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Home My WebLink AboutBUSINESS PLAN 7/21/2003 (COPY)TELEPHONE (80~5) 327-3205 SAMUEl-. C, BARNES, D,P.M, PODIATRIC PHYSICIAN AND SURGEON OFFICE HOURS -- - TM ° 2227 - ~ 9TH STREET ~.",t' APl;OINTMENT BAKERSFIELD. CAt. IFORNIA 93301 TEEEFHONE[ (661 ) 327-3205 BREND;A.K. ,BARNES, D. PoM. PODIATRIC PHYSICIAN AND SURGEON OFFICE HOURS 222'7 - 19TH sTREET EY ,~PPOINTNIENT EAKERSFIELD, CALIFORNIA 9330 B~E R $ F~ ~tRm ~ OFFICE OF E~IRONMENTAL SERVICES tn~fittrtt~s~r 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATE~ALS ~NAGEMENT PLAN ., .. ~STRUCTIONS: ' ' 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 business as a whole. 4. Be as brief and concise as possible. 5. You may also attach Business Owner / Operator Form and Chemical Description Form(s) to the fi'ont of this plan instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA , LOCATION: '~"~ k '"' ~ 7"I['' ;; MAILING ADDRESS: PRI~d~Y AeTIVITY: CGf ' EMERGENCY NOTIFICATION CONTACT ,, ... TITLE BUS. PHONE .24 HR. PHONE HAZA IS MATERIALS MANAGEMENT PLAN SECTION II. 1: DISCOVERY AND NOTIFICATIONS A, LEAK DETECTION AND MONITORING PROCEDURES: 3. " B. EMPLOYEE AND AGENCy NOTIFICATION: C. E~RO~~ ~SPONSE ~AGE~: D. EMERGENCY MEDICAL PLAN: 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION I1.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: B. RELEASE CONTAINMENT AND/OR MITIGATION: ~j , . '. '.~ ;~ . '.''~, -..-,, ._. - , ~ ~. c,,.,,,.,,.~~~co~2oc~=s.~ ~,./ ~' ..; ?"..,: r . .... .-- '- mm~ ~uf-o~s ~Oc~nO~ oF s~-o~Fs ~ Yom F~Cm~ ' ' SPECIAL: LOCK BOX: :YE~ IF YES, LOCATION: 3 PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: , B. WATER AVAILABILITY (FIRE HYDRANT): ' HAZARDOUS MATERIAL~ MANAGEMENT PLAN SECTION ITI: TRAINING NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: CERT~ICATION I, 2,~ O~ ~-~% c ~ox~ ,~ERTIFY THAT THE ~OVE ~FORMATION IS ACC~TE. I ~ERST~D THAT T~S ~FO~ATION W~L BE USED IO FULFIL ~ F~'S OBLIGATIONS ~ER THE "CAL~O~ HE~ A~ S~ETY CODE" ON ~~OUS ~TE~LS (D~. 20 C~TER 6.95 SEC..25500 ET AL.) A~ THAT ~ACC~TE ~O~TION CONST~TES PE~Y. SIGNATURE TITLE DATE CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST ~' 1715 Chester Ave., 3r~ Floor, Bakersfield, CA 93301 ADDRESS ~7 ~ ~ 5 r PHONE NO. FACILITY CONTACT ~~ ~ BUSINESS ID NO. 15-210- ov e owes Section 1: Business Plan and Invento~ Program ~ Routine ~ombined ~ Joint Agency ~ Multi-Agency ~ Complaint ~ Re-inspection OPERATION C V COMMENTS Appropriate permit on hand ~rC.~e.x) ~O~c.O--~ ~ ~ Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials t..,.,e/ac~T~ ~" Verification of quantities Verification of location ~ ~ ~, O~' Proper segregation of material Verification of MSDS availability Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping 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 ) 326-3979 '~"'" Business Site Responsible Party ~,.~x, White- Env. Svcs. Yellow- Station Copy Pink- Business Copy Inspector: ITE DIAGRAM ! ! · · FACILITY DL~GRAM ~' ] CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 SITE AND FACILITY DIAGRAM INSTRUCTIONS FOR HAZARDOUS MATERIALS MANAGEMENT PLANS These instrUc~ons explain the use of the site diagram'and the facility diagram: No _rma!!y, small and medium' Size businesses will only have to submit a site diagram. If you have subdivided your bUsiness into smaller areas because of the oomplexity or size, then you will be c~ompleting and additional detail map, facility di~-"fot each ofthese areas. Include insuuctions that show the route to your business it it is in a ret~ote locafion.~ ~' ~- ' · SITE DIAGRAM INSTRUCTIONS The site diagrmn is used to show your busine~ and to indicate the budnesses that immediately surround your property, usually within 300 feet. If you will be showing specific area detail on facility diairams, use the site diagram to show an overall layout of the plant. Ifyou will not be submitting facility diagrams, the site map must include all of the following information: 1. Check the box on the top lei~ comer ofthe form provided that indicated."Site Diagram". ' 2. Print the name of your buSine.~, as shown in your ttMMP, on the top of the diagram. 3. Label the location of the hazardous materials and identify them by name and type of hazard (ie. Flammable liquid, corrosive solid). "' 4. Label the location of utility shutoff points for gas, electric and water services. S. Label the location of'fire hydrants. 6. Label portions of the building protected by automatic sprinkler systems. 7. Label the direction representing north on the diagram. (The diasram form provided includes a.O0r~"arrow). Map labelins"must euily understandable', the use or'abbreviatiOnS or symbols. Ir'you must use them, prOvide a lesend explainin8 your systeml Maps may be retumed~ for corr~:tion ifyou fail to. fOllow the~ in,rub'ion. FACILITY DIAGRAM INSTRUCTIONS " .-. Facility diasrams are supplements to the. site diagram.' Use them t° show the subdivision details ora large businessi' ,- ' ~ ' .~'' .,~ 1. Check the boX in the upper right hand comer of the form provided that indicated "Facility Diagram".' 2. Print the n~ of your business as shown on your HMbJP. Print the name of the area tl~t.this ~r~r~. ~ n~ne ,hould · 3. Indi~e".wlfi~' ~'~ the di~nma ~ '~md tl~ total numb~ di~,~a~ tl~t ~u ~m indudinll. Ifa nmp i'~~d the fir~ of four would be l~el~l #I o£4. '4. Follow i~u~°,~' 0 .~'0 'for ~ite ~ ~ the specific included on each fatty di~-~. : '' ": ~;'' :' 2 1715 Chester Ave., CA 93301 (661) 326-3979 H~RDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION ' ' (one fo~ per material per building or a~a) ~ NEW ~ ADD ~ DELETE ~ REVISE 200 Page ~ of ~~./. ~:~~.' '.' ..'.-:'-:~':::~'?:~ ~::~ ::-:'.'.::: ,.'~AC"~,~,.~o.~,O~-'~.,-: ::..', '.. BUSINESS NAME (~me ~ FACILI~ ~ME ~ DBA - O~ng Busings ~) 3 _:_~.~,/ ~.. ~~ CHEMICAL LOCATION ..... '~ ~: ~/~ i CHEMICAL LOCATION ~ CONFIDENTIAL (EPC~) 205' = T~E SECRET ~ Y~ ~ No 206 CHEMICAL NAME ~C ~ C ~ ~ ~[ If S.Dj~ to EPC~, refer tO i.st~ions 207 = COM~NNAME ~ EHS' ~ Y~ ~ No 208 CAS" 209 ~ "*]~'EHs i;'Y~,' ~ ~ ~IJw'must ~ ~ FIRE CODE H~RD C~SSES (C~plete if r~u~t~ by J~l fire ~i~ 210 ' ~PE ~ p PURE ~ m MIXTURE ~ w WASTE 211 J ~DIOACTIVE ~Y~ ~No 212 ~ CURIES 213 PHYSICALSTA~ ~ s SOLID I LIQUID ~g ~S 214 ~ ~RGESTC ~ ~ FED H~RD ~TEGORIES ~ 1 FIRE ~ 2 REACTIVE ~ 3 PRESSURE REL~SE ~ 4 ACU~ H~L~ ~ 5 CHRONIC HEALTH 216 (Ch~ all that apply) ANNUAL WASTE . 217 ~IMUM 2~8 AVENGE 2~9 STATE WASTE CODE 220 A~UNT ~ ~ ~ ~ ~ ~ ~ ~'~ ~ DAILY A~U~ DAILY A~UNT UNITS' ~ ga ~L ~ ~ CU ~ ~ lb LBS ~ tn TONS 221 DAYS ON SITE 222 ' If EHS, am~n~ mus~ be in lbs. STOOGE CONTAINE~ ~a ABOVEGROUND TANK ~ e P~STI~NONM~ALLIC DRUM ~ i FIBER DRUM ~ m G~SS BO~LE ~ Q ~IL ~R 223 (Check all that apply) ~ b UNDERGROUND TANK ~ f CAN ~ j BAG ~ n P~STIC BO~LE ~ r OTHER '~c TANK INSIOE BUILDING ~ g ~RBOY ~ k BOX ~ o TOTE BIN ~ d S~EL DRUM ~ h SILO ~ I CYLINDER ~ p TANK WAGON STOOGE PRESSURE ~ a AMBIE~ ~ aa ABOVEAMBIE~ ~ ba BELOWAMBIE~ 224 STO~GETEMPE~TURE ~' aAMBIE~ ~ aa ABOVEAMBIE~ ~ ba BELOWAMBIENT ~ c CRYOGENIC 225 ..... .......... .... ........... .......... ....... ........ :: ::~/0~? · ~:::: :.?.::,::~o~scp~~:::.L:.:.~::~;{:L.:.::?:: .:....::;.~::.~.~ :~,..:. ::..??; .::;:::-..::~s.#..... ..:.::......::.:~:. ::.:' ::.:.~:.::::::: :::::::::::::::::::::::::::::::::::: :4 ::.:' . '~"~'""' ..... "'~':'"'"'= :'"'"'~" .................. ' ........... 1 226~ 227 ~Y~ ~No 228 ~ 229 ,, I 2 230 231 ~ Yes ~ No 232 233 4 238 239 ~ Y~ ~ No 240 241 5 242 243 ~ Y~ ~ No 244 245 :,': .... ':::::':...':.::.:,:f:-.:.~":."~:..':~:':'..:":"~'-:':.:'.L>%~:;';::" ~:,:'.'?,'..:?:'.?::::..:',~:;....: '..'. '..": ....... .;:.~.'::::':::~.:::::>..",?/~.::>? .' "..,:..:...:?'.'.:.... :..~:-:'/."/~::.::":: :,..' ".' ..'. -, :.v..:.:,,>' '.:..'.:,.: PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE ~I~NAT~RE -~ ~ DATE 24~ UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd = BRENDA K BARNES, DPM SiteID: 015-021-002321 = Manager : BusPhone: (661) 327-3205 Location: 2227 19TH ST ,, %~L~' Map : 102 CommHaz : City : BAKERSFIELD ~' Grid: 25D FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 01 SIC Code:8011 EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title BRENDA BARNES / DPM SAMUEL BARNES / DPM Business Phone: (661) 327-3205x Business Phone: (661) 327-3205x 24-Hour Phone : ( ) - x 24-Hour Phone : ( ) - x Pager Phone : ( ) - x Pager ,Phone : ( ) - x Hazmat Hazards: ~t~ '~ React Contact : BRENDA K BARNES, DPM , Phone: (661) 327-3205x MailAddr: 2227 19TH ST ~ State:; CA City : BAKERSFIELD Zip ': 93301 Owner BRENDA K BARNES, DPM Phor~e: (661) 327-3205x Address : 2227 19TH ST State: CA City : BAKERSFIELD Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: L ~'~(-~ c~.~. ~ ~ o.~:Do hereby certify that I have (l*ype or ~inl name) reviewed the ~ached h~ardous materials manage- ment plan for ~-{ ~5 ~ .~,~and that i~ along wi~h (~me of any ~e~ions ~ns~i~u~e a ~mpls~s and ~rr~ ~a> agemem plan for my la, lily. 1 07/15/2003 s v,c s 1715 ChesterAve., (661) 326-3979 Bakersfield, CA HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS SECTION I. - BUSINESS IDENTIFICATION DATA: The Business Owner / Operator Form, Chemical Description Form(s) and other Forms (e.g.: underground storage tank information, hazardous'waste treatment, etc., as needed) may be submitted as the first section of the Hazardous Materials Management Plan in order to avoid duplication of information for initial submissions. HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 'II. 1 - DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: Describe the procedures and equipment used to detect any release or threatened release of a hazardous material from any storage container, tank, or vessel at your business. Please provide a written explanation that also includes the make and model number of any automated or electronic leak detection equipment in use at your facility. B. EMPLOYEE AND AGENCY NOTIFICATION: What agencies and or corporate officials,are notified in case of a hazardous materials spill or emergency -- What procedures are used to notify these parties? At a minimum, you must call 9-1-1 and the Office of Emergency Services at 1-800- 852-7550 to report any spills that are a threat to life, safety or the environment, or for other non-emergency spill reporting, please call our office at (661) 326-3979. C. ENVIRONMENTAL RESPONSE MANAGEMENT: Please describe who will be responsible for what activities (notifying authorities, clean-up companies, etc.), and what the chain-of-command is at your facility for making sure these activities are carried out. D. EMERGENCY MEDICAL PLAN: Summarize your plan for handling medical emergencies occurring at your business. List the local medical facility capable of handling an accident involving Hazardous Materials used at your business. -. ...~. HAZARB MATERIALS MANAC SECTION II.2 - RELEASE RESPONSE PLAN .A. HAZARD ASSESSMENT AND PREVENTION MEASURES: Explain the procedures that you have developed and implemented to help prevent an incident from occurring. These steps could include, but are not limited to, storage methods, container types, segregation, safety equipment, and/or procedures used. B. RELEASE CONTAINMENT AND/OR MITIGATION: Explain the procedures that you have developed and implemented to assist in keeping a hazardous materials incident af~,our business as small or confined as possible. C. CLEAN-UP AND RECOVERY PROCEDURES: Explain what clean up procedures will be implemented in case of a release at your business. This should address small spills, as well as a major release of material once the material is contained. Hazardous Waste: Please provide the name of the hazardous waste company that regularly removes the wastes from your business, and how often that waste is removed. Please keep all disposal receipts for the last three years available on site for inspection. UTILITY SHUT-OFFS List locations of shut offs using compass points and known or obvious landmarks. If you have a lock box containing keys and maps of the facility for the Fire Department to use, please list its location also. PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. Private Fire Protection: Describe on-site fire protection for your business or facility unit, including sprinklers, fire extinguishers, alarm systems and private response teams. B. Water Availability (Fire Hydrant): Give the location of the closest water supply or fire hydrant to be used by the Fire Department in case of an emergency. 2 SECT[ON III - TRA List the number of employees that are working in the area of the hazardous materials, use or storage. Include all employees who have any occasion to be in those areas. Give the location where Material Safety Data Sheets (MSDS) are kept on file. The MSDS must be readily available on site in a place where employees can access them. , Give a brief summary of your Hazardous Materials Training Program. Employees are required by State law to have a program which provides employees with initial and refresher training in the following areas: 1) Methods for safe handling of the hazardous materials used by your business. 2) The Cal OSHA Hazard Communication Standard. 3) Correct use of emergency response equipment and supplies available at your business. 4) The prevention, minimizing and clean up procedures you have developed for your business. 5) The emergency evacuation plans you have developed, as well as, your notification procedure and medical plan. 6) Procedure to coordinate with and assist the local emergency personnel that may respond to your business 7) Who and how to call for immediate assistance in the event of an accident involving hazardous materials. CERTIFICATION Please fill in your name, title, and sign and date on the signature line. IMPORTANT You must return this plan, inventory forms, and map within 30 days of receipt. If you have any questions please call us at (661) 326-3979 Thank you for helping to keep our All America City cleaner and safer. CITY OF BAKERSFIi OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS FACILITY INFORMATION INSTRUCTIONS BUSINESS OWNER / OPERATOR FORM I. FACILITY IDENTIFICATION: Enter the reporting period (year beginning and ending) for the facility information. Enter the business name and site address and phone number of your business. Do not use P.O. box numbers. Enter the Dun & Bradstreet or federal tax identification number for your business. Enter the Standard Industrial Classification (SIC) number for your business. Each type of business has a Standard Industrial Classification code number. Some common SIC codes are listed on the back of this page. Other SIC codes may be obtained from your worker's compensation insurance forms, the State of California Employment Development Department, or by calling our office at (661) 326-3979. Enter the name and phone number of the person responsible for operating the business. II. OWNER INFORMATION: List the legal business owner or corporation name and provide the headquarter address or residential address if owned by an individual and phone number. III. ENVIRONMENTAL CONTACT: Identify the person who is primarily responsible for environmental compliance at the business. This person may be either the business owner, one of the emergency contacts, an environmental manager, or consultant. IV. EMERGENCY CONTACTS: List the name, title, and phone numbers of two people at the business who can respond if the Bakersfield Fire Department requires additional information or other assistance. These contact persons must have keys or access to all areas of the facility, be available for emergency call-outs, and have decision-making authority to call on other resources (such as hazardous waste clean-up companies) as necessary. V. CERTIFICATION: The business owner or operator must sign, date, and also identify the document preparer. COMMON sTA ~N ~DA~INDUSTRIAL CLASSIFI£ CODES 0111 Wheat production 0724 Cotton ginning 5821 Eating places 0115 Com production 0541 Grocery store 5813 Drinking places (Alcohol service) 0131 Cotton production 1541 Dry cleaners 5983 Fuel oil dealers 0139 Field crops, except cash 2911 Oil refineries grains '- 5984 LPG dealers 3441 Welding/fabrication - 0161 Vegetables & melons 7342 Pest control structural 0172 Grapes 7532 Auto top, body, 3443 Welding/fabrication - upholstery repair 0173 Tree nuts boiler Auto paint shops 0174 Citrus fruits 3569 Machine shop 7533 Auto exhaust repair 0175 Deciduous tree fruits 4222 Cold Storage 7536 Auto glass replacement 0179 Other tree fruits & nuts 4925 Compressed gas supplier 7537 Auto transmission 0192 General farms, primarily 5093 Automobile salvage repair crop 5169 Chemical supply 7538 General auto repair 0241 Dairy farms 5511 Motor vehicle dealers 7542 Car washes 0252 Chicken eggs (new & used) 8071 Chemical laboratory 0253 Turkey eggs 5521 Motor vehicle (used only) 2851 Paint manufacture 5531 Auto & home supply stores 0291 General farm, primarily livestock & animal 5541 Gasoline service stations specialties CITY OF BAKERSF~D~ OF ENVIRONMENT~SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 BUSINESS OWNER i OPERATOR IDENTIFICATION FACILITY INFORMATION Page Of __ .. i-f"::i:.i...;' .' '.. '-i <:i..'i'i::/. ;:.::?.';" . '...L{ '....~L FACILITY IDENTiFi'CATION.:<.".i., '.' ',. ' '"'.' · ' -- -- ~b2--' BUSINESS NAME (Same as FAClLITY NAME or DE~A- Doing Busjness As) ~ ' 3 [ BUSINESS PHONE SITE ADDRESS DUN & ~o~ SIC CODE B~DSTREET ..... (4 Digit ~) COUN~ ~ ~ 108 OPE~TOR NAME ~o9 OPE~TOR PHONE ~o ...,, ,:,,,. - .' ,, ~, ,-, ,¥~,C.<~ ,~--~ ?.~ ~,~ ~,,.~,? ,, ~,~-?,'~,,~ ,::,}~?,~h:,:',,'. , ',,b~'-":",,~',;>' -< ', .~ '. , -~ ,; ,'.,j,;,?'L-~'7-~? ~,-? '+ "v ~'~..,,~, ~', ,~,' ,,?~,',.~?",,~?~ ,d,~ ,.. ,:,w · ,,: ,. ~ : ~,, .,, ,,:, . ,,., ....................... .~ ......... ~ ....... , ...... ~ ,~,~,,,~ ....... , ~,,~ ~, ~ .... ';,,,', .,". .... · · .- : , ~,, '-, ~< <.,,'~' ,.,~,,,":, ',~ ~ ~,. .¥.'; ~'~' ,.x: -',,.II.,'OWNERINFORMATION ,, ,, :, <, ' ,'. ,': ', · · OWNER ~ILING,. ~ := , x;...- -:..:~ ,' ::..' · .',:.: .;,¥x~,.:-'?;7 ', ~':t,.'-':' ;~:" '.".:'~'...?d<:;.~': ~ "'-,:' "2: ~"-- ~': ::,' ? ;. 