Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
BUSINESS PLAN
Hazardous Materials/Hazardous Waste Unified Permit . CONDITIONS OF .PERMIT ON REVERSE SIDE Permit ID#:: 015-000-001910 WALGREENS #3294 LOCATION: 2628 MT VERNON AVE IELD This oermit is issued for the following: [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials [] Risk Management Program [] H=,~rdous Waste On-Site Treatment 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: Office of Ev~ices'''~' .Expir?!ionDate:' 'June 30.. 2003 Issue Date ITE DI~GRA~ [ Business ~ame~ FACILITY DIAGRA~ ! Business Address: Plot Plan Attachment Stori~: Store Number: 3¢-~z'/' Address: ¢¥_¢2~ Mo~-(- V'~-,-,-,o,.-. /~'v¢~,~ ~eF._ 4'AP..O "" 0 I..3 ~J'NIFIED PROGRAM I~PECTION CHECKLIST SECTION 1 Business Plan and Inventory Program Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME 4 INSPECTION DATE INSPECTION TIME ADDRESS ' ' ' P No. of Employees FACILITYCONTACT Business ID Number Section l: Business Plan and Inventory progmm [] Routine [] Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection ( C=Compliance ) OPERATION COMMENTS -t, V=Violation .^.o ..... ................................................. BUSINESS P~N CONTACT INFORMATION ACCURATE ................................................................................... VISIBLE ADDRESS CORRECT OCCUPANCY ........................................................................ VERIFICATION OF INVENTORY MATERIALS PROPER SEGREGATION OF MATERIAL VERIFICATION OF MSDS AVAI~BILI~E VERIFICATION OF HAT MAT TRAINING EMERGENCY PROCEDURES ADEQUATE HOUSEKEEPING FIRE PROTECTION SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE?: EXPLAIN: [] YES O QUESTIONS REG~PECTION? PLEASE CALL US AT (661) 326-397{ White - Environmental Services Yellow - Station Copy Pink - Business Copy + WALGREENS #3294 Manager : DAVE MARCUS Location: 2628 MT VERNON AVE BusPhone: Map : 103 SiteID: 015-021-001910 + City : BAKERSFIELD (661) 871-3035 CommHaz : Minimal Grid: 22A FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 08 EPA Numb: SIC Code:5912 DunnBrad: ~+ Emergency Contact / Title DAVE MARCUS / MANAGER Business Phone: (661) 871-3035x 24-Hour Phone : (661) 588-8450x Pager Phone : ( ) - x -{~--~kR4~- / ASSIST MANAGER Business Phone: (661) 871-3035x 24-Hour Phone : (661)-837 I125x Pager Phone : ( ) ~-~koCk Hazmat Hazards: Fire Press ImmHlth I Contact : Phone: (661) 871-3035x MailAddr: 2628 MT VERNON AVE State: CA City : BAKERSFIELD Zip : 93306 Owner WALGREENS Phone: (841) 940-2500x Address : 200 WILMONT RD State: IL City : DEERFIELD Zip : 60015 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No + Emergency Directives: += Hazmat Inventory == One Unified List + +== Alphabetical Order Ail Materials at Site + ......................... · ....... + ....... + ........... + ..... + + .... +- - -+ Hanmar Common Name... ISpecHazlEPA HazardsI Frm I DailyMax lUnitlMCP ................................ + ....... + ........... + ..... + .......... + .... + .... FIXER L 40.00 GAL Low HELIUM F P IH G 434.00 FT3 Min PHOTO CHEMICAL CONTAINING SILVE L 10.00 GAL Min PHOTOGRAPHIC STABILIZER IH L 40.00 GAL Min I, ~)O,~,-c ~.vg-~-vs Do hereby certify that ! hays (Type or print name) r~v~wad the a~ached h~ardous m~Ierials man~ge- rr~?~t p~an for LL/~,~t'-~r~.~,, and that i'i along with any corrections consti~to a ~ o~plete and correct man- agement p~n ~o[ my ~cili~.~ ;/ ~ .... J .......... Si~na~re ~ate 01/25/2002 + WALGREENS #3294 += Inventory Item 0002 +== COMMON NAME / CHEMICAL NAME FIXER FILM FIXER Location within this Facility Unit INSIDE PHOTOPROCESS STORAGE RM SiteID: 015-021-001910 + Facility Unit: Fixed Containers at Site + Map: Grid: I Days On Site 1365 +- -+ += STATE =+= TYPE ===+== PRESSURE ===+ TEMPERATURE ==+ .... CONTAINER TYPE I Liquid I Mixture I Ambient I Ambient I PLASTIC CONTAINER 4 ~ + + ~= 4 ~ AMOUNTS AT THIS LOCATION I Largest Container Daily Maximum Daily Average 1.00 GAL 40.00 GAL 40.00 GAL HAZARDOUS COMPONENTS %Wt. 15.00 Ammonium Thiocyanate 10.00 Ammonium Thiosulfate 5.00 Sodium Sulfite 4 =+===4 ITSecret RS No INo IBi°HazNo -1- +===4 HAZARD ASSESSMENTS ===~ Radioactive/AmountNo/ Curies I EPA Hazards RS No No No 5== CAS# 1762954 7783188 7757837 =4 ==+=====+ NFPA I USDOT# MCPI/// LOW + ~-=====+ += Inventory Item 0003 +== COMMON NAME / CHEMICAL NAME HELIUM Location within this Facility Unit INSIDE PHOTOPROCESS STORAGE AREA Facility Unit: Fixed Containers at Site + + Map: Grid: + Days On Site 365 -+ CAS# 7440-59-7 += STATE=+= TYPE ===+== PRESSURE ===+ TEMPERATURE ==+ .... CONTAINER TYPE I Gas I Pure I Above Ambient I Ambient I PORT. PRESS. CYLINDER + ~ AMOUNTS AT THIS LOCATION I Largest Container Daily Maximum Daily Average 217.00 FT3 434.00 FT3 217.00 FT3 +== ~ --- ~___ HAZARDOUS COMPONENTS -- +===+ + I ~===+ ~ + +===+ ...... 4 - HAZARD ASSESSMENTS ===+ -a ~ ..... + ITSecretl RSIBioHazI Radioactive/Amount I EPA HazardsI NFPA USDOT# I MCP No No No No/ Curies F P IH / / / Min += '}'===+= .... =4 ---- ~ + ------'4 k =====+ 2 01/25/2002 + WALGREENS #3294 += Inventory Item 0004 +== COMMON NAME / CHEMICAL NAME PHOTO CHEMICAL CONTAINING SILVER HAZARDOUS WASTE W/SILVER Location within this Facility Unit INSIDE PHOTOPROCESS STORAGE AREA == SiteID: 015-021-001910 + Facility Unit: Fixed Containers at Site + + Map: Grid: Days On Site 365 -+ CAS# I =+ += STATE =+= TYPE ===+== PRESSURE ===+ TEMPERATURE ==+ .... CONTAINER TYPE ..... + Liquid I Waste I Ambient I Ambient I PLASTIC CONTAINER I ~ ~ ~ ~ + ~ AMOUNTS AT THIS LOCATION + Largest Container { Daity Maximum I Daily Average I 10.00 GAL 10.00 GAL 10.00 GAL ~ ~ + + + 0.50 Silver HAZARDOUS COMPONENTS +===% ITSecret RS HAZARD ASSESSMENTS ===4 Radioactive/AmountNo/ Curies EPA Hazards I +===4 + I I +----==+== + +========+=====+ NFPA I USDOT# MCPI/// Mis + ~=====+ += Inventory Item 0001 +== COMMON NAME / CHEMICAL NAME PHOTOGRAPHIC STABILIZER FILM STABILIZER Location within this Facility Unit INSIDE PHOTOPROCESS STORAGE RM Facility Unit: Fixed Containers at Site + Map: Grid: + Days On Site 365 CAS# += STATE =+= TYPE ===+== PRESSURE ===+ TEMPERATURE ==+ .... CONTAINER TYPE I Liquid I Mixture I Ambient I Ambient I PLASTIC CONTAINER + AMOUNTS AT THIS LOCATION ILargest Container Daily Maximum I Daily Average 1.00 GAL 40.00 GALI 40.00 GAL %Wt . 