HomeMy WebLinkAboutBUSINESS PLAN ~.~M P
PLA~
SITE DIAGRAM
Business Name:
FACILITY DIAGRAM
Business Address:
For Office Use Only
First In Station:
, Inspection Station:
Area Map # of
NORTH
'' 0
.... ~i~¥~OF BAKERSFIEL
P.O. BOX 2057'
BAKERSFIELD, CALIFORNIA 93303-2057'
ADDRESS CORRECTION REQUESTED
DO NOT FORWARD
33~.6
BA:~ERSF.[EL
CA"
Certified
PIT STOP.
Auto Service
SPECIALIZING IN:
Elec. · Brakes · Tune-ups · Frt. End
Auto Air · Engine Work · Tires · Batteries
Mobile and Fleet ~ervice Available
CHRIS ESPY 322-0558
33 t 6 Panama St. Bakersi'ield, CA 93301
., . Bakersfield Fire Dept.
Hazardous Materials Division
~ .~-, 2130 "G" Street-
' , B~A. 93301
HAZARDOUS MATERIALS MANAGEMENT PLAN
1. To avoid further action, return this form within 30 days of receipt.
2. TYPE/PRINT ANSWERS IN ENGLISH. RECEIVED
3. Answer the questions below for the business as a whole.
4. Be brief and concise as possible. IS~P 1 fl I~1~
SECTION 1' BUSINESS IDENTIFICATION DATA
~AZ..UA1. ~.~I¥.
BUSINESS NAME'
LOCATION' '~3/~'
MAILING ADDRESS'
CITY: ~'~'~ ~
STATE:~"~/ ZIP' ~'"~?0(/ PHONE:
DUN & BRADSTREET NUMBER:
SIC CODE:
PRIMARY ACTIVITY:
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT TITLE
BUS. PHONE 24 HR. PHONE
Bakersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 3: TRAINING:
NUMBER OF EMPLOYEES:
MATERIAL SAFETY DATA SHEETS ON FILE:
BRIEF 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
TIMEEXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION:
I, · ~.,/q~'-, ~5'?~ CERTIFY THAT THE ABOVE INFOR-
MATION 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.
.... S!G~NAT_U R E TITLE DATE
FD1590
Bakersfield Fire Dept.
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
Facility Unit Name'
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES:
B.. EMPLOYEE NOTIFICATION AND EVACUATION'
C. PUBLIC EVACUATION:
D. EMERGENCY MEDICAL PLAN:
'Bakersfield Fire De '
Hazardous Materials Di~n
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 7:
MITIGATION, PREVENTION AND ABATEMENT PLAN:
A. RELEASE PREVENTION STEPS:
B, RELEASE CONTAINMENT AND/OR MINIMIZATION:
C. CLEAN-UP PROCEDURES:
SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)'
NATURAL GAS/PROPANE:
ELECTRICAL:
SPECIAL:
LOCK BOX: YES~
IF YES, LOCATION'
SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY:
A. PRIVATE FIRE PROTECTION:
WATER AVAILABILITY (FIRE HYDRANT)'
">~:~ ra~'and Ag~iCulture ~ standard Business . .'. -:;: · . ~.. .'.:..':'.'. '. ,":-,. ~.:~.:' :.... · Page.. --
,"PHONE %: ~ 5z~=5~ PHO~'~,%:'~ ~2Z ~ .... ' -- -- - -
~" ': :~J' i ' - ,r ' ;: ' :: '
i 2 3 4 5 6 7 8 9 10 11 12 ; 13 . 14
Tra~s Ty~e · Max Average Annual Measure # Days Cent ' Cent Cent Use ~,o~ation Where . .~ ~ i % by Names of Mixture/Cc~onents
Code Code A mt Am~ Amt Units on Site Type Press Tem~ . Code Stored in Facility : w~ See Instructions'
' (Check all that apply) :.... : '
:? ;, Component # 2 Name :& C.A.S. N~mber
· Fire ' Hazard ~ Sudden Release ~ R~ivity ~ Iu"~uediate '~-~ Delayed "- f;,~¢~
of Pressure .,. Health . Health ',!.!'i' ;J!- Component # 3 Name & C.A.S. Number
.I I I I I I I I I I I .....
{,,~j,,; -. ~ .'. , , :, .~- '.. . ,, .
Ph1~ical and Health Hazard C.A.S. Number : Component # I Name ~& C.A.S. Number
· (Check all that apply)
. . ~ ' ~ 5;: . , i Component # 2 Name & C.A.S. Number ' .
'" ' . -
:~ -' of Pressure '- Health Health Compo~ent # 3 Name ~& C'.A:S. Number
~.,.,: , ,, ~..i ·
Physical'and'Health 'Hazard C.A.S. Number -" Component # i Name & C.A.S. Number
,:']: (Check all that apply) ": Component # 2 Name.& C.A.S. Number
':: ~ ~ire ~a,=d [] Sudden ~eas. ~1 ~otivity [] ~iate ~ Oe~ay~ __
':,, ~,' of Pressure Health Health Component # 3 Name & C.A.S. Number
I } I { I' } I I I I
.¢ .... ~ Component # i Name & C~A.S. Number '
Physical and Health Hazard C.A.S. Number
"?.. (Check all that apply) ' Component # 2 Name & C.A.S. Number
:': 1~ ~ire .a,=d I:~ .~udde, ,e~eas. ~ .eactivity El :==edia~e ~ oe:ay~
:: .. of Pressure. Health Health Component # 3 Name & C.A.S. Number
:,' :: -:
'~?:.: . :. ' . Nam~ t Title . 24 Hr. Phone Name . , . · .. Title 24 ~ Phone
:..,:::. .. : · : ,: .... . ...
::'Certification · (READ AND SIGN AFTER COMPLETING ALL SECTIONS).
I 'certify under peanlty of law that I haver personally exam/ned and am familiar with the information submitted in th~s end all attached documents end that hased on my inquiry of those .
res~ons~ble' for ob~/n~ng the information. I believe that the submitted information is true,~-~accurate' and complete._
{'' N~ME.AND OFFICIAL TITLE OF OWNER/oPERATOR OR OWNER/OPEraTOR'S AU'~'nuKIZED ~S~'~e~TIVE SI~N/tT~RE .~. DA~E SI~NED ..... _