HomeMy WebLinkAboutBUSINESS PLAN ITE DIAGRAM [--1. FACILITY DIAGRAM '
Az-aa Map ~ o~
m~ Ncr-.h Name of Ar~a:
" ~ ROOF SURVEY REPORT
For /~u ~ e z~Z Z=-~' ~
Survey made by.
Roof surveyed Survey No.
Sketch of Roof:
(Not necessarily to scale)
Type of Deck Thickness of Parapet Walls
Present Roofing. Height of Walls
' Pitch Construction of Walls
Type and Thickness of Insulation
RF-43 REV, 10-62
RETURN PAYMENTS'TO: -
~ . . PLEASE MAKE CHECKS PAYABLE TO:
CITY .OF BAKERSFIELD, J~,ZA~DOL,'lt.S. ~AI"EI~JI:R'L$ Dj,t/J.S ION
.. P..O. BOX 2057 , ,...,f. _ "- : - CITY OF BAKERSFIELD
~' ': ,' : ' '~, ' :- ':" "'::*, '~'' ', ,';'" ' " ~ ' ' '" r
"PE~,~'i ~ ~EE S,. FO.~ 'JUL9~ .~. 1 9 ' :~05'/~' Pa'y'~e'nt L': .'
' ~" "' ,'vIuSTF~ETUI~N THiS COPy .WITH ~,,~YM~:~'. . . ,, ,;,- . ,,.;, ~.~,,
RETURN PAYMENTS TO: '
CITY OF BAKERSFIELD
P.O. BOX 2657
BAKERSFIELD, CA 93303-205~'-,
ACCOUNT NO.
PLEASE MAKE CHECKS.PAYABLE TO:
'CITY OF BAKERSFIELD
CONCERNING THIS BILL, PLEASE PHONE: ~ . . ~h "~,:;. .... .; ..
INVOICE NUMBER
j~ PRINTED ON REGENESIS® POST CONSUMER RECYCLED PAPER CUSTOM E R CO PY
CITY 'O'F BAKERSF ' '
BAKERSFIELD, CALIFORNIA 93303-2057
ADDRESS C~RRECTION REQUESTED.
~ HICKORY
RETU~ T~ SENDER
'' I N ICKORY. "O~SE N~38.930~
[230 ~ST~ ST
aA~ERSFIELO. 'CA 93301 .
HM389301
Account Number
ACCOUNTS RECEIVABLE ADJUSTMENT
January 18, 1995
Date New Ao~=ount
New Addrese
Esther Duren Close Aocount
From Servloe Chan.qe
Other Adjustments X
Fire Department- Hazardous Materials Division
Department/Division
HICKORY HOUSE
Billing Name
1230 18TH STREET
Billing Address
Site Address
Parcel # (If Applicable)
Landlord Name & Address (If Applicable)
ADJUSTMENT
Last Billed Correct Billing Adjustment to Effective Date of
Billing Change
110.00 0 <113.33> 1-11-95
f
Remsrks: THIS BUSINESS CLOSED SOMETIME BEFORE THE FISCAL YEAR. WE WILL WIRTE OFF
THE CURRENT BILL PLUS THE ADDITIONAL FINANCE CHARGES.
Bakersfield Fire~
HAZARDOUS MATERIALS DIVISION
Date Completed
Business Name: ~'~CC Ico,,,'~
Location: [.~O ~ ~.
Business Ide~ificaion No. 21~000 ~op of Business Plan)
Station No. I Shi. ~ Inspector
Adequae Inadequae
Verificaion of Inventoff Maerials
VerEication ~ Ou~t~ies ~ ~ NOV I 0 1995
Verification of Locaion ~ ~ HA7 k~AT. ~!V.
Proper Segregation of Maeri~
Comments: d~ ~ ~ 5 ~
Verification of MSDS Availabli~
er of Employees
Verificaion d H~ Ma Training
Comments:
Verification of Abaement Supplies & Procedures
Comments:
Emergency Procedures Posted
Containers Properly ~beled
Comments:
Verification of Facility Diagram
Sp~ial H~ards Associated with this Facility:
All Items O.K. ~
~--~ ~ .~~ Correction Needed ~
Business Owner/Manager
FO 1652 (Rev. 1-90) White-Haz Mat Div. Yellow-Slation Copy Pink. Business Copy
Bakersfield Fire Dept.
Hazardous Materials Division
· . .-,.~-~ HAZARDOUS MATERIALS MANAGEMENT PLAN
SE.CTIDN, 37! TRAINING:
? .
:~MATERIAL SAFETY DATA SHEETS ON FILE:
BRIEF SUMMARY OF TRAINING PROGRAM'
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
T1MEEXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION:
I, .~./~'~1'~ ~'~i L~ £ CERTIFYTHATTHE ABOVE INFOR-
MATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO
FULFILL MYFIRM'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,
SIG NATURE TITLE DATE
2,
Bakersfield Fire Dept. ~
Hazardous Materials Division RECEIVED
2130 "G" Street 4UI; ~p ,5 19~
· Bakersfield, CA. 93301 '-~ H,~, ~T.
DIV.
HAZARDOUS MATERIALS MANAGEMENT PLAN
INSTRUCTIONS:
1. To avoid further action, return this form within 30 days o~' receipt. RECEIVED
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer tine questions below for the business as a whole.
