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Home My WebLink AboutBUSINESS PLAN HMMP PLAOi MAP SITE .DIAGRAM FACILITY DIAGRA-I~I~ [22] Bbs~ness Name: , , ,. Arsa HMMP PLA~ MAP SITE DIAGRAM FACILITY DIAGRAM NorTh Name of Area: Page: 1 Account Billing/Collection Activity Inquiry SUTL108 Acct : 474101 Cyc St: CL Bill'$t: FB Cyc: 5 Rt: Seq: SSN : Parcel: .... Svc Cls :e Name : LOONEY BALLOONEY Svc Add: 117 CHESTER AVE Amt due: 17.65 Current Period Postings Lst Pmt: -123.00 Type Desc Date Amount Receipt # Pmt Dte: 04/06/94 -- Prior Bills -- Date Balance 01/01/95 0.34 11/28/94 17.31 01/01/94 0.00 01/01/93 0.00 01/01/92 0.00 01/01/91 0.00 02/15/90 0.00 Enter '/' For Bill History,'P' To Print Report, '/C' For Credit and Deposit History or 'XX' To Exit ....... ~ CITY OF t~AKIERSFIELD P.O. BOX 2057 BAKERSFIELD, CALIFORNIA 93303-2057 ADDRESS ~ORRE(TION REQUESTED .. . R~TURN T~ ~NQE~ R~TU~I T~ ~RNO~{R iii.dh .dh lhdh.lh.lh.ll...lllh.lh.lh,d . '' ' :'~. ~ :. ~ .... ~~- ~.:~ ~: . - - .117 C~'ESTE-R 'A.V . . :.'t,:~. BAKERSFIE~D~ 'CA 93301 ,,,,. ii,1,;'-,;i'l.,'B:,ii.,,,,;,il ;I,l;~l;,ill',,',l,h,,,lllh,ll,;i,t I -~%~RETURN PAYMENTS TO: : PLEASE MAKE CHECKS PAYABLE TO: CITY OF BAKERSFIELD H.~,~Z,.Aj~OU~ MATE,~.;j, AL~.~,j)ij, V,j.,~jOj~. , . P.O, BOX 2057 ' ' " ~ CITY OF BAKERSFIELD BAKERSFIELD CA 93303-2057 ~CCOUNT NO.-t~'ff ~'~[~ '"" :,'~a'~'ardous Hateria. ts .Harn~'t(~g Fees~. .... "' '"'.:., ' . ',:V,~.."~.~(:.b~;xr-.~, -,-' ,: ~'. C?;. S"";:-;;C~.' ' ' :; .'."'. '. ..... . ~ u.....~-:-~' u. :;=,~- ~:: HM474101. Account Number ACCOUNTS RECEIVABLE ADJUSTMENT January 24, 1995 Date New Account New Address Esther Duran Close Account From Service Chan.qe Other Adjustments X Fire Department. Hazardous Material8 Division Department/Division LOONEY BALLOONEY Billing Name 117 CHESTER AVE Billing Address Site Address Parcel # (if Applicable) Landlord Name & Address (If Applicable) ADJUSTMENT Last Billed Correct Billing Adjustment to Effective Date of Billing Change <17.65> 1-11-95 Approved By~ Remarks: THIS BUSINESS CLOSED SOMETIME LAST YEAR. WE ARE GOING TO WRITE OFF THE FINANCE CHARGES ON THIS ACCOUNT. ~ ~ ~[l~kersfield Fire Dept. HAZARDOUS MATE. LS INSPECTION ? Hdl~dous Materials DivisiorP' Date Completed / Location: ,,'-) CH~'(-~ /3,-O~. Business ldentification No. 215-000 C~(.PI:~-/ (Toper Business Plan) Station No. ~ Shift ~ Inspector Dopaduro limo: ~ Inspo~on lime: ~ ~ ~doquato Inadoquato ~ / G Vorifica~on of Invonto~atorials ~ ~:~'~: ~Segregafion of Mat~ ~ Veri, ~z Mat Training Coming: ~Common~: Emergency procedures~ Commen~: Containers P~ Labeled Vorific~Facili~ Diagram 8pool ~s Facili¥ / All Items O.K D Business Owner/Manager PRINT NAME SIGNATURE Correction Needed I"1 White-Haz Mat Div Yellow-Stal~on Copy Pink-Business Copy ~, :,: . .~ HAZARDOUS MATERIALS. INVENTORY .,~.:~ :,.~.:. :~ ,.: :~,:~;:~:: ;~.. .... . :,; ~. :'... i. ' ~l .!.'