HomeMy WebLinkAboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit
CONDITIONS OF PERMIT ON REVERSE SIDE
............
PERMIT ID# 015-0214)00824 ../~i?i~ ~i, ?::iiiiiiii!!!iii i::'" ..!!!!!:!~!!!!!!!::!i!i i! !'.~i!!~!!!}:~!iil iii~ ~k i~oagement Program
LOCATION ' 1621 COLUMBU~¥:?}~i~;~?:~:?: B~$~i~LD CA
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'~ii;;;'"L.-..::%,:.?:~iii ~ii~' .~i~i~' ~.iii~i~;: ......... ~'""""~'"'"".'.~'.:;:':~ '"i~! ~i~. 'i~: ~..,~' ~, '~ ~::~"
':~ ",*. "' , *:~:*~:!i:,,:~.'''= :il ~i~ ?~i ~ ,,,,,~i~' ~ .~"
Issu~ by:
B~ersfield Fke Depa~ment Approved by:
OFFICE OFE~RON~AL S~ ~CES .~ ~ph "uey~
1715 Chewer Ave., ~rd Floor
Office
of~enml
Scmi~
B~e~fiel~ CA 93301
Voice (805) 32~3979
F~ (80S)~26-0S76 Expiration~t~: dun~ ~0~ ~O00
"WE CARE"
HAZARDOUS MATERIAL RELEASE REPORT FOR
FIRE DEPARTMENT Notify CA O.E.S. (800) 852-7550 2t01 H STREET
S. D. JOHNSON BAKERSFIELD, 93301
FIRE CHIEF 326-3911
Company Name '~'('.~gZ J:/~(~'~
Hazard Level - Low
Moderate
High
Extreme (Acute)
Estimated Quantity of Release /0
/
Time ~-'00 ~ Date'
Duration of Release Date
Medium into which release occurred:
Health risks know or anticipated:
Proper Precautions:
Contact Person
Telephone Number
HAZARDOUS MATERIAL.RELEASE FOLLOW UP REPORT
Number of People Affected by Release
Extent of Any Health Related Problems:
Dates of Cleanup
Contractor
Contractor's Respresentative ~V
Time of' Contractor Arrival ~'-~
Description of Extent of Contamination
Water
Air
Other
Description of Cleanup Procedures Used
Qaulity of Hazardous Materials Removed (identification procedures,
lab results if available)
Registered Hauler Utilized Hauler
Material Transported to Manifest#
Time and Date Job was Completed
Current Status of Site
Report By~
Agency '
SITE/~ACILITY DIAGR~ ~ ~2 ~
FORM 5
BUS[NESS NAME: w[OO'R: OF
NORTH SCALE: _..
DATE: / / FACILITY ~IE: UNiT =: OF
(CHECK ONE) SITE DIAGR.~! FACILITY DIAGR.~!
I(Inspecto~"s Comments): -OFFICIAL USE ONLY-
CITY OF BAKERSFIELD FIRE DEPARTMENT ~
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301
FACILITY NAME J,.uc_.,~'~ ,~J-o~ INSPECTION DATE ~tS -/V-to
. !
ADDRESS Jl~.i~9 Co/u/~J)o$ PHONE NO. cg72-6'?_.
FACILITY CONTACT BUSINESS ID NO. 15~210-
INSPECTION TIME ,~ ./VVO NUMBER OF EMPLOYEES
Section 1: Business Plan and Inventory Program
/~ Routine [] Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection
OPERATION C V COMMENTS
Appropriate permit on hand
Business plan contact information accurate
Visible address
Correct occupancy
Verification of inventory materials
Verification of quantities
Verification of location
Proper segregation of material
Verification of MSDS availability
Verification of Haz Mat training
Verification of abatement supplies and procedures
Emergency procedures adequate
Containers properly labeled
Housekeeping
Fire Protection ~
Site Diagram Adequate & On Hand ' /~7,,z~ f~, .~7.~,~,._
C=Compliance V=Violation
Any hazardous waste on site?: [] Yes
Explain: .... ~ ///J ~ ' I ~
Questions regarding this inspection? Please call us at (661) 326-3979 Business Site Responsible Party
White- Env. Svcs. Yellow- Station Copy Pink- Business Copy Inspector: 4~
APRIL 1991 PAGE 1
LUCKY STORES INC. S~
General Information
RECEIVED
'~U£_[~' #278 ] [NAY 2 0 1991
Location: 1621 COLUMBUS ST, BAKERSFIELD, CA 93305 HA~.~ ~4A%~1~
Ident Number:
Contact Name Title Business Phone Home Phone
k/~jILL KOSTAN STORE MGR (805) 872-5232 (805) 664-8800
ELLE'S DEFFES ASST MGR (805) 872-5232 (805) 395-0277
Administrative Data
v/~l~ail Addrs: 4801 WHITE LN D&B Number:
City: BAKERSFIELD State: CA Zip: 93309-
Comm Code: 215-013 BAKERSFIELD STATION 13 SIC Code:
Owner: LUCKY STORES INC Phone: (714) 739-7466
Address: 6565 KNOTT AVE Contact: SHAWN THOMPSON
City: BUENA PARK CA 90620 SAFETY MGR
/
jital Number of Associates: 94 Hours of Operation:
Yght 40 Associates Business Hours 6 A.M. - 12 MIDNIGHT_
30 Associates Stock Crew (only) 12 MIDNIGHT 6
A.M.
APRIL 1991 PAGE 2
LUCKY STORES INC
Hazmat Inventory List
TO BE PROVIDED WITHIN 60 DAYS AS AGREED TO BY RALPH HUEY.
APRIL 1991 PAGE 3
LUCKY STORES INC
Notif./Evacuation/Medical
1) Aqencv Notification
· In situations in which a hazardous material spill or leakage occurs, notify the
Division Safety Office (714) 73g-7806, during normal business hours (8 a.m. - 5 p.m.,
Monday - Friday), for further instructions on notification of appropriate agencies.
· During non-operational hours telephone the Duty Safety Representative by paging
(714) 255-4620. If the Duty Representative does not return the call within 30 minutes,
notify your District Safety Representative.
· The Safety Representative shall notify the local fire department {805) 326-3979 of
the incident. After contacting the Division Safety Manager a decision will be made as
to whether the State Office of Emergency Services will be notified (800) 852-7550.
2} Associates Notif./Evacuation
· If in-store managements opinion is the store must be evacuated or you're instructed
to evacuate by local authorities {fire dept/police dept) do so according to
established policy and procedure. Refer to Red/Gray Emergency Procedure Bulletin
/ for instructions.
· Management shall walk through store informing associates to leave the store
immediately through safest exit.
· Public address system shall only be used in situations that require immediate
evacuation, to minimize panic among customers and associates.
3) Public Notif./Evacuation
· Refer to Red/Gray Emergency Procedure Bulletin for instructions.
· Store management and associates shall walk through store informing customers to
leave purchases in store and exit through safest exit.
° Public address system shall only be used in situations that require immediate
evacuation, to minimize panic among customers and associates.
4) Emerqenc¥ Medical Plan
~/~ ~·Ass°ciates °r cust°mers wh° sustain injury°r illness due t° hazard°us material
pill or leakage shall be referred to company designated medical clinic for treatment.
If injury or illness is serious or life threatening notify paramedics or emergency
services immediately.
APRIL 1991 PAGE 4
LUCKY STORES INC
Mitiqation/Prevent/Abatement
1) Release Prevention
· Items packaged for resale are in small quantity containers.
· Store use items are contained in manufacturer approved containers.
2) Release Containment
· Put up "Caution Wet Floor" signs or rope off area to prevent customers/associates
from entering spill area.
!
· If strong or irritating odors are present, warn others to maintain safe distance
from spill area.
· If material is dry, keep associates/customers from walking through material,
spreading it to other areas.
· If material is wet or liquid, sprinkle absorbent material around edge of spill to
contain liquid.
3) Clean Up
· Use appropriate protective equipment as required by Material Safety Data Sheet
(MSDS).
· If spill is greater than one gallon notify the Safety Department immediately for
clean-up instructions.
· If material spilled is dry, scoop or gently sweep up dry material and place in
double bagged plastic trash bag. Do not sweep vigorously as you may spread material.
~/~ · If material spilled is wet or liquid, sprinkle absorbent material around edge of
spill. Gently sweep absorbent to center of spill to absorb liquid. Gently sweep up
used absorbent and place in double bagged plastic trash bag.
· Label trash bag as "HAZARDOUS MATERIAL" and place in warehouse temporarily.
· Wet mop area of spill with mild detergent and water.
· Save used absorbent, mop, product container and wash water. Contact the Safety
Department (714) 739-7806 for proper disposal instructions
· Thoroughly wash hands/arms with soap and water after clean-up.
4) Other Resource Activation
· Safety Representative shall request additional assistance such as Haz-Mat clean-up
service if situation requires.
APRIL 1991 PAGE 5
LUCKY STORES INC
Site Emerqencv Factors
1) Special Hazards
· Propane tanks are stored outside building for use by floor buffer.
· Refrigeration system uses freon #'s 12,22,502 for cooling of food product throughout
store.
2) Utility Shut-Offs
A) GAS - NONE
B) ELECTRICAL - SOUTH BACK SIDE OF STORE
C) WATER - FRONT OF STORE AT CURB
D) LOCK BOX - NO
E) FIRE SPRINKLER - BAKERY DEPT/PREP ROOM NORTHEAST CORNER
F) ALARM CO - ADT ALARMS - BAKERSFIELD (805) 322-1961 CRIME CONTROL -
SYSTEM NUMBER - K030010545
3) Fire Protec./Avail. Water
PRIVATE FIRE PROTECTION -
* STORE IS EQUIPPED WITH AUTOMATIC SPRINKLER PROTECTION WHICH IS MONITORED BY ADT
ALARMS - CRIME CONTROL (805) 322-1961, 24 HOURS A DAY, 7 DAYS A WEEK.
· PORTABLE MULTIPURPOSE (ABC) FIRE EXTINGUISHERS MOUNTED THROUGHOUT BUILDING
APRIL 1991 PAGE 6
LUCKY STORES INC Traininq
1) Paqe 1
· Material Safety Data Sheets are on file for all hazardous materials used in the
store.
· All associates receive initial Hazard Material Communications Training at the time
of their initial assignment.
· Training includes but is not limited to 1) video entitled "Chemical Safety", 2)
Discussion of hazardous materials in the department, 3) location of MSDS, 4)
Question/answer period.
· Associates receive re-fresher training on hazardous materials on an annual basis.
· Emergency procedures are randomly covered with associates and are posted throughout
the store on Emergency Procedure Bulletins (Red/Gray Poster).
a:278.haz
,P-ART B - 1987 HAZARDOUS MA, d~RIALS INVENTORY PAGE _l 0F ~.
= i~STRUCTIONS: READ ALL THE INSTR"~CT:DNS BELOW AN0 0N PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT ,R~PORT
WASTES ON REVERSE SIOE.)
- ~. COMPLETE A SEPARATE FORM FOR EACH BUILDING, 0UT000R AREA, 0R ROOM WHERE HAZAR00US MATERIALS ARE LOCATED. USE BOX BELOW T0
. THE LOCATION 0F THE HAZARDOUS MATERIALS LISTED ON THiS FORM. (HAZARDOUS WASTE 0N PART C.}
~LOCAT~ON OF HAZARDOUS MATERIAL~;
]ROOM NAME
OR NUMBER BUILDING NAME OR NUMBER OUTDOOR AREA
NAME OR NUMBER
2. COMPLETE COLUMNS 1-5 FOR ~ACH HAZARDOUS MATERIAL STORED 0R HANDLED A~ ~HE LOCATION SPECIFIED ABOVE REGAROLESS 0F ~H~ OUAN~IT
INCLUDE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS, CHEMICALS MANUFACTURED 0R REPACKA~ED, AND CHEMICALS DISTRIBUTED. USE TH~ C0OE5
TABLE I AT TH~ BOTTOM OF THIS FORM TO COMPLETE COLUMN 4.
3. R~TURN COMPLETED INV~NTORY AN0 APPLICATION IN ~NCLOSE0 S~LF-A00RESS~0 ENV~LOPE
F~LL ~N A & B FOR EACH HAZARDOUS MATERIAL OR HA~RDOU$ ES~MATE MAXIMUM ESTIMAT~ TOTAL LIST ALL THE TYPES
' ~ ~v~
MATERIAL MIXTURE. USE EXACT SPELLING. QUAN~TY HANOLED 0R STORED 0UANTITY HANOLED 0R 0F CON~AINERS
A. PRODUCT NAME OR COMMON NAME 0F HAZARDOUS MATERIAL. AT ANY ~ME IN 1987 AT STORED DURING 1987 USED TO STORE
ABOVE LOCATION. INCLUOE AT ABOVE LOCATION. HAZAR00US MATERIAL-
B. CHEMICAL NAME ~ND PERCENT(%) CONCENTRATION OF UNITS. (i.e, LBS. GALLONS, EVEN IF ONLY BRIEFLY. USE TABLE I. mE
ALL INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLUDE UNmTS.
B. ACIDI~ 5.0 % GLASS
% 60 G~. 2,400 G~. PLASTIC NO
%
HOUS~OLD (RETAIL)
A. C~CON- FISH ~SION
e- NITROGEN 5.0
~ONIAC~ ~%~OGEN .,4 ~ 5 G~. 200 G~. GLASS NO
PHOSPHORIC ACID (P~O~ 2.0
wn~nT.n (RETATT,1
A. CWACON- SRVTN ~P~Y
B. CARRAR~, 5.0
TNERT g~-0 % 5 G~. 200 G~. G~SS NO
~TT~T,~ (RETATT,~
A~ ORCA -
s. AC~WAV~ 4.0
TRTF~TNE ~.25 % 5 G~. 200 G~. GLASS NO
~ T COT.FOT. ~. 00
,nn~T,~ (R~TATT,1
PFTRAT.~T~ S~T.V~ 57.0 ~ 6 G~. 240 G~. GLASS
TMFRT 18.0 ~ PLASTIC NO
~n~m~nT.n [RETATT )
B. HAT.A~TON 50.0
~.~w~ ~OT.V~W~ 33.0 ~ 5 G~. 200 G~. PLASTIC NO
INERT 17.0'
A. ~WACON- ~NT SP~Y
B. CARRAR~. 5.0
TN~RT 95.0 ~ 5 G~. 200 G~. GLASS NO
TABLE 1 STORAG~ CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold OFFICE USE ONLY
A = Me,al Containers ~<5 gallons) F = Bags L = Pressure Vessel - Nol gortablo
8 = 0rums, Barrels, Carboys G Boxes, Carbons. Cases M = Tank Car/Trailer ~NSP. ID DATA E~RY
C = Undergroun~ Tanks H =SumO or Pit N =SealeO Source Iradioactive material)
D = Aboveground Tanks I = Industrial Processing E~uigmenI 0 = UnsealeO Source (ra~ioaclive material) ~NS~ INIT ~ DATA E~RY INIT
P = Other container tyDe. sDecify
E = Glass Containers J = Comgressed Gas CylinOers PA~E ~ 0A~ .
09/30/93~ LUCK TORES INC ~278 215-000- 82.4 Page i
Overall Site with 1 Fac. Ur, it
Ger;era 1 I r~format i c,r~
Locat or~: 1621 COLUMBUS ST Map: 103 Hazard: Low
Comn~ur~ity: BAKERSFIELD STATION 08 Grid: 16D F/U: 1 AOV: 0.0
~- Contaot Name i Title ........... ~-- Busir~ess Phr, ne_ ........ ~ 24-Hour. Phc, r~e-
L~.~8~-.~-~.~ ASST MANAGER (805) 8'72-5232 x (805
~.~./-.-~.1.~
Cc, r~m C,:,d~ ~-~.~ BAKERSFIELD ST~T~DN O~ S~C C,:,d~
City: BUENA PARK Zip: 90620-
Sumn~ary RECEIVED
:OC[ 2 ~ ~995
ALLEN I~UIGNON O0 her~w~ c~.~i? ~h~ ~ haw
merit plan for L ~ e/~~s~d.~h~ it along
~rre~[ons consfitu~s a compls~s and corr~ m~-
[)9/3[)/93 LUCK TORES INC #278 215-000- 824 Page 2
Hazrs~at Irsverftory List irs MCP Order
02 - Fixed Cor~tair~ers on Site
Pl r~-Ref Na~e/Haz apds For~ Max Qty MCP
02-002 BLEACH Liquid 55 High
Reactive~ I~ed Hlth GAL
02-003 AP~MON I A SOLUTION Liquid 55 Moderate
Reactive, I~ed Hlth GAL
02-001 MOTOR OIL Liquid 200 Mini~a 1
Fire, Delay Hlth GAL
09130193 LUCK TORES INC ~278 215-000- 824 Page 3
(:)2 - Fixed Cor~tair~ers or~ Site
Hazmat Ir~ver~tory Detail ir~ MCP Order
C~' ' ']~' 55
~-0~ ~ BLEACH Liquid High
Reactive~ Iron, ed Hlth GAL
CAS ~: Trade Secret: No
Fore, I: Liquid Type: Pure Days: 365 Use: CLEANING
Daily Max GAL I Daily Average GAL I A'nnual A~nount GAL ---
55 I 25.00 I 500.00
Storage F Press T Temp ~ Locatior~
PLASTIC CONTAINER ~mbientl~r~bier~g}SfiLES FLOOR
-- Cor~c - ~ Cc, mpor, erres [-- MCP [Guide
~00.0% Bleach High ~ 45
02-003 AMMONIA SOLUTION Liquid ~ Mc, derat e
Reactive, Immed Hlth GAL
CAS ~: Trade Secret: No
Form: Liquid Type: Mixture Days: 365 Use: CLEANING
Daily Max GAL ........ [~ Daily Average GAL ---~ Anr~ual A~our~t GAL ---
55 ] 25.00 ~ 500.00
Storage .]- Press T Te[np -~ Location
PLASTIC CONTAINER lAmbier~t/Ambier~tlSALES FLOOR
-- []or~c ~ .... Ccm~por~er~ts T-. MCP -~uide
30.0%~]monia Solut ior~ /Moderatel 60
/ I
02-001 MOTOR OIL Liquid 200 Mi r~i~J~a 1
Fire, Delay Hlth GAL
CAS ~: 'l"rade Secret: Nc,
Form: Liquid Type: Pure Days: 365 Use: LUBRICANT
...... Daily Max GAL. - ......... Daily Average GAL ..... ]- ...... Ar~r~ual Amour~t GAL ....
200 ~ 100.00 ~ 2, 000.00
Stc, rage F Press T Te[np --[ Locatior~
PLASTIC CONTAINER ~ A~nbierrblAmbierrb ~ SALESFLOOR
-- Corec -7 Cc, mpor~errts F- MCP -~.Guide
100 0% lMir~i~nal ~ 27
. . lMotor Oil, Petrc, leu~ Based
09/30/93 LUC STORES INC ~278 215-000 ~824 Page 4
O0 - Overall Site
<D> Notif. /Evacuation/Medical
<1> Agency Notification
IN SITUATIONS IN WHICH A HAZARDOUS MATERIAL SPILL OR LEAKAGE OCCURS, N[]TIFY
THE DIVISION SAFETY OFFICE (714) 739-Az~B~ DURING NORMAL BUSINESS HOURS (8
A.M. - 5 P.M., MONDAY - FRIDAY), FOR ~b~THER INSTRUCTIONS ON NOTIFICATION OF
APPROPRIATE AGENCIES.
DURING NON-OPERATIONAL HOURS TELEPHONE THE DUTY SAFETY~ REPRESENTATIVE
~. (714) ~~~~-HE DUTY REPRESENTATIVE ~'S ~1' RET~~ ~ C~LL~
~:FI:I~J 3{:~ql~t]~, ~.YOUR DISTRICT SAFETY REPRESENTATIVE.
THE SAFETY REPRESENTATIVE SHALL NOTIFY THE LOCAL FIRE DEPARTMENT (805)
326-3979 OF THE INCIDENT. AFTER []ONTACTING THE DIVISION SAFETY MANAGER A
DECISION WIEL BE MADE AS TO WHETHER THE STATE OFFICE OF EMERGENCY SERVICES
WILL BE NOTIFIED (800) 852-7550.
<2> E~ployee Notif./Evacuation
IF IN STORE MANAGEMENTS OPINION IS THE STORE MUST BE EVACUATED OR YOU' RE
INSTRUCTED TO EVACUATE BY LOCAL AUTHORITIES (FIRE DEPT/POLICE.DEPT) DO SO
ACCORDING TO ESTABLISHED POLICY AND PROCEDURE. REFER TO RED/GRAY EMERGENCY
PROCEDURE BULLETIN FOR INSTRUCTIONS.
MANAGEMENT SHALL WALK THROUGH STORE INFORMING ASSOCIATES TO LEAVE THE STORE
IMMEDIATELY THROUGH SAFEST EXIT.
PUBLIC ADDRESS SYSTEM SHALL ONLY BE USED IN SITUATIONS THAT REQUIRE
IMMEDIATE EVACUATION, 'TO MINIMIZE PANIC AMONG CUSTOMERS AND ASSOCIATES.
<3> Public Notif. /Evacuation
REFER TO RED/GRAY EMERGENCY PROCEDURE BULLETIN FOR INSTRUCTIONS.
STORE MANAGEMENT AND ASSOCIATES SHALL WALK THROUGH STORE INFORMING CUSTOMERS
TO LEAVE PURCHASES IN STORE AND EXIT THROUGH SAFEST EXIT.
PUBLIC ADDRESS SYSTEM SHALL ONLY BE USED IN SITUATIONS THAT REQUIRE
IMMEDIATE EVACUATION, TO MINIMIZE PANIC AMONG CUSTOMERS AND ASSOCIATES.
<4> Eraergency Medical Plan
ASSOCIATES OR CUSTOMERS WHO SUSTAIN INJURY OR ILLNESS DUE TO HAZARDOUS
MATERIAL SPILL. OR LEAKAGE SHALL BE REFERRED TO COMPANY DESIGNATED MEDICAL
CLINIC FOR TREATMENT.
IF INJURY OR ILLNESS IS SERIOUS OR LIFE THREATENING NOTIFY PARAMEDICS OR
EMERGENCY SERVICES IMMEDIATELY.
09/30/93 LUCK ]'ORES INC ~278 215-00~ Page 5
ex.') - Overall Site
<D> Not if. /Evacuat iors/Medical
<4> E~s~erge~scy Medical Plat, (Cor, tir~ued)
09/30/93 LUC STORES INC ~278 215-000- Page 6
00 - Overall Site
<E> Mit igat ior~/PreverJt/AbaterJ~t
<1> Release Prever~tion
ITEMS ARE PACKAGED IN SMALL CONTAINERS FOR RESALE. ITEMS ARE SAFETY SEALED
AND DISPLAYED ON A LEVEL, SECURE SURFACE IN A MANNER TO PREVENT ACCIDEN'I'AL
DISLODGMENT. CERTAIN CHEMICALS KEPT AT DIFFERENT LOCATIONS TO PREVENT
MIXING. ABATEMENT PROCEDURES ARE 'TO EFFECT CLEAN-UPS WITHOUT CONTACT WITH
SKIN AND TO REMOVE ANY ]"RACES FROM THE EXPOSED SURFACE. IT IS THEN DISPOSED
OF IN A SAFE MANNER TO AVOID FURTHER CONTACT.
<2> Release Cor~tairm~er~t
PUT UP "CAUTION WET FLOOR" SIGNS OR ROPE OFF AREA TO PREVENT
CUSTOMERS/ASSOCIATES FROM ENTERING SPILL AREA.
IF STRONG OR IRRITATING ODORS ARE PRESENT, WARN OTHERS TO MAINTAIN SAFE
DISTANCE FROM SPILL AREA.
IF MATERIAL IS DRY, KEEP ASSOCIATES/CUSTOMERS FROM WALKING THROUGH MATERIAL,
SPREADING IT TO OTHER AREAS.
IF MATERIAL IS WET OR LIQUID, SPRINKLE ABSORBENT MATERIAL AROUND EDGE OF
SPILL TO CONTAIN LIQUID.
<3> Clear~ Up
USE APPROPRIATE PROTECTIVE EQUIPMENT AS REQUIRED BY MATERIAL SAFETY DATA
SHEET (MSDS).
IF SPILL IS GREATER THAN ONE GALLON NOTIFY THE SAFETY DEPARTMENT IMMEDIATELY
FOR CLEAN UP INSTRUCTIONS.
IF MATERIAL SPILLED IS DRY, SCOOP OR GENTLY SWEEP UP DRY MATERIAL AND PLACE
IN DOUBLE BAGGED PLASTIC TRASH BAG. D[] NOT SWEEP VIGOROUSLY AS YOU MAY
SPREAD MATERIAL.
IF MATERIAL SPILLED IS WET OR LIQUID, SPRINKLE ABSORBENT MATERIAL AROUND
EDGE OF SPILL. GENTLY SWEEP ABSORBENT 'TO CENTER OF SPILL TO ABSORB LIQUID.
GENTLY SWEEP UP USED ABSORBENT AND PLACE IN DOUBLE BAGGED PLASTIC TRASH BAG.
LABEL TRASH BAG AS "HAZARDOUS MATERIAL" AND PLACE IN WAREHOUSE TEMPORARILY.
WET MOP AREA OF SPILL WITH MILD DETERGENT AND WATER.
SAVE USED ABSORBENT, MOP, PRODUCT CONTAINER AND WASH WATER. CONTACT ]'HE
SAFETY DEPARTMENT (714) 739-~700~] OR PROPER DISPOSAL INSTRUCTIONS.
THOROUGHLY WASH HANDS/ARMS WITH SOAP AND WATER AFTER CLEAN-UP.
<4> Other Resource Activatior~
09/30/93 LUCK TORES INC ~278 215-000- 824 Page 7
00 - Overall Site
<E> Mit i gat ior~/Preverr~/Abatement
<4> Other Resource Activation (Cor~tirsued)
09/30/93 LUC STORES INC $~278 ~i' ~ ~
- 5- 0 C)0-o00824 Pa ge 8
00 - Overall Site
<F> Site Emerger~cy Fac. tots
<1> Special Hazards
PROPANE TANKS ARE STORED OUTSIDE BUILDING FOR USE BY FLOOR BUFFER.
REFRIGERATION SYSTEM USES FREON $$'S 12,22,502 FOR COOLING OF FOOD PRODUCT
THROUGHOUT STORE.
<2> Utility Shut-Offs
A) GAS - NONE
B) ELECTRICAL - SOUTH BACK SIDE OF STORE
C) WATER - BACKROOM CENTER SOUTH WALk.
D) SPECIAL - FIRE SPRINKLER AND ALARM SYSTEM
E) LOCK BOX - NO
<3> Fire Protec. /Avail. Water.
PRIVATE FIRE PROTECTION - STORE IS EQUIPED WITH A AUTOMATIC SPRINKLER
X T ' N ~ '-'H ~ R.q
i::'ROTECTION SYSTEM, ALARM SYSTEM, AND FIRE E, I GUIo E~
FIRE HYDRANT - ??????????
<4> Building Occupar~cy Level
09/30/93 LUCK TORES INC -~278 215-000-( 24 Page 9
O0 - Overall Site
<G> Trair~irsg
< 1> Page 1
WE HAVE 94 EMPLOYEES AT THiS FACILITY
WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE
BRIEF SUMMARY OF TRAINING: MATERIAL SAFETY DATA SHEETS ARE ON FILE FOR ALL
HAZARDOUS MATERIALS USED IN THE STORE.
ALL ASSOCIATES RECEIVE INITIAL HAZARD MATERIAL COMMUNICATIONS TRAINING AT
THE TIME OF THEIR INITIAL ASSIGNMENT.
TRAINING INCLUDES BUT IS NOT LIMITED TO 1) VIDEO ENTITLED "CHEMICAL SAFETY",
c~ ~'~-
2) DIsCUssION OF HAZARDOUS MATERIALS IN THE DEPARTMENT, 3) LOCATION OF MSDS,
4) QUESTION/ANSWER PERIOD.
ASSOCIATES RECEIV RE-FRESHER TRAINING ON HAZARDOUS MATERIALS ON AN ANNUAL.
BASIS.
EMERGENCY PROCEDURES ARE RANDOMLY CONVERED WITW ASSO[]IATES AND ARE POSTED
THROUGHOUT THE STORE ON EMERGENCY PROCEDURE [~ULLETINS (RED/GRAY POSTER)
<2> Page 2 as r~eeded
<3> Held for Future Use
<4> Held for Future Use
0~/30/~3 LUC~ TORES INC ~278 2i5-000- 824 Page i0
00 - Ove'rail Site
<G> Trair~ir~g
<4> Held fnr Future Use (Cor, tir, ued)
09/30/93 LUCK TORES INC $~278 215-000- 24 Page I1
00 - Overall Site
<H> RMPP DATA
<1> Release Cor~tainr~erst
<2> Offsite Corssequer~ces
<3> In House Capabilities
<4> Plar~t Shutdowr~ Ir~structiors
PARTB~[g87 HAZARDOUs MATERIALS INVENTORY ~AGE 2 OF 8
~ INSTI~UCTi0NS: READ ~LL THE h$ BELOW A~'4O ON PAGE 4. PHOTOCOPY EXTRA OF THIS FORM SE=0~E COMPLETING IT. ,~EFO~T HA~A~C
WASTES ON REVERSE'SiDE
~. COMPLETE A SEPARATE FORM FOR EACH BUILDING. OUTDOOR AREA, OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE BOX BELOW TO SPEC
THE LOCATION 0F THE HAZARDOUS MATERIALS LISTED 0N THIS FORM. (HAZARDOUS WASTE 0N PART C.)
LOCAT ON OF HAZARDOUS MATERIALS:
]ROOM NAM6 OUTDOOR AREA
OR NOMBE~ . BUILDING NAME OR NUMBER NAME OR NUMBER
2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED 0R HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS 0F THE
tNCLUOE RAW MATERIALS. FINISHED CHEMICAL PR00UCTS, CHEMICALS MANUFACTUREO 0R REPACKAGED, AND CHEMICALS DISTRIBUTED. USE THE COORS
TABLE I AT THE BOTTOM OF THIS FORM T0 COMPLETE COLUMN 4.
3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE.
FILL IN A & O FOR EACH HAZARDOUS MATERIAL OR HA~RDOUS ES~MATE MAXIMUM ESTIMATE TO,TAL LIST AL~ THE TYPES ~A'V~
MATERIAL MIXTURE. USE EXACT SPELLING. ~UAN~TY HANOLED OR STORED QUANTITY HANDLED OR OF CONTAINERS
A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. A~ ANY ~ME iN 1987 AT STORED DURING 1987 USED TO STORE ' SAFE-
ABOVE LOCA~ON. INCLUDE AT ABO~ LOCATION. HAZARDOUS MATERIAL -
B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i,e, LBS, GALLONS, EVEN IF ONLY BRIEFLY, USE TABLE 1. THE
~ HAZA;
AL~ INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLUDE UNITS. MATE:
A, RF,~.T. nOG & Ck~ ~ (A[~OSO[)
a. ~ NO~ D[~ONE 1.9
~E%A~D CO~O~S .1 ~ 24 IDS. 960 ~SS. ~[OSO[
I~[[T 98.0 ~ C~ NO
EOUS~O~D ([~AI[).
A. RE~[ DOG & CA~ (SOLID)
~. ~ IC~O~OBENZER[ 20.0
~ ~IDINES 2.0 ~ 50 [SS. 2,000 [~S. C~SO~
~I~ 2.0
IN~[~ 75.0
*. S~c~[~ - s~c~c[9~ - ~s; co~o~ _~ c~
~[0~ so[v~. 98,~2 ~ 10 C~. 400
T~ . ~ ~ ~AS~IC
HOUS~OLD (RETAI~)
A. SPECT~CIDE (ROSE) ~ROSOL
S. D~AZINON . ~
YMERT ~.~ ~ 350 OZ. 10,000 OZ. AEROSOL
~ C~ NO
~Ollg~Ol.D ~RETATL)
A. gP~CT~CIDE ANT & ROA~ SP~Y
8. O,O -DTE~ Q ,500 ~
pYRE~RIMS .05~ ~ 200 OZ. 8,000 0Z. ~ NO
TEC~MTC~ B~PERO~ BUTOXIDE ,%~! % C~
p~TROT, ET~ DTSTTT,T,ATE 95,862 ~
INERT ,, ~, ~2~ ....
P~OT~T~ SOT,V~NT ,28 ~ 10 G~. 400 G~. PLASTIC NO
IN~RT 99,22 ~
~o~rs~o~,~ ~W~T~TZ.) ......
A OReO WEED-b-GON
8. D TME~,~[INE 22,4
TNERT 77,6
~ 20 PTS. 800 PTS. ~T~ C~ NO
TABLE 1 STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = ComDressed Gas Manifold OFFICE USE ONLY
A = Metal Containers (45 gallons) F = Bags L = Pressure Vessel - Not portable
6 = 0rums, Barrels, Carboys G = 8oxes, Cartons. Cases M = Tank Car/Trailer ~Nsr. io DATA E~RY tO ....
C = Underground Tanks H = Sump or Pit N = Sealed Source (radioactive material)
0 = Aboveground Tanks I = Industrial Processing EQui0ment 0 = Unsealed Source (radioactive material) ~NSP INIT ~ 0ATA E~RY INIT
P = Other container ty~e, s~emfy
E Glass Containers J = Compressed Gas Cylinders P~GE 5 0AR
PART B- lg87 HAZARDOUS N1AT?~itIALS INVENTORY PAGE 3 .OF 8.
,
I STRUCTIONS: READ ALL THE INST~qUCT',0NS BELOW AND ON PAGE 4 PHOTOCOPY EXTRA COP~ES OF THIS FORM BEFORE COMPLET,NG IT, ,~E~OaT
WASTES ON ~EVERSE SIOE~
~. COMPL~TE A SEPARATE FORM FOR EACH BUILDING. OUTDOOR AREA. 0R ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE BOX ~ELOW T0 SF~.2
THE LOCATION 0F THE HAZARDOUS MATERIALS LISTED 0N TH~S FO~M (HAZAROOUS WASTE ON PART C.)
"LOCATION OF HAZARDOUS MATER ALS;
}ROOM NAM~ OUTQOOR AREA
OR NUMBER . BUILDING NAME OR NUMBER NAME OR NUMffiER
2. COMPLETE COLUMNS 1-5 FOR EACH HAZAR00US MATERIAL STORE0 0R HANOLE0 AT THE LOCATION SPECIFIE0 ABOVE, REGAROLESS 0F THE
INCLUDE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS. CHEMICALS MANUFACTURED 0R REPACKAGED, AND CHEMICALS DISTRIBUTED. USE THE CODES
TABLE 1 AT THE BOTTOM 0F THIS FORM T0 COMPLETE COLUMN 4.
3. RETURN COMPLETED INVENTORY AN0 APPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE.
~ILL IN A & B FQR ~ACH HAZAR~QUS MATERIAL QR HA~RDOUS ~S~MAT~ MAXIMUM ~ST~MAT~ TQTA~ LI~T A~ TH~ TYP~ --
MATERIAL MIXTURE. ~SE EXACT SPELLING. QUAN~TY HANOLED 0~ STOR~D Q~ANTIT~ HANOLED ~ ~ ~0NTAIN~
A. PRODUCT NAME 0R COMMON NAME 0F HAZARDOUS MATER[AL. AT ANY DEE IN 1987 AT STORED DURING 1987 ~ USED T0 STORE SAFE-
ABOVE LOCADON. ~NCLUDE A~ ABOVE LOCATION. ~ HAZARDOUS MATERIAL - SMEE-
B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION 0F UN~TS. (Le. Las. GALLONS. EVEN IF ONLY BRIEFLY. ~ USE TABLE t
HAZ;:
ALL INGREDIENTS {N HAZARDOUS MATERIAL. etc.) INCLUDE UNITS.
A. OR~O ~D-B-GON ~OSO~
~N~ 99.28 % 30 ~BS. Z, 200 ~BS. A~OSO~
% C~ NO
A. O~O ~UG S~ ~OSO~
S~I~N , ~1 ~ 25 ~BS, Z ,0OO ~BS, AS~OSOL
O~FR ISO~RS .009 ~ C~ NO
PE~OLE~. DISTILLATE 11, ~00
INERT , ~{. 100
A. OReO ~ED-B-GO~ ' LIOUID SP~Y
I~ERT 99.60 ~ 40 P~S. 1,600 PIS. PLASIlC
HOIIR~OT,D (RETAIl, 5
A. OR~O TRTOX VEGETATION KILLER
S. PROMETON 1.86
INERT ~,~4 % 20 QTS. 800 QTS. MET~
~ C~S N0
~OITSE~OT,D (RETAIL] ....
A. OR~O KLEE~P-G~SS KILLER
IKOPROP~INE S~T OF GL~HOSAT ~.0
INERT 95.0 % 10 G~ 400 G~. PLASTIC NO
%
HOITg~HOT,D (RETATT.~
A. OR~O ~T/ROA~/HO~ET/WASP ~ROS.OL
8. ~CARRO~TE 1. O ~
PETROLEI~ DISTTLLATE 82.~ % 24 PTS. 960 PTS. ~ROSOL
TNKRT 16 · 7 ~ C~ NO
%
A, C~W~ - COPH~R MT~ (SOLID)
s. RTRW~NTNE ALMOLOID , ~0%
TN~V 99,70~ 24 LBS. 1,000 LBS. C~BO~ NO
~A~LE 1 STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Com0resseU Gas Manifold OFFICE USE ONLY
A = Metal Containers (<S gailons) F =Bags L =PressureVesseI-Not~ortaDie
8 0rums. Barrels, Carboys G Boxes, Cartons, Cases M = Tan~ Car/Trailer ~NSF I~ ~ATA ENTRY
C = Underground Tanks H = Sum0 or Pi~ N = Sealed Source (radioactive material)
0 = Aboveqround Tanks I = Industrial Processing E~uiDment 0 = Unseale~ Soured ~ra~ioactive material) INSP ~Ni~ ~ 0ATA E~TR~
P = 0t~er container type, specify
E = Glass Contmners J Compresse~ Gas Cylinders PAGE 5
PART B - 1987 HAZARDOUS MATERIALS INVENTORY
~; I-NST~lJ~TIONS: REAO ALL THE BELOW ArlO ON PAGE 4. PHOTOCOPY EXTRA OF TH~S FO~M SE,'--O,qE COMPLET!NG IT ,~E~'O~T
WASTES ON REVERSE StOE.~
1. COMPLETE A SEPARATE FORM FOR EACH BUILDING. OUTDOOR AREA. OR ROOM WHERE HAZAROOUS MATERIALS ARE LOCATED. USE BOX BELOW TO $~_C
THE LOCATION OF THE HAZAROOUS MATERIALS LISTED ON THIS FORM. /HAZAROOUS WASTE ON PART
LOCATION OF HAZARDOUS MATERIALS: _ _
~lOOM NAME OUTDOOR AREA
NAME OR NI.JMBER
OR NUMBEFt SUILDING NAME OR NUMOER
2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANOLED AT THE LOCATION SPECIFIED ABOVE. REGARDLESS OF THE QUANTJ'
INCLUOE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS, CHEMICALS MANUFACTURED OR REPACKAGED, AND CHEMICALS DISTRIBUTED, USE THE CODES
TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4.
3. RETURN COMPLETED INVENTORY AN0 APPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE.
FILL IN A & S FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS ESTIMATE MAXIMUM ESTIMATE TOTAL LIST ALL THE TYPES .,
-- HAVE
MATERIAL MIXTURE. USE EXACT SPELLING. QUANTITY HANDLED OR STORED 0UANTITY HANOLED OR OF CONTAINERS MA~E
A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TIME IN 1987 AT STORED DURING 1987 USED TO STORE SAFE-
ABOVE LOCATION. INCLUDE AT ABOVE LOCATION, HAZARDOUS MATERIAL. SHEE~
B, CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (ime. LBS. GALLONS, EVEN IF ONLY BRIEFLY. USE TABLE I. THE
HAZ;~
ALL INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLU0E UNITS. MATE:
A. DIXAL ANT KILLER DUST
s. BENDIOCARB 1.0
inert 99.0 % 12 LBS. 400 LBS. CARDBOARD
~ CAN NO
HOUSEHOLD (RETAIL) ,
A, ORTM DIAZINON GRANULES
s. DIAZ INON 2.0
INERT 98.0 % 12 LBS. 400 LBS. CARDBOARD
~ CAN NO
H, OUSEHOLD (RETAIL)
A. ORTHO FLEA-B-GON
s. CHLORPYITOS .50
XYLENE SOLVENT .33 % 24 ~Ts. 1,000 PTS. PLASTIC NO
INERT 99.17
%
HOUSEHOLD (RETAIL)
A. BUG FOGGERS/FUMIGATORS
s. PERMETHRIN 12.6
..... INERT 87.4 % 100 LBS. 4,000 LBS. AEROSOL
% CANS NO
HOUSEHOLD (RETAIL)
f- AEROSOL BUG SPRAY BLK. FLAG/RAID
E~. PHENOL METHYLCARBAMATE .95
RELATED COMPOUNDS .05 % 200 LBS. 8,000 LBS. AEROSOL NO
PETROLEUM DISTILLATE 8O,~O %
INERT 18.50
, HOUSEI~OLD (RETAIL)
! A. ROACH BAIT TRAYS
~ s. TETRAHYDRO -S 1, ~.5 ~
1 INERT ?8.35 % 30 LBS. 1,200 LBS. CARDBOARD
% BOXES NO
HOUSEHOLD (~ETAIL ~ , ,
IA" ANTI-FREEZF. (AUTOMOTIVE)
s. ETHYLEN~ GLYCOL BASE
% 30 GAL. 1,200 GAL. PLASTIC
% BOTTLES NO
HOUSEHOLO (R~AIL~ , ,
~ TABLE I STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K - Compressed Gas Mamlold OFFICE USE ONLY
A = Metal Containers (<S gallons) F = Bags L = Pressure Vessel - Not p~rtabte
· 8 = Drums, Barrels, Carboys G 8oxes, Cartons, Cases M = Tank Car/Trailer iNSP.
C = Underground Tanks H = Sump or Pit N = Sealed Source (radioactive material)
0 = Aboveground Tanks I = industrial Processing Equipment 0 = Unsealed Source (radioactive material) INSP ~N~T
P --- Other container type, specify
E = Glass Containers J Compressed Gas Cyhnders PAGE 5 0ArE 0~rE
INSTRUCTIONS: REAO ALL THEINST,~t~T;ONS BELOW ANOON PAGE 4. PHOTOCOPY EXTRA S OF THIS FORM BEFORE COMPLET;NG IT ~RE~ORT
~, WASTES ON REVER~OE.)
I, COMPLETE A SEPARATE FORM FOR EACH BUILOING, OUTDOOR AREA, OR ROOM WHERE HAZAROOUS MATERIALS ARE LOCATED. USE BOX BELOW TO
THE LOCATION OF THE HAZARDOUS MATERIALS LISTED ON THIS FORM. (HAZAROOUS WASTE ON PART C.)
LOCATION OF HAZARDOUS MATERIALS:
ROOM NAME OUTDOOa AaEA
OR NUMBER ~UILOING NAME OR NUMBER NAME OR NUMGER
2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED 0R HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANTa;
INCLUDE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS, CHEMICALS MANUFACTURED 0R REPACKAGED, ANO CHEMICALS DISTRIBUTED. USE THE CODES
TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4.
3. RETURN COMPLETED ~NVENTORY ANO APPLICATION IN ENCLOSE0 SELF-A00RESSE0 ENVELOPE.
FILL JN A & 6 ~OR EACH HAZARDOUS MATERIAL OR HAZARDOUS ES~MATE MAXIMUM ESTIMATE TOTAL UST ALL THE TYPES
~ HAVE
MATERIAL MIXTURE. USE EXACT SPELLING. QUAN~TY ~0R STORE0 QUANTITY HANOLEO 0R ' 0F CONTAINERS MATE:
A, PRODUCT NAME 0R COMMON NAME 0F HAZARDOUS MATERIAL. AT ANY ~ME iN 1967 AT STORE0 0URING 1967 USE~ TO STORE SAFE-
ABOVE LOCATION. INCLUOE AT ABOVE LOCATION, HAZARDOUS MATERIAL - SHEE-
B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION 0F UN~TS. (i.e. LBS, GALLONS, EVEN IF ONLY BRIEFLY. USE TABLE 1. THE
AL~ INGREDIENTS IN HAZARDOUS MATERIAL, etc.) INCLUDE UNITS. MATE=
s. MORPHOLINE
% 50 PTS. 2,000 PTS.
% C~S NO
~. PE~OLE~ DISTILLATES
~ 25 PTS. 1,000 PTS.
% C~S NO
A. TIRE P~C~E S~ ~RO~O~
~- PETROLE~ DISTILLATES
~ 12 PTS. 500 PTS.
A. RE~IGE~T- 12. ~ROSOL
a D ICHLORODI~4OROME~E 5.0
CCI3F~.. ~ ~ 24 PTS. 1,000 PTS
~ C~ NO
f. MOTOR 0~LS
a PE~OLE~ DISTILLATES
~ 100 G~. 4,000 G~.
% C~S NO
HOUS~OLD (RETAIL)
A. PROP~IE ~EL
S' PROP~E GAS 100 %
~ 30 ~I~ER~ 1,200 ~IT ; ~
NO
HOUSEHOLD (RETAIL)
A. MO~ B~L$ (SOLID)
a. P~IC~OROBENZENE .... 100
% C~BO~ NO
% 30 LBS. 1,200 LBS.
Hous~0LD (RETAIL)
TABLE 1 STORAGE CONTAINER TYPES. {LIST ALL THAT APPLY) K = Compressed Gas Manifold OFFICE USE ONLY
A = Metal Containers (45 gallons) F = 8acs L = Pressure Vessel - Net ~ortable
9 = Drums. Barrels. Carboys G 8oxes, Cartons, Cases M = Tank Car/Trailer INSP. 10 , 0ATA ENTRY 1O'~
C = Underground Tanks H = Sum0 or Pit N = Sealed Source {radioactive material)
O = Aboveground Tanks I = Industrial Processing EQuioment 0 = Unsealed Source {radioactive material) iNsP INIT 0ATA E~RY INIT
P = Other container type, specify
E Glass Containers J Compressed Gas Cylinders PAGE 5 o~
PART 8 - 1987 HAZARDOUS MAaT~RIALS INVENTORY PAGE . 6 OF ~_
I'~STRUCTIONS: READ ALL THE INSTR'~TIONS BELOW AND ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT. (REPORT HAZAP~
WASTES O~ REVERSE S~OE.'~
1. COMPLETE A SEPARATE FORM FOR EACH BUILDING. OUTDOOR AREA. OR ROOM WHERE HAZAROOUS MATERIALS ARE LOCATED. USE BOX BELOW TO SPES
THE LOCATION OF THE HAZARDOUS MATERIALS LISTEO ON THIS FORM. (HAZAROOUS WASTE ON PART
LOCATION OF HAZARDOUS MATERIALS:
COMPLETE ALL ITEMS IN SOX BUSINESS LUCKY STORE #
· NAME __ _ ~ ADDRESS
I ROOM NAME OUTDOOR AREA
/OR NUMBER .... BUILDING NAME OR NUMBER NAME OR NUMBER
2. COMPLETE COLUMNS 1-5 FOR EACH HAZAROOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANTI
iNCLUDE RAW MATERIALS, FINISHED 'CHEMICAL PRODUCTS, CHEMICALS MANUFACTUREO OR REPACKAGEO, AND CHEMICALS DISTRIBUTED, USE THE CODES
TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4.
3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF*AOORESSEO ENVELOPE.
II
I
I
/
I
FILL IN A & O FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS EST1MATE MAXIMUM ESTIMATE TOTAL LIST ALI. THE TYPES ,, ,F .
' HAVE
MATERIAL MIXTURE. USE EXACT SPELLING. QUANTITY HANOLED OR STORED QUANTITY HANDLED OR OF CONTAINERS MAT~_
A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TIME IN 1987 AT STORED 0URING 1987 USED TO STORE SAFE-
ABOVE LOCATION. INCLUDE AT ABOVE LOCATION, HAZARDOUS MATERIAL- '
B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i.e. LBS. GALLONS, EVEN IF ONLY BRIEFLY, USE TABLE 1. THE
HAZ~
ALL INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLUDE UNITS.
A. HOUSEHOLD GLUES / E-POX-E'S
8.
NO NAME % 10 LBS. 120 LBS. CARDBOARD
% PLASTIC NO
%
HOUSEHOLD (RET6IL)
A. HAIR SPRAY~ AEROSOL
S. SD ALCOHOL %
BUTANE / PROPANE % AEROSOL
VINYL ACET~E/¢ROTONIC ACID ~ 100 LBS 4,000 LBS. CANS NO
BENZYL ALCOHOL
HOUSEHOhp (RETAIL J
A. KITCHEN - METAL
s. ~QDIUM SILICOFLUORIDE
SULFAMIC ACID ~ 50 PTS 2,000 PTS PLASTIC
~ CANS NO
T-TOT T.q ~FTOT,T) (RF. TATT.')
A. 0V~N
S. ,qODTUH RYD~{Q~TDE % METAL
~ 100 LBS. 4,000 LBS AEROSOL
~ CANS NO
T4'(3TT~ P~OT,D (RKTAIL~
A. W T TC.~t F.N / BAT~4 CT,F AN~,,~ (LIME-A-WAY~
s. PHOSPHORUS ~, 8
% 24 PTS. 1,000 PTS. PLASTIC NO
w OTT,R'FfT4'OT,D (RF, TAIL] , ,
a. ?OTT.ET BOWL CT.~ANER
Sl HY~DROGF, N cRLORTDE 8.50 %
ALM~q'. .75 % 20 GAL. 800 GAL. PLASTIC NO
TNF. RT 90,75 %
%
A. AT~ V~F.qHENER AEROSOL
B.
% 500 PTS 10,000 PTS
% CANS NO
T-TDTT~R F, ROT.D (~ETATL'}
TABLE 1 STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold OFFICE USE ONLY
A = Metal Containers (<5 gallons) F = Sags L = Pressure Vessel - Not portable
B Drums, Barrels. Carboys G Boxes, Cartons, Cases M = Tank Car/Trailer INSP. ID . DATA ENTRY lO _,
C = Underground Tanks H = Sump or Pit N = Sealed Source (radioactive material)
0 = Aboveground Tanks I = Industrial Processing Eduioment 0 = Unsealed Source (radioactive material) INSP INIT ~ DATA ENTRY INIT __
P = Other container type, specify
....., E Glass Containers J Compressed Gas Cylinders PAGE 5 DA~ DATE
-PART B - i987 HAZARDOUS MATERIALS INVENTORY PAGE 7~ OF 8
IH'STR~JCTIONS: READ ALL THE INST'[lIONS BELOW AND ON PAGE 4. PHOTOCOPY EXTRA C OF THIS FORM BEFORE COMPLET{NG IT. ~,REPORT
WASTES ON REVERSE SIDE.)
1. COMPLETE A SEPARATE FORM FOR EACH BUILDING. OUTDOOR AREA. OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE 80X BELOW TO SPEC::
THE LOCATION OF THE HAZARDOUS MATERIALS LISTED ON THIS FORM. (HAZARDOUS WASTE ON PART C.)
ILOCATION OF HAZARDOUS MATERIALS: .....
COMPLETE ALL ITEMS IN BOX. NBUASMI~1:55 LUCKY STORE # ADDRESS
ROOM NAME OUTDOOR AREA
OR NUMBER , BUILDING NAME OR NUMBER NAME OR NUMBER
2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANTIT'~
INCLUDE RAW MATERIALS, FINISHED CHEMICAL PR00UCTS, CHEMICALS MANUFACTURED OR REPACKAGEO, AN0 CHEMICALS 01STRIBUTED. USE THE CODES
TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4.
3. RETURN COMPLETED INVENTORY AND APPLiCATiON IN ENCLOSED SELF-ADDRESSED ENVELOPE.
FILL IN A & S FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS ES~MATE MAXIMUM ESTIMATE TOTAL LIST ALL THE TYPES .~ *F
-- ~'AVE
MATERIAL MIXTURE. USE EXACT SPELLING. QUANTITY HANDLED OR STORED QUANTITY HANOLE0 OR OF CONTAINERS MATE;
A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY I'IME IN 1987 AT STORED DURING 1987 USED TO STORE SAFET'.
ABOVE LOCATION. INCLUDE AT ABOVE LOCATION, HAZARDOUS MATERIAL- SHE~:
B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i.e. LBS, GALLONS, EVEN IF ONLY BRIEFLY. ! USE TABLE 1. THE
ALL. INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLUDE UNITS. MATE;
A. DRAIN CLEANERS (SOLED)
s. LYE 100
% 25 LBS. 1,000 LBS METAL
~ CANTS NO
HOUSEHOLD (;RETAIL)
A. DRA]~N CLEANERS (LIQUID)
s. SODIUM HYDROXIDE' 1.7 %
SODIUM HYPOCHLORITE 6.0 ~ 20 GAL. 800 GAL. PLASTIC NO
INERT 92.3
%
HOUSEHOLD ~RETAIL~
A. ~HOUSEHOLD BLEACH LIQUID/SOLID
6. SODIUM HYPOCHLORITE 5.25 '-%
INERT 94.75 % 300 GAL. 1,200 GAL PLASTIC NO
HOUSEHOLD (RETAIL)
A. HYDROGEN PEROXIDE SOLUTION
s. HYDROGEN PEROXIDE (10-VOLUME) 3.0
INERT 97.0 % 10 GAL. 400 GAL. PLASTIC NO
%
%
HOUSEHOLD (RETAIL)
A. GEP~MIC IDE DISINFECTANT
s. PINE OIL 52.7
SOAP 11.4 % 10 QTS. 400 QTS. PLASTIC NO
ISOPROPYL ALCOHOL 7.0
INERT 24.4
~9USEHOLD (RETAIL) .
Al RUBBING ALCOHOL
s. ISOPROPYL ALCOHOL 70.0 %
INERT 30.0
~ 50 PTS 2,000 PTS. PLASTIC NO
%
~O~$EHOLD (RETAIL5
A. AMMONIA
m. %
~ 30 GAL. 1 , 200 GAL. PLASTIC NO
HOUSEHOLD (%E~AIL) ,
TABLE 1 STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compresse{:l Gas Manifold OFFICE USE ONLY
A = Metal Containers (<5 gallons) F = Bags L = Pressure Vessel - Not portable
B = 0rums, Barrels. Carboys G Boxes. Cartons, Cases M = Tank Car/Trailer INSP. l0 DATA ENTRY ID __
C = Un(ierground Tanks H = Sump or Pit N = Seale~ Source {radioactive material)
D = Aboveground Tanks I = Industrial Processing Equipment O = Unsealed Source (radioactive material) INSP INIT DATA ENTRY INIT ~
P -- Or,er container type, specify
E = Glass Containers J Compressed Gas Cylinders PAGE 5 0A~
PART B - 1987 HAZARDOUS MATERIALS INVENTORY PAGE _ 8 OF 8
% -' ~I'NS'~'RUCTIQNS'. REAO ALL THE )NS BELOW ANO ON PAGE 4. PHOTOCOPY EXTRA OF THIS FORM BEFORE COMPLETING IT. /REPORT HATA~
WASTES ON REVERSE SIDE.)
1. COMPLETE A SEPARATE FORM FOR EACH 8UILDiNG. OUTOOOR AREA. OR ROOM WHEREHAZAROOUS MATERIALS ARE LOCATED. USE BOX BELOW
THE LOCATION OF THE HAZARDOUS MATERIALS LISTED ON THIS FORM. (HAZARDOUS WASTE ON PART
ILOCATION OF HAZARDOUS MATERIALS:
oo PLET ALL ITeMs IN BOX. T. UC CY sTo E # .ADDRESS
ROOM NAME ~ ' QUTOQQR AREA
OR NUMBER BUILDING NAME OR NUMBER NAME OR NUMBER
2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANT:
iNCLUDE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS. CHEMICALS MANUFACTURED OR REPACKAGED. AND CHEMICALS DISTRIBUTED. USE THE CODES
TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4.
3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE.
.
FILL IN A & ia FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS ESTIMATE MAXIMUM ESTIMATE TDTAL~ LIST ALL THE TYPES
~ ~'AVE
MATERIAL MIXTURE. USE EXACT SPELLING. QUANTITY HANOLEO OR STORED QUANT TY HANOLED OR OF CONTAINERS MAT~
A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TIME IN 1987 AT STORED OURING 1987 USED TO STORE
ABOVE LOCATION, INCLUDE AT ABOVE LOCATION, MAZARODUS MATERIAL- SHE,-
D. CHEMICAL NAME AN.,D, PERCENT(%) CONCENTRATION OF UNITS. (i.e. LbS, GALLONS,, EVEN ~P ONLY eRIEFLY. USE TAeLE t, THE
HAZ,: --.
ALI. INGREDIENTS IN HAZARDOUS MATERIAL, e~c.I INCLUOE UNITS.
A. CHARCOAL/LIGHTER ~FLUID, ,
~. PETROL El_r~l DISTILLATES 100
% 15 GALS. 600 GALS. METAL
% PLASTIC NO
HOUSEHOLD {RETAIL) ,
A. SPOT R~--~OVER - HOUSEHOLD
~. 1 ~ 1 ~ 1-TRICHLOROETH/~IE 100 %
% 12 PTS. 50 PTS. I~ETA.L.
CI~I~ ~UID HOUSEHOLD (~ET~L) ,, ,
A.
A.
A.
A.
%
A.
B. %
TABLE 1 STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold OFFICE USE ONLY
A = Metal Containers (<5 gallons) F = Bags L = Pressure Vessel - Not portable
,~ B = Drums. Barrels. Carboys G = Boxes. Cartons, Cases M = Tank Car/Trailer ~NSP. iD __ DATA ENTRY iD
, . C -- Underground Tanks H = Sump or Pit N = Sealed Source (radioactive material)
': O = Aboveground Tanks I = industrial Processing EQuipment 0 = Unsealed Source (radioactive material) ~NSP INIT,~ DATA ENTRY ~Nlr
P = Other container type. specify
, E Glass Containers J = Compressed Gas Cylinders PAGE 5 OATE . OA]'E
NSTRUCTIONS: READ ALL THE INSTRUCTIONS BELOW AND ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT. (REPORT HAZARDOUS MATERIALS ON REVERSE SIDE.)
1. COMPLETE A SEPARATE FORM FOR EVERY BUILDING, OUTDOOR AREA, OR ROOM WHERE HAZARDOUS WASTES ARE LOCATED. USE THE BOX BELOW TO SPECIFY THE LOCATION OF THE HAZARDOUS WASTES LISTED
ON THIS FORM
.OCATION OF HAZARDOUS WASTE:
BUSINESS NAME ADDRESS
,,ROOM NAME BUILDING NAME OUTDOOR AREA
NUMBER OR NUMBER . NAME OR NUMBER
2. COMPLETE COLUMNS .1-7 FOR EACH HAZARDOUS WASTE GENERATED, STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANTITY. USE THE CODES IN TABLE 1 & 2 AT THE BOTTOM
OF THIS FORM TO COMPLETE COLUMNS 5 AND 6. PLACE THE INITIALS N.A. IN ANY COLUMN THAT DOES NOT APPLY TO THE BUSINESS.
3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE.
FILL IN A AND B FOR EACH HAZARDOUS WASTE OR HAZo ESTIMATE AVERAGE .' ESTIMATE MAXIMUM · LIST ALL THE '
ARDOUS WASTE MIXTURE. USE EXACT SPELLING. MONTHLY QU~ ; OUANTITY ~ ' QUANTITY ~'~'~ED TYPE~-~-F · WASTE TREATMENT B. ~ IF WASTE DISPOSED OF ON SITE.
A. GIVE COMMON NAME OR DEPARTMENT OF TRANS-; ~ ~' .' ~ , ~ . . CONTAINERS ' ' AND/ORDISPOSAL
PORTATION SHIPPING NAME (DOT) OF WASTE. ~E .' ~ '....... 1-~~ / -'. USED TO STORE ' . C. GIVE WASTE HAULER'S EPA
B. GIVE CHEMICAL .NAME AND PERCENT % CONCEN- · LOCATION. INCLUDE ~TION. '. LOC---ATION,.EVENIF WASTE. USE . METHODS. USE I~ NUMBER. ASK HAULER
TRATION OF ' ALL INGREDIENTS IN HAZARDOUS UNITS. (I.e, LBS, INCLUDE UNITS. :' ONLY BRIEFLY. TABLE t BELOW. TABLE 2 BELOW. OR CONSULT WASTE MANIFEST.
~'~E. GALLONS) INCLUDE UNITS. " A. B. C.
%
?ABLE 1: STORAGE COnTAiNER TYP£S. List ali that apply. ?~l.~ ~ - TRE^TMENT & DISPOSAL TYPES Bisposal Types
~,1~1 ali that apply. OFFICE USE ONLY
A = Metal Containers (<5 gallons) I = Industrial Processing Equipment Treatment/ypes ~10 = Sewer, without clarinet or treatment
= Ground around business
B -~,Drums, Barrels, Carboys J = Compressed Gas Cylinders O1 = Sewer, with clarlfler or treatment 22 = Trash.or garbage INSP. ID DATA ENTRY ID __
'C = .~nderground Tanks K = ComPressed Gas Manifold 02 = Recycle 23 = .A. Ir,.rmeased during processing
D = ~boveground Tanks L Pressure Vessel Not portable 03 Incineration 24 = wa~erw, ay, except ocean
E = Glass Containers M = Tank Car/Trailer 04 = Neutralization 25 = Storm Dram INSP. INIT DATA ENTRY INIT
F =,Bags N = Sealed Source (radioactive material) 05 = Filtration ~ = !njectio. n well
= Idazaroous waste landfill
· ~ = Boxes, Cartons, Cases 0 = Unsealed Source (radioactive material) 06 = Stabilization Pond 28 = L_and ap. plicall.on DATE DATE
H = S'ump or Pit P = Other container type, specify 07 = Treatment Pond 29 = ucean msposm
30 = Surface Impoundment
31 = Transfer Station
· ,/~.,~,/ / BAKERSFIELD CITY FlEE DEP~TMENT
-~ 2130 "G" STREET R E C E { V [ D
~ BAKERSFIELD, CA 93301
(805) 326-3979 JUL 2 2 1987
OFFICIAL USE ONLY
~US INESS/NAME
HAZARDOUS lVLZkT E R I ALS ~~.
BUSINESS PLAN AS A WHOLE
INSTRUCT IONS:
1. To avoid further action, return this forra 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
A. BUSINESS NAME: LUCKY STORES, INC. Store #278
B. LOCATION / STREET ADDRESS: 1621 Columbus St.
CITY: Bakersfield ZIP: 93305 BUS.PHONE: (805) 872-5232
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving the release or threatened release of a
hazardous material, call 911 and 1-800-852-7850 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 AND TITLE DURING BUS. HRS, AFTER BUS. HRS.
A. Bill Kostan / Manager Ph# 872-7359 Ph#,,834-9558 (805)
B. Don Scheppmann / Assistant Manager Ph# 872-5232 Ph# 831-9744 <805~
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE:
B. ELECTRICAL: INSIDE FRONT PART OF BUILDING BY LIOUOR CAGE/SOUTH BACK WALL
C. WATER: Backroom center mouth wnll.
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
MEDICENTER
34th & Q St~
Bakersfield, CA 93305
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 YES NO
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES: .......................... (~ NO YES NO
C PROPER USE OF SAFETY EQUIPMENT:... ................ ~'~-~ NO ~ NO
E DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES
SECTION ?: HAZARDOUS MATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 P0~ A
SOLID/ 55'GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS:.,~ ....
I, ~ , 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.)a~ inaccurate information constitut, es perjury.'
~0' / / ,
- 2B -
BAKERSFIELD CITY FIRE OEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFICI.4L USE ONLY ....
iD# 11419
BUSINESS NAME:LUcky Stores Inc. #2?8
BUSINESS 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~ ~ACILITY ~IT N~:
SECTION 1: ~ITIGATION, PRE~ION, ABATEME~ PROCEDL~ES
Items. are packaged in small containe'rs fo~ resale,
I~ems are safety sealed add displaye~ o~ a level, secure surface
in a manner to p~ewent accidental dislod~ent.
Certain chemicals kep~ at ~ifferent locations to prevent mixing..
abatement procedures are to effect clean-u~ps without e~tact wi~h
Skin and to remove any traces from the exposed su~rface. I~ is then
disposed of in a safe manner to avoi~ fu~her contact,
SECTION 2: NOTIFICATION .&YD EVACUATION PROCEDL~,ES AT THIS L~.'IT ONLY
911,
Verbal or public- . address system, depending on the severity
or safest' method.. Directions given t'o nearest exit.
qA ~
i.D. ~ FORM 4A-1 Page ~of.,
NON--TRADE SECRETS
HAZARDOUS MATERI ALS INVENTORY
BUSINESS NAME: OWNER NAME: FACILITY UNIT
ADDRESS: ADDRESS: FACILITY UNIT NAME:
CITY, ZIP: CITY,ZIP:
PHONE ~: PHONE #: ~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
:ODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT ~/T. CHEMICAL OR 'COMMON NAME CODE GUIDE
"
i
;AME: TITLE: S GNAT,RE: DATE:
[MERGENCY CONTACT: TITLE: PHONE '~. BUS' HOURS:
AFTER BUS HRS:
[ME~GENCY CONTACT: TITLE: PHONE ~ BUS HOURS:
'RINCIPAL BUSINESS ACTIVITY: AFTER BUS HRS:
- aA-1 -