/f'~u
MAT.' DIV.
SECTION 1' BUSINESS IDENTIFICATION DATA
BUSlNESS NAME' ~:retl L.-E~ ~,. DBA.
LOCATION' I z. 3 o- I g' ~ ,~.
MAILING ADDRESS: 5".,~p,.~ F_...
CITY: 'l'"5...,q--~..~..g~.~_~d-... STATE:(---~ ZIP: ¢'-¢~o/ PHONE:
DUN & BRADSTREET NUMBER: ¢~'-'" SIC CODE: ":~ \
PRIMARY ACTIVITY' ~5~c-'r'~O7~
OWNER: )V~-,~,c~/,/ ~. Lc_
MAILING ADDRESS: ."/~30 /~~ ~Jr.
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT TITLE BUS. PHONE 24 HR. PHONE
l, /r")~/~;(.r~ ~. Lc ~ C~,~FI'~'.,'--- 3o) '7-q',,}-
Bakersfield Fire Dept.
Hazardous Materials Division ,~ .~, ~
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN:
A, RELEASE PREVENTION STEPS:
B, RELEASE CONTAINMENT AND/OR MINIMIZATION:
C. CLEAN-UP PROCEDURES:
SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)'
NATURAL GAS/PROPANE:
ELECTRICAL: h~cY- ~&.~(
WATER:
SPECIAL:
LOCK BOX' YES/NO IF YES, LOCATION:
SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY:
A, PRIVATE FIRE PROTECTION:
B, WATER AVAILABILITY (FIRE HYDRANT):
4. FDir:
Bakersfield Fire Dept.,
· Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
Facility Unit Name: I~-;.C.tC ~. ~., t-\ c~, % ~ '~, ¢ ~-~ (i~ ,~ ~,.~'~-
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES'
~-t~,; c~'~ q ~1 '~
B, EMPLOYEE NOTIFICATION AND EVACUATION'
C. PUBLIC EVACUATION:
D, EMERGENCY MEDICAL PLAN
CITY of BAKERSFIELD
Farm andAgticulture t1 Standardausiness FlHAZARDOUS
HAT ERTALS
T NVENTORY
NON--TRADE SECRETS Paqe ___ of~
BUSINESS NAME: ~l'c~0~m,~, ~//~Lx~£ OWNER NAME: ~6~i-~/bA7 /-..~ NAME OF THIS FACILITY: tL~'c~-~ ~'~
LOCATION; I~-- I-~'J~-- ~..~-. ADDRESS: ~ ~ ~o~ ~,oe ~ STANDARD IND CLASS CO~
CITY. ZIP: '~.~ ~, ~ ~ CITY. ZIP: B~~'~ ~ Ca~ DUN AND BRAD~TREET NUMBER
PHONE ~: ~?-~=~ PHONE ~: ~4~ ~ - - '
" REFER TO~N~~~S ~'~ PROP~ CODES - -
frans lyre Max Av~rpge Annual Hgaspre I ~e Cunt Cunt Cunt Us tocatjon.~he{e.
Names of ~Jxture/Coe~onents
Code ~oae AeL AmC ESL unlcS on Type Press Temp Co3eStored ~n eac~:y ~ See ]nstru:Ltons
Physical I~d Health Hazard C,A,a, Number ~ ~ b-~l-~ Component II Nale I C,A,S, Humber
(Check al/ that apply)
'/~elayed Component 12- Nam8 t C.A,a, Humber
Fire Hazard ~ Reactivity ~ Health ~ Suddeno¢PressureRelease ~ Immediate Health Component 13 Name I C,A,S, Number
Physical led Health ~azard C,A.S. Number Component II Name I C,A,S, Number
~Check. 41/ that app/yl
Component I~ Name I C.A.S. Number
~ Fire Hazard ~ Reactivity ~ Belayed ~ Sudden Release ~ lmmedia:e
Health of Pressure Health
Component 13 'Name I C.A,a, Humber
Physical and Health Ualard C.A.a. Number Component II Name I C,A,$, Number
(Check all that app/yl
Component
12
Name
C,A,5,
Number
~ Fire Hazard ~ Reactivity ~ Delayed ~ Sudden Release ~ Immediate
Health of Pressure Health ~ - -
Component 13 Name I C,A.S. Number
Physical and Health Ua~ard C,A.S. Number Component II Name I C,A,S, Number
{Check all that apply)
ComponenL 12 Hame I C.A.a. Number
~ Fire Hazard ~ Reactivity ~ Oelayed ~ Sudden Release ~ lmmedia[e
Health of Pressure Health
Component 13 Name I C.A.S, Number
"ertification (Re~d and sion after com~leting,all sec~ipnq)
~ certih un]er nenall~ of law that lhav~¢ersonalh examlne~ndam fami~a[.~it~thetn[orms[lpn ~u~miLtf~ in this,lnd all
a~[ac~ed'dgc.men[s an~ that base~ om my tn~uiry of those ~nd~v~duals respons~D~e tor obtaining the tn~ormacton. I be~eve that the
submitted tn[ormat[oo ~s true, accurate, amd co[Het~.
~'~e ofi¢ieJ ti~i~f ~vn~rtoo~r~or o~ o~nerlop~rator'S authorized reoresentatl~e ~ure