HomeMy WebLinkAboutBUSINESS PLAN 10/29/2003 Hazardous Materials/Hazardous Waste Unified Permit
~ CONDITIONS OF PERMIT ON REV.ERSE SIDE
This ~ermit is issued for the followin_a:
[] Hazardous Materials Plan
r-t Underground Storage of Hazardous Materials
[3 Risk Management Program
[3 Hazardous Waste On-Site Treatment
PERMIT ID # 015-021-002343
WARREN LIU & ,::~ ~,.
LOCATION: 3600 DE SOUZA \~. CA 93309
~ !?: General D.entistry
I 3600 De Souza PI., Suite A
B~kersfield, CA 93.309
.... . (661) 834-3600
OFFICE OF ENVIRONMENTAL SERVICES ' ' ,~ ' ·
1715 Chester Ave., 3rd Floor Approved by: ' '(-~RalpI{Huey'D~~i Issue Date
Bakersfield, CA 93301 Om¢¢of£~ironn~S~r~ices
Voice (661) 326-3979
FAX (661) 326-0576 Expiration Date: 'Ju~
SHIRLEY MAN DDS SiteID: 015-021~0~2343
Manager. : %~ BusPhone: (661) 834-3600
Location: 3600 DE SOUZA PLA ~,~ Map : 123 CommHaz :
City : BAKERSFIELD~v Grid: llB FacUnits: 1 AoV:
CommCode: BAKERSFIELD STATION 0'7 SIC'Code:8021
EPA Numb: DunnBrad:
Emerq~.ncY Contact / Title Emer~nc~ ContDct / ,_vTitle
~TB~S-~ness Pno~e-%' '(661) 834-3600x Sd~fnes~ Ph6ne: ( )~_7 £~;5~X
24-Hour Phone : (&¢~)~.%W-F~o~ x 24-Hour Phone : (~)~.-~00 x
Pager Phone : ( ). - x Pager Phone : ( ) - x
Hazmat Hazards: React
Contact : Phone: (661) 834-3600x
MailAddr: 3600 DE SOUZA PLA State: CA
City : BAKERSFIELD Zip : 93309
Owner SHIRLEY MAN DDS Phone: (661) 834-3600x
Address : 3600 DE SOUZA PLA State: CA
'City : BAKERSFIELD Zip : 93309
Period : to TotalASTs: = Gal
Preparer: TotalUSTs: = Gal
Certif'd: RSs: No
"ParcelNo: ....... ~ - ....
Emergency Directives: ~
I, L~/~*Lvu~'J C.. t~ _ Do hereby certify tha~ t have
{Typ~ or ~.t n~e)
reviewed the a~ached h~ardous mate~als ma~ag~-
ment p~n ~or~Ete~ ~, ~and that it along ~ith
(~b ol B~tne~)
any ~e~ions con~itute a ~mple[e and ~rre~ man-
agement plan for my ~acili~y.
/o
1 10/21/2003
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (661) 326-3979
HAZARDOUS MATER/ALS MANAGEMENT PLAN
INSTRUCTIONS:
1. To avoid further action, return this form within 30 days of receipt.
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business as a whole.
4. Be as brief and concise as possible.
5. You may also attach Business Owner / Operator Form and Chemical Description Form(s)
to the front of this plan instead of completing SECTION I. below for initial submission.
MAILING ADDRESS:
CITY: /b PtC,bYt'$-~b-t--O STATE:
PRIMARY ACTIVITY:
OWNER: 5 ~t ~ ~L'L~'"(
MAILING ADDRESS:
EMERGENCY NOTIFICATION
CONTACT TITLE BUS. PHONE 24 HR. PHONE
2. Lo a-o-v.z~ b~u~ ~w- 3mo
' HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION II. 1: DISCOVERY AND NOTIFICATIONS
A. LEAK DETECTION AND MONITORING PROCEDURES:
B. EMPLOYEE AND AGENCY NOTIFICATION: .................
.?
C. ENVIRONMENTAL RESPONSE MANAGEMENT:
D. EMERGENCY MEDICAL PLAN:
2
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION II.2: RELEASE RESPONSE pLAN
A. HAzARD ASSESSMENT AND PREVENTION MEASURES:
B. RELEASE CONTAINMENT AND/OR MITIGATION:
C. CLEAN-UP AND RECOVERY PROCEDURES:
UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)
NATURALGAS/PROPANE: DOtJt-TH C.L-~N"FL-Yt.- OC~ bSO~LOt'~0-.
ELECTRICAL:. k~'Ot~'r'~ O...L¢~'O~ ~.,~ ~30 t t.-OCtO C,- ,,
WATER:. S°OTH ~t C/.y~O (..~-~.7FL .C.9-~- iV3LIP-~IJD 6- LOT-
SPECIAL:
LOCK BOX: YES IF YES, LOCATION:
PRIVATE FIRE PROTECTION/WATER AVAILABILITY
A. PRIVATE FIRE PROTECTION: .. dL~h M Ut'-C-WLk--"~ ~ ~ ~?- ,A.-L/~Y2-,t~ 1~ ~
B. WATER AVA~IL~Y (F~ ~NT):
flAZ~OUS ~TE~LS ~AGE~NT PL~
SECTION Ill: TRAININQ
NUMBER OF EMPLOYEES: C~
MATER/AL SAFETY DATA SHEETS ON FILE: i~-O j ~t3 ~-~ Ct_~,.
BRIEF SUMMARY OF TRAINING PROGRAM:
CERTIFICATION
I, 5 ~/L-?[2"l ~' CERT1FY THAT THE ABOVE
INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE
A~ S~.TY COD~." O~ ~.~a:~OVS ~TE~aALS <DIV. ~-0 C.,~T~R ~.~ S~.C. ~S00
ET ^~..~ ^~ THAT INACCV~T~ ~ORM~TtON CONSTrrVT~.S ?~.~W¥.
~__---SI~NAT~RF~ o- -- TITLE D'ATE
/
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (661) 326-3979
HAZARDOUS MATER/ALs MANAGEMENT PLAN
INSTRUCTIONS
SECTION I: - BUSINESS IDENTIFICATION DATA:
The Business Owner / Operator Form, Chemical Description Form(s) and other Forms
(e.g.: underground storage tank information, hazardous waste treatment, etc., as needed)
may be submitted as the first section of the Hazardous Materials Management Plan in
order to avoid duplication of information for initial submissions.
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION II. 1 - DISCOVERY AND NOTIFICATIONS
A. LEAK DETECTION AND MONITORING PROCEDURES:
Describe the procedures and equipment used to detect any release or threatened release of a
hazardous 'material from any storage container, tank, or vessel at your business. Please
provide a written explanation that also includes the make and model number of any
automated or electronic leak detection equipment in use at your facility.
B. EMPLOYEE AND AGENCY NOTIFICATION:
What agencies and or corporate officials are notified in case of a hazardous materials spill
or emergency -- What procedures are used to notify these parties? At a minimum, you
must call 9-1-1 and the Office of Emergency Services at 1-800- 852-7550 to report any.
spills that are a threat to life, safety or the environment, or for other non-emergency
spill reporting, please call our office at (661,) 326-3979.
C. ENVIRONMENTAL RESPONSE MANAGEMENT:
Please describe who will be responsible for what activities (notifying authorities, clean-up
companies, etc.), and what the chain-of-command is at your facility for making sure these
activities are carried out.
D. EMERGENCY MEDICAL PLAN:
Summarize your plan for handling medical emergencies occurring at your business. List
the local medical facility capable of handling an accident involving Hazardous Materials
. used at your business.
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION II.2 - RELEASE RESPONSE PLAN
A. HAZARD ASSESSMENT AND PREVENTION MEASURES:
Explain the procedures that you have developed and implemented to help prevent an
incident from occurring. These steps could include, but are not limited to, storage methods,
container types, segregation, safety equipment, and/or procedures used.
B. RELEASE CONTAINMENT AND/OR MITIGATION:
Explain the procedures that you have developed and implemented to assist in keeping a
hazardous materials incident at your business as small or conf'med as possible.
C. CLEAN-UP AND RECOVERY PROCEDURES:
Explain what clean up procedures will be implemented in case of a release at your business.
This should address small spills, as well as a major release of material once the material is
contained.
Hazardous Waste: Please provide the name of the hazardous waste company that
regularly removes the wastes from your business, and how often that waste is removed.'
Please keep all disposal receipts for the last three years available on site for inspection.
UTILITY SHUT-OFFS
List locations of shut offs using compass points and known or obvious landmarks. If you
haVe a lock box containing keys and maps of the facility for the Fire Department to use,
please list its location also.
PRIVATE FIRE PROTECTION/WATER AVAILABILITY
A. - Private Fire Protection: Describe on-site fire protection for your business or
facility unit, including sprinklers, fire extinguishers, alarm systems and private
response teams.
B. Water Availability (Fire Hydrant): Give the location of the closest water supply
or fire hydrant to be used by the Fire Department in case of an emergency.
SECTION III - TRAINING.
List the number of employees that are working in the area of the hazardous materials, use
or storage. Include all employees who have any occasion to be in those areas.
Give the location Where Material Safety Data Sheets (MSDS) are kept on file. The MSDS
must be readily available on site in a place where employees can access them.
Give a brief summary of your Hazardous Materials Training Program.
Employees are required by State law to have a program which provides employees with initial and
refresher training in the following areas:
l) Methods for safe handling of the hazardous materials used by your business.
2) The Cai OSHA Hazard Communication Standard.
3) Correct use of emergency response equipment and supplies available at your business.
4) The prevention, minimizing and clean up procedures you have developed for your business.
5) The emergency evacuation plans you have developed, as well as, your notification
procedure and medical plan.
6) Procedure to coordinate with and assist the local emergency personnel that may respond to
your business
7) Who and how to call for immediate assistance in the event of an accident involving
hazardous materials.
CERTIFICATION
Please fill in your name, title, and sign and date on the signature line.
IMPORTANT
You must return this plan, inventory forms, and map within 30 days of receipt.
If you have any questions
please call us.at (661) 326-3979
Thank you for helping to keep our All America City cleaner and safer.
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (661) 326-3979
HAZARDOUS MATERIALS FACILITY INFORMATION
INSTRUCTIONS
BUSINESS OWNER / OPERATOR FORM
I. FACILITY'IDENTIFICATION:
Enter the reporting period (year beginning and ending) for the facility information.
Enter the business name and site address and phone number of your business. Do not use
P.O. box numbers.
Enter the Dun & Bradstreet or federal tax identification number for your business.
Enter the Standard Industrial Classification (SIC) number for your business. Each type of
business has a Standard Industrial Classification code number. Some common SIC codes
are listed on the back of this page. Other SIC codes may be obtained from your worker's
compensation insurance forms, the State of California Employment Development
Department, or by calling our office at (661) 326-3979.
Enter the name and phone number of the person responsible for operating the business.
II. OWNER INFORMATION:
List the legal business owner or corporation name and provide the headquarter address or
residential address if owned by an individual and phone number.
III. ENVIRONMENTAL CONTACT:
Identify the person who is primarily responsible for environmental compliance at the
business. This person may be either the business owner, one of the emergency contacts,
an environmental manager, or consultant.
IV. EMERGENCY CONTACTS:
List the name, title, and phone numbers of two people at the business who can respond if
the Bakersfield Fire Department requires additional information or other assistance.
These contact persons must have keys or access to all areas of the facility, be available for
emergency call-outs, and have decision-making authority to call on other resources (such
as hazardous waste clean-up companies) as necessary.
V. CERTIFICATION:
The business owner or operator must sign, date, and also identify the document preparer.
COMMON STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODES
0111 Wheat production 0724 Cotton ginning 5821 Eating places
0115 Corn production 0541 Grocery store 5813 Drinking places
(Alcohol service)
0131 Cotton production 1541 Dry cleaners
5983 Fuel oil dealers
0139 Field crops, except cash 2911 Oil refineries
grains 5984 LPG dealers
3441 Welding/fabrication -
0161 Vegetables & melons 7342 Pest control
structural
0172 Grapes 7532 Auto top, body,
3443 Welding/fabrication - upholstery repair
0173 Tree nuts boiler Auto paint shops
0174 Citrus fruits 3569 Machine shop 7533 Auto exhaust repair
0175 Deciduous tree fruits 4222 Cold Storage 7536 Auto glass
replacement
0179 Other tree fruits & nuts 4925 Compressed gas supplier
7537 Auto transmission
0192 General farms, primarily 5093 Automobile salvage repair
crop
5169 Chemical supply 7538 General auto repair
0241 Dairy farms
5511 Motor vehicle dealers 7542 Car washes
0252 Chicken eggs (new & used)
8071 Chemical laboratory
0253 Turkey eggs 5521 Motor vehicle (used only)
2851 Paint manufacture 553 ! Auto & home supply
stores
0291 General farm, primarily
livestock & animal 5541 Gasoline service stations
specialties
2
FI~ CITY OF BAKERSFIELD~
;:"f~~ OF E OF ENVIRONMENTAL SEIIVICES
1715 Chester Ave., CA 93301 (661) 326-3979
"""'~~'~~"'""~-' BUSINESS OWNER/OPERATOR IDENTIFICATION
FACILITY INFORMATION
Page__[ of
BUSINESS NAME (Same as FACILI~ NAME or DBA- Doing Business ~) 3 BUSINESS PHONE
SIT~ ADDRESS ~o3
,o,
B~DSTREET (4 Digit ~)
COUN~ ~~ ~o8
OPE~TORNAME ~ [4[~[~N ~ ~09 OPE~TORPHONE ~ ~. ~O~ ~o
ADDRESS - ~3
CONTACT NAME ~ Kt~LC_.X ~ ,,~ ,'i CONTACT PHONE ~3~--B~ O-e
CONTACT m~UN~ ~ ~~ "" '
~ ADDRESS
.
~ CITY ~ ~ SLAIN 121 ZIP ~22
TITLE ~ ~ ~ {~ 125 TITLE 130
BUSINESS PHONE ~~~ 126 BUSINESS PHONE ~--~O-O 131
24-HOUR PHONE ~~ ~O O 127 24-HOUR PHONE ~ ~ ~ --~ ~00 132
PAGER ~ 128 PAGER ~ 133
Ce~ifi~on: Based on my inqui~ of ~ose individuals responsible for obtaining the information, I cedi~ under penal~ of law that I have personally examined
and am familiar with the info~ation submiEed in this invento~ and believe the information is tie, accurate, and mmplete.
~ES OF O~E~PE~TOR (print) a36 TITLE OF OWNE~OPE~TOR 137
UPCF (7~99) S:\CU PAFORMS\OES2730.TV4.wpd
STATE WASTE CODE 220
If the hazardous material is a waste, enter the appropriate California 3-digit hazardous waste code as listed
on the back of the Uniform Hazardous Waste Manifest. A list of common State Waste Codes are included
on page 4 of these instructions.
UNITS 221
Check the unit of measure that is most appropriate for the material being reported on this page: gallons,
pounds, cubic feet or tons. NOTE: If the material is a federally defined Extremely Hazardous Substance
(EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units
that the material is stored in (gallons, pounds, cubic feet, or tons).
DAYS ON SITE 222
List the total number of days during the year that the material is on site.
STORAGE CONTAINER 223
Check all boxes that describe the type of storage containers in which the hazardous material is stored.
NOTE: If appropriate, you may choose more than one.
STORAGE PRESSURE 224
Check the one box that best describes the pressure at which the hazardous material is stored.
STORAGE TEMPERATURE 225
Check the one box that best describes the temperature at which the hazardous material is stored.
HAZARDOUS COMPONENT I - 5 (% by weight) 226, 230, 234, 238,242
If a range of percentages is available, report the highest percentage in that range.
HAZARDOUS COMPONENT 1 - 5 Name 227, 231,235,239, 243
When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous
components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to
manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-
carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than five hazardous
components are present above these percentages, you may attach an additional sheet of paper to capture the
required information. When reporting waste mixtures, mineral and chemical composition should be listed.
HAZARDOUS COMPONENT I - 5 EHS 228,232,236, 240, 244
Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as
defined in 40 CFR, Part 355, or "N" for no, if it is not.
HAZARDOUS COMPONENT 1 - 5 CAS 229, 233,237, 241,245
List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture.
III. SIGNATURE: 246
Please print name, title, sign and date each chemical description form.
If you have any questions
please call us at (661) 326-3979
3
'CALIFORNIA WASTE CODES
Code Description Code Description
[norganics 241 Tank bottom waste
111 - Acid solution 2 < pH < 7 with metals 251 Still bottoms with halogenated organics
(antimony, arsenic, barium, beryllium, 252 Other still bottom waste
cadmium, chromium, cobalt, copper, lead, 261 PCB's and material containing PCB's
mercury, molybdenum, nickel, selenium, silver, 271 Organic monomer waste (includes unreacted
thallium, vanadium and zinc) resins)
i 12 Acid solution without metals 272 Polymeric resin waste
113 Unspecified acid solution 281 Adhesives
121 Alkaline solution pH >12:5 with metals (see 291 Latex waste
111) 311 Pharmaceutical waste
122 Alkaline solution without metals 321 Sewage sludge
123 Unspecified alkaline solution 322 Biological waste other than sewage sludge
! 31 Aqueous solution (2 < pH < 12.5) containing 331 Off-spec, aged or surplus organics
reactive anoins (azide, bromate, chlorate, 341 Organic liquids (nonsolvents) with halogens
cyanide, fluoride, hypochlorite, nitrite, 343 Unspecified organic liquid mixture
perchlorate and sulfide anions) 351 Organic solids with halogens
132 Aqueous solution with metals (see 111)
133 Aqueous solution with total organic residues Sludges
10% or more 411 Alum and gypsum sludge
134 Aqueous solution with total organic residues 421 Lime sludge
less than 10% 431 Phosphate sludge
135 Unspecified aqueous solution 441 Sulfur sludge
141 Off-spec, aged, or surplus inorganics 451 Degreasing sludge
151 Asbestos containing waste 461 Paint sludge
161 FCC Waste ' 471 Paper sludge/pulp
162 Other spent catalyst 481 Tetraethyl lead sludge
171 Metal sludge (see 111) 491 Unspecified sludge waste
172 Metal dust and machining waste (see 111)
181 Other inorganic solid waste Miscellaneous
511 Empty pesticide containers 30 gal or more
Organics 512 Other empty container 30 gal or more
211 Halogenated solvents (methylene chloride, 513 Empty containers less than 30 gal
chloroform, TCE, TCA) 521 Drilling mud
212 Oxygenated solvents (acetone, butanol, M~K) 531 Chemical toilet waste
213 Hydrocarbon solvents (stoddard solvent, 541 Photo chemical/photo processing waste
xylene) 551 Laboratory waste chemicals
214 Unspecified solvent mixture 561 Detergent and soap
22 ! Waste oil and mixed oil 571 Fly ash, bottom ash, and retort ash
222 Oil/water separation sludge 581 Gas scrubber waste
223 Unspecified oil - containing waste 591 Baghouse waste
231 Pesticide rinse water 611 Contaminated soil from site clean-ups
232 Pesticide and other waste associated with 612 Household wastes
pesticide production
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
INSTRUCTIONS
CHEMICAL DESCRIPTION FORM
Make as many copies of the chemical description form as necessary to report your entire inventory of
hazardous materials. Report every hazardous material handled in quantities equal to or exceeding 55
gallons of a liquid, 500 pounds ora solid or 200 cubic feet of a gas. Report any amount of any
hazardous waste being generated or handled on site.
I. FACILITY INFORMATION:
Check the appropriate box for a new inventory or for additions, revisions or deletions to an existing
inventory.
Enter the business name at the top of the form. Enter the page number in the right hand corner. Describe
the exact location of the hazardous waste or material being reported. NOTE: Chemical location
information is considered confidential unless you check "no."
Ifa site map is being submitted, you may refer to the map number and grid coordinates for the approximate
location of the material, as shown on the map.
II. CHEMICAL INFORMATION:
Each of the instructions below correspond to the entry field with the same number on the chemical
description form.
CHEMICAL NAME 205
Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the
hazardous material. This should be the International Union of Pure and Applied Chemistry (IUPAC) name
found on the Material Safety Data Sheet (MSDS). NOTE: If the chemical is a mixture or a hazardous
waste, do not complete this field; complete the "common name" field instead.
TRADE SECRET 206
Check "Y" for yes if the information in this section is declared a wade secret, or "N" for no, if it is not.
State requirement: If yes, and business is not subject to EPCRA, disclosure of the designated trade secret
information is bound by Health and Safety Code, Section 25511. Federal Requirement: If yes, and business
is subject to EPCRA, disclosure of the designated Trade Secret information is bound by Title 40 Code of
Federal Regulations (CFR) and the business must submit a "Substantiation to Accompany Claims of Trade
Secrecy" form (40. CFR 350.27) to USEPA.
COMMON NAME 207
Enter the common name or trade name of the hazardous material or mixture containing a hazardous
material.
EHS 208
Check "Y" for yes if the hazardous material is an Extremely Hazardous Substance (EHS), as defined in 40
CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section blank and
complete the section on hazardous components below.
CAS # 209
Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the
CAS number of the mixture if it has been assigned a number distinct from its component& If the m'ixture
has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous
components in the section below.
FIRE CODE HAZARD CLASSES (Please leave blank) 210
HAZARDOUS MATERIAL TYPE 211
Check the one box that best describes the type of hazardous material: pure, mixture or waste. If waste
material, check only that box. If mixture or waste, complete hazardous components section.
RADIOACTIVE - 212
Check "Y" for yes if the hazardous material is radioactive or "N" for no, if it is not.
CURIES 213
If the hazardous material is radioactive, use this area to report the activity in curies. You may use up to
nine digits with a floating decimal point to report activity in curies.
PHYSICAL STATE 214
Check the one box that best describes the state in which the hazardous material is handled: solid, liquid or
gaseous (gas).
LARGEST CONTAINER 215
Enter the total capacity of the largest container in which the material is stored.
FEDERAL HAZARD CATEGORIES 216
Check all the physical and health hazards associated with the hazardous material:
PHYSICAL HAZARDS:
Fire: Flammable Liquids and Solids, Combustible Liquids, Pyrophorics, Oxidizers
Reactive: Unstable Reactive, Organic Peroxides, Water Reactive, Radioactive
Pressure Release: Explosives, Compressed Gases, Blasting Agents
HEALTH HAZARDS:
Acute Health (Immediate): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, other hazardous
chemicals with an adverse effect with short term exposure.
Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with
long term exposure.
ANNUAL WASTE AMOUNT 217
If the hazardous material being inventoried is a waste, provide an estimate of the annual hmount handled.
MAXIMUM DAILY AMOUNT 218
Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which
is handled in a building or adjacent/outside area at any one time over the course of the year. This amount
must contain at a minimum last year's inventory of the material reported on this page, with the reflection of
additions, deletions, or revisions projected for the current year. This amount should be consistent with the
units reported in box 221.
AVERAGE DAILY AMOUNT 219
Calculate the average daily amount of the hazardous, material or mixture containing a hazardous material,
in each building or adjacent/outside area. Calculations shall be based on the previous year's inventory of
material reported on this page. Total all daily amounts and divide by the number of days the chemical will
be on site. If this is a material that has not previously been present at this location, the amount shall be the
average daily amount you project to be on hand during the course of the year. This amount should be
.............. ;~ ..... consistent with the units reported inbox 2~21 and should notexceed,that,of maximum daily amount . .................
2
IA ~;~ ~ CITY OF BAKERSFIELI~
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
(one form per matetfal per building or area)
{:~::NEW [] ADD ~ DELETE ~ REVISE ~ Page
BUSINESS ~ME (Same as FAClLI~ ~ME ~ DBA - D~ng Busin~ ~) 3
CHE.ICAL LOCATION 3COa bCz SO~'~A ~C ~¢~S~S C~/ C~ 9*~ 201~ CONFIDENTIALCHEUICAL LOCATION{EPCg) OY~ ~No 202
FACILI~ ID ~~ =~ ~?~ '?<~" {~J ~';~ l][ [~J~ ~ ~'~ ~ ~ i~ '~ ~q ~ ~ 1 ~P~(op~naO 203 I~ GRID~(opt~na~ 2~
~: :,. ~;*~'j~;;~;¥~'~; ,~.~ ~;-~*~:.~:.'=~'::~:~g:~vF~ ..?; ; :~'..:~.::5~:i:~.; . .... ':~:~ .C:?';~''~ -'. ~: ¢:]';~;;' . '- ' ~']'~ ;":' *~"': * ": " .'~.~.'
20~ T~D~ SECRET
CHEMICAL
If Subj~ to EPC~, ref~ to instm~ions
207
FIRE CODE H~RD C~SSES (~mplete if ~u~t~ by I~1 fire
210
~PE
p PURE ~ m MITRE ~w WASTE 211 ~ ~DIOACT[VE ~Y~ ~No 212 ,
CURIES
213
PHYSICAL STATE ~ ~' ~ ~RGEST CONTAINER ~ ~ ~O~ ~ 215
~ SOLID ~1 LIQUID ~ 9 ~S 214 ~
FED H~RD CATE~RIES ~ 1 FIRE ~ 2 R~CTIVE ~ 3 PRESSURE REL~SE ~ 4 ACUTE H~L~ ~ 5 CHRONIC H~LTH 216
(~ all that apply)
ANNUAL WASTE I ,-~~ 219 S TA~ WAS~ CODE 220
IO
~ DAILYA~U~ _ ~ ~- DAILYA~U~ ~ ~
A~UNT
UNITS* ~ga GAL ~ ~ CU~ ~ lb LBS ~ tn TONS 221 DAYSONS~E 222
· ff EHS. am~nt must be in lbs. ~ O
STO~GE CO~AINER ~ a ABOVEGROUND TANK' ~ e P~STIONONM~ALLIC DRUM ~ i FIBER DRUM ~ m G~SS BO~LE ~ q ~IL ~R 223
(Check all ~at apply)
~ b UNDERGROUND TANK ~ f CAN ~ j BAG ~ n P~STIC BO~LE ~ r OTHER
~ c TANK INSIDE BUILDING ~g ~RBOY ~ k BOX ~ o TOTE BIN
~ d S~EL DRUM ~ h SILO ~ I CYLINDER ~ p TANK WA~N
STOOGE PRESSURE ~ a AMBIE~ ~ aa A~VE AMBIENT ~ ba BELOW AMBIE~ 224
STO~GE TEMPE~TURE ~ a AMBIENT ~ aa ABOVE AMBIENT ~ ba 8ELOWA~IE~ ~ c CRYOGENIC 225
2 230 231 .~ Y~ ~ NO 232 233
3 234 235 ~ Y~ ~ No 236 237
J 4 ~ 238 ~9 241
~ , D Y~ D NO 240
. 5 I 242 243 ~Y~ ~No 244 245
. ,C:'.::~ ~:= :. >~, :,:~>~;~;~9~T~-~;> ~:5;;~;~ ~r~'~ ~,f ~'~;4 ~;~ ~4~ ~&~>~;~:>~ ,'; :~.~. ~:~:,~,~ :: ~:~:~:: ~ ~ ~5,~ ~,'~ ~ '.~<~ ¢,~; :..:> , ', :*~r: , ·
[ ~RINT "A~ & T'~ OF Au~"O~i~ CoMPX~ R~ESENCAT'ivE '"~7~ DATE 246
UPCF (7~99) S:\CUPAFORMS\OES2731 .TV4.wpd
CITY OF BAKERSFIELD FIRE DEPARTMENT '~q ~) ''~/''-~
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROG~M INSPECTION CHECKLIST
1715 Chester Ave., 3~d Floor, Bakersfield, CA 93301
FACILITY NAME
ADD.SS ~ ~e ~ e~ ~ ,,~., PHONE NO. ~- ~
FACILITY CONTACTX[C~il ~ ~f~FD BUSINESS IDNO. 15-210-
~SPECTION TIME NUMBER OF EMPLOYEES
Section 1: Business Plan and lnvento~ Program /~ ~ ~ / /
~ Routine ~ombined ~ Joint Agency ~ Multi-Agency ~ Complaint ~ Re-inspection
OPERATION C V COMMENTS
Appropriate permit on hand ~ ~.q...r,--~ 7- ~ rT'~
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
C=Compliance V=Violation
Any hazardous waste on site?: [~ Yes [~ No I f ~ /]
Explain: Ct, J~'/'~ I~-~.~.-'"~. ~
Questions regarding this inspection? Please call us at (661) 326-3979 Business Site Res'pt~d4,' ble Party
White- Env. Svcs. Yellow- Station Copy Pink- Business Copy Inspector:
CITY OF BAKERSFIELD FIRE DEPARTMENT
OFFICE OF' ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave., 3r~ Floor, Bakersfield, CA 93301
FACILITY NAME 'D£5' L to/ t rq~x~,d OO~ INSPECTION DATE
Section 4: Hazardous Waste Generator Program EPA ID # ~A,~ C900
[] Routine I~- 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 kepi closed when not in use
Weekly inspection of storage area
Ignitable/reactive waste located at least 50 feet from property line
Secondary containment provided v/ ~;L(-~ ~'~
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 J~)~fJ
C=Compliance V=Violation
Inspector: ! ~
Office of Environmental'Services (661) 326-3979 BuSiness Site<~espo s~le ~art~,
White - Env. Svcs. Pink - Business Copy