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SiT EDIAGRAM FACIL! TY DIAGRAM
Ncr-~h Name of Ar-_m:
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"CITY OF BAKERSFIELD.,
I' ."'STATEMENT ,~E ~CcOuNT
P.O. BOX 2057 ' 'l'" ' '
'"-BAKERSFIELD CA 93303;2057 l'"" ACCOUN~ NO. ~6~ ['~0[ , ,
. CITY OF BAKERSFIELD
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GITY OF BAKERSFIELD'. ,:- ''-,' .~ !~',STATEMENTOFACCOUNT-',~>~,
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P'O"B°X:~°57 "" ' : ']
BAKERSFIELD CA' 9330'3-2057
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'CITY' OFBAKERSFELD%"'~ ' STATEMENT 'OF ~L'~~.'~?~?~ ' '?: '~' '
PO BOX 2057 ~ '.: ' '' ' ~ · ' : ~"~ "-" ' "~'"
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.. ACC~uNT.,,NO..~.68r&:26,,~.....' ::: CITY OF BAKERSFIELD
-HO;Zardous .Mater t-a t s: ~a::nd,t,i'n~' Sa t an ce .1.!'7-. '7[., ~(
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. P.O. BOX20~'7. "' '"':"~ "~ ' " ' ~' '" CITY OF BAKERSFIELD
' BAKERSFI~*~,CA 93303-2057'~ ACCOUNT NO; ~N685~0Z: ' ' ·
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P.BAO' BOX'2057'I: , :, ,;I:,, ,',' :'t "~,r : ~:' ....... :~ ' CITY OF BAKERSFIELD
KERSFIELD 0A'93~(~3-'2~)57 AOCOU'~O
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,} . :'.B~'ERSFIELD, CA 933085:2'057 ACC'OUNT
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Bakersfield Fire Dept.
Hazardous Materials Division
RECEIVED
,,' 2130 "G" Street
HAZARDOUS MATERIALS MANAGEMENT PLAN
INSTRUCTIONS: * ~' i,.-. '~,:, , .
1. To ovoid further action, return this form within 30 days of receipt.
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business os o whole.
4. Be brief and concise as possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
BUS.NESS NAME' £"~$,Y ff~,' 7'*~ .g,,~,6'* ~
MAILING ADDRESS: ~ ~ ~ C H~~~ ~/~
CITY:~/~~ STATE' C~ ZIP:~/ PHONE:
DUN ~ BRADSTREET NUMBER: ?~1~~ ~ SIC CODE:
PRIMARY ACTIVITY: ~~ ~~ ~
OW~E~: ~~ C ~~
MAILING ADDRESS: ~ ~ ~~ "~r
SECTION 2: EMERGENCY .NOTIFICATION:
CONTACT TITLE BU§, PRONE'~' 24 HR. PH'ONE
FD15~
Bakersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
SEGTION &:-,,1'RAINING:
BRIEF SUMMARY OF TRAINING PROGRAM'
SECTION 4: EXEMPTION REQUEST:
I CERTIFy .UNDER PENALTY OE:PERJUR-Y THAT MY BUSINESS IS.~EXEMPT, F,ROM THE
REPORTING REQUIREMEI~I~S OF CHAPTER 6.95 OF THE "CAI~IFORNIA'HEAE'TH &
s~,FETY CODE" FOR THE FOLLOWING REASONS'
WE DO NOT HAND, gE.HAZARDOUS MA. TERJALS.
WE DO HANDLE HAZARDOUS MATERIALS, BUT THE.QUANTITIES AT NO
TIMEEXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASONi
SECTION 5: CERTIFICATION:
I, ~O','q''/ ~I~/J~T~,/~/ CERTIFY THAT THE ABOVE INFOR-
MATION IS ACCURATE. l UNDERSTAND THAT THIS INFORMATION WILL BE USED TO
'FULFILL MYFIRM'S OBLIGA,TIONS,UNDER THE "CALIFORNIA HEA.LTH AND SAF, ETY CODE"
ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.]'AND THAT
INA. CcUR'ATE INFORMAilON'CONSTITUTES PERJURY. ' ~ "': .... ,
SIGNATOFRE TITLE DATE
FD1590
Bakersfield Fire Depl
Hazardous Materials Divi~
, 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):
NATURAL GAS/PROPANE:
ELECTRICAL: ~ff~ ~}~ _~
SPECIAL: .
LOCK BOx: YES/N'~ IF YES, LOCATION'
'k....,~
SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY:
A. PRIVATE FIRE PROTECTION:
B, WATE~ AVAILABILITY {FI~E HYDRANT)'
4. FDT5~
Bakersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
Facility Unit Name:
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES:
c,qxx
B. EMPLOYEE NOTIFICATION AND EVACUATION:
C. .;:PUBLIC EVACUATION:
D, EMERGENCY MEDICAL PLAN:
TT¥ of B^KERSF ELD
Farm and Agriculture ['] Standard Business I-IHAZARDOUS
t,4AT ER TAgS
TNVENTORY
NON--TRADE SECRETS
BUSINESS NAME' ~5~ ~g/~ .S.~/--~ OWNER NAME-
LOCATION: ~,~'~;o ¢N~$~",~_ ~ ADDRESS:
CITY. ZIP'~~/~-~- ~7 -- CITY. ZIP'~-~~ DUN AND BRADSTREET NUMBER--~'~
PHONE ~- ' ~-~/ - - PHONE ~' '
I 2 3 ~ 5 6 I 8
Trans [7Qe Hax Average Annual ,easure I ~y~ Cont Cont Cont Us tocqtion Whece.
Code Looe AmL ~m[ EsL Un~Ls on 5~ce Type Press Temp Co~e
Storea ~n
Phvsica and Health Hazard C,A,S, Number Component I1 Name t C,A.S. Number
(Check all that
U Fire Hazard U Reactivity- Hea h~a~¢'d U Sudden Release
of Pressure Healbh
Component 13 Name ~ C.A.S. Number
Physical and Health Hazard C,A.S. Humber Component II Name I C.A,S. Humber
(Check all that apply)
Component 12 Name ~ C.A.S. Number
~ Fire Hazard ~ Reactivity ~ Delayed ~ Sudden Release ~ Immedi~te
Health of Pressure
Health
Component 13 Name S C.A.5. Number
Physical and Health Hazard C.A.S. Number Component I1 Name & C.A.S. Number
(Check all that appl~)
Component 12 Name S C.A.S. Number
~ Fire Hazard ~ Reactivity ~ Oetayed ~ SuddenReiease ~ Immediate
Hearth of Pressure Health
Componen~ 13 Name
Physical and Health Hazard C,A,S, Number Component II Name I C.A,S, Humber
(Check all that apply)
Component I2 Name & C,A.S. Number
~ Fire Hazard ~ Reactivity ~ 0elated ~ Sudden Release ~ Im~pdi~Ae
Health of Pressure
Health
Component 13 Name & C,A.S, Number
EHERGENCY CONTACTS fll
~me Tftle
',ertifigatioq ,(Re~d cnd.~ign af~¢r complcti(~g.all sectipn~)
: certify unoer penm~tX 9?~aW t,4t I n~vepe(sonaHLex~mlnqO~qo~m rami~af,~it~ the. jn~orma~]pn ~u~mitt~d in this ~nd all
~t~acned,docvments, In~ ~!~ oa~o o~.mf I~q~ry gf.~nos~ 1nolvlou~/~ respo~slo/t for oo~a~,~ng :ne lnforma~ion, ~ believe that the
;uoe][[eo lnforeaLlon IS true, accurate, ano complete,
~~f~~e of o~ner/operator u~ o, ner/operator's authorized representative
2130 "G" STREET
B XERSFIELD, CA 9O301
(805) 026-3979
?
l OFFICIAL USE ONLY
ID#
USINESS NAME
HAZARDOUS MATERI ALS
BUSINESS PLAN AS A WHOLE
FORM 2A
INSTRUCTIONS: "
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 IDENTIFICATION DATA
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 OF EMERGENCY:
NAME_~N~D TITLE DURING BUS. HRS. AFTER BUS. HRS.
A.~_~ ~-~ ~~_~ Ph# ~3 ~ I Ph~ ~ ~ ~
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE: 0/A .
B. ELECTRICAL:
C. WATER: ~-.'T'
D. SPECIAL:
E. LOCK BOX: YES ~ N~_~,~, 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 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:...- .................................... YES NO YES NO
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES: .......................... YES NO YES NO
C. PROPER USE OF SAFETY EQUIPMENT: .................. YES NO YES NO
D. EMERGENCY EVACUATION PROCEDURES: ................. YES NO YES NO
E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES NO YES NO
SECTION 7: HAZARDOUS I~TERIAL
CIRCLE YES OR NO
DOES YOUR BUS'INE~S HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POU~ A
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YE~NO
I, 0~I~-~ ~e'~~ , certify that the above information is accurate.
I und~rs~afid th~at this ~nformation will be used to fulfill my firm's obligations under
the new California Health and Safety code on Hazardous ~aterials (Dlv. 20 Chapter ~.05
Sec. 25~00 Et Al.) and that ~naccurate information constitutes perjury.
S IGNAT TITLE'S)- OLO ~'iL,~'d_ DATE
BAKERSFIELD CITY FIRE DEPARTMENT
I.D. # FORM 4A-1 Page ~of
NON--TRADE SECRETS
HAZARDOUS I~IATERI ALS I NVENTORY
--, ~t~T--S OWNER NAME: C)~-t~~~ FACILITY UNIT
ADDRESS: ~O Ot~_~ -- ADDRESS: ~0'~ ~~ ' FACILITY UNIT NAME:
CITY, ZIP: ~~_~(~C5 ~ ~%o( CITY,ZIP:~~E~($_L~
PHONE ~: ~ %~ ~qq { PHONE ~: ~ ~ ~ mOFFiCiAL USE CFIRS CODE
ONLY
1 2 3 4 5 6 7 8 9 10
TYPE NAX ANNUAL CONT USE LOCATION IN THIS · BY HAZARD D.O.T
CODE A~OUNT A~OUNT UNIT CODE CODE FACILITY UNIT . NT. CHE~IqAL OR COMMON NANE CODE GUIDE
NAME: TITLE: SIGNATURE: DATE: ~!~1~
~H~R~NCY CONTACT: ~~ TITLE: · BUS :S':
EMERGENCY CONTACT: O ~O TITLE: ~~ PHONE ~ BUS URS:
PRINCIPAL BUSINESS A~TIVITY: ' ~T~ AFTER BUS BRS:
- 4A-1 -