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HomeMy WebLinkAboutBUSINESS PLAN Hazardous Materials/Hazardous waSte-Unified' Permit CONDITIONS Ol= .PI=R~IT O~ I::ll:::~l=F:l$1= $1Dl= .* , ' · [] Hazardous Materials Plan '[~ Unde~round Storage of H~h,.ardous MarsHals Permit ID #:: 015-000-000323 [3 Risk Management Program UI H~rdous Wast® Or,Site Tnmtm~ THOMAS D HALL DDS INC LOCATION: 4000 STOCKD^LE HWY H IELD ~ ?r'~ ~ ~ .... · .~ . Issued by: Bakersfield Fire Department  1715 Chester Ave., 3rd Floor ^pprovedby: Issue Date Bakersfield, CA 93301 · Voice (661) 326-3979 FAX (661) 326-0576 Expiration Date: aun~ Thomas D. Hall, DDS Business/' O~ D~s Office Rcs~om ~..~ E~RGEN~ ~ ........ ...... · H_az Waste !' (~ Fire Ext',ing~j'sher~ .: '". ' ~[~_'] "FirSt Aid Kit · Safety M~.u._al 0 Water Fountain (~ Eye Wash Station ?~*' SmokcDctector "~i-'-~pillKit a MSDSManual 'l~ Medication ~,~ Sterilizer, ~' Fire Alarm "~ Emergency Kit ~ X-Ray 0 Sprinkler (~.~afetv C'anm'nlinn~'~..~r.~ (gl g~ n; ~; 9~9.. i 14 Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This permit is issued for the following: . ~,~?? ~i: '~ .?~ :7' ",¢:!i ~ ii~ ?" ;[i~",,~U~d...[ground Storage of Hazardous Materials' PERMIT ID# 01S-021000323 ' ., ~ii¢ii~i:il i,,i;¢!::iiii~iii:,i!!!iiiii:ili:ii:~' ! !!':!!!!!?:?i!: i!! ?.::!! !!:,i!!!!!: ,i'~iiiiii!~!!~'~ki?~nagement Program ¢!'! ~,: ,i/~:~ .... ?~ii ,.::.: ?;.?i~:~;ii;iiiii;??i;:.;i i;': "!'J;:. ~!ii~a~d6~s Waste LOCATION ' 4000 .~7:.. Issu~ by: 1715 Chewer Ave., 3rd Floor fi/ ~ph Hu~~ O~ee of ~ml S~id~ B~e~el~ CA 93301 Voice (805) 32~3979 F~ (80S)~2~-0S76 Expiration Date: ~n~ ~O~ ~O00 I TE/FAC ILI TY ~,o~, ~ ~7~ Z-2 3 NORTH SCALE: BUS INESS NA~IE: LOOR: OF DATE: / / ~ACILITY NA~.E: UNIT 2: OF (CHECK ONE) SITE DIAGRAM--~//' FACILITY DIAGR.k~I %~ o 0 O 0 I omments): -OFFICIAL USE ONLY- - 5A - : ~ ~IT[ OIAGR.AN (Requir~dJ[ems) -z- -c . ~; 1. Address: Identlfy.~ 9. Lock (ke! ~ principle buildings by the Street numbers. 10, NSDS 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 b. ~asonry 3. Stars Drains. Culverts, Yard Drains c. Wood 4. Drainage Canals, Ditches. d. Gates Creeks, 13. Powerllnes 5. Buildings a. Frame construction 14. Guard Station b. Nasonry construction 15. Storage Tanks: Identify the c. Metal construction capacity in gal. a. Above ground d. Access Door .__~- ........ - 6. ..... utiii-~y~n~r a. Gas 16. Diking or Berm b. Electricity I?. Evacuation Routs c. Water 18. Evacuation Area: - Identify the ?. Fire Suppression Systems: location where a. Fire Hydrants employees wail meet. b. Fire Sprinkler 19. Outside Hazardous Connections Masts Storage c. Fire Standpipe 30. Outside Hazardous Connections Materiel Storage d. Mater Control Valves 21. Outside Hazardous for protection systems Hatertal Use/Handling e. Fire Pu~p 22, Type of Hazardous Material/Waste Stored 8, Fire Department Access or Used (See Helow) ~VPE o~ a~auous ~TEs[A~ F - Fllable S .- Explosive L - Llquld R - Radiologlcai ~ ~C----Corrcalvs O-*,, Ox/dAzer O' - Oas P - Poison ....... - ' - - - Water Reactive T - Toxic g - Solid 'H - Cryogenic 0 - Waste B - Rttotogtcal Example: Flammable Liquid - FACILITY DIAGRA~ (Required items tn addition to the, 1. Risora ~or Sprinklers 8. Fire Escapes 2. Partitions g. Air Conditioning Units 3. Stairways: Indicate the 10. #lndo~a levels oerved from highest to lowest. 11. Inside Huardoua Waste Storage 4. Escalator: Indicate the levels served from l{. Inside Hazardous highest to lo~emt. Mmtariala 9tora~e 5. Elevator 13. Inside Hazardous Materials Use/Handling 6. Attic Access 14. se~er Drain-Inlets 7. Skylights THOMAS D HALL, DDS INC SiteID: 015-021-000323 Manager : ~%%~% SusPhone: (661) 587-6453 Location: 3612 COFFEE RD A Map : 123 CommHaz : Low City : BAKERSFIELD Grid: 02A FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 0~k,, SIC Code: EPA ~umb: DunnBrad: Emergency Contact / Title Emergency Contact / Title THOMAS D HALL / OWNER LYNDA DEL RIO / ADMINISTRATOR Business'Phone: (661) 587-6453x Business Phone: (661) 587-6453x 24-Hour Phone : (661) 587-6453x 24-Hour Phone : ( ) - x Pager Phone : (661) 747-2652xCELL Pager Phone : (661) 747-2651xCELL Hazmat Hazards: Fire Press React ImmHlth DelHlth Contact : Phone: (661) 587-6453x MailAddr: 3612 COFFEE RD A State: CA City : BAKERSFIELD Zip : 93308-5027 Owner THOMAS D HALL, DDS Phone: (661) 587-6453x Address : 3612 COFFEE RD A State: CA City : BAKERSFIELD Zip : 93308-5027 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: Res: No Emergency Directives: = Hazmat Inventory One Unified List --Alphabetical Order Ail Materials at Site Hazmat Common Name... [SpooHazlEPA HazardsI Frm I DailyMax IUnitlMcP NITROUS OXIDE P IH DH G 656.00 FT3 Hi OXYGEN F P IH G 184.00 FT3 Low WASTE FIXER R L 5.00 GAL Min Kc-PO' 1 01/15/2003 THOMAS D HALL DDS INC ~iteID: 015-021-000323 Manager :~,~k OC~-~ ~ A BusPhone: (661) 326-1151 Location: .~v~v ST ...... ~nUY II Map : 123 CommHaz : Low City : BAKERSFIELD ~fi~LR~ Grid: 02A FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 07 SIC Code: EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Tit~e.~t_ THOMAS D HALL / OWNER ~?-~qS~ I ~M~~ / Business Phone: (661) ~ .. ~ Business Phone: (~[)$~7 -~q~x 24-Hour Phone : (C$I~ .~=LLI~3~: 5f7%~ 24-Hour Phone : ( ~, ) X ~Phone : ,(~t~t)~,z~-_~x [ ~ Phone : (~[ ...... ~ ~m~ _ z 33_ _ _c~_~z~_ ...... +_ _ _~, g ............................... Hazmat Hazards: Fire Press React ImmHlth DelHlth .............................................................................. Contact : Phone: (661) MailAddr: 3612 COFFEE RD A State: CA City : BAKERSFIELD Zip : 93308-5027 ........ Owner Phone: (661) Address : 3612 COFFEE RD A State: CA City : BAKERSFIELD Zip : 93308-5027 .................. - ............................................................ Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: Res: No .............................................................................. Emergency Directives: += Hanmar Inventory One Unified List +== Alphabetical Order All Materials at Site +- + -+ ........... + ..... +o -+ .... +-_ -+ Hazmat Common Name... ISpooHazlEPA HazardsI Frm I DailyMax IUnitlMCPI ................................ + ....... + ........... + ..... + .......... + .... +- - -+ NITROUS OXIDE P IH DH G 656.00 FT3 Hi OXYGEN F P IH G 184.00 FT3 Low WASTE FIXER R L 5.00 GAL Min I, [,-H.~J~[ ~© Do hereby certify that I have (Type o~ print name) reviewed the attached hazardous rnaterials manage- m~nt plan for"T/"o~o-lt ~ and that it along with (Name of Business) any corremions constitute a complete and correct man- agement plan for my ~'acility. + THO~S D ~LL DDS INC SiteID: 015-021-000323 += Inventory Item 0002 Facility Unit: Fixed Containers on Site +== COMMON NAME / CHEMICAL NAME .............................. ~ ~+ NITROUS OXIDE I Days On Site 1365 Location within this Facility Unit Map: Grid: + -+ i¢oc io i 'de 10024-97-2 + ...... 4 += STATE=+= TYPE ===+== PRESSURE ===+ TEMPERATURE ==+ .... CONTAINER TYPE { Gas I Pure I Wove A~ient I A~ient { PORT. PRESS. CYLINDER 4 4. AMOUNTS AT THIS LOCATION ~-+ I Largest Container Daily Maximum I Daily Average 656.00 FT3 656.00 FT3 656.00 FT3 ~ 4 ~ZARDOUS COMPONENTS 4.===+ 100.00 Nitrous Oxide No 10024972 4 ~ 4.===+======== ~===4 ~ HAZARD ASSESSMENTS ===+ 4. + ..... ITSecretl RS}Bi°Hazl Radi°active/Am°unt I EPA Hazards I NFPANo No No No/ Curies P IH DH / / / USDOT# } MCPHi 4 ~==24 ~ t ~ t +=====+ += Inventory Item 0001 -- Facility Unit: Fixed Containers on Site +== COMMON NAME / CHEMICAL NAME + OXYGEN I Days On Site [365 Location within this Facility Unit Map: Grid: +- ~TL~- z~'~O~-~ DOCk I CAS# 'o i e. I 7782-44-7 + ..I- += STATE=+= TYPE ===+== PRESSURE ===+ TEMPERATURE ==+ .... CONTAINER TYPE IGas I Pure I Above Ambient I Ambient I PORT. PRESS. CYLINDER 4 + t ~ +== ===+ + ...... + AMOUNTS AT THIS LOCATION == Largest Container I Daily Maximum I Daily Average 184.00 FT3 184.00 FT3 184.00 FT3 + 4.-- + + ~ HAZARDOUS COMPONENTS --- + = = = + ............... 100.00 Oxygen, Compressed No 7782447 + 1- 4-===+ ~ ~===4 ~ HAZARD ASSESSMENTS ===+ ~ ~ ..... I TSecret INo NoRS I Bi°HasINO Radioactive/AmountNo/ Curies EPAF P HazardsIIH NFPA/// USDOT# MCP 4 ~-==24 t 1' + '1 +=====+ 2 02/15/2002 + THOMAS D ~LL DDS INC SiteID: 015-021-000323 + += Inventory Item 0003 Facility Unit: Fixed Containers on Site + +== COMMON NAME / CHEMICAL NAME + ==+ WASTE FIXER I Days On Site I SPENT PHOTOG~PHIC FIXER 365 Location within this Facility Unit Map: Grid: +- -+ INSIDE DARK ROOM I CAS# I += STATE =+= TYPE ===+== PRESSURE ===+ TEMPE~T~E ==+ .... CONTAINER TYPE I Liquid I Waste I Ambient I Ambient I PLASTIC CONTAINER ~ ~ +-- + + ~--+ ~ ~ AMO~TS AT THIS LOCATION I Largest Container Daily Maximum I Daily Average 5.00 GAL 5.00 GAL 5.00 GAL ~ ===4 + ~ ~ ~ZARDOUS COMPONENTS ~===+= RS %Wt' Isilver INo I CA8#7440224 ~ -~===~ ~ ~ZARD ASSESSMENTS ===+ ~ + ..... + ITSecretl RSlBioHazl Radioactive/Amount I EPA Hazards NFPA USDOT# I MCP No No No No/ Curies R / / / Min -3- 02/15/2002 + THOMAS D HALL DDS INC SiteID: 015-021-000323 + ~ .- Fast Format + += Notif./Evacuation/Medical == Overall Site + +== Agency Notification 01/19/2000 + CALL 911. + + +=== Employee Notif./Evacuation -- 01/19/2000 + EMERGENCY EVACUATION PLAN REVIEWED MONTHLY AT STAFF MEETINGS. ONE FRONT DOOR AND ~ BACK DOOR~. EMERGENCY NUMBERS ON PHONE. + + + .... Public Notif./Evacuation 01/19/2000 + FRONT DOOR, ~ BACK DOOR~. += + + ..... Emergency Medical Plan 01/19/2000 + I Old NEAREST HOSPITAL - MERCY HOSPITAL 4 02/15/2002 + THOMAS D HALL DDS INC SiteID: 015-021-000323 += Fast Format += Mitigation/Prevent/Abatemt - Overall Site +== Release Prevention 05/08/1990 MASTER EMERGENCY SWITCH TO SHUT OFF ALL GASES IN CASE OF EMERGENCY. MYSELF AND STAFF HAVE BEEN TRAINED ON ALL TECHNIQUES FOR 02 AND N202. EVACUATION PLAN IN CASE OF EMERGENCY FOR OURSELVES AND PATIENTS. + ..... +=== Release Containment ---+ I + .... Clean Up Other Resource Activation -5- 02/15/2002 + THOMAS D HALL DDS INC SiteID: 015-021-000323 + + Fast Format + ~+= Site Emergency Factors Overall Site + +== Special Hazards + +=== Utility Shut-Offs 01/19/2000 + A) GAS --IN TIIE BLDC~~- ~tt~ ~o_k~GhS~ B) ELECTRICAL - IN THE BLDG C) WATER - ON THE ST D) SPECIAL - NONE E) LOCK BOX - NO + .... Fire Protec./Avail. Water -- 01/19/2000 + PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS. I IRE HYDRANT -,~8~%~f =~O~t¢ THE CG~JER CZ STOCF~DL~ HWY D3~ MCDO~AT,D way (~U;~. ii= Building Occupancy Level .... -6- 02/15/2002 ~T~OMAS D HALL DDS INC SiteID: 015-021-000323 + Fast Format + Training Overall Site + +== Employee Training 01/19/2000 + WE HAVE ~ EMPLOYEES AT THIS FACILITY. WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE. BRIEF SUMMARY OF TRAINING: INFORM THEM ABOUT OXYGEN. +=== Page 2 - - ................ ~ + + .... Held for Future Use + + + Held for Future Use + -7- 02/15/2002 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3'd Floor, Bakersfield, CA 93301 FACILITY NAME ~ ~ ~ DD<~ INSPECTION DATE ['~-/1~//~ Section 4: Hazardous Waste Generator Program EPA ID # !/~ ~:: ~ ~-'~ ~ Routine [] Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number (Phone: 916-324-1781 to obtain EPA ID #) Authorized for waste treatment and/or storage Reported release, fire, or explosion within 15 days of occurrence Established or maintains a contingency plan and training Hazardous waste accumulation time frames / Containers in good condition and not leaking Containers are compatible with the hazardous waste / Containers are kept closed when not in use / Weekly inspection of storage area / Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided Conducts daily inspection of tanks Used oil not contaminated with other hazardous waste Proper management of lead acid batteries including labels Proper management of used oil filters Transports hazardous waste with completed manifest Sends manifest copies to DTSC Retains manifests for 3 years / / Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal C=Compliance V=Violation Insoector' (~k.) l /V'~"~ Office of Environmental' Services (661) 326-3979 Party White - Env. Svcs. Pink - Business Copy Ja~ .L 0 auuu i SitelD:. 215-000-000323· THOMAS D HALL DDS INC ~ '"" ~ ..... ' Manager : !c~/.~/ BusP~one: (805) 326-1151 Location: 4000 STOCKDALE HWY H . /~ ~ 123 CommHaz : Low City : BAKERSFIELD Grid: 02A Fac.~nits: 1 AOV: CommCode: BAKERSFIELD STATION 03 SIC Code: EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title THOMAS D. HALL / / Business Phone: (805) 326-1151x Business Phone: ( ) - x 24-Hour Phone : (805) 871-0603x 24-Hour Phone : ( ) - x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact : Phone: ( ) - x MailAddr: 4000 STOCKDALE SU H HWY State: CA City : BAKERSFIELD Zip : 93309 Owner THOMAS D HALL Phone: (805) 326-1151x Address : 4000 STOCKDALE SU H HWY State: CA 'City : BAKERSFIELD Zip : 93309 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: -- Hazmat Inventory One Unified List -- MCP+DailyMax Order Ail Materials at Site Hazmat Common Name... ]SpeoHazlEPA HazardsI Frm I DailyMax [UnitlMcP NITROUS oxIDE P IH. DH G 652.00 FT3 Hi OXYGEN F P IH G 184.00 FT3 Low !,' ~'-1'1'~ ~JI ~ Do hereby certify that I have reviewed the attached hazardous materials manage- ment plan " a complete and correct man · ''." any corrections__ constitute ' · .:..... agementplan for my fadlity, .. -1- 12/21/1999 Do hereby certify that I have revie;ced the attached Hazardous Ma~eriais bu_i~es~ ~ian for (name of business) and that it along with the attac~hed additions or corrections constitute a complete and correct Business Plan for my facility. si~na~ur-e date - Do hereb5~ cert~ =-- ' _~,~ that I have reviewem the att'ached Hazardous Materials busines~ ~lan (name of business) and that it along with the attached additions or corrections constitute a commlete and correct Business Plan for my facility. szgna~ure date ~.~ ,,~.:' ..~ j.'.% ....'~. -,~,. ~,x CZT¥ of BA.KERSF[ELD _~,,,~ ,.~ ,, ,~ ,,, ~_. -~ ,.~ "II"E C,-tRE" ~ ~ ,,~ Do hereby certify that I have reviewed the attached Hazardous ~1aterials business Dlan for (name of business) and that it along with the attached additions corrections consti' ~ ~u~e a complete and correct Business Plan for my facility. =i,a'rla~ur BUSINESS N~1E THOMAS D HALL DDS !NC ID NUMBER Z1S-OOO-~Z~O3Z3 LoCflTION 4~00-H STOCKDALE f~WY HIGH HRZRRD RATING 2 1, OVERVIEW LAST CHANGE 10/07/8B BY ESTER JURIS CODE Z1S-O~? JURtS BAKERSFIELD STATION MAP PAGE ~23 GRID OZA FACILITY UNITS I HAZARD RRTINO 2 RESPONSE SUMMARY ZR SEC 4) NO PRIVATE RESPONSE 'TERM. EMERGENCY CONTACTS ZA SEC THOMAS O. HALL - 326-.1151 OR 871-0603 UTILITY SHUTOFFS ZA SEC A) GAS - IN THE BLDG B) ELECTRICAL - IN THE BL[~ C) WATER - ON 'tHE STREET D) SPECIAL -- NONE E> LOCI< BO>( - NO Z. NOTIFICATION / PUBLIC EVACUATION LAST'CHANGE / / BY < NO INFORMATION RECOROEO FOR THIS SECTION PSGE ! 01/Z0/89 10:SG M~TERtAL SAFETY DATA SYSTEMS, tNCo (805) 648-6800 BUSINESS NAME THOMAS D HALL DOS INC ID N R Z1S--OOO-OOO~Z'3 LOCATION 4f~O-H STOCKDALE HWY HIGH HAZARD RATING i~. HAZ MAT TRAINING SUMMARY LAST CHANGE / / BY < NO INFORMATION RECORDED FOR THIS SECTION > 4. LO£AL EMERGENCY MEDICRl. ASSISTANCE q I ~ ~-~ ~ ~~ "LRST CHRNGE t0/07/8B BY ESTER PAGE Z O1/ZO/SB 10:SG MATERIAL SAFETY DATA SYSTEMS, INC..(805) 648-6800 BUSINESS NAME THOMAS O HALL DOS INC ID N R LOCATION 40(~-H STOCKOALE HWY HIGH HAZARD RATING FACILITY UNIT R, OVERALL HAZRRDOUS MATERIRLS INVENTORY ERST CH~NGE-l'O/O?'/88 BY ESTER ID TYPE NRHE MAX AMI' UNIT HAZARD LOCATION CONTAINMENT USE i PURE OXYGEN SGZ FT3 HIGH OUTSIDE FRONT DOOR PORTABLE PRESS. CYL. WELDING/SOt. DERING ID PERCENT COMPONENTS HAZARD LIST Z~59.00 t0~.0 OXYGEN, COMPRESSED HIGH" ' Z PURE NITROUS OXIDE 3G00 FT3 MODERATE SEPERATE SHED PORTABLE PRESS. CYL. ANESTHETIC ID PERCENT COMPONENTS HAZARD LIST Z~4S,00 t~.0 NITROUS OXIDE MODERR'rE FIRE PROTECTION / WATER SUPPLIES L~ST CHANGE 10/07/88 BY ESTER SEC 4> FIRE EXTINGUISHERS FOR FIRE PROTECTION. SEC S) FIRE HYDRRNT ZOF'¥ FROM THE CORNER OF SI'OCKDRLE HWY RND MCDONALD WRY (NW CORNER). PAGE 3 ~I/ZO/AB 19:SG MATERIRL SRFETY DRTfl 'SYSTEMS, tNC. (805) 848-6800 BUSINESS NAME ]'HOM~S D HALL DDS INC ID N R ZiS-OOO-OOO3Z3 LOCATION 4000-H STOCKDALE FIWY HIGH HAZARD RATING D, EMPLOYEE NOTIFICATION / EVACUATION - ' LAST CHANGE 10/07188 BY ESTER SEC 1) EMERGENCY EVBCUAI'ION PLAN REVIEWED MONTHLY BT STAFF MEETINGS, ONE FRONT DOOR AND TWO BACK DOORS. EMERGENCY NUMBERS ON PHONE,. E. MITIGATION / PREVENTION I ABATEMENT LAST CHANGE ;0/07/88 BY ESTER SEC 1) MASTER EMERGENCY SWITCH TO SHUT OFF ALL GASES IN CASE OF EMERGENCY. MYSELF END STAFF HAVE BEEN TRAINED ON ALL TECHNIQUES FOR 02 AND NZOZ. EVACUATION PLAN IN CASE OF EMERGENCY FOR OURSELVES AND PATIENTS, PAGE 4 011Z0t89 tO:SG MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-G800 CITY of BAKERSFIELD N 0 N ~ ~ ~~0~ ~ ~0~ COD~ Fire Hazard ~ J g~ttv~ty [ ~ ~ r (C~k oil t~t o~ly)~ ..... . ~ H~lth of P~su~ H~lth [ H~lth~ of Pr~sure H~lth for~,obtoining t~ inf~ti~, [ ~)ieve t~t t~ su~itt~ info~ti~ is t~, occurate, and c~ol~.~ BAKERSFIELD CIT~ FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 (805) 326-3979 OFFICIAL USE ONLY BUSINESS N~E HAZARDOUS ~ATERI ALS ~SI~SS P~ ~S ~ ~HO~ ~OR~ 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 ~.j~ A. BUSINESS NAME: ~ ~AC :~' ~~ QOL.i~c- B. LOCATION / STREET ADDRESS: ~OA~CkOma~ ~ 2~,~ CITY: ~~PI~LO ZIP: q%~Ofl BUS,PHONE: 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: /}~5. $ ~v,cF.- NAME AND TITLE DURING BUS./,flRS. AFTER BUS. HRS. B. Ph# Ph# SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE A. NAT. GAS/PROPANE: B. ELECTRICAL: C. WATER: 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: L~)CAL E1WERGENCY 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 HANDLIN0 OF HAZARDOUS MATERIALS:...- .................................... (~ NO ~ NO B. PROCEDURES FOR COORDINATING ACTIVITIES WITH RESPONSE AGENCIES: .......................... (~YE-~5 NO ~YE~ NO C. PROPER uSE OF SAFETY EQUIPMENT: .................. ~ NO ~ NO D. EMERGENCY EVACUATION PROCEDURES:" ................. NO NO E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES~ YES CIRCLE~OR NO DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUN~F A SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... ~NO I,--7~.'~vm~ ~'O,~cc- , 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 2~30 "G" STREET BAKERSFIELD, CA 93301 OFFICIAL USE ONLY BUS I NESS PLAN SINGLE FACILITY UNIT FORM 3A 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# H FACILITY UNIT NA~%fE: '-7~-~-%-~ ~ ~+~O~i ~. SECTION 1: MITIGATION, PRE~ION~ ABATEMEN~ PROCEDb~ES SECTION 2: NOTIFICATION .~%~ EVACUATION PROCEBL~ES 'AT THIS b~IT ONlY - 3A- SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY A. Does this Facility Unit contain Hazardous Materialso NO If YES, see B. If NO, continue with SECTION 4. B. Are any of the hazardous materials a bona fide Trade Secret YES If 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. 5ist only the ~ ~raae secrets on form 4A-2. SECTION 4: PRIVATE FIRE PROTECTION SECTION 8: LOCATION OF WATER SUPPLY FOR USE BY E~RGENCY RESPO~ERS SECTION 6: LOCATION OF UTiLi~ S~'T-OFFS AT THIS b~IT O~TY. A. NAT. OAS/PROPANE~ ~~ ~0 o C. WATER: ~g~T g~ O~ /gCOG . D. SPEC!AL: E. LOCK BO~: YES .~ ~F YES, LOCATIOn: , .ISDSs iF YES SiTE PLANS? YES / FLOOR Pr. AxS? YES / SO :,:ES'S? YES / ¥0 - 3B - · I BAKERSFIELD CITY FIRE DEPARTMENT I.D. # FORM 4A-1 Page of-' NON--TRADE SECRETS HAZARDOUS MATERI ALS INVENTORY ADDRESS:_ /-~/)~m)~~ .:~- ADDRESS: /~)~ ~ ~E~ACILITY UNiT NAME: CITY, ZIP: ~~/ - ~ q~ CITY,ZIP: ~ ~~ 3~ PHONE ~: ~V~~ PHONE {': ~? {<~O~ ' {OFFICIAL USE CFIRS CODE { ONLY 1 2 3 4 5 6 7 8 9 10 TYPE MAX ANNUAL CONT ~USE LOCATION IN THIS · BY ~ HAZARD D.O.T ~0DE A,0UNT A~0UNT UNIT C0DE C0DE FACILITY UNIT , WT. CHEmiCAL OR COMMON NAME C0DE GUIDE NAME: TITLE: O~ SIGNATURE: DATE:~/f8 EMERGENCY CONTACT: ~Oll,~} ~,~ TITLE: ~~ P.ONE · BUS HOURS: AFTER BUS HRS: ~ ~M~.oH~cv CONTACT: ~,~_~ TITLE: ~~ . ., ~HONH ~ .US HOURS: %~,~% ....... P.]~CIPAL BUSINESS ~CT]V]TY: ~_~ ~-' AFTER ~US HRS: gO*O~ .... - 4A-1 -