The URL can be used to link to this page

Home My WebLink AboutBUSINESS PLAN 4/5/2001 (2) II Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This permit is issued for the following: [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials I-I Risk Management Program El Hazardous Waste On-Site Treatment PERMIT ID # 015-021-002225 KERN CARDIOLOGY LOCATION 2323 ~i¢ 93301 OFFICE OF ENVIRONMENTAL SER VICES' · c" 'JIJ[. 2 3 [tO§! 1715 Chester Ave., 3rd Floor Approved by: .o~ Bakersfield, CA 93301 CoRat~Pc~cHe ~EeYv..[~.~tv' ._..~---'7.m,~erv,¢~.~, Issue Date Voice (661) 326-3979 FAX (661) 326-0576 ExpimtionDate: '-Iun~_ .'lfl~ l}flfl~ l~estrooms Exam 1 Exam 2 Exam 3 Exam 4 Dr, Office 1 Dr. Office 2 Computer ~ ~ '~00m Thallium Vi 0,00m Echt ~ Kitchen Hallway ~;;~ ~ R~roomHallway .- ~ ~ ~ st~s Lab 2~- Dr, Office 3 ~.~Waiting Room ~.~ ~ BillingOffice~ ~x , [ St~.~ta~l~ ~Legend:~s prlnkl~ r' Oxygen Tanks /Exit to Main Hallway ~ Fire Extinguishers II Site Diagram I Kern Cardiology Medical Group Inc. 2323 16th Street, Suite 305 '~ Fire Hydrants Truxtun Avenue I ~ I Mercy Hospital 16th Street Site: Mercy Medical Plaza 2323 16th Street ~IOLOGY MEDICAL GRiP KERN INC. Sam Singh, M.D. Diplomate American Board of Internal Medicine Diplomate Subspecialty Board of Cardiovascular Medicine ~ ~ O~ April 5, 2001 ~ ~ Office of Environmental Service Dept. 1-7-1-5 Ghester AvecSuite-300 Bakersfield, CA 93301 To Whom it May Concern, The State of California has requested that Kern Cardiology Medical Group Inc., inform the Bakersfield City Fire Dept., that we have these Radioactive Sources on our premises. Please see the attached Radioactive Source List provided by Syncore listing the sources that are in our suite. Our Radiation Safety Officer is Donald Comforth M.D. which can be reached at 661-633-3688. Kern Cardiology Medical Group Inc.'s reason to have these Radioactive Sources on the premises is for Nuclear Medical Testing. This letter is to comply with the State of California's Contamination Regulations. Should you have any questions please feel free to call our office. Sincerely Yours, Carol Langille, Office Manager .. '. .. 2323 16th Street · Suite 305 · Bakersfield, CA 93301 · (66l) 327-0807 · Fax (661). 327-7593 KERN C DIOLOGY MEDICAL GRiP INC. Sam Singh, M.D. Diplomate American Board of Internal Medicine (~-'~i Dipl°mate Subspecialty B°ard °f Cardi°vascular Medicine ~/~ O~ April 5,2001 ~ Office of Environmental Service Dept. 171-5 Chester Ave, Suite-300 Bakersfield, CA 93301 To Whom it May Concern, The State of California has requested that Kern Cardiology Medical Group Inc., inform the Bakersfield City Fire Dept., that we have these Radioactive Sources on our premises. Please see the attached Radioactive Source List provided by Syncore listing the sources that are in our suite. Our Radiation Safety Officer is Donald Cornforth M.D. which can be reached at 661-633-3688. Kern Cardiology Medical Group Inc.'s reason to have these Radioactive Sources on the premises is for Nuclear Medical Testing. This letter is to comply with the State of California's Contamination Regulations. Should you have any questions please feel free to call our office. Sincerely Yours, Carol Langille, Office Manager 2323 16th Street · Suite 305 · Bakersfield, CA 93301 · (661) 327-0807 · Fax (661) 327-7593 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ~,/"M F-~;b~o~.o~f_ INSPECTION DATE ADDRESS 2 .~ ,i~,.~, I/..-'/~ ~,a,'"~ ~o-~ PHONE NO. ~'~.? -,-0 8'o7 FACILITY CONTACT L~,~. 3'/"'/6/4.- BUSINESS IDNO. 15-210- ~.- 2. 9.~.~' INSPECTION TIME I th Ina/~'~-~ NLIMBER OF EMPLOYEES Section I: Business Plan and Inventory Program '[~outine {~ Combined I~ Joint Agency [~] Multi-Agency ~l Complaint ~] Re-inspection OPERATION C V COMMENTS Apprgpriate permit on hand Business plan contact information accurate ' Visible address Correct occupancy Verification of inventory materials Verification of quantities Verification of location 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 Explain:Anyhazard°uswaste°nsite?: [~Yes ~No ~..x /'~~~ '~.,~,~~/~' _t~ ' Questions regarding this insp~on? Pl~aaa call us at (66 I) 326-3979 Business Site ResponS~le Party White- Env. Svcs. Yellow- Station Copy Pink- Business Copy Insp¢ctor:._t~. KERN CARDIOLOGY MEDICA OUP SiteID: 015-021-002225 Manager : ~~' BusPhone: (661) 327-0807 Location: 2323 16TH ST 305 Map : 102 CommHaz : Minimal City : BAKERSFIELD Grid: 25D FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 01 SIC Code: EPA Numb: DunnBrad:77-045734 Emergency Contact / Title Emergency Contact / Title DR SABARJIT SINGH / OWNER ~AWN AUBRY ~;.~'~/ NUC MED TECH Business Phone: (661) 327-0807x Business Phone: (661) 327-0807x 24-Hour Phone : ( ) - x 24-Hour Phone : (661) 589-9212x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire ImmHlth DelHlth Contact : DAWN AUBRY~3-im~ ~o~5 Phone: (661) 327-0807x MailAddr: 2323 16TH ST 305 State: CA City : BAKERSFIELD Zip : 93301 Owner DR SABARJIT SINGH Phone: (661) 327-0807x Address : 2323 16TH ST 305 State: CA City : BAKERSFIELD Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: _._)ar'a6,~i.f.3 in~hn,.,~. Do hereby certify that I have (T)m~ o~ min~ reviewed the attached hazardous mater)als manage- ment plan for~,~n~arc{;ol~ v and that it along with (Name of Bu~tn~'~ any corrections constitute a complete and correct man- agement plan for my fac li~. -1- 08/22/2003 KERN CARDIOLOGY MEDICA OUP SiteID: 015-021-002225 Fast Format ~ Training Overall Site Employee Training ~3/2001 WE HAVE 6 EMPLOYEES AT THIS FACILITY. ~ WO YOU HAVE MSDS SHEETS ON FILE??????? (YOU NEED TOO!!!) BRIEF SUMMARY OF TRAINING PROGRAM: Page 2 Held for Future Use Held for Future Use 8 08/22/2003 KERN ~IDIOLOGY MEDICAL GP~P INC. Sam Singh, M.D. Diplomate American Board of Internal Medicine Diplomate Subspeeialty Board of Cardiovascular Medicine September 5, 2003 Bakersfield Fire Department Prevention Services 1715 Chester Ave. Bakersfield, CA 93301 Attn: Ralph Huey Reg: Site ID//015-021-002225 Kern Cardiology Medical Group Inc. Kern Cardiology Medical Group Inc. has an Exposure Control Plan that provides practical, detailed guidance for compliance for all of our Hazardous Materials. The MSDS sheets sent to us from our Medical Suppliers are keep in a file and are given to the appropriate departments. Kern Cardiology Medical Group Inc. has yea~ly~aini-ng~d~e-s(in~ of hlYemployees on the safety of our Nuclear Thallium Lab. 2323 16th Street · Suite 305 · Bakersfield, CA 93301 · (661) 327-0807 · Fax (661) 327-7593 KERN CARDIOLOGY MEDICAI SiteID: 015-021-002225 Manager : BusPhone: (661) 327-0807 Location: 2323 16TH ST 305 Map : 102 CommHaz : Minimal City : BAKERSFIELD Grid: 25D FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 01 SIC Code: EPA Numb: DunnBrad:77-045734 Emergency Contact / Title Emergency Contact / Title DR SABARJIT SINGH / OWNER DAWN AUBRY / NUC MED TECH Business Phone: (661) 327-0807x Business Phone: (661) 327-0807x 24-Hour Phone : ( ) - x 24-Hour Phone : (661) 589-9212x Pager Phone : ( ) - x Pager Phone : ( ) - x ....................................... +_ Hazmat Hazards: Fire ImmHlth DelHlth .............................. Contact : DAWN AUBRY Phone: (661) 327-0807x MailAddr: 2323 16TH ST 305 State: CA City : BAKERSFIELD Zip : 93301 Owner DR SABARJIT SINGH Phone: (661) 327-0807x Address : 2323 16TH ST 305 State: CA City : BAKERSFIELD Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: Res: No Emergency Directives: += Hazmat Inventory = One Unified List + +== Alphabetical Order Ail Materials at Site + + -+ ....... +- -+- + -+ .... +- - -+ Hazmat Common Name... ISpeoHazlEPA HazardsI Frm I DailyMax IUnitlMCPI + -+ ....... +- -+- + -+ .... +- - -+ OXYGEN F IH DH G 2300.00 FT3 Low I,..~.~,~j'~'~/.~,'~e/~,.~. Do hereby certify that I have ~ryp~ or p~n: reviewed the at'~ched h~ardous mate~als manage- ment pla:~ for~n~a,d,oioq~?~d that it along with (Na~ of any corre~ions constitut~complete and corre~ man- / agement plan for my f~cili~. ~ -' 02/12/2002 '+ KERN CARDIOLOGY MEDICAL~GROUP SiteID: 015-021-002225 += Inventory Item 0001 Facility Unit: Fixed Containers at Site +== COMMON NAME / CHEMICAL NAME ---4 OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: +- IN STRESS LAB 1 AND 2 CAS# 7782-44-7 + ------4 .... += STATE =+= TYPE ===+== PRESSURE ===+ TEMPERATURE ==+ .... CONTAINER TYPE ..... I Gas I Pure I. Above Ambient I Ambient I PORT. PRESS. CYLINDER += 4 ~ + ~ += ~ AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average 1150.00 FT3 2300.00 FT3 1150.00 FT3 q =====4 ~ =====+ += + ......... HAZARDOUS COMPONENTS +===4 %Wt. Ioxygen, Compressed N~SI CAS# 100.00 7782447 += + +== + + +===+ ....... + HAZARD ASSESSMENTS ===4 + ~ ..... ITSecret N~S Bi°Haz IRadi°active/Am°untNo No No/ Curies EPA HazardsIF IH DH NFPA/// IUSDOT# MCP + +===+= .... =4 ---- ~ ~ + ~=====+ 2 02/12/2002 O CE OF ENVIRONMENTA RVICES 1715 Chester Ave., CA 93301 (661) 326-3979 BUSINESS OWNER / OPERATOR IDENTIFICATION FACILrFY INFORMATION Page Of I ° . ": ...... ..... ..' .I. FACILITY iDENTiFICATION.. . . F^C,UTYID# l!i~!l i?: ~ YearBegiW~.O~ ~oo YearEnding 700~.~.' '" ' ' c' '" .:~ '4)~' .:".' 6'~.,, ¢ .~ ' '~ <',, ... ".,..' ';'.."¢.,.~. ~ ,'"~'%~';.' ".~;."¢.q~'.' '.,'. ~.-: ~ ~. /..- · ' ' ·' ' · ~. ' ": ,',', '..;< - ' '. '.'. ..'. .,',. '.'',', '~ ?'.....,, ' .' ' · ' '.' · ~.. %~-.? ..: ' E,~~' ' *'~'.~..' '~%E~. :;.. '" ..% ¢.. :?~.~, .~(, .: :'; .~"¢'¢,, .. .' '.. ,. · ' ".. C', ,-..~..~%.., ¢,,'.'q~ ~ ~ ',.'~,., .., ,..: '.. ', · ~ ~.. ,. ?'. ' '.. ~.. ' .... · · CONTACT MAILING~ BUSINESS PHONE ~ ~ O~ ~ ~ 126 BUSINESS PHONE ~ ~ 0~07 131 Ce~ification: Based on my inquii~o~;~ individuals responsible for obtaining the info~ation, I ~i~ under penal~ of law ~atl have personally examined and am familiar with the informa .i~bm~ed in this invento~ and believe the information is tBe, aocumte, and complete. SIGNATURE OF OWNE~OPE~T~R . ~ ~ DATE _ 134 NAME OF DOCUMENT PREPARER 135 v NAMES OF OWNE~OPE~T~E~ ~ . ~36 TITLE OF OWN~OPE~TOR / ~3~ UPCF (7~99) S:\CUPAFORMS\OES2730.TV4.wpd + KERN CARDIOLOGY MEDICAL GROUP SiteID: 015-021-002225 + Fast Format += Notif./Evacuation/Medical Overall Site +== Agency Notification 07/23/2001 E TANK, OXYGEN, WITH REGULATORS. + +=== Employee Notif./Evacuation 07/23/2001 911. + + .... Public Notif./Evacuation 07/23/2001 OFFICE MANAGER IS TO REPOND TO EMERGENCY AGENCY, THEN TO PRESIDENT OF KERN CARDIOLOGY MEDICAL GROUP, SARABJIT SINGH, MD. + + Emergency Medical Plan 07/23/2001 911. -3- 02/12/2002 ~ KERN CARDIOLOGY MEDICAL GROUP = SiteID: 015-021-002225 + ~ Fast Format + += Mitigation/Prevent/Abatemt == Overall Site + +== Release Prevention -- 07/23/2001 + OXYGEN TANKS ARE SECURED TO CARTS AND ARE OUT OF FOOT TRAFFIC FOR SAFETY. TANKS ARE CHECKED BY SUPPLIER MONTHLY FOR LEAKS. +=== Release Containment 07/23/2001 + OXYGEN TANKS ARE SECURED TO CARTS AND ARE OUT OF FOOT TRAFFIC FOR SAFETY. TANKS ARE CHECKED MONTHLY BY SUPPLIER FOR LEAKS. += + + .... Clean Up = 07/23/2001 + OXYGEN ONLY. ~ Other Resource Activation + -4- 02/12/2002 ~ KERN CARDIOLOGY MEDICAL~GROUP SiteID: 015-021-002225 + Fast Format += Site Emergency Factors Overall Site +== Special Hazards I +=== Utility Shut-Offs 07/23/2001 A) GAS - ON ROOF B) ELECTRICAL - SUB PANELS IN UTILITY ROOM C) WATER - INSIDE ROOM IN FRONT OF BLDG D) SPECIAL - NONE E) LOCK BOX - OVER ELEVATOR ROOM FRONT OF BLDG AND BLDG MANAGER FOR MERCY HOSPITAL, ROGER YATES AT 322-7081. + .... Fire Protec./Avail. Water 07/23/2001 PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS AND BLDG IS SPRINKLERED. NEAREST FIRE HYDRANT - ONE ON THE CORNER OF A ST AND 16TH ST. Building Occupancy Level -5- 02/12/2002 % KERN CARDIOLOGY MEDICA OUP SiteID: 015-021-002225 + Fast Format += Training = == Overall Site +== Employee Training 07/23/2001 WE HAVE 6 EMPLOYEES AT THIS FACILITY. we YOU HAVE MSDS SHEETS ON FILE??????? (YOU NEED TOO!!!) BRIEF SUMMARY OF TRAINING PROGRAM: + +=== Page 2 + .... Held for Future Use + q Held for Future Use ==+ -6- 02/12/2002 Sam Singh, M.D. Diplomate American Board of Internal Medicine Dipl°mate Subspecialty B°ard °f Cardiovascular Medicine ~/4~/~ ~ ~ April5,2001 ~ ~' ~* ' ' Office of Environmental Service Dept. 1715 Chester Ave; Suite 300 ............. Bakersfield;-CA- 93 3 01 ......................................................................... To Whom it May Concern, The State of California has requested that Kern Cardiology Medical Group Inc., inform the Bakersfield City Fire Dept., that we have the~e Radioactive Sources on our premises. Please see the attached Radioactive Source List provided by Syncore listing the sources that are in our suite. Our Radiation Safety Officer is Donald Cornforth M.D. which can be reached at 661-633-3688. · Kern Cardiology Medical Group Inc.'s reason to have these Radioactive Sources on the premises is for Nuclear Medical Testing. This letter is to comply with the State of California's Contamination Regulations. Should you have any questions please feel free to call our office. Sincerely Yours, Carol Langille, , Office Manager_ ............ : ..... r .................. : ............ , ......... 2323 16th Street · Suite 305 · Bakersfield, CA 93301 · (661) 327-0807 · Fax (661) 327-7593 Syncor® &cot Health Physics Servfces ,- The Service Difference:"" SEALED SOURCE LEAK TEST pg. 1 Location: KERN CARDIOLOGY Test Date: 02/06/01 2323 16TH STREET ~$o5- - 102089 BAKERSFIELD, CA 933Oi Next Due:~!~~01;?~ili NUCLEAR MEDICINE Counting Instrumer~ Make: LUDLUM Model: 2200 Serial#: 101331 ID: Customer Instrument?: No Ba-133 00101 11/05/92 '0,109uCi 0,063uCi 16 "23025 16.56% Co-57 693-65-14 08/01/00 0,110uCi 0,068uCi 155 119412 79,76% - Cs-137 "- 00111 07~20~93 .... 0,107uCi -- 0,090uCi .......... 8 ..........15415 - -7.80.% Da-133 S-6017001-09 239,000uCi 04/16/90 15 0,00000000 Pass :" ' ' Vial Reference Srce CAPINTEC .117,081 uCi Co-57' 567-75-3 5.574mCi 08/01/98 160 0,00000285 Pass Vial Reference Srce IPL 533,420uCi Cs-137 58117001-01 103,300uCi 03120190 8 0,00000000 Pass Vial Reference Srce CAPINTEC 80.332uCi Comments and Recommendations: Sealed source leak testing must be performed periodically in accordance with your facility license conditions. Performed by: EDWARD CORROS Radiation Safety Officer The Service Difference:"" SEALED SOURCE LEAK TEST pg. 1 Location: KERN CARDIOLOGY Test Date: 02/06/01 2323 16TH STREET ~$05- - 102089 BAKERSFIELD, CA 933Oi Next NUCLEAR MEDICINE Counting Instrument: Make: LUDLUM Model: 2200 Serial#: 101331 ID: Customer Instrument?: No ..... Ba-133- .... 00-1-01- -1-1/0'579~-'-- ~'O~-fO-g~ci----~.O63uCi - ~¥6-- ---23025 -- Co-57 693-65-14 08/01/00 O.110uCi O.068uCi 155 119412 79.76% Cs-137 00111 07~20~93 O. 107uCi O.090uCi 8 15415 7.80% Ba-133 S-8017001-09 239.000uCi 04/16/90 15 0.00000000 Pass ;'" Vial Reference Srce CAPINTEC 117.081 uCi Co-57 ,567-75-3 5.574mCi 08/01/98 160 0.00000285 Pass Vial Reference Srce IPL 533.420uCi Cs-137 58117001-01 103.300uCi 03/20/90 8 0.00000000 Pass Vial Reference Srce CAPINTEC 80.332uCi Comments and Recommendations: Sealed source leak testing must be performed periodically in accordance with your facility license conditions. Performed by: EDWARD CORROS Radiation Safety Officer '~El~~-'~r-'"7~'--~" F~i~ CITY OF ~AgRSFIEL~ ~ ~ ~ s ~ ~ O CE OF ENVIRONMENTAL SERVICES . ~ FI~ W ~Rr~r 1715 Chester Ave., CA 93301 (661) 326-3979 CHEMICAL DESCRIPTION (one fo~ per mate~al per building or ama) ~W ~ ADD ~ DELETE ~ REVISE 200 Page '.' .' -. ..,. BUSINGS NAME (Same as FAClLI~ NAME or DBA - Doing Busin~ ~) _ ' 3 CHEMICAL LOCATION . M~ ~ ~ ~ · . ~ ~ ~ 20a CHEMICAL LOCAIION ~ Y~ ~ No 202 FACILIW ID ~ [ ~ [:{.~',~ I I [~':': I ~ J I J J I 11 ~P 8 (op~naO 203 GRID ~ (o~t~naO 2~ ' _,. ' .., .~..;;::..' ~. '..':'.?~../.;, ..'?..:?;:~': ~.~ II.'C,EMICAL INFORMATION'?'~' . ::...."':: 205 T~DE SECRET ~ Y~ ~o 206 CHEMICAL ~ME O ~~ If Subj~ to EPC~ refer to instm~i~s 207 CAS~ 209 *If EHS is'Y~.' ~ ~ ~low must ~ ~ ~s. FIRE ~DE H~RD C~SSES (~mplete if r~u~t~ by I~1 fire ~i~ 210 W.E ~PURE D m U,~.E D w W*STE 2. ~D,O*CT[V~ D V~ ~o 2~2 ~ CUR~ES 2~3 PHYSICAL STATE ~ S SOLID ~ ' LIQUID ~S 214 ~RGEST CONTAINER (~) 215_. FED H~R~ CATEGORIES ~ ~ PRESSURE REL~SE ~ 4 acura H~CTH ~ S C.aO.~C .~k~H 2~ {Ch~ all that a~ply) a FIRE ~ 2 R~CTIVE A~U~ DAILY A~UNT ~ f ~. DAILY A~UNT ~ UNITS* ~ ga GAL ~ d CU ~ ~ lb LBS ~ tn TONS 221 DAYS ON SITE ~2 · If EHS. amount must be in lbs. ' SYO~GE CONTAINER ~ a ABOVEGROUND TANK ~ · P~STI~NONMETALLIC DRUM ~ i FIBER DRUM ~ m G~SS BO~LE ~ q ~IL CAR 223 (Check all that apply) ~ b UNDERGROUND TANK ~ f CAN ~ j BAG ~ n P~STIC BO~LE ~ r OTHER ~ c TANK INSIDE BUILDING ~ g ~R~Y ~ k BOX ~ o TOTE BIN ~ d S~EL DRUM ~ h SILO ~CYLINDER ~ p TANK WAGON STOOGE PRESSURE ~ AMBIE~ ~ aa ABOVE AMBIENT ~ ba BELOW AMBIENT ~4 STOOGE TEMPE~TURE ~ AMBIE~ ~ ~ A~VE AMBIE~ ~ ba BELOWAMBIE~ ~ c CRYOGENIC 225 . ' .:.' :: ,. ~= = '..'9;?: ?. %?~;/:~:;':;' ... '., .... , ='/~..':?;;~:~'~;,;5'~::~.:':.&~.2~':??i,¢,';3~'~'/~!,..'. ':: '.' ?'.?:. '~ :' · Y,':.'"~?:' ' ~ · ..' :....%~:,..:~?.: ;~ +. :: '." ::',~%:' .. -' ..'.. = =::~.;::~:~:'¢~.~aDous~;~eO~E~= ".~'..:'.;.:/::; ',:'.."?: '. ': :'"' :.~'-:~' ;4:~.~."".:: :;~:~" "':'" ~' .'~:' ": ' ':'.'.~9 [ : .. . 2 230 231 ~ Yes ~ No 232 233 3 2~ ~5 ~ Y~ ~ No 236 237 4 238 239 ~ Y~ ~ No 240 24~ 5 242 243 ~ Y~ ~ No 244 245 AU.ORiiED'coMPANY RE'RE ~[TX[}E~ PRINT NAME & TITLE Of ~ ~,~ ~~ ~ , ~' .... SIGNATURE ..... ' " DATE 246 UPCF (7~99) S:\CUPAFORMS\OES2731 .TV4.wpd ~ ~'tR£ I OFFICE OF ENVIRONMENTAL SERVICES tn~,Attrt~t~r 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS MAN[AGEMENT PLAN INSTRUCTIONS: 1. To avoid ~her action, return th~fo~ within 30 days of receipt. 2. T~E~T ANS~RS IN ENGLISH. 3. ~swer the questions below for the business as a whole. 4. Be as briefed concise as possible. 5. You may also attach Business Omer / Operator Fo~ ~d Chemical Description Fo~(s) to ~e front of~is pl~ instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA us , ss m: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II. 1' DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: U 7hn~ 0~0~ $ ~ d,4~.s ',( 02 Ta,,ts W f4n r~6./.~4o..r B. EMPLOYEE AND AGENCY NOTIFICATION: q// C. ENVIRONMENTAL RESPONSE MANAGEMENT: O~ZT/~e- ,/'~a,a~_,~-e,,-- /',S % D. EMERGENCY MEDICAL PLAN: 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION I1.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES' O>cr.,~*h q-an~:s ,~,-e. $~e~.Z 40 ~a,-4s ,,~d.. ere ~ r/~. B. RELEASE CONTAINMENT AND/OR MITIGATION: C. CLEAN-UP AND RECOVERY PROCEDURES: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) ~q~TURAL GA~PROPANE:a'~oe>0 C--.,ct .~ ~Oor ~om ELECT~CAL: ~ro~d ~ loov, C~, It&vt Ooo~ SPECIAL: LOCK BOX: ~O IF YES, LOCATION: P~VATE FI~ PROTECTION~ATER AVAIL~ILITY A. PRIVATE FIRE PROTECTION: B. WATER AVAILABILITY (FIRE HYDRANT): 3 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING NUMBEROF EMPLOYEES: ~O MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: CERTIFICATION I, -- ~ , ~. CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE'' ON HAZARDflkUS MATERIALS .(DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURAT~qP~RMATION CONSTITUTES PERJURY. SIGNATURE "-k }d ~" \ xl/ TITLE DATE 4