~: '::/. ,.' ~."'},? :, :.':si.H~i':/:',;~Fi' . · ',.:' ':/? , Page o£ Faro and. Ag=loulture ~' Standard Busi,ess : . ." ; ', ',' · ',' :; ,.: ~;,: ' '.' :; :¢,,: ', ¢~:~;}'f~]..,{- · :4 F. ;'/: '- / ' , NON - ~E SEC~T . .':. ..'-... :~'::-.,~ .... - .,-: . -- ......... CITY ,ZIP: , /(/~ , ~ ~'~& ~ ~ CITY, ZIP. J~ ~ % ~ U~ . ,,~ ......... ~ , : , _ ~s ~e ~ ~ve~age ~nual Neas~e I Da~ / Cont ' Cont ' Cont ' Use ~at~on ~e~ :: . ~,}:?~:~:~:~, t ~ . N~s of C~e ~t ~ ~t Units on Site ~ P~eaa ~ Code S~d ~n~~ ~ '~/:~?~/ ~ '~ Bee Ph~=al and ~l~h ~'za~ C.A.S. N~r '.' I 1 N of Pr~su~ : ~,~lth H~lth ' ~]{;::, · Co~onent t 3 N~ &' C.~;SJ N~ y~ ~, ~.~ t I I I I ,I I .I I I I ".'.., ....... · Ph~tcal and R~lth ~za~ C.A.S. N~er '. Co~onen~ ~ I N~ :& C.A.S. ~ ' "%& 4',:, ~ ~. ~ ' · (Check 'all 't~ apply) ~ :. ' ' .. of P~eaaure '. ~h ~h ~ Co~on~ ~ 3 '~ '~C.A.a. ~ ' "' . :..,~.~'.-., ...; .:,r.:~;..~' ': . '/ . · ph~tcal' and R~l~h ~ C.A.S. N~er · ;/, · Co~onent ~ i N~ &'C.A.S.. N~~ , ' · :,::''' :9 ~ ,~ 5-':' ,v (Che=k all t~t apply) '~'~ .. Co~onent ~ 2 N~ & C.A~S. N~ , i . ~ ~i~ ~,,~ ~ s,~., ~.... ~ ~.~i~i~ ~ ~i,~. ~ ,.~,~ ': Ph~tcal"and R~l~h ~za~ C.A.S. N~ . Co~onent ~ 1 N~ & C.A.S. N~ " .7., .:~r ~', of Pressu~ H~lth H~lth ~ , Co~onen~ ~ 3 N~"& C~A.S. N~ .. E~RGENOY CONTACTS Jl LC ( ~ ~ ~'~y~Y~ J2 - -- : Title ~4 ~ Phone N~ ~ Title < ,.. 24 ~. Phone N~e.. '.,., r:::,.'::: · , c=ificatt~ (~D ~ SIGN AFTER COMPLETING ~L SECTIONS) . . . ,~.~ ~ " . *~. ~ ..~:. :.: LOONEY BALLOONEY 215-000-001377 Page 1 02/27/92 Overall Site with 1 Fac. Unit General Information Location: 117 CHESTER AV . Map: 103 Hazard: Minimal Community: BAKERSFIELD STATION 06 Grid: 31C F/U: 1 AOV: 0.0 LiContact Name Title Business Phone 24-Hour Phone ILZER IOWNER 1(805) 322-5559 x (805) 872-4942, N (805) 327-2722 x (805)~' Administrative Data Mail Addrs: 117 CHESTER AV D&B Number: City: BAKERSFIELD State: CA Zip: 93301- Comm Code: 215-006 BAKERSFIELD STATION 06 SIC Code: 5947 Owner: CHERYL HILZER Phone: (~9~f)~?~-- ~F~ Address: 15125 SAN DOMINGO PL State: CA City: BAKERSFIELD Zip: 93306- Summary 02/27/92 LOONEY BALLOONEY 215-000-001377 Page 2 02 - Fixed Containers on Site Hazmat Inventory Detail in Reference Number Order 02-001 HELIUM Gas 864 Minimal · Fire, Pressure, Immed Hith, Delay Hlth FT3 CAS #: Trade Secret: No Form: Gas Type: Pure Days: 365 Use: OTHER Daily Max FT3I Daily Average FT3 ] Annual Amount FT3 864 ~ 576.00 30,000.00 Storage~~Press T Temp Location METAL CONTAINR-NONDRUMIAmbientlAmbientlSHED BEHIND STORE -- Conc Components MCP ~List 100.0% IHelium IMinimal I 02/27/92 LOONEY BALLOONEY 215-000-001377 Page 3 00 - Overall~Site <D> Notif./Evacuation/Medical <1> Agency Notification CALL 911 <2> Employee Notif./Evacuation VERBAL NOTIFICATION - EVACUATE BUILDING <3> Public Notif./Evacuation <4> Emergency M~'dical Plan ...... CALL 911 - NO PLAN' 