HomeMy WebLinkAboutBUSINESS PLAN -PlERC~ ~d,
(Inspector's Comments): -OFFICIAL USE ONLY-
ITE/FACI LITY GRAM
;~-~- ~'~' FORM 5
NORTH SCALE: BUSINESS NAME: ~o&,,61/~..j ,~-~_p~Z7 ~.~. FLOOR:/ OF /
(CHECK ONE) SITE DIAGR.~ FACILITY DIAGR.~ /
(Inspecto~'s Comments): -OFFICIAL USE ONLY-
- 5A -
BAKERSFIELD CITY FIRE DEPAKTNENT
BAKERSFIELD, CA 93301 -
OFFICIAL USE ONLY
ID#
USINESS NAME
HAZARDOUS MATERI ALS
BUSINESS PLAN AS A WHOLE
FORM 2 A
'/6
INSTRUCT IONS: '
1. To avoid further action, return this form by ~.,~t "
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 IDENTIFICATION DATA
B. LOCATION / STREET ADDRESS: C.~3~--!~"* ~'~/"~'~::~ ~,, '
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving 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 0F E~ERGENCY:
N~E ~ND TITLE DU~ING BUS. HRS. AFTER BU~ HRS.
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT.
B. ELECTRICAL: 22)~;'~"~ _
C. WATER: l~.~/,~/~'
D. SPECIAL:
E. LOCK BOX: YES ~ IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS? YES / NO MSDSS? YES / NO
FLOOR PLANS? YES / NO KEYS? YES / NO
2A -
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE TRAINING
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
,MATERIALS:...- .................................... (~NO ~ NO
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES: .......................... ................. ~ NO ~NO
C. PROPER USE OF SAFETY EQUIPMENT: .................. NO NO
D. EMERGENCY EVACUATION PROCEDURES: ~-~NO NO
E..DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: .......~'"--'~YES N~N~ YES(~
'SECTION 7: HAZARDOUS MATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS OF A
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YES(~
I, f~_/-~. ~~~_,~','~ , certify that the above information is accurate.
I understand'that this inf6rmation 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
BARERSFIELD, CA ~3301
OFFICIAL USE ONLY
ID#
BUSINESS NAME:
BUSI NESS PLAN
SINGLE FACILITY UNIT
FORM SA
INSTRUCTIONS 1. TO avoid further action, this form must be returned by:
2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
.3. Answer the questions below for THE FACILITY UNIT LISTED BELOW
4. Be as BRIEF and CONCISE as .possible.
FACILITY UNIT# FACILITY UNIT NAME:
SECTION 1: MITIGATION, PREVENTION, ABATEMEN'r PROCEDbqlES.
SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THIS UNIT ONLY
- SA -
SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY
A. Does this Facility Unit contain Hazardous Materials? ...... YES NO
If YES, see B.
.. If NO, continue with SECTION 4.
B.. my of the hazardous materials a bona fide Trade Secret NO
If No ,mplete a separate hazardous materials inventory
form : NON-TRADE SECRETS ONLY (white form #4A-l)
If Yes, com [ete a hazardous materials inventory form
TRADE NLY (yellmq form ~4A-2) in addition t, non-trade
secret form. t only the trade secrets on form 4
SECTION 4: PRIVATE FIRE 'ECTION
SECTION 5: LOCATION OF WATER SUPPLY FOR RESPONDERS
SECTION 6: LOCATION OF UTILITY SHUT-( AT THIS b._~NJT ONLY.
A. NAT. ¢AS/PROPAN~'~
B. ELECTRICAL:
C. WATER:
D. SP~:
E. LOCK BOX: YES / NO IF YES, LOCATION:
IF VES, SITE PLANS? YES / NO MSDSs? YES / NO
FLOOR PLANS? YES / NO KEYS? YES / NO
- 3B -
BAKERSFIELD CITY FIRE DEPARTMENT
I.D. t~ FORM 4A-1 Page .. oft._
NON--TRADE SECRETS
HAZARDOUS MATERI ALS INVENTORY
BUSINESS NAME: OWNER NAME: /'~d'~ ,,~ FACILITY uNIT
ADDRESS:~ ~_ ~_ ~Z:.~..: ADDRESS: '- ' FACILITY UNIT NAME:
PHONE ~: ~ PHONE *: ~/~9~7~~/ [OFFICIALONLY USE CFIRS COD'E
1 2 3 4 5 6 7 8 9 10
TYPE ~AX ANNUAL CONT USE LOCATION IN THIS % BY HAZARD D.O.
CODE A~OUNT A~OUNT UNIT CODE CODE FACILITY UNIT WT. CHEMICAL OR CO~ON NAME CODE GUI[
//CF
NAME TITLE: ~~~ SIONATU~: ~ DATE:~--~
EMERGENCY -- TITLE:~ ~HONE ~ BUS~OURS:~~
AFTER BUS HRS: ~
PRINCIPAL BUSINESS ACTIVITY:~ ~ ~ ~ ~ AFTER BUS HRS: