 - Overall Site
<G> Training
<1> Page 1
WE HAvE 30 EMPLOYEES AT THIS FACILITY
WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE
BREIF SUMMARY OF TRAINING: MONTHLY WITH FIRE DRILLS AND DURING ORIENTATION
OF ALL.NEW EMPLOYEES
<2> Page 2 as needed
<3> Held for. Future Use
<4> Held for Future Use
10/24/90 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 1
~ Overall Site with 1 Fac. Ur, it
REGEIVED
Ger, eral Ir, format i
9
Locatic, r,: 1205 8TH ST Map: ~03 H~i~'~*~V'
Ident Number: 215-000-000899 Grid: 3lA A~'~-'~~'"~TI';:;~ V.{1: O. 0
Contact Name 'Title Business Phc, ne ~ 24 Hc, ur Phc, ne]
RONALD OHAVER OWNER ~5) )334-2200 (~O5-) 589-8-443
· ~IH D~NOV~N MAINTENCE SUPERVISIOR (805)334-2200 (805) 831-9606
II I I I I
' Administrative Data
Mail: Addrs: 1205 8TH ST D&~ Number: 77-0119162
City: BAKERSFIELD State: CA Zip: 93301-
Coma Cc, de: 215-OO6 ~AKERSFIELD STATION 06 SIC Cc, de:
' Owner: RONALD D. O~ HAVER Phc, ne: 805 ) 589 - 8443
Address: 17054"ROSEDALE HIG~AY State: CA
City: BAKERSFIELD Zip: 93312
[ ~Urllrllar~
~vs~ Oo hereby certify that I have
reviewed the attached hazardous materials manage-
ment plan for ¥~-T~LEY CON¥^:b$Ci~]~Tr~{~t~ilong with
any corrections constitute a complete and correct man-
agement/P]~ for my facility.
10/24/90 VALLEY CONVALESCEN]' HOSPITAL 215-000-000899 Page 2
Hazmat Inventory List in MCP Order
02 - Fixed Containers on Site
Pln-Ref Name/Hazards Form Quantity MCP
02-001 OXYGEN ? 1,255 Low F'T3
1(:)/24/9(-) VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page
00 - Overall Site
<D) Notif. /Evacuatinr~/Medical
<1> Agency Not ificati¢,r,
911
"OFFICE OF EMERGENCY SERVICES
1-800-852-7550
<2> Employee Notif./Evacuatior,
CALL 911, REPORT SPILL, AND DETERMINE MATERIALS. LOCATE SPILL, DETERMINE
CONTENT'S AND AMOUNT ]'HEN FOLLOW EVACUATION PROCEDURE. DETERMINE IF
NEIGHBORHOOD IS IN DANGER.
Public Notif. /Evac~aation
IN~ERCOR
iC~IVi~ ¥IR~ ^C^RM SY$?E~ iND NO~I~¥ ?BiN iND ?ROCEDORE.
<4> Emerger,cy Medical Plar,
SAN JOAQUIN COMMUNITY - 2615 EYE ST - 327-1711
TRANSFER AGREEMENT 8-1-86.
10/24/90 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 4
00 - Overall Site
<E> Mi t i gat i or,/Prevent/Abat emt
<1> Release Prevention
PRESSURIZED BYLINDERS PROPERLY CHAINED. ALL SUPPLY
DOORS
LOCKED
AND
SECURED.c OXYGEN TANKS HAVE CAPS AND PROPER REGULATORS.
<2> Release Cor,tainmer, t
SHUT OFF VALVE, REMOVE LEAKING 02 TANK, REPLACE TANK.
<3> Clellar, Up
EVACUATE PREMISE' S.
