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Home My WebLink AboutBUSINESS PLAN 8/2003L L,t. 0'1' II II : 0 ~W STINE OFFICE BUILDING $i~ & SITE PLAIV II North Milaz~o & Associa~ Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE PERMIT ID # 015-021-000311 LOCATION 201 RD This ~ermit is issued for the followin_~: [] Hazardous Materials Plan [] Underground Storage of HazardOus Materials [] Risk Management Program [] Hazardous Waste On-Site Treatment ~3309 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: OfficeofEvi~nme~lfl Services - 'June 30; 2003 Issue Date ITE DIAGRAM Business Name: ~.~~ Business Address: '1 o LI.J , · ~ q~ UNIFIED PROGRAI SPECTION CHECKLIST SECTION 1 Business Plan and Inventory Program Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 ~iness ID Number / 15-021- ~O,~,..,v// ,~: :-:-' i~;::~.". ': i - .-':'"'· · ~ ', secti°n i; BUSiness Plan, and Inventory'Program ' R [] Combined i-I Joint Agency [] Multi-Agency C1 Complaint [] Re-inspection C V ~ C=Compliance '~ OPERATION x. V=Violation ! y[] APPROPRIATE PERMIT ON HAND ~'~ ~'1 BUSINESS PLAN CONTACT INFORMATION ACCURATE .~' [] VISIBLE ADDRESS ~ [] CORRECT OCCUPANCY ~ [] VERIFICATION OF INVENTORY MATERIALS ,~ [] VERIFICATION OF QUANTITIES ,J~ [] VERIFICATION OF LOCATION ,J~ {'=} PROPER SEGREGATION OF MATERIAL ~{~ [] VERIFICATION OF MSDS AVAILABILITYE J~ [] VERIFICATION OF HAT MAT TRAINING ~ [] VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~ [] EMERGENCY PROCEDURES ADEQUATE ~ [] CONTAINERS PROPERLY LABELED ~ [] HOUSEKEEPING ~ [] FIRE PROTECTION ~l"[] SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE?: COMMENTS [] YES j~l- NO EXPLAIN: QUESTIONS REGARDING THIS INS~ON? PLEASE CALL US AT (661) 326'3979~_ ~ Inspe~or --- ~ ~-(~; Party ~'*y~ ~ Yellow- S~ation Copy Pink- Business Copy White- Environmental Services HEALTHSOUTH/SOUTHWEST SURGICAL CT Manager : Location: 201 NEW STINE RD 130 City : BAKERSFIELD CommCode: BAKERSFIELD STATION 11 EPA Numb: Emergency Contact~ / ~ Title ......... o,.==~, RN ADMINISTRATOR Business Phone: (661) 396-8900x 24-Hour Phone : (661) Pager Phone : ( ) SiteID: 015-021-000311 BusPhone: (661) 396-8900 Map : 123 CommHaz : Moderate Grid: 03B FacUnits: 1 AOV: SIC Code: ,DunnBrad: Emergency Contact! / Title ~ELLY ~ARD~R, RN / SAFETY OFFICER Business Phone: (661) 396-8900x 24-Hour Phone : (661)~x Pager Phone : ( )~~x Hazmat Hazards: Fire Press React ImmHlth DelHlth Contact : MailAddr: 201 NEW STINE RD 130 City : BAKERSFIELD Phone: (661) 396-8900x State: CA Zip : 93309 Owner HEALTHSOUTH CORPORATION Address : ONE HEALTHSOUTH PARKWAY City : BIRMINGHAM Phone: (800) 765-4772x State: AL Zip : 35243 Period : to TotalASTs: = Preparer: TotalUSTs: = Certif'd: RSs: No Gal Gal Emergency Directives: ~b~foo LINDA BLOOMQUIST, RN i~ ADMINISTRATOR ~22:7:~ OR 589-6256. ~ Hazmat Inventory --Alphabetical Order NITROGEN ....... NITROUS OXIDE OXYGEN PROPANE E WAS,TE FIXER ~iewed th~ ~ached h~ardous materi~s F P - IH G F P IH G F IH DH G F P IH G R L One Unified List Ail Materials at Site IDailyMax Unit MCP ~100.00 FT3 Min 564.00 FT3 Hi 2000.00 FT3 Low 1500.00 FT3 Hi 5.00 GAL Min p/an for my 01/30/2003 HEALTHSOUTH/SOUTHWEST SURGICAL CT ~ Inventory Item 0001 -- COMMON NAME / CHEMICAL NAME NITROGEN Location within this Facility Unit INSIDE GAS STORAGE RM NW CORNER OF BLDG SiteID: 015-021-000311 Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# 7727-37-9 F STATE ~ TYPE Gas /Pure PRESSURE TEMPERATURE I Above Ambient ~ Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 228.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 1100.00 FT3 Daily Average 550.00 FT3 I%Wt. I 100.00 Nitrogen HAZARDOUS COMPONENTS INoRS CAS# 7727379 ITSecretI RSIBioHaz No No No HAZARD ASSESSMENTS Radioactive/Amount I EPA Hazards No/ CuriesI F P IH NFPA/// I USDOT# MCP Min ~ Inventory Item 0004 -- COMMON NAME / CHEMICAL NAME NITROUS OXIDE Location within this Facility Unit INSIDE GAS STORAGE RM NW CORNER OF BLDG Facility Unit: Fixed Containers on Site Map: Grid: Days,On Site 365 CAS# 10024-97-2 rSTATE ~ TYPE Gas Pure PRESSURE, TEMPERATURE Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 282.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 564.00 FT3 Daily Average 282.00 FT3 %Wt. I 100.00 Nitrous Oxide HAZARDOUS COMPONENTS N 10024972 HAZARD ASSESSMENTS Radioactive/Amount I EPA Hazards No/ CuriesI F P IH NFPA /// USDOT# IMCP Hi -2- 01/30/2003 HEALTHSOUTH/SOUTHWEST SURGICAL CT ~.Inventory Item 0002 ~ COMMON NAME / CHEMICAL NAME OXYGEN Location within this Facility Unit INSIDE GAS STORAGE RM NW CORNER OF BLDG siteID: 015-021-000311 Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# 7782-44-7 F STATE -- TYPE Gas /Pure PRESSURE , TEMPERATURE Ambient I Ambient Above CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 337.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 2000.00 FT3 Daily Average 1000.00 FT3 %Wt. 100.00 HAZARDOUS COMPONENTS Oxygen, Compressed N 7782447 HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies F IH DH NFPA /// USDOT# MCP Low Inventory Item 0005 -- COMMON NAME / CHEMICAL NAME PROPANE Location within this Facility Unit OUTSIDE NW CORNER OF BLDG BARNYARD Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# 74-98-6 FSTATE TYPE Gas ~Pure PRESSURE TEMPERATURE [ Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 1500.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum I 1500.00 FT3 Daily Average 750.00 FT3 I%Wt. I 100.00 Propane HAZARDOUS COMPONENTS Yes CAS# 74986 HAZARD ASSESSMENTS Radioactive/Amount I EPA Hazards No/ CuriesI F P IH NFPA /// I USDOT# MCP Hi 3 01/30/2003 HEALTHSOUTH/SOUTHWEST SURGICAL CT ~ Inventory Item 0003 -- COMMON NAME / CHEMICAL NAME WASTE FIXER Location within this Facility Unit INSIDE XRAY DEVELOPING MACHINE IN OR SiteID: 015-021-000311 Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# STATE TYPE PRESSURE Ambient Waste Liquid TEMPER3kTURE Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container 5.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 5.00 GAL Daily Average I 5.00 GAL %Wt. ISilver HAZARDOUS COMPONENTS 7440224 HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies R NFPA/// I USDOT# Min -4- 01/30/2003 F HEALTHSOUTH/SOUTHWEST SURGICAL CT SiteID: 015-021-000311 Fast Format = Notif./Evacuation/Medical Overall Site --Agency Notification 12/06/2000 XRAY DEVELOPER, FIXATIVE IS SUPPLIED AND MONITORED BY SIGMA IMAGING INC. DAILY SAFETY ROUNDS ARE MADE OF MEDICAL GASES, PROPANE TANK AND OR XRAY PROCESSORE CHEMICALS. NO MONITORING EQUIPMENT IS LOCATED AT OUR FACILITY. -- Employee Notif./Evacuation 12/o6/2ooo 911, CHEMTREC 800-424-9300, POISON CONTROL, OFFICE OF ES 326-3979, MANUFACTURER OF PRODUCT, 'SUPPLIER OF PRODUCT, OES 800-852-7550 AND/OR · ~%~A ADMINISTRATOR HEALTHSOUTH LINDA BLOOMQUIST 2&~B--~/589-6256;-F~ Public Notif./Evacuation 12/06/2000 IN THE EVENT OF A DISASTER THE PERSON IN CHARGE OF THE FACILITY SHALL NOTIFY AS NEEDED: APPROPRIATE EXTERNAL AUTHORITY (FIRE, POLICE, ETC), ADMINISTRATOR, SAFETY OFFICER, NURSE MANAGER, RN ON DUTY, MEDICAL DIRECTOR. *ANY STAFF MEMBER BECOMING AWARE OF A DISASTER SHOULD NOTIFY THEIR IMMEDIATE SUPERVISOR. IN THE ABSENCE OF THE ADMINISTRATOR THE INDIVIDUALS LISTED ABOVE WILL ACT AS ADMINISTRATOR. Emergency Medical Plan 1 /o6/2ooo EQUIPMENT AVAILABLE:SPILL KIT, EMERGENCY EYE WASH STATION, EMERGENCY SHOWER, FIRST AID, EMERGENCY MEDICAL CART, MALIGNANT HYPERTHERMIA BOX AND VENTILATORS. IN THE EVENT OF A MEDICAL EMERGENCY, PT OR STAFF MEMBER WOULD BE STABILIZE'D, 911 WOULD BE ACTIVATED AND INJURED PERSON(S) WOULD BE TRANSPORTED VIA AMBULANCE AS NECESSARY. TRANSFER AGREEMENT IN PLACE WITH SAN JOAQUIN HOSPITAL: IF SAFE TO DO SO EVACUATE ANYONE IN IMMEDIATE AREA OF THE SPILL OR VAPOR RELEASE, ADMINISTER IMMEDIATE MEDICAL ATTENTION TO ANYONE EXPOSED, NOTIFY DEPT ADMINISTRATOR AS QUICKLEY AS POSSIBLE, OBTAIN MSDS FOR SPILLED MATERIAL TO DETERMINE IMMEDIATE HAZARD AND PRECAUTION, PREVENT SPREAD, CONFINE, DISPOSE AS PER MSDS OR CALL APPROPRIATE AGENCY FOR CLEANUP. -5- 01/30/2003 F HEALTHSOUTH/SOUTHWEST SURGICAL CT SiteID: 015-021-000311 Fast Format Mitigation/Prevent/Abatemt Release Prevention Overall Site 12/06/2000 ALL FLAMMABLE LIQUIDS ARE SEGREGATED AND SECURED IN LOCKED METAL CABINET. BIOHAZARDOUS WASTE IS STORED IN SEALED CONTAINERS THAT ARE STORED IN LOCKED SHED IN GATED AREA ADJACENT TO OUR BLDG. MEDICAL GASES ARE SECURED WITH CHAIN AND LOCKED IN STOREROOM ADJACENT TO BLDG. NUMBER OF TANKS ARE KEPT TO A MINIMUM. -- Release Containment 12/06/2000 XRAY DEVELOPER/FIXATIVE IS STORED IN CLOSED CONTAINERS WITH SPILL TRAY BENEATH. HAZARDOUS MATERIALS ARE KEPT TO A MINIMUM AS POSSIBLE. ZERO STORAGE OF MERCURY THERMOMETERS ETC. Clean Up 12/06/2000 SMALL SPI~LLS ARE CLEANED UP USING SPILL KIT, LARGER SPILLS WOULD BE CONTAINED/CONFINED AND IF NON-EMERGENY WOULD CONTACT OFFICE OF ENVIRONMENTAL SERVICES, IF EMERGENCY WE WOULD CALL 911 AND 800-852-7550 FOR CLEANUP. HAZARDOUS WASTE REMOVAL,~MEDICAL WASTE SYSTEMS ON WEEKLY BASIS AND AS NECESAARY XRAY DEVELO[PE~/FIXATIVE ExcHANGE PERFORMED BY SIGMA MEDICAL IMAGING I~C. ~io~ct~ Other Resource Activation -6- 01/30/2003 F HEALTHSOUTH/SOUTHWEST SURGICAL CT SiteID: 015-021-000311 Fast Format Site Emergency Factors Special Hazards Overall Site --Utility Shut-Offs 12/o6/2ooo A) GAS - IN FLOWER BED ADJACENT TO GATED AREA SW CORNER OF BLDG B) ELECTRICAL - IN ELECTRICAL RM INSIDE PACU RECOVERY ROOM C) WATER ABOVE CEILING PANEL AT FRONT LOBBY D) SPECIAL - MEDICAL GASES MAIN SHUT OFF VALVE IN CORRIDOR IN SURGERY AREA E) LOCK BOX - NO SPRINKLER MAIN LOCATED IN STE 300 OFFICE AT SE END OF COMPLEX. -- Fire Protec./Avail. Water 12/06/2000 PRIVATE FIRE PROTECTION - FIRE SPRINKLER SYSTEM SHARED WITH ENTIRE COMPLES. WATER TAMPER/ALARM MONITORED BY TELTEC ALARM CO. CURRENTLY RENEGOTIATING 24HR FIRE MONITORING SYSTEM. 