HomeMy WebLinkAboutBUSINESS PLAN 12/4/2003 ITE DIAGRAM
Business Name:
Business Address:
FACILITY DIAGRAM
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ITE DIAGRAM
Business Name:
Busineaa .Addte~:
FACILITY DIAGRAM
IT~ DIAGRAM
Business Nmne:
Business Address:
FACILITY DIAGBAM
Hazardous Materials/Hazardous Waste Unified Permit
CONDITIONS OF PERMIT ON REVERSE SIDE
This ~ermit is isSued for the followin_=.:*
[] Hazardous Materials Plan
[] Underground Storageof HazardOus Materials
[3 Risk Management Program
[] Hazardous Waste On-Site Treatment
PERMIT ID # 015-021-002093
SULTZE CHIROPRACT
LOCATION 345
Issued by:
Bakersfield Fire Department
OFFICE OF ENVIRONMENTAL SER VICES'
1715 Chester Ave., 3rd Floor
Bakersfield, CA 93301
Voice (661) 326-3979
FAX (661) 326-0576
Approved by:
Expiration Date:
Office of Evirot~lff~ices~''~'
Issue Date
'June 30. 2003
ITE DIAGRAM
Business Name:
Business Address:
FACILITY-l) [AGRAM [
ST'
SULTZE CHIROPRACTIC
M~nager :
Location: 345 H ST ~&'~
City : BAKERSFIELD
CommCode: BAKERSFIELD STATION 06
EPA Numb:
SiteID: 015-021-002093
BusPhone: (661) 327-2588
Map : 102 CommHaz : Minimal
Grid: 36D FacUnits: 1 AOV:
SIC Code:4941
DunnBrad:77-025-4824
Emergency Contact / Title
STUART A SULTZE DC / OWNER
Business Phone: (661) 327-2588x
24-Hour Phone : (661) 835-0937x
Pager Phone : ( ) - x
Emergency Contact / Title
JON R MORRIS DC / EMPLOYEE
Business Phone: (661) 327-2588x
24-Hour Phone : (661) 872-4575x
Pager Phone : ( ) - x
Hazmat Hazards: RSs
Fire Press
ImmHlth
Contact :
MailAddr: 345 H ST
City : BAKERSFIELD
Phone: (661) 327-2588x
State: CA
Zip : 93304
Owner STUART A SULTZE DC
Address : 345 H ST
City : BAKERSFIELD
Phone: (661) 327-2588x
State: CA
Zip : 93304
Period :
Preparer:
Certif'd:
ParcelNo:
to
TotalASTs: =
TotalUSTs: =
RSs: Yes
Gal
Gal
Emergency Directives:
I. ~u,~r-,rt'".~'uC/'~ ~Do hereby ce~ify ~hat ~ have
~y~ or ~nt n~e)
reviewed th~ a~ach~d h~ardous materials manage-
ment plan for~~- c~~~ ~~ ~
any co~e~ions constitute a complete and ~rre~ man-
agemen~ plan for my facility.
1 12/01/2003
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA f661~ 326-3979
HAZARDOUS MATERIALS MINAGEMENT P
INSTRUCTIONS:
2.
3.
4.
5.
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 as brief and concise as possible.
You may also attach Business Owner / Operator Form and Chemical Description Form(s)
to the fi'ont of this plan instead of completing SECTION I. below for initial submission.
SECTION I: BUSINESS IDENTIFICATION DATA
BUSINESS NAME:
LOCATION:
C. hi co¢ c_B
MAILING ADDRESS: 3q6 ~1- ~t'-e6JC
CITY: _~OJ~_ .~'X'. _q~V~Q,~ STATE:
PRIMARY ACTIVITY: C~h'~ ~' 0 p~X~"~C
ZIP: q~'~PHONE: ~ t -3~--.7-~
OWNER: ~71. _I~('~
MAILING ADDRESS: ..
PHONE:bM'32,7-261~3
EMERGENCY NOTIFICATION
CONTACT
TITLE
BUS. PHONE
24 HR. PHONE
blol ~I?Z-
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION II. 1: DISCOVERY AND NOTIFICATIONS
Ao
LEAK DETECTION AND MONITORING PROCEDURES:
Bo
EMPLOYEE AND AGENCY NOTIFICATION:
Co
ENVIRONMENTAL RESPONSE MANAGEMENT:
Do
EMERGENCY MEDICAL PLAN:
~ q~
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION II.2: RELEASE RESPONSE PLAN
A. HAZARD ASSESSMENT AND PREVENTION MEASURES:
Bo
RELEASE CONTAINMENT AND/OR MITIGATION:
Co
CLEAN-UP AND RECOVERY PROCEDURES:
UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)
NATURAL GAS/PROPANE:
ELECTRICAL: % ~q t_/-b~ ~
WATER: I O CO_-t-mCJ.
SPECIAL:
oO :ck, o'g ce_
LOCK BOX: YESO IF YES, LOCATION:
PRIVATE FIRE PROTECTION/WATER AVAILABILITY
ho
Bo
PRIVATE FIRE PROTECTION:
WATER AV~L~ILITY (FI~ ~~NT):
3
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION III: TRAINING
NUMBER OF EMPLOYEES: q
MATERIAL SAFETY DATA SHEETS ON FILE:
BRIEF SUMMARY OF TRAINING PROGRAM:
CERTIFICATION
· -
Ii ~'qt'x ~ ~{~.t'~C,~'keo k CERTIFY THAT THE ABOVE INFORMATION
IS ACCURATE. I LTNDERSTAND 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. 25S00 ET AL.) AND
THAT INACCURATE INFORMATION CONSTITUTES PERJURY.
SIGNATURE
gI~TLE {/
I~AT~
FACILITY INFORMATION
Page Of
FACILITY ID # ~,~ ~ ~ Year Beginning , ! / / leo Year EC'diog/_ ~o~
BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) ~ _ 3 / BUSINESS PHONE _s,--...,, lo2
DUN &
CA
lO6
103
zip ~ 2 3~) ~' lo,
SIC CODE lo7
(4 Digit_. #) . -.. ._
lO8
OPE~TOR NAME ~'rL]~~UCT'Z.~ ~c.~, ,o~
OWNERNAME ~S/~~&-i~z,,~""~__~-,..~.. ~ OWNERPHONE ~Z~ ~ ~~ ~12
OWNER ~ILING
ADDRESS ~'~ ri ~ ( ', - 113
CONTACT MAILING
ADDRESS
CITY ~~~. ~ - . 120 STATE~ 121 ZI'P ?'~3~ V ,22
NAME
TITLE
BUSINESS PHONE
24-HOUR PHONE ~) ? '~, -" ~"(~' ?,.~"
127
BUSINESS PHONE Z ~ 7 ' Z...,.~-~ ~:~ 131
24;HOURPHONE ~'~ '~ -- (~)?~/' ,3~
PAGER# /k~ b ~.,)'~.~.., ,2s PAGER`#. A,J'~¥~.)~-~' ' ' '- - ' ' ,33
.~ ~ ::: ~ ~ ~:~%~,~:;;~.~"~:.~:~.~4;~;,~¢~;~:: .:.:~~:~?~:f~.,~%~;~:~.? :.'~:~:~:'~2~ :: ":.~;~;!J~,~'. ?~:: ':: ::~:~::'~., ,, ~ ,~: .:e :~ ::'~:-~ ~ I
Ce~ifica~on: Based on my inqui~ of ~ose individuals responsible for obtaining [he info~ation, I ~di~ under penal~ of law ~at I have pe~onally examined
and am ~miliar wi~ the info~ation submiBed in ~ie invento~ and believe the info~aUon is tree, accurate, and complete.
136
DATE/(~ /~~// Y~4 NAME OF DOCUMENT PREPARER '~
TITLE OF OWNER/OPERATOR
0 ~ ~z,,,-.--~/c. ~r r~/,"-~-~-"o,,,.._.
135
137
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OF ENVIRONMENTAL Si
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
(one form per matedal per building or area)
=~EW [] ADD [] DELETE [] REVISE 200 Page __ of
BUSINESS NAME (Same as FACILITY NAME oF DBA - Doing Business As) 3 ]
FAC L ~,D # ~ ~ ':' ~ ~P # (o~.ona~ 203 GR D # Iop.ona~ ~
,.~ :~ ~ ::: ~ :;~:?~-' ..~:~ ~:~?~s~· ~ ~e::~.~:~:e:.~:~,~: ~'~: ~e:~ II'~CHEMIC E: INFORMA~ON {~:~:~:::~:-~:?~,?,~ ~ ~'-? ~?'--.- ~ ~:~ ~:':' ~::~, ~"~'~-~'~/~ '-~ ~:~- ~ -'~" ~ ~-~
CHEMICAL NAME
COMMON NAME
CAS #
FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief)
205 TRADE SECRET [] Yes [] No 206
If Subject to EPCRA, refer to instructions
210
TYPE [] p PURE
PHYSICAL STATE [] s SOLID
FED HAZARD CATEGORIES I'"] 1 'FIRE
(Check all that apply)
ANNUAL WASTE 217
AMOUNT
,20-25/... U.,TS'
[] m MIXTURE ~,w...W..A~T~E~,~.211 I RADIOACTIVE J']Yes []No
I
~1 LIQUID g GAS 214
LARGEST CONTAINER
[] 2 ~EACTlye [] 3 PRESSURE REI~EASE [] 4 ACUTE HEALTH
MAXIMUM 218 I AVERAGE
DAILy AMOUNT I DAILY AMOUNT
[] ga GAL - -. [] cf CUFT [] lb LBS [] tn TONS
* If EHS, amount must be in lbs.
212 CURIES
213
215
[] 5 CHRONIC HEALTH 216
219 STATE WASTE CODE 220
DAYS ON SITE 222
221
STORAGE CONTAINER
(Check all that apply)
[]a ABOVEGROUNDTANK
I-lb UNDERGROUNDTANK
[]c TANKINSIDEBUILDING
I--id STEELDRUM
e PLASTIC,/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTTLE [] q RAIL CAR 223
[] f CAN [] j BAG [] n PLASTIC BOTTLE [] r OTHER
[] g CARBOY [] k BOX [] o TOTE BIN
-[] h SILO []1 CYLINDER [] p TANKWAGON
STORAGE PRESSURE [] a AMBIENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT 224
STORAGE TEMPERATURE [] a AMBIEN'[ [] aa ABOVE AMBIENT [] ba BELOW AMBIENT [] c CRYOGENIC 225
226 227 [] Yes [] No 228 229
230 - 231 [] yes [] _ . 233
234 235 [] Yes [] No 236 237
238 239 [] Yes [] No 240 241
242 243 [] Yes [] No 244 245
PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE
SIGNATURE DATE 246
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