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Home My WebLink AboutBUSINESS PLAN · " ;'~~~ OTV o~ S~RS~,,~L~ i, ~'~ }FFICE OF ENVIRONMENTAL iVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: I. 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 fi'ont of this plan instead of completing SECTION I. below for initial submission. sEcTIoN I: BUSINESS IDENTIFICATION DATA LOCATION: ~00[ ~ ~q'-[ (' i' MAILING ADDRESS: OWNErU W~~ ~/i~m~4 , ?HONE: mmn~OADDR~SS: '~O01 /~~ ~ EMERGENCY NOTIFICATION . ~ CONTACT TITLE BUS. PHONE' 24 HR. PHONE H~OVS MATERIALS I~IANAG~.t ir~T PLAN SECTION [I. 1' DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: B. EMPLOYEE AND AGENCY NOTIFICATION: C. ENVIR. ONM~NTAL RESPONSE MANAGEMENT: .... ~.~,~~ ~r~ ~e~-,. '"" D. EMERGENCY MEDICAL PLAN: 2 HA~DOUS MATERIALS MANAGEi PLAN SECT[ON [I.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEAsuREs: ~1~ ~r~¥ ,~::~.. 7'0 .~,,r ~ ~_ .~ .... ~ ro~.~ ,~. ~~. B. - R. ELEASE C,O.NT~.NT A'ND/OR.MITIGATION:"" : - .. C. CLEAN-UP AND RECOVERY PROCEDURES: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY') NATURALGAS/PROPANE: ~0f4xTE~7 ~ ~ ELECTRICAL:, : WATER:' SPECIAL: LOCK BOX: YES IF YES, LOCATION: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION:(.~-h ~ AI~C, ~--JlZ~ O'A"P/NIZ;~~ Old coh~ B. WATER AVAILABILITY (FIRE HYDRANT): ~ Al;y~z~[~l)(' ~ Pr. 3 HAi~tDOUS MATERIALS MANAGE PLAN. ', ... SECTION III: TRAINING ( NUMBER OF EM~PLOYEES:~'~). ., ' .. ~MATERIAL SAFETy DAyA SH]~ETS 'ON~ FIL, E: B~EF S~Y OF T~~G PROG~: CERTIFICATION ~s ^ccu~. nm~s~,rD ~ ams n,~o~~o~ wr~ ~ us~ ~o F~F~L ~ F~'S OBLIGA~ONS ~ER ~E "C~O~ ~~ ~ S~E~ CODE" ON ~~OUS ~~S ~. 20 d~R 6.95 SEC. 25500 nT ~.) A~ ~T ~ACC~~ ~O~ON CONS~ES PE~Y. SIGNATURE TITLE DATE 4 CITY OF BAKERSFIELD FCE OF ENVIRONMENTAL SE 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS FACILITY INFORMATION INSTRUCTIONS BUSINESS OWNER / OPERATOR FORM I. FACILITY IDENTIFICATION: ""--"- Enter the reporting period (year beginning and ending) for the facility information. Enter the business name and site address and phone number of your business. 'Do not use P.O. box numbers. Enter the Dun & Bradstreet or federal tax identification number for your business. 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 the back of this page. Other SIC codes may be obtained from your worker's compensation insurance forms, the State of California Employment Development Department, or by calling our office at (661) 326-3979. Enter the name and phone number of the person responsible for operating the business. II. OWNER INFORMATION: List the legal business owner or corporation name and provide the headquarter address or residential address if owned by an individual and phone number. III. ENVIRONMENTAL CONTACT: Identify the person who is primarily responsible for environmental compliance at the business. This person may be either the business owner, one of the emergency contacts, an environmental manager, or consultant. IV. EMERGENCY CONTACTS: List the name, title, and phone numbers of two people at the business who can respond if the Bakersfield Fire Department requires additional information or other assistance. These contact persons must have keys or access to all areas of the facility, be available for emergency call-outs, and have decision-making authority to call on other resources (such as hazardous waste clean-up companies) as necessary. V. CERTIFICATION: The business owner or operator must sign, date, and also identify the document preparer. CO~IMON STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODES 0111 Wheat production 0724 Cotton ginning 5821 Eating places 0 t 15 Corn production 054 l Grocery store 5813 Drinking places (Alcohol service) 0131 Cotton 'production 1541 Dry cleaners 5983 Fuel oil dealers 0139 Field crops, except cash 2911 Oil refineries grains 5984 LPG dealers 3441 Welding/fabr~tion- 0161 Vegetables & melons' 7342 Pest control structural · '0172 Grapes ......... 7532 Auto top, body, 3443 Welding/fabrication - upholstery repair 0173 Tree nuts boiler Auto paint shops 0174 Citrus fruits 3569 Machine shop 7533 Auto exhaust repair 0175 Deciduous tree fruits 4222 Cold Storage 7536 Auto glass replacement 0179 Other tree fi'uits & nuts 4925 Compressed gas supplier 7537 Auto transmission 0192 General farms, primarily 5093 Automobile salvage repair crop 5169 Chemical supply 7538 General auto repair 0241 Dairy farms 5511 Motor vehicle dealers 7542 Car washes " 0252 Chicken eggs (new & used) 8071 Chemical laboratory 0253 Turkey eggs 5521 Motor vehicle (used only) 285'1 Paint manufacture 5531 Auto & home supply stores 0291 General farm, primarily livestock & animal 5541 ,Gasoline service stations specialties 2 srA rE W.-\S rE CODE ~ 220 · It' the hazardous waste, enter the appropriate Calitbmia 3-d'~ hazardous waste code as listed on the back or' the Unitbrm Hazardous Waste Manifest. A list of common State Waste Codes are included on page 4 of these instructions. UNITS 221 Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet or tons. NOTE: If the material is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons). DAYS ON SITE -..~ 222 List the total-number of'days during the year that the material is on site. STORAGE CONTAiNER 223 Cheek all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: If appropriate, you may choose more than one. STORAGE PRESSURE 224 Check the one box that best describes the pressure at which the hazardous material is stored. STORAGE TEMPERATURE 225 Check the one box that best describes the temperature at w, hich the hazardous material is stored. HAZARDOUS COMPONENT I - 5 (% by weight) 226, 230, 234,238,242 If a range of percentages is available, report the highest percentage in that range. HAZARDOUS COMPONENT 1 - 5 Name 227, 231,235,239, 243 When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer io manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non- carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures, mineral and chemical composition should be listed. HAZAKDOUS COMPONENT 1 - 5 EHS 228, 232, 236, 240, 244 Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "N" for no, if it is not. HAZARDOUS COMPONENT 1 - 5 CAS 229, 233,237, 241,245 List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. III. SIGNATURE: 246 Please print name, title, sign and date each chemical description form. If you have ,any questions please call us at (661) 326-3979 ODL~ ,IFQRNIA WASTE C .. .~. C~dc Description Code Description [nor~anics 241 Tank bottom waste [ I [ A. cid solution 2 < pH < 7 with metals 25 [ Still bottoms with halogenated organics (antimony. arsenic, barium, beryllium, 252 Other still bottom waste cadmium, chromium, cobalt, copper, lead, 261 PCB's and material containing PCB's mercury, molybdenum, nickel, selenium, silver, 271 Organic monomer waste (includes um:eacted thallium, vanadium and zinc) resins) 112 Acid solution without metals 272 Polymeric resin waste 113 Unspecified acid solution 281 Adhesives 121 Alkaline solution pH > 12.5 with metals (see 29I Latex waste l 1 l) 311 Pharmaceutical waste 122 Alkaline solution without metals 321 Sewage sludge 123 Unspecified alkaline solution 322 Biological waste other than sewage sludge 131 Aqueous solution (2 < pH < 12.5) containing 331 Off-spec, aged or surplus organics reactive anoins (azide, bromate, chlorate, 341 Organic liquids (nonsolvents) with halogens cyanide, fluoride, hypochlodte, nitrite, 343 Unspecified organic liquid mixture perchlorate and sulfide anions) 351 Organic solids with halogens 132 Aqueous solution with metals (see 111) 133 Aqueous solution with total organic residues Sludges, 10% or more 411 Alum and gypsum sludge 134 Aqueous solution with total organic residues 421 Lime sludge less than 10% 431 Phosphate sludge 135 Unspecified aqueous solution 441 Sulfur sludge 141 Off-spec, aged, or surplus inorganics 451 Degreasing sludge 151 Asbestos containing waste 461 Paint sludge 161 FCC Waste 471 Paper sludge/pulp 162 Other spent catalyst 481 Tetraethyl lead sludge 171 Metal sludge (see 111) 491 Unspecified sludge waste 172 Metal dust and machining waste (see 111) 181 Other inorganic solid waste Miscellaneous 511 Empty pesticide containers 30 gal or more Organics, .512 Other empty container 30 gal or more 211 Halogenated solvents (methylene chloride, 513 Empty containers .less than 30 gal chloroform, TCE, TCA) 521 Drilling mud 212 Oxygenated solvents (acetone, butanol, MEK) 531 Chemical toilet waste 213 Hydrocarbon solvents (stoddard solvent, 541 Photo chemical/photo processing waste xylene) 551 Laboratory waste chemicals. 214 Unspecified solvent mixture 56! Detergent and soap 221 Waste oil and mixed oil 571 Fly ash, bottom ash, and retort ash 222 Oil/water separation sludge 58 ! Gas scrubber waste 223 Unspecified oil - containing waste 59 ! Baghouse waste 231 Pesticide rinse water 611 Contaminated soil from site clean-ups 232 Pesticide and other waste associated with 612 Household wastes pesticide production .L S.~CUPAFORMS'~IIAZMAT.FACILITY INFO INST 4 ~ FIR~ W ~t~a#rt~!~r , 17~J'Chester Ave., CA 93301 (661 6-3979 ~ HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one !o~m L.~ NEW [] ADO [] 0ELETE 1'~ REVISE 200 P~c~e ~ of __ I. FACILITY INFORMATION ' CONFIDENTIAl. (EPC~) II, CHEMICAL INFORMATION 20~ FIRE CODE ~fib~C~M~ if r~mt~ by I~ ~ ~ 210 ~ ...... PURE ~ m MITRE ~ w WASTE 211 . mOIOACTNE ~ y~ ~'~" e0hi~" 213 s ~LIO ~ LIQUID ~ g ~ 214 PHYSI~L STATE ~RGEST CO~AINER 215 FED ~D ~TE~RIES ~ 1 FIRE ~ 2 ~CT~ ~3 ~U~ ~E ~ 4 ACUTE H~L~ ~ 5 ~RONIC H~L~ .WASTE 217 ~ ~IMUM 218 z A~ 219 STATEWAS~OE I DAILY ~U~ ~. ~ DAYS ON S~E.~-- STOOGE ~AINER (Check all ~at app.) ~GROUND T~K ~ e ~STI~ALLIC DRUM ~ i FIBER ~UM ~ m G¢SS BO~LE ~ ~ b UNDER~OUND T~K ~ f ~ ~ j ~G ~ n P~S~C BO~LE ~ ~ OTHER ~ c T~K INSIDE BUI~INO ~ g ~Y ~ k ~X ~ o TOTE BIN d ~EL DRUM ~ h SILO ~ CYLINDER ~ p TANK WA~N STOOGE ~ESSURE ~ a ~81E~ ~ ~ ~BIE~ ~ ~a 8ELOW~BIE~ ~4 STOOGE TE~TU~ ~a ~BIE~ ~ ~ ~ ~1~ ~ ba BELOW ~BIE~ ~ c ~YOGENIC %~ H~RDOUS COMPONE~ EHS ~ CAS 2 230 i 231 ~ ~y~ ~No 232 i 3 234 ~ 235~ ~y~ ~o 236j JPCF (7/99) S:\CUPAFORMS\OES2731 .'rV4.wpd Ha Materials Inventory - Chemical ;ption ,~ ,~. : yOU hdn{Jl~! Il /~)~r ~,H;~hl¥ ~ i~j~r~.lle ,luanhtma .~lual ~o .3~ .]reeler than 500 ~unds. 55 gallons. ~00 cub~ feet of gas (calculated Jt qu.lnhl~eS ~or ~n,C~ In ~m~]¢~*1~c¥ PI,In ,S required =o 0e IdOpled pursuant ~o I0 CFR Pads 30. 40, o¢ 70. The comple/~ ,nvenlow $~ould re~ec~ JII repo~able quanllliet Jla us~ ~or WleCfrOmC luOm~s~On and are {~e Same Js :~e num0ermg used ,n 27 CCR. Ao0endix C, {~e 8us~ness Secbon o~ ~ne Umfied Pr~ram Oats Oict~ona~.) Please number .iii 3~s o~ ./~ur su~m~l~3i, rh,s nel0s your CUPA ot ~ ~denh~y w~el~er ~he su0m*l~al ~s comolele and 4 any ~ages are se0arated. I. FACtLI ~Y ~0 NUMBER - rh,s number ~s ass~g~ 3y ~e CUPA or ~. rh,s is the un~ue numar w~c~ ~denlifies your ~ac~li~. 3. ~USINESS NAME - Emer ~e ~ull ~al name o~ the ~us~ness. 2~. A~OIOELETE/REVISE - Indicia ~ the ma{er~al ~$ ~mg add~ ~o (~e ~nvenlow. delet~ ~rom ~e ~nven~o~. or i~ the info~alion previou~ subm~Eed is ~ng r~i~d. NOTE: You may c~se ~o leave c~is Olan~ ~f you resubmit ~ur enlire invento~ annualS. ~ ~ 201. CHEMICAL LOCATION - Enter ;he building or outs~ adjacent area w~ere ~he hazardous maletialYs ~andl~. 'A che~l'~at i~ s~or~ ~em;erature. ~n multiple ;o~l~ns w~lhm a 0u;Iding. ~n 0e reposed on a sidle ;~e. NOTE; This in~atiqn is. nol suDject to public disclosure ;u~ua~l ~ HSC 202. CHEMICAL~CAT~ON CONF;OENTIAL - EPC~ - All ~usinesses which are subject ;o t~e Emergency Planning and Communi~ Righl ;o Know A~t (EPC~) must check 'Yes' ;o kee0 chem~l I~a{ion in[o~a;~n ~n~denlial. If the business d~s no{ wish ~o keeO c~emi~l I~;Jon in~ormalion ~n~dential c~eck 'No'. 203. MAP NUMBER - If a map .s included, emer the numar o; the mao on which the lo, lion o~ the h~ardous material ;s sho~. 2~. GRIO NUMBER · I~ gr~d c~r~inates are used. emer ;~e gr~d c~rdina;es of the map tha; corres~nd to t~e ~ation of the hazardous material. If appli~ble, mul~ple g~ coordinales can be 205. CHEMICAL NAME · Enler ~e proper chemical name as~iat~ ~lh the Chemi~l Abs~act SemPe (CAS) number of ;he haza~ous International Union of Pure and Ao;li~ ChemisW (IUPAC) ~me found on ~e Material Safe~ 0a~a Sheet (MSDS). NOTE: ~m;le{e this ~eld; ~plele the 'COMMON ~ME' ~e~ inst~d. 2~. T~E SECRET - Chec~ ~es' E the informal~ in ~ ~on is ~ a t~e sepal. ~ 'No' ~ il is no~' S~e t~uiremen~ If yes. and b~iness is no{ su=~ to ~C~ di~e of ~e ~s~t~ ~e s~et info~n ~ ~und by HSC ~25511. F~eml requirement: If ~s. and busings is ~ub~ ~ ~C~. d~um o~ ~e da~lN T;~ ~uel info~a~ ~ ~und by 40 CFR and Ihe ~si~ · must submil a 'Su~n~n to A~mp~y C~i~ o~ T~e ~ f~ (40 CFR ~.27) ~ USEP~ · ~ ~ .' '. 207. COMMON N~E - Eh;et ~e ~m~ n~e or ~de n~e of ~e h~ua matedal ~ m~um m;i~ a haza~ous metal. 208. EHS - Ch~ ~es. if ~he h~a~s mattel is an ~e~N Ha~a Subs~e (EHS). as defin~ ~ 40 CFR. Pa~ ~. ~ ~ If the male~l is a m~um ~n~ining an EHS. leave th~ sect~ b~nk a~ ~plete ~e s~n on ~r~us ~m~nts be~w. 209. CAS ~ - Enter the Chem~al ~stm~ Sewi~ (C~) numar f~ ~e h~ar~us ~teHal. F~ m~lures, enler ~e CAS numar of the m~ure if it has b~n a~ a num~; d~in~ from i~ ~mponen~. Il ;he mixture has ~ ~S number, leave ~is ~lumn b~nk and m~ the ~S num~m of the ~d~ual h~a~s ~m~nen~ ~n the appropdale s~n bel~. 210. FIRE COOE H~RD C~SSES - Fire C~e H~ard C~es descd~ to ~mt responders the ~ and level of h~ardous materials whi~ a busine~ haoles. Th~ info~at~n shall onN be provided if the l~l ~re c~ie~ deems ~t ne~a~ and requests the CUPA or ~ ~o ~ll~t it. A list o~ the hazard classes and insulins on how {o dateline whi~ ~ss a malapai falls u~er are incl~ in the ap~ndi~s of ~le 80 of the Un~o~ Fire ~e. If a mal~iat has mom ~an aopli~ble hazard class i~lude all. ~n~ CUPA or ~ f~ guiana. 211. H~DOUS MATERI~ ~PE - Ch~ the ~e ~ that ~sl dead,s ~e ~e of ~a~ mate~ pure. m~ure or ~ste. If ~ste mattel. If mixture or waste, comp~te h~ardous ~en~ 212. ~DIOACTIVE - Ch~k 'Yes' if ~e hazards ~te;~ ~ ~d~e ~ 'No' if it is ~L 213. CURIES - If the hazardous mate6al is r~e, ~ th~ ~ tO re~ ~e a~i~ in ~des. Y~ may use up ~ nine d~ wi~ a ~a~g d~al ~int to re~ a~ity in ~des. 214. PHYSI~ STATE. Ch~ ~e one ~x ~at ~t d~s ~ s~te ~ ~ ~ ~s mate~l is handle: solid, I~uM ~ gas. 215. ~GEST CONTAINER - Enter ~ to~l ~p~i~ of t~ ~st mntai~t in wh~ ~e mate~l ~ st~. . 216. FEOE~L H~RD CATEGORIES - Ch~k all ~t~ ~at d~d~ ~e ph~i~l a~ h~l~ ~s a~t~ ~ ~e ~za~s mater~l. PHYSICAL ~RDS I H~L~ ~RDS Fire: F~mmable Liqu~ and ~l~s. ~mb~fible L~u~s, ~mphoH~, Oxid~ers ~ Ac~e Health (Immediate): H~h~ To~. To.c, I~n~, ~i~em, Reactive: Unstable Rescale, Organ~ Perox~es, Water R~e, ~d~ o~r hazar~ ~b ~ an ~eme effe~ ~lh s~ term ex.ute Pressure Release: Explosives. ~mpressed Gases, B~sti~ Agents Chronic Health (Delayed): Ca~n~ens. o~er h~ar~ ~mi~ ~ an ~veme eff~ wi~ ~ te~ ex.sure · 217. AVENGE DALLY ~OUNT - Cal~late ~e avenge da~ly amount of ~e h~ar~uS ~tedal or m~ture ~n~ining a h~ar~us matedal, in ea~ building ~ adja~nU ~=~e area. Ca~ulaaons s~ll be ~s~ on ~e p~us yea~s inven~ of ~te~l re~ m ~b ~ge. To~I all daily a~un~ and d~e by da~ the ~emi~l will ~ on site. If [h= is a male~l ~at ~s not prev~s~ been presen~ at ~is I~on, the amount shall ~ ~he average ~i~ a~unl y~ proj~t to be on hand du~ the ~ur~ of ~e year. Th~ am~nt sh~ ~ ~sisten~ ~ ~e uni~ m~ed in ~x 221 a~ s~uM no{ ex~ ~at of m~imum daiN amount. 218. M~IMUM DAILY ~OUNT - Enter ~e ma~mum a~n~ ofe~h h~ar~us material ~ mixture ~a~ing a ~zardous mattel, whi~ adjacenUou=~e area at any one time ~er ~e ~me of the year. ~is am~nt must ~n=~ at a minimum ~st yea~s ~ven~ of p~e. with the reRe~n of ~dit~, dele~. ~ revises pm~ed f~ ~e cu~ent year. ~ ~nt sh~M ~ ~tent w~ ~ un~ m~ in ~ ~1. 219. ANNUAL WASTE ~OUNT. If the ~s male~l ~ i~ento~ is a ~ste, ~e an esSma~e of ~e annual a~unt ha~l~. ~0. STATE WASTE CODE - If the ha~rdous mate~l is a ~ste, enter ~e ap~te California ~it h~a~us waste ~e es 0st~ ~ ~d ~ of ~e Unifo~ H~s Waste Manifest. 221, UNITS - Ch~k the unit o~ measure that is most ap~opda{e ~or the ~teHal ~i~ repo~ on th~ page: gallons, pounds, ~b~ feet or ~ns. NOTE: If the ~teHal b a ~ederal~ de,ned Extremely Hazard.s Subs~n~ (EHS), all a~unls must ~ re~ in ~un~. If mate~al is a m~ure ~n~aining an EHS, the ma{edal is stored in (gallons, ~unds, cubic ~L ~ tons). 222. DAYS ON SITE - List the to~al number of days during the ~ar ~al ~e mamrial is on site, 223. STOOGE CONTAINER - Ch~k all ~xes that des~ =he type of stooge ~ntainers in which ~e hazardous material is stored. NOTE: If appropriate. ~u may ch~se more than one. 224. STOOGE PRESSURE - Check the one box that best desk.s the pressure a~ which the hazardous material is stored. 225. STOOGE TEMPE~TURE - Check ~e one box ~hat ~st dead.s the temperature at which t~e haza~ous mate~l is s~red. 226. H~DOUS COMPONENTS 1-5 (% ~Y WEIGHT) - Enter the ~ntage ~h~ of ~e h~ardous ~mponent in a m~ure. If a range of patten[ages ~ availab~, re~ ~he h~hest percentage in that ra~e. (Re~ r~ com~nents 2 through 5 in 230. 2~, 2~, a~ 242.) 227, H~RDOUS COMPONENTS 1-5 N~E - When repo~i~ a hazardous material ~at is a mixture, IIs~ up to ~ve ~em~el ~mes of haza;dous ~nenls in that mixture by per. n{ weigh~ (re,er to MSDS or. in the ~se of trade s~re~, re,er to manufacture;). All hazardous c~nenls in the mlx~ute present a~ greater ·an l%by~h[i~no,~rcin~en~,~ 0.1% by~htifcarcin~en~,s~uld~m~. If more than rwe h~ar~us ~mponen~ am present a~ve these percen;ages, ~u may attach an addit~al sheet o; pa~r to capluro Ihe requir~ ;nformat~n. ~en repoding waste mixtureS, mineral and chemi~l ~m~si~n should be listed. (Re~ ~or comp~enls 2 ~hr~gh 5 in 231,235, 239, and 243.) 228..H~RDOUS COMPONENTS 1-5 EHS - Che~ "Ye~' if the ~mponent of the mixture is cons~er~ an Extremely Hazar~us Substance as de,ned in 40 CFR, Pa~ 355, or 'No' ~it ts not. (Repo~ for com~nents 2 through 5 in 232. 236. 240. and 244.) ~29. H~ROOUS COMPONENTS 1.5 CAS ~- ~sl ihe Chem~31Abstra~ Sew~e (CAS) numbers as reis;ed to Ihe hazardous ~m~nents in the mixture, (Repeal for 2-5.) 246, LOCALLY COLLECTED INFORMATION - This space may ~ us~ by the CUPA or ~ to collect any additional ;n~o~malion necessa~ ~o meal.the requiremen~ o; their, individual pr~rams. Con~act [~e CUPA or ~ for guidan~. UPCF (1/99) 7 OES Fo~ 27~ I CITY OF BAKERSFIELD "~ >~ ~ OFFJ~E OF ENVIRONMENTAL S,~VICES "~rttttt I . 171~Ehester Ave., CA 93301 (661)~16-3979 '~~ '~--' BUSINESS OWNER/OPERATOR IDENTIFICATION FACILITY INFORMATION Page ~ OI __ I. FACILITY IDENTIFICATION FACILITY ID # 't I ' Year Beginning ,oo Year Ending 8USIN~S_._S.... NAME~y0j~(Same as FACILITY NAME o, DBA: 6(~in'g'B;,siness~a.S[:H.{ [/(.~..~ ~1~. J:~" ~ .......... ............ 3 "BUSINESS PHONE ' ~';~"l ' 1~"~--~ ..... ,02 S,TEADDaESS qOOl /~i;~P-s,t ~ ,o~ DUN & 106 SIC CODE 107 BRADSTREET (4 Digit #) COUNTY ~ OPE~TORNAME ~%~ ~[~0~ '~ OPE~TORPHONE ~1. tl~0 ,,o II. OWNER INFORMATION o~.~.,a~e ~. ~~._~~ .............. ,,, owner,.o.e _..~. 1~ "~ OWNER MAILING ' ~4 ; STATE ~, ~s ' ZIP 116 III. ENVIRONMENTAL CONTACT CONTACT ~ME ~i CONTACT PHONE CONTACT MAILING ADDRESS CITY ~2o ' STATE ~2~ ZIP -PRIMARY- IV. EMERGENCY CONTACTS ~ECONDARY- BUSIN~SSPHONE ~t' [1~ . ......................... 126 ~ BUSINESS PHONE ~ql' [1~ .... : .............. .: ..................... 3ACER~ 128;: PAGER~ V. CERTIFICATION Certification: Based on my inqui~ of ~ose individuals res~nsible for obtaining the Informallon. I ce~i~ under penalty of law that I have personally examin~ and am familiar with the information submitted in ~Js invento~ and believe the informalJon Is ~e, accurate, and ~mplete. JPCF (7~99) S:\CUPAFORMS\OES2730.T'/4.w13cl Business OwnedOperator Identific&on Please suPmJt me ~us~ness Actr~,t~es page. Owner/OiDeralor IdentiflcalJon page (DES F~11~2730), and Hazardous Materials · Chemical Oescnpl~on pages (DES Form 2731) for all hazardous matenals inventory submissions. For the inventory to be considered complete ' . · ,s ;age must 0e signed 0y ~e appropriate 'qo(e: ~e numbecng o! ~te ,nsO'uc~ons fo;lows ~e data element numbers that are on the UPCF pages. These data element numbe~ are used jr electronic submission and are the same as ~he numbenng used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dicl~ona Please number all pages of ,/our suomiltal. Th~s helps your CUPA or ~ identJ~ whether' the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER · This number is assigned by the CUPA or AA. This is the unique number whic~ identifies your facility. 3. BUSINESS NAME - Eh[er ~e full legal name of ~he business. 100. BEGINNING DATE - Enter [he 0eginning year and date of the report. (YYYYMMDO) 101. ENDING DATE - Enter the ending year and date of the report. (YYYYMMDD) 102. BUSINESS PHONE - Enter the phone number, area code first, and any extension. 103. BUSINESS SITE ADDRESS - Enter the sb'eet address where the facility is located. No post office box numbers are a/lowed. This information musi provide a means to geegraphically locate the facility. 104. CITY - Ehter the city or unincorporated area in whic~ business site is located. ' ... 105. ZIP CODE - Enter the zip code of business site. The extra 4 digit zip may also be adde~l. ' "" 106. DUN & BRAOSTREET Enter the Dun & Bradstreet number for the facility. The Dun & Bradstreet number may be obtained by calling . (610) 882-7748 or by Intemet. 107. SIC COPE - Enter the pdmary Standard Industrial Classification Code number for pdmary business activity. NOTE: If code is more than 4 digits, report only the first four. 108. COUNTY - Enter the county in which the business site is located. 109. BUSINESS OPERATOR NAME - Enter the name of the business operator. . 110. BUSINESS OPERATOR PHONE - Enter business operator phone number, if different from business phone, area code first, and any extension. 111. OWNER NAME - Enter name of business owner, if different from business operator. . .~ 112. OWNER PHONE - E.nter the business owners phone number if different from business phone, area code first, and any extension. 113. OWNER MAILING ~DDRESS - Enter the ovme~s mailing address if different from business site address. , .., , ... 114. OWNER CITY - Enter the name of the db/for the owner's mailing address, 115. OWNER STATE - Enter the 2 character state abbreviation for the owner's mailing address. 116. OWNER.ZIP CODE - Enter the zip code for the owner=s address. The exb"a 4 digit zip may also be added. 117. ENVIRONMENTAL C(~NTACT NAME - Enter the name of the person, if different from the Business .Owne. r or Opera.tot, who rece!v,es all environmenlal correspondence and will respond to enforcement activity. 118. CONTACT PHONE - Enter the phone number, if different from Owner or Operator, at which the.environm .ental contact can be contacted, area. code firsL and any extension. ' 119. CONTACT MAILING ADDRESS - Enter the mailing address where all environmental contact correspondence should be senL if different from lhe site address.' ~ 20. CITY - Enter the name of the city for the environmental contact=s mailing address. 121. STATE - Enter the 2 character state abbreviation for the environmental contact~ mailing address. 122. ZIP CODE - Enter the zip code for the environmental contact=s mailing address, The extra 4 digit zip may also be added. 123. PRIMARY EMERGENCY CONTACT NAME - Enter the name of a representative that can be contacted in case of an emergency invoMng hazardous materials at the business site. The contact shall have FULL facility access, site familiarity, and aubhority to make decJsione for the business regarding inddent mitigation. 124. TITLE - Enter the title of the pdmary emergency contact. 125. BUSINESS PHONE - Enter the business number for the primary emergency contact, area code first, and any extensions. 126. 24-HOUR PHONE - Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day, If it is not the contact's home phone number, then Ihe sa, vice answering the phone must be able to immediately contact the individua,,I stated above. ~ . ,. 127. PAGER NUMBER - Enter the pagei' number for the primary emergency contact, if available. . - 128. SECONDARY EMERGENCY CONTACT NAME, Enter Ihe name of a secondary representative It,at can be contacted.in the event .till. the pdrnary emergency contact is not available. Th~ centact~shall have FULL facility access, site familiarity, and authority to make decisionsfor, lhe business' regarding incident mitigation. 129. TITLE - Enter the title of the secondary emergency con,ct. · 130. BUSINESS PHONE - Enter the business telelShode number for the secondary emergency contact, area code first, and ah*y extensionl 131. 24-HOUR PHONE - Enter a 24-hour phone number for th,e .secondary emergency contact. The 24 hour phone number must be one which is answered 24 hours a day. If it is not th'e conta;ct's home phone number, then the service answering the phone must be able to immediately contact the individual stated above. 132. PAGER NUMBER - Enter the pager number ~or the secondary emergency contact, if available, 133. ADDITIONAL LOCALLY COLLECTED INFORMATION - This space may be used for CUPAs or AA.s to co,act any addilional information neCessary to meet the requirements of their individual programs. Contact your local agency for guidance. 134. OATE- Enter the date that the document was signed. (YYYYMMDO) 135. NAME OF DOCUMENT PREPARER - Enter the full name of the person who prepared the inventory submittal information. 136. NAME OF S GNER .En~r the full pdnted name of th person signing the page. The signer certifies to a familiarity with thc in~armation submitted'and thai~ based on the Signer=s inquiry of th~{~ indMd~als responsible for obtaining the information, al [he inf~'rmaUon ' submitted is true, accurate and complete. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE - The Business Owner/Operator, or officially desl{~nated representative of the OwnedOl~erator, SI~311 sign in the space provided. This signature certifies that the signer is familiar with the ~~.' · .'~ . information submitted and that based on [her signer=s inqu!ry of those lndlvidua s responsible for. pbtain!ngthe.information it is the . . ~. signer=$ belief that the submitted information is Irue, accurate and completo. 137..TITLE OF SIGNER - Enter the flue of the pemon signing the page. ~' ~.t..~',, OF E OF' ENVIRONMENTAL ¥'ICES "/ 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 FACILITY INFORMATIOi~i Busmess Activities Addendum Page al I. FACILITY IDENTIFICATION OBA/~:ACILIT'~ NAME II1. CONSOLIDATED PERMIT ACTIVITIES Is your Facility Compliance Plan subject to review by... for satisfying the conditions of these permits? ' H. DEPARTMENT OF TOXIC SUBSTANCES CONTROL OYES ~NO v' STANDARDIZED PERMIT · All Modifications OYE~ ONO v' Non-RCRA HAZARDOUS WASTE FACILITY OYES ONO , v' RCRA HAZARDOUS WASTE FACILITY "~1~' SAN JOAQUIN VALLEY UNIFIED AIR POLLUTION OYES ~NO v' AUTHORITY TO CONSTRUCT CONTROL DISTRICT OYES ONO v' PERMIT TO OPERATE J. STATE WATER RESOURCES CONTROL BOARD OYES ~)NO v' WASTE DISCHARGE REQUIREMENT (WDR) -'NTRAL VALLEY REGIONAL WATER QUALITY CONTROL OYES ~NO v' GENERAL PERMITS .dOARO OYES,. ONO v' SPECIFIC PERMITS OYES ONO v' NATIONAL POLLUTION DISCHARGE ELIMINATION SYSTEM (NPDES) K. CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD OYES '~NO v' REGISTRATION PERMIT L. KERN COUNTY RESOURCE MANAGEMENT AGENCY ,'.,,. ENVIRONMENTAL HEALTH SERVICES PERMITS OYES ~)NO v' Domestic Water Well Permit OYES ONO v' Haz Mat Monitoring Well Permit OYES~ONO v' Septic System Permit OYES,~, ONO v' Public Swimming Pool Permit OYES ,ONO ~'~ Food Facility Construction Permit OYES ONO v' Solid Waste Local Enforcement Agency ~ (LEA) Related Permits : OYES,~ONO V' Medical Waste Related Permits PERMIT NOTE: V' If you checked YES to any part of Sections III-H to III-M above, then please address all applicable permit requirements in the Facility Compliance Plan. CITY OF BAKERSFIELD_ . o OF ENVIRONMENTAL S . [¥'ICES · ,nttrntt r 1715 Chester Ave., CA 93301 (661) 326-3979 FACILITY INFORMATION "'~'" Business Activities P3ge I. FACILITY IDENTIFICATION 08~FACILI ~ NAME 3 I1. ACTIVITIES DECLA~TION ~]- ~A~RDods'~'T~I~'~ .... ~YES ;~NO 4 V OES FORM 2731 (Chemi~lO~pli~ F~) 1. Have on site (for any purpose) hazardous materials at or ' ~ ~ CONSOLIDATED COMPLIANCE P~N above 55 gallons for liquids, ~0 pounds for solids, or 200 ~ .~ i Minimum r~uir~ planninR elements: cu ~ for compress~ gases (include liquids in ASTs and ~ ' ,. e Emergency Response Plan USTs)? ~ ~ ~ Maps 2. Have any amount of an explosive matedal foyer ~an ; OYES ~NO s ~ e Training ammunition) on site? : ' · Prevention · Ce~ifications Have onsite RS at greater than the ~reshold planning ~, ~ RISK MANAGEMENT P~N (R~ ~Dmil IO US~A) quantities established by the California Accidental ~ CONSOLIDATED COMPLIANCE P~N . Release Preven~on program (CalARP)? · Inco~orating CalARP Program Elements C. UNDERGROUND STOOGE TANKS (USTs) OYES ~NO 7 ~ UST FACiL'IT~'~-~ ..................... ~. Own or operate Underground Storage Tanks? } ~ UST TANK FORM (me p~ ~k) Intend to upgrade exisang or instil new USTs? OYES ONO ~ ~ UST FACILI~ FORM ~ UST TANK FORM " ~ UST INSTAL~TION FORM (~e ~ t~k) '~.'"'T'~NK~LOSURE / REMOVAL' OYES ~NO e ~ UST TANK FORM 1. Need to repoA closing a UST ~at held hazardous materials or waste? 2. Need to repo~ the closure/removal of a tank that ~s OYE~ ONO ~o ~ TANK CLOSURE FORM classified as hazardous waste and clean~ onsite? "-~'~0~ GROUND PETRO~'~ STOOGE TANKS fASTs) OYES ~NO ,1 ~ cO~-~L~D~C~-~PLIANCE P~N Own or operate ASTs a~ve these ~resholds: any tank ~ ~ Incorporating F~eral Spill Preven~on capaci~ is grater ~an 660 gallons or the total ~paci~ .. Control and Countermeasure (SPCC) for the facili~ is greater ~an 1,320 gallons. Elements pursuant to 40 CFR PaR 112 '~RD~US WASTE: ...... ~ EPA ID nu~::~de on this page 1. Generate hazardous waste? OYES ~NO 12 To obtain EPA I~. please phone (916) 324-1781 2. Recycle more than 100 k~mo of recyclable materials at OYES ~NO ~3 ~ RECYCLING FORM the same Io~tion it was generated? 3. Recycle more than 100 kg/mo o~ recyclable materials at OYES ~NO ~4 ~ RECYCLING FORM an offsite location different from the point of generation? 4. Treat Hazardous Waste on site? OYES ~NO ~5 ~ TP FACILITY FORM (DTSC Form 1772) ~ TP UNIT FORM (one per unit) 5. Subject to Financial Assurance requirements? OYES ~NO ~ ~ CERTIFICATION OF FINANCIAL ASSU~NCE 6. Consolidate Hazardous Waste generated at a remote OYES"~No ~7 ~ REMOTE WASTE / CONSOLIDATION SITE site? NOTIFICATION FORM Intend to consolidate other Cai/EPA agency permits? e Incorporating all other environmen~l (1~ yes, please ~mplete Section III and attach) pe~it requirements per 27 CCR 1~10 ~ you checked YES to any part of Sections IIA-IIG above, the~ In addition to the forms requested above, please Submit OES Form 2730. UPCF (7/99) $:~CU PAFORMS~CTIVlTY.wpd