HomeMy WebLinkAboutBUSINESS PLANHazardous Materials/Hazardous Waste Unified Permit
Permit ID#:: 015-000-O00731
CUNNINGHAMiVETERIN
-~-~ CONDITIONS'~OFPERMIT ON REVERSE SIDE
· · ' This _Permit is issued for the followin?,
[] Hazardous Materials Plan
[3 Underground Storage of Hazardous Materials
[3 Risk Management Program
n Hazardous Waste On-Site Treatment
LOCATION: 2703 M ST
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:
· E~p~iion Date:
· Oflic¢ofEv~Services ~
'June 30; 2003
issue Date
Hazardous Materials/Hazardous Waste Unified Permit
CONDITIONS OF PERMIT ON REVERSE SIDE
.......... ,,~.~,,~,'~;~'?m,',~,,,~,~,~ ........ This permit is issued for the following:
PERMIT ID# 015-0214)00731 .d~i~i ~i. !,,,[[!!:i~:!!iiiiii? 'i !!!['~i~.!?!!!!!::::!![!!i ,,.,,,! ~ ~'~k ~anagement Program
~i%*". '~ ,,,~ ",~b~,;~ ............ ~'= ~ [E ~" )0: ~, ' ; ~ ~i"i ~"h 'q:i ~ ' ......
.................... ~,, ,,,~ .... ~ ..,
~;",.... '.ii ~'~. ~¢." I ..................... "' ' , ~¢ ',~i~' II~ ~l.i~l~,~ ~ ~,~,~li,~i~,'~, ~,~ !,,I :~ "...
Issued by:
Bakersfield Fire Department
OFFICE OF ENVIR ONMENTAL SER VICES
1715 Chester Ave., 3rd Floor
Bakersfield, CA 93301
Voice (805) 326-3979
FAX (805) 326-0576
Approved by:
Expiration Date:
June 30, 2000
ITE/FACILITY D I~AG R~%1~4
4
NORTH
(CHECK ONE) SITE DIAGR.~M
FLOOR: / OF /
~. ~,~..
· ' ~NIT ~:/OF /
FACILITY DIAGR.~M
Inspector's Comments):
-OFFICIAL USE ONLY-
Manager :
Location: 2703 M ST
city : BAKERSFIELD
BusPhone:
Map : 103
AUG12 ~0~ Grid: 30
CommCode: BAKERSFIELD STATION 04
EPA Numb: ~L u ~ ~6"On~O&~/
SIC Code:
DunnBrad:
SiteID: 015-021-000731
(661) 327-9614
CommHaz : Low
FacUnits: 1 AOV:
Emergency Contact / Title
CATALINA B PARAYNO /
Business Phone: (661) 327-9614x
24-Hour Phone. : (~/~.~) SJ7-1i3-Sx
Pager Phone '~.- (44~) ~ ~zg~x
Emergency Contact / Title
DR OVIDIO PARAYNO /
Business Phone: (661) 327-9614x
24-Hour Phone~ _~ ~01 5177x
Pager Phone
Hazmat Hazards:
Fire Press ImmHlth
Contact : OVlPI~ ~ ~-~T~[~A
MailAddr: 2703 M ST
City : BAKERSFIELD
Phone: (661) 327-9614x
State: CA
Zip : 93301
Owner
Address
City
OVIDIO ~CATALINA PARAYNO
::~2'~ ~(
Phone: (661) 327-9614x
State: CA
Zip : ~-3~ ~O~
Period : to TotalASTs: =
Preparer: TotalUSTs: =
Certif'd: RSs: No
ParcelNo:
Gal
Gal
Emergency Directives:
01-10-01 PER WILLIAM NAREZ, BUSINESS SOLD 8/00 SEND BILL TO 2703 M ST.
I, OV'~f~l~A-. PA-I%~tJ 0. Do hereby certify that t have
ffype or ~n~ ~)
reviewed the a~ached h~ous
ment plan for Y~, I~FtT~ and that ~t ~cn~ w~h
~y ~e~i0ns ~nmi~ute a ~mp~e~e and ~rr~ man-
agement plan for my faciiityo
-1- 08/04/2003
CUNNINGHAM VETERINARY HOSPITAL
Manager :
Location: 2703 M ST
City :.BAKERSFIELD
CommCode: BAKERSFIELD STATION 04
EPA Numb:
BusPhone:
Map : 103
Grid: 30
SIC Code:
DunnBrad:
SiteID: 015-021-000731
(805) 327-9614
CommHaz : Low
FacUnits: 1 AOV:
Emergency Contact / Title
C.A~ Cr~-E,ii}!CY~i / ~7~%J~
Business Phone: (805) 327-9614x
,,2~-Hcur Ph3~ : (~05) 322~0'D58~
Pager Phone : (~9) G~q -l~x
Emergency Contact / Title
....... N~J~n'vl /'~. 6~p~ F~lz,~~c
Business Phone: (805) 327-9614x
2~-, Phone : ~ou~ 3~-o~oo~
Pager Phone : (~o(--~1~$ x
Hazmat Hazards: Fire Press ImmHlth
Contact : Phone: ( ) - x
MailAddr: 2703 M ST State: CA
City : BAKERSFIELD Zip : 93301
Address : 541 NORD AVE
City : BAKERSFIELD
Phone: (805)
State: CA
Zip : 93312
Emergency Directives:
327-9614x
Period : to ~v~D TotalASTs: = Gal
Preparer: Gal
Certif d: ~ ~ 5 ~otalUSTs: =
' RS s: No
~ Hazmat Inventory
--As Designated Order
One Unified List
Ail Materials at Site
DailyMax Unit MCP
1686.00 FT3 Low
OXYGEN F P IH G
~C~0~D)~fl~-- --F--~L- IH G --
~, 6JV'lo~u~ ~'or~^'zA~/~op..t..~) Do hsreby ce~i~ lhat ] have
reviewed ~h~ a~achod h~ardous ma~e~a,s mm :~ge.
'/~ ~'
men~ plan fo~.~u~ Y~land ~ha~ R along wi~h
(Na~ of ~o~e~) --
any corre~ions ~ns~i~u~ a complete and correc~ man-
agement plan ~or r~y ~aciMyo
09/05/2000
CUNNINGHAMVETERINARY HOSPITAL
= Inventory Item 0001
-- COMMON NAME / CHEMICAL NAME
OXYGEN
Location within this Facility Unit
OUTSIDE WALL SURGERY
SiteID: 015-021-000731
Facility Unit: Fixed Containers on Site
Map: Grid:
Days On Site
365
CAS#
7782-44-7
F STATE TYPE
Gas Pure
PRESSURE TEMPERATURE
I Above Ambient I Ambient
CONTAINER TYPE
PORT. PRESS. CYLINDER
Largest ContainerFT3
AMOUNTS AT THIS LOCATION
Daily Maximum I
1686.00 FT3
Daily Average
843.00 FT3
HAZARDOUS COMPONENTS
%Wt. I
100.00 Oxygen, Compressed
S CAS#
N 7782447
~Secret N~SIBioHaz
No No
HAZARD ASSESSMENTS
Radioactive/Amount EPA Hazards
No/ Curies F P IH
NFPA
///
USDOT# I MCP
Low
= Inventory Item 0002
-- COMMON NAME / CHEMICAL NAME
NITROUS OXIDE
Location within this Facility Unit
SURGERY O/S WALL
Facility Unit: Fixed Containers on Site
Map: Grid:
Days On Site
365
CAS#
STATE ~ TYPE
Gas ~Pure
PRESSURE TEMPERATURE
Above Ambient I Ambient
CONTAINER TYPE
PORT. PRESS. CYLINDER
Largest Container
FT3
AMOUNTS AT THIS LOCATION
Daily Maximum
326.00 FT3
Daily Average
250.00 FT3
%Wt.
~0 O0 Nitrous
HAZARDOUS COMPONENTS
CAS#
TSecretNo N~SIBi°HaZNo
HAZARD ASSESSMENTS
Radioactive/Amount EPA Hazards
No/ Curies F P IH
NFPA
///
USDOT#
MCP
Hi
2 09/05/2000
F CUNNINGHAM VETERINARY HOSPITAL
SiteID: 015-021-000731
Fast Format
~ Notif./Evacuation/Medical
--Agency Notification
CALL 911
Overall Site
03/23/1990
-- Employee Notif./Evacuation
ROUTINE FIRE SAFETY PROCEDURES.
ACCESSABLE.
03/23/1990
6 EXITS, ALL CLEARLY VISIBLE AND EASILY
-- Public Notif./Evacuation
03/23/1990
IN THE EVENT OF AN EMERGENCY, PUBLIC WILL BE DIRECTED OUT THE FRONT EXIT OF
THE BUILDING. THIS WILL PUT AT LEAST 3 WALLS AND CONSIDERABLE DISTANCE
BETWEEN THE PUBLIC AND THE COMPRESSED GAS CONTAINERS. EMPLOYEES WILL NOTIFY
THE PUBLIC OF THE NATURE OF THE SITUATION, AND KEEP PEOPLE CLEAR OF THE
Emergency Medical Plan
EMERGENCY ROOM AT SAN JOAQUIN - 2615 EYE ST - 327-1711
03/23/1990
-3- 09/05/2000
F CUNNINGHAM VETERINARY HOSPITAL
SiteID: 015-021-000731
Fast Format
= Mitigation/Prevent/Abatemt
--Release Prevention
Overall Site
04/17/1992
02 TANKS SECURED TO WALL WITH CHAINS TOP AND BOTTOM. NO OIL USED ON 02
EQUIPMENT. NO SPARKS OR OPEN FLAME NEAR ANY 02 EQUIPMENT OR LINES. FIRE
EXTINGUISHERS AT FRONT AND BACK DOORS. 3 OUTDOOR WATER HOSES.
-- Release Containment
CONTAINERS ARE OUTSIDE OF BUILDING, GAS ONLY.
ATMOSPHERE.
04/17/1992
RELEASE WILL BE INTO OPEN
-- Clean Up
GAS ONLY
04/17/1992
-- Other Resource Activation
-4- 09/05/2000
F CUNNINGHAM VETERINARY HOSPITAL
SiteID: 015-021-000731
Fast Format
Site Emergency Factors
Special Hazards
Overall Site
--Utility Shut-Offs
A) GAS - FRONT OF BUILDING
B) ELECTRICAL - SOUTHWEST CORNER OF BUILDING
C) WATER - FRONT OF BUILDING
D) SPECIAL - NONE
E) LOCK BOX - NO
04/17/1992
-- Fire Protec./Avail. Water 04/17/1992
PRIVATE FIRE PROTECTION - TWO WATER OUTLETS WITH ATTACHED HOSES ON EITHER
SIDE OF THE OXYGEN AND NITROUS OXIDE TANKS
FIRE HYDRANT - CORNER OF M ST AND GOLDEN STATE HWY
Building Occupancy Level
-5- 09/05/2000
F CUNNINGHAM VETERINARY HOSPITAL
SiteID: 015-021-000731
Fast Format
Training
-- Employee Training
WE HAVE.~EMpLOYEES__ AT THIS FACILITY
Overall Site
09/10/1991
WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE
EMPLOYEES TRAINED AND REVIEWED ON THE PROPER HANDLING AND EMERGENCY
PROCEDURES ASSOICATED WITH COMPRESSED OXYGEN AND NITROUS OXIDE GASSES
Page
--Held for Future Use
Held for Future Use
6 09/05/2000
CITY OF BAKERSFIELD
CLAIM VOUCHER
Vendor No.
CLAIMANT'S NAME AND ADDRESS:
Cunningham Veterinary Hospital
431 W Los Feliz Road
Glendale, CA 91204
I certify that this claim is correct and valid, and is a proper
charge against the City Agency and account indicated.
(AUTHORIZED SIGNATURE OF CITY AGENCY
Date: 04-01-99 Initials of Preparer
CITY DEPARTMENT: FINANCE
PLEASE PROVIDE SHORT EXPLANATION OF PAYME (Including Contract Number if Applicable)
This customer made a duplicate payment on this years Haz Mat bill in the amount of $128.50.
We have since made an adjustment to the California State surcharge in the amount of $8.50
leaving them with a credit of $137.00.
Dept.
0000
El/Objt
7900
Pr~ect#
VOUCHER TOTAL
Invoice #
Amount Date of Invoice
$137.00
$137.00
SECTION 72, PENAL CODE
Section 72, Presenting False Claims. Every person who with intent to defraud,
'presents for allowance or for payment to any state board or officer, or any
county, town, city district, ward or village board or officer, authorized to allow
or pay the same if genuine, any false or fraudulent claim, bill, account, voucher,
or wdting, is guilty of a felony.
FINANCE DEPT. USE ONLY
Examined & Approved for Payment Amount
STATEMENT OF ACCOUNT
CITY OF BAKERSFIELD
1501TRUXTUN AVE
BAKERSFIELD, CA 93301-5201
TO:
(805> 32&-397~
CUNNINGHAM VETERINARY HOSPITAL
LOS FELiZ RD
OLENDALE, CA 91~04
DATE:
4/01/99
CUSTOMER NO: 3080
CUSTOMER TYPE: ES/
3080
CHAROE
SSO01
DATE DESCRIPTION
3/01/99 BEGINNING BALANCE
2/04/99 PAYMENT
3/31/99 Charge adjustment
CA STATE SURCHARGE
REF-NUMBER DUE DATE
4/30/99
TOTAL AMOUNT
.00
128.50-
8. 50-
FOR GUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE
CALL THE NUMBER AT THE TOP OF THIS STATEMENT.
CURRENT OVER 30 OVER 60 OVER
8. 50-
DUE DATE:
5/03/99
PAYMENT DUE:
TOTAL DUE:
137.00--
$137.00--
DATE:
PLEASE' DETA:CH AND"/S~ND THIS COPY WITH REMITTANCE
4/01/99 DUE:"DATE: 5/03/99
REMIT AND HAKE CHECK PAYABLE TO:
CITY OF BAKERSFIELD
PO BOX 2057
BAKERSFIELD CA 93303-2057
(805)
CUSTOMER NO: 3080
CUSTOMER TYPE: ES/
TOTAL DUE:
3080
$137. 00-
CUS~~NO. ~ ~C)~
MISCELLANEOUS RECEIVABLES ADJUSTMENT
CUSTOMER NAME
MAILING ADDRESS
SITE ADDRESS
STATE
NEWACCOUNT i
ADDRESS CHANGE ~
CLOSE ACCT j ~
' FINANCE CHARGE I ,I
OTHER ADJ i~_1
PARCEL NUMBER
(IF APPUCABLE)
ADJUSTMENT
CHG DATE
CHARGE CODE
ADJUSTMENT AMOUNT
REMARKS: '~--~ ~,
/
APPROVED BY
STATEMENT OF ACCOUNT
CITY OF BAKERSFIELD
1501 TRUXTUN AVE
BAKERSFIELD, CA ~3301-520i
TO:
(805.) 32&-3~79
CUNNINGHAM VETERINARY HOSPITAL
431W LOS FELIZ RD
GLENDALE, CA 91204
DATE'
9/01/98
CUSTOMER NO' 3080
CUSTOMER TYPE: ES/
3080
CHARQE
DATE DESCRIPTION
REFND
S/01/98 BEGINNING BALANCE
b/24/98 PAYMENT
8/19/98 MR INT REFUND VCHRS
REF-NUMBER DUE DATE
TOTAL AMOUNT
110.00
128. 50-
18. 50
FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE
CALL THE NUMBER AT THE TOP OF THIS STATEMENT.
CURRENT OVER 30 OVER 60 OVER 90
DUE DATE: 10/01/98
PAYMENT DUE:
TOTAL DUE:
18. 50-
$18. 50-
BAKERSFIELD.
TO:
THIS COPY WITH 'REMITTANCE
CUSTOMER NO:
3080
CUSTOMER TYPE: ES/
TOTAL DUE:
3080
$18.50-
CITY OF BAKERSFIELD
CLAIM VOUCHER
Ivendor No. I
CLAIMANT'S NAME AND ADDRESS:
Cunningham Veterinary Hospital
431 W. Los Feliz Rd.
Glendale, CA 91204
I certify that this claim is correct and valid, and is a proper
charge against the City Agency and account indicated.
(AUTHORIZED SIGNATURE OF CITY AGENCY)
Date: 08-12-98 initials of Preparer:
;ITY DEPARTMENT: FINANCE
PLEASE PROVIDE SHORT EXPLANATION OF PAYME (Including Contract Number if Applicable)
This business overpaid their Hazardous Materials bill by $18.50. For that reason they now have a
credit of $18.50 which we will be refunding.
Dept.
0000
El / Obit Project # Invoice # Amount Date of Invoice
79OO
VOUCHER TOTAL
$18.50
$18.50
SECTION 72, PENAL CODE
'Section 72, Presenting False Claims. Every person who with intent to defraud,
~ presents for allowance or for payment to any state board or officer, or any
county, town, city district, ward or village board or officer, authorized to allow
or pay the same if genuine, any false or fraudulent claim, bill, account, voucher,
or writing, is guilty of a felony.
FINANCE DEPT. USE ONLY
Examined & Approved for Payment Amount
BAKERSFIELD
FIRE DEPARTMENT
MEMORANDUM
DATE: July 30, 1998
TO: Susan Chichester
FROM: Esther Duran
SUBJECT: Claim Voucher
Please issue a Claim Voucher to refund over payment of $18.50 made by
Cunningham Veterinary Hospital. They made a payment of $18.50 on 6/15/98
and then sent a payment of $128.50 on 6/24/98. The second payment caused
them to have a credit of $18.50. Please send a refund of $18.50 to:
Thank you,
Cunningham Veterinary Hospital
431 W Los Feliz Rd
Glendale, CA 91204
/ed
STATEMENT OF,.**,'""',.]UN]"..,..
CITY OF BAKERSFIELD
1501 TRUXTUN AVE
BAKERSFIELD., CA 9330!-:5201
(805~ ~6.-~9,,9
CUNNiNGHAM VETERINARY HOSPITAL
43i W LOS FELiZ RD
GLENDALE, CA 91204
DATE: 6,;30/98
CUSTOMER NO: 3080
CUSTOMER TYPE: ES/ 3080
CHARGE
DATE DESCRIPTION
REF-NUMBER DUE DATE TOTAL AMOUNT
6/11/98 BEGINNINg BALANCE
6/15/98 PAYMENT
6/'~.4/98 PAYMENT
28. 50
18. 50-
28. 50-
FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE
CALL THE NUMBER AT THE TOP OF THiS STATEMENT.
CURRENT OVER R
~0 OVER 60 OVER 90
DUE DATE' 7/30/98
PAYMENT DUE'
TOTAL DUE'
18. 50-
$18. 50-
DATE'
PLEASE DETACH AND SEND THIS COPY WITH REMITTANCE
6/30/98 DUE DATE: 7/30/98
REMIT AND MAKE CHECK PAYABLE TO:
CITY OF BAKERSFIELD
PO BOX 2057
BAKERSFIELD CA 93303-2057
CUSTOMER NO' 3080
CUSTOMER TYPE: ES/
TOTAL DUE:
3080
$i~.50-
CITY OF BAKERSFIELD
ellaneous Receivables In
7/31/98
L6:34:39
Custome L' ID :
Last invoice :
Current balance :
Pending ..... :
3080
6/30/98
o/oo/oo
18.50-
.00
Name: CUNNINGHAM VETERINARY HOSPITAL
Addr: 431 W LOS FELIZ RD
GLENDALE, CA 91204
A ACTIVE ENVIRONMENTAL SERVICES
Type options, press Enter. Combined Detail
5=Display
Opt Trans Date Code Description
6/30/98 stmrn Statements Processed
6/24/98 PAYMENT
6/15/98 PAYMENT
6/11/98 stmrn Statements Processed
6/10/98 HM0.05 HAZ MAT HANDLING FEE
6/01/98 stmrn Statements Processed
6/01/98 SS001 CA STATE SURCHARGE
5/01/98 stmrn Statements Processed
4/01/98 stmrn Statements Processed
Amount
0O
128 50-
18 50-
00
110 00
00
18 50
.00
.00
Chg Bnk G
Balance Typ Cd L
18 50-
18
110
128
128
18
18
50 - 00 Y
00 00 Y
5O
5O
5O
50 A
00
00 +
F3=Exit F12=Cancel * = Pending
STATEMENT OF ACCOUNT
CITY OF BAKERSFIELD
1501TRUXTUN AVE
BAKERSFIELD, CA 93301-5~0i
(805) 326-3~79
TO:
CUNNINQHAM VETERINARY HOSPITAL
431 W LOS FELIZ .RD
OLENDALE, CA 9~04
CUSTOMER NO: . 3080
DATE'
cuSTOMER TYPE: ES/
8/01/98
3080
CHARQE
DATE DEsCRIpTION
6/30/98 BE~INNIN~ BALANCE
REF-NUMBER DUE DATE
TOTAL AMOUNT
18. 50--
FOR OUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE
CALL THE NUMBER AT THE TOP OF THIS STATEMENT.
CURRENT OVER 30 OVER 60 OVER
DUE DATE:
8/31/98
PAYMENT DUE:
TOTAL DUE:
18.50--
$18.50-
ITH =REMITTANCE
CUSTOMER NO:
~C'A-"~3303'2057
3080
CUSTOMER TYPE: ES/
TOTAL DUE:
3080
$18. 50-
02/24/92
~"/RECEIVED
CUNNINGHAM VETERINARY HOSPITAL 215-000-00073~AR 2 199~age
Overall Site with 1 Fac. Unit ARs'd ............
General Information
Location: 2703 M ST Map: 103 Hazard: Low
Community: BAKERSFIELD STATION 01 Grid: 30 F/U: 1AOV: 0.0
Contact Name Title Business Phone 24-Hour Phone-
C.A. CUNNINGHAM (805) 327-9614 x (805) 322-8958
D.R. CUNNINGHAM (805) 327-9614 x (805) 322-8958
Administrative Data
Mail Addrs: 2703 M ST D&B Number:
City: BAKERSFIELD State: CA Zip: 93301-
Comm Code: 215-001 BAKERSFIELD STATION 01 SIC Code: 8980
Owner: N$~;;AN E. CU::~iNC:IAM ~ ~ ~ ~-~~tPhone: (805) 327-9614
..... /v,.,(
Address: ~I .... ~ ~ '~ State: CA
City: BAKERSFIELD Zip:J~3_3~ q~/~
Summary
reviewed th.,. ~.ti~c?~.~d ~:az ,a~:lous ma!~rials, m~nage-'
merit .plan tot ~ ~6 that ,t along with
any corrosions oonstitut~ a complete and ~rr~ man-
~emem plan for my facUi~.
02/24/92
CUNNINGHAM VETERINARY HOSPITAL 215-000-000731
.02 - Fixed Containers on Site
Hazmat Inventory Detail in Reference Number Order
Page 2
02-001
OXYGEN
· Fire, Pressure, Immed Hlth
Gas 1686 Low
FT3
CAS #: 7782-44-7
Trade Secret: No
Form: Gas
Type: Pure
Days: 365
Use: MEDICAL AID OR PROCESS
Daily Max1,686FT3 I Daily Average 843.00FT3
Annual Amount FT3 --
6,744.00
Storage Press T Temp Location
PORT. PRESS. CYLINDER Above ~AmbientlOUTSIDE WALL SURGERY
-- Conc
100.0% IOxygen, Compressed
Components
MCP
Low
iList
02-002
NITROUS OXIDE
· Fire, Pressure, Immed Hlth
Gas 326 High
FT3
CAS #:
Form: Gas Type: Pure
Daily Max FT3
326 I
Trade Secret: No
Days: 365 Use: ANESTHETIC
Daily Average FT3 ~ Annual Amount FT3
250.00! 652.00
Storage Press T Temp Location
PORT. PRESS. CYLINDER Above IAmbientlSURGERY O/S WALL
-- Conc Components I MCP
100.0% INitrous Oxide IHigh
iList
02/24/92
CUNNINGHAM VETERINARY HOSPITAL 215-000-000731
00 - Overall Site
<D> Notif../Evacuation/Medical
Page
<1> Agency Notification
CALL 911
<2> Employee Notif./Evacuation
ROUTINE FIRE SAFETY PROCEDURES.
ACCESSABLE.
6 EXITS, ALL CLEARLy VISIBLE AND EASILY
<3> Public Notif./Evacuation
IN THE EVENT OF AN EMERGENCY, PUBLIC WILL BE DIRECTED OUT THE FRONT EXIT OF
THE BUILDING. THIS WILL PUT AT LEAST 3 WALLS AND CONSIDERABLE DISTANCE
BETWEEN THE PUBLIC AND THE COMPRESSED GAS CONTAINERS. EMPLOYEES WILL NOTIFY
THE PUBLIC OF THE NATURE OF THE SITUATION, AND KEEP PEOPLE CLEAR OF THE
AREA.
<4> Emergency Medical Plan
EMERGENCY ROOM AT SAN JOAQUIN - 2615 EYE ST - 327-1711
02/24/92 CUNNINGHAM VETERINARY HOSPITAL 215-000-000731 Page
00 - Overall Site
<E> Mitigation/Prevent/Abatemt
<1> Release Prevention
02 TANKS SECURED TO WALL WITH CHAINS TOP AND BOTTOM. NO OIL USED ON 02
EQUIPMENT. NO SPARKS OR OPEN FLAME NEAR ANY 02 EQUIPMENT OR LINES. FIRE
EXTINGUISHERS AT FRONT AND BACK DOORS. 3 OUTDOOR WATER HOSES.
<2> Release Containment
<3> Clean Up
<4> Other Resource Activation
02/24/92
CUNNINGHAM VETERINARY HOSPITAL 215-000-000731
00 - Overall Site
<F> Site Emergency Factors
Page
5
<1> Special Hazards
<2'> Utility Shut-Offs
A) GAS - FRONT OF BUILDING
B) ELECTRICAL - SOUTHWEST CORNER OF BUILDING
C) WATER - FRONT OF BUILDING
D) SPECIAL - NONE
E) LOCK BOX - NO
<3> Fire Protec./Avail. Water
PRIVATE FIRE PROTECTION - TWO WATER OUTLETS WITH ATTACHED HOSES ON EITHER
SIDE OF THE OXYGEN AND NITROUS OXIDE TANKS
FIRE HYDRANT - ????????????
<4> Building Occupancy Level
02/24/92'
CUNNINGHAM VETERINARY HOSPITAL
00 - Overall Site
<G> Training
215-000-000731
Page
<1> Page 1
'WE HAVE 6 EMPLOYEES AT THIS FACILITY
WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE
EMPLOYEES TRAINED AND REVIEWED ON THE PROPER HANDLING AND EMERGENCY
PROCEDURES ASSOICATED WITH COMPRESSED OXYGEN AND NITROUS OXIDE GASSES
SEMI-MONTHLY.
<2> Page 2 as needed
<3> Held for Future Use
<4> Held for Future Use
CITY
of BAKERSFIELD
( ~5'De or ~,~q n; name
Do hereby certify that I have reviewed the
RECEIVED
JAN 1 9 I989
A,~?i ............
attached Hazardous Materials business plan
for
. o~ business )
and that it along with the attached additions
or corrections constitute a comDlete and correct
Business Plan for my facility.
CITY of BAKERSFIELD
NO N-- T RAD E S E C RE TS ' P~ge.~__of_[._
LOCATION: ~l.?~-q ~ d~--.~ ....... [ .... v ADDRESS: Q-~/~-e~c-t~--~i-~-~°' ....... STANDARD
CITY, ZIP: ~C~~ ~/ CITY, ZIP: ~F~e~ ~,35~ DUN AND BRADSTREET NUMBER
PHONE ~: ~--~--~t~ PHONE ~: ~ ~~,~ __ - -
~ ~ f~U~fO~ ~R ~OP~ COD~
t~ C~e ~t Mt Est Un~ts m Stte I~ ~. TM ~ St~ tn FKtJfty~"
~ltk of P~ ~lth ........ ' .....
,P~icll ~ ~lth fllzl~ C.l.S. ~ ~t II ~ b C.l.S. ~
(C~k ell t~t ~pply)
- r--~ r--~~~ r--~ ~t I~ ~&C.A.5. ~
~lth of P~ ~lth
..... L_I L_.i2 ..... l ['1 l:: ! ! I_ ! ............
P~lcal ~ ~lth ~zaH C.A.S. ~ ~t I1 h i C.A.S. ~
(C~k ~11 t~t a~ly)
H~l~h of P~su~ N. Ith ' '
~.__~__t ......... ,L ........... ~ .......... ] ..... j. ....... t ].~~ ...... ! .......................
H~lth of Prflsuee Health .... - ......
~t 13 ~&C.A.S. ~
.................
Certification (Read and sign after completing ali sections)
I c~rt*fy onder ~lty of law that I have oerso~allyexamined a~d aB f~iliar vith the tnformtio~ submtted in this aed all etjt~ehed docue~ts. ~d that based on ay in*lutry of the~e fndtvtd,els e~pensible
for obtainin9 the jOtoeeatton. I believe that the suheitte~ intoeeation is true. accurate, ~d~r, lealeta. /~ /
/
OUNNINGHAM
VETERINARY
HOSPITAL
DOGS CATS CAGE PETS
2703 M Street Bakersfield, California 93301 (805) 327-9614
SIC #: 8980
I
B~SINESS NAME CUNNIN~m~M VETERINARY HOSPITAL
LOC~TION Z703 M ST
ID Nu~R 21S-~OO--O(~O73!
HIGH HAZARD RrSTING Z
1. OVERVIEW
JURIS CODE Z!5-OO1
MAP PAGE 103 GRID
LAST CHANGE 10/20/88 BY
SURIS BAKERSFIELD STATION
FACILITY UNITS 1 HRZARO RATING
RESPONSE SUMMARY
Z~ SEC ~) NO PRIg~TE RESPONSE 'rEaM.
EMERGENCY CONTACTS ZA SEC
C.A. CUNNINGHRM - 3Z?-9~14 OR
D.A. CUNNINGHRM - 3Z?-9614 OR ~22-8958
UTILITY SHUTOFFS ~ SEC
A) GAS - FRONT OF BLDG B) ELECTRICAL - S~ CORNER OF BLDG
C) ~ATER - FRONT OF BLDG D) SPECIAL - NONE
E) LOCK'BOX - NO
RECEIVED
JAN 2 1989
.......
2. NOTIFICATION / PUBLIC EVGCUATION
LAST CHA~E Z / 20 89 BY )]on C'%~J_qgheLm
In the event, of an emergency, public will be directed out the front exit of the
building. This will put at least 3 walls and considerable distance between the
public and the cc~pressedgas COntainers. Employees will notify the public of'
the nature of the situation, and keep people clear of the area.
< NO INFORMATION RECORDED FOR THiS SECTION
PRGE I
12/2'7/88 17:ZG
MATERIAL. S~FETY DATA SYSTEMS, INC. (805) G48-G800
BUSINESS NRME CUNNINGHAM VETERINARY HOSPITAL
LOCATION 2703 M ST
ID NUMBER ZlS-~00-000731
HIGH HAZARD RATING 2
-~. H~Z MAT TRAINING SUMMARY
LAST CHANGE 1 / 20/89 BY Don Cunningham
8 employees trained and reviewed on the proper handling and emergency procedures
associated with compressed oxygen and. nitrous o~Jde gasses semi-r~Dnthly.
< NO INFORMATION RECORDED FOR THIS SECTION >
4. LOCGL EMERGENCY MEDICAL ASSIST~tNCE
LAST CHANGE 08/30188 BY ESTER
SEC 5) EMERGENCY ROOM AT SAN JOAQUIN - 2$1S EYE ST - 327-171t
PAGE Z
1Z/27/88 17:28
MATERIAL SAFETY DATA SYSTEMS, INC. (805) 848-8800
BUSINESS NAME CUNNI~
LOCATION 270~ M ST
FACILITY UNIT
9ETERINA~Y HOSPITAL ID
HiGH HAZARO RATING Z
OVERALL HAZAROOUS MATERIALS INVENTORY
LAST CHANGE 10/28188 BY UAL.
ID TYPE NAME MAX AHl' UNIT HAZARD
LOCATION CONTAINMENT USE
PURE OXYGEN
OUTSIDE WALL SURGERY PORTABLE PRESS. CYL.
ID PERCENT COMPONENTS
235B.~ 100.0 OXYGEN, COMPRESSED
SG2 PT3 HIGH
MEDICAL AID OR PROCESS
HAZARD LIST
HIGH
PURE NITROUS OXIDE
SURGERY O/S WALL PORT6BLE PRESS. CYL,
ID PERCENT COMPONENTS
'~4S.~ l e,~.~ NITROUS OXIDE
326 FT3 MODERRI~
ANESTHETIC
HRZARO LIST
MODERATE
FIRE PROTECTION / WATER SUPPLIES
L~ST CHANGE 1 /20/89 BY DonC oDDingham
Two water outlets wi~h attached hoses on either.side of' the oRygen and nitrous
oxide tanks.
< NO INFORMATION RECORDED FOR THIS SECTION
PAGE 3
IZ/ZT/88 17:ZG
MATERIAL SAFETY DATA SYSTEMS, INC. (885) 648-6800
BUSINESS NAME CUNNINGHAM VETERINARY HOSPITAL
LOCATION 2703 M ST
ID NUMBER Z!5-0~-~7~1
HIGH HAZARD RATING
D. EMPLOYEE NOTIFICATION / EVACUATION
LAST CHANGE 06/30/88 BY ESTER
SEC Z) ROUTINE FIRE SAFETY PROCEDURES. G EXITS, ALL CLEARLY VISIBLE ~ND
EASILY ACCESSABLE.
MITIGATION / PREVENTION / ABATEMENT
LAST CHANGE 0G/30/88 BY ESTER
SEC 1) 0% TANKS SECURED TO WALL YITH -CHAINS TOP AND BOTTOM. NO OIL USED
ON OZ EQUIPMENT. NO SPARKS OR OPEN FLAME NEAR ANY 02 EQUIPMENT OR
LINES, FIRE EXTINGUISHERS RT FRONT AND BACK DOORS, 3 OUTDOOR
UAl'ER HOSES,
P~qGE 4
12/27./88 17:26
MATERIAL SAFETY D~tTA SYSTEMS, INC. <B05) G48-G800
Business Name:
Location:
Hazardous Materials Inspection
Date Completed ~' 1~ '~
C~,J,~,d~t~ V~'~,~/~/ ~~, RECEIVED
JUt 0 3 1909
Plan ID # 215-000
Station No. ZT/
Verification of Inventory Materials
Verification of Quantities
Verification of Location
Proper Segregation of Material
Comments:
HAZ. MAT. DIV.
(Top right comer Business Plan)
Inadequate
Verification of MSDS Availability
Number of Employees /[
Verification of Haz Mat Training
Comments:
Verification of Abatement Supplies & Procedures
Comments:
Emergency Procedures Posted
Containers Properly Labeled
Verification of Facility Diagram
Special Hazards Associated with this Facility:
Violations:
FO 1652 (Rev. 3-89) White-Haz Mat Div. Yellow*Station Copy Pink-Business Office
BAKERSFIELD Ci~[ FIRE DEPARTMENT
2120 "S" S%2REET
BAKERSFIELD. CA 98301
(805) 326-39T9
S E P 3 1988
A s'd ............
IXESS NAME
OFFICIAL USE ONLY
ID=
i-i/.-'kZ .~i~ ~ 0 U S ~E~ ~-kLS
BUSINESS PLAN AS A WHOLE
FORM 2A
1. To avoid further action, return this form by
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business as a whole.
4. Be as brief and concise as possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
B. LOCATION / STREET ADDRESS: ~, ~
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving the release or threatened release of a
hazardous material, call g!! and t-800-852-75S0 or 1-916-427-4341. This will notify
your local fire department and the State Office of EmerLency Services as required by
law. -
EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:
N~XE AND TITLE DURING BUS. HRS.
SE~!ON S: LOCATION OF I~ILI~ S~-OFFS FOR BUSI~SS AS A r~OLE
AFTER BUS. HRS.
A. NAT. GAS/4~4~grN~5:
B. ELECTRICAL:
C. WATER:
D. SPECIAL:
E. LOCK BOX: YES /~ IF YES, LOCATION:
IF YES, DOES IT CONTAIN S~TE PLANS?
FLOOR PLANS?
YES / NO
YES / NO
MSDSS? YES ./ NO
KEYS? YES / NO
SECTION ~t: PRIVATE RESPC3NSE TE~LM _"OR FJUSI.YESS AS A WHOLE
SECTION ~: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOI~ BUSINESS AS A WHOLF
SECTION 8: EMPSO%rEE TRAINING
E}!PLCS~RS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPL0'~2ES WITH
REFRESHER TRAiXiNG iN THE FOLLOWING AREAS.
CIRCLE YES OR NO INITIAL
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
>~TER!ALS: ....................................... YES N0 YES
B. PROCEDURES FOR COORDiNATiNG ACTIVITIES
WITH RESPONSE AGENCIES: .......................... YES ~0 YES X0
C. PROPER USE OF SAFET~f EQUIPMENT: .................. YES ~0 YES 'NO
D. E?,!EEGE:'~CV EVACUATION PROCEDURES: ................. - YES XO YES
E DO YOU .~INT~IN EMPLOYEE TRAI~I~G RECORDS: ....... YES NO YES ~0
REFRESHER
SECTION T: FAZARDOUS MATERIAL
CIRCLE YES - NO - NONE
DOES YOUR BUSI)~ESS HANDLE HAZARDOUS ~,~TERIAL IN QUANTITIES ~r ~
~,S~ THAX 500 POUYDS OF A
SOLID, $5 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YES NO
I, certify that the above information is accurate.
r understand that this information will be used to fulfill my firm's obligations under
the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter
Sec. 2~500 Et Al.) and that inaccurate information constitutes perjury.
'SIGNATURE TITLE DATE
BAKERSFIELD CI/~' FIRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
BUSINESS
OFFICIAL USE ONLY
ID#
BUSINESS PLAN
SINGLE FACILITY UNIT
FORM SA
INSTRUCTIONS 1. To avoid further action, this form must be returned by:
2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
3. Answer the questions below for THE FACILITY UNIT LISTED BELOW
4. Be as BRIEF and CONCISE as possible.
'
SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES
' '~ '~ I' , ~ ' ; --~ -- '~"
SECTION 2: NOTIFICATION .~YD EVACUATION PROCEDL-R. ES AT THIS 5~IT ONLY
SECTION 4: PRI,,VATE., RESPONSE TEAM FOR BUSINESS AS A WHOLE
SECTION ~: LOCAL EMERGENCY MEDICAL ASSIST~YCE FOR YOUR BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE ~RAINING
EMPLOYERS ARE REQUIRED TO HAVE A PROGP~I WHICH PROVIDES ~MPLOYEES WITH INITIAL
REFRESHER TRAINING IN THE FOLLOWING AREAS.
CIRCLE YES OR NO INITIAL
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
.MATERIALS: .......................................
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES: .......................... ~E~ NO
C. PROPER USE OF SAFETY EQUIPMENT: .................. ~ NO
D. EMERGENCY EVACUATION PROCEDURES: ................. YES
E. DO YOU ,MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES
REFRESHER
gO
YES ~
YES
SECTION "f: F, AZARDOUS MATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS ~TERIAL IN QUANTITIES LESS THAN 500 ?0L~I1S-DF A
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC" FEET OF A COMPRESSED G~S: ...... Y~_S" NO
I, /~ i~ ~'~9 ¢. , certify that the above information is accurate'
I understand that this infg~mation will be used to fuifiiI my firm's obligations under
the new California Health and Safety code on Hazardous Materials (Div. ZO Chapter ~.95
Sec. 2~$00 Et Al.) and that inaccurnte information constitutes per3ury.
DATE
- 2B -
BAKERSFIELD CITY FIRE DEPARTMENT .
I .D. # FORM 4A-I Page ..... .,~
HAZARDOUS
ADDRESS
zip:
NON--TRADE SECRETS
IVlATER I ALS I I~{VE NTORY
ADDRESS: ~ ~~ I/~ ~ F~CILITY DNiT NAt. IE:__
PIIONE ~: ~~ %~~. [OFFICIAl, USE CFIR~
I
ON[,Y ...
FACII, ITV UNIT ~:
I 2 3 4 5 6 7 8 9 10
TYPE HAX ANNUAL CONT USE LOCATION IN TillS ~; BY IIAZAtllJ
CODE____~ASJ_OUNT AMOUNT UNIT CODE __C_O~_E._ FACILITY UNIT kiT. CHE_MI__~AL OR COM~ION NAA_IE COl)l:
,HA~IE: TITLE: ~0~ ~ SIONATURE: ,~ DATE:.
'~HERGEHCV CONTACT: TITLE: PHONE
: AFTER BUS HRS: ~~.~
~MERGENCV CONTACT: ~0~ _~.~n_~.~.~ TITLE;
P~INCIPAL BUSINESS ACTIVITY:
IUSINESS
BAKERSFIELD CITY FIRE DEPARTMENT
2130 "$" STREET
BAKERSFIELD, CA 93301
(805) 326-3979
RECEIVED .2A)SP ~
JUN 3 0 1987
Ans'd ............
NAME
OFFICIAL USE ONLY
ID#
HAZARDOUS MATERIALS
USINESS PLAN AS A WHOLE
FORM 2A
INSTRUCT IONS:
1. To avoid further n, return this form by
2. TYPE/PRINT ANSWERS iNGLISH.
3. Answer the questions b~ .ow for the business as a whole.
4. Be as brief and concise s possible.
SECTION 1: BUSINESS
DATA
A. BUSINESS NAME:
B. LOCATION / STREET ADDRESS: ~
CITY: /~z~er~'ze, id ziP:
o/
BUS.P~ONE: (2~ o=.2 7- ?g/~z
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving the lease or threatened release of a
hazardous material, call 911 and 0 or 1-916-427-4341. This will notify
your local fire department and the State Offi, of Emergency Services as required by
law.
EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:
NAME AND TITLE , , .... BUS. HRS. AFTER ~US. HRS.
SgCTIO~ 8: BOC~TI0~ OF ~I~I~ S~-OFFS ~OR BUSI~SS OBg
~. E~CTRrCAn: .~.
D. SPECIAL:
E. LOCK BOX: YES /~ IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANSP YES / NO .DSS? YES / NO
FLOOR PLANS? YES / NO KEYS9 YES / NO
- 2A -
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR
BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE
EMPLOYERS ARE REQUIRED TO
REFRESHER TRAINING IN THE
A PROG
,LOWING AR!
WHICH PROVIDES EMPLOYEES WITH INITIAL AND
CIRCLE YES OR NO
A. METHODS FOR SAFE HANDLING
MATERIALS.
B. PROCEDURES FOR COORDINATING AC'
WITH RESPONSE AGENCIES: .......
C. PROPER USE OF SAFETY EQUIPMENT
D. EMERGENCY EVACUATION PROCEDURi
E. DO YOU MAINTAIN EMPLOYEE TRA]
'ITIES
INITIAL REFRESHER
(~ NO (~ NO
NO (~ NO
NO (~ NO
: ....... YES YES
SECTION 7: HAZARDOUS MATER]
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE
SOLID 55 GALLONS OF A LIQ{
MATER:
OR 200 CUBIC
certify
IN QUANTITIES LESS THAN 500 POUF A
OF A COMPRESSED GAS: ...... ~ NO
the above information is accurate.
SIG
lnac~
- 2B -
l
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
SECTION $: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A PROGR~M WHICH PROVIDES k-MPLOYEES WITH INITIAL .~\~
REFRESHER TRAINING IN THE FOLLOWING AR~4S.
CIRCLE YES OR NO INITIAL
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
.MATERIALS:...- ....................................
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES: ..........................
C. PROPER USE OF SAFETY EQUIPMENT: .................. ~ NO
D. EMERGENCY EVACUATION PROCEDURES: ................. YES
E. O0 YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES
REFRESHER
YES ~
YES
SECTION ?: MAZARDOUS ~ATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS ~T~RIAL IN QUANTITIES LESS THAN ~00 POL~J~F A
SOLID, 55 GALLONS OF A LIQUID~OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... Y~ MO
I, ~ ' ~,~9 /~,~ , certify that the above information is accurate'
I understand that this infg~mation will be used to fulfill my firm's obligations under
the new California Health and Safety code on Hazardous Materials (Div. Z0 Chapter 6.95
Sec. 25~00 Et Al.) and that inaccurate information constitutes per3ur¥.
DATE
- 2B -
BAKERSFIELD CITY FIRE DEPARTM~E~
2130 "G" STREET
BAKERSFIELD, CA 93301
(805) 326-3979
IUSINESS NAME
OFFICIAL USE ONLY
ID:
INSTRUCTIONS:
HAZARDOUS MATERIALS
,USINESS PLAN AS a W~OLE
FORM 2A /
1. To avoid further n, return this form by
2. TYPE/PRINT ANSWERS IN ISH.
3. Answer the questions for the busines~
4. Be as brief and concise possible.
whole.
SECTION 1: BUSINESS IDENTIFI
A. BUSINESS NAME:
B. LOCATION / STREET ADDRESS:
CITY: ZIP: BUS.PHONE: ( )
SECTION 2: EMERGENCY NOTI
g the tel
or threatened release of a
r 1-916-427-4341. This will notify
Emersency Services as required by
In case of an emerMency
hazardous material, call 911/~ 1-8C
fire depar--~me.n~d the State Office
local
your
,E,~PLOYEES TO NOTIFY IN ~ASE OF EMERGENCY:
B. / Ph~ Ph~
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A ~LE,
A. NAT. GAS/PROPANE:
B. ELECTRICAL:
AFTER BUS. HRS.
Ph~
C. WATER:
D. SPECIAL:
E. LOCK BOX: YES ." NO IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS?
FLOOR PLANS?
YES ./ N0 MSDSS? YES / NO
YES / ~0 KEYS? YES / NO
BAKERSFIELD CITY FIRE DEPARTMENT
2~30 "G" STREET
BAKERSFIELD, CA 93301
BUSINESS NAME:
OFFICIAL USE ONLY
ID#
BUSI NESS PLAN
SINGLE FACILITY UNIT
FORM 3A
INSTRUCTIONS 1. To avoid further action, this form must be returned by:
2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
3. Answer the questions below for THE FACILITY UNIT LISTED BELOW
4. Be as BRIEF and CONCISE as possible.
SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES
SECTION 2: NOTIFICATION .~%~ EVACUATION PROCEDb~ES AT THIS 5~'IT ONLY
NON--TRADE SECRETS ',
HAZARDOUS MATERI ALS . I NVENTORY .,
BI/SINESS NAME: ~INGH~ERINARY HOSPI~N~ OWNER NAME: ~ ~(~ ~ ,,FACILITY UNIT ~: ~
Al}DRESS: 2703~,,.~,,~t~ ~, ADDRESS: ~)~/ ~~ ~ ~C~LITY UNIT NAME:
CITY, ZIP: ~A<E~SFiELD. ~,r~ ..... ~ CITY,ZIP: ~~reF~
PIIONE ~: ~ ?--~ ~Z~ PIlONE ~: -~--~ap [6FFIciAL USE CFIRS co~g
' - -- I ONLY
1 2 3 4 5 6 7 8 9 1 0
oYPE MAX ANNIIAL CONT USE LOCATION IN THIS % BY }lAZARD D.O.T
DE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT {qT. CHEMIi~AL OR COMMON NAME CODE GUIDE
NAME: /~/~//.f~, ,~- , TITLE: SIGNATURE:
EMERGE~dY- CONT/~CT: t- TITI, E: · t. PIIONE BUS ROUR$:
~o AFTER BUS HRS:
EHE~R.ENCY CONTACT: ~d~ ~&&'- ~ TITHE: PHONE ~ BUS ROURS:
PRINCIPAL BUSINESS ~C~IVITY: ~ogt~e~& ~.~~ ~/)d~ ~ ~ AFTER ~OS,