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Home My WebLink AboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This _~ermit is issued for the followin_~: [] Hazardous Materials Plan c1 Underground Storage of Hazardous Materials [] Risk Management Program [] Hazardous Waste On-Site Treatment PERMIT ID # 015-021-002200 ,:~ "., ''~ ..... · WILLIAM D BARKER DD~'::~C L'- :~7%:,' :': LOCATION 4124 ~Mbri~E "<~,,' i:i'~ 93309 ~-. '~ 5" 3~,~, ~/ OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Approved by: "(...Ralpl/Huey, D~~"~! Issue Date Bakersfield, CA 93301 OmceorEvironm~S~ices Voice (661) 326-3979 FAX (661) 326-0576 ExpimtionDate: June 30, 2003 WILLIAM D BARKER DDS INC SiteID: 015-021-002200 Manager : PHYLLIS SNOW BusPhone: (661) 834-4111 Location: 4124 ARDMORE AVE Map : 123 CommHaz : Minimal City : BAKERSFIELD Grid: llA FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 07 SIC Code:8021 EPA Numb: DunnBrad:95-364-9306 Emergency Contact / .Title Emergency Contact / Title PHYLLIS SNOW / OFFICE MANAGER MICHELLE PHILLIPS / DENT HYGIENIST Business Phone: (661) 834-4111x Business Phone: (661) 834=4111x 24-Hour Phone : (661) 871-8092x 24-Hour Phone : (661) 664-8163x pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: React Contact : PHYLLIS SNOW Phone: (661) 834-4111x MailAddr: 4124 ARDMORE AVE State: CA City : BAKERSFIELD Zip : 93309 Owner WILLIAM BARKER Phone: (661) - 66x47248 Address : 9117 MCINNES BLVD State: CA City : BAKERSFIELD Zip : 93311 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: Hazmat Inventory One Unified List Alphabetical Order Ail Materials at Site Haz~t Common Name... · SpecHaz EPA Hazards Frm DailyMax IUnitlMCP / R L 5.00 GAL Min (Ty~e or pdm nm'ne) reviewed the attached h~ardous materi~s merit plan for ,, WIL]JIAM D B~KER DDS INC SiteID: 015-021-002200 = In~rentory Ite~0001 Facility Unit: Fixed Containers at Site WASTE FIXER ~ Days On Site WASTE DENTAL FIXER AN~ REPLENISHER ~ L~cation within this~Facility Unit Map: Grid: j DAR~OOM: & W OUTSIDE ST~ ,RAGE~ ,~ CAS# F STATE -- TYPE PRESSURE~------T TEMPERATUR-E/ CONTAINER TYPE /Liquid Waste Ambient ~1 Ambient/ PLASTIC CONTAINER I AMOUNTS AT, THIS LOCATION ~argest Container I/'D~i~l~ ~ '-- Ma-~imum Daily Average 5.00 GAL 5>0~0 GAL 5.00 .GAL --~--I%w1Silver~~HAZARDOUS COMPONENTS ~ N~ Is CAS# 7440224 TSec~et RS B~H~ i.. HAZARD ASSESSMENTS z Radioactive/Amount EPA Hazards USDOT# MCP No INo,.I/No No/ Curies R / / Min -2- 04/08/2003 O~CE OF ENVIRONMENTAL RVICES 1715 Chester Ave., CA 93301 (661) 326-3979 WNER / OPERATOR IDENTIFICATION ~ FACILITY INFORMATION ~ I. FACILI~ IDENTIFICATION FACL~ID~ ?~ i j,~] : ', ! ' ' Year Beginning ~ ~oo Year Ending BUSJN~ S~ ~A~E (Same as F~LI~A~E ~A7 Doing~s~) ~ ~. 3 : BUSINESS PH~N~ __ . j , , , ,02 OUN · ENVIRn~, .... ~ERVICES'°~ SIC CODE 107 ! (4 Digit¢) COUN~ ~ T : II. INFORMATION ': I I ~ 112 OWNE~ MAILING ~ , ~ CONTAGT NAME ~ 17 CONTACT MAILING~ 11~ : IV; :;:, EM:ERG ENoY"CONTACTS' '::' ~ECONDARY- ,4-HOU~PHONE U~ J 51 ) 5~'~ ,27 24-HOURPHONE ~ I ~bd~J_~._~ ............ ,32__. ~ 128 ~ ~ . ,, , ~ ,..~,:,, ~ . . .. ~ Ce~fic~fiom B~sed o~ m~ ~qu~ of those ~d~v~d~a~s ~espo~s~b~e fo~ obt~ the ~fo~m~fio~, ~ ~ u~de~ pe~ of ~aw that have pe~so~H~ e~ed a~d a~ f~m~ha~ ~th the mfo~at~o~ s~bm ~ed ~ th~s ~ve~to~ a~ be~eve the ~fo~afio~ ~s t~e, accurate, a~d ~p~ete. ' -~IG~T~ OF O~E~OPE~TOR DATE 134 NAME OF DOCUMENT PREPARER ~35 .... ~-A-MES OF OWN~OPE~TOR (print) 136 TITLE OF OWNE~OPE~TOR 137 UPCF (7~9 }) S:\CUPAFORMS\OES2730.TV4.wpd /,~~.~;,a...__~ ' CITY OF BAKERSFIELI~ I FtRW ~ OFFICE OF ENVIRONMENTAL S~VICES ~,4nr~r 1715 Chester Ave., CA 93301 (661) 326-3979 "~'~~"~' H~RDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION W (one fo~ ~er m~te~al per bulldthg ~[ ~a) . ~ ADD ~ DELETE ~ REVISE 2~ Page ~ of ~US)~ESS ~AME (Same as F~I~ NA~E ~ DBA - Doing Busin~ ~) ~ 3 FACILI~ ID #:}~D~;~[~l [~ 1. ~P ~ (op~naO 2~ 203 GRIDi~(optionaO~ 205 T~DE SECRET ~ Y~ ~ No 206 CHEMICAL NAME If Subj~ to EPC~, refer lo insl~i~s CAS, 209 FIRE CODE H~RD C~SSES (~plete if r~u~t~ by I~1 fire ~i~ ~PE ~ p PURE ~ m MIXTURE WASTE 211 ~DIOACTIVE ~ Y~ , o 212 CURIES 213 FED H~RD ~TEGORJES ~ 1 FIRE ~ 2 R~CTI~ ~ 3 PRESSURE REL~SE CUTE H~LTH ~ 5 CHRONIC H~LTH 216 (Ch~ all thai apply) ~uNTANNUALWAST~r)~_ ~~ )~17 I ~ / ~ )__ 218 UNITS' ~,:~L ~dCu, ~ lb LBS D tnTONSTM 221DAYS ON SITE- 222 * If EHS, am~nt must be in lbs. , STOOGE CO~AINER ~a ~e (Check afl that apply) ABOVEGROUND TANK P~STI~NONM~ALLIC DRUM ~ i FIBER DRUM .~ m G~SS BO~LE ~ q ~IL ~R 223 Db UNDERGROUND TANK ~f CAN ~j BAG ~n P~STICBO~LE ~r OTHER ~ c T~K INSIDE BUILDING ~ g ~R~Y ~ k BOX ~ o TOTE BIN ~ d S~EL DRUM ~ h SILO ~ I CYLINDER ~ p TANK WAGON ~ AMBIENT ~ aa ABOVE AMBIE~ ~ ba BELOW AMBIE~ 224 STOOGE PRESSURE STOOGE TEMPE~TURE ~a AMBIE~ ~ aa A~VE AMBIENT ~ ba BELOW AMBIE~ ~ c CRYOGENIC 225 ~4 235 ~ Y~ ~ NO 236 237 238 239 ~ Y~ ~ No 240 241 242 243 ~ Y~ ~ No 244 245 PRINT NAME & TITLE OF AU~ORIzED COMPANY REPRESENTATIVE A SI~ATURE DATE 246 UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd O ICE OF ENVIRONMENTAL RVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION [] ADD [] DELETE [] REVISE 200 Page I. FACILITY INFORMATION BUS,IN. ESS NAME (Same as FA.C~ITY NAM. E or DBA - Doing Busin._~ As) II. CHEMICAL INFORMATION 205 ~ T~DE SECRET ~ Y~ ~ No 206 CHEMI~L NAME If Subj~ to EPC~, ref~ to instm~i~s FIRE CODE H~RD C~SSES (~plete if r~u~t~ by I~1 fire 210 ~PE ~ p PURE ~ m MIXTURE WASTE 211 ~ ~DIOACT~E ~ Y~ o 212 CURIES 213 FED H~RD ~TEGORIES ~ 1 FIRE ~ 2 REACTIVE ~ 3 PRESSURE RELEASE ~ACUTE H~LTH ~ ~ 5 CHRONIC H~LTH 216 (Ch~ all that apply) . O lb LBS O tn TONs 221 DAYS ON sITE 222 / ' If EHS, am~nt must be in lbs. ~_ ,~ (Check all that apply)ABOVEGROUND TANK P~STI~ONMETALLIC DRUM ~ i FIBER DRUM ~ m G~SS BO~LE ~ q ~IL ~R 223 b UN~RGROUND TANk ~ f CAN ' ~ j BAG ~n P~STIC BO~LE ~ r OTHER ~ c 'T~K INSIDE BUILDING ~ g ~RBOY ~ k BOX ~ o TOTE BIN ~ d STEEL DRUM ~ h SILO ~ I CYLINDER ~ ~ TANK WAGON STOOGE PRESSURE ~ AMBIE~ ~ aa ABOVE AMBIE~ ~ ba BELOW AMBIE~ 224 STOOGE TEMPE~TURE .~AMBIE~ ~ aa A~VEAMBIENT ~ ba BELOWAMBIE~ ~ c CRYOGENIC 225 2 230 ~ 231 233 ~ ~ Y~ ~ No 232 ~ 235 ~ Y~ ~ No 236 3 ~4 4 ~ 238 I 239 OY~ ONe 240 241 5 ~ 242 243 ~ Y~ ~ NO 244 245 PRINT NA~ & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE 246 UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd ~"~f-~ s ~ ~--~-~-~ ~ O~ICE CITY OF BAKERSFIEI OF ENVIRONMENTAL~I[RvICES ~~~r 1715 Chester Ave., CA 93301 (661) 326-3979 ~'~' H~RDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION ~ ADD ~ DELETE ~ REVISE 2~ Page ~ of I. FAClLI~ INFORMATION BUS~NESS NAME (Same as F~I~ NA~E ~ DBA - Opng Busi~ ~) 3 CHEMICA~ ~OCATION 20~ CHEMICAL LOCATION ~ Y~ ~ No 202 ~ CONFIDENTIAL (EPC~) II, CHEmiCAL INFOE~ATION , 205 ! T~DE SECRET ~ Y~ ~ No 206 CHEMICAL NAME ~ If Subj~ to EPC~. refer to COM~N NAME [ EHS' ~ Y CASe 209 FIRE CODE H~RD C~SSES (~plete if r~u~t~ by I~1 fire 210 U p PURE ~ MIXTURE U w WASTE 211 i ~DIOACTIVE U Y~ ~ 212 ~PE CURIES 213 PHYSICAL STATE SOLID ~1 LIQUID ~ g ~S 214 i ~RGESTCONTAINER 215 FED H~RD ~TEGORtES ~ I FIRE ~ 2 REACTIVE ~ 3 PRESSURE RELEASE ~ 4 ACUTE H~LTH ~ 5 CHRONIC HEALTH 216 (Ch~ all that apply) ANNUAL WASTE pq ~ ~ 217 ~ ~,~M ~m 218 ] AVENGE 219 STATE~DE DAYS ON SITE 222 UNITS' ~ ga ~L U dCU~ LBS U ,nTONS 221 ' If EHS. am~nt must be in lbs. STOOGE CO~AINER ~ a ABOVEGROUND TANK ~ e P~STI~ONMETALLIC DRUM ~ i FIBER DRUM ~ m G~SS BO~LE ~ q ~IL ~R 223 (Check all that apply) ~ b UNDERGROUND TANK B f CAN ~j BAG B n P~STIC BO~LE ~r I CC T~KINSlDE BUILDING ~g ~R~Y ~k~ BOX ~o TOTE BIN I~)'~l I ~ d STEEL DRUM ~ h SILO ' ~ I CYLINDER ~ ~ TANK WAGON ~a AMBIE~ ~ aa ABOVE AMBIENT ~ ba BELOW AMBIE~ 224 STOOGE PRESSURE ~AMBIE~ ~ aa A~VEAMBIE~ ~ ba BELOWAMBIE~ ~ c CRYOGENIC 225 STOOGE TEMPE~TURE I 226 227 ~ Y~ ~ No 228 2~ 2 230 231 ~ Y~ ~ No 232 233 3 ~4 235 ~ Y~ ~ No 236 237 4 ~ 238 239 ~ Y~ ~ No 240 241 5 242 243 ~ Y~ ~ No 244 245 .:, ":,;~ '.' .' .: ~ :,"~/~,~ ;,:111. SIGNATURE , PRINT NAME & TI~E OF AUTHORIZED COMPANY REPRESENTATIVE ~ SIGNATURE DATE 246 UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: 1. To avoid further action, return this form within 30 days of receipt. 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. 5. You may also attach Business Owner / Operator Form and Chemical Description Form(s) to the front of this plan instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA MAILING ADDRESS: PRIMARY ACTIVITY: OWNER: . EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II. 1' DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: B. EMPLOYEE AND AGENCY NOTIFICATION: C. ENVIRONMENTAL RESPONSE MANAGEMENT: D. EMERGENCY MEDICAL PLAN: 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: RELEA~ CONT~ENT A~/OR MITIGATION: C. CLEAN-UP AND RECOVERY PROCEDURES: UTILITY S~T-OFFS (LOCATION OF S~T-OFFS AT YO~ FACILITY') LOCK BOX: YE~ IF YES, LocATION: P~VATB FI~ ~ROTBCTION~ATBR AVAIB~ILITY A. PRIVATE FIRE PROTECTION: B. WATER AVAILABILITY (FIRE HYDRANT): HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING NUMBER OF EMPLOYEES: ~ O B~EF S~Y OF T~~G PROG~: CERTIFICATION I, ~t~-,-,a-~ ~. ~-[~-~'~-- ,B~5 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 MATEPdALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERIURY. SIGNATURE TITLE DATE