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Home My WebLink AboutBUSINESS PLAN 11/20/2003Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This hermit is issued for the following: [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials [3 Risk Management Program [] Hazardous Waste On-Site Treatment PERMIT ID # 015-021-002220 ACCURATE SMOG LOCATION 6600 c~ 93313 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: Expiration Date: Office ofEv~Services ~ ,~UL 2 3 ~o0~ Issue Date 'June 30. 2003 ITE DIAGRAM ~-~ FACILITY DIAGRAM u~essSrrl: l~I.~G~,Name: ~ ~Acn~rr~ l~I~Glt~, Business Address: ECTION_CHECKLIST SECTION 1-Business Plan and Inventory Program Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 PH0~?'---- No. of Employees ADDR~ -- ~ ~G~ ~C~;,,~ C~s *~ ~ ~ Business ID Number ..................... ' ne , Section 1: Business Planand InventorY program uti [] Combined [] ,Joint ^gency [] Multi-Agency [] Complaint [] Re-inspection V (' C=Compliance '~ OPERATION \ V=Violation ~/ [] APPROPRIATE PERMIT ON HAND 0 BUSINESS PLAN CON_TACT ,NFoR_MATIO__N_ ACCURATE ~~ORRECT' [] VISIBLE ADDRESS COMMENTS VERIFICATION OF LOCATION [] PROPER SEGREGATION OF MATERIAL [] VERIFICATION OF MSDS AVAILABILITYE [] VERIFICATION OF HAT MAT TRAINING [] VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES [] EMERGENCY PROCEDURES ADEQUATE [] CONTAINERS PROPERLY LABELED [] HOUSEKEEPING FIRE PROTECTION [] SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE?: [~ YES ~)~ No Inspector _ · Badge No. ~')%Z~J~'~~Wh~-Environmental Services Yellow-Station Copy Business Site Responsible Party Pink - Business Copy ACCURATE SMOG TEST ONLY Manager : Location: 6600 SCHIRRA CT B City : BAKERSFIELD CommCode: BAKERSFIELD STATION 09 EPA Numb: JUL 3 2OO3 BusPhone: Map : 123 Grid: 16D SIC Code: DunnBrad: eID: 015-021-002220 (661) 836-3080 CommHaz : Minimal FacUnits: 1 AOV:' Emergency Contact / Title GLORIA LAUB / OWNER Business Phone: (661) 836-3080x 24-Hour Phone : (661) 588-1467x Pager Phone : ( ) - x Emergency Contact / Title ALICIA JACKSON / ASSISTANT MGR Business Phone: (661) 836-3080x 24-Hour Phone : (661) 833-6498x Pager Phone : ( ) - x Hazmat Hazards: Contact : MailAddr: 6600 SCHIRRA CT B City : BAKERSFIELD Phone: (661) 836-3080x State: CA Zip : 93313 Owner GLORIA J LAUB Address : 801 SPIRIT LAKE DR City : BAKERSFIELD Phone: (661) 588-1467x State: CA Zip : 93312 Period : Preparer: Certif'd: ParcelNo: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: t, Do hereby' eertFv .*hat I have n'yp~pdnt'n=~' "' reviewed the attached hazardous materials manage- merit plan for and that it along with - {Name o~ ~usineso) any corrections constitute a complete and correct man- agement plan for my facility. Signature Date 1 06/16/2003 ACCURATE SMOG TEST ONLY ~ Hazmat Inventory -- MCP+DailyMax Order Hazmat Common Name... ZERO GRADE AIR UN 1002 iteID: 015-021-002220 By Facility Unit Fixed Containers at Site ISpocHaz[EPA HazardsI Frm I DailyMax IUnitlMCP G 400.00~FT3 Min 2 06/16/2003 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~lVllVl~ ~Vl~ / ~lVll ~ ~ ZERO GRADE AIR UN 1002 Days On Site 365 Location within this Facility Unit Map: Grid: 1 CYLINDER ON N WALL CAS# 1 CYLINDER IN CENTER OF BLDG ~ STATE -- TYPE PRESSURE Ambient Pure Gas TEMPERATURE Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container I 400.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 400.00 FT3 Daily Average 300.00 FT3 I%Wt. I 100.00 Air HAZARDOUS COMPONENTS CAS# 0 HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA/// I USDOT# Min Ag.Definedl: Ag. Defined5: Ag. Defined8: -- Ag. Definell MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined6: Ag. Definedg: Ag.Defined4: Ag. Defined7: Ag.Definel0: -3- 06/16/2003 ACCURATE SMOG TEST ONLY eID: 015-021-002220 Fast Format ~ Notif./Evacuation/Medical --Agency Notification WHEN CONNECTING CYLINDER WE DO A SOAK TEST. Overall Site 07/20/2001 -- Employee Notif./Evacuation VERBAL ORDER. 08/15/2001 Public Notif./Evacuation 07/20/2001 ALL EMERGENCY PHONE NUMBERS ARE LISTED AND ALL EXIT SIGNS ARE POSTED. Emergency Medical Plan MING AND ACHE MEDICAL CENTER. 07/20/2001 -4- 06/16/2003 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 Fast Format Mitigation/Prevent/Abatemt Release Prevention Overall Site 07/20/2001 SOAK TEST FOR LEAKS WHEN INSTALLED. VALVE IS SHUT OFF AT END OF EACH BUSINESS DAY. -- Release Containment USING PURE AIR, CALLED ZERO AIR. VENTED INTO THE ATMOSPHERE. 07/20/2001 -- Clean Up NONE. 07/20/2001 Other Resource Activation -5- 06/16/2003 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 Fast Format Site Emergency Factors Special Hazards Overall Site --Utility Shut-Offs A) GAS - OURSIDE E WALL OF BLDG B) ELECTRICAL - OUTSIDE W WALL OF BLDG C) WATER - OUT IN FRONT NEAR SIDEWALK D) SPECIAL - NONE E) LOCK BOX - NO 08/15/2001 Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - 2 FIRE EXTINGUISHERS. o8/ 5/2ool NEAREST FIRE HYDRANT - APPROXIMATELY 100 FT. Building Occupancy Level -6- 06/16/2003 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 Fast Format ~ Training Overall Site -- Employee Training 08/15/2001 WE HAVE 4 EMPLOYEES AT THIS FACILITY. NO MSDS SHEET FOR THE ZERO AIR, SUPPLIER IS MAILING FORM ON 8-10-01. BRIEF SUMMARY OF TRAINING PROGRAM: EACH TECH IS FAMILIAR WITH THE TANKING AND RETANKING PROCEDURE. Page 2 Held for Future Use Held for Future Use -7- 06/16/2003 + ACCURATE SMOG TEST ON NTER Manager : Location: 6600 SCHIRRA CT B City : BAKERSFIELD CommCode: BAKERSFIELD STATION 09 EPA Numb: == SiteID: 015-021-002220 + BusPhone: (661) 836-3080 Map : 123 CommHaz : Minimal Grid: 16D FacUnits: 1 AOV: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title GLORIA LAUB / OWNER ALICIA JACKSON / ASSISTANT MGR Business Phone: (661) 836-3080x Business Phone: (661) 836-3080x , 24-Hour Phone : (661) 588-1467x 24-Hour Phone : (661) 833-6498x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: I Contact : Phone: (661) 836-3080x MailAddr: 6600 SCHIRRA CT B State: CA City : BAKERSFIELD Zip : 93313 Owner GLORIA J LAUB Phone: (661) 588-1467x Address : 801,SPIRIT LAKE DR State: CA City : BAKERSFIELD Zip : 93312 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: Res: No Emergency Directives: += + += Hazmat Inventory One Unified List + +== Alphabetical Order Ail Materials at Site + ................................. + ....... + ..... + + + .... +- - -+ Hazmat Common Name... ISpecHazlEPA HazardsI Frm I DailyMax IUnitlMCPI ................ + ....... + ........... + ..... + .......... + .... +- - -+ ZERO GRADE AIR UN 1002 G 400.00 FT3 Min I,~'J-~;~ 3', L/~,u/~ Do hereby certify thru I have (Type or print name) reviewed the attached hazardous materials mar:age- ment plan for _and that it along with (Name of Business) any corrections constitute a complete and correct man- agement plan for my facility. o3/21/2oo2 + ACCURATE SMOG TEST ~NTER += Inventory Item 0001 - +== COMMON NAME / CHEMICAL NAME = ZERO GRADE AIR liN 1002 Location within this Facility Unit' 1 CYLINDER ON N WALL 1 CYLINDER IN CENTER OF BLDG SiteID: 015-021-002220 Facility Unit: Fixed Containers at Site Days On Site 365 Map: Grid: + ................ CAS# += STATE =+= TYPE ===+== PRESSURE ===+ TEMPERATURE ==+ .... CONTAINER TYPE ..... IGas IPure IAmbient IAmbient I PORT. PRESS. CYLINDER ~ + ~ ~ ~ + ==+ AMOUNTS AT THIS LOCATION I Daily Maximum 400.00 FT3 400.00 FT3 HAZARDOUS COMPONENTS Largest Container %Wt. I 100.00 Air Daily Average I 300.00 FT3 + 4 7===4 + TSecretINo No RS I Bi°HamI No ~ 7===4 + _-=+===+ ==+ 7===+ 7 HAZARD ASSESSMENTS ===~ Radioactive/Amount EPA Hazards I NFPA NO/ Curies / / / 7==: ~=====+ USDOT# MinMCP I 7 ~=====+ 2 03/21/2002 + ACCURATE SMOG TEST ONL NTER SiteID: 015-021-002220 + Fast Format + += Notif./Evacuation/Medical +== Agency Notification Overall Site + o7/2o/2ool + WHEN CONNECTING CYLINDER WE DO A SOAK TEST. +=== Employee Notif./Evacuation VERBAL ORDER. 08/15/2001 + + .... Public Notif./Evacuation 07/20/2001 + ALL EMERGENCY PHONE NUMBERS ARE LISTED AND ALL EXIT SIGNS ARE POSTED. Emergency Medical Plan ..... MING AND ACHE MEDICAL CENTER. o7/2o/2ool + -3- 03/21/2002 + ACCURATE SMOG TEST ONL NTER == SiteID: 015-021-002220 + Fast Format + += Mitigation/Prevent/Abatemt +== Release Prevention Overall Site + 07/20/2001 + SOAK TEST FOR LEAKS WHEN INSTALLED. VALVE IS SHUT OFF AT END OF EACH BUSINESS DAY. +=== Release Containment USING PURE AIR, CALLED ZERO AIR. VENTED INTO THE ATMOSPHERE. + o7/2o/2ool + =+ ..... Clean Up NONE. 07/20/2001 + ==+ Other Resource Activation _--_--+ 4 03/21/2002 + ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 + Fast Format + += Site Emergency Factors +== Special Hazards Overall Site + =+ +=== Utility Shut-Offs 08/15/2001 + A) GAS - OURSIDE E WALL OF BLDG B) ELEC,TRICAL - OUTSIDE W WALL OF BLDG C) WATER - OUT IN FRONT NEAR SIDEWALK D) SPECIAL - NONE E) LOCK BOX NO ..... Fire Protec./Avail. Water 08/15/2001 + PRIVATE FIRE PROTECTION - 2 FIRE EXTINGUISHERS. NEAREST FIRE HYDPJkNT - APPROXIMATELY 100 FT. + Building Occupancy Level - -5- 03/21/2002 + ACCURATE SMOG TEST ONLY CENTER += SiteID: 015-021-002220 + = Fast Format + += Training Overall Site + +== Employee Training 08/15/2001 + WE HAVE 4 EMPLOYEES AT THIS FACILITY. NO MSDS SHEET FOR THE ZERO AIR, SUPPLIER IS MAILING FORM ON 8-10-01. BRIEF SUMMARY OF TRAINING PROGRAM: EACH TECH IS FAMILIAR WITH THE TANKING AND RETANKING PROCEDURE. +=== Page 2 + .... Held for Future Use Held for Future Use - -6- 03/21/2002 ACCURATE SMOG TEST ONLY CENTER Manager : Location: 6600 SCHIRRA CT B City : BAKERSFIELD CommCode: BAKERSFIELD STATION 09 EPA Numb: SiteID: 015-021-002220 BusPhone: (661) 836-3080 Map : 123 CommHaz : Minimal Grid: 16D FacUnits: 1 AOV: SIC Code: DunnBrad: Emergency Contact GLORIA LAUB Business Phone: 24-Hour Phone : Pager Phone : / Title / OWNER (661) 836-3080x (661) 588-1467x ( ) - x Emergency Contact / Title ALICIA JACKSON / ASSISTANT MGR Business Phone: (661) 836-3080x 24-Hour Phone : '(661) 833-6498x Pager Phone : ( ) - x Hazmat Hazards: Contact : ~_ Mai%Addr: 6600 SCHIRRA CT B City : BAKERSFIELD Phone: (661) 836-3080x State: CA Zip : 93313 Owner GLORIA J LAUB Address : 801 SPIRIT LAKE DR City : BAKERSFIELD Phone: (661) 588-1467x State: CA Zip : 93312 Period : to TotalASTs: = Preparer: TotalUSTs: = Certif'd: RSs: No Emergency Directives: /j~p~_~ 6L44~O_~)~t " ' . Gal Gal = Hazmat Inventory --Alphabetical Order Hazmat Common Name... ZERO GRADE AIR UN 1002 ISpecHazI One Unified List Ail Materials at Site EPA Hazardsl Frm ] DailyMax IUnit MOP G 400.00 FT3 Min I, ~'~o/e/~ J_~c~ ~ Do hereby certify that ~ h~vo reviewed the a~ached h~rdous m~te~l~ m~na~e~ ment plan for~and that it aion~ with any corrections ~nstitute a complete and correct man. agement plan for my facili~, 07/20/2001 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 = Inventory Item 0001 Facility Unit: Fixed Containers at Site ~JtJtvuvtt;J.%l £~IZ~tvtJ~ / [Ji'lJ:StV!.L ~ ~vl~ ZERO G~E AIR ~ 1002 Days On Site 365 Location within this Facility Unit Map: Grid: ~ERE E~CTLY IS IS LOCATED???????? i~ ~'~~ ~~1. CAS~ sTATE ~ TYPE Gas [Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container 400.00 FT3 AMOUNTS AT THIS LOCATION Daily Maximum 400.00 FT3 Daily Average 300.00 FT3 %Wt. I 100.00 Air HAZARDOUS COMPONENTS CAS# TSecret No J oRSJBiOHaz N No HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies NFPA /// JUSDOT# Min -2- 07/20/2001 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 Fast Format ~ Notif./Evacuation/Medical --Agency Notification WHEN CONNECTING CYLINDER WE DO A SOAK TEST. Overall Site 07/20/2001 Employee Notif./Evacuation HOW ARE YOU GOING TO NOTIFY YOUR EMPLOYEES OF AN EMERGENCY IN THE SO THAT THEY CAN EVACUATE??????????????? 07/20/2001 BUILDING -- Public Notif./Evacuation 07/20/2001 ALL EMERGENCY PHONE NUMBERS ARE LISTED AND ALL EXIT SIGNS ARE POSTED. Emergency Medical Plan MING ANDACHE MEDICAL CENTER. 07/20/2001 3 07/20/2001 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 Fast Format ~ Mitigation/Prevent/Abatemt --=.Release Prevention Overall Site 07/20/2001 SOAK TEST FOR LEAKS WHEN INSTALLED. VALVE IS SHUT OFF AT END OF EACH BUSINESS DAY. Release Containment USING PURE AIR, CALLED ZERO AIR. VENTED INTO THE ATMOSPHERE. 07/20/2001 -- Clean Up NONE. 07/20/2001 Other Resource Activation -4- 07/20/2001 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 Fast Format Site Emergency Factors Special Hazards Overall Site --Utility Shut-Offs GIVE THE LOCATION OF THE SHUT OFF POINTS NOT THE NAME OF SUPPLIER. A) GAS - f~.tk~'DlO~. ~___~9..~7' '~d/~ZL ~?~ ~t;LDIH~- C) WATER - O~(~ ~ ~ ~,~ ~fm~ ~;~ ~~ D) SPECI~- ~U~ E) LOCK BOX - ~~ 07/20/2001 -- Water__-~____- _ Fire Protec./Avail. PRIVATE FIRE PROTECTION -~IRE.. EXTINGUISHE~OR 07/20/2001 A SPRINKLERED BUILDING) NEAREST FIRE HYDRANT - GIVE THE LOCATION???????????? Building Occupancy Level -5- 07/20/2001 ACCURATE SMOG TEST ONLY CENTER SiteID: 015-021-002220 Fast Format Training -- Employee Training Overall Site 07/20/2001 WE HAVE 4 EMPLOYEES AT THIS FACILITY. DO YOU HAVE AN MSDS SHEET FOR THE ZERO AIR, IF NOT YOU NEED TO OBTAIN ONE AND KEEP IT ON FILE. ~<"~-,/~' BRIEF SUMMARY OF TRAINING PROGRAM: EACH TECH IS FAMILIAR WITH THE TANKING AND RETANKING PROCEDURE. -- Page 2 --Held for Future Use Held for Future Use 6 07/20/2001 CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: 1. To avoid further action, return this form within 30 days of receipt. 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. 5. You may also attach Business Owner / Operator Form and Chemical Description Form(s) to the fi'ont of this plan instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA LOCATION: CITY: PRIMARY STATE: ZIP: ~S~/3PHONE: ~'36 ---~O ~ ow m MAILING ADDRESS: ~61 g~e,~ /_.,~XZ~__ EMERGENCY NOTIFICATION PHONE: I~£~z~rz-r-~ CONTACT TITLE BUS. PHONE 24 HR. PHONE .5--~-1~-~ 7 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II. 1: DISCOVERY AND NOTIFICATIONS Ao LEAK DETECTION AND MONITORING PROCEDURES: Bo EMPLOYEE AND AGENCY NOTIFICATION: Co EN'V/RONMENTAL RESPONSE MANAGEMENT: DJ EMERGENCY MEDICAL PLAN: HA~I~ARDOUS MATERIALS MANAGEMENT PLAN SECTION II.2: RELEASE RESPONSE PLAN ' A. HAZARD ASSESSMENT AND PREVENTION MEASURES: B. RELEASE CONTAINMENT AND/OR MITIGATION: Co CLEAN-UP AND RECOVERY PROCEDURES: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL WA rU:' SPECIAL: LOCK BOX: YES(~ IF YES, LOCATION: PRIVATE FIRE PROTECTION/WATER AVAILABILITY he PRIVATE FIRE PROTECTION: WATER AVAILABILITY (FIRE HYDRANT): 3 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING NUMBER OF EMPLOYEES: L1L MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: CERTIFICATION I, ~---~/,~ ,_7-, ]__~t~/~ CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFU_,L MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATIQN CONSTITUTES PERJURY. ~NJ~A_~~'- ~~ ~-- ~ -~9/DATE HAZ MAT MNOMNT PLAN & INSTRUC 4 ,, .i~,.: a s s ~ OFt~E OF ENVIRONMENTAL ~RVICES ~-'-F}~7 ~ 1715 Chester Ave., CA 93301 (661) 326-3979 ., BUSINESS OWNER / OPERATOR IDENTIFICATION FACILITY INFORMATION Page 0~' I. FACILITY IDENTIFICATION FACILITY ID # I t ~ Year Beginning ,oo Year Ending BUSINESS NAME (Same a~s FACILITY~NAME or DBA- Doing Business As) 3 BUSINESS PHONE SITE AODRESS ~ ~ OO ~'~f~ O~ 5~ ~ DUN & ~ SIC CODE 8~DSTREET (4 Digit g) OPERATOR NAME lo9 OPERATOR PHONE II. OWNER INFORMATION OWNER NAME ~--~-LE(~ //:}- T L.-FYLA~' ,,, OWNERPHONE OWNER MAILING T 114 i STATE~¢,~ 115 ZiP III. ENVIRONMENTAL CONTACT CONTACT NAME CONTACT MAILING ADDRESS CONTACTPHONE .e 119 CITY 12o ' STATE 12~ ZIP -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- BUSINESS PHONE ~--_~ ~ --~O ~ (~ ,26 ! BUSINESS PHONE ........... ' ................................................................. ,;;"~ ';~:.;,~;',;.0;~ ........ 24-HO.UR., H.? .N..E_.... _c~.~.~.~_. :.L.~ b_~ ........................... F .................................................................................. PAGER # ,. 128 PAGER # V. CERTIFICATION Certification: Based on my 'inquiry of those individuals responsible for obtaining the inl'ormation, I certify under penalty of law that I have personally examined and am fan,},).!iar with the informa%~ .... ;~--;'.'.ed in this inventory a,~-' ~elieve the information Is true, accurate, and complete, ............ :,;. ........ !.. . . ........... :.:... NAMES OF-OWNER/OPEI~ATgR (pdnt) ~3~ TITLE OF OWNEPJOPERATOR 3 IPCF (7/g9) S:~CUPAFORMS\OES2730.TV4.wpd ness Owner/Operator Identific~ Please ~u0m~I the Business A¢IfvdJeS page. Ihe Business Owner/O~erator IdenlJficalJon page IDES Fomq 2730), a~d Ha,.'ar(~au$ Materials - Chemicat Oesc~p~ion aages (DES Form 273 I) for all hazardous materials inventory submissions. For the inventory to be considered ~h,s page must be s~gned by (he appropriate individual. ',IDle: ~e numbenng of the ~nslnJctions follows ~he data element numbers that are on the UPCF pages. These data element numbe~ are used jr electronmc su0mmsslon and are the same as ~e numi0enng used in 27 CCR. Appendix C. the Business Section of the Umfied Program Data Dictionary.) Please number ,~11 pages o1' your suOmlltal. Th~s helps your CUPA or AA, idenlJb/whether the submittal is complete and it' any gages are separated. 1. FACILITY ID NUMBER - This number is assigned by the CUPA or A.A. This is ~e unique number which identities yOur t'acJlil't. 3. BUSINESS NAME - Enter the full legal name of the business. 100. BEGINNING bATE - Enter the beginning year and date o1' the report. (YYYYMMOO) 101. ENDING DATE · Enter the ending year and date of the report. (YYYYMMDO) 102. BUSINESS PHONE - Enler the phone number, area code first, and any extension. 103, BUSINESS SITE ADDRESS - Enter the street address where the facility is located. No post office box numbers are allowed. This information must provide a means ~o geographically locate the facility. 104. CITY - Enter the city or unincorporated area in which busine~s site is located. 105. ZIP COOE- Enter the zip code of business site. The extra 4 digit zip may also be added. 106. OUN& BRADSTREET - Enter the Oun& Bradslreet number for the facility. The Dun & Bradstreet number may be obtained by calling (610) 882-7748 or by Intemet. 107. SIC COOE- Enter the pdmary Standard Indust,dal Classification Code number for pdma~/business activity. NOTE: If code is more than 4 digits, report only the first four. 108. COUNTY - Enter the county in which the business site is located. 109. BUSINESS OPERATOR NAME - Enter the name of the business operator. 110. BUSINESS OPERATOR PHONE - Enter business operator phone number, if different from business phone, area code first, and any extension." 111. OWNER NAME - Enter name of business owner, if different from business operator. 112. OWNER PHONE - Enter the business owneCs phone number if different from business phone, area code first, and any extension, 113. OWNER MAILING ADDRESS - Enter the owner's mailing address if different from business site address. 114. OWNER CITY - Enter the name of the city for the owner's mailing address. 115. OWNER STATE - Enter the 2 character state abbreviation for the owner's mailing address. 116. OWNER ZIP CODE - Enter the zip code i'or l~e owner~ address. The extra 4 digit zip may also be added. 117. ENVIRONMENTAL CONTACT NAME - Enter the name of the person, if different from the Business Owner or Operator, who receives all environmental correspondence and will respond to enforcement activity. 118. CONTACT PHONE - Enter the phone numbs, if different from Owner or Operator, at which the environmental contact can be contacted, ' area code first, and any extension. 119. CONTACT MAILING ADDRESS - Enter the mailing address where all environmental contact correspondence should be sent. if different from the site address. ~ 20. CITY - Enter the name of the dry for the environmental contact=s mailing address. 121. STATE - Enter the 2 character state abbrevia~n for the envfronmental contact~ mailing address. 122. ZIP CODE - Enter the z. Jp code for the environmental contact=s mailing address. The ex, ira 4 digit zip may also be added. 123. PRIMARY EMERGENCY CONTACT NAME - Enter the name of a representative that. can be contacted in case of an emergency invoMng hazardous materials at the business site. The contact shall have FULL fadlity access, site familiarity, and authority to make decisions for the business regarding inddent milJgalJon. 124. TITLE - Enter the title of the primary emergency contact. 125. BUSINESS PHONE - Enter the business number for the pdmary emergency contact, area code first, and any extensions. 126. 24-HOUR PHONE - Enter a 24-hour phone number for the pdmary emergency contact. The 24-hour phone numbe~: must be one which is answered 24 hours a day. If it is not the contacts home phone number, Ihen the service answering the phone must be able to immediately contact the indMdual stated above. 127. PAGER NUMBER- Enter the pager number fo~ the pdmary emergency contact, if available. 128. SECONDARY EMERGENCY CONTACT NAME - Enter Ihe name of a secondary representative Ihat can be contacted in the event that ti-~e primary emergency contact is not available. The contact shall have FULL fadlity access, site familiarity, and authority to make decisions for the business regarding incident mitigation. 129. TITLE - Enter the title of the secondary emergency contact. 130. BUSINESS PHONE - Enter the business telephone number for the secondary emergency contact, area code first, and any extensio~i · 131. 24-HOUR PHONE - Enter a 24-hour phone number i'or the secondary emergency contact. The 24 hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individual stated above.. 132. PAGER NUMBER - Enter the pager number for the secondary emergency contact, if available. 133. ADDITIONAL LOCALLY COLLECTED INFORMATION - This space may be used for CUPAs or AAs to collect any additional information necessary to meet tho requirements of their indMdual programs. Contact your local agency for guidance. 134. DATE - Enter the date that the document was signed. (YYYYMMDD) 135. NAt,,IE OF DOCUMENT PREPARER - Enter the full name of the person who prepared the inventory submittal informalion. 136. NAME OF SIGNER - En~r the full pflnted name of the person signing Ihe page. The signer certifies to a familiarity with the information submitted and that based on the signer=s inquiry of those individuals responsible for obtaining the information, all the information submitted is true, accurate and complete. SIGNATURE OF OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE - The Business Owner/Operator, or ol"flcially designated representative of the OwnedOperator. shql sign in the space provided. This signature certifies that the signer is familiar with the information submitted and that b3.,;,~.J .:~' !ho signer=<J inquiry of those individuals responsible for obtaining the information il is the signer=s belief that the submilted informalion is true, accurate and complete. 137. TITLE OF SIGNER - Enter the title of the person signing the page. OFfiCE OF ENVIRONMENTAL ICES 1715 Chester Ave., CA 93301 (661)326-3979 ~ NEW ~2] ADD l--] DELETE ~ REVlSE 200 I. FACILI~ INFORMATION CHEMICAL LOCATION 201 CHEMI~L LO~TION CONFIDENTIAL (EPC~) ~ Y~ ~ No 202 J II. CHEMICAL INFORMATION ............................................................................................................................... ~o~- --f~bi~-C'&~f ................. CHEMICAL NAME E] Yes [] No If Subject to EPCRA, refer to instructions 207 COMMON NAME:: EHS° [] Yes r~ No 208 CAS # 'FIRE CODE HAZARD CLASSES (Complete if requested by '1o~-al 209 . 210 ]:Y~ ................ E] p PURE ~m MIXTURE [] w WASTE 211 ; RADIOACTIVE I['-Jyes I-]No 212 CURIES 2~3 PHYSICAL STATE [] s SOLID Eli LIQUID .,~g GAS 214' LARGEST CONTAINER 215 FED HAZARD CATEGORIES [] 1 FIRE t r'"'~:k all that apply) E] 2 REACTIVE ~$ PRESSURE RELEASE [] 4 ACUTE HEALTH [] S CHRONIC HEALTH 216 ALWASTE 217 ; MAXIMUM [.~ 218 i AVERAGE 36 219 STATE WASTE COOE 220 .... ,.)UNT i DAILY AMOUNT 0 0 DAILY AMOUNT O UNITS' [] ga GAL [] ~ CU FT [] Ih LBS [] tn TONS 221 DAYS ON SITE 222 ° If EHS. amount must be in lbs. STORAGE CONTAINER [] a ABOVEGROUND TANK (Check all that apply) E]b UNDERGROUND TANK [] c TANK INSIDE BUILDING [] d STEEL ORUM STORAGE PRESSURE AMBIENT STORAGE TEMPERATURE AMBIENT [] e PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTTLE E] q RAIL CAR 223 [] t CAN [] j BAG [] n ~LASTIC 8OTTLE [] r OTHER [] g CARBOY [] k BOX [] o TOTE BIN [] h SILO ~1 CYLINOER [] p TANK WAGON ( [] aa ABOVE.AMBIENT [] ba BELOW AMBIENT 224 [] aa ABOVE AMBIENT [] ba BELOWAMBIENT [] c CRYOGENIC 225 %WT HAZARDOUS COMPONENT I EHS I CAS# 2 230 ' 231 ~ ~y~ ~No 232 : ............. L ............................................................. L ..................... L ................................... 3 234 ~ 235t' ~Y~ ~No 236 ~ : _ ...... ~ ......................................................................................................... ~ ....................; ................................. 4 2:38I 239 ~y ~ [ 241 .................................................................................................................. ......... ................ 5 ~ 242 ~ 243 ~ ~y~ ~No 244 ~ 245 ._[ ................... J ......................................................................... ~ .............................. o~ TI ifa TH R NTATIV -~ I ~T RE DATE 246 JPCF (7/99) S:\CUPAFORMS\OES273 l'.TV4.wpd Hazardous Materials Inventory - Chemical Description Jre ,~$etl 'or .H~'.'ctro~'uc 'tub~n~$s~on Jnd are Ihe Sar'ne ,.is :~e numOenng used ,n ~7 CCR. Appendix C. ~e Bus,ness Secbon of the Un~ed Pr~ram Dale Oicl~ona~.) Please num0er ]~J 3aq~s o(yau~ ~uo~ml(al. rh~s ~elps your CCPA ot ~ ~denb(y w~e{~er ~he su0m~(lal ,s ~mplele and ~f any pages a~e sepa~a(ed. I. FACILITY I~ NUMBER - Th~s number ~s 3ss~gn~ 3y (~e CUPA Or ~. Th~s ~S ~e un~e numar w~c~ ~denl~es your ~acdiW, 3. BUSINESS NAME - Enter ~e tull I~al name of '.~e Ousiness. 200. AOCIOELETE/REVISE - Indicia ~ the malarial ~S ~mg add~ [o [~e ~nven~o~. delet~ from ~be ~nvento~, or if the info.alton previously subm~ed is ~ng NOTE; You may c~oose (o leave ~h~s 01an~ ,f you resu0mR your entire invento~ annually. 201. CHEMICAL LOCATION * Enler t~e Du~lO~ng or ouls~d~ adjacent area where the hazardous material ~3 handle. A chem~l that ~3 stored al Ihe same pressure a~ ~emperature. in multiple lo. lions w~lhm a =u~lding. ~n be reposed on a single page. NOTE: This info~ation is not subject ~o public disclosure pumuant ID HSC ~25506. 202. CHEMICAL LOCATION CONFIOENT~AL. EPC~ · Ail ~usine~es which are subject ~o t~e Emergency Planning and Communi~ Righ( (o Know Act (EPC~) mus~ check 'Yes* ~o ~eep cheracol location m~o~ation ~n~den{ial. I~ the business d~s nol wis~ (o keep chemi~l l~{Jon information con~dential check 'NO'. 203. MAP NUMBER - If a map ~s included, enter the numar plebe map on which the ~[ion o~ the h~ardous ma{ariel is sho~. 2~. GRI~ ,~tUMBER. If 9nd c~rdinates a~e used, ~n~er ~he 9nd c~rdinates of the map [ha~ corres~nd [o the l~ation Pi the hazardous material. If appli~ble, multiple coordinates can be iist~. 205. CHEMICAL NAME. Enler the proper chemical name as~ial~ ~lh the Chemi~l Abs~act Se~e (CAS) number of the hazardous material. This sh~M be the International Union of Pure and Appli~ Chem~s~ (IUPAC) ~me found on the Material Safe~ Data Sheet (MSDS). NOTE: If the ~emi~l is a mixture, ~mplete this field; complete ~e 'COMMON NAME* ~eM inst~d. 2~. T~GE SECRET - Check ~es' ~ the ~nformal~n ~n ~ ~ is ~a~ a I~e sepal ~ ~o' ~ is noL S~te r~uirement: If yes. and business is no{ sub~ to EPC~ di~ute of the ~s~ ~e s~ret infomart ~ ~und by HSC $25511. .. F~eml requirement: If yes, and busings is ~ub~ ~ EPC~. d~sum 0f lhe d~l~ T~ ~et inf~a~ is ~und by 40 CFR and the must submit a 'Su~ntia~n to A~m~ny C~ ofT~e S~ f~ (40 CFR ~.27) to USEPA. 207. COMMON N~E - Enter ~he ~m~ name or ~de n~e of ~e h~ar~ material ~ m~um ~ini~ a haza~o~ mate~l. 208, EHS - Ch~k ~es' if lheh~ard~s malarial i3 an ~e~ Ha~o~ Subs~ (EHS). ~ ~n~ ~ 40 CFR, Pa~ 3~, Ap~ndix A. If the male~J is a ~ntaining an EHS, leave [his section blank and ~mplete the s~n on ~zar~us ~m~nents beDw. 209. CAS ~ - Enter the Chemical Abstra~ Se~ice (C~) numar f~ ~e h~ar~us material. For m~res, enter the CAS numar of [he m~ture if it has b~n a~ a numar dis{inct from its ~mp~enffi. ~hemix~rehas~Snumber~eave[his~umnb~nkandmp~he~Snumbers~f~heind~dua~h~a~s ~mponen~ Jn the appropriate s~tion bel~. 21~ F~RE C~DE H~RD C~SSEs - Fire C~e H~a~d c~es descd~ t~ ~m~ res~ndets the ~ and ~eve~ ~f h~a~us ma~e~a~s which a business hand~es~ Th~ in~o~a~ion shall only be provided ii ~he I~1 ~re c~ief deems i~ ne~a~ and requests ~e CUPA or ~ to ~ll~t iL A list pi the hazard classes and ins~ on ~ow ~o determine whi~ class a ma(ariel ~alls u~er are incl~ in the ap~ndi~s o~ ~cle 80 of lhe Un~o~ Fire C~e. If a malarial has mo~e ~an app~i~ble hazard class, i~lude all. ~n~ CUPA or ~ f~ guidan~. 211'. H~RDOUS MATERI~ ~PE - Ch~ the one ~x that ~s[ dead.s ~e ~e of h~ardous ma~e~l: pure, m~ure 0r ~ste. If ~ste material, ~k only t~t I~ mixture or waste, complete h~ardous ~nenffi s~on. 212. ~GiOACTIVE. Ch~k 'Yes' if ~e ~za~s ma(e~ b md~e or 'No' if i( is 213. CURIES - If ~e hazardous male~al is rad~ctNe. ~ th~ ~ to re~ ~e a~i~ in ~Hes. Y~ may use up to nine ~ wi~ a floating d~imal ~int to re~ ac~vity in curies. 214. PHYSICAL STATE - C~ ~e one ~x ~at b~t d~s ~ s~te in ~ ~ h~rd~s mate~l is handle: solid. I~u~ ~ gas. - 215. ~GEST CONTAINER - Enlet ~e total ~paci~ o~ the ~est ~ntai~r in whi~ ~e mate~l ~ st~. . 216. FEDE~L H~RD CATEGORIES - C~ck all ~t~ ~al d~ ~e physJ~J and h~J~ ~s a~t~ ~ ~e ~za~ous malarial. PHYSICAL ~RDS H~L~ ~RDS Fire: Flammable Liquids and ~l~s. Comb~s~ble L~u~s, ~ph~. O~d~em Acute Heal~ (ImmOlate): H~h~ Tox~, To~c. I~nts, Sensit~em, ~s~, Reactive: Unstable Reactive. O~an~ Perox~es. Water R~ve. ~d~Ne other hazar~ ~em~ls ~th an ~veme effect ~th sho~ {erin ex.ute Pressure Release: Explos~es. Compresse~ Gases, B~sting Agents Chronic Heallh (Delayed): Ca~e~. o~er hazardous chemi~ls ~ an adveme erst with ~ te~ ex.sure 217. AVENGE DAILY AMOUNT - Cal~late ~e average dai~ a~unt of ~e h~ar~ ~le~al or m~ture ~ntaining a h~ar~us material, in ea~ buildi~ ~ ~ja~nU outside area. Calculalions shall be ~s~ on ~e p~ious yeaffs inven~ of mate~al re~ ~ ~ ~ge. To~l all daily amoun~ and d~ide by ~ numar of da~ {he chemi~l wilt ~ on site. if {his is a ~tefial ~a~ ~s not pr~sly been present at ~is ~tion. ~he am~nt shall ~ Ihe average ~i~ a~un{ y~ proj~{ to be on hand duH~ the ~urse of ~e year. Th~ am~nt sh~ ~ ~nsistent ~ ~e uni~ m~ed in ~x 221 and should not ex~ ~at of m~imum dai~ amount. 218. ~IMUM DAILY AMOU~ - Enter ~e maximum am~nt of each h~ar~us material or mixture ~i~ a hazard.s material, which is ~ndled in a buiMi~ ~ adjacen~outside area at any one time over ~e ~me of t~ year. This am~nt must ~n~in al a minimum ~st years invento~ of ~e ~te~l repo~ ~ page. with the re~e~ion of addit~ns, delete, ~s p~ed f~ ~e currenl year. ~ a~nt shou~ ~ ~lent wJ~ ~e unJ~ re.fled in ~ 219. ~NUAL WASTE ~OUNT - If the ~za~s malarial ~ing i~ento~ is a ~ste. provue an asante of ~e annual a~un[ handle. 220. STATE WASTE CODE - If the hazardous material is a ~ste, enter ~e appr~r~ie California 3~il haza~ous waste ~e as listed on ~e ~ck of [he Unifo~ Hazardous Waste ManifesL 221. UNITS - Check the unit of measure that is mosl approp~ate for the ~lefial ~i~ repo~ on this p~e: gallons, pounds, ~b~ feet or tons. NOTE: If the ~[e~l federally defined Extremely Hazardous Substan~ (EHS), all a~unts must ~,re~ in ~unds. If material is a m~ure ~nlaining an EHS, repo~ ~e units the material is sto~ed in (gallons, ~unds, cub~ ~L or 222. OAYS ON SITE - List the total number o~ days dunng the ~ar ~at the material is on site. 223. STOOGE CONTAINER - Check all ~xes tha~ des~ ~e type of storage ~ntainers in which ~e haza~ous material is stored. NOTE; I~ appropriate, you may 224. STOOGE PRESSURE - Check the one box that ~sl des~bes the pressure at which the hazardous material is stored. 225. STOOGE TEMPE~TURE. Check the one box ~ha[ ~st dead.s the temperature a~ which (he haza~ous ma{edal is s~(ed. 226. H~RDOUS COMPONENTS 1-5 (% BY WEIGHT) - Enter the ~r~n~ge we~ht o~ the hazardou~ '~mponent in a mixture. If a range o~ percentages is available, ~epo~ ~he h~hest percentage in [hat range. (Re~ ~ ~m~nen~ 2 through c ;~ ~,3.2~, , ' and 242.) 227. H~ROOUS COMPONENTS !'5 NAME - When ~epo~i~ a h~ardous mateHal ~at ~3 a mixture, list up to ~ve chemical ~mes of hazardous componenls in that mixture by percen~ weight (re[et Io MSOS or, in the ~se o~ trade secret, reler to manufactu~e~). All hazardous c~nents in the mix,ute present at greater {hen 1% by w~ [~hl i~ non~arCjn~enJc, or 0.~% by ~ighl [f carcin~en~, should be repo~. If more than ~ve h~a~dous ~mponents are present above lhese percentages, you may attach an additional sheet of paper to caplure the required in~ormalion. ~en re~ing waste mix[ufos, mineral and chemlc~! should be listed. (Repo~ for componenls 2 through 5 in 231. 235, 239. and 243.) 228. H~ROOUS COMPONENTS ~.5 EHS . Check 'Yes' i{ {he ~mponen( of {he mlxiure ~s conside~ an Extremely Hazar~us Substance as defined in 40 CFR, Pa~ 355, or "No" itit is not. (Repo~/o~ com~nenls 2 Ihrough 5 in 232, 236, 240, and 244.) 229, tI~AROOUS COMPONENTS 1-5 CAS - Lisl ~he Chemicsl Abslra~ Se~ice (CAS) numbers as ~ela(ed to the hazardous ~m~nents in the mixture. (Repeat tot 2-5.) 246. LOCALLY COLLECTED INFORMATION - This space may be us~ by lhe CUPA o~ ~ to collect any addilional ~nfo~matJon necessa~ to meet [he requiremenls Pi Iheir · ndiwdual pr~rams. Contac~ (~e CUPA or ~ ~ot guidan~. LtPCF (h'99) 7 DES Fora) 273 i