HomeMy WebLinkAboutBUSINESS PLAN iTE DIAGRAM
Business Name:
FACILITY DIAGRAM ~~'
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Business Address:
For .Office Use Only
First In Station:
Inspection Station:
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Bakersfield Fire Dept.
Hazardous Materials Division
2130 "G" Street
Bakersfield, CA. 93301
HAZARDOUS MATERIALS 'MANAGEMENT .PLAN
INSTRUCTIONS:
1. :ro avoid further action, return this form within 30 days of receipt.
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business as o whole. --~
4. Be brief and concise as pos~ible.
SECTION 1: BUSINESS IDENTIFICATION DATA
BUSINESS NAME:
LOCATION:
MAILING ADDRESS:
STATE: C~ ZIP: P??v~ PHONE:
DUN & BRADSTREET NUMBER:
SIC CODE:
PRIMARY ACTIVITY:
OWNER'
.MAILING ADDRESS:
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT TITLE
· ~.,,/~ ./-;.,.,~.~ ,~,~,0~,~
/
BUS. PHONE
24 HR. PHONE
~.~- %oo~
FD1590
~ Bakersfield Fire Dept.
.- Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT. PLAN
SECTION 3: TRAINING:
NUMBER OF EMPLOYEES:
MATERIAL SAFETY'DATA SHEETS ON FILE: /(/~s '-
BRIEF'SUMMARY OF TRAINING PROGRAM: ,-. / , , ,
. · , ~ · ' C/ ,rd, "
SECTION 4: EXEMPTION REQOESf:' ;
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 I~IATERIALS.
....... ' .......WE DO HAND~'E'- ~I-AZART~OUS MATI~RIALS, BUT THE 'QUANTITIES-~T:NC)-
TIMEEXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION: ·
I, A /g,~_/~,,~, A'~. Vo,,,,) CERTIFY THAT THE ABOVE INFOR-
M TION'IS ACCURATE. 1UNDERSTAND THAT THIS INFORMATION'WILL BE USED TO
FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CAL F'ORNIA HEALTH AND SAFETY CODE"
ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT
INACCURATE INFORMATION CONSTITUTES PERJURY.
SIGNAJ~RE ~''.
TITLE DATE
Bakersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS 'MANAGEMENT PLAN
SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN:
RELEASE PREVENTION STEPS:
RELEASE CONTAINMENT AND/OR MINIMIZATION:
CLEAN-UP PROCEDURES:
SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY):
NATURAL GAS/PROPANE: 5, t.J,
'ELECTRICAL: /t/, (.,g. /~s,Z/~,
WATER: ~, ID.' Co,-~.~- ~/'
SPECIAL'
LOCK BOX: (~NO"" IF YES, LOCATION:
SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY:
A, PRIVATE FIRE PROTECTION: /,~
B. WATER AVAILABILITY (FIRE 'HYDRANT)'
FD1590
~ Bokersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS. MANAGEMENT PLAN
Facility Unit Name:
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES:
· ~¢ ,of;f;~z~ ~.~ /0-/~¢-~ ~z;;;~- ~. ~/,' .'v~//%'/~,~/
C. PUBLIC EVACUATION'
D EMERGENCy MEDICAL PLAN: ~.- ". ~'
. · . ,,~,-~.~ ~,,~ ..~,llb~ Z,,,J/,J
CITY OF BAKERSFIELD
~ Farm and Agriculture ~Standard Business
HAZARDOUS MATERIALS INVENTORY
NON - TRADE SECRET
LOCATION: ~q0q ~'~ I,Ja~ ~D~SS:
CITY, ZIP: ~/~9/~fff ~FZ/ CITY, ZIP:
Page { of ;
NAME OF THIS FACILITY: P/.~.~/~O~.r,'~ P/.~
STANDARD IND. CLASS CODE:
DUN AND BRADSTREET NUMBER/FEDERAL ID #
REFER TO INSTRUCTIONS FOR PROPER CODES
1 2 3 4 5 6 7 8 9 10 1! 12 13 14
Trane Type Max - Average Annual Measure # Days Cent Cent Cent Use Location Where % by Names of Mixture/CompOnents
Code Code Amt Amt Amt Units on Site Type Type Press Code Stored in Facilit~ wt See Instructions
~sical and Health Hazard C.A.S. ,~er 7Uq0--$7-1 component # 1 Name & C.A.S. Number ~'/t[~;
heck all that apply) Component # 2 Nam~ & CoAoSo Number
~ Fire Hazard ~/Sudden Release [] Reactivity .l~ Iim~ediate ~] Delayed
of Pressure ~ealth Health Component # ~ Name & C.A.S. Number
Physical and S~lth Hazard C.A.8. N~er 77~ '-gq--7 Co=ponent ~ ~ ~ ~ C.~.8. N~er
(Check all that apply)
u Component 92 N~ a C.A.S. Nu~er
~ --Fire Hazed dden ~lease ~ R~ct~vity ~ I~tate ~ Delay~
of Pressure Health H~lth Component 9 3 N~ & C.A.S. N~er
Physical and H~lth Hazard . C.A.S. N~er 7 ~/'9 ~-~ Component 9 i N~ & C.A.8. Nu~er
(Check all that apply)
Component 8 2 N~ & C.A.S. Nu~er
~ Fire Hazed~Sudden Release ~ R~ctivlty ~ I~iate ~ Delay~
of Pressure H~lth . ~lth Component 8 3 Na~ & C.A.S. Nu~er
Physical and .~lth Hazard C.A.S. Nu~er Component . i,--, c.~:s...¢., '4'~ 0,".~/77~3- 9Y' ~ )
of Pressure H~lth H~lth Component ~ 3 N~ &' C.A.8. Nu~er
Na~ ~tle 24 Hr. Phone N~e- ] Title ~ 24 Hr Phone
C~rtif~cation (READ AND SIGN AFTW. R COMPLETING ALL SECTIONS)
i'~A~ertify under peanlty of law that I hayer personally examined and am familiar with the information submitted ~n th~s and all attached documents and that based on m~ inquiry of those
-' ~vi~u,als responsible for obtaining the ~nformation. I believe that the submitted information ~s true, accurate, end complete.
, ,, ,
· NAME AND OFFICIAL TITLE OF O%~NER/OPERATOR OR OWNER/OPERATOR'S AUTHORIZED K~KESENTATIVE