HomeMy WebLinkAboutBUSINESS PLAN 10/16/2003CALIFORNIA WATER
Location: 4507 PLANZ RD
City : BAKERSFIELD
CO 184
CommCode: BAKERSFIELD STATION 07
EPA Numb:
BusPhone:
Map : 123
Grid: 14A FacUnits:
Site~15-021-002374
~61) 396-2400
CommHaz :
1 AOV:
SIC Code:4941
DunnBrad:
.Emergency Contact / Title
M~STKiCT MGR
Business Phone: (661) 396-2400x
24-Hour Phone : (661) 396-2400x
Pager Phone : ( ) - x
Emergency Contact / Title
TIM TP.E~._OA_P / ASST D,IST MGR
Business Phone: (661) 396-2400x
24-Hour Phone : (661) 396-2400x
Pager Phone : ( ) - x
Hazmat Hazards:
React ImmHlth
Contact : 5~,~,,
MailAddr: 3725 S H ST
City : BAKERSFIELD
Phone: (661) 396-2400x
State: CA
Zip : 93304
Owner CALIFORNIA WATER SERVICE COMPANY
Address : 3725 S H ST
City ~-~ : BAKERSFIELD
Phone: (661) 396-2400x
State: CA
Zip : 93304.
Period :
Preparer:
Certif'd:
ParcelNo:
to
Emergency Directives:
TotalASTs: =
TotalUSTs: =
RSs: No
District Manager-Tim Treloar
Asst. Dist Manager-Bill Harper
Contact Person-Tamara Johnson
(S~ame Ph_one Numbers
(Type or print name)
reviewed the attached hazaroO.s materials manage-
/9.
ment
plan
for_~/:. /~(~/17-~',~ and th~,~t it along with
(N.me of 8usine~,s~ --
any corrections constitute a complete and correct man-
agement plan for my facility.
Gal
Gal
-1- 10/10/2003
0'/: - 0:/': 06 76 ?
· o:~vtc~: o~ ~'~mot~a,m~~'s~avtc~.s
t715 Chester Ave., Bakersfield, CA (661~ 326-39'79
<
INSTRUCTIONS: .. · _
· H~a
. ~$oo/
To avoid filrthcr acrfor~ return this form within 3'0 days of receipt.
TYP~~ ANSW'ERS~EN ENGLISI-I.
Answer' the questions: below for the bUSiness as a'whole.
· Be as brief and'concise'as POssible.· '
You may a/so at~: ch BUSineSS OWner / Operator Form and ~hemica/Descr/pti°n Form, (s).
'to the.front of this pian instead °f ¢OmPle~g SECTroN'L belbw f61/nitiaI'submto, si~
SECTION'I: BUSINESS; IDENTIFICATION DATA
r, OC^:ON:
Rd~I~O ADDR2ESS:
PRIMARY A~:
oWNS: - F~z /m r/w//
.. M. Arr.[NG ADDRESs:
EM/~RGENCY NoTIFIcATION
' TITLE BUS. PHONE
24 ~ PHONE
..
CONTACT
//4'z'za/,,v ~,'/Z,o
EMERGENCY M'~.r)ICAL PLAN::
./'f'EO/f,4L. Ifi. f/$1",~A/f'f INdvz~O ,df I~,gOV/LDEiD '6
2
SECTION ri.2:
HAZARDOUS ~LATERIAL$ fi,'/.~NAGEB4.ENT PLAN
RELEASE' RESPOMS E PLAN
HAZARD ASSESSMENT AND pREVEIVTION MEAS~:.
Bo
RELEASE CONTAZN'MENT ASN-D/OR. MTT~GAT~ON:
WATER:'
SPECIAL:
LOCK BOX:
s, oc noN:
PRIMATE F~ PROTECTION/WATER AV~rLABIt?TY''?
A. PR.WATE FIRE PROTECTION: F/£c/ Z';C'7-z4/d:d/jy./Z',~'. ~,'V':'-;'/7-£
WATBi~.'AVAH'.ABFr.~y (FEEE H-YD~)i /fid'AL.
3
MATERLkL SAFETY DATA SHEETS ON FILE:
SRZF2. SUMMARy OF TRAINING PaOGRAM:
~tr~-~ I 1715 Chester Ave., CA 93301 (661) 326-3979' :'
.: rm r
FAC1LJTY ID# (FOr of~c~ use only - please leave
o~^clu~ ~ .... ' .........
I. FACILITY IDENTIFICATION
" 11. ACTIVITIES DECLARATION
-. .
A. HAZARDOUS MATERIALS
1.' Ha~/e':on Site (eot'any purP6se) hazardouSmatedals at or
· above 55 gallonsfd~_,l.iquid~' 500.ooundS for Solids; or 200
cuft for compressed'gases:(inctude liquids in ASTs'and
USTs)?
2. Have any amount_ of:an explosive material (Other t~an
ammunition.) on site?
B. REGULATED'SUBSTANCES (RS)
OYES (~O '~
Have ansite RS-atgr'eater than the threshold planning
quantifies established bY the California Accidental
Release Prevention~program (calARP)?
UNDERGROUND STORAGE TANKS (USTs).
Own or operate Underground'Storage. Tanks?'
Intend to upgrade existing or install new USTs? ·
D. TANK CLOSURE / REMOVAL
1. Need to'rePort ct0s!ng, a UST that'held hazardous
materials or waste?:: ' :- ',. ~
2.. Need to report th~ Ctosur~'removal"of a tank. that'was
classified as ha~rdous waste and c~eaned 0nsite?
E. , ABOVE.. GROUND- PETP,.OLEUM STORAGE TANKS (ASTs)
Own or operate, ASTs'above these thresh°Ids: any tank
capadty is greater than 660 gallons or the total capacity
for the facility is gfeate? than' 1,32ffgallons.
'" OYES
OyES rhO
'OYES (~N0
F. HAZARDOUS WASTE:
1. Generate hazardous waste?'
2. Recycle more than':100 kg/mo:of:recyctable materials at
'oYES
OYES' (~O
OYES' (~O
OYES (~NO
OYES (~ffNO
the same location it was-generated? ' ' ["OYES
RecycJe more t~an-100 kg/m0:bf'reCYclable materials at : · (~O
an of/site lo. cation different from ~e point.of generation?
T~eat Hazardous Waste on site?' _ '
Subject to F~nancial Assurance requirements?
Consolidate Hazardous Waste generated at a remote
site? .
OYES
OY~:S
OYeS ~NO
· . O¢-ES (~O
G. PERMIT CONSOLIDATION ZONE~
. Intend ~ consolidate o~er Cai/EPA agency permits?
(If yes, please complete Section III and attach)
If Yes,. Please Complete...
'OES FORM 2731 (chemica oes~,~ Fo~m)
MinimUm ~ui~' planning, el~e~.
· Eme~en~ R~panse Pl~
t Maps·
Training
Pmv~on
C~o~s
OES FORM 2731 (Ch~nica
RISK. MANAGEMENT P~N (~v ~it t~ us~A)
~NSOUDA~D COMPLIANCE P~N ·
· ln~m0mflng ~RP P~mm El'~en~"
' UST FACILITY FORM
UST Tg(NK FORM'(,oae,~rta.,u~) · "'
UST FACILITY FORM
UST TANK FORM
UST INSTALLATION FORM (one' per tan~)
UST TANK' FORM (aosum sec~on-.one' p~' tan~)
TANK. CL6[SU, RE FORM'.'
CONSOLJDATED COMPLIANCE PLAN
· '; Incorpo. rafi-ng 'Federal spill':Prevention
Control and Countermeasure (SPCC)
Elements pursuant to 40 CFr=, Part 112
EPA ID number--p~ovide on this page
To obtain EPA'ID~, please phon~ (916) 324-1781
RECYC~NGFORM
RECYCLING FORM
TP FACILITY FORM (DTSC Form 1772)
TP'UNIT FORM (one per unit)
' GERT]FtCATiON OF FINANCIAL ASSURANCE
REMOTE WASTE Z CON$OLJD~TION SITE
NOTIFICATION FORM
coNsoLiDATED COMPLIANCE' PLAN:
nco~orating all other environmental.
permit requirements per 27CCR' 10410
3TE:
J If you checked YES to any part of Sections liA-IIG above, theft in' addiUon to the forms requested-above, please Submit OES Form 2730.
S;~.CU PAFORMStACTlVI'Pf .wpd
UPCE (7/991
· OrS SS L
OFF[CE OF ENArlRO~NT~ SERVICES
171.5 :Chester Ave., Bakersfield, CA 93301 (661) 326-3979
I. FACILITY IDENTIFICATION
FAClIJT~ IO # (FOr office use o~ly - please Ieee l~anl~ ) 2
OS~VFA~UT~; ~
'. FACIlJTY INFORMATION
Business Activities Addendum
Is your .Fa~¢ility, Compliance· plan ,subject to review, by.;,.
DEPARTMENT (DF T~XIC SUBSTANCES, CONTROL OYES
: ' .. III. CONSOLIDATED PERMIT ACTIVITIES
fo~ satisfying~ the condi~'ons of these permits?
Ho
t. SAN JOAQUINYALLEY UNIFIED-AIR POLLUTION
i' CONTROL DISTRICT
J. sTATE WATER RESOURCES. coNTRoL BOARD
( ~NTP~L VALLEY REGIONAL wATER QUALITY CONTROL
OYES ~f~O '
o~Es
/
'-~OARD ..' . ' .
'K. CALIFORNIAINTEGRATEDWASTE MANAGEMENT BOARD
OYES
OYES
., O~rEs. ~ho.
OYEs
OXEs
OYES
OYES '..(~O
(~ES ONO
· . -. Ali:'MOdEigations,, ..
Non-RCP-~ HAZARDQUSWASTE FACILITY
RCRA'HAZARDOUS WASTE FACILI'?Y..
AUTHORITY m.CONsTRUc~T ,
'v' - PERMI~'TQ OPERATE" ·
GENERAL pERMITS
WASTE' DISCHARGE REQUIREMENT
SPECIFIC PERMITS
NA~oNAL P.OELUTION DISCHARGE.
E~MINAT1ON SYSTEM (NPOES)'
~... --REGiSTRATiQNPERMiT.
L KERN COUNTY RESOURCE MANAGEMENTAGENC¥
OYES (~O'
OYES
OYES
"oYEs ~o
OYES (~0
OYES ~0
OYES (~"N 0
' ENVIRONMENTAL HEALTH SERVICES PERMIT,S.
~'. ' . . .'Domestic'Water Well Pon'nit
Haz Mat'MonitOrinG V~e!l Permit
Septic Syste~ Permit '
Public Swimming-Pool Permit
Pood Facility Consl~uction permit
Solid Waste Local"Enforcement Agency
(LEA) Related PemIitS'
Medical Waste R~tated Permits.
INDUSTRIAL W~(STE WATER DISCHARGE
PERMIT
M. CITY OF BAKERSFIELD WASTE-WATER DIVISION
NOTE:
v' If you checked YES 'to'any part of Sections III-H' to III-M above, then pleaseaddress all applicable permit requirements in the.Facility Compliance Plan.
CITY OF BAKE~F
OFFICE O'F'ENV-IRONM]ENTAL SERVICES
.. 1715 Chester Ave., CA 93301 (661) 326-3979.
BUS'INES~S OWNER l OPERATOR'iDENTIFICATION
FA(;ILITY INFORMATION
i ' ' I. FACI~TY IDENTIFICATION
' FACILJTY~ID#. J i ~ i'*'- ,i i ~' i ' '~ i" ;i ,i 11 Year Beginning., 2~/
!' BUSINI~SS NAME (Same as FACILJ'r"Y NAME or OBA- 0Ding 8asineas As)
Year Ending
!'
8USJ-NESS PHONE',.
.,. SIT1-= ADDRESS'
101
102
103
DUN a ' mS ~. sIC'CODE' , ~o7'
~ ' IL oWNER INFQRMA~ON
O~ER NAME" ~ '~ O~ER PHONE
OWNER MAILING
ADDRESS
.q?~.5". 5',~,f#- " ~ ' jF~££ T ·
IlL ENVIRONMENTAL CONTACT
112
118
119
.-PRIMARY"· ' IV. EMERGENCY CONTACTS ' , ~ECONDARy.
2~HOUR PHONE ~H~ '~ ~ 2~HOUR PHONE
V. CEETIFI6ATION
Certification:' Based on my inqUiry of those !ndividuals responsible for obtaining the information, I certify undec penalty of law that I have personally examined
and am famili~r~vit~ the information submitted in .[hi~ inventory and believe the information is' line, accu .m, te, and'complete. :
135
137
Business Owner/Operator Identification
Please submit the Business Ac~vities page; the Business Owner/Operator IdenlJflca~on page :(OES Fern1 2730), and Hazardous Materials.- C. Jl~licat,.
Oes~'f0tion pages ((DES Form 2731) for all hazamous matehais.inventory' sul)missions. F~r the inventory t~ be-considered complete
this page must be signed by the appmpmate individual.
Note: the numbering of the insa'uc~ons follows the data element numbers that are on, the UPCF pages.. These data element numbe~ am use~, "-
.~r elec~nic submission and are the same as the numbering used in 27 CCP,, Appendix C, the Bi.~iness Sec~o~ of the Unified Program Data.;~ic~nary.)
Please' numt)er all pages of your sui)mittal. This helps your CUPA or AA idenl~fY wttether the submittal is complete and if any pages am separated.
1. FACII.JTY ID NUMBER '- This number is assigned by the CUPA or AA. This is the unique number which identifies your facility.
3..~ BUSINESS NAME - E~ter the full legat name of. the business. '
100. BEGINNING DATE - E,qter the beginnir~g year and date of the report. (YYYYMMDD)
101. ENDING DATE: Enter the ending year and date of the report. (YYYYMMDD~'
102.~' BUSINESS PHONE - Enter the pt~one number, area code ~t, and any e~ctension.. ' '
103.. BUSINESS SITE ADDRESS - Enter the s~'eet address where the facility is located. No post office box numbem are allowed. This ir~rmati~)n
_-. must pmvide a means ~o geogaphiually locate the facility.
104. CI'~Y ~ Enter the city or uninc~rboreted ar~a in which business site is located.
105. 7~p CODE -. E~ter the z~p c.~le of business site. The exa'a 4 digit zip may also be added.
106. DUN & BRADSTREET - Enter the Dun & Bradstreet number for the fadlity. The Dun & Brads~eet number may be obtained by calling
(610) 882-7748 or by Intemet. ...
107....SIC CODE - Enter the pdrna~/.StandardlndUS~al Classification Code number for pdmary business activity. NOTE: Jf code is more than
.4 digits, .report only the flint four.
108. COUNTY ~ Enter the county in which1 the business site is located.
109. BUSINESS OPERATOR NAME - Enter the name of the business operator.. . '
110. BUSINESS OPERATOR PHONE - Enter bUS/n~es operator pl~one number, if different.frOm business phone4 ama c~de first, and any extension.
"1 ;I 1. OWNER'NAME - Enter name of buainess owner, if different from business operator.
112. OWNER PHONE - Enter the.business owner's phone number if different fTorn business'phone, area code fimt, and any extension. '
113.. OWNER MAIIJNG ADDRESS - Enter the ~ner's mailing address if different from business site addres~
114. OWNER CI,TY - Errter the name of the cily for the owner's mailing address.
115. OWNER ,5'q'ATE. Enter the 2 cflara.cter state abbreviation for the owners mailing~address.
116: OWNER ZIP CODE - Enter the zip code fo~' the owner~ address: The ax'ira 4 digit zip_may also be added.. .
117.' ENVIRONMENTAL CONTACt. NAME - Enter the name of the person, if different from.the Business OWner or Operator, who receives all
envimnmentel .correspondence and will respond to erff0rcement activity.
118. CONTACT PHONE ~ Enter the phone number, if different fi'Om Owner or Operator, at which the environmentel contact can be contacted, area
code ~mt, and any extension.
119. CONTACT MAI/_JNG ADDRESS - Enter the' mailing address where all environmental contact correspondence should be sent, if different ' from the
site add _re~'~__~ - .... ..
120. c]'r'Y - Enter the name of the city for the. environmental conlact=s mailing address...
121. STATE - Enter the 2 character state adbreviation for the envfmnmental contact=s mailing address.
122_ ZIP CODE - Enter the zip c~e for the environmental contact=s mailing address; The'ex~ra 4 digit zip may also be added~
123. PRIMARY EMERGENCY CONTACT NAME - Enter the name of a representative that can be i:°ntacted in case of an emercjency involving
-, .... . hazardous materials atthe busines~ site. The contact shall-have FUEL. fac~k'y access, site fatallY'y, and authority.to make decriers
for the business regarding incident mitigal~on.
124. TITLE: Enter the ~e o~ the primary emergency contact.
125. BUSINESS PHONE - Enter the bUsiness number ~r the pdmary emergency contact, area code flint, and any extension~.
126. 24-HOUR PHONE - EDter a 24-hour phone numbe~ for the primary emen3ency contact. The 24-hour ~'hone number must be one which is
anSWered 24 hours a day. If it is not the contacts home phone number, liken the so.ica answering,the phone must be able to
immediateJy contact the individual stated above.
127. PAGER NUMBER - Enter the pager number for the primary emergency contact, if available.
12.J). SECONDARY EMERGENCY CONTACT NAME - Enter the name of a secondary.representative that can be contacted in the event that the primary
. emergency contact is net available. The contact shall have FULL facility a _cce~___. site familiarity, and aUlherity t~ make decisions for the business
regarding incident mitigation.
129. TITLE * Enter the litleof the secondary emergency contact,
130. BUSINESS PHONE - Enter the business telephone number for the secondary emergency contact, area cc~e first, and any extensie~
131. 24-HOUR PHONE - Enter a 24--hour phone number for the secondary emergency contact, The 24 hour Phone number must be'one which is
answered 24 hours a day. If it is not the contact's home phone number, th, .e;~,? the se~ica answering the phone must be able to
immediately contact the individual stated above.
132. PAGER NUMBER - E~ter the pager number for the secondary emergency contact,-if available.
133. ADDITIONAL LOCALLY COLLECTED INFORMATION - This space may be used for CUPAs or AAs to col'lect any additional'information
necessary to meet the requirements of their indk, idual programs. Contact your lOcal.agency, for'guidance.
134. DATE - Ente~' the date that the document was signed. (YYYYMMDD) ': .~ 'i' ~' ' ' ' · '
135. NAME OF 0OCUMENT PREPARER - Enter the full name of the person who prepared the inventory submittel inforrnalion.
136. NAME OF SIGNER - En .t~' the full pdnted name of the person signing the page. The signer cer~e~ to a-familiarity wi'd1 the informalion
submitted and that based.on the signer~ inquiry of those individuals responsible ~r or)raining the information, ail the information
sui)mitted is true, accurate and complete.
SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE - The Busines~ Owner/Operator, or officially designated
representalive of the OwnerlOpemtor, shall sign in the space provided. This sigria~re cerlffles that the signer is familiar with the
information submitted and that based on the sign~ inquiry of those individuals responsible for obtaining the inform:~tion it is
s~gn~ belief that the submitted information is l~ue, accurate and complete.
OF SIGNER - Enter the tilie of the person signing the page.
137.
BUSINg=SS NAME (Same as FACIMT~ NAME or DBA ~ Doing BuSiness As)
CITY OF BAKERSFIELD
.OFFICE oF EN3rIRONMENTAL SERVICES
1715 Chester Ave.,. CA 93301 (661) 326-3979
HAZA.~ RD•US, MATERIALS INVENTORY
'CHEMICAL DESCRIPTION
2J30
I. FACILITY INFORMATION
~ne. form per material oer building or
Page · ~ of
201! cHEMICAL LOCATION
{ CONFIDENTIAL (EPCRA)
203 GRID
· ,' II. CHEMICAL INFQRMATION · '. ·;
.. 2os; m~b~ S~CR~' .'ri Ye~ IS~N0 200
FiRE CODE HAZARD CLASSES (Cqm, pie{e if requested by
TYPE ' · I'-]'p PURE [~1 MIXTURE r-]~ w WASTE 211 i RADIOACTIVE [] Yes 212 CURIES :213 -
2~4 i LA~GESTCONTAINER
PHYSiC"ALSTATE 'r-'] $ ~01-1o ' ~] L/QUI{2) [T~J g GAS
FED HAZARD CATEGORIES [] 1 FiRE [] :2 REACTI~E [] 3 PRESSURE P'ELEAsE [] 4. AcuTE HEALTH -" CHRONIC HEALTH ~a/~J~/~t'~' :216
(r~.~ all that apply)
ALWA~TE,~/I/J ~t' 2'~7 J MAXIMUM :218 i AVERAGE 219 , S'TATEWA.~TECODE 2213
A,.,,jUNT <:~'U{./ } DALLY AMOUNT ~ J DALLY AMOUNT ~ ' . :
' If EHS..am°Urmt mL~St 6e~n lbs.' '
STORAGE CONTAINER ,~:)d~. y' ..
~a ABOVEGROUND TANK ~ e. ~ONM~A~C D~UM ~ i R~ DRUM
(~ ~ ~at ap~y) ~ b UND~GR~ND T~K ~ f ~ ~ j ~G "
' ~ c T~K.INSIDE aU~mNG ~ g ~OY ~ ~ aOX
' ~ d ~DRUM ~ h SILO ~ I ~ND~
LM~ PLASTI~ 80TTI,.~
[--Io TOTE
[] ~ TAN~ W^C-pN
[]q RAIL CAR 223
[] r O'rHER '
2 :.. 2ao ]
IlL SIGNATURE
P=,NT NAME & TITLE QF AUTHORIZED COMPANY REPRE~ENTAT]VE
233
237
245
UPCF (1/99) 7 OES Form 2731
Hazardous Materials inventory, chemical Description -~'.
You must complete a separate Hazardous MaiD,dais Inventory - Chemical Dssc~t3tidn peg&/or each hazaraous mstenai (hazarclou~ substenca~ and hazardou~ wsste) that
~,ou handle at your facJJity in aggregate quantifies equal to or greater than 500 pounds` ~5 gallons. 200 cubic feet of ges (calculated at s'tandarcl tem~3emtura and'preesure)
or the fectsrai thresnold p~aoning quantity for Extremely Hazardous Substances, wnioAeve~' is Jess. Also compfate a page for eactt radioac~ve material handled aver
quantities t'or which an emergency plan is rec~uiracl to be adDiCted pu~uant to 10 CFR Parts. 30, 40, or 70. The completed inventory should reflect all regonabis quantifies
of hazardous mate~ais at your facility, reported eegara/ifiy/or eadl3 building or outside adjacent area. with setsarate pages for unique occurrences of physical state, storage ··
temperature and storage pressure. (Note: the numbering of the instructions fdlidw~ the data aement numbem that are on the UPCF pagea. These data element numbem
· are usecl for aleca'onic submission and are the same as the'numbering used in 27 OCR, 'Apgendix C, the 8u,~nees Section of the Unified Program Oats Dictiona~.) Pisase
numbe~ all'pages of your submittal This heibs your CtJPA or AA identify whether the submittal is compista ana~ if any pages are Sel3aratsd.
1[ FACltJTYIDNUMnER-:Thisnuml3erisaesigned~3YtheCUPAorAA. This is the unklue number wilidil idantifins your Pacifity. ~.~
3. 8USINES3 NAME - Enter the/ua legal name of the business.. ·
200. AOD/0ELETE/REVISE - Indicate if the material is being added to the inventory, deleted ~'om the inventory, or, if the !nformation previcuaiy submitted ia being revisitS.
NOTE; You may choose to leave tills blanJ( if you reS~3mit your entire inventory annually.
"- 201. cHEM!cAL LOCATI'ON - Enter ~a bui~thg or outside/at,scent area wilere the hazardous material is ben,lied. A chemical that is stnred at'the same pressure and,
,temPerature, in mulUple Iocati?ns within a bugding, can be reported on a single page. NOTE; This inf~'matfOn is'not subject to public discJosure pumuant to HSC
§25506. .. ' ' . · . .
202. cHEMICAL LOCA3qON CONFIDENTIAI~ - ~aC~A - All businessos which are subject to the Emergen,~/Planning and Community Right to Know Act (F_.PCJ:L~.) must
chec~ "Yes' to kesp chemical location information confidential If the business 'd°es not wish to keep chemical Iocaaon information confidential chect~. "No'.
203. MAP NUMBER; if a map iS inc~udsd, enter the number of the map on which the Iocation'of the hazar~3us matadai L~ shown. '
204. GRID NUMBER - if grid caordlnatss are used. enter t~e grid co?rdinates of the map that corresponcl to ~e Ioca~ian of the hazardous material, if applicable' multiple grid
' coordinates can 'be listed. ' '
205..CHEMIC-,AL ·NAME- Enter the proper c~emicai name ss,~3cfatad with the chemical ,~bstract serwce (CAS)' number of the ttazard0us material.. ThL~ should be the
. In[ematlona Union of Pure and Applied Chemistry (IUPAC) name found on the Material ,Safety Dam ,Sheet (Macs). NOTE; If the chemical is a mixture, do not
c0mP~ets?hiS field; campists the 'COMMON NAME'* field instead. · ·
206. TP, AOE SECRET - Chec~ "Yes" if the information in this section is decismd a trade secret,' or "No' if it is not.
State rboU~remant: If yes,' and business is ndl subject to ERC3~,A, diss~sure of the designated trade sec~t i~formal~3n is bound by HsC §2,5511.
Federal requirement: If ye~ ancl business is ~ubject to EPCRA, discidsum ~3f the designated Trade ~ecrat infomlaflon is bound, by 40 C[=R and the buainees
· must submit a. '$ubstanfistidn to Accompany Cb]ires of Trade Secrecy' form (40' CFR 3,~0..27~ tn USERA; -
207. COMMON NAME - E~ter the common name or trade name of the hazardous matas,ial or mixture containing a h--~,~ous matedaL
208. EH.S-C~ec~ "Yes' if the hazardouS mat'ertat is an ExtmmelyHazardausSubstance (EHa), as dafined in 40 C~P~ Part 3.55, Appendtx.~ if the material is a mixture
': containing an EHS, leave this section blank and complain the sec~3n on hazardous companents baiOw.' ·"
209. CAS # - Eqter the Chemical Abstract Sec'vice (CAS) number for the hazardous material For mixtures, enter the CA~ number of the mixture if it has'been assigned a
nurnlSer d~5'tinct '/mm i~ components, if the mixture hoe no CA,S number, leave this column blank and rapo~'t the CAS numbers of the individual hazardous
· cnmponants in the appropriata sec, don be~°w. ' ,' ' - ' · '
210. F!RE CODE HAZARD Ct. ASSES - Rte Code Hazard cisSSes desc~be to fimt'respondem the type and level of hazardous materfais which a business handles. This
. isformation shall only be provided if the local fire chief deems it neCeSSary and requests the CUPA or AA to collect iL A Jlst of the hazard classes and instant, ns
on how'to detenwine which cldss a ma~dat falls under are thciuded in the appendices of Artiste 80 of the Uniform ~re Code.' If a matedai has ~ore ~ one. - ' '
· applicable hazard cJe_~_, indiude ail Contact CCIPA or AA for guk~ance'
2.11. HAZARDOUS MAT'F_RIAL TYpE - Chec~ the one box. that best d~sc~ibe~ the type of hazardous material; pure, mixture Or waste. If Waste material, chec~ only that ba~ -.
If mixture or waste, compistalhazardous components sect~n. ' '
212. RADIOACTIVE - Check "Yes" if {he hazardous msterlal.is radtoac~ve or "No' if it is not . · '
213. CZJRIES - if the hazardous matarlat is raclfoactive' ~se thi-~ area to report the-activity i~ curies. You may use up to nine dig,s with a-finst~g decimal point to report '
· ac~vity in cudes; · -
214. PHYSICAl. STATE - C~ec~ the one box that best deSC~bes the state in which the hazardous material is handled: solid, liquid o~; gas.
21.5. I..ARGEST CONTAINER - Enta,7 the total capacity of fl~e largest c~,ntainsr in which the matadal is stared. ' . . . ,
216. FEDERAL HAZARD CATEGORIES - Chec~ all cateqodes that describe the pi'~ysicai and health hazards associated with the h'aza~Hn~ material.
PHYSICAL- HAZARDS HF-.ALTH HAZARDS
Fire: Flammable [Jquids and Solids, Cambustibta I_jqulds, P?mphorids` Oxidizem Acute Health (Immedfatej.- Highly Toxic, Toxic, Imtants~ Senaitiz~ C0rfoaives.
· Rea~tive: Unstabifi Reactive' O ,r~lanic Peroxides, Water Reactive' Radidactive . other hazardo~ ~_~ ct~emi~.~!~ with an adverse effect wfih sho~t term et,,~,.~_.ra
P~essure Release: Exl3tosJves`' Compressed Gases. Blasting Agents ' Chronic Health (Delayed): Cardinagens, other hazardous chemicals with an
. adverse effect with long term e ~.',~_~um ·
217. AVERAGE DAILY AMOUNT - Calculate the average daily amount of the hazardous material or mixture containing a tiaza.,~ous rnateriat, in each building ar adjacent/.
outside area. Caicutations s_hail be based ~3n the previous yeal~$ inventory of matadal reported on this page' Tot~ ail daily amounts and divide by the number of
days the chemical will be on site. If this is a matsdal that has not previdusly been present at this location, the amount shall be the average dally amount you
· , project to be ?q hand dunng the course of the year. This amount should be consistent with the units reported in box 22.1 and silOUid not exceed that of maximum
dally amount. .
2,18. MAXIMUM DALLY AMOUNT ~ Enter the maximum amount of eactl hazardoua'matedsI or mixture containing a hazardous material, whicil ~s handled in a building or
adjacent/outside area at any one time over the coume of the year. This amount must contain at a minimum isst yea~$ inventory of the materisi rePc-,'ted on this
page, with the refiectidn of additions, deletions, or revisions projected for the current year. This emouiit should be c~qststant ~ the units rapeded in box 221.
21.9. ANNUAL WA~TE AMOUNT - If the hazardous material being inventoried is a waste, provide an estimate of the annual amOunt handled.
220. ,STATE WASTE CODE - If the hazardous material is a waste, ester the appropriate California 3-digit hazardous waste code as listed on the bec~ of the uniform
Hazardous Waste Manifest.
221. UNITS - Chec~ the unit of rneaaura that is m°st appropdats for the matsdai being'raperted on this page: gallons, pounds, cubic feet or tons, NOTE; If the matsdai is a
federally defined Extremsiy Hazardous Substance (EHS), ail amd .unis must be reported in pounds. If roatarial is a mixture ~ontaining an EHS, report the units that
the matedai is stored in (gallons, pounds, cubic feel or tons).
22.2. DAYS oN SITE - LJSt the total number of days during the year that the materidl is on site.
22.3. STORAGE CONTAINER - Chec~ all boxes that describe the b/po of storage containers in ~vnich the hazar(tous maisdai is stored. NOTE; If appropriate, you may
choose mum than one.
224. STORAGE PRESSURE - Chec~ the one box that best describes the pressure at wnictl the hazarclous n'f~tariai is stored.
225. STORAGE TEMPERATURE - Chec~ the one box that best describes the temperature at which the hazardous matedat is stored.
226. HAZARDOUS COMPONENTS 1-5 (% BY WEIGHT) - Enter the percentage weight of the hazar~3us component in a mixture. If a range of percentages is avallabla,
report the highest percentage in thst range. (Report ~or components 2 through 5 in 230, 234, 238, and 242_)
227. HAT..ARDOUS COMPONENTS' 1-5 NAME - When rapontng a hazard°us mstmiai that is a mixture, list up to We chemical names of hazardous componsnis in that
mixture by percent weight (raferto MSDS or, in the casa'of trade sesrats, refer to manufacturer).. All hazardous components in the mixture present at greater
than 1% by weight if hOn..carcinogenic, or 0.1% by weight if carcinagenic, should be reported. If mom than five-h ,.a,Z. ardous compO, nents are present abcve these
pamentages, you may attach an additional sheet ~r paper to ca0tura the required in~rmatidn. When reporting west~ mixtures, fflinerai and chemical composition
should he listed. (Eepe~t for components 2, through 5 in 231,235. 239, and' 243.)
Z28. HAZARDOUS COMPONENTS 1-5 EHS - Chec~ "Yes" [f the comi3onant of the mixture is considered aa ~(tremeiy Hazardous SUbstance as defined in 40 C~R,
Part 355, or "No' if. it is noL (Report for components 2. through 5 in 232. 236, 240, and 244.)
229. HAZARDOUS COMPONENTS 1-5 CAS - List the Chemical Adstraot Sea/ice (CA.~) numbers aa related to the hazardous cumponants in the mixture. {Ret3ea[ for
246. LOCALLY COI~J.EC'TED INFORMATION * This space' may be used by the CUPA or AA to collect any additianai information necaesary to meet the re--ants of their
individual programs. Contact the CUPA or AA for guidance..
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