3 FIRE EXTINGUISHERS, FIRE ALARM CONTROL PANEL, 4 MANUAL PULL STATIONS, 2 DUCT SMOKE DETECTORS, 8 AUDIO VISUAL SIGNAL DEVISES, 4 STROBE DEVICES, 1 VALVE TAMPER SWITCH/WATER FLOW DEVICE. FIRE HYDRANT - NEW STINE RD NEXT TO HEALTHSOUTH SIGN. Building Occupancy Level 7 01/30/2003 F HEALTHSOUTH/SOUTHWEST SURGICAL CT SiteID: 015-021-000311 Fast Format Training -- Employee Training WE HAVE ~EMPLOYEES AT THIS FACILITY. Overall Site 12/06/2000 WE HAVE MATERIALS SAFETY DATA SHEETS ON FILE KEPT IN PREOP, YELLOW BINDER. BRIEF SUMMARY OF TRAINING PROGRAM: ALL EMPLOYEES RECEIVE INITIAL TRAINING ON HIRE AND ANNUALLY THEREAFTER IN EDUCATION DAY. CURRENTLY.WORKING ON INSTITUTING SELF PACED MODULE FOR ANNUAL REVIEW. ALL EMPLOYEES ARE TRAINED AS NEEDED WHEN NEW ITEM IS USED IE. NEW MSDS. ANNUAL SAFETY EDUCATION DAY -- Page 2 -- Held for Future Use Held for Future Use 8 01/30/2003 HEALTHSOUTH/SOUTHWEST SURGICAL CT Manager : Location: 201 NEW STINE RD 130 City : BAKERSFIELD CommCode: BAKERSFIELD STATION 11 EPA Numb: SiteID: 015-021-000311 BusPhone: (661) 396-8900 Map : 123 CommHaz : Moderate Grid: 03B FacUnits: 1 AOV: SIC Code: DunnBrad: Emergency Contact / Title L%nda Bloomqui~t 'RN / ADMINISTRATOR Business Phone: (661) 396-8900x 24-Hour Phone : (661) ~3-0612 ~ Pager Phone : ( ) - x Emergency Contact / Title i~.elle.y H~h~herRN / SAFETY OFFICER Business Phone: (661) 396-8900x 24-Hour Phone : (661) 589266034.1 Pager Phone : ( ) - x Hazmat Hazards: Fire Press React. ImmHlth DelHlth Contact : MailAddr: 201 NEW STINE RD 130 City : BAKERSFIELD Phone: (661) 396-8900x State: CA Zip : 93309 Owner HEALTHSOUTH CORPORATION Address : ONE HEALTHSOUTH PARKWAY City : BIRMINGHAM Phone: (800) 765-4772x State: AL Zip : 35243 Period : to TotalASTs: = Preparer: TotalUSTs: = Certif'd: RSs: No Gal Gal Emergency Directives: LINDA BLOOMQUIST, RN ~-.. ~ ADMINISTRATOR 322-4744 OR 589-6256. = Hazmat Inventory ----Alphabetical Order Hazmat Common Name... NITROGEN NITROUS OXIDE OXYGEN PROPANE WASTE FIXER i, Lt~ ~i~ ~ ~ ~¥pe o,' p~n! ~mo) One Unified List Ail Materials at Site ISpecHazlEPA HazardsI Frm F P IH G F P IH G F IH DH G E F P IH G Do hereby certify ~at ! have L reviewed the attached hazardous materials ma~ag,~- rnent plan for $o,,.l.~,,.,.,l. .. "'3 '3 and that it along with (Nam~ of any corrections constitute a complete and correct man- agement plan for my facility. 1100.00 FT3 Min 564.00 FT3 Hi 2000.00 FT3 Low 1500.00 FT3 Hi 5.00 GAL Min 10/29/2001 HEALTHSOUTH/SOUTHWEST SURGICAL CT ~ Inventory Item 0001 -- COMMON NAME / CHEMICAL NAME NITROGEN Location within this Facility Unit INSIDE GAS STORAGE RM NW CORNER OF BLDG SiteID: 015-021-000311 Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# 7727-37-9 STATE TYPE Gas Pure PRESSURE , TEMPERATURE Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 228.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 1100.00 FT3 Daily Average 550.00 FT3 %Wt. I 100.00 Nitrogen HAZARDOUS COMPONENTS IRSI CAS# No 7727379 ITSecret No S BioHaz Radioactive/Amount EPA Hazards N No , No/ Curies F P IH NFPA/// I USDOT# Min ~ Inventory Item 0004 -- COMMON NAME / CHEMICAL NAME NITROUS OXIDE Location within this Facility Unit INSIDE GAS STORAGE RM NW CORNER OF BLDG Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# 10024-97-2 [= STATE TYPE Gas Pure PRESSURE , TEMPERATURE Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 282.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 564.00 FT3 Daily Average 282.00 FT3 %Wt. 100.00 Nitrous Oxide HAZARDOUS COMPONENTS TSecret No RSlBioHazl HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards INo No No/ Curies F P IH NFPA /// USDOT# IHiMCP -2- 10/29/2001 HEALTHSOUTH/SOUTHWEST SURGICAL CT ~ Inventory Item 0002 -- COMMON NAME / CHEMICAL NAME OXYGEN Location within this Facility Unit INSIDE GAS STORAGE RM NW CORNER OF BLDG SiteID: 015-021-000311 Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# 7782-44-7 FSTATE -- TYPE Gas Pure PRESSURE , TEMPERATURE Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 337.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 2000.00 FT3 Daily Average 1000.00 FT3 %Wt. 100.00 HAZARDOUS COMPONENTS Oxygen, Compressed IRSI CAS# No 7782447 HAZARD ASSESSMENTS I Radi°active/Am°unt EPA Hazards INo/ Curies F IH DH NFPA /// USDOT# I MCP Low ~ Inventory Item 0005 -- COMMON NAME / CHEMICAL NAME PROPANE Location within this Facility Unit OUTSIDE NW CORNER OF BLDG BARNYARD Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# 74-98-6 r STATE ~ TYPE Gas /Pure PRESSURE TEMPERATURE I Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 1500.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 1500.00 FT3 Daily Average I 750.00 FT3 I%Wt. I 100.00 Propane HAZARDOUS COMPONENTS Yes 74986 TSecret No RS BioHazl HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No NoI No/ Curies F P IH NFPA /// USDOT# MCP Hi -3'- 10/29/2001 HEALTHSOUTH/SOUTHWEST SURGICAL CT ~ Inventory Item 0003 -- COMMON NAME / CHEMICAL NAME WASTE FIXER Location within this Facility Unit INSIDE XRAY DEVELOPING MACHINE IN OR SiteID: 015-021-000311 Facility Unit: Fixed Containers on Site Map: Grid: Days On Site 365 CAS# STATE -- TYPE PRESSURE Liquid Waste Ambient TEMPERATURE Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container 5.