HomeMy WebLinkAboutBUSINESS PLAN Bakersfield Fire Dept. RECEIVED
0 Hazardous Materi~Js Division {J~N I 7 1972
~ ' .~ 2130 "G" Street
HAZ.
MAT.
DIV.
,// ~/ %~, /...Bakersfield, CA. 93301
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 brief and concise as possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
BUSINESS NAME' BAKERSFIELD ADVENTT,q~
LOCATION: 3333 Bernard St.
MAILING ADDRESS: same
CITY: Bakersfield STATE: CA ZIP: 93306 PHONE: 871-1591
DUN & BRADSTREET NUMBER: SIC CODE:
PRIMARY ACTIVITY' ~ - ~ schoo~
OWNER'
MAILING ADDRESS:
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT TITLE BUS, PHONE 24 HR. PHONE
1. David Ferch - Maint. 871-1591 872-9138
Samir Berbawy principal 87'1 - 1591 872-8534
2.
FDI5~
Bakersfield Fire Dept.
" Hazardous Materials Division
, HAZARDOUS MATERIALS MANAGEMENT PLAN
,.~ '., '..~.i,,i ,:; i ~
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 THE "CALIFORNIA HEALTH &
SAFETY CODE" FOR THE FOLLOWING REASONS:
WE DO NOT HANDLE HAZARDOUS MATERIALS.
x WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO
.... ' ........ TIMEEXCEED THE MINIMU.M-REPORTING-QUANTITIES.
OTHER. (SPECIFY REASON)
SECTION 5: CERTIFICATION:,
I, Samir Berbawy CERTIFY THAT THE ABOVE INFOR-
. MATION 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.
'el Principal January 14, 1992
' 'SIG~'-~TURI~~'' - ~' TITLE DATE
2,
CITY of BAKERSFIELD
"WE CARE"
January 7, 1992
FIRE DEPARTMENT 2101 H STREET
S. D. JOHNSON BAKERSFIELD, 93301
FIRE CHIEF 326-3911
Bakersfield Adventist Academy
3333 Bernard Ave.
Bakersfield, CA 93306
Dear Sir:
Your Underground Storage Tank for gasoline was removed on 1-3-92.
OUr records show that storage of gasoline in that tank was the only
Hazardous Material in reportable quantity stored at your facility
at 3333 Bernard Ave.
If you wish to file exempt from theHazardous Materials Management
Plan and Inventory RePorting Requirements you must complete and
exemption request. I have enclosed a set of blank forms for your
convenience. Completion of the Hazardous Materials Management Plan
sections (1) Business Identification Data, (4) Exemption Request
and (5) Certification must be completed and returned to this office
in order to become exempt from these state reporting requirements.
We have also included a cover letter to business owners briefly
summar.izing the filing requirements.
If we can be of any further assistance please do not hesitate to
call.
Sincerely yours,
~alph E. Huey
~azardous Materials Coordinator
REH/ed
Encl.
Bakersfield Fire Dept.
HAZARDOUS MATERIALS DIVISION
Date CompletedI
Business ~rl'.L.~P..~ F~ ~ ,z~t,/~o,,//.~ ?' ~r...,¢ e-,,,,.?
Identification No. 215-000 - oo/o/,/(Top of Business Plan)
JAM 0 5 1992j
~tation No.~ Shift -~ Inspector
HAZ. M&T. DIV.
Adequate Inadequate
Verification el Invento~ Matedals ~ I~]
Verification el Ouantities
Verification of Location
Proper Segregation of Material ,~
Comments: O~[)~,~3u~.-~ ~.,,~oc/,,.,~':' .'T'4.N~-.. /.s
Verification of MSDS Availablity
Number of Employees
Verification of Haz Mat Training ~
0~.C°mments:
Verification of Abatement Supplies & Procedures
Comments:
Emergency Procedures Posted ,~
Containers Properly Labeled f~'
Comments:
Verification of Facility Diagram //~
,/
Special Hazards Associated with this Facility:
Violations:
Correction Needed
usiness OWner/Manager
FD 1652 (Rev. 1-90) White-Haz Mat Div. Yellow-Station Copy Pink-Business Copy
HAZARDOUS MATERIALS DIVISION
/ 2130 G Street, Bakersfield, CA 93301
,b0v~ (S05) 326-3970
RECEtv
/\~3 UNDERGROUND TANK QUESTIONNAIRED/::~'
/ BOX TO INDICATE ~CORPO~TION ~INDIVlDUAL ~PARTNEESHIP ~LOCALAGENCYDI~IC~ ~COUN~AGENCY ~ STATE AGENCY ~DE~LAGENCY
EMERGENCY CONTACT PERSON (PEIMAR~ EMERGENCY CONTACT PERSON (SECONDAE~ optionol
DAYS: NAME (~$T, FIRS~ PHONE No. WITH AR~ CODE ~ DAYS: NAME (~ST. Ft~ PHONE ~. WITH AR~ CODE
_~IGHTS: NA~ (~Sf. FIRS~ ~SNE ~. WITH AR~ CO~ _[. NIGHTS: NAME (~ST. FI~ PHONE ~. WITH AR~ CODE
I1, PROPER~ OWNER INFORMATION (MUST BE COMPLETED)
NAME CARE OF ADDRE~ IN~RMATION
MAILING OR STRE~ ADDRESS ~ ~OX ~ INDIVIDUAL ~ LOCAL AGENCY ~ STATE AGENCY
~~ ~~~ TO INDICATE O PARTNERSHIP O COU"~ A~ENCY O FEOE"L AOENCY
CI~ NAME ~ ' ZIP CODE PHONE No. WITH AR~ CODE
III, TANKOWNEE INFORMATION (MUST BE COMPLETED)
NAME CARE OF ADDRE$~ INFORMATION
MAILING DE STREET ADDE~ ' ~ SOX ~ [N~IVIDUAL ~ LOCAL AGENCY ~ ~TATE AGENCY
CI~ NAME STA~E ZIP CODE PHONE No. WI~H A~EA CODE
OWNER'S DATE VOLUME PRODUCT IN
TANK No. INSTALLED STORED SERVICE
Y/N
Y/N
YIN
Y/N
Y/N
DOYOU HAVE FINANCIAL RESPONSIBILITY? (~U TYPE ~_~
~.'~ ~-,'~ Fill one segment ~ for each tank, unless all nks and piping are
constructed of th~ame materials, style and )e, then only fill
one segment out. please identify tanks by owner ID #.
I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN
j A. OWNER'S TANK I.D.# B. MANUFACTURED BY:
C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GN, LONS: ~)
III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOXES A, B. ANDC, ANDALLTHATAPPLIESINBOXD
A. TYPE OF [] 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR LINER , [] 95 UNKNOWN
SYSTEM [] 2 SINGLE WALL [] 4 SECONDARy CONTAINMENT (VAULTED TANK) [] 99 OTHER
1 BARESTEEL [] 2 STAINLESS STEEL [] 3 FIBERGLASS [] 4 STEELCLAD W/ FIBERGLASS REINFORCED PLASTIC
B. TANK
MATERIAL 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM [] 8 100% METHANOL COMPATIBLEW/FRP
(PrimaryTank) [] 9 BRONZE [] 10 GALVANIZED STEEL [] 95 UNKNOWN [] 99 OTHER
[] 1 RUBBER LINED [] 2 ALKYD LINING [] 3 EPOXY LINING [] 4 PHENOLIC LINING
C. INTERIOR
LINING [] 5 GLASS LINING [] 6 UNLINED J~ 95 UNKNOWN [] 99 OTHER
IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES_ NO__
D. CORROSION [] i POLYETHYLENE WRAP [] 2 COATING .':',~ .r-'-~ 3 Vlly~L WRAP .~. [] 4 FIBERGLASS REINFORCED PLASTIC
PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE ~, ,-.-~g5 UNKNOWN ', [] 99 OTHER
IV. PIPING INFORMATION CIRCLE ~, IFABOVEGROUNDOR U IF UNDERGROUND, BOTH IF APPLfCABLE
A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER
B. CONSTRUCTION A tJ I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN
C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE
CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLEW/FRP
PROTECTION A IJ 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER
D. LEAK DETECTION [] 1 AUTOMATIC LINE LEAK DETECTOR [] 2 LINE TIGHTNESS TESTING [] 3MONITORINGINTERSTITIAL [] 99 OTHER ,,/,~.,~,/~
V. TANK LEAK DETECTION
[] 6 TANK TESTING [] 7 1NTERSTITIALMONITORING [~L91 NONE [] 95 UNKNOWN [] 99 OTHER
I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN
A. OWNER'S TANK L D. # S. MANUFACTURED BY:
C. DATE INSTALLED (MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS:
III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C. AND ALL THAT APPLIES IN BOX D
A. TYPE OF [] 1 DOUBLE WALL [] 3 SINGLE WALL WITH EXTERIOR LINER [] 95 UNKNOWN
SYSTEM [] 2 SINGLE WALL [] 4 SECONDARY CONTAINMENT (VAULTED TANK) [] 99 OTHER ,
B. TANK [] 1 BARE STEEL [] 2 STAINLESS STEEL [] 3 FIBERGLASS [] 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC
MATERIAL [] 5 CONCRETE [] 6 POLYVINYL CHLORIDE [] 7 ALUMINUM [] 8 100% METHANOL COMPATIBLEW/FRP
(PrimaryTank) [] 9 BRONZE [] 10 GALVANIZED STEEL [] 95 UNKNOWN [] 99 OTHER
[] 1 RUBBER LINED [] 2 ALKYD LINING [] 3 EPOXY LINING [] 4 PHENOLIC LINING
C, INTERIOR
LINING [] 5 GLASS LINING [] S UNLINED [] 95 UNKNOWN [] ~ OTHER
IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL ? YES__ NO__
D. CORROSION [] I POLYETHYLENE WRAP [] 2 COATING [] 3 VINYL WRAP [] 4 FIBERGLASS REINFORCED PLASTIC
PROTECTION [] 5 CATHODIC PROTECTION [] 91 NONE [] 95 UNKNOWN [] 99 OTHER
IV. PIPING INFORMATION C~RCLE A tF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE
A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER
B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL .& U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER
C. MATERIAL AND A U 1 BARE STEEL A IJ 2 STAINLESS STEEL A U 3 POLYViNYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE
CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100°/o METHANOL COMPAT[BLEW/FRP
PROTECTION A U 9 GALVANIZED STEEL ~, U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER
D. LEAK DETECTION [] 1 AUTOMATIC LINE LEAK DETECTOR [] 2 LINE TIGHTNESS TESTING [] 3 INTERSTITIAL
MONITORING [] 99 OTHER
V, TANK LEAK DETECTION
I
~ ~ BAKERSFIELD CITY FIRE DEPARTMENT
' 2130 "O" STREET
BAKERSFIELD, CA 93301
- (805) 326-3979
OFFICIAL USE ONL~~
ID,
BUSINESS N.~IE
HAZARDOUS. ~q3%TERI ALS
BUSINESS PLAN AS A WHOLE
~OR~ 2A
INS~UCTIONS: "
1. To avoid further action, return this form by
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.
SECTION 1: BUSINESS IDE~IFICATION DATA
B. LOCATION / STREET A DRESS:
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency i.nvolving the release or threatened release of a
hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify
your local fire department and the State Office of Emergency Services as required by
law.
EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:
NAME AND TITLE ~i~,~~ DURING BUS. HRS. AFTER BUS '.HRS.
S...-.~~ ~[~pa~,,~ Prin~,~at .Ph#~71'/~t Ph# ~)'~7~.--~'~'~g'/
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE: ~;lo ~ S h~a ~a~
B ELECTRICAL: ~:::~,~o ~ S~, Z~-.~O.
D. SPECIAL:
E. LOCK BOX: YES /~ IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS? YES / NO ~SDSS? YES / NO
FLOOR PLANS? YES / NO KEYS? YES / NO
- 2A -
SECTION 4: PRIVATE RESPONSE TEA~ FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE T~INING
EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND
REFRESHER TRAINING IN THE FOLLOWING AREAS.
CIRCLE YES OR NO INITIAL REFRESHER
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
~TERIALS:...- .................................... YES ~ YES ~
..................
D. EMERGENCY EVACUATION PROCEDURES: ................. ~ .YES
E. DO YOU ~INTAIN EMPLOYEE TRAINING RECORDS: ....... YES YES
SECTION ?: ~Z~DOUS ~RI~
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS OF_f.~A
SOLID,
55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... . YES ~
I,_~--~~ ~,~~ , certify that the above information is accurate.
I understand that this information will 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 constitutes perjury.
BAKERSFIELD CITY FIRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFICIAL USE ONLY
ID#
BUSINESS NAME:
BUSINESS PLAN
SINGLE FACILITY UNIT
FORM 3A
INSTRUCTIONS 1. To avoid further action, this form must be returned by:
2. TYPE/PR!XT YOUR ANSWERS IN ENGLISH.
3. Answer *.he questions below for THE FACILITY UNIT LISTED BELOW
4. Be as BRIEF and CONCISE as possible. )
SECTION 1: MIT, IGATION, PRE~NTION~ ABATEMENT PROCEDURES
SECTION 2: NOTIFICATION .~\q] EVACUATION-PROCEDL-RES AT THIS LTiT ONLY
- 3A -
SECTION 3: HAZARDOUS >!ATERIALS FOR THIS UNIT ON'LY
A. Does this Fac5. t}~ Unit contain Hazardous Matei-J.a!s? ......
!f YES, see B.
If NO, continue with SECTION 4.
B. Are an~' of the hazardous materials a bona fi~e T~-ade Secret YES
If No, complete a separate hazardous materials inventory
form marked: NO~-TRADE SECRETS ONLY (white form
If Yes, complete a haza~'dous mate~'ials inventouy fol'm marked:
TRADE SECRETS ONLY (yellow form :4A-2) in addi~i,]n to the non-trade
secret form. List only the trade secrets on fo:'~ 4A-2.
SECTION 4: PRIVATE FIRE PROTECTION
SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPONDERS
SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT
A..Y.:Vf. GOS.'PROPANE':
D SPEC'
r I..OCK BOX: ::_, (.XO] . '"C' '
,.. '":S ' r: YES, I ..... .,TIOX:
iT %'ES, STTE PLAX'S? VES .,/ ...vt ~fS13Ss? .... ,,'~:., \'0.
FLOOR PI,ANS? YES /' NO !,:Ex;S? YES ' NO
3B -
BAKERSFIELD CITY FIRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFICIAL USE ONLY
ID#
BUSINESS NAME:
BUS I NE S S PLAN' '~
SINGLE FACILITY UNIT
FORM SA
INSTRUCTIONS 1. To avoid further action, this form must be rerun-ned by:
2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
3. Answer the questions below for THE YACII,!TY UNIT LISTED BELOW
4. Be as BRIEF and CONCISE as possible.
SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES
all ch~c.,a,(~, o~.. o,,~ oery clos~ ~,p~,.u~.o+
SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THIS L%',.IT ONLY
SECTION 3: HAZARDOUS :.'!ATERIALS FOR THIS UNIT
A. Does this Facility Unit contain [~azarc!ous
If YES, see B.
If N0, continue with SECTION 4.
B. Are any of the hazardous materials a bona fide Trade Secret YES
If No, complete a separate hazardous materials inventory
form marked: NflN-TRADE .SECRETS ONLY (white form =.!A-l)
If Yes, complete a hazardous materials invento?y forth marked:
TRADE SECRETS ONLY (~'eliow form ~4A-2) Jn addition to the non-trade
secret form. Llst only the trade secrets on for~:~ 4A-2.
SECTION 4: PRIVATE FIRE PROTECTION
SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY ENiERGENCY RESPONDERS
SECTION 6: LOCATION OF UTILITY SHIrT-OFFS AT THIS Di!T OS;LY.
A..MAT. GAS '""
. I'i~0P .... E:
D. SPECIAL:
~... · .' . T r~(, ~ 'f'l
YES, SITE PLANS? YES /
,'~ :,:rvco
FLOOP, PL-Lx:S? YES "
BARERSFIELD CITY FIRE DEPARTMENT
2130 "6" STREET
BARERSFIELD, CA 93301
OFFiCiAL USE ONLY
ID#
BUSINESS NAME:
BUSINESS PLAN
SINGLE FACILITY UNIT
FORM 3A
INSTRUCTIONS 1.. To avoid further action, th_~s form must be l~eturned by:
2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
3. Answer *.he questions below for THE FACILITY UNIT LISTED BELow
4. Be as BRIEF and CONCISE as possible.
SECTION 1: ~ITIGATION) PRE~N~ION~ AB4TEMENT PROCEDURES
SECTION 2: NOTIFICATION ASq] EVACUATION PROCEDL-RES AT THIS L~IT ONLY
-i*c.~ woad- t~ ~o, re,,,.so~qo ftt, c~,.,~ ,..,~,i~ ~.~ ~
- 3A -
SECTION 3: HAZARDOUS :,~ATERIALS FOR THIS UNiT ONlY
A.. Does this Facility Unit contain Hazardous Ma.~c_ ]. .. ~' F*. ' '.'° ......... Q
If YES, see B.
If NO, continue w~.th SECTION 4.
B. Are an~ of the hazardous materlals a bona fide Trade Secret YES
If No, complete a separate hazardous materials inventory
form marked: NaN-TRADE SECRETS ONLY (white fc~rm e..tA-1)
If Yes, complete a hazardous materia!s inventory form mar'.<ed:
TRADE SECRETS' OXr,Y (~'el]ow form ¢4.4-2) Jn addition to the non-trade
secret fopm. L_~st only, the tpade secrets on for[:'.. ~A-2.
SECTION 4: PRIVATE FIRE PROTECTION
SECTION 5: LOCATION OF h'ATER SUPPLY FOR USE BY EMERGENCY RESPONDERS
SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT O~7LY.
..4 NAT c..~ ~ PROP..\:fE':
B. ELECTRICAL:
C. WATER:
D. SPECIAL:
OfT r~ ,' :::S ~) Tr 5"ES, [.,,f.-,TIO×:
.... , ~ (3 ~ . ~-~- ' . r~ * ~
:, $'E'q St"r PLAXR? YES "C' 3i:.-',DRs? x...,
,,~ ,¥c.-, -,r, X~. ."(EV,c.? ':'ES ' NO
.ri O0P, r~..~, o: ~;..S " .
BAKERSFIELD CITY FIRE DEPARTMENT
I.D. ~ FORbl 4A-1 Page / of"/
NOl'q-- TRADE SECRETS
HAZARDOUS MATERI ALS I NVEN'TORY
PHONE ~: ~)1 ~ l~q~ P~ONE ~: ~~ , [OFFICIAL ONLY USE CFIRS CO~E
1 2 3 4 5 O 7 8 9 10
TYPE ~AX ANNUAL CONT USE LocATIoN IN T~IS · BY ~AZARD D.O.T
.CODE A~OUNT A~OUNT UNIT CODE CODE FACILITY UNIT ~T. C~E~IqAL OR CO~ON NA~E CODE GUIDE
EHEROENCY CONTACT: ~eo~ ~v~g~r~ TITLE: ~Ui,l~, ~r~-d$ ~fe~ PHONE * BUS HOURS:
AFTER BUS HRS:
- 4h-1 -
BAKERSFIELD CITY FIRE DEPARTMENT
NON--TRADE SECRETS
HAZARDOUS MATERI ALS INVENTORY
ADDRESS: ~ ~~ ~v~ ADDRESS: ~ FACILITY UNIT NAME:..~Ai~, ~'"~'..
1 2 3 4 5 6 7 8 9 10
TYPE MAX ANNUAL CONT USE LocATIoN IN THIS · BY HAZARD D.O.T
CODE A~OUNT AMOUNT UNIT CODE CODE FACILITY UNIT WT. CHEMICAL OR COMMON NAME CODE GUIDE
AFTER BUS HRS:
'EMERGENCY CONTACT: S~ ~VD~ TITLE: ~r/~ti, paJ PHONE ~ BUS HOURS:
'PRINCIPAL BUSINESS ~CTIVITY: ' ~~, , , AFTER BUS HRS:
- 4A-1 -
BAKERSFIELD CITY FIRE DEPARTMENT
FORM 4A-1 Page'
'NON--TRADE SECRETS ~
HAZARDOUS MATERI ALS I NVENTORY
ADDRESS: ~33 'W~°f~e~~' ~. ADDRESS: S~ FACILITY UNIT NAME: ~0
PHONE {: ~3{-}~q~ PHONE ~: ~o~ [~FFICIA'L USE CF~RS CODE
ONLY
1 2 3 4 "5 6 7 8 9 10
TYPE MAX ~NNUAL CONT USE LOCATION IN THIS · BY HAZARD D.O.T
CODE A~qUNT A~OUNT UNIT CODE CODE FACILITY UNIT WT. CHEMIqAL OR COMMON N,AME CODE GUIDE
1
EMERGENCY CONTACT: ~eo~ ~~ TITI,E: fi~,%q, .gvo~ ~ePHONE { BUS HOURS:..
AFTER BUS HRS: ~22~ O)o
"RINCIPAL BUSINESS ACTIVITY:, ~t~w~ AFTER BUS HRS: ,,, ~
- 4A-I -
' ...'"--"o -':: c-~;.~> lC) [ ~,,,.~,:~::r:5.:'.~¢
..'"?~:-,'. ~:,'~ CITY oj' BAKERSFIELD' ,%!,.?',.~ ,,':~:-.:~
",:¥,.0.--?.,..~....., ..,.....:,.....:.' >..." u ~;;:Z:'.?
(Z,v~e or ~rinz name) JAN
Do hereby: cer~±£y that I have rev±eyed t~he
attached Hazardous MaZerials business ~lan
(name of business)
and that it alon~ with the attached additions
or corrections constitute a complete and correct
Business Plan for my facility.
BU;~NEoo NAME BAKERSF F~DVENTIST ~CF)DEHY ID NUt~) Z 1S-O(~O-~(~IQI
LOCATION ~,f333 BERNARD ST HIGH H~IZARD RATING
OVeRVieW
LAST CHANGE 11/24/87 8¥ ESTER
JURIS CODE ZlS-~'~8 SURIS BAKERSFIELD STATION 88
MAP PAGE 183 GRID 228 FACILITY UNITS ! HAZARD RATING 2
RESPONSE SUMMARY
2A SEC 4) iF WE HAD A MINOR EMERGENCY WE HAVE FIRE EXTINGUISHERS IN EVERY
ROOM THAT HANDLES HAZARDOUS MATERIAL.
EMERGENCY CONTRCTS ~ SEC Zl
.Szso.-~--'G-T'C-VE-HENDERSON - 8?l-t~Sl OR B?2-G2~G
SAMIR BERBAWY 871-1:91 OR 87Z-8S34
UFILITY SHUTOFFS 2A SEC 3)
A) GAS - PICO & SHELLY LN 8) ELECTRICAL - PtCO & SANDY LN
C) WATER -PICO & SHELLY LN O) SPECIAL.- NONE
E) t. OCK BOX- NO
NOTIFICATION / PUBLIC EVACUATION
LAST CHANGE / / BY
< NOiNV6RM6TION RECORBE~ FOR TMIg SECTION >
PAGE I I2/IG/88 1S:IG
MATERIAL SAFETY DATA SYSTEMS, INC. (885) G48-GB~
BUSINESS NAME ~J~KERSFI~I~ ADVENTIST ACADEMY ID NUMB~Z15-~--OO1eI8
LOCATION ~ BERNARD ST HIGH HAZARD RATING 2
~. NAZ MAT TRAINING SUMMARY
LAST CHANGE / / 8Y
0 INFORMATION ~CORDED FOR THIS SECTION >
LOCAl,. EMERGENCY MEDICAL ASSISTANCE
LAST CHANGE 11/Z4/87 BY ESTER
SEC B) WE WOULD CA1LL Bi1.
PAGE 2 12/tG/88 tS:IG
MATERIAL SAFETY DATA SYSTEMS, INC.
BUSINESS NAME BAKERSFI RBVENTI~, RCROEMY ID NUMB
LOCATION ~33~ BERNARD ST HIGH HAZARD RATING
FACILITY UNIT
OVERALL H~ZARDOU~ MATERIALS INVENTORY
LAST CHANGE 11/24/87 8Y ESTER
TYPE NAME MAX RMT UNIT HAZARD
LOCATION CONTAINMENT USE
PURE GASOLINE <REGULAR) 500 GAL HIGH
OUTSIDE ~ESI' gALL ~S FT UNDERGROUND TRNKS FUEL
ID PERCENT COMPONENTS HAZARD LIST
~1,82,~ 100,0 C~SOLINE HIGH
2 PURE GASOLINE (REGULAR) ~ GAL HIGH
NORTHEAST gALL METAL CONTAINERS FUEL
ID PERCENT COMPONENTS HAZARD LIST
1t8Z.~ t~,~ G~OLIN~ HIGH
FIRE PROTECTION t YATER SUPPLIES
LAST CHANGE 1tI~4/87 BY ESTER
~A SEC 4) FIRE EXTINGUISHERS FOR FIRE PROTECTION.
SEC G) FIRE HYO~ANT CORNER OF 'SANDY LN & RICO ~V.
PAGE 3 tZ/tG/88 I~:IG
MATERIAL SAFETY DATA SYSTEMS~ INC. (80S) G48.-G800
· BUSINESS NAME BAEER~ ADVENTIST ACADEMY ID 1~-~-~t018
LOCATION 33~3 BERNARD ST HIGH HAZARO RATING
D. EMPLOYEE NOTIFICATION / EVACUATION
LAST CHANGE 11/24/87 8¥ ESTER
~ 2) CALL FIRE DEPARTMENT FROM HOUSE NEXT DOOR.
MITIGATION / PREVENTION / ABATEMENT
L~iST CHANGE I t/Z4/87 BY ESTER
3A SEC ~) ~E HAV~ VERY ~MA~L OUnN~T~ES O~ ~nznnOous ~n~m~LS. CCEnN-UP
PEGE 4 ' IZ/IG/88 IS:IG
MATERt~L S~FETY DATA SYSTEMS, INC. (80S> G48-GBQ~
.. CITY of BAKERSFIELD -- : '~
. . -' ' Page I of~
~ .. ~ ~"
LOCATION: ~3J~ ~~ S¢ .... : ...... ~DRgS5: STANDARD IHD.
C~TY, Z~P: ~~~ ~ ~ ' CITY, ZIP: · DUN AND BRADSTREET HUMBER
PHONE ~: ~l--~ PHONE ~: - -
~ TO IHS~UCTIONS FOR PROP~ CODES
Irons Ty;e Max Average Annum ~asure ' I ~ Cmt Cmt Cmt Use L~atlm V~re tN~t' Na~s of Hixture/Cm~ts
Code Code ~t Amc Est Units m Site Ty~ Prfll Tmp C~e .. Stor~ In Facility See lnscructJml
Ph sical ~nd Health Hazard C.A.~. Num~ Cm~t II Naw ~ C.I.$.
IC~k all t~t a~pl~) '
~mt 12 NaN & C.l.S. Number
-- r ~ [d ~ [~dm flelease ~ ~ IKtate
e Hazard ~--~ Reactivity -- ~lay~ --
Health of Pressure HMIth
~t I~ NaN & C.A.S. Humber
~2_~_l.J.~. ..... J..-~L__.I_._~__J~I~.I~ I ~ P~ ~ !~~ 1~_~_~ 't~o ~-~-~_ ' ....
P~ical and H~lth H~x~rd C.A.~. lu~e ~mt II I,~ ~ C.I.$.
{C~k ~11 t~t ~pply)
~-~ r-~ -- r~ ' r--~ Ca.mt 12 NaN & C.l.S.
~--~ Fire Hazard =--d Reactivity ~ ~ ~lay~ =--d ~ddm Release =--d
Health , oi Prusu~e H~lth ...........
~t I1 Nam ~ C.A.S.
._~e__L.~,.~,k?-~, .... 1 to l~/l~,~.l t~ ~, I~ l~ l ~ ~ ~" ~ ~z~~ ~*;~ .......
Ph~ical and H~41th Hazard C.A.$. N~e ~mt II N~ ~ C.A.$.
{C~k ~il t~t apply)
~mt It N4~ ~ C.A.S.
r~;-- "[--j r--, [--j
-~rfre Hazard Reactivity ~- ~ Oelay~ ~dd~ Release ~--J i~fate
Health of Pr~sure Health .........
C~t I~ Na~ & C.A.S. Numar
..~...t__.~ ..... J__u. ........ t._.~' J.~J~m[ ,'~;" ;~ .;~, [ ~* ~ [~_. ~~
P~ical and Health Hazard C.l.S. blhr Ca.et Il Nam i C.l.S.
(ChKk all that apply) ,
[-- · H~zard ~ ~ Reactivity [ ~ Delayed [--~ ~dd~ Release ~--3 I~tace
Health of Pr~suee Health ....
C~t I~ dam & C.A.S. Numar
n~me .......................... I~El~ ............ ~l'ff~'P~; ....... li~ .............. TI ~l'np'~} .........
....... ~-d~
Certification (Read and sY~n after coaple:lng all sections)
certtfy under ~alty of 1~, that I have personally examined,and am familiar ~tth t~ tnfor~t~lsu~itt~ tfl thts a~ ell attec~ d~uemrs, and t~t ~sed m ~ inqui~ of t~se tndtvt~als
~o~ obtaiAing t~ i~for~:t~. ! believe t~t t~ suDaitteg inrOr~tiffi iS t~e, accurate, Ina c~ ete~
~ -. RECEIVED
CITY of BAKERSFIELD
'6PR 0 6
N O N -- 'If R A D E S E C R E T S HAZ. ~AT._ , DIV.
LOCATION: ~ ~~ ~ ~ ADDRESS: ' STANDARD IND. CLASS CODE ,.
CITY, ZIP: ~/~ ~O~ CXTY, ZXP: DON AND BRADSTRE~T
~tI2 ~ i C.A.S. ~ I
-- -- ~t ~ ~&C.A.S. ~
L~ F~re Hazaed RHctiv~ty ~le~ ~--~ ~ Reline ~--J I~Jlte
H~lth of P~m ~lth
(C~k ,11 t~t ~wly)
H~lth of Pe~sure Health ..... -- ......... ~.......
NERGENCY
C~TACTS
CertificatJ~ (Reid a~d sJE~ after completing all sections)
I certtfv ~dee ~lty of 1~ t~t I ~ve ~rsmally exai~n~ end aa f~iliir eith t~.infoe~tim su~Jtt~ in this ~ ell ettK~ ~ts. ~ t~t Ms~ m ~ i~t~ of t~e tMivt~lll
for o~taining t~ inf~ti~. I ~lieve tM, t~ suMittH info~ti~ is t~. accurate. ~d
CITY of BAKERSFIELD ' "
Far, and Agriculture '~-----~ Standard Business ~ "H'AI~A'Z'iI~L~L~'DOUS
LOCATION:...~ ~f~ ~' ' -- ~ADDRESS: STANDARD IND. CLASS CODE '
CITY, ZIP: ~~ .. CITY, ZIP: · DUN AND BRADSTREET NUMBER
~ TO ~S~U~T~ONS ~OR PROP~ CODZS
Co~e Co~e let l~t Est Units '. ~ Stte Iy~ Prell Tap C~e .. Stor~ tn Facility Nt See lnstructi~5
Physical and Health Hazard C.l.~. Nue~r Cffiffinent II Na~ & C.l.S. Nulben
(C~k a]] t~t apply)
~ Fire Hazard [ ] Reactivity ~--J OelayN [--~ ~dd~ Release ~--J
Mea Ith of' Pressure H~ I th .............................................................
C~t ~ Na~ & C.A.S. Number
Ph~ical and Health Hazard C.A.~. Numar tin,mt II Na~ i C.A.S. Numar
-- r--] r--n r--n C~t [2 NaN & C.I.$. Numar
~2~ Fire Hazard [ ] Reactivity [-- ~]oV~ u--J ~dd~ Release u_J im~late
' Health · of .Prs~ure HHlth .............
Caom~t ~ Nam & C.A.S. Number
(C~k all t~t apply)
r - ~ r - ~ r - ~ r - ~ C~t 12 NaN & C.A.S. Numar
~JFfreNaza~d ~--~ Reactivity ~--J Delayed ~--J Sudd~ Release ~--J ]~late ·
Health of, Pressure Health
Ph~ical ~n~ Health Hazard C.k.~. ~r CM~t II N~ & C.1;'S. Numar
(ChKk all that
~ ~ Fine Hazard ~ ~ Reactivity ~--J Oelayed u--~ Sudd~ Release ~ ~
Health of Pressure Health ...............
C~t I~ NaM & C.A.S. Number
~ERGENCY CONTACTS 01 12 '
Certification (Read and sJKn after completing ail.sections)
~ certify under ~alty of ~aw that ~ have oersonal~y examined and as faa~l~ar etth t~ ~nforaat~ subettt~ tn th~s a~ all attac~ d~ue~cs, and t~t based ~ ay ~n~u~ry of t~se ~ndtv~duals res~s~ble
for obtaining t~e ~nfor~t~on, ~ believe t~t the submitted ~nformat~ ~s true, accurate, and c~olete.
" BAKERSFIELD
~ CITY of
Farm and 19riculture ~ Standard Business ~ H~I~LZJ~$~.R~)OUS Md~L~Iq 1:1-~:~.-T' ~T~_jS ~ ~~~.0~'
[oc~t~o.: ma~-"~~"-s~ . ~...~ss: sT~..~. ~... c~ass ~o.~
CITY, ZIP: ~.~~ ~ff. ~ A ~'0 ~ CITY, ZIP: - DUff A~D BRADSTREET NUmBeR
PHONE ~: ~0 1~ t~qt PHONg ~: - -
~ tO Z~S~UC~ZONS ~OR PROP~ CODg3
lrans Ty~e Max Averaqe ~nual ~asure I ~ ~mt ~t ~ Use [~a~t~ Nhere ~Nbyt Nn~s of Mixture/C,~mts
Code (:ode ~C ~C Est Units '. m Site ly~ PresJ INp C~e .. Stor~ In Facility See Inscructi~s
o1~l , ,
r-- r--~ r--~ r--~ r--~ ~t 12 NaN & C.A.S. Nuiber
~ ~ Fire Hazard ~ u Reactivity ~ ~ ~h~ ~_u ~dd~ Release '--
-- -- -- ~ ~ I~tace
~e~lth of Pressure HMIth
S..L~-I_'~...~ ..... l ...... ~r} .... 1_._~ .... l-~-k~_~f~.~_~~23~~~.'.~.(_~./~
P~ical and Health Hazard C.A.~. lum~ ~C II la~ i C.A.S.
(C~k all t~t apply)
~--~ - r--~ r--~ r~ Cm~mt 12 NoN i C.A.S. Nue~r
u--J Firl Hazard ~ ~ Reactivity u-- ~lay~ u--~ ~ddm Release ~--J IMitate ·
~c 13 Na~ A C.A.S. Nulbe~
Ph~ic~i ,nd Heeith Htzard C.A.S. lu~ ~c II NsM & C.A.S. Nul~
-- r -- i r -- 1 r-- a r ~ ~t 82 NaN & C.A.S. Num~
~ ~ Fire Hazard ~--J Reactivity ~--J Oelay~ u--u ~dd~ Release ~--J
Health of. Pressure Health '
- C~mt 13 NaN ~ C.A.S. Nue~r
P~ical and Health Hazard C.A.S. ffui~r CM~C If NaM & C.A.S. Xui~r '
(C~k all ChaC a~ply)
--J Fire Hazard ~--J Reactivity Oelayed -- ~dd~ R,leese ~--J I~tete
Health of Pressure Health .....
' Cm~t 13 Nam & C.A.S. Number
.... ~~_~Z. .. ,. ~~ ................
Certtficati~ (Read and s JEff after coapJetJnE ali
I certify under ~alty of la~ that I have oersonally exaain~ and ae faat1~ar etth t~ tnfor~ttm.subattt~ tn this a~ i~1 Itt~ d~um~:s, and t~t ~sed m ~ inqui~ of t~se Individuals res~s~ble
for obtaining t~ inter, tim. I ~)ieve t~t tM suoaitt~ tnfo~tt~ is t~e, accurate, are c~al~. . j //
...... ~ ....... .~_.~.~ .......... ~ ........... : ................. ~._~=~~ ..............
o, ..................
BAKERSFIELD
CITY of
Far, ami Agriculture '~.d Standard 8usiness ~9. ' HAZARDOUS MATI~-R'I' ALS T
':
CITY, Z~P: ~.~+~[~ ~o~ ' C~TY. ZZP: · DUN AND BRADSTREET NUMBER
~ ~0 ZWS~UC~ZO~S FO~ PRO~ CODES
Irans Type Max Average Annual ~asure ' I ~ Cml ~t Cml Use L~atlm N~re ~N~~ Na~s of Nixture/C~mts
C~e C~e ~t Art Est Units ~ Site Ty~ Presl T~p C~e .. Stor~ tn Facility See Inscructi~s
Physical ami Health Hazard C.A.~. Numar C~eflt Il Nam & C.A.S. Number '
IC~k att t~t apply)
~--~ Fire Hazard ~--~ Reactivity =--~ ~lay~ [--q--J ~dd~ Release [~ I~late
Health of Pressure H~lth
~t I] Nam & C.A.S. Nuebee
P~ical and Health Hazard ' C.A.~. Numar ~mt II Na~ & C.A.S. Numar
(C~ck ail t~t apply)
~--J Fire Hazard ~--a Reactivity ~--J ~lay~ ~--J ~ddm Release ~ m~latm
Health . of P~ssure HNIth
~t I~ Nam & C.~.S. ~mbee
P~ical ami Health Hazard C.A.S. flu~ ~mt II Nam & C.A.S. Numar
(C~k all t~t apply)
~--a F~re Hazard ~--J Reactivity ~--a Oelay~ ~ ~ ~ddm Release ~--a [~fate
Health of- Pressure Health ' .' :: , .......
. Ca.et 13 Nam & C.A.S. Nue~e
P~ical and Health Hazard C.l.S. hl~r Ca.mt 11 NaN & C.l.S.
(ChKk all that apply)
r -- ~ r -- ~ r -- q r-- ~ r--~ CM~mt 12 NaM & C.A.S. Ndmber
~--d Flee Hazard ~--~ Reactivity ~d 0elay~ ~--J ~dd~ Release ~--d i~taCe
Health of Pr~sure Health .... _
.' ~mt I] NaM & C.A.S. Numar
· ~ ~-~ .........
Cert~ftcat~ (Read and si~n after cosplettn~ all sections)
[ certify under ~alty of la= that I have personally examin~ ami aa famiBar vita t~ ~nforMttm su~ttt~ tn this a~ all Ittlc~ d~ue~:s, and t~t ~s~ m W ~nquiw of t~se fnd~v~dualf res~s~ble
for obta~niAg the infor~ttm, ! believe t~t t~ suomttt~ info. tim ~S t~e, accurate, and c~.
fl;;; TI 5;fieF755;;$lSF'Ofl [~;;755;F;ESF i'auE~Flz~a r . ;ET;S Si);;[GF;' 0$TT'ST~ia ..........................
".. CITY of BAKERSFIELD
'~ . . . - ~ Page
LOCATION: ~~ ~t~ ~ ' ADDRESS: STANDARD IND. CLASS CODE
CITY, ZIP: ~o~$~ ~~ .... CITY, ZIP: . DUN AND BRADSTREET NUMBER
PHONE ~: ~T~- ~ ~--~ / PHONE ~: _ _ - _ _
~ TO I~S~UCTIO~S FOR PROP~ COD~S
Trans Type Max Average Annual ~asure ' I ~s Cmt C~t C~t Use LKatt~ Nhene IN~ NaMs of Nixture/C~ts
Code Code bC AmC Est Units '. m StCe Ty~ P~ess TNp C~e -. Stor~ tn FaciHcy See Inst~cti~s
Physical and Health Hazard C.A.~. ffua~r CM~nent 11 Na~ & C.A.S. Numbe~ '
(C~k all cMO 'app)y)
~--~ Fire Hazard ~--~ Reactivity ~layH ~--~ ~dd~ Release ~Ktate ~t 12 NaN i C.A.S. NumbeP
Health of Pressure HMIth
~Kt 13 NaN A C.A.S. Number
~_LeJ .... J. ....... 1 ..... ~_ .... L~. ..... 15~I,.~:k~_~j.?* ~~2~~k~:~.~e ~;~.._~.~_vk~ .....
P~ical and Health Hazard C.A.~. NUB~ ~mt 11 NaN & C.A.S. Num~
(C~k ail C~t apply) :
-- r-- a r-- 1 r-- ~ r ~ Cm~C 12 NaN i C.A.S. Numar
[ ~ Fire Hazard ~--~ ReaccNtty ~--~ ~lay~ ~--u ~$d~ Release ~--u IMitate
Health · of Prusure HNlCh
~om~t 13 NaN & C.A.S. Number
.... L_L .......... L ............ Z ........... ! I [ I I i~ I ......
~h~tc~l and H~4lth Hazard C.A.I. ~u,~r N~mt II ~ I C.A.I.
(C~k 4II t~t 4p~ly)
Health of Fressure Health ......
C~ffit I~ Nam I C.A.S. Numar
.... I~,,L,,,21 .............. [ .......... l._J~' C ~' i l__l .....
Ph~ical and Health Hazard C.A.S. Numar CM~mt l1 NaN i C.A;'S.
(ChKk all chat apply)
~ ~ Ff~e Hazard u Reactivity ~--~ Oelayed ~dd~ Release -- I~aCe
Health of Pr~sure Health '~-
CM~t il NaN & C.A.S. Num~
Certification (Read and s~gn after compJetJnE ail sections)
[cerctfy under ~atCy of ~a~ ChaC ; have De~spn~Hy exa~i.n~.and a= fa=~]i;r ~tCh ~ ~nfor~aC~m,su~ttc~ tn thts a~ ~t] ltt~c~ dKu=~s, Ind ~ Msed m W inquiw of t~se indtvtdu~ts res~slb;e
for obtaining the inter.tim, I be)~eve C~c ~ suo=itc~ ~nTor=aC~m ~s true, agcurace, ano cmp~ece= ~
N~F~[)'6[ti~i$1'~ fflF6T'6I~/oB~;$i~F'OFSG[~r76B~F$[~ j'$Gt~BF~[E~Ei;J 51~$[GF[ ' ' O)ti'Si~[)~ .........................