HomeMy WebLinkAboutBUSINESS PLAN ~ETURN PAYMENTS TO: PLEASE MAKE CHECKS PAYABLE TO:
CITY OF BAKERSFIELD
P.O. BOX 2057 ~ ' ~ CITY OF BAKERSFIELD
BAKERSFIELD, CA 93303-2057 ACCOUN~ NO. ( ~ ~ ~] .~ RETURN THIS COPY WITH PAYMENT
INQUIRIES CONCERNING THIS BILL, ~EASE PH~E:
~KERSF[ELD~ CA 9330~
MUST ~ETU~N ~OOPY WITH _PAYMENT
KERN COHTY HEALTH DEP/il;ITlVl]ZNT PERMIT
I N%rENTORY RECORDING SHEET
PACILIW ~0~ ~Cr~l~ ~, TANK * / CAPACITY /0/~ PRODUCT ~0~/~ ~ ~ONTH/YEAR _
EQUATI ON 1 ~ -
~ 2 3 4 5 6 ~ ~ ~ s 9 ~0 ~ ~ ~2 ~3
DATE GAUGING I~ENTORY INVENTORY READING READING METERED ADJUSTMENT BEFORE ,~ :AFTER INVENTORY GAUGING
SAI,~S DELIVERY ~' DELIVERY
,.DAY/HOUR INCHES GALLONS GALLONS GALLONS GALLONS GALLONS - GALLONS INCHES 'GALS I~CHES GALS GALLONS INCHE~
I .EREBY CERTIFY T.AT THIS IS A TRUE AND ACCU~TE REPORT. SIGN*TU~E DATE /--t~' ~ 7
~. Health 580 4113 1018 (6/86)
.R~URN PAYMENTS TO: PLEAS,E/V~KE CHECKS PAYABLE TO:
P.O. BOX 2057 cITY OF'BAKERSFIELD.,
BAKERSFIELD, CA 93303-2057 ACCOUNT'NO.
/
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'ATE H~NDATED PF, u~RA~ : ,,
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~AKERSF[ELD~ CA
CUSTOMER COPY : ..... ~.,,:,, ::. .... .: .... ...... ,.
Bakersfield Fire Dept.
Hazardous Materials Division RECEIVED
2130 "G" Street /~UI~ I 6 19§9
~~~ Bakersfield, CA. 93301 ~ HAZ. MAT. DIV.
HAZARDOUS MATERIALS MANAGEMENT PLAl~.~e
1. TO avoid further action, return this form within 30 days of rece,l~,. ~
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for tl~e business as a wt~ole.
4. Be brief and concise as possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
BUSINESS NAME: L I~J ~/- ~_ ~,,t~/__~l['*_ _-"r'~
LOCATION: ~z]'O I~~
MAILING ADDRESS:
CITY' ~~ STATE:~ZIP:q~! PHONE:
DUN & BRADSTREET NUMBER' SIC CODE'
PRIMARY ACTIVITY', ~~/~ ~
OWN :
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT TITLE BUS. PHONE 24 HR, PHONE
1,
Bakersfield Fire Dept. '~
Hazardous Materials Division
~x.~i..:,~.; HAZARDOUS MATERIALS MANAGEMENT PLAN
\,' i Ct..S E.C..TI OJ~,,3: TRAINING:
MATERIAL SAFETY DATA SHEETS ON FILE: ~.~%
BRIEF SUMMARY OF TRAINING PROGRAM: ~ ~)1~' '~'~.~ ~..~'"j~-~)/~,
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:
I, ~~V.~' ,~-O~D~ ~-- CERTIFY THAT THE ABOVE INFER-
MATION IS ACCURATE, I UNDERSTANDTHATTHISINFORMATION 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,
SIGNAI~E TITLE DATE
2.
,~1530
: ~ .:. Bakersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
Facility Unit Name: ~o~-~. ~.e,.~ ~ ~ ~_~,,.
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES:
L,~ ~t~s ~c.
B. EMPLOYEE NOTIFICATION AND EVACUATION:
C, PUBLIC EVACUATION'
D, EMERGENCY MEDICAL PLAN:
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-OF_FS AT YOUR FACILITY):
ELECTRICAL:
WATER'
SPECIAL:
LOCK BOX: YESO IF YES, LOCATION' "
SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY:
A, PRIVATE FIRE PROTECTION'
B. WATER AVAILABILITY (FIRE HYDRANT)'
4, FDI590
CITY of BAKERSFIELD '"
Farm andAgticulture [] Standard Business .~HAZARDOUS MATERIALS I'~NVENTORY
NON--TRADE SECRETS Page ___/__ of
BUSINESS NAME' / ~,,,t~.A~-
LOCATION: ..... ,~d~_Zql.~ ~ .... ~.~ ~, OWNER NAME: ~~ ~O~E NAME OF THIS FACILITY:
CITY.PHONE ZIP~~ ~ol - ADDRESS; ~f ~,o~o~z' STANDARD IND. CLASS CODE'~~~
CITY.~J~ ~[~~ZIP: ~ e~o~ DUN AND BRADSTR~ET NUMB~
I 2 ~ 4 5 6 ~ II 12
Code ~ooe Amt Am: EsL Un~LS on ILe ~ype ~ress ~emp Co~e Stored In kacli~ See Instructions
Physical and Health 'Hazard C.A.S. Number ~ G~I fl Component II Name I C,~.l~um~r~ .... " -
(Check al/ thaL apply)
~ Fire Hazard ~ Reactivity ~ DelayedHealth ~ Suddenof Pressure Release ~ Im~?~ Component 12 Name I C.A.S. Number ~SO
ComponenL 13 Name I C.A.S. Number
W II I I , I ,
'PhySical ~0d ~ealth Ua~ard C.A.S. Humber Component II Hame ~ C.A.S. Number
(Check HI that app/~J
~ Fire Hazard U Reactifity a DelayedHem~th n Suddenof Pressure Release ~ [m~i~ Component J2 Hame, C.A.S. Humber
Component 13 Hame I C.A.S. Number
Physical and HealthUazard C.A.S Humber Component II Name I C.A.$. Number
(Che~k all that apply) ·
~ Fire Hazard n Reac[ifity ~ DelayedHeal[h ~ Suddenof PressureRelease ~ ],~i~ Component 12 Name & C.A.S. Number' ~
Component 13 ~ I C,A,S, Humber
Physical lcd ~ealth UalArd C,A.S, Number Component II Name I C.A,S Number
{Check 41l that ApP/H
Component 12 Name I C,A.S. Number
~ Fire Hazard ~ Reactivity ~ Delayed ~ Sudden Release ~ Immediate
Hea ICh of Pressure
Health
Component 13 Name. I C.A,S, Number
. ~ ~. &/~ ~ -, ,,. ..
EMERGENCY CONTACTS ¢~ ~ ~p3~r/-[Pl~gJ~~/~. ~~
~me ~ IICle ~one ~ TIT .... 2T~( Phone
CerLifj ati0 Re and i n af r corn 1 ting ~11 s c~io.ns) '
X ,certify. un'er pertain, o~ thc I ~,vrpeesona~.examinq~eq~ ~, famil,aC, vit~ ~e InformaL,on 8ubmiLte~ in this ,nd ,!1 _
aC~ached'~QSumen~, ~n~ t~ oasea on. my inquiry 9L chose Inalv~oue~s responsible for obtaining the
,~T~cl~rr~ o~ d~nqr~er~o¢ u~ ownerloper~tor:s 8uthori~e~ reore~nta[ive- ~qna[ure ~
OHMMP PLA~ MAP
SITE DIAGRAM ~ FACILITY-DIAGRAM