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 5.00 GAL Daily Average 5.00 GAL %Wt. ISilver HAZARDOUS COMPONENTS IRSI CAS# No 7440224 TSecret No IRSlBioHazl HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards INo I No No/ Curies R NFPA /// USDOT# IMinMCP 4 10/29/2001 F HEALTHSOUTH/SOUTHWEST SURGICAL CT SiteID: 015-021-000311 Fast Format ~ Notif./Evacuation/Medical --Agency Notification Overall Site 12/06/2000 XRAY DEVELOPER, FIXATIVE IS SUPPLIED AND MONITORED BY SIGMA IMAGING INC. DAILY SAFETY ROUNDS ARE MADE OF MEDICAL GASES, PROPANE TANK AND OR XRAY PROCESSORE CHEMICALS. NO MONITORING EQUIPMENT IS LOCATED AT OUR FACILITY. -- Employee Notif./Evacuation 12/06/2000 911, CHEMTREC 800-424-9300, POISON CONTROL, OFFICE OF ES 326-3979, MANUFACTURER OF PRODUCT, SUPPLIER OF PRODUCT, OES 800-852-7550 AND/OR --~ ' ADMINISTRATOR HEALTHSOUTH LINDA BLOOMQUIST 322-4744/589-6256; ' - .-77 396-8900/,..' -- Public Notif./Evacuation 12/06/2000 IN THE EVENT OF A DISASTER THE PERSON IN CHARGE OF THE FACILITY SHALL NOTIFY AS NEEDED: APPROPRIATE EXTERNAL AUTHORITY (FIRE, POLICE, ETC), ADMINISTRATOR, SAFETY OFFICER, NURSE MANAGER, RN ON DUTY, MEDICAL DIRECTOR. *ANY STAFF MEMBER BECOMING AWARE OF A DISASTER SHOULD NOTIFY THEIR IMMEDIATE SUPERVISOR. IN THE ABSENCE OF THE ADMINISTRATOR THE INDIVIDUALS LISTED ABOVE WILL ACT AS ADMINISTRATOR. Emergency Medical Plan 12/06/2000 EQUIPMENT AVAILABLE: SPILL KIT, EMERGENCY EYE WASH STATION, EMERGENCY SHOWER, FIRST AID, EMERGENCY MEDICAL CART, MALIGNANT HYPERTHERMIA BOX AND VENTILATORS. IN THE EVENT OF A MEDICAL EMERGENCY, PT OR STAFF MEMBER WOULD BE STABILIZED, 911 WOULD BE ACTIVATED AND INJURED PERSON(S) WOULD BE TRANSPORTED VIA AMBULANCE AS NECESSARY. TRANSFER AGREEMENT IN PLACE WITH SAN JOAQUIN HOSPITAL: IF SAFE TO DO SO EVACUATE ANYONE IN IMMEDIATE AREA OF THE SPILL OR VAPOR RELEASE, ADMINISTER IMMEDIATE MEDICAL ATTENTION TO ANYONE EXPOSED, NOTIFY DEPT ADMINISTRATOR AS QUICKLEY AS POSSIBLE, OBTAIN MSDS FOR SPILLED MATERIAL TO DETERMINE IMMEDIATE HAZARD AND PRECAUTION, PREVENT SPREAD, CONFINE, DISPOSE AS PER MSDS OR CALL APPROPRIATE AGENCY FOR CLEANUP. -5- 10/29/2001 F HEALTHSOUTH/SOUTHWEST SURGICAL CT SiteID: 015-021-000311 Fast Format Mitigation/Prevent/Abatemt Release Prevention Overall Site 12/06/2000 ALL FLAMMABLE LIQUIDS ARE SEGREGATED AND SECURED IN LOCKED METAL CABINET. BIOHAZARDOUS WASTE IS STORED IN SEALED CONTAINERS THAT ARE STORED IN LOCKED SHED IN GATED AREA ADJACENT TO OUR. BLDG. MEDICAL GASES ARE SECURED WITH CHAIN AND LOCKED IN STOREROOM ADJACENT TO BLDG. NUMBER OF TANKS ARE KEPT TO A MINIMUM. -- Release Containment 12/06/2000 XRAY DEVELOPER/FIXATIVE IS STORED IN CLOSED CONTAINERS WITH SPILL TRAY BENEATH. HAZARDOUS MATERIALS ARE KEPT TO A MINIMUM AS POSSIBLE. ZERO STORAGE OF MERCURY THERMOMETERS ETC. Clean Up 12/06/2000 SMALL SPIULLS ARE CLEANED UP USING SPILL KIT, LARGER SPILLS WOULD BE CONTAINED/CONFINED AND IF NON-EMERGENY WOULD CONTACT OFFICE OF ENVIRONMENTAL SERVICES, IF EMERGENCY WE WOULD CALL 911 AND 800-852-7550 FOR CLEANUP. HAZARDOUS WASTE REMOVAL, BFI MEDICAL WASTE SYSTEMS ON WEEKLY BASIS AND AS NECESAARY. XRAY DEVELO[PER/FIXATIVE EXCHANGE PERFORMED BY SIGMA MEDICAL IMAGING INC. Other Resource Activation -6- 10/29/2001 F HEALTHSOUTH/SOUTHWEST SURGICAL CT SiteID: 015-021-000311 Fast Format Site Emergency Factors Special Hazards Overall Site --Utility Shut-Offs 12/06/2000 A) GAS - IN FLOWER BED ADJACENT TO GATED AREA SW CORNER OF BLDG B) ELECTRICAL - IN ELECTRICAL RM INSIDE PACU RECOVERY ROOM C) WATER - ABOVE CEILING PANEL AT FRONT LOBBY D) SPECIAL - MEDICAL GASES MAIN SHUT OFF VALVE IN CORRIDOR IN SURGERY AREA E) LOCK BOX - NO SPRINKLER MAIN LOCATED IN STE 300 OFFICE AT SE END OF COMPLEX. Fire Protec./Avail. Water 12/06/2000 PRIVATE FIRE PROTECTION - FIRE SPRINKLER SYSTEM SHARED WITH ENTIRE COMPLES. WATER TAMPER/ALARM MONITORED BY TELTEC ALARM CO. CURRENTLY RENEGOTIATING 24HR FIRE MONITORING SYSTEM. 3 FIRE EXTINGUISHERS, FIRE ALARM CONTROL PANEL, 4 MANUAL PULL STATIONS, 2 DUCT SMOKE DETECTORS, 8 AUDIO VISUAL SIGNAL DEVISES, 4 STROBE DEVICES, 1 VALVE TAMPER SWITCH/WATER FLOW DEVICE. FIRE HYDRANT - NEW STINE RD NEXT TO HEALTHSOUTH SIGN. Building Occupancy Level 7 0/2 /2001 F HEALTHSOUTH/SOUTHWEST SURGICAL CT SiteID: 015-021-000311 Fast Format Training Overall Site -- Employee Training 12/06/2000 WE HAVE 15 EMPLOYEES AT THIS FACILITY. WE HAVE MATERIALS SAFETY DATA SHEETS ON FILE KEPT IN PREOP, YELLOW BINDER. BRIEF SUMMARY OF THAINING PROGRAM: ALL EMPLOYEES RECEIVE INITIAL TRAINING ON HIRE AND ANNUALLY THEREAFTER IN EDUCATION DAY. CURRENTLY WORKING ON INSTITUTING SELF PACED MODULE FOR ANNUAL REVIEW. ALL EMPLOYEES ARE TRAINED AS NEEDED WHEN NEW ITEM IS USED IE. NEW MSDS. ANNUAL SAFETY EDUCATION DAY -- Page 2 Held for Future Use Held for Future Use 8 10/29/2001 HEALTHSO TH, Southwest Surgical Center 201 New Stine Road Bakersfield, California 93309 November 8, 2001 Dear Ms. Duran: Here is the information you requested on Southwest Surgical Center. I have made the necessary changes on the management plan. Please call me regarding any questions you may have regarding this information. Sincerely, Linda Bloomq~ Administrator _hsmemo.dot 11/8/01 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ~~ ~--~ ~/~ ~SPECTIONDATE , ADD,SS ~J ~~ ~~ ~/~ PHONE NO. FACILITY CONTACT ~CZ t~ z ,c~~ BUSINESS ID NO. 15-210- ~/~-- ~SPECTION TIME /~~, ~' NUMBER OF EMPLOYEES ~ ~J~ Section 1: Business Plnn nnd Invento~ Progrnm ~in~ ~ Combined ~ Joint Agency ~ Multi-Agency ~ Complaint ~ Re-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials Verification of quantities Verification of location Proper segregation of material Verification of MSDS availability Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection ~.. Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardous waste on site?: [~l Yes ~'o Explain: ~,~5'"~/e,~ c,z.m, e'~::'~)~ Questions regarding this inspection? Please call us at (661) 326-3979 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy 'Busings; S-ii~ ~es~sible Party Inspector: ~~ .,~,,~P~'/O" 201 New Stine Road, Suite 130 Bakersfield, CA 93309 661 396-8900 Fax 661 397-2929 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: 2. 3. 4. 5. To avoid further action, return this form within 30 days of receipt. TYPE/PRINT ANSWERS IN ENGLISH. Answer the questions below for the business as a whole. Be as brief and concise as possible. You may also attach Business Owner / Operator Form ~and Chemical Description Form(s) to the front of this plan instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA LOCATION: MAILING ADDRESS: CITY: '~~'~ STATE: PHONE: .]'~Y~) - ~,~-- ~773. EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II. 1: DISCOVERY AND NOTIFICATIONS A. LE D TECTION MONITO_m .. PRp ? t S:, . '-B. EM?LOYEE 'AND-AG~NCY'NOTIFICATIONi ...... -' C. ENVIRONMENTAL RESPONSE MANAGEMENT: ' , ' ' ,qg'z~(../24/9 ~/~.,~: ~ .... '.-' .'Bn~....~',-v'_.': ...... ,...:-. ...... ~.~,.~ 4,,.,~'a~--~ az.~:~..,'~.- .... D. E~RGENCY ~DICAL PLAN: _' ..... ~.,.,. A.~,~ ~.~... , ~~h ~:_..~..~ ..... .' ---- , ~ ~ ~~ ~ n~~"- ~:--~ / -~' ' ou _. z ~ ~.~-., /n~ n~ ~.. /~~ h .... ~ -., . HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II.2: RELEASE RESPONSE PLAN HAZARD ASSESSMENT AND PREVENTION ME.AS,URES: - ~,h, az~ ,-2.. z_ _ , ~'~/""r*/'' ""'""'""~ , . . Bo RELEASE CONTAINMENT AND/OR MITIGATION: , ~. ,, ~,,..,,.~,-- IR~ ~ ~,~ ~ ~ ~"~'~'~ ~"~ ~ ~ ~~. ~ ~1~, ~' . ~; · , ~ C. CLEAN-UP AND RECOVERY P~ROCEDURES: ' ~,~ ~ a,,, '/~, r/~,~ 1. ~ ~/~.-. ~ , , ~ ~ UTILITY S~-OFFS (LOCATION OF S~-OFFS AT YO~ FACILITY) PRIVATE FIRE PROTECTION/WATER AVAILABILITY HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING NUMBER OF EMPLOYEES: //~'~ BRIEF SUMMARY OF TRAINING PROGRAM: CERTIFICATION I, ~9~ ~ ~ CERTIFY THAT THE ABOVE INFORMATION IS A~~T~. ~UNDERSTAND THAT THIS INFO~TION V~ILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE_INFORMATION CONSTITUTES PERJURY. SIGN~AT~RE ~ DATE HEALTHSOUTH SURGERY CENTERS ANNUAL SAFETY & EDUCATION DAY Introduction: Safety Rules and Guidelines Environment of Care (EOC) A. EOC Philosophy (1) B. Employee Guidelines to EOC (Safety) Manual (1) C. OSHA Regulations (2) D. The Right Attitude Towards Safety (2) Il. Risk Management A. Incident Reporting (3) B. Unsafe Medical Device Reporting (4) C. Surgical Procedure and Site Validation Policy (5) D. Drug and Alcohol Policy (6) III. Security Management A. Workplace Violence (7) B. Code Orange (7) C. Personal Safety (8) D. Confidentiality (9) IV. HazardOus Communication A. Employee Right to Know (10) B. MSDS Sheets (10) C. Compressed Gas Safety (11) D. Hazardous Waste (12) Video: MSDS/Hazardous Communication Emergency A. B. C. D. E. F. Preparedness Disaster Plan: Code Yellow (13) Cardiac Arrest: Code Blue (13) Malignant Hyperthermia: Code MH (13) Bomb Threat: Code Brown (13) Inclement Weather: Code Greea (13) Response to Community Persons with emergencies VI. Life Safety Management Plan (14) A. Fire Prevention (15) B. Fire: Code Red (16) C. Fire Extinguishers (17) D. Emergency Evacuation/First Aid (17) VII. Utilities Management A. Power Failure (18) B. Utility Failures: Contingency Plan (18) C. Main Utility Shut-Off Valves (Walk-Through) VIII. Equipment A. B. C. D. Safety Electrical Safety (19) Equipment Failures (19) Laser Safety (20) Radiation Safety (20) IX. Body Mechanics A. Safe Lifting Techniques (21) B. Tips For Healthcare Workers (21) Video: Protecting Your Back Xe Infection Control A. Exposure Plan: Bloodborne Pathogens//666 (22) B. Universal P~ecautions and PPE #675d (23) C. TB