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HomeMy WebLinkAboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit .~ CONDITIONS OF.PERMIT ON REVERSE SIDE · . .. ~..'~-,'.~?,~%: ~ ~ : ! i. · This _Permit is issued for the following: [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials Permit ID #:: 015-000-002014 13 Risk Management Program DAVIS HOME IMPROVEM [] Hazardous Waste On-Site Treatment LOCATION: 5880 DISTRICT BLVD 3 OFFICE OF ENVIRONMENTAL SER VICES' : c" ~ 1715 Chester Ave., 3rd Floor Approved by: ': · "(,... Ralpl{Hucy, D~'~'-~- i issue Date Bakersfield, CA 93301 ~. ' oaic~or~'rs~i~ '~ Voice (661) 326-3979 ~' FAX (661) 326-0576 : Expiration Date: Ji~e 30. 2003 FINANCE DEPARTMENT P.O. BOX 2057 BAKERSFIELD, CALIFORNIA 93303 R~URN SERVICE REQUESTED R~TURN TO SENDER NO FORNARD ORDER ON FILE UNABLE TO FORNARD RETURN TO SENDER o;? li,i,,,,lt,,,lt,il,,",ll,'~:iiiil' STATEMENT DF ACCOUNT CITY OF BAKERSFIELD M u BOX 2057 BAKERSFIELD, CA 93303-2057 DATE~ 8/01/00 TO: DAVIS HOME IMPROVEMENT8 ~600 DISTRICT BLVD~102~,~ ~AKERSFIELD CA CUSTOMER ND · ~o~o CUSTOMER TYPE~ ES/ 36907 6/0i/00 BE~:INNINQ BALANCE 218.00 FOR QUESTIONS OR CHANQES TO YOUR ACCOUNT PLEASE ~L~ THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER 90 218.00 TOTAL DUE: $218.00 CITY OF BAKERSFIELD RETURN SERVICE ~:,, ~ P.O. SOX 2057 . r'.~,-~ :~ , ~-~' o ~"- ~,~Ub~ UU ~ ~,:. / BAKERSFIELD, CALIFORNIA93303 -;~ :'~;;'~ ~ ~L[. ~'~ ~-r~'"~N' C'~T~ ~; RETURN SERVICE REQUESTED~ ~,-~r~c.~,~ ,~.~ .~r~., .... :~_~. ~ Ii Ji,,,I,IIl,,,,I,I CITY OF BAKERSFIELD . ~ .... ::: RETURN '--~ ' P.O. BOX 2057 ;~, ~L:';'e] ~~ :, _ ~.~ BAKERSFIELD, CALIFORNIA 93303 ' ~ .'o"eo! ~ - RETURN SERVICE REQUESTED ~Oe,~ *:' , ,z:-,",.'.:, · li',l,,,',lh,,lh-il,,,,~lh,,h I1' · ~::::nn, -?:',n:. License Detail Page 1 of 2 California Home : Thursday, April 17, 2003 License Detail CALIFORNIA CONTRACTORS STATE LICENSE BOARD Contractor License # 545457 DISCLAIMER A license status check provides information taken from the CSLB license data base. Before relying on this information, you should be aware of the following limitations: · CSLB complaint disclosure is restricted by law (B&P 7124.6). If this entity is subject to public complaint disclosure, an icon will appear below. Click on the icon to obtain additional complaint information. · Per B&P 7071.17, only construction related civil judgments known to the CSLB are disclosed. · Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. · Due to workload, there may be relevant information that has not yet been entered onto the Board's license data base. Extract Date: 04/1712003 * * * Business Information * * * DAVIS HOME IMPROVEMENTS 4909 STOCKDALE HWY BAKERSFIELD, CA 93304 Business Phone Number: (661) 398-0417 Entity: Sole Ownership Issue Date: 1012811988 Expire Date: 10/31/2004 * * * License Status * * * This license is current and active. All information below should be reviewed, * * * Classifications * * * [~'~[PAINTING AND D~TING ]1 ~IGENERAL CTORII * * * CeAifications * * * ~l ' Description ' Il ~IHOME IMPROVEMENT CERTIFICATIONI h ttp ://www2.cslb.ca.go v/CSLB_LIB RAR Y/License+ DetaJl.asp 4/17/2003 License Detail Page 2 of 2 * * * Bonding Information * * * CONTRACTOR'S BOND: This license filed Contractor's Bond number 6302405 in the amount of $7,500 with the bonding company SURETY COMPANY OF THE PACIFIC Effective Date: 10/0511996 Contractor's Bonding History * * * Workers Compensation Information * * * This license has workers compensation insurance with the STATE COMPENSATION INSURANCE FUND Policy Number: '1659128 Effective Date: 10/13/2001 Expire Date: 10/13/2003 Workers Compensation History Personnel List SalesPerson List License Number RecLuest Contractor Name Request Personnel Name Request Salesperson Request Salesperson ,Name Request © 2002 State of California. Gray Davis, Governor. Conditions of Use Privacy Policy http://www2.cslb.ca.gov/CSLB_LIBRARY/License+Detail.asp 4/17/2003 davis shop.jpg (1280x960x24b jpeg) , -. :;! DAVIS HOME IMPROVEMENTS SiteID: 015-021-002014 Manager : TIM DAVIS BusPhone: (661) 398-0417 Location: 5880 DISTRICT BLVD 3 Map : 103 CommHaz : Moderate City : BAKERSFIELD Grid: 15B FacUnits: 1 AOV: CommCode: OUT OF:BUSINESS/HAZ-MATL'S SIC Code: EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title TIM DAVIS / INST MANAGER BOB CLARK / PARTNER Business Phone: (661) 398-0417x Business Phone: (661) 398-0417x 24-Hour Phone : (661) 747-4701x 24-Hour Phone : (661) 979-7678x Pager Phone : ( .) - x Pager Phone : ( ) - x Hazmat Hazards: Contact : TIM DAVIS Phone: (661) 398-0417x MailAddr: 5880 DISTRICT BLVD 3 State: CA City : BAKERSFIELD Zip : 93313 Owner TIM DAVIS Phone: (661) 747-4701x Address : 4909 STOCKDALE HWY 345PMB State: CA City : BAKERSFIELD Zip : 93309 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: 10-27-00 HAS NOT REVISED BUSINESS PLAN YET. BUSINESS REMOVED HAZARDOUS MATERIAL WHEN THEY MOVED FROM 5650 DISTRICT #102. Hazmat Inventory One Unified List Alphabetical Order Ail Materials at Site Hazmat Common Name... ISpeoHazlEPA HazardsI Frm DailyMax lUnitlMcP ::'-7 . F DAVIS HOME IMPROVEMENTS SiteID: 015-021-002014 Fast Format = Notif./Evacuation/Medical Overall Site --Agency Notification 04/14/2000 WHAT AGENCIES ARE YOU GOING TO NOTIFY IN CASE OF AN EMERGENCY??????? -- Employee Notif./Evacuation 04/14/2000 HOW ARE YOU GOING TO NOTIFY YOUR EMPLOYEES OF AN EMERGENCY???????? -- Public Notif./Evacuation 04/14/2000 HOW ARE YOU GOING TO NOTIFY THE PUBLIC OF AN EMERGENCY????????? Emergency Medical Plan 04/14/2000 WHAT MEDICAL FACILITY ARE YOU GOING TO USE IN THE EVENT OF AN EMERGENCY???? -2- 11/04/2002 DAVIS HOME IMPROVEMENTS SiteID: 015-021-002014 Fast Format = Mitigation/Prevent/Abatemt Overall Site -- Release Prevention 04/14/2000 HOW DO YOU KEEP FROM HAVING A RELEASE?????????? --Release Containment 04/14/2000 HOW DO YOU CONTAIN A RELEASE ONCE IT HAS HAPPENED????????? -- Clean Up 04/14/2000 HOW DO YOU CLEAN UP THE RELEASE THAT HAS BEEN CONTAINED?????? Other Resource Activation -3- 11/04/2002 F DAVIS HOME IMPROVEMENTS SiteID: 015-021-002014 Fast Format F Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs 04/14/2000 LIST YOUR UTILITY SHUT OFFS????????? A) GAS - B) ELECTRICAL - C) WATER - D) SPECIAL - E) LOCK BOX - -- Fire Protec./Avail. Water 04/14/2000 LIST YOUR PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS, SPRINKLER SYSTEM???? NEAREST FIRE HYDRANT - ?????????? Building Occupancy Level -4- 11/04/2002 DAVIS HOME IMPROVEMENTS SiteID: 015-021-002014 Fast Format = Training Overall Site -- Employee Training 04/14/2000 HOW MANY EMPLOYEES DO YOU HAVE AT THIS FACILITY????????? DO YOU HAVE MSDS SHEETS ON FILE????????? GIVE A BRIEF SUMMARY OF YOUR TRAINING PROGRAM: -- Page 2 --Held for Future Use Held for Future Use -5- 11/04/2002 MR430107 ~ CITY OF BAKERSFIELD i 8/10/01 M~Fcellaneous Receivables In~ry 16:20:14 Customer ID . . . : 30378 Name: DAVIS HOME IMPROVEMENTS Last statement : 8/01/01 Addr: 5880 DISTRICT BLVD #3 Last invoice : 0/00/00 BAKERSFIELD, CA 93313 Current balance : 394.00 Pending ..... : .00 A ACTIVE ENVIRONMENTAL SERVICES Type options, press Enter. Combined Detail 5=Display Chg Bnk G Opt Trans Date Code Description Amount Balance Typ Cd L 6/01/00 SS001 CA STATE SURCHARGE 10.00 218.00 A 00 - 6/01/00 HM017 HAZ MAT ANNUAL INSPE 50.00 208.00 A 00 - 6/01/00 HM009 HAZ MAT HANDLING FEE 158.00 ' 158.00 A 00 - 5/01/00 stmrn Statements Processed .00 .00 N Bottom F3=Exit F12=Cancel * = Pending Davis Home Improvements 5880 District Blvd. #3 Bakersfield, Ca. 93309 661 398-0417 August 8, 2001 Office of Environmental Services Mr. Huey, I am writing in regards to the letter that was sent to us and the phone conversation we had on 8/8/01. I now understand the invoice amount you are billing for and I don't have a problem paying what we have incurred. We no longer handle any of the hazardous material we were back in 1999. We no longer have employee's that apply this material. The last time we had a disposal was 12/00 and this cleaned out our facility of any remaining hazardous material. Thank you for your time in this matter. Gina Davis Davis Home Improvements MR430101 CITY OF BAKERSFIELD 8/01/01 Miscellaneous Receivables Inquiry 16:46:42 Customer ID . . . : 30378 Name: DAVIS HOME IMPROVEMENTS Last statement : 6/30/01 Addr: 5880 DISTRICT BLVD %3 Last invoice : 0/00/00 BAKERSFIELD, CA 93313 Current balance : 394.00 Pending ..... : .00 A ACTIVE ENVIRONMENTAL SERVICES Previous balance : 394.00 Deposit balance : .00 T~pe options, press Enter. Open Activity l=Select Opt Code Description Current Overdue Total due HM009 HAZ MAT HANDLING FEE I .00 324.00 324.00 - HM017 HAZ MAT ANNUAL INSPECTION .00 50.00 50.00 - SS001 CA STATE SURCHARGE .00 20.00 20.00 Bottom F3=Exit F7=Pending activity F8=Charge hsty Fg=Payment hsty F10=Combined detail F11=Invoice inquiry F12=Cancel F13=Auto charges F14=Depo$it detail F21=Other tasks August 1, 2001 Davis Home Improvements Tim Davis/Bob Clark F~RE C.~EF 5880 District Blvd.,//3 RON FRAZE Bakersfield, CA 93313 ADMINISTRATIVE SERVICES V~ CERTIFIED mil 2101 'H' Street Bakersfield. CA 93301 VOICE (661)326-3941 Subject: Revocation of Davis Home Improvements; Permit to FAX (661) 395-1349 O~ rate SU.PaESSION SERWCES 2101 '.' S~r,t Dear Mr. Davis and Mr. Clark: Bakersfield. CA 9,3,301 vOiCE (661)326-a941 FAX (661) 395-1349 Your "Permit to Operate" at 5880 District Blvd. #3, known as Davis Home PREVENTION SERVlCF~ Improvements is being revoked effective Monday, August 13, 200 I, at 5:00 p.m. 1716 Ch.,Io,^~. This "Permit to Operate" is being revoked due to failure to pay current as well as Bakersfield, CA 93301 VO,CE (661) a~6-.~51 past due fees. ENVIRONMENTAL SERVICES This action can be avoided by bringing your account current prior to that time. If 1715 Ches~rAv°. you have any questions, please call me at (661) 326-3979. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 Sincerely, TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (~1) 3~-5763 Ralph E. Huey, Director Office of Environmental Services RI-IXdb cc: Walter Port, Jr., City Attorneys Office Steve Underwood, Environmental Services Esther Duran, Environmental Services Drew Sharpies, Treasury May 3, 2001 Mr. Tim Davis Davis Home Improvements 5650 District Boulevard, # 102 Bakersfield, CA 93313 Dear Mr. Davis: FIRE CHIEF Enclosed, please find the Site and Facility Diagram Instructions packet, when your RON FRAZE Hazardous Materials Management Plan and Inventory were submitted it was lacking ADMINISTRATIVE SERVICES the diagram portion. Please draw and submit the diagram(s) of your facility by 2101 "H" Street Bakersfield, CA 93301 June 8, 2001. VOICE (661) 326-3941 FAX (661) 395-1349 The diagram should include the following: SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 1) name of your business; . VOICE (661) 326-3941 FAX (661) 395-1349 2) businessaddress; 3) indicate which direction is North; PREVENTION SERVICES 4) the cross streets neighboring business addresses (within 300 feet) 1715 Chester Ave. Bakersfield, CA 93301 5) entrances and exits VOICE (661) 326-3951 FAX (661) 326-0576 6) location of utility shut-offs; 7) location of the nearest fire hydrant; ENVIRONMENTAL SERVICES 8) portions of the building protected by automatic sprinkler system; and most 1715 Chester Ave. Bakersfield, CA 93301 importantly VOICE (661) 326-3979 FAX (661) 326-0576 9) the location of the hazardous material(s). TRAINING DIVISION If you have any questions, please feel free to call me at (661) 326-3658. 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661)399-5763 Thank you for your assistance. Sincerely, RALPH E. HUEY, DIRECTOR OFFICE OF ENVIRONMENTAL SERVICES Esther Duran, Accounting Clerk II Office of Environmental Services ED\db Enclosures MR430101 ~ CITY OF BAKERSFIELD ~30-'-01 3112101 ~ellaneous Receivables InqUiry 11:02:22 Customer ID . . . : 30378 Name: DAVIS HOME IMPROVEMENTS Last statement : 3/01/01 Addr: 5880 DISTRICT BLVD #3 Last invoice : 0/00/00 BAKERSFIELD, CA 93313 Current balance : 394.00 Pending ..... : .00 A ACTIVE ENVIRONMENTAL SERVICES Previous balance : 394.00 Deposit balance : .00 Type Options, press Enter. Open Activity l=Select Opt Code Description Current Overdue Total due HM009 HAZ MAT HANDLING FEE I .00 324.00 324.00 HM017 HAZ MAT ANNUAL INSPECTION .00 50.00 50.00 SS001 CA STATE SURCHARGE .00 20.00 20.00 F3=Exit F7=Pending activity FS=Charge hsty F9=Payment hsty F10=Combined detail Fll=Invoice inquiry F12=Cancel F13=Auto charges F14=Deposit detail F21=Other tasks Lri Postage $ · 3,4 _ri Certified Fee 2 · ]. 0 Postmmk Return Receipt Fee 1 , 5 0 ~ (Endorsement Required) Here r-~ Restricted Delivery Fee r'-t (Endorsement Required) ~.~ Pomgoa r~. $ 3.94 ul I Re~Flplept's ~lame (Pl~ease Print Clearly) (To be Completed by malta0 I'l *' - ~=[ oavls .ome improvements ~,...,,~*~,~-~-,~,;-~-~;.-~-~-~,: ............ ~.~ ......... . ............. . .......... .. [C3 ["5~SO-IT[ t'f£~-ts Ct Blvd 'fi3 August 1, 2001 Davis Home Improvements Tim Davis/Bob Clark FIRE CHIEF 5880 District Blvd.,//3 RON FRAZE Bakersfield, CA 93313 ADMINISTRATIVE SERVICES VIA CERTIFIED MAIL 2101 "H" Street Bakersfield, CA 93301 VOICE (661)326-3941 Subject: Revocation of Davis Home Improvements; Permit to FAX (661) 395-1349 Operate SUPPRESSION SERVICES 2101 "H' Street Dear Mr. Davis and Mr. Clark: Bakersfield, CA 93301 VOICE (661)326-3941 FAX (661) 396-1349 YOUr "Permit to Operate" at 5880 District Blvd. #3, l~own as Davis Home PREVENTION SERVICES Improvements is being revoked effective Monday, August 13, 2001, at 5:00 p.m. 1715 ChesterAvo. This "Permit to Operate" is being revoked due to failure to pay current as well as Bakersfield, CA 93301 VOICE (661) 326-3951 past due fees. FAX (661) 326-0576 ENVIRONMENTAL SERVICES This action can be avoided by bringing your account current prior to that time. If 1715 Chester Ave. you have any questions, please call me at (661) 326-3979. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661)326-0576 Sincerely, TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661)399-5763 Ralph E. Huey, Director Office of Environmental Services RH~db cc: Walter Porr, Jr., City Attomeys Office Steve Underwood, Environmental Services Esther Duran, Environmental Services Drew Sharpies, Treasury ~R430101 g~ CITY OF BAKERSFIELD ~ 8/01/01 / M~cellaneous Receivables In~[iry 16:46:42 ! Customer ID . . . : 30378 Name: DAVIS HOME IMPROVEMENTS Last statement : 6/30/01 Addr: 5880 DISTRICT BLVD ~3 Last invoice . : 0/00/00 BAKERSFIELD, CA 93313 Current balance : 394.00 Pending ..... : .00 A ACTIVE ENVIRONMENTAL SERVICES Previous balance : 394.00 Deposit balance . : .00 Type options, press Enter. Open Activity 1=Select Opt Code Description Current Overdue Total due HM009 HAZ MAT HANDLING FEE I .00 324.00 324.00 - HM017 HAZ MAT ANNUAL INSPECTION .00 50.00 50.00 - SS001 CA STATE SURCHARGE .00 20.00 20.00 Bottom F3=Exit F7=Pending activity F8=Charge hsty F9=Payment hsty F10=Combined detail F11=Invoice inquiry F12=Cancel F13=Auto charges F14=Deposit detail F21=Other tasks DECK COAT . O 5" s~uo ~u. roa ~ PAINT[NO 5650 DISTRICT BLVD. ~ 102 BAKERSFIELD 93313 OFFICE: (661)398~417 ALT.~: (800)607- 5333 T~ DA~8 INST~.LATION MANAGER ~.DAVIBHDMEIMPROV[MENT. OOM OFFICE OF ENVIRONM AL SERVICES · [ ~NrrAL SERVICEI · UNIFIED PROGRAM INSPECTION CHECKLIST _ ,-, 1715 Chester Ave., 3rd Floor, BakerSfield, CA 93301 ~-~. FACILITY NAME ..~.~A,',]~ e~--~,~' t,',,'c~' INSPECTION DATE t' ~/~o ADDRESS ~-6~ ~sr,'a¢~ '~ tO't_ PHONENO. FACILITY CONTACT '~D.,,~ f'),,---~'~g BUSINESS ID NO. 15-210- INSPECTION TIME t I ~ 45'- NUMBER OF EMPLOYEES e ~"-- · 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 v~' ~t_~--~E'- Visible address Correct occupancy Verification of inventory materials t/ ~0 t~ ~ ~ &~x/ ! a/g Verification of quantities Verification of location Proper segregation of material Verification of MSDS availability Verification of Haz Mat training ,~ ,~ ~-~-- ~/tO~O '~ Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled ~ :~L~~c~ -~ Housekeeping FirePr°tecti°n ~' ~-~ ( {O Site Diagram Adequate & On Hand ~ ~E~ C=Compliance V=Violation Any hazardous waste on site?: ~ Yes ~0 -~] ~ Explain: ~' ~ ~,3 Wt~/ ~[~ ~~~R Questions regarding this inspection? Please call us at (805) 326-3979 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Inspector: CITY OF BAKERSFIELD FI~E4)EPARTMENT OFFICE OF ENVIRONMF~TAL SERVICES . UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME t'~,~'J5 ~c~' , ~p INSPECTION DATE r, fo ADDRESS _q'-6~-O F)~sr~,c~- ~ tO't. PHONENO. -29cg-O4t''') FACILITY CONTACT 'T;,,,a Oa,,.r~ ' BUSINESS ID NO. 15-210- INSPECTION TIME t t: 4 ~ NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program ~Routine [] Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION Ci V COMMENTS Appropriate permit on hand ~ ~"t.oe/~ Business·plan contact information accurate .~.,,' / v~ pkC_t~- Q~pc~'r'C~ Visible address Correct occupancy Verification of inventory materials t/ O ~ t"/~, ~a~"~r,) 6,x/ ! a/5 ?. Verification of quantities Verification of location . ? Proper segregation of material Verification of MSDS availability Verification of abatement supplies and procedures -' ,,. Emergency procedures adequate Containers properly labeled t/ '/-~"CA-~,^~¢~ -1(~ Housekeeping Site Diagram Adequate & On Hand ~ (Dg...E-4:5~ ~c.z,4?~C~ C=Compliance V=Violationt~ Any hazardous waste on site?: [] Yes l~No ,.~ t t~ / Questions regarding this inspection? Please call us at (805) 326-3979 . Site Responsible Party White- Env. Svcs. Yellow'- Station Copy Pink- Business Copy Inspector:. 12/18/1999 81:25 8855894881 DAVIS HOME IMPROVEM$ PAGE 81 Davis Home Improvements 4909 Stockdale Hwy #345 Bakersfield, Ca. 93309 661-398-0417 661-587-3743 fax To: Mr. Wines ~ '~~ From: Tim Davis Re: Inspection list 12/18/1999 81:25 8855894881 DAVIS HOME IMPROVEMS PAGE 82 Davis Home Improvements 4909 Stockdale Hwy #345 Bakersfield, Ca. 93:513 661.398-0417 City of Bakersfield Fire Department Dec. 10, 1999 Office of Environmemal Services 1715 Chester Ave, 3rd Floor Bakersfield, Ca. 93301 Re: Unified Program Inspection Checklist Mr. W~nes, O.n Nov. 11, 1999 we had a routine inspection of our facility. On our inspection report there were a few things that needed to be done, Currently we are moving our facility to another location. I am asking for more time to provide the changes you requested. If you have any questions, please call me at 398-0417, Thank you for your cooperation. Sincerely, Tim Davis Davis Home Improvements CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 HAZARDOUS MATERIALS INVENTORY FACILITY DESCRIPTION CHECK IF BUSINESS IS A FARM [ ] BUSnV~SS ~AM~ '.~r~ 3 '~ ~ FAC~I~ N~ C~Y STA~ Z~ NA~ OF BUS.SS SIC CODE D~ & B~S~T ~~ OWNER/OPERATOR 1"~-'t ~ C)/~t S PHONE cn'Y ST^T~ zn, ~3.XcF/ EMERGENCY CONTACTS BUSINESS PHONE gq9 2~,7 24HOmPHO~ ~9- 470 / 1 ~OUS MATERIALs INV~NTOI Business Name Add.ss C]~MICAL DESCRIPTION I~I~/TOR¥$TATU$:New[ ]Addition[ ]l~:vision[ ]~elction[ ] Chec~ifchemicaiisaNONTrad~[ ]Trad~Seoret[ ] Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HF~TH HazardCa~ories F~[r_..{diemiv~[ { Sudden Reiea~ of Pr, mur~[ ] t-.,,~diateHeaith(Acu,~)[ ]DeiayedHealth(Chroui¢)[ 5) WASTE CLASSIFICATION (3-digit c.~ fium DHS Form 8022) USE CODE 6> PHYSICAL STAre SOUd [ { Uquia ['-'1/O0 i I Pu~ [ 7) AMOUNT AND TIME AT FACILIT~dy~F- UNITS OF I~URE 8) STORAOECODES Avera~ Daily.~u~ b"~'~ Curi~s [ ] b) Pressure: Anuual Amount c) T .emPoraUa~ Lar~ Siz~ Coutainor ,~"~ # Days on Si~ Citr, le Which Months: All Year, $, F, ~ A, ~ .r, $, A, S, O, IV, D 9) MD(TURE: L~ COMI~ CAS# % WT AHM th~ three most hazardous 1) /dd ~ rV'~-/'~c-. ~/~'~ {~--t'c% [ ] chemical componeut~ or 2) ~C~/~ [ ] any AHlVl comp~aeum ~) [ ] 10)LOCATION 1) INVENTORY STATUS: New [ ]Addition[ ]Revision[ ]Deletion[. ] Check if chemical is a NON Trade Secret [ ]Trad~Secm[ ]' 2) Common Name: '~-'~ ~_c)~'-~ -'["C_~ -/r_~v.~ 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical ~ Health PHYSICAL HEALTH I-~,~tCat~es F~i IRemive[..lS~Rel=seofPressu~[ ] {a~UateH~th(Acu~)[ IDelayed~th(~)[ S) WASTE CLASSUUCATION O-disit ~ from DHS Form 8022) USE CODE 6) PHYSICAL STATE solid[ ] Liquid[ ] Oas[ ] Pure[ ] MixU~[ ] Waste[ ] Radioa~ve[ ] 7) AMOUN'r AND ~ AT FACILITY ~ OF MEASURE 8) STORAGE CODES Max/mum Daily Amount ~} ~ Lbs [ ] Gal [ ] fl3 [ ] a) Containec. Averase Daily Amount {'90 Curies [ ] b) Pressure: Annual Amount c) Temperature # Days on Site Civic Which Mouths: All Year, $, F, IVl, A, M, $, J, A, S, O, N, D chemical componeum or 2) ~ ~c.~a ~'- [ ] any AH:M camlx, n~nm 3) ~d~'ccu c~e: ~-- [ ]. PRINT Name & Title of Authorized Company Reprementativ~ k, '"' ~f~ture x,~ Date Pa~e .. of C~E. MICAL DESCRIFFION 1 ) INVENTORY STATUS: New [ ] Addilion [ ] Revisim [ ] l~leliou { ] Ch~k ifch~micai is a NON Trad~ ~ [ ] Trad~ ~ [ ] 2) Couuuon Name: "~-~. ' ~ 3) IX)T # (op,ionai) 4 ) Physical & Health PHYSICAL HEALTH H~,,-ntCa~'sori~s Fir~[ ]R~miv~[ ]Su~kaR~l~a.~of~[ ] ~I-kalm(A~u~)[ ]Dday~iI-Ieal~h(Chruui¢)[ ] ~> WAS~ CL~SS~CAnON (~.diSi~ ~ ~ D~ Fora, S0m) US~- CODE ~> P~SlCAL STA~ SoUd [ { Uq~d [/b~< Ca, i ] ~ [ ] ~ I ~] Wa~ 7) AMOUNT AND lIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES.. Am'a~ Daily Amoum ~e'O Curi~ [ ] b) Pmsm~ A~uai Amou,U ¢) T~mlxramre Lar{~s~ $iz~ C~U, ia~r # Days on $i~ Ci~m Whic, h lVi~ug~s: All Y~ar, $, F, M, A, M, $, $, A, S, O, N, D 9) lVIIX3URE: Lis~ COIvIPONENT cAS# % WT ABM ch~uicaicompou~msor2) CyzF~'~vcc,-,~ ~c.,c/'-. ~.~- [ ] any ~ comlmmts 3) [ ] 1)[NVENTORYSTATUS:N~v[ ]Ag~iliou[ ]R~isi~m[ ]Del~iou[ ]Cher, kifcJ~muicalisaNONTrad~S~cr~[ ]Tra~.,~[ ] 2) Commou Name: 3) DOT # (optiouai) Chemical Name: AHM [ ] CAS # ~) WAST~ CLASS~CATIO~ (~USi~ ~x~ from DltS l~orm S0~) USE ~) ?HYS~CAI. STAT~ SoUd [ ] Liquid [~r Oa~ [ ] Pur~ [ ] {~xU~e [ ] Wa~ 7) AMOUNT AND TIME AT FACILITY UNITS OF ME~URE 8) STORAGE CODES Maxim-,,, Daily Amouut ~ lbs [ ] Oal [ ] a5 [ ] a) Comin~ Average Daily Amouut Curies [ ] b) Pressure: Annual Amount ¢) Temperature Largest Siz~ Coutain~' # Days ou Sit~ Circl~ Which Momhs: All Year, .1, F, M, A, M, .l, J', A, $, O, N, D 9) MIXTURE: List COMPO~ CA~# % Wi AHM ~he ~ moa hazardous1) [ ] chemical c~mponm~s or 2) [ ] any AI~ c~mponm~s 3). [ ] { 0)LOCATION -_-.'.ieve ac submir,~d infom~ou is uu~, ar~'ura~ and ~ompk-~. ~ [ · RINT Name & T~tie ofAuthofized Coml~ny R~tmve ! g'i'~mmr~ . · ItAZ~OUS MATERIALs I~VENTOI~ " Page Business Name Addll~ CwI~MICAL DF.~CRIFI'ION I)I~/E'~ORYSTATUS;~v[ ]Addi~oa[ ]Revision( ]Delet~oa( ] Cl~c. kff~emicalisa~ONTrad~Sccre~[ ]TradeSccr~[ ~) Common ~am~; ~) DOT # (op~iom~l) Chemical ~am~: AH~ ( ] CAS # 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire [ ] Res~iv~ [ ] S,~ Relesse ofPms.su~ [ ] Imm.~tjst. Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (l-digit co& frmn DI-IS Form ~022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Gas[ I Pum[ I Mixture[ ] Waste[ ] Radioa~ive[ I 7) A~OtmT A~O Tt~ At F^ctt.rrv tmrrs OF ~m~St~ S) STOP. AOE COD~S l~axim,,~iiy.s, mouut .~-bs[ lC, at Iiu[ I a)Com~: Avera~ Daily Amouat Cur~[ I b) Pressm~ Annual Amou~ ¢) Temlxgamm Large~ Siz~ ¢outaingr # Deys on $it~ Cimla Which Monthr AII Yesr, $, F, M, A, M, I, $, A, S, O, N, D~ 9) MIXTURE: List COMPONENT CASa % WT AttM chemical compoueurs or 2) [ ] anyAf~~ts 3) ' [ ] I 0)LOCATIO~ I)INVENTORYSTATU'S:N~w[ ']Addition[ ]Rm~iou[ ]Deletion[ ] ch~.kifchemic~lisaNONTradeSecrct[ ]Trad~[ ] 2) Conunon Name: 3) DOT # (optional) Chemical Nam~ AHM [ · ] CAS # 4) Physical & H~alth PHYSICAL HEALTH PammiCat~gories Fim[ ]Res~iw[' ]SuddmRelgas~ofPr~saum[ '] Iumgdla~Health(Acum)[ ]DelayedHealth(Clmmi~)[ ] s) WASTE CLASSn~CAT~ON (~di~i~ ~d~ from Dm Form S022) USE CODE 6) PHYSICAL STATE Solidi ] Liquid[ ] Gas[ ] Pum[ ] Mixture[ ] Wa.sm[ ] Radioa~iw[ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount Lbs [ ] Gal [ ] ft3 [ ] a) Containe~.. Average Daily Amount Curies [ ] b) Pressure: Annual Amoum ¢) Temperature Largest $iz~ Container # Days on Sit~ Circle Which Months: All Year, $, F, M, A, M, $, $, A, S, O, bi, D 9) MIXTURE: List COMPONENT CA~# % WT AHM the thr~ most hazardous 1). [ ] chemical components or 2) [ an), AFIM components 3), [ ] I 0)LOCATION I ~ under p~alty of law, tha~ I hav~ IX~Sonally ~xamiued and am tamiliar with tl~ iufonmtion on ~s and all attadmt dmmnm~ I PRINT Name & Title of Au~hor/z~ Company Representative Signature Dat~