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Home My WebLink AboutBUSINESS PLAN CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 . 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 as brief and concise as possible. SECTION 1- BUSINESS IDENTIFICATION DATA BUSINESS NAME: LOCATION: ~-~0 c~Y: ~ DUN & BRADSTREET NUMBER~ SIC CODE:__ OWNER: BI/L6 ~tvC_-tg MAII.ING ADDRESS: . ! ~0 ~ 0~oJV,, ~T- ~C. O~ q~.,~ > SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 ~ PHONE ~- ' HAZARD-OUS MA-TE~S MANAGEMENT PLAN~ SECTION 3: TRAININO NUMBER OF EMPLOYEES: ~ MATE~ SAFETY DATA SHI:~I~.TS ON FILE: BRrI=F S~Y OF TRAINING PROGRAM: SECTION 4: EXEMPTION REQUEST I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXF. MPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH & SAFETY CODE" FOR THE FOLLOWING REASONS: WE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5: CEKTIFICATION I, '~[e2,~ A ~ .,0,- ~ C.~ ~ CERTIFY THAT THE ABOVE INFORMATION 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 CHAPTEK 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. SIGNATURE TITLE DATE 2 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 HAZARDOUS MATERIALS INVENTORY FACILITY DESCRIPTION CHECK IF BUSINESS IS A FARM [ ] BUSINESS NAME FACILITY NAME CITY ~' NA~ OF BUS.SS SIC CODE DUN & BRAE)STREET NUMBER OWNER/OPERATOR q~_ ~0, 5 ~n c,,,~ PHONE MAILING ADDRESS ~o~0 1 {)dw~x ST' CITY ~(~, STATE ~t/~ ZIP EMERGENCY CONTACTS BUSINESS PHONE /~c~e{t~9 24 HOUR PHONE BUSINESS PHONE ,pen,/t~ 24 HOUR PHONE 1 Page of ~C~ DES~O~ 1) ~ORY STA~S: N~ [~A~on [ ] Rcmm~ [ ] ~le~ [ ] C~ ffc~ is a NON T~ S~ [ ] T~ ~ [ ] 2) Comon Nme: ~ [ ~5c,[ 3) ~T ~ (opfi~) ChrONic: ~[ ] C~ 4) Ph~i~ ~ H~ P~SIC~ ~Camg~ F~[~R~ve[~~Rel~of~[ ] lmm~H~(Acum)[~hy~H~(C~c)[ ] 5) WAS~ C~S~CA~ON (3~t ~ ~o~ D~ F~ 8022) USE CODE 6) P~SIC~STA~ So~d[ I Liq~d[~ ~[ ] ~[ ] ~e[ ] W~[ ] ~ve[ ] 7) ~O~ ~ ~ AT FAC~ ~ OF ~~ 8) STOOGE COD~ ~D~y~omt IB~, L~[ ]~[ff]~[ ] a)Con~ Av~e D~y ~o~t IO~ C~ [ ] b) ~: ~ Da~ on Si~ C~le ~ M~: ~ Y~, I, F, ~ & ~ ~, ~, & S, O, N, D 9) ~: Lira CO~~ C~ % ~ · e ~ mo~ ~ 1) [ ] ch~ ~m or 2) " [ ] my ~ ~mm 3) [ ] 10~A~ON 1)~ORYSTA~S:~[ ]A~fion[ ]Re~[ ]~lefi~[ ] Ch~ch~isaNONT~~[ ]T~~[ ] Ch~N~e: ~[ ] C~i 4) ~i~ & H~ P~SIC~ ~ Camgm~ F~ [~ R~five [ ] S.~ Rel~ of ~ [~ tmm~ H~ (A~m) [~h~ H~ (C~e) [ ] 5) W~ C~S~CA~ON (3~t ~ ~ D~ F~ 8022) USE CODE 7) ~O~ ~ ~ AT FAC~ ~ OF ~~ 8) STOOGE CODES Av~e D~y ~omt ~ C~ [ ] b) ~: ~ ~o~t ~ c) T~~ t Days ~ Site C~le ~ M~: ~ Y~, J, F, ~ ~ ~ ~, J, ~ S, O, N, D 9) ~: Li~ CO~~ C~t % ~ · e ~ mo~ ~ I) [ ] ih~ wm~n~ or 2) [ ] my ~ wm~ ~) [ ]. 10)L~A~ON I ~ m~ ~ of ~w~ ~ I ~ve ~y ~ md ~ f~ ~ ~e ~fion ~ ~ ~d ~ ~ ~~. I ~eve ~e ~ ~o~ is ~, ~ ~d ~ple~. P~ N~e & Title of Au~o~ Comfy R~m~ve Si~e Page of Business Name Address CHEMICAL DESCRIPTION 1 ) INVENTORY STATUS: New ~Add/tion [ ] Rev/s/on [ ] Deletion [ ] Check/fchemical is a NON Trade Secret { ] Tr~d~ Secret [ 2) Common Name:0_ oot, r 3)DOT # (opUo ) Chemical Name: AHM [ ] CAS # 4 )'Physical & Health PHYSICAL HEALTH Hazard Categories Fh'e~'--~]React/ve[L].$~_d_,mReleaseofPressure[ ~ImrnediateHealth(Acute)[ ]DelayedHealth(Chrotfic){ 5) WASTE CLASSIFICATION (3-d/git code fi'om DHS Form 8022) USE CODE ~) ?h'YStCAL STATE SoUd [ ] Liquid [,~C, as { ] i'm £ ] Mixture [ ] Waste [ ] RadioaCtive [ ] 7) AMOUNT AND TIME AT FACILITY ~ OF MEAS~ 8) STORAGE CODES Maximum Daffy Amount l0 lC Lbs { ] C..ti [~ ~ [ ] a) Contains. Average Daily Amount tc~ It' Cur/es [ ] b) Pressure: Annual Amount o~ c) Tem.nemture Largest Siz~ Contain= / # Days on Site Circle Which Months: All Year, $, F, M, A, M, I, $, A, S, O, N, D 9) MIXTURE: List COMPONEKF CAS# % WT AHM the three most ha-*rdous l) [ ] chemical compon~,,ts or 2) : any AHM componmts ~) [ ] 10)LOCATION 1) INVENTORY STATUS: New [ ]Addition[ ]Revision[ ]Deletion[ ] ChcckifchemicalisaNONTradcSccret[ ]TradeSecret[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AI-IM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire[ ]Reactive[ ]$uddenReleaseofPresstu~[ ] rmmediateHealth(Acute)[ ]DclayedHealth(Chronic)[ ] s) WASTE cnAssnuc^uoN O-aisit code from Dm ~orm S022) USS CODS 6) PHYSICAL STATE Solidi ] Liquid[ ] Gas[ ] Pure[ ] Mixture[ ] Waste[ ] Puidi~ve[ ] 7) AMOUNT AND ~ AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] fl3 [ ] a) Containex:. Average Daffy Amount Curies [ ] b) Pressure: Annual AmOunt c) Temperature Largest Size Container # Days on Site Circle Which Months: All Year, .r, F, M, A, M, 1, $, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS# % WT AHM the three most hazardous 1) [ ] chemical components or 2) [ ] any AHM components 3) [ ] ! 0)LOCATION certify under penalty of law, that I have personally examined and am lhngliar with thc inlbrnmtion on this and all attached ~ts. I bclicvc the submitted information is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Da~ OUS MATERIALS I~NVENTOI Page of ,,, Business Name .... Add~ CII~M~CAL DESCRIPTION 1 ) INVENTORY STATUS: New [ ] Add/t/on [ ] Revision [ ] Deletion [ ] Check/fchemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: i 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4 ) Physical & Health PHYSICAL HEALTH H~o. rd Categories Fire [ ] Rea~ive [ ] S~_-t_d~ Release of Pressure [ ] Tmr.~!,t~_ Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE Ct. ASS~CATION (3-d/git oode a~.n Dm Form S022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Cas[ ] Pure[ ] Mixture[ ] Waste[ ] Radioactive[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES · Yaxim.m Daily Amount Lbs [ ] C-al [ ] ~ [ ] a) Contains. : ' Average Daily Amount Cur/es [ ] b) Pressure: Annual Amount ¢) Temperature Largest Size Contains' # Days on Site Cimla Which Month~: All Year, $, F, M. A. M, l, $, A, S. O, N, D 9) MIXTURE: List COlVlPO~ CAS# % WT AHM the three most hazardous 1) [ ] chemical components or 2) : [ ] any AHM components 3) [ ] 10)LOCATION I)INVENTORYSTATUS:New[ ]Addition[ ]Revision[ ]Deletion[ ] Check/fchemicalisaNONTradeSectet[ ]Tradesoctet[ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire[ ]Rea~/ve[ ]$.~,-~ReleaseofPressure[ ] Immed/ateHealth(Acute)[ ]DehyedHealth(Chwni¢)[ ] 5) WASTE Ct. ASSn.'tC^TIO~q (3-d/Sit oo~ from OHS Form S022) USE CODE 5) PHYSICAL STATE Solidi ] Liquid[ ] Gas[ ] Pure[ ] Mixture[ ] Waste[ ] Red/oaative[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MFASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] fl3 [ ] a) Container:. Average Daily Amount Cur/es [ ] b) Pressure: Annual Amount c) Temperature Largest Size Container # Days on Site Cix~le Which Months: All Year, $, F, M, A, M, $, I, A, S, O, N, D 9) MIXTURE: List COMPO~ CAS# % WT AHM the three most hazardous 1) [ ] chemical componen~ or 2) [ ] any AHM componems 3) [ ] lO)LOCATION / c. ert/~ under penalty of law, that I have personally examined and am l~mi!iar with th~/nforlnation on th/s und all a~ t~~. I believe the subm/tted information is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION. PREVENTION AND ABATEMENT PLAN A. RELEASE PREVENTION STEPS: B. RELEASE CONTAINMENT AND/OR MINIMIZATION: C. CL~-AN-UP PROCEDURES: SECTION 8: ~~ $~=O~S ~OCA~ON OF S~-O~S AT YO~ FAC~ NATURAL GAS/PROPANE: ELECTRICAL: ~ ~ ~ ~-~o~ ~ ~4o~c ~q,L~. ~xk'x {I SPEC~: LOCK BOX: ~S~ · ~S, LOCA~ON: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: B. WATER AVAILABILITY (FIRE HYDRANT): 4 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCED(.rRE$ A. AGENCY NOTIFICATION PROCEDURES: B. EMPLOYi~.I~. NoTIFIcATION AND EVACUATION: C. PUBLIC EVACUATION: D. EMERGENCY MEDICAL PLAN: