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Home My WebLink AboutBUSINESS PLAN 12/28/1999TERRANCE M LUKENS DDS Manager : Location: 3807 SAN DIMAS ST 13 City : BAKERSFIELD CommCode: BAKERSFIELD STATION EPA Numb: BusPhone: Map : 103 Grid: 19B SIC Code: DunnBrad: SiteID: 215-000-000840 -(~ 327-0835 CommHaz : Low FacUnits: 1 AOV: Emergency Contact TERRANCE LUKENS Business Phone: 24-Hour Phone : Pager Phone : / Title ( ) 327-0835x ( ) 872-1014x (~) - x Emergency Contact / Title ROBERT LUKENS. ~. / ~r~ ~B~cin~: (,805) ~ 24-Hour Phone : ~) 325-2382x Pager Phone : (~1 ) - x Hazmat Hazards: Fire Press ImmHlth Contact : -?~er~t~a/k tu~x(5~,Tl>5 MailAddr: 3807 SAN DIMAS ST 13 City : BAKERSFIELD Owner TERRANCE M. LUKENS DDS Phone: (~ 6/) ~7 - 0~3~ x State: CA Zip : 93301 Phone: (~ 327-0835x. Address : 12101 CATTLE KING City : BAKERSFIELD State: CA Zip : 93306 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = ~al Certif'd: RSs: No Emergency Directives: = Hazmat Inventory --MCP+DailyMax Order Hazmat Common Name... One Unified List Ail Materials at Site ISpecHazlEPA HazardsI Frm DailyMax lunit IMCP 600.00 FT3 Hi 562.00 FT3 Low NITROUS OXIDE F P IH.__x G OXYGEN F P ~J~(~4) G ~, ._~'~ I uiy,..5 ~,~_ Do hereby certify.that I have .... ,q'~p3 6r ~d~t reviewed '~h$ a~ached h~a~ous marcels manage- ment plan fo~ L~a~5 .~,~ ~ that it a~ong with any ~rm~ion~ ~nsfitut, a ~mplete and ~ff~ 12/21/1999 OFFICE 327-0835 TERRANCE M. LUKENS D.D.S., INC. G EN ERAL DENTISTRY 38o7 SAN DIMAS OFFICE HOURS SUITE B BY APPOINTMENT BAKERSFIELD, CALIFORNIA 93301 Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE Permit ID#:: 015-000-000840 TERRANCE M LUKENS DDS LOCATION: 3807 SAN DIMAS ST 13 Issued by: !RSg'IELD This ~ermit is issued for the followin_.: [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials [] Risk Management Program [] Hazardous Waste On-Site Treatment Approved by: (~ ~_[Plttt?eY'.D~~ OfficeofEvimnn~r~TServices ~ ExpimtionDate: June 30. 2003 Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Issue Date Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE PERMIT ID# 015-021.000840 TERRANCE M LUKENS DDS LOCATION 3807 Issued by: ~ ~ ~ ..... Thisoermit is issued for the followin : :~:._.~....::.:~ ...... 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 ORTH SCALE: BUSINESS NAME DATE:? //~ o~/F~Cr~IT¥ N~'~E: · FLOOR: ~OF (CHECK ONE) SITE DIAGR.~M FACILITY DIAGR.~M ~ l( Inspector's Comments): -OFFICIAL USE ONLY- - SA - SITE DIAGRAM (Require~ 1, Address: Identify th~ principle buildings by the Street numbers. 2, Street(s), Alleys. Prlve~aya, and Perkins Areas adjacent to the property. Include the street naars. 3, Stora Drains, Culverts, Yard 0rains 4. Drainage Canals, Ditches, Creeks, S. Buildings a, Franc construction b, Hasonry construction c. Natal construction d. Access Door 6. Utility Controls a. Gas b. Electr.iclty c. #eter ?. Fire Suppression Systens: a~ Fire Hydrants b. Fire Sprinkler Connection, c. Fire Standpipe Connections d. #star Control Valves for protecClon ayaCens e. Fire Pu~p a. Fire Department Access 9, Lock (key) 10. HSD$ Storage Box 11. Railroad Tracks 12. Fence or Barrier a. Wire b. Nasonry c. Wood d. Gates 13. Powerllnes 14. Guard Station 15. Storage Tanks: Identify the capacity tn gal. a. Above ground b. Underground 18. Diking or Bars I?. Evacuation Route 18. Evacuation Area: Identify the location where employees will meet. 19. Outside aazardous #aero Storage Outside Hazardous #atorial Storage 21. Outside H~zardous Naterlal Use/Handling 22. Type of Hazardous Xaterlal/#aate Stored or Used (See aelow) F = Flammable C - Corrosive 0 - Oxidizer O - Oas P - Poison # - Water Reactive T - Toxic D - Waste B · Stlologlcal [xanple: Flammable ~lqu/d - FL FACILITY DqAGRA~ (Required Items in addition to the abo~e) l. Rilerl [or Bprinkll~-I l. Partltlona 3. $talr,ays: Indicate t~e 10. levels served froa highest to lo-est. 11. 4. Escalator: Indicate the levela served from 1~. highest to lowest. $. Elevator O. Attic Access ?, Skylight; = ~xploslve L - Liquid R - Radiologlcal S - Solid 'H - Cryogenic Firs Estella Air Conditioning Units Windows Inside ~aaardous Waste Storage Inside Hazardous Na'terials Storage 13. Inside Bazardous ~atarlals Use/Handling 14.,,Se~er Drain Inlets ECEW~O IL! TY DIAGRAM . Area Ncr--~. CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ADDRESS FACILITY CONTACT INSPECTION TlME INSPECTION DATE PHONE NO. 5'2 BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program Routine ~,.Combined I~ Joint Agency [~l Multi-Agency ~ Complaint ~ 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 quantities 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?: ~[Yes [~] No Explain: Quesqions regarding thig inspection? Please call us at (661 ) 326-3979 Bustness SitetResponsible Party White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Inspector: CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME "[C~ ADDRESS % ~2,-7 FACILITY CONTACT INSPECTION TIME INSPECTION DATE ~ 'trl°'C. PHONE NO. BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program [2] Routine 3~[Combined' [21 Joint Agency [2] Multi-Agency [,.] Complaint Re-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials {.d'tA,,~ ~=,~L-.¢.../ ~t'rre. t.~O~to~. Verification of quantities V&ification 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?: ~ Yes [2] No EXplain: O,P~Xff'- q: ~C~- uesuons regaroing mis inspection? Please call us at (661) 326-3979 Busin~es~ Si~'lte Re s~po~'rty White- E:nv. Svcs. Yellow- Station Colby pink- a~in~s Cos,y Inspector: FACILITY NAME CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301 INSPECTION DATE Section 4: Hazardous Waste Generator Program EPA ID # [] Routine ~l- Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V: COMMENTS Hazardous waste determination has been made ~ {~5 O/~ EPA ID Number (Phone: 916-324-1781 to obtain EPA ID #) Authorized for waste treatment and/or storage J Reported release, fire, or explosion within 15 days of occurrence ]t/ Established or maintains a contingency plan and training Hazardous waste accumulation time frames N Containers in good condition and not leaking Containers are compatible with the hazardous waste Containers are kepi closed when not in use Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided Conducts daily inspection of tanks Used oil not contaminated with other hazardous waste Proper management of lead acid batteries including labels Proper management of used oil filters Transports hazardous waste with completed manifest ~ Sends manifest copies to DTSC Retains manifests for 3 years Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal C=Compliance V=Violation Inspector: Office of EnvironmentaiServices (661) 326-3979 Busin~s~s SitetResl~onsible Party White - Env. Svcs. Pink - Business Copy TERRANCE M LUKENS DDS SiteID: 215-000-000840 Inventory Item 0002 Facility Unit: Fixed Containers on Site %.:%21vllvl%2.1.%l .L~Z-'%/vl.t~ / %JllJ:51vli %..J-'},.1J .L~4_/-'%/Vl.l:5 NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: E OF ~ACi~ DC~- Sg~T~ ~ %~-~ DL~~ /(-tA~u:~/.. cAS# FSTATE i TYPE PRESSURE i TEMPERATUREI CONTAINER TYPE Gas Pure Above Ambient Below Ambient PORT. PRESS. CYLINDER Largest ContainerFT3 AMOUNTS AT THIS LOCATION Daily Maximum 600.00 FT3 Daily Average 300.00 FT3 %Wt. 100.00 Nitrous Oxide HAZARDOUS COMPONENTS 10024972 HAZARD ASSESSMENTS I Radi°active/Am°unt IEPA HazardsNo/ Curies F P IH NFPA /// USDOT# Inventory Item 0001 Facility Unit: Fixed Containers on Site ~jUtvllvl~,2~ l~l_,qJ.VlJ:5 / ~l'J.~;IVl-I-~-~-l~ l~lZ-~J.Vl~ OXYGEN Days On Site ! 365 Location within this Facility Unit M. ap: Grid: [-- STATE ~ TYPE I PRESSURE I TEMPERATURE CONTAINER TYPE Gas /Pure Above Ambient Below Ambient PORT. PRESS. CYLINDER Largest ContainerFT3 AMOUNTS AT THIS LOCATION Daily Maximum ~ 562.00 FT3 Daily Average 281.00 FT3 HAZARDOUS COMPONENTS 100.00 Oxygen, .Compressed N 7782447 HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies F P IH NFPA /// USDOT# MCP Low -2- 12/21/1999 F TERRANCE M LUKENS DDS SiteID: 215-000-000840 Fast Format = Notif./Evacuation/Medical --Agency Notification CALL 911 Overall Site 05/18/1990 Employee Notifo/Evacuation CALL 911 NORMAL EVACUATION SHUTDOWN OF SYSTEM 05/18/1990 Public Notif./Evacuation 05/18/1990 IN CASE OF FIRE, BUILDING EVACUATED, GASES SHUT OFF (USUALLY OFF), ALL EMPLOYEES TRAINED IN EVAUCATION AND IN PROPER EMERGENCY PROCEEDURES I.E. FIRE EXTINGUISHER, GAS VALVES SHUTDOWN, CPR. ETC. Emergency Medical Plan NEAREST HOSPITAL - MEMORIAL - 420 34TH ST - 327-1792 05/18/1990 -3- 12/21/1999 F TERRANCE M LUKENS DDS SiteID: 215-000-000840 Fast Format ~ Mitigation/Prevent/Abatemt --Release Prevention INSTRUCTION OF ALL PERSONNEL IN HANDLING AND MAINTAINENCE. GAS IS RESTRAINED PROPERLY & VALVED PROPERLY Overall Site 04/16/1992 ~Release Containment PROTABLE PRESSURIZED CONTAINER 04/16/1992 -- Clean Up GASES ONLY 04/16/1992 Other Resource Activation -4- 12/21/1999 F TERRANCE M LUKENS DDS SiteID: 215-000-000840 Fast Format Site Emergency Factors Special Hazards Overall Site --Utility Shut-Offs A) GAS - WEST SIDE OF BUILDING B) ELECTRICAL - WEST SIDE OF BUILDING C) WATER - EAST SIDE OF BUILDING D) SPECIAL - NONE E) LOCK BOX - NO 05/21/1990 Fire Protec./Avail. Water 05/21/1990 PRIVATE FIRE PROTECTION - FIRE EXTINGUISHER MAINTAINED IN OFFICE FIRE HYDRANT - 38TH STREET APPROXIMATELY 200 FEET AWAY Building Occupancy Level -5- 12/21/1999 F TERRANCE M LUKENS DDS SiteID: 215-000-000840 Fast Format ~ Training -- Employee Training WE HAVE 7 EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE ALL EMPLOYEES ARE TRAINED IN HOW TO MAINTAIN AND SHUT OFF ALL COMPRESSED GASSES. IN CASE OF ANY WARNING OF FIRE, I.E. SMOKE ETC., ALL GASSES ARE CHECKED TO MAKE SURE THEYARE SHUT OFF. THEY ARE KEPT SHUT OFF EXCEPT WHEN IN USE. Overall Site 04/16/1992 Page 2 Held for Future Use Held for Future Use -6- 12/21/1999 BAKERSFIELD CITY FIRE DEPARTHENT 2130 "O" STREET BAKERSFIELD, CA 93301 (805) 326-3979 OFFICIAL USE ONLY BLSiNESS /~' : % ~C- NAME HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 2A INSTRUCTIONS: 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:'- B. LOCATION BUS.PHONE: 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 DU~ING BUS. HRS. A~TER BUS. HRS. SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WMOLE B. ELECTRICAL: (,-/~X't'-fl~ ~ 7~L) I C. WATEr: ~W .~ ~,-3£ ~ 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 TE~ff4 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:...- .................................... ~[E~q NO B. PROCEDURES FOR COORDINATING ACTIVITIES WITH RESPONSE AGENCIES: .......................... C. PROPER USE OF SAFETY EQUIPMENT: .................. D. EMERGENCY EVACUATION PROCEDURES: ................. E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... SECTION ?: HAZARDOUS NATERIAL CIRCL~OR NO REFRESHER NO NO NO NO NO NO NO DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS0?._~ SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YE~_~...~ I,' l ~£6~(~(_ ,-~% ' , certify that the above information is accurate. I understand that this inforGation.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. A1.) and tha/~inaccurate information constitutes perjury. BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 BUS I 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 be]ow for THE FACILITY UNIT LISTED BELOW 4. Be as BRIEF and CONCISE as possible. - ~ SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES SECTION 2: NOTIFICATION BaND EVACUATION PROCEDURES AT THIS UNIT ONLY d 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 4. . 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-1) Yes, complete a hazardous materials inventory form marked: ~E SECRETS ONLY (yellow form ~4A-2) in addition to'the ~de t form. List only the trade secrets on form 4A-2. SECTION 4: FIRE PROTECTION SECTION 5: LOCATION OF SUPPLY FOR USE EMERGENCY RESPONDERS SECTION 6: LOCATION OF UTILITY A. NAT. OAS/PROPANE] AT THIS UNIT ONLY. B. ELECTRICAL: C. WATER: D. SPECIAl, E. LOCK BOX: YES / NO IF YES, LOCATION: IF YES, SITE PLANS? FLOOR PLANS? YES / NO MSDSs9 YES ./ NO YES / NO KEYS? YES / NO - SB - BAKERSFIELD CITY FIRE DEPARTMENT I.D. # FORM 4A-1 NON--TRADE SECRETS HAZARDOUS MATERI ALS I NVENTORY ADDRESS: ~6~ %~~{~.~ . ~-~i ADDRESS: I%(¢1 .(~ .g¢~ FAC~LI~ Page ,.of,~ FAC.ILITY UNIT UNIT NAME:J~I-'~ ICIAL USE CFIRS CODE PHONE #: ~'-;~ /~/~ [OFF - '- [ ONLY 1 2 3 4 5 6 7 8 9 10 TYPE MAX ANNUAL CONT USE LOCATION IN THIS % BY HAZARD D.O.T CODE AMOUNT AMOUNT ~JNj_.T CQDE CODE FACILITY UNIT WT. CHEMICAL OR COMMON NAME ~ZODE GUIDE NAME: __ TITLE: __ SIGNATURE: t ~ DATE EMERGENCY CONTACT: -'~rr,.~o~,4' ~ ~.,,t~. TITLE: Oc~,_~ [/ PHONE # BUS HOURS: - / AFTER BUS HRS: EMERGENCY CONTACT: ,. TITLE,: . PHONE # BUS HOURS: PRINCIPAL BUSINESS ACTIVITY: ~.,._~.l_,,~'~.. (.'~ ~1[ .,,../ AFTER BUS HRS: - 4A-1 - C/T¥ (t>-~e or prin~ name Do hereby certify that I have reviewed the attached Hazardous Materials business ~lan A~'~ ............. for (name of business) and that it along with the attached additions or corrections constitute a comDlete and correct 7 / mate 1. OVERVIEW JURIS CODE HAP PAGE 10~ LAST CHANGE Ii/Gl/S8 13Y VAL -,Zt5-~04 JtJRIS P~AI(ERSFtELD STATION ,44 GRID tgB FACILITY UNITS i HAZARD RATING Z RE;~PON~c SUMMARY ZR SEC ~) CALL 911 AND FOLLOW ~,:VACURT,~ON PL. RN EHERGENCY CONTACTS ZA SEC Z) TERRANCE LUKENS - 327-0835 OR 87Z~ ROBERT LUKENS - 3Z?-08~5 OR 3ZS-Z38Z UTIL!TY"SHUTOFFS ZA SEC R) GAS - Y SIDE OF BLDG B) ELECTRICAL - ~ SIDE OF BLDG C) WATER - E SiDE OF 8LOG O) SPECIAL - NONE E) LOCK BOX - NO Z. NOTIFICATION / PUBLIC EVACUATION LAST CHANGE !!/ ! /~BY ( NO INFORMATION RECORDED FOR THIS SECTION > PAGE ti/tS/88 ~B:44 MATERIAL SAFETY DATA SYSTEMS, INC. (805) G48-GSeO L. (:)E ~:iT ! 0 N ~ e,,.--:,_ - ..... ,']. I--tRZ i~'lWF FIRi:~Ii~.IZNG SUftMf~R¥ Lff~ST CHANGE < NO iNFORMATION RECORDED FOR Tills SECTION .> 4. LOCAL EMERGENCY MEDICAL ASSISTANCE L~ST CHANGE 1Z/01/88 BY VRL SEC S) NEAREST HOSPITAL - MEMORIAL - 4Z0 34TH ST - 3ZT-I?gZ PAGE ~ !Z/I~/88 0g:44 ~IRTERIRL SAFETY DATA SYSTE~tS, INC. (805) G48-GS¢O !--t ]; (;¥-{ i-!£~Zi~.I..R[;} RAT?_t,!6 '" ~'~. OVERALL ,.A~.r'l,x[]uL... .tf"~ R:.R.[ALS iNVENTORY t_fiST CHANGE 12/Ol188 i~Y TYPE NAME LOC~T~ON CONT~INMENT PtJRE OXYGEN E END BACK DOOR PORT~BI_E PRESS. CYL. ID PERCENT COMPONENTS Z~5~.00 100.0 OXYGEN, COMPRESSED PURE NITROUS OXIDE E OF BACK DOOR PORTABLE PRESS. CYL. ID PERCENT, COMPONENTS Z345.00 10~.0 NITROUS OXIDE MAX AMT tJNIT HAZARD USE Z81FT3 HIGH ANESTHETIC HAZRRO LIST HIGH 6~ FT3 MODERATE ANESTHETIC HAZARD LIST MODERATE B. FIRE PROTECTION / WATER SUPPLIES SEC 4) 3R SEC S) NO PRIVATE FIRE PROTECTION FIRE HYDRANT PAGE 3 'ii/15/88 ,'..~9:44 MATERIAL SAFETY DRTR SYSTEMS., INC, 805) G48-68'~0 LUKE [3 ! ['iR ~; ST D. I:i'~°L(]YF-E..,,, NOTiF',iCRTION / EVACUt:YTIO?,I i_.~ST CHANGE !£/0'i/88 8Y VAI_ SEC Z) CALL 8 1 1 NORMAL EVACUATION SHUTDOWN OF SYSTEM E, MITIGATION / PREVENTION / ABATEMENT LAST CHANGE IZ/01/88 BY VAL SEC I) INSTRUCTION OF ALL PERSONNEL IN HANDLING AND MRINTRINENCE. GAS IS RESTRAINED PROPERLY t VALVED PROPERLY PAGE IZ/1S/G8 (~: ~4 MATERIAL SAFETY DATA SYSTEMS, INC. (,80!5) 848-6800 CITY of BAKERSFIELD (HAZARDOUS MATERI ALS I NVENT.ORY' Firm and l~lriculture ~ Standard Business NON--'I/RADE S ECRE'rS ' Page CITY. ZIP~ ~-~r~t~/'- ~/' ~ CITY. ZIP: ~,~/.~[~ DUN AND BRADSTREET NUMBER PHONE S:--,-~{3~% I ~ PHONE *: ~{~t~ ~ - - -- -- - -- _ _ - ~ ~=~'I~U~ZO~ ~R ~OP~ COD~ I , 2 ] 4 S (~e C~e ~t ~t Est Units m Site T~ ~1 lW ~ .. St~ in FKtlIIy ~ ~ Iqt~tiw of P~. ~lth .......... -~-~.J ..... ~. ..... 1~ ..... t ....... l_._g___l~.l~..l~sh~_~5~~~~_~:~ ~~~~ '__ P~icll ~ ~lth Hezl~ C.l.S. (C~k lll t~t - - ~-~ ~-~ ~-~ , h of ~ ~lth ............ P~tc~l ~ Mlth ~za~ C.l.S. (C~k ~11 t~t e~ly) Health of P.~su~ Mlth ..... , h ~-- ................. __L_ti ......... k ............ ~ .......... (C~k all t~t ;~ _ a Fire Hezard ~--~ ~tivity ~ie~ ~--a ~ Reline ~--a I~tete H~lth of c~c~ ~i~ ...................... } ............ · y in(Wiry of those tmltvtdu~ls ~eSl~s'ible ................ :.. 03/18/92 TERRANCE M LUKENS DDS 215-000-000840 Overall Site with 1 Fac. Unit General Information Page 1 Location: 3807 SAN DIMAS ST 13 Map: 103 Hazard: Low I I Community: BAKERSFIELD STATION 04 Grid: 19B F/U: 1AOV: 0.0 I Contact Name , Title i Business Phone 24-Hour Phone] ITERRANCE LUKENS I [(805) 327-0835 x (805) 872-1014! IROBERT LUKENS (805) 327-0835 x (805) 325-2382! Administrative Data Mail Addrs: 3807 SAN DIMAS ST #13 D&B Number: City: BAKERSFIELD State: CA Zip: 93301- Comm Code: 215-004 BAKERSFIELD STATION 04 SIC Code: Owner: TERRANCE M. LUKENS DDS Phone: (805) 327-0835 Address: 12101 CATTLE KING State: CA City: BAKERSFIELD Zip: 93306- Summary RECEIVED M6,R 3 1 1992 HAZ. MAT. DIV. Do hereby certity that I have ~y~ or ~tm ~) , ',' :?=3.rdous materials manage- review~ ~he ~nd that it ~ong with ment plan any correcUons consU'~te a complete and ~rr~ man- agemen, plan form: ,7;it:. /., ,% 03/18/92 TERRANCE M LUKENS DDS 215-000-000840 02 - Fixed Containers on Site Hazmat Inventory Detail in Reference Number Order Page 02-001 OXYGEN · Fire, Pressure, Immed Hlth Gas 562 Low FT3 CAS 9:7782-44-7 Form: Gas Type: Pure Daily Max FT3 562 Trade Secret: No Days: 365 Use: ANESTHETIC I Daily Average FT3 Annual Amount FT3 281.00 I 1,124.00 Storage Press T Temp PORT. PRESS. CYLINDER Above {Below Location END BACK DOOR -- Conc 100.0% IOxygen, Compressed MCP List Components ILow I -- Notes 02-002 NITROUS OXIDE Gas 600 High · Fire, Pressure, Immed Hlth FT3 CAS #: Form: Gas Type: Pure Daily Max FT3 600 Trade Secret: No Days: 365 Use: ANESTHETIC Daily Average FT3 T Annual Amount FT3 300.00~ 1,200.00 Storage Press T Temp Logation PORT. PRESS. CYLINDER Above {Below IE OF BACK DOOR -- Conc Components MCP 100.0% INitrous Oxide High .List -- Notes 03/18/92 TERRANCE M LUKENS DDS 215-000-000840 00 - Overall Site <D> Notif./Evacuation/Medical Page <1> Agency Notification CALL 911 <2> Employee Notif./Evacuation CALL 911 NORMAL EVACUATION SHUTDOWN OF SYSTEM <3> Public Notif./Evacuation IN CASE OF FIRE, BUILDING EVACUATED, GASES SHUT OFF (USUALLY OFF), ALL EMPLOYEES TRAINED IN EVAUCATION AND IN PROPER EMERGENCY PROCEEDURES I.E. FIRE EXTINGUISHER, GAS VALVES SHUTDOWN, CPR. ETC. <4> Emergency Medical Plan NEAREST HOSPITAL - MEMORIAL - 420 34TH ST - 327-1792 03/18/92 TERRANCE M LUKENS DDS 215-000-000840 00 - Overall Site <E> Mitigation/Prevent/Abatemt Page <1> Release Prevention INSTRUCTION OF ALL PERSONNEL IN HANDLING AND MAINTAINENCE. GAS IS RESTRAINED PROPERLY & VALVED PROPERLY <2> Release Containment <3> Clean Up <4> Other Resource Activation 03/18/92 TERRANCE M LUKENS DDS 215-000-000840 00 - Overall Site <F> Site Emergency Factors Page 5 <1> Special Hazards <2> Utility Shut-Offs A) GAS - WEST SIDE OF BUILDING B) ELECTRICAL - WEST SIDE OF BUILDING C) WATER - EAST SIDE OF BUILDING D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - FIRE EXTINGUISHER MAINTAINED IN OFFICE FIRE HYDRANT - 38TH STREET APPROXIMATELY 200 FEET AWAY <4> Building Occupancy Level 03/18/92 TERRANCE M LUKENS DDS 215-000-000840 Page 00 - overall Site <G> Training 6 <1> Page 1 WE HAVE 7 EMPLOYEES AT THIS FACILITY DO YOU HAVE MATERIAL SAFETY DATA SHEETS ON FILE? y ~ ALL EMPLOYEES ARE TRAINED IN HOW TO MAINTAIN AND SHUT OFF ALL COMPRESSED GASSES. IN CASE OF ANY'WARNING OF FIRE, I.E. SMOKE ETC., ALL GASSES ARE CHECKED TO MAKE SURE THEY ARE SHUT OFF. THEY ARE KEPT SHUT OFF EXCEPT WHEN IN USE. <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use Suzanne Calvillo Office Manager Dima~ Orth~lontic Center (661) 634-9344 3807 San Dimas St., Ste. C (661) 634-0270 - Fax Bakersfield, CA 93301 SAN DIMAS ORTHODONTIC~MTER Manager Location: 3807 SAN DIMAS C City : BAKERSFIELD CommCode: BAKERSFIELD STATION 04 EPA Numb: SiteID: 015-021-002364 BusPhone: (661) 634-9344 Map : 103 CommHaz : Grid: 19B FacUnits: 1 AOV: SIC Code:8021 DunnBrad: Emergency Contact / Title SUZANNE CALVILLO / OFFICE MANAGER Business Phone: (661) 634-9344x 24-Hour Phone : ( ) - x Pager Phone : ( ) - x Emergency Contact Business Phone: ( 24-Hour Phone : ( Pager Phone : ( / Title / ) - X ) - x ) - x Hazmat Hazards: React Contact : SUZANNE CALVILLO MailAddr: 3807 SAN DIMAS C City : BAKERSFIELD Phone: (661) 634-9344x State: CA Zip : 93301 Owner Address : 3807 SAN DIMAS C City : BAKERSFIELD Phone: (661) 634-9344x State: CA Zip : 93301 Period : Preparer: Certif'd: ParcelNo: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: I, F~[,l~l~l']e ~}~/;1/~}_ Do hereby oo~i~ that l have reviewed the a~ached h~ardous mate~als manage- m~t p~n for o~ ~i~5 ~h~ and t~t it ~ong with ~y ~e~ions ~nmitute a ~mplete and ~rre~ man- agement plan for my facility. 10/17/2003 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3~" Floor, Bakersfield, CA 93301 / _A ADDRESS ~cg~o~ ~ o,,~,~ 4x<... PHONE NO. 63,~'5/-f/-/ FACILITY CONTACT <So'z,,,~o.r,.~c r_.23L~tt..to BUSINESS ID NO. 15-210- INSPECTION TIME NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program Routine q? [~-Combined [~ Joint Agency ~ Multi-Agency ~.~ Complaint [~ Re-inspection OPERATION C V COMMENTS Appropriate permit on hand /x/~'--a., Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials Verification of quantities 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: ~t-'~ ~ f' it Co.~ Yes ~ No Questions regarding this inspection? Please call us at (66 I) 326-3979 -l~iness Site Responsible'Part~ White- Env. Svcs. Yellow- Station Co~y Pink- Business Copy Inspector: CITY OF BAKERSFIELD FIRE DEPARTMENT omc or UNIFIED pROG~M INSPECTION CHECKLIST 1715 Chester Ave., 3~ Floor, Bakersfield, CA 93301 FACILITY NAME ~ 0,~ C_.a~,,-~t~c C_.<-,,~.~INSPECTION DATE ADDRESS ~e,(O"7. ~ o,~,w~ 4~;~... PHONE NO. FACILITY CONTACT <~o'Z'','~a¢ .,,0~ou.co BUSINESS ID NO. 1 INSPECTION TIME NUMBER OF EMPLOYEES Section 1: Business Plan and InVentOry Program Routine [~[Combined [~} Joint Agency ~ Multi-Agency _Zo fo, vi Complaint OPERATION C V COMMENTS Appropriate permit on hand " Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials Verification of quantities 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 Re-inspection C=Compliance V--Violation Any hazardous waste on site?: [~} Yes ,.l~ No Explain: D,.J~%T~ ~ !gC,'''~-- .- '. : Questions regarding this inspection? Please call us at (661 ) 326-39'/9 White - Env. Svcs. Yellow - Station Copy' ' ~'"~" 'Pinl~~- Business Copy "~usih~ss Site ResPonsible ~Party Inspector: ~ ~',"0~-'$ ~CITY OF BAKERSFIELD FIRE DEPARTMENT ~]~ ~_~ ~]~ OFFICE OF ENVIRONMENTAL SERVICES ~,~. --~_~ .. "~W UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3ra Floor, Bakersfield, CA 93301 FACILITY NAME ~ f3,~/x~ O~4oc2~c,c.. C~rt:5-rc.- INSPECTION DATE Section 4: Hazardous Waste Generator Program EPA ID # [] Routine [] Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number (Phone: 916-324-1781 to obtain EPA ID #) Authorized for waste treatment and/or storage Reported release, fire, or explosion within 15 days of occurrence Established or maintains a contingency plan and training Hazardous waste accumulation time frames Containers in good condition and not leaking Containers are compatible with the hazardous waste Containers are kept closed when not in use Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided t,," ~' {9~ ~op.~jtO~ Conducts daily inspection of tanks Used oil not contaminated with other hazardous waste Proper management of lead acid batteries including labels Proper management of used oil filters Transports hazardous waste with completed manifest Sends manifest copies to DTSC Retains manifests for 3 years Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal C=Compliance V=Violation Office of Environmental'Services (661) 326-3979 Busine~r/Site Responsible Party White - Env. Sves. Pink - Business Copy