The URL can be used to link to this page

Home My WebLink AboutBUSINESS PLAN~'~ ~ ~ THOMAS A GORDON DDS ({ ,, ,~ ~aR ~'~~+i 500 OLD RIV-ER RD #225 ~. ~ \ - ~ 3~ ~~ ~ ~~ n ~~ ~., ~~~:, Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE PERM1T ID # 015-021-002131 THOMAS GORDON DB LOCATION: 500 OLD RIVER RO~[~'?-? ,~:.~. · ' ~'. '.i ~ .- This Dermit is issued for the followin_a: [] Hazardous Materials Plan [3 Underground Storage of HazardOus Materials [] Risk Management Program [] Hazardous Waste On-Site Treatment AKERSFIELD CA 93311 Issued by: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES' 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Approved by: Expiration Date: June 30. 2003 Issue Date Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This oermit is issued for the following: [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials I:] Risk Management Program [] Hazardous Waste On-Site Treatment PERMIT ID # 015-021-002131 THOMAS A GORDON, dba ADEPT DENTAL. CA 93311 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: Office of Eviro~ Services June 30; 2003 FEB 8 ~001 ' Issue Date Adept Dental l~'s Pemml Office Dr~s Re~troom Opemtory #1 Opemtory #2 Operatory #3 Restroom 1 ~_~ Consultation Room · Front Office [] Haz Waste 4~ Eye Wash Station ~:~ Stefilimr Patient Waiting Room Compressor Room (~Safety Compliance $~awie~a (818) 552-2114 Opemtory ~4 Operatory. #5 Room Laboratory Lunch Room Safety M~mual MSDS Mamlal ~¢CZ¢ X-R~ Water Fountain Medication Sprinkler CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN I R~.C'.EIVED I -1-1-1~$TRUCTIONS:I .JAN 1 1 200!~J.] 1. To avoid fur~.ction, rearm within 2. TYPE/PRINT ~IQS WER~I19~ENGLI S H. 3. 4. - 5. 30 days of receipt. Answer the questions below for the business as a whole. Be as brief-and conciseas 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 BUSINESS NAME: LOCATION: ~ 00 MAILII%IG ADDRESS: 500 Old CITY: Bakersfield PRIMARY ACTIVITY: Dent'.al OWNER: Dr Thomas ~dept Dental Office Old River Rd. Ste~225 River Rd ste #225 STAT~ Ca Gordon MAILING ADDRESS: ~an a~,q ~ .... ~,q .~,-^ ..~ __ZIP:93311PHONE561 6641814 PHONE: ~1 ~/11 al 4 Bakar.qfi ~1 d Cal ~ZS~I ~ EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II. 1: DISCOVERY AND NOTIFICATIONS LEAK DETECTION AND MONITORING PROCEDURES: The machine is checked daily (visional) A0 Bo EMPLOYEE AND AGENCY NOTIFICATION: verbal Co ENVIRONMENTAL RESPONSE MANAGEMENT: Asst would notify managment. Xray solution are called for pick up. D0 EMERGENCY MEDICAL PLAN~. Persons are referred to Mercy Southwest 400 Old River Rd 663-6000 Bakersfield, Ca 93311 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION I1.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: Location of Hazard container in coroner away from traffic and out of walk way. .of darkroom Bo RELEASE CONTAINMENT AND/OK. MITIGATION: __Se~Qndar¥.cQntain.e.rs'provided~ .... CLEAN-UPANDRECOVERY PROCEDURES: Spill kits on location Xray solutions will be called for pick-up UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NA/IJ~LGAS~PROPPdXFE: Down stairs.:south side of build, ina ELECTRICAL:~Wall paneI East'~'s~de~ of darkroom. SPEC~L: v ~ LOCKBOX: ~O IFPS, LOCATION: down gta~s_ . ~nnrs PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. ' PRIVATE FIRE PROTECTIQN: Fire dept. only B0 WATER AVAILABILITY (FIRE HYDRANT): North & south side building HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING NUMBER OF EMPLOYEES: 1 8 MATERIAL SAFETY DATA SHEETS ON FILE:, yes sterlization area. BRIEF SUMMARY OF TRAINING PROGRAM: Verbal and written records of proper storageo& disposal of Hazardous waste (xray developer "fixer" solution. CERTIFICATION I, ? ~er,sa.~/XJ~c.~;~//7'5 . 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 4 THOMAS A GORDON DDS Manager : 6~-~o ~ ~ , Location: ~500 OLD RIVER RD 225 City : BAKERSFIELD BusPhone: Map : 123 Grid: 06B CommCode: BAKERSFIELD STATION 11 EPA Numb: SIC Code: DunnBrad: SiteID: 015-021-002131 (661) 664-1814 CommHaz : Minimal FacUnitS~- 1 AOV: Emergency Contact THOMAS'A GORDON Business Phone: 24-HoUr Phone : Pager Phone : / Title / DDS (661) 664-1814x (~) ~$- ~o~x ( .) - x Emergency Contact Business Phone: 24-Hour Phone : Pager Phone : / Title / ~ ~ ar (~&l)~ -~9~x ( ) - x Hazmat Hazards: React Contact :"~f...