<4> Other Resource Act i vat i or,
10/24/90 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 5
00 - Overall Site
<F> Site Erslergency Factors
<1) Special Hazards I'
<2> Utility Shut-Offs
A) GAS - OUTSIDE SOUTHEAST SIDE OF BUILDING 8; OUTSIDE ROOM 3 NORTHWEST SIDE
OF BUILDING
B) EL~ECTRICAL - OUTSIDE DOOR TO LAUNDRY TO THE LEFT
C) WATER - SOUTHEAST SIDE NEAR M ST
E>D) LuCKS~'ECIAL~ BOX--~W~l~4E 5 ~NO '~ Ee.C.,i[~4~ ~-~-~ Or~ \r~t;b_ ~ ~,\~.r--~d~C~) ~)¢Z~r ~)~)~
<3> Fi~e Protec. /Avail. Water
PRIVATE FIRE PROTECTION - SPRINKLER SYSTEM THROUGHOUT FACILITY, SMOKE
DETECTORS, PULL ALARM MINISCAN 424 ALARM SYSTEM
FIRE HYDRANT - NORTHEAST SECTION OF BUILDING NEXT TO 8TH ST ENTRANCE GATE.
<4> Held for Future use
10/24/90 VALLEY CONVALESCENT HOSPITAL 215-000-000899 Page 6
O0 - Overall Site
<G> Training
<1> Pa~e 1
!
WE H~VE 30 EMPLOYEES AT '[HIS FACILITY
DO YOU HAVE MATERIAL SAFETY DATA SHEETS ON FILE? YES
BREIF SUMMARY OF TRAINING:
MONTHLY WITH FIRE DRILLS AND DURING ORIENTATION OF ALL NEW EMPLOYEES.
<2> Page 2 as r, eeded
<3> Held for Future Use
<4) Held for Future Use
~ cTI'Y of BAKER,_c;FIELD '~
i HAZARDOUS MATERIALS INVENTORY
Farm and ~,gticulture Fi SlJandard Business E]
I NON--TRADE SECRETS Pa~e of__
BUSINESS NAME: VALLEY CONVALSCENT HOSPITAIOWNER NAME' RON O'HAVER NAME OF THIS FACILITY: VALLEY CONVALS_CEI~_J~OSPTTAT,
~ c t~o.. ~ '.~-". '.'.~., mo~,~ss. ~ ". ~' ~w
C?T~, ZIO;ga~g¢~. ~X ~3a04 citY. zlP}7_~e~b,' ~t 0~312 DuN AND BRADSlREE, NUMBER ................
PHONE ~: '~5 ~-22u0 - PHONE fl: ~89-8443 - -
-- -- REFER TO~NSTRUUTIOMS-~R-PROPER CODES
, ~ ~ , s s ~ 8 ~ ,o ,, ,~ ,~ ,,
Code code Amt Amt~ Es~ Untts on ~ype Press ~emD Stored
See instructtons '
~[?' I,~,::-' I ta~ I r.o~q I.~1 365 I -¢ I t I ~ I.~,- I o~ STORAGE ROOMS 02 OXYGEN
(Check all that ap~IH 1~ ~NDERS
~ [ir~ ,~zard ~ r~acti~i(~ ~ Celmd ~ Sudden r~l~ase ~ l~diat~
, Health of Pressure Health
~ Component 13 NAme I C.A.S. Humber
I I I I I I I I I I I
PhySical ADd ~ell[h HAzard C.A.S. Number Component II Namo I C.A.S, Number
(Check !1/ ~hlC Ippl~}
Componen~ 12 Name I C.A.S, Number
~ Fire Hmrd ~ Reactivity ~ Delayed ~ Sudd~nRelease ~
Nea/~h of Pressure
Component 13 Name I C.A.S. Humber
Physical Ind Health Hmrd C.A.S. Humber Componen~ II Name I C,A.S. Humber
(Check 811 that apply)
Componen~ 12 Name I C.A.S. Number
~ Fire Hmrd ~ Reactivity ~ Delayed ~ Suddenrelesse ~ Immediate
Health of Pressure Health
Component 13 Name I C.A.S, Number
I I I I ' I I I I I I I
Physical Ifld Health Hazard ' C.A,S. Number Component II Name I C,A,S, Number
(Check ali that apply)
Component I~ Name I C.A.5. Number
~ Fire Hazard ~ Reactivity ~ Belayed ~ Sudden Release ~ Immedi~.t~
Health of Pressure ·Healt~ "
Component 13 Name t C.A.S. Number
EHERGENCY CONTACTS ff
[er&ijtioq,(Re~ ahd sign af~pr cpmpl~ti~tg,oll.
certify unoer pen~ oI~ Lh~L~ h~ve~ersonm~ exmn~q~qa ~ ~J~.~J~Lhe ~n(or~mon ~u~iLL~ Jn ~Js
at~ached .dOc~mc$,suDmttteo ,morma[,o,ln~ls. wue,t~at baSeUac, curare,on.my ,nolnquirYcomplece.gf' ~hose ,nolv,oua/s respomm ,or obtaining ~he ,nrormmon. I believe tha~the
~{Tr~le of o~netl~perator u~ owner/operator's amorized reparative
ersfield Fire Dept.
~ ~q~'~ Hazardous Materials Inspection
~i~' Date Completed ~ 2. I ~ 0
Bus~e~ N~e: ~ V ~'~.s c. ~ ~' S e ~ ~
REGEIVED
Loca~on: [20~ 8 ~ ~,
Plan ID ~ 215-000 8~ (Top right comer Business Pl'an) HAZ. MAT. DIV.
Station No. ~F S~ ~ Inspector
Adequate Inadequate
Vehficafion of [nvento~ Materials
Verification of Quantities
Verification of Location ~'-
~oper Se~egafion of MatefiE
Verification of MSDS Availab~iw
Nmber of Employees ~ ~
Verification of Haz Mat Trai~ng
Co~5:
Ve~cafion of Abatement Supples k Procedures ~N/h
Co~5:
~e~encyPr~ed~es Posted ~tc ~ ~ ~
Containers Properly Labeled
Co~5:
Ve~cafion of Faci~w Dia~m
Speci~ Haz~ds ~sociated ~th t~s Fac~W: ~[~N ~
Violafiom:
FD 1652 (Rev. 3-89) White-Haz Mat Div. Yellow-Station Copy Pink-Business Office
B XE SFI .U) FI E REC-IVEDF
B~ERSF~ELD, CA 9330~
OFFICIAL USE ONLY
B~SINESS S~E
HAZARDOUS ~IATE R I ALS
BUSINESS PLAN AS A WHOLE
FOR~I 2A
INSTRUCTIONS: O0 ~B99
1. TO avoid further action, return this form bi
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.
sEcTION 1: BUSINESS IDENTIFICATION DATA
B.,' LOCATION / STREET ADDRESS:
SECTION 2: E~4~RGENCY NOTIFICATIONS
In case of an emergency involving the release or threatened release of a
hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4841. This will notify
your local fire department and the State Office of Emergenc~ Services as required
la~.
EMPLOYEES TO NOTIFY IN CAS~ OF EMERGENCY:
NAME AND TITLE ~_c~3 DURING BUS. HRS. AFTER BUS. HRS.
SECTION 3: LOCATION OF UTILITY SR~3T-OFFS FOR BUSINESS AS A W~OLE
A. NAT. GAS/PROPANE:
B. ELECTRICAL: ~o~(d~ ~d~ ~o~ ~ C~gr? ~ ~ C~
C. WATER: ~ o ~
D. SPECIAL:
E LOCK BOX: YES / NO IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS.° YES / NO MSDSS? YES / NO
FLOOR PLANS9 YES / NO KEYS? YES / NO
2A -
SECTION 4~ PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND
REFRESHER TRAINING IN THE FOLLOWING AREAS.
CiIRCLE YES OR NO INITIAL REFRESHER
Bi. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES: .......................... Y~. NO ~E_~ NO
C. PROPER USE OF SAFETY EQUIPMENT: ..................{ NO~ NO
D.. EMERGENCY EVACUATION PROCEDURES: ................. NO NO
E!. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... NO NO
SECTION ?: HAZARDOUS MATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS OF A
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... Y~ NO
, certify that the above information is accurate.
I understand that this information will be used to fulfill my firm's obligations under
the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter 6.95
Sec. 25500 Et Al.) and that inaccurate information cons~titutes perjury.
SIGNA TITLE /~m,2 ~ ~0. DATE
!
.... KERN COUNTY FIRE DEPARTMENT
5642 VICTOR STREET
BAKERSFIELD, CA 93308
OFFICIAL USE ONLY
BUSINESS NAME:
BUSINESS PLAN
SINGLE FACILITY UNIT
FORM
INSTRUCTIONS
, ~. To avoid furtl~er aotion, this form must be returned by: ~U6 0 5 1987
I 2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
i 3. Answer the questions below for THE FACILITY UNIT LISTED BELOW
' 4. Be as BRIEF and CONCISE as possible.
