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HomeMy WebLinkAboutHAZARDOUS WASTE " ~ ....... ~ "'%'----~'-" ~ ' OFFICE OF ENVIRONMENTAL -sERvICES Business Identification No. 215-000 -Oo o Fo '7 '7 (Top of~, Business Plan) Station No. ..,7 · Shift /Or- ' Inspector . · Adequate Inadequate ~ -Adequate Inadequate Address Visable, .." [] ' '[] . Emergency Procedures Posted I-I [] ' _ _ .7""'"~rrect OccUpancy [] [] ,' ' ' Containers Properly Labled [] [] Verificati.o.n o. ! I~Matedals I-I [] comments: ' __ V.e?, ar, opof_.' s [] []. . ' _ _Vedficat!on of Location,...... [] [] Verification of Facility DiagramO [] ' ~gation °f Maten'al ~ ~ ' Housekeeping [] r'l~ ^ , ' ' - - ' ' '~. Fire Protection [] [] Comments:~ _ _ ~ - Electrical [] [] ._ .~ .... ~ Comments: ' __ ~ MSDS Availablity .il [] '~. ~-~ ' ~f Employees; ~_ _ _ ~ UST Monitoring Program [] [] · ' Comments: . · Verification of Haz Mat Training [] [] ~ · ' ' . · . .'"7,,~ermits t'l [] C6mments: ' ' __ ' Spill ~ [] [] · '" - ' ' HoldOpen Device~[] [] Verification of ' Hazardous Waste EPA No. Abbatement Supplies and Procedures [] [] · Proper Waste Disposal [] ri"--- Comments: Seconda~ Containment [] [] Secudty II.. 13 Special Hazards Associated with this Facility: / , All Items O.K D ~ Business. owner/Manager PRINT NAME SIGNATURE Correction. ·Needed Il ®~ White-Haz Mat Div. Yellow-Station Copy Pink-Business Copy ' ", For Office Use Only First In Stction: Area MoD # of Inspection Stotton: N 0 RTH ' · ~.~:~ BAKE IELD CITY FIRE DEPARTMENT` ' OFFICE OF ENVIRONMENTAL SERVICES ~, 1715 CHESTER AVENUE, 3RD FLOOR BAKERSFIELD, CA 93301 (805) 326-3979 -, HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: · . 1. To avoid further act on, return this form within 30 days of receipt.~__ L~ · 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. ~<,-9,.--..~. 4. Be brier and concise as possible. SECTION 1' BUSINESS IDENTIFICATION DATA ~_~ BUSINESS NAME:HOLLodl~g LOCATION: ,~'~2'~ ~Pl¢-r-0~ .~f--,, ~ / ~ DUN & BRADSTREET NUMBER· SIC CODE: SECTION 2: EMERGENcy NOTIFICATION: CONTACT TITLE BUS. PHONE 24 HR. PHONE Bakersfield Fire Dept. ~azardous Materials ,Division HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3: TRAINING: NUMBER OF EMPLOYEES: 5 " MATERIAL SAFETY DATA SHEETS ON FIUE: J~00 BRIEF SUMMARY 'oF TRAINING PROGRAM: SECTION 4: EXEMPTION REQUEST: ! CERTIFY UNDER PENALTY OF PERJURY THAT-MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6,95 OF THE "CALIFORNIA HEALTH & SAFETY CODE" FOR THE FOLLOWING REASONS: WE OD NOT HANDLE H~,ZARD©US MATERI~£S. '" WEDO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO 'TJMEEXCEEO 'THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION: I, CERTIFY THAT THE ABOVE INFOR- MATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CAL..IEORN A HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.9r5 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION.CONSTITUTES PERJURY. SIGNATURE TITLE DATE .-- '-- -:~ Bakersfield F~re Dept. ~ ,-- ":IHaZardous ~aterials Division HAZARDOUS MATERIALS MANAGEMENT' PLAN FaciliW unit Name: ~0 L 0 ~ / SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES: A:'" AGENCY NOTIFICATION PROCEDURES: B. EMPLOYEE NOTIFICATION AND EVACUATION: C. PUBLIC EVACUATION: O, EMERGENCY MEDICAL PLAN: B ~k~rsSeld. Fire Dept. Hazardous 1V~aterials Division ...... ~,¢ HAZARDOUS' MATERIALS MANAGEMENT PLAN SECTION 7' MITIGATI©N, PREVENTION AND ABATEMENT'PLAN' A. RELEASE PREVENTION STEPS: RELEASE'CONTAINMENT ANO/OR MINIMIZATION' C. CLEAN-UP PROCEDURES: SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)' · ' ' - ' "'" '" ' ' -' " ';' ' ' FY""" * ~ NATURAL GAS/PROPANE: O~ 0..~:. b,);l~,~ LOCESOX: YES~ tFYES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAI~BILI~:. A. PRIVATE FtRE PROTECTiON' FIre ~X ~'~1/~r ' B.WATER AVAILABILITY (FIRE HYDRANT)' ~ro.~ o ~- e,,,i¢-/-',,,~ ,/,';~'~' - . ......... -. - - Bak~rsf~elcl Fire Dept. .-- "'IHazardous ~aterials Division HAZARDO US MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PI~OCI:DUEES: A: ' AGENCY NOTIFICATION PROCEDURES: B. EMPLOYEE NOTIFICATION AND EVACUATION: C. PUBLIC EVACUATION: O. EMERGENCY MEDICAL PLAN: ~ · BAKEF~FI'ELD CITY FIRE DE~ART. MENT OFFI,CE OF ENVIRONMENTAL SERvICEs . ~,= 171~' CHESTER AVENUE, 3RD FLOOR BAKERSFIELD, CA 93301' ~,.~ ¢05) 326-3979 HAZARDOUS MATERIALS' INVENTORY FACILITY DESCRIPTION CHECK IF BUSINESS IS A FARM [ ] FACILITY NAME SITE ADDRESS '~ ~00 .~/¢¢~r~0~/ ~; 4~'/0 CITY ~rl~ STATE ¢,4-, ZIP ~ SiC CODE : DUN & 8~DSTREET NUMBER OWNER/OPERATOR , ~'¢-&~/1¢~1 ~, .~//0 ~¢ PHONE MAILING ADDRESS ~}~¢ ¢~¢~¢r ~, '. EMERGENCY CONTACTS BUS~NESS ~, ,ONE ~, f'- ?Y'2- ¢ ~,,HOUR PHONE NAME ¢[4~," / ~¢.~/~ TITLE '"~¢ BUSINESS PHONE ~¢~ ~..~ ~ 24-HOUR PHONE BAKERSFi,[LD CiTY FIRE DEPAi MENT HAZARBOUS MATERIALS INVENTI RY -' Page-~'~ ~o~~ CHEMICAL DESCRI~ION '-:" ' IN~TORYSTA~S: New[ ] A~A~n[ ] Re--mn[ 1 ~n[ ] Ch~chem~aNON~ES~'[']'.~~R~ [ ] Chem~ N~e: ~M [ ] CAS · PH~IC~ & H~ PHYSIC~ H~ H~D CA~RIES Fire [ ] Re~e [ ] Sudden Rele~e of Pressure [ ] Imme~ime He~ (Acme) [ ] ~ He~ (Chmnm) [ ] WAS~ C~SSIRCA~ON (3~igR ~de ~m OHS Fo~ 8022) USE CODE PH~Ic~sTA~ Sol~ [ ] ~qu~ (~ G~ [ ] Pure [ ] M~ure [ ] W~te [ ] ~, [ ] ~OU.T ~ ~E ~T ~C~U~ U.(~S O~ ~SU~E S) STO~eE COOES M~mum OmlyAmount: /0~ ~/~. [~ [ ] ga [~ ~3 [ ] ~) Con~ A~e O~ A~unt: ~ I curies [ ] b) Pressure: Annu~ ~ount: ~ OD c) Tem~r~m: ~est Size'Contmner: ~ ~ . ~Da~OnSite Circte~ichMonths~ . F. M. A. M. J. J. A. S. O. N. D' the throe most h~d~us 1). ~r A~ d~ COMPON~ CAS~ %~ ~M chemi~ com~nenm or CHEMICAL DESCRI~ION IN~NTORYSTA~S; New[ ] Add~ion[ ] Re,sion( ] Delet~n( ] Che~chemi~maNON~DES~ [ ] ~ESECR~'[ ] PHYSICAL & H~ . PHYSICAL H~ H~D CA~GORIES Fire [ ] Rea~e { ] Sudden Reiemeof PressUre [ ] Immedi~e He~ (Ac~e) [ ] ~l~d He~ (Chmnm) [ ] WAS~ C~SSIFICA~ON (~i~it co~e from DHS Fo~ 8022~ USE CODE PHYSlCAL STA~ Solid { ] Dquid ~ Gm [ ]' Pure [ ]Mmure [ ] Wrote [ I Rad~ [ ] AMOUNT AND ~ME AT FAClU~ UNITS OF M~SU~E 8) sTO~GE CODES Minimum Omly Amount: ~ I~ [ ] g~ [~ ~ [ ] a) Cont~ne~ Average O~N Amount: ~ .cunes [ ] b) Pressure: ~nu~ Amount: 7~O c) Tem~re: ~gest Size Cont~neE .: -' ~- q ~ / ~ Da~ On Site' / - ' ~'~ ~ Cir~e~ich Month~;~l~ J..~. M, A, M, J, J, A, S, O, N, O MITRE: ~st COMPON~ C~ · % ~ ' ~M the three most h=~oos 1) ~ f( ~ f-- [ ] c~emi~ com~nen~ or ~ ~M ~m~nents 2) __ I~ ~ ~ ~.~ ' -. [ ] ce~~ u~er pe~ of law. ~at I have pe~ ex~tn~ ~ ~ t~iJi~ wire ~e miD--on suDml~ on ~ ~ ~ ~ ~~ I ~etieve m~ · ~bm~ in~on is ~e. accu~. ~ comple~ 'RI~ N~e & ~ffe of ~nz~ Com~ Re, senSe ., Sig~m ~' BAKERSFIELD CITY FIRE DEPARTMENT ' ' ,, HAZ/ DOUS MATERIALS INVENTORY Page__of__ 3 u si n~;s Name Address .~'.. CHEMICAL DESCRIPTION 1~,) ~NVENTORY STATUS: New [ ] Addition [ ], Revision [ ] Deletion [ ] Check if chemical is a.NON TRADE SECRET [ ]. TRADE SECRET [ ] 2) Common Name: . ~'~'~' 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive 5) WASTE cLAssIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid. [ ] Liquid [] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FAClMTY UNITS OF MEASURE 8) STORAGE CODES . Maximum Dally Amount: lbs [ ] gaJ [ ] ~3 [ ] a) Container:. Average Dally Amount: cudes [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: # Days On Site CimleWhich Months: All Year, J, F, M, A, M, J, J, A, S. O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1). [ ] chemical components or any AHM components 2) [ ] 3) [ ] 10) Location CHEMICAL DESCRIPTION 1 ) INVENTORY STATUS: New [ ] Addition { ] Revision [ ] Deletion [ ] Check if chemicaJ is a NON TRADE SECRET [ ] 'TRADE SECRET [ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PhYSICAl HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLAssIFICATION' (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TiME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: lbs [ ] gal [ ] ft3 [ ] a) Container: Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: # Days On Site Circle Which Months: AIl Year, J; F, M. A, M. J, J, A, S, O, N. D 9) MIXTURE: List . COMPONENT CAS # % WT' AHM the three most hazardous '~). [ ] chemical components or r [] any AHM components 2) 10) Location personally examined and am familiar with the infomation submitted on this and all attached documents. I believe th! submitted informa~fon is b'ue, accurate, and complete. . PRINT Name & Title Of Authorized Company Represente#ve Signature Date BAKERS[ ELD CITY FIRE DEPARTMENT 'HAZARDOUS MATERIALS INVENTORY Page of~_. Business Name ,J-J~ jj...o ~,u~.~// j~,'~'~'~/~ Address CHEMICAL DESCRIPTION* 1) INVENTORY STATUS: New [ ] Addition [' ] Revision [ ] *Deletion [ ]. Check ff chemical is a NON ~:~DE $.ECRET! [ .] TRADE SECRET [, ] 2) Common Name: 3) DOT # (optional). Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [. ] Immediate Health (Acute) [ ] Delayed Health (ChrOnic) [ ] ' 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE* 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FAClUTY UNITS OF MEASURE 8) STORAGE CODES MaYdmum Daily Amount: lbs [ ] gal [ ] 1t3 [ ] a) Container:. Average Dally Amount: cudes [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size'Container: # Days On Site Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM · the three most hazardous 1) [ ] chemical components or any AHM components 2[ [ ] [ 10) Location CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] .Revis!on [ ] Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES ' Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: lbs [ ] gal [ ] fi3 [ ] a) Container: Average Daily Amount: cudas [ ] b) Pressure: Annual Amount: c) Temperature: largest Size Container: # Days On Site Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List COMPONENT CAS # % WT AHM the three most hazardous 1) [ chemical components or anY AHM components 2) [ ] 3) [ l 10) Location personally examined and am familiar with the infomation submiffed on this and all attached documents. I believe submitted information is true, accurate, and complete. PRINT Name & Title of Authorized Company F~epresentative Signature - Date