~4~. L~ki~ . /~ MailAddr:'500 OLD RIVER RD 225 City : BAKERSFIEL~ Phone: (661) 664-1814x State: CA Zip : 93311 Owner I~HOMAS A GORDON DDS Address : 500 OLD RIVER RD 225 City, : BAKERSFIELD Phone: (661) 664-1814x State: CA ,Zip : 93311 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: = Hazmat Inventory --As Designated Order Hazmat Common Name... WASTE FIXER ISpecHazI One Unified List Ail Materials at Site EPA Hazardsl Frm I DailyMax lunit MCP R L 5.00 GAL Min (Type or print narne~ reviewed the attached hazardous materials mar.,age- ment plan fo~and that it along with any corrections constitute a complete and correct man- agement pla~ for my facility. , . ~gnature -- Date 12/04/2000 THOMAS A GORDON DDS SiteID: 015-021-002131 = Inventory Item 0001 Facility Unit: Fixed Containers at Site ~lvUVl~ ~vl~ / ~1 ~/-'~L~ ~vl~ WASTE FIXER Days On Site 365 Location within this Facility Unit Map: Grid: INSIDE DARKROOM CAS# i ----- STATE ~ TYPE PRESSURE TEMPERATURE · Liquid /Waste I Ambien.t I Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container5.00 GAL AMOUNTS AT THIS LOCATION Daily~Maximum5.00 GAL Daily Average 5.00 GAL %Wt. Silver HAZARDOUS COMPONENTS TSecret No I oRSIBi°Haz N No HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA USDOT# /// MCP Min 2 12/04/2000 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ADDRESS ~OO FACILITY CONTACT ~SPECTION TIME INSPECTION DATE c o - PHONE NO. 6,Co,-/- ~'~ BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Section 1: ~/Routine Business Plan and Inventory Program [] Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Appropriate permit on hand V 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 V Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled I/ Housekeeping Fire Protection vf Site Diagram Adequate & On Hand V C=Compliance V=Violation Any hazardous waste on site?: [] Yes [] No Explain: Questions regarding this inspection? Please call us at (805) 326-3979 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Bu'sine~s ~i~e Responsib~i~a~rt~ Inspector: FACILITY NAMEr--s' ADDRESS ~ Oo~ FACILITY CONTACT INSPECTION TIME INSPECTION DATE [3/~.~//'co PHONE NO. BUSINESS ID NO. 15-210- t'~"~d NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program [] Routine ~,Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION 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 COMMENTS Thomas A. Gordon, D.D.S. General Dentistry We Keep Our Patients Smiling! 500 Old River Rd., Ste. 225 103 Adkisson Way Taft, CA 93268 Bakersfield, CA 93311 Off. (661) 763-5133 off. (661) 664-1814 Fax (661) 664-01 29 Fax (661) 763-5440 www.adeptdentalcare.com II C=Compliance ' V=Violation Any hazardous waste on site?: ~Yes [~l No Explain: L~c5l'~ ~-10~ ¢~'t~--~--~. Questions regarding this inspection? Please call us at (661) 326-3979 Xl3u~ge~ :~ite kesponsXible Party White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Inspector: CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME "~o ~e--VO~) INSPECTION DATE (0 Section 4: Hazardous Waste Generator Program EPA ID # [] Routine ~.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 Hazardous waste accumulation time frames Containers in good condition and not leaking Containers are compatible with the hazardous waste Containers are kept closed when not in use Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided ~ ~t~ga~' ~c2.6x/~r>~' 'Uf~ 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 hazardous 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 ~ Inspector: [/~ lcd ~5 Office of Environmental'Services (661) 326-3979 "B~usi~ess Site Responsible Party White - Env. Svcs. Pink - Business Copy o ,rc Smv c s 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one form per material per buikfing or ama) ~EW O ADD I-I DELETE [] REVISE 200 Page of BUSINESS NAME (Same aa FACILITY NAME m' DBA - Doing Business As) 3 CHEMIC, ALLOCATiON [PJ*~,O~_~. ['~/~['~),*v~ 201i CHEMIC, ALLOCATION I--Iyaa r-]No 202 I CONFIDENTIAL (EPCRA) FACILITY ID # I I 1 MAP # (opE•ne/) 203 GRID # (op~fone/) 204 CHEMI~L ~E COMMON NAME - .- ~o~ 210 i I CURIES 213 ! 212 FIRE CODE HAZARD CLASSES (Compile if requested by local fire TYPE [] p PURE [] m MIXTURE [~.~WASTE 2. NAD~C'T~VE [] Yes [] No PHYSICAL STATE [] $ SOUD ~..LIQUID [] g GAS 214 LARGEST CONTAINER ~.~'"'-'-' 215 FED HAZARD CATEGORIES 0'1 I~IRE []2 REAC¥1VE * 03 PRESSURERELE~E 1'-14 ACUTE .E.M.-TH * r-J5 CHRONIC HEALTH .... 216 (checx an mat apCy) 219 STATE WASTE CODE 220 ANNUAL WASTE 2t7 f MAXlIWJM ,.~'T". 218 I AVERAGE AMOUNT DAILY AMOUNT DAILY AMOUNT u.iTs'"'~ GAL [] of CU ~T [] ,, ,-s [] ~ ToNs °'If EHS. amount must be in lbs. 221 DAYS ON SiTE 222 STORAGE CONTAINER []a ABOVEGROUNDTANK I~e. PI.ASTIC/NONMETALUC DRUM []i FIBERDRUM []m GLASS BOTTLE r'lq RAILCAR 223 (Check all ~hat apply) [] b UNDERGROUND TANK [] f CAN [] j BAG [] n PLASTIC BOTTLE [] r OTHER [] C TANK INSIDE BUILDING [-~ g CAllbOY [] k BOX [] o TOTE BIN [] d STEEl. DRUM [] h SILO [] I CYUNDER [] p TANK WAGON STORAGE PRESSURE ~ AMBIENT [] aa ABOVE AMBIENT [] ba BELOWAMBIENT 224 238 239 [] Yea [] No 240 241 -242 ................................................................... 243 D-Y~-D N~-'24~' ........................ 245 UPCF (7~99) S:\CUPAFORMS~OES2731.TV4.wpd