02/27/92 LOONEY BALLOONEY 215-000-001377 Page 4 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention GAS BOTTLE MANIFOLD SYSTEM AND PROPERLY CHAINED <2> Release Containment <3> Clean Up <4> Other Resource Activation 02/27/92 LOONEY BALLOONEY 215-000-001377 ~ Page 5 00 - Overall Site <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - NONE B) ELECTRICAL - BACK WALL OUTSIDE OF BUILDING C) WATER - FRONT CURB D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS FIRE HYDRANT - CORNER OF LST STREET AND CHESTER AVENUE <4> Building Occupancy Level 02/27/92 LOONEY BALLOONEY 215-000-001377 Page 6 00 - Overall Site <G> Training <1> Page 1 WE HAVE 2 EMPLOYEES AT THIS FACILITY WE DO NOT HAVE MSDS SHEETS ON FILE AT THIS TIME (6-23-89) HANDS ON TRAINING ON USE AND TRANSPORTING HELIUM BOTTLES. <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use BAK~iSI~IELD CITY FIRE DE~RTMENT - ~ 2130 'G' STREET BAKERSFIELD, CA. 93301 RECEIVED · (805) 326-3979 APR $1989 OFFICIAL USE ONLY ~ ~~'~--~ ...... ' ...... BUSINESS NAME HAZARDOUS MATERIALS ~¢~C~ / BUSINESS PLAN AS A WHOLE ~ FORM 2A INSTRUCTIONS; 1. To avoid fur~he~ ac~on, ~e~u~n [h~s from w~h~n 30 days of ~ece~p~. 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer ~he ques[~ons below for =he bus,ness as a who~e. 4. Be as brief and concise as possible. SECTION 1: BUSINESS IDENTIFICATION DATA A. BUSINESS NAHE: ~k~ ~ B. LOCATION / STREET ADDRESS: CITY:. ~,~-~ Z[P:~ BUS. PHONE: (~0~) SECT[QN 2: EHERGENCY NOT[F[CAT[ONS In case of an emergency ~nvo]v~ng [he release or ~hrea~ened re]ease a hazardous ma~er~a], cai] 911 and 1-800-852-7550 or 1-916-427-4341. Th~s w~]] no~fy your local f~re depar%men[ and [he S%a~e Off~ce of Emergency Services as required by law. ENPLOYEES TO NOTZFY [N CASE OF ENERGENCY: NAHE AND TITLE DURING BUS. HRS. AFTER BUS. HRS. B SECT[ON 3; ~O~ATZ~N ~F UTZLZTY SHUT-OFFS FOR BUSZNESS AS A WHOLE A. NATURAL GAS/PROPANE: D. SPEC[AL: E. LOCK BOX: YES / ~_[F YES, LOCATION' IF YES, DOES IT CONTAIN SITE PLANS? YES / NO NSDSS? YES / NO FLOR PLANS? YES / NO KEYS? YES / NO SECTION 4: PRIVATE RESPONSE TEAM FOR BUS~NESS A~ A WHOI, E SECTION 5: LOCAL EMERGENCY MEDICAl, ASSISTANCE FOR YOUR BUSINESS AS A WHQL~ qll SECTION 6: EMPLOYEE TRAINING EMPLOYERS ARE REQUIRED TO HAVE A TRAINING PROGRAM WHICH PROVIDES EHPLOYEES WITH INITIAL AND REFRESHER TRAINING IN THE SAFE HANDLING OF HAZARDOUS MATERIALS, A, NUMBER OF EMPLOYEES AT THIS FACILITY B. -DO YOU HAVE MSDS (MATERIAL SAFETY DATA SHEETS) FOR EACH HAZARDOUS MATERIAL YOU HANDLE ~ ~'-' C. GIVE A BRIEF SUMMARY OF YOUR HAZARDOUS MATERIALS TRAINING PROGRAM: SECTION 7; EXEMPTION REQUEST I CERTIFY UNDER PENALTY OF PERJURY THAT HY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREHENTS OF CHAPTER 6.95 OF THE CALIFORNIA HEALTH AND SAFETY CODE FOR THE FOLLOWING. REASONS: WE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS HATERIALS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 8: CERTIFICATION I, ~~' ~/'/h~j~/ , 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 (805) 326-3979 " OFFICIAL USE ONLY ~ I1 BUS~NESS N,~iVlE ~ D ~ ~ ,~,., HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 3A ~NSTRUCT[ON~ 1. To avoid further action, th~s form must be returned by: 2. TYPE/PRINT YOUR ANSWERS IN ENGLISH. 