HomeMy WebLinkAboutBUSINESS PLAN SITE/FACILITY DIAGRAM FORM
DAIE: /' / FACILITY NA~ME: UNIT ~ OF
(CHECK ONE) SITE DIAGRAM / FACILITY DIAGR.~M
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(Inspector's Comments): -OFFICIAL USE ONLY-
HAZARDOUS MATERIALS
BUSINESS PLAN AS A WHOLE RECEIVED
' I.o To avoid further action, return this from uithin 30 .days of race,pt. '
2. TYPE/PRINT ANSWERS IN ENGLISH. ,: .....
3. Answer the questions belo~ for th~ business:, as,,.a uhole~.,~,'"'
4. Be as brle~ and concise as possible
SECTION*I: .BUSINESS IDENTIFICATION DATA" .. ~, : .........
SECTION 21 EMERGENCY NOTIFICgTION~ ....
In case of'an'emergency~ involving the r~laase or'threatened relaase of
a hazardous material, call 911 and I-BOO-B~Z-?.~SO or 1-~1B-427-4~41 This
atll no{try your local fire dep~r[ment and the State Office of Emergency
Services as required by law. : ~:'. ' ~" ' '"
EMPLOYEES TO NOTIFY; IN CASE OF EMERGENCY: " ..
NRHE ~NO TITLE "~ '~: ' DUff[N8 BUS. HRS.' ~FTER BUS. HRS.
O. SPECIAL:
E.' LOCK BOX: YES /~IF YES, LOCATION: .-
IF YES, DOES IT CONTAIN SITE PLANS? YES / rio MSDSS? YES /
FLOOR PLANS? YE~ / NO ~EYS? YE3 /
SECTION ,~: PRIVATE RESPONSE TJ~AM FOR 8USI~IESS AS A WH~LE -' ,~' '
SECTION S: 'k0C6k EMERGENCY MEDICAL ~,S,SIST~NCE FOR YOUR BUSINESS 6S a WHOLE
SE~T~.ON ~:" EMPLOYEE TRAiNiNG
'-EMPLOYERS' 'ARE REQUIRED TO HAUE A TRAINING PROGRA~ WHICH PROUIDES E)tPLOYEES WITH INITIAL AND REFRESHER TRAINING IN THE SAFE HANDLING OF HAZARDOUS
~. NUMBER OF EMPLOYEES ~T THIS F~CILITY
C. GiVE A BRIEF SUHMARYJF YOUR HAZARDQUS ~ATERIALS TRAINING PROGRAMt
:~ECTION 7: ' ~XEHPTiON REQUEST.
I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEHPT FROM THE
REPORTIN~ REQUIREMENTS OF CHAPTER G.9~ OF THE CALIFORNIA HEALTH AND SAFETY
COOE,FOR.THE ~OLLO~IN6 REASONS: . ~ , ,,-.. ~ ~ ....
gE O0 NOT HANOLE HAZARBOUS HATERIALS.-
~E O0 HANDLE HAZAROOUS ~TERIALS, BUT .THE QUANTITIES AT NO
.., ~ TIHE',.EXCEED THE ~NI~UH REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 8: CERT IF~ATION
.I.,' ~,~" , c~rt~fy thai the abov~ ~nforma~on
acc~te. [ underS{and that this ~nformatJon u~11 be used to fulfill my
f~s obJ~gat~on~ under the neu California Health and Safety code
Hazardous ~ateP[als (D~v. 2~ Chap{e~ ~.9~.S~c. ZS~e E~ ~1.) and {ha~
~naccura~e ~nforma~ion constitutes
SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY
A. Does tht. s Fac[litg Unit cont,iu Ha~nrdo,s ~at. erJa!s? ........
If YES, see B.
If NO, continue ~ith SECTION 4,
B. Are ::my of the hazardous materials :-t bonu fide Tr;t,.ie
- ; .- · ...... If NO, "complete a.'separate hazardous materials Inventory'
form marked: NON-TRADE SECRETS ONLY (~vhite form
If Yes. complete a hazardous materials Inventory form ,~arked:
TRADE SECRETS ONLY (~ello~ form ~4A-a)lln addition to the ~on-tra~e
SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMEROENCY RESPONDERS
,
, i,""" SECTION .6,~., LOCAT.!O~ OF .,~TILI~ S~wOFFS.. AT..TH.IS. UNIT,..ONL~ ..... ~.... .. ..,:...,. ,. . ., .... ' .... ->., :.- .,.-~., ·
: ~'+" ' .": '?., :':"~:~'.A. '.NAT..GAS iPROpAN~ :~?i~.:,~ ~;,:..:.;::,:: .... ";'"'!;: :".' '.: t..'. ~
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B. 'ELECTRICAL:
';~,t .' ) !'.'. ~
!
C. WATER:
O. SPECIAL:
E. LOCK BOX: YES /~IF YES, LOCATION: '
IF YES, SITE PLANS? YES / NO MSDSs? YES "NO
FLOOR PLANS? YES ,/ NO KEYS? YES .' NO
3~ -
BAKERSFIELD CiTY FiRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFICIAL USE ONLY
BUSIN£SS NA,~iE:
BUSINESS PLAN
FORM 3A
INSTRUCTIONS
,,,~'.,:..~:;..;.~:~: ?.~..,';.~.i!,.~?.~o .avoid:further ..~o.tton;., th.ls..form must be.'returned by: . ' ....-.- ..... '.
.. ':.:.. ~:......, ._2. ~YPE/PRINT YOUR ~SWERS IN ENGLISH. ... ....
~ ' ' 3. Answer the questions' below for THE FACILITY UNIT LISTED BELOW
'" '" "4~ 'Be a~'BRIEF'and cONcISE'~s possible.' .... " .... ' "
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SECTION 1: ~ITIGATION, PRE~ION, ABATEME~ PROCED~ES
SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THIS UNIT ONLY
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