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Home My WebLink AboutBUSINESS PLANHazardous Materials/Hazardous Waste Unified Permit . CONDITIONS OF PERMIT ON REVERSE SIDE Permit ID#:: 015-000-000823 ALBERTSONS #6381 This 0ermit is issued for the following; [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials [] Risk Management Program [] Hazardous Waste On-Site Treatment LOCATION: 2705 S H ST 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: June 30. 2003 Issue Date Hazardous Materials/Hazardous WaSte Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE ..... ,~¢~i~"¢???Y'?' ~'!~,,, ~,~ This - -"perm,L is issued for the '-" ' -m.ow~ng: .,~?:?'"i.;~,,¢r~!?;~'~r'''~''"':::;i iiiiiiiil;~ !! i~iiiii;;;:: ;}ili~ i~e;round Storage of Hazardous Materials PERMIT ID# 015-0214}00823 ,,~¢i¢7ii~ '!,.~i;~,,i!;;iil;:}:'~=~:,i:, iii? !!!!:!:!!! i! i ?!?~i:'. !i}:ii~,~!!~Ei:~agement Program. LOCATION 2705 S H Issued by: Bakersfield Fire Department OFFICE. OF ENVTR ONMENTAL SER VICES 1715 Chester/~ve., 3rd Floor Bakersfield, CA 93301 Voice (805) 326-3979 FAX (805) 326-0576 Approved by: Expiration Date: June 30, 2000 FIRE CHIEF RON F'RAZE ADMINISTRATIVE SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (661) 326-3941 FAX (661} 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 · VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (661) 399-4697 FAX (661) 399-5763 May 3,2001 Mr. Ron Hobbs Albertson's #6381 2705 South H Street Bakersfield, CA 93307 Dear Mr. Hobbs: Enclosed, please find the Site and Facility Diagram Instructions packet. When your Hazardous Materials Management Plan and Inventory were submitted it was lacking the diagram portiOn, please draw and submit the diagram(s) of your facility by June 8, 2001. The diagram should include the following: 1) 2) 3) 4) 5) 6) 7) 8) 9) name of your business; businesS address; indicate which direction is North; the cross streets neighboring business addresses (within 300 feet) entrances and exits location of utility shut-offs; location of the nearest fire hydrant; portions of the building protected by automatic sprinkler system; and most importantly the location of the hazardous material(s). If you have any questions, please feel free to call me at (661) 326~3658. Thank you for your assistance. Sincerely, RALPH E. HUEY, DIRECTOR OFFICE OF ENVIRONMENTAL SERVICES Esther Duran, Accounting Clerk II Office of Environmental Services ED\db Enclosures ,A lbm'tsons' September 26, 2000 Ralph E. Huey Hazardous Materials Coordinator City of Bakersfield Fire Department 1715 Chester Ave., 3ra Floor Bakersfield, CA 93301 Hazardous Materials Management Plan Update - Albertsons Bakersfield Locations Dear Mr. Huey: The following corrections need to be made to the corresponding Hazardous Materials Management Plans. ~.~1')' 'Store #6379 - 8200 Stockdale Hwy Grocery Manager - Lorie Davenport No other changes g)~Store #6358 - 2691 Mt. Vernon Ave. ~,~,~No changes 3)~'Store #6349 - 4200 Ming Ave. Grocery Manager - Dennis Johnson No other changes Store #6325 - 7900 White Lane Grocery Manager - Sylvia Cruz No other changes ;5)'~Store g6381 - 2705 "H" St. (~o~ No changes Emergency/Home Phone#: 661-664-6920 Emergency/Home Phone#: 661-834-9675 Emergency/Home Phone #: 661-665 - 1760 If you should have any questions, or require additional information, please do not hesitate to contact me at 208/395-6339. Sincerely, ALBERTSONS INC. aura A Kidwai /~au.n . · Environmental Projects Specialist /lark F:~C Y NTHI AkENV [RONM\ALI.~TOR£\Bkrs fld3.do¢ ALBERTSON'S, INC. / GENERAL OFFICES / 250 PARKCENTER BOULEVARD / P.O. BOX 20 / BOISE, IDAHO 83726 / 208-395-6200 Manager : Location: 2705 S H ST City : BAKERSFIELD CommCode: BAKERSFIELD STATION 01 EPA Numb: RW-CEIVED| 215-0 000 2 usPhone: ~ 831-4'/~ I N 1 0 2000 ~ap : 102 CommHaz : Low ?rid: 24D FacUnits: 1 AOV: SIC Code: 5411 DunnBrad:00 ~i-371~o0~Z~;~% Emergency Contact / Title PEPPER D?.FFE~on ~0%~ / STORE Business Phone: (8~5) 831-4785x 24-Hour Phone : (8~) m3~-BB~-x Pager Phone : (~) - x Emergency Con%ac~ / Title ~r0a6w~ Business Phone: (6~5) ~831-4785x 24-Hour Phone : (~YS) ~71~~$1'q~i Pager Phone : (66~) - x Hazmat Hazards: Fire ImmHlth DelHlth Phone: (20~) State: ~ ~5 Zip : 93309 Address City : Phone: (~) ~--~ State: ~ I1~ Zip : 90~20 ~7~ Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: = Hazmat Inventory --MCP+DailyMax Order Hazmat Common Name... BLEACH AMMONIA SOLUTION MOTOR OIL I, C. Lee Mumford Uy~orp~nt~) ISpecHaz IH F IH O0 hereby cer~ lh~ I haDv:~ reviewed ihs atiached hazardous mais~als manage- ment plan for, ,fil~o~ and ~hat il alo~ ~ith ~a~ Of ~) any ~rr~ions ~nsiiluts One Unified List Ail Materials at Site agerneni plan/bt m7 ~ac~i~y. EPA HazardsI Frm DailyMax ]Unit)MCP L 55.00 GAL Hi L 55.00 GAL Mod L 200.00 GAL Min Albertson ;'~"~'~'~. by ~/ ' C. Lee Mum{:ord~ . --1-- 12/14/1999 F ~UCi(Y STORES iNC #27~ SiteID: 215-000-000823 ='Inventory Item 0002 Facility Unit: Fixed Containers on Site BLEACH /~o~ ~c~L0~t~-~ ~ =_ Days On Site 365 Location within this Facility Unit Map: Grid: SALESFLOOR CAS# 7681-52-9 F STATE ~ TYPE ; PRESSURE Liquid /~ I Ambient TEMPERATURE Ambient CONTAINER'TYPE PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average GAL I 55.00 GALI 30.00 GAL HAZARDOUS COMPONENTS ~Wt .~: ~-~- ~'~ HAZARD ASSESSMENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards No N° No No/ Curies IH 7681529 NFPA/// I USDOT# ---- Inventory Item 0003 Facility Unit: Fixed Containers on Site ~lV~Vl~ ~vl~ / ~ 1 ~/-~/~ ~Vl~ AMMONIA SOLUTION Days On Site 365 Location within this Facility Unit Map: Grid: SALESFLOOR CAS# STATE TYPE PRESSURE Ambient Mixture Liquid TEMPERATURE Ambient CONTAINER TYPE PLASTIC CONTAINER Largest ContainerGAL AMOUNTS AT THIS LOCATION Daily Maximum 55.00 GAL Daily Average 30.00 GAL HAZARDOUS COMPONENTS 30.00 Ammonia Solution, Conc. Less Than 20% N 1336216 ITSecret No HAZARD ASSESSMENTS NoRS Bi°Haz l Radi°active/Am°unt I EPA Hazards INo' No/ Curies F IH NFPA /// USDOT# MCP Mod -2- 12/14/1999 ~ ~UC~Y STORES iNC ~279 ~ Inventory Item 0001 -- COMMON NAME / CHEMICAL NAME MOTOR OIL Location within this Facility Unit SALESFLOOR SiteID: 215-000-000823 Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# F STATE ~ TYPE LiqUid /Pure 'PRESSURE Ambient TEMPERATURE Ambient CONTAINERTYPE PLASTIC CONTAINER Largest Container GAL AMOUNTS AT THIS LOCATION Daily Maximum I 200.00 GAL Daily Average 100.00 GAL I100.00 Motor Oil, HAZARDOUS COMPONENTS Petroleum Based TSecret No NoRSIBi°HaZNo HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies F DH NFPA/// I USDOT# I MCPIMin -3- 12/14/1999 SitelD: 215-000-000823 Fast 'Format = Notif./Evacuation/Medical --Agency Notification Overall Site 11/02/1993 IN ONS IN EICH~ ~ ~Z~DOUS mTERI~:~SPILL.. OR LEDGE OCC~S, NOTIFY THE ~IVI2~ OF S~F~.Y OFFICE (V!!) 722 C~, D~ING NO~ BUSINESS HO~S (8 ~.M. - B P.M., MOdeM - FRIDAY), FOR F~THER INSTRUCTION ON NOTIFICATION OF APPROPRIATE AGENCIES. [~?~-~17~_ D~ING NON-OPE~TIONS HO~S TELEPHONE THE DUTY SEC~ITY OFFICE AT~ ........... ~ ~Y RB~RBSBNTATiVB TO =~L Di~;A SiNC~E YOL~ ETY REPRESENTA'~'~E o~ ~A~'~Tf i~AGE~.' THE ~FE~ REPRESENTATIVE~NOTIFY THE LOC~ FIRE DEP~TMENT ~ q{~ - ~ OF THE INCIDENT. AFTER CONTACTING THE~-DIVISiGN OF SAUETY ~JACE~ A DECISION WILL BE ~E ~ TO EETHER THE STATE OEFICE OF EMERGENCY SERVICES WILL BE. NOTIFIED (800) 852-7550. ~A~~% ~l'~~{ ~ -- Employee Notif./Evacuation 11/02/1993 IF IN-STORE MANAGEMENTS OPINION IS THE STORE MUST BE EVACUATED OR YOU'RE INSTRUCTED TO EVACUATE BY LOCAL AUTHORITIES (FIRE DEPT/POLICE DEPT) DO SO ACCORDING TO ESTABLISHED POLICY AND PROCEDURES. MANAGEMENT SHALL WALK THROUGH STORE INFORMING ASSOCIATES TO LEAVE THE STORE IMMEDIATELY THROUGH SAFEST EXIT. PUBLIC ADDRESS SYSTEM SHALL ONLY BE USED IN SITUATIONS THAT REQUIRE IMMEDIATE EVACUATION, TO MINIMIZE PANIC AMONG CUSTOMERS AND ASSOICATES. Public Notif./Evacuation 11/02/1993 REFER TO RED/GRAY EMERGENCY PROCEDURE BULLETIN FOR INSTRUCTIONS. STORE MANAGEMENT AND ASSOCIATES SHALL WALK THROUGH STORE INFORMING CUSTOMERS TO LEAVE PURCHASES IN STORE AND EXIT THROUGH SAFEST EXIT. PUBLIC ADDRESS SYSTEM SHALL ONLY BE USED IN SITUATIONS THAT REQUIRE IMMEDIATE EVACUATION, TO MINIMIZE PANIC AMONG CUSTOMERS AND ASSOCIATES. --4--' 12/14/1999 STOKES ~. ~27-D SiteID: 215-000L000823 Fast Format Notif./Evacuation/Medical Emergency Medical Plan Overall Site 11/02/1993 HOSPITAL: BAKERSFIELD MEMORIAL -420 34TH STREET BAKERSFIELD, CA. ~ (805) 327-1792 ASSOCIATES OR CUSTOMERS WHO SUSTAIN INJURY OR ILLNESS DUE .TO HAZARDOUS MATERIAL SPILL OR LEAKAGE SHALL BE REFERRED TO COMPANY DESIGNATED MEDICAL CLINIC FOR TREATMENT. IF INJURY OR ILNESS IS SERIOUS OR LIFE THREATENING NOTIFY PARAMEDICS OR ,EMERGENCY SERVICES IMMEDIATELY. -5- 12/14/1999 f mucKY STOrmS T~;C #279_ SiteID: 215-000-000823 Fast Format Mitigation/Prevent/Abatemt Release Prevention Overall Site 11/02/1993 ITEMS ARE PACKAGED IN SMALL CONTAINERS FOR RESALE. ITEMS ARE SAFETY SEALED. ITEMS ARE DISPLAYED ON A LEVEL, SECURE SURFACE, IN A MANNER TO PREVENT ACCIDENTAL DISLODGMENT. CERTAIN CHEMICALS KEPT AT. DIFFERENT LOCATIONS TO PREVENT MIXING. --Release Containment PUT UP "CAUTION WE~ FLOOR" SIGNS OR ROPE OFF AREA TO PREVENT CUSTOMERS/ASSOCIATES FROM ENTERING SPILL AREA. 11/02/1993 IF STRONG OR IRRITATING ODORS ARE PRESENT, WARN OTHERS TO MAINTAIN.SAFE DISTANCE FROM SPILL AREA. IF MATERIAL IS DRY, KEEP ASSOCIATES/CUSTOMERS FROM WALKING THROUGH MATERIAL, SPREADING IT TO OTHER AREAS. IF MATERIAL IS WET OR LIQUID, SPRINKLE ABSORBENT MATERIAL AROUND EDGE OF SPILL TO CONTAIN LIQUID. -- Clean Up 11/02/1993 USE APPROPRIATE PROTECTIVE EQUIPMENT AS REQUIRED BY MATERIAL SAFETY DATA SHEET (MSDS) ~'r~q~r~ IF SPILL IS GREATER THAN ONE GALLON NOTI~FY THE SAFETY DEPARTMENT IMMEDIATELY FOR CLEAN-UP INSTRUCTIONS. IF MATERIAL SPILLED IS DRY, SCOOP OR GENTLY SWEEP UP DRY MATERIAL AND PLACE IN DOUBLE BAGGED PLASTIC TRASH BAG. DO NOT SWEEP VIGOROUSLY AS YOU MAY SPREAD MATERIAL. IF MATERIAL SPILLED IS WET OR LIQUID, SPRINKLE ABSORBENT MATERIAL AROUND EDGE OF SPILL. GENTLY SWEEP ABSORBENT TO CENTER OF SPILL TO ABSORB LIQUID. GENTLY SWEEP UP USED ABSORBENT AND PLACE IN DOI/BLE BAGGED PLASTIC TR3kSH BAG. LABEL TRASH BAG AS'"HAZARDOUS MATERIA: AND PLACE IN WAREHOUSE TEMPORARILY. WET MOP AREA OF SPILL WITH MILD DETERGENT AND WATER. SAVE USED ABSORBENT, MOP, PRODUCT CONTAINER AND WASH WATER. CONTACT THE ~ DEPARTMENT (.3~4) 7~9-63~_0. FOR PROPER DISPOSAL INSTRUCTIONS. Other Resource Activation -6- 12/14/1999 SiteID: 215-000-000823 Fast Format Site Emergency Factors -- Special Hazards Overall Site 07/31/1991 PROPANE TANKS ARE STORED OUTSIDE BUILDING FOR USE BY FLOOR BUFFER.- REFRIGERATIONS SYSTEM USES FREON.#'S 12,22,503 FOR COOLING OF FOOD PRODUCT THROUGHOUT STORE. , --Utility Shut-Offs 07/31/1991 A) GAS - BACK OF BUILDING - NORTHWEST CORNER ABOVE SPRINKLER SHUT OFF B) ELECTRICAL - UPSTAIRS IN MOTOR ROOM INSIDE OFFICE C) WATER - NORTHWEST CORNER OUTSIDE OF STORE AT TRASH CAN AREA D) SPECIAL - FIRE SPRINKLER BACK OF STORE NORTHWEST CORNER E) LOCK BOX - NO -- Fire Protec./AvailWater 07/31/1991 PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS AND AUTOMATIC SPRINKLER SYSTEM; ADTALARMS - BAKERSFIELD; CRIME CONTROL FIRE HYDRANT - ? Building Occupancy Level -7- 12/14/1999 SiteID: 215-000-000823 Fast Format Training -- Employee Training WE HAVE 83 EMPLOYEES AT THIS FACILITY. Overall Site 07/31/1991 WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE EMPLOYEES INFORMED ABOUT EXPOSURE TO HAZARDOUS MATERIALS AND SAFE WORK PROCEDURES AT TIME OF NEW HIRE AND WHENEVER A NEW CHEMICAL IS INTRODUCED INTO THE WORKPLACE. ALL ASSOCIATES RECEIVE INITIAL HAZARD MATERIAL COMMUNICATIONS TRAINING AT THE TIME OF THEIR INITIAL ASSIGNMENT. TRAINING INCLUDES BUT IS NOT LIMITED TO 1) VIDEO ENTITLE "CHEMICAL SAFETY", 2) DISCUSSION OF HAZARDOUS MATERIALS IN THE DEPARTMENT, 3) LOCATION OF MSDS, 4) QUESTION/ANSWER PERIOD. ASSOCIATES RECEIVE RE-FRESHER TRAINING ON HAZARDOUS MATERIALS ON AN ANNUAL BASIS. EMERGENCY PROCEDURES ARE RANDOMLY COVERED WITH ASSOCIATES AND ARE POSTED THROUGHOUT THE STORE ON EMERGENCY PROCEDURE BULLETINS (RED/GRAY POSTER) -- Page 2 Held for Future Use Held for Future Use -8- 12/14/1999 January 6, 2000 Bakersfield Fire Department Environmemal Services 1715 Chester Ave. Bakersfield, CA 93301 Submittal of Hazardous Materials Management Plans for Albertson's #6373 and Albertson's #6381 Dear Sir or Madame: Please find enclosed the completed Hazardous Materials Management Plans for the following locations: Albertson's #6373 41621 Columbus St Bakersfield, CA 93305 Albertson's #6381 2705 S. "H" Street Bakersfield, CA 93304 If you should have any questions on this matter or require additional information, please do not hesitate to comact me at (208) 395-5245. Sincerely, ALBERTSON'S INC. Laura Summers Environmental Compliance Manager Enclosure: CC' Cynthia Forsch, 74100 / File Steve Sistler, #6373 Ron Hobbs, #6381 ALBERTSON'S, lNG. / GENERAL OFFICES / 250 PARKCENTER BOULEVARD / P.O. BOX 20 / BOISE, IDAHO 83726 / 208-395-6200 CITY OF BAKERSFIELD PO BOX 2057 BAKERSFIELD. CA, 93303 RE: Notice to change "Bill to Name" December, 15, 1999 .. Dear Vendor, With the merger of AIbertsons and Lucky Stores Inc. and Savon, the decision has been made to change the name of the Store from Lucky and Lucky/Savon to AIbertsons. Please change your "Bill to Name" to Albertsons. Along with the name change, each store has been assigned a new store number. On the back side of this letter is a listing of all old and new store numbers, all store invoices should reference this new store re,tuber. The legal entities remain the same with no change io the Taxpayer Identification Numbers, Lucky North's is 942531892 and Lucky South's is 940760700. Both are wholly owned by Albertsons who's taxpayer identification ntlmber is 820184434. Thauk you for your help with this. Sincerely, Albertsons, inc., No,hem &Southem California Old Lucky Store Number to New Albe~sons Store Number Old ASC l New ADS' Old A$C I New ABS O~d ASC New ABS Old ASC I New ABS Old ASC New ABS Old ASC New ABS O~d ASC New Str~ I Str~ Str~ I Str~ St~ Str~ Str~ I Str~ St~ Str~ Str~ Str~ Str~ Str~ 00001 07001 00092 07292 00190 07290 00307 07207 00428 06128 00523 06322 00659 06360 00002 07102 00097 07097 00194 07294 00310 07208 00430 06130 00524 06124 00663 06362 00004 07004 00098 07098 00197 07297 00312 07212 00432 06334 00528 06528 00664 06343 00006, 07106 00100 07002 00198 07298 00318 07213 00433 06530 00530 06129 00667 06367 00007 07107 00102 07103 00199 07295 00320 07220 00435 06135 00535 06134 00672 06572 00008 07108 00103 07003 00203 06710 00322 07222 00436 06535 00537 06137. 00673 06573 00009 07109 00104 07014 00204 06704 00325 07225 00437 06537 00539 06534 00677 06170 00010 07010 00107 07111 00205 06712 00328 07228 00438 06538 00541 06341 00678 06378 00011 07011 00108 07104 00207 06707 00329 07229 00439 06139 00542 06142 00681 06015 00012 07012 00109 07009 00209 06709 00330 07226 00440 06540 00544 06544 00689 06017 00015 07115 00110 07110 00214 06714 00332 07232 00441 06141 00547 06547 00684 06020 00016 07016 00111 07211 00215 06315 00333 07233 00443 06143 00550 06348 00685 06022 00017 07117' 00112 07007 00216 06716 00336 07236 00444 06144 00555 06752 00687 06024 00019 07019 00113 07013 00217 06715 00338 07238 00445 06145 00557 06756 00689 06089 00021 0~018 00116 07116 00218 06718 00343 07243 00446 06146 00560 06760 00697 06026 00023 07123 00117 07017 00219 06719 00344 07244 00448 06148 00563 06763 00704 06027 00024 07124 00118 07198 00221 06721 00346 07246 00449 06549 00566 06166 00721 06029 00025 07125 00119 07219 00222 06722 00347 07247 00450 06350 00569 06169 00732 06030 00026 07026 00120 07020 00223 06723 00348 07248 00451 06151 00572 06571 00734 06036 00028 07128 00121 07021 00224 06724 00350 07059 00453 06753 00575 06575 00735 06035 00030 ,07030 00123 07023 00226 06725 00351 07151' 00454 06154 00576 06104 00739 06039 00031 07131 00124 07112 00227 06727 00352 07152 00455 06557 00577 06374 00741 06041 00033 07033 00125 07130 00229 06729 00354 07150 00457 06156 00585 06007 '00742 06040 00034 07034 00126 07126 00232 06732 00356 07056 00460 06160 00586 06008 00746 06047 00036 07029 00127 07127 00236 06736 00357. 07160 00461 06161 00587 06010 00759 06059 00038 07038 00128 07120 00237 06737 00358 07114 00462 06162 00589 06012 00784 06043 00041 07041 00129 07129 00238 06738 00359 07159 00463 06353 00590 06013 00785 06044 00042 07142 00130 07113 00239 06739 00360 07060 00464 06342 00602 06102 00786 06045 00043 07143 00131 07031 00240 06740 00362 07162 00465 06365 00603 06502 00787 06046 00044' 07144 00132 07132 00241 06741 00364 07164 00466 06366 00604 06516 00788 06048 00045 07045 00133 07133 00246 06746 00365 07065 00467 06167 00605 06105 00789 06088 00048 07148 00134 07134 00247 06747 00366 07166 00469 06370 00606 06106 00850 06344 00049 07049 00135 07035 00251 06751 00367 07168 00470 06570 00607 06519 00851 06351 00050 07050 00136 07036 00253 06553 00369 07169 00474 06174 00611 06111 00852 06352 00053 07053 00137 07037 00254 06754 00371 07071 00475 06175 00614 06114 00855 06355 00054 07154 00140 07040 00255 06755 00372 07172 00478 06103 00615 06115 00856 06356 00057 07057 00142 07141 00257 06757 00373 07173 00479 06179 00616 '06316 00857 06357 00058 07158 00144 07145 00258 06758 00375 07175 00480 06180 00618 06118 00858 06354 00060 07094 00150 07058 00263 06361 00376 07178 00482 06182 00619 06119 00859 06559 00061 07061 00153 07153 00268 06368 00377 07177 00483 06183 00623 06123 00862 06562 00064 07064 00154 07054 00272 06372 00378 07178 00484 06319 00625 06~27 00865 06565 00065 07165 00155 071.55 "00~78~ 06373 00379 07179 00486 06184 00626 06526 00866 06566 00067 07067 00156 07156 '~00279 ) 06381 00380 07080 00488 06581 00627 06522 00867 06567 00068 07068 00157 07157 00282 06382 00381 07181 00489 06~89 00628 06328 00868 06568 00069 07069 00158 07161 00285 06385 00397 07197 00491 06191 00629 06529 00869 06569 00070 07270 00159 07119 00287 06786 00401 06501 00494 06194 00631 06131 00871 06371 00071 07171 00163 07163 00288 06788 00402 06101 00497 06196 00633 06533 00872 06172 00072 07072 00164 07231 00289 06790 00403 06503 00498 06598 00636 06136 00875 06173 00075 07075 00166 07066 00292 06792 00404 06505 00499 06596 00638 06138 00876 06176 00076 07076 00167 07167 00293 06793 00406 06107 00501 06706 00639 06539 00877 06177 00077 07180 00168 07265 00295 06795 00408 06308 00503 06303 00642 06542 00878 06578 00081 07081 00170 07240 00296 06794 00409 06109 00505 06305 00643 06543 00880 06577 00082 07182 00173 07242 00297 06797 00413 06513 00508 06508 00645 06545 00883 06383 00083 07183 00175 01249 00299 06783 00414 06113 00509 06509 00646 06546 00887 06387 00086 07186 00182 07256 00300 07121 00417 06717 00510 06521 00648 06548 00888 06588 00087 07087 00~83 07283 00302 07202 00418 06518 00511 06711 00651 06550 00088 07188 00184 07284 00303 07203 00420 06120 00513 06313 00654 06554 00090 07095 00185 07286 00305 07204 00421 06121 00517 06517 00655 06155 00091~ 07191 00188 07288 00306 07216 00426 06126 00518 06132 00656 06556 h:\iws\dala~iorenumber$\luckyoldnew.xl$ 10/07/96 LUCKY STORES INC #279 215-000-000823 Overall Site with 1 Fac. Unit General Information Page 1 Location: 2705 S H ST City : BAKERSFIELD uon~act Name Title "- / STORE MANAGER Business Phone: (805) 831-4785x 24-Hour Phon~ : (~4~J~-Tui ~$5~x P~e : (~0~)~i9 -~$~/ x Map:102 Haz:2 Type: 3 Gr3~ 24D F/U: 1 AOV: 0.0 ~~S / ASSTMANAGER Business Phone: (805) 831-4785x 24-Hour Phone : ~?x ~ : (~z)F7/ -~3-x Administrative Data Mail'Addrs: 4801 WHITE LN City: BAKERSFIELD Comm Code: 215-001 BAKERSFIELD STATION 01 D&B Number: 00-691-3719 State: CA Zip: 93309- SIC Code: 5411 Owner: LUCKY STORES INC Address: 6565 KNOTT AV City: BUENA PARK Summary Phone: (714) 739-6310 State: CA Zip: 90620- {~DV 1 4 i996 HAL MAT. DI¥. I, ~F%C~--~C'F~, ,, Oo hereby certify that I have (fy,;.? er print name) reviewed the at~tached hazardous materials manage- for~,~.¢~.~o,~/ and that it a,on, with me,nt plan any corrections constitute a complete and correct man- agement plan ~L ignature " Pln-Ref LUCKY STORES INC #279 215-000-000823 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site Name/Hazards Form Max Qt¥ Page MCP 2 02-002 BLEACH · Immed Hlth Llquid 55 High GAL 02-003 AMMONIA SOLUTION · Fire, Immed Hlth Liquid 55 Moderate GAL 02-001 MOTOR OIL · Fire, Delay Hlth Liquid 200 Minimal GAL lO/O 7/ 6 LUCKY STORES INC #279 215-000-000823 02 - Fixed Containers on Site Hazmat Inventory Detail in MCP Order Page 3 '02-002 BLEACH · Immed Hlth Liquid 55 High GAL CAS #: 7681-52-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: CLEANING Daily Max GAL Daily Average GAL 30.00 Annual Amount GAL .... 660.00 Storage PLASTIC CONTAINER Press T Temp IAmbient IAmbient I SALESFLOOR Location - Conc 100.0% IBleach Components MCP ---~uide High J 45. 02-003 AMMONIA SOLUTION · Fire, Immed Hlth Liquid 55 Moderate GAL CAS #: 7664-41-7 Trade Secret: No Form: Liquid Type: Mixture Days: 365 Use: CLEANING Daily Max GAL55 I Daily Average30.00GAL Annual Amount GAL ...... 660.00 Storage PLASTIC CONTAINER Press T Temp I Ambient~Ambient I SALESFLOOR Location - Conc~ Components 30.0% I Ammonia Solution, Conc. Less Than 20% MCP----~uide IModerateI 60 02-001 MOTOR OIL · Fire, Delay Hlth Liquid 200 Minimal GAL CAS #: 64742-65-0 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: LUBRICANT Daily Max GAL 200 Daily Average GAL 100.00 Annual Amount GAL - 2,400.00 Storage PLASTIC CONTAINER Press T Temp I Ambient I Ambient I SALESFLOOR Location - Conc ~ Components 100.0%IMotor Oil, Petroleum Based MCP ---TGuide IMinimal I 27 10/0'7/~6~ ~' LUCKY STORES INC #279 215-000-000823 Page 00 - Overall Site <D> Notif./Evacuation/Medical 4 <1> Agency Notification CALL 911 IN SITUATIONS IN WHICH A HAZARDOUS MATERIAL SPILL OR LEAKAGE OCCURS, NOTIFY THE DIVISION OF SAFETY OFFICE (714) 739-6310, DURING NORMAL BUSINESS HOURS (8 A.M. - 5 P.M., MONDAY - FRIDAY), FOR FURTHER INSTRUCTION ON NOTIFICATION OF APPROPRIATE AGENCIES. DURING NON-OPERATIONS HOURS TELEPHONE THE DUTY SECURITY OFFICE AT BUENA PARK (714) 739-6774. ASK THE DUTY REPRESENTATIVE TO CALL DIANA SINCLARE YOUR DISTRICT SAFETY REPRESENTATIVE OR SAFETY MANAGER. THE SAFETY REPRESENTATIVE SHALL NOTIFY THE LOCAL FIRE DEPARTMENT (805) 326-3979 OF THE INCIDENT. AFTER CONTACTING THE DIVISION OF SAFETY MANAGER A DECISION WILL BE MADE AS TO WHETHER THE STATE OFFICE OF EMERGENCY SERVICES WILL BE NOTIFIED (800) 852-7550. <2> Employee Notif./Evacuation IF IN-STORE MANAGEMENTS OPINION IS THE STORE MUST BE EVACUATED OR YOU'RE INSTRUCTED TO EVACUATE BY LOCAL AUTHORITIES (FIRE DEPT/POLICE DEPT) DO SO ACCORDING TO ESTABLISHED POLICY AND PROCEDURES. MANAGEMENT SHALL WALK THROUGH STORE INFORMING ASSOCIATES TO LEAVE THE STORE IMMEDIATELY THROUGH SAFEST EXIT. PUBLIC ADDRESS SYSTEM SHALL ONLY BE USED IN SITUATIONS THAT REQUIRE IMMEDIATE EVACUATION, TO MINIMIZE PANIC AMONG CUSTOMERS AND ASSOICATES. <3> Public Notif./Evacuation REFER TO RED/GRAY EMERGENCY PROCEDURE BULLETIN FOR INSTRUCTIONS. STORE MANAGEMENT AND ASSOCIATES SHALL WALK THROUGH STORE INFORMING CUSTOMERS TO LEAVE PURCHASES IN STORE AND EXIT THROUGH SAFEST EXIT. PUBLIC ADDRESS SYSTEM SHALL ONLY BE USED IN SITUATIONS THAT REQUIRE IMMEDIATE EVACUATION, TO MINIMIZE PANIC AMONG CUSTOMERS AND ASSOCIATES. <4> Emergency Medical Plan HOSPITAL: BAKERSFIELD MEMORIAL 420 34TH STREET BAKERSFIELD, CA. (805) 327-1792 lO/O ?/b LUCKY STORES INC #279 215-000-000823 Page 00 - Overall Site <D> Notif./Evacuation/Medical 5 <4> Emergency Medical Plan (Continued) ASSOCIATES OR CUSTOMERS WHO SUSTAIN INJURY OR ILLNESS DUE TO HAZARDOUS MATERIAL SPILL OR LEAKAGE SHALL BE. REFERRED TO COMPANY DESIGNATED MEDICAL CLINIC FOR TREATMENT. IF INJURY OR ILNESS IS SERIOUS OR LIFE THREATENING NOTIFY PARAMEDICS OR EMERGENCY SERVICES IMMEDIATELY. LUCKY STORES INC #279 215-000-000823 00 - Overall Site <E> Mitigation/Prevent/Abatemt Page 6 <1> Release Prevention ITEMS ARE PACKAGED IN SMALL CONTAINERS FOR RESALE. ITEMS ARE SAFETY SEALED. ITEMS ARE DISPLAYED ON A LEVEL, SECURE SURFACE, IN A MANNER TO PREVENT ACCIDENTAL DISLODGMENT. CERTAIN CHEMICALS KEPT AT DIFFERENT LOCATIONS TO PREVENT MIXING. <2> Release Containment PUT UP "CAUTION WED FLOOR" SIGNS OR ROPE OFF AREA TO PREVENT CUSTOMERS/ASSOCIATES FROM ENTERING SPILL AREA. IF STRONG OR IRRITATING ODORS ARE PRESENT, WARN OTHERS TO MAINTAIN SAFE DISTANCE FROM SPILL AREA. IF MATERIAL IS DRY, KEEP ASSOCIATES/CUSTOMERS FROM WALKING THROUGH MATERIAL, SPREADING IT TO OTHER AREAS. IF MATERIAL IS WET OR LIQUID, SPRINKLE ABSORBENT MATERIAL AROUND EDGE OF SPILL TO CONTAIN LIQUID. <3> Clean Up USE APPROPRIATE PROTECTIVE EQUIPMENT AS REQUIRED BY MATERIAL SAFETY DATA SHEET (MSDS) IF SPILL IS GREATER THAN ONE GALLON NOTIFY THE SAFETY DEPARTMENT IMMEDIATELY FOR CLEAN-UP INSTRUCTIONS. IF MATERIAL SPILLED IS DRY, SCOOP OR GENTLY SWEEP UP DRY MATERIAL AND PLACE IN DOUBLE BAGGED PLASTIC TRASH BAG. DO NOT SWEEP VIGOROUSLY AS YOU MAY SPREAD MATERIAL. IF MATERIAL SPILLED IS WET OR LIQUID, SPRINKLE ABSORBENT MATERIAL AROUND EDGE OF SPILL. GENTLY SWEEP ABSORBENT TO CENTER OF SPILL TO ABSORB LIQUID. GENTLY SWEEP UP USED ABSORBENT AND PLACE IN DOUBLE BAGGED PLASTIC TRASH BAG. LABEL TRASH BAG AS "HAZARDOUS MATERIA: AND PLACE IN WAREHOUSE TEMPORARILY. WET MOP AREA OF SPILL WITH MILD DETERGENT AND WATER. SAVE USED ABSORBENT, MOP, PRODUCT CONTAINER AND WASH WATER. CONTACT THE SAFETY DEPARTMENT (714) 739-6310 FOR PROPER DISPOSAL INSTRUCTIONS. THOROUGHLY WASH HANDS/ARMS WITH SOAP AND WATER AFTER CLEAN-UP. <4> Other Resource Activation LUCKY STORES INC #279 215-000-000823 00 - Overall Site <E> Mitigation/Prevent/Abatemt Page <4> Other Resource Activation (Continued) LUCKY STORES INC #279 215-000-000823 00 - Overall Site <F> Site Emergency Factors Page. 8 <1> Special Hazards PROPANE TANKS ARE STORED OUTSIDE BUILDING FOR USE BY FLOOR BUFFER. REFRIGERATIONS SYSTEM USES FREON #'S 12,22,503 FOR COOLING OF FOOD PRODUCT THROUGHOUT STORE. <2> Utility Shut-Offs A) GAS - BACK OF BUILDING - NORTHWEST CORNER ABOVE SPRINKLER SHUT OFF B) ELECTRICAL - UPSTAIRS IN MOTOR ROOM INSIDE OFFICE C) WATER - NORTHWEST CORNER OUTSIDE OF STORE AT TRASH CAN AREA D) SPECIAL - FIRE SPRINKLER BACK OF STORE NORTHWEST CORNER E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS AND AUTOMATIC SPRINKLER SYSTEM; ADT ALARMS - BAKERSFIELD; CRIME CONTROL FIRE HYDRANT - ? <4> Building Occupancy Level 10/07/96 LUCKY STORES INC #279 215-000-000823 00 - Overall Site <G> Training Page 9 <1> Employee Training WE HAVE 83 EMPLOYEES AT THIS FACILITY. WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE EMPLOYEES INFORMED ABOUT EXPOSURE TO HAZARDOUS MATERIALS AND SAFE WORK PROCEDURES AT TIME OF NEW HIRE AND WHENEVER A NEW CHEMICAL IS INTRODUCED INTO THE WORKPLACE. ALL ASSOCIATES RECEIVE INITIAL HAZARD MATERIAL COMMUNICATIONS TRAINING AT THE TIME OF THEIR INITIAL ASSIGNMENT. TRAINING INCLUDES BUT IS NOT LIMITED TO 1) .VIDEO ENTITLE "CHEMICAL SAFETY", 2) DISCUSSION OF HAZARDOUS MATERIALS IN THE DEPARTMENT, 3) LOCATION OF MSDS, 4) QUESTION/ANSWER PERIOD. ASSOCIATES RECEIVE RE-FRESHER TRAINING ON HAZARDOUS MATERIALS ON AN ANNUAL BASIS. EMERGENCY PROCEDURES ARE RANDOMLY COVERED WITH ASSOCIATES AND ARE POSTED THROUGHOUT THE STORE ON EMERGENCY PROCEDURE BULLETINS (RED/GRAY POSTER) <2> Page 2 <3> Held for Future Use <4> Held for Future Use (])9/3(])/93 LUCK TORES INC ~279 215-000-( 23 Page Overall Site with 1 Fac. Ur, it Ger, eral Ir, fc, rr,~at i Locatior~: 2705 S H ST Map: 102 Hazard: Low Commur, ity: BAKERSFIELD STATI[]N 01 ~/ Grid: 24D F/U: 1 AOV: 0.( Cor, tact Name ---T Title T ......Busir, ess Pho'r',e ...... T124-Hour Phone] LARRY BENTON ISTORE MANAGER J.(805) 831-4785 x I 209) 781-9054, ~ARVtN ~.~R~. ASST MANAGER (8(])5) 831-4785 x 805) B~2--~ Mail Addrs:'~'~'~(' ' "-'~O~ ~ITE L~ D&B Number: 00-E, 91-S719 City: BAKERSFIELD State: CA Zip: 93309- Corem Code: 215-001 BAKERSFIELD STATION 01 SIC Code: 5411 Owr, e~-: LUCKY STORES INC Phor, e: (714) Address: 6565 KNOTT AV,~ ..... State: CA City: BUENA PARK ~ 'Zip: 90620- Summary RECEIVED HAZ ~'~ AT_.O.~,4. 09/30/93 LUCK~IToRES INC $$279 215-00( Hazr~at Ir~verstory List irs MCP Order Page 2 02 - Fixed Corstairsers ors Site Plrr-Ref Nars~e/Hazards Form Max Qty MCP BLEACH Immed Hlth Liquid ~ Hi gh GAL 02-003 AMI'iONIA SOLUTION Fire, I~med Hlth Liquid 55 Moderate GAL 02- 001 MOTOR OIL. Fire, Delay Hlth Liquid 200 M i rs i rs~ a 1 GAL 09/30/93 [)2 - Fixed CorJtair, ers c,r, Site Hazn~at Ir~ver~tory Detail ir~ MCP Order Page BLEACH I ~med Hlth Liquid ~ High GAL CAS ~: 7681-52-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 []se: CLEANING Daily Max GAL 55 ...... F-~ Daily Average GAL 3o. co Ar~r~ual A~nour~t GAL ~. 66¢). 00 Stor~age PLASTIC CONTAINER Press T Te[~p Arab i erst lAmb i er, tI SALESFLOOR Locat i or~ .... Corec ..... 1 100.0% IBleach Con~por~er~t s )'~i MCP ---FGui de gh ~ 45 02-003 AMMONIA SOLUTION Liquid Fire, Iron, ed Hlth ~ ~ ~, Moderate GAL CAS ~: 7664-41-7 Trade Secret: Nc, Fc, rm: Liquid Type: Mixture Days: ~6~ Use: CLEANING Daily Max GAL ...... Daily Average GAL 55 I 30.00 Ar~r~ual A[m:,ur~t GAL ....... 660.00 St ora ge PLASTIC CONTAINER . Press' T Tem[~ .--[ Ambient t Ambient I SALESFLOOR Locat i or~ -- Corec --~ S0.0%~ Amn~or, i a So i ut i or~ · Compor~er~t s Fl - MCP ---FGuide oderate i '60 MOTOR OIL Fire, Delay Hlth Liquid 200 M i r, i ma 1 GAl_ CAS $~: 64742-65-0 'Trade Sect. et: Nc, Form: Liquid Type: Pur-e ......... Daily Max GAL 200 ) Days: 365 Use: LUBRICANT Daily Average GAL ~ Ar~r~ual A~c, urrt GAL ..... 100.00 ) 2,400.00 St orage PLASTIC CONTAINER Press T 'ren~p --~ j A~nbier, t J A~bi er, t I SALESFLOOR Locat i c,r, Cc, r~c --I Cc,~npor:er, t s 100.0%~Motor Oil, Petroleum Based [-~ii MC[:' ----FGu i de r~i~a 1 ~ 27 09/30/93 LUCK~TORES INC ~279 215-000-,'~0823 Page 4 0('}~ - Overall Site <D> Not if. /EvacuatiorJ/Medical <1> Agency Notification CALL 911 IN SITUATIONS IN WHICH A HAZARDOUS MATERI~mSPlLL OR LEAKAGE OCCURS, NOTIFY ]'HE DIVISION OF SAFETY OFFICE · ~14) 739-;~EC&, DURING NORMAL T.~USINESS HOURS (8 A.M. - 5 P.M., MONDAY - FRIDAY), FOR ~FURTHER INSTRUCTION ON NOTIFICATION OF APPROPRIATE AGENCIES. DURING NON-OFERK~]IONS~ HOURS .]ELE~HONE ]HE DU~ .... -~Y RI .............. ~4 30 i,;ii' .' ~, FY YOUR DISTRICT SAFETY REPRESENTATIVE. o~ THE SAFETY REPRESENTATIVE SHALL NOTIFY THE LOCAL. FIRE DEPARTMENT (805) 326-3979 OF THE INCIDENT. AFTER CONTACTING THE DIVISION OF SAFETY MANAGER A DECISION WILL BE MADE AS TO WHETHER THE STATE OFFICE OF EMERGENCY SERVICES WILL BE NOTIFIED (800) 852-7550. <2> Employee Not if./Evacuatior~ IF IN-STORE MANAGEMENTS OPINION IS THE STORE MUST BE EVACUATED OR YOU' RE INSTRUCTED TO EVACUATE BY LOCAL AUTHORITIES (FIRE DEPT/POLICE DEPT) DO SO ACCORDING TO ESTABLISHED POLICY AND PROCEDURES. MANAGEMENT SHALL WALK THROUGH STORE INFORMING ASSOCIATES TO LEAVE THE STORE IMMEDIATELY THROUGH SAFEST EXIT. PUBLIC ADDRESS SYSTEM SH~LL ONLY BE USED Ihi SI]"UA]'IONS THAT REQUIRE IMMEDIATE EVACUATION, TO MINIMIZE PANIC AMONG CUSTOMERS AND ASSOiCATES. <3> Public Notif./Evacuatio'n REFER TO RED/GRAY EMERGENCY PROCEDURE BULLETIN FOR INSTRUCTIONS. STORE MANAGEMENT AND ASS[]CIATES SHALL WALK 'THROUGH STORE INFORMING CUSTOMERS -TO LEAVE PURCHASES IN STORE AND EXIT THROUGH SAFEST EXIT. PUBLIC ADDRESS SYSTEM SHALL ONLY BE USED IN SITUATIONS THAT REQUIRE IMMEDIATE EVACUATION, '1"0 MINIMIZE PANIC AMONG CUSTOMERS AND ASSOCIATES. <4> Ernerger~cy Medical Plan HOSPITAL: BAKERSFIELD MEMORIAL 420 34]'H STREET BAKERSFIELD, CA. (8(. ~) 32'7-1792 09/30/93 LUCK~-'TORES INC 45279 2i5-000-~0823 ~ Page O0 - OYerall Site <D> Not'if./Evacuat iorl/Medical 5 <4> Erl~erger~cy Medical Plar~ (Cor~tir~ued) ASSOCIATES OR CUSTOMERS WHO SUSTAIN INJURY OR ILLNESS DUE TO WAZARDOUS MATERIAL SPILL OR /.EAKAGE SHALL BE REFERRED TO COMPANY DESIGNATED MEDICAL CLINIC FOR TREATMENT. IF INJURY OR ILNESS IS SERIOUS OR LIFE THREATENING NOTIFY PARAMEDICS OR EMERGENCY SERVICES IMMEDIATELY. 09/30193 LUCK~TORES INC ~279 2i5-000-00323 00 - Ove'~all Site <E> Mit igatiors/Prever~t/Abater~t Page 6 <I> Release Prever~tion ITEMS ARE PACKAGED IN SMALL CONTAINERS FOR RESALE. iTEMS ARE SAFETY SEALED. ITEMS ARE DISPLAYED ON A LEVEL, SECURE SURFACE, IN A MANNER TO PREVENT ACCIDENTAL DISLODGMENT. CERTAIN CHEMICALS KEPT AT DIFFERENT LOCATIONS TO PREVENT MIXING. <2> Release Cor~tairm~er~t PUT UP "CAUTION WED FLOOR" SIGNS OR ROPE OFF' AREA TO PREVENT CUSTOm, ERS/ASSOCIATES FROM ENTERING SPILL AREA. IF STRONG OR IRRITATING ODORS ARE PRESENT, WARN OTHERS TO MAINTAIN SAFE DISTANCE FROM SPILL AREA. IF MATERIAL IS DRY, KEEP ASSOCIATES/CUSTOMERS FROM WALKING THROUGH MATERIAL, SPREADING IT TO OTHER AREAS. IF MATERIAL IS WET OR LIQUID, SPRINKLE ABSORBENT MATERIAL AROUND EDGE OF SPILL TO CONTAIN LIQUID. <3> Clear~ Up USE APPROPRIATE PROTECTIVE EQUIPMENT AS REQUIRED BY MATERIAL SAFETY DATA · SHEET (MSDS) IF SPILL IS GREATER THAN ONE GALLON NOTIFY THE SAFETY DEPARTMENT IMMEDIATELY FOR CLEAN-UP INSTRUCTIONS. IF MATERIAL SPILLED IS DRY, SCOOP OR GENTLY SWEEP UP DRY MATERIAL AND PLACE IN DOUBLE BAGGED PLASTIC TRASH BAG. DO NOT SWEEP VIGOROUSLY AS YOU MAY SPREAD MATERIAL. IF MATERIAL SPILLED IS WET OR LIQUID, SPRIN~<LE ABSORBENT MATERIAL AROUND EDGE OF SPILL. GENTLY SWEEP ABSORBENT TO CENTER OF SPILL TO ABSORB LIQUID. GENTLY SWEEP UP USED ABSORBENT AND PLACE IN DOUBLE BAGGED PLASTIC TRASH BAG. LABEL TRASH BAG AS "HAZARDOUS MATERIA: AND PLACE IN WAREHOUSE TEMPORARILY. WET MOP AREA OF SPILL WITH MILD DETERGENT AND WATER. SAVE USED ABSORBENT, MOP, PRODUCT CONTAINER AND WASH WATER. CONTACT THE SAFETY DEPARTMENT~(714)~TSg-~F[]R PROPER DISPOSAL INSTRUCTIONS. THOROUGHLY WASH HANDS/ARMS WITH SOAP AND WATER AFTER CLEAN--UP. <4> Other Resource Activation 09 /30 / 9 3 00 - Overall Site Page 7 <E> Mit igat ior~/Prever, t/Abate~t <4> Othe~~ Resou~ce Activatior~ (Cor~tir~ued) 09/30/93 LUCK~TORES INC ~2"79 215-000-0~23 Page 00 - Overall Site <F> Site E~ergency Factors 8 <1> Special Hazards PROPANE 'rANKS ARE STORED OUTSIDE BUILDING FOR USE BY FLOOR BUFFER. REFRIGERATIONS SYSTEM USES FREON ~'S 12,22,503 FOR COOLING OF FOOD PRODUCT THROUGHOUT STORE. <2> Utility Shut-Offs A) GAS - BACK OF BUILDING -NORTHWEST CORNER ABOVE SPRINKLER SHUT OFF B) ELECTRICAL - UPSTAIRS IN MOTOR ROOM INSIDE OFFICE C) WATER - NORTHWEST CORNER OUTSIDE OF STORE AT TRASH CAN AREA D) SPECIAL - F~RE SPRINKLER BACK OF STORE NORTHWEST CORNER E) LOCK BOX - NO <3> Fire Protec. /Avail. Water PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS AND AUTOMATIC SPRINKLER SYSTEM; ADT ALARMS- BAKERSFIELD; CRIME CONTROL FIRE HYDRANT - ? <4> Building Occupancy Level 00 - Overall Site <G> Trai rsir~g <1> Page 1 WF HAVE 83 EMPLOYEES AT THIS FACILITY. WE HAVE MATERIAl_ SAFETY DATA SHEETS ON FILE EMPLOYEES INFORMED ABOUT EXPOSURE TO HAZARDOUS MATERIALS AND SAFE WORK PROCEDURES AT TIME OF NEW HIRE AND WHENEVER A NEW CHEMICAL IS INTRODUCED INTO THE WORKPLACE. ALL ASSOCIATES .RECEIVE INITIAL HAZARD MATERIAL COMMUNICATIONS TRAINING AT THE TIME OF ]'HEIR INITIAL. ASSIGNMENT. TRAINING INCLUDES BUT IS NOT LIMITED TO i) VIDEO ENTITLE "CHEMICAL SAFETY", 2) DISCUSSION OF HAZARDOUS MATERIALS IN THE DEPARTMENT, 3) LOCATION OF MSDS, 4) QUESTION/ANSWER PERIOD. ASSOCIATES RECEIVE RE-FRESHER TRAINING ON HAZARDOUS MATERIALS ON AN ANNUAL BAS I S. EMERGENCY PROCEDURES ARE RANDOMLY COVERED WITH ASSOCIATES AND ARE POSTED ]'HROUGHOUT THE STORE ON EMERGENCY PROCEDURE BULLETINS (RED/GRAY POSTER) <2> Page 2 as rseeded <3> Held f,z,r Future Use <4> Held ~or Future Use 09/30/93 LUCK~TORES INC ~279 215-000-0e823 00 - Overall· Site <G> Trair~ing Page <4> Held for Future Use (Cor~tir, ued) 09/30/93 'JI"ORES INC ~279 215-000- )823 00 - Ove'rall Site <H> RMPP DATA Page 11 <1> Release Cor~tairm~er~t <2> Offsite Cor~sequer~ces <3> Ire House Capabilities <4> Plar~t Shutdowrs Ir~structiorl APRIL 1991 LUCKY STORES INC. General Information PAGE I Location: 2705 S. H STREET, BAKERSFIELD, CA Ident Number: 93301 RECEIVED 2 0 ;991 HA~, ,~4AT. DIV. Contact Name Title LARRY BENTON STORE MGR MARVIN BYRD ASST MGR Business Phone (805) 831-4785 (805) 831-4785 Administrative Data Home Phone (209) 781-9054 (805) 832-6751 Mail Addrs: 4801 WHITE LN City: BAKERSFIELD Comm Code: 215-013 BAKERSFIELD STATION 13 D&B Number: State: CA Zip: SIC Code: 93309- Owner: LUCKY STORES INC Address: 6565 KNOTT AVE City: BUENA PARK CA 90620 Total Number of Associates: 83 Phone: (714) 739-7466 Contact: SHAWN THOMPSON SAFETY MGR Hours of Operation: Day 28 Associates Night 12 Associates Business Hours 7 A.M. -. 11 P.M. Stock Crew (only) 11 P.M. - 7 A.M. APRIL 1991 LUCKY STORES INC Hazmat Inventory List PAGE 2 TO BE PROVIDED WITHIN 60 DAYS AS AGREED TO BY RALPH HUEY. APRIL 1991 LUCKY STORES INC Notif./Evacuation/Medical PAGE 3 1) Aqencv Notification · In situations in which a hazardous material spill or leakage occurs, notify the Division Safety Office (714) 739-7806, during normal business hours (8 a.m. - 5 p.m., Monday - Friday), for further instructions on notification of appropriate agencies. · During non-operational hours telephone the Duty Safety Representative by paging (714) 255-4620. If the Duty Representative does not return the call within 30 minutes, notify your District Safety Representative. · The Safety Representative shall notify the local fire department (805) 326-3979 of the incident. After contacting the Division Safety Manager a decision will be made as to Whether the State Office of Emergency Services will be notified (800) 852-7550. 2) Associates Notif./Evacuation · If in-store managements opinion is the store must be evacuated or you're instructed to evacuate by local authorities (fire dept/police dept) do so according to established policy and procedure. Refer to Red/Gray Emergency Procedure Bulletin for instructions. · Management shall walk through store informing associates to leave the store immediately through safest exit. · Public address sYstem shall only be used in situations that require immediate evacuation, to minimize panic among customers and associates. 3) Public Notif./Evacuation · Refer to Red/Gray Emergency Procedure Bulletin for instructions. · Store management and associates shall walk through store informing customers to leave purchases in store and exit through safest exit. · Public address system shall only be used in situations that require immediate evacuation, to minimize panic among customers and associates. 4) Emerqencv Medical Plan · Associates or customers who sustain injury or illness due to hazardous material spill or leakage shall be referred to company designated medical clinic for treatment. · If injury or illness is serious or life threatening notify paramedics or emergency services immediately. APRIL 1991 LUCKY STORES INC Mitiqation/Prevent/Abatement PAGE 4 1) Release Prevention · Items packaged for resale are in small quantity containers. · Store use items are contained in manufacturer approved containers. 2) Release Containment · /Put up "Caution Wet Floor" signs or rope off area to prevent customers/associates f.~om entering spill area. ~ /. If strong or irritating odors are present, warn others to maintain safe 'distance ~-/ from spill area. · If material is dry, keep associates/customers from walking through materiial, spreading it to other areas. · If material is wet or liquid, sprinkle absorbent material around edge ofI spill to contain liquid. 3) Clean Up · Use appropriate protective equipment as required by Material Safety DataI Sheet (MSDS). · If spill is greater than one gallon notify the Safety Department immediately for clean-up instructions. · If material spilled is dry, scoop or gently sweep up dry material and pllace in double bagged plastic trash bag. Do not sweep vigorously as you may spread imaterial. I If material spilled is wet or liquid, sprinkle absorbent material arounld edge of /spill. Gently sweep absorbent to center of spill to absorb liquid. Gentl~ sweep up ~/used absorbent and place in double bagged plastic trash bag. · Label trash bag as "HAZARDOUS MATERIAl" and place ~n warehouse ~emporari~ly. · Wet mop area of spill with mild detergent and water. · Save used absorbent, mop, product container and wash water. Contact th~ Safety Department (714) 739-7806 for proper disposal instructions · Thoroughly wash hands/arms with soap and water after clean-up. 4) Other Resource Activation · Safety Representative shall request additional assistance such as Haz-Mat clean-up service if situation requires. 'APRIL 1991 LUCKY STORES INC Site Emerqencv Factors PAGE 5 1) Special Hazards · Propane tanks are stored outside building for use by floor buffer. Refrigeration system uses freon #'s 12,22,503 for cooling of food product throughout store. 2) Utility Shut-Offs A) GAS - BACK OF BUILDING - NORTHWEST CORNER ABOVE SPRINKLER SHUT OFF ELECTRICAL - UPSTAIRS WEST SIDE OF BUILDING IN MOTOR ROOM WATER - NORTHWEST CORNER OUTSIDE OF STORE AT TRASH CAN AREA D) LOCK BOX - NONE E) FIRE SPRINKLER - BACK OF STORE NORTHWEST CORNER F) ALARM CO - ADT ALARMS - BAKERSFIELD (805) 322-1961 CRIME CONTROL - SYSTEM NUMBER - K030010117 3) Fire Protec./Avail. Water yP~VATE FIRE PROTECTION - k~/, STORE IS EQUIPPED WITH AUTOMATIC SPRINKLER PROTECTION WHICH IS MONITORED BY ADT ALARMS - CRIME CONTROL (805) 322-1961, 24 HOURS A DAY, 7 DAYS A WEEK * PORTABLE MULTIPURPOSE (ABC) FIRE EXTINGUISHERS MOUNTED THROUGHOUT BUILDING APRIL 1991 1) Paqe 1 LUCKY STORES INC Traininq PAGE 6 · Material Safety Data Sheets are on file for all hazardous materials used in the store. · All associates receive initial Hazard Material Communications Training at the time of their initial assignment. · Training includes but is not limited to 1) video entitled "Chemical Safety", 2) Discussion of hazardous materials in the department, 3) location of MSDS, 4) Question/answer period. · Associates receive re-fresher training on hazardous materials on an annual basis. · Emergency procedures are randomly covered with associates and are POsted throughout the store on Emergency Procedure Bulletins (Red/Gray Poster). a:279.haz CITY of BAKERSFIELD "II/E C,4 RE" Charles Smith tyoe .or Drin~ name) Do hereb7 certify that I 'have reviewed the attached Hazardous Materials business olan for (name Lucky stores of business) and that it along with the attached additions or corrections constitute a. comDlete and correct Business Plan for/my s ~na~ur,e facility. d'at e ~', Oz i BUSINESS NAME LUCKY STORES INC ~Z79 ID NUMBER ZIS-OOO-OO~8Z~ LOCATION Z70S S H ST HIGH HAZARD RATING I. OVERVIEW JURIS COOE MAP PRGE 102 EAST C'HANGE 07/1S/88 BY ESTER ZIS-O(~l JURIS BAKERSFIELD STATION 01 GRID Z4D 'FACILITY UNI!S 1 EIAZARO RATING ~ RESPONSE SUMMARy zn SEC 4) NO PRIVATE RESPONSE TEAM EMERGENCY CONTACTS 2A SEC Z) 8~E~T~--~-4w78~--O~-8-~Z---q~S-~ Mike Holyfield·- 805/831-4785 6~ · E~--OUNN ~--8-~--~8B--O~-gw~'4--'MM~ 805/398-0204 UTILITY SHUTOFFS Z~ SEC ~) M~vin Byrd - 805/831-4785 or 805/832~6751 ~) G~S - NONE 8) ELECTRICAL - UPSTAIRS IN MOTOR RM INSIDE OFFICE C> W~TER - BACKROOM W WALL D)~SPECI~L - NONE E) LOCK 80X - NO Z. NOTIFICATION / PUBLIC EVACUATION LAST CHANGE / / BY < NO INFORMATION RECORDED FOR TEl]iS SECTION > PAGE t. lZ/15/88 MRTERIRL SAFETY DATR SYSTEMS, INC. (80S) 848-680(~ BUSINESS NAME LUCKY LOCATION Z?OS )RES INC ~279 ID.N~ ST, 215-OOO-OOO8Z~ HAZRRD R~TING Z 3. HAZ M/~T TR/~INING SUMMARY LAST CH~NOE / / BY < NO INFORMATION RECORDED FOR THIS SECTION > LOCAL EMERGENCY MEDICAL RSSISTAN£E LAST CHANGE / / BY ( ND ~NFOR~T~ON RECORDED FOR TH~S SECTION ) - PPIGE Z 12/15188 09:33 MRTERISL SSFETY DR'F~ SYSTEMS, INC. (805) 848-GB00 BUSINESS NAME LUCKY STORES INC ~279 LOCATION 2705 S H ST FACILITY UNIT 01 ID NUMBER Z1$-OOO-OOOAZ3 ~HIOH HAZARD RATING Z R. OVERALL H~ZARDOUS MATERIALS INVENTORY EASTCHANGE'IO/OG/B8 BY ESTER · ID TYPE NAME MAX flMT UNIT HAZARD LOCATION CONTAINMENT USE 1 PURE MOTOR OIL " ZOO GAL S~LESFL00R PLASTIC CONTAINER[S] LUBRICANT ID PERCENT COHRONENTS Z808.00 100;0 MOTOR OIL UNKNOWN HAZARD LIST UNKNOWN PURE BLEACH SS GAL SALESFLOOR PLASTIC CONTAINER[S] CLEANING ID PERCENT COMPONENTS 1165.03 t00.0 BLE~CH PURE AMMONIA' SRLESFLOOR PLASTIC CONTAINER[S] ID PERCENT COMPONENTS 10Z4.0Z 30.0 LIQUID AMMONIA SS GAL CLERNING UNKNOWN HAZRRD LIST UNKNOWN MODERATE HAZARD LiST MODERAI'E EP .. ,ROTECT ON Z : ATER SUPPLIES LAST CHANGE / / BY < NO INFORMATION RECORDED FOR THIS SECTION > PRGE 3 12/15/88 09:33 MRTERIRL SRFETY .DATA SYSTEMS, INC, (805) 648-6800 BUSINESS NGME LUCKY, )RES INC ~279 I0 NI Z15-000~.000823 LOCATION 270S ST HAZARD RATING EMPLOYEE NOTIFICATION / EvAcuATION LAST CHANGE 0?115188 BY ESTER SEC Z) 9;1, VERBAL OR PUBLIC ADDRESS SYSTEM, DEPENDING ON THE SEVERITY OR SAFEST METHOD. DIRECTIONS GIVEN TO NEAREST EXIT. E. MITIOATION / PREVENTION t ABATEMENT LAST CHANGE 07115/88 BY ESTER SEC 1) ITEMS'ARE PACKAGED IN SMALL CONTAINERS FOR RESALE. ITEMS 8RE ,SAFETY SEALED. ITEMS ARE DISPLAYED ON A LEVEL, SECURE SURFACE, IN A MANNER TO PREVENT ACCIDENTAL DISLODGMENT. CERTAIN CHEMICALS KEPT Al" DIFFERENT LOCATIONS TO PREVENT MIXING. ABATEMENT'PROCEDURES ARE TO EFFECT CLEAN-UPS WITHOUT CONTACT WITH SKIN AND TO REMOVE ANY TRACES FROM THE. EXPOSED.SURFACE. 'IT-IS THEN'DISPOSED IN A SAFE'MANNER TO A~OID FURTHER CONTACT. . PAGE 4 12/1S/88 O9:~ MATERIAL SAFETY DRTR SYSTEMS., INCJ (805) G48-GS~ BAKERSFIELD CITY FIRE DEPARTI~IENT 2130 "O" STREET · ' B~RSFIELD, CA' 9330~ (805) 326-3979 RECEIVED JUl. 2 2 ,'i,s'd .... ~ ....... I BUSINESS NAME OFFICIAL USE ONLY ID# HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 2A 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 A. BUSINESS NAME: LUCKY STORES, INC. #279 B. LOCATION / STREET ADDRESS: 2705 S "H" St. CITY: Bakersfield, CA ZIP: 93301 BUS.PHONE: (805) 831-4785 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-?$50 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. A. Gael Hunt / Manager Ph# 805/831-4785 Ph# 805/832-9534 B'. Jeff Dunn / Assistant Manager Ph# 805/831-5769 Ph# 805/834-6046 SECTION 3: LOCATION. OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE A. NAT. GAS/PROPANE: None B. ELECTRICAL: Upstairs in motor room - inside the office for lights o~ly, C. WATER: Backroom west wall ~ D. SPECIAL: E. LOCK BOX: YES /f~ IF YES, LOCATION: IF YES, DOES IT CONTAIN SITE PLANS? FLOOR PLANS? YES MSDSS? YES KEYS? YES / NO YES / NO 2A - BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA. 93301 OFFICIAL USE ONLY BUSINESS NAME: LUOKY STORES~ INC~. #2?9 1412'8 BUSINESS 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 be!o~v for THE FACILITY UNIT LISTED BELOW 4. Be as BRIEF and CONCISE as .possible. FACILITY L~IT# FACILITY UNIT N~E: SECTION 1: MITIGATION, PREVENTION, ABATEMEN~r PROCEDbq~ES I.t;ems~ are: packaged-, in.. small. containers:.,, fe.r--.,resale.- I~ems are-.-safe~y-.seale~,'-. Ite.ms~...are-.dis~laFe'd.~ en~a-le.vel, secure surface, i~--,~fmaTn.h?~. ~ o. preven%~ accidental ,-. dislod~en-t.. Certiin che~cals, ke'pt~ at-~di.fferent.,.locations..~to-p~eveni~-.miEing, Aba~em'ent:-Pr6~6'~du~es: ~'r~ "t6'~ 8fleet': 5I~ah.~h.~-'~ith~6fit ' ~sntaSt-~ith skin' and' tO'""gem~5ye ~n~ tra~-~;s.-~ fib'om' ~h~[-e~'d~sdbfacs(7~% It. is' then dispose~ in. a safe manner to avoid fumther contact, SECTION 2: NOTIFICATION .&~D EVACUATION PROCEDL~ES AT THIS %~IT ONLY 911, V~rb.al'~6~ ~hli~,addres;s-..-system~--dependinE-,-.on the--~everity or safest method. Direcgions given to nearest exit. BAKERSFIELD CITY FIRE DEPARTMENT I.D. ~ FORM 4A-1 Page ~o~ NON--TRADE SECRETS HAZARD'OUS MATERI ALS I NVENTORY BUSINESS NAME: OWNER NAME: FACILITY UNIT #: ADDRESS: ADDRESS: FACILITY UNIT NAME: CITY, ZIP: CITY,ZIP: PHONE ~: PHONE #: {OFFICIAL USE CFIRS CODE { ONLY NAME: TITLE: SIGNATURE DATE: EMERGENCY CONTACT: TITLE: PHONE # BUS HOURS: o. AFTER BUS HRS: EMERGENCY CONTACT: TITLE: PHONE # BUS HOURS: PR'iNCIPAL BUSINESS ACTIVITY: AFTER BUS HRS: _ 4A_l'~' ORTH SCALE: DATE: ./ / (CHECK ONE) SITE/FACILITY FORM 5 BUSINESS NAME: FAC I L ITY NAME: SITE D I AGR.~M D I AG RAM FLOOR: UNIT ~ FACILITY D I AGR.%M O2" 0F' .s/-/ 1 j'? ( Inspector's. CommentJ): -OFFICIAL USE ONLY- PART B- I§87 HAZARDOUS MA~IALS INVENTORY 8 IN~TRUCTIONS: READ ALL THE INSTRUCTIONS BELOW A;;D ON PAGE 4. PHOTOCOPY EXTRA COPIES OF ~'HIS FORM 8EPORE COMPLETING IT. ~REFORT WASTES ON RE~/ERSE --1'. COMPLETE A SEPARATE FORM FOR EACH BUILDING, OUTDOOR AREA, OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE BOX BELOW TO SPEC .THE LOCATION OF THE ~AZAROOUS MATERIALS LISTED ON THIS FORM. (HAZARDOUS WASTE ON PART C.) LOCATION OF HAZAROOUS MATF..R ALS: COMPLETE ALL ITEMS IN BOX. ~U~I~NESS ROOM NAME I OR NUMBERBUILDING NAME OR NUMBER LUCKY STORES //, ADDRESS OUTDOOR AREA NAME OR NUMBER 2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE OUANTi {NCLUDE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS. CHEMICALS MANUFACTURED OR REPACKAGED, AN0 CHEMICALS DISTRIBUTED. USE THE CODES TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4. 3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE. FrLL IN A & 8 FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS ESTIMATE MAXIMUM ESTIMATE TOTAL LIST ALL THE TYPES ,, ~F - MATERIAL MIXTURE. USE EXACT SPELLING. OUANTITY HANOLEO OR STORED QUANTITY HANOLEO OR OF CONTAINERS MATr- A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TIME IN 1987 AT ST.OREO 0URING 19B? USED TO STORE ] SAFE' ABOVE LOCATION. INCLUDE AT ABOVE LOCATION. HAZAR00US MATERIAL- B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i.e. LBS. GALLONS, EVEN IF ONLY BRIEFLY. USE TABLE 1, THE ALL. INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLUDE UNITS. DISTILLED .WE.TTE VINEGA.R ACIDITY _5. O °/0 GLASS ~ 60 GAL. 2., 400 (;AL. PLASTIC NO % HOUSEHOLD (RFTAIL3 CRAcoR -FISH EMULSION a. NITROGEN .5. O ~ONIAC~ NI~O~EN ,4 ~ 5 G~. 200 O~. GLASS NO PHOSPHORIC ACID (P,O~ ~.d ~mm~nT,D (RETATI,1 A. CNACON- K~VIN SP~Y TW~RT 9~-o % 5 G~. 200 G~. G~SS NO oran - OR~ENEX Ac~PHATE .4.0 TRTFORTNE ~.25 % 5 G~. 200 G~. GLASS NO DTCnT.WOT, 3,00 TNERT Sq. 75 OR~O - BTAMTNON DTAMTN~N 25.0 p~mRnT.~ ROT.V~NT ~7.0 ~ 6 G~. 240 G~. GLASS TNERT 1~- 0 ~ PLASTIC NO ~R~Q - HAT,A~TdN CNflCON- ANT SP~Y CARBAR~ 5,0 TM~T 95,0 ~ 5 G~. 200 G~. GLASS NO TA8LE I STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressea Gas Manif(Jld OFFICE uSE ONLY Metal Containers (<5 gallons) F = Bags L = Pressure Vessel - Not l~ortal~le Drums, Barrels, Carl~oys G Boxes, Cartons. Cases M = Tank Car/Trailer ~NS~. 10 __ DATA ENTRY 10 Underground Tanks H = Sump or Pit N = Seale~ Source (ra~lioactive materiat) Aboveground Tanks I = Industrial Processing Eouipment 0 = Unsealed Source (raclioactive material) rasp INIT __ DATA ENTRY INIT P = Other container type, specify Glass Containers J Comoresse~l Gas Cylinders PAGE 5 0A~ .. DArE PART B -1987 HAZARDOUS d. SINVENTORY ~.~,~E 2 OF 8 INSTRUCTIONS: REAO ALL THE INSTRUCT:~;S BELOW ANO ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT. ,REPORT WASTES ON REVERSE SiDE 1/COMPLETE A SEPARATE FORM FOR EACH BUILDING. OUTOOOR AREA, OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE BOX BELOW TO SPEC THE LOCATION OF THE HAZAROOUS MATERIALS LISTED ON THiS FORM. (HAZARDOUS WASTE ON PART C.) LOCAT ON OF HAZARDOUS MATERIALS: ROOM NAME OR NUMBER BUILDING NAME OR NUMBER STORE ¢f , ADDRESS OUTDOOR AREA NAME OR NUMBER 2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANTIT INCLUDE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS, CHEMICALS MANUFACTURED OR REPACKAGED, AND CHEMICALS DISTRIBUTED. USE THE CODES . TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4. 3, RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-AOORESSED ENVELOPE, FILL IN A & B FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS ESTIMATE MAXI,MUM ESTIMATE TOTAL LiST ALI. THE TYPES ~VE MATERIAL MIXTURE. USE EXACT SPELLING. DUANTITY HANDLED OR STORED QUANTITY HANDLED OR OF CONTAINERS MATEG A. PRODUCT NAME OR COMMON NAME OF HAZAROOUS MATERIAL. AT ANY TIME IN 1987 AT STORED DURING 1987 USED TO STORE SAFE- ABOVE LOCATION. INCLUOE AT ABOVE LOCATION. HAZAROOUS MATERIAL- B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i.e. LBS. GALLONS, EVEN IF ONLY BRIEFLY, USE TABLE 1. NAZAC' ALL INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLUOE UNITS. A. EF~.T, T~OC. & CAT S~RA¥ (AEROSOLi a. HET~YL NONrTL DETONE 1.9 RELATED CO~O~S .1 ~ 24 ~SS. 960 [SS. ~OSO~ INERT 98.0 ~ C~ NO HOUS~OLD (RETAIL) a. REPEL DOG & CAT (SOLID) s. P~IC~OROB~ZENE 20.0 ~K~ P~IDI~S 2.0 ~ 50 LBS. 2,000 LBS. C~BO~ NO INERT 75.0 A. SPEC~ - SPEC~CIDE - PEST CONSOL ~ G~ 'PETROLE~f SOLVEN% 98,92 ~ 10 G~. 400 G~. INERT ,58 % PLASTIC NO HOUSEHOLD (~TAI~) A. SPECT~CIDE (ROSE] ~ROSOL 8. D~AZTNO~ , ~ INERT 99,5 ~ 350 OZ. 10,000 OZ. AEROSOL ~ C~ NO MOU~OLD (RETAIL] A SPECT~CTDE ~T & ROA~ SP~Y PYR~RTMS .052 ~ 200 OZ. 8,000 OZ. ~ NO TEC~NICAT, ~I~ERO~ BUTOXIDE ,%~1 ~ C~ PETRQT.RI~ DIgTTLLATE 95, ~ ~ , INERT 3,325 A. RTD-A-BIIG LTOIITD gP~Y ' S. C~T,ORPYRYTOg .50 ~ P~OT,EI~ gOLVE~ .28 ~' 10 G~. 400 G~. PLASTIC NO TN~R~ 99.22 ~ MOUREWOLD (RETATT,~ A. OR~O WEED-B-GON o. D TME~[IN~ 22,4 TWERT 77,6 ~ 20 PTS. 800'PTS. ~T~ C~ NO TABLE 1 STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold A = Metal Containers (<5 gallons) F = Bags L = Pressure Vessel - Not portable B = Drums, Barrels, Cartaoys G Boxes, Cartons, Cases M = Tank Car/Trailer INSP. iD C = UndergrounCl Tanks H = Sump or Pit N = Sealed Source (radioactive material) 0 = Aboveground Tanks t = Industrial Processing EQuipment 0 = Unsealed Source (radioactive material) INSP INIT E Glass Containers J Compressed Gas CylinDers P = Other container type, specify PAGE 5 OAr~ OFFICE USE ONLY OATA ENTRY l0 ~ 0ATA ENTRY INIT __ DATE PART B - Ig87 HAZARDOUS MA/ALS INVENTORY PAGE 3 OF S INSTRUCTIONS: READ ALL THE iNSTRUCTIONS BELOW AND ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT ~RE?ORT .AZ.'-:' WASTES ON REVERSE SIDE) 1. COMPLETE A SEPARATE FORM FOR EACH'BUILDING, OUTOOOR AREA, OR ROOM WHERE HAZAROOUS MATERIALS ARE LOCATED. USE BOX BELOW TO SFE THE LOCATION OF THE HAZARDOUS MATERIALS LISTED ON THIS FORM. (HAZAROOUS WASTE ON PART C.) LOCATION OF HAZARDOUS MATER ALS OOM.LETE ALL,TEMS,. Box. LuCkY L STORE // AOSRESS OUTDOOR AREA NAME OR NUME)ER 2, COMPLETE COLUMNS 1-5 FOR. EACH HAZARDOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE OUANT: INCLUDE RAW MATERIALS. FINISHED CHEMICAL PRODUCTS, CHEMICALS MANUFACTURED OR REPACKAGED, AND CHEMICALS DISTRIBUTED. USE THE CODE£ TABLE I AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4. 3. RETURN COMPLETED INVENTORY ANDAPPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE. FILL IN A & B FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS EST1MATE MAXIMUM ESTIMATE TOTAL LIST ALL THE TYPES MATERtAL M~XTURE. USE EXACT SPELLtNG. QUANT)TV HANDLED OR STORED QUANTITY HANDLED OR OF CONTAINERS MA'T A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TIME IN 1987 AT STORED DURING 1987 USED TO STORE SAFE- ABOVE LOCATION. INCLUDE AT ABOVE LOCATION, HAZARDOUS MATERIAL- B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i.e. LBS, GALLONS, EVEN IF ONLY BRIEFLY, USE TABLE 1. THE ALL INGREDIENTS IN HAZARDOUS MATERIAL. etc,) INCLU0F_ UmTS. A. ORTI~0 .WEED-B-CON AEROSOL B. DIMETHYLAMINE SALTS .72 % INERT 99.28 % 30 LBS. 1,200 LBS. AEROSOL % CAN NO HOUSEHOLD CRETAIL ) A, ORTHO BUG SP~y AEROSOL a. TETRAME~HRIN · 200 % SUMITHRIN .191 ~ 25 LBS. 1,000 LBS. AEROSOL OTI4ER ISOMERS ,009 ~ CAN NO PETROLEUM D%~T%LLATE 11,500 .. TNERT ~)~), IOO A. ORTHO WEED-B-QON LIOUID SPRAY B. DIMETHYLAMINE SALTS ,40 TNERT 99.60 % 40 PTS. 1,600 PTS. PLASTIC NO T-/OURk-~-/OT,D (RETAIL ~ A. DRTNO TRTOX VEGETATION KILLER B. PROMETQ~q 1.86 % INERT 98.14 % 20 QTS. 800 QTS. METAL % CANS NO % HOUSEHOLD (RETAIL]. A. ORq~O KLEKNUP-GRASS ~- ISOPROPYLAMINE SALT OF GLYPHOSAT ~.0 TNERT 95.0 % 10 GAL 400 GAL. PLASTIC NO A. ORq~O ANT/ROACH/HORNET/WASP AEROSOL B. METHYT.CARBOMATE 1, O % PEq'~OT.Elll~ DTSTTT.LAT~ 82.~ % 24 PTS. 960 PTS. AEROSOL TN]~T 16,7 FlF)l'T R 'F~OT,D (RETATT.') A. (l.(3~lCF. -- C(3PRI~.R MT3( (.ROT.TO) B. .qq~¥~WNTNE ALKOLOTD , ~0% TNFRT 99,70% 24 LBS. 1,000 LBS. CARDBOARD NO TABLE I STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold A = Metal Containers (<5 gallons) F = Bags L = Pressure Vessel - Not I)ortable B = Drums, Barrels, CarDoys G = Boxes. Cartons, Cases M = Tank Car/Trailer INSP. C = Underground Tanks H = Sump or Pit N = Sealed Source (radioactive material) O = AboveDround Tanks I = Industrial Processing Equioment 0 = Unseated Source (radioactive material) E = Glass Contamers J = Compresseu Gas CyiinUers P = 0t,er container typo. specify PAGE 5 OFFICE USE ONLY DATA ENTRY lO __ DATA ENTRY IF~T ,, DATE PARTS- 1987 HAZARDOUS MA~T~IALStNVENTORY PAGE 4 OF 8 INSTRUCTIONS: REAO 4LL THE INSTRUCT',ONS BELOW ADJO ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLBTIN5 IT .qEPORT WASTES ON REVERSE SiDE,~ 1. COMPLETE A SEPARATE FORM FOR EACH BUILDING. OUTDOOR AREA, OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED, USE BOX BELOW TO SPE. THE LOCATION OF THE HAZARDOUS MATERIALS LISTED ON THIS FORM. (HAZAROOUS WASTE ON PART 03 LOCATION OF HAZARDOUS MATERIALS; COMPLETE ALL ITEMS IN BOX. BUSINESS NAME ROOM NAME OR NUMBER BUILDING NAME OR NUMBER LUCKY STORE # ADDRESS OUTDOOR AREA NAME OR NUMBER 2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE. REGAROLESS OF THE QUANT: iNCLUDE RAW MATERIALS, FINISHED CHEMICAL PROOUCTS, CHEMICALS MANUFACTURED OR REPACKAGED, AND CHEMICALS DISTRIBUTED. USE THE CODE'- TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4. 3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-AOORESSED ENVELOPE. FILL ~N A &B FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS ESTIMATE MAXIMUM ESTIMATE TOTAL LIST ALL THE TYPES MATERIAL MIXTURE. USE EXACT SPELLING. QUANTITY HANOLED OR STORED DUANTITY HANDLFO OR OF CONTAINERS A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TIME IN 1987 AT STORED DURING 1987 USED TO STORE ABOVE LOCATION. INCLUDE AT ABOVE LOCATION. HAZAROOUS MATERIAL- SHE£ 8, CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i.e. LSS, GALLONS, EVEN IF ONLY BRIEFLY. USE TAeLE t HAZ-' ALL INGREDIENTS IN HAZARDOUS MATERIAL. etc,) INCLUDE UNITS. A. DIXAL ANT KILLER DUST a. BENDIOCARB 1.0 inert 99.0 % 12 LBS. 400 LBS. CARDBOARD ~ CAN NO HOUSEHOLD (RETAIL) A. OR%HO DIAZINON GRANITES E~. DIAZ INON 2.0 INERT 98.0 % 12 LBS. 400 LBS. CARDBOARD ~ CAN NC' HOUSEHOLD (RETAIL) A ORTHO FLEA-B-GON 8. CHLORPYITOS .5 0 XYLENE SOLVENT' .33 ~ 24 PTS. 1,000 PTS. PLASTIC NO INERT 99.17 HOUSEHOLD (RETAIL) A. BUG FOGGERS/FUMIGATORS s. PERMETHRIN 12 · 6 INERT 87.4 ~ 100 LBS. 4,000 LBS. AEROSOL ~ CANS NO % HOUSEHOLD (RETAIL) A AEROSOL BUG SPRAY BLK. FLAG/RAID s' PHgNOL METHYLCARBAMATE · 95 RELATED COMPOUNDS .05 % 200 LBS. 8,000 LBS. AEROSOL NO PETROLEUM DISTILLATE 80.50 INERT 18.50 % HOUSEHOLD (RETAIL] A. ROACH BAIT TRAYS s. TETRAHYDRO -5 1 · 65 INERT 98. ~5 % 30 LBS. I, 200 LBS. CARDBOARD % BOXES NO % HOUSEhOlD (gETA~L~ A. ANTI-FREEZE (AUTOMOTIVE) S. ETHYLENE GLYCOL BASg % 30 GAL. 1,200 GAL. PLASTIC % BOTTLES NC % ~OOSE~OT.Q TABLE I STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Mandold OFFICE uSE ONLY A = Metal Containers (<:5 gallons) F = Sags L = Pressure Vessel - Not portable B = Drums, Barrels, Carboys G = Soxes, Cartons, Cases M = Tank Car/Trailer [NSP. I0 OAT.', ENTRY l0 __. C = Underground Tanks H = Sump-or Pit N = Sealed Source (radioactive material) 0 = Aboveground TanKs I · = Industrial Processing Equipment 0 = Unsealed Source (radioactive material) raSP INIT .~ 0A"A ENTRY INIT P = Other container type, specify E Glass Containers J Compressed Gas Cyhnoers PAGE 5 0AT~ ~A~E __ PART B- 1987 HAZARDOUS MAlmLmRIALS INVENTORY PAOE 5 OF 8 INSTRUCTIONS: READ ALL THE INSTRUCTIONS BELOW AND ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT. I. REPORT H4Z-t;: WASTES ON REVERSE SIDE.) 1. COMPLETE A SEPARATE FORM FOR EACH BUILDING. OUTDOOR AREA. OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE 80X BELOW TO SPE,: file LOCATION OF THE HAZARDOUS MATERIALS LISTED ON THIS FORM. /HAZARDOUS WASTE ON PART C.) (LOCATION OF HAZARDOUS MATERIALS: COMPLETE ALL ITEMS iN BOX. NBU"SJ'NESS ...... LUCKY STORE # ~ADORESS ~ ROOM NAME OR NUMBER r BUILDING NAME OR NUMBER OUTDOOR AREA NAME OR NUME)ER 2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANT( INCLUDE RAW MATERIALS. FINISHED CHEMICAL PRODUCTS. CHEMICALS MANUFACTURED OR REPACKAGED, AND CHEMICALS DISTRIBUTED. USE THE CODES. TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4. 3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE. I FiLL iN A & 8 FOR EACH HAZAROOUS MATERIAL OR HAZAROOUS ESTIMATE MAXIMUM ESTTMATE TOTAL LiST ALL THE TYPES -- FArE MATERIAL MIXTURE. USE EXACT SPELLING. QUANTITY HANDLED OR STORED QUANTITY HANOLE0 OR OF CONTAINERS MATE: A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TiMEiN 1987 AT STORED DURING 1987 USED TO STORE SAFE- ABOVE LOCATION. INCLUDE AT ABOVE LOCATION. HAZARDOUS MATERIAL - SHEET , THE B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UN~TS, (i.e. LBS, GALLONS. EVEN IF ONLY BRIEFLY. USE TABLE I. HAZ~ ALL INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLUDE UNITS, MATE: A.' COOLING SYSTEM FLUSH (AUTOMOTIVE) e. MORPHOL INE % % 50 PTS. 2,000 PTS. % CANS NO HOUSEEOLD (RETAIL)I B. PETROLEUM DISTILLATES % ~ 25 PTS. 1,000 PTS. MET~ ~ ~ CANS NO HOUSEHOLD (,RETAIL) A: TIRE PUNCTURE SEAL AEROSOL s. PETROLEUM DISTILLATES ~ 12 PTS. 500 PTS. ~ CAN NO . ,HOUSEHOLD (RETAIL) A. REFRIGERANT- 12 AEROSOL' s. D I CHLOROD I~L4OROMETHANE 5.0 CCI2F2 % 24 PTS. 1,000 PTS ._~ % CAN NO HOI~SEHOLD ~. RETAIL) A. MOTOR OILS a, P~TROLEUM DISTILLATES ~ 100 GAL. 4,000 GAL. ~ CANS NO ~QUSEHOLD CRE~AIL) A. . pROPA~)~ FUEL s. PROPANE GAS 100 % ._~ % 30 CYLINDER~ 1,200 UNIT: __~ ~ ~ NO HOUSEHOLD (RE~AIL) A: MOTH BALLS' (SOLID) S. PARAD I CHLOROBENZENE 100 % CARDBOARD NO ~ 30 LBS. 1,200 LBS. HOUSEHgLD (RETA~IL) TABLE I STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold OFFICE USE ONLY A = Metal Co.tainers (<5 gallons) F = Bags L = Pressure Vessel-Not portable 8 Drums. Barrels, Carboys G Boxes. Cartons, Cases M = Tank Car/Trailer rasP. tO OATA ENTRY lB C = Underground Tanks H = Sump or Pit N = Sealed Source (radioactive material) D = Aboveground Tanks I -- Industrial Processing EQuipment 0 = Unsealed Source (radioactive mate.at) INSP iNiT ~ DATA ENTRY INIT P = Other container type. specify E = Glass Containers J = Comgressed Gas Cylinders PA~ .~ o~r~_ ____ PART B - 1987 HAZARDOUS MArtIALS INVENTORY PAGE 6 OF 8 INSTRUCTIONS: READ ALL THE INSTRUCTIONS.BELOW AND ON PACE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT. iREPORT HAZA~ . WASTES ON REVERSE SIDE.) 1..COMPLETE A SEPARATE FORM FOR EACH BUILDING. OUTDOOR AREA. OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE BOX BELOW TO SPEC THE LOCATION OF THE HAZARDOUS MATERIALS LISTED ON THIS FORM. (HAZARDOUS WASTE ON PART C.) ILOCATION OF HAZARDOUS MATERIALS: ........ COMPLETE ALL iTEMS IN BOX. ~,h~A'~mc~° LUCKY S~O~ ~ ADDRESS ,, 2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANOLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANTI- INCLUDE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS, CHEMICALS MANUFACTURED OR REPACKAGED, AND CHEMICALS DISTRIBUTED. USE THE CODES TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4. 3. RETURN COMPLETED INVENTORY AND APPLICATION iN ENCLOSED SELF-ADDRESSED ENVELOPE. F~LL.IN A & B FOR EACH HAZARDOUS MATERIAL OR HA~ROOU$ [S~MATE MAXIMUM ~STIMATE TOTAL LIST ALL -- ~v~ MATERIAL MIXTURE. USE EXACT SPELLING. 0UAN~TY HANOLE0 0R STORE0 0UANTITY HANOLE0 0R 0F CONTAINERS MATE: A. PRODUCT NAME 0R COMMON NAME 0F HAZARDOUS MATERIAL. A~ ANY ~ME IN 1987 AT STORED DURING 1987 USED T0 STORE SAFE: ABOVE L0CA~ON. INCLUDE AT ABOVE LOCATION. HAZARDOUS MATERIAL - SHEET B: CHEMICAL NAME AN~ PERCENT(%) CONCENTRATION 0F UNITS. (i.e. LBS, GALLONS, : EVEN IF ONLY BRIEFLY. USE TABLE i. THE AL~ INGREDIENTS IN HAZARDOUS MATERIAL. e~c.) INCLUDE UNITS. MATE: ~' ~OUS~O~ O~U~S / E-~O~-~S ~. ~0 ~ ~ ~0 ~S. ~20 ~S. C~O~ A. NAIR SPAYS ~ROSOL a. SD ~COHOL BUT~E/PROP~E ~ ~ROSOL VI~ ACETAT~/CROTONIC ACID % 100 LBS 4,000 LBS. C~S NO BENZ~ ~COHOL HQUS~OLD (RETAIL) A. KITTEN - MET~ CL~ER$ a, SODI~ SILICO~UORIDE S~F~IC ACID % 50 PTS 2,000 PTS PLASTIC ~ C~S NO ~IT~T.~ (RETATT,~ A. OVEN CT,FANER~ 8. gODTT~ M~ROXTDE % ~T~ ~ 100 LBS. 4,000 LBS ~ROSOL ~ C~S NO W~TTg~OT,D (RETA~L~ A. KTTC~FN/RA~ CLEANER (LI~-A-WAY~ S. PHOSPHORUS ~, 8 ~ 24 PTS. 1,000 PTS. PLASTIC NO B. ~ROCEN C~ORID~ 8.50 AT.r~ .75 ~ 20 G~. 800 G~. PLASTIC NO TW~RT 90,75 % A. ATR ~E~ENER AEROSOL ~ c~s NO TABLE I STORAGE. CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold A = Metal Containers (<5 gallons) F = Bags L = Pressure Vessel - Not portable n 0rums, Barrels, Carboys G Boxes, Cartons, Cases M = Tank Car/Trailer INSP. ID C = Underground Tanks H -- Sump or Pit N -- Sealed Source (radioactive material) O = Aboveground Tanks I = Industrial Processing E~uipment 0 = Unseale~t Source (raflioactive material) [NsP IN~T __ E Glass Containers J Compressed Gas Cyhnaers P = Other container type, specify OATE PAGE 5 OFFICE uSE ONLY DATA ENTRY I0 ~ OATA ENTRY INIT __ DATE PARTB-lg87HAZAROOUSMA ALS INVENTORY PAGE 7 OF 8 IN~JTRUCTIONS: READ ALL THE INSTRUCTIONS BELOW ANO 'ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT. (REPORT HAZARL' ' WASTES ON REVERSE SIDE.) I. COMPLETE A SEPARATE FORM FOR EACH BUILDING, OUTDOOR AREA, OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE BOX BELOW TO SPEE THE LOCATION OF THE HAZAROOUS MATERIALS LISTED ON THIS FORM. (HAZARDOUS WASTE ON PART LOCAT ON OF HAZARDOUS MATERIALS: COMPLETE ALL iTEMS ,N aOX. ~,~ESS LUCKY STORE # ~ROOM NAME OUTOOOR AREA OR NUMBER BUILDIN~ NAME OR NUMBER __ NAME OR NUMBER 2. COMPLETE COLUMNS 1-5 FOR EACH HAZARDOUS MATERIAL STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE OUANTIT INCLUDE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS, CHEMICALS MANUFACTURED OR REPACKAGED, AND CHEMICALS' DISTRIBUTED. USE THE CODES TABLE 1 AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4. 3. RETURN COMPLETED INVENTORY AND APPLICATION tN ENCLOSED SELF-ADDRESSED ENVELOPE. FILL IN A & B FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS ESTIMATE MAXIMUM ESTIMATE TOTAL LIST ALL THE TYPES · MATERIAL MIXTURE. USE EXACT SPELLING. QUANTITY HANDLED OR STORED QUANTITY HANDLED OR OF CONTAINERS ~'AYE MATE; A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TiME IN 1987 AT STORED DURING 1987 USED TO STORE SAFET ABOVE LOCAT10N. INCLUDE AT ABOVE LOCATION, HAZARDOUS MATERIAL- SHEET B, CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i.e. LBS, GALLONS. EVEN IF ONLY BRIEFLY. USE TABLE I. THE HAZA;' ALi. INGREDIENTS IN HAZARDOUS MATERIAL. etc.) INCLUDE UNITS. MATEF A. DRAIN CLEANERS (SOLID) s. LYE 100 ~ 25 LBS. 1,000 LBS METAL ~ CANS NO HOUSEHOLD (RETAIL) , A. DRAIN CLEANERS.. {LIquID) S. SODIUM HYDROXIDE 1.7 SODIUM HYPOCHLORITE 6.0 %% 20 GAL. 800 GAL. PLASTIC NO INERT 92.3 HOUSEHOLD (RETAIL) A. HOUSEHOLD 5LEACH LIQUID/SOLID s. SODIUM HYPocHLoRITE 5.25 INERT 94.75 % 300 GAL. 1,200 GAL PLASTIC NO HOUSEHOLD (RETAIL) A. 'HYDROGEN PEROXIDE SOLUTION s. HYDROGEN PEROXIDE (10-VOLUME) 3.0 INERT 97.0 %%' 10 GAL. 400 GAL. PLASTIC NO HOg~EHOLD (RETAIL) , A, GEtLMIC IDE DISINFECTANT e. PINE OIL 52.7 SOAP 11.4 %% 10 QTS. 400 QTS. PLASTIC NO ISOPROPYL ALCOHOL 7.0 INERT 24.4 ~OUSEHOLD (RETAIL) A. RUBBING ALCOHOL s. ISOPROPYL ALCOHOL 70.0 INERT 30.0 % 50 PTS 2,000 PTS. PLASTIC NO ~0gSEHOLD A. AMMONIA B % ~ 30 GAL. 1,200 GAL. PLASTIC NO HOUSEHOLD TABLE'1 STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold OFFICE USE ONLY Metal Containers (<5 gallons) F -- Bags - L = Pressure Vessel - Not portable Orums. Barrels. Carboys G Boxes, Cartons, cases M = Tank Car/Trailer raSP. 10 DATA ENTRY lO , Underground Tanks H = Sump or Pit N = Sealed Source (radioactive material) Aboveground Tanks I = Industrial Processing Equipment O = Unsealed Source (radioactive materi~l) INSP INIT DATA ENTRY INIT P = Other container type, specify Glass Containers J Compressed Gas Cylinders PAGE 5 D~E 0aT~ PART B: 1987 ItAZARDOUS MAiii~IALS iNVENTORY PAGE 8 OF 8 INSTRUCTIONS: READ ALL THE INSTRUCTIONS BELOW AND ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT. IREPORT HAZAR~ WASTES ON REVERSE SIDE.) 1. COMPLETE A SEPARATE FORM FOR EACH 8UILOING. OUTDOOR AREA, OR ROOM WHERE HAZARDOUS MATERIALS ARE LOCATED. USE BOX BELOW TO S?E THE LOCATION OF THE HAZARDOUS MATERIALS LISTED ON THIS FORM. (HAZAROOUS WASTE ON PART C.) LOCATION OF HAZARDOUS MATERIALS; COMPLETE ALL ITEMS IN BOX. NAMEBUSINESS T,UCKY ROOM NAME OR NUMBER BUILDING NAME OR NUMBER STORE # __ AOORESS .... OUTDOOR AREA NAME OR NUMBER 2. COMPLETE COLUMNS 1-5 FOR EACH HAZAROOUS MATERIAL STORED OR HANOLED AT THE LOCATION SPECIFIED ABOVE. REGAROLESS OF THE QUANT' INCLUOE RAW MATERIALS, FINISHED CHEMICAL PRODUCTS, CHEMICALS MANUFACTURED OR REPACKAGED, ANO CHEMICALS DISTRIBUTED. USE THE COOE~ TABLE I AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMN 4. 3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-AOORESSEO ENVELOPE. FILL IN A & B FOR EACH HAZARDOUS MATERIAL OR HAZARDOUS ESTIMATE MAXIMUM' ESTIMATE TOTAL LIST ALL THE TYPES " MATERIAL MIXTURE. USE EXACT SPELLING. QUANTITY HANOLED OR STORE0 QUANTITY HANOLEO OR OF CONTAINERS MAT; A. PRODUCT NAME OR COMMON NAME OF HAZARDOUS MATERIAL. AT ANY TiME IN 1987 AT STORED DURING 19a7 USED TO STORE SAFE ABOVE LOCATION. INCLUDE AT ABOVE LOCATION, HAZARDOUS MATERIAL - B. CHEMICAL NAME AND PERCENT(%) CONCENTRATION OF UNITS. (i.e, LBS. GALLONS. EVEN IF ONLY BRIEFLY. USE TABLE 1. AL[. INGREDIENTS lN HAZARDOUS MATERIAL. etc,) INCLUDE UNITS. MA'r~ A. CHARCOAL/LTGHTER F'LUI9 a. ?F. TROLEUM DISTILLATES 100 % 15 GALS. 600 GALS. METAL % PLASTIC NC HOUSEHOtD (RETAIL) A. SPOT REMOVER - HOUSEHOLD S. 1,1,1-TRICHLOROETHANE 100 % 12 PTS. 50 PTS. METAL. ~ CAN NC OLEANINC FLUID HOUSEHOLD (RETAIL) A. 8. % A. 8. % A. 8. % % A. 8. % A. 8. TABLE 1 STORAGE CONTAINER TYPES. (LIST ALL THAT APPLY) K = Compressed Gas Manifold OFFICE USE ONLY A = Metal Containers (~5 gallons) F = Bags L = Pressure Vessel - Not portable B = Drums, Barrels, Carboys G 8oxes, Cartons, Cases M -- Tank Car/Trailer INSP. ID 0ATA ENTRY In ~. C = Underground Tanks H = Sump or Pit N = Sealed Source (radioactive material) 0 Abovegrounrl Tanks I = In~lustmal Processing E(:luil~ment 0 = Unsealed Source (radioactive material) rasp INIT.~ 0ATA ENTRY INIT P = Other container typo, specify E Glass Containers J Compressed Gas Cylinders PAGE 5 0AT~ 0Ar~__ NSTRUCTIONS: READ ALL THE INSTRUCTIONS BELOW AND ON PAGE 4. PHOTOCOPY EXTRA COPIES OF THIS FORM BEFORE COMPLETING IT. (REPORT HAZARDOUS MATERIALS ON REVERSE SIDE.) 1. COMPLETE A SEP__~ARATE FORM FOR EVERY BUILDING, OUTOOOR AREA, OR ROOM WHERE HAZARDOUS WASTES ARE LOCATED. USE THE BOX BELOW TO SPECIFY THE LOCATION OF THE HAZARDOUS WASTES LISTED ON THIS FORM. - OCATION OF HAZARDOUS WASTE: OOM NAME BUSINESS NAME __ ADDRESS BUILDING NAME OUTDOOR AREA NUMBER OR NUMBER NAME OR NUMBER ' 2. COMPLETE COLUMNS,l-7 FOR EACH HAZARDOUS WASTE GENERATED, STORED OR HANDLED AT THE LOCATION SPECIFIED ABOVE, REGARDLESS OF THE QUANTITY. USE THE CODES IN TABLE 1 & 2AT THE BOTTOM OF THIS FORM TO COMPLETE COLUMNS 5 AND 6. PLACE THE INITIALS N.A. IN ANY COLUMN THAT DOES NOT APPLY TO THE BUSINESS. 3. RETURN COMPLETED INVENTORY AND APPLICATION IN ENCLOSED SELF-ADDRESSED ENVELOPE. I FILL IN A AND B FOR EACH HAZARDOUS WASTE OR HAZ-. ESTIMATE AVERAGE · ' ESTIMATE MAXIMUM. ESTIMATE TOTAL LIST ALL THE ' ARDOUS WASTE MIXTURE. USE EXACT sPELLING. MONTHLY ~ ; QUANTITY HANDLED . '... QUANTITY HANDLED TYPE~-~'F ' - wAST"~EATMENT · B. ~ IFWASTE DISPOSED OF ON SITE. A. GIVE COMMON NAME OR DEPARTMENT OF TRANS-: ~, '' ~ ' ', ~ · . CONTAINERS ' ' ANDIORDISPOSAL PORTATION SHIPPING NAME (DOT) OF WASTE. ~E · · TiMEiN 1987 AT' ......, 198__.ZAT ABOVE B. GIVE CHEMICAL NAME AND pERCENT % CONCEN- L-"~ATION. INCLUDE ' A-'~'~TION, . '. LOCATiON, EVEN IF WASTE. USE ' METHODS. USE kD. NUMBER. ASK HAULER ' TRATiON OF AL.__~ INGRED-"-~ENTS IN HAZARDOUS UNITS, (I.a. LBS, INCLUDE UNITS. ~' . ONLY BRIEFLY. TABLE '~ TE. GALLONS) INCLUDE UNITS. A. B...._.~_ C. I : . TABLE 1: STORAGE CONTAINER TYPES. List all that apply. TABLE 2 - TREATMENT & DISPOSAL TYPES Disposal Types OFFICE USE ONLY List all that apply. A = Metal Containers (~5 gallons) I -- Industrial Processing Equipment Treatment Types 2210== GroundSewer' withoUtaround clarifierbusinessOr treatment B = Drums, Barrels, Carboys J -- Compressed Gas Cylinders 01 = Sewer, with clarlfler or treatment 22 = Trash.or garbage . INSP. ID DATA ENTRY ID __ C ~= ~nderground Tanks K = Compressed Gas Manifold 02 = Recycle 23 = .A.h, Teleased duTing processing D ,.~ Aboveground Tanks L = Pressure Vessel - Not portable 03 = Incineration 24 = ~aterw. ay~ except ocean E = Glass Containers M = Tank Car/Trailer 04 = Neutralization 25 = ~torm Dram INsP, INIT DATA ENTRY INIT CF.~- Ba. gs N = Sealed Source (radioactive material) 05 = Filtration 26 = !njeclio. n well 2~ I~azaroous waste landfill ~ Bo'xes, Cartons, Cases O = Unsealed Source (radioactive material) 06 = Stabilization Pond 28 = L..and ap, plicati.on DATE DATE I~ = Stl'mp or Pit P = Other container type, specify 07 = Treatment Pond 29 ucean msposal 30 .Surface I_mpoundment 3! ~ransfer station