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HomeMy WebLinkAboutHAZARDOUS WASTE BUS PLAN! Permit Opera Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE ........ ~.~,,,,?~"?~!':?:?i?i?~!???~,~,~, ....... This permit is issued for the following: D" ...... ~,~,~?f?~'~'~ ~i~i~:~i,::;:i,'::'::ilf,,::::;;;:;:iiii:::9.:::i:?E~!Hazardous Materials Plan ,?'~i!*:]"i'.:~i~,i::!!:/?:':Ri ;ili!i i i?. iiiiiiiii~iii~erground Storage of Hazardous Materials CARLOS AUTO REPAIR ,~,~,,,~-~ ,,~:i.?,- ,~i~,,~?...,~.-~i,,?:.:,:~?,.~:-".~. :~.~.~:-' :,,,..~:,~!~.,~?ii?,~..:,~i~ous Waste LOCATION 1131 NILES ii!,:iiii?~¢;i~i~,iill :i :;/ BA~S~j~D CA ~i, ~.,,..'...,;il ii? ?7 -,; '''~" ............ ,"::.,.'% ". '~..i~iB~:,l~ ~ ,~ ~l'J~ ~:. '~' ' ........ TAN H~RDOUS SUBSTANCE CAPACI~Y: ;~;~GAL ~E~:'];~;;~,~;**: :~1~(,~ ~'~.~{~*~; ~ {~;;; ;;:~AN~~ ~A~K PIPING PIPING PIPING PIPING ::~;:;"""::~.~--......~ '~"' ~:'~'~,,,..-, IN~[' '~;~; ~ ~'~'i'~ ~NIt~ ~:~Ni~oR TYPE TYPE METHOD ~ ONITOR .......... ,~. GAL WASTE OIL 200 __ ~?"::"::" ,:::'.:u ~u S ,,~:~C SW S C~VI~ N/A · ~:.-..-"--'~ ':~ ~*:u~ .'%,' r.. "?: ~,~' ' ~ ~ 'h,..? .,.;:' ~,~t~. ~' ~ ~' lssu~ by: ~~~ Bakersfield Fke Depa~ment Cheaer Approv~ by: ~~~-' 1715 Av~., }rd ~loor ~c~  B~enfiel~ CA 93301 Voice (805) 326-3979 F~ (805)~26-0S76 Expiration Date: dUn~ ~0~ ~000 %' S~TE DIAGFL~M 3umness Nc:me: FACILITY DIAGRAM Fcr C,"fica Use CnW !nsmec:~cn StcTion: Are<: Mc~ .~ NORTH ~f STATEMENT OF ACCOUNT CITY OF 8A~ ..... ~' ~ P 0 ~OX 2057 BAKERSFIELD, CA 93303-2057 TO: CUSTOMER NO: CHARGE DATE CARLOS AUTO REPAIR'/.' -P'A½ERSFIELD, '= ~ ",' ?/oi/oo BEr~ I NN!f',io, ' ..... "~" ' CUSTOMER TYPE: ES/ UE- DATE DATE: 10/01/00 FOR GUESTIONS OR CHANOES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. 9449 TOTAL AMOUNT 368. CURRENT OVER 30 OVER 60 OVER 90 - 3458._25 DUE DATE: 10/3i/00 PAYMENT DUE' 388.25 TOTAL DUE- $368.25 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD P 0 BOX 2057 TO: CUSTOMER NO' (661) 32&,3979 ~ CARLOS AUTO REPAIR ii3i NILES ST BAKERSFIELD, CA~9~05 '~ ~449 DATE: 9/01/00 CUSTOMER TYPE: ES/ 9449 8/01/00 BEQINNINQ BALANCE /REF-NUMB- -r~- ~,, AME)E~N-T 368. 25 FOR 8UESTIONS OR CHANQES TO YOUR PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER &O OVER 90 170.00 DUE DATE: 10/02/00 198.25 PAYMENT DUE' 368.25 TOTAL DUE' $3~8.25 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD P 0 BOX 2057 T ,~AF..E,=..SF~E~.D, CA 93303-20~7 TO: CARLOS AUTO REPAIR iisi NILES ST BAKERSFIELD, CA gSg05 DATE: 8/01/00 CUSTOMER NO: ~449 CUSTOMER TYPE: ES/ ~RE~=NL~.ER--DUE,,-DATE 3~8.25 FOR QUESTIONS OR CHAN~ES TO YOUR ACCOUNT PLEASE .~L~ THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER &O OVER ~0 170.00 I78.25 TOTAL DUE: $368.25 CUSTOMER NO: 9449 CUSTOMER TYPE: TOTAL DUE: $368.25 STATEMENT OF ACCOUNT CITY OF BAKERSFIELD P 0 BOX 2057 BAKERSFIELD, CA ~3303-2057 TO: CARLOS AUTO REPAIR il3i NILES ST BAKERSFIELD, CA 93305 (661) 326-3979 DATE: 11/01/00 CUSTOMER NO' ~44~ CUSTOMER TYPE: ES/ CHARGE DATE DESCRIPTION REF-NUMBER DUE'DATE TOTAL AMOUNT 10/01/00 BE~INNIN~ BALANCE 3~8.25 FOR ~UESTIONS OR CHANQES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. CURRENT OVER 30 OVER 60 OVER ~0 DUE DATE: 1~/0i/00 PAYMENT DUE: TOTAL DUE: $368.25 ' ~AKERSFiELD CUSTOMER,~NO: CA (661) CUSTOMER TYPE: ES/ TOTAL DUE: ~44~ $368.25 FACILITY NAME 0--4r~io% 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 INSPECTION DATE [ O -- PHONENO. T>'2-q -- ~'z'~'-''~' BUSINESS IDNO. 15-210- NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program []~l/Routine [] Combined [] Joint Agency [] Multi-Agency ~ Complaint [~1 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 vt ', Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardous waste on site?: Explain: [do/~ ~'¢o&_ rb~-o~0 fi_.. ~es [~ No Questions regarding this inspection? Please call us at (661) 326-3979 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy ~usineSs'Site Responsible Party Inspector: ~q~gT ¢o'Tle-~,~ CARLOS AUTO REPAIR Manager : I~ ~At~z- ~4~ Location: .t~I~,~o ST City : BAKERSFIELD SiteID: 015-021-001744 BusPhone: (661) 324-3225 Map : 103 CommHaz : Low Grid: 28A FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 02 EPA Numb: .~ SIC Code:7538 DunnBrad: Emergency Contact / Title CARLOS PAGUAGA / OWNER Business Phone: (661) 324-3225x~%~.~ 24-Hour Phone : (661) 6~-~o~c~- ~ Pager Phone : ( ) - x Emergency Contact Business Phone: ( 24-Hour Phone : ( Pager Phone : ( / Title / ) - x ) - x ) - x Hazmat Hazards: Fire DelHlth Contact : MailAddr: 1131 NILES ST City : BAKERSFIELD Phone: (661) 324-3225x State: CA Zip : 93305 Owner CARLOS PAGUAGA Address : 1131 NILES ST City : BAKERSFIELD Phone: (661) 634-0264x State: CA Zip : 93305 Period : Preparer: Certif'd: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: = Hazmat Inventory --As Designated Order Hazmat Common Name... WASTE OIL One Unified List Ail Materials at Site ISpeoHazlEPA HazardsI Frm I DailyMax UnitlMcP F DH L 55.00 GAL Low 1 07/19/2000 CARLOS AUTO REPAIR Manager : Location: 1131 NILES ST City : BAKERSFIELD CommCode: BAKERSFIELD STATION 02 EPA Numb: ~.~,~ ~z~:.~zL_~/ ~lEe±D: ~1b-000-001744 Bu~Phone: (805) 324-3225 Ma~ : 103 CommHaz : Low Gr~d: 28A FacUnits: 1 AOV: SIC Code:7538 DunnBrad: Emergency Contact CARLOS PAGUAGA BuSiness Phone: 24-Hour Phone : Pager Phone : / Title / OWNER (805) 324-3225x (805) 634-0264x ( ) - x Emergency Contact Business Phone: 24-Hour Phone : Pager Phone : / Title / ( ) - x ( ) - x ( ) - x Hazmat Hazards: Fire DelHlth Contact : MailAddr: 1131 NILES ST City : BAKERSFIELD Phone: ( ) State: CA Zip : 93305 X Owner CARLOS PAGUAGA Address : 1131 NILES ST City : BAKERSFIELD Phone: (805) State: CA Zip : 93305 634-0264x Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: : Hazmat Inventory --Alphabetical Order One Unified List Ail Materials at Site Hazmat Common Name... ISpecHazlEPA HazardsI Frm DailyMax Unit MCP WASTE OIL F DH L GAL Low i, (~i ¢\05 ¢ckqOo, Of~Do hereby certify that I' ", {Type or print nan~e~ reviewed tbs attached hazardous materials ment plan ~,, that along with any corrections constitute a complete and correct msn- agement plan for my facility. ~~gna~Jre 06/08/1999 CARLOS AUTO REPAIR SiteID: 215-000-001744 = Inventory Item 0001 Facility Unit: Fixed Containers at Site ~vUVl~ ~Vl~ / ~1 ~,~Mu WASTE OIL Days On Site 365 Location within this Facility Unit Map: Grid: ~ CAS# FSTATE TYPE Liquid~I Waste ~k/ PRESSURE Ambient TEMPERATURE CONTAINER TYPE Ambient ~1 DRUM/BARREL-METALLIC Largest Container 55.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum GAL Daily Average GAL %Wt. 100.00 Waste Oil, HAZARDOUS COMPONENTS Petroleum Based CAS# TSecret No HAZARD ASSESSMENTS Radi°active/Am°unt I EPA HazardsINO/ Curies F DH NFPA /// USDOT# I MCP Low 06/08/1999 CARLOS AUTO REPAIR SiteID: 215-000-001744 Fast Format ~ Notif./Evacuation/Medical -- Agency Notification TELEPHONE IN SHOP TO CALL 9-1-1. Overall Site 08/12/1996 -- Employee Notif./Evacuation VERBAL 08/12/1996 -- Public Notif./Evacuation THROUGH GATE TO NORTH CORNER OF YARD. 08/12/1996 Emergency Medical Plan FIRST AID KIT IN OFFICE. KERN MEDICAL CENTER: 1830 FLOWER STREET, 326-2000. 08/12/1996 3 06/08/1999 CARLOS AUTO REPAIR SiteID: 215-000-001744 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site --Release Prevention 08/12/1996 WASTE OIL D~I~ED FROM PANS I~rO --Release Containment ABSORBANTS AVAILABLE TO CLEAN UP' SPILLS. 08/12/1996 -- Clean Up 08/12/1996 ENVIROPUR WEST PICKS UP WASTE OIL BAKERSFIELD UNIFORM AND TOWEL PICKS UP ABSORBANTS. Other Resource Activation -4- 06/08/1999 CARLOS AUTO REPAIR SiteID: 215-000-001744 Fast Format Site Emergency Factors Special Hazards Overall Site Utility Shut-Offs NATURAL GAS/PROPANE: N/A ELECTRICAL: INSIDE WEST WALL OF SHOP WATER: ?? SPECIAL: N/A 08/12/1996. Fire Protec./Avail. Water 08/12/1996 PRIVATE FIRE PROTECTION: PORTABLE FIRE EXTINGUISHERS, FIRE HYDRANT IN ALLEY SOUTHEAST OF PROPERTY. Building Occupancy Level -5- 06/08/1999 CARLOS AUTO REPAIR SiteID: 215-000-001744 Fast Format Training -- Employee Training NUMBER OF EMPLOYEES: ???? ~ MATERIAL SAFETY DATA SHEETS ON FILE: N/A WASTE OIL BRIEF SUMMARY OF TRAINING PROGRAM: ????? Overall Site 08/12/1996 -- Page 2 --Held for Future Use Held for Future Use -6- 06/08/1999 MISCELLANEOUS RECEIVABLES ADJUSTMENT NEWACCOUNT ~ ADDRESS CHANGE CLOSE ACCT OTHER ADJ CUSTOMER NAME MAILING ADDRESS CITY STATE ZIP CODE SITE ADDRESS PARCEL NUMBER ADJUSTMENT ~CHG DATE I : i CHARGE CODE ADJUSTMENT AMOUNT APPROVED BY FACILITY NAME C p,.L ADDRESS FACILITY CONTACT INSPECTION TIME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CH ECKLIST 1715 Chester Ave., 3r~ Floor, Bakersfield, CA 93301 INSPECTION DATE PHONE NO. 32 ~- 3 BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program [~Routine [] Combined [22i Joint Agency 121 Multi-Agency 121 Complaint ~.j 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 Containers properly labeled Housekeeping ,/ Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardous waste on ,site?: .[~ Yes [21 No Explain: [,O~-~T ~ CD '~ Questions regarding this inspection? Please call tis at (805) 326-3979 While - Env. Svcs. Yellow - Station Copy Pink - Business Copy Business Site Responsible Party Inspector: BAKERS ELD CITY FIRE DEPJ TMENT HAZARDOUS MATERIALS DIVISION I715 'CHESTER ',AV£~ BAKERSFIELD, GA. 93301 HAZARDOUS MATERIALS MANAGEMENTPLAN INSTRUCTIONS: To avoid further action, return this form within 30 days of receipt. ~PE1PRINT ANSWERS IN ENGLISH. Answer the auestions Oelow for ~he business cs a whole. Be I~riet cna concL~e cs ~ossiDle. SECTION 1' BUSINESS IDENTIFICATION DATA ~USINESS NAME: C i-~,~S ~z.)~ ADDRESS: SIC CODE: SECTION 2: EMERGENCY NOTIFICATION: CONTAC";' TITLE ~US. PHONE 2~ HR. PHONE :azardous ~a~eriais Division HAZAEDOUS MATEEIAL$ MANAOEMENT PLAN SECTION 3: TRAINING: NUMBER OF-EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: ,~d/A ~^~.-n.~ o~c. ,~,,,jc,c.., BRIEF SUMMARY OF TRAINING PROGRAM: SECT[ON 4: EXEMPTION REQUEST: "": , _HALt, OF ,~'ERJURY ~ .... " ' ~" ~ CERTIFY UNO-'-:, ':~' -v - ,,~A~ MY ~UStNE~'~ IS 6' = ,..,(,...MPT FROM THE ,REPORTING REGUIRE:'vlENTS CF CHAPTER 5.c-75 OF THE "CALIFORNIA HEALTH & SAFETY CODE" FC.R THE FOLLOWING REASONS: WE DO NOT HANDLE HAZARDCUS MATE:',~IALS. WE DO ''~ ^' '- " -' - ' ,,,--,NDL= mAZ'ARDCUS MATERIALS, SUT ~HE QUANTITIES AT NO TiM~ .... -, -, r_:,(C;::_, ~= MINIMUM RE?CRTiNG ~.UANTrTtES. SECTION 5: CERTIFiCATiON' i, ,,~./~ '~ ._.xf~r~b'Z~¢../:).¢¢~, CERTIFY THAT THE ABOVE INFOR- MATION'IS ~CC~R~-~. ~-NDERSTANO THAT THIS INFORMATION WILL 8E USED TO FULFILL MY FIRM'S CSLIGATIC, NS UNDER THE "CALIFORNIA"mEAL.HZ AND SAF~ CODE" ON HA~RDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT IN~INFQRMAT[C N. CONSTITUTE5 PERJURY. - si~ATuRE TITLE OA~E. Hazardous HAZARDOUS MATERIALS MANAGEMENT PLAN Facility Unit Name: SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES: AGENCY NOTIFICATION PROCEDURES: EMPLOYEE NOTIFICATION AND EVACUATION: E:MERGENC',z MEDICAL B ~kersfielc]. Fire Dept. Hazardous ~aterisJs D[~sion HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: RELEASE PREVENTION STEPS: O,C- i~ tFL-/~C'O . ,,~'co -r/~/d't~ u<. ,,~ ~ RELEASE-CONTAINMENT AND/OR MINIMIZATION: SECTION 8: UTILITY SHUT-OFFS (,L~,,..,.,-..,tICN OF SHUT-OFFS AT YOUR FACILtTY) WATER' L~ .... rES/NC) ,~ ~.,...~Cv' SECTION 9: PRIVATE FIRE PROTECTiON/WATER AVAILABILITY: A. PRIVATE FiRE PROTECTION: ~"-{ro~ WATER AVAILABIUTY (FIRE HYDRANT)' SITE DIAGFL~M Business Nc:me: BuSiness AC:Cress: FAGZI. JTY DIAGRAM Far Office Use Only !nscec:ian Stc,'tan: NORTH ot BAKERSFIELD CITY FIRE DEPARTMENT · HAZARDOUS MATERIALS INVEN'i RY 3usiness Name (~/~LO~ Address Page._oL CHEMICAL DESCRIPTION 1) INVENTORY STATUS: NewJ~i~ Addition( ] Revision[ ] Deletion[ ] Cheei(ifclmmioaiisaNONTRAD~SECRET' [ ]" TRADE SECRET [ ] 2) Cerumen Name: ~/:~,~""[~ 4:~ ~ (-- 3) DOT # ChemicaJ Name: AHM [ ] CAS 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARDCATEGQRIES Fire [~ Reacave[ ] Sudden Release of Pressure [ ] ImmediateHeaith'(Acute) [ ] DelWedl'MallJt(Chronio) 5) WASTE CLASSIFICATION ~. '7_ { ,(3-digit code from DHS Form 8022) USE CODE '~ ~ 6) PHYSICAL STATE Solid { ] Liquid [,~ Gas [ ] Pure [ ] Mixture [ ] Waste ~ Radiea¢~ [ ] AMOUNT AND TIME AT FAClUTY Mammum Daily Amount: Average Daily Amount: Annual Amount: largest Size'Container. # Days On Site UNITS OF MEASURE 8) STORAGE CODES lbs [] gal [] ft3 [ ] a) Container. cunas[ ] b) Pressure: c) Temperature: Cimle Which Months: All Year. J, F, M, A. M, J, J, A, S, O, N, D COMPONENT CAS # 9) MIXTURE: List % WT AHM the mree most hazardous / (~---~ [ ] chemical components or any AHM components 2). [ ] 3). [ ] 10) Location (..)/~J~C'~-C~J'xJO T~,J ~ OUT~O~' 5; c.3 ~_~__.)~f'~ (:3(5'- S~O~' CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New { ] Addition [ ] Revision [ ] Deletion [ ] Check if chemicai is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Hea~th (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACIUTY Maximum Daily Amount: Average Daily Amount: Annual Amount: Largest Size Container: # Days On Site UNITS OF MEASURE curies [ ] 8) STORAGE CODES a) Container: b) Pressure: c) Temperature: Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, O 9) MIXTURE: List the three most hazardous chemical components or any AHM components ~) 2) 3) COMPONENT CAS # % WT AHM [] [] [1 10) Location cer~fy under penally of law, tllat I have personally examinee1 ancJ am famitiar w/th Ute infome~ion~$ =ubmitted infermation is lrl~e, accurate, and complete. Signature~ PRINT ~ ~ Title of Aulh~r~zed~,omp~rRepresentatlve and all aeecheO documents. I believe Date BAKERSF LD CITY FIRE DEPARTMENT HAZARt:)OUS MATERIALS INVENTORY usiness Name Address Page_of__ CHEMICAL DESCRIPTION: INVENTORY STATUS: New I ] Addition ( ] Revision [ ] Deletion [ ] Cheek if chemicaJ i~ · NON TRADE SECRET [ ] TRN:~ SECRET [ ] 2) Common Name: 3) DOT e Chemical Name: AHM [ ] CAS 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEC..-~RIES Fire [ ] Reactive ( ] Sudden Release of Pressure [ ] Immediate Health(Acute) [ ] Delayed He~tt(Cluonic) [ ] 5) WASTE CLASSIFICATION .(3-digit code from OHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ]. 7) AMOUNT AND TIME AT FAClUTY Maximum Daily Amount: Average Daily Amount: Annual Amount: Largest Size Container: # Days On Site UNITS OF MEASURE 8) STORAGE CODES lbs [ ] ga [ ] ~t3 [ ] a) Conmner. curies [ ] b) Pressure: c) Temperature: Cimle Which Months: All Year, J, F, M, A, M, J, J, A, S, O. N. D 9) MIXTURE: List the three most hazardous chemical components or any AHM components COMPONENT CAS # % W'F AHM ~) [] 2). [ ] 3) [ ] 10) Location CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New[ ] Addition[ ] Revision( ] Deletion[ ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid { ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount: Average Daily Amount: Annual Amount: Largest Size Contmner: # Days On Site UNITS OF MEASURE 8) STORAGE CODES lbs [ ] gal [ ] ~3 [ ] a) Container. curies [ ] b) Pressure: c) Temperature: Circle Which Months: All Year, J, F, M, A, M, J, J, A, S, O, N, D 9) MIXTURE: List the three most hazardous chemicaJ compenents or any AHM components COMPONENT CAS # %WT AHM ~). [] 2) [ ] 3) [ ] 10) Location cer~fy un~er penalty of law, that I have personally exarnine<~ and am familiar with the infomaOon submitted on this ~ ali allacl~e~i ~locumen~ I believe .~bmiitecl informabon is true, accurate, and complete. RINT Name & 7~tle of Authorized Company Representa#ve Signature Date BAKEII~FIELD CITY FIRE DEPARTMENT ~ OFFICE OF ENVIRONMENTAL SERVICES 1715 CHESTER AVENUE, 3RD FLOOR ' ~ ,~(~ BAKERSFIELD, CA 93301 ~4 ~-~' (805) 326-3979 """ (_,~6~ck HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: SECUON" -~USINESS iD' " '-"^ ~ '~ CODE' £E'-Ti'^N~ ',,., ~' :MZOGENC',/_., .NOTtF!CAT;C',~..,. cc;<,:.:,c: '"'~ .... lQ --'~ mR. ,",m NE 6 $4 - 0?--44- HAZARDOUS MAIER~A[$ MANAGEM~NI PtAN SECTION ,3: TRAINING: NUMBER Cf: EMPLOYEES' MATERIAL SAFE?,/DATA SHEETS ON FILE: BRIEF ~UMMARY CF TRAINING PROGR/-,M. '~ECTfCN ~' -. :,-,:.,"IPTfCN REQUEST: /ECTICN 5: 'CE.qT[F!C.Z, TiCN: · , ~ E;";.TiF',¢ -' ',', - --- ~ ,'-':,'~ ~ ~ .... '.:,aCVE !NFCR- ' '"-: ~ ,~L ~ ~,~ ,-,,~ ,~,-,~ :r-:,~, ~r'~r-, r' '-' ' Nr",_,xMA,~CN WiLL := USED TO :UL'--:II MYF!2;"¢ ........r',,,o .............. =>,L!m ,aND SAF_=?¢ CODE' 'SN H,,z, LA.R"'""': ~ '' ~'~.,..~ M,-,,, ::',iALS (~"' ' ""'c :.C. 255C0 ET ,-,L., .-'.ND THAT iNACCURATE iNFCRMAT;CN C"',x~::-: '-:~ ::,': ~, ,."',v ,~IGNAi u,~r_ TITLE DATE ..... HAZARDOUS MATERIALS MANAGEMENT PLAN Fcciiify Unit N~:me: SECTION 6' NOT[FICATi©N AND 5VACLJATiCN PR©CSDURES' AGF_NC':' NCTiFiCATICN s~C"' .... c-'' 13 a~ers~_ek~ ?;~e De~c. HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: :,,.. =.,-,,., = -' ,q E'/ENT!C N ~'r,_- = ~, :R =LEA£E-C C NTAIN M ENT ,-, N ?',' C'',._, , >,,1tN IM,Z,~, ~N' ~'ECTICN '"' ?RIVATE FiR: ?RCTECTIC"' ~ _ ,,,, ,..,,-., ~x AVAILABILIT",": WATER AVAILABILITY (FIRE HYORANq' ~,,3 Ad.-C---Y ~ ¢ c~' ¢'&~¢'~-<-'rr¢ BAKERSFIELD CITY FIRE DEP ,RTMENT H DOUS MATERIALS INVEI R ORY }usiness Name ~5,v?,.Lc_3 % A-~J'i--c..3 Address Page_of_ CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New {~] Addition [ ] Revision { ] Deletion { ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: /../%2~' 5~_.. ~ [ ~ 3) DOT # (option,d) ChemicaJ Name: AHM [ ] CAS #. 4) PHYSICAL & HEALTH HAZARD CATEGORIES HEALTH Immediate HeeJth (Acute) [ ] Delayed Hea~th (Chronic) 5) WASTE CLASSIFICATION "7.."'~ ( (3-digit code from DHS Form 8022) USE CCDE /-----~ 6) PHYSICAL STATE Solid [ ] Liquid ~' Gas [ ] Pure [ ] Mixture { ] Waste ~ Radioactive [ ] ' 7) AMOUNT AND TIME AT FACILITY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: /~'~ lbs [ ] ga~ ~ ft3 [ ] a) Container: Average Daily Amount: cunes[ ] b) Pressure: Annual Amount: c) Temperature: !_argest Size'Container: # Days On Site PHYSICAL Fire [~' Reactive [ ] Sudden Releaseof Pressure Circle Which Months: All Year. J, F, M, A. M, J, J, A, S, O, N, D 9) MIXTURE: Dst the three most hazardous chemical components or any AHM components COMPONENT CAS # % w'r; AHM 1) [] [ ] [] 10) Location ~)'AJ'b~,~C~AJ~) CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemicaJ is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT # (option-i) ChemicaJ Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAT..~O CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ } Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3-dig~t code fi.om DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TiME AT FACIUTY Maximum Daily Amount: Average Daily Amount: Annum Amount: Largest Size Container: # Oays On Site UNITS OF MEASURE 8) STORAGE CODES tbs [ ] ga~ ( ] fi3 [ ] a) Container: curies [ ] b) Pressure: c) Temperature: Circle Which Months: All Year, J, F, M, A, M. J. J, A, S, O, N, D 9) MIXTURE: Ust the three most hazardous chemicaJ components or any AHM components COMPONENT CAS # % WT AHM ~) [] 2) [ ] 3) [] 10) Loc. re:ion certify unoer pena~y o/taw, may i nave ~3ersona/ly examtneo aha am reran/ar w/~ ~ne /ntoma~on s~i$ eno ~ut artacneo document, l believe me · submittedinformat]'onis~'ue, accurate, andcomplete. ~/7/~ PRINT Name & Title of Au~onzeci Corn:)any F{eoresentetJve Sigr~re ~[ Date BAKERSFiljrD CITY FIRE DEPAR ENT HAZARD13US MATERIALS INVENTOWY ~siness Name Address Page_of _ ' CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion { ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT # (optionaJ) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive ( ] Sudden Release of Pressure [ ] Immediate HeaJth (Acute) [ ] Delayed HeaJth (Chronic) 5) WASTE CLASSIFICATION ,(3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TiME AT FACILITY Maximum Daily Amount: Average Daily Amount: AnnuaJ Amount: Largest Size Container: # Days On Site UNITS OF MEASURE 8) STORAGE CODES lbs [ ] gal [ ] ft3 [ ] a) ContaJner: cunes[ ] b) Pressure: c) Temperature: Circle Which Months: All Year. J. F, M, A, M. J, J, A. S, O, N, D 9) MIXTURE: List the three most hazardous chemicaJ components or any AHM components COMPONENT CAS # % WT AHM 2) [ ] 3) [ 1 10) Location CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ ] Addition [ ] Revision { ] Deletion ( ] Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Name: 3) DOT # (optionaJ) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive ( ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed HeaJth (Chronic) [ ] 5) WASTE CLASSIFICAT~ON (3-digit code from OHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] Liquid [ ] Gas [ ] Pure [ ] Mixture { ] Waste [ ] Radioactive [ ] 7) AMOUNT AND TiME AT FACILITY Maximum Daily Amount: Average IDa~iy Amount: Annuai Amount: Largest Size Container: # Days On Site UNITS OF MEASURE 8) STORAGE CODES lbs [ ]gai [ ] ~3 [ ] a) Container: curies [ ] b) Pressure: c) Temperature: Circle Which Months: All Year. J, F, M. A, M. J, J, A, S, O. N. D 9) MIXTURE: List the three most hazarOous chemicaJ components or a. ny AHM components COMPONENT CAS # % ~ AHM ~) [] 2), [ ] 3) [ I 1 O) Location cer~f~ uno'er pena~y of law, thor t have ~ersonady examtneo eno am laminar win ~he ~nfomar~on suDmirteo on ~his and ail attached documents, i Del~eve ~e uDmitte~t information is t~'ue, accurate, end complete. )RINT Name & Title of Au~tionzecl Com~any F{epresentatJve Signature Date