HomeMy WebLinkAboutBUSINESS PLAN BAKERSFIELD CITY FIRE DEPARTMENT
2130 "S" STREET
B~KERSFIELD, CA 93301
(805) 326-3979
i OFFICIAL USE ONLY
USINESS NAME
HAZARDOUS i~TER I ALS ~c'l~k
BUSINESS PLAN AS A WHOLE
FORM 2A
INSTRUCTIONS: "
1. To avoid further action, return this form by
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business as a whole.
4. Be as brief and concise as .possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
B. LOCATION / STREET ADDRESS: ,~.~/d3(3 ~ ~7~537'"
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving the release or threatened release of a'
hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify
your local fire department and the State Office of Emergency Services as required by
law.
EMPLOYEES TO NOTIFY IN CASE 0F EMERGENCY:
NA.M~. AND TITLE~; ~ DURING BUS. HRS. AFTER BUS. HRS.
B. Ph# Ph~
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WI{OLE
A. NAT. GAS/PROPANE: /-~ _~. /'!~-~'-~ ~.~ ~.~J~'
B. ELECTRICAL: /_~2. ,_~. g~fT_~F. ~/
C. WATER: /~j] .//~././~'~ ~
D. SPECIAL: ~x/,~
E. LOCK BOX: YES / NO IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS? YES / NO MSDSS? YES /' NO
~/~-~7 FLOOR PLANS? YES / NO KEYS? YES / NO
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SECTION 4: PRIVATE RESPONSE TE;%~ FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND
REFRESHER TRAINING IN THE FOLLOWING AREAS.
CIRCLE YES OR NO INITIAL REFRESHER
A. METHODS FOR SAFE HANDLING OF HAZARDOUS ~
~TERIALS:...' .................................... x~(~ NO~NO
WITH RESPONSE AGENCIES: .......................... ~ NO ~'~ NO
c. ~ROPER ~SE OF SAFET~ EQUIPMENT: .................. ~" NO ~
NO
D. EMERGENCY EVACUATION PROCEDURES: ................. f-YES"D NO ~S~ NO
E. DO YOU ~fAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES ~ YES ~
SECTION 7: }{AZARDOUS ~4ATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE ~AZARDOUS ~RTERIAL IN QUANTITIES LESS THAN 500 POU~~ A
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ......
I, '~/._~73 /~/7. ~/~/~/--~3 /~'/,/2~,. certify that the above information is accurate.
I understand that this information will be used to fulfill my firm's obligations under
the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter 6.95
Sec. 25500 Et Al.) and that inaccurate information constitutes perjury.
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BAKERSFIELD CITY FIRE DEPART~IENT
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFiCiAL USE
BUSINESS NAHE:
BUS I NESS PLAN
SINGLE FACILITY UNIT
FORM 3A
INSTRUCTIONS 1. To avoid further action, this form ~nust 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# FACILITY b'NIT NAME:
SECTION 1: MIT!GATION~ PREVE~"rlON, ABATEME~'T PROCEDURES
SECTION 2: NOTIFICATION ~ EVACUATION PROCEDL~ES AT THIS L~iT ONLY
SECTION 3: HAZARDOUS MATERIALS FOR THIS b~IT ONLY
A. Does this FaciIity Unit contain Hazardous Materials? Y~S~'~'~-
If YES, see B.
If NO, continue with SECTION 4,
B. Are any of the hazardous materials a bona fide Trade Secret YES N(~0~
If No, complete a separate hazardous materials inventory
form marked: NON-TRADE SECRETS ONLY (white form ~4A-1)
If Yes, complete a hazardous materials inventory form marked:-
TRADE SECRETS ONLY (yellow form ~4A-2) in addition to the non-trade
secret form. List only the trade, secrets on form 4A-2.
SECTION 4: PRIVATE FIRE PROTECTION
SECTION 5: LOCATION OF WATER SL~PLY FOR USE BY EMERGENCY RESPONDERS
SECTION 6: LOCATION OF UTILITY Sh~T-OFFS AT THIS bLNIT ONLY.
A. NAT. GAS/pROpANE]
D. SPECIAL:
E. LOCK BOX: YES /&q'")IF~.... YES, LOC&TION:
IF !'ES, SITE PLAX'S? YES
FLOOR PLANS? YES ./ ~' KEYS9 YES i' NO
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BAKERSFIEI, D CITY FIRE DEPARTMENT 'x
NON--TRADE SECRETS
~.~2] HAZ AR'DOUS MATERI ALS INVENTORY
BUSINESS' NAME: .~ ,/~.~. OWNER NAME:~"~-~ / . FACILITY UNIT #: ,~
ADDRESS: ..... _ . ~ . ~,, _ADDRESS: /~ ~~FAC~Y UNIT NAME:
PHONE ':~ ' [OFFICIAL USE CFIRS CODE
PHONE ~': ~ - ~ ONLY
1 2 3 4' 5 6 7 8 9 10
TYPE MAX' ANNUAL CONT USE LOCATION IN THIS % BY HAZARD D.0.T
.
. CODE AMOUNT AMOUNT UNIT CO'DE CODE FACILITY UNIT ~T CHEMICAL COMMON NAME CODE GUIDE
L,
NAME:
EMERGENCY CONTACT: TITLE:~rzz/4/~ NE · B HOURS:
~ '- AFTER ~S MRS:
EMERGENCY' CONTACT TITLE: _ '~~ . PHONE ~ BUS HOURS:
PRINCIPAL. BUSINESS ACTIVITY: AFTER BUS HR$:
SITE/FACILITY DIAGRAM
FORM
NORTH SCALE: BUSINESS N~[E: FLOOR: OF
DAT~?~ .~/ FACTLITY NAME: UNIT ~: OF
(CHECK ONE) SITE DIAGR,~M FACILITY DIAGR.~M v'/
I(Inspector's Comments): -OFFICIAL USE ON'LY-
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