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Home My WebLink AboutBUSINESS PLAN Hazardous Materials/Hazardous Waste Unified Permit '~ CONDITIONS OF ~PERMIT ON REVERSE SIDE ~ · .. .~, ' This mit is issued for the followin~_: - [] H~aRIous I~terlals Plan 0 Underground Storage of H~*-~rdous Materials' · Permit ID #:: 015-000-000471 ' D RiskManageme. tProgmm FRITCH EYE CARE SURGICA ~ HazardOus WasteOn-~;ite Treatment LOCATION: 2525 EYE ST IELD OFFICE OF ENVIRONMENTAL SER VICES' · ,~' .' 1715 Chester Ave.; 3rd Floor Bakersfield, CA 93301 . Voice (661) 326-3979 · FAX (661) 326-0576 ExpimtionDate: Ju~e 30.. 2005 Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE ........... ~,~;,~,,~;~,~,,~,~,~,~ ......... This permit is issued for the fOllowing: ~ ~¢~', ~"i~=[ !~ilr ~:':J'?:~:!:::i ii } ii!!ii~ ~i ?'::::i ;:~i:,B::;iiO~e[ground Storage of Hazardous Materials PERMIT ID# 015~21~00471 .~,~:~?~ ~ ;[~:~- '~ :??~:~::~?.:;~;~?,~;~?,~k[~Oagement Program ~xS-:--~ '?-~ ~-, '"~:' ?- ~'~ ~'. ~% . '~.~. ~. :.~,..-, : ... =~ ..... :%. '~ ~ .~,~.~,*~,'.~..- ¥ ~; .~ ............. ~ ~ ~-.~ ..C~~ B~ersfield F~e D.aRment Approv~ by: O~CE OF E~R O~AL S~ ~C~ 1715 Chewer Ave., 3rd Floor B~e~fiel~ CA 93301 Voice (805) 32~3979 F~ (805)~6~57b Expiration Date: PATH OF. EGRESS ~ ~o ~~~ ~/~~ ~~ o~ RUSSELL - ~SOC~S (Air Conditionin~ Units are roof mounted) ~ .' -. .__~- ~_ i SU~IC~ ~ CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301 FACILITY NAME ~'ci-~_K =,,.e_ Cedar'- INSPECTION DATE ADDRESS ~O.,.q ~,,le_ ~'v- PHONENO. FACILITY CONTACT ~co~ '-~,~.Z~-' BUSINESS ID NO. INSPECTION TIME ~-~-~ ,~', ~ NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program [~Routine ~ Combined ~l Joint Agency ~ Multi-Agency [~ Complaint ~ [~l Re-inspection OPERATION C VI COMMENTS Appropriate permit on hand v/ .~/ ~ ~.~[ Business plan contact information accurate v/ ,~.~ ~.~-'a~ --/'- . Verification of inventory materials ~ ..,~.~',~ 4~'-Z7 o~-~t-,-~[~,~ Verification of quantities v' ~-~ 9rd; ~ Verification of location I/ Proper segregation of material Verification of MSDS availability Verification of Haz Mat training ~,, Verification of abatement supplies and procedures v Emergency procedures adequate "/ ~"~.~,ro_ k~c,.~e~. '~ v,. Containers properly labeled Housekeeping v' ~Ie.e,~ ~ ~eke.~6 Fire Protection Site Diagram Adequate & On Hand v/ C=Compliance V=Violation Any hazardous waste on site?: ~][ Yes [~]"No 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: iFRITCH EYE CARE SURGICAL CENTER SiteID: 015-021-000471 Manager : DANA GAINES RN BusPhone: (661) 327-8511 Location: 2525 EYE ST ~ ~f~ ~ I Map : 103 CommHaz : Low City : BAKERSFIELD Grid: 30A FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 01 SIC Code: 8011 EPA Numb_:. DunnBrad: ~er~cy ~tac~ / ~me I~ Business Phone: (661)~ . 1(] Business Phone: (661)/~ 24-Hour Phone : (661) 393-5D79~_. _ IH 24-Hour Phone : (661Y - x ~Pa~er Phone : ( )U&f~ ~ ~3 ~ Pa~er Phone : ( ) - x HapHazards: ~ ~ ~ Contact D~A CA ...... ~ :~ ' ~'~ .... - Phone: (661) MailAddr: 2525 EYE ST~ ~[~~ State: CA City : B~ERSFIELD~ Zip : 93301 O~er ..... LES D .,.._TC .... D Phone: (661) Address : 2525 EYE S~ ~U[~ ~/ State: City : B~ERSFIEL~ Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: = Hazmat Inventory One Unified List ----Alphabetical Order Ail Materials at Site Hazmat Common Name... ISpocHazlEPA Hazards)Frm DailyMax IUnitIMcP NITROUS OXIDE F P IH G 1350.00 FT3 Hi OXYGEN F P IH G 1300.00 FT3 Low -1- 03/14/2001 FRITCH EYE CARE SURGICAL CENTE~-~-._-~-~--]~-~-F~/-:-L--~! SitelD: 215-000-000471 Location: ~-,1~- , ~ M~p : 103 Com~az : Low 2525 EYE ST City : B~ERSFIELD . . ~'=-J~:-- ' ~id: 30A FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 01 SIC Code:8011 EPA Nu~: DunnBrad: Emergency Contact / Title Emergency Contact / Title CHARLES FRITCH ~ j/ O~O~ ~~~d~3~ Business Phone: ~ 327-8511x Business Phone: J~i,327-8511~ 24-Hour Phone Q~q!SO5) CD2 ~n?gx~7-~ll 24-Hour Phone : Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire Press ImmHlth Contact : ~~ ~O~ ~-5)~-~ Phone: ~J )~ -~>~lj x MailAddr: 2525 EYE ST State: CA City : BAKERSFIELD Zip : 93301 Owner CHARLES D. FRITCH MD Phone: o~ 327-8511x Address : 2525 EYE ST State: CA City : BAKERSFIELD Zip : 93301 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: . ~ her~, c®~i¥ ~ ~ h~v~ reviewed ~ .a~achsd h~a~s ma~a~s manag~ any corre~io~ co~sfi~u~ ~ ~D~ ~nd ~ ~a~- agement plan f~r my ~ciH~, 1 11/01/1999 FRITCH EYE CARE SURGICAL CENTER SiteID: 215-000-000471 ~ Hazmat Inventory By Facility Unit -- MCP+DailyMax Order Fixed Containers on Site Hazmat Common Name... ISpooHazlEPA HazardsI Frm I DailyMax Unit MCP NITROUS OXIDE F P IH G 1350.00 FT3 Hi OXYGEN F P IH G 1300.00 FT3 Low -2- 11/01/1999 FRITCH EYE CARE SURGICAL CENTER SiteID: 215-000-000471 ~ Inventory Item 0002 Facility Unit: Fixed Containers on Site NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: STORAGE ROOM REAR OF BLDG CAS# 10024-97-2 r STATE -- TYPE PRESSURE ~ TEMPERATURE CONTAINER TYPE Gas Pure Above Ambient Below Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average FT3 1350.00 FT3 1350.00 FT3 HAZARDOUS COMPONENTS %Wt. R[NoRS~ CAS# 100.00 Nitrous Oxide 10024972 HAZARD ASSESSMENTS TSecretINo N~S I Bi°HasINo Radi°active/Am°unt I EPANo/ Curies F P HazardsiH NFPA///. USDOT# HiMCP = Inventory Item 0001 Facility Unit: Fixed Containers on Site ~lVUVl~ ~Vl~ / ~ £ ~Z%J~ ~Vl~ OXYGEN Days on Site 365 Location within this Facility Unit Map: Grid: STORAGE ROOM REAR OF BLDG CAS# 7782-44-7 F STATE [ TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Gas Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average FT3I 1300.00 FT3 1300.00 FT3 HAZARDOUS COMPONENTS 100.00 Oxygen, Compressed N 7782447 TSecret S BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No N No No/ Curies F P IH / / / Low -3- 11/01/1999 F FRITCH EYE CARE SURGICAL CENTER SiteID: 215-000-000471 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 11/28/1990 FOR SINGLE PATIENT PROBLEM: NOTIFY NURSE AND/OR DOCTOR. IF PATIENT RESPONDS BUT NEE~TRANSPORTATION TO HOSPITAL, DIAL~911 FOR AMBULANCE SERVICE TO TRANSPORT. CA'SAN JOAQUIN COMMUNITY HOSPITAL EMERGENCY RO~M, ~ AND NOTIFY THEM OF PATIENT ARRIVAL. ( -3q&3coo REMEMBER TO SEND A COPY OF PATIENT'S INSURANCE INFORMATION AND ANY.MEDICINES OR PERTINENT CHART INFORMATION. -- Employee Notif./Evacuation 11/28/1990 IT IS THE RESPONSIBILITY OF ANY INDIVIDUAL WHO NOTICES A FIRE TO IMMEDIATELY · ACTIVATE THE FIRE ALARM SYSTEM BY USING THE MANUAL PULL STATION IN THE WAITING ROOM OR BY THE EMERGENCY EXIT. CHIMES WILL BE HEARD IN THE SUITE AND THE FIRE BELL WILL SOUND IN THE OUTSIDE CORRIDOR. WHEN THE ALARM SYSTEM IS ACTIVATED IT AUTOMATICALLY SIGNALS THE FIRE DEPT WHICH SENDS A FIRE TRUCK TO THE CENTER. ANY OPERATIVE PROCEDURE CURRENTLY IN PROGRESS WILL BE TERMINATED. THE DOCTOR AND THE CIRCULATING NURSE WILL CONCURRENTLY EITHER ASSIST EVACUATION OF THE PATIENT IN THE OPERATING ROOM OR WILL EVACUATE ANY PATIENT IN THE RECOVERY ROOM AREA. THE SCRUB NURSE AND THE ANESTHESIOLOGIST WILL EVACUATE THE PATIENT FROM THE OPERATING ROOM ON A GURNEY TO THE HALLWAY. -- Public Notif./Evacuation 11/28/1990 DIAL 80 ON ANY PHONE AND ANNOUNCE NEED FOR EVACUATION. REMEMBER TO ALSO CALL OPERATING ROOM EXTENSION 258 OR 270 BECAUSE CALL SYSTEM IS NOT HEARD Emergency Medical Plan 11/28/1990 NOTIFY NURSE AND/OR DOCTOR EVALUATE: DETERMINE NEED FOR TRIAGE TREAT IF IN OUR AREA OF EXPERTISE IF YOU NEED PATIENT(S) TRANSFERRED, DIAL 911 AND FOLLOW OUTLINE TO TRANSPORT PATIENT(S) TO HOSPITAL EMERGENCY ROOM. -4- 11/01/1999 F FRITCH EYE CARE SURGICAL CENTER SiteID: 215-000-000471 Fast Format = MitiHation/Prevent/Abatemt Overall Site --Release Prevention 11/28/1990 MEDICAL GASES BEHIND LOCKED DOORS IN APPROVED CONTAINERS WITH APPROVED MANIFOLDS AND CONTROLS. --Release Containment 11/28/1990 OXYGEN AND NITROUS OXIDE ARE USED ON ANESTHESIA AND MEDICAL EQIUPMENT IN THE OPERATING ROOMS. EXTRA TANKS ARE STORED IN SEPARATE ROOM IN RACKS OR BEHIND CHAIN. IN THE EVENT GAS WAS LEAKING FROM TANK, BOTH GASES WOULD DISSIPATE INTO THE AIR RAPIDLY WITHOUT INNURY OR HARM. EVACUATION OF THE AREA AS A PRECAUTION. -- Clean Up 11/28/1990 CLEAN UP WOULD BE LIMITED TO CHECKING TANKS FOR STABILITY AND TO BE SURE VALVES WERE TURNED OFF. Other Resource Activation 5 11/01/1999 FRITCH EYE CARE SURGICAL CENTER SiteID: 215-000-000471 Fast Format Site Emergency Factors Overall Site -- Special Hazards 08/12/1991 RADIOISATOPES ON HAND RADIATION HAZARD --Utility Shut-Offs 08/12/1991 A) GAS - SOUTHEAST CORNER & WEST SIDE B) ELECTRICAL - NORTHWEST CORNER & WEST SIDE MIDWAY C) WATER - WEST SIDE OF BUILDING APPROXIMATELY 15 FT D) SPECIAL - NONE E) LOCK BOX - NO -- Fire Protec./Avail. Water 08/12/1991 PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS ARE LOCATED IN REQUIRED AREAS AND ROUTINELY CHECKED FOR REQUIRED MAINTAINANCE. PARKING STRUCTURE AND BOTH FLOORS OF ENTIRE OFFICE BUILDING ARE EQUIPPED WITH SPRINKLERS. SHUT OFF VALVES ARE CHECKED ANNUALLY. FIRE HYDRANT - NORTHWEST CORNER OF PROPERTY, CORNER OF EYE STREET AND 26TH STREET Building Occupancy Level 6 11/01/1999 FRITCH EYE CARE SURGICAL CENTER SiteID: 215-000f000471 Fast Format ~ Training Overall Site -- Employee Training 09/09/1992 WE HAVE 100 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE BRIEF SUMMARY OF TRAINING: WE HAVE A SAFETY COMMITTEE CONSISTING OF ONE MEMBER FROM EACH DEPARTMENT. THEY IDENTIFY THOSE ITEMS IN THEIR AREA THAT REQUIRE MSDS SHEETS AND INSTRUCT THE EMPLOYEES ACCORDINGLY. FOUR TIMES A YEAR AT OUR GENERAL STAFF MEETINGS THERE IS AN AREA ON SAFETY ON THE AGENDA. -- Page 2 --Held for Future Use Held for Future Use -7- 11/01/1999 11/02/93 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 1 Overall Site with 1 Fac. Unit General Information Location:.2525 EYE ST Map: 103 Hazard: Low Community: BAKERSFIELD STATION 01 Grid: 30A F/U: 1AOV: 0.0 Contact Name Title Business Phone'l----r124-H°ur Phone- CHARLES FRITCH (805) 327-8511 x 805) 393-5079 8~W MCHONE ~' (805) 327-8511 x 805) 393-1063 dOAN Administrative Data Mail Addrs: 2525 EYE ST D&B Number: City: BAKERSFIELD State: CA Zip: 93311- Comm Code: 215-001 BAKERSFIELD STATION 01 SIC Code: 8011 Owner: CHARLES D. FRITCH MD Phone: (805) 327-8511 Address: 2525 EYE ST State: CA City: BAKERSFIELD Zip: 93301- Summary RECEIVED HAZ ~,,!AT. r31V I, ~o~. k)l-~'""~- Do hereby certi~ that I have (Type or pdnt name) reviewed the ~ttached h~e, rdous materials manage- ment plan for~'~ ~ ~and that it along with any corre~ions constitute a ~mp~et9 and corre~ man- agement plan for my f~cili~,. 11/02/93 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 2 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site Pln-Ref Name/Hazards Form Max Qty MCP 02-002 NITROUS OXIDE Gas 1350 High · Fire, Pressure, Immed Hlth FT3 02-001 OXYGEN Gas 1300 Low · Fire, Pressure, Immed Hlth FT3 11/02/93 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 3 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order 02-002 NITROUS OXIDE Gas 1350 High · Fire, Pressure, Immed Hlth FT3 CAS #: 10024-97-2 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3 I Daily Average FT3 I Annual Amount FT3 -- 1,350 I 1,350.00 ! 1,350.00 Storage Press T Temp~ Location PORT. PRESS. CYLINDER Above ~Below ISTORAGE ROOM REAR OF BLDG -- Conc Components MCP --/Guide 100.0% INitrous Oxide IHigh ! 14 02-001 OXYGEN Gas 1300 Low · Fire, Pressure, Immed Hlth FT3 CAS #: 7782-44-7 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3I Daily Average FT3 I Annual Amount FT3 -- 1,300 ~ 1,300.00 1,300.00 Storage I Press T Temp Location PORT. PRESS..CYLINDER IAbove IAmbientlSTORAGE ROOM REAR OF BLDG -- Conc Components MCP ---~uide 100.0% IOxygen, Compressed ILow ! 14 11/02/93 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 4 00 - Overall Site <D> Notif./Evacuation/Medical <1> Agency Notification FOR SINGLE PATIENT'PROBLEM: NOTIFY NURSE AND/OR DOCTOR. IF PATIENT RESPONDS BUT NEED TRANSPORTATION TO HOSPITAL, DIALL 911 FOR AMBULANCE SERVICE TO TRANSPORT. CAL SAN JOAQUIN COMMUNITY HOSPITAL EMERGENCY ROMM, 835-3000, AND NOTIFY THEM OF PATIENT ARRIVAL. REMEMBER TO SEND A COPY OF PATIENT'S INSURANCE INFORMATION AND ANY MEDICINES OR PERTINENT CHART INFORMATION. <2> Employee Notif./Evacuation IT IS THE RESPONSIBILITY OF ANY INDIVIDUAL WHO NOTICES A FIRE TO IMMEDIATELY ACTIVATE THE FIRE ALARM SYSTEM BY USING THE MANUAL PULL STATION IN THE WAITING ROOM OR BY THE EMERGENCY EXIT. CHIMES WILL BE HEARD IN THE SUITE AND THE FIRE BELL WILL SOUND IN THE OUTSIDE CORRIDOR. WHEN THE ALARM SYSTEM IS ACTIVATED IT AUTOMATICALLY SIGNALS THE FIRE DEPT WHICH SENDS A FIRE TRUCK TO THE CENTER. ANY OPERATIVE PROCEDURE CURRENTLY IN PROGRESS WILL BE TERMINATED. THE DOCTOR AND THE CIRCULATING NURSE WILL CONCURRENTLY EITHER ASSIST EVACUATION OF THE PATIENT IN THE OPERATING ROOM OR WILL EVACUATE ANY PATIENT IN THE RECOVERY ROOM AREA. THE SCRUB NURSE AND THE ANESTHESIOLOGIST WILL EVACUATE THE PATIENT FROM THE OPERATING ROOM ON A GURNEY TO THE HALLWAY. <3> Public Notif./Evacuation DIAL 80 ON ANY PHONE AND ANNOUNCE NEED FOR EVACUATION. REMEMBER TO ALSO CALL OPERATING ROOM EXTENSION 258 OR 270 BECAUSE CALL SYSTEM IS NOT HEARD THERE. <4> Emergency Medical Plan 11/02/93 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 5 00 - Overall Site <D> Notif./Evacuation/Medical <4> Emergency Medical Plan '(Continued) NOTIFY.NURSE AND/OR DOCTOR. EVALUATE: DETERMINE NEED FOR TRIAGE TREAT IF IN OUR AREA OF EXPERTISE IF YOU NEED PATIENT(S) TRANSFERRED, DIAL 911 AND'FOLLOW OUTLINE TO TRANSPORT PATIENT(S) TO HOSPITAL EMERGENCY ROOM. 11/02/93 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 6 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention MEDICAL GASES BEHIND LOCKED DOORS IN APPROVED CONTAINERS WITH APPROVED MANIFOLDS AND CONTROLS. <2> Release Containment OXYGEN AND NITROUS OXIDE ARE USED ON ANESTHESIA AND MEDICAL EQIUPMENT IN THE OPERATING ROOMS. EXTRA TANKS ARE STORED IN SEPARATE ROOM IN RACKS OR BEHIND CHAIN. IN THE EVENT GAS WAS LEAKING FROM TANK, BOTH GASES WOULD DISSIPATE INTO THE AIR RAPIDLY WITHOUT IN~NURY OR HARM. EVACUATION OF THE AREA AS A PRECAUTION. <3> Clean Up CLEAN UP WOULD BE LIMITED TO CHECKING TANKS FOR STABILITY AND TO BE SURE VALVES WERE TURNED OFF. <4> Other Resource Activation 11/02/93 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 7 00 - Overall Site <F> Site Emergency Factors <1> Special Hazards RADIOISATOPES ON HAND RADIATION HAZARD <2> Utility Shut-Offs A) GAS - SOUTHEAST CORNER & WEST SIDE B) ELECTRICAL - NORTHWEST CORNER & WEST SIDE MIDWAY C) WATER - WEST SIDE OF BUILDING APPROXIMATELY 15 FT D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail~ Water PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS ARE LOCATED IN REQUIRED AREAS AND ROUTINELY CHECKED FOR REQUIRED MAINTAINANCE. PARKING STRUCTURE AND BOTH FLOORS OF ENTIRE OFFICE BUILDING ARE EQUIPPED WITH SPRINKLERS. SHUT OFF VALVES ARE CHECKED ANNUALLY. FIRE HYDRANT - NORTHWEST CORNER OF PROPERTY, CORNER OF EYE STREET AND 26TH STREET <4> Building Occupancy Level 11/02/93 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 00 - Overall Site <G> Training <1> Page 1 WE HAVE 100 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE BRIEF SUMMARY OF TRAINING: WE HAVE'A SAFETY COMMITTEE CONSISTING OF ONE MEMBER FROM EACH DEPARTMENT. THEY IDENTIFY. THOSE ITEMS IN THEIR AREA THAT REQUIRE MSDS SHEETS AND INSTRUCT THE EMPLOYEES ACCORDINGLY. FOUR TIMES A YEAR AT OUR GENERAL STAFF MEETINGS THERE IS AN AREA ON SAFETY ON THE AGENDA. <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use ~'~' ~ ~ Bakersfield Fire Dept. ~ v/ HAZARDOUS MATERIALS DIVISION Date Completed Businessldentification No. 215-000- oo¢ ~ 71 ¢opof Business Plan) ~T~ P 7: I'~/~ ~ ~ Adequate Inadequate , Verification of Invento~ Materials ~ Verification of Qu~tities ~ Verification of Locaion ~ Proper Segregation of Materi~ ~ Comments: Verification d MSOS Availabli~~ ~~ Verification d H~ Uat Training ~ Number of Employees Comments: '~ Verification of Abaeme~ Supplies & Procedures ~ ~ Commonts: Emergency Procedures Posted ~ Containers Properly ~beled ~ Comments: Verification of Facility Diagram ~ Special H~ards Associated with this Facility: .~ ~ ~ ~ ,~/ All Items O.K. ~ ~-~z, Correction Needed ~ B~eSs Owne'r/Manage( FD 1652 (Rev. 1-90) White-Haz Mat Div. Yellow-Station Copy Pink-Business Copy 08/05/92 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 1 Overall Site with 1 Fac. Unit General Information I Location: 2525 EYE ST Map: 103 Hazard: Low Community: BAKERSFIELD STATION 01 Grid: 30A F/U: 1AOV: 0.0 Contact Name i Title Business Phone 24-Hour Phone] CHARLES FRITCH I (805) 327-8511 x (805) 393-5079! VIVIAN SPARKS I (805) 327-8511 x (805) 399-2600! Administrative Data Mail Addrs: 2525 EYE ST D&B Number: City: BAKERSFIELD State: CA Zip: 93311- Comm Code: 215-001 BAKERSFIELD STATION 01 SIC Code: 8011 Owner: CHARLES D. FRITCH MD Phone: (805) 327-8511 Address: 2525 EYE. ST State: CA City: BAKERSFIELD Zip: 93301- Summary RECEIVED HAZ. MA~ 01~ I have - ('1'ype or prim reviewed the attached hazardous materials manage- ment ptan for ?,-.'J-¢ A cc,, ,-. and that it along with - (Name of Businejts) any co.ffections constitute a complete and correct man- agement plan for my facile. ...... . . . ~ ~ / 08~05/92 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 2 02 - Fixed Containers on Site Hazmat Inventory Detail in Reference Number Order 02-001 OXYGEN Gas 1300 Low · Fire, PressUre, Imbed Hlth FT3 CAS #: 7782-44-7 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3 I Daily Average FT3 I Annual Amount FT3 -- 1,300 ~ 1,300.00 1,300.00 Storage I Press I Temp I Location PORT. PRESS. CYLINDER Above IAmbient STORAGE ROOM REAR OF BLDG -- Conc Components MCP ~List 100.0% IOxygen, Compressed 'lBow 02-002 NITROUS'OXIDE Gas 1350 High · Fire, Pressure, Immed Hlth FT3 CAS #: 10024-97-2 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3I Daily Average FT3 I Annual Amount FT3 1,350 ~ 1,350.00. 1,350.00 StorageI Press T Temp~ LocatiOn PORT. PRESS. CYLINDER Iabove ~Selow ISTORAGE ROOM REAR OF BLDG - Conc Components MCP List 100.0% INitrous Oxide . IHigh I 08/05/92 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 3 00 - Overall Site <D> Notif./Evacuation/Medical <1> Agency Notification FOR SINGLE PATIENT PROBLEM: NOTIFY NURSE AND/OR DOCTOR. IF PATIENT RESPONDS BUT NEED TRANSPORTATION TO HOSPITAL, DIALL 911 FOR AMBULANCE SERVICE. TO TRANSPORT. CAL SAN JOAQUIN COMMUNITY HOSPITAL EMERGENCY ROMM, 835-3000, AND NOTIFY THEM OF PATIENT ARRIVAL. REMEMBER TO SEND A COPY OF PATIENT'S INSURANCE INFORMATION AND ANY MEDICINES OR PERTINENT CHART INFORMATION. <2> Employee Notif./Evacuation · IT IS THE RESPONSIBILITY OF ANY INDIVIDUAL WHO NOTICES A FIRE TO IMMEDIATELY ACTIVATE THE FIRE ALARM SYSTEM BY USING THE MANUAL PULL STATION IN THE WAITING ROOM OR BY THE EMERGENCY EXIT. CHIMES WILL BE HEARD IN THE SUITE AND THE FIRE BELL WILL SOUND IN THE OUTSIDE CORRIDOR. WHEN THE ALARM SYSTEM IS ACTIVATED IT AUTOMATICALLY SIGNALS THE FIRE DEPT WHICH SENDS A FIRE TRUCK TO THE CENTER. ANY OPERATIVE PROCEDURE CURRENTLY IN PROGRESS WILL BE TERMINATED. THE DOCTOR AND THE CIRCULATING NURSE WILL CONCURRENTLY EITHER ASSIST EVACUATION OF THE PATIENT IN THE OPERATING ROOM OR WILL EVACUATE ANY PATIENT IN THE RECOVERY ROOM AREA. THE SCRUB NURSE AND THE ANESTHESIOLOGIST WILL EVACUATE THE PATIENT FROM THE OPERATING ROOM ON A~GURNEY TO THE HALLWAY. <3> Public Notif./Evacuation DIAL 80 ON ANY PHONE AND ANNOUNCE NEED FOR EVACUATION. REMEMBER TO ALSO CALL OPERATING ROOM EXTENSION 258 OR 270 BECAUSE CALL SYSTEM IS NOT HEARD THERE. 08/05/92 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 4 00 - Overall Site <D> Notif./Evacuation/Medical <4> Emergency Medical Plan (Continued) NOTIFY NURSE AND/OR DOCTOR EVALUATE: DETERMINE NEED FOR TRIAGE TREAT IF IN OUR AREA OF EXPERTISE IF YOU NEED PATIENT(S) TRANSFERRED, DIAL 911 AND FOLLOW OUTLINE TO TRANSPORT PATIENT(S) TO 'HOSPITAL EMERGENCY ROOM. 08/05/92 FRITCH EYE CARE SURGICAL CENTER' 215-000-000471 Page 5 · 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention MEDICAL GASES BEHIND LOCKED DOORS IN APPROVED CONTAINERS WITH APPROVED MANIFOLDS AND CONTROLS. <2> Release Containment OXYGEN AND NITROUS OXIDE ARE USED ON ANESTHESIA AND MEDICAL EQIUPMENT IN THE OPERATING ROOMS. EXTRA TANKS ARE STORED IN SEPARATE ROOM IN RACKS OR BEHIND CHAIN. IN THE EVENT GAS WAS LEAKING FROM TANK, BOTH GASES WOULD DISSIPATE INTO THE AIR RAPIDLY WITHOUT INJURY OR HARM. EVACUATION OF THE AREA AS A PRECAUTION. <3> Clean Up CLEAN UP WOULD BE LIMITED TO CHECKING TANKS FOR STABILITY AND TO BE SURE VALVES WERE TURNED OFF. <4> Other Resource Activation 08/05/92 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 6 00 - Overall Site <F> Site Emergency Factors <1> Special Hazards RADIOISATOPES ON HAND RADIATION HAZARD <2> Utility Shut-Offs A) GAS - SOUTHEAST CORNER & WEST SIDE B) ELECTRICAL - NORTHWEST CORNER & WEST SIDE MIDWAY C) WATER - WEST SIDE OF BUILDING APPROXIMATELY 15 FT D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS ARE LOCATED IN REQUIRED AREAS AND ROUTINELY CHECKED FOR REQUIRED'MAINTAINANCE. PARKING STRUCTURE AND BOTH FLOORS OF ENTIRE OFFICE BUILDING ARE EQUIPPED WITH SPRINKLERS. SHUT OFF VALVES ARE CHECKED ANNUALLY. FIRE HYDRANT - NORTHWEST CORNER OF PROPERTY, CORNER OF EYE STREET AND 26TH STREET <4> Building Occupancy Level 08/05/92 FRITCH EYE CARE SURGICAL CENTER 215-000-000471 Page 7 00 - Overall Site <G> Training <1> Page 1 BRIEF SIJI~r~R¥ OF TRAINING: We have a safety committ onsisting of one member from each department, l. hey identify those //ems in their area that require MSDS sheets and instruct the employees ac~.6rding]y. Four times a year at our general staff meetings there ~an/area/-- on safety on the agenda. <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use RADIOACTIVE MATERIALS REGISTRATION ~ . Attention: Radiation Safety Officer ' ~' The Kern County Fire Department Hazardous Materials Bureau is requesting information on the types of radiological devices, sources, amounts, and levels of radiation being handled by your business. This information is required in order to satisfy State law and County ordinance regarding the hazardous material release response plan and inventory program administered locally by the Kern County Fire Department. (Section 25503.5a, California Health and Safety Code; and Section 80.103c, Kern County Ordinance Code G-5232) RECEIVED Promptly flu out and return within seven (7) days of receipt. . OCT 0 9 1991 Business Name~"~~ Fritch Eye Care Center HA7 I~aAT..DIV. mu~A~c,~ =Ak~ A~C:~aa 2525 Eye Stree; Bakersfield, CA Business Ma£l£ng &ddress (if different) Radiation Safety Officer ~~~---- Business Phone327-8511 RADIOLOOICAL SOURCES OR DEVICES HANDLED - Use Additional Pages if Necessary DEVICE NAME ELEMENT/ISOTOPE MAX. QUANTITY (curies) GENERAL DESCRIPTION OF PROCESSESr EQUIPMENTr AND STORAGE: , 'U '1 SIGNATURE TITLE Owner 7 ~ x~~~~~2v~~~~ ~ KCFD HMCu 10/O9/90 FR~[TCH E. YE~RE SUR6ICAL CENTER ;='15-i-OOO471 I~ECEIVEtie Ove~all~ Site with 1 Fac. Ur, it~ NOV 0 6 19~ Ge~eral Informat ion Locatior~: 2525 EYE ST Map: 103 Hazard: Low Ider~t Number: 215-000-000471 Grid: 30A Area of Vul: O. Contact Name Title ~ , Busir~ess Phor~e ......... ~= 24 Hour Phone~ CHARLES FRITCH ~ (805) 32'7-8511 x ~ (805) 393-5079~ Vivian Sparks. [(805) ~e'Z-S~II x 14805) 300=2~{0,0 Rdrninistrative Data Mail Rddrs: 25~5 EYE ST D&B Number: City: BRKERSFIELD 'State: C~ Zip: Corem Code~ ~15-OO1 BRKERSFIEUD SI'RI'ION O1 SIC Code: Ow~,er: CHRRLES D. FRITCH MD Phor, e: (805) 327-8511 Rddress: 2525 EYE ST State: City: BAKERSFIELD Zip: 93301- Su~]~fla~y ~, ~/~/~s.~. ~'~b.~g__Q O0 hereby ce.r;;~ that any .-; ........... agement plen for my f~c[iJCy. 10/09/90 FRITCH EYE RE SURGICAL CENTER 215-C~-00o471 Paqe 2 Haz~nat Inventory List ir, MCP Order 02 - Fixed Containers on Site Pln-Ref Na~e/Hazards For~ Quant ity MCP 02-002 NITROUS OXIDE ? 1~350 High FT3 02-001 OXYGEN ? 1,484 Low FT3 1(:)1(:)919(:) FRITCH EYE PRE SURGICAL CENTER 215-0g000471 Page 3 O0 - Overall Site <D> Notif. /Evacuation/Medical Ager, cy Not i ficat ior, FOR SINGLE P^T;ENT PROBLEM: Notify nurse and/or doctor. If patient responds but needs transporation to hospital, dial gl l for ambulance service to transport. Ca;; San ]oaquin Community Hospital Emergency Room, 835-3000, and notify them of patient arrival. Remember to send copy of patient's insurance information and any medicines or pertinent chart information. <2> Employee Notif./Evacuation IT IS THE RESPONSIBILITY OF ANY INDIVIDUAL WHO NOTICES A FIRE TO IMMEDIATELY ACTIVATE THE FIRE ALARM SYSTEM BY USING THE MANUAL PULL STATION IN THE WAITING ROOM OR BY THE EMERGENCY EXIT. CHIMES WILL BE HEARD IN THE SUITE AND ]'HE FIRE BELL WILL SOUND IN THE OUTSIDE CORRIDOR. WHEN ]'HE ALARM SYSTEM IS ACTIVATED IT AUTOMATICALLY SIGNALS THE FIRE DEPT WHICH SENDS A FIRE TRUCK TO THE CENTER. ANY OPERATIVE PROCEDURE CURRENTLY IN PROGRESS WILL BE TERMINATED. THE DOCTOR AND THE CIRCULATING NURSE WILL CONCURRENTLY EITHER ASSIST EVACUATION OF 'THE PATIENT IN THE OPERATING ROOM OR WILL EVACUATE ANY PATIENT IN THE RECOVERY ROOM AREA. THE SCRUB NURSE AND THE ANESTHESIOLOGIST WILL EVACUATE THE PATIENT FROM THE OPERATING ROOM ON A GURNEY TO THE HALLWAY. <3> Public Notif. /Evacuation Dial 80 on any phone and announce need for evacuation. Remember to also call Operating Room extension 258 or 270 because call system is not heard there. <4> Emergency Medical Plan 1) Notify nurse and/or doctor 2) Evaluate: determine need for triage 3) Treat if in our area Of expertise 4) If you need patient(s) t~i~nsferred, dial 911 and follow ou~tline to transPort patient(s) to 10/0r9/90 ~ ~ FRITcH EYE ~m~qRE SURGICAL CENTER 21~-0~-000471 Page 4 O0 - Overall Site <D> Not i f. /Evacuat ior,/Medical <4> Er,~erger, cy Medical Plar, (Cor, tir, ued) 4) (con't) hospital Emergency Room. 10/09/90 FRITCH EYE SURGICAL CENTER 215-(]~-000471 Page 5 00 - Overall Site <E> Mi t i gat i or,/Prever~t/Abat e~t <1> Release Prever, tior, MEDICAL GASES BEHIND LOCKED DOORS IN APPROVED CONTAINERS WITH APPROVED MANIFOLDS AND CONTROLS. <2> Release Cor, tair, mer, t Oxygen and nitrous oside are used on anesthesia and medical equipment in the Operating Rooms. Extra tanks are stored in separate room in racks or behind chain. In the event gas was leaking from thank, both gases would dissipate into the air rapidly without injury or harm. Evacuation of the area as a precaution. <3> Clear, Up Clean up would be limited to checking tanks for stability and to be sure valves were turned off. <4> Other Resource Act i vat i or, 10/09/90 FRITCH EYE SURGICAL CENTER 215-C~000471 Page 6 (')0 - Overall Site <F> Site EmergerJcy Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - SOUTHEAST CORNER & WEST SIDE B) ELECTRICAL - NORTHWEST CORNER & WEST SIDE MIDWAY C) WATER - WEST SIDE OF BUILDING APPROXIMATELY 15 FT D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec. /Avail. Water PRIVATE FIRE PROTECTION - ???????????? Fire hydrant on NW corner of property, corner of Eye Street and 26th Street. Fire extinguishers are located in required areas and routinely checked for required maintainance. FIRE HYDRANT - Parking structure and both floors of entire office building are equipped with sprinklers. Shut off valves are checked annually. <4> Held for Future use 10/09/90 FRITCH EYE SURGICAL CENTER 215-00000471 Page 7 O0 - Overall Site <G> Training <1> Page 1 WE HAVE ?? EMPLOYEES AT THIS FACILITY 60 employees (including full-time and part-time employees) DO YOU HAVE MATERIAL SAFETY DATA SHEETS ON FILE? BRIEF SUMMARY OF 'TRAINING: Page (2 as r, eeded <3> Held f,z,r Future Use <4> Held for Future Use FRITCH EYE CARE CENTER 2525 Eye street, Bakersfield, CA 93301 (805) 327-8511 FAX (805) 327-9809 CHARLES D. FRITCH, M.D. November 5, 1990 Ralph E. Huey Hazardous Materials Coordinator City of Bakersfield 2101 H Street Bakersfield, CA 93301 RE: Hazardous Materials Management Plan Dear Mr. Huey: Enclosed please find the Fritch Eye Care Center report which you requested. There were several areas that we questioned as to exactly what you were wanting. We will be happy to comply with any additional items that need completing which we did not address. Any questions you might have should be addressed to Elizabeth Ross the Operating Room Supervisor. Sincerely yours, Sheran Smith Executive Secretary enclosure CII'Y of BAKERSFIELD HAZARDOUS MATERIALS INVENTORY Farm and Agriculture [I Standard Business I] NON--TRADE SECRETS Pa~je of I 2 3 i 5 6 1 8 9 10 II I~ ~/~y H~es or pixture/C~onents Ir~ns ~y~e pax Average Annual Hea~ure I~[e GonL Gont ~ont ~8 Location.iheEe. Code cool l~,m~ Alt EsL Units on /ype Press /emp Stored In facility~[___ See Instru:tlons Physical'and He~l~h~Ha~ard C.A,a. Humbe~ IO~q-~-~ .. Component II Hame I C,A,S, Number ~o~ IC~eck All that apply) ~- Component 12 Name I C,A.S. Humber ~ Fire Hazard ~ Reactivit~ ~ Delayed ~SuddenRele~se ~ Immediate Health of Pressure Health . {C~eck all that applyl 0~~ -- Cokponent I~ Name I C.A.S. Number ~ Fire H~.rd B Reactivity B Oelayed ~Sudden Release ~ l"~i~ Hal/th oJ Pressure Component IJ ~lm8 I C,A,S, Humber s 'l .q,I , l.. I¢. __ ~ Fire Hazard ~ Reactivity ~ Delayed' ~ Sudden Release ~ i~media~e ~/~ Hea/L~ ' of Pressure Health Componen~ 13 Name I C,A.5. Humber Physical Ind Health Haltrd C,A,S, Humber ~. ~~ Co~ponenL II Ham8 I C,A,S. Number ~-~~ Itheck all that appl~l ~ Component Ii Hame t C,A,a. Number ~Fire Hazard . ~ Reactivit~ ~0elayed ~Sudden Release ~ Health of Pressure CompoAen& 13 Namo I C,A,S, Number EMERGENCY CONTACTS fl lNlme .... TI[Il ' ~fi~e Naae T!II~ -- CerLifiaLio .(Re~d ~.nfl.~ign af~pr cqmpT~ci(]g.m)l secqipn~) ~ cerL))y un'er enalt~ gf)mp ln{t mnavepeEsona/~.exmmlnq~qolm ~amillm(.WiLb the)nlormmt)pn submitted in &his.lnd mil ~ ) information, ~lc~ched.docueen~s, anO ~pac oaseo on.m~ Inquiry 9[.Lno.se in~lVl~Ua/s responsible ~or obtaining one ! believe tha~. . . ~~i~1~ ownerlOperkt~[OR owner~operator ~ aut~ri~ed representative BAKERSFIELD, CA 9330! (805) 326-3979 OFFICIAL USE ONLY BUSINESS NAME HAZARDOUS MATERI ALS BUSINESS PLAN AS A WHOLE FORM 2A 1. To avoid further action, return this form by RECEIVED P. TYPE/PRINT ANSWERS IN ENGLISh. 3. Answer the questions below for the business as a whole. AU~ 61987 4. Be as brief and concise as possible. SECTION 1: BUSINESS IDENTIFICATION DATA LOCAZZO / STR T ADDreSS: CITY:~O~ ~) a~ ZIP: ~l I BUS.PHONE: (~ 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 OF EMERGENCY: NAME AND TITLE DURING BUS. HRS. AFTER BUS. HRS. B.,,.~L3L; _~ /x~. ~(_D~--~/--~J, ~,~J' Ph#'-~-7-~-~/7 Ph# SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE D. SPECIAL: ' ,, U V E. LOCK BOX:~ ~ IF YES, LOCATION:~/F~-3~/~/~'[5 /~ O~)/O~./--~fQ/~.tg/~7~f/~ IF YES, DOES IT CONTAIN SITE PLANS? ~ / NO MSDSS? YES / NO FLOOR PLANS?~ / NO ~ ~/ NO (NO~E: Air Conditionin~ Units are roof mounted) - 2A - SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE d. 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 MATERIALS:...' .................................... ~NO (~ NO B. PROCEDURES FOR COORDINATING ACTIVITIES WITH RESPONSE AGENCIES: .......................... ~ NO ~ NO C. PROPER USE OF SAFETY EQUIPMENT: .................. NO NO D. EMERGENCY EVACUATION PROCEDURES:.' .......... . ...... NO NO E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... NO NO SECTION ?: HAZARDOUS ]~ATERIAL CIRCLE YES OR NO DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS OF A SOLID, $$ GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YES ~ I, Charles D. Fritch, M.D. , 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. BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 OFFICIAL USE ONLY ID# BUSINESS NAME: BUS I NESS PLAN SINGLE FACILITY UNIT FORM 3A 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# FACILITY UNIT NAME: Vri'k&h F.y~ ~mr~ S,~rgical center SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDbqRES . · Medical gases behind.- locked- doors, ~in~".a-p~'roved~-contai-ne.r-~-.:~?~-~:~':~ with approved manifolds and controls. SECTION 2: NOTIFICATION ~\~ EVACUATION PROCEDL~ES AT THIS L~IT ONLY See attached Fire Emergency Evacuation procedures. SECT!OY 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY A. Does this Facility Unit contain Hazardous Materials? ...... ~ NO If YES, see B. If NO, continue with SECTION 4. B. Are any of the hazardous materials a bona fide Trade Secret YES~'~, 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 No : . .~ SECTION 8: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPO~ERS See attached site plan. SECTION 6: LOCATION OF UTiLiTY SH%~-OFFS AT THIS UNIT ONLY. See Attached Site A. NAT. GAS./PROPANE'2 Plan. Air Conditioning Units are roof mounted. B. ELECTRICAL: C. WATER: D. SPECIAL: E. LOCK BOX~-~./ NO IF YES, LOCATION: Electrical Shut off only, Equipment Room YES, S'''~r:':,,,. PLANS? ~/ .~;0 ,'4SD~s? v~S.... " .Ye. '9,") IMMEDIA~LY Iotl~te the fl~l t~m ~em ~ ~ the ', .. . me~l ~1 mtlm ~ t~ welti~ ~m ~':~ the eme~ :~t, .. '" n.. CMmm'~l ~ the ~te ~'t~ Flw II t~ .., . ~ . , ~,,. ,. :',':.,. ':, r,.,,, 3.: Wh'~' t~ l~,m',;~em 'b .~ I~t~ *' t'i~bm il . 'l.liY'dpb'" the .... ~1~ D~m~t, wMeh ~ n FI~' ~"to t~ ~tor, , - '5.' ~ ~o~n ~ ~'~t~N~ ~11 ~ly the ~tl~t from t~.~tl~. Rmj,,,~,'l::~ to t~ bllwly. ., ,_ , ., ~: . , . ~,,. :., ,: ..:, .* ~,.-,.,-.~ . . .. ,'. .. ?. All ~tl~e ~'~ w~t~ ~m~,m.-"~.'~ ~tfl~ of the fl~ i~' 9. 'Allto ~~1~ f~m~em~ ~r~~i~'t0 {~,'~ ~m ~~ the ~..:' " . , x. '-.,- :, ",. :,t : * ~.'~. '.; ','~:,. ".. ~ ... '~; .. . r - ..., .'- .. , ' ~ - .;: ..... .:.~:., .--~ - .-. . , ~.,,~' - :""~ ', ~ : 'v ? · ." , ' .* -, , · .,': ~¥.:'.... 1..: : . :-' ..... :?. . .~:.?. .; . :. ., . - ,.: .... , , - "-., · .. · ,..,.~:~.~ :~. :" BAKERSFIELD CITY FIRE DEPARTMENT I.D. # FORM 4A-1 Page /" of ' / ,,, NON--TRADE SECRETS HAZARDOUS MATERI ALS INVENTORY BUSINESS NAME: ~E.;~-C_~ ~ C_-~r~ ~r~.~--~-~'~0WNER NAME: ~l~ ~. ~~ ~ FACILITY UNIT ~: A~DRESS: ~ E~ ~. ADDRESS:~2~]~ ~. FACILITY UNIT NA~E: CITY, zIP:, ~,~G~t~ ~ ~~ i CITY,ZIP: ~~t~i PHONE ~: ~-~1 PHONE ~: ~-~ [ I [OFFICIAL USE CFIRS CODE [ ONLY 1 2 3 4 5 6 7 8 9 10 TYPE ~AX ANNUAL CONT USE LOCATION IN THIS ~ BY HAZARD D.O.T CODE A~0UNT A~OUNT UNIT CODE CODE FACILITY UNIT ~T. CHEMICAL 0R C0~0N NA~E CODE GUIDE NAME ~~ O- ~;~ ~O. TITLE: ~.O. SIGNATURE: /'/ ~/ / ~ E~-ERGENCY CONTACT: ~_~5 ~.~~ ~ TITLE: ~ HONE · BUS HOURS' AFTER BUS HRS: ~- E~E~GENCY CONTACT:~',~ ~. ~l~t~ TITLE:~.~. .... PHONE ~ BUS HOURS:~Z~-~I'i ' P~.~NCIPAL BUSINESS ACTIVITY: ~'~.~. AFTER BUS HRS: S-I TE/FACI LI TY D I AGRA1M FORM 5 ~ORTH SCALE: BUSINESS NAME: FLOOR: OF DATE: / / FACILITY N~E: UNIT ~: OF (CHECK ONE) SITE DIAGR.~! ×× FACILITY DIA6R.a~ XX ~EE ATTACHED SEE ATTAC~RD (Inspector's Comments): -OFFICIAL USE ONLY- SiTE D[AGRA){ iRked items) 1. Address: Identify the 9. Lock (key) Box principle buildings by the Street numbers. 10. MSDS Storage 2. Street(a), Allays. 11. Rallro~d Tracks Drlvewaye, and Parking Areas adjacent to the 12. Fence or Barrier property. Include the a. Wire street names. b, Masonry 3. Storm Drains. Culverts. Yard Drains c. Wood 4. Drainage Canals, Ditches, d. Gates Creeks, 13. Powerlines §. Buildings a. Frame conutruction [4. Guard Station b. Masonry construction IS'. Storage Tanks: Identify the c. Metal construction capacity in gui. a. Above ground d. Access Door b. Underground Utility Controls a. Gas 16. Diking or Berm b. Electricity 17. Evacuation Route c. Water 18. Evacuation Area: Identify the 7. Fire Suppression Systems: location where a. Fire Hydrants employees will meet. b. Fire Sprinkler 19. Outside Hazardous Connection8 Waste Storage c. Fire Standpipe 20. Outside Hazardous Connections Nateria! Storage d. Water Control Valvee 21. Outside Hazardous for protection systems Haterial Use/Handling e. Fire Pump {2. Type of Hazardous Material/Malta Stored B. Fire Oepartment Access or Used (See Below) TYPE OF HAZ~DOUS MATERIAL F --Flassable E - Explosive L - Liquid R - Radiological C - Corrosive 0 - Oxidizer O - Gao P - Poison w - Water Reactive T - Toxic g - Solid H - Cryogenic O · Waste B - Etiological Example: Flauable Liquid - FL FACILITY DIAGRAM (Required items in addltlon to the above) 1. Risers for Sprinklers 8. Fire Escapes 2. Partitions O, Air Conditioning Units 3. Stairways: Indicate the 10. Windows levels served from highest to lOeelt. 11. Inside Xuardoun Waste Storage 4. Escalator: Indicate the levels served from 13. lneide Hazardous highest to lowest. #aterlaln Storage S. Elevator 13. Inside Hazardous Materials Use/Handling 6. Attic Access 14. Sewer Drain Inlets 7.'Skylighte