SECTIO~ 1: ~ITIGATION, PREVEI~ION, ABATEI~I~I' PROCEDURES
SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THIS UNIT ONLY
HMCU-6
SECTION 3: HAZARDOUS NATERIALS FOR TfIIS UNIT ONLY
A. Does this Facility Unit contain HaZardous Materials? ...... ~ NO
If YES, see B.
If NO, continue with SECTION 4.
B. Ar'e any of the hazardous materials a bona fide Trade Secret as
defined by Section 6254.7 of the Government Code? ......... YES
If No, complete a separate hazardous materials inventory
form marked: NON-TRADE SECRETS ONLY (~hite form #4A-l)
If Yes, complete a hazardous materials inventory form marked:
TRADE SECRETS ONLY (yellow form .#4A-2) in addition to the non-trade
secret form.' List only the trade secrets on form 4A-2.
'!SECTION 4: PRIVATE FIRE PROTECTION
;SECTION 6: ~OCATION OF
iA. NAT. GAS/PROPANE:
~B. ELECTRICAL:
~. C.
.I
J
D. SPECIAL:
E. LOCK BOX: YES ~ IF YE~, LOCATION:
IF YES, SITE PLANS? YES / NO MSDSs? YES / NO
FLOOR PLANS? YES / NO KEYS? · YES / NO
fI~CU-6
BAKERSFIELD CITY FIRE DEPARTMENT '
I.D. # FORM 4A-1 Page ~of-
NON--TRADE SECRETS
HAZARDOUS MATERIALS INVENTORY
BUSINESS NAME: VALLEY CONVALESCENT HOSPITAL OWNER NAME: RONALD D. O'HAVER FACILITY UNIT #:
ADDRESS: 1205 8TH STREET ADDRESS: 5726 DONNA AVENUE FACILITY UNIT NAME:
CITY, ZIP: BAKERSFIELD, CA 93304 CITY,ZIP: TARZANA, CA 91356
PHONE #: (805) 324-9468 PHONE #: (818) 34~1449 ' [OFFICIAL USE cFiRS CODE
I
ONLY
1 2 3 4 5 6 7 8 9 10
TYPE MAX ANNUAL CONT USE LOCATION IN THIS · BY HAZARD D.O.T
CODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT. WT. CHEMICAL OR COMMON NAME CODE GUIDE
NA~E: TITLE: SIGNATURE: DATE:
E~ERGENCY CONTACT: TITLE: PHONE · BUS HOURS:
AFTER BUS HRS:
E~ERGENCY CONTACT: TITLE: PHONE ~ BUS HOURS:
PRINCIPAL BUSINESS ACTIVITY: AFTER BUS HRS:
4A-1 -
BAKERSFIELD CITY FIRE DEPARTMENT
I.D. ~ FORM 4A-1 Page of"
NON--TRADE SECRETS
HAZARDOUS MATERI ALS INVENTORY
BUS:INESS NAME: VALLEY CONVALESCENT HOSPITAL OWNER NAME: RONALD D. O'HAVER FACILITY UNIT #:
ADDRESS: 1205 8TH STREET ADDRESS:. 5796 DONNA AVENU~ FACILITY UNIT NANE:
CITY, ZIP: BAKERSFIELD, CA 93306 CITY,ZIP: TARZANA,.CA 91356
PHONE ~: (805) 326-9668 PHONE ~: (818) 343-1449 ~FICIAL ~SE CFIRS C00E
/
ONLY
I 2 3 : 4 5 6 7 8 9 10
TYPE ~AX ANNUAL CONT USE LOCATION IN THIS · BY HAZARD D.O.T
CODE AMOUNT A~OUNT UNIT CODE CODE FACILITY UNIT WT. CHEMICAL OR CO~ON NAME CODE GUIDE
NAME:: TITLE: SIONATURE: DATE:
EMERGENCY CONTACT: TITLE: PHONE # BUS HOURS:
: AFTER BUS HRS':
~MERGENCY CONTACT: TITLE: , PHONE # BUS HOURS:
· 'RINCIPAL BUSINESS ACTIVITY: AFTER BUS HR$: