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PERMIT ID # 015:021-002035
AQUAGEOSCIENCES, I
LOCATION 6851
Issued by:
Bakersfield Fire Department:~:i 'i':' ':~''i:'~' -: ::~;:,:'~-:'::'-' ,-i' '- ~-' :..:. '-:','.'!:::; ~ ::' : · ii ~?':!~'": "?':~.'~':::!~?:":'~.::::?~"
' 1 r '. ::~ : ' '-:" .Appmv~by''~ ~/~~ ' '"
1715 Chester Ave, 3rd F oo ";. ' ' - - -~ - . ' ~~~/~~ -
Bakersfield, CA 93301 -' . . ~, . ' . -" .".' : . . :... :' '- '~ceofE~~~ic~ ~ . .: ·
Voice (661) 326-3979 ·
F~ (66~) 326-0576 Exp~,ionDat~: "June 30~ 1003
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM iNSPECTION CHECKLIST
1715 Chester Ave" 3~ Fi°°r' Bakersfield' CA 93301
FACILITY NAME ~QUA 660go~¢~66~ ~SPECTION DATE {.O-
AI)D~SS ~$~1'~,~ ~ PHONENO.
FACILITY CONTACT BUSINESS IDNO. 15-210- O~o
~SPECTION TIME ~_. ~ NUMBER OF EMPLOYEES '~'
Section 1: Business Plan and Inventory Program
Routine {~ Combined [~ Joint Agency [~ Multi-Agency ~ Complaint {~l Re-inspection
OPERATION C V COMMENTS
Appropriate permit on hand
Business plan contact information accurate
Visible address
Correct occupancy
Verification of inventory materials
Verification of qucntities
Verification of location
Proper segregation of material
Verification of MSDS availability
Verification of Haz Mat training
Verification of abatement supplies and procedures
Emergency procedures adequate
Containers properly labeled
Housekeeping
Fire Protection
Site Diagram Adequate & On Hand
C--Compliance V=Violation
Any hazardous Waste on site?:
Explain:
Yes ~
Questions regarding this inspection? Please call us at (661) 326-3979
White - Env. Svcs. Yellow - Station Copy Pink - Business Copy
Business Site Responsible Party
Inspector: ~C:O'''r'7 q ~
I 2001
BUSINESS NAME (Same as F^OLITY NAME or DBA- Doing Business A~) -~ I BUSINESS PHONE
AquaGeoscien¢es, Inc_ i 661 -836-8100
SITEADDRESS
6851 McDivitt Drive Suite D
101
102
103
CITY Bakersfield
DUN& 77-0241 949
BRADSTREET
COUNTY Kern
lo4 [ CA ZIP 9 3 31 3 ,os
lo6 I SIC CODE lo7
(4 Digit #) 8 0 71
108
OPERATOR NAME Phillip Goalwin l~ I OPERATOR PHONE 66;1-R'3,6;-R1 ~R l~o
.................. ',?. :': ~": ~'~ ::? ~' 'Z :<%;?-'¥~'~!~' '~,",~;~::','~:-~'""1 .'" ORMATION :'~,*~' "%:¥-~ '" ~'' ":--",~'~:" "',' ""::" -~ "*~ :'"r,' '~ ............ ,' "~ '~'~
. .-;.,,~,-,;,,.,.: .:-,,. .......... . ,~..~ ..... ~,;,, .... I OWNERINF .: ......... ~,.,.-.:..--..,.. ....... - ........ ......._..,.... .....
· ' . . ':, .;; .' ~'...r..;;~¥7:;;~ir;;~:;t.~t.=%;;(.!~,:~'~V;,.~;, ..~¢-;.C~tr~.~.r.... ,.,,. ~:..~.,... , : . -. ::;...~...:. ,: :;.:: -.,;~ .::..;: ...: .,.,,*.. ;~,.~,. : ::...~ .:..'.'," ' ;. .- '...:"
OWNERNAME Phillip Goalwin m OWNERPHONE 66! -836-8! 00
OWNER MAILING
ADDRESS 6851 McDivitt DriVe Suite D ~1~
City Bakersfi?,ld . 114 STATE CA ~'s ZiP ~31 3
CONTACT NAME 2h&[[~p GO~[W&~ ' '7 ~ CONTACT PHONE { 661-587-0585
CONTACT~ILING I 405 Ensley
ADDRESS ..
CITY
NAME Phillip Goalwin
Bakersfield '2°ISTATE CA 12~ t ZiP 93312 ~=
',';": C'%~-"'" .... .b*' ......... ' ' ' ........ '~":'~.":;,":.:~:. · " ;, '- ' ' .. ." ...... -' .: ;
· "~'- """~',",~¥'~'"~ " ............. ","', ..... ~."" ..... -IV -EMERGENCY'CONTACTS ~"-:' ...... '-'.~, ...... ,-~ECONDARY-. .... . ...... ,
123 NAME Drew Picard
125 130
TITLE LabOratory Manager
TITLE Owner
BUSINESS PHONE ' 661 -836-81 00 ~6 BUSINESS PHONE 661 -836-81 00 · ~3~
24-HOUR PHONE 661 -587-0585 127 24-HOUR PHONE 661 -589-9066 ~3~
PAGER # 128 PAGER # 133
", :¢'~.',,r,,.~,~, ..... ~'.~..-.:':.,.':,?~,'.,~..',~.;~ ,:.~t~,:-~'--:-~":: V'~-.CERTIFICATION,.:-?:.:%-'.:~.,-:,:~;:-.-':' ;' ~: ':: - ~:.:':. i:.:':::':'..v,.:'...'-'-';~': .' · .. · ::,:: :,:
.... , .->~". =~ ff.::'.t~'.&:',~ · '. "..'~.:,:~2~;.7' %!'7. -X¢~/Z;%';4%;-~':P ,;:,'"~,, · :., '- :...,: -...: ,' .... '~ .; .--.v.,z.~. -~;:.':.7%'~,? ,,P..' '.~ ;',- *:,:. ' ::' ' , · :'. ' ' '
Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law thlat I have personally examined
and am familiar with the informatl~/n submitted In this inventory and believe the Information Is true, accurate, and complete. I
~IG E"OF OWNEPJOP TOR DATE ~34 NAME OF DOCUMENT PREPARER
_.~-LL~ ~ ~ 5/26/00 Drew Pic!rd
NAMES OF OWNeR/OPERATOR (print) ,36 TITLE OF OWNEPJOPERATOR
Phillip Goalwin Phillip Goalwin-Owner
135
137
3PCF (7/99)
S:\CUPAFORMS\OES2730.TV4.wpd
CITY OF BAKERSFIELD ~
OFFICE OF ENVIRONMENTAL sERVICES
1715 Chester Ave., Bakersfield, CA (661) 326-3979
HAZARDOUS MATERIALS MANAGEMENT PLAN
INSTRUCTIONS:.
2.
3.
4.
5.
To avoid further action, remm this form within 30 days of receipt.
TYPE/PRINT ANSWERS IN ENGLISH.
Answer the questions below-for the business as a whole.
Be as brief and concise as possible.
You may also attach Business Owner / Operator Form and Chemical Description Form(s)
to the front.of this plan instead of completing SECTION I. below for initial submission.
SECTION I: BUSINESS IDENTIFICATION DATA
BUSINESS NAME:
LOCATION:
MAILING ADDRESS:
CITY: Bakersfield
PRIMARY ACTMTY:
AquaGeosciences, Inc.
~851 M~Divi~ Drixro Rhine D
6851McDivitt Drive Suite D
STATE: .CA ZIP: 9331 3PHONE: ~f0~2t2~_~ 1 00
Environmmnkm] C~n~ul~n~
OWNER: Phillip Goalwin
MAILINGADDRESS: 6851 McDivitt Drive Suite'~:D
PHONE: 661,836-81 00
EMERGENCY NOTIFICATION
CONTACT
1. Phillip Goalwin
TITLE BUS. PHONE
Owner 661 -836-81 00
24 HR. PHONE
661-587-0585
HAZARDOUS MATERIALS MANAGEMENT PLAN
~SECTION II. 1' DISCOVERY AND NOTIFICATIONS
A. LEAK DETECTION AND MONITORING PROCEDURES:
No automated leak detection devices installed, needed.
I (one) I galon water waste in glass container is all on location.
Bo
EMPLOYEE ANDAGENCYNOTIFICATION:
1. office of Emergency Services 1-800-852-7550
2. 911 If emergency situations would arise.
Co
ENVIRONMENTAL RESPONSEMANAGEMENT:
1. ghillip Goalwin - Owner
2. Owner-assigned Personnel to make sure any response or
emergency activities are carried out.
D0
EMERGENCY MEDICAL PLAN:
1. Call 911 if needed for emergencies.
2. Notifyowner;.,
3. Tend to emergency as needed.
4. .Nearest Hospital- Mercy Southwest, 400 Old River Road.
2
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION II.2: RELEASE RESPONSE PLAN
A. HAZARD ASSESSMENT AND PREVENTION MEASURES;
1. Healt and Safety Plan available to all employees.
2. MSDS sheets available to all employees.
B. RELEASE CONTAINMENT AND/OR MITIGATION~
C0
Evacuate area of release of unecessary personnel.
Wear suitable Personal Protection Equipment (PPE).
Contain the release and eliminate source.
. 1' to 3. Same as Above·
' '4. Take up and .containerize as described under Federal, State,
and local regulations·
UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)
NATURAL GAS/PROPANE:
ELECTRICAL:
WATER:
SPECIAL:
Outside SE corner of Office
(rear)
Panel 1QQoted. in SE corne~ Offic~ (~hop~ area.
Outside NW of Office Buildinq.
LOCK BOX: YES/NO
IF YES, LOCATION:
PRIVATE FIRE PROTECTION/WATER AVAILABILITY
A. PRIVATE FIREPROTECTION: Fire Sprinkler System Installed.
Bo
WATER AVAILABILITY (FIRE HYDRANT):
Front North of Office.
'3
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION III: TRAINING
NUMBER OF EMPLOYEES: 7
MATERIAL SAFETY DATA SHEETS ON FILE:' YEs
BRIEF SUMMARY OF TRAINING PROGRAM:
40 hour HAZWOPER Train~ed Employees
CPR Trained Employees
H2S Trained Employees
CERTIFICATION
I, Drew Picard CERTIFY THAT THE ABOVE INFORMATION
IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO
FULFILL MY FIRM'S OBLIGA~/ONS UNDER THE "CAL~ORNIA HEALTH AND SAFETY
CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND
THAT INACCURATE INFORMATION CONSTITUTES PERJURY.
SIGNATURE . ~.~TITLE DATE
4
usmessAddreSS: ~Y ~c3! ~e.~o,~-- [~ ~o~e ~
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
EW I'"l ADO I-'l DELETE I'-I REVISE
.- ......:,:,.,.-.:,. ~...; ,:,,.:.::~:.,. ?.?,,;.-~=?-..., '."~='".,~;:"-:
· :~.:5:;~ ::,. ,5.% i.~ FAClUTY INFORMATION
', ,;: ,: '~' ~ ~ ~- ?, ',..:,..'.. ~... ~. ,:, - .... .
'~USINESS NAME (Same ~s FACILITY NAME o~ DBA - O~ng Business
(one form per matedal l~er building or a~
CHEMICAL LOCATION
! CONFiDENT[AL (EPCRA)
~ ,,~. . 1 MAP # (opOonal) 203 [ GRIO # (optionaO
,~ :~ II .5
· · -v '"" ;-'.,,:.. .....;.: ..:,. .... 5:1,~'-; ,..:;, ~...h: . !. '.' -:'-N-i ,~ ... 7' .'".: · ~' ·
: . =,'.~i .:".'::'~7'.: :..' "5!'~ i~'?'~I?I'I?I?''':5'':'''' ~:~iJI''C~IEMICAI'''INFORMATIO :!'"Q': '":"J: ."~;.': "' ki.. _ .i~ .......
_ _ _ : _ . ,~. ., ,:.. ..... .., "-"" """ ~"~':=~ '''" ''''" .... "' -' ' .... '
HEMICAL NAME ~ ~ 205 TRADE SECRET [] Yes
.. _
___--- ','-: '- ---c. r..- ,,.,,. ,--,,,.,,
7
FED HAZARD CATEGOR~BS [] ~ F~RE [] 2 REACT~ ~E~PRESSURE RELEASE [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH
(c~ed< a, u~at apCy) ~
5 218 AVERAGE ' ~ 219 STATE WA.,.~.~ CO D E
ANNUAL WASTE .~ 217 MAXIMUM DAILY AMOUNT '/"
AMOUNT DAILY AMOUNT
UNITS' [] ga GAL '[~;;~U FT [] lb LBS I I tn TONS 221 DAYS ON SITE · If ENS, amount must be ~n [DS.
sTORAGE CONTAINER [] a ABOVEGROUND TANK [] ·PLASTIC. JNONMETALLIC DRUM [] i FIBER DRUM
(Clleckall~atapply) Db UNDERGROUND TANK r-}f CAN {'-}j BAG
F-~ c TANK INS,DE BUILDING [] g CARBOY
[] d STEEL DRUM [] h SILO ~,'CYLINDER
[] m GLASS BOTTLE [] q RAIL CAR :
[] n PLASTIC BOTTLE [] r OTHER
[] o TOTE BIN
[] p TANK WAGON
STORAGE PRESSURE [[~J~8 IE NT
[] aa ABOVE AMBIENT
[] ba BELOW A,~tBIENT
S:\CUPAFORMS\OES2731'TV4
UPCF (7/99)
CITY OF BAKERSFIELD
OFFICE OF. ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
~EEW [] ADD [] REVISE 200
(one fora1 per mate~al I~er building or a~
~UStNE$S NAME (Same a~. FACILITY NAME o~ DBA · Do~ng Business As)
~ ]. ....... ~,o.~na~ 203 I GRID ~(opt~na0
' ~ t?,~ t I ~'~ ~ I ~'' ~ ..~ ..... :,.~.... , ..,.... ::,....,.-:. ....
~ : ~5 ~5~.~::~ =~'. ':~5~ ':~:. ~57 ~!~;~:.'..~ .~.:)~i~?:~;::::....'~'~c~' ~,~o',~no, ?'~:~: x:, ? .,.~ 5'..~ '... "~:: . '.
........... 205 T~DE SECRET
FIRE CO0~ H~D C~SS~S (~plete ff r~u~t~ ~y i~ ~e ~i~
If Subjec~ [o EPCRA, refer to instructions
EHS' [~ Ye~ ~ 2
CURIES ~
TYPE ~'I~URE E:] m MIX-rURE [] W WASTE 211 I RADIOACTIV~ [] Ye~ ~ 2t2
PH S,CALSTATE so,,0 I RGEST= A,NER
FE0 HAZARD CATEGORIES [] 1 FiRE [] 2 REACT[V~ t{~3,~SURE RELEASE [] 4 ACUTE HEALTH
(Ched( all ~at apply)
· If EHS. amount must be in lbs.
o, C.RON,¢" -TH :
=,, ST^' WASTE CODE :
221
DAYS ON S~TE
STORAGE CONTAINER r"] a AROVEGROUND TANK [] · PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM
(C~eckall~atapply) []b UNOERGROUNDTANK []f CAN []j BAG
[] C TANK INSIDE BUILDING [] g CARBOY [] k BOX
[] d STEEL DRUM [] h SILO
[] m GLASS BOTTLE [] q RAIL CAR
[] n PLASTIC BO3-FLE [] r OTHER
[] o TOTE BIN
[] p TANK WAGON
STORAGE PRESSURE [[~],,,,$'~tAMA,MBIENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT :
STORAGE TEMPERATURE [~:~ a"~Aa AMBIENT E] aa ABOVE AMBIENT [] ba BELOWAM~IENT [] c CRYOGENIC
~ ,,".~ ~-'~;~'.~a ;:~-. ~.:'~.~;~\-, ~.,,~r~;~'>:~'.!;.;; ~.'~.,:':e · ,:': -;-,'.~ CF.~' ': ~','..:::;.~ '
. -. ' .. ;,T~';.-.~*,i, .~:~.':..~:..:~;-,;.~-~.';,.~-':;. .''..:~.:.'.';,:c~. :~t'~/-E'-.~..,-.:.'-'...~ ~..-*-~M.~,..':~ ;.':' ,~..~- ;' · .'' ."-..
....... '- ' ............. ...... "~ ....... , ...... PONENT: ...... = ......... ' ........ : ...... :.-- '- .: :"-~.'" , ........ ' '
235 [] Ya~ [] No 236
3 234
__ ·. ~.~.:~,., ~; .:. :., ,.~,.
, :,'. ,. .. "i:' ~; ;~?. ,:): ,... '~;~-~-'~° ~ ' ' ~ '"' ~" '
PRINT NAME & TITLE OF AUTHORIZED COMPAI"Pf REPRESENTATIVE
UPCF (7/99)
S:\CUPAFORMS\OES2731.TV4
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
~EW
ADD [] DELETE' n REVISE
· .. ~...~,.-. :..'.. ......
· :,.-;..~?;~y;. :.... ,:.'.;~'.~'?:.;~'::"~C: .:,:";' '! !:.:~,~.):;~.;:...,.~...kl.-"FACIETY. IN~O~M,~Ti~ {' i !":: :':
(one fon~ per matedaf per building or a~
BUSINESS NAME (Same as FACILITY NAME ~ DBA * D~ng Business As)
. ' ('C~ 201i CHEMICAL LOCATION
C'E ICALLOCAT'ON b'XOp l" cem Cbxe ,c \ 3% SL eLueS'
FACILI~ID~ , ~] I I~¥. 1 ~(op~naO 203 I GRIO~(opt~naO
' ~ [~ I I ~ I '1 t .~ ' ~ ........ :...,~. ..... .., .... ..;_ :.. ....:. · · . ~:. ·
205 [ TRADE SECRET [] Yes [~'~o ,~'
If Subject ID EPCRA. refer to instruc:ions
207
{~{~RE [] m MIXTURE
EHS' DYes ~ ~
209 *ff EHS h°Ycm.' aU a=o,,_ ,~ 'b~tow ~ be ;,, E,s
2
~R~ES 2
~ 2,2
[] w WASTE 211 { RADIOACTIVE
E RELEASE [] 4 ACUTE HEALTH
PHYSiCAL STATE [] s SOLID []1 LIQUID
FED HAZARD CATEGORIES [] 1 FIRE
(Ched( all I~at apply)
ANNUAL WASTE ~
AMOUNT
/
[] 2 REACTIVE
MAXIMUM
DALLY AMOUNT
[] ga GAL
,,,-%~,..~..,,.~',~ . 218 [ AVERAGE '
- ~u rr D ,,~ LES [] ~ TONS
[] $ CHRONIC HEALTH
219 I STATE WASTE CODE
i DAYS ON S~I'E
22~ }
' If EHS, amount must be in lbs.
sTORAGE'CONTAINER [] a ABOVEGROUND TANK [] e PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM
(Check all ~hat apply) [] b UNDERGROUND TANK [] g CAN [] j BAG
I~c TANK INSIDE BUILDING [] g CAREOY
[] d STEEL DRUM [] h SILO
[] m GLASS BOTTLE [] q RAIL CAR
[] n PLASTIC BOTTLE [] r OTHER
[] o TOTE BIN
[] p TANK WAGON
STORAGE PRESSURE
[] aa ABOVE AMBIENT
[] ba BELOWAMEIENT
STORAGE TEMPERATURE ~a A/a AMBIENT [-] aa ABOVE ,*J,~IENT [] ba ~
........ ~,...~ , ~.,..,~ ..... - .......... ~.,:. ,...~ -- CAS~:.,- .,.
2 230 ~ ~ ~
23S ~ y~ ~ No 23S
UPCF (7/99)
S:\CUPAFORMS\OES2731'TV4
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
CO~,I~/ON NAME
209
\\o- 5q-3
-TYPE ~URE [] m MIXTURE
(one fon'~ per m~ateda113er building or•ri.
r-]yes ~'~o 2 '
if Subject to EPCRA. re[er to in$[mc:~ions
[] w WASTE 211 t RADIOACTI~'~ []yes ~ 212
~;URIES
PHYSICAL STATE [] s SOLD
FED HAZARD CATEGORIES [~1 FIRE [] 2 RF_.ACT[V~
(Check all Bal apply)
T'-MAXIMUM
ANNUAL WASTE O 217 IDAILY AMOUNT
AMOUNT
[] 3 pRESSURE RELEASE [] 4 ACUTE HEALTH ~RO'NIC HEALTH
~ -/ ~ 218 ~VERAGE ' 219 STATEWASTE COCE
[] ga GAL [] ¢/ CU FT
· If EHS, amount must be in lbs,
[] lb LBS [] m TONS
STORAGE CONTAINER [] a ABOVEGROUND TANK [] · pLASTiC/NONI~IETALLIO DRUM [] i FIBER DRUM
(C/~eckall~atapply) ('-Ih UNOERGROUNOTANK ['~f CAN []j BAG
[] k BOX
[] C TANK INSIDE BUILDING [] g CARBOY
[] I CYLINDER
[] d STEEL DRUM [] h SILO
~'m GLASS BOTTLE
[] n PLASTIC BOTTLE
[] o TOTE BIN
[] p TANK WAGON
[] q RAIL CAR
[] r OTHER
STORAGE PRESSURE
[] aa ABOVE
[] ba BELOW ANIBIENT
238 L 239 [] Yes [] No 240
~ . ~ / [] Yes [] No 2-I
S:\CUPAFORMS\OES2731'TV4
UPCF (7/99)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL.DESCRIPTION
(one fon~ per ma ter~al ~er building or a~
PaGe
CHEMI~L LO~T]ON
CHEMIC, AL NAME
COMMiON NAME
PHYSICAL STATE [] s SOLID [~QUID [] g CAS 214 i LARGEST CONTAINER
FED HAZARD CATEGORIES ~"~FIRE r'~ 2 .EACTIV~ [] 3 PRESSURE RELEASE [~ACUTE HEALTH
(Che~k ail l~at apply) [
( DAILY AMOUNT DALLY AMOUNT
AMOUNT
UNITS' [] ga CAL [] d CU FT [] ~b LBS F-) tn TONS
'ff~. ~ ' If EHS, amoun[ must be in lbs.
STOP,AGE CONTAINER [-l a ABOVEGROUND TANK [] e PLASTICYNONMEI'ALLIC DRUM [] i FIBER DRUM
(Check all ~at apply) [] b UNOERGROUNO TANK [] f CAN [] j BAG
[] k sox
[] c TANK INSIDE BUILDING [] g CARBOY
F'] I CYLINDER
[] d STEEL DRUM [] h SILO
209
[]Yes
If Subject to EPCP,.A, fei'er [O instructions
EHS' [] Ye~ ~ 2
*If EHS is'Y~,' gl am~mcs ~low mu~ be in ~
'-'---~ RIE S
212
J~ONIC HEALTH
~.,.~._~>f 219 STATE WASTE COCE
221
~SS Bo'FrLE
[] n PLASTIC BoI-FLE
[] o TOTE BiN
[] p TANK WAGON
DAYS ON SITE
[] q PAIL CAR
[] r OTHER
2
STORAGE PRESSURE ~/'A~AMBIENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT
~ c CRYOGENIC
231 ~y~ ~No 232
4 238 o 240 ~
5 242 I ~~ '~;.<,.
' ":.'~: ' "~'~:"~'~'?~'~" .............. k~'~" S~O~T . - -
S:~CUPAFORMS~OES2731 '~'~
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 CheSter Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL.DESCRIPTION
EW {-'] ADO r't DELETE [] REVISE ~ ~- ......... . ...... ,_. ,.. : .. ¢; ;..~ ,~ ..... .. · '
... ,.+?.,.?,.. ,. ,:.:;':.;~?:,~:'&:'/:,....:::.:~.,;cn.%,;.~I.=FAClUTYINFORMATM · ,~ .... .......
~-- ' - ('(~ k t e 201' CHEMI~AL LOO~a'TION
~~: :,,.;,;.,~'.~:~,.': .-~L,':,.. :..;..':.: · f.'. :
T ' ' ~ ~'.'-; · ;::.F, ~;::: ,~?'.;~: ::..' '~:? ~'~:':'~:~.?.':?,':. II.'~EMIC~'INFORMATI.0N .;:f' "~ ""."'; "- ..... ' ' ::: ~_.'~
. .~.:..,:';f,~'. :. ::,,~ ,:..?::~..:? ,,..:': .. ~',:.~::t.;.':;..'~ .' .... .,'-'.~-~"'"' .... '"~ 205 ~
TYPE
PHYSIC. AL STATE
FED HAZARD CATEGORIES
(Check ail t~at apply)
ANNUAL WASTE
STOR,AGE CONTAINER
(Cl~eck all ~at apply)
~r~RE [] m MIXTURE
[] s SOLID ~UID
r-] ~ FIRE [] 2 REACTIVE
DAILY
UN~S'
[] a ABOVEGROUND TANK
[] b 'UNDERGROUND TANK
[] c TANK INSIDE BUILDING
[] d STEEL DRUM
STORAGE PRESSURE ~'~B lENT
(one fo/m per r~ter~al per building o~' ar[.
I-lyes [~i~'o 2 '
If Subiect ID EPCRA. refer to instructions
~207
t EHS' r"iw ~ ~
209 [ "If ERS b'Y~.' a,Q ~ bck~w ~ be ia Ib~
V~ ~ ~RiES
[] w WASTE 2tl RADIOACTIV~ [] Ye~ ~ 212
LARGEST CONTAINER ~.
[] g GAS 214
~ 3 PRESSURE REL~SE ~ 4 AC~E H~L~ ~ONIC H~LTH
~ dcu~ ~bLSS ~ mTONS
~ ga ~L
· ~ EHS, am~nt must be in lbs.
[] e pLASTIC.~NONMETALLIC DRUM [] i FIBER DRUM [~SS BOTTLE
[] f CAN [] i BAG [] n pLASTIC BOTTLE
[] k BOX [] o TOTE BIN
[] g CARBOY
[] h SILO [] I CYLINDER [] p TANK WAGON
[] ba BELOW AMBIENT
219 STATE WASTE CODE
DAYS ON Sn'E
[] q RAiL CAR
[] r OTHER
[] aa ABOVE AMBIENT
...........
STO~,G~ ,E~,~RA ....~", A~E~E ^~"~ ~~.~ ~;<~ '~:'; ~: .~,~:~?~'"'
~: ,:i,'Z.:.?;;:":-" "'""~..~:_~. ""
.
2 ' 230 [
~ 235 ~ Ym~ No 236
239 ~ y~ ~ No 240
4 238
.
S:\CUPAFORMS\OES2731'TV4
UPCF (7199).
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave. CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL.DESCRIPTION
i,.COMM~)N NAME
['-]Yes ~t*o 2 '
PHYSICAL STATE
! EHS' []yes [~o 2
[] w WASTE
211 I RADIOACTIVE
[] $ SOLI(~ ~[~Vl LIQUID . [] g
FED HAZARD CATEGORIES ~'~IRE' [] 2 REACTIVE [] 3 PRESSURE RELEASE [] 4 ACU'I'E HEALTH
(Check all t~at apply)
-- '~~ MAXIMUM [ DALLY AMOUNT 'L~.
AMOUNT [] tn TONS
UNFrS' [] ga GAL [] cf CU FT [] lb LBS
~-i, ~::)f · if EHS. amount must be in lbs.
STOP, AGE CONTAINER [] a ABOVEGROUND TANK [] · pLASTIONONMETALLIO DRUM [] i FIBER DRUM
[] i BAG
(Check all ~al apply) [] b UNDERGROUND TANK [] f CAN [] k BOX
[] ¢ TANK, INSIDE BUILDING [] ~ CARBOY [] I CYLINDER
[] d STEEL DRUM [] h SILO
"--"-'-"'--'--~ RI E S
[] yes ~ 212
~,~O NIC HEALTH
219 STATE WASTE CODE
~'~"LAS S BOTTLE
[] n pLASTIC BOTTLE
[] o TOTE BIN
[] p TANK WAGON
[] q RX~L ~
[] ¢ OTHER
STOP, AGE PRESsuRE [~,,~.i"'~AMBIENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT
TOP. AGE TEMPERATURE ' '~'-[~ 'ME, lENT .::~-'~:/? .~ . ~, '~ . ~-~ .. ,,
...... I I I q '
T 2~8
242 ~~.: · . . ""7'- '
'l ~~:~???.~':'~.'...::"' '. :.'- '. '.::"
. ....... . ...... ; ,- . ~ ; ~ .. . . , -,,
S:~CUPAFORMS~OES273~'~4
~ CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
I-~.~..aa~---,--,-- HAZARDOUS MATERIALS INVENTORY
CHEMICAUDESCRIPTION (o.o
~USINESS ~ME (Same ~ FACIM~ ~ME ~ DBA - ~ng Busm~ ~)
~ ~ CHEMI~LLO~TION ~ Y~ ~ 2
· · · ' ' 205 t T~DESECRET
~R~ES
~ROEST ~AINER
pHYSI~L STAT~ ~ s SOLID ~QUID ~ g ~S ~14
['-]Ye~ [~[~o 2 '
FED HAZARD CATEC.,ORtES F-~ 1 FIRE []~R~CTIV~ [] 3 PRESSURE RELEASE [~A~AC~E HEALTH [] S CHRONIC HEALTH
A,~aUNT [] d CU ~ ~ ~b LaS ~ m TONS 2~ ~
UN~S' D ga ~L
* ff EHS. am~nt must be in lbs.
STOOGE CO~AINER ~ a ABOVEGROUND TANK ~ e p~STI~NONM~ALLIC DRUM ~ i FIBER DRUM ~SS BO~LE ~ q ~IL ~R
(C~eck all ~at apply) ~ b UNDERGROUND TANK ~ f ~N ~ j BAG ~ n p~STIC BO~LE ~ r OTHER
~ k BOX ~ o TOTE BIN
~ c TANK INSIDE BUILDING ~ g ~RBOY ~ I CYLINDER ~ p TANK WAGON
~ d STEEL DRUM ~ h SILO
STOOGE PRESSURE ~BIE~ ~ aa A~VE AMBIE~ ~ ba BELOWAMBIE~
STOOGE TEM~TURE ' ~IE
s:\CUPAFORMS\OES2731.TV4
UPCF (7199)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
EW r-I ADO (-] DELETE n REVISE 200
BUSINESS NAME (Same as FACILITY NAME o~ DBA - D~ng 8us~nass
(one form per m, atetfal per builEing or a~.
, *it' EHS h'Y~,' dj ~u t~tow ~ b~ ta ~s
l--if 2
~RIES ;
~U"E O m MI~U"E O WWASTE 21' { ~DIOACT~ OY~ ~ 212
FED ~RD ~TE~RIES ~ ~ 2 R~CT~ ~ 3 PRESSURE REL~SE ~ 4 AC~E H~L~ ~NIC H~LTH :
(Ch~ all ~at apply) ;
i DAYS E ;
~f UN~S' ~ ga ~L ~ ~ CU~ ~ lb LBS ~ ~ TONS 221 ~
' E EHS, amen[ must be in lbs.
~ r OTHER
STORAGE CONTAINER [] a ABOVEGROUND TANK [] · PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM
(C~eckall~ata~ply) I-lb UNOERGROUNDTANK El! CAN ['-Ij BAG
~'] c TANK INSIDE BUILDING [] g CARR4Dy [] k BOX
[] 1 CYLINDER
[] d STEEL DRUM [] h SILO
~OTrLE
[] n PLASTIC BOTTLE
[] o TOTE BiN
[] p TANK WAGON
STORAGE PRESSURE ~BIENT
[] aa ABOVE AMBIENT
[] ba BELOW AMBIENT
STOR.~,GE TEMPERATURE ~iENT [] aa ABOVE AMBIENT [] ba BELOWA~I~ ~ c CRYOGENmC
.~...~ : . ~..;:'~'..'~.'Y:';~;/~:."
~~'~*~ ~ :~?:~:;::¢:~ V'??~ ~',~:~C-;~'~ ;: ;"' ~ ': CAS ~:' ~':"-:~':
: 4 238 ~9
: ;,: ,. · .:.....,..,..
- . , ·, ~ ~;.... '.-~,:. ~'.:~:,5-~.: ~t, :~'. ...... ' "-~ .... :~ d~ ~ ,~[:::~:'::~:&~.:t::;?~4;?-~-Y.: · ':'. ' ' '
· . .. ,..,:.. ...... .~;~ ~..~-~%'.~,¥;,>~ ~:?;?&'~:'.-~.~'<;:7~:-':- :. . .... · _
~.' . · · -2:~,;~ ~:-.' ,- -.--- '. ~.-F~D~;F. ": ~.; .:~ .?~ . .._..~ ;..% ~,~ G%~>~:~:.,~., ~.& .. ~,.,. , ......... ~ DATE
S:\CUPAFORMS\OES2731.TV4
UPCF (7/99)
~ FIR~ M
J~.A R TM~T
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
f'l ADO I"1 DELETE O REVISE
· "~.,~4': "...- ...75.,~:;
......... -' ~.I-'~ '~ !':5 FAcluTY. INFORM IOH
(One fon'n per matetfal l~er bu!lding or ar[.
Page ~7~ O' ~
-'-~USINESS NAME (Same ~ FACILITY NAME ot DBA - D~ng Business As)
p%
ock (s-eo e cc
CHEMIOAL LOCATION
C.EMI L O TION 5t, o ceo,,
'"::':": .... ':' '::" 255:{5",:.:...?..5": .' · :.'
CHEMICAL NAME
COMk~)N NAME
FIRE CODE HAZARD CLASSES (C~nplete if requested by local fire ct~ie~
TYPE [~;]'I~'"URE [] m MIx't'URE
[--]Yes
If Subjec~ 1o EPCRA. refer to instructions
207
EHS' [] yes
[] w WASTE 2~ J RADIOAGTiV~ []Yes ~ 2t2
CURIES
PHYSICAL STATE [] s SOLID ~LIQUID [] g C,,AS 214
FED HAZARD CATEGORIES [] 1 FIRE
(~he<~,all Bat apply)
ANNUAL WASTE ~ 217
AMOUNT
UNFrS'
[] 2 RE, ACTIVE [] 3 PRESSURE RELEASE [] 4 Acu'rE HEALTH [] 5 CHRONIC HEALTH
DALLY AMOUNT DALLY AMOUNT :
i DAYS ON SITE
['-] ga GAL [] cf CUFT [] lb LBS [] tn TONS 221 { ~(k
· If EHS, amount must be in lbs,
STORAGE CONTAINER
(Check all ~at apply)
[]a ABOVEGROUNDTANK
l-lb UNDERGROUNDTANK
{~]c TANKINSIDEBUILDING
J'--] d STEEL DRUM
[] e pLASTIC/NONMETALLIC DRUM [] i FIBER DRUM Jj~G~SS BO'I-rLE [] q RAIL CAR
[] f CAN [] j BAG [] n PLASTIC BOTTLE [] r OTHER
[] g CARBOY [] k BOX [] o TOTE BIN
[] h SILO [] 1 CYLINDER [] p TANK WAGON
STORAGE PRESSURE
[] aa ABOVE AMBIENT
[] ba BELOWAMBIENT
STORAGET'EMP~RATURE [~aAMBIENT D aa ABOVEAMBIE~ ' ' E..~. ~ ........ 0~;.~CR. YO.G,E'NI~.,;F~'. '~'~.'::'~
';"e ' . ' ........... - ,:;-- :HAZARDOUS CO PO~E~.;~:.:'.-=-:.~,~ ....... .-...,':: .......... , ....
---- -- -- -- 23 I []Yes []No 232 ,
2~ 23s j []w,[]No ~s ·
:no []x~s []No 24O
4 238
[] Yes [] NO 244
5 242
S:\CUPAFORMS\OES2731
UPCF (7t99)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL.DESCRIPTION
(one fon'n per. jT~terfal I~er building or a~
Page *~b.- Of ~
2011 CHEMI~L LO~TION
~T~DE SECRET
COMMON NAME
"~PE {~;~5'~RE [--~ m MIXTURE [] w WASTE
[]Yes ~
211 { RADIOACTPXE [] yes
'----'--'------~RIES
212
PHYSICAL STATE [--~ s SOLID ~LIQUID
FED HAZARD CATEGORIES [~
(Chedc ail thai. apply)
217
[] 2 R~ACT{~
'~' MAXIMUM
DAILY AMOUNT
UNITS' [] ga C'~L
[] g C.~S 214 I LARGEST CONTAINER
[] 3 pRESSURE RELEASE [] 4 ACUTE HEALTH
% \ ~- 218 ~--AVERAGE
[] d CU Fl' [] {b LBS [] tn TONS
HEALTH
219 [ STATE WASTE COCE
{ DAYS ON SiTE
· ff EHS, amounl must be in lbs.
ANNUAL WASTE /~
STORAGE CONTAINER [] a ABOVEGROUND TANK [] · PLASTICJNONMETALLIC DRUM [] i FIBER, DRUM
(Ci~eckalltl~ata~ply) []b UNDERGROUNOTANK []f CAN E]j BAG
[] k 8ox
[] c TANK INSIDE BUILDING [] g CARBOY
[] I CYLINOER
[] d STEEL DRUM [] h SILO
~"'~SS BOTTLE [] q RAIL CAR
[] n PLASTIC BOTTLE [] r OTHER
[] o TOTE BIN
r-] p TANK WAGON
STORAGE PRESSURE ~[/~81ENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT
...~ .-,... '~;y,:?,:~:;;:~:~,.?y{~i.~r.~:j~:;.'..i:d..:,:~.. ,, ,::"~ ·,. ~ .... .. ....
235 [] Yes [] No 236
'3 2~__~ 239
4 238.
.. '.:-. '. '...:'' ..'::',.'. __'
,' 7- ~;1 F !. -: F. '- __:' ~ DATE
· .. ... · .':.~:"~?;;;:,?~%~..
\CUP
UPCF (7199)
CITY OF BAKERSFIELE
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICALDESCRIPTION
(one form per matedal per building or a~
' O ADO [] DELETE [] REVISE ....
~EW . ~ .... . ~:. ,.,~:.:}~ c~-.:..' -=-h:::'t;.~ ~::[ ¢;', ·
.............. "'. ...... · .............. oN'.:;{.'.:.:,.:?.':?;;::: '.' '"
· "¥..:,~::.......¢ ..-'.: :':," '¢':.:%'Z ~': .,-,., :.:*.~';' ~ ;'. :.;'~. I/FACIU~.INFORMATi : *
'. ,: '. ".~..;',':;'.X'-.:"-;.?'~'.-.%";' ,; ':' "" ',~ ........ -
~HEMI~L LO~TION
J CONFIDENTIAL (EPC~)
,:.. .... .[,~,,.' <:,..; ..... ~. ' -:~.~-: '~.. JB ' :' ' ..' -: , .",
CHEMI~L ~ME
207
EHS'
COMMON NAME ,,c---_L/ i ~/'~'-..L./ ^ /'
· ,-, C~ I IAYJ
r-1 y~s ~
['-']Yes ~-I~'o 2
If Subject [o EPCP. A, refer to inswu~ions
*ff EHS {,'Y~.° ail am~usts tx:low mu_mt ~ ia lbs
2O9
TYPE {~,i~RE [] m MIXTURE [] w WASTE
[] s SOLID ~IQUIO
211 j RADIOACTIVE
PHYSICAL STATE
(Ch~ att ~at apply) ~I~M ~ ¢ I ~ 218 y AVENGE
A~U~ ~ UN~S' ~ ga ~L ~ d CU~ ~ lb LBS ~ ~ TONS
' ~ EHS, amen[ must be in lbs.
-'--"-------"-'--"~0 RI E S
STORAGE CONTAINER
(Cl~eck alt mat apply)
E]a ^BOVEOROUNDTA~K
r-]b UNOEROROUNDTANK
r'Jc TANKINSIDEBUILDING
i--Id STEELORUM
[] g C, AS~214 LARGEST CONTAINER
E] 4 ACUTE HEALTH
[~5,,~ NIC HEALTH
[] · PLASTICJNONMETALLIC DRUM [] i FIBER DRUM ~OTI'LE
[] f CAN [] j BAG [] n pLASTIC BOTTLE
[] k BOX [] o TOTE BIN
[] g CARBOY
[] I CYLINDER [] p TANK WAGON
[] h SILO
219 i STATE WASTE COCE
221 ! DAYS~.,~N~_~E
[] q RAIL CAP,
[] r OTHER
STORAGE PRESSURE ~'~MA,MBtENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT
-- [] c CRYOGENIC
?:.~:, ~., '. CAs ~..Z'~".-'-:.:': :.
1 ~ ~ 227 l[]yes
_-- 231 []Yes []No 232
2 230
235 Yes[] No 236
3 234
_ __ ~9 j [] yes [] No
4 , 2:)8 ~ '--'---'---'-'---
243 J [] Yes [] No 244 .--------------
· . . . ,. , .,,. OATE
PRINT ~ k
S:\CUPAFORMS\OES2731 .TV.;
UPCF (7/99)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
r3 ADO c' I'-I DELETE J~ REVISE -i ~ ' '
J] '-~USINESS NAME (Same ~ FACILI~ ~E ~ ~BA - ~ng Busin~ ~) .... '
CHEMI~L LO~TION . ~ ~e~ ~(~ 2Ol~ CHEMI~L LO~TION
(one fo~ per ma tedal per buildln__~ or a~
r~yes [~'o 2 '
if Subject to EPCRA. refer to instructions
207 -
. 'It' El'iS b'Y~.' a~ ~L~ below ~ be h, lbs
212
CURIES
~ ~'~RE [] m MIXTURE [] w WASTE 211 j RADIOACTIVE E]Yes
PHYSICAL STATE [] S SOLID ~LIQUID [] g GAS 214 FLARGEST CONTAINER
FED HAZARD CATEGORIES
~ [] 2 REACTIYE [] 3 PRESSURE RELEASE J'-J 4 ACUTE HEALTH
[~CHCH RD NIC HEALTH'
(Check att t~at apply)
MAXIMUM
ANNUAL WASTE DALLY AMOUNT
AMOUNT
UNITS' [] ga GAL [] cf CU FT
~.__.~.~___ 'If EHS, am~nt must ~e in ,~s.
DALLY AMOUNT
DAYS ON SI'rE ;
[] lb LBS F} tn TONS
221 i
STORAGE CONTAINER ri a ABOVEGROUND TANK [] · PLASTiCJNONMETALLIC DRUM [] i FIBER DRUM
(Cl~eckall~atapp{¥) Flb UNOERGROUNOTANK []f CAN []j BAG
[] k SOX
[] c TANK INSIDE BUILDING [] g CARBOY
[] I CYLINDER
[] d STEEL DRUM [] h SILO
J~.,m~SS BO'I-t'LE [] q PAIL CAR
J"'J n PLASTIC Bo'CrLE [] r OTHER
[] o TOTE BIN
[] p TANK WAGON
STORAGE PRESSURE [[~BIENT
[] aa ABOVE AMBIENT
[] ba BELOW AMBIENT
STORAGE TEMPERATURE IENT [] aa ABOVEA,~IENT [-1 ba BELOW AMBIENT [] c CRYO. GENIC ......
_ ; I -- - 231 ~ []No 232
2 230
235 I r"]yes[]No 236
3 234
, 5 242
S:\CUPAFORMS\OES2731"fV4
UPCF (7/99)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
EW I-~ ADO [] DELETE ' [] REVISE 2~3
....... ... ...... .., .~..~..r.-;...:.;...~.,,,.~,~,~c~;;..,~-~.~.?:...:i::~".. ·
. .'~,:%;'~ "-...: .~ ~':.,-:. ~.':...4 :.:~...'.::.:~.::,'m"..~.:'~L'FA~IH~I~FOR~ATiO~
~USINESS ~ME (Same ~ FACILI~ ~ME ~ D~ - ~9 gusm~ ~)
(one fora1 per ma tedal oer building or a~
CHEM.C*'LO~T'ON b'X ' ceo,,. C¼ewx~co,- fl-oro. ~0f! C.E~,.~''O~T'ON
CHEMIC, AL NAME
COMMON NAME
C)o
1 fire ohie~
TYPE ~"~rURE [] m MIXTURE
[] w WASTE 211 I RADIOACTIV~ []Yes
207
2O9
[]Yes [][~o 2
If Subject lo EPCRA. refer to instructions
EHS' DYes
'If EHS i.s'Y~.' all a.m~u~U t~l°w ~ be ia Ib'~
212
~RIES
PHYSICAL STATE [] $ SOLID ~ [] g GAS
214 I LARGEST CONTAINER
FED HAZARD CATEGORIES ~ [] 2 REACTiV~ [] 3 PRESSURE RELEASE D 4 ACUTE HEALTH
(Chec~ all ~at apply) [
A~U~ DALLY A~U~ DALLY A~U~
UN,S* ~ ga ~L ~ d CU ~ ~ lb LBS ~ ~ TONS
' ~ EHS. am~nt must be ;n lbs.
STOOGE CO~AINER ~ a ABOVEGROUNO TANK ~ · P~STI~NONM~ALLIC DRUM ~ i FIBER DRUM
(C~eck all ~at apply) ~ b UNDERGROUND TANK ~ f ~N ~ j BAG
~ c TANK INSIDE BUILDING ~ g ~RBOY ~ k BOX
~ d STEEL DRUM ~ h SILO ~ I cYLINDER
6~'C~HRONIC HEALTH
L "'Cji'"'- 219 { STATE WASTE CODE
I
i DAYS ON SIT~
[]~SS Bo]-rLE
[] n PLASTIC BO'ffrLE
[] o TOTE BIN
[] p TANK WAGON
[] q R~IL CAP,
[] r OTHER
STORAGE PRESSURE ~BIENT
[] aa ABOVE AMBIENT
[] ba BELOWAMBIENT
STORAGE TEMP~R,~TURE L~ a~AaA.MBiENT [] aa ABOVE AMBIENT [] ba BELOW A~I~ ~ c CRYOGENIC .
%~.~:~<:':. :~' CAS .: :, .. :~ :.
--~ ~ 23~ ~y~ ~No232
2 230 ~
s m I ~ ~b.. ' "':.:". :: '.:.~'::.
.......... . ..... ,~z~:¢~:,;~:.z'a~'[~%~[~::~m?j~F~t%:~.~:t?'~';:~. ¥.:-.:. . . : . .?.-. ,..:. ;.
S:~CUPAFORMSXOES2731 .W'
UPCF (7199)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
(one form per matedal l~er building or ag
TYPE ~RE [] m MIXTURE
209
WASTE 211 I RADIOACTIVE. [] Yes ~
E]Yes [~o 2
2.
[]Yes ~"~o 2
If Subject to EPCRA. refer ID instructions
EHS' [] yes ~ ~
· *if EHS Ls'ycs.' all am~u~u below ~ be ~, lbs
2
~URIES ~
212
PHYSICAL STATE
FED HAZARD CATEGORIES
(Check all t~at apply)
ANNUAL WASTE
AMOUNT
STORAGE CONTAINER
[] s SOLID
~FIRE ~'1 2 REACTIV~ [] 3 PRESSURE RELEASE
DALLY AMOUNT DALLY AMOUNT
UNFrS' [] ga GAL [] c~ CU Fl' [-1 lb LBS [] tn TONS
· ff EHS, amount must be in ll3s.
[-"] a ABOVEGROUND TANK [] · pLASTiC~NONMETALLIC DRUM [] i FIBER DRUM [~"~BO"~'LE
~ HEALTH I[~].,~,~H RD NIC HEALTH
219 STATE WASTE CODE
221 O~j~(~N SITE
[] q RAIL CAP,
(Check all ~at apply)
[] b UNOERGROUNDTANK [] f CAN
[] c TANK INSIDE BUILDING [] g CARBOY
[] d STEEL DRUM [] h SILO
[] j BAG [] n pLASTIC BOTTLE
[] k BOX [] o TOTE BIN
[] I CYLINDER [] p TANK WAGON
[] r OTHER
STOP.AGE pRESSURE
[] aa ABOVE AMBIENT
[] ba BELOWAMBIENT
S ...... .r=,,oco~,'ruRE ~ ' [] aa ABOVE AMBIENT [] ha BELOW AMBIENT [] C CRYOGENIC
227 [] Yes [~2
_-- 231 ~
2 230
234
S:\CUPAFORMS\OES2731.TV4
UPCF (7t99)
· CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
· EW r'l ADO [] DELETE I"] REVISE 200
-BUSINESS NAME (Same a.~ FACILITY NAME o~ DBA - D~ng Business As)
C~T~O~ ~. ~ . ' 2mi CHEMiCaL LOCATIO~
' ~ ttf~ I [~ I [. ~ ' ' .~ ....... .,.... , ..... .:.....:-.-..~,, : '.'.:. :.. ·
- :~'~: ~;~? :~';': : ' '":~"::'~' :~f :' II '~EMIC['INFORMA~ON ~ ?': :':'::' :''~:''' "' ':
: ., ~, .. ~ :~.., .:...~,: .. · ;.. ?,.~,.:~, .... . ..... , .. ~
. .,'".-7 ~'.f': .; ",; ,':',.':~,'.:;:'."' - : .... "'.: .... "" "'' ' 205 : T~DESECRE
207
CAS#
Io$ -- fiD-
209
(one fo~n per matetfal per building~a~
J--]Yes ~[~o 2 '
If Subject to EPCRA, refer ID inslmc~ions
°It EHS h'Yc~, · .It amo~U b~I°~ Inu~t bc in lbs
TYPE ~URE [] m MIXTURE
[] w WASTE 211 t RADIOACTIVI~ []Yes ~ 212
~-~RIES
UN~S' D ga ~L D d CU~ D lb LBS D ~ TONS 221 ~ ~t(
* ff EHS, am~nt must be in lbs.
STOOGE CO~AINER ~ a ABOVEGROUNO TANK ~ e P~STIONONM~ALLIC DRUM ~ i FIBER DRUM ~ BO~LE ~ q ~IL ~
(C~eck all ~at apply) ~ b UNDERGROUND TANK ~ ~ ~N ~ j BAG ~ n P~STiC BO~LE ~ r OTHER
~ c TANK INSIDE BUILDING ~ g ~RBOY D k BOX ~ o TOTE B~N
~ d STEEL DRUM ~ h SILO ~ I CYLINDER ~ p TANK WAGON
STORAGE PRESSURE
[] aa ABOVE AMBIENT
[] ba BELOWAMBIENT
;. ..... ;,,..~ -'-:;'-:HAZARDOUS 60 .P,O. NEN~.,~,. ~, ... :'~'.~t ............ " .'-
--2 230 f 23~ []Yes E]No232
3 2~4 235 y'"-~l-lN'~ 236 I
4 238 240.~
243 [] Yes [] No 244
5 242 . · "':;.] ".:i ':f;:...
· ...., ~, . . ........%~,.-~;~ ~.:.;. ,~._. ,~.;..'y/~_~-~,.,-, ~?.,.- ..~...~ ~,. ....... .~-.:......~..~., :.,..- ....
.: . ' ";:~t;,h~:[?-?.-r,h' '.:T'.'-.~. · , . · ~ -' ' ' -- '
~R ....................... ~ / ,~ ( \ ~ (' \
DATE
S:\6UPAFORMS\OES2731'TV4
UPCF (7t99)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
EW i'-I ADO r-I DELETE [] REVlSE 200
(one fonw per mafedal per building or a~
--~SINESS NAME (Same as FACILITY NAME o~ DBA - Do~ng Busine~ Aa)
~ CONFIDENT~L (EPC~)
CHEMI~L ~ME I ~ ( ( [ . -- I A ~ ~ t If S~bi~ ~0 EPC~. refer lo inst~i~s
CAS #
209 [ ' ~ ' ' '
'it' EHS b*Yc's.' ~ ~:~,nu belOW ~ be i= lbs
'~PE ~URE [] m MIX'DJRE [] w WASTE 211
pHYSICAL STATE [] S SOLID [~lO [] g GAS 214
RADIOACTIVE [] Yes
LARGEST CONTAINER
~"0 RIE S ,~
FED HAZARD CATEGORIES [] 1 F~RE ~R~CTIVE [] 3 PRESSURE RELEASE ~.,~"E~EALTH [~RONIC HEALTH
(Che~3( all b~at apply) 219 STAT~ WASTE CODE
ANNUAL WASTE DAYS ON SITE
A~UNT 22f ~, ( ~
STORAGE CONTAINER
UNITS' [] ga GAL [] d CU FT [] lb LBS [] tn TONS
· ff EHS, amount must be in Ihs.
ABOVEGROUND TANK [] · pLASTiC/NONMETALLIC DRUM [] i FIBER DRUM ~'~SS BO~LE
[] f CAN [] j BAG []" PLASTIC BOTTLE
[] k BOX [] o TOTE SIN
[] g CARBOY
· I/-'ll CYLINDER [] p TANK WAGON
[] ~ S~LO
[] q RAIL CAR :
(Cl~eck alt ~at apply)
'El b UNOERGROUNDTANK
[] c TANK INSIDE BUILDING
[] d STEEL DRUM
[] r OTHER
STOP,~GE PRESSURE ~J'~"~AM8 lENT
[] aa ABOVE AMBIENT
[] ba BELOWAMBIEN'F
~a AMBIENT [] aa ABOVEAMSIENT [~ ba BELOWA,~IENT [] c CRYOGENIC
~', ?..'k~'~.: '
[]Yes []No 232
2 ; 230 ~ I
--; 234
, 5 242 .... . .... , ~, ,,,., · ..,
: ~ , ~.,.,.~.;.::~',u:'~..:~,t-,,i::~'.,.;,}~p~?.¢'r.'.::~ . ;:5: ':;
; -
i :. ,,' ' .. . :'~: .:~;?..-.X:i~: .,.. . . ¢ - ', '": ~" ' ....
-- DATE
S:\CUPAFORMS\OES2731.TV4
UPCF (7/99)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
~EW
ADD I'~ DELETE n REVISE
(one fo~ per mate~al per budding or a~
-'~USINESS NAME (Same a~ FACILITY NAME ~' DBA - Doing Buslne~ As)
~xcsuw ID ~' ., [~ I I I~fl I I il ~ ~ (op~naO 203 GRID ~ (opt~naO
[ ~ [~ I t ~ I I,, '. .I. ....... : ........ ~..:~. ::..:...... .:......:.~..
TRADE SECRET [] Yes ~'~'o 2 '
CHEMICAL NAME
207 .
TYPE
~'ORIES 2
212
[~uPuRE [] m MIX-rlJRE O w wASTE 211 I RADIOACTIV~ [] Yes ~
s~SOLIO r'~ i LIQUID r-] g GAS 214 I LARGEST CONTAINER ~)C~ 5i.~((~ L~'%' s
PHYSICAL STATE
FED H,.~.ARD CATEGORIES
(Ched( all t~at apply)
ANNUAL WASTE
A~UNT
[] 1 FIRE r-] 2 REACTI'V~ [] 3 PRESSURE RELEASE [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH ;
D~iLv ^~u~ DA~LV ^~ouNT : '
~ , DAYS ON S~ :
UN'S' ~ ga ~L ~ d CU~ ~ lb LBS D ~ TONS 221 ~ ~(f
' ~ EHS, am~nt must ~e in les.
~ · p~STIONONU~ALLIC DRUM ~ i FIBER ORU~ ~ m G~SS 80~LE ~ q ~IL ~R
~ g ~RBOY ~ k BOX D o TOTE BIN
~ h SILO ~ I CYLINDER ~ p TANK WAGON
STOP, AGE CONTAINER
(Check all mat apply)
[~J a ABOVEGROUND TANK
[] b UNDERGROUND TANK
[] c TANK INSIDE BUILDING
[] d STEEL DRUM
STORAGE PRESSURE [[~B IE NT
[] aa ABOVE AMBIENT
[] ba BELOWAMBIENT
, 239 [] Ye~ 0 No 240
4 23~ ~ 245 []Yes []No 244
5 22'[- ....... .-
DATE
~REPRESENTATIVE~ i ~ ~)'(-~
S:\CUPAFORMs\oES2731.TV,i
UPCF (7/99)
CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
EW f-I ADO [] DELETE {~ REVISE 2~X)
'.. '-: '. '.?~..ifc-.:~,, .:.""" g...'~'~',..::,',i.' '! .'.;-:' :' .."~:F~.:-' ...'. -'' : '
-~USiNE$S NAME (Same ~,~ FACILITY NAME or DBA - Doing Busines. s As)
(one fo/m per matetfal per buildin~.~r a~
CHEMICAL NAME
COMMON NAME
C~S#
5L~- rue5 201[ CHEMICAL LOCATION
[ CONFIOENT[AL (EPCRA)
203 I GRID # (opt~onaO
209
If Subje~ [o EPCR.A. fei'el to insttuc~ions
EHS' DY~ ~ ~
'It' EHS is'Y~s,' ~ ~n~ b~I°w ~ be b lbs
3HYSICAL STATE
-'ED HAZARD CATEGORIES
(Chec~ all ~at apply)
ANNUAL WASTE
AMOUNT
[] m MIXTURE
[] I LIQUID
CURIES
r-~ w WASTE 211 RADIOACTIVE [] Yes ~ 212
[] g GAS 214 LARGEST CONTAINER
[] 1 FIRE [] 2 REACTi'v~ [] 3 PRESSURE RELEASE [] 4 ACUTE HEALTH
DALLY AMOUNT ~ -- i
UNITS' [] ga GAL [] cf CU FT (~I~BS [~ tn TONS 221 } DAYS ON srj:e
· If EHS, amount must be ~n lbs.
[] a ABOVEGROUND TANK [] · pLASTIC/NONMETALLIC DRUM [] i FIBER DRUM ~ m G~S~,~,%.BEYTTLE
~,,~5'~LASTIC BOTrLE [] r OTHER
(Check all ~at a~ply)
[] b UNDERGROUND TANK [] ! cAN [] i BAG
[] c TANK INSIDE BUILDING [] g cARBOY [] k BOX [] o TOTE BIN
[] d STEEL DRUM [] h SILO [] I CYLINDER [] p TANK WAGON
[] q RAIL cAR
STOPAGE PRESSURE ~j~BIENT
[] aa ABOVE AMBIENT
[] ba BELOW AMBIENT
2 230
3 234
4 238
5 2~2
235 [] Yes[] No 236
243
,..
~,.~,:~-.i':':', .. ?:':.',',.. ' .,.': '
.'.-<~.'.t~.- -'-t.' · ' : "..:ir. "'
UPCF (7/99)
S:\CU PAFORMS',OES2731 .tV.1
CITY OF BAKERSFIELDe
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
(one fo~n pe/' ma tedal ,oer building or aG
Page ~
TYPE [] m MIXTURE
2O9
[] w WASTE 211 j RADIOACTI~- I-lyes
If Subject to EPCRA. refer Io inst~Ctions
EHS' ['~ Ye~ ~o 2
*ff EHS i~'Ycs,' gl ~ts b~low m~. be in lbs
212 ~;URIES
~RE
PHYSICAL STATE ~ E]I LIQUID
FED HAZARD CATEGORIES [] 1 'FIRE [] 2 REACT[V~
(Chedc afl ~at apply)
.7~~~MAXIMUM
ANNUAL WASTE DALLY AMOUNT
AMOUNT
rkO_ / uNrrs' [] ~ CAL
[] 3 PRESSURE RELEASE [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH
.. AILY AMOUNT
DAYS ON SiTE
[]ucurr ~ []t. TONS 221 ~1[
· If EHS, amount must be in lbs.
STORAGE CONTAINER
(Check alt t~at apply]
[] a ABOVEGROUND TANK [] e PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] rn GLASS BOTTLE [] q RAIL CAP-,
~Om.E []r OTHER
[] b UNDERGROUND TANK [] f CAN [] j BAG
[] c TANK INSIDE BUILDING [] g CARBOY r"] k BOX [] o TOTE BtN
[] d STEEL DRUM [] h SILO [] I CYLINOER [] p TANK WAGON
STORAGE PRESSURE ~81ENT
[] aa AI~i)VE AMBIENT
[] ba BELOWAMBIENT
-- ~ 230
235 ~-No 236
~ ~y~ ~ No 240~9
~ ; 238
' ..." '.~ ~ DATE
.., . . .'=.~:..:~; . p.~:_..~,~~;:~,~'
S:\CUPAFORMS\OES2731.TV4
UPCF (7199)
J~ CITY OF BAKERSFIELD -
OFFICE OF ENVIRONYIENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
(one fo~m per ma ter~al per building~rs~
~EW f-J ADO [] DELETE [] REVlSE ............. ..~. . . ..
· ........ . ..... :: ............... · ..... :~,.~.- ~ .:.,. F.,.'- ~:.-. ::~}~.:, ~;~.:'. ~:.. :.~!.'-." '~'i ...... ~:~: ..... ~. "h .:~'. .... : ....
'.,. ..,: , ~ .'".~ ?~:;,' ),,...:::'-.
~USINE$S NAME (Same as FACILITY NAME ~' DBA - Do~ng Business A~)
CHEUlCAL LOCATION ' ¢ ~O eX` ~ ~ C 20~, CHEMICAL LO~T~O~
:...::~:~'.:, :....~,; ..-~.~.=~?......:-: ~.....~..~.:~?.., ~~L,~q~~°" .
CHEMIC. AL NAME
COMMON NAME
fire
TYPE
PHYSIC,AL STATE
FED HAZARD CATEGORIES
(Chec~ ail ~at apply)
ANNUAL WASTE
A~UNT
207
209
I"-~Yes [~[~d~'o 2 '
If Subject to EPCRA,. re,er to ins[n.~c~ions
*it' EHS is*Yes,' ail am~u~u below mu~t be iu lbs
m MIXTURE [] w WASTE 211 { RADIOACTIV~ DYeS ~ 2t2 CURIES
~t"~OLiD F']l LIQUID . [] g OAS 214 ~RGEST~AINER
FIRE ~ 2 R~CT~ ~ 3 PRESSURE REL~SE ~ 4 AC~E H~L~ ~NIC H~LTH
~AVE~GE '~ 219 ~ STA~WAS~CE
DALLY A~U~ {
DAYS ON
~ gn ~L ~ ~ CU ~ ~ I~ LBS ~ ~ TONS 2~ ~ ~
* ff EHS, am~nt must be in lbs.
STORAGE CONTAINER
(Check all ~at apply)
[] a ABOVEGROUND TANK [] e PLASTIC/NONMETALLIC DRUM [] i FleER DRUM [~ m ~ BOTTLE [] q RAIL CAR
D b UNDERGROUND TANK [] f CAN [] j BAG ~,,~I""-pLASTIC BOTTLE [] r OTHER
r-] c TANK INSIDE BUILDING [] g CARBOY [] k BOX ~ o TOTE BIN
[] d STEEL DRUM [] h SILO [-].1 CYLINDER [] p TANK WAGON
STORAGE PRESSURE ~81ENT
[] aa ABOVE AMBIENT
[] ba BELOW AMBIENT
UPCF (7/99)
~ CITY OF BAKERSFIEL
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
(one [o,'m per matedal per building or a~
* EW I-I ADO [-I DELETE r~ REVISE ............... . ~
· ~.:.:;~",;':: "..: . c':'.~".. :.~ ;¥'.'... :" :..*,~. .: :.:~.,::-.~:,.:.; ~I.,FAGILITYINFORMATION - .r:*~. *.: . ..... ~
BUSINESS NAME (Same as FAC L '
[ CONFIDENTIAL (EPCP, A)
"~"0 RIE S
[] W WASTE 211
[] g GAS 214 LARGEST CONTAIN
:EO HAZARD CATEGORIES
(Ched( all ~at apply)
ANNUAL WASTE
AMOUNT
[] 1 FIRE [] 2 REACTIV~ [-'] 3 PRESSURE RELEASE ~ 4 Acu'rE HEALTH [] 5 CHRONIC HEALTH
DAILY A~ uff.~._~L.~ .,~ DALLY AMOUNT
DAYS ON SiTE
a ~a GAL ~ ~ cu~ g ,~ LBS [] ~ TONS 2~
iTs.
STORAGE CONTAINER
(Check all ~at apply)
[] a ABOVEGROUND TANK [] · PLASTICJNONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTTLE [] q RAIL CAR
[] b UNDERGROUND TANK [] f CAN ~ j BAG [~TIC BOTTLE [] r OTHER
[] c TANK INSIDE BUILDING [] g CARBOY [] k BOX [] o TOTE
[] d STEEL DRUM [] h SILO [] I CYLINOER r'] p TANK WAGON
STONAGE PRESSURE
~BIENT
[] aa ABOVE AMBIENT
[] ba BELOW AMBIENT
STORAGE TEMPERATURE
?~'::~%w¥.
2 230
3 234
ABOVE AMBIENT
[] ba BELOW A,~IFJ~'T [] c CRYOGENIC
239 [] y~ [] No 240
4 238
5 242
, -,.
· , .... · '. "~ ~(~.N..A.I ~.~: ..:~,;~,-.~.~.~.' ? ..... ~.; U~',,; .';:-. ~: ....· .
· ';' ',~..'"! i "' Y,';~.':;;',:~.L;'.';;; ;.
........ ~W.:..',.i ~ ~. ,~: ,-.:. -.: -. .
UPCF (7/99)
S:\CUPAFORMS\OES2731.TV4
FACILITY NAME
ADDRESS ~g.~' ~
FACILITY CONTACT
INSPECTION TIME
CITY OF BAKERSFIELD FIRE DEPARTMENT
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301
INSPECTION DATE
PHONE NO.
BUSINESS IDNO. 15-210-
NUMBER OF EMPLOYEES
Section 1: Business Plan and Inventory Program
Routine l~l Combined [~l Joint Agency [~l Multi-Agency [~ Complaint [~ Re-inspection
OPERATION
Appropriate permit on hand
Business plan contact information accurate
Visible address
Correct occupancy
Verification of inventory materials j
Verification of quantities
Verification of location
P}oper segregation of material
Verification of MSDS availability
Verification of Haz Mat training '
Verification of abatement supplies and procedures
Emergency procedures adequate
Containers properly labeled
COMMENTS
Housekeeping
Fire Protection
Site Diagram Adequate & On Hand
f Groundwater Scientists * Environmental Consultants
Philip Goa!win
Principal Hydrogeologist
R.G. #4779
6851 McDivitt Dr., Suite D (805) 836-8100
-l~akersfield, CA 93313 Fax (805) 836-8800
(800) 301-424~_.
C=Compliance V=Violation
Any hazardous waste on site?:
Explain:
~Yes [~ No
Questions regarding this inspection? Please call us at (66 I) 326-3979
White - Env. Svcs.
Yellow - Station Copy
Pink - Business Copy
/' us' ess Site'Responsible PartY-'
Inspector:
State of California--Environmental Protection Agen
COMPLAINT REPORT FORM
(Use ball-point pen)
Department of Toxic Substances Control
Log Number:
., INFORMANT
- Name:
Address:
'City: ZIP:
Phone: ( )
ALLEGED RESPONSIBLE PARTY
Name: . / . ~ .....
.
[] Confidential OR nonymous: (Check one) County Code*: /' D Phone: (
COMPLAINT .DATA
.Is this an emergency? [] Yes "~o If yes, call the Offic. e of Emergency services (OES): 800-852-7550
Date Complaint ece' ed: :- ,/cRe(.ceived By:
Log Number:
Notifications made (yes r0p. 65 ____ Local. Agency Who?
Date of Incident: __.. ('",,/~q ~ /'~d.~ _ Allegation Code*:
. . ~
Response Code °: ~
COMPLAINT COORDINATORS ONI~.Y .
Region/Agency Referred To.~,v-~' ~" ~, ~ .~j
Response Date: - . Investigator:
Date Assigned:
Note: Information to be transferred to complaint'log is highlighted in bold italic print. Attach an addendum if necessary.
~;:~ * Se(~ c~de, on reverse side.
~[~..~,~'P ' .Whitc~ RegionalOffice Yellow'Fog Pink--Investigations
DTSC 1017 (10/91)
(Formerly DHS 8231 and DHS 8073)
Green--Informant
91 93088