1.00 1.00 1.00 HAZARDOUS COMPONENTS Hexamethylenetetramine Sodium Dodecylbenzene Sulfonate Dipropylene Glycol ~===% } ITSecretlNo NoRSIBi°HazINo 4 +===4 ~ HAZARD ASSESSMENTS ===4 Radioactive/AmountNo/ Curies EPA Hazards IH No No + -I- NFPA /// CAS# 100970 25155300 106627 + +=====+ I USDOT# :l MCP I, Mis + ~=====+ 3 01/25/2002 + WALGREENS #3294 + - SiteID: 015-021-001910 + Fast Format + += Notif./Evacuation/Medical +== AHency Notification Overall Site + 01/13/1999 + NOTIFICATION OF THE PROPER AUTHORITIES IS THE RESPONSIBILITY OF THE PHOTO LAB MANAGER, STORE MANAGER, OR DESIGNATED ALTERNATE IN CASE OF EMERGENCY. +=== Employee Notif./Evacuation 01/13/1999 + PHOTO LAB OPERATORS ARE NOTIFIED OF THE PRESENCE OF AN EMERGENCY REQUIRING EVACUATION BY VERBAL COMMUNICATION OR WITH THE STORE ALARM SYSTEM IF ONE EXISTS. ALL PHOTO LAB EMPLOYEES WILL EVACUATE IMMEDIATELY FOLLOWING THE WARNING. THERE ARE NO CRITICAL OPERATIONS WHICH WILL BE PERFORMED IN THE PHOTO LAB PRIOR TO EVACUATION. + .... Public Notif./Evacuation 01/13/1999 + AFTER EVACUATION, PHOTO LAB OPERATORS WILL CONGREGATE IN THE PARKING LOT, A SAFE DISTANCE FROM THE FRONT OF THE STORE. ALTERNATE CONGREGATION POINTS MAY BE SPECIFIED IN THE STORES SITE-SPECIFIC EMERGENCY ACTION PLAN. THE PHOTO LAB MANAGER OR STORE MANAGER WILL BE INFORMED OF PHOTO LAB OPERATORS' SAFE EVACUATION. EmerHency Medical Plan -4- 01/25/2002 + WALGREENS #3294 += SiteID: 015-021-001910 + Fast Format + += Mitigation/Prevent/Abatemt +== Release Prevention == Overall Site + 01/13/1999 + TO MINIMIZE SPILLS IN THE PHOTO LAB, OPERATORS PRACTICE GOOD HOUSEKEEPING. PHOTOPROCESSING CHEMICALS ARE TYPICALLY STORED IN DELIVERY CONTAINERS AND KEPT IN THE DELIVERY CONTAINERS PRIOR TO USE TO AVOID ACCIDENTAL SPILLS. PHOTOPROCESSING CHEMICALS ARE STORED AWAY FROM HEAVY TRAFFIC AREAS. SPILLS THAT DO OCCUR IN THE PHOTO LAB ARE USUALLY VERY SMALL IN VOLUME AND CAN BE READILY CLEANED UP. +=== Release Containment - 01/13/1999 + IF A SPILL DOES OCCUR, OPERATORS PUT ON PERSONAL PROTECTIVE EQUIPMENT (GLOVES, GOGGLES, AND APRON) PRIOR TO INITIATING CLEAN-UP ACTIVITIES. THE CLEAN-UP PROCEDURES VARY DEPENDING ON WHETHER ON-SITE SILVER RECOVERY IS PERFORMED IN THE STORE OR IF THE USED PHOTOPROCESSING CHEMICALS ARE TRANSPORTED OFF-SITE FOR TREATMENT. ..... Clean Up == 01/13/1999 + COMMODITY RESOURCE & ENVIRONMENTAL HANDLES WASTE DISPOSAL 1-800-943-2811. Other Resource Activation -5- 01/25/2002 + WALGREENS #3294 SiteID: 015-021-001910 + - Fast Format + += Site Emergency Factors -- +== Special Hazards I Overall Site + +=== Utility Shut-Offs A) GAS - OUTSIDE NE CORNER OF BLDG B) ELECTRICAL - INSIDE NW CORNER OF BACK RM C) WATER - OUTSIDE NW CORNER OF PROPERTY D) SPECIAL - NONE E) LOCK BOX - NO 01/13/1999 + + .... Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - SPRINKLERED BLDG. 12/20/1999 + NEAREST FIRE HYDRANT - OUTSIDE NW CORNER OF PROPERTY. -+ Building Occupancy Level -6- 01/25/2002 + WALGREENS #3294 SiteID: 015-021-001910 + Fast Format + += Training == Overall Site +== Employee Training 01/13/1999 WE HAVE 40 EMPLOYEES AT THIS FACILITY. WE DO HAVE MSDS SHEETS ON FILE IN A BINDER IN PHOTO PROCESSING DEPT. BRIEF SUMMARY OF TRAINING PROGRAM: TRAINING BINDER IN MANAGERS OFFICE WHICH CONTAINS OVERVIEW OF TRAINING PROGRAM AND EMPLOYEE TRAINING RECORDS. +=== Page 2 ==+ + .... Held for Future Use I + Held for Future Use -7- 01/25/2002 FACILITY NAME ADDRESS FACILITY CONTACT INSPECTION TIME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CH ECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 7 PHONE NO. ~Y7/- 2~e3"~,$~- BUSINESS ID NO. 15-210- ~'/~'/~' NUMBER OF EMPLOYEES ~ Section 1: Business Plan and Inventory Program ~[xRoutine [] Combined [] Joint Agency [21 Multi-Agency [21 Complaint I~ Re-inspection OPERATION C V COMMENTS Appropriate permit on hand ~ Business plan contact in,brmation accurate ~// ,/~"~'fft~,/~ ~ ~'t~,ff~r Visible address ~' Correct occupancy ~t Verification of inventor),' materials .4/ Verification of quantities Ce Verification of location C Proper segregation of material ~' Verification of MSDS availability t~ Verification of Haz Mat training ~ Verification of abatement supplies and procedures ~ Emergency procedures adequate ~ Containers properly labeled ~ Housekeeping ~ /)/ Site Diagram Adequate & On Hand C C=Compliance V=Violation Any hazardous waste on site?: [21 Yes '~.No Explain: Questions regarding this inspection? Please call us at (805) 326-3979 White - Env. Svcs. Yclloxv - Station Copy Pink - Business Copy B~ssinXess%~te [(~ponsible Party Inspector: ~/'/~ ADMINISTRATIVE SERVICES 2101 'H" Street Bakersfield, CA 93301 VOICE (805) 326-3941 FAX (805) 395-1349 SUPPRESSION SERVICES 2101 "H" Street Bakersfield, CA 93301 VOICE (805) 326-3941 FAX (805) 395-1349 PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (805) 326-3951 FAX (805) 326~0576 ENVIRONMENTAL SERVICES 1715 Chester Ave. Bakersfield, CA 93301 VOICE (805) 326-3979 FAX (805) 326-0576 TRAINING DIVISION 5642 Victor Ave. Bakersfield, CA 93308 VOICE (805) 399-4697 FAX (805) 399-5763 Dear Business Owner: This notice is meant to act as a reminder that the California Health and Safety Code, Chapter 6.95, requires any handler of hazardous materials to revise their hazardous materials business plan within 30 days of any one of the following events: (~) A 100 per cent or more increase in the quantity of a previously-disclosed material. (2) Any handling of a previously-undisclosed hazardous material, subject to the inventory requirements of Chapter 6.95. (3) Change in business ownership. (4) Change in business address. (5) Change of business name. Any questions regarding these required revisions, please call the Hazardous Materials Division at (805) 326-3979. Sincerely yours, Director, Office of Environmental Services FACILITY NAME ADDRESS ,~d,~fffl' ~'~7~,//~'~,'~ FACILITY CONTACT INSPECTION TIME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 7 PHONE NO. ~Y7/- ~ BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program ~lkRoutine [] Combined [] Joint Agency 121 Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Appropriate permit on hand ~d Business plan contact intbrmation accurate 'V' /~/~'~ ~ ~p~ Visible address ~cJ Correct occupancy ff Verification of inventory' materials ~ Verification of quantities C~ Verification of location C 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 I~ Fire Protection ~ Site Diagram Adequate & On Hand C C=Compliance V=Violation Any hazardous waste on site?: [] Yes [] No Explain: Questions regarding this inspection? Please call us at (805) 326-3979 While - Env. Svcs. Yellow - Station Copy Pink - Business Copy B~ssin~te ~ 3onsible Party Inspector: ,~Z'7 + WALGREENS ~3294 Manager : DAVE MARCUS Location: 2628 MT VERNON AVE City : BAKERSFIELD CommCode: BAKERSFIELD STATION 08 EPA Numb: := SiteID: 015-021-001910 + BusPhone: (661) 871-3035 Map : 103 CommHaz : Minimal Grid: 22A FacUnits: 1 AOV: SIC Code:5912 DunnBrad: Emergency Contact DAVE MARCUS Business Phone: 24-Hour Phone : Pager Phone : / Title.--~ / MANAGER (661) 871-3035x (661) 588-8450x ( ) - x Emergency Contact LULA BROOKS Business phOne: 24-Hour Phone : Pager Phone : + / Title / ASSIST MANAGER (661) 871-3035x (661) 837-1125x ( ) - x -+ I Hazmat Hazards: Fire Press ImmHlth I ~ + Contact : Phone: (661) 871-3035x MailAddr: 2628 MT VERNON AVE State: CA City : BAKERSFIELD Zip : 93306 Owner WALGREENS Phone: (841) 940-2500x Address : 200 WILMONT RD State: IL . City : DEERFIELD Zip : 60015 -+ Period : to TotalASTs: = Preparer: TotalUSTs: = Certif'd: RSs: No Emergency Directives: Gal Gal += Hazmat Inventory +== Alphabetical Order + Hazmat Common Name... FIXER HELIUM PHOTO CHEMICAL CONTAINING SILVE .PHOTOGRAPHIC STABILIZER One Unified List + Ail Materials at Site + + -+- -+ ..... +- -+ .... +- - -+ ISpooHazlEPA HazardsI Frm I DailyMax lUnitlMCPI ~ ....... + ........... + ..... + .......... + .... +- - -+ L 40.00 GAL Low F P IH G 434.00 FT3 Min L 10.00 GAL Min IH L 40.00 GAL Min I, Do hereby certify that I have (Type or prin,, name) r:-, ,:.,.,~d the attached hazardous m~:.xef~a~s manage- r;':.:¢,..".',t glen for and ~:i~t :'[ along corrections constitute a complete ar, d cocrect man- agement plan for my facility. -1- Ol/25/2oo2 Signature Qa[e WALGREENS #3294 Manager : DAVE MARCUS Location: 2628 MT VERNON AVE City : BAKERSFIELD SiteID: 215-000-001910 BusPhone: ~ 871-3035 Map : 103 CommHaz : Minimal Grid: 22A FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 08 EPA Numb: SIC Code:5912 DunnBrad: Emergency Contact / Title DAVE MARCUS ~1/ MANAGER Business Phone: ,(J~O~) 871-3035x 24-Hour Phone ~d%(8~3) 588-8450x Pager Phone : ( ) - x Emergency Contact L~ Title Y~N-CEL GD~C~A '~KO0~.%/ ASSISTANT MGR Business Phone~(805) 871-3035x 24-Hour Phone~(8~9) ~3~-~3-75x Pager Phone : ( ) b%-~%%~x Hanmar Hazards: Contact :'~VC ~6~5 MailAddr: 2628 MT VERNON AVE City : BAKERSFIELD Owner WALGREENS Fire Press ImmHlth Phone: (~M~5) 871-3035x State: CA Zip : 93306 Phone: Address : 200 WILMONT RD City : DEERFIELD State: IL Zip : 60015 Period : Preparer: Certif'd: to TotalASTs: = Gal TotalUSTs: = Gal RSs: No Emergency Directives: = Hazmat Inventory --Alphabetical Order Hazmat Common Name... FIXER HELIUM PHOTO CHEMICAL CONTAINING SILVE PHOTOGRAPHIC STABILIZER One Unified List 9 Ail Materials at Site 9 ISpecHazlEPA HazardsI Frm F P L IH G L IH L DailyMax UnitIMCP 40 GAL Low 434 FT3 Min 10 GAL Min 40 GAL Min 08/25/1999 WALGREENS #3294 ~ Inventory Item 0002 -- COMMON NAME / CHEMICAL NAME FIXER FILM FIXER Location within this Facility Unit INSIDE PHOTOPROCESS STORAGE RM SiteID: 215-000-001910 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# STATE -- TYPE PRESSURE Ambient Mixture JLicluid TEMPERATURE Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container 1.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 40.00 GAL Daily Average I 40.00 GAL %Wt. 15.00 10.00 5.00 HAZARDOUS COMPONENTS Ammonium Thiocyanate Ammonium Thiosulfate Sodium Sulfite RS No No No CAS# 1762954 7783188 7757837 TSecretINo NoRSIBi°HaZNo HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA I USDOT# I MCP / / / Low = Inventory Item 0003 -- COMMON NAME / CHEMICAL NAME HELIUM Location within this Facility Unit INSIDE PHOTOPROCESS STORAGE AREA Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# 7440-59-7 STATE ~ TYPE Gas /Pure PRES SURE TEMPERATURE I Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 217.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 434.00 FT3 Daily Average 217.00 FT3 %Wt. 100.00 Helium HAZARDOUS COMPONENTS CAS# N 7440597 TSecretI RSIBioHaz No No No HAZARD ASSESSMENTS Radi°active/Am°unt I EPA HazardsINo/ Curies F P IH NFPA /// USDOT# Min 2 08/25/1999 WALGREENS #3294 = Inventory Item 0004 -- COMMON NAME / CHEMICAL NAME PHOTO CHEMICAL CONTAINING SILVER HAZARDOUS WASTE W/SILVER Location within this Facility Unit INSIDE PHOTOPROCESS STORAGE AREA SiteID: 215-000-001910 Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# STATE T TYPE PRESSURE Ambient Waste }Liquid TEMPERATURE Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container 10.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 10.00 GAL Daily Average I 10.00 GAL %Wt. 0.50 Silver HAZARDOUS COMPONENTS S CAS# N 7440224 TSecret ~S BioHaz No N No HAZARD ASSESSMENTS Radioactive/Amount I EPA Hazards No/ Curies I. NFPA /// USDOT# MCP Min = Inventory Item 0001 -- COMMON NAME / CHEMICAL NAME PHOTOGRAPHIC STABILIZER FILM STABILIZER Location within this Facility Unit INSIDE PHOTOPROCESS STORAGE RM Facility Unit: Fixed Containers at Site Map: Grid: Days On Site 365 CAS# STATE T TYPE PRESSURE Ambient Mixture Liquid -- TEMPERATURE Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container 1.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 40.00 GAL Daily Average 40.00 GAL %Wt. 1.00 1.00 1.00 HAZARDOUS COMPONENTS Hexamethylenetetramine Sodium Dodecylbenzene Sulfonate Dipropylene Glycol oRS CAS# N 100970 ~o© 25155300 106627 TSecret N~S BioHazI HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No No No/ Curies IH NFPA/// I USDOT# MCP Min -3- 08/25/1999 F WALGREENS #3294 SiteID: 215-000-001910 Fast Format ~ Notif./Evacuation/Medical --Agency Notification Overall Site 01/13/1999 NOTIFICATION OF THE PROPER AUTHORITIES IS THE RESPONSIBILITY OF THE PHOTO LAB MANAGER, STORE MANAGER, OR DESIGNATED ALTERNATE IN CASE OF EMERGENCY. -- Employee Notif./Evacuation 01/13/1999 PHOTO LAB OPERATORS ARE NOTIFIED OF THE PRESENCE OF AN EMERGENCY REQUIRING EVACUATION BY VERBAL COMMUNICATION OR WITH THE STORE ALARM SYSTEM IF ONE EXISTS. ALL PHOTO LAB EMPLOYEES WILL EVACUATE IMMEDIATELY FOLLOWING THE WARNING. THERE ARE NO CRITICAL OPERATIONS WHICH WILL BE PERFORMED IN THE PHOTO LAB PRIOR TO EVACUATION. Public Notif./Evacuation 01/13/1999 AFTER EVACUATION, PHOTO LAB OPERATORS WILL CONGREGATE IN THE PARKING LOT, A SAFE DISTANCE FROM THE FRONT OF THE STORE. ALTERNATE CONGREGATION POINTS MAY BE SPECIFIED IN THE STORES SITE-SPECIFIC EMERGENCY ACTION PLAN. THE PHOTO LAB MANAGER OR STORE MANAGER WILL BE INFORMED OF PHOTO LAB OPERATORS' SAFE EVACUATION. Emergency Medical Plan -4- 08/25/1999 F WALGREENS #3294 SiteID: 215-000-001910 Fast Format ~ Mitigation/Prevent/Abatemt --Release Prevention Overall Site 01/13/1999 TO MINIMIZE SPILLS IN THE PHOTO LAB, OPERATORS PRACTICE GOOD HOUSEKEEPING. PHOTOPROCESSING CHEMICALS ARE TYPICALLY STORED IN DELIVERY CONTAINERS AND KEPT IN THE DELIVERY CONTAINERS PRIOR TO USE TO AVOID ACCIDENTAL SPILLS. PHOTOPROCESSING CHEMICALS ARE STORED AWAY FROM HEAVY TRAFFIC AREAS. SPILLS THAT DO OCCUR IN THE PHOTO LAB ARE USUALLY VERY SMALL IN VOLUME AND CAN BE READILY CLEANED UP. --Release Containment 01/13/1999 IF A SPILL DOES OCCUR, OPERATORS PUT ON PERSONAL PROTECTIVE EQUIPMENT (GLOVES, GOGGLES, AND APRON) PRIOR TO INITIATING CLEAN-UP ACTIVITIES. THE CLEAN-UP PROCEDURES VARY DEPENDING ON WHETHER ON-SITE SILVER RECOVERY IS PERFORMED IN THE STORE OR IF THE USED PHOTOPROCESSING CHEMICALS ARE TRANSPORTED OFF-SITE FOR TREATMENT. -- Clean Up 01/13/1999 COMMODITY RESOURCE & ENVIRONMENTAL HANDLES WASTE DISPOSAL 1-800-943-2811. Other Resource Activation 5 08/25/1999 F WALGREENS #3294 SiteID: 215-000-001910 Fast Format Site Emergency Factors Special Hazards Overall Site --Utility Shut-Offs A) GAS - OUTSIDE NE CORNER OF BLDG B) ELECTRICAL - INSIDE NW CORNER OF BACK RM C) WATER - OUTSIDE NW CORNER OF PROPERTY D) SPECIAL - NONE E) LOCK BOX - NO 01/13/1999 -- Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - SPRINKLERED BLDG 01/13/1999 NEAREST FIRE HYDRANT - OUTSIDE NW CORNER OF PROPERTY. Building Occupancy Level 6 08/25/1999 WALGREENS #3294 ~~~~~~~~ SiteID: 215-000-001910 Training &&&&&&~&&~~&~&~&~&~~&&~&&~&&&&~&~ Overall Site i~& Employee Training ~&~&~~&~&~~~&~&~&~&&& 01/13/1999 WE HAVE 40 EMPLOYEES AT THIS FACILITY. WE DO HAVE MSDS SHEETS ON FILE IN A BINDER IN PHOTO PROCESSING DEPT. BRIEF SUMMARY OF TRAINING PROGRAM: TRAINING BINDER IN MANAGERS OFFICE WHICH CONTAINS OVERVIEW OF TRAINING PROGRAM AND EMPLOYEE TRAINING RECORDS. IVendor No. CLAIMANT'S NAME AND ADDRESS: Walgreens #3294 2628 Mt Vernon Ave Bakersfield, CA 93306 CITY OF BAKERSFIELD CLAIM VOUCHER I certify that this claim is correct and valid, and is a proper charge against the City Agency and account indicated. (AUTHORIZED SIGNATURE OF CITY AGENCY) Date: 04-01-99 Initials of Preparer: ClTY DEPARTMENT:FINANCE PLEASE PROVIDE SHORT EXPLANATION OF PAYME (Including Contract Number if Applicable) This customer made a duplicate payment on this years Haz Mat bill in the amount of $237.25. We have since made an adjustment to the California State surcharge in the amount of $8.50 leaving them with a credit of $245.75. Dept. 0000 El / Obit Project # Invoice # Amount Date of Invoice 790O VOUCHER TOTAL $245.75 $245.75 SECTION 72, PENAL CODE Section 72, Presenting False Claims. Every person who with intent to defraud, presents for allowance or for payment to any state board or officer, or any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. FINANCE DEPT. USE ONLY Examined & Approved for Payment Amount STATEMENT OF ACCOUNT CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA 9330i-5201 TO: WALQREENS ~3294, 2628 MT VERNON AVE BAKERSFIELD, CA 93306 (805) 325-3979 DATE: 4/01/99 CUSTOMER NO: CHARGE SSO01 21801 DATE DESCRIPTION 3/01/99 BEgINNiNG BALANCE 3/01/9~ PAYMENT 3/31/99 Cha~ge adjustment CA STATE SURCHARGE CUSTOMER TYPE: ES/ 2~508 REF-NUMBER DUE DATE TOTAL AMOUNT 4/30/99 .00 237.25- 8. 50- FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER 8. 50- DUE DATE: 5/03/c2c2 PAYMENT DUE' TOTAL DUE' 245.75-- $245.75- (805) CUSTOMER NO: 21801 CUSTOMER TYPE: ES/ TOTAL DUE: 26508 $245.75- CUST TYP! MISCELLANEOUS RECEIVABLES ADJUSTMENT NEW ACCOUNT ADDRESS CHANGE CLOSEACCT ' FINANCE CHARGE j OTHER ADJ CUSTOMER NAME MAILING ADDRESS CITY ZIP CODE~ ~ C) ~:D SITE ADDRESS PARCEL NUMBER ~F,~'PUCAeL~ ADJUSTMENT CHG DA'~ E CHARGE CODE ADJUSTMENT AMOUNT REMARKS: ~--~ / APPROVED CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Cheste~g~., Bakersfield, CA (805) 326-3979 INSTRUCTIONS: fri':~ 1. To avoid further action, return this form within 30 days o ece'pt. ~ 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 USn'CESS NAME: LOCATION: MAILING ADDRESS: CITY: DUN & BRADSTREET NUMBER: STATE: ~ ZIP: PHONE: SIC CODE:~ PRIMARY ACTMTY: ~_~OWNER: /.x2~---q_._q ,~~ING ADDRESS: SECTION 2: ,EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 3' TRAINING NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHF. ETS ON FILE: BR~F'SUMMARY OF TRAINING PROGRAM: SECTION 4: EXEMPTION REQUEST I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS' OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH & SAFETY CODE" FOR THE FOLLOWING REASONS: WE DO NOT HANDLE HAzARDous MATERIALS. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION I, CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. SIGNATURE TITLE DATE 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES A. AGENCY NOTIFICATION PROCEDURES: Notification of the proper authorities is the responsibility of the photo lab manager, store manager, or designated alternate in case of emergency. Bo EMPLOYF. F. NOTIFICATION AND EVACUATION: Photo' lab operators are notified of the presence of an emergency requiring evacuation by verbal communication or with the store alarm system if one exists. All photo lab employees will .evacuate immediately following the warning. There are no critical operatiOns which will be performed in the photo lab prior to evacuation. C. PUBLIC EVACUATION: After evacuation, photo lab operators will congregate in the parking lot, a Safe distance i from the front of the store. Alternate congregation points may be specified in the store's , site-specific Emergency Action Plan. The photo lab manager or store manager will be informed of photo lab operators' safe evacuation.. .' . D. EMERGENCY MEDICAL PLAN: HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIOATION, PREVENTION AND ABATEMENT PLAN To minimize spills in the photo lab, operators practice good housekeeping. Photoprocessing chemicals are typically stored in delivery containers and kept in the delivery containers prior to use to avoid accidental spills. Photoprocessing chemicals are " stored away from heavy traffic areas. Spills that do occur in the photo lab are usually very small in volume and can be readily cleaned up. RELEASE CONTAINMENT AND/OR MINIMIZATION: Co If a spill does occur, operators put on personal protective equipment (gloves, goggles, and / apron) prior to initiating clean-up activities. The clean-up procedures vary depending on whether on-site silver recovery is performed in the store or if the used photoprocessing -chemicals are transported off-site for treatment. ' ~LEAN-UP PKOCE~DUREs: "~'- ...................... SECTION 8: UTII.!TY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: ELECTRICAL: Ir.3 ~, O~ WATER: ~'o SPECIAL: LOCK BOX: YES/NO IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: WATER AVAII.ABK,ITY (FIRE HYDe): Oo'v~,~e tOOt) C__0. tqre., c>,c q'CzceC~q.5-¥., 4 ~usincss Name It~RDOUS MATERIALS INVENTtY Addn~ CliEMICAL DESCRHrI~ON Page~of~ INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Ddetion [ ] Chack if chemical is a NON Trad~ Sea.~¢t [ ] Trada ~el [ I 2) Common Name: '~ ("/~ ~ ~-~ q._ t ~.~ Chemical Name:. 4) Physical & Health ' HsTsrd Categories Fir~ [ 5) WASTE CLASSIFICATION 6) PHYSICAL STATE Solid 7) AMOUNT AND TIME AT FACILrFY~ Maximum Daily Amount Average Daily AmoUnt Annual Amount Largest Size ConUfiner # Days on Site 3) DOT # (optional) ~atM[ I c~s# PHYSICAL HEALTH ]Reactive[ ]Su_dd~ReleaseofPressure[ ] hnmediateHealth(Acute)[ ]DelayedHealth(Chwni¢)<[~/3_ ,. (3-digit code from DHS Fonn ~022) USE CODE Liquid [,~ ass [, ] ~ [ ] Mixture.S' Wast~ [ ] Radioactive [ ] ul, rrrs OF ME~URE S) STORAOE CODES Lbs[ ]C.,al[~[ ] a)Contain~ Curies [ ] b) Pressure: ~ _ ¢) Tempamtu~ ~0~3-~ Circle Which Months: All Year, J, F, M, A, M, .l, .l, A, S, O, N, D COMPONEKr CAS# % WT 9) IVffXTURE: List the three most hazardous chemical componems or any AHM components [ ] [ ] [ ] 1) INVEKFORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] 2) Common Name: '~ ~ ~"-( y''' Chemical Name: 4) Physical & Health Hazard Categories Fire~] Reactive [ 5) WASTE CLASSIFICATION 6) PHYSICAL STATE Solid[ ] Liquid[/~ PHYSICAL ] Sudden Release of Pressure [ O-digit cod~ from DI-I~ Form c~s[ ] 7) AMOUNT AND TIME AT FACILIT~A/] Maximum Daily Amount Average Daily Amount Aunu~ Amount Largest Siz~ Container # Days on Site Lbs[ ] Gal [~] 1~3 [ C~es [ ] l Trade Sec~ [ ] Circle Which Months: Check if ~mical is a NON Trad~ S~ [ ~) DOT # (optional) ~ ~a~M[ ] CAS# ] Immediate Health (Acute) [ ]DelayedHealth(Chronic)~. USE CODE Mixture~ W~,~[ ] P,~tioactive[ 8) STORAGE CODES ~ 0 ] a) Container:. b) Pressure: ( c) Temperature ' ,a~ AIl Year, $, F, M, A, M, $, $, A, S, O, N, D 9) MIXTURE: Lis~ the three most b,o-,xlous chemical components or any AHM components COMPONEKr CAS# % WT [ ] [ ] [ ] 10)LOCATION (~og,O~ FMr--~E'~'cW-~'-gS ~~ ~ I certify under penalty of law, that I have lx~sonally ~mined and am familiar with the infonuation on this and all attached documents. I believe thc submitted iaformation is true, accurate and complete. Signatu~ Dat~ PRINT N~me & Tide of Authorized Company Rqx~ntative 8usine~s Name HAZARDOUS MATERIALS INVENTORY Address Page~ 1 ) INVENTORY STATUS: New [ CHEMICAL DESCRIPTION Revision.[ ] Deletion [ ] Check ifchemicai is a NON Trade Sec~t [ ] Trade Sec~t [ ] 2) Common Name: Chemical Name: 4) Physical & Health Hazard Categories Fi~ 5) WASTE'CLASSIFICATION I-Reactive [ 3) DOT # (optional), At-tM[ { c~# PHYSICAL HEAL TH ] Sudden Rel~.~ o£~ ~ lmm,~!,.e H~lth (AcuI~) [ ] Delayed I-I~th (Clmmic) [ (3-digit code from DHS Form ~022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid 7) AMOUN'r ANI) TIME AT FACILITY' Mu~ximum Daily Amount ,~ ~ Average Daily Amount ~-- ! '9 Annual Amount ~ t '7 Largest Size Cuntainer 2. ! '~ # Days'on $it~ '3 ~'"' 9) MIXTURE: Li~t the three most hazardous 1) chemical componmt~ or 2) any AHM compomm~ 3) c~'l Pu~{~l Mixtu~[ l' War~[ ] ~%~tiomiv~[ ] UNITS OF MEASURE 8) STORAGE CODES Lb~[ ]Cai[ ]~ a)Coatain~. curies [ ] b) l=~re: c) T~m~'a~ Circle Which Months: COMPONENT AIl Yesr, ~, F, M. A. M. $, ~, A. S, O, N, D CAS# % WI' [ ] [ ] I) INVENTORY STATUS: N,-w [ 2) Couuuou Nau~:., Ch~uuicai N~rr, e: ] Aaditim [ ] P,.md~iun [ ] Deletion [ ] 4) Physical & Health PHYSICAL Hazard Categories Fire [ ] Rea~ive [ ] Suddm Release ofPr~.s~re [ $) WASTE CLASSIFICATION J~)~)l I (3-digit ~ from DH8 Form 8022) 6) PHYSICAL STATE Solid [ ] Liquid [~] Gas [ ] Pure [ ] 9) MIXTURE: List /he thr~ most lmmrdom I) chemical components or 2) any AHM components 3) Ch~,kifch~muicalisaNONTrad~S~[ ]Tmd~S~n~[ ] 3) DOT # (optioml) AHM[ ] c~s# ] r...,.af,,,~ H~Ith (Acu~) [ ] D~y~! H~Ith (Clu~c) ~ USE CODE Mixtu~ [ ] . wastet~{ ~lio~ive [ ] 7) AMOUNT AND TIME AT FACILITY UNITS OF MEAS~ 8) STORAGE CODES Maximum Daily Amount ~O Lbs [ ] Gal [~e'] 123 [ ] a) Contains. Average Daily Amount f O Curies [ ] b) Pre~mu~: ! Annual Amount /OOO c) Temperature Largest Sm Container # Day~ on Site 3 coS- tin:lc Which Monde: All Year, $, F, M, A, M, I, I, A, S, O, N, D 5'! COMPONENT 10)LOCATION CAS# % WT [ ] [ ] I certify under penalty oflaw, that I have persunally examined and am familiar with the/nforma6on on tl~ and all attached documents. I believe the submittcd int'onnation is true, accurate and complete. PRINT Name & Tide of Authorized Company Representative Signature Date FACILITY NAME LO'~'~ % ADDRESS 9..(o 9,. g FACILITY CONTACT INSPECTION TIME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CH ECKLIST 1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301 INSPECTION DATE ~'-/4 t'~ PHONE NO. ~--rt BUSINESS ID NO. 15-210- aaC-r.~ NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program Routine 4~ Combined ~ Joint Agency [~ Multi-Agency [~l Complaint [~ Re-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact intbrmation 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 0 Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand 1 Any hazardous waste~n site?: t[~ Yes [~ No Explain: Questions regarding this inspection? Please call us at (805) 326-3979 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Business Site Responsible Party Inspector:.~/ /5~JttO~'~ FACILITY NAME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301 INSPECTION DATE Section 4: Hazardous Waste Generator Program EPA ID # CAO~-OOOOO t-74g' [] Routine ~1 Combined [] Joint Agency [~ Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA 1D Number (Phone: 916-324-1781 to ohtain EPA ID /4) Authorized tbr waste treatment and/or storage Reported release, fire. or explosion within 15 days ofoccurance Established or maintains a contingency plan and training Hazardous waste accumulation time fl-ames b/' Contain'ers in good condition and not leaking Containers are compatible with the hazardous waste vt/ Contaiuers are kept closed ~vhen not in use Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided Conducts dailv 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 hazardous waste ~vith completed manifest Sends manifest copies to DTSC Retains manifests tbr 3 years Retains hazardous waste analysis for 3 years Retains copies of used ()il receipts for 3 years Determines if waste is restricted ti'om land disposa! C=Conmliance V=Violation ~. / I.spector: Office,of Environmental Services (805) 326-3979 Business Site Responsible Party \Vhite - Env. Svcs. Pink - Business Copy FACILITY NAME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 INSPECTION DATE Section 5: Hazardous Waste Tier Permit Treatment Program [] Routine 4~ Combined I~ Joint Agency [] Multi-Agency ~ Complaint [] Re-inspection Onsite Treatment Unit Tier: l~l PBR [] CA ~ CESW Unit number & name: [] CESQT [~ CEL [] CECL OPERATION C V COMMENTS All h~ardous wastes treated are generated onsite Onsite treatment notification tbrms available and complete Onsite treatment unit tier and/or count is correct on form Unit number is correct on notification tbrm Number of tanks or containers is correct on form Treatment monthly volume is correct on form Waste identification & treatment is correct on form Complies with residual management requirements ~" Properly closed a treatment unit Complies with tank and containment certification Developed and maintains a written inspection log Meets pretreatment standards for waste discharge Developed and maintains a Closure Plan on site [PBRI Developed and maintains a Waste Analysis Plan and Waste Analysis Records IPBRI Maintains Training Records on site IPBRI, Obtained local permits for treatment operaiions IPBRI Identifies and labels Treatment Units IPBRI C=Compliance V=Violation ~ Inspector: ,~~ Office of Environmental Services (805) 326-3979 Business Site Responsible Party CA=Conditionally authorized CECL=Conditionally exempt commercial laundry CEL=Conditionally exempt limited White - Env. Svcs. CESW=Conditionally exempt specified wastestream CESQT=Conditionally exempt small quantity treatment PBR=Permit by rule Pink - Business Copy ~ · · . ( Department of Toxic Substances Contro! State of California - California Environmental' Protection Agency ' ,~ Page 1 of "7 oNSiTE HAZARDOUS WASTE TREATME~' NOTIFICATION FORM' FACILITY sPEcIFICNOTIFICATION' ' ~-]: Initial FOr Use by Hazardous Waste ·Generators Performing Treatrnen~ [~Amended - · Under Conditional Exempffon and: .Conditional: Authorization, and by.Permit By. Rule Facilities Please refer to the attached Instructions before completing this form. You may notify for more than one permitting tier by using this notification form, DTSC 1772. You must attach a separate Unit SPecific n°tificati°n f°rm f°r each.unit at this location.. There are different unit spec~c notification forms for five'of the categories and an additional notification form for transportable treatment units ' u onl have to submit forms for the tier(s)/category(ies) that cover your unit(s). Discard or recycle the Other unused ('ITU s). Yo y . ' ..... ..... i., ...... ,i indicate the total number of pages at the top of each page at rms, Number each age o]your comp(etea noajlcauonpuc^,~.~ -,,- · · '., - ' ..... ..... ~ ':~'ds must be f,°u. ,o .... ~ ' PPut your EPA ID Number on each page. Please provtae att oy the mjormaaon r.e, qu. es,ea:, ,,~. :,,~,__ oy__. " .~ ,.~ ...... ,, :- ,:~: .... :,~' Please tvve the information provtaea on tn. ts ]orm an, atty. completed except those that state tJ atjyer, ent or tj uva,,,,~,~ ...... . attachments. The notification fees are assessed on the basis of the highest tier the notifier will operate under and will be collec'ted by the State Board of Equalization. DO NOT SEND YOUR FEE PAYMENT wITH THIS NOTIFICATION FORM. F ~ NOTIFICATION CATEGORIES ~ ' ' . Indicate the. number Of units you operate in each tier. This will also. be the number of unit specific notification forms you II Lst.attach. Conditionally Exempt Small Quantity Treatment operators may not operate units under any other tier. Number of .units and' attache,d: unit sPecific notifications for each tier reported. A. Conditionally Exempt-Sinai! Quantity Treatment (CESQT) D. B. I COnditionally Exempt-Specified Wastestream (CESW) E. F. Permit by Rule (PBR) CE--Commercial Laundry (CE-CL) Conditionally Exempt-Limited (CEL) II.' GENERATOR IDENTIFICATION' EPA iV NUMBE c o 2_0 °o £ ' FACILITY NAME (DBA-Doing Business As). PHYSICAL LOCATION CITY' COUNTY CONTACT PERSON. (Fire NAme): CA ZIP 9 3 3VO'- (Last Name) PHONE .NUMBER(gO~) gT/ - ,,~.o, a3~ MAILING ADDREss, IF DIFFERENT: COMPANY NAME STREET. CITY "cOUNTRY ' ~ONTACT PERSON DTsc 1772~ (1/96) (0nly comple/e if not USA): (First i~m~) ~¢~-A~ 3e, ~r~. 2// STATE A,/O-~ ZIP 2770~i- (L~st Name) ' .. Page 1 YES EPA ID NUMBER (~ OO t'7~- RADIOACTIVE MATERIALS OR~ WASTE . Does the facility'use, store or treat, radioactive materials Or radioactive waste? 'Page 2 oF ~, IV. TYPE OF COMp-ANY: STANDARD INDUSTRIAL CLASSIFICATION (SIC)CODE: 'Use either One or two SIC codes (a four digit numbeO that best describe your company'S products, services, or industrial activity. Example: 7384 Photofinishing lab 7218 Industrial launderers First: ,.ff, C)/~.,~ '~'7'~q://.. ~7'tg,ct'~ Second: ~7~o°~/ '/~A/07~O/°~t)~''~lA/f~ /--,6b~ PRIOR PERMIT STATUS: NO ~ 5. Check yes or no to each question: Did you file a PBR Notice of Intent to Operate (DTSC Form 8462) in 1992 for this location?' Do you now have or have you ever held. a state or federal hazardous waste facility full permit or .interim status for any of these treatment~ units? Do. you now. have or have you ever held a state or federal: full permit or interim status for any other hazardous waste activities at this location? Have you ever held a variance issued by the Department of Toxic Substances Control for the treatment you are now notifying for at this location? Has this location ever been inspected by the state or any local agency as a hazardous waste generator? pRIOR-ENFORCEMENT HISTORY: NOt required from conditionally exempt generators or Commercial laUndries. Within the last three Years, has this facility been the subject of any convictions, judgments, settlements, or final: orders resulting from an action by any local, state,'0r federal environmental, hazardous waste, or Public health. ~nforcement agency? (For the purposes of this form., a. notice of violation does not constit, ute an order and need not be reported: unless it was nbt corrected and became a final order.): if you ansWered· Yes,.check this box and attach a listing of'convictions, judgments, settlements, or ordem mid~ a COPY of the cover ·sheet from each document. (See the Instructions for more informa, tion) ATTACItMENTS: Attachments are not required from commercial laundries. .. A plot plan/map detailing the location(s) of the covered unit(s) in relation to the facility boundaries. A unit specific notification form for each un)t to be COvered at this location. DTSC 1772 (1/96) Page 2 EPA ID-NUMBER etq,~ O0000174!. ,~ . ' ' Page3 CERTIFICATIONS:. This form must be signed by an authOrized corporate offiCer'or'any other per&in, has operational control fi'nd performs decision-makingfunctions that'govern operation of the facility (per Title 22;. California Code of Regulations (CCR) Section 66270. II). All three copies must have original signatur&: Waste Minimization I certify that I: have a p?ogram in place to red:uc~ the. voiiume; quantity, and: tox!c[t~' of was. te- gener.ated to.the degree I have' determined to be economically practicable, and~. that I, have, sel'ected~ the practicable., method~ of treatment, disposal currently available to me which minimizes the present an'd~ ~uture threat, to. human, healtk and Tiered Permitting Certification. I certify that the unit or uniti described in these'd0cuinenis meet the eligibii{iy hhd Oi~eratin~. requirements of state statutes and regulations for the indicated; p~nnittihg kier, including generator and: secondary containment, requirements. I understand that if any of the units operate under Permit by Rule or Cbnditional Authorization, I Will also the required financial assurance for closure of the treatment unit by October l', 1996. ' I certify under penalty of law that this document and all. attachments were prepared, under my. direction or sUpervisiOn in~ accord~ce. with a system designed to assure that qualified personnel- properly gather'` and evaluate the information, submit[ed:,. inquiry of the person or persons who manage the system, or those directly responsible for gathering the information',, the information, is, to the best of my knowledge and belief, true, aceui-ate, and complete.. I am aware that there are substantial penalties for submitting false information:, including the poss.ibility of fines and imprisonment for knowing violations. Name (Print or T/~lSe) Signature ' IXe Title Date Signed REQUESTING A SHORTENED REVIEW PERIOD: Generators 'operating under CA and/or CE are legally authorized to operate 60 days after submitting a complete notification. DT$C may shorten the time period between notification and authorization when the owner or operator establishes good cause. If you need to be authorized sooner than the standard 60-day period, please che[~c the box below and state the reason. Y~ur authorization will be automatically effective on the date your completed notification form is received by DT$C. (Use additional sheets, if necessaryO Reason: · OPERATING REQUIREMENTS: 'please note that generatOrs treating hazardOus waste onsi'te are .required to comply with a number of operating requirements which differ depending on the tier(s). These operating requirements~ are set fo)th in the statutes and. regulatiOns,... . some. ~°f which--~, are.. referenced in the Tier-ffpecific Fact Sheets available from.DTSC's regional and headquarters 'offi'ces; SUBMISSION PROCEDURES: 'AIt three forms must have original signatures; not photocopies. YoU must submit two copies of this completed notification by eertifiedl mail', return receipt requested, to: Department of Toxic Substances Control Program Data Management Section, HQ-10 Attn: TP Notifications - Form 1772 400 P Street, 4th Floor, Room 4453 (walk in only) P.O. Box 806. Sacramento, CA 95812-0806 You- must also submit one eo~¥ of the notification and attachments to the local' regulatory agency in your jurisdiction as listed in: Appendix 2 of the instruction materials. ~ou must also retainl a copy 'pm of y~our operating recoM(.- =' . ' ' PLEASE, DO NOT SEND yOUR FEE PAYMENT WITH: Tm~ FoRM-, DTSC 1772 (!/96) . .. \ . Page3 EPA ID NUMBER 'Page 4/of ,CONDITIONALLY EXES<I-PT - SPECIFIED WASTEST~AMS' UNIT SPECIFIC NOTIFICATION · '(pursuant to Health and 'Safety, Code Section 25201.5(c)y The Tier-Specific Fast Sheets contain a sumraary of tile operating requirements, for this category, please review those requirements carefully befOre compl'eting or submitting:this notification~ package. UNIT NAI~IE /~6/~12>~/'ff)/ 8&0a' ' UNIT ID NUMBER' aff/~ ,~ ~/ NLrMBER OF TREATMENT-DEVICES: ~ Tank(s) . -~-.' Container(s)/C0ntai~ner Treatment Area(s): Each unit must be clearly identified and labeled on the plot plan attached· to Form 177Z ASsign your own unique number to each unit. 'The number can be sequential (I, 2, 3) or using any system you choose. Eater the estimated monthly total volume of hazardous waste treated by this unit; This should be the maximum or highest amount treated in any month. IndiCate in the narrative (Section II) if your operations haue seasonal' variations. WASTESTREAMS AND TREATMENT PROCESSES: Estimated Monthly Total Volume Treated: Pounds and/or C~' 0 ~) gallons YES 'NOTE S. Is the waste treated in this unit radioactive? Is the waste treated in this unit a bio_hazardous/infectious/medical waste? Is remotely generated hazardous waste (HSC 25110.10) treated in this unit? 'The following are the eligible wastes~reams and treatment processes. '~ · Please check all applicable boxes: Treating reSins mixed or cured' in accordance with. the manufacturer's instructi~ns (including one-part and pre-impregnated materials)~ Treating containers of 1i0 gallons or less capacity that contained: hazard0usy waste by rinsing! Or physical:~ processes', such as crushing, shredding, grinding, or puncturing. Drying special wastes, as classified' by the department pursuant to Title 22, CCR, Section 66261.124, by pressing or by passive or heat-aided evaporation to remove water; Magnetic separation or screening to remove components from special wasfe, as. classified; by the department pursuaftt to Title 22, CCR, Section 6626L124¥ NO AUTHORIZATION IS NEEDED to neutralize acidic Or alkaline (basO Wastes fr6m the regonerati'0n' of'. ion exchange media, used to demineralize water:.' {To be eiigible f°r this exemPtiom: this. waste cannot cOntain more than 10 percent acid or base by weigM.) (Effective January I-, '1995). .' NO AUTHORIZATION IS NEEDED to neutralize acidic Or alkaline (base) wastes from the food proceSsing industi'y. (Effective January 1, 1996)'. Recovery of silver from photofinishing, The volume limit for conditional exemption, is 500 gallons per generator (at the same location) in any calendar month. Silver recovery from photofinishing .is completely exempt from authoriZation, requirements; if the.. quantity treated is 10 allons'or less in. any ealendar month, DO not complete this fqrm. if you qualif,~ Sot this. .. ' ~.g .... .,Ocum6ntation verifYing your eligibility for tliis'i exemption, su-eh a~ developer. ,nvo,ees ) exemption. [metmn u · .' :. Page 10 NOTE DTSC 1772B (1/96) EPA ID NUMBER' CONDITIONALLY EXEMPT- SPECIFIED W~STESTREAIvlS UNIT SPECIFIC NOTIFICATION '(pursuant to Health and Safety Code..Section 2520L5(c))~ · 8. Gravity separation of, the following, including the USe of, flo~culants and demuisifiers if,: . . [~ a. The settling of solids~ from: the waste where the resulting aqueous/liquid: stream, is not, haZardbus'~ . · [5-~: b. The separation of oil/Water mixtures and separation sludges, if the average oil rec0vefed per month, is~ [ess, than 25 barrels (42 gallons per b~rrel). (NOTE: AB 483 (Ch 625, 1995)allows· Certain used:' oil/w, a?er separation under.new the CEL category: See Form t772L and CEL Fact Sheet.). [~]: 9. Neutralizing acidic Or alkaline (basic) material: by a sta~e certified laboratory, a.laboratory operated, by an educational institution, or a laboratory which treats less than one gallon of onsite generated hazardous waste in anY single batch. (To be eligible for conditional eXemption, this waste cannot contain more than 10 pe~rcent aci'd or base by weight.) [---] 10. Hazardous'waste treatment is carried out in quality control or quality assurance laboratory at a facility that: is not an offsite hazardous waste facility. [] ' 1L A wastestream and treatment technology combination, certified by the Department pursuant to SectiOn 25200.1.5 of the Health and Safety Code as appropriate for authorization under CESW. Please enter certification number: (See Appendix 5) [-~: 12. The treatment of formaldehyde or glutaraldehyde by a health ~are facility using a technology combination .certified by the Department pursuant, to section 25200.1.5 of the, Health and~ ' Safety Code. - Please enter certification number: II. NARRATIVE DESCRIPTIONS: Provide a brief deS cripti°n of the specific waste treaied and the treatrnent Process used. 2'., T,i~EA-FMEN,TPROCESS(ES) USED: 8ILV, E~ /~Q~)~ff"~Y' /dX[l-/' III':... !~jSIDUAL MANAGEMENT: Cliecf: Yes or'No td each questiOn as it applies to all residuals from thi.._~s treatment unit. ', YES:' NO. : · ' discharge non-hazardous aqueous Waste, to a publicly owned .treatment works (poTVO/sewer? ~:!'.. 2. Do you. discharge non-hazardous aqueous waste under an NPDES permit? ~ ~"~! ' 37. Do yOu have your residual hazardous waste, hauled offsite by a registered hazardous waste hauler?' · If you dO:, where is the waste sent? Check all that apply; ~' a~ Offsite recycling ' ~]i b. Thermal treatment' E~!'. c. Disposal to land [--} d; Further treat, meAt - Do: y6u dispose of non-hazardOus solid, waste residues at an offsite location? . Other'method: o,f dispbsal~ Specie:' DTsc 1772B (1/96) ..... page EPA ID NUMBER d/4£ o 7 z,3 · CONDITIONALLY EXEMPT - SPECIFIED' WASTES'F .RE'AMS: UN}T SPECIFIC N©TIFICATION~., (pursuant to Health and Safety Code Section 25201.5(c)). rage Ct IV. BASIS FOR NoT NEEDING- A FEDERAL PERMI~T: to demonstrate eligibility for one of the onsite treatment tiers~ facilities are requi'red to provide the b'as(s for determining that In order ' ..... ......... e Conservation and Recovery Act (RCRAy and the federal· a hazardOus waste permit is not requirea unaer me feaerat ~xesoutc ~ . · regut[~tions adopted under RCRA (Title 40, Code of Federal~ Regulations (CFR)). ~ ' · Choose the reason(s)~ that de.s. cribe the operation of your onsite treatment .units: . ' The hazardous waste being treated is not a hazardous waste und'er' federal law although it is regulated as a hazardous, waste under California state law. The waste is treated, in wastewater treatment units (tanks), as defined in. 40' CFR Part 260.10, and discharged to a publicly owned treatment works (POTW)/sewering agency or. under an NPDES permit. 40 CF~R 264. l(g)(6)and* 40 CFR 270.2. '... The waste is treated in elemehtary neutrali:zation unRs~ as del'reed in. 40 CFR Part 260.10, and discharged to a POTW/sewering agency or under an, NPDES permit. 40 CFR 264,.1(g)(6) and 40 CFR 270~2. The waste is treated in a totally enclosed treatment facility as defined in 40 CFR Part 260.10; 40 CFR 264. l(g)(5). The company generates no more than 100 kg (approximately 27 gallons) of hazardous waste in a calendar month and is eligible as a federal conditionally exempt small quantity generator. 40 CFR 260.10 and 40 CFR 261.5. The waste is treated in an accumulation tank. or container within, 90 days for over 1000 kg/month generators and' 180: Or 270 days for g~nerators of '100 to 1000 kg/month. 40 CFR 262~.34~:, 40 CFR 270. ~(c)(2)(i):, and~. the Preamble. to the March 24, 1986 Federal Register. Recyclable materials are reclaimed to recover economically significant amounts of silver or other precious metal:s, 40 CFR 261.6(a)(2)(iv), 40 CFR 264. l(g)(2),, and 40 CFR 266.70:. [] 8~ EmptY'. cont'ainer rinsing and/Or treatment. 40 C~R 26L7. [] '9. Other: Specify: TRANSPORTABLE TREATMENT UNIT: Check Yes or No: Please refer to the Instructions for more informati°n` YES [7--']: Is this unit a. Transportable Treatment Unit? If you answered yes, you must also complete and attach Form 1772E to this page. (. DTSC 1772B (1/96) Page 12