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Home My WebLink AboutBUSINESS PLAN,~ I I I ~I (~ II I ,GOLDEN STATE EYE CENTER i~~ ~~ 1001 TOWER WAY S. #150 II ~ Per I. it Operil.te to Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This oermit is issued for the following: ItI Hazardous Materials Plan o Underground Storage of Hazardous Materials o Risk Management Program o Hazardous Waste On-Site Treatment Permit ID #:: 015-000-001307 GOLDEN STATE EYE CENTE LOCATION: 1001 TOWER WAY 150 Issued by: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Approved by: Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Expiration Date: Issue Date June 30, ,2003 Per it to Operil.te Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This permit is issued for the following: ":Hª~ardous Materials Plan round Storage of Hazardous Materials agement Program Waste 1001 PERMIT ID# 015-021.Q01307 GOLDEN STATE EYE CENTE LOCATION Issued by: ~ TOWER Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (805) 326-3979 FAX (805)326-0576 *~ ph Huey, ffiee of ental Servi es June 30, 2000 Approved by: Expiration Date: ~.I.. - -, r: .-'- À- --.. .. - . '-' .I.. .-o..u C".._.Yl FOR:vt 5 - \ .. ~ '. I I ¡ I· I·..· ~ORTñ SC~L~: BUSIXESS ~Å~E: /If: .50' GtJLlJEN S7fJTE EYE" t!.E"NTE"R D.\1"!:3 /~llae FACILITY ~~'!E: Ft\:CR: / :1F' / (CHE:a ONE) SIn: D IACiWI / FAC::trTY DIAC:t~'t I I I I L-:;¡7 =: nJ:" ò'{. 13 -wA-~R. ~~TOFF 6 ,~s ~ ., f.\1A.1"bJ:P "I=e Grur'\ ~ DRIVF....A-':! @ .-- - - - - - j '/ . ,-.., P B R A R i> is H K R Po ¡¿~ I W G- " E ~ w ® II> Y J ~-._----j : ~ - .. -I . . --'I I I I ® :. _ _ __ _ _ J ~ I ~ I.ÞUl "" an A ~ 'J ® t db ~" To ~OHAW~ \00 I -roUJ g~ lù f>.~ C.llA."~ TO W.G:J"" .q^'d Itt~, C!q,Je (.., <'~ :.;i,. 1f'¿. (V <.<.\ . I -- ~ 'AIi'¡; pf' ~~ )Ñ£,- ,",01 P~R~I~' 1=0 (;~PE'JJ' CS TRllCTlL eé --- ,- , ~rnspector's COllllen ts) : -oF:!CZAL CSE o~ty- i - SA - . ~ ~I . ';:).L. -.-.. co .~'- ... -.. .A. ~ :. I...J J.. --'~ C"._~..."l. ~ORTñ e ¡ I SC~LE: BUSIX£SS ~Å~£: /':¡S'',.pp,.. t;OLDeAJ S7RTt" ~t¡f: ~Ewr~}¿. CAT=:: 3 .!,;¿/ ¡PI? FACa¡¡y ~~\!E: FOR:vr 5 -- :-tï:CR: I :)7 I (CHE:CX ONE) SIn: CIAGWI FAC:trTY DrAG~~~ ~ I I I I (.~¡7 =: n~ .,." . FIR E' ÞI4.LL t ·B~LL \Þl O~~qe~ L ~E"R. Roo"" w S'TC. -w ¡; IE'/..AM F:)lAM u , 1\1 : £vAc .., ARGfI! E'.AM e)-AM )c E)..AM '--1' s I(~ LIC foJT S tt R' eR.!) "t I.u ~ IT"" ÞI 6 , . . S E5.i1 ~f'T1tiNr ¿_- OFr:IC.G Rl:C.oV.~:J ..., A-'1'I)I' Roo M 0 ~ Dt>ntf:'L. P " wo~~ T I' 8IAS''''~S ~oOM , "çp~~ C ~ ~ ' . L.. ¡>rcEP;"o~ ope~ATIN' R ROðt.-\ 0 W >P'Tn." Roo t.J\ 0 fD; No. S E'"1'Ule",~ ~L)t. ows o..''''ÞowS ':DoLlBu;; pANËl) e,. i í If' b'#.lbÇ ',t\! b~AwPR. rö ReeD ~ ENTR.~ EVAe. ~R¡-A. E'~lr Fo Qee\) ~ e NTR~ ~LEc.Te. 't:. GE"~,"eATO~ Inspec:o~'s Comments): -aF:¡C¡AL CS£ OXLY- 6b/o¿--~ 0":/;7'T~ 6Pé---- C¿;;--;.../"TC-<- /oo/7õw<?"'A:- L--v~ ..s-Od-é- /~~ # /JO? J:T~ø ~ - SA - /~ UNLFfED PROGRAM INSPECTION .CHECKLIST SECTION 1: Business Plan and Inventory Program • . ~~* Prevention Services B A e R s F _, n 900 Truxtun Ave., Suite 210 P~dr<E Bakersfield, CA 93301 aRrdN Tel.: (661) 326-3979 . Fax: (661) 872-2171 . . FACILITY NAME INSPECTION DATE INSPECTION TIME C.yy~ ADDRfE~SS ~.~/J , r ~r.~~ /vD~- WG~t. W ..~ ~7L/ PH~ON7E'7NO.Q` ~+~y c7~I~~/~% 1 NO OF EMPLOYEES /~~ FACILITY CONTACT L ~ BUSINESS ID NUMBER 15-021- `~i b Tb~ bN~ d / Lld' ROUTINE r _- -- Y .-: a _ ~d Section 1: Business Plan and Inventory Program ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V ~ C=Compliance- OPERATION V=Violation COMMENTS - ^ APPROPRIATE PERMIT ON HAND L td' ~ / L~1 ^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE ,~ ~/ L~ ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY C ~Y _ / L`J ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ~ , ,/ LET ^ VERIFICATION OF LOCATION f ~ ^ PROPER SEGREGATION OF MATERIAL ` ` - r L~' ^ VERIFICATION OF MSDS AVAILABILITY y L,d ^ VERIFICATION OF HAZ-MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~/ iCa' ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? EXPLAIN: QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 •~~ cT1~ d3 / J Inspector (Please Print) Fire Prevention / 1" In /Shift of Site/Station # Bu Hess Site / Responsi e ( lease Prin ^ YES ^ NO White -Prevention Services - Yellow- Station Copy Pink -Business Copy FD 2155 (Rev. 09105 7' GOLDEN STATE EYE CENTER BusPhone: Map 102 Grid: 34B SiteID: 015-021-001307 Manager MELISSA PERRYMAN Location: 1001 TOWER WY 150 City BAKERSFIELD CommCode: BFD STA 11 EPA Numb: SIC Code: DunnBrad: (661) 327-4499 CommHaz Low FacUnits: 1 AOV: Emergency Contact / Title Emergency Contact / Title RONALD L MORTON / PRESIDENT MELISSA PERRYMAN / OFFICE MANAGER Business Phone: (661) 327-4499x Business Phone: (661) 327-4499x 24-Hour Phone (661) 834-7555x 24-Hour Phone (661) 392-9534x Pager Phone (661) 900-7777x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth Contact MELISSA PERRYMAN Phone: (661) 327-4499x MailAddr: 1001 TOWER WY 150 State: CA City BAKERSFIELD Zip 93309 Owner RONALD L MORTON MD Phone: (661) 834-7555x Address 7700 SADDLEBACK DR State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT ~NT'D J U ~ ~. 8 ~~07 t3ased on m;: inatairv of those Inc~ividuais responsible ;cr obt,;rning the inform~atiorr, I certify under penalty of la ,sr that 1 have personally examined and am familiar with the information submitted and believe the information is tru e, accurate, and ,;~ ~mplete. f7ate -1- 07/11/2007 ,~ F GOLDEN STATE EYE CENTER ~ Hazmat Inventory ~ MCP+DailyMax Order = = SiteID: 015-021-001307 ~ By Facility Unit ~ Fixed Containers on Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP OXYGEN F P IH G 557.00 FT3 Low -2- 07/11/2007 -3- o~/ii/aoo~ F GOLDEN STATE EYE CENTER ~ Inventory Item 0002 COMMON NAME / CHEMICAL NAME OXYGEN Location within this Facility Unit SURGERY RM/RECOVERY RM/LOCKER RM STATE T TYPE PRESSURE _ Gas I Pure Above Ambient SiteID: 015-021-001307 ~ Facility Unit: Fixed Containers on Site ~ Days On Site 365 Map: Grid: CAS# 7782-44-7 TEMPERATURE CONTAINER TYPE Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Co557100rFT3 Daily 557100m FT3 I Daily 557r00e FT3 tl~~.yrc~vu~ Lvlnrvivl;lv~1~5 %Wt. RS CAS# 100.00 Oxygen, Compressed No 7782447 riHGAtCL 1-~55L~~51~11'~1V~1~5 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Low -4- 07/11/2007 F GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 11/29/2000 ~ CALL 911. Employee Notif./Evacuation 09/17/1992 NO EVACUATION NECESSARY FOR OXYGEN RELEASE. Public Notif./Evacuation 02/26/2007 N/A Emergency Medical Plan 11/29/2000 POTENTIAL EMERGENCIES AT THIS BUSINESS WOULD BE HANDLED BY PHYSICIAN OR REGISTERED NURSE. IF THEY WERE NOT AVAILABLE TRANSPORT TO MERCY HOSPITAL, 2215 TRUXTUN AVE, 327-3371. -5- 07/11/2007 F GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 11/29/2000 ~ ALL OXYGEN TANKS ARE HELD BY SUPPORT TRANSPORT CARRIERS OR ANCHORED TO THE WALL WITH CHAIN. Release Containment RELEASE OF OXYGEN NO CONTAINMENT NECESSARY. 11/29/2000 Clean Up 11/29/2000 RELEASE OF OXYGEN, NO CLEAN UP NECESSARY. GREATEST DANGER IS TANK FALLING WITH VALVE BREAKING INJURING PERSONNEL VIA RAPID MOVEMENT OF TANK FROM PRESSURE WITHIN. V1.11C 1_ iCCu7V U1 lLC 1-11.: 1..1 VGL l~l V11 -6- 07/11/2007 ,. ~. P GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ aNv~:iai na~,aLU~ Utility Shut-Offs 11/20/2006 A) GAS - E SIDE BLDG FRONT CRNR B) ELECTRICAL - E SIDE BLDG FRONT CRNR C) WATER - FRONT SIDEWALK MIDDLE E D) SPECIAL - NONE E) LOCK BOX - NO Fire Protec./Avail. Water 01/31/2007 PRIVATE FIRE PROTECTION - BLDG SPRINKLERS, EXTINGUISHERS, ALARM PULLS, EVACUATION MAPS, AND FIRE DRILLS ALL FOR FIRE PROTECTION. FIRE HYDRANT - BACK OF BLDG, ACROSS ST FRONT E, ACROSS ST FRONT W, AND STANDPIPE CONNECTION FOR SPRINKLERS FRONT E CRNR. Building Occupancy Level 3 PART-TIME EMPLOYEES AND 1 FULL-TIME EMPLOYEE 03/03/2006 -7- 07/11/2007 y' ;~ F GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 02/26/2007 ~ MATERIAL SAFETY DATA SHEETS ON FILE. BRIEF SUNIl~fARY OF TRAINING PROGRAM: QUARTERLY SAFETY MEETINGS WITH ALL PERSONNEL, DOCUMENTATION MAINTAINED. rayc ~ 17c1u 1V1 rul.uLC V5C nciu tvi rul.uiC UDC -8- 07/11/2007 s '% u GOLDEN STATE EYE CENTER BusPhone: Map 102 Grid: 34B SiteID: 015-021-001307 Manager MELISSA PERRYMAN Location: 1001 TOWER WY 150 City BAKERSFIELD CommCode: BFD STA 11 EPA Numb: SIC Code: DunnBrad: (661) 327-4499 CommHaz Low FacUnits: 1 AOV: Emergency Contact / Title Emergency Contact . / Title RONALD L MORTON / PRESIDENT MELISSA PERRYMAN / OFFICE MANAGER Business Phone: (661) 327-4499x Business Phone: (661) 327-4499x 24-Hour Phone (661) 834-7555x 24-Hour Phone (661) 392-9534x Pager Phone (661) 900-7777x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth Contact MELISSA PERRYMAN Phone: (661) 327-4499x MailAddr: 1001 TOWER WY 150 State: CA City : BAKERSFIELD Zip : 93309 Owner RONALD L MORTON MD Phone: (661) 834-7555x Address 7700 SADDLEBACK DR State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. 2 ~ c~ ~Dat ENTD ~" ~ B ~ 3 ~Q07 Si nature ~ -1- 01/31/2007 r. ~ GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers on Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP OXYGEN F P IH G 557.00 FT3 Low -2- 01/31/2007 -3- 01/31/2007 ih -f F GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ ~ Inventory Item 0002 Facility Unit: Fixed Containers on Site ~ COMMON NAME / CHEMICAL NAME ~ OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: SURGERY RM/RECOVERY RM/LOCKER RM CAS# 7782-44-7 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE = Gas TPure ~-Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 557.00 FT3 557.00 FT3 557.00 FT3 nt~~t~ttLVU~ ~c~inrvl~~lv~t~5 %Wt. RS CAS# 100.00 Oxygen, Compressed No 7782447 riHGHKL 1-~ 551'~5J1~1i51V-15 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Low -4- 01/31/2007 ~ti r, F GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 11/29/2000 ~ CALL 911. Employee Notif./Evacuation 09/17/1992 NO EVACUATION NECESSARY FOR OXYGEN RELEASE. ,~ ru.u11~. 1VV1.11. / ~vat=ua~.lvtr ~u~ v~.~ce~~ ~e~ o ~212~~ Emergency Medical Plan 11/29/2000 POTENTIAL EMERGENCIES AT THIS BUSINESS WOULD BE HANDLED BY PHYSICIAN OR REGISTERED NURSE. IF THEY WERE NOT AVAILABLE TRANSPORT TO MERCY HOSPITAL, 2215 TRUXTUN AVE, 327-3371. -5- 01/31/2007 z ~ F GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 11/29/2000 ~ ALL OXYGEN TANKS ARE HELD BY SUPPORT TRANSPORT CARRIERS OR ANCHORED TO THE WALL WITH CHAIN. Release Containment 11/29/2000 RELEASE OF OXYGEN NO CONTAINMENT NECESSARY. Clean Up 11/29/2000 RELEASE OF OXYGEN, NO CLEAN UP NECESSARY. GREATEST DANGER IS TANK FALLING WITH VALVE BREAKING INJURING PERSONNEL VIA RAPID MOVEMENT OF TANK FROM PRESSURE WITHIN. V1.11C 1. .RC~VUL I:C HC: l.1Vdl.1 Vi1 -6- 01/31/2007 zti -i F GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ aY~c:ldi nc«caius Utility Shut-Offs 11/20/2006 A) GAS - E SIDE BLDG FRONT CRNR B) ELECTRICAL - E SIDE BLDG FRONT CRNR C) WATER - FRONT SIDEWALK MIDDLE E D) SPECIAL - NONE E) LOCK BOX - NO Fire Protec./Avail. Water 01/31/2007 PRIVATE FIRE PROTECTION - BLDG SPRINKLERS, EXTINGUISHERS, ALARM PULLS, EVACUATION MAPS, AND FIRE DRILLS ALL FOR FIRE PROTECTION. FIRE HYDRANT - BACK OF BLDG, ACROSS ST FRONT E, ACROSS ST FRONT W, AND STANDPIPE CONNECTION FOR SPRINKLERS FRONT E CRNR. Building Occupancy Level 03/03/2006 3 PART-TIME EMPLOYEES AND 1 FULL-TIME EMPLOYEE -7- 01/31/2007 1 F GOLDEN STATE EYE CENTER SiteID: 015-021-001307 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 11/20/2006 ~ MATERIAL SAFETY DATA SHEETS ON FILE. u~,~ ~- ~a.~l' S l~ a-1'~.. Ctl,.,l ~ ~ Y~-~ ,~ 1 ~!-YY~QV 1 ~-ft 11Y~ rage ~ atclu iVL rutr utc V.7C nclu iVt rul.ulC VAC -8- 01/31/2007 :.. + GOLDEN STATE EYE CENTER =____________________________ SiteID: 015-021-001307 + Manager BusPhone: (661) 327-4499 Location: 1001 TOWER WAY 150 Map 102 CommHaz Low City BAKERSFIELD Grid: 34B FacUnits: 1 AOV: CommCode: BFD STA 11 SIC Code: EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title RONALD L MORTON / PRESIDENT MELISSA PERRYMAN / OFFICE MANAGER Business Phone: (661) 327-4499x Business Phone: (661) 327-4499x 24-Hour Phone (661) 834-7555x 24-Hour Phone (661) 392-9534x Pager Phone (661) 900-7777x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth Contact Phone: (661) 327-4499x MailAddr: 1001 TOWER WAY 150 State: CA City BAKERSFIELD Zip 93309 Owner RONALD L MORTON MD Phone: (661) 834-7555x Address 7700 SADDLEBACK DR State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: ~ PROG A - HAZMAT ~J11 +~ IYI~~ ~ +~ ~~~6 Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law 4hat I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. i t r ~ ~ ` S g a u e Date -1- 03/03/2006 ._/~a.y.,nor'"]vti_.........-..'r-..w~......r.~-..-.,...-+ .... .....:......r~,.r ....r..-t.... is rnt~~.._..-.+~i•.+..' ... _. .: ~!'. ^.y_..: ~._.~rY ... ~ 1 Y 'err .I .. r.~. n. r.... ...r.+-_. 'i.. ~/ v.. -. INSPECTION RECORD ENT'D JAN ~.1 Bakersfield Fire Dept. 1715 Chester Ave. Bakersf field, CA 93301 ~r<e J nsp,~~~-T~n ~~ DATE: FACILITY ADDRESS: ~ ZIP: FE FACILITY NAME: ~/'~ ~ ~ ~ ~" ~-~ ~.~5^ ~° ~ l O 1 ti° -~ ' _ MANAGER NAME: 0. ~ P L... ~ ~ (' ~S ( BUSINESS OWNER NAME, ADDRESS, ZIP CODE FACILITY PHONE . ~~--,'G.~i BILL TO: (IF DIFFERENT FROM ABOVE}--NAME, ADDRESS, ZIP CODE, PHONE No. OCC TYPE OCC LOAD /~c~" No. OF FLOORS ~ HI RISE BLDG. YES O NO RISER DATE VIOLATION NOTICE CORRECTION: 1. DATEbFREINSPECTION 2. ~ / ~ ~ ~.1f~ 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. NOTES i f t 1 ~ - CUSTOMER: U I n ~/ t~ ~% .Y C ~'L.-tO ,F~- i+/~ INSPECTOR: ( ~ _ , ~ ~ AP No. ~~ FIRE PREVENTION SERVICES (661) 326-3979. WHITE ORIGINAL-OWNER YELLOW-INSPECTOR'S COPY PINK-FILE FD1952 Bakersfield Fire Dept. UNIFIED PROGRAM INSPECTION CHECKLIST -~ Enironmental Services _- . ;, -: ~~ 1715 Chester Ave SECTION 1 Business P{an and {nventory Program Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME INSPECTION DATE INSPECTION TIME -- --~, ~-N ~-F4T_£-- ~`y' ~C -- C~ suT~ i2 OJT l J~O -~~~~~~ ---~--- -- --- ADDRESS PHO E N No. of Employees FACILITYCONTACT ENT°D JAN 12 Business ID NumGer ~L ~ ~ € k ~+' ~ ~9 N 2006 15-021- 4~13~j .. Section 1: Business Plan ar-d Inventory Program Routine ^ Combined ^ Joint Agency ^MuIti-Agency ^ Complaint ^ Re-inspection ~% ~ \V=Voatlonnce~ OPEFYATION COMMENTS I~ ^ APPROPRIATE PERMIT ON HAND I~1 ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE is ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ ~ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION C~ ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITYE ^ VERIFICATION OF HAT MAT TRAINING ~J ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES C~I ^ EMERGENCY PROCEDURES ADEQUATE Ip ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING r~ ^ FIRE PROTECTION ~ C~ ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE: ^ YES ^ NO EXPLAIN: QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (66 ~~ 326-3979 ~~ ----- -- ~ a-~---~~2~~-- ------(~=- f~- --- --- - Inspector (Please Print) Fire Prevention 1st-InlShift of Site White -Environmental Services Yellow -Station Copy ~~. Bu iness Site Responsible P (Please Print) rn B N Pink -Business Copy ~O ~~ ;\. GOLDEN STATE EYE CEJIIk . SiteID: 015-021-001307 CommCode: BAKERSFIELD STATION EPA Numb: ~") ~'" ~~ ~ 11 BusPhone: Map : 102 Grid: 34B (661) 327-4499 CommHaz : Low FacUnits: 1 AOV: Manager Location: 1001 TOWER WAY 150 City BAKERSFIELD SIC Code: DunnBrad: Emergency Contact RONALD L MORTON Business Phone: 24-Hour Phone : Pager Phone : / Title / PRESIDENT (661) 327 -44 99x (661) 834-7555x (661) 337-6170x Emergency Contact MELISSA PERRYMAN Business Phone: 24-Hour Phone : Pager Phone : / Title / OFFICE MANAGER (661) 327-4499x (661) 392-9534x ( ) - x Hazmat Hazards: Fire Press ImmHlth Period : Preparer: Certif'd: ParcelNo: to Phone: (661) 327-4499x State: CA Zip : 93309 Phone: (661) 834-7555x State: CA Zip : 93309 TotalASTs: = Gal TotalUSTs: = Gal RSs: No Contact : MailAddr: 1001 TOWER WAY 150 City : BAKERSFIELD Owner Address City RONALD L MORTON, MD : 7700 SADDLEBACK : BAKERSFIELD Emergency Directives: "I I, r2GY\ltJ d L· ~ r-/rnA.. [))© 006'®~Y CSfii~ ~hæl~ ~ ~~® (rVP3 fP p?lnt~) r~~@ws©1 U'ì/S $lïtachoo Û"O~t§¡rdo!Js matsi"Îªls mBlIi1~~®-- ~1i1~ ~~ ~olrbðld~JîS~~þw;/Cir ~ ~&'9Sl~ öft ~~Oú'&~ wift~ (NMIo ~ ~¡jtOO) m)f OOITOOltó@!n~ OO~$~ö~m~ tal oorm¡9)~sft~ ;mYn!©1rom~~ m&.ì8'iJ- ~M®~ ~rru mlr my ~al(Ci~ni~. þ--;;:: JI('i(o~ -1- 08/13/2003 UNI~IED~'ROGRAM INSPECTION CHECKLIST SECTION 1 Business Plan and Inventory Program Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY ,E AooREs FACILITYCONTACT V Vumber 15-021- po~3v7 i~ Section 1: Business Plan and Inventory Program L9~Routine ^ Combined O Joint Agency ^Mnlti-Agency ^ Complaint O Re-inspection C rLI V ^ \V=Vioatiolnnce~ OPERATION APPROPRIATE PERMIT ON HAND ----- --- COMMENTS ---- - -- - - - l~' -- ^ ^ - -- - -- BUSINESS PLAN CONTACT INFORMATION ACCURATE VISIBLE ADDRESS T 6 Z.~ ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS Q ^ VERIFICATION OF QUANTITIES 0 ^ VERIFICATION OF LOCATION ' ^ PROPER SEGREGATION OF MATERIAL ICJ ^ VERIFICATION OF MSDS AVAILABILITYE ~) ^ VERIFICATION OF HAT MAT TRAINING QJ ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~I ^ EMERGENCY PROCEDURES ADEQUATE la ^ CONTAINERS PROPERLY LABELED m ^ HOUSEKEEPING QI ^ ^ FIRE PROTECTION SITE DIAGRAM ADEQUATE Sr ON HAND ANY HAZARDOUS WASTE ON SITE: ^ YES EXPLAIN: C~1 No QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (66~~ 326-3979 nspector Sadge No. White -Environmental Services Yellow - Stalan Copy ~Li~L~/ t S i/ ~C ~ siness Site Responsible rty Pink -Business Copy ( f ,~ r i1 ~, .;: {58 irty`• •~~ CITY OF BAKERSFIEI.D F1RE DEPARTMENT ~ ~ OFFICE OF ENVIRONMENTAL SERVICES ~ ~~ UNIFIED PROGRAM INSPECTION C.HECKI.IST 4 ~w„~' ;~~~_ 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 OCj 2 4 2003 FACILITY NAME ~ r~ ~ tJ~C. ~ ~~ INSPECTION DATE ~b -' 2L ' a3 _ ADDRESS ! ~ D~ T u PHONE NO. ~S~2 - ?3`~/ FACILITY CONTACT -~~ ~ '- BUSINESS ID NO. 15-210- o ~ ~-0Z / - ~°~ 3D j' INSPECTION TIME___ NCIMBER OF EMPLOYEES _ Section 1: Business Plan and Inventory Program [~ Routine ^ Combined ^ Joint Agency ^MuIti-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 ~ ~AJ l~ Proper segregation of material f Verification of MSDS availability Gti.. i_ ~/~ Verification of Naz Mat training ~ /3 a 9 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: Questions regarding this inspection? Please call us to (66l) 326-3979 White -Env. Svcs. Yellow • Station Copy Pink • Business Copy .>~.~ .. a Q,,~- Business Si Re onsible Pa Inspector: ~~ l ~`-' '~.-""¡' . GOLDEN STATE EYE CENTER . ~- ) Sit e I D : 0 15 - 02 1 -,0 0 13 07 ~~usPhone: (661) 327-4499 4\, Map: 102 CommHaz: Low ~~' Grid: 34B FacUnits: 1 AOV: SIC Code: DunnBrad: Manager : Location: 1001 TOWER WAY 150 City BAKERSFIELD CommCode: BAKERSFIELD STATION 11 EPA Numb: Emergency Contact RONALD L MORTON Business Phone' 24-Hour Phone ...['a.~cr Phone / Title Emergency Contact MELISSA PERRYMAN Business Phone: 24-Hour Phone Pager Phone / Title / OFFICE MANAGER (661) 327-4499x (661) 392-9534x () x Hazmat Fire Press ImmHlth Contact : MailAddr: 1001 TOWER WAY 150 City BAKERSFIELD Period Preparer: Certif'd: to Phone: (661) 327-4499x State: CA Zip 93309 Phone: (661) 834-7555x State: CA Zip 93309 TotalASTs: = Gal TotalUSTs: = Gal RSs: No Owner Address City RONALD L MORTON, MD 7700 SADDLEBACK BAKERSFIELD Emergency Directives: p= Hazmat Inventory f== Alphabetical Order One Unified List ~ All Materials at Site 9 SpecHaz EPA Hazards DailyMax MCP F P IH G 557.00 FT3 Low Hazmat Common Name. . . OXYGEN -1- 01/22/2003 i" ;- ~ It // - GOLDEN STATE EYE CENTER // SiteID: 015-021-001307 Manager : Location: City / ///~/ ( // " // BusPhone: Map : 102 Grid: 34B (805) 327-4499 CommHaz : Low FacUnits: 1 AOV: CommCode: EPA Numb: 1001,- TOWER WAY 150 BAKERSFIELD " BAKERSFIELD STATION 11 , , I SIC Code: DunnBrad: Emergency Contact / Title RONALD L. MORTON I PRESIDENT Business Phone:~'(~ 327-4499x 24-Hour Phone :\dJi\(ß.e-S") 834-7555x Pager Phone :~~\(M5l 337-6170x Emergency Contact / Title MELISSA PERRYMANll'lÞ4. OFFICE MANAGER Business Phone: (.s.&51 327 -4499x 24-Hour Phone :(dok~) 392-9534x Pager Phone () x I Hazmat Hazards: Period Preparer: Certif'd: to Fire Press ImmHlth Phone: ( x ftECE\VEO State: CA Zip 93309 "0'1 '2. <) ~ 7 Phone: ( 834-7555x \RON- ~,",'CES State: CA Zip 93309 TotalASTs: Gal TotalUSTs: = Gal RSs: No Contact: MailAddr: 1001 TOWER WAY 150 City BAKERSFIELD Owner Address City RONALD L MORTON, M.D. 7700 SADDLEBACK BAKERSFIELD Emergency Directives: F Hazmat Inventory f== As Designated Order Hazmat Common Name. . . One Unified List ì All Materials at Site ì EPA Hazards DailyMax MCP OXYGEN F P IH I, 'Kcmo.Ld L ¡,Ao('mn ,.)..1) Do hereby certify that I have (rype or print name) G 557.00 FT3 Low reviewed the attached hazardous materials macage- ment plan for b6lclrn S+()te Í-w. Gtv and that it along with (Name of Bu¡¡¡¡fess) any corrections constitute a complete and correct man- agement plan for my facility. tÅ1ô!~)0.t;/v -1- 11/21/2000 \' e e F GOLDEN STATE EYE CENTER p= Inventory Item 0002 = COMMON NAME / CHEMICAL NAME OXYGEN SiteID: 015-021-001307 1 Facility Unit: Fixed Containers on Site ì Location within this Facility Unit SURGERY ROOM RECOVERY ROOM LOCKER ROOM Days On Site 365 Map: Grid: CAS # 7782-44-7 STATE - TYPE Gas Pure PRESSURE ---- TEMPERATURE Above Ambient Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container FT3 AMOUNTS AT THIS LOCATION Daily Maximum 557.00 FT3 Daily Average 557.00 FT3 HAZARDOUS C MPO NTS %Wt. RS CAS # 100.00 Oxygen, Compressed No 7782447 o NE TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Low HAZARD ASSESSMENTS -2- 11/21/2000 ¡ ¡. .. e e F GOLDEN STATE EYE CENTER I f= Notif./Evacuation/Medical ~ Agency Notificatio,n LCALL 911 Employee Notif./Evacuation SiteID: 015-021-001307 ì Fast Format ì Overall Site ì 09/17 /19921 09/17/1992 NO EVACUATION NECESSARY FOR OXYGEN RELEASE. Public Notif./Evacuation Emergency Medical Plan 08/18/1997 POTENTIAL EMERGENCIES REGISTERED NURSE. IF AT THIS BUSINESS WOULD BE HANDLED BY PHYSICIAN OR THEY WERE NOT AVAILABLE: TRUXTUN AVE - (~ 327-3371 MERCY HOSPITAL - 2215 -3- 11/21/2000 " e e í GOLDEN STATE EYE CENTER ëëëëëëëëëëëëëëëëëëëëëëëëëëëëë SiteID: 015-021-001307 j íëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Fast Fornaat j íë Mitigation/Preventl Abatenat ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Overall Site j íëë Release Prevention ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 09/17/1992 j o 0 o ALL OXYGEN TANKS ARE HELD BY SUPPORT-TRANSPORT CARRIERS OR ANCHORED TO THE 0 o WALL WITH CHAIN. 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëë Release Contaimnent ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 09/17/1992 j o 0 o RELEASE OF OXYGEN NO CONTAINMENT NECESSARY o o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëë Clean Up ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 09/17/1992 j o 0 o RELEASE OF OXYGEN - NO CLEAN UP NECESSARY. GREATEST DANGER IS TANK FALLING 0 o WITH VALVE BREAKING INJURING PERSONNEL VIA RAPID MOVEMENT OF TANK FROM 0 o PRESSURE WITHIN. 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëëë Other Resource Activation ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf ¡, '. e e í GOLDEN STATE EYE CENTER ëëëëëëëëëëëëëëëëëëëëëëëëëëëëë SiteID: 015-021-001307 j íëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Fast Fornnat j íë Site Emergency Factors ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Overall Site ¡ íëë Special lIazards ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëë Utility Shut-Offs ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 08/18/1997 j o 0 o A) GAS - E SIDE BLDG, FRONT CORNER o B) ELECTRICAL - E SIDE BLDG, FRONT CORNER o C) WATER - FRONT SIDEWALK E OF MIDDLE o D) SPECIAL - NONE o E) LOCK BOX - NO o 0 o o o o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëë Fire Protec.lAvail. Water ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 08/18/1997 ¡ o 0 o o PRIVATE FIRE PROTECTION - BUILDING SPRINKLERS; ÈXTINGUISHERS; ALARM PULLS; 0 o EV ACUA TION MAPS AND FIRE DRILLS ALL FOR FIRE PROTECTION. 0 o o o o o o FIRE IIYDRANT - IN BACK OF BLDG; ACROSS ST FRONT E; ACROSS ST FRONT WAND o STANDPIPE CONNECTION FOR SPRINKLERS FRONT E CORNER. 0 o 0 o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëëë Building Occupancy Level ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf -5- 11/21/2000 i' ;, :-- ... e e í GOLDEN STATE EYE CENTER ëëëëëëëëëëëëëëëëëëëëëëëëëëëëë SiteID: 015-021-001307 ¡ íëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Fast Format ¡ íë Training ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Overall Site ¡ íëë Employee Traúning ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 09/17/1992 ¡ o 0 o WE HAVE 3 PART TIME EMPLOYEES AND 1 FULL TIME EMPLOYEE AT THIS FACILITY o o o o WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE o o o o BRIEF SUMMARY OF TRAINING: o o o âëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëë Page 2 ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o âëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëë Held for Fuvure Use ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ 0 0 o o âëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëëë Held for Fuvure Use ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o âëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf -6- 11/21/2000 .. _~ ..9 - GOLDEN STATE EYE CENTER TI>F.rEIVE··'--' .L'- ". V ~<\.~ e // . Manager : . Location: 1001 TOWER WAY 157'¥':/ City BAKERSFIELD BusPhone: Map : 102 Grid: 34B SiteID: 215-000-001307 ft;0 1 ç.8-&51 327-4499 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 11 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title RONALD L. MORTON ~VPRESIDENT Business Phone: ('8"&51 327-4499x 24-Hour Phone : (~) 834-7555x Pager Phone : (~) 337-6170x Emergency Contact MELISSA PERRYMAN Business Phone: 24-Hour Phone : Pager Phone : / Title ~0V OFFICE MANAGER (-8-ð"5') 327-4499x (5U5") 392-9534x ( ) - x Hazmat Hazards: Fire Press ImmHlth Owner Address City RONALD L MORTON, M.D. : 7700 SADDLEBACK : BAKERSFIELD Phone: ( ) State: CA Zip : 93309 Phone: (~~) 834-7555x State: CA Zip : 93309 - x Contact : MailAddr: 1001 TOWER WAY 150 City : BAKERSFIELD = Gal Gal period: £: to Preparer: ~ Certif 'd: - 0 ~~v(~ / \ X- '- Emergency Dj V~· '- ~q ""~ ~ \)f' }JJ I tV. ~\ ",2t \}-' ~ / Y ~ ~ , {'\) TotalASTs: TotalUSTs: RSs: No = 1, J~()ncLld L, µor~1"\ (Tttpa or printnamø) reviswoo1 ths att~chOO 1ñ~~S mtal~sti'ÜtØl~S mtalnag~o Do rnŒìre~y ooiii~ ~h~ ß ñ1tal\J® msnt fjJian for..6cldeê~ ~ lmÞ1\OO ~~f i~ alliOn@ with ( WI~) SlrRY rorrsdñ~ris \Cons~i~Wt~ Sl ©©m~ls~® tal~~ OOIT~d mano sgsMsnt pl2l\'1 ~(»Ij' WJV ~cm~. ,. ~ ID~ I <îs~qt) (¡ate -1- 10/11/1999 e F GOLDEN STATE EYE CENTER p= Hazmat Inventory p== As Designated Order e SiteID: 215-000-001307 ì By Facility Unit ì Fixed Containers on Site 1 specHazEPA Hazards Frm I DailyMax IUnitMCP Hazmat Common Name... OXYGEN F P IH G 557 FT3 Low -2- 10/11/1999 e F GOLDEN STATE EYE CENTER p= Inventory Item 0002 = COMMON NAME / CHEMICAL NAME OXYGEN e SiteID: 215-000-001307 1 Facility Unit: Fixed Containers on Site 1 Days On Site 365 Location within this Facility Unit SURGERY ROOM RECOVERY ROOM LOCKER ROOM Map: Grid: CAS # 7782-44-7 STATE - TYPE Gas Pure PRESSURE ---- TEMPERATURE Above Ambient Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container FT3 AMOUNTS AT THIS LOCATION Daily Maximum 557.00 FT3 Daily Average 557.00 FT3 HAZARDOUS COMPONENTS %Wt. RS CAS # 100.00 Oxygen, Compressed No 7782447 HAZARD E MEN TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Low ASS SS TS -3- 10/11/1999 '. ' e e F GOLDEN STATE EYE CENTER I p= Notif./Evacuation/Medical r==~:e::: Notification Employee Notif./Evacuation SiteID: 215-000-001307 ~ Fàst Format ~ Overall Site ~ 09/17/1992 ] 09/17/1992 NO EVACUATION NECESSARY FOR OXYGEN RELEASE. Public Notif./Evacuation Emergency Medical Plan 08/18/1997 POTENTIAL EMERGENCIES AT THIS BUSINESS WOULD BE HANDLED BY PHYSICIAN OR REGISTERED NURSE. IF THEY WERE NOT AVAILABLE: CRIo ( MERCY HOSPITAL - 2215 TRUXTUN AVE - (~ 327-3371 -4- 10/11/1999 .. e e í GOLDEN STATE EYE CENTER ëëëëëëëëëëëëëëëëëëëëëëëëëëëëë SiteID: 215-000-001307 íëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Fast Format íë Mitigation/Prevent/Abatemt ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Overall Site íëë Release Prevention ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 09/17/1992 ¡ o 0 o ALL OXYGEN TANKS ARE HELD BY SUPPORT-TRANSPORT CARRIERS OR ANCHORED TO THE 0 o WALL WITH CHAIN. 0 o 0 åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëë Release Containment ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 09/17/1992 ¡ o 0 o RELEASE OF OXYGEN NO CONTAINMENT NECESSARY o o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëëë Clean Up ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 09/17/1992 ¡ o 0 o RELEASE OF OXYGEN - NO CLEAN UP NECESSARY. GREATEST DANGER IS TANK FALLING 0 o WITH VALVE BREAKING INJURING PERSONNEL VIA RAPID MOVEMENT OF TANK FROM 0 o PRESSURE WITHIN. 0 o 0 åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëëëë Other Resource Activation ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj · " e e í GOLDEN STATE EYE CENTER ëëëëëëëëëëëëëëëëëëëëëëëëëëëëë SiteID: 215-000-001307 ¡ íëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Fast Format i íë Site Emergency Factors ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Overall Site ¡ íëë Special Hazards ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëë Utility Shut-Offs ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 08/18/1997 ¡ o 0 o o A) GAS - E SIDE BLDG, FRONT CORNER o B) ELECTRICAL - E SIDE BLDG, FRONT CORNER o C) WATER - FRONT SIDEWALK E OF MIDDLE o D) SPECIAL - NONE o E) LOCK BOX - NO o o o o o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëëë Fire Protec./Avail. Water ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 08/18/1997 ¡ o 0 o PRIVATE FIRE PROTECTION - BUILDING SPRINKLERS; EXTINGUISHERS; ALARM PULLS; o EVACUATION MAPS AND FIRE DRILLS ALL FOR FIRE PROTECTION. o o o o o o FIRE HYDRANT - IN BACK OF BLDG; ACROSS ST FRONT E; ACROSS ST FRONT W AND o STANDPIPE CONNECTION FOR SPRINKLERS FRONT E CORNER. o o o o o o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëëëë Building Occupancy Level ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj o -6- 10/11/1999 ::r... " '. ....'\. e e í GOLDEN STATE EYE CENTER ëëëëëëëëëëëëëëëëëëëëëëëëëëëëë SiteID: 215-000-001307 íëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Fast Format íë Training ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Overall Site íëë Employee Training ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 09/17/1992 ¡ o 0 o WE HAVE 3 PART TIME EMPLOYEES AND 1 FULL TIME EMPLOYEE AT THIS FACILITY 0 o 0 o WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE 0 o 0 o BRIEF SUMMARY OF TRAINING: 0 o 0 åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëë Page 2 ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëë Held for Future Use ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ 0 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëëë Held for Future Use ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf // ../ ~/ ../' /~ / -7- 10/11/1999 Manager : Location: City "' /''- B//' 1001 TOWER WY 15 ' Y , / BAKERSFIELD e " :Ii GOLDEN STATE EYE CENTER SiteID: 215-000-001307 BusPhone: Map : 102 Grid: 34B (805) 327-4499 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 11 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title RONALD L. MORTON / PRESIDENT ' :¡V\eU5SA - P¡:;ïeRY~A,J / OFFICE MANAGER Business Phone: (805) 327-4499x Business Phone: (805) 327-4499x 24-Hour Phone : (805) 834-7555x 24-Hour Phone : (805) 3'l2-'1S34- K Pager Phone : (~05 ) 331 -(p J1D x Pager Phone : ( ) - x Hazmat Hazards: Fire Press ImmHlth Agency-Defined Topic Title f= Hazmat Inventory p== MCP+DailyMax Order One Unified List ~ All Materials at Site ~ Hazmat Common Name... SpecHaz EPA Hazards DailyMax MCP OXYGEN F P IH G 557 FT3 Low ~. ROnQld L. lAor-trm ¡v/j;) ~ (Y~@v~~ 00 B1®V'®19>y OOrai~ ~ro®!1 0 ~® rlSY'ð~W®~ fth® ®~\C~&J©1 ~~~~OO~ MBlOIÖ'\¿Ii5\ß"" (gj«'Ø~ 1(Qj® ffl~Yi),BJ©®o M®O'iW pllEJiI'iJ 90Y~~ 9r~ ~~~ fi~1E1ß '~-/1r;" . . ~"I&OOÞ Ou ~~~ WUMi1 ~rüY' ooQ'r~!@ftS OOfi1$!1ð~~~® ~ OOm~~~® ®~ ©©W®©\1 ffl@UiJo ~®m®m ~t.mYi) U@IJ ffl1f ~@8ålìV. IYl _ ~~fìhi:l -1- 07/28/1997 ? 'i e e F GOLDEN STATE EYE CENTER p= Inventory Item 0002 ~ COMMON NAME / CHEMICAL NAME OXYGEN SiteID: 215-000-001307 ì Facility Unit: Fixed Containers on Site ì Days On Site 365 Location within this Facility Unit SURGERY ROOM RECOVERY ROOM LOCKER ROOM CAS# 7782-44-7 STATE - TYPE Gas Pure PRESSURE ---- TEMPERATURE Above Ambient Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest Container Daily Maximum Daily Average FT3 557.00 FT3 557.00 FT3 Ma}\imum Stored Maximum Open Use Maximum Closed Use FT3 FT3 FT3 AMOUNTS AT THIS LOCATION HAZARDOUS COMPONENTS ~ CAS# I 7182447 %Wt. 100.00 Oxygen, Compressed -2- 07/28/1997 ¡, '* e e F GOLDEN STATE EYE CENTER r-- F Notif./Evacuation/Medical ¡=: Agency Notification - CALL 911 Employee Notif./Evacuation SiteID: 215-000-001307 ~ Fast Format ~ Overall Site ~ 09/17/19921 09/17/1992 NO EVACUATION NECESSARY FOR OXYGEN RELEASE. Public Notif./Evacuation Emergency Medical Plan 09/17/1992 POTENTIAL EMERGENCIES AT THIS BUSINESS WOULD BE HANDLED BY PHYSICIAN OR REGISTERED NURSE. IF THEY WERE NOT AVAILABLE: MERCY HOSPITAL 2215 TRUXTUN AVE BAKERSFIELD, CA. (805) 327-3371 -3- 07/28/1997 '. e e F GOLDEN STATE EYE CENTER I f= Mitigation/Prevent/Abatemt Release Prevention SiteID: 215-000-001307 ~ Fast Format ~ Overall Si te ~ 09/17/1992 ALL OXYGEN TANKS ARE HELD BY SUPPORT-TRANSPORT CARRIERS OR ANCHORED TO THE WALL WITH CHAIN. Release Containment 09/17/1992 RELEASE OF OXYGEN NO CONTAINMENT NECESSARY Clean Up 09/17/1992 RELEASE OF OXYGEN - NO CLEAN UP NECESSARY. GREATEST DANGER IS TANK FALLING WITH VALVE BREAKING INJURING PERSONNEL VIA RAPID MOVEMENT OF TANK FROM PRESSURE WITHIN. Other Resource Activation I -4- 07/28/1997 ~ o'¢ e e F GOLDEN STATE EYE CENTER r F Site Emergency Factors r Special Hazards Utility Shut-Otts SiteID: 215-000-001307 ì Fast Format =¡ Overall Site ì I 04/01/1994 A) GAS - EAST SIDE BUILDING, FRONT CORNER B) ELECTRICAL - EAST SIDE BUILDING, FRONT C) WATER - FRONT SIDEWALK EAST OF MIDDLE D) SPECIAL - NONE E) LOCK BOX - NO CORNER Fire Protec./Avail. Water 04/01/1994 PRIVATE FIRE PROTECTION - BUILDING SPRINKLERS; EXTINGUISHERS; ALARM PULLS; EVACUATION MAPS AND FIRE DRILLS ALL FOR FIRE PROTECTION. FIRE HYDRANT - IN BACK OF BUILDING; ACROSS STREET FRONT EAST; ACROSS STREET FRONT WEST AND STANDPIPE CONNECTION FOR SPRINKLERS FRONT EAST CORNER Building Occupancy Level -5- 07/28/1997 / /J. ~"), r- ''C - e F GOLDEN STATE EYE CENTER I F Training Employee Training SiteID: 215-000-001307 ~ Fast Format ~ Overall Si te ~ 09/17/1992 WE HAVE 3 PART TIME EMPLOYEES AND 1 FULL TIME EMPLOYEE AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE BRIEF SUMMARY OF TRAINING: c: Held for Future Use Held for Future Use -6- 07/28/1997 i I 1 .J -- e CITY of BAKERSFIELD ~~ " / Fire Department M.R. Kelly Acting Fire Chief "WE CARE" IÝ!ðAd- ()3 /q9i 7 IMPORTANT 1715 Chester Ave., Ste. #300 Bakersfield, CA 93301 (805) 326-3979 / DO NOT DISCARD Dear Business Owner: California Law requires that all Businesses, which at any time during the year handle reportable quantities of hazardous materials, file a Hazardous Materials Business plan, including inventory of hazardous materials, with the local administering agency. Your business has filed such a plan. This same regulation requires that these businesses 'review the business plan submitted to determine if revisions are needed, and to certify to the administering agencies that the review was made and that any necessary changes were made to the .~ plan. To facilitate this review we have enclosed a computer print-out of the plan you have submitted. Please review this plan in its entirety and make any necessary revisions on the print-out. When the review and revisions are completed sign the first page of the plan in the appropriate space certifying that the plan is complete and correct. Return the business plan along with any revisions to this office within 30 days of receiving these forms. If you have any questions or if we can be of any assistance please do not hesitate to call 326- 3979. r;-::::--~'.'---;'-:~"~--'._'.'."-;_.--'''--.-l~ A",V:X ê)S l qq~ I:r,\¡_ r(;" ¡:,;,' '; :~.' ,-U· ~ I .. II! 1 :¡":-::'":'::''' <.: ,', ! ; Sincerely yours, . \\\;;(1/\ UA'R ') '~IQOt¡ f;~'"' 1,1¿ // ~~' /1 1'1 ,IYIt\ 3, ""', ~ 1\ \ ì ' / t/ ,,' , \', i e.- : ~ ;., "'./"- \l" Ij '-'---'--"--' -. - L____.__..__·_· ...- ~:~~u';u~~terials Coordinator P.S. Please note that we have also enclosed a booklet published by the California Office of Emergency Services. This booklet is a guide to the notification requirements in cáse of a Hazardous Materials Spill or Release. -.. -- _. e e t / ,'" ,j ~~(Ç~~W~~~e " 03/23/94 GOLDEN STATE EYE CENTER 215-000-0013 Overall Site with 1 Fac. Unit MAR 3 1 1994 General Information 0" Location: 1001 TOWER WY 150 Map:102 Haz:2 Type: 1 Community: BAKERSFIELD STATION 11 Grid: 34B FlU: 1 AOV: 0.0 ~ Contact Name Title Business Phone - 24-Hour Phone RONALD L. MORTON PRESIDENT (805) 327-4499 x (805) 834-7555 €:A-RQL. nIR!:EN~M..lJ OFFICE MANAGER (805) 327-4499 x (805) .s.ea 66-4-& - MILLER Administrative Data ' :J 0:;; . ~ ~ J-Z; Mail Addrs: 1001 TOWER WY 150 D&B Number: City: BAKERSFIELD State: CA Zip: 93309- Comm Code: 215-011 BAKERSFIELD STATION 11 SIC Code: Owner: RONALD L MORTON, M.D. Phone: (805) 834-7555 Address: 7700 SADDLE BACK State: CA City: BAKERSFIELD Zip: 93309- .. Summary 1 I RONALD L. MORTON Do "'e..by certify that I hav& · (TJP8 Of ,*"nàIM) l, M. D. reviewed the attaChed hazardous materials manage-- GOLDEN STATE EYE CENTER ' with' ment plan for and that it along (N*IM or ÐuIIn8II) any corrections constitute a complete and correct mart- agement plan for my faciUty. 'of,.", ~~~/91. {I .~ e e ß \- 03/23/94 GOLDEN STATE EYE CENTER 215-000-001307 Hazmat Inventory List in MCP Order Page 2 02 - Fixed Containers on Site PIn-Ref Name/Hazards Form Max Qty MCP 02-002 OXYGEN ~ Fire, Pressure, Immed Hlth Gas 557 Low FT3 .. e e ;. .. 03/23/94 GOLDEN STATE EYE CENTER 215-000-001307 02 - Fixed Containers on Site Page 3 Hazmat Inventory Detail in MCP Order 02-002 OXYGEN ~ Fire, Pressure, Immed Hlth Gas 557 Low FT3 CAS =It: 7782-44-7 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3 ----r-- Daily Average FT3 --r-- Annual Amount FT3 557 I 557.00 I' 8,355.00 , Storage ~ Press PORT. PRESS. CYLINDER ¡Above I Temp Location Ambient SURGERY ROOM RECOVERY ROOM LOCKER ROOM - Conc l 100.0% Oxygen, Compressed Components ~ MCP -¡Guide Low I 14 .. e e , ;r 03/23/94 GOLDEN STATE EYE CENTER 215-000-001307 00 - Overall Site Page 4 <D> Notif./Evacuation/Medical <1> Agency Notification CALL 911 <2> Employee Notif./Evacuation NO EVACUATION NECESSARY FOR OXYGEN RELEASE. <3> Public Notif./Evacuation <4> Emergency Medical Plan POTENTIAL EMERGENCIES AT THIS BUSINESS WOULD BE HANDLED BY PHYSICIAN OR REGISTERED NURSE. IF THEY WERE NOT AVAILABLE: MERCY HOSPITAL 2215 TRUXTUN AVE BAKERSFIELD, CA. (805) 327-3371 ~ e e i 03/23/94 GOLDEN STATE EYE CENTER 215-000-001307 00 - Overall Site Page 5 <E> Mitigation/Prevent/Abatemt <1> Release Prevention ALL OXYGEN TANKS ARE HELD BY SUPPORT-TRANSPORT CARRIERS OR ANCHORED TO THE WALL WITH CHAIN. <2> Release Containment RELEASE OF OXYGEN NO CONTAINMENT NECESSARY <3> Clean Up RELEASE OF OXYGEN - NO CLEAN UP NECESSARY. GREATEST DANGER IS TANK FALLING WITH VALVE BREAKING INJURING PERSONNEL VIA RAPID MOVEMENT OF TANK FROM PRESSURE WITHIN. <4> Other Resource Activation -~ .> "" e e .r: . 03/23/94 GOLDEN STATE EYE CENTER 215-000-001307 00 - Overall Site Page 6 <F> Site Emergency Factors I <1> Special Hazards <2> Utility Shut-Offs A) GAS - EAST SIDE BUILDING, FRONT CORNER B) ELECTRICAL - EAST SIDE BUILDING, FRONT CORNER C) WATER - FRONT SIDEWALK EAST OF MIDDLE D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - BUILDING SPRINKLERS; EXTINGUISHERS; ALARM PULLS; EVACUATION MAPS AND FIRE DRILLS ALL FOR FIRE PROTECTION. FIRE HYDRANT - IN BACK OF BUILDING; ACROSS STREET FRONT EAST; ACROSS STREET FRONT WEST AND STANDPIPE CONNECTION FOR SPRINKLERS FRONT EAST CORNER <4> Building Occupancy Level / ~ t';. "~ e e ~.¿'"' 03/23/94 GOLDEN STATE EYE CENTER 215-000-001307 00 - Overall Site Page 7 / <G> Training <1> Page 1 WE HAVE 3 PART TIME EMPLOYEES AND 1 FULL TIME EMPLOYEE AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE BRIEF SUMMARY OF TRAINING: <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use C' ' e e ~ .. . 07/291èj2 GOLDEN STATE EYE CENTER 215-000-001307 Overall Site with 1 Fac. Unit Page 1 General Information Location: 1001 TOWER WY 150 Community: BAKERSFIELD STATION 11 Map: 102 Hazard: Low Grid: 34B FlU: 1 AOV: 0.0 Contact Name RONALD L. MORTON C OL IRKENDALL Title Business Phone (805) 327-4499 x (805) 327-4499 x 24-Hour 'Phone (805) 834-7555 Administrative Data Mail Addrs: 1001-150 TOWER WY City: BAKERSFIELD Comm Code: 215-011' BAKERSFIELD STATION 11 D&B Number: State: CA Zip: 93309- SIC Code: Owner: RONALD L MORTON, M.D. Address: 7700 SADDLE BACK City: BAKERSFIELD Phone: (8b5)~4-~ State: CA , Zip: 9330 - Summary RECBVED ¡SEP 1 1 1992 HA7. M,4 T. OIV. {JfC ¡, ;(:1ta.1/l1o.r/ol1 Do h'7reby certify ~~~ ~ ~ave (Type or print name) re"ö®wsd the attached Ì'la¿Bn...vus n'aterial~ ffl~Iiîl®~~o GÔ~¿/1 5'ÞI¿ m~nt plan for E\¡¿ ~I'II-~ r and that iR ~¡~iî@ woRth , (lWJrie 01 Business) ~úîl? OOf~~ctilJns constitute a C(j)M~~S~S ®n©l OOKìi'~ m~ij'ìJo t§¡gem®vmt L9J~ij'ìJ ~©Ii' mW ~f§\©Ö~~~o f0 (' 1,1;. r, ._~ 1f6< ' ~IQ, ð~/t:Ç'L>-___ / . 1 ¡ ~ i " e e 07/29/tJ2 GOLDEN STATE EYE CENTER 215-000-001307 02 - Fixed Containers on Site Page 2 Hazmat Inventory Detail in Reference Number Order ETHYLENE OXIDE ~ . e, Pressure, Delay Hlth Gas E e Trade Secret: No Form: Gas ( I PORT. P~~~~~qe ~~~:s I ~ - Co l ~ 0.0% Ethylene Oxide (EPA) Amount FT3 - 180.00 Components 02-002 OXYGEN ~ Fire, Pressure, Immed Hlth Gas 557 Low FT3 CAS #: 7782-44-7 Trade Secret: No Form: Gas Type: Pure Days: 365 OR PROCESS Daily Max FT3 ----r-- Daily Average FT3 557 I 557.00 Amount FT3 8,355.00 Storage r Press PORT. PRESS. CYLINDER Above - Conc l 100.0% Oxygen, Compressed T Temp Location Ambient SURGERY ROOM f £'¿ccvt2r..j Room; ¡ oc.l.. er J:.oom Components I~ MCP --rList Low ¡, e e 07/29/92 GOLDEN STATE EYE CENTER 215-000-001307 00 - Overall Site Page 3 <D> Notif./Evacuation/Medical <~> Agency Notification CALL 911 , ! I I <2> Employee Notif./Evacuation NO EVACUATION NECESSARY FOR OXYGEN RELEASE. -FOR EO RELEASE FOR 4 HOtJRS- <3> Public Notif./Evacuation <4> Emergency Medical Plan POTENTIAL EMERGENCIES AT THIS BUSINESS WOULD BE HANDLED BY PHYSICIAN OR REGISTERED NURSE. IF THEY WERE NOT AVAILABLE: MERCY HOSPITAL 2215 TRUXTUN AVE BAKERSFIELD, CA. (805) .327-3371 e e 0'7/29/92 GOLDEN STATE EYE CENTER 215-000-001307 00 - Overall Site Page 4 <E> Mitigation/Prevent/Abatemt <1> Release Prevention ALL OXYGEN TANKS ARE HELD BY SUPPORT-TRANSPORT CARRIERS OR ANCHORED TO THE WALL WITH CHAIN. GERIE3.II ETJIYl.EÞŒ OXIDE CYLINDER (!: Jl' 1 1/2) ARJi: VEPT -HI r.F..NTRAL sur PLY ROOM' DR.J\»7ER IN ORIGINAL SHIPPING BOXT ¡nTH SEPARATE CONT <'GAS OR 'PÐE8~mR.p; ru.I9.TN~) <2> Release Containment RELEASE OF OXYGEN NO CONTAINMENT NECESSARY <3> Clean Up RELEASE OF OXYGEN - NO CLEAN UP NECESSARY. GREATEST DANGER IS WITH VALVE BREAKING INJURING PERSONNEL VIA RAPID MOVEMENT OF PRESSURE WITHIN. FALLING FROM <4> Other Resource Activation / , I e It ,.. + . 07/29/92 GOLDEN STATE EYE CENTER 215-000-001307 00 - Overall Site' Page 5 <F> ,Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - EAST SIDE BUILDING, FRONT CORNER B) ELECTRICAL - EAST SIDE BUILDING, FRONT CORNER C) WATER - FRONT SIDEWALK EAST OF MIDDLE D) SPECIAL - NONE E) LOCK BOX - NO r I <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION- BUILDING SPRINKLERS; EXTINGUISHERS; ALARM PULLS; EVACU~TION MAPS AND FIRE DRILLS ALL FOR FIRE PROTECTION. FIRE HYDRANT - IN BACK OF BUILDING; ACROSS STREET F~ONT EAST; ACROSS STREET FRONT WEST AND STANDPIPE CONNECTION FOR SPRINKLERS FRONT EAST CORNER <4> Building Occupancy Level - '. e e -:; '" . 07/29/92 GOLDEN STATE EYE CENTER 215-000-001307 00 - Overall Site Page 6 <G> Training , <1> Page 1 .3 WE HAVE ;(PART TIME EMPLOYEES AND 1 FULL TIME EMPLOYEE AT THIS FACILITY DO YOU HAVE MATERIAL SAFETY DATA SHEETS ON FILE? y~s HANDLE E 0, NURSE AND ~ANDLING. o AREA AND STO NS FOR USE AND R. c&- ú..-~ <2> Page 2 as needed \ <3> Held for Future Use <4> Held for Future Use CITY OF BAKERSFIELD HAZARDOUS MATERIALS INVENTORY page-LofL o Farm and Agriculture 0 Standard Business NON - TRADE SECRET OWNER NAME: n.¡£ I d ¿. !1:1ð ADDRESS: 7700 SCi CITY, ZIP: PHONE ,I: &olde/1' S k~ NAME OF THIS FACILITY: Et<> C~rì+e.r STANDARD IND. CLASS CODE. ¿foil DUN AND BRADSTREET NUMBER/FEDERAL ID t - -- - - -- PROPER CODES 12 Location Where Stored in Facilit 13 , by wt 14 Names of Mixture/Components See nstructions Physical and Health Hazard C.A.S. Number 75-Jl..J -?f Component /I 1 Name , C.A.S. Number 2-% (Check all that apply) 0 0 o Reactivity D ŒJ Component /I 2 Name , C.A.S. Number Fire Hazard Sudden Release Imediate Delayed ot Pressure Health Health Component /I 3 Name , C.A.S. Number Physical and Health Hazard C.A.S. Number Component /I 1 Name , C.A.S. Number (Check all that apply) 0 0 0 0 o Delayed Component /I 2 Name , C.A.S. Number Fire Hazard Sudden Release Reactivity IDDDediate of Pressure Health Health Component , 3 Name , C.A.S. Number Physical and Health Hazard C.A.S. Number Component /I 1 Name , C.A.S. Number (Check all that apply) p 0 o Reactivity 0 0 Component , 2 Name , C.A.S. Number Fire Hazard Sudden Release IDDDediate Delayed of Preseure Health Health Component , 3 Name , C.A.S. Number Name Title Component , 1 Name , C.A.S. Number, Component /I 2 Name , C.A.S. Number Component /I 3 Name , C.A.S. Number 12 24 Hr. Phone Name Title. 24 Hr Phone Physical and Health Hazard C.A.S. Number (Check all that apply) o Fire Hazard 0 Sudden Release 0 Reactivity Cl'Immediate 0 Delayed of Preesure Health Health EMERGENCY CONTACTS #1 Certification (READ AND SIGN AFTER COMPLETING ALL SECTIONS) I certify under peanlty of law that I haver personally examined and am familiar with the information submitted in this and all attached documents and that based on my inquiry of those: individuals responsible for obtaining the information. I believe that the submitted information is true, accurate, and complete. Dltd lei L. 'óY () á) ¿' AND OFFICIAL TITLE OF OWNER/OFERATOR OR OWNER/OPERATOR'S AUTHORIZED REPRESENTATIVE ~- 61ft /17- DÁTE StGNED ~Bakersfield Fire I!pt. . Hazardous Materials Inspection ~ Date Completed Business Name: (~/DeA/ SÏÁTE .... ~ - é:. V~- " ~AJ / /--R.. , . f/ I sc:J l(Jol ~ ~ Plan ID # 215-00001 J07 (Top right comer Business Plan) Location: Station No. ( ( Shift ~{} () Inspector R~/7-90 RECEIVED AUG 2 0 1990 HAl.. MAT. DIV. Adequate Inadequate B 0 B 0 B 0 0- 0 Verification of Inventory Materials Verification ot'Quantities Verification of Location- Proper Segregation of Material Comments: Verification ofMSDS Availability D ~ Number of Employees Verification of Haz Mat Training o Comments: ~ Verification of Abatement Supplies & Procedures IT Comments: o Emergency Procedures Posted er- a- Containers Properly Labeled Comments: o D EJ 0 ~-deet ~~ Verification of Facility Diagram Special Hazards Assoc~ted with J;þis Facility: ~~ ~ (-I-- '-Ñ~f' Violations: i\ FD 1652 (Rev. 3-89) White·Haz Mat Div. Yellow-Station Copy Pink·Business Office -, , '~~.. ,- -"~.~'~A="·""ôti'·"P;;fi;;;;~;";;·~; 5=':;0 ," ,- , -~~ ' " "'-~~- , "£ -to 51<...,1/. If r (S /If/t i r¡ , UJt . ¿ @~/oPfJ cv ØaL' i '~~,HfG. , j".> oo-'-t ~ ßu51/JtS5. '--f¡¿5f)rJ/.2f {C£I'11Iof, '6t Í(~'~J bM.{ -fh¿ ð<¡tl /(LefFt~ ,f '(n (û5l #7~-f/ld J~lYIeOfLt..Jo ~e.fÞ''¡ 'If áú.r. , ¡h¿ td?/fI/All{/'tI ht .¡N Ft/e. ~{ · iJ5 f-l~d.~ ~,Facf ýt/þ'1f -/{16 I ßCd.t;ð ¿'SL(1~ c}A¿ , ftú.-(. ¡hC- () '-I of:. G.<6¡:¿ &t;~ vIt iVL .¡;~ ck':út~é .;0 J(~ ;J/t~C1P r. ,~ , '-. --0 --"i~.~_ 1;00 n 3 1ft( O~ b 'Yó /Ftèðll.. - ':. T':'-;~"":;;~~~~~~-~~-- :Y~? \ L~ ~~ ~."t ~-} ':., , ,.': ...~~ -f L._ : ,....: . ~::: .;.'j ï 1 , ' J I I I ê-' i'~ / £~AKq-. . ," 0 _ ., .s'þ' : ~ ...' ~, ') ,t:; _..\' (' U :;- 0, f _:-:~ "- -'" , , ...- " ".\,C'~, ,.: .' ./' ",~l.l'--' e,· ¡,"'~, " _'-'"!d)..ß:-. './ ..~ e e 1307 ~,~~~~~ CITY of BAKERSFIELD t(A01 :ir?:~~-\J /~-:-;:'= 1/ I - ''"' " -,- .. WE CARE" ? ¡---1 -~ %\~ -.; ::::;::: ()(' r ~.. ~, /~ ~--~:..:~~~~,~".,~ "1JI'líí~ ® T Lois Watkins, RN, OR Supervisor Ityue or prin~ name) Do hereby ce:::-t i fy tha t I hai.-e revie~,'ed the RECEIVED -.1 A N 3 1 19R 9 Ans'd.. ............ attached Hazardous Materials business plan for GOLDEN STATE EYE CENTER (name of business) and that it along with the attached additions or corrections constitute a complete and correct Business Plan for my facility. o· ~~ ~~) SiF:na¡::ure, ¡~/)iJ (Yr- . &:? ~r¡ /y} ~" ~ ~0!O 'ò6 'l Januar~ 24, 1989 date êR '- .', ,- / i' BUSINESS NAME GOLOE~A;E EYE CENTER LOCRTION 1001-150 TOWER WY 10 NaR 2t5-000-00t307 HIGH HAZARD RATING 2 t" OVERVIEW LAST CHRNGE ØB/12/~8 BY ESTER JURIS CODE 215-011 JURIS BAKERSFIELD STRTION 11 MAP PAGE 102 GRID 348 FACILITY UNITS t HRZARD RATING 2 RESPONSE SUMM,ARY ZA SEC 4) PHYSICIAN AND REGISTERED NURSE AVA<bLABLE MOgT TIMES DURING BUSINESS DAY. l.JHEN NOT. MERCY HOSPITAL QUICKLY AVAILABLE. ALL EMPLOYEES CPR CERTIFIED. FIRE. DISASTER AND CPR DRILLS HELD REGULARLY. EQUIPMENT AVAIl.ABlE FOR MINOR MEDICAL EMERGENCIES UP TO AN INCLUDING T~CHEOTOMY" EMERGENCY CONTACTS ZA SEC Z} RONALD L, MORTON - 327-4499 OR 834-7555 CAROL KIRKENDALL -. 327-4499 OR 834-1791 UTILITY SHUTOFFS 2A SEC 3) A) GAS - E SIDE BLDG. FRONT CORNER B) ELECTRICAL - E SIDE Bl.DG, FRONT CORNER C) WATER -- FRor:·n SIDEWALK E OF MIDDLE Q) SPECIAL - NONE E> LOCK BOX - NO 2. NOTIFICATION / PUBLIC EVACUATION LAST CHANGE I / BY ~~~~~~~~~~ ~~øJL D-Aß-~. ~ ~ ~ ~ ~. ~ ~ ~& ~o~ RECO~~HfIS~~~~ ~ ~~ ~~ ~ 0.lU;~ ~J- WAA k JUWLJ r~ F ~lt.t~. PAGE 1 tZlZ3/8809:32 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-680Ø , ~ -. BUSINESS NAME GOLDEt~ATE EYE CENTER LOCATION 1001-150 TOWËR WY ID N_R Z 15-'000-001307 HIGH HAZARD RATING 2 3. HAZ MAT TRAINING SUMMARY, LAST CHANGE / / BY Cè~ ~ ~ ~ eu.u-ðJU_ óQ b -V (2U.J¿CL ~ ~ . ~ 1:w-Ð ~ ~,&l.L E-V ~~ ~). ~ ~ ~ ~(~OR;:OR~S~C~. p~~ ~~ ~~1flM-Q t ~ ~~ ~~ ~ ~ ù;L &P-~ ~~. ~,'n~M_l9"A--Q ~~ (tsz>~./~J ~~L~Jj) ~ Ll,r~~ .~~ [W-tlo&-o~~ £ -0) ~ OAR ~~ )ÏY\. ~~ 4. LOCAL EMERGENCY MEDICAL ASSISTANCE LAST CHANGE 08/12/88 BY ESTER ZA SEC 5) POTENTIAL EMERGENCIES AT THIS BUSINESS WOULÖ BE HANDLED BY PHYSICIAN OR REGISTERED NURSE. IF THEY L~ERE NOT AvAILABL.E, MERCY HOSPITAL - 2215 TRUXTUN AVE - 327-3371. PAGE Z 1 ZIZ318'8' 0!'r~2fZ" MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 .. BUSINESS NAME GOLDE~ATE EYE CENTER LOCATION 1001-150 TOWER WY FACILITY UNIT 01 10 filaR Z 15-000-001307 HIGH HAZARD RATING Z A.. OVERALL HAZARDOUS MATERIAl.S INVENTORY LAST CHANGE 10/13/88 BY ESTER 10 TYPE NAME l.OCATION CONTAINMENT ~THYLENE OXIDE CENTRAL SUPPLY ROOM PORTABLE PRESS. CYl. 10 PERCENT COMPONENTS 1204.00 100.0 ETHYl"ENE OXIDE ([PH> ldJ9lð I?-'O F5'8~D~ 2 PURE OXYGEN CHAA)NGING Rt1/RECOVERY RM PORTABLE PRESS, CYl, 10 PERCENT COMPONENTS 2359..00 100.0 OXYGEN, COMPRESSED MAX AMT UNIT HAZARD USE µ ~~'d-ðÒ ~ . -H8- FT3 EX/REME STERILIZING HAZARD LIST EXTRËM€ EP 557 FT3 HIGH MEDICAL AID OR PROCESS HAZARD UST HIGH B. fIRE PROTECTION 1 WATER SUPPLIES LAST CHANGE 08/12/88 BY ESTER 3A SEC 4) BLDe SPRINKLERS; EXTiNGUISHERS; ALARM PULLS; EVACUATION MAPS AND FIRE DRILLS ALL FOR FIRE PROTEcnON. 3fì SEC 5) FIRE HYDRANTS IN BACI< OF BLQ(~; ACROSS STREET FRONT EAST; ACROSS STREET FRONT WEST AND STANDPIPE CONNECTION FOR SPRINKLERS FRONT EAST CORNER. PAGE 3 tZlZ3/8B 0t:¡:3Z MATERIAL SAFETY DATA SYSTEMS. INC. (805) 649-6800 " , , .. BlJ5Ii\!ESS NAME GOLDE.ATE EYE CENTER LOCATION 1001-150 TOWER WY 10 NaR ZlS-000~ØØ13Ø7 HIGH HAZARD RATING Z O. EMPLOYEE NOTIfICATION I EVACUATION LAST CHANGE 0S/tZ/SS BY ESTER 3A SEC Z> NO EVACUATION NECE5SA~Y FOR OXYGEN RELEASE. EVACUATION NECESSARY FOR ËO RELEASE FOR 4 HOURS. E. MITIGATION I PREVENTION 1 ABATEMENT LAST CHANf,E 08/t use BY ESTER 3A SEC 1) ALL OXYGEN TANI<S ARE HELD BY SUPPORT-TRANSPORT CfiRRIERS OR ANCHORED TO THE Wf)LL WITH CHAIN. SERIES II ETHYl.ENE OXIDE CYLINDER (5" X 1 112") ARE KEPT IN CENTRAL SUPPLY ROOM DRAWER IN ORIGINAL SHIPPING BOX WITH SEPARATE SECTION FOR EACH CYLINDER. THEY ARE HANDLED ONLY WHEN USED AND EMPTY CONTAINERS ARE DISCARDED INTO TRASH AFTER USE AS PER MFG INSTRUCTIONS (NO GAS OR PRESSURE REMAINS}. CONTAINMENT OR CLEAN UP: RELEASE OF OXYGEN - NO CLEAN UP NECESSARY. GREATEST DANGER IS TANK FALLING WITH VALVE 8REAKING IN.JURING PERSONNEL VIA RAPID MOVEMENT OF TANK FROM PRESSURE WITHIN. RELEASE OF EO - OPEN ALL DOORS AND LET AIR Pf\SS FOR 4 HOURS. KEEP AIR FANS ON (AS PER MANUAL INSTRUCTIONS FROM COMPANY). PAGE 4 12/23/8B 09:32 MATER! AL SAFETY DATA SYSTEMS. I NC. (805) 648,-6800 f,re end Aqrlcu hurl '--' Stendlrd Bus'""s BUSINESS NAME: LOCATION: 0 CITY, ZIP: PHONE II: , 1 I ren, type looM tad. J .... Mt 5 Annue I fit , .....Ul'l Unit. . Aver... Mt " CIT}' of BAKER:il'l~LU ~ ~ :8: HAZARDOUS MATERXALS XNVENTORY' NON-TRADE SECRETS OWNER NAME: P LCì1ì LlJ! ~ h, ntL,~tí:JV\., rVÜì NAME OF TitS U-fJL!.TY: ADDRESS :t'JQ 5..d d..i...J. ..dJ. ./ . STANDARD IND. CLASS CODE CITY, ZIP: K /J~;:...o ~():'7./^ Cì ~ ~£.) C, DUN AND BRADSTREET NUMBER PHONE II: ,(~..I- f ':;'('"':. - ~ IUlI"D ro XlISnwcrXOD ro. 1'IfOIÞ" CØDØ <' ...... '.. II , IIIyI CII SI t. n . LocettCII..... 13 Ur . II __ of .t.t....tt _4' See IlIItl'llCtt_ -e (1_1 mt .. c:-t 12 .... C.U. ...... ,.'TI't ,.-, ,.-, r~ ,.-, ~ fll'lllll" 1..-..1 a..cttvtty 1..-..1 IIIleyed v.:N ~ Ill... 1..-..1 I....t.t. ....1 th of ,.....,. ....Ith "r J -..t 13 .... C.I.S. ..... , ""'I~I eN ....lth ....aN : It.." In tlllt ...1,) C.A.S. ....._ ( .1 .4111" .... C.A.S. ...... c..-t 12 .... u.s. ...... ,.-, ,.-., ~-, r--' ,.-, L _.. fll'l "'11I'd I.. _..I IIHcttvtty I.. -... IIII.yed I.. -... SuddIII ..I.... I.. -... I....t.t. ....Ith of 'I'IIIUI'I ....Ith ____JL______L____________~__________JL_____________J_..___l ~le.1 eN ....lth ......... (Check .11 tlllt ",I,) .......t IJ .... u.s. ..... -- --1. JL C.A.S. ..... .__________________ t'J J !Mt" .... C.A.S. ..... c..-t 12 .... C.I.S. ...... ,..-, ,.-, r-, r-' r-, L - ... fll'l Helll'd I.. _..I IIHctlvity I.. -... OII.yed I.. -... SudcIIn ..I.... I.. -... I....t.t. ....Ith of 'rllSUI'I ....hh ----------- -- c..c.-t 13 .... C.A.S. ...... I "fAGENCY CØlJacTS .. : I¡¡¡- I !I 't..-t ie,fiCII (Re.d end .jp .fter co.pJeting eU ."ction./ II c.rtify under IIIIIIlty of 1.. thlt I hi". DlrSCIIll1y ....Intd and .. f..ili.r .lth thl tnfor..tian .u..tttlll tn tht. II1II .nettac" ~tI. II1II thlt IInIll CII Iff inquiry of t.... tndt"i"'lIl'IIlClllib\. ,'or oit'ini"9 thl inf....ttan. I ..Ii.... thlt the .u"ittld int_tian is t!'VI. ICcur.t.. and c"'M /L.A;-A. , . J .£~~~~'~~~~r~rl-~~~~~~~1~r.törT¡¡¡(fiõriiinijriiiñ(ifi;¡ 5;¡ñit{;.(~ . ...------------------, Diti-¿~ :s - ,,1-________________ --- ¡; '.....¡; e tJ"':;t;!~~te fy£ Ronald L. Morton, M.D: Ronald M. Kosh, 0.0. (1 ,/ r 9); ~' November 10, 1988 Mr. Ralph Huey Hazardous Materials Division 2130 G street Bakersfield, CA 93301 Dear Mr. Huey; e . .~ '. ¡y/V .~ V vJV \~o1 ~ t r: f: ,'/ I:- NOli ", " l ~. j,9S..,:~f ,4/lt : ' - . "~..,.."" ...~.. ~ '" I¡~~....:~." As per our conversation of today I am enclosing the forms HM3777 and an amended form 4A-l for the correction of our inventory status of ethylene oxide. If there is a question, please call me at your convenience. My work hours are M - Th, 8:00 - 4:30. Thank you for your assistance in filling out the proper paperwork. You and your staff have been very helpful each time I have contacted your office and this means a lot. -Sincerely yours, .~ Lois Watkins, RN Operating Room Supervisor Enclosures - 2 , 1001 Tower Way, Suite 150 Bakersfield, CA 93309 805/327-4499 ~ '~ e e ACUTELY HAZARDOUS MATERIALS REGISTRATION FORM TIllS FORM MUST BE COMPLETED BY TIIE OWNER OR OPERATOR OF EACH BUSINESS IN CALIFORNIA WIllCH AT ANY TIME HANDLES ANY ACUTELY HAZARDOUS MATERIAL IN QUANTITIES GREATER THAN 500 POUNDS, 55 GALLONS OR 200 CUBIC FEET OF GAS AT STP.1 TIllS FORM SHALL BE COMPLETED AND SUBMITrED TO YOUR LOCAL ADMINISTERING AGENCY. (§25533 & 25536 Health & Safety Code) Note instructions on reverse Business Name GOLDEN STATE EYE CENTER Business Site Address 1001 Tower Way, Bakersfield, CA 93309 Business Mailing Address (if different) Business Phone (805) 327-4499 Business Plan Submission Date2 3-25-88 Process Designation3 surgical equipment sterilization ACUTELY HAZARDOUS MATERIALS HANDLED4 -USE ADDITIONAL PAGES IF NECESSARY- CHEMICAL NAME QUANTITY ETHYLENE OXIDE 22 cylinders(4 oz ea.) GENERAL DESCRIPTION OF PROCESSES AND PRINCIPAL EQUIPMEN-r5: Ben Venue Gas sterilizer for surgery items. System is completely enclosed with a venting system to the roof. Processing is automatic with no handling except to throw the cannister away after the process is completed. Aeratiòn has been 12 hours when cannister is handled. SIGNATURE ø~ TITLE OR Supervisor PRINTED NAME Lois Watkins, RN DATE November 10, 1988 California Office of Emergency Services FORM HM 3777 (1-15-88) - e ~ 40' ,t1 INSTRUCTIONS: Superscripts: 1. Quantities for RMPP compliance are "equal to or greater than" the minimum criteria and apply to chemicals handled "at anyone time". 2. Businesses handling reportable quantities of Acutely Hazardous Materials that have not submitted a business plan MUST contact local Administering Agencies. The business plan submission date will assure the Administering Agency that a business plan has been submitted and is on fIle. This will also immediately identify businesses that have not submitted business plans. 3. "Process Designation" is provided as a reporting option (with the approval of the Administering Agency) for facilities that can most easily report by process. Thus, facility RMPP registration data could be submitted in a similar fonnat to a business plan that is divided by process. "By process" data can initiate an emergency response to a process incident rather than a general emergency response to a major facility. Process designation can simplify inspections for major facilities and improve future emergency response. -~---"'-------~"'-- _. --~-- ~-~ -'-'- - "' ------ ---~ - - '.~--_. --------------~_. 4. Refer to the EPA list of Extremely Hazardous Substances from the Federal Register (Volume 52, No. 77, p. 13397 ~,April22, 1987). Each chemical has a threshold planning quantity. This list may be changed by EPA on an annual basis. Updates of this list may be available early in 1988. To comply with ÚÙs element, you may attach a copy of the inventory submitted to your Administering Agency from your business plan and highlight all Acutely Hazardous Materials. It is recommended that facilities list all extremely hazardous chemicals handled in quantities equal to or in excess of 1) 500 pounds, and 2) any EPA threshold planning quantity less than 500 pounds. 5. Do not include Trade Secret infonnation in these descriptions. General: For emergency response purposes, it would be desirable to describe the following to the Administering Agency: 1. Batch Process: &. What raw materials? b. What operating pressure range? c. What operating temperature range? d. Batch capacity rating? e. Product characteristics? (e.g., chemical state, flammability, toxicity, etc.) f. Critical process points and characteristics? 2. Continuous process: (similar infonnation as above.) Note: ---. - ---- .- --"'- - - -, - -- -- - . - --- - ---. ---. . .-. "Pursuant to §25534, the Administering Agency may require the submission of a Risk Management Prevention Program (RMPP), if the Administering Agency determines that the handler's operation may present an acutely hazardous materials accident risk. The handler shall prepare the RMPP in accordance with subdivision (c) [of §25534]. The RMPP shall be prepared within 12 months following thè request made by the Administering Agency pursuant to this section." (§ 25534 (a) Health and Safety Code) An amendment to the RMPP must be submitted to the Administering Agency within 30 days of: 1. Any additional handling of acutely hazardous materials. 2. Any material or substantial alterations to business activities. 3. Change of address, business ownership, or business name. (§ 25533 (c) HealÚ1 & Safety Code) · EVERY BUSINESS REQUIRED TO SUBMIT AN RMPP SHALL IMPLEMENT THE APPROVED RMPP . California Office of Emergency Services FORM HM 3777 (1-15-88) OWN!R "AMEI Ronald. L. Morton, MD F^CII.ITV UNIT': j, AIJURE881 7700 Saddleh:H~k PAC 11.1 TV UN I T NAME: surgi~ëiiIer II . AMEAI~~~ _ ~~E_ ~" UAK";.na:I~..1J tll\' ~IUI~ 1JLI'AUI..l:.lil FORM 4A-1 NON-TRADE SECRETS IIAZARDOUS MATERI ALS' INVENTORY '111<; II:SS NMIF.: Golden State Eye Center ',IIlIII':~S: 1001 Tower Way I I Y. 7. I ¡; : Gakersfield, CA 93309 I I II II E .: 32'1- 4lf:91j CITY,ZIPI Bakersfiel fi, CA ooz.'Z(\O PIIONB . I 8 34-7555 10 F F I C I A I. " 5 E C FIR S c n \I F I ONLY --- .", , 1111: :! :) ,,5 ß ., 8 9 'I^X ANNIIAI. (:o"T USR I.OCATION IN TillS · nY MWI/tll MltHJN1' UN I T euy!t cu!!~ f AC I L I TV UN I T 1fT, clIU!!ì.AL O.JLQºtH!ºN NAME 3Ö d .. - - ---;õ6- --~ .~ylinde~s ft3 04 36 Central supply room 100 Ethylene oxide l~o p, o¿I" . ~_ ~ dI /J '... "'.. ~ <. ;¡ ~. - -1. ,/J AI #,fJ 6P f!I' Æ'I,.,;"... Ú ./ff~ "A 11 ~. (J . (/ JJ (¡ ~ "" '='" f/ rø,¡ (f íf, ~ (1 if v ~ -v "'" "'" "'6 ~ 2 2 ft3 04 27 ~=8~~~§t!ftgF88æ 100 Oxygen - M cylinder ---.-- M p p .--.. - -- --- 100 Oxygen - E cylinder . 3-recovery area 3 3 ft3 04 27 .' ."" .- - .- . --- - --- r ;1(: C II r 10 "^7.^IW 11,,11 .. .s!WL !!~qP!: NFLG NFLG NFLG --.--.- -- -- --. --" ---.. -- ---.. , -- ---" --- --. --e --- -- -- - ...-" --.. - .. -. " - . .,"E' "l.J. l¡~atklns TïTï.E:AdfilJ.nl.strator SION^TUREI "l'.lIlir,iië:Ÿ-Ï;otnM:T: R. Morton, MlJ TITI.EI ·Director 'rill'" cnUTACT: Carol Kirkendall TITLEI Office Manap;er "^'" /lIISUII~SS ACTIVITY: l-\mbulatory ~urgery Center b~i¡ø rllONE . nuš-ÏinuRS: AFTER nus IIRS: P"ONE . nus "OURS: AFTER DUS. IIRS: - ..,,,-, - -'.' - '---::r::--;z -- ß ^ T E : --L. :.... r:.g g ! 327-4499 - 834-7555 327-4499 834-1791 ---- ,I .. e e CITY of BAKERSFIELD "WE CARE" FIRE DEPARTMENT D.S, NEEDHAM FIRE CHIEF OCTOBER 13, 1988 2101 H STREET BAKERSFILED, 93301 326·3911 GOLDEN STATE EYE CENTER 1001 TOWER WAY BAKERSFIELD, CA 93309 DEAR MS. LOIS WATKINS: THE"' ENCLOSED "ACUTELY HAZARDOUS MATERIALS REGISTRATION FORM" MUST BE COMPLETED BY ANY BUSINESS, HANDLING ~BOVE THE MINIMUM REPORTING QUANTITY OF ANY MATERIAL ON THE EPA LIST OF EXTREMELY HAZARDOUS SUBSTANCES. (FED. REGISTER VOL. 52, NO. 77, P. 13397). YOUR COMPANY HAS REPORTED HANDLING THE FOLLOWING ACUTELY HAZARDOUS MATERIALS: ETHYLENE OXIDE PLEASE RETURN THE COMPLETED ACUTELY HAZARDOUS MATERIALS REGISTRATION FORM TO: HAZARDOUS MATERIALS DIVISION 2130 G STREET _" BAKERSFIELD, CA 93301 IF YOU HAVE ANY QUESTIONS REGARDING THIS FORM PLEASE CALL RALPH HUEY AT 326-3979. SINCERELY YOURS, RALPH E. HUEY HAZARDOUS MATERIALS COORDINATOR REH/ed ENCLOSURE , . e e ----"' BAKERSFIELD CITY FIRE DEPAR~~ 2130 "G" STREET BAKERSFIELD, CA 93301 (805) 326-3979 RECEIVED MAR 2-8 1988 Ans'd.. .......... 1~;2 -3 ~ ~@MfJ, II "OFF I C rAL lJSE 'ONLY- :.~ c " !D#- u:01307 '. us H-mSS ~A.'1E , HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM .;?A Y!ù aJlo ~ =y:i2i2 Gt-é . - ,. 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 Golden State Eye Center A. BUSINESS NAME: B. LOCATION / STREET ADDRESS: CITY: Bakersfield 1001 Tower Way, Suite 150 ZIP: 93309 BUS.PHONE: (805) 327-4499 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. E~PLOYEES TO NOTIFY IN CASE OF E~ERGENCY: NAME AND TITLE ( . ) DURING BUS. HRS. AFTER BUS. HRS. A. Honald -£.. Morton, MD Dlrector Ph# 327-4499 Ph# 834-7555 B. Carol Kirkendall (Office Mgr.)Ph# 327-4499 Ph# 834-1791 SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE A. NAT. GAS/PROPANE: ea.st side building, front corner B. ELECTRICAL: same as gas C. WATER: front sidewalk east of middle D. SPECIAL: E. LOCK BOX: YES ,I NO IF YES, LOCATION: east side building toward front IF YES. DOES IT CONTAIN SITE PLANS? YES / ~ MSDSS? YES / NO FLOOR PLANS? YES /..s!L KEYS? YES / ~O Fire station has key - 2A - e e "'('. ..¡ ;.,.. .....' ;£..- " <to', , . x' SECTION 4: PRIVATE RESPONSE TE~~ FOR BUSINESS AS A WHOLE Physician and registered nurse available most times during business day.. When not, Mercy Hospi tal ~µickly available.. All employees CPR certi fied, and fire, disaster and CPR drills held regularly.. Ei~Pft~4~javailable for minor medical emergencies up to and including trecheostomy. _ SECTION 5: LOCAL EMERGENCY ~EDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE Potential emergencies at this bu'siness would be handled by physician or registered nurse. If they were not available, Mercy Hospital,is availabl e. " , '-".' SECTION 6, EMPLOYEE TRAINING ~~~:.~~" E~PLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES E~PLOYEES WITH INITIAL A~D REFRESHER TRAINING IN THE FOLLOWING AREAS. CIRCLE YES OR NO INITIAL A. ~ETHODS FOR SAFE HANDLING OF HAZARDOUS ~TERIALS:................. 0..0....0...........0. @ NO B. PROCEDURES FOR COORDINATING ACTIVIT~ES WITH RESPONSE AGENCIES:....o. ........, ........... 'NO C. PROPER USE OF SAFETY EQUIPMENT:.................. YES NO D. EMERGENCY EVACUATