HomeMy WebLinkAboutBUSINESS PLAN ORM 5
NORTH SCALE: C ~USINESS NAME: O~L~,g~D SmLa~+f'~:¢~°~~e~- oF
DATE: ~ ,/~.CV~9 FACILITY NAME: UNIT -~: IOF 4
(CHECK ONE) SITE DIAGRAm!
FACILITY DIAGR~W
· l(Inspector's Comments): -OFFICIAL USE ONLY-
REFERRAL TO FINANCE DEPARTMENT FOR COLLECTION
ReJferring Depar~ent/Section
Person Making Referral
Account NumDer
Type Uof Billing
Name(~usiness Name~ of Con~ercial AcCount)
Site Address
Mailing Adares~'v
Telephone Number
Owner's Name-,~Address and Telephone Number
Billing Period: From To
Month/Year
Month/Year
Amount Due
List Collection'Efforts by Department Prior to Referral: /t~.l~f~-, ~
Comments
THIS BILLING HAS BEEN VERIFIED AS ACCURATE AND VALID
Authorized Signature
(Original to Cash Management, copy to Accounts Receivable)
· NM 6/8/90
BAKERSFIELD CITY FIRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
(805) 326-3979
BUSINESS NAME
OFFICIAL USE ONLY
ID#
INSTRUCTIONS:
HAZARDOUS MATERIALS
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
A. BUSINESS NAME: O'~]'~'l".~g.-) ~"~'~-~S ~ ~~,k ~ ~e.
B. LOCATION / STREET ADDRESS: ~0 ~ ~
CITY: ~Ag~Z~'~P ZIP: q~BO~ BUS.PHONE: (~) 3Z~'~
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving the release or threatened release of a
hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify
your local fire department and the State Office of Emergency Services as required by
law.
EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:
NAME AND TITLE DURING BUS. HRS.
AFTER BUS. HRS.
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE: ~u.%~4 ~_..~[) O{='.~:)O~.~C~i~%
B. ELECTRICAL: _5'00'¥H ~;'*~:~ ~ gO}}~},~'~
C. WATER:__ ~'~,~a-~% ~_~ ~ -]~;~');~'~Q~'~X
D. SPECIAL &
E. LOCK BOX: YES / ~IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS?
FLOOR PLANS?
YES / NO
YES / NO
MSDSS? YES / NO
KEYS? YES / NO
2A -
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
SECTION 6: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND
REFRESHER TRAINING IN THE FOLLOWING AREAS.
CIRCLE YES OR NO INITIAL
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
MATERIALS:...' .................................... YES '~f~N~ YES NO
B. PROCEDURES FOR COORDINATING ACTIVITIES
.......................... YES (~0~ YES NO
WITH
RESPONSE
AGENCIES:
C. PROPER USE OF SAFETY EQUIPMENT: .................. (f~..~. NO YES NO
D. EMERGENCY EVACUATION PROCEDURES: ................. ~ NO .YES NO
E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YES N~O~ YES NO
REFRESHER
SECTION 7: HAZARDOUS MATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS O~
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YES~:~N<9~
I, .~-~. ~9~/~ , certify that the above information is accurate.
I 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 6.95
Sec. 25500 Et Al.) and that inaccurate information constitutes perjury.
SIGNATURE
DATE
BAKERSFIELD CITY FIRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
BUSINESS NAME:
OFFICIAL USE ONLY
ID#
BUSINESS 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.
FACILITY UNIT#
FACILITY UNIT NAME:
SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDU~R~E~.z~A~,.//
SECTION 2: NOTIFICATION A.N/) EVACUATION PROCEDbqlES AT THIS UNIT ONLY
SECTION 3: HAZARDOUS MATERIALS FOR THIS UNiT ONLY
.A. Does this Facility Unit contain Hazardous Materials? ...... YES NO
If YES, see B.
If NO, continue with SECTION
B. Are any of the hazardous materials a bona fide Trade Secret YES NO
If No, complete a separate hazardous materials inventory
form marked: NON-TRADE SECRETS ONLY (white form #4A-l)
If Yes, complete a hazardous materials inventory form marked:
TRADE SECRETS ONLY (yellow form #4A-2) in addition to the non-trade
secret form. List only tile trade secrets on form 4A-2.
SECTION 4: PRIVATE FIRE PROTECTION
SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY E~I~E. RGENCY RESPONDER$
SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY.
A. NAT. C-,AS/PROPANe":
B. ELECTRICAL:
C. WATER:
D SPECIAL:
E LOCK BOX: YES / NO IF YES, LOCATION:
YES S**=
, z,~ PLANS?
FLOOR PLANS?
YES / NO MSDSs?
YES / NO KEYS?
YES / NO
YES /' NO
- 3B -
BAKERSFIELD CITY FIRE DEPARTMENT
NON--TRADE SECRETS
HAZARDOUS I~IATE R I ALS INVENTORY
BUSINESS NAME: d~,L~-'~L.~ <~L-~:5 Y'2~d~,~/~,~ .~,. O~NER NA~E: ~~ ~~
....
CITY, ZIP: ~~%~_~ ~{~ ~} CITY,ZIP: ~,~ ~5~ ,
PHONE ~: ~-~q-~ , PHONE ~: ~qq qU~'~
Page
FACILITY UNIT #:
FACILITY UNIT NAME:
FFICIAL USE CFIRS CODE
'NLY
1 2 3 4 5 '6 7 8 9 10
TYPE MAX ANNUAL CONT USE LOCATION IN THIS % BY HAZARD D.O.T
)C. ODE AMOUNT AMOUNT UNIT CODE C.0DE FACIL..!TY UNIT .. .WT.. CHEMIqAL O.R .COMMON NAME CODE GUIDE
NAME TITLE: ~ SI~NATURE:~,~~,~.~.,-..-~.~._" '~-~,~'--
DATE:
EMERGENCY CONTACT: ' TITLE:,, P~-_-_-_-_-_-_-_-_-~, I~-~ PHONE # BUS HOURS:
AFTER BUS HRS: ]qq~'~
EMERGENCY CONTACT: ~l~[l~ T~~~ TITLE: ~1~~ .. PHONE { BUS HOURS:
PRINCIPAL BUSINESS ACTIVITY: ~[~ AFTER BUS HRS: ~'"' ' ' '
- 4A-1 -