5,k.. ::.' :.."::'. 'h:¢-.; :.:.'~;.~; .' .V ' ~',~'.?'..~',~:.: '~' ~5~.~., "~< · '.; . , : ::' ~ .: '" : '::?' '"::: %:" .:,',~ :'~:"::.~.:~ s:?;~,..':~;." '.~'cv?.?,:;?5~ 5~;~: '5'q:~.?u:?:d~::~::~::~'~5.:;',¢ :; '~III':'EN~RON~ENT~L,CONTAC~..;':~',?::(,5?~; ~' "::".-,: ': :",'~:;~-.:, ,',. .:: ,:.. L.:q::' ?.: :?..~:;,~,L ..:.:.,?'.;,;-.: .. '.'.:.. · '~,. ;:~-'~.;~.:,~ ?'?. ~`h:':?~:.~h~;:~;?:;`%~i/-~?~.~`~`~:~:~?`~g~`(~?L~:¥~:~¥~:`~;~:~xb>~`:~=:~.~`~.~`~:~ ~2,:.'. ,'...~:~*~ '.:;....,,,'~;'. :'.~,~.'?.?.;:¢,;~'d~t;%':,"~'?.'"'..- ?.'"'." :7' ~':':'.'.,"',:,'::./':", :,'~.." CONTACT ~ILING ~9 ADDRESS ~~ k ~ ~ ~ · '.,'.-': ""::'-. '.""%. '"':';;PRIMARYz-"~',. ".'~. ~ d',t~%,;.. ,.;, IV~'~EMERGEN~Y'CON~A~$ ~";' ,:'::'?~;~:.¥~ :,q', ,.'. ~E~ONDARY, ~':~.? .,';". ,.:.~,"'. ";"~ "',; ~;, '; '-' "~,'";~'" ' ",/,-,':. ~','. ",~,'~.~'?', "."~ ,~,~7'" ;"-"~"'~" "~"~"~", ,', ~ z" ,-'~n ,,', · ' ",~ · ....: .... ~ '?"~ ?:'~'~""','"':" · ..... ' ': ..... TITLE ~ ~ ~.~ ~ ~25 TITLE ~30 PAGER ~ '~- 128 ' PAGER ~ 133 ' · ' ,. :.' .?. ¥'~. '.;' 'd ..'%~:. >'.?';":.-".'~ ' ..?.. 'q;~.%.'. ;&./""',.:;? · .'- .".' ~' . .' <":',.. ;. · ...... } ~.. :.,..:,':~ · , :'........ Codification: Basod on my inqui~ of ~oso individuals rosponsiblo for ob~inin~ tho in[o~ation, I ~i~ undor penal~ of law ~at I have porsonallg and am familiar with tho info~ation su~mi~od in this invonto~ and befievo th~ information ~s truo, accurate, and completo. ~IGN~RE ~ OWNE~OPE~TOR DATE 134 NAME OF DOCUMENT PREPARER 135 NAMES OF OWNE~OPE~TOR (print) ~36 TITLE OF OWNE~OPE~TOR ~37 UPCF (7/99) - S:\CUPAFORMS\OES2730.TV4.wpd STATE WASTE COD 220 If the hazardous material is a waste, enter the appropriate California 3.odigit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. A list of common State Waste Codes are included on page 4 of these instructions. UNITS 221 Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet or tons. NOTE: If the material is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons). DAYS ON SITE 222 List the total number of days during the year that the material is on site. STORAGE CONTAINER 223 Check all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: If appropriate, you may choose more than one. STORAGE PRESSURE 224 Check the one box that best describes the pressure at which the hazardous material is stored. STORAGE TEMPERATURE 225 Check the one box that best describes the temperature at which the hazardous material is stored. HAZARDOUS COMPONENT I - 5 (% by weight) 226, 230, 234, 238,242 Ifa range of percentages is available, report the highest percentage in that range. HAZARDOUS COMPONENT I - 5 Name 227, 231,235,239, 243 When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non- carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these percentages, you may attach an additional sheet Of paper to capture the required information. When reporting waste mixtures, mineral and chemical composition should be listed. HAZARDOUS COMPONENT I - 5 EHS 228,232,236, 240, 244 Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substanci~ as defined in 40 CFR, Part 355, or "N" for no, if it is not. HAZARDOUS COMPONENT 1 .- 5 CAS 229, 233,237, 241,245 List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. III. SIGNATURE: 246 Please print name, title, sign and date each chemical description form. If you have any questions please call us at (661) 326-3979 CALIFORNIA WASTE CODES Code Description Code ~ Descriotion Inorganics 241 Tank bottom waste 111 Acid solution 2 < pH < 7 with metals 251 Still bottoms with halogenated organics (antimony, arsenic, barium, beryllium, 252 Other still bottom waste cadmium, chromium, cobalt, copper, lead,' 261 PCB's and material containing PCB's mercury, molybdenum, nickel, selenium, silver, 271 Organic monomer waste (includes unreacted thallium, vanadium and zinc) resins) 112 Acid solution without metals 272 Polymeric resin waste 113 Unspecified acid solution 281 Adhesives 121 Alkaline solution pH >12.5 with'metals (see 291 Latex waste 111 ) 311 Pharmaceutical waste 122 Alkaline solution without metals 321 Sewage sludge 123 Unspecified alkaline Solution 322 Biological waste other than sewage sludge 131 Aqueous solution (2 < pH < 12.5) containing 331 Off-spec, aged or surplus organics reactive anoins (azide, bromate, chlorate, 341 Organic liquids (nonsolvents) with halogens cyanide, fluoride, hypochlorite, nitrite, 343 Unspecified organic liquid mixture perchiorate and sulfide anions) 351 Organic solids with halogens 132 Aqueous solution with metals (see 111) 133 Aqueous solution with total organic residues Sludges 10% or more 411 Alum and gypsum sludge 134 Aqueous solution with total organic residues 421 Lime sludge less than 10% 431 Phosphate sludge 135 Unspecified aqueous solution 441 Sulfur sludge 141 Off-spec, aged, or surplus inorganics 451 Degreasing sludge 151 Asbestos containing waste 461 Paint sludge 16 I. FCC Waste 471 Paper sludge/pulp 162 Other spent catalyst 481 Tetraethyl lead sludge 171 Metal sludge (see 111) 491 Unspecified sludge waste 172 Metal dust and machining waste (see 111) 181 Other inorganic solid waste Miscellaneous 511 Empty pesticide containers 30 gal or more Organics 512 Other empty container 30 gal or more 211 Halogenated solvents (methylene chloride, 513 Empty containers less than 30 gal chloroform, TCE, TCA) 521 Drilling mud 212 Oxygenated solvents (acetone, butanol, MEK) 531 Chemical toilet waste 213 Hydrocarbon solvents (stoddard solvent, &'3_~D Photo chemical/photo processing waste xylene) 551 Laboratory waste chemicals 214 Unspecified solvent mixture 561 Detergent and soap 221 Waste oil and mixed oil 571 Fly ash, bottom ash, and retort ash 222 Oil/water separation sludge 581 Gas scrubber waste 223 Unspecified oil - containing waste 591 Baghouse waste 231 Pesticide rinse water 611 Contaminated soil from site clean-ups 232 Pesticide and other waste associated with 612 Household wastes pesticide production 4 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS INVENTORY INSTRUCTIONS CHEMICAL DESCRIPTION FORM Make as many copies of the chemical description form as necessary to report your entire inventory of hazardous materials. Report every hazardous material handled in quantities equal to or exceeding 55 gallons of a liquid, 500 pounds of a solid or 200 cubic feet of a gas. Report any amount of any hazardous waste being generated or handled on site. I. FACILITY INFORMATION: Check the appropriate box for a new inventory or for additions, revisions or deletions to an existing inventory. Enter the business name at the top of the form. Enter the page number in the right hand corner. Describe the exact location of the hazardous waste or material being reported. NOTE: Chemical location information is considered confidential unless you check "no." Ifa site map is being submitted, you may refer to the map number and grid coordinates for the approximate location of the material, as shown on the map. II. CHEMICAL INFORMATION: Each of the instructions below correspond to the entw field with the same number on the chemical description form. CHEMICAL NAME 205 Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the International Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: If the chemical is a mixture or a hazardous waste, do not complete this field; complete the "common name" field instead. TRADE SECRET 206 Check "Y" for yes if the information in this section is declared a trade secret, or "N" for no, if it is not. State requirement: If yes, and business is not subject to EPCRA, disclosure of the designated trade secret information is bound by Health and Safety Code, Section 25511. Federal Requirement: If yes, and business is subject to EPCRA, disclosure of the designated Trade Secret information is bound by Title 40 Code of Federal Regulations (CFR) and the business must submit a "Substantiation to Accompany Claims of Trade Secrecy" form (40 CFR 350.27) to USEPA. COMMON NAME 207 Enter the common name or trade name of the hazardous material or mixture containing a hazardous material. EHS 208 Check "Y" for yes if the hazardous material is an Extremely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section, blank and complete the section on hazardous components below. CAS ti 209 Enter the Chemical Abstract (CAS) number for the hazardous material or mixtures, enter the CAS number of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the section below. FIRE CODE HAZARD CLASSES (Please leave blank) 2 I0 HAZARDOUS MATERIAL TYPE 211 Check the one box that best describes the type of hazardous material: pure, mixture or waste. If waste material, check only that box. If mixture or waste, complete hazardous components section. RADIOACTIVE 212 Check "Y" for yes if the hazardous material is radioactive or "N" for no, if it is not. CURIES 213 If the hazardous material is radioactive, use this area to report the activity in curies. You may use up to nine digits with a floating decimal point to report activity in curies. PHYSICAL STATE 214 Check the one box that best describes the state in which the hazardous material is handled: solid, liquid or gaseous (gas). LARGEST CONTAINER 215 Enter the total capacity of the largest containei- in which the material is stored. FEDERAL HAZARD CATEGORIES 216 Check all the physical and health hazards associated with the hazardous material: PHYSICAL HAZARDS: Fire: Flammable Liquids and Solids, Combustible Liquids, Pyrophorics, Oxidizers Reactive: Unstable Reactive, Organic Peroxides, Water Reactive, Radioactive Pressure Release: Explosives, Compressed Gases, Blasting Agents HEALTH HAZARDS: Acute Health (Immediate): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, other hazardous chemicals with an adverse effect with short term exposure. Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long term exposure. ANNUAL WASTE AMOUNT 217 If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled. MAXIMUM DAILY AMOUNT 218 Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or adjacent/outside area at any one time over the course of the year. This amount must contain at a minimum last year's inventory of the material reported on this page, with the reflection of additions, deletions, or revisions projected for the current year. This amount should be consistent with the units reported in box 221. AVERAGE DAILY AMOUNT 219 Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each building or adjacent/outside area. Calculations shall be based on the previous year's inventory of material reported on this page. Total all daily amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this location, the amount shall be the average daily amount you project to be on hand during the course of the year. This amount should be ..... consistent with the units reported in box 221 and should-not exceed that of maximum, daily amount.