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Home My WebLink AboutUNDERGROUND TANK FILE #1SITE/FACILITY FORM NORTH SCALE: BUSINESS NAME: DATE: ~// /~7 FACILITY N~ME: FLOOR: OF UNIT ~: OF (CHECK ONE) SITE DIAGRAM FAC IL ITY D IAGR.a~M 4 f(Inspector's Comments): -OFFICIAL USE ONLY- SiTE O[AGRAM (R._ ed ltess) 1. Address: ldentlf¥ the principle buildings by the Street numbers. 2. Street(a). AlXeya. Driveways, and Parking Areas adjacent to the property. Include the street names. 3. Slurs Oratns, Culverts, Yard Drains 4. Drainage Canals, Ditches. Creeks, S. Buildings a. Frame construction b. Masonry construction c. Metal construction d. Access Door 6. Utility Controls a. Gas b. Electricity c. Water 7. Fire Suppression Systems: a. Fire Hydra~ts 9. Lock (key) Box 10. MSDS Storage Box Il. Railroad Tracks 12. Fence or Barrier a. Wire b. Masonry c. Wood d. Gates 13. Pomerllnes 14. Guard Station 15. Storage Tanks: Identify the capacity in gal, a. Above ground 36. 17. 18. b. Fire Sprinkler 19. Connections c. Fire Standpipe 20. Connections d. Water Control Valves for protection systeml R1. e. Fire Pump 22. 8. Fire Department Access b. Underground Diking or Berm Evacuation Route Evacuation Area: Identify the location where employees mill Outside Hazardous Waste Storage Outside Hazardous Material Storage Outside Hazardous Material Use/Handling Type of Hazardous Material/Waste Stored or Used (See Below) TyPE OF HAZ~DOUS MATERIAL F m Flammable K - Ii, plosive L - Liquid C - Corrosive 0 - Oxidizer G - Gas W = Water Reactive T - Toxic S - Solid D · Waste B - Etiological Example: Flammable Liquid - FL FACILITY D[AGRA~ (Required Items In addition to the abo~e) 1. Risers for Sprinklers 8. 2. Partitions 3. Stalrway8: Indicate ~he 10. levels served ~rom highest to lo~lt. 4. Escalator: Indicate the levels ~erved from la. highest to lo.est. 5. Elevator 13. 6. Attic Access 14. ~. Skylights R · Radlologlcal P - Poison Cryogenic Fire Escapes Air Conditioning Units #ladDie Inside Hazardous Waste Storage Inside Hazardous Materials Storage Inside Hazardous Materials Use/Handling Se~er Drain Inlets ~Bakersfield Fire Dept. HAZARDOUS MATERIALS DIVISION Business Name: Location: Business Identification No. 215-000 Station No. ~ Shift Date Completed F-.',/~__. A u/) T) F') /~- Inspector Verification of Inventory Materials Verification of Quantities Verification of Location Proper Segregation of Material (Top of Business Plan) Adequate Inadequate Comments: Verification of MSDS Availablity Number of Employees Verification of Haz Mat Training mmen's~* erification of Abatement Supplies & Procedures ts: Emergency Procedures Posted L Containers Properly Labeled 8~H~ Hazc°mments: Verification of Facility Diagram ards Associated with this Facility: / B%%ine~s Ow'her/Manager FD 1652 {Rev. 1-90) All Items O.K. I~ Correction Needed I~ White-Haz Mat Div. Yellow-Station Copy Pink-Business Copy CIT?' oj' BAKERS_FIELD (t,v~e or Drin~ name) ,i~H 8 4. '~989 Do herebT certify that I have reviewed the attached Hazardous }Iaterials business plan RECE!VCr3 ~or name of susiness) ~ili¢ U ............ and that it along with the attached additions or corrections constitute a complete and correct Business Plan for my facility. sl~nanure date BUSINESS NAME MEARS EXCAVATION LOCATION 2617 EL CABALLO ID NUMBER 215-000-000543 HIGH HAZARD RATING 2 1 . OVERV I EW LAST CHANGE 09/15/88 BY ESTER JURIS CODE 215-005 JURIS BAKERSFIELD STATION 05 MAP PAGE 123 GRID 13A FACILITY UNITS 1 HAZARD RATING 2 RESPONSE SUMMARY 2A SEC 4) NO PRIVATE RESPONSE TEAM. EMERGENCY CONTACTS 2A SEC 2) BILL MEARS - 831-0377 MAE MEARS' -~ 831-0377 UTILITY SHUTOFFS 2A SEC 3) A) GAS - NE CORNER OF HOUSE B) ELECTRICAL - SW CORNER OF GARAGE C) WATER - CENTER OF DRIVEWAY NEXT TO STREET D) SPECIAL - NO E) LOCK BOX - NO Ans'd NOTIFICATION / PUBLIC EVACUATION LAST CHANGE / / BY < NO INFORMATION RECORDED FOR THIS SECTION PAGE 1 12/27/88 11:10 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME MEARS EXCAVATION LOCATION 2617 EL CABALLO 3 . HAZ MAT TRAINING ID NUMBER 215-000-000543 HIGH HAZARD RATING 2 SUMMARY LAST CHANGE / / BY < NO INFORMATION RECORDED FOR THIS SECTION > EMERGENCY MEDICAL ASSISTANCE LAST CHANGE 09/15/88 BY ESTER 2A SEC 5) NEAREST HOSPITAL PAGE 2 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 12/27/88 11:t0 BUSINESS NAME MEARS EXCAVATION LOCATION 2617 EL CABALLO FACILITY UNIT 01 ID NUMBER 215-000-000543 HIGH HAZARD RATING 2 A e OVERALL HAZARDOUS MATERIALS INVENTORY LAST CHANGE 09/15/88 BY ESTER ID TYPE NAME LOCATION CONTAINMENT MAX AMT UNIT HAZARD USE PURE REGULAR GASOLINE BESIDE DRIVEWAY GARAGE ID PERCENT COMPONENTS 1182.00 100.0 GASOLINE UNDERGROUND TANKS 1000 GAL HIGH FUEL HAZARD LISTS HIGH PURE DIESEL BACK OF LOT ABOVE GROUND TANKS ID PERCENT COMPONENTS 1178.03 100.0 DIESEL FUEL NO.1 FUEL 500 GAL MODERATE HAZARD. LISTS MODERATE FIRE PROTECTION / WATER LAST CHANGE SUPPLIES / / BY < NO INFORMATION RECORDED FOR THIS SECTION PAGE 3 12/27/88 11:10 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME MEARS EXCAVATION LOCATION 2617 EL CABALLO ID NUMBER 215-000-000543 HIGH HAZARD RATING 2 n e EMPLOYEE NOT I F I CAT I ON / EVACUAT I ON LAST CHANGE 09/15/88 BY ESTER 3A SEC 2) CALL 911 (EMERGENCY) E e MITIGATION / PREVENTION / ABATEMENT LAST CHANGE 09/15/88 BY ESTER 3A SEC 1) OUR PUMP HOSES HAVE SAFETY NOZZLES AND THEY ARE AUTOMATIC SHUT-OFF NOZZLES. LEAVE IMMEDIATELY. PAGE 4 12/27/88 11:10 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 CITY of BAKERSFIELD HAZARDOUS MATERI ALS I --NVENT'O RY' NON--TRADE SECRETS Page .... of BUSINESS NAME: ~_~ ~_~e~t.d~?~,.a~/ OWNER 'NAME: /~,',1/ /~ .,/'~__4~/q2-~ NAME OF TI~ FACILITY: LOCATION: ~(~S~'~:ff/~'~6~-'~I-~g ..... ' ADDRESS: ~Uil E~ 6~b~n STANDARD IND. CLASS CODE CITY, ZIP: ~ff~-/~ ~- ~O~ CITY, ZIP: -~Wr~c~,;~ ~ ~%o~ DUN AND BRADSTREET NUMBER of P~b ~lth ..................... t t ,,t ~ J ~ ~t-- j J - HNIth of PP~lU~l ~lth .......... ~NE~GENCY C~TACTS I1 CertJficetian.(Read and sign after compJetJng a]] sections/ I cerV~f,y u~der penalty of 1~ t~t I ~ve ~rsmellyex~in~ ~ ~ feeillar vJth t~ tnf~tim suhJttd tn this ~ ell ett~ ~ts, ~ t~t ~s~ m W J~t~ of t~e tMtvJ~is ~sible for obtJinino t~ inf~tim. [ ~ieve t~t t~ lu~itt~ infOmCim is t~, iccurate, ~d tinplate. BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 (805) 326-3979 RECEIVEB //,.~ ........ usINESS NAME OFFICIAL USE ONLY ID# HAZARDOUS 1WJkTERIALS 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: ~. ~OCATZO~ / .ST~T ADDreSS: c~: ~~,~ b~ z~P: BUS.PHONE: (t~t)-{"~ [;:>~.?JO2~ 77 SECTION 2: EMERGENCY NOTIFICATIONS Ih case of an emergency involving the release or threatened release of a hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4541. This will notify your local fire department and the State Office of Emergency Services as required by law. EMPLOYEES T0 NOTIFY IN CASE 0F EMERGENCY: NAME AND,TITLE DURING BUS. HRS. A. ~,'~'~-~.~,~-' Ph# ~31 ~>377 AFTER BUS. HRS. Ph# q~'~ SECTION 3: LOCATION 0F UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE ~. ELECTRICAL: C. WATER: D. SPECIAL: E. LOCK BOX: YES / ~) IF YES, LOCATION: IF YES, DOES IT C0NTAIN SITE PLANS? FL00R PLANS? YES / NO YES / NO MSDSS? YES / NO KEYS? YES / NO 2A - SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE 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:...' ....... · ............................. YES NO YES NO B. PROCEDURES FOR COORDINATING ACTIVITIES WITH RESPONSE AGENCIES: .......................... YES NO YES NO C~ PROPER USE OF SAFETY EQUIPMENT:... ................ YES NO YES NO D. EMERGENCY EVACUATION PROCEDURES: ................. YES NO ~YES NO E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES NO YES NO REFRESHER SECTION 7: HAZARDOUS MATERIAL CIRCLE YES OR NO DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS OF A SOLID, 58 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YES NO I, ~11/ ~_C{~J , certify that the above information is accurate. I understand that this information will be used to fulfill my firm's obligations under the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter 6.95 Sec. 28800 Et Al.) and that inaccurate information constitutes perjury. - 2B - BAKERSFIELD CITY FIRE DEPARTMENT 2~30 "G" STREET BAKERSFIELD, CA 93301 OFFICIAL USE ONLY 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 below for THE FAC!-LITY UNIT LISTED BELOW 4. Be as BRIEF and CONCISE as .possible. FACILITY UNIT# FACILITY UNIT N~MI~: SECTION II'MITIGATION, PREVENTION, ABATEMEN~f PROCEDURES SECTION 2: NOTIFICATION ~\~ EVACUATION PROCEDURES AT THIS UNIT ONLY SECTION 3: HAZARDOUS ~TERIALS FOR THIS UNIT ONLY A. Does this Facility Unit contain Hazardous Materials? ..... ~0 If YES, see B. If NO, continue with SECTION 4. B. Are any of the hazardous materials a bona fide If~No, complete a separate hazardous mate] for~ marked: NON-TRADE SECRETS ONLY (white If Y~s, complete a hazardous materials i TRADE\ SECRETS ONLY (yellow form #4A-2) secre~\~form. List only the trade sec \ SECTION 4: PRIVATE FIRE PROTECTION . \ \ \ \ Secret YES NO inveqtory form marked: addition to the non-trade on form 4A-2. SECTION 5: LOCATION WATER FOR USE BY EMERGENCY RESPONDER. S SECTION 6: LOCATION OF A. NAT. GAS./'PROPAN~} ,ITY SHUT-OFFS AT THIS UNIT ONLY. B. ELECTRICAL: C. WATER: D, E. LOCK BOX: YES / NO IF YES, IF YES, SITE PLANS? FLOOR PLANS? LOCATI YES / NO MSDSs~X, YES / NO KEYS? YES / NO YES / NO - 3B - I.D. # BAKERSFIELD CITY FIRE DEPARTi~IENT FORM 4A-1 NON--TRADE SECRETS HAZARDOUS MATERI ALS INVENTORY BUSINESS NAME: ADDRESS: ~/? Page OWNER NAME: j~/'// ,~fi~'-'q FACILITY ADDRESS: ,.~-/7~-_~,0,-~,~-LZ~ FACILITY UNIT NAME: PHONE #: ~-~g/~77 UNIT [OFFICIAL USE CFIRS CODE I ONLY 1 2 3 4 5 6 7 8 9 10 TYPE MAX ANNUAL CONT USE LOCATION IN THIS ~ BY HAZARD D.O.T CODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT WT. CHEMIC'AL OR COM[4ON NAME CODE GUIDE. NAME: TITLE: SIONATURE: DATE: EMERGENCY CONTACT: -TITLE: PHONE # BUS HOURS: AFTER BUS HRS: EMERGENCY CONTACT: TITLE: .. PHONE # BUS HOURS: PRINCIPAL BUSINESS ACTIVITY: AFTER BUS HRS: - 4A-1 -