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Home My WebLink AboutBUSINESS PLAN (2)Hazardous Materials/Hazardous Waste Unified'Permit CONDITIONS OF:PERMITON REVERSE SIDE 1ELD Permit ID #:: 015-000-000539 KERO TV' LOCATION: 321 21ST ST .' ;. , ' This _.ermit is issued for the followil~_ · ~- . [] Hazardous Materials Plan ' .' .: ..D Underground Storage of Hazardous Materials .. El Risk Management Program ._ · D Hazardous Waste on-Site Treatment ,,. Issued by: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES' 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Approved by: Expiration Date: June 30. 2003 Issue Date Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE PERMIT ID# 015-021000539 KERO TV LOCATION 321 21 ST ~, =?,~,~?,~;~,,~.,~,=, .............. This permit is issued for the following: ' ?,~' i"?,;';:~;~ ...... :~i::i:;;;;;::i;i;;;~:i::i;;;;=:=:i;~:~i ;!!?.::!~.!Hazardous Materials Plan .,~,,,,'~:~i':"!~ ,,!~, !";i~"~:'~'~':;ii i!iiL ~..~{};~!!!ii~i~,. ;ii~iil; F;:::: i~:i:~:~ O:~ae:[ground Storage of Hazardous Materials ~-.-..... '5 '~.-,~ :~' '~;~v~4~i~==,~.':. .:~..: ~=... ~' "~. ..'~. i~ir ~ %.:~.~;' "*"~ .;'i ~ ~ ..... ~*%'?~ .,,,~:.~[,='~ .,~ ~. ',. Issuedby: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (805) 326-3979 FAX (805) 326-0576 Approved by: Expiration Date: June 30, 2000 TE/.FAC I L I T¥ FORM '~ ~F-~~,-~- ~: .... (CHECK ONE) SITE DIAGRAM FACILITY ] ...... ......., ~ ! ~ ~ .'[ ' , ~ I I~ " ~ ~ ~,~._' ~ ~I' ' --' I; ~;;," ~ · ~,~ i · ~. e · , ~ .. '.m~;~ · _e , I~ ~ .i "~ ~lil :i..'._ i" I '~ ' ' 'Ii' ' !~;/.' ~ , ~ ' ~ '-"". I~ ' --~ ' 7~ ' - -:~_ ~ -I ill .' . ~ '~ ~1'~ I~: '~ I~ [ ~ ~ .... r ,.' ' ' , " ~ ~ .~ I ~, ~ r~ . :~ ............. ~ ...... [(Inspector's Comments): p0FFICIAL USE ONLY- - ~A - TE/FACILI TY D FORM (CHECK ONE) SITE DIAGR,~M FACILITY DIAGR.~X &,w i--it ~ ;, ~., ~ ~ ! ~,· U L----I ~'~ ~ o '~ ...... . "~-.. .'.' f .' ,,, (Inspecto~'s Comments): -OFFICIAL USE ONLY- TE/FACI LI TY ~DI RAM FORM 8 %. I(Tnspector's Comments): -OFFICIAL USE ONLY- - 5A - 1. Ad,rems: Identi~RP' 9. Lock (k~ 3ox principle buildings by the Street nusbera. 10. MSD$ Storage Box 2. Street(s), Alleys, 11. Railroad Tracks Driveways. and Parking Areas adjacent to the 12. Fence or Barrier property, include the a. Wire street names. b. Masonry 3. Storm Drains, Culverts, Yard Drains c. Mood 4. Drainage Canals, Ditches. d. Gates Creeks, 13. Powerllnes 5. Buildings a. Frame construction 14. Guard Station b. Masonry construction IS. Storage Tanks: Identify the c. Metal construction capacity In gal. &. Above ground d. Access Door b. Underground 6. Utility Controls a. Gem 16. Diking or Berm b. glectriclty 17. ivmcuatioo Route c. Water 18. Evacuation Area: - Identify the ?. Fire Suppression Systems: location where a. Plre Hydrants employees will neet. b. Fire Sprinkler 19. Outside Hazardous Connections Masts Storage c. PAre Standpipe 20. Outside Hazardous Connections Watarial Storage d. Mater Control Valves 21. Outside Hazardous for protection systems Material Uae/Handling e. Fire Pu~p 22. Typ~ of Hazardous Material/Waste Stored 8. Fire Department Accema or Used (See Below} TYPE OF HAZARDOUS M~TERIA~ F - Flammable g m g.~ploalve. L - Liquid R - RadJologlcal C m Corrosive 0 - Oaidlzer O , Oas P · Poison M - Mater Reactive T · Toxic S - Solid 'H - Cryogenic O - #sate B · Ht/ologtcal Exaaple:Flamble Liquid - FL FACILITY O[AGRA~ (Required trill tn addition to the 1. Risers roe 9prinklere 8. Fire Escapee 2. Partitions B. Air Conditioning Units 3. Stairways: Indicate the lO. Windows levels servmd From highest to lo~eat. 11. Inside Hazardous Mamts Storage 4. Escalator: Indicate the levels served from la. Inside Hazardous highest to Inmost. Materials Storage 5. Elevator 13. Inside Hazardous Materials Ume/Handling B. Attic Access 14. sewer Drain Inlets 7. Skylights CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3r'~ Floor, Bakersfield, CA 93301 ADDRESS 7Z.{ 7-..! -cT' PHONE NO. FACILITY CONTACT"7'~&~ L,-)/W//3ff_~/--5/ BUSINESS ID NO. 15-210- INSPECTION TIME _..../~ .~.q,,A/ ' NUMBER OF EMPLOYEES Business Plan and Inventory Program [~ Routine {~ Combined [~ Joint Agency ~'~vlulti-Agency ~ Complaint [~ Re-inspection OPERATION C /V COMMENTS Appropriate 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 V 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 ffNo Questions regarding this inspection? Please call us at (661) 326-3979 Business Site Responsible ~rty KERO TV SiteID: 015-021-000539 Manager : ~_/~ ~4~ BusPhone: (661) Location 321~21ST ST Map : 103 CommHaz : Low City : BAKERSFIELD c~%% %%%% Grid: 30B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 04 SIC Code:4833 EPA Numb: DunnBrad:07-796-3585 Emergency Contact / Title Emergency Contact / Title 'TOM WIMBERLY / CHIEF ENGINEER RICH GREENHALGH / ENGINEER Business Phone: (661) 637-2323x337 Business Phone: (661) 637-2323x342 24-Hour Phone : (661) 834-2309x 24-Hour Phone : (661) 664-7439x ......D~g~ho~ ., (CC'~, 321 2424~ ~Pa~r Phone .. ~a~).~_ ~-~ 724~x Hazmat Hazards: Fire ImmHlth DelHlth Contact : MASTER CONTROL Phone: (661) 637-2317X MailAddr: -B~--5~-321 21ST ST State: CA City : BAKERSFIELD Zip : Owner MCGRAW-HILL BROADCASTING Phone: (661) 637-2323x Address : 321 21ST ST State: CA City : BAKERSFIELD Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: -1- 08/22/2003 KERO TV SiteID: 015-021-000539 ~ Hanmar Inventory By Facility Unit -- MCP+DailyMax Order Fixed Containers on Site Hazmat Common Name... ISpooHazIEPA HazardsI Frm DailyMax IUnitlMCP DIESEL F IH DH L ~ GAL Low 2 08/22/2003 KERO TV SiteID: 015-021-000539 ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site -- COMMON NAME / CHEMICAL NAME DIESEL Days On Site 365 Location within this Facility Unit Map: Grid: ??? OUTSIDE OF STRUCTURE CAS# 68476-34-6 Liquid/Pure Ambient Ambient ABOVE GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average ~O~ -225.00' GAL ~OO ~-~ GAL ~OO ~5''00' GAL I I HAZARDOUS COMPONENTS I I %Wt. RS CAS# 100.00 Diesel Fuel No. 2 No 68476302 TSecret S BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No N No No/ Curies F IH DH / / / Low -4- 08/22/2003 F KERO TV SiteID: 015-021-000539 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 12/01/1999 CALL 911. -- Employee Notif./Evacuati~_,~~O~· 06/08/1992 NOTIFICATION IS BY PUBLIC ADDRESS~SYSTEM IN LOBBY. NORMALLY A DESIGNATED WARDEN ON BOTH FLOORS WOULD VERIFY THIS. -- Public Notif.~Evacuation 06/08/1992 PUBLIC ADDRESSA~YSTEM. A DESIGNATED WARDEN ON BOTH FLOORS WOULD EVACUATE. Emergency Medical Plan 12/01/1999 NEAREST HOSPITAL. -5- 08/22/2003 KERO TV SiteID: 015-021-000539 Fast Format ~ Mitigation/Prevent/kbatemt Overall Site -- Release Prevention ~O~¢~T~;~ 06/08/1992 DIESEL FUEL KEPT IN EXTREMELY STURD~~BASE ~GENERATORo-l%~r~L-BSR-. OPERATOR OF GENERATOR CHECKS FOR FUEL LEAKS WHEN GENERATOR IS IN USE. -- Release Containment 06/08/1992 GENERATOR WOULD BE TURNED OFF IF LEAK OCCURS TO MINIMIZE EXTENT OF LEAKAGE. -- Clean Up 06/08/1992 SPILLED OR LEAKED DIESEL FUEL WILL BE PUMPED INTO DRUM AND ABSORBED WITH "SORB" COMPOUND FOR FURTHER DISPOSAL. Other Resource Activation -6- 08/22/2003 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3'd Floor, Bakersfield, CA 93301 FACILITY NAME I~/~0 '"'C V/ INSPECTION DATE q-/ ?- 0 7_.- ADDRESS ~'~7 'l 2 I ~t- ~"T PHONE NO. 6 ~ 7-- FACILITY CONTACT 7~o'v, vt /~J~zT~,q./? BUSINESS ID NO. 15-210- INSPECTION TIME ~,O o4',,~ NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program Routine [~ Agency Multi-Agency Complaint [~ Re-inspection Combined Joint ! OPERATION C V COMMENTS Appropriate permit on hand b/ Business plan contact information accurate t/t 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 b/ Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand '4/ C=Compliance V=Violation Any hazardous waste on site?: ~] Yes Explain:~7' Questions regarding this inspection? Please call us at (661) 326-3979 Business Site Responsil~le Party White- Env. Svcs. Yellow - Station Copy Pink- Business Copy Inspector: CLAIM VOUCHER Vendor No. I certify that this claim is correct and valid, and is a proper charge against the City Agency and account indicated. CLAIMANT'S NAME AND ADDRESS: KERO TV Channel 23 (AUTHORIZED SIGNATURE OF CITY AGENCY) 321 21 st Street Bakersfield, CA 93301-4120 9-27-00 Initials of Preparer: ED CITY DEPARTMENT: PLEASE PROVIDE SHORT EXPLANATION OF PAYMENT: (Including Contract Number if Applicable) This business made a duplicate payment on their hazardous materials billing leaving them with a credit of $170.00 which we will fully refund. ' Dept. Base El / Objt Project # Invoice # Amount Comments on check stub 0000 123 7900 170,00 voucz{~.R TOTAL $170.00 IoSECTION 72, PENAL CODE FINANCE DEPT. USE ONLY Section 72, Presenting False Claims. Every person who with intent to defraud, presents for allowance or for payment to any state board or officer, or any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, Examined & Approved for Payment Amount r writing, is guilty of a felony. MR4~0107 CITY OF BAKERSFIELD 9/21/00 Oscellaneous Receivables I~iry 10:23:50 Customer ID . . . : 2983 Name: KERO TV CHANNEL 23 Last statement : 9/01/00 Addr: 321 21ST ST Last invoice : 0/00/00 BAKERSFIELD, CA 933014120 Current balance : 170.00- Pending . . ~ . . : .00 A ACTIVE ENVIRONMENTAL SERVICES Type options, press Enter. Combined Detail 5=Display Chg Bnk G Opt Trans Date Code Description Amount Balance Typ Cd L 9/01/00 stmrn Statements Processed .00 170.00- -- 8/'29/00 PAYMENT 170.00- 170.00- 00 Y 8/14/00 PAYMENT 170.00- .00 00 Y 8/01/00 stmrn Statements Processed .00 170.00 6/01/00 stmrn Statements Processed .00 170.00 6/01/00 SS001 CA STATE SURCHARGE 10.00 170.00 A 6/01/00 HM017 HAZ MAT ANNUAL INSPE 50.00 160.00 A 6/01/00 HM005 HAZ MAT HANDLING FEE 110.00 110.00 A 5/01/00 stmrn Statements Processed .00 .00 + F3=Exit F12=Cancel * = Pending STATEMENT OF ACCOUNT CITY OF P 0 BOX 2057 BA½ERSFIELD, CA 93303-2057 (661) 326-3979 DATE: 9/01/00 TO: KERO TV CHANNEL 23 ~i 2i~T 8T BAKERSFIELD, CA 93~01-41~0 CUSTOMER NO' 2983 CUSTOMER TYPE: ES/ 2983 Cui=n= DATE nco~=IPTION REF-NUMBER DUE DATE TOTAL AMOUNT 8/0i/00 BEQiNNINQ BALANCE 170.00 8/14/00 PAYMENT 170.00- 8/29/00 PAYMENT 170.00- FOR GUESTIONS OR CHANQES TO YOUR PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER 90 DUE DATE: 10/02/00 PAYMENT DUE: 170. O0- TOTAL DUE' $170. 00- .... ~:" · PL'EA~E DETACH AND SEND THZ~ COPY WITH REMITTANCE DATt~:' ?/01/00 DUE DAT~: 10/0~/00 , .. REMiT AND MA~,E CHECK PAYABLE TO: CITY OF PO BOX ~057 CUSTOMER NO: 2983 CUSTOMER TYPE: ES/ 2983 TOTAL DUE: $170.00- KER0 TV SiteID: 215-000-000539 {.qn~/ Manager : BusPhone: ......... Location: 321 21ST ST /0QI2 ~'1999 ~ ! Map: 103 CommHaz : Low City : BAKERSFIELD /1~~,~_%~.~ |' Grid: 30B FacUnits: 1 AOV: CommCode: BAKERSFIELD S.T~T-I~0N~0. " / SIC Code:4833 EPA Numb: DunnBrad: 07 -796 -3585 Emergency _~Con.tac, t . / Title C~;¢f~r~3,a .~Emergency C~q~a. ct -.Z~/[ Title Business phone: (~)637-2~23x~~7 Business Phone: (~)63~-~x~ 24-Hour Phone : (~ ~F~-2~ 24-Hour Phone : (~ SJ~ Pager Phone: ~) ~ Pager Phone : ~( ) ~ -~%%~'z~ ~/~11 Hazmat Hazards: Fire Im~lth DelHlth Contact : ~~ C~o~ Phone: (~/)~ ~ MailAddr: ~ F2/ 2z~~ee~ State: CA City : BAKERSFIELD Zip : 9330/I Owner MCG~W-HILL BRO~OASTING Phone: ~.~~ Address : 321 21ST ST State: CA City : BAKERSFIELD Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif 'd: RSs: No Emergency Directives: revlew~d the at~ached hazardous ma~ls manage- . men~ plan for ~0 ~~) ' any ~rm~ions ~n~tu~ g ~mpis~s =nd ~ct man- agemem plan ~ 1 10/11/1999 KERO TV SiteID: 215-000-000539 ~ Hazmat Inventory By Facility Unit --As Designated Order Fixed Containers on Site Hazmat Common Name... ISpeoHazlEPA HazardsI Frm I DailyMax Unit MCP DIESEL F IH DH L 225 GAL Low -2- 10/11/1999 KERO TV SiteID: 215-000-000539 = Inventory Item 0001 Facility Unit: Fixed Containers'on Site ~UlV~VlU~ ~vl~ / ~ ± ~Z..-~D ~Vl~ DIESEL Days On Site 365 Location 'within this Facility Unit Map: Grid: ??? OUTSIDE OF STRUCTURE CAS# 68476-34-6 F STATE I TYPE PRESSURE --[ TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient ABOVE GROUND TANK AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 225.00 GAL[ 225.00 GAL 225.00 GAL HAZARDOUS COMPONENTS %Wt. ~SI CAS# 100.00 Diesel Fuel No. 2 N 68476302 I,HAZARD ASSESSMENTS TSecret RS BioHazl Radioactive/Amount I EPA Hazards NFPA USDOT# MCP No N°llNo No/ Curies F IH DH / / / Low -3- 10/11/1999 F KERO TV SiteID: 215-000-000539 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 06/08/1992 CALL 911 --,Employee Notif./Evacuation 06/08/1992 NOTIFICATION IS BY PUBLIC ADDRESS SYSTEM IN LOBBY. NORMALLY A DESIGNATED WARDEN ON BOTH FLOORS WOULD VERIFY THIS. -- Public Notif./Evacuation 06/08/1992 PUBLIC ADDRESS SYSTEM. A DESIGNATED WARDEN ON BOTH FLOORS WOULD EVACUATE. Emergency Medical Plan 06/08/1992 NEAREST HOSPITAL -4- 10/11/1999 i KERO TV ~~~~~~~~~ SiteID: 215-000-000539 i~ Mitigation/Prevent/Abatemt ~~~~~~~ Overall Site i~ Release PreVention ~~~~~~~~~ 06/08/1992 O o DIESEL FUEL KEPT IN EXTREMELY STURDY FUEL BASE ON GENERATOR TRAILER. o OPERATOR OF GENERATOR CHECKS FOR FUEL LEAKS WHEN GENERATOR IS IN USE. O O O o GENERATOR WOULD BE TURNED OFF IF LEAK OCCURS TO MINIMIZE EXTENT OF LEAKAGE. O O o SPILLED OR LEAKED DIESEL FUEL WILL BE PUMPED INTO DRUM AND ABSORBED WITH .'. o "SORB" COMPOUND FOR FURTHER DISPOSAL. O O O -5- 10/11/1999 KERO TV &&~&&&&&&&~&&&&&&&~&&~&~&&~&&&&&&&~&&&&&& SiteID: 215-000-000539 i& Site Emergency Factors &&&&&&~&&&&~&&~&&&&&&~&~&&&~&~&&&~& Overall Site i~ Special Hazards ~&~~~&&&~~~~~&~~~i A) GAS - SOUTHEAST CORNER OF BUILDING B) ELECTRICAL - SOUTHWEST CORNER OF INTERIOR GARAGE C) WATER - CENTER SOUTH SIDE OF BUILDING IN ALLEY D) SPECIAL - NONE E) LOCK BOX - NO ~&&&&&eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeef PRIVATE FIRE PROTECTION - BUILDING FULLY SPRINKLERED, MONITORED BY ADT CO2 AND DRY EXTINGUISHERS PLACED AT STRATEGIC LOCATIONS IN BUILDING. FIRE HYDRANTS - 1 - WEST OF BUILDING ACROSS 21ST ST FROM CENTRAL PARK. 2 - NORTHWEST CORNER OF 21ST AT V ST. 3 - SOUTHWEST CORNER 20TH AT V ST. -6- 10/11/1999 /~iJ~ER~ TV ~~~~&&&~&&~&~&~&&&&~&&~&~&~ SiteID: 215-000-000539 i~ Trainin~ ~~~&~&~~~~&~~&&~~ Overall Site i~ Employee Trainin~ ~~~~~~~~~ 05/16/1990 ° 5'0 o WE HAVE~MPLOYEES AT THIS FACILITY 0 o WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE O o WE A.DVISE ALL EMPLOYEES OF THE HEALTH HAZ_~RDS, FIRE HAZJ~RDS, SPILL hAI'D CLE_~N' o UP HAZARDS FROM THE MSDS INFORMATION O O O O O O O CITY OF BAKERSFIELD CLAIM VOUCHER I Vendor No. I certify that this claim is correct and valid, and is a proper charge against the City Agency and account indicated. CLAIMANT'S NAME AND ADDRESS: KERO TV Channel 23 (AUTHORIZED SIGNATURE OF CITY AGENCY) 321 21st Street Bakersfield, CA 93301-4120 Date: 04-01-99 Initials of Preparer: :ITY DEPARTMENT: FINANCE PLEASE PROVIDE SHORT EXPLANATION OF PAYME (Including Contract Number if Applicable) This customer made a payment of $357.00 which was double this years Haz Mat bill. We have since made an adjustment to the California State surcharge in the amount of $8.50. They currently have a credit of $187.00. Dept. El / Obit Project # Invoice # Amount Date of Invoice 0000 7900 $187.00 VOUCHER TOTAL $187.00 I SECTION 72, PENAL CODE FINANCE DEPT. USE ONLY Section 72, Presenting False Claims. Every person who with intent to defraud, presents for allowance or for payment to any state board or officer, or any county, town, city district, ward or village board or officer, authoriZed to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, Examined & Approved for Payment Amount or wdting, is guilty of a felony. STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA 93301-5201 (805) 32~-3979 DATE: TO: KERO TV CHANNEL 23 321 21ST ST BAKERSFIELD, CA 93301-41~0 CUSTOMER NO: ~83 CUSTOMER TYPE: ES/ ~83 CHARGE DATE DESCRIPTION REF-NUMBER DUE DATE TOTAL AMOUNT 3/01/~9 BEGINNING BALANCE 178.50 ~/~3/99 PAYMENT 357.00- SSO01 3/31/99 Cha~ge adjustment 4/30/99 8.50- CA STATE SURCHARGE FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER bO OVER 90 8.50- DUE DATE: 5/03/99 PAYMENT DUE: 187.00-- TOTAL DUE: $187.00-- PLEASE DETACH AND 8END THIS COPY WITH REMITTANC~ ~ DATE: 4/01/99 DUE DATE: 5/03/99 REMIT AND MAKE CHECK PAYABLE TO: CITY OF BAKERSFIELD PO BOX 2057 BAKERSFIELD CA 93303-2057 (805) 32&-3979 CUSTOMER NO: 2983 CUSTOMER TYPE: ES/ 2~83 TOTAL DUE: $187.00- cusTII~ NO~ ~ g~ MI$CI=L~NI=OU$ RI=CI=IV^BLI=$ ADJUSTMENT DATE ,_~'-I I -~(3~ NEW ACCOUNT i ADDRESS CHANGE CLOSE ACCT i · FINANCE CHARGE I OTHER ADJ I CUSTOMER NAME ~FO -~/ ~ ~J ~ MAILING ADDRESS ~.-~ ! ~,--~__~-AF-. ,-,.-~ ~' CITY ~'~ P..(-% --~i C_~.'[A STATE 04- ZIP CODE ~57_~O/-L/ SITE ADDRESS PARCEL NUMBER (IF APPUCABLE) ADJUSTMENT i CHG DATE I CHARGE CODE ADJUSTMENT AMOUNT I I APPROVED BY ~ State o~ Ca(iJornia--EnvironmentoJ Protection Agency See Instructions on 6. Department of Toxic substances Cant, Form Approved OMB No. 2050-0039 (Expires 9-30 Sacramento, Ca{iforn~a Plen~, ~e. Form designed for use on elite 1. G ..... tor's US EPA ID No. Manifest Do,merit No, 2. Page 1 In~r~tion in Ihe s~aded areas is not required by Federal law. UNIFORM HAZARDOUS 3. G .... alor's N ..... d Mailing Address ~ ~~,.~,~:.~;~:r.~~'~,s.~:~?~,,~.~~~>~/~.~. ?.~¢~,~.¢',~':~%~,~?~,',~?,%~:;~ ~ 7 T~ansporter 2 Company Name 8. US EPA ID 9. 10. US EPA ID Number 11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Numberl 1No.2. ContalnerSType IQuonti~3. Total 1Wi/Vol4. Unit ~::~/~~]~(, [;~ ' R 15. Special Handling Instructions o~d Additional 16. GENERATOR'S CERTIFICATION: I hereby declare ~ot the contents o~ this cons gnment are fully and accurately descrlb~ above by sh packed, marked, and labeled, and are in all res~cts in proper condition for transport ~y highway according to apphcable international andPr°pernationa~ go~rnment Pp ng name regulations.are If I am a large quanti~ ge~rator, I c~ti~ that I have a pr~r~ n p ace ~o reduce lhe volume and toxici~ of waste generat~ ~ the d~ree I have determined to ~ economically practicable and that I have selected the practicable method o~ treatment storage or d sposal currently available to me which m[nimJzes the present and ~ture thr~t and t~e environment; OR if ~ am a small quant ~ generator ha~ ma~e a go~ fai~ effort to minimize ~ waste generation a~ select the best was~ man ement method that ~ available to me and that I can af~ord. ' lj ~ ~ ' q Printed/~ped ~pme~ ~ / -- J Signature~ ~ ~ ~onlh ~ay, ~ear ' I , 17. Transporter 1 Acknowledgement of Receipl~f Martials ~ P~d/Typed Nome J Signature~~ '' Mon,h B 1 ~ Trans~rter ~ Ac~n~le~flement o~ R~ceiDt o~ Moferlals ~ Prin~ed/Typed Nome E Signature Month Day Year 19. Discre~ncylndica,ionSpace I I I I I F Z -- A C I L I 20. Facili~erator Certification ma~eri~ manifest exc~s noted in Item 19. Y T Printed/Typed Nome ~ Signature ~ Monlh Day Y~r DISC 8022A (4/97) Blue. GENERATOR 5ENDS THIS COPY 10 DTSC WITHIN 30 DAYS EPA 8700~22 To: P.O~ Box 400, Sacramento, CA 95812-0400 KERO TV SiteID: 215-000-000539 Manager : BusPhone: (805) 327-1441 Location: 321 21ST ST Map : 103 CommHaz : Low City : BAKERSFIELD Grid: 30B FacUnits: 1AOV: CommCode: BAKERSFIELD STATION 04 SIC Code:4833 EPA Numb: DunnBrad:07-796-3585 Emergency Contact / Title ! Emergency Contact / Title _ ~ Business Phone' (805) 3~-T~u~u~ Business Phone- (805) ~ ~Yo 24-Hour Phone : (805) ~gx3--~x--~8~24-Hour Phone : (805) 5~8-~8~$/~ Pager Phone : (~d3~2f-3-3~x -l' Pager Phone : Q~ ~/-~3~x Hazmat Hazards: Fire ImmHlth DelHlth Agency-Defined Topic Title ---- Hazmat Inventory One Unified List -- MCP+DailyMax Order Ail Materials at Site Hazmat Common Name... ISpecHazlEPA HazardsI Frm DailyMax Unit MCP DIESEL F IH DH L 225 GAL Low -1- 04/25/1997 KERO TV SiteID: 215-000-000539 ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site -- COMMON NAME / CHEMICAL NAME DIESEL Days On Site 365 Location within this Facility Unit W SIDE INTERIOR GARAGE CAS# 68476-34-6 r STATE -- TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Pure Ambient Ambient ABOVE GROUND TANK AMOUNTS STORED AND IN USE Lrgst Cont.this Loc GAL DailyMax this Loc GAL DailyAvg this Loc GAL 225.00 225.00 DailyMax Stored GAL DailyMax Open Use GAL DailyMax Closed Use GAL %Wt. I HAZARDOUS COMPONENTS EHS CAS# 100.00 Diesel Fuel No. 2 No 68476302 -2- 04/25/1997 KERO TV SiteID: 215-000-000539 Fast Format ~ Notif./Evacuation/Medical Overall Site -- Agency Notification 06/08/1992 CALL 911 -- Employee Notif./Evacuation 06/08/1992 NOTIFICATION IS BY PUBLIC ADDRESS SYSTEM IN LOBBY. NORMALLY A DESIGNATED WARDEN ON BOTH FLOORS WOULD VERIFY THIS. Public Notif./Evacuation 06/08/1992 PUBLIC ADDRESS SYSTEM. A DESIGNATED WARDEN ON BOTH FLOORS WOULD EVACUATE. Emergency Medical Plan 06/08/1992 NEAREST HOSPITAL 3 04/25/1997 KERO TV SiteID: 215-000-000539 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site -- Release Prevention 06/08/1992 DIESEL FUEL KEPT IN EXTREMELY STURDY FUEL BASE ON GENERATOR TRAILER. OPERATOR OF GENERATOR CHECKS FOR FUEL LEAKS WHEN GENERATOR IS IN USE. -- Release Containment 06/08/1992 GENERATOR WOULD BE TURNED OFF IF LEAK OCCURS TO MINIMIZE EXTENT OF LEAKAGE. -- Clean Up 06/08/1992 SPILLED OR LEAKED DIESEL FUEL WILL BE PUMPED INTO DRUM AND ABSORBED WITH "SORB" COMPOUND FOR FURTHER DISPOSAL. Other Resource Activation -4- 04/25/1997 KERO TV SiteID: 215-000-000539 Fast Format Site Emergency Factors Overall Site Special Hazards -- Utility Shut-Offs 06/08/1992 A) GAS - SOUTHEAST CORNER OF BUILDING B) ELECTRICAL - SOUTHWEST CORNER OF INTERIOR GARAGE C) WATER - CENTER SOUTH SIDE OF BUILDING IN ALLEY D) SPECIAL - NONE E) LOCK BOX - NO -- Fire Protec./Avail. Water 06/08/1992 PRIVATE FIRE PROTECTION - BUILDING FULLY SPRINKLERED, MONITORED BY ADT CO2 AND DRY EXTINGUISHERS PLACED AT STRATEGIC LOCATIONS IN BUILDING. FIRE HYDRANTS - 1 - WEST OF BUILDING ACROSS 21ST ST FROM CENTRAL PARK. 2 - NORTHWEST CORNER OF 21ST AT V ST. 3 - SOUTHWEST CORNER 20TH AT V ST. Building Occupancy Level -5- 04/25/1997 KERO TV SiteID: 215-000-000539 Fast Format Training Overall Site -- Employee Training 05/16/1990 WE HAVE 12 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE WE ADVISE ALL EMPLOYEES OF THE HEALTH HAZARDS, FIRE HAZARDS, SPILL AND CLEAN UP HAZARDS FROM THE MSDS INFORMATION -- Page 2 Held for Future Use Held for Future Use -6- 04/25/1997 03/18/92 KERO TV 215-000-000539 ~ ?age 1 Overall Site with 1 Fac. Unit L !~ General Information Location: 321 21ST ST Map: 103 Hazard: Low Community: BAKERSFIELD STATION 01 Grid: 30B F/U: 1AOV: 0.0 Contact Name Title Business Phone 24-Hour Phonell NORMAN HALL (805) 327-1441 x (805) 399-410111 TOM BLACK (805) 327-1441 x (805) ~~,~,, Administrative Data Mail Addrs: P O BX 2367 D&B Number: 07-796-3585 City: BAKERSFIELD State: CA Zip: 93303- Comm Code: 215-001 BAKERSFIELD STATION 01 SIC Code: 4833 Owner: MCGRAW-HILL BROADCASTING Phone: (805) 327-1441 Address: 321 21ST ST State: CA City: BAKERSFIELD Zip: 93301- Summary 03/18/92 KERO TV 215-000-000539 Page 2 02 - Fixed Containers on Site Hazmat Inventory Detail in Reference Number Order 02-001 DIESEL Liquid 225 Low · Fire, Immed Hlth, Delay Hlth GAL CAS #: 68476-34-6 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GALI Daily Average GAL I Annual Amount GAL 225 I 225.00 225.00 Storage~lPress T Temp Location ABOVE GROUND TANK IAmbient~AmbientlW SIDE INTERIOR GARAGE -- Conc Components MCP List 100.0% IDiesel Fuel No.2 IL°w I -- Notes 03/18/92 KERO TV 215-000-000539 Page 3 00 - Overall Site <D> Notif./Evacuation/Medical <1> Agency Notification CALL 911 <2> Employee Notif./Evacuation NOTIFICATION IS BY PUBLIC ADDRESS SYSTEM IN ~OBBY. NORMALLY A DESIGNATED WARDEN ON BOTH FLOORS WOULD VERIFY THIS. <3> Public Notif./Evacuation <4> Emergency Medical Plan NEAREST HOSPITAL 03/18/92 KERO TV 215-000-000539 Page 4 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention PREVENTION - DIESEL FUEL KEPT IN EXTREMELY sTURDy FUEL BASE ON GENERATOR TRAILER. OPERATOR OF GENERATOR CHECKS FOR FUEL LEAKS WHEN GENERATOR IS IN USE. MITIGATION - GENERATOR WOULD BE TURNED OFF IF LEAK OCCURS TO MINIMIZE EXTENT OF LEAKAGE. MENT - SPILLED OR LEAKED DIESEL FUEL WILL BE PUMPED INTO DRUM AND~ ORBED WITH."SORB" COMPOUND FOR FURTHER DISPOSAL. <2> Release Containment <3> Clean Up <4> Other Resource Activation 03/18/92 KERO TV 215-000-000539 Page 5 00 - Overall Site <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - SOUTHEAST CORNER OF BUILDING B) ELECTRICAL - SOUTHWEST CORNER OF INTERIOR GARAGE C) WATER - CENTER SOUTH SIDE OF BUILDING IN ALLEY D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water ~ ~.. PRIVATE FIRE PROTECTION - BUILDING FULLY SPRINKLERED, MONITORED BY ~ ~ ................... CO2 .... ~,~ ,~T.'.v. -- ' ..... -,~ ,.~u~ AND DRY EXTINGUISHERS PLACED AT STRATEGIC LOCATIONS IN BUILDING. FIRE HYDRANTS - 1 - WEST OF BUILDING ACROSS 21ST ST FROM CENTRAL PARK. 2 - NORTHWEST CORNER OF 21ST AT V ST. 3 - SOUTHWEST CORNER 20TH AT V ST. <4> Building Occupancy Level 03/18/92 KERO TV 215-000-000539 Page 6 00 - Overall Site <G> Training <1> Page 1 WE HAVE ~2 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE WE ADVISE ALL EMPLOYEES OF THE HEALTH HAZARDS, FIRE HAZARDS, SPILL AND CLEAN UP HAZARDS FROM THE MSDS INFORMATION <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use Bakersfield Fire HAZARDOUS MATERIALS DIVISION Date Completed Business Name: ~ .--i~..(...) '--1-. ~ , Business Identification No. 215-000 ~ ~ o~ (Top of Business Plan) Station No. ~ Shift ~ Inspector ~Co'~.'~ Adequate Inadequate Verification of Inventory Materials Verification of Quantities ~Co Verification of Location -'~ Proper Segregation of Material mments: Verification of MSDS Availablity Number of Employees Verification of Haz Mat Training Comments: Verification of Abatement Supplies & Procedures Comments: Emergency Procedures Posted Containers Properly Labeled Comments: Verification of Facility Diagram Special Hazards Associated with this Facility: Violations: All Items O.K. ~ Correction Needed ~] Business Owner/Manager FD 1652 (Rev. 1-90) White-Haz Mat Div. Yellow-Station Copy Pink-Business Copy ..'~ -,,' ~o,~ CITY of BAKERSFIELD ~,~ '~ ,, '.'~ '-.~[...~ .~. ~, ..: .... ' ~?_~ ,",~?,',~ .~ ' HAZ. ~AT. DiV, Do hereb3' certify that I have revie~ed the attached Hazardous FIaterials business nlan (name of business) and that it along with the attached additions or corrections constitute a complete and correct Business Plan for my facility. szgna~ure B~.~SINESS NAME KERO TV ID ~R 215-000-000539 LOCATION 321 21ST ST HIGH HAZARD RATING 2 1 o OV3EI~V I ]Er~q LAST CHANGE 05/13/88 BY ESTER JURIS CODE 215-001 JURIS BAKERSFIELD STATION 01 b~AP PAGE 103 GRID 30B FACILITY UNITS 1 HAZARD RATING 2 RESPONSE SUMMARY 2A SEC 4) NO PRIVATE RESPONSE TEAM EMERGENCY CONTACTS 2A SEC 2) NORMAN HALL - 327-1441 OR 399-4101 TOM BLACK - 327-1441 OR 392-1850 UTILITY SHUTOFFS 2A SEC 3) A) GAS - SE CORNER OF BLDG B) ELECTRICAL - SW CORNER OF INTERIOR GARAGE C) WATER - CENTER S SIDE OF BLDG IN ALLEY D) SPECIAL - NONE E) LOCK BOX - NO 2 . NOTIFICATION / PUBLIC EVACUAT ~[ ON LAST CHANGE / / BY < NO INFORMATION RECORDED FOR THIS SECTION > PAGE 1 12/27/88 10:51 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME KERO TV ID R 215-000-000539 LOCATION 321 21ST ST HI HAZARD RATING 2 3 o HAZ MAT TRAINING SUMMARY LAST CHANGE / / BY .,, < NO INFORMATION RE~ORDED FOR THIS SE~ION > ~ A o LOCAL EMERGENCY MEDICAL ASSISTANCE i LAST CHANGE 05/13/88 BY ESTER 2A SEC 5) NEAREST HOSPITAL PAGE 2 12/27/88 10:51 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME KERO TV ID IR 215-000-000539 LOCATION 321 21ST ST HI~ HAZARD RATING 2 FACILITY UNIT 01 A. OVERALL HAZARDOUS MATERIALS INVENTORY LAST CHANGE 05/13/88 BY ESTER ID TYPE NAME MAX AMT UNIT HAZARD LOCATION CONTAINMENT USE I PURE #2 DIESEL FUEL 225 GAL MODERATE W SIDE INTERIOR GARAGE ABOVE GROUND TANKS FUEL ID PERCENT COMPONENTS HAZARD LISTS 1179.01 100.0 DIESEL FUEL NO.2 MODERATE FIRE PROTECTION / WATER SUPPLIES LAST CHANGE 05/13/88 BY ESTER 3A SEC 4) BLDG FULLY SPRINKLERED, MONITORED BY CRIME CONTROL INCLUDING RATE OF RISE HEAT SENSORS IN MOST OF BLDG. CO2 AND DRY EXTINGUISHERS PLACED AT STRATEGIC LOCATIONS IN BLDG. 3A SEC 5) 3 FIRE HYDRANTS: 1 - 300 FT W OF BLDG ACROSS 21ST ST FROM CENTRAL PARK. 2 - NW CORNER OF 21ST AT V ST. 3 - SW CORNER 20TH AT V ST. PAGE 3 12/27/88 10:51 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUS~_NESS NAME KERO TV ID 215-000-000539 LOC~£ION 321 21ST ST HI~ HAZARD RATING 2 D . EMPLOYEE NOTIFICATION / EVACUATION LAST CHANGE 05/13/88 BY ESTER 3A SEC 2) NOTIFICATION IS BY PUBLIC ADDRESS SYSTEM IN LOBBY. NORMALLY A DESIGNATED WARDEN ON BOTH FLOORS WOULD VERIFY THIS. E ~ MITIGATION / PREVENT I O5] / ABATEMENT LAST CHANGE 05/13/88 BY ESTER 3A SEC 1) PREVENTION - DIESEL FUEL KEPT IN EXTREMELY STURDY FUEL BASE ON GENERATOR TRAILER. OPERATOR OF GENERATOR CHECKS FOR FUEL LEAKS NHEN GENERATOR IS IN USE. MITIGATION - GENERATOR WOULD BE TURNED OFF IF LEAK OCCURS TO MINIMIZE EXTENT OF LEAKAGE. ABATEMENT - SPILLED OR LEAKED DIESEL FUEL WILL BE PUMPED INTO DRUM AND ABSORBED WITH "SORB" COMPOUND FOR FURTHER DISPOSAL. PAGE 4 12/27/88 10:51 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 668-6800 CITY of BAKER5I i LD NON--TRADE SECRETS NA~ O~ T~ FACILITY: ~ ~), ~,~ ~~ STANDARD IND. CLASS CODE of ~ ~lth k 011 tbt o~ly) ..... blth of ~ blth (C~k ~11 t~t ~Jy) ........ ~t fl ~iC.i.S.~ · ~lth of Prfl~re blth ..... CerOfic,etJan (Read and-siKh after colpJetJnE all section~) for obtoini~ t~ tflf~ttm. I ~li.e tMt t~ lu~itt~ inf~ti~ is t~, K~rotl, ~ ~letl. ~,~ ~ / / ~ SECTION 3: HAZARDOUS MATERIALS FOR THIS b~IT ONLY A. Does this Facility Unit contain Hazardous Materials? ...... ~ NO If YES, see B. If NO, continue with SECTION 4. B. Are any of the hazardous materials a bona fide Trade Secret YES ~ If No, complete a separate hazardous materials inventory form marked: NON-TRADE SECRETS ONLY (white form #4A-l) If Yes, complete a hazardous materials inventory form marked: TRADE SECRETS ONLY (yellow form #4~-2) in addition to the non-trade secret form. List only the trade secrets on form 4A-2. SECTION 4: PRIVATE FIRE PROTECTION SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY E~RGENCY RESPO~ERS SECTION 6: LOCATION 0F UTILI~ S~T-OFFS AT THIS UNIT ONLY. A. NAT. GAS/PROPAN~ B. ELECTRICAL: C. WATER: D. SPECIAL: E. LOCK BOX: YES / NO IF YES, LOC IF YES, SITE PLANS? YES / NO MSDSs? YES / NO FLOOR PLANS? YES / NO KEYS? .YES / NO - 3B - BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 98801 OFFICIAL USE ONLY ID# BUSINESS NA~E: BUS I NESS PLAN SINGLE FACILITY UNIT FORM 8A INSTRUCTIONS 1. To avoid further action, this form must be returned by: 2. TYPE/PRINT YOUR ANSWERS IN ENGLISH. 3. Answer the questions belo~w for THE FACILITY UNIT LISTED BELOW 4. Be as BRIEF and CONCISE as possible. FACILITY LrNIT# FACILITY b~NIT NAME: SECTION 1: MITIGATION, PREVENTION, ABATEMEN"r PROCEDI~q{ES SECTION ~: NOTIFICATION ~ EVACUATION PROCEDU~ES AT THIS UNIT ONLY - 3A - SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE SECTION 8: LOCAL EMERGENCY MEDICAL ASSISTanCE FOR YOUR BUSINESS AS A WHOLE SECTION 6: EMPLOYEE TRAINING EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND REFRESHER TRAINING IN THE FOLLOWING AREAS. MATERIALS .~0 ~ NO B. PROCEDURES FOR COORDINATING ACTIVITIES WITH RESPONSE AGENCIES: .......................... ................. ~~ NO ~ NO C. PROPER USE OF SAFETY EQUIPMENT: .................. Y~ NO NO D. EMERGENCY EVACUATION PROCEDURES: Y~__y..~_~)SNO NO E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... ~,~ NO NO SECTION 7: HAZ~uRDOUS MATERIAL CIRCLE YES OR NO DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 PO~ A SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... I, ~,~ , certify that the above information is accurate. I 6n~erstand that this information will be used to fulfill my firm's obligations under the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter 6.95 Sec. 28500 Et Al.) and that inaccurate information constitutes perjury. SIGNATURE TITLE ~ :j .~ BAKERSFIELD CITY FIRE '' BAKERSFIELD CA 93301 ~,: (805) 326-3979 OFFICIAL USE ONLY USINESS N~E HAZARDOUS ~TERI ALS BUSINESS PLAN AS A WHOLE ~OR~ 2A 000539 I~S~UCTI ORS: ~. To a~oJd fU~the~ action, ~etu~ this fo~m by 3. Ans~e~ t~e ~uestJo~s be~o~ for the bus~ess as a ~o~e. ~. Be as brief ~d concise as possible. $~CT~ON ~: BUS~N~SS ID~I~ICATIOR DATA SECTION 2: EMERGENCY NOTIFICATIONS In case of an emergency involving the release ov threatened'release of a hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify your local fire department and the State Office of Emergency Services as required by law. EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY: NAME AN~ TITLE DURING BUS.HRS. AFTER BUS._ HRS. SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE C. WATER: .... /,F/ ~I~F-F.. D. SPECIAL: E. LOCK BOX: YES ~ IF YES, LOCATION: IF YES, DOES IT CONTAIN SITE PLANS? YES / NO MSDSS? YES / NO FLOOR PLANS? YES / NO KEYS? YES / NO - 2A - I.D. BAKERSFIELD CITY FIRE FORM 4A-1 HAZARDOUS DEPARTMENT Page J___of ADDRESS ' BUSINESS NAME: ~.~ ~_.~ ADDRESS :~ CITY, ZIP: NON--TRADE SECRETS I~[ATER ! ALS INVENTORY ~~~/~AC I L I TY UNIT FACILITY UNIT NAME: , IP: PHONE #: {OFFICIAL USE CFIRS CODE { ONLY EMERGENCY CONTACT: PRINCIPAL BUSINESS ACTIVITY: - 4A-1 EMERGENCY CONTACT: ~ TITLE: ~ O~'~'' "---'---"-PHONE # BUS HOURS:. .... _- _.. 1 2 3 4 5 6 7 8 9 10 TYPE MAX ANNUAL CONT USE LOCATION IN THIS % BY HAZARD D.O.T COI1E AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT WT. CHEMII~AL OR COMMON NAME CODE OUIDE .,_ .. ,,_. _J/ NAME: ~ ~~ .T,I~LE:~SIGNATZ~E:- ' t DATE:~~