Exposure Control Plan #673 (24) D. Handwashing (25) XI. Patient Rights and Responsibilities A. Advance Directives (26) B. AMA Procedure (26) C. Release of Medical Records (26) XII. Abuse & Neglect Recognition and Reporting A. Child Abuse (27) B. FAder Abuse (28) XIII. Preventing Workplace Hazards A. Good Housekeeping/Fall Prevention (29) B. Ergonomic Injuries/Office Hazards (29) HEALTHSOUTIt SURGERY CENTERS OWNERSHIP/REPORTING STRUCTURE PARENT HEAL THSOUTIt CORPORA TION (Owns 100% of the Stock of National Surgery Centers) SUBSIDIARY NATIONAL SURGERY CENTERS, INC. (OWns 100% of the Stock of National Surgery Centers - Bakersfield, lnc.) SUBSIDIARY NATIONAL SURGERY CENTERS - BAKERSFIELD, INc. (This is the General Partner & Tax Matters Partner for both of the Centers) One HealthSouth Parkway P.O. Box 380546 Birmingham, AL. 35243 LIMITED PARTNERSHIP Sonthwest Surgery Center 201 New Stine Road, Suite 130 Bakersfield, CA. 93309 The following physicians h'ave ownership interest Clement Alade, M D PR Chandrasekaran, MD Alfred Coppola, MD Scott Davis, DPM Gregory George, M D Mark Hamilton, DPM Michele Kraft, DPM Marshall Lewis, MD Matthew Malerich, MD Lee Marek, DPM Mark Miller, DPM Thomas Nelson, DPM Young Paik, MD Livan Pasahoc, DPM Albert Swafford. MD. Michael Tivnon, MD Nicholas Valos, MD Steven Yaplee, MD 1715 Chester Ave., CA 93301 (661) 326-3979 *,~..,.'a~~.. ~__.. HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one fom~ per mate~al ~er building or a~) ~W I-] ADD [] DELETE [] REVISE 200 Page ~ of CHEMICAL LOCATION ./~ J... ~ .~ ~ - -- . . .. 201 CHEMICAL LOCATION ~ ~ : T~ESEC~ ~Y~ ~No ~ ~N ~ ~Z ~ CAS # FIRE CODE HAZARD CLASSES (Cem, p~,e ~f req~,~ by Ioc~ fire chleO 2~0 TYPE ~("I~PURE ~ m MIXTURE [] w WASTE 211 RADIOACTIVE ~--]Yes ~-No 212 CURIES PHYSICAL STATE [] $ SOLID •l LIOUID ~ GAS 2'14 LARGEST CONTAINER ~..~.~ 215 FED HAZARD CATEGORIES [] 1 FIRE ' [] 2 REACTIVE [~ PRESSURE RELEASE [] 4 ACUTE HEALTH (Check all ~at apply) [] $ CHRONIC HEALTH 216 DAILY AMOUNT ~O0 218 AVERAGEDAILY AMOUNT ..~..~*~) 219 STATE WASTE CODE UNITS' [] ga GAL -/'~E CU FT [] lb LBS [] tn TONS 221 DAYS ON SITE * If EHS, amount must be in lbs. ANNUAL WASTE AMOUI~r (CheckSTORAGEall tnatcoNTAINERapply) [] a ABOVEGROUND TANK [] · PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTTLE [~] q RAIL CAR 223 [] b UNDERGROUND TANK [] f CAN [] j BAG [] n PLASTIC BOTTLE [] r OTHER [] c TANK INSIDE BUILDING [] g CARBOY [] k BOX [] 0 TOTE BIN [] d STEEL DRUM [] h SILO ~,~.CYLINDER [] p TANK WAGON STORAGE PRESSURE [] a AMBIENT ~ ABOVE AMBIENT [] ba BELOW AMBIENT 224 STORAGE TEMPERATURE ~ AMBIENT [] aa ABOVE AMBIENT [] be BELOW AMBIENT [] c CRYOGENIC 225 2 ; 23o 23~ 234 235 238 239 242 []Yes [] No Z32 [] Yes ~] No 236 233 237 241 DATE 246 UPCF (7/99) S:~CUPAFORMS~OES2731 .'rv4.wlxl .~.~.~ ~l~ CITY OF BAKERSFIELD~ B r OFFICE OF ENVIRONMENTAL SEi~ICES 1715 Chester Ave., CA 93301 (661) 326-3979 ' ' H~RDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION(o., ~ ~ Page ~EW D ADD D O~L~E 0 REVISE ~ . - ,~ ~..~ ~.~,~:,~,',~:~.~,~':,~:~,~'~a~~~ ~'~L~F~~FO~ON''~'' :,~.~ ,T '" :~"<~*~:: ~::~ '~:~ ', BUSINESS ~E (~e ~ FACIL~ WE ~ ~ - ~ng 8~n~ ~) , CHEMI~L LO~TIQN ~1 ~NFIDE~L (E~) CHEMICAL LOCATION [] Yes [] No 202 CHEMICAL NAME COMMON NAME CAS # FiRE CODE HAZARD CLASSES (CampMie if requested by local fire ~ TYPE PHYSICAL STATE r-] s SOUD I-Ii LIQUID FED HAZARD CATEGORIES D 1 FIRE (Chec~ all that apply) ANNUAL WASTE 2t 7 AMOUNT UNffS' 205 2O7 TRADE SECRET [] Yes [] No 206 ff Subject to EPCRA. refer to instructions EHS* []Yes []No 206 : 210 [] w WASTE 21t I RADIOACTIVE [] Yes ~a'.. GAs ...~4 ~GESTCONT~NER · [] 2 REAc'r~E I~ .REssuRE REL~SE D, ACUTE HEALTH DA,LYAMOUNT(~,! ~ DA,LYAMOUNT [] ga GAL [] ,~ CU ~r [] lb LBS [] m TONS * If EHS, amount must be In lbs. 212 CURIES 213 [] $ CHRONIC HEALTH 216 /t~ 219 STATE WASTE CODE 220 DAYS ON SITE 222 . 221 STORAGE CONTAINER (Check all that apply) [] e ABOVEGROUND TANK [] b UNDER~UND TANK [] c TANK INSIDE BUILDING [] d STEEL DRUM [] · PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTTLE [] q RAIL CAR 223 r-If CAN []j BAG I-In PLASTIC Bo'n'LE EJr OTHER []g CARBOY []k BOX , []0 TOTE BIN r'l h SILO ,~ CYLINDER [] p TANK WAGON STORAGE PRESSURE I--I · AMBIENT ,~ ABOVE AMBIENT [] ba BELOW AMBIENT 224 [] bs BELOWAMBIENT STORAGE TEMPERATURE ~e~AlvlBIENT [] aa ABOVE AMBIEI~ Dy,, •'No I-lyes r"] No 232 [] c CRYOGENIC 225 234 D yes I-I No 23~ 241 238 239 [] Yes [] No 240 245 242 243 [] yes r'] No 244 ~ITATIVE 246 UPCF (7~99) S:~CUPAFORMS\OES2731 .TV4.wpd ~ CITY OF BAKERSFIELI~ OFI~I~E OF ENVIRONMENTAL SERVICES 17lB Chester Ave., CA 93301 (661) 326-3979 "~"'~~~'" ~'"' HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one fon~ per mate~fal ;)er building or ama) 'll~dr:W I'"] ADO ~ DELETE ~ REVISE ~ . Page BUSINESS ~E (~e ~ FA~IL~ ~ME ~ p~ - ~ng B~n~ ~) 201 CONFIDENTIAL (EPCRA) CHEMICAL LOCATION [] Yes [] No 202 CHEMIC, ALLOCATION FACILI~ ID $ ~ · ; CHEMI~L ~E COM~N ~ CAS # FIRE CODE HAZARD CLA~ES (Complete if reqt~i~ by local fire chtet) TYPE 210 PHYSICAL STATE FED HAZARD CATEGORIES (Check all that apply) ANNUAL WASTE AMOUNT [] p PURE [] m MIXTURE ~ WASTE 211 [ RADIOACTIVE [] Yes [] a soup ~:FL.~U,D [] g C~S :~4i LA.~ESTCONT/~RER [] I FIRE · [] 2 REACTIVE . [] 3 PRESSURE RELEASE [] 4 ACUTE HEALTH m~LVmOUm ,' ~,¥ AMOUNT UNITS' ~ GAL [] d CU FT [] lb LBS [] tn TONS · If EHS, amount must be in lbs. 212 CURIES 213 ,l~ CHRONIC HEALTH . , 216 219 STATE WASTE CODE 220 DAYS ON SITE 222 221 STORAGE CONTAINER [] a ABOVEGROUND TANK [] e PLASTI~NMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTrLE [] q RAIL CAR 223 (Check all that apply) I'-Ib UNDERGROUND TANK []f CAN []j BAG ,J~PLASTIC BOTTLE []r OTHER [] c TANK INSIDE BUILDING [] g CARBOY [] k BOX . [] o TOTE BIN [] d STEEL DRUM [] h SILO [] I CYLINDER [] p TANK WAGON STORAGE PRESSURE ~ AMBIENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT 224 STORAGE TEMPERATURE ':~,.a A-.u-~-!ENT [] aa ABOVE AMBIENT [] be BELOW AMBIENT [] c CRYOGENIC 225 []¥. DNO 220 231 [] Yes [] NO 232 237 23s []¥es[]NO 23B 24~ 239 [] Yes [] No 240 242 2~ •Yes ON• 2~ 24~ S:\CUPAFORMS\OES2731 .TV4.wpd UPCF (7/99) a~D_lri: ~_~.~-- ---., CITY OF BAKERS FIELI~MATERiALS INVENTORY OFFICE OF ENVIRONMENTAL SERVICES ~.~~r 1715 Chester Ave., CA 93301 (661) 326-3979 ~ ~' H~RDOUS Cheml~l Description Form (one ~ per maMHal per buffd~ or ama) ~ Page ADD ~ n;I ~E ~ R~ISE ~1 CHEMI~L LO~TION D Y~ CHE~LO~T~O" ~S~O~ ~ 5~ ~ ~ C~ ~ GC'?G - .:.. ~,.~,~..~, ,.:~.:~,:~:,~.. :<., ,~.~,~.~. ,r , 205 T~DE SECR~ D Y~ 2o7 COMMON NAME 2O9 CAS # :IRE CODE HAZARD CLASSES (Complete if requested by local fire cllie0 1~ PURE [] m MIXTURE PHYSICAL STATE [] $ SOLID []1 LIQUID ~ GAS FED HAZARD CATEGORIES (Chectc all ~hat apply) ANNUAL WASTE AMOUNT if Subject to EPCRA. ref~ to iinstructions EHS° [] Yes [] NO 2~ ~ w WASTE 211 ] RADIOACTIVE214 LARGEST CONTAINER DYes ~'~ 212 ]CURIES ._f ACUTE HEALTH 5 CHRONIC HEALTH [] I FIRE [] 2 REACTIVE ~ PRESSURE RELEASE 217 t MAXIMUMDALLY AMOUN~/"* '~ C.,-// 218 I AVERAGE DAllY AMOUNT ~,~.~_. 219 STATE WASTE CODE DAYS ON SITE UNITS* [] ga GAL D cf cu FT [] lb LBS [] In TONS 221 * If EHS. amount must be in lbs. 210 1 213! 215 216 22O []q RAIL CAR 223 [] r OTHER STORAGE CONTAINER (Check all ~at apply) [] a ABOVEGROUND TANK [] · PLASTI~ONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTTLE [] b UNDERGROUND TANK [] f CAN [] j BAG [] n PLASTIC BOTFLE [] c TANK INSIDE BUILDING [] g CARBOY [] k BOX [] o TOTE BIN [] d STEELDRUM [] h SILO J~LCYIlNDER [] p TANKWAGON STORAGE PRESSURE [] a AMBIENT [] ba BELOW AMBIENT 224 STORAGE TEMPERATURE /__~_n Ai~_A!ENT [] ba BELOW AMBIENT [] c CRYOGENIC 226 23O 234 238 242 227 [] yes [] NO 228 231 [] Yes [] NO 232 235 [] Yes [] NO 236 239 [] Yes [] NO 240 243 [] Yes [] NO 244 241 245 F~tm 2731(3/99) ~ CITY OF BAKERSFIELD~ OFFICE OF ENVIRONMENTAL SEI~VICES ~ARF,wfr 1715 Chester Ave., CA 93301 (661) 326-3979 "~'~~'~' H~RDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one form per mate~fal per building or ama) '~EW [] ADD [] DELETE [] REVISE Page of BUSINESS NAME (Same as FACILITY NAME ~ ,DBA - D~ng Business As) 3 201 CONFIDENTIAL (EPCRA) ,7 " CHEMICAL LOCATION FACILI~ ID ~ ~ ~ I ~ ~ (op~naO ~ GRID ~ (op~naO ~ ........... "'~' '"' '' ~ ~ ' .... ~ T~ESECR~ ~y~ ~ ~ CHEMI~L ~E ~.~ ff Subj. to EPC~ ~. ,o ins~ ~7 COMMON NAME CAS # FIRE CODE HAZARD CLASSES (C~mple~e if requested by local fire chtet) EHS* []Yes []No 2{~ i 210 TYPE ~ PURE [] m MIXTURE [] W WASTE 211 RADIOACTIVE ayes ~4do 212 CURIES 213 PHYSICAL STATE [] s SOLID r-Il LIQUID ~. g GAS , 214 FED HAZARD CATEGORIES ~ FIRE · [] 2 REACTIVE [~ PRESSURE RELEASE [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH 216 (Chec~ all that apply) * ' .~ ~ 219 STATE WASTE CODE 220 ANNUAL WASTE ~AC... 217 J MAXIMUM DA~LYAMOUNT ~J. 218 J AVERAC.~ DALLY AMOUNT [] lb LBS [] In TONS 221 DAYS ON SITE 222 STOR~NER [] a ABOVEGROUND TANK [] · PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTI'LE [] q RAIL CAR 223 (Check all that apply) , 'Z7 ~ [] b UNDERC-,-,-,-,-,-,-,-,-~OUND TANK [] f CAN [] j BAG [] n PLASTIC BOTTLE [--I r OTHER I.~'~ ~0 TANKINSlDE BUILDING []g CARBOY r'lk BOX ~o TOTE BIN I~'~' [] d STEEL DRUM [] h SILO /~1 CYLINDER [] p TANK WAGON STORAGE PRESSURE [] · AMBIENT ~-aa ABOVE AMBIENT [] ba BELOW AMBIENT 224 JaAMBIENT [] aa ABOVE AMBIENT [::] be BELOWAMBIENT STORAGE TEMPERATURE []Yes O'No ~ [] c CRYOGENIC 225 ~J~ ......... .. £,,~' .. ~. --~ 231 OYes 0No232 23s •YesONo 236 241 238 239 [] Yes [] No 240 245 242 243 [] yes [] No 244 UPCF (7/99) S:\CUPAFORMS\OES2731 .'l%/4.wpd 1715 Chester Ave., 3rd Floor, Bakersfield,. ii}.,'CA 93301 ~-/ ~ ~ ~.' FACILITY NAME ADDRESS 20~ MC'-'u.a FACILITY CONTACT INSPECTION TIME INSPECTION DATE PHONE NO. BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program [~l Routine [~ Combined [~l Joint Agency [~ Multi-Agency [~ Complaint .J~Rc-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials Verification of quantities Verification of location Proper segregation of material Verification of MSDS availability Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled v/ ~-- C~ ~'(C.-~ (~ Housekeeping Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation hazardous waste on site?: J~es I~ No Any Explain: ...... Questions regarding this inspection? Please call us at (661) 326-3979 White - £nv, Svcs. Yellow - StatiOn Copy Pink - Business Copy ~le Party Inspector: cITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL S~ER-VtCES---~'~7 UNIFIED PROGRAM INSPECTION CHEC~IST 1715 ~h'~st'e:r Ave.,.3~d FlOor, Bakersfield, CA 93301 FACILITY NAME ~~' ~c~ ~.SPECTION DATE ADD'SS ~t ~ 5r,~ff ~ (..~ PHONE.NO. FACILITY CONTACT .... ..~.. BUS'ESS ID NO. 15-210- ~SPECTION TIME NUMBER oF.EMPLOYEES Section 1: Business Plan and Invento~ Program · ~ Routine ~ Combined ~ Joint Agency ~ Multi-Agency ~complaint ~e.inspection. OPERATION' " C V. COMMENTS Appropriate permit on hand . Business plan Contact information accurate Visible address ,. Correct occupancy Verification of inventory materials Verification of quantities · Verification of location Proper segregation of material , · Verification of MSDS availability Verification of Haz Mat training Verification of abatement supplies and procedures Emergency Procedures adequate · Containers properly labeled ~ ~'~ C~ ~'¢6~ (e~'-UJ4'"Ot~ Housekeeping' Fire ProteCtion Site Diagram Adequate & on ·Hand . ' ' C=Compliance V=Violation .. Any hazardous Waste on site?: ~Y~s' [~No ~"~~s~' EXplain: Questions regarding this inspection? Please call us-at (661) 326-3979 e Party White - Env. Svcs. Yellow - Stati6~ Copy Pink - Business Copy · Inspector: -.;~t . \' . CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ~Ea~'~st't~oc'~-t ADDRESS ~2o ~ t-rO.o Sx-,,,a~ ~g { 3o FACILITY CONTACT ttc--cc-r' INSPECTION TIME INSPECTION DATE g//{~/2_000 PHONE NO. -:3 e/(o - BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program Routine ~Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact information accurate .~'~' pt.~,a.s~= ¢o,',~P(..O~ ~/ t2E"--'~%} ' Visible address Correct occupancy Verification of inventory materials Verification of quantities Verification of location Proper segregation of material Verification of MSDS availability Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation b,J/[~0' % b 0 ~5 Any hazardous waste on site?: ~--Yes [] No Explain: Questions regarding this inspection? Please call us at (661) 326-3979 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy B~sines~ s~t · R~p-onsible Party Inspector: (.~xJ / ,-J~L~ · ADDRESS 20 ~ t40.o' FACILITY CONTACT INSPECTION TIME Section 1: Routine ~CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3ra FlOor, Bakersfield, CA 93301 INSPECTION DATE Iii / t 5"/'z °cJ° PHONE NO. '~'6 I ~ ~ O o BUSINESS ID NO. 15-210- ·NUMBER OF EMPLOYEES Complaint .Re-inspection BUsiness Plan and Inventory Program ,~LCombined [21 JOint Agency [~l Multi-Agency OPERATION . C V COMMENTS Appropriate permit on hand' Business plan contact information accurate ..~ Vilible address Correct occupancy Verification of inventory materials Verification of quantities Verification of location Proper segregatiOn of material Verification of MSDS availability Verification of Haz Mat training .... Verification of abatement supplies and prOcedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand · ..~ C=Compliance V=Violation ~ Any hazardous waste on site?: [~Yes [] No Explain: Questions regarding this inspection? Please call us at (661) 326-3979 · White - Env. Svcs. Yellow - Station Copy Pink - Business Copy fiuSiness Sit ~ 'k~ponsible Party Inspector: /~,-4~-5 FACILITY NAME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 im, c no r,xr Section 4: Hazardous Waste Generator Program EPA ID # [] Routine Ji~ Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number (Phone: 916-324-1781 to obtain EPA ID #) Authorized for waste treatment and/or storage Reported release, fire, or explosion within 15 days of occurrence Established or maintains a contingency plan and training HaTardous waste accumulation time frames Containers in good condition and not leaking Containers are compatible with the hazardous waste Containers are kep~ closed when not in use Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided \ Conducts daily inspection of tanks / Used oil not contaminated with other hazardous waste Proper management of lead acid batteries including labels / Proper management of used oil filters Transports h_aTardous waste with completed manifest Sends manifest copies to DTSC Retains manifests for 3 years Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal la\ C=Compliance V=Violation Inspector: bO Office of Environmental' Services (661) 326-3979 Business Site Re~si-ble Party White - Env. Svcs. Pink - Business Copy