3. Answer the ~uest~ons belo~ for THE FACILITY UNIT LISTED BELO~ 4. Be as BRIEF and CONCISE as possible FACILITY UNIT ~ / FACILITY UNIT NANE: ~K~ ~[~v SECT[ON 1: HIT[GAT[ON, PREVENTION, ABATENENT PROCEDURES SECTION 2: NOTIFICATION 'AND EVACUATION PROCEDURES AT THE UNIT ONLY SECTION 3' HAZARDOUS MATERIALS FOR THIS UNIT ONLY A. Does this Facility Unit contain Hazardous Materials? ...... Y~E~ NO If Yes, see B. If NO, continue with SECTION 4 B. Are any of the hazardous materials a bona fide Trade Secret? YES NO Zf NO, complete a separate Hazardous materials inventory form marked- NON-TRADE SECRETS ONLY (white form #4A-1) If YES, complete a hazardous materials inventory form marked: TRADE SECRETS ONLY (Yellow form ¢4a-2) in addition to the non-trade. secret form. List only the trade secrets on form 4A-2. SECTION 4: PRIVATE FIRE PROTECTION SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPOND~R~ {Fire Hydrant} SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT TH[~ UNiT ONLY, A. NATURAL GAS/PROPANE: B. ELECTRICAL: C. WATER: D, SPECIAL: E. LOCK BOX: YES / NO IF YES, LOCATION: IF YES, SITE PLANS? YES / NO MSDSs? YES / NO FLOOR PLANS? YES / NO KEYS? YES /' NO - 3B - CITY of BAKERSFIELD N O N -- '17 R A D E S E C R E T S ' %qe .... of CITY, ZIP: 13~Lt3 ~}~l CITY, ZIP: DUN AND BRADSTREET NUMB~ ' ~ PHONE ~: ~g ~ ~ ~ PHONE ~: - - ~ ~ X~U~XO~ ~ ~0~ COD~ ~ ~ 3 4 S ~ 1 I t 10 II 1~ 13 14 Irens Ty~ ~x A~l~ ~1 ~SU~ I ~ C~t ~t ~t b L~tt~ ~ T ~ i ~ llxtn/~tl C~e C~e Mt Mt Est Un*ts m Site I~ ~l I~ ~ -. St~ tn F~Jllty ~ ~ I~t~ti~ Ph~ical/~ HHlth ~ze~ C.A.S. ~ ~t II ~ i C.l.S. ~ ( ~11 t~t ..ly) of Pm~ ~lth ~ 13 ~&C.A.S. ~ ..... L.,I ............ l .............. 1 ...... -___J ..... 1 ...... I--_I__L2,, I ; P~icll ~ blth HIIIN C.A.S. ~ ~t II ~ i C.A.S. ~ (C~k ell t~t apply) - r--~ v-- ~--~ r--~ ~t ~ ~&C.A.S. ~ ~lth of P~ ~lth .... L_I L .......... L. L ..... ! ...... I l;;l I I ......... IC~k ~11 t~t HNIth of Pm~g~ ~lth .......... tZ L , L ......... .... 1 ............................... J I _.! .... I. ! _1 .... t _- (C~ ~11 t~t ~1~) - -- ~--~ -- -- C~t 12 ~C.A.~. ~ HNIth of Pr.sure Health ........... Rii': ................................ ~l'R~'P~i ..... Qi' ' ...... ~T'~' " Certtficati~ (Read and sign after co.pletJng all sections) c~rttfy ~der ~lty of lae t~t I ~ve ~rsmallyexemnff e~ am fmiliar with t~ tnformtim su~tt~ tfl this ~ ell IttK~ ~ts. ~ t~t ~sK m W i~tW of t~e l~tvJ~ls r~sible forgobtaininQ ~ Jflf~tlm, I ~lieve t~t t~ su~JttK Jflfo~ti~ is t~, Accurate, end cmplete. ................... SITE/FACILITY D I AGR~kM FORM NORTH SCALE: BUSINESS NAME: FLOOR: .OF (CHECK ONE) SITE DIAGRAM '~ FACILITY DIAGRAM //7 O~ ~ //,~ e__~t~s~-v-~ . (Inspector's Comments): -OFFICIAL USE ONLY- - 5A - SITE DIAGRAM (Req 1. Address: Identify the 9. Lock (key) Box ~ { principle buildings i , by the Street numbers. 10. MSDS Storage Box ' 2. Street(s), Alleys, 11. Railroad Tracks Driveways, and Parking Areas adjacent to the 12. Fence or Barrier property, Include the a. Wire street names. b. Masonry 3. Storm Drains, Culverts, Yard Drains c. Wood 4. Drainage Canals, Ditches, d. Gates Creeks, 13. Powerlines §. Buildings a. Frame construction 14. Guard Station b. Masonry construction 15. Storage Tanks: Identify the c. Metal construction capacity in gal. a. Above ground d, Access Door b. Underground 6, Utility Con=rolm a. Gas 16. Diking or Berm b. Electricity 17. Evacuation Route c. Water 18. Evacuation Area: Identify the 7. Fire Suppression Systems: location where a. Fire Hydrants' employees will meet. b. Fire Sprinkler 19. Outside Hazardous Connections Waste Storage ' ' c. Fire Standpipe 20. Outside Hazardous Connections Material Storage d. Water Control Valves 21. Outside Hazardous for protection systems Material Use/Handling e. Fire Pump 22. Type of Hazardous Material/Waste Stored 8. Fire Department Access or Used (See Below) TYPE OF HAZAROOUS MATERIAL F = Flammable E - Explosive L = Liquid R = Radiological C = Corrosive 0 - Oxidizer O = Gas P = Poison Water Reactive T = Toxic S = Solid H = Cryogenic D = Masts B o Etiological Example: Flammable Liquid = FL FACILITY DIAGRAM (Required items in addition to the above) 1, Risers for Sprinklers 8. Fire Escapes 2. Partitions 9. Air Conditioning Units 3. Stairways: Indicate the 10. Windows levels served from highest to lowest. 11. Inside Hazardous Waste Storage 4. Escalator: Indicate the levels served from 12. Inside Hazardous highest to lowest. Materials Storage 5. Elevator 13. Inside Hazardous Materials Use/Handling 6. Attic Access 14. Sewer Drain Inlets Bakersfield Fire Dept. Hazardous Materials Division RECEIVED 2130 "G" Street OC[ 1 7 19§9 Bakersfield, CA. 93301 H~,Z. MAT. DIV. HAZARDOUS MATERIALS MANAGEMENT PLAN 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business os o whole. 4. Be brief °nd concise os possible. SECTION l: BUSINESS IDENTIFICATION DATA / MAILING ADDRESS: ~'-¢~"~'~"~ ~ CITY: STATE: ~ ZIP: PHONE: DUN & BRADSTREET NUMBER: SiC CODE' MAILING ADDRESS: o~,¢..4,e~ ~ ,¢,~I~" SECTION 2: EMERGENCY NOTIFICATION: TITLE BUS, PHONE 24 HR, PHONE FD15C¢. Bakersfield Fire Dept. Hazardous Materials Division HAZARDOUS MATERIALS MANAGEMENT PLAN SEcTIOI~ ~3: TRAINING: NUMBER OF EMPLOYESS: 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. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIMEEXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION: I, CERTIFY THAT THE ABOVE INFO R- 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.) ANO THAT INACCURATE INFORMATION CONSTITUTES PERJURY. SIGNA,~UR E (~ TITLE f /DATE FOlEC - Bakersfield Fire Dept~ Hazardous Materials Division HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: A, RELEASE PREVENTION STEPS: B. RELEASE CONTAINMENT AND/OR MINIMIZATION: C. CLEAN-UP PROCEDURES: SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)' ELECTRICAL' WATER: SPECIAL: LOCK BOX: YES/ IF YES, LOCATION' SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A, PRIVATE FIRE PROTECTION: B, WATER AVAILABILITY (FIRE HYDRANT)' L~. Bakersfield Fire Dept. Hazardous Materials Division HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES: A. AGENCY NOTIFICATION PROCEDURES: B, EMPLOYEE NOTIFICATION AND EVACUATION: C, PUBLIC EVACUATION' D, EMERGENCY MEDICAL PLAN CITY of BAKERSFIELD HAZARDOUS MATERIALS INVENTORY Farm and Agriculture D Standard Business~ ~ NON--TRA,DE SECRETS LOCATION; ' ADDRESS; 'ytxY (ls~. ~q~c, ' STANDARD IND. CLASS CODk: CITY. ZIP: ~..A/~2~ ~:. ~'~ol,' CITY. ZIP: ~rs¢,~¢~ ~,~7o~ DUN AND BRADSTREET NUMBER -- ~' ~ ~ -- REFER TO XNSiRUU~ON~'~'U~ H~OHb~ CODES - - ~rans !y,e ,ax Average xnnua, .~' Measure '~e Cont Cont Cont Bs Ha~es of ~Jxture/Components Code coae Amt,.~ ~qt~ Est t?~ Un,ts on Type Press Tem~ Co~e/[~Storea ~nrac~cy See Znstruct~ons p , I u Iw -I C.A.5. ,umb~ Componen~ii Name&C.A.S. Number (Check al/ ChaL apply) Component 12 Name t C.A.S. Number ~ Fire Hazard ~ Reactivity ~ Belayed ~Sudden Release ~ ]mmedi.a~e Heal~h ~ o~ Pressure HealCD Cemponen~ 13 Name t C.A.S. Number Physical IDd Health ~azard C,A.S, Number Component II Name t C,A,S, Number {Check al/ Chat App/H Componen~ 12 Name & C.A.S. Number D Fire Hazard D ReacHvi&y D Delayed D Sudden Release D Immpdi~e Hem(Ch of Pressure Hea~cD Componen~ 13 Name t C.A.S. Number Physical and Health Ualard C,A,S, Number Component Il Name t C,A,S, Number {Check ~1] th~C ~DPIY/ Component Name C,A,S, Number D Fire Hazard D Reactivity ~ Belayed D Sudden Release ~ Immediate Health of Pressure Health Co~ponen: I3 Naee& :.A.S. Nueber Physical add Health Nalard C,A,S, Number Component II Name t C,A,S, Number (Check 411 Chat app]H ... Compoflen~ t2 Name I C.A.S. Number D Fire Hazard D Reactivity D ~layed D Sudan Release D ~alCh of Pressure Compoflen~ 13 Name I C,A,S. Number EMERGENCY 0ONTAOTS "10~~ ~~2.~-~~Mr V,0ne "2~ Name ~ u ii&le T~Cle erti[iatioq ,(Re~d and.~f¢n after compl~ti~g,all sectipna) ~acned.dQcgmenc~, afl~ &~c Daseo on.my Inquiry ~.cnose inDiviDuals responsible Tot oOCaln~fl9 cna IflrorAaclOfl, I believe Cha~ ~he suomlttea intormaclOn.l~true, accurate,, and complex, ~Reme ene oftctai titie of owne~ooer~.or~ ovner/ooerator s authorized representative Signature eH~'I A~ SITE DIAGRAM E~] FACILITY DIAGRAM --~ NorTh Name of Area: