HomeMy WebLinkAboutBUSINESS PLAN
]3a/~ersfie]d ~'zre Dep~:.
Hazardous Ma~:erials Division
21g0 "G" Street:
Bakersfield, CA. 0:3801
RECEIVED
HAZARDOUS MATERIALS MANAGEMENT PLAN
INSTRUCTIONS:
2.
3.
4.
To avoid further action, return this form within 30 days of receipt.
TYPE/PRINT ANSWERS IN ENGLISH.
Answer the questions below for the business as a whole.
Be brief and concise as possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
BUSINESS NAME', ~'~,,~. ~'~ ~..,{d (/,g,//
LOCATION' ~ ~00 ~' .~
MAILING~ADDRESS: ~qoq ~~,~~
CIT~~~- STATE:~ ZIP:~~HONE: ~
.~UN&BRADSTREETNUMBER: ~ ..... SIC CODE:
~,~A~ ACT,V,~:
~L~ A~O~ES~: ~~ /~
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT
TITLE BUS. PHONE 24 HR. PHONE
FDI59~
~SECTION '3~.'
Bakersfield Fire Dept.
Hazardous Materials Divisim
HAZARDOUS MATERIALS MANAGEMENT PLAN
TRAINING:
?N.~JMBER OF EMPLOYESS:
MATERIAL SAFETY DATA SHEETS ON FILE'
BRIEF SUMMARY OF TRAINING PROGRAM:
SECTION 4: EXEMPTION REQUEST:
I 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 DO NOT HANDLE HAZARDOUS MATERIALS.
WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO
TIMEEXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION:
I, . 4 ~ CERTIFY THAT THE ABOVE INFOR-
MATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE' USED TO
FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE"
ON HAZARDOUS MATERIALS (DIV, 20 CHAPTER 6.95 SEC, 25500 ET AL.) AND THAT
INACCURATE INFORMATION CONSTITUTES PERJURY.
SIGNATURE TITLE DATE
FD1590
HaZardous Materials Inspection
Date Completed
Plan ID # 215-O00-oot.~4Top right comer Business Plan)
?
Station No. I Shift 'l,~ Inspector /,~, d-~ ~ t/,73 ~ 6£~,~,i~
/
· Adequate Inadequate
Verification of Inventory Materials~
Verification of Quantities
Verification of Location
~oper Se~egafion of Matefim
/' ~ ~ ~0oo
Verification of MSDS Availabfli.
0 ets
Nmber of ~pl y
~ Ve~cafion of Abatement Supples
CO~B:
~e~ency Pr~ed~s Posted
Containers Properly Labeled
Comments:
Verification of Facility Diagram
Special Hazards Associated with this Facility:
,'5
Violations:
FD 1652 (Rev. 3-89) White-Haz Mat Div. Yellow-Station Copy Pink-Business Office
~ 2130 'G' STREET
BAKERSFIELD, CA. 9330
(805) 326-3979
OFFICIAL USE ONLY
ID#
BUSINESS NAME
RECEIVED
HAZARDOUS MATERIALS
191) 9
BUSINE88 PLAN A8
A
WHOLE
FORM 2A
INSTRUCTIONS:- -
1. To avoid further action, return this from within 30 days of receipt.
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions be]ow for the business as a whole.
4. Be as brief and concise as possible.
SECT[ON 1:
A.
B.
BUSINESS IDENTIFICATION DATA
: ~-~ /' /
LOCATION / STREET ADDRESS: ~0¢ ~* ~'
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving the release or threatened re]ease of
a hazardous material, cai1 911 and 1-800-852-7550 or 1-916-427-4341, This
wil] notify your loCal fire department and the State Office of Emergency
Services as required by ~aw.
EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:
NAHE AND TITLE DURING BUS. HRS.
AFTER BUS. HRS.
SECTION 3:
B.
C.
D.
E.
LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
NATURAL GAS/~ROPANE:
ELECTRICAL:
SPECIAL'~ --
LOCK BOX: YES ~ NO~ IF YES, LOCATION:
IF YES, DOES IT CONTAZN SZTE PLANS? YES / NO NSDSS? YES / NO
FLOOR PLANS? YES / NO KEYS? YES / NO
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLF
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
SECTZON 6: EMPLOYEE TRAiNiNG
EMPLOYERS ARE REQUIRED TO HAVE A TRAINING PROGRAH WHICH PROVIDES EHPLOYEES
WITH INITIAL AND REFRESHER TRAINING IN THE SAFE HANDLING OF HAZARDOUS
HATERIALS.
A. NUMBER OF EMPLOYEES AT THIS FACILITY f
B. 'DO YOU HAVE NSDS (HATERIAL SAFETY DATA SHEETS) FOR EACH HAZARDOUS
HATERIAL YOU HANDLE ~ ~. -.
C. GIVE A BRIEF SUHMARY oF'YOUR HAZARDOUS HATERIALS TRAINING PROGRAM:
SECTION 7: EXEMPTION REQUEST
I CERTIFY UNDER PENALTY OF PERJURY THAT NY BUSINESS IS EXEMPT FROM THE
REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE CALIFORNIA HEALTH AND SAFETY
CODE FOR THE FOLLOWING. REASONS:
WE DO NOT HANDLE HAZARDOUS MATERIALS.
WE DO HANDLE HAZARDOUS HATERIALS, BUT THE QUANTITIES AT NO
TIME EXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 8; CERTIFICAT]~QN
I, · 7~FZ~_~.% , 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.
SIGNATURE /w~ TITLE _ DATE
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLF
~,~. z~.. - _.,?, '. .~ ,_..
/~"" ? L_ ^~ v,-' .~ c,~, ~, --~ '~
SECTION 5' LOCAL EMERGENCY MEDICAL ASS[STANCE FOR YOUR BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A TRAINING PROGRAM WHICH PROVIDES EMPLOYEES
WITH INITIAL AND REFRESHER TRAINING IN THE SAFE HANDLING OF HAZARDOUS
MATERIALS.
A. NUMBER OF EMPLOYEES AT THIS FACILITY
B. 'DO YOU HAVE MSDS (MATERIAL SAFETY DATA SHEETS) FOR EACH HAZARDOUS
MATERIAL YOU HANDLE ? ~'
C. GIVE A BRIEF SUMMARY OF'YOU~ HAZARDOUS MATERIALS TRAINING PR~G_R~M:~___
~ECTION 7: EXEHPTION
I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE
REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE CALIFORNIA HEALTH AND SAFETY
CODE FOR THE FOLLOWING REASONS:
WE DO NOT HANDLE HAZARDOUS MATERIALS.
WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO
TIME EXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 8: CERTIFICAT~(~N
/~.','~/.,'.~/~_-_~ , certiCy tha~ the above in¢ormation is
accurate. ~ understand ~ha~ %his information wi~ be used ~o ¢u~¢i~ my
firm's obligations under ~he new California Health and SaCe~y code on
Hazardous Ha~eria]s (Div. 20 Chapter 6.95 Sec. 25500 E~ A].) and %ha~
inaccurate in¢orma~ion constitutes perjury.
BAK~SFIELD CITY FIRE DEP~TMENT
2130 'G' STREET
BAKERSFIELD. CA. 93301
(805) 326-3979
OFFICIAL USE ONLY
BUSINESS NAME
ID#
HAZARDOUS MATERIALS
BUSINESS PLAN AS A WHOLE
FORM 3A
__. ~NSTRU.CTION~ .....
1. To &void further acl~ion, t~his form must be returned by:
2. TYPE/PRINT YOUR ANSI~ERS IN ENGLISH.
3. Answer the quesl~ions below t=or THE FACILITY UNIT LISTED BELOI~
4. Be as BRIEF and CONCISE as possible
SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES
SECTION 2; NOT[F]~CATION 'AND EVACUATION PROCEDURES AT THE UNIT ONLY
~ECTION 3:
HAZARDOUS MATERIALS FOR THIS UNIT ONLY
Does this Facility Unit contain Hazardous Materials? ......
If Yes, see B.
Zf NO, continue with SECTION 4
Are any of the hazardous materials a bona fide'Trade Secret?
If NO, complete a separate Hazardous materials inventory
form marked: NON-TRADE SECRETS ONLY (white form #4A-1)
Zf YES, complete a hazardous materials inventory form marked:
NO
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 SUPPLY FOR USE BY EMERGENCY RESPONDERS
(Fire Hydrant)
SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY,
A. NATURAL GAS/PROPANE: ~O~E
D. SPECIAL:
E. LOCK BOX:
YES ~F YES, LOCATION:
IF YES, SITE PLANS? YES / NO
FLOOR PLANS? YES / NO
MSDSs? YES / NO
KEYS? YES / NO
CITY of BAKERSFIELD,
F~,', and Jqrieulture L--~ Standard ,,s~.,ss ~ Z']:A~-ARZ:)OT.~'~' MA'I']~::I~'I' A~S
BUSINESS NAHE: ~M W OWNER NAHI HAHE OF
~-ut.a,,u. :4~ ,~c:~OO (',,'~VC,~ ~. ADDRESS: ~_~ ~/~.~. ~ STANDARD IND. CLASS CODE
CITY, ZIP: ~~~, ~. ~~ CITY, ZIP: ~~/~~ ~~ ~ DUN AND BRADSTREET NUMBER ....
~ ~ ~U~O~ ~R ~OP~ COD~
'(~e C~e Mt Mt Est Units m Site I~ ~ ~ ~ .. St~ In FKtII~y ~
~t 13 ~iC.i.S. ~
-- ~--~ ~--~ ~--~ Wt I~ ~&C.A.S. ~
With of P~ MIth ~t 13 ~ & C.A.S. ~
~ r--~ r--~ r--~ r--~ ~t ~ ~&C.A.S. ~
H~lth of P~su~ Mlth -~-
/ ~t' ~ ~ ~.~.~. ~ { .....
._~_t '_~ _~_a ~ ~.p_ ]~ ~t"~ ~~j_~A~ e~ 0"' L ..........
~., ,~, ,~ .-. _ ....... ~ ..~ .................. ~ I~
Fire H~/ard ~ ~ MCtivity u a ~la~ [ ~ ~ Reline --
H~lth of Pe~sure Health
~ n~-~ .......
Certtficatie~ (Read and sign after compJeting al/ sections) ~' .
certify under Nnalty of la. that I have oersonallyexamined and am faliliar ~tth t~ tnfor~ti~u~itt~ tn this ~ il1 ett~ ~ts ~ ~t ~s~ ~ ~ i~i~ of t~t~i}i~ls ~sible
for obtai(in3 t~inf~tim. [ ~l~ve tMt t~ su~itt~ ~ti~ is ,:~ accurate, ~ cMo/eta