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SITE DIAGRAM FACTLITY DIAGRAM
Nc--~ Name of
~ Bakersfield Fire Dept. ~
HAZARDOUS MATERIALS DIVISION
Date Completed
Business
Name:
Location: ~/c:, / ~ 3-'-,
,~,~.,~ Business Identification No. 215-000 ~' 'rr~ (Top of Business Plan) JUL 2 li f991
StationNo.[ Shift ~:~ Inspector p, (.~,..,~'-T'~
.....
Adequate Inadequate
Verification of Invento~ Materials I~]
Verification of Ouantities I~] I~]
Verification of Location ~] I~]
Proper Segregation of MaterialI~] I~]
ents:
Verification (~__~D~Availablity~]
Nu~pl~oyees ~
V~efification of Haz Mat Training ~
Verification of Abatement Supplies & Procedures
Comments: ~
"'~ Emergency Procedures Posted~-'~ I~
Containers Pr~/~~ ~
Comments:
Verification of Facil~y Diagram I~]
Special Hazards Associated with this Facility:
Violations:
All Items O.K. I~
Correction Needed I~
Business Owner/Manager
FD 1652'(Rev. 1-90) White-Haz Mat Div. Yellow-Station Copy Pink-Business Copy
CITY of BAKERSFIELD
Farm and Agticulture Fi Standard Business I~-HAZARDOUS MATERIALS INVENTORY
NON--TRADE SECR. ETS Pa~je /
BUSINESS NAME: ~,~ ~<~o~.,f,~~NER NAME:~,,cA~./. ~<~ NAME OF THIS FACILITY:~,~
LOCATION; ~/~ /~ ~ · 'ADDRESS; ~//~ ~. ~ ~ STANDARD IND, CLASS CODE~ -- _'
irans [y~a Hax Average Annual N~aspre I ~e {on[ ~ont ~onL Us [oc~tion.~he[e
Code code AmC Ret Est . units on ~ype Press /emp Co~eStored tn PaClllLy~[ See Instructions
Physical and Health Hazard ~ C.A.S. Humber Component II ~e I C.~.S. Humber ~~¢~
Component I~ Name I C,A,S, Number
~FireHazard ~ Reactivitr ~ Oelayed ~ Sudden Release ~
Health of Pressure
Component 13 Name I C.A.S. Number
Physicsl mod Health Hazard ~ C,A.S. Number ~ Component II Name I C,A,S, Number ~s ~ ~ ~-/~T
(Check al/ that app]yl -
Component I~ Name I C,A,S, Number
~ Fire Hazard ~ Reactivity ~ Delayed ~ Sudden Release ~
Hem ICh of Pressure
Component 13 Name I C,A,S, Number
Physical and Health Hazard C.A.S. Number Component Il Name I C,A,S, Number
ICheck a11 that apply)
Component I~ Name I C.A.S, Number
~ Fire Hazard ~ Reactivity ~ Delayed '~ Sudden Release ~ lm~i~
Health of Pressure
Component t3 Name I C,A,S, Number
Physical and Health Ualard C.A.S. Number. Component II Name I C,A,S, Number
(Check 411 &hat
Component I~ Name I C.A.S. Number
~ Fire Haz4rd ~ Reactivity ~ Delayed ~ Sudden Release ~'
Health of Pressure
Component 13 Name I C.A.S. Number
Cer[ifi arid Re and f naf ~ co~ 7 ~ f ~ ~77 c fens)
[ cer[l~y un'er oena,~, o~ th,t ]~,v~pe{sonaf~.examlnq~eq~ ~, [milla[.vit¢~e~nfocmatton ~u~mittpd in this.end all
a:~acned,dQcgeenta, an~ tbac oaseo on.my ~nqu~ry Q~.tnose ~nolvleuams Fesponslome tor ob:a~n~ng the ~ntoreauon. I bem~eve that the
suomlt:eo inlormatlo~ ls true, accura:e, ano coepme:e.
~~~le of owneriooerator ~ owner/operatorrs autflorlZeO representative
Bakersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 3: TRAINING:
NUMBER OF EMPLOYESS: -~
BRIEF SUMMARY OF TRAINING PROGRAM: /~,,~,/,/e.. .
SECTION 4: EXEMPTION REQUEST:
I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE
REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH &
SAFETY CODE" FOR THE FOLLOWING REASONS:
WE 'DO NOT HANDLE HAZARDOUS MATERIALS.
WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO
TIMEEXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION:
MATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO
FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE"
'ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT
INACCURATE INFORMATION CONSTITUTES PERJURY.
~ c~"~_~:~---''- o~,-...-~ / -/~'.-v /
SIGNATURE TITLE DATE
FO15~,.'
Bakersfield Fire Dept.
O r,\v"~ RECEIVED
Hazardous Materials Divisiopzx
2130 "G" Street ~,;,~,~ ,v _~ JAN 2 5 1991
'Bakersfield, CA_ 0330~
HAZARDOUS MATERIALS MANAGEMENT PLAN
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 b~siness as a whole. '
4. Be ~rief ana concise as po~ible.
SECTION 1: BUSINESS IDENTIFICATION DATA
BUSINESS NAME: ~,'~. ~~ ~0~/~ ~,'r
LOCATION: ~/~ /~'~
MAILING ADDRESS: ~/o /~'~ ~-
CITY:.~~,'~ STATE: ( ~ ZIP: ~3o( PHONE: ,~-oDoo
c~ T~ ~.~.~.
DUN~BRAOSTREETNUMBER: ~1-~-q~_~ SICCODE:
PRIMARY ACTIVITY: ~~~ ~ ~y~
OWNER: ~;¢~( ~.~
MAILING ADDRESS: ?/o ~¢~ ~¢_ ~~,~/~~ .
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT TITLE BUS. PHONE 24 HR. PHONE
FD15c
~.~. ~.~... 4. Bakersfield Fire Dept. ~' '~'
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 7: MITIGATION, PREVENTION AND ABATEMEfi¥ PLAN:
A. RELEASE PREVENTIONSTEPS: /~'.~¢j-~ '-'/~k<i c,"-,~f::'$ o,,,~ ~"~ ~'o,-v')"~,'.-~
B. RELEASE CONTAINMENT AND/OR MINIMIZATION:
Co,vc,-dT~ F~,--r,'~.,-- -',-,,-,'( c,-,-¢,w,,,-,,-,,,,--'/-
C. CLEAN-UP PROCEDURES:
/"aRdor ~ ~i~ses ...',
SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)'
SPECIAL'
LOCK BOX: YES N~N~ IF YES, LOCATION:
i
SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY:
A. PRIVATE FIRE PROTECTION: Sire ~x~l'-"'~
B. WATER AVAILABILITY (FIRE HYDRANT):
4, FDIS~'
Bakersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
Facility Unit Name:
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES'
B. EMPLOYEE NOTIFICATION AND EVACUATION: ,,"~'O -'~ ,,~
C. PUBLIC EVACUATION:
D. EMERGENCY MEDICAL PLAN'