HomeMy WebLinkAboutBUSINESS PLAN ITE DIAGRAM [ 1 ' FA~ DIAGRAM
Business Name:
Business Address:
' ~ ,TERIAL IN TI N~ ' ~'" - Bakersfield Fire Dept.
HAZARDOUSMATERIALS IN~ECTION" ' ~ '-- ~ .~...~
................ ' ' ~ CE OF ENVIRONMENTAL' SER VICEs
· 'r ~ 17 15 Chester Ave
Date Completed \ \-q-c-1
Business Name: ~<5'fS~ ~:7:~f-~ ¢:~'~.c_.~'~ ~c-45T% ''
Location: c--~_~t~ '~::::~---J,2~ c..~5~,.~ C~V~ '-
Business Iden~fica~on No. 215-000 ~ ~q ~ gop of Business Plan) ~':
Station ,o. ~ '- Shift ~ Inspector, L~t~ ;.~~.
~alTime:[,.;~O Depa~ureTime: ':["-~ cfionT,~~¢~ )
A~quate Inadequate ff ~ Ad. Mate Inadequate
Address Visable ~ D ' ~y ProCures Posted· ~
Co~ect Occupancy ~ . D Containem Properly LaNed ~
Verification of Invento~ Materials ~ ~ 'Comments:
VerifiCation of Quantities~
Verification of L~ation ~ ~ '" Verification of Facili~ Diagram~
P~r Segregation of Matedal ~ ~ Housekeeping .. ~.~
Fire Protec~on
Comments: Electrical ~.
Comments: :'
Verification of MSDS Availabli~ ~
Numar of Employees: ~ MST Monitoring Pro'ram- D
Comments:
Verification of H~ Mat Training ~ D .....
Pe~its ~
Comments: Spill Control ~
Hold Open Device D
Vedfi~tion of H~ardoUs Waste EPA No.
~tement Supplies and Pr~edures ~
Proper Waste Disposal ~
Comments: Seconda~ Containment D
Secud~ ~
8pe~ial Hazards Associated with this Facili~:
~ola~ons:
/ All Items O.K
Business O~Nanag~ PRINT NAME SIGNATURE Correction Needed
~ite-H~ Mat Div. Yellow-Station Copy Pink-Business 'C~y
KSA OUP ARCHITECTS
Bakersfield, California 93309
.(805) 834-1331
FAX (805) 834-1376
Ken Sorenson Architect AIA . .
Derek Holdsworth Architect AIA
November_5,~1999 .....
City of Bakersfield
Office of Environmental Services
Hazardous Materials Division
1715 Chester Avenue, Suite 300
Bakersfield, CA 93301
Attention: Ralph Huey
Dear Mr. Huey;
Effective this date, there are no hazardous materials located on our property at 4660 Amedcan
Avenue, Bakersfield, CA.
The unused portion of your hazardous materials "fee" can be forwarded to the above address.
Sincerely;
KSA Group Architects
nson ~ ·
~AIA
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (805) 326-3979
\
~STRUCTIONS: /
1. To avoid ~nher actio~ re~ ~s fo~ ~t~n 30 days of receipt.
2. T~E~ ~S~RS ~ ENGLISH.
3. ~swer th~ quesfiom below for
4. Be ~ briefed concise ~ possibl~
SECTION 1: BUS.SS ~E~ICATION DATA
~OC~ON: ~&~
~.~G ~D~SS:
CITY: STA~: ~ Z~:- ~ PHO~:
D~ & B~S~ET ~ER: SIC CODE:
P~Y ACTI~:
O~R: ~
MAILING ADDRESS:
SECTION 2: EMERGENCY NOTIFICATION
CONTACT TITLE BUS. PHONE 24 I-IR. PHONE
'~-- ~_.. HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION-3.:_TRAINING
NUMBER. OF EMPLOYEES:'~' ~'-'-~-~_._~_
MATERIAL SAFETY DATA SHEETS ON FILE:
BRIEF SUMMARY OF TRAINING PROGRAM:
SECTION 4: EXEMPTION REQUEST '
I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM
THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF TI-IE ',CALIFORNIA HEALTH ' ·
& SAFETY CODE" FOR THE FOLLOWING REASONS:
WE DO NOT HANDLE HAZARDOUS MATERIALS.
WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT
NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: 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 HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500
ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY.
SIGNATURE TITLE ' DATE
2
HAZARDOUS MATERIALS MANAGEM]~NT PLAN
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES
A. AGENCY NOTIFICATION PROCEDURES:
B. EMPLOYEE NOTIFICATION AND EVACUATION:
4660 American Ave~-- /
Bakersfield, Caliform,~f3309
(805) 834-133'1
, FAX (805) 834-1376
D. EMERGENCY MEDICAL PLAN:
Ken Sorenson Arc~hit.e.c_t:AIA---~
President .
)
HAZARDous MATERIALS MANAGEMENT PLAN
"$EC-T~ION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN
· A. RELEASE PREVENTION-STEPS:._
B. RELEASE CONTAINMENT AND/OR MINIMIZATION:
C. CLEAN-UP PROCEDURES:
SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)
NA~ GAS/PROPANE:
ELECTRICAL: <~-~'0~
WATER:
SPECIAL:
LOCK BOX: YES/NO IF YES, LOCATION:
SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY.
A. PRIVATE FIRE PROTECTION:
B. WATER AVAILABILITY (FIRE HYDRANT):
ZARDOUS MATERIALS INVENT~/Y
Business Name ~-~-'~- ~'~ Addre~ 4~ ~,~Cr~tC~M ~ Page of~
CHE~C~ DESC~ON,
I) ~ORY STA~S: New ~fion [ ] Re,sion [ ] ~le~on [ ] , Ch~k ifch~ is a NON Tm~ S~et [ ] Tm~ ~ [ ]
2) Co~on N~e: ,~t~0~ ~ ~~/A 3) ~T ~ (op~o~)
Ch~N~e: ~[ ] C~t
4) Physi~ & H~ P~SIC~ ~
H~d Categod~ F~e [ ] R~cfive [ ] S~ Rel~ of~e~ [ ] ~ate H~ (Acu~) ~ ~lay~ H~ (C~c) [
s) ws s022) cow
6)P~SIC~STA~ Solid[ ] Liq~d.[ I ~ ~ ~e[ ] W~e[ ] ~ve[ ]
7) ~O~ ~ ~ AT FAC~ ~ OF ~~ 8) STOOGE CODES
ch~ ~nm~ or 2) [ ]
I)~ORYSTA~S:New[ ]A~[ ]Re,sion[ ]~le~on[ ] Ch~~aNO~T~~[ ]T~~[ ]
2) Co~on N~e: 3) ~T ~ (op~o~)
Che~ N~e: ~ [ ] C~ ~
4) Physi~ & H~ P~SIC~
~dCategofi~ F~[ ]R~ve[ ]S~Rel~of~[ ] lmm~a~H~(A~)[ ]~lay~H~(C~g)[ ]
5) W~ C~S~CA~O~ (3~t ~ ~ D~ Fo~ ~22) USE CODE
7) ~O~ ~ ~ AT FAC~ ~ OF ~~ 8) STOOGE CODES
M~D~ly~o~t L~[ ]G~[ ]~[ ] a) C~
Av~age D~ly ~o~t G~ [ ] b)
~gest S~e C~
~ Days on Si~ C~le ~ch M~: ~ Y~, J, F, ~ ~ M, J, J, & S, O, N, D
ch~ ~m~n~ or 2) [ ]
~y ~ ~m~n~m 3) [
0 )L~A~ON
P~ N~e & Title of Au~ Comfy R~~ve ( ~ ~ Si~e
ItA~RDOUS MATERIALS INVENTO~ Page
Business Name Address
CHEMICAL DESCRIPTION
I)[NVENTORYSTATUS:New[ ]Addition[ ]Revision[ ]Deletion[ ]. Check if chemical is a NON Trad~ Secret [ ]TradeSeeret[ ]
2) Common Name: 3) DOT # (optional)
Chemical Name: AHM [ ] CAS #
4 ) Physical & Health PHYSICAL HEALTH
I-IazardCategories Fire[ ]Reactive[ ]Sudd_~nReleaseofPressure[ ] Immediate Health (Acute) [ ]DelayedHealth(Chroni¢)[ ]
5> w^sTE Ct.~SS~CAT~ON ,,, (3-~t ~ from Dm Form 8022} USE CODE
6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ J Waste [ ] Radioactive [ ]
7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES
Maximum Daily Amount Lbs [ ] Oal [ ] fo [ ] a) Contain~
Average Daily Amount Curies [ ] b) Pressure:
Annual Amount ¢) Temperature ·
Largest Size
# Days on Site Circle Which Montlm: All year, I, F, M, A, M, $, $, A, S, O, N~ D
9) MIXTURE: List COMPONENT CAS# % WT AHM
the three most ~-,,*,~lous 1) [ ]
chemical components or 2) [ ]
any AHM components 3) [ ]
10)LOCATION
I)INVENTORYSTATUS:New[ ]Addition[ ]Revision[ ]Deletion[ ] Check ifchemical is a NON Trade Secret [ ]TradeSeeret[
2) Common Name: 3) DOT # (optional)
Cherui.c~ Name: AHM [ ] CAS #
4) Physical & Health PHYSICAL HEALTH
Hazard Categories Fire[ ]Reactive[ ]SuddenR¢leaseofPressure[ ] tmmediateHealth(Acute)[. ]DelayedHealth(Chroni¢)[ ]
~> WASTE CLASSn~C^T~ON O-aisit coa~ finn Dm Form S022) USE COVE
6) PHYSICAL STATE Solid [ ] Liquid [ ] Ou[ ] ~[ ] Mixture [ ] Waate [ ] Ibatioactive[ ]
7) AMOUNT AND TllVIE AT FACILII'Y UNITS OF MEASURE 8) STORAGE CODES
Maximum Daily Amount Lbs [ ] Gal [ ] fO [ ] a) Container.
Average Daily Amount Curies ~ ] b) Pressure:
Annual Amount ¢) Temperature
Largest Size Container
# Days on Site Circle Which Months: All Year, J, F, M, A, M, $, $, A, S, O, N, D
9) MIXTURE: List COMPONENT CAS# % WT AHM
the three most hazardous 1) [ ]
chemical components or 2) [ ]
any AI-IM components 3) [ ]
10 )LOCATION
! certify unchn' penalty of law, that I have personally examined and am fanfiliar with tim'information on this and all atta~ documents; I
believe the submitted information is true, accurate and complete.'
PRIlqT Name & Title of Authorized ComPany Represeutativ¢ Siguature . Date