HomeMy WebLinkAboutBUSINESS PLAN 6/12/2001 6/12/01 16:!0 '~661 326 0576 BFD flAZ ~IA'I' DIV ~014
HAZ
06/12:01 ~l~J:14 '~661 326 0576 BFD
_~ CITY OF BA~RSFIELD
~~~r Off,ICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (661) 326-~979
HAZARDOUS MA_NAGEMENT PLAN
mST UCr .O S:
I. To avoid rue&er action, return this fo~ wi~in 30 days of receipt.
2. T~E~K~T ANS%~RS ~ ENGLISH.
3. ~swer fl~e questions below for the business as a whole.
4. Be ~ brief ~d concise ~ possible.
5. You ma7 Mso a~ach Business Omer / ~emtor Fc~ md Chemic~ Description Fo~(s)
to the ~ont of~is Plm hstead ofcomplet~g SE~ON I. below for initial submission.
SECTION I: BUSIN'ESS ID.ENT1TICATION DATA
BUSINESS NA~ME: .BIG BEAR_FIREWORKS, INC.
UNIT C
LOCATION: 2351E. BRUNDAGE, BAKERSFIELD, CA 93307
MAiLFNGADDRESS: 2820 PEGASUS RD., SUITE # 2
CITY: BAKERSFIELD STATE: CA ZLP: 93308 PHONE: 661 -393-2779
PR.LMARY ACTMTY: FIREWORKS WHOLESALER
OV~rN~R: BRUCE ZOLDAN PHONE: 330-746-1064
MAILING ADDRESS: 555 MARTIN LUTHER KING JR. BLVD., YOUNGSTOWN,
EMkt,'.GENCY NOTIFICATION
CONTACT TITLE BUS. PHONE 24HR. PHONE
[. aOHN BROWN ACCOUNT MANAGER 661-393-2779 66~-900-1010
ROGER JOBE ADMINISTRATIVE ASISTANT 661-393-2779
2.
OO/ig~01 1~:15 ~'~61 326 0576 BFD HAZ bAT DIV ~020
HAZARDOUS MATERIALS i~L4.NAGEB, IENT PLAN
SECT[ON [[. i' .DIS. CQ.V.ER.Y A,NrD NOTIFICATIONS "
A. LEAK DETECTION AND MONITORiNC, PROCEDURES:
N/A
B. E!V[PLOYEE AND AGENCY NOTIFICATION:
AGENCY NOTIFICATION - CALL 911 FOR FIRE DEPARTMENT IN CASE
OF FIRE. CALL AMERICAN PYROTECHNICS 410-778=6825 FOR ADDITIIONAL
INFORMATION. CALL 911 FOR MEDICAL EMERGENCY.
C. ENVIRONMENTAL RESPONSE MANAGEMENT:
.N/A
D. EMERGENCY MEDICAL PLAN:
CALL EMERGENCY MEDICAL CARE FIRST AID AS NECESSARY FOR
INJURY SUSTAINED.
06,/12,'01 16:i5 '~'§§1 326 0576 BFD HAZ MAT DIV ~021
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION [[.2: RELEASE RESPONSE PLAN ....
A. HAZARD ASSESSMENT AND PKEVENTION MEAS[~ES:
TSecreE RS B±oHaz Rad±oactive/amounE EPA Hazards NFPA USDOTg MCP
No No No NO/ curies F IH DH //// UnR
B. RELEASE CONTAINMENT AND/OR MITIGATION:
N/A
C. CLEAN-UP AND RECOVERY PROCEDURES:
IF A SPILL OCCURED ALL MATERIAL SHOULD BE SWEPT UP, PLACED IN
THE PROPER LABEL BOX AND RETURNED TO OUR MAIN WAREHOUSE FOR
DISPOSAL. SHOULD FIRE OCCUR t NORMAL DISPOSAL AND REMOVAL
OF BURNED MATERIAL WOULD BE TAKEN.
UTILITY SHUT-OF.ES, (LOCATION OF ,S..HUT-OFFS AT YOUR FACILITy)
GAS -
NATLFRAL OAS/PROPANE:
SPECIAL: .... .~a::, .,q,,'v~
LOCK BOX: YE~ IF YES, LOCATION:
PRI%'ATE FI'RE PROt'ECTION/WATER AVAILABILITY
A. PRI\,'/:t i'E FIRE PROTECTION:
WATER AVAILABILITY (F[ILE HYDRANT):
NEAREST FIRE HYDRANT _ BY DRIVEWAY WAREHOUSE SIDE.
06."12/01 16:16 '~661 326 0576 BFD HAZ MAT DIV ,"c"' ' ~ [~022
HAZARDOUS bIATER[ALS MANAGEMENT PLAN
$SCTION !II: TRAINING
NUMBER OF EM-PLOYEES: 6 ....
MATERIAL SAFETY DATA SHEETS ON FILE: YES
BRIEF SUMMARY OF TRAINING PROGRAM:
EMPLOYEES ARE INSTRUCTED AS TO THE USE OF FIRE EXTINGUISHERS, WATER
HOSES WHICH ARE ALSO AVAILABLE. EMPLOYEES ARE NOT ALLOWED TO SMOKE
IN OR AROUND WAREHOUSE. FOLLOW EMERGENCY RESPONSE & MATERIALS
SAFETY DATA SHEET.
CERTIFICATION
I,... RYNE CONDER CERTIFY TI~LA.T 'tHE ABOVE INFORaM. ATION
IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION W/LL BE USED TO
FULFU..L 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 INFORMATIQN CONS/TrUTES PERJURY.
MAT/~qO~"l' PLAN
06/12/01 16:00 8§61 326 0576 BFD HAZ MAT DIV ~]008
CITY' OF BAKERSF! i,/~ ·
...... '.' OFFICE OF ENVIRONMENTAL SERVICES .,
~.lnrM~r 1715 Chester Ave., CA 93301 (661) 326-3979
FACILITY IN~OR,,%I.A rlON
I. FACIEITY IDENTIFICATION
II. ACTIVITIES DECLARATION
Does Your Faci/b"" / . If Yes, Please Complete...
?. Have on site tier any purpose) hazardous materials at or v' CONSOLIDATED COMPLIANCE PLAN
acove $$ g~llons ,'"or liquids. 500 pounds for solids, or 200 : Minimum requi,.'ed plannin.q eleme,'l.lS;
cuft for compressed gases (include liquids in ASTs and , · Emergency Response Plan
USTs)? / · Maps
2. Have any amount of an explosive material (other than ~)YES ('"~NO 5 · Training
ammunition) on site? · Prevention
· Certifications
Have onsite RS at greater than the threshold planning v' RISK MANAGEMENT PLAN (AMP So~m,~ m USEPA}
quantities established by the California Accidental v' CONSOLIDATED COMPLIANCE PLAN
Reiease Prevention program (CatARP)? · Incorporating CaIARP Program Elements
'. Own o,' operate Underground Storage Tanks? v' UST TANK FORM (o~e ~e~
Intend ~.o upgrade existing or Install new USTs? OYES ~/',~O e v,' UST FACILITY FORM
v' UST TANK FORM
v~ UST INSTALLATION FORM (o.e
~ Need to repo~ closing a UST that _held hazardous
rnalerials or waste?
'L Need [o report the closure/removal of a tank that was OYES (~NO ~0 ¢ TANK CLOSURE FORM
cJassified as hazardous waste and cleaned onsite?
Own or operate ASTs above these thresholds', any lank · Incorporating Federal Spill Prevention
capacity is greater than 660 gallons or the total capaci.h/ Control and Countermeasure (SPCC)
for the facility Is greaier than 1,320 gallons. Elements pursuant to 40 CFR Part 112
*. Generale hazardous waste? OYESq~NO ~z To obtain EPA ID#. please phone (916) 324.1781
2. Recycle more t,han 100 kg/mo of recyclabte materials' at OYES ~NO ~3 v' RECYCLING FORM
the same location it was generated?
3. Recycle more It',an 100 kg/mo Of recyctabie materials ai C;YES t~)NO ,~ */ RECYCLING FORM
an offs~te location differen~ (rom the point el' generalion?
4. Treat Hazardous Waste cn site? (.)YES t~jNO ~ ~' TP FACILITY FORM {OTSC Form 1772)
v/ TP UN!T FORM (one per unit)
5. Subject to Fic..ancia~ Assurance requiremenis? ' OYES (~NO ,.~ ,,/ CERTIFICATION OF FINANCIAL ASSURANCE
~. Consolidate Hazardous Wasle generated at a remote OYES NO ~7 ~' REMOTE WASTE I CONSOLIDATION SITE
silo? : . NOTtFICATiOI'i FORM
L'~lend to conso;idate othe~ -I/EPA agency permits? e Inccrporatin9 all otb. :nvironmental
{~f yes, please complete S,.. Itt and altech) f permit requirements per 27 CC.°, 104~,0
)'f E
· ¢! you ct,co, ed 'r¢'q lc any pad et Sections ifA-IlO adore, Ihe~ irt addition to lhe/orms requesled above, please .¢'.,~m!l DES Form 2730.
UPCF (/~geil SACUP^FORMS~ACTIVIT¥ wpd
O6,/12701 16:01 ~'661 326 0576 BFD HAZ MAT DIY [~]007
~'~ ,~ CITY OF BAKERSFIELD ~
~'~;i'~' OFFICE OF ENVIRONMENTAL SERVICES
~r~r ~
'~' - 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979
"' ~ACIL.!TY
i~us!r~¢.SS Acllv~hes
c(
I. FACILITY IDENTIFICATION :
F~cEL:.w :o * i~ ¢'& ~se ~,y '. ~e~ ]~ ~i~,~> .............................................. ~ ' k~':O · .............
Ill. CONSOLIDATED PERMIT ACTIVITIES
Is ymJr Facilib/Compliance Plan subject to review by...___~ i for satisfying the cor~ditions of these permits?
'' '~...-' '-~PARTMENT OF TOXIC~Ci~S~ANOES CONTROL ~S~N5 ....... P .........~~i~-~t~ .............. ·
· Ail Modifi~tions
OYES ~NO ¢ Non-.RC~ HA~ROOUS WASTE FACILITY
OYES ~NO ¢ RC~ H~ARDOUS WASTE FACILITY
L' -~A',q ~5~;55~[~E~Y UNIFIED AIR POLLUTION ~ = ~k .................
L~Y-S O ~ AUTHORI~ TO CONSTRUCT
CONT¢OL OISTRICT
OYES NO ¢ PERMIT TO OFE~TE
' 'j, STATE WATER RESOURCES CONTROL BOAR0 OYES"~ ,
O ¢ WASTE DISCHARGE REQUIREMENT (~R)
~TP~ VALLEY REGIONAL ~VATER QUALI~ CONTROL OYES ~NO I ~ GENE~L PERMITS
.~ o~
OYES ~NO ~ ¢ SPECIFIC PERMITS
~ ¢ NATIONAL POLLUTION DISC~RGE
OYES O ~ ELIMINATION SYSTEM (NPOES)
~7~;~CiF~X-~Y~~A~%~E~4~~-'~V~"~o . ~ REGIST~TION PERMIT
L. KER~ COUNTY RESOURCE MANAGEMENT AGENCY ~N ENVIRONMENTAL HEALTH SER~CES PERMITS
OYES 0 ¢ ~mesfic Water Well Pe~it
· OYES ~NO ¢ Haz Mat Mcnitor/ng Well Pe~nit
OYES ~NO ¢ Septic System Permit
OYES ~NO ¢ Public Swimming P~ Permit
OYES ~NO ¢ Food Facflily Constructicn Permit
OYES ~NO ¢ Sotid Wasle Lo~l Enforcement Agency
(LEA} Relat~ Permits
OYES ~NO ¢ Medi~l Waste Related Permits
.................................. ~.., .... ..:~ .....;g;~ ......
~,~, cra( os eA~RS~¢LO WAS, ..... ~ n~V, 56~ .......~"~'¢~S- ~'d .......7 ........ ~di'~4~'i/','i"WA~f~"WAY~'5¢~A~b'~' ........
PERMFI
r~Ol'E:
g' II you c~oc~ed 'Y~3 ~o any pan of ~eetlon, II~-H io III-M above. Ihen please ~dress al} appli[a~le permit requiremenls in the Facility Oompllsne~
06//.2/01 16:02 '~6§1 326 0576 BFD IIAZ .~tAT DiV
~ ~~ O~ICE OF ENVIRO~'MENTAL~ERVICES
~ rt~m ~ 1715 Chester Ave., CA 93301 (66 I) 326-3979
~a~r~r.
FACILITY INFORMATION
I. FACILI~ IDENTIFICATION
F~C,LITY ID ~ J ~ ~ Year Beginning ~ Year En~i~
..j I 200] 2001
~.5~NESS HAME (Same ~5 FAC~Li~E ~O6'A~ ~ ~s,n'ess ~) .... ~" BUSINESS PHONE ' ' -'
AODRESS
'~ CA ZIP 93307
~o~ SiC CODE ~;-
8~ADSTREET 9~-31 ~318 (4 Digit ~J 8810-87~2-8018
,~OUNTY KERN
C, PE~A'TOR NAME RYNE CONDER ~ ' OPE~TOR PHONE 209-491 -5180
II. OWNER INFORMATION
NAME BRUCE ~O~DA~ BB~t ~C. ~ O~ERPHONE 330-~46-~064
~:;,DRESS 555 MAR~ ~U~HER KZ~G ~R. BBVD.
III. ENVIRONMENTAL CONTACT
C. NTACTNAME RY~E OO~DER ~ CONTAOTPHONE ~-800-~33'-~
~.~ORESS '
~ODE~O ~2o , STATE CA ~2~ ZIP 95356
-PRIMARY- IV. EMER6ENOY CONTACTS -SECONDARY-
JOHN BROWN '= ; NAME ROGER JOBE
K.C. ACCOUNT MANAGER ~z~ ~ TITLE ADMINSTRATIVE ASISTANT
........... PHONE 661-393-2779 ,~ ~ 8US~NESSPHONE 661-393-2779 ,~
PHONE CELL 661-900-1 010 '~ ' 24-HOURPHONE -~
N/A ,~ PAGER ~
V. CERTIFICATION
, cf,c~-~ion: Based on my inqut~ o~ those ~ ';luaJ3 responsible for ob/ninlng ~e in~c~aflon, I ce~J~ unde¢ pertly of law {hal I have personally examined
tamilmr with the inlorma~ion submlltea m [his invenJo~ and believe the information Is true, accurate, and com01ete.
CE~RA~ VA~B~Y RBGIO~AB MA~AGBR
::' (7i99) S :\CU PAF ORM SLOE S2730.TV4 .w~.:d
06/12,"01 16:05 ~661 326 0576 BFD HAZ MAT DIV [~010
,-~~~ .... OFFICE OF EN~ [RONMENTAL SERVICES
~ ~ r~r 1715 Chester AVe., CA 93301 (661) 326-3979
Y~' .... ' HA~RDOUS MATERIALS INVENTORY ~~';
CHEMICAL DESCRIPTION
I. FACILI~ INFORMATION
t1. CHEMICAL INFORMATION
CLASS "C" COMMON 1 .4 G FIREWORKS
~o~,~c-~ CLASS "C" SAFE AND SANE FIREWORKS ~.s'
2~0
EDH~D~TEGG~E$ · ~ FIRE ~2 ~CT~ ~3 PRESSURER~L~SE ~4 AC~EH~LTH ~5 CHRONICHE.~.~
:hat 3poiy)
~WASi~ 217 } b~t~OM 2~8 i A~GE 219 S'fATEW~TE~DE
UN~TS' ~ ga ~ ~ d CU ~ ~ ~ LeS ~ ~ 7ONS 22~ ~YS ON
COntAINER ~ a A~OUND T~K ~ · ~S~'NONM~LIC DRUM ~ i FtS~R ORUM ~ m G~ BO~LE
~ ~ UNOE~GROUNO T~K ~ f ~N ~ J ~G ~. ~ST~C 80~E ~ r OTHER
~ c T~K INSIDE BUlkO~ ~ g ~SOY ~ k ~X ~ o TOTE
~ d STEEL DRUM ~ h SiLO ~ I CYLINDER ~ p TANK WAGON
PRESSURE ~ a ~IE~ ~ ~8 A~SIE~ ~ ba 8ELOW~IE~
TEM~TURE ~ $AM$1E~ ~ a= A~E~IE~ ~ ba 8ELOW~aIE~ ~ c ~YOGENIC
%'~ H~RDOUS COMPONENT EHS ~ CAS
220 ~ 227 ~Y~ ~No 228 ~
230 . 23~ ~Yes ~NC 232 .
~':..; ; 235 ~ Yes ~ No 236 j
~38 J 239 ~Y~ ~Ne 240 [
...... J ............................................................................................................. ~ ..................................
242 243 I ~Yo:. I NO 244 ~ 245
;': t' 7/':39) S :\CUPAFORMS\OE S2731. TV4.wpc
06/12,"01 1.6:06 '~661 326 0576 BFD HAZ ,qAT DIV ~011
q
Hazardous Materla/s Inventory. Chem/ca! Description
NOTE. You may c~ose (o ;ea,e m,s ~n~ ,~ ~eu resubm,i ~ur enUre invenlcrf a~nual¥ -
~2~305.
~0~. ~.'.[ICA~ ~OC~ ~10~ CO~10CN/I~L. EPC~ · Ail ~e$ wfl,c~ 3r~ $~b~cf (o '.h~ Emergency Pta~m~g a~ Commum~/~ighl to K~0w Act (E~C~)
miema~na~ ~on of P~e and Appli~ Chem~ {~UPAC) ~me foun~ ~ the Me(et~f Se(e~ Oa~a ~ee~ (M$CS). NOTE; If t~e ~em~J is 8 at, lure.
~mp;ele Ih~s ~e~d: c~ple~e the 'CCMMCH ~ME' ~e~ ~nst~d.
2~ T~OE SECRET · C~ec~ 'Yes' ~ tee ~nfo~ma~ ~, ~ ~n is ~ar~ a (~e sec, et c,' 'No' ,1 ~ ;~ not.
mu~{ submil a 'Suos~Alia~n ~ ~a~ C~ ~ T~e S~ f~m (40 CFR ~.27} ~ U$EPA,
n,~m~' d~(inct ~m J~ ~mp~en~. If t~s m,x~ur~ has ~ ~S numOer, leave I~ia ~[umn b~nk and ~'~p~ I~ ~S numbers of the ~al h~a~
~nen~ ;n ~he appro~nelo s~n ~e~cw.
2~0. FiRE CODE H~O C~SSES - FWe ~e H~a,d C~es ~es~ lo fi~t :es~ets the ~ ~n~ ;evel ofh~ar~ous maleHals wh~h a ~sines$ ha~;~.
on h~ {o delermJne whJ~ class a me,anal falls ~ar are i~ ~ the ap~nd~s of ~{e ~ o~ the Un~o~ Fire ~. tfa maledal has ~re Ihan
appli~ole ~Za~ class, i~ude ail ~n~ CUPA ~ r~
:f mix,ute ;r wasle, c~mp~te h~a,d~3 ~en~ s~n.
at,wily In ~nes,
;: 5. FEC~L H~D ~TEGO~JES - Check eft ~[~ ~a~ de~ ~e ph~f end h~l~ ~s a~t~ w~ ~ ~za~ male~L
~ PHYSICAL
- , ' ' ~ H~L~ ~ROS i
· eac/~e. Or~an~ Perox~es, W~er R~e. ~d~e ~ O[~r haz~ ~em~)s ~m 3n ~veme effe~ ~[h s~ff ~'m ex~e
P~e~sure Release: Exp~sives, Compressed G~ses. 8es:/nG A~enls J Chron)c Heml~'~ (Oe/ayedJ: C~, omer h~r~u~ c~[~b ~
~ adveme efl~t w~lh ~ le~ ex,sure
217. AVenGE OA~NT. C~Jcu~(e me average ~;lly a~un( of ~ h~3r~u~ ma[edal cr m~tute ~ta~n~ a' ~ar~U$ ~(eHal. in each ~ifo;~
days tr.e cnem~t '~t ~ ~ s~e. Il this ~ a ~ief~l ~at ~s n~ prev~sly been present at ~is I~U~. the am~n/shail ~ Ihe average ~ e~nl
p~o/~[ to ~e cn ~nd ~[~ lhe ~se ~ ~e year. Yh~ amen{ ~ ~ ~sistent ~ b~e un/~ re~ed in ~x 221 a~ shou~ ~ ~ ~t O(
Cai~ amount
218. ~IMUM DALLY A~OU~ - Ente~ the n~xJ~m ~n[ o( e;~ h~ar~us maledal ~ mixture ~(a~ a ~zard~s mata~l, w~ ~ ~ted ~ a bu)~
page. with ~e re~e~ el addit~n~, ~le~s, ~ ~v~t pm~ed f~ ~e c~fenl yea~. ~ a~nt sheu~ ~ ~le~{ wi~ ~e ~ re~ed I~
;. 13. ~NNUAL W~TE ~OUNT · l( Ihe ~rd~s malapai ~ invenloH~ is a ~ste, ~ov~e an esUmete of me annual a~vnl
Hazardous Wasle Manifest.
(;~e maledal i~ ~t~ ~n (~allons, ~unds. cubic/~l, ~
223 S TCP~GE CONTArN~R. CD~k all ~xos {ha~ des~,~ the {ype of $/o~ge ~nlainers in which mo haza~ous maker/al is sro(ed. NOTE: It a~ropda/e. ~u may
224.5i'O~GE PRESSURE - Chec~ (he one box (flat ~$i ~es~b0S Ih9 prss~u~e a~ when the hazardous ,~ate(:al is stored.
228, H~AqOOUS COMPONENTS 1-5 ('A 8Y WEIGHT). Er. tar l/re ~t~nfago wash( o¢ tho hazardou.' ",~mP~on[ in a mixture, if a range of percentages ;= availabie. .'e~on (ho ~;ghesl percenlago in Iha[ range. (Re~ ~ core.necks; m~gh 5 In 230, 2~, ' ~ 2~2.~
[nan 1% Oy '~e~ht il n~a.,cin~enic, o¢ 0.1% by ~t,t il ~(cln~en~. s~ould ~ ~eport~. II more Ulan five h~ardous ~mp~on{~ ate pre30~;l above these
~-~oul0 Do Ii,led. (Re~ Eot c~mDone~ls ~ ~ou~h 5 in 231. 235. 23~. a~ 243.)
r~azl 355, 0¢ 'NO' ,i){ ~S nOt. (}'(~pO~ lo( Com, pu~en{s 2 IhrCug~ 5 ~n 232. 236. 240, and ' : ~
22S. H.,xZ,xKOOUS CCMPOP4ENTS 1.5 CAS · L,sf Eno Cr.~,m~i Abstract So,iCe (CAS) ~umbe;s os .~:.~[0o ~o ~ho na~azdou~ ~m~non(~ in ~ho m/xlure. (Re,oat fnr 2.5)
,.7., I
06/12/01 1.6:03 8661 326 0576 BFD HAZ MAT DIV [~009
ness Owner/Operator iden iation ,..
.~r electronic suOm~ss~O~ Jnd Jr~ (~ ~me 3s '~e numOenng uS~ ~n 27 CCR, Ao~endix. C, ~e Bus,ness S~tion of ~e Un~fi~ P~r3m
: ~AC:L, T'¢ 10 NbN~ - Th~s r. umger ~S ~SSfg~ oy ~he CUPA C( .~. Th~S ~S The u~tque numoef w~s~ ;d~tifies ./our t3c~hr/
~9 s. ENOiNO 0ATP - E~ef l~e ending y~ an~ date of me r~n. (Y~MMOD)
~02. 8USiblESS PHONE - Enl~ ~e ~ne number, 3r~ ~e 6mt, and any ~ten~on.
!03. 6~SINESS SITE ADDRESS. Enter the s~eet addre~ ~ere ~e Acili~ is Io~(~. No ~st office ~x nwmbem are allowS. ~is [nfo~afion
must 0rovide a means ~0 9~hi~tly ~o~te ~e ~ciii~t.
:O~. Ct~ - Enler ~e ci~ or un~n~ area ,n .~ 0usin~ sffe is
;05. ZfP COdE. Enl~ ~he zip c~e et gusJne~ mia. ~e extra 4 digR zip may al~ be add~.
:0e. CL'~: & S~ADSTREET · Enler ~J~e Oun& ~rads~r n~Der ~o~ ~.e [a~li~. The Oun& BmdsJreel numbe~ may be ob/aln~ ~y
[6 ~.3; 582-7748 or by Internal.
~ 07. SiC COdE - ~nter ~e pnma~/Sla~dard Industrial CJa~ifi~don C~e number for ~ma~ bu~n~ ac~. NOTE: If c~e ~s mere
~0~. CCUN~ - Enler ~e ~un~ in ~i~ ~e busine~ site is Io~t~.
109. BUSINESS OPE~TOR ~ME - E~er ~e ~me et ~e busin~ operator.
110. BUSINESS OPE~TOR PHONE - Eni~ ~n~ ~tor ~ne num~. if di~l ~m busln~ ~e. area ~e ~mL e~ any ~en~on.
11 ~. O~ER ~E - Enl~ ~me of ~sin~ ~ff, ~ different ~m b~in~ ~tor,
~ ~2. O~ER PNONE. Enter ~ busine~ ~s ~ne number if different ~m bus[n~ p~, ar~ ~e flint, arid any
t ~3. O¥~ER M~.ILiHG ADORES5 - ~nie~ ~e ~s mailing adders if different ~m busin~ si[e addr~.
: ~4. O¥~ER CI~. Enler ~e r~me of ~e ci~ ~ ~e ~e(s maili~ addre~.
~ ;5. OWNER STATE - Enler ~e 2 ~amcter s~ie abbra~on ~or ~e o~s ma~l~ addr~.
~ ~. OV,~EA Z;P CO~E - Enrac ~e zip ~de for me o'~er~ addr~. ~e ex~ 4 dJgff ~p may al~ be add~.
~; 7. ENVIRONMENTAL CONTACT NAM~ - Enter ~e name of ~e ~r~n, if dih~rent from ~e ~usin~s ~er or Opera,or, 'M~ r~eives
~ 18. CONTACT PHONE - Enter ~e p~ne numbs, if differenl ~m ~er or Operator, at ~ich ~e en~mnm~J ~nmct ~n be ~d~. ' ar~
119. COPITACT ~JLING ADORE~ - En~er ~e mailic~ addr~ ~ere all en~nmenml ~n~c~ ~~e~ ~hould be senL ~ d~ff~ent site addr~.
, '~!, STATE - Enter ~e 2 ~amcler s~te ab~e~a~ ~ ~e en~r~men~l ~n~ct~ mai~ addr~.
123. PRlk,~RY EMERGENCY CO~ACT ~E - Emir ~e ~me of a mpr~e ~t ~n ~ ~n~ct~ ~ ~se o[ an eme~e~ in~M~
~a~dous real,als a~ ~e b~in~ ~te. ~e ~n~ct shall have FULL ~dll~/a~, site ~miliad~, a~ au~ to make d~isic~
for ~e bus~n~ r~ardi~ ;nddec~
124. TITLE · Ent~ ~e ~e of ~e pdma~ emergenw
125. 8US!NESS PHONE - Enter ~e business num~ ~ ~e p,dma~ emergen~ aon~ct, a[~ ~e ~mt, a~ any exte~c, ns.
l~e. 24-~CU~ PHONE - Enler a 2~our p~ne numb~ for ~e pdma~ em~en~ ~cmcL ~e 2~ p~ numar must be ~ ~flJ~
a~ 24 houm a day. ff R is ~l ~e ~n~s ~me p~ num~, ~ ~e ~ a~H~ ~e p~ns m~t ~ nble
;27. PAGER NUMBER - Enter E;e pager ~mber ~ De ~me~ ~ergen~, ~n~
128. EECONDAR"f' ~{ERGENCY CO~ACT ~ME - Eh:er ~e ~me o~ a s~8~ r~r~i~ve ~at ~n ~ ~n~ct~ in Lhe ~ent ~at ~e pHmar~
~me~gen~ ~n~ is r~[ availab{~. ~e ~lact shall have FULL ~dt{~ ~, site ~miitad~, a~ a~fi~ {o make d~ons ~
(~arding it~den( mi~ga6on.
~ ~9. 'FrFLE - En~e~ ~e ~[J8 of ~e se~nda~ emetic/~nmcL
130 5USiNES5 PHONE - E~ter ~e bus;ne~ (daphne numar fo( ~e s~a~ eme~enw ~, area ~e first, a~ any extension.
~ 3;. 2~-HOUR PHO~4E - Enter a 24-hour phone num~ For ~e se~nde~ emerge~ ~n~cL The 24 ~ur ~ne number must be one ~ich
~nswer~ 24 houm a day. it ~t is nm ~he ~n~'s home ph~e numbs, ~ ~e sew[~ e~edng ~e p~o~ taus: ~ abte to
~ 2Z. PA?.~ NUNI~EF~ - Enle~ ~e pager number ~r ~e se~nda~ emergen~ ~n~ct, ~f a~ilabJe.
33. A~DiTIONAL LO~LLY COLLECTEd INFOR~TION - This space may be used ~or CUPAs or ~ to ~llect any addilion~l ]nformafar;
n~ssa~ ~o mee~ ~e r~uiremenJs ol 9:e~r i~dual pr~rams. Consol ~r Io~1 age~ [or guldan~.
36. ~,ME O¢ SIGNER - En~r ~e fut~ pdmed name at the pecan signing ~o page. The sig;~cr ce~fi~ ~ a ~amillari~ wi~h ~e
submitl~ a~ eat based on ,~o signe[~ inqu(~ Oi ~tcse individuals rospcnsiaJe for ob~ini~ ~e inlo~ation, ail ~e info.aLan
submi:t~ is hue, a~rate and ~mpiele.
StG,NATUR5 OF OWNE~' OPE~ FOR OR DESIGNATED REPRESENTATIVE - Tho Business ~'nerlOperalor, o¢ o/ficiat[y designated
reprosen~ve of lbo ~ner/Op~tor. st, 'q sign in ~e s~ace p¢o~td~, This sfgnature ~fi~ ~at ~e signor is Wmiltar ~lh
,n~ondal;on submRt~ a2d ~at based on Ihe sigr¢)r~ inqul~ o~ ~ose i~l~duals ¢os~nsJbfe eot Ob~/ni,~ ~e %~ormadoc it ;s
s,gner=3 belial 3~a( 5no 3~bm!t~ ;r,~m~a¢on is. ~do, a~fate and ~mplole.
37 r~T LE OF SIGHER - Enter ~e UUo el tho pemon s~ning ~e page.