HomeMy WebLinkAboutBUSINESS PLANIMPORTANT~ MESSAGE
FOR A.M.
DATE TIME
M
OF
PHONE NO.
MESSAGE
SIGNED
ASSOCIATED L1-A2334
OATE: / / FACIL£TY .~AM.E: UNiT :: .~.F
(CHECK ONE) SITE DrAGR.%~! FACILITY
.l(,, rnspec~:or" s Commen~s): -OFFIC]2AL USE ONLY-
]. Address: [dentt! 9. Lock
by the ~treet numDer~, ia. ~SDS Storage
~. Street(el. Alleys. I1. Railroad TDncks
Driveways. and Perkin~
Areas adjacent ~ Cae IZ. Fence or ~arrter
property. £nclude ~e s. Wire
.~ street names.
~. ~aaonr¥
3. Stcr~ Drains. Culverts.
Yard D=a~ns c. ~cod
· - 4. O~aina~e Canal~, O~tches, d. Gates
13. Pewerllnes
3. Buildings
a. Fr~ construction 14. ~uard Statlon
b. Naaonry construction 15. Storage Tanks:
~denC~f? the
c~ Neca~ construction ~ci~ la ~l.
a. ~ ~und
d. ~eua ~oor
....~ ~ .-~' -~. b.- ~e~u~
b. FI~ Sgr~Lor lg. ~Xde ~ "- '
~. F&re Standpipe ~0. Out, ida liazardoum
W--. Water Reactive T - Toxic ~ - Solid R - C~entc
O - Wmmte B - ~tiolo~lca~
Example: Flammable Liquid - FT,,
~ACILITY 9IAGRAM (Requirmt items in addition to the abo~e)' -
1. Risers for Sgriniiler~ 8. Fire ~scapes
2. Partitions 9, A~r ~oflditioning Units
3. Stairways: Indicate the -10. Windowo
levels served from
hl~eat to lowest. '1I. Inside Hazardous Waste
$tora~s
4. £scaiacor: Ifldlcace CAe
levels served from 12. Inside Hazardous
hi~fleat to lowest. Nateriais Stora~
~. Klnvator 13. Inside ~azardous
~ateriala
8. Attic Access
14. Sm.~r Oraln Inlets
?. Skylights
BAKERSFIELD CITY FIRE DEPARTMENT R E C E [ V E D
2130 "G" S~EET
B~RSFIELD, CA 93301 MAY18 1988
(805) 326-3979 ~S'~ ............
' ~
4
001280
BUSINESS PL~ AS A WHOLE
FORR 2A
INSTRUCTI 0NS:
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: ~ /~)7 ~z~D~P 3'~-~--
.... -:.- c~: ~~,~ ~ z~P: ~ sus. P.ONS: (~>~) ~~'
.... '. ..... -,. 4. . ;. ;-.L': ...... '.: "' ;,,T.., ' 57';,' ......
.~,;~ff SB~O~ 2= ~6~ ~O~CA~O~S '. 7: ? ; ..t. ., ';;'; .: ;.71 :..:; .;, ' ':C-;Z, .7'? ,: ./.L.-"-';
7 '..~:X:.; ,.,,'.- ' :;.: ' - ~': ' ..... ' .... : : ' ':
'.' In case of an e~e~gency involvlng the ~elease o~ threatened ~elease of a -.-.
hazardous aate~laI, call 91'1 and 1-800-8~2-7550.on 1-916-427-4341;. Thls wi'll notl~
.- -, ~ou~ local 'fi~e depa~t=ent and the State Of~lce of Eae~gency Services .as requi~e~ b~
.. la~/';':: ./,' '{~;':":':-; ..... .--
ENPLOYEES TO NOTIFY IN CASE OF E~ERGENCY:
NA~E A~ TIT~ D~ING BUS. HRS. AFTER BUS. ~RS.
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE:
B. ELECTRICAL: /~')
C. WATER:
D. SPECIAL:
E. LOCK BOX: YES /(~' IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS? YES / NO MSDSS? YES / NO
FLOOR PLANS? YES / NO KEYS? YES / NO
SECTION 4: PRIVATE RESPONSE TE~ FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EXERGENCY .~EDICAL ASSI,ST~CE FOR YOLg BUSINESS AS A WHOLE
EMPLOYERS ARE REQUIRED TO ~ 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:.... .................................... ~Y.~NO YES NO
B. PROCEDURES FOR COORDINATING ACTIVITIES .< ~ '~ ~ -
WITH RESPONSE AGENCIES: .................... ~b.<"....'~N0 ~S NO
C. PROPER USE OF SAFETY EQUIPMENT: ........ i'. ...... '... ~ NO YES NO
D. EMERGENCY EVACUATION PROCEDURES: ................. - Y~ NO YES NO
E, O0 YOU ~INTAIN EMPLOYEE TRAINING RECORDS: ....... YES <~ YES NO
SECTION ?: ~Z~DOUS ~RI~
CIRCLE ~S .~%<NO - ~
DOES YOUR BUSINESS ~LE ~ZARDOUS ~{?ERIAL IN QUANTITIES LESS THAN 500 POUN~F A
SOLID, ~$ GALLONS 0F A LIQUID, OR ~00 CUBIC FEET 0F A COMPRESSED GAS:...~.. YE~N0
I, C~ ~e~_~- , certify that the above information is accurate.
I understand that this information wili'be used to fulfill my firm's obli~ations under
the new California Health and Safety code on Hazardous-Materials (Div. ~0 Chapter 6.9§
Sec. 25500 Et Al.) and that inaccurate information constitutes perjury.
SIGNATURE TITLE ~ DATE
BAKERS?!'-rD Ci~ ~ r ~EE DE.-'-.\F,'W:?:'~',
:r~S"TRUCTI ONS
- 1. ~0 ~avoid fur-.her :~c-~on.--tJuLs form mus~ be're~.~ned
4. Be as BRI~ ~d CONCISE as possible.
A. Does uhis Facility unl~ contnin Haznrdous .~at_.~
If '.z~S, see B.
If ~0, continue with SE~iOI 4.
B. .A~--_ ~ny of ~he h~zurdous materials a bona fide Trade Secret
!f No, complete a separate hazardous ma~ariais inventory
form marked: IOM-~ADE SECR~S O5~,Y (whi~e form =4A-!)
If Yes, compie~ a hazardous ma~eriais inven=cry form marked:
~ADE S=u~.~.=T'o Ok%Y (yellow form ~A-Z) in addition to ~he non-~rade
secr~= fo~m. Lis~ oaly the =rude secre=z on form 4A-~.
'<
A. XAT.
CC, .: YES LCCATiCZ:
iF ".'ES. $ .'..~ .or A"'~, .... ';-'-'_. ,' ?:0 .HSDSs? 7.--_.~ "~.,,.,
FLOOR P.r..%:/S7 ':'---S ' :<0 '.<~".'S? '.fEZ .X'O
BAKERSFIELD CITY FIRE DEPARTMENT
I.D. # FORM 4A-1 Page
NON--TRADE SECRETS
.AZARDOUS MATERX ~-S Z NYE.TORY
,O8!~Y
1 2 3 4 5 6 g 8 9 10
TYPE MAX ANNUAL CONT USE LOCATION IN THIS ~ BY HAZARD D.O.T
CODE AMOUNT AMOUNT UNIT CODE CODE F6CILITY ~NIT ~T. CHENIGAL OR COMMON NAME CODE GUIDE
~ ,,
~H~: TIT. LE:~' ......... SIONATURE: ~ ...............