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Home My WebLink AboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF ~PERMIT ON REVERSE SIDE This _oermit is issued for the followino: El H.~-nlous Materials Plan El Underground Storage of Hazardous Materials Permit ID #:: 015-000-000381 13 Risk Management Program D Hazardous Waste On-Site Treatment CHARLES S NICHOLSON III LOCATION: 820 34TH ST 201 :IELD OFFICE OF ENV1R ONMENTAL SER VICES' . 1715 Chester Ave., 3rd Floor Approved by: Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Expiration Date: June 30:2003 Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE · ..~..~,~;~,,,;~,;~?~.?~,,,.;,~./....:~.;~p,.!~,~?,,~,,~,~ ........ This permit is issued for the following: .... ??T !:5 !i::~'~'~*'% iiii!iiil, i iiii!iiii;:~?iiiiali~e[ground Storage of Ha~rdous Materials PERMIT ID~ 015~21000381 ~'*'~?~ ~,J;,¥~ ~ ~:~' .J~?~}~%~ ~¥~;:: ~,;~k ~agement Program ~ ~r.' ~.',~ ~'" ~ ~. '~ '~ :: ~ :?;~. ::~ ::::~: ':::;~ ~ :::~,~ .-:~ ~: ~`~=- ~= ::::~.~ ..~ ~e~d~s Waste CHARLES S NICHOLSON Ill ~'"'.. ~,.,... · ~.. "'.-..~, ~ ". ~" ..... ~:.~;{q~i~i~~¢-~"'" ',~::~51 .~ ..., ,~ '--.. '~.~ '~........ Is~ by: B~emfield Fke Depa~ment Approv~ by: O~CE OF E~R O~L 1715 Chewer Ave., ~rd Floor B~er~el~ CA 9~01 Voice (805) ~2~3979 F~ (80S)~6~57. Expiration Date: dun~ ~O~ ~OO0 '~' '~' SITE/FACILITY DIAGRi%~X NORTH SCALE: BUSINESS NAME: FLOOR: OF DATE: / / FACILITY NAME: UNIT ~: OF (CHECK ONE) SITE DIAGR.~%! FACILITY DIAGR.~ ~ ~,~:: e, , 9~? .......... (Inspecto~'s Comments): -OFFICIAL USE ONLY- - SA - SiTE OIAGR~J~ (Reql Items) ~- z 'd 1. Address: Identify the 9. Lock (ke~) Box principle buildings by the Street numbers. 10. MSDS Storage Box 2. 'Street(si. Alleys. Il. 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. Wood 4. Drainage Canals. Ditches. d. Gates Creeks, 13. Powerlines 5. Buildings a. Frame construction 14. Guard Station b. Masonry construction 15. Storage Tanks: Identify the c. Metal construction capacity in gal. a. Above ground d. Access Door b. Underground 6. Utility Controls a. Gas 16. Diking or Berm b. Electricity 17. Evacuation Route c. Water 18. Evacuation Area: Identify the ?. Fire Suppression Systems: location where a. Fire Hydrants employees will meet. b. Fire Sprinkler iD, Outside Hazardous Connections Waste Storage c. Fire Standpipe 20. Outside Hazardous Connections Matsrial Storage d. Water Control Valves 21. Outside Hazardous for protection syste=s Material Use/Handling e. Fire Pump 22. Type,of Hazardous Material/Waste Stored 8. Fire Department Access or Used (See Below) TyPE OF HAZARDOUS MATERIAL F - Flumaable E - Explosive L - Liquid R - Radiologica! C - Corrosive 0 - Oxidizer 0 - Gas P - Poison # - Water Reectlve T - Toxic $ - Solid B - Cryogenic O - Waste B - Etiological Example: Flammable Liquid - FL FACILITY DIAOR~ (Required items in addition to the above) i. Risers for Sprinklers 8. Firs Escapee 2. Partitions 9, Air Conditioning 3. Stair.aye: Indicate the 10. level~ sewed from hlghelt to lowest. 11, Inside Hazardoul MasSe Storage 4. Escalator: Indicate the levels servsd from 12. Inside Hazardous highest to lowest. Materials Storage $. Elevator 13. Inside Hazardous Materials Uae/Handling 6. Attic Access 14. Se~er Drain Inlets 7. Skylights ~ ~ '~]~l OFFICE OF ENVIRON/MENTAL SERVICES ~~~_ 1715 Chester Ave., 3rd ~ioor,/Bakersfield, CA 93301 ~SPECIION TIME.,, 1 ~ ~ { ~ ~NUMBER OF EMPLOYEES - OPERATION C V[ COMMENTS Appropriate pe~it on hand Business plan contact info~ation accurate Visible address Co.eot occupancy Verification of invento~ materials Verification of quantities ~~ Proper segregation of material Verification of MSDS availability ~ Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containem properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardous waste on site?: [~ Yes I~ No Explain: Questions regarding this inspection? Please gall us at (661) 326-3979 Business Site Responsible Party White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Inspector: CHARLES S NICHOLSON III DDS SiteID: 015-021-000381 Manager : BusPhone: (805) 327-7878 Location: 820 34TH ST 201 Map : 103 CommHaz : Low City : BAKERSFIELD Grid: 19B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 04 SIC Code: EPA Numb: DunnBrad:77-008-4205 Emergency Contact / Title Emergency Contact / Title6~~ Cm LES NICHOLSON / PRESIDE Business Phone: (805) 327-7878x ' Business Phone: (805) 327-7878x 24-Hour Phone : (805) 664-1673x 24-Hour Phone : (805) 393-8411x Pager Phone, : (805) 632-3851x Pager Phone : ( ) - x Hazmat Hazards: Fire press ImmHlth Contact : Phone: ( ) - x MailAddr: 820 34TH ST 201 State: CA City : BAKERSFIELD Zip : 93301 Owner MR. DAVIS C/O MANCO ABBOTT Phone: (805) 324-8542x Address : 5000 CALIFORNIA AVE State: CA City : BAKERSFIELD Zip : 93309 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: ~O~3 / ~ Hazmat Inventory One Unified List --Alphabetical Order All Materials at Site Hazmat Common Name... ISpooHazlEPA HazardsI Frm I DailyMax IunitlMcP NITROGEN F P IH G 510.00 FT3 Min NITROUS OXIDE F P IH G 64.00 LBS Hi · OXYGEN F P IH G 843.00 FT3 Low I, Do hereby ce~i~ th~ I have reviewed the a~ached haza~ous mate~als manage- ment plan for~2~ ~,'/?/~//~a~d that it along with (Na~ of Busine~) -- any corrections constitute a complete and corre~ man- agement plan ~r my ~cili~. "~~ 07/24/2001 CHARLES S NICHOLSON III DDS SiteID: 015-021-000381 = Inventory Item 0003 Facility,Unit: Fixed Containers on Site -- COMMON NAME / CHEMICAL NAME NITROGEN Days On Site 365 Location within this Facility Unit Map: Grid: HALLWAY CLOSET CAS# 7727-37-9 STATE ~ TYPE PRESSURE TEMPERATURE CONTAINER TYPE Gas /Pure I Above Ambient ] Ambient I PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average FT3 510.00 FT3 I 255.00 FT3 100.00 Nitrogen No 7727379 TSecret RS BioHazI HAZARD ASSESSMENTS I Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Min = Inventory Item 0004 Facility Unit: Fixed Containers on Site -- COMMON NAME / CHEMICAL NAME NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 10024-97-2 F STATE ~ TYPE I PRESSURE I TEMPERATURE ICONTAINER TYPEGas | Above Ambient Ambient PORT PRESS CYLINDER ~Pure . . AMOUNTS AT THIS LOCATION -- Largest Container I Daily Maximum I Daily Average LBSI 64.00 LBS I 32.00 LBS HAZARDOUS COMPONENTS 100.00 Nitrous Oxide No 10024972 TSecret S BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# No N No No/ Curies F P IH / / / Hi 2 07/24/2001 CHARLES S NICHOLSON III DDS SiteID: 015-021-000381 = Inventory Item 0001 Facility Unit: Fixed Containers on Site -- COMMON NAME / CHEMICAL NAME OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: HALLWAY CLOSET CAS# 7782-44-7 FSTATE i TYPE PRESSURE ~ TEMPERATURE CONTAINER TYPE Gas Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average FT3I 843.00 FT3 422.00 FT3 HAZARDOUS COMPONENTS %Wt. RN~oRS CAS# 100.00 Oxygen, Compressed 7782447 HAZARD ASSESSMENTS TSecretl ~SIBioHaz Radioactive/Amount I EPA Hazards] NFPA USDOT# I MOP No N No No/ Curies F P IH / / / Low 3 07/24/2001 F CHARLES S NICHOLSON III DDS SiteID: 015-021-000381 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 02/28/1991 CALL 911 NON EMERGENCY CALL 326-3979 -- Employee Notif./Evacuation 02/28/1991 VERBAL NOTIFICATION & CALL 911. -- Public Notif./Evacuation 02/28/1991 LOCAL NURSE WOULD CALL ALL CLIENTS Emergency Medical Plan 02/28/1991 MEMORIAL HOSPITAL - 420 34TH STREET - 327-1792. -4- 07/24/2001 F CHARLES S NICHOLSON III DDS SiteID: 015-021-000381 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site --Release Prevention 02/28/1991 GASES ARE CHAINED AND STORED WITH PROPER VALVES AND FITTINGS. --Release Containment 02/28/1991 SHARPS CONTAINERS FOR NEEDLES AND TEETH CleanUp 02/28/1991 CONTAINERS ARE PICKED UP - SECURITY ENVIRONMENTAL SYSTEM Other Resource Activation -5- 07/24/2001 F CHARLES S NICHOLSON III DDS SiteID: 015-021-000381 I Fast Format F Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs 07/31/1997 A) GAS - CLOSET IN LAB B) ELECTICAL - PANEL IN DEVELOPING ROOM C) WATER - 34TH STREET D) SPECIAL - NONE E) LOCK BOX - NO -- Fire Protec./Avail. Water 07/31/1996 PRIVATE FIRE PROTECTION - 3 FIRE EXTINGUISHERS, ONE IN FRONT OFFICE AND ONE IN THE LUNCH ROOM, ONE BY X-RAY ROOM. FIRE HYDRANT - FRONT OF BUILDING ON 34TH STREET - NORTH END NEAR DRIVEWAY. Building Occupancy Level j -6- 07/24/2001 CHARLES S NICHOLSON III DDS SiteID: 015-021-000381 Fast Format ~ Training Overall Site -- Employee Training 07/31/1996 WE HAVE 15 EMPLOYEES AT THIS FACILITY. WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE. BRIEF SUMMARY OF TRAINING: ALL EMPLOYEES HAVE HAD OSHA TRAINING. Page 2 I --Held for Future Use Held for Future Use 7 07/24/2001 MISCELLANEOUS RECEIVABLES ADJUSTMENT CLOSE ACOT · FINANCE CHARGE I · OTHER ADJ SITE ADDRESS PARCEL NUMBER OF APPUCABI. E) ADJUSTMENT I CH.~G DATE ~ ADJUSTMENT AMOUNT REMARKS: '~-T~, CHARLES S NICHOLSON III DDS 006 ~U IO~/ I SitelD: 215-000-000381 Manager : By ....... ~M~;PhOne: (805) 327-7878 Location: 820 34TH ST 201 .' : 103 CommHaz : Low City : BAKERSFIELD Grid: 19B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 04 SIC Code: EPA Numb: DunnBrad:77-008-4205 Emergency Contact / Title Emergency Contact / Title CHARLES NICHOLSON / PRESIDENT NATHAN PETTY / CEO Business Phone: (805) 327-7878x Business Phone: (805) 327-7878x 24-Hour Phone : (805) 664-1673x 24-Hour Phone : (805) 393-8411x Pager Phone : (805) 632-3851x Pager Phone : ( ) - x Hazmat Hazards: Fire Press ImmHlth Agency-Defined Topic Title = Hazmat Inventory One Unified List -- MCP+DailyMax Order Ail Materials at Site ISpecHazlEPA Hazards Frm DailyMax Unit MCP Hazmat Common Name... NITROUS OXIDE F P IH G 64 LBS Hi OXYGEN F P IH G 843 FT3 Low NITROGEN F P IH G 510 FT3 Min I, /~J~[~/,~ ~'/-'/'7 Do hereby certify that l have (Type or I~nt name) reviewed the attached hazardous materials manage- ment plan for ~,3/~/~m~. 7~nd that it along with any corrections constitute a complete and correct man- agement plan for my facility. 1 06/23/1997 CHARLES S NICHOLSON III DDS SiteID: 215-000-000381 ~ Inventory Item 0004 Facility Unit: Fixed Containers on Site -- COMMON NAME / CHEMICAL NAME NITROUS OXIDE Days On Site 365 Location within this Facility Unit CAS# 10024-97-2 FSTATE -- TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Gas Pure II Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS STORED AND IN USE Lrgst Cont.this Loc LBS DailyMax this Loc LBS DailyAvg this Loc LBS 64.00 32.00 DailyMax Stored LBS DailyMax Open Use LBS DailyMax Closed Use LBS HAZARDOUS COMPONENTS EHS CAS# %Wt. No 10024972 100.00 Nitrous Oxide -2- 06/23/1997 CHARLES S NICHOLSON III DDS SiteID: 215-000-000381 ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site -- COMMON NAME / CHEMICAL NAME OXYGEN Days On Site 365 Location within this Facility Unit HALLWAY CLOSET CAS# 7782-44-7 rSTATE TYPE PRESSURE i TEMPERATURE i CONTAINER TYPE Gas Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS STORED AND IN USE Lrgst Cont.this Loc FT3 DailyMax this Loc FT3 DailyAvg this Loc FT3 843.00 422.00 DailyMax Stored FT3 DailyMax Open Use FT3 DailyMax Closed Use FT3 HAZARDOUS COMPONENTS EHS CAS# %Wt. 100.00 Oxygen, Compressed No 7782447 3 06/23/1997 CHARLES $ NICHOLSON III DDS SiteID: 215-000-000381 ~ Inventory Item 0003 Facility Unit: Fixed Containers on Site NITROGEN Days On Site 365 Location within this Facility Unit HALLWAY CLOSET CAS# 7727-37-9 ~ STATE TYPE PRESSURE i TEMPERATURE i CONTAINER TYPE Gas Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS STORED AND IN USE Lrgst Cont.this Loc FT3 DailyMax this Loc FT3 DailyAvg this Loc FT3 510.00 255.00 DailyMax Stored FT3 DailyMax Open Use FT3 DailyMax Closed Use FT3 HAZARDOUS COMPONENTS EHS CAS# %Wt. 100.00 Nitrogen No 7727379 -4- 06/23/1997 CHARLES S NICHOLSON III DDS SiteID: 215-000-000381 Fast Format ~ Notif./Evacuation/Medical Overall Site -- Agency Notification 02/28/1991 CALL 911 NON EMERGENCY CALL 326-3979 Employee Notif./Evacuation 02/28/1991 RBAL NOTIFICATION & CALL 911. -- Public Notif./Evacuation 02/28/1991 LOCAL NURSE WOULD CALL ALL CLIENTS Emergency Medical Plan 02/28/1991 MEMORIAL HOSPITAL - 420 34TH STREET - 327-1792. -5- 06/23/1997 CHARLES S NICHOLSON III DDS SiteID: 215-000-000381 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site -- Release Prevention 02/28/1991 GASES ARE CHAINED AND STORED WITH PROPER VALVES AND FITTINGS. Release Containment 02/28/1991 SHARPS CONTAINERS FOR NEEDLES AND TEETH -- Clean Up 02/28/1991 ALL CONTAINERS ARE PICKED UP - SECURITY ENVIRONMENTAL SYSTEM Other Resource Activation 6 06/23/1997 CHARLES S NICHOLSON III DDS SiteID: 215-000-000381 Fast Format F Site Emergency Factors Overall Site Special Hazards -- Utility Shut-Offs 07/31/1996 A) CLOSET IN LAB B) ELECTICAL - PANEL IN DEVELOPING ROOM C) WATER - 34TH STREET D) SPECIAL - NONE E) LOCK BOX - NO -- Fire Protec./Avail. Water 07/31/1996 PRIVATE FIRE PROTECTION - 3 FIRE EXTINGUISHERS, ONE IN FRONT OFFICE AND ONE IN THE LUNCH ROOM, ONE BY X-RAY ROOM. FIRE HYDRANT - FRONT OF BUILDING ON 34TH STREET - NORTH END NEAR DRIVEWAY. Building Occupancy Level -7- 06/23/1997 CHARLES S NICHOLSON III DDS SiteID: 215-000-000381 Fast Format ~ Training Overall Site -- Employee Training 07/31/1996 WE HAVE ].5 EMPLOYEES AT THIS FACILITY. WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE. BRIEF SUMMARY OF TRAINING: ALL EMPLOYEES HAVE HAD OSHA TRAINING. Page 2 -- Held for Future Use Held for Future Use 8 06/23/1997 [)6/2?/96 CHARLES ICHOLSON I I I DDS 215-0(~.)~~'~i~ ~~. ~/"~c ........ age 1 Overall Site with 1 Fac, Unit General Ir~forn~atior~ ~ ~L Location: 8~J 34TH ST Map:lOi~~ City : BAKERSFIELD Grid: 19B F/U: 1 AOV 0.0 Cor~tact Name ~ T itl~ --~ C~ac~ Name T i~ Business Phone: (805) 327-7878x Busir~ess~-'~ ~ ~hone: (~~- 24-Hour Phone : (805) 664-.I673x 24-Hour Phor~e : Pager Phor~e : (~) ~-~/x Pager Phone : ( ) - x Admir~istrat ive Data Mail Addrs: 820 34TH STREET ~ D&B Nun~ber: 77-008-4205 City: BAKERSFIELD State: CA Zip: 93301- Comm Code: 215-004 BAKERSFIELD STATION 04 SIC Code: Address: .... iG?H S ~.,~ /9 · State: CA City: BAKERSFIELD Zip: 9330~- Summary ~V/~/~,~..~ ~ Do hereby certify that ! have (l'y:, ~ ,-"~. print nar~e) -- reviewed the attached ~z~.~dogs,materials man~e- merit nlan for ~~~and tha~ it a~ong ~ ~ine~) - any ~rre~ions constitute a complete and ~rre~ man- agement plan for my facili~. 06/27/96 CHARLES SHOLSON III DDS 215-00e}00381 Page 2 Haz~s~at Ir~ver~tory List in MCP Order 02 - Fixed Corstair~ers on Site Pl r~-Ref Na~e/Hazards For~ Max Qty MCP 02-004 NITROUS OXIDE Gas l ~t~~'-~, "' High Fire, Pressure, Im~ed Hlth 02-001 OX YGEN Gas 843 Low Fire, Pressure, I~med Hlth FT3 02-003 NITROGEN Gas 510 Mini~al Fire, Pressure, I~s~ed Hlth FT3 06/27/96 CHARLESWNICHOLSON III DDS 215-00~}0038i Page 3 02 - Fixed Contair~ers on Site Hazr~lat Ir~ventory Detail ir~ MCP Order 02-004 NITROUS OXIDE Gas 0 High Fire, Pressure, I~ed Hlth CAS ~: 10024-97-2 Trade Secret: No For~: Gas Type: Pure Days: Use: MEDICAL AID OR PROCESS ~ Daily Max Daily Average Ar~r~ual F~our~t Storage i' Press - 'Fe~p ~ Locat ior~ PORT. PRESS. CYLINDER ~Above A~bier~t ~ -- Ccmc ~ Co~por, er~t s ~HF-i MC~ .....r~u i de 100.0%~Nitrous Oxide gh ~ i4 02-001 OXYGEN Gas 843 Low Fire, Pressure, Inlr~ed Hlth FT3 CAS ~: 7782-44-7 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3 Daily Average FT3 Ar~r~ual Amour~t FT3 --- 843 422.00 6,744.00 Storage T Press T T'e~p ~ Location PORT. PRESS. CYLINDER ~Above ~Ambier~t~HALLWAY CLOSET -- Conc ~ Co~npor~er~ts F-- MC~ ............ i-Guide 100.0%/Oxyger~, Co~pressed ~Low / 14 02-003 NITROGEN Gas 510 Mir, i~al Fire, Pressure, I~ed Hlth FT3 CAS 45: 7727-37-9 Trade Secret: No For~: Gas Type: Pure Days: 365 Use: DRILLING Daily Max FT3 Daily Average FT3 ~ Ar~r~ual Ar~our~t FT3 ~- 510 ! 255.00 ~ 1,530.00 Storage F Press T ]"emp ~ Locat ic, r~ PORT. PRESS. CYLINDER ~Above ~Ambier~t~HALLWAY CLOSET -- Corec Ccm~por~er~t s MCP -Gu i de 100.0% I Nitroger~ ILow ~ i~'= 06/2?/96 CHARLES ICHOLSON III DDS 2i5-00W000381 Page 4 00 - Overall Site <D> Notif. /Evacuation/Medical <1> Agency Notification CALL 911 NON EMERGENCY CALL 326-3979 <2> E~ployee Notif./Evacuatio~ VERBAL NOTIFICATION & CALL 911. <3> Public Notif./Evacuation LOCAL NURSE WOULD CALL ALL CLIENTS <4> Er~ergency Medical Plar~ MEMORIAL HOSPITAL - 420 34TH STREET - 327-1792. 06/27/96 CHARLES ~NICHOLSON III DDS 215-00~)00381 Page 5 O0 - Overall Site <E> Mit i gat i o'rs/Prevent/Abat emt <1> Release Prevention GASES ARE CHAINED AND STORED WITH PROF.'ER VALVES AND FITTINGS. <2> Release Containment SHARPS CONTAINERS FOR NEEDLES AND TEETH <3> Clean Up ALL CONTAINERS ARE PICKED UP - SECURITY ENVIRONMENTAL SYSTEM <4> Other Resource Activation 06/27/96 CHARLES ~I~ICHOLSON I I I DDS 215-00~.~.-~00381 Page 6 00 - Overall Site <F> Site EmergerJcy Factors <1> Special Hazards <2> Utility Shut-Offs A) CLOSET IN LAB B) ELECTICAL - PANEL IN DEVELOPING ROOM C) WATER - 34TH STREET D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec. /Avail. Water PRIVATE FIRE PROTECTION .-~flRE EXTINGUISHERS, []NE IN FRONT OFFICE AND ONE IN THE LUNCH ROOM/, ~f~ ~-~y /~//-~ F-~, FIRE HYDRANT -- FRONT OF BUILDING ON 34TH STREET - NORTH END NEAR DRIVEWAY. <4> Buildir, g Occupar, cy Level I 106/27/96 CHARLES ICHOLSON I I I DDS 215-0(~000381 Page O0 - Overall Site <G> Trair~ir~g <1> Er~ployee Trair~i'r~g WE HAVE ?~EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE BRIEF SUMMARY OF TRAINING: ALL-~.,,~"' ~ HAVE HAD OSHA TRAINING <2> Page 2 <3> Held for Future Use <4> Held for Future Use / 02/01/94 CHARLES S NICHOLSON III DDS 215-000-000381 Page 1 Overall Site with 1 Fac. Unit General Information Location: 38.O5--S-~ Map: 103 Hazard: Low Community: BAKERSFIELD STATION '04 Grid: 19B F/U: 1 AOV: 0.0 Contact Name Title Business Phone 24-Hour Phone- CHARLES NICHOLSON (805) 327-7878 x (805) 664-1673 () -~x (')~!- ~ ' ~,,[//Administrative Data Mail Addrs'. ~v~on~ ~..,,~' ~,-~S ST SU~B-- D&B Number: 77-008-4205 City: BAKERSFIELD State: CA Zip: 93301- Comm Code: 215-004 BAKERSFIELD STATION 04 SIC Code: Owner: DR. SINGH Phone: (805) 327-0807 Address: 2323 16TH ST SU 305 State:' CA City: BAKERSFIELD Zip: 93301- Summary RECEIVED 1 7 1994 HAZ. MAT. DIV. ,, reviewed the attached hazardous maledeJ~ manage- mere ~'for, and.that It atong with ~of~) a~ ~e~lOl~ ,constitute a ¢omi31ele a~dlx)m~ maa. 02/01/94 CHARLES S NICHOLSON III DDS 215-000~000381 Page 2 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site Pln-Ref Name/Hazards Form Max Qty MCP 02-001 OXYGEN Gas 843 Low · Fire, Pressure, Immed Hlth FT3 02-003 NITROGEN Gas 510 Minimal · Fire, Pressure, Immed Hlth FT3 02/01/94 CHARLES S NICHOLSON III DDS 215-000-000381 Page 3 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order 02-001 OXYGEN Gas 843 Low · Fire, Pressure, Immed Hlth FT3 CAS #: 7782-44-7 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3I Daily Average FT3 I Annual Amount FT3 843 ~ 422.00 6,744.00 Storage Press T Temp Location PORT. PRESS. CYLINDER Iabove ]AmbientlHaLLWaY CLOSET -- Conc Components MCP ---~uide 100.0% IOxygen, Compressed ILow ! 14 02-003 NITROGEN Gas 510 Minimal · Fire, Pressure, Immed Hlth FT3 CAS #: 7727-37-9 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: DRILLING -- Daily Max FT3 Daily Average FT3 Annual Amount FT3 t 510 I 255.00 I 1,530.00 Storage Press T Temp Location PORT. PRESS. CYLINDER IAbove /Ambion~IHALLWAY CLOSET -- Conc Components MCP ---lGuide 100.0% INitrogen ILow J 21 · 02/01/94 CHARLES S NICHOLSON III DDS 215-000-000381 Page 4 00 - Overall Site <D> Notif./Evacuation/Medicai <1> Agency Notification CALL 911 NON EMERGENCY CALL 326-3979 <2> Employee Notif./Evacuation VERBAL NOTIFICATION & CALL 911. <3> Public Notif./Evacuation LOCAL NURSE WOULD CALL ALL CLIENTS <4> Emergency Medical Plan MEMORIAL HOSPITAL - 420 34TH STREET - 327-1792. 02/01'/94 CHARLES S NICHOLSON III DDs 215-000-000381 Page 5 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention GASES ARE CHAINED AND STORED WITH PROPER VALVES AND FITTINGS. <2> Release Containment SHARPS CONTAINERS FOR NEEDLES AND TEETH <3> Clean Up ALL CONTAINERS ARE PICKED UP - SECURITY ENVIRONMENTAL SYSTEM <4> Other Resource'Activation 02/01/94 CHARLES S NICHOLSON III DDS 215-000-000381 Page 6 00 - Overall Site <F> Site Emergency Factors <1> Special'Hazards <2> Utility Shut-Offs ~A) CAS - HALLWAY CIA)SET <LIo~- -- ~ -- --k~b./ B) ELECTICAL - PANEL IN DEVELOPING ROOM C) ~.~R'- SAN Dib~,FRONT-O-F--~t4%q~5~~,./-- D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - 2.FIRE EXTINGUISHER~, ONE IN FRONT OFFICE AND ONE FIRE HYDRANT - FRONT OF BUILDING ON~ - NORTH END NEAR DRIVEWAY <4> Building Occupancy Level 02/01/94 CHARLES S NICHOLSON III DDS 215-000-000381 Page 7 00 - Overall Site <G> Training <1> Page 1 WE HAVE 6 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETs ON FILE BRIEF SUMMARY OF TRAINING: ALL GIRLS HAVE HAD OSHA TRAINING <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use 02/01/94 CHARLES S NICHOLSON III DDS 215-000-000381 Page, 8 00 - Overall Site <H> RMPP DATA <1> Release Containment <2> Offsite Consequences <3> In House Capabilities <4> Plant Shutdown Instruction MATER~ l~en;field Fire Dept. Hazardous Materials Division Date Completed /_//,_ Business Name: {'~j/~Gr/tS ~' ~; ~/~o~ ~ ~ ~' Location: ~ ~'~ ~. ~ ~'/~/" ~o~oi~ ~}c~d~e~,~ Business Identification No. 215-000 (Top of Business Plan) Station No. Y Shift ~ Inspe~or ~ ~ ~,p/1' Arrival Time: / z~ ~ ~ Depa~re Time: / ~ ~'D Inspe~on Time: Adequate Inadequate Verification of Invento~ Materials ~ ~ RECEIF~D ~, Verifica~on of Ouan~es ~ ~ J~N ~ropor 8~Fofla~on of Matorial ~ Common~: Vorifica~on o~ MSD8 ~vailabili~ ~ ~umbor of fimployoos: Vorifica~on of Haz Mat lraininfl ~ Common~: Vorifica~on of ~batomont 8upplios &Procoduros ~ Common~: Emergency Procedures Posted ~ Containers Proper~ Labeled ~ Commen~: Verification of Facil~ Diagram ~ Special Hazards Associated wi~ ~is Facile: ~ ~ Violations: ~~ ~~' -~~ .//~~d~de ~_ /'"'~ ~"~- ...... All Items O.K Busin~ ~erNanager PRINT ~ME S~NA~URE ~ Correction Needed Wh~H~ Mat D~ Yellow-Cation ~py Pink-Busings ~py 03/10/93 CHARLES S NICHOLSON III DDS 215-000-000381 Page Overall Site with 1 Fac. Unit General Information Location: 3805. SAN DIMAS ST B Map: 103 Hazard: Low Community: BAKERSFIELD STATION 04 Grid: 19B F/U: 1 AOV: 0.0 Contact Name Title Business Phone 24-Hour Phone- CHARLES NICHOLSON (805) 327-7878 x (805) 664-1673 ( ) - x ( ) - Administrati.ve Data Mail Addrs: 3805 SAN DIMAS ST SUB D&B Number: 77-008-4205 City: BAKERSFIELD State: CA Zip: 93301- Comm Code: 215-004 BAKERSFIELD STATION 04 SIC Code: Owner: DR. SINGH Phone: (805) 327-0807 Address: 2323 16TH ST SU 305 State: CA City: BAKERSFIELD Zip: 93301- Summary RECEIVED 'APR 8' 1993 HAZ, MAT. DIV. DO hereby certify that i have reviewed the attached hazardous materials manage~ ment plan for_C~$. Flich°l~o~]A,~nd that it along with (~ orlSu~in,e~) - any corrections constitute a complete and correct rnan- gement Pla~for~facility. 03/10/93 CHARLES S NICHOLSON III DDS 215-000-000381 Page 2 Hazmat Inventory List in MCP Order .~ 02 - Fixed Containers on Site Pln-Ref Name/Hazards Form Quantity MCP o~-oo~~o~s o~ ~~ ~.~. ~ressure, Immed ~ 0~~.~.~~_..~ 02-001 OXYGEN Gas 843 Low · Fire, Pressure, Immed Hlth FT3 02-003 NITROGEN Gas 510 Minimal · Fire,. Pressure, Immed Hlth FT3 03/10/93 CHARLES S NICHOLSON III DDS 215-000-000381 Page 3 02 - Fixed Containers on Site Hazm~/~nventory Detail in MCP Order 02-002 NITROUS OXIDE W~J~ Gas 1689 Hi~ ~ire, Pressure, Immed Hlth CAS %.'~?~~~ Trade Secret: No . ,~-~×~. Form: Gas ~e ' Days. 365 ~ETIC ~ ~ Amount FT3 -' ~ ~b. 13,513.00 ~...-~'Y6nc I ' Components' ~ ~uide f 100.0% INitrous Oxide . IHigh~14 02-001 OXYGEN Gas 843 Low · Fire, Pressure, Immed Hlth FT3 CAS #: 7782-44-7 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3843 I Daily Average422.00FT3 I Annual Amount6,744.00FT3 Storage Press I Temp Location PORT. PRESS. CYLINDER Iabove ~AmbientlHaLLWaY CLOSET -- Conc Components MCP --TGuide 100.0% IOxygen, Compressed ILow ~ 14 02-003 NITROGEN Gas 510 Minimal · Fire, Pressure, Immed Hlth FT3 CAS #: 7727-37-9 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: DRILLING Daily .Max FT3I Daily Average FT3 ] Annual Amount FT3 510 ~ 255.00 1,530.00 Storage Press T Temp Location PORT. PRESS. CYLINDER Iabove IAmbientlHaLLWaY CLOSET -- Conc~ Components ~ MCP ---~Guide 100.0% INitrogen ILow ~ 21 03/10/93 CHARLES S NICHOLSON III DDS 215-000-000381 Page 4 00 - Overall Site <D> Notif./Evacuation/Medical <1> Agency Notification CALL 911 NON EMERGENCY CALL 326-3979 <2> Employee Notif./Evacuation VERBAL NOTIFICATION & CALL 911. <3> Public Notif./Evacuation LOCAL NURSE WOULD CALL ALL CLIENTS <4> Emergency Medical Plan MEMORIAL HOSPITAL - 420 34TH STREET - 327-1792. 03/10/93 CHARLES S NICHOLSON III DDS 215-000-000381 Page 5 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention GASES ARE CHAINED AND STORED WITH PROPER VALVES AND FITTINGS. <2> Release Containment SHARPS CONTAINERS FOR NEEDLES AND TEETH <3> Clean Up ALL CONTAINERS ARE PICKED UP - SECURITY ENVIRONMENTAL SYSTEM <4> Other Resource Activation 03/10/93 CHARLES S NICHOLSON III DDS 215-000-000381 Page 6 00 - Overall Site <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - HALLWAY CLOSET B) ELECTICAL - PANEL IN DEVELOPING ROOM C) WATER - SAN DIMAS, FRONT OF BUILDING D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water ~ PRIVATE FIRE PROTECTION '~ FIRE EXTINGUISHERS, IN FRONT OFFICE AND ONE IN THE BACK LOUNGE.. FIRE HYDRANT - FRONT OF BUILDING ON SAN DIMAS - NORTH END NEAR DRIVEWAY <4> Building Occupancy Level 03/10/93 CHARLES S NICHOLSON III DDS 215-000-000381 Page 7 00 - Overall Site <G> Training <1> Page 1 WE HAVE 6 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE BRIEF SUMMARY OF TRAINING: ALL GIRLS HAVE HAD OSHA TRAINING <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use BAKERSFIELD CITY FIRE DEPARTMENT HAZARDOUS MATERIALS DIVISION 2130 "G" STREET BAKERSFIELD, CA. 93301 (805) 326-3979 HAZARDOUS MATERIALS INVENTORY INSTRUCTIONS RECEIVED FACILITY DESCRIPTION: !/t, PR § 19c),~ Check if your business is a farm. HAZ. MAT. DiV. Enter the full legal name and site address of your busineSs. Do not use post office box numbers. Give a brief description of the nature your business activities. 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 page 4. Other SIC codes may be obtained from your worker's compensation insurance forms, the State of California Employment Development Department by giving them your employer number, from the U.S. Labor Department or from the Standard Industrial Classification Manual.' Enter the Dun & Bradstreet or federal tax identification number for your business. Enter the name of the owner, their mailing address and phone number. EMERGENCY CONTACTS: List tWo persons who have full access to the facility, 'including locked areas, and 'that are knowledgeable about your materials and process. .... CHEMICAL DESCRIPTION: 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. Enter the full legal name and site location of your.business at the top of the form. Enter the page number in the right hand corner. Each of the instructions below correspond to the entry field with the same number on the chemical description form. Se~eml3er 30. 1992 1 REGION V L~P~ sTANDARD FOI~I 1. Check the appropriate box for a new inventory or for additions, revisions or deletions to an existing inventory. Check nontrade secret unless the chemical composition meets the criteria for trade secret status per Section 6254.7 of the California Government Code and Section 1060 of the California Code of Evidence. Copy trade secret pages onto yellow paper before submitting your .inventory so that they will be easily identified. 2. Enter the common name or the manufacture's product name. Enter the standard chemical name. If a pure material is 'an acutely hazardous material (AHM), check the box labeled AHM. Report the components of mixtures under item 9 below. 3. Enter the Dept. of Transportation (DOT) identification number and the Chemical Abstract .i Service'-(OAS) nUmber for this chemical. CAS numbers are commonly found on Material ' Safety Data Sheets. 4. Check the box(es) which describe the physical and health hazards associated with the chemical. 5. If the material 'is a waste, enter the appropriate three-digit California waste code. California's nonrestricted waste codes are listed on page 4 of these instructions. Questions regarding the waste classification codes and requests for hazardous waste manifest form #8022 may be addressed to the Department of Health Services, Toxic Substances Control Program at (916) 322-3670. Enter the appropriate use code from the following list. USE CODES 01. Additive 20. Fungicide 39. Washing. 02. Adhesive 21. Grinding 40. Waste 03. Aerosol 22. Heating 41. Water Treatment 04. Anesthetic 23. Herbicide 42. Welding/soldering 05. Bactericide 24. Insecticide 43. Well injection 06. Blasting 25. Instructional 44. Oil treatment 07. Catalyst 26. Lubricant 45. Resale 08. Cleaning 27. Medical aid/process 46. Aircraft systems 09. Coolant 28. Neutralizer 47. Battery electrolyte 10. Cooling 29. Painting 48. Breathing air 11. Drilling 30. Pesticide 49. Drafting aid 12. Drying 31. Plating 50. Finished product 13. Emulsifier/demulsifier 32. Preservative 51. Fire protection 14. Etching 33. Refining 52. Hydraulic equipment 15. Experimental 34. Sealer 53. Road/Hwy maintenance 16. Fabrication 35. Spraying 54. Testing 17. Fertilization 36. Sterilizer 55. Wholesale chemicals 18. Formulation 37: Storage 99. Other - specify. 19. Fuel 38. Stripper Se!~ernber 30, 1992 2 REGION V L.EPC STANDARD FORM 6. Check the boxes which describe the physical state of the chemical. Pure materials are 100% of the chemical listed in item #2. Chemicals that have been diluted with water or combinations of two or more chemicals should be reported as mixtures and the components listed in Under item #9. 7. Enter the maximum daily amount, the average daily amount and the ('otal annual amount of material in storage or use at your facility. Enter.the largest container size and the number of days/year that the material is on site. Circle the months that the material is on site. Enter the units of measure. Report solids in pounds, liquids in gallons, gases in cubic feet and radioactive materials in curies. 8. Select the appropriate storage codes from the lists below. a) CONTAINER CODES 01. 'Underground tank 09. Glass container(s) 02. Aboveground tank '" 10. Plastic container(s) 03. Fixed Pressurized tank 11. Box(es) 04. Portable pressurized cylinders 12. Bag(s) 05. Insulated tank 13. Metal containers (not drums) (includes cryogenics) 14. In machinery or processing 06. Drums or barrels - metallic . equipment 07. Drums or barrels - non-metallic 15. Bin(s) 08. Carboy(s) 99. Other-specify b) PRESSURE CODES t - The material is stored at ambient (normal atmospheric) pressure. 2 - The material is stored at greater than ambient pressure. 3 - The materials is stored at less than ambient pressure. c) TEMPERATURE COOES 4 - The material is stored at ambient (surrounding) temperature. 5 - The material is stored at greater than ambient temperature. 6 - The material is stored at less than ambient temperature. 7 - The mat'erial is stored under cryogenic conditions 9. Enter the maximum % concentration by weight of the three MOST hazardous components in the material. Round up to the nearest whole number percentage. Enter the CAS. number for each component of the mixture. If the component is an acutely hazardous material, check the box labeled AHM. 10. Briefly describe the location of the material within the building/facility using compass directions and obvious landmarks. Se~emDer 30, 1992 3 REGION V LEPC STANDARD FORM COMMON STANDARD INDUSTRIAL CLASSIFICAT! (SIC) CODES Olll Wheat production 0724 Cottonginning 5821 Eating places 0115 Corn production 0541 Grocery Store 5813 Ddnking places 0131 Cotton production 1541 D~y cleaners (alcohol service) 0139 Field crops, except cash grains 2911 Oil refineries 5983 Fuel oil dealers 0161 Vegetables & melons 3441 Welding/fabrication- structural 5984 LPG dealers 0172 Grapes 3443 Welding/fabrication-boiler 7342 Pest control 0173 Tree nuts 3569 Machine shop 7532 Auto top, body, 0174 Citrus fruits 4222 Cold storage upholstery repair 0175 Deciduous tree fruits 4925 Compressed gas supplier Auto paint shops '1 0179 Other tree fruits & nuts 5093 Automobile salvage 7533 Auto exhaust repair 0192 General farms, primarily crop 5169 Chemical supply 7536 Auto glass replacement 0241 Dairy farms 5511 Motorvehicledealers (new & used 7537 Auto transmission repair 0252 Chicken eggs 5521 Motorvehicte (used only 7538 General auto repair 0253 Turkey eggs 5531 Auto & home supply stores 7542 Car washes 2851 Paint manufacture 5541 Gasoline service stations 8071 Chemical Laboratory 0291 General farm, primarily livestock & animal specialties NONRESTRICTED WASTE CODES Code Description Code Description Inor,qanics 111 Acid solution 2< pH <7 with metals ( antimony, arsenic, 272 Polymeric resin waste barium,beryllium, cadmium, chromium, cobalt, copper, lead, 281 Adhesives mercury', molybdenum; nickel, selenium, silver, thallium, vanadium and zinc) 291 Latex waste 112 Acid solution without metals 311 Pharmaceutical waste 113 Unspecified acid solution 321 Sewage sludge 322 Biological waste other than sewage sludge 121 Alkaline sotution pH > 12.5 with metals (see 111) 122 Alkaline solution without metals 331 Off-spec, aged or surplus organics 123 Unspecified alkaline solution 341 Organic liquids (nonsotvents) with halogens 343 Unspecified organic liquid mixture 131 Aqueous solution (2 < pH < 12.5) containing reactive anions 351 Organic solids with halogens (azide, bromate, chlorate, cyanide, fluoride, hypochlorite, nitrite, perchlorate and sulfide anions) 132 Aqueous solution with metals (see 111 ) Sludc~es 411 Alum and gypsum sludge 133 Aqueous solution with total organic residues 10% or more 421 Lime sludge 134 Aqueous solution with total organic residues less than 10% 135 Unspecil~ed aqueous solution 431 Phosphate sludge 141 Off-spec, aged. or surplus inorganics 441 Sulfur sludge 451 Degreasing sludge 151 Asbestos containing waste 461 Paint sludge 161 FCC Waste 471 Paper sludge/pulp 162 Other spent catalyst 171 Metal sludge (see 111) . 481 Tetraethyllead sludge 172 Metal dust and machining waste (see 111)' 491 Unspecified sludge waste 181 Other inorganic solid .waste Miscellaneous Orcjanics 511 Empty pesticide containers 30 gal or more 211 Halogenated solvents 512 Other empty containers 30 gal or more 513 Empty containers less than 30 gal (methylene chloride, chloroform, TCE, TCA 521 Drilling mud 212 Oxygenated solvents (acetone, butanol, MEK) 531 Chemical toilet waste 213 Hydrocarbon solvents (stoddard soivent, xylene) 214 Unspecified solvent mixture 541 Photo chemical/photo processing waste 221 Waste oil and mixed oil 551 Laboratory waste chemicals 222 Oil/water separation sludge 561 Detergentand soap 571 Fly ash. bottom ash, and retort ash 223 Unspecified oil - qontaining waste 231 Pesticide rinse water 581 Gas scrubber waste 232 Pesticides and other 591 Baghouse waste 611 Contaminated soil from site clean-ups waste associated with pesticide production 241 Tank bottom waste 612 Household wastes 251 Still bottoms with halogenated organics 252 Other still bottom waste 261 PCB's and matedai containing PCB's 271 Organic monomer waste (includes unreacted resins) (Restricted was!.,e codes are listed on the back of form #8022) Septernl:er 30, 1992 4 REGION V LEPC STANDARD FORM BAKERSFIELD CITY FIRE DEPARTMENT HAZARDOUS MATERIALS DIVISION 2130 "G" STREET BAKERSFIELD, 'CA. 93301 (805) 326-3979 HAZARDOUS MATERIALS INVENTORY FACILITY DESCRIPTION CHECK IF BUSINESS IS A FARM [ ] BUSINESS NAME pr. C.h_~rle~ ~. ~icho!som :]:IL~ pbs FACILI~ NAME SITE ADDRESS ~06 ~ DI'~.& ~ ~'+¢ ~ CI~ ~~K~'~}~ STATE ~i~rn~ ZIP SIC CODE ~0~1 DUN & BRADSTREET NUMBER q~- O0 OWNER/OPERATOR _~1I". MAILING ADDRESS ~0Fo C~TY ~b&l~F[~ ld EMERGENCY CONTACTS NAME \lol~ -l-?~oco TITLE BUSINESS PHONE 3~-~8 24-HOUR PHONE NAME ~~r';B~) ~J/ TITLE BUSINESS PHONE ~q-q~q¢ 24-HOUR PHONE Se~emOer 30, lge~ REGION V LEPC STANDARD FORM BAKERSFI .D'ClTY FIRE DEPARTMENT HAZARDOUS MATERIALS INVENTORY Page_Eof__ CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Oeletion~ Check if chemical is NON TRADE SECRET [ ] TRADE SECRET Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE [ ] Uquid [ ] Gas'~. Pure ~ Mixture [ ] Waste [ ] Radioactive [ ] 6) PHYSICAL STATE Solid 7) AMOUNT AND T1ME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: lbs [. ] gal [ ] ft3 [ ] a) Container: Average Dally Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: L~rgest Size Container: ~# Days On Site Circle Which Months: All Year, J, F, M, ,A, ,M, J, J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1) [ ] chemical components or any AHM components 2) [ ] 3) [ ] CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New[ ] Addition[ ] Revision[ ] Deletion[ ] Check if chemical is a NON TRADE SECRET [ ] TF[ADE SECRET [ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION ,(3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: Ihs [ ] gal [ ] ft3 [ ] a) Container: Average Daily Amount: cudes [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: # Days On Site Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1). [ ] chemical components or any AHM components 2) [ ] 3) [ 1 O) Location / betieve the submitted information is ~ue, accurate, and complete. PRINT Name & Title of AUthorized Company Representa~ve Signature Date BAKERS ELD CITY FIRE DEP/ TMENT $ , HAZARDOUS MATERIALS INVENTORY Page of Business Name Address CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS Cf 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE COOE 6) PHYSICAL STATE Solid [ ] Uquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Dally Amount: lbs [ ] gal [ ] 1t3 [ ] a) Container: Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: Cf Days On Site. Circle Which Months: All Year, J, F, M, A, M, J,~..J., A, S, 0., N:. D 9) MIXTURE: List COMPONENT CAS Cf % WT AHM the three most hazardous 1) [ ] chemical components or [ ] any AHM components 2) 3) [ ] 1 0) Location CHEMICAL DESCRIPTION 1 ) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check i~ chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT Cf (optional) Chemical Name: AHM [ ] CAS # 4) PHYsiCAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSI~FICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: lbs [ ] ga/ [ ] ft3 [ ] a) Container: Average Dally Amount: curies [ ]~ b) Pressure: Annual Amount: c) Temperature: Largest Size Container: Cf Days On Site CircleW~ich Months: All Year. J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: Ust COMPONENT CAS Cf % WT AHM the three most hazardous 1) [ ] chemical components or [ ] any AHM components 2) 3) [ ] lo) Lo .ion personally examined and em familiar with the infomatJon submitted on this and all attached documents. I believe th,', submitted informa~on is ~'ue, accurate, and complete. PRINT Name & Title of Authorized Company Representative Signature Date BAKERSFIELD CITY FIRE DEPAF MENT HAZARDOUS MATERIALS INVENTORY Page of Business Name Address CHEMICAL DESCRIPTION 1). INVENTORY STAT_US: New[ ] Addition[ ] Revision[ ] Deletion[ ] Check if chemical is aNONTRADE SECRET [ ] TRAOE SECRE'Y [ 2) Common Name: 3) DOT # (optional} Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE. 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACtLITY UNITS OF MEASURE 8) STORAGE CODES M~ximum Daily Amount: lbs [ ] gal [ ] ~t3 [ ] _ a) Container: Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: # Days On Site . Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, D . 9) MIXTURE: Ust COMPONENT CAS # % WT AHM the three most hazardous 1) [ ] chemical components or any AHM components 2) [ ] 3) [ ] 1 O) Location CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New[ ] Addition[ ] Revision[ ] Deletion[ ] Check ifchemicaJ is aNON TRADE SECRET [ ] TRADE SECRET 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES M~ximum Daily Amount: lbs [ ] gal [ ] ft3 [ ] a) Container: Average Daily Amount: cudes [ ] b) Pressure: Annual Amount: c) Temperature: L.argest Size Container: # Days On Site Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1 ) [ chemical components or any AHM components 2) [ 3) [ 1 O) Location i cer~'~ under penat~/of law, that I have personally examined and am familiar with the infomatJon submitted on this and all attached documents. submitted inforrnat~on is true, accurate, and complete. Date PRINT Name & Title of Authorized Company ~epresentatlve Signature ~akersfield Fire Dept. HAZARDOUS MATERIALS DIVISION Date Completed Business Name: ~ r/~ ~ ~' ~ ~ o ~ ~' ~ ~,~- Locaion: ~ ~ ~ ~'~ ~ Business Identification No. 21~000 ~ F / Fop of Business_ --Plan) Station No. ~ Shift ~ Inspector Adequate Inadequate Verification of Invento~ Uaerials ~ Verification of Quantities ~ Ver~icaion of Locaion ~ Proper Segregation of Material~ Comments: Verification of MSDS Availabli~~ Number of Employees Verification of H~ Mat Training ~ Comments: Vorifieation of ~b~omo~ 8upplios & Procoduros ~ Commonts: Emergency Procedures Posted ~ Containers Properly Labeled ~ - Comments: Verification of Facility Diagram ~ Special H~ards Associated with this Facility: ~~ ~ ~~ AIIItemsO.K. ~ ~ ( ~ //~' ~ Correction Needed Business Owner/Man~er FD 1~ (~v, 1-90) ~im-H~ ~t Biv. Yellow-Sat~n ~py Pink-Busin~ 10/C)8/90 CHARLES~NICHOLSON III DDS 215-, ss1RECEfYEO Pa_qe Overall Site with 1 Fac. Ur, it FEB 5 1991 General Information Location: 3805 SAN DIMAS ST B Map: 103 Hazard: Low Ident Number: 215-000-000381 Grid: 19B Area of Vul: 0.0 ~ Contact Name ~ Title Business Phone ~ 24 Hour Phone~ ~CHARLES NICHOLSON ~ (805) 327-7B78 x ~(805) 833-2595 ~ (805) 3~7-7878 x ~ (~0~) ~dmir~istrative Data Mail Addrs: 3805 SAN DIMAS ST SUB D&B Number: City: BAKERSFIELD State: CA Zip: 93301- Comm Code: 215-004 BAKERSFIELD STATION 04 SIC Code: Owner: DR. SINGH Phone: (~0~) Address: 2323 16TH ST SU 305 State: CA City: BAKERSFIELD Zip: 93301- Summary 10/08/90 CHARLES S NICHOLSON III DDS 215-000-000381 Page 2 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site Pln-Ref Name/Hazards Form Quantity MCP 02-002 NITROUS OXIDE ? i,689 High FT3 02-001 OXYGEN ? 843 Low FT3 02-003 NITROGEN ? 5i0 Minimal FT3 10/08/90 CHARLES PNICHOLSON I I I DDS 215-001.)00381 Page 3 00 - Overall Site <D) N,z,t if. /Evacuat ior~/Medical <1> Ager~cy Notificatic, r~ <2> Er~ployee Notif. /Evacuatior~ VERBAL NOTIFICATION & CALL 911. <3> Public Notif. /Evacuation <4> Er~erger, cy Medical Plan 4~0 34TH STREET - 327-1792. MEMORIAL HOSPITAL - ':" 10/08/90 CHARLES S NICHOLSON III DDS 215-000-000381 Page 4 O0 - Overall Site <E> Mit igat iorJ/Preverlt/Abatemt <1> Release Prever~tion GASES ARE CHAINED AND STORED WITH PROPER VALVES AND FITTINGS. <2> Release Cor, tairm~er, t <3> Clea~ Up <4> Other Resource Activation 10/08/90 CHARLES CHOLSON III DDS 215-00t )381 Page 5 O0 - Overall Site <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - HALLWAY CLOSET B) ELECTICAL - PANEL IN DEVELOPING ROOM DC)) SPEC WATERiAL- -????????????NONE L~Dcf¥~_~o~ ~ E) LOCK BOX - NO <3> Fire Protec. /Avail. Water PRIVATE FIRE PROTECTION - ??????????????? FIRE HYDRANT - ??????????????? <4> Held for Future use 10/08/90 CHARLES S NICHOLSON III DDS 215-000-000381 Page 6 00 - Overall Site <G> Training <1> Page 1 WE HAVE ?? EMPLOYEES AT THIS FACILITY DO YOU HAVE MATERIAL SAFETY DATA SHEETS ON FILE? BRIEF SUMMARY OF TRAINING: <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use Bakersfield Fire Dept. Hazardotts Materials'Inspection · Date Completed Plan iD # 21S-OOO~nnXS! (Top fight comer Bush-tess Plan) Station No ...... q , Shift., , ~. . Inspector Adequate Inadequate YerificaflOn of Inventory Materlals Verification of Quantities [~ [-'-1 Yerification of Location ~ [-] Proper Segregation of Material [~ [--1 Comments: ~ 5 Verification of MSDS Availability ' NUmber of Employees ~. ~ , .... Verification of Haz Mat Trainln§ [~ [---] Veritlcatlon of Abatement Supplies & Procedures [~ [] ':': ,' Emergency Procedures'~osted [~- [--] : ContalnersProperly Labeled . ~ [--] 'Verlfleafl0~l of Facility Diagram · ' Special Hazards Assodated with this Facility; ,~,,~ FD ~652 (Rev. 3-89] White-Haz Mat Div. Yellow-Station Copy Pink-Business Office BA E.SFIELD ciw FI.E DEPA T NT// _ 2130 "G" S~EET ~ ~ ~ B~RSFIELD, CA 90301 SEP 1987 (805) 326-3979 ~'~ Ans'd... OFFICIAL USE ONLY HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 2A INSTRUCTIONS: .- 1. To avoid further action, return this form by 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. SECTION 1: BUSINESS IDENTIFICATION DATA A. BUSINESS NAME: Charles S."Nicholson III D.D.S. B. LOCATION / STREET ADDRESS: 3805 San Dimas Suite ~B CITY: Bakersfield, Ca. ZIP: 93301 BUS.PHONE: (805)32?-?878 SECTION 2: EMERGENCY NOTIFICATIONS In case of an emergency involving the release or 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 AND TITLE DURING BUS. HRS. AFTER BUS. HRS. A. Charles S. Nicholson III D.D.S. Ph# 327-787~ Ph# 833-2595 B. Kathy Frantz - Office Manaqer Ph# 327-7878 Ph# SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE C. WATER: 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 - SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YO~ 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. CIRCLE YES OR NO INITIAL REFRESHER A. METHODS FOR SAFE HANDLING OF HAZARDOUS MATERIALS:.... .................................... Y~ NO YES ~ B. PROCEDURES FOR COORDINATING ACTIVITIES ~~ ~ WITH RESPONSE AGENCIES: .......................... YES C. PROPER USE OF SAFETY EQUIPMENT: .................. YES D. EMERGENCY EVACUATION PROCEDURES: ................. ~N,~O YES E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES ~ YES SECTION 7: HAZARDOUS MATERIAL CIRCLE YES OR NO DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POU~3'S~8~ A SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YE~,~NO 1,3~~~-~~ , certify that the above information is accurate. I understand that this information will be used to fulfill my fi~m's obligations under the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter 6.95 Sec. 25500 Et Al.) and that inaccurate information constitutes perjury. BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 OFFiCiAL USE ONLY BUSINESS NAME ' ~-~ ~ ~ · ''~' ~'~>~'~i~ ,u~ ~ ~'~- ~ !C~ ID# BUS I NESS PLAN SINGLE FACILITY UNIT FORM INSTRUCTIONS 1. To avoid further action, thJs form must be returned by: 2. TYPE/PRINT YOUR ANSWERS IN ENGLISH. ~. Answer the questions belo~ for THE FACILITY UNIT LISTED BELOW 4. Be as BRIEF and CONCISE as possible. SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDDqlES SECTION 2: NOTIFICATION A~%q] EVACUATION PROCEDURES AT THIS UNIT ONLY ~ 3A - A. Does this Facility Unit contain Haza~/~teria!s? ...... YES NO If YES, see B. y . · If NO, continue with SECTIOn/ B. Are any of the hazardous m~,t~rials a bona fide Trade Secret YES NO If No, complete a sepam~~lca~l~i~ntory form marked: NON-TR~SECRETS ONLY (white form #4A-1) If Yes, complete a/hazardous materials inventory form marked: TRADE SECRETS ~ (yellow form #4A-2) in addition to the non-trade secret fo~/List only the trade secrets on form 4A-2. SECTION 4: PRIV~E FIRE PROTECTION SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPO~ERS SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS b~IT ONLY. A. NAT. GAS./PROPAN~ B. ELECTRICAL: C. WATER: D. SPECIAL: E. LOCK BOX: YES / NO IF YES, LOCATION: IF YES, SITE PLANS? YES / NO MSDSs? YES / NO FLOOR PLANS? YES / NO ,KEYS? YES / NO - 3B - BAKERSFIELD CITY FIRE DEPARTMENT I.D. # FORM 4A-1 - Page ..... NON--TRADE SECRETS .HAZARDOUS MATERI ALS INVENTORY BUSINESS NAME: .C~a~les/S,~NicholsOn.'I!I~:DD~?'.:~?. owNER NAME: Dr. Singh FACILITY UNIT ADDRESS: 3805J~';~5~uit~'~B' ---- ~" q .... ~ ADDRESS: 2323 16th Street Suite 305FACILITY UNIT NAME: C I TY, Z I P: ~B~3~_~f~ield;f,~CaJ 5~93301 C I TY, Z I P: Bakersfield, Ca. 93301 PHONE ~: %_~Q5~27~78 PHONE ~ 805-327-0807 ]OFFICIAL USE CFIRS CODE ONLY 1 2 3 4 5 6 7 8 9 10 TYPE MAX ANNUAL CONT USE LOCATION IN THIS~- % BY HAZARD D.O.T .CODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT WT. CHEMICAL OR COMMON NAME CODE GUIDE NAME: Par~la L. Britts~l TITLE: Boo~eeper S GNATUR~ ........... ~ ( ....... (( ........ DATE:9-2-87 EMERGENCY CONTACT: CN~]~ R_ ~icholson TITLE: ~ctor P~0NE ~ BUS ~OURS: 327-7878 AFTER BUS 8RS: 833-2595 EMERGENCY CONTACT: Kathy Frant~ TITLE: Office ~anager PSONE ~ BUS HOURS: 327-7878 PRXNCXPAL BUSINESS ACTIVITY: Oral and Maxillofacia]. Surgery AFTER BUS HRS: 833-9234 - 4A-~ -