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SITE DIAGRAM ~ FACILITY DIAGRAM
Business Nc:me: ,.~ <~ ~ c.O~o-cE~--
For Office Use Only
First In Station: Area Ma~ # of
lnsoection Station: NORTH
MISCELLANEOUS RECEIVABLES ADJUSTMENT
A~D~S8 CHANGE
CLOSE ACCT j
· FINANCE CHARGE I.
· OTH~. =J
CUSTOMER NAME ~ '~ .~ L~,o~,~ ~~
MAILING ~DRESS ~X X X ~¢~.~.C ~ ~,
PARCEL NUMBER
O~ APPUC,~.E)
ADJUSTMENT
I CHG DATE CHARGE CODE I ADJUSTMENT AMOUNT
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REMARKS:
Post-it' Fax Note 7671
J & $ 'Arn~lesale
1028 B~ S~et
B~el~ CA 93~05
August 28, 1~98 ,.', ~
'~ i,".j' . .,.:.~:?,.,.
Garbage Pick-up ~
To the City of Bakersfield
We will no louser u~d 81ubage pick-up due to
DATE; ~ j
Will Call ~ ~het (Pleose ~lt ou~ ell#fig info--don) New Semice ~ TIME;
~ Renter ~ Ca~s
ADDITIONAL ~ Tan ~ Grin ~ Re-sta~ Service i L~ Field Ch~k fptease e~t~.low] By: Date;
Removed COMM~N~. S/~. OTHER:
OW ~Tan ~Bin ID~ ,
............ Love/of 9~lce
Hazardous Materials/Hazardous WaSte Unified permit
CONDITIONS OF PERMIT ON REVERSE SIDE
........... ,~,~.~,~¢~,;???;?.?,.:?~.~,,~,..~,, ......... This permit is issued for the following:
:4':?'~ ,; .,.?.:~; x~x~,,~ ~;;~,= ¢~i',~,~' ?~?Onde:[ground Storage of Haza dous Materials
J&S WHOLESALE ~,o.n,~u ,~
LOCATION 1028 BAKER
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;~i,,:'"'" :~ '~'J-~;"~= =~"~ ~ ................. :;~,.,, ~ h,,,~:',.~r ~, ¢'a~,~:¢,¢~i~,~!~i,~..' ,~
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Issu~ by:
0 B~ersfield Fire DePa~me~t Approv~ by:
OFFICE OF E~ O~3L S~ ~CES
171~ Che~e~ Ave., ~a Floor f~~
B~e~fiel& CA 93~01
Voice {805) ~26-~979
, F~ (80s)~26-0s76 Expiration Date: dun~ ~O~ ~OOO
~ -..- (805} 326-3979
HAZARDOUS MATERIALS MANAGEMENT PLAN
To avoid furmer action, re~urn this form within 30 days of receipt.
~PE/PRINT ANSWERS
3. Answer ~he questions De~ow ~cr ~e ~usiness cs a wBole.
5e bdef aha concise cs
SECTION 1' BUSINESS IDENTIFICATION DATA
NAMe.
:'~CATION' IO~ ~4~ ~
~,~;~:: NUM .... SiC COD'-'
,, mix , ,-~,,, ~ ~ , WHOLESALE DISTRIBUTORS
A~ All Othe~ Convenience Store Needs
1028 Baker St. (Corner of Baker~ Lake)
(805) 327.5600
SECT]ON 2: EMERGENCY NOTIFICATION: Fax (805) 327-5695 Masoud Abbasi
CONTACT - -~ -
~ ~US. ~HONE ~4 H~. PHONE
:ardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 3: TRAINING:
NUMBER OF EMPLOYEES: ~
MATERIAL, SAFE~ DATA SHEETS ON F'LE:
BRIEF SUMMARY OF TRAINING PROGRAM:
us,-,,,Jc- GL,~E-'¢ ~' ~.,o¢
SECTfON 4,: EXEMPTION REQUEST:
[ C E s"'-'""'..,' , ,_. ,'-,
, :,tlr., UNDER ?ENALTY OF =eR JURY THAT'MY =USiNESS IS EXEMPT FROM THE
REPC. RTING x:~,u,Rc~''''c×lz~ CF CHAPTER x,. =. OF ~"'
,._,,..,,._!x .... '¢...., ,, ,c "CALIFORNIA H'-'
"" '"-' , CLLOWING r;:,.~,--..,,,~.
SA::'':v C,.x'C= cCH THE :, '
",",/E LQ NOT HANDLE H,.'-'.iz, RCCUS MATERIALS.
..,~ ,.,-,NOLE ~A..Z.R ,,...,.. ',., ,, :'""3~ ,", ,~
,.,,., ,.,~,-,, ~,.,,,.-,,...,, BUT iht. GUANTITiES AT NO
~,w~z..x~z'_, ira: '."41NIMu ,¥iRTiNG ,~UANTITIc~
STHER (S?ECr=V,, , ,~,,_..~..,cc ', cC;..:,.
SECTION 5: CERTIFICATION:
CERTIFY THAT THE ABOVE INFOR-
MARON IS ACCURATE. I '"'" '' '"'
UNOcxS~N~ THAT THIS INFORMATION WILL BE USED TO
rULrtLL MY F'. ~M S OBLIGATIONS UNO:F, ,m: ~,-,U, ~'RNIA HEALTH AND SAFETY CODE"
ON m~Z_AROQUS MATERIALS (CIV. '2C .~r',,~tcR 6.95 SEC. 25,500 ET AL.) AND THAT
INACCURATE INFORMATION CONSTITUTES r..RJURY.
TITLE DATE. - .....
oa~e~s~e~a ~re ~e~.
>~'~:" ;~ PIazardous ~ateriais Di~s~on
HA~RDOUS MATERIALS MANAGEMENT PLAN
Facili~ Unit Name:
SECTION6: NOTIFICATION AND EVACUATION PROCEDURES:
S, --MPLC.,'YEE NOTiFECATICN AND EVACUATION'
- z,.,,
,...,. ~,=L[C ACUATiCN:
D. z:vlERG,z.',IC / ,"vtE:..,~iC,.~L ?LAN:
Bakersfield. Fire Dept.
Hazardous Materials Division .......
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 7' MITIGATION, PREVENTION AND ABATEMENT PLAN:
B. RELEA~,E-CONTAINMENT AND/OR MINIMIZATION:
SECTION $: UTILITY SHUT-OFFS "_Ch'': m: ....
~,-~t~C,N ~r SHUT-,OFFS AT YOUR rAC~LI!Y)
NATURAL ~,-,~/ ....', ,-,
,'¢ ,--, i z%:I .
SECTION 9: PRIVATE FIRE PRCTECT1ON/WATER AVAILABILITY:
A. ?RIVATE FiRE PROTECT[CN: "'"~o~'"T,fl.-~C..'"
B. WATER AVAILABILITY (FIRE HYDRANT'): '
BAKER ,5 IELD CITY FIRE DEP i :ITMENT
HAZ. ,RDOUS MATERIALS INVENTORY Page_of__
Business Name ~ ~ ~ CD~c~"6--cC'L'~' · Address (0 Z ~ ~¢---,'~
CHEMICAL DESCRIPTION
1) INVENTORY STATUS: New [4~ Addition [ ] Revision [ } Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TRADE sECRET [ ]
2) Common Name: CL[/'~f~O.L'~L-' ~_..1~_~/.~ ~--/,-r.~/~ 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 (Chro.nic) [ ] '
5) WASTE CLASSIFICATIQN (3-digit code fi-om DHS Form 8022) USE CODE
6) PHYSICAL STATE Solid [ ] Liquid ~ Gas [ ] Pure ~' Mixture [ ] Waste [ ] Radioactive [ ]
7) AMOUNT AND TIME AT FAClUTY UNITS OF M .F_AS~ 8) STORAGE CODES
Maximum Daily Amount: 7(~ ' Ihs [ ] gal ~ ft3 [ ] a) Container:
Average Daily Amount: ~---~' cudes [ ] b) Pressure:
Annual Amount: .~ c) Temperature:
Largest Size*Container: (~.T'
# 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 ) ~""TC~C-~-w~J~/'I J~: ~"T't L4.~~ [ ]
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 [ ] TRADE SECRET [
2) Common Name: /~.r..~T'C.~ (~ ~ 4._ 3) DOT# (optional)
Chemical Name: AHM [ ] CAS #
4) PHYSICAL & HEALTH PHYSICAL HEALTH'
HAZARD CATEGORIES Fire J~] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ]
5) WASTE CLASSIFICATION (3-digit code fi-om 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 [ ] gal ~ fi3 [ ] a) Container: ~)
Average Daily Amount: ,.~ cudas [ ] b) Pressure:
Annual Amount: ~ c) Temperature:
Largest Size Container: ~'C_ ..'.:.
# 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) [ ]
certify uncl. gj'~/e'~'alty.of /aw, that / haJ/e personally examined and am familiar with the Jnfoma~ion submitted on thi~l and ~/I attached documents. / believe th.
PRINT Name & T/tle of AuthorizeifCompany F~epresentatJve Signature Date
BAKERSFI D CiTY FIRE DEPAFJMENT
HAZARDOUS MATERIALS INVENTORY Page_of.~
;Jusiness 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~_~1~ 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.~'j' Mixture [] Waste [ ] Radioactive [ ]
7) AMOUNT AND TIME AT FAClETY UNITS OF MEASURE 8) STORAGE CODES
Maximum Daily Amount: "'"~ lbs [ ] gat [~ 1t3 [ ] a) Container: (~'
Average Daily Amount: ~Oc-) cudes [ ] b) Pressure:
Annual Amount: /~ c) Temperature:
Largest Size Container:
# Days On Site ~G~' Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, D
9) MIXTURE: List COMPONENT CAS # %.~ AHM
the three most hazardous 1) ...~ C..~ ~"~ I L~ ~'t~ (_.~ f,~." P C)~- ~,..0/~'~ []
chemical components or
any AHM components 2) [
3) [ ]
10) Location (~ ~/~ O~c- ~..~_~/"~ - A <~//-- (~
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 #
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
Maximum Daily Amount: lbs [ ] gal. [ ] it3 [ ] 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). [ ]
10) Location
cerO'fy under penaJ~/ of /aw, that I have personally examineci and am familiar with the infomatJon submitted on this and all attached documents. I believe th~
submitted information is m/e, accurate, and complete.
PRINT Name & Title of Authorized Company Representative Signature Date