HomeMy WebLinkAboutBUSINESS PLAN
BAKERSr'I~LD CITY FiRE DP...PAHIM~NI
BAKERSFIELD, CA. 93301 (805) 326- 3979
oFFICIAL USE ~
BUSINESS NAME
HAZARDOUS MATERIALS
BUSINESS PLAN AS A-WHOLE
FORM .2A
INSTRUCTIONS: H,~_~, MAT. DIV.
1. To avoid further action, return this from withi'n 30 days of receipt.
2. TYPE/PRINT ANSWERS IN ENGLISH,
3. Answer the questions below for the business as a whole.
4. Be as b¢~ef and concise as possible.
SECTION 1: BUSINESS ~DENTIF[CAT[ON ~ATA, .
/
A. BUSZNESS NAME: ~ ~
SECTION 2: ·EMERGENCY NOTIFICATIONS
In case o¢ an emergency ~nvo3vSng the release or threatened re~ease o¢
a hazardous mater~a], cai3 91t and 1-800-852-7550 or 1-916-427-4341. Th~s
will notify your local fire depar~men~ and ~he S~ate Office of Emergency
Services as required by law,
EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:
NAHE AND TITEE DURING BUS, HRS, AFTER BUS, HRS.
SECTION 3: kOCATION OF UTILITY SHUT-OFFS FOR BUS~NESS AS A WHOLE
A. NATURAL GAS/PROPANE: ~ 0 ~
C. WATER: ~~~ ~ ~ ~ 2~/~'~& J,~.
D. SPECIAL:
E. LOCK BOX: YES / NO ~F YES, LOCATION'
~F YES, DOES ~T CONTAIN S~TE PLANS? YES / NO NSDSS? YES / NO
FLOOR PLANS? YES / NO KEYS? YES / NO
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
e Cx/
SECTION fi: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A TRAINING PROGRAM WHICH PROVIDES EMPLOYEES
WITH INITIAL AND REFRESHER TRAINING IN THE SAFE HANDLING OF HAZARDOUS
MATERIALS.
A. NUMBER OF EMPLOYEES AT THIS FACILITY
B. DO YOU HAVE MSDS {MATERIAL SAFET~y DATA SHEETS) FOR EACH HAZARDOUS
MATERIAL YOU HANDLE ? . ,~ ~'" 'y ~ , · '
C. GIVE A BRIEF SUMMARY OF YOUB R~ZARDOUS MATERIALS TRAINING PROGRAM:
SECTION 7: EXEMPTION REQUEST
I CERTIFY UNDER PENALTY OF PERJURY THAT.MY BUSINESS IS EXEMPT FROM THE
REPORTING REQUIREMENTS OF CHAPTER 6,95 OF THE CALIFORNIA HEALTH AND SAFETY
CODE FOR THE FOLLOWING REASONS:
///~E DO NOT. HANDLE HAZARDOUS MATERIALS,
-- b,~' WE DO HANDLE.HAZARDOUS MATERIALS, BUT ThE QUANTITIES ,AT"~'
TIME EXCEED THE MINIMUM REPORTING QUANTITIES,
OTHER (SPECIFY REASON) ~
SECTION 8: CERtIFiCATiON
I, ._. /~-/¢~IF~-f¢ , ceriify that the above information is
accurate. ~' understand that. this .informationw'ill 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. 25500 Et Al.) and that
inaccurate information~~tes perjury.
SIGNATURE ~~~==;~---'-TITLE ("~~_/'~ DATE ~*--~5~
B RSFIELD CITY FIRE DEPARTMENT
2130 "G' STREET
BAKERSFIELD. CA. 93301
(805) 326,3979
OFFICIAL USE ONLY
ID#
BUSINESS N^i~tE
HAZARDOUS MATERIALS'
· BUSINESS PLAN AS A WHOLE
FORM 3A
INSTRUCTIONS
1. To avoid further ac%ion, %his form must be returned by:
2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
3. Answer the questions be3ow ~or THE FACILITY UNIT LISTED BELOW
4. Be as BRIEF and CONCISE as possible
FACILITY UNIT ~ FACILITY UNIT. NAME:
SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES
Verbal.notification
/~~ Ca%l 911
ION ~: NOTIFICATION 'AND ~VACUATION PRoCEDuRES AT THE UNIT ONLY
All Our containers are approved with pressure relief valves.
~ECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY ,' ,
.~ Does this Facility Unit contain HazardoUs Materials?..~... NO
A YES
~ If Yes, see B,
NO, continue with SECTION 4 . .
B. Are~,ny of the hazardous materials a bona fide Trade Secret? YES NO
If NO,~omplete a separate Hazardous materials inventory
form ma~ed: NON-TRADE SECRETS ONLY (white fOrm #4A-1) .
If YES, c~mplete a hazardous materials inventory form marked:
TRADE SECRetS ONLY (Yellow form #4a-2) in addition to the non-trade
secret form~ List only the trade secrets on form 4A-2. .
SECTION 4: PRIVATE~FI%ROTECTION
SECTION 5: kOCATION OF wATER SUPPLY FOR USE BY EMERGENCY REsPONDER$
(Fire Hydrant)
SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONkY.
A. NATURAL GAS/PROPANE'
B. ELECTRICAL: ~ '
C, WATER: -
D.
SPECIAL:
.
E. LOCK BOX: YES / NO IF YES, LOC~ON:
IF YES, SITE PLANS? YES /~1~0 MSDSs? YES / NO
· FLOOR PLANS? YES / N% KEYS? YES / NO
- 3@ -
CITY of BAKERSFIELD
Far, and Aqriculture ~ Standard eusiness ~-~ ~-~AZAZ~.DOUS Av~ATlm~Z~.I kT'-S
. N O N-- 'r RAD E S E C R E T S' ' Page .... of ....
LOCATION: '~4~ ~~ ~ ADDRESS: ~) ~//,~. ~¢~_~ ~ STANDARD IND. CLASS CODE
.CITY, ZIP: ~~ -~'~~ CITY, ZIP: · ~ ~r .... ~~¢~ DUN AND BRADSTREET NUMBER
~ ~ ~UC~O~ ~0~ ~0~ ~OD~ - -
t ~ 3 4 5 6 7 8 g I0 11 12 1]
'Irons Ty~ ~x Average ~nual ~asu~ I ~ Cmt ~t Cmt ~l L~attm N~ve ~ ~ N~ of Ntxtu~/~ts
C~e C~e bt ~t Est Units ~ Site Tyro Pr~s Trap C~e .. Sto.~ tn F~ciltty Nt ~ Insc~ims
.~I_~_I~__iL~__=I_~ .... ~~~.j~~_~ .......
P~ic~l ~d ~lth ~a~e~d C.l.S. ~ C~t 81 ~ & C.l.S.' ~
I(.~K ell t~t apply)
~ ] Fire Haz~ed ~--a Raactivity ~ el~se ~--a I~tate
Health of P~sure ~lth ............
i_i .... 1 ............ 1 .............. 1 I ..... 1 ...... L,,~..LS..: L .... _..
P~ical and H~kh Hazard C.A.S. ~ ~t II Nm i C.A.S. ~
(~k ail t~c apply)
r--q r--n -- -- --n ~t 12 Nm&C.A.S. ~
u--J Fire Hazard u--J bactivtty [ ] h~a~ [-] ~ n,~fl. [-~
H~lth of P~ ~lth ..................
~t I] ~&C.I.S. ~
.... L_L '- k ........... l I I L_ ! 1: L _ [ .........
P~ical ~d H~lth H~za~ C.A.S. ~ ~t I1 ~ & C.A.S. ~
(C~k all t~t a~ply) --
~t 12 N~&C.A.S. N~
[--] Fire Hazaed [--~ Reactivity [--~ ~la~ [-] ~dd~ aelHse [~] I~tate
Health of Pe~suPe Health ....
~ k '" -~ ~ i~ ...................
.... L__[ ........... [ ...................... 1 I L_I ....... ! __
P~icol ~ H~lth ~zard C.A.S. Nu~r Cm~mt I1 Nm & C.l.S. N~
(C~k all t~ a~iy) .......................
~-] -- r--~ -- -- C~t 12 NmAG.A.S.
Health of P~s~e Health ............... ~ .............................................
~NERGENCY C~TACTS I1 12
R~-: .................... T .............. T~[T~ ......... ~ ............. 2i'R;-P~i ........ ,i~ .............................. T~li .... ~ ................. 21'ff~'P~l ........
Certificati~ (Read and sJKn after completJnE all sections)
] certify ~de~ ~;}ty of ~a~ t~t I ~ve ~rsmaHye~amm~ end a~ fam~Har ~th t~ ~nfor~t~m su~tt~ ~n this ~ al] ~ d~ts, and t~t
~i~i~5THEl~l~il~li~5T~iF~;~i~F~iF7E5~Fi~5F~i~[~FlI~;i~Fiii~iEl;i ~i~Ei~-~ .......... Oi~i ....
~£ ~AV£ MOVED .......... 0~ NE~ ADD~ESS ~S~
28:0 :A~AVEN D~VE
~AKE~S:~ELD, CA ~08
(80~) ~2~-02~
FAX (805) 324-0298
,
PLEASE MAKE A NOTE OF IT, THANK YOU