HomeMy WebLinkAboutBUSINESS PLAN " ,SITE/FACILITY.
EYEMEDICAL CLINIC OF BAKEi~SFIELD, INC. FORM 5
2500 'H' STREET
BAKERSFIELD, CALIFORNIA 93301
NORTH SCALE: BUS INESS NAME:
DATE: ./ / FACILITY N~fE:
FLOOR: / OF
UNIT ~: OF
(CHECK ONE) SITE DIAGRA~
FACILITY DIAGR.%~
(Inspector's Comments):
-OFFICIAL USE ONLY-
Eb:ICAL CLINIC OF BAKERSFIELD, ,INC.
2500 'H' STREET
'BAKERSFIELD, CALIFORNIA 93301
NORTH SCALE: BUS INESS NAME:
SI TE/FACI LI TY
IF ORM 5
,t
D I
FLOOR: ! OF
DATE: / / FACILITY NAME: UNIT ~: OF
(CHECK ONE) SITE DIAGRAM
FACILITY
Inspector's Comments);
L
-OFFICIAL USE'ONLY-:'
BAKERSFIELD CITY FIRE DEP~d{
2130 "~" STREET
BAKERSFIELD, CA 93301
(805) 326-3979
lM~:DICAI- CI3~IC OF BAKERSFIELD,
9500 'H' STREET
,,A,,<.,-t,,~ml:l n CALIFORNIA 93301
OFFICIAL USE ONLY
ID#
HAZARDOUS ~[ATE R I ALS
BUSINESS PLAN AS A WHOLE
F O[l~I 2A
000.1,90
INSTRUCTIONS:
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 I~YEMEDICAL CLINIC OF BAKERSFIELD,
2500 'H' STREET
BAKERSFIELD, CALIFORNIA 93301
A. BUSINESS NAME:
B. LOCATION / STREET ADDRESS:
CITY:
ZIP:
BUS.PHONE: (~o~-) ~q-~/2Y?
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.
Ph# ~z~ _ cz '2 -~ 7 ..... ' .....
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE: ~'-
B. ELECTRICAL: ¢~Azr-~,,~-
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
- 2A -
SECTION 4: PRIVATE RESPONSE TEA~ FOR BUSINESS AS A WHOLE
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
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
MATERIALS:...' .................................... ~.~E~ NO
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES: .......................... ~E~ NO
C. PROPER USE OF SAFETY EQUIPMENT:.. ................ ~ NO
D. EMERGENCY EVACUATION PROCEDURES: ................. NO
E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES NO
SECTION 7: HAZARDOUS MATERIAL
REFRESHER
NO
ES NO
NO
YES NO
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS OF A
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YES ~'
I unuu~'~.u 6~at ~his information will b~ 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.
DATE
BAKERSFIELD CI3~ FIRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
BUSINESS NAME:
OFFICiAl, USE ONLY
EYE MEDICAL-CLINIC OF~B-A. KERSFIELD, INC.
25b0 '_H' STREET
BAK.ERSFI_ELD, CALIFORNIA 93301
ID#
BUS I NESS PLAN
SINGLE FA, CI LI TY UNIT
FOI{M 3A
INSTRUCTIONS 1. To avoid further action, this form must be re'turned by:
2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
3. Answer the questions below for THE FACILITY UNIT LISTED BELOW
4. Be as BRfEF and CONCISE as possible.
FACILITY UNIT~
FACILITY UNIT NA3{E:
SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES
SECTION 2: NOTIFICATION AND EVACUATION PROCEDb~ES AT THIS UNIT ONLY
- 3A -
SECTION 3: HAZARDOUS MATERIALS FOR THIS; bUilT O~.~LY
A Does this Facility Unit contain Hazardous ~ateria] ..........
If YES, see B.
If NO, continue with SECTION 4.
NO
Are any of the hazardous materials a bona fide Trade Secret YES NO
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 #4.A-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
SECTION 6: LOCATION OF UTILITY SHIfT-OFFS AT THIS UNIT ONLY.
B. ELECTRICAL:
C. WATER:
D. SPECIAL:
E. LOCK BOX: YES .'/~____t_~'' IF YES, .LOCATION:
IF YES, SITE PLANS? YES / NO
FLOOR PLANS?. YES / NO
~SDSs'? YES / NO
KEYS? YES .I NO
- 3B -
I.D. #
BUSINESS NAME:
ADDRESS: I,',
CITY, ZIP: 250_O'H'~STREi~_ ....
PHONE ~: ~9 BAKERSFIELD, CALiFOPNL~ 9~
BAKERSFIELD CITY FIRE DEPARTMENT
FORM 4A- 1
NON--TRADE SECRETS
Page
MATERIALS INVENTORY
OWNER NAME:~-~/~ ~ ~"///,,'~"4~/~/ ,/~,4~ FACILITY UNIT #:
ADDRESS: '/'~,c~,'~ ~/~//~,~-~"~,~.d~'/'~:~'~''/~/' F&CILIT~ UNIT NAME:
PHONE ~: ~-/~ IoFFICIAL USE CF~RS COOE
I ONLY
I
1 2 3 4 5 6 7 8 9 10
TYPE MAX ANNUAL CONT USE LOCATION IN THIS · BY HAZARD D.0.T
CODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT WT. CHEMICAL OR COMMON NAME CODE GUIDE
NAME: ,~9,~ ~. ~ ~-~,¢,m~,</~r TITLE: ~~. SIONATURE: DATE
~O~NCV CO~TACT:~W~ ~d T~TL~:~/~ ~4, ~ON~ m .US .OU.S: ~v-~
~~Z AFTER BUS H"S: ~
EMERGENCY CONTACT:~ ~~ TITLE ~ PHONE ~ BUS HOURS:
PRINCIPAL BUSINESS ACTIVITY: ~ ~/¢~ ~/~/~ AFTER BUS HRS: ~-~/
- 4A-1 -
DAVID J. EVANS, ~.D.
~,~.~ or pr~nn name
Do hereby cert
_z,, that I have reviewed the
attached Hazardous Materials business plan
fo~
and
the Eye Medical Clinic of Bakersfield,
(name of business)
that it along with the attached
or
corrections
constitute
a comDlete
Business Plan for my facility.
RECEIVED
RECEIVED
addi t i ons,lAN 3 1
Ans'd
and correct
date
q;O0 I- Z~
BUSINESS NAME EYE i"~J~CAL
LOCATION ZS00 H ST
CLINIC OF BAKERSFIELD ID N~ER Z15',-000-080490
HIGH HAZARD RATING Z
1, OVERVIEW
JURIS CODE'
MAP PAGE 102
LAST CHANGE 06/13/88 BY ESI'ER
ZLS-001 JURIS BAKERSFIELD STATION 01
GRID ZSB FACILITY UNITS 1 HAZARD RATING Z
RESPONSE SUMMARY
ZA SEC 4) NO PRIVATE RESPONSE TEAM
EMERGENCY CONTACTS ZA SEC Z)
OR. O.J, EVANS - 324-47?? OR 324-47??
SANDI POPOV - 3Z4-477'? OR ~Z~.~--~J~
UTILITY SHUTOFFS ZA SEC 3)
A) GAS - E SIDE OF BLL')G RIGHT OF STAIRS B) ELECTRICAL - CENTER OF BLD6 AT
SHORT HALLWAY NEAR WOMEN'S RESTROOM C) WATER - EAST SIDE OF BLDBj SOUTH SIDE
OF STAIRS (GREEN CASE) D) SPECIAL - NONE E) LOCK BOX - NO
Z. NOTIFICATION / PUBLIC EVACUATION
LAST CHANGE / / BY
Call (local areas) near-by bu§inesses and inform them of fire or gas
leak when time allows (after leaving building).
< NO INFORMATION RECORDED FOR THIS SECTION >
PAGE
lZ/Z3/88 1G:24
MATERIAL SAFETY DATA SYSTEMS, INC. (805) G48-G800
BUSINESS NAME EYE MEOICRL CLINIC OF BAKERSFIELD ID NUMBER 215-OOO-OOO490
LOCATION Z5OO H ST HIGH HAZARD RATING Z
~. HAZ MAT TRAINING SUMM~RY
LAST CHANGE / / BY
DICHLORODIFLUOROMETHANE is a disburstant. If leak occurs, pass word
(over speaker) to evacuate the building -- ventilate the building.
Call 911 and have them bring large fans.
< NO INFORMATION RECORDED FOR THIS SECTION >
LOCAL EMERGENCY MEDICAL ASSISTANCE
LAST CHANGE 06/13/88 BY ESTER
SEC S: NEAREST HOSPITAL.
San Joaquin Community Hospital
2615 Eye Street
Bakersfield, CA 93303
327-1711
MATERIAL SAFETY DATA SYSTEMS, INC. (BOB) G48-G800
1Z/Z3/88 lB:Z4
BUSINESS NAME EYE ICAL CLINIC OF BAKERSFIELD ID
LOCATION ZS00 H ST
FACILITY UNIT
Z1S-000-00~490
HIGH HAZARD RATING
A. OVERALL HAZARDOUS MATERIALS INVENT(]RY
LAST CHANGE 08/13/88 BY ESTER
ID TYPE NAME MAX AMT UNIT HAZARD
LOCATION CONTAINMENT USE
PURE DICHLORODIFLUOROMETHANiE
~3 ROOM PORTABLE PRESS. CYI..
ID PERCENT' COMPONENTS
1086,(~I) 100,0 DICHLORODIFLUOROMETHANE
648 FT3 [.OW
MEDICAL AID OR PROCESS
HAZARD LIST
LOW
PURE DICHORODIFLUOROMETHANE is located in Room # 3 at the Northeast corner
of the building.
Natural gas outlet is at the far West wall of the building, center,of building
above counter - opposite wall.
Fire Extinguishers (3) downstairs
FIRE PROTECTION / WATER SUPPLIES
· , LAST CHANGE 06113188 BY ESTER
FIRE PLUG AT 26th and H Streets, S~6~heast corner
SEC 4> SONITROL ALARM CENTER 3Z~.-AZOZo ALARM & SMOKE DETECTOR FOR FIRE
PROTECTION. and sprinklers throughout the building.
3R SEC S)
PAGE
1Z/Z3/88 tG:Z4
MATERIAL. SAFETY DATA SYSTEMS, INC. (80S) G4B-68~O
BUSINESS NAME EYE MEDICAL CLINIC OF BAKERSFIELD ID NUMBER Z1S-000-~0490
LOCATION 2500 H ST HIGH HAZARD RATING Z
Explosive- gas under pressure. In case of fire pass the word over
speaker to evacuate.
MITIGATION / PREVENI'ION / ABATEMENT
LAST CHANGE 0G/13/88 BY ESTER
SEC l:
DICHLORODIFLUOROMETHRNE - 324 FT3 X Z CYLINDERS PROPERLY STORED,
HOSE CORRECTLY CONN. "EXPLOSIVE." ALSO PORTABLE OXYGEN ,15 FT3
"EXPLOSIVE,"
P f'lGE 4
MATERIAL SAFETY DRT~ SYSTEMS, INC. (805) G48-G800
1ZtZ3/88 1G:Z4
CITY of BAKERSFIELD
HAZARDOUS MATERI ALS I NVENT.ORY'
NON--TRADE SECRETS
Page .... of
BUSINESS NAME: ~'¢~ .,~$W/~ ~__./~'/g OWNER NAME: ./'/A~_~/~ ~ .,~/_/,~/// NAME OF T~S FACILITY:
~.;~;~l~: '~ ~/T o-~ ~ ~[[~[S~7"-~bUU H' 5tree~ STANDARD IND. CLASS CODE
CITY. ZIP: ~~//~w~ ~ CITY. ziP:Bakersfield. CA 93301 DUN AND BRADSTREET NUMBER
PHONE ~:/~2 ~q~o e,O~ *: 805-324-4777 __ - ___ -
~ ~ Z~U~ZO~ ~H ~OP~ COD~
c~e C~e Mt Mt Est Un,ts ~ Site l~ ~1 IW ~ St~ tn F~tltty ~ I~t~t~
--~
~--~ Fire Hazard ~- ~ R~tiv~ty ~- ~ ~l~th~-~ ~ hi~ [ ] I~tlte ' _ ....
~t
2L[,21 ............ ] .............. 1 ] ..... 1 ...... L-_!: I ~2. I ..........
wRh o~ ~ ~h
-]-L__I h' ....... 1 [ ' I _1 ...... !, ~ ! .... I I ............
P~tcal ~ Mlth
(C~k ~11 tMt a~iy)
~--~F~eHazard ~--~ Rflct*vi~y ~--~
Hfllth of P~suq HNIth .....................
P~ic~! ~ H~lth
(C~k 811 t~t
~-~
L--J Fire H~zard ~--J ~Ctivity ~--J ~ie~ ~-] ~ ~l~e ~ I~lete ,
~m.c~ cm~c~ ,~VID d. [V~5~ M.B. 805-324-4777 . SA~BR~ popOv O[[IC[ MaR. 805-664-8355
........................................ n;li ....................... IT'RFP~i ....... ~i' TI;1T .~F'~, .......
Certtficatio~ (Read and siRn after completing a11 sections)
I certt[y uflder ~lty of lee that I ~ve ~rs~ellyexamin~ K lB f~ililr .tth t~ ~nfor~ti~ subittK tn this
for obtaining t~ inf~ttm. I ~lieve t~t t~ su~itt~ info~ti~ is t~, accurate, ~d
DAVID d. EVANS, M.D.
30 January 89
~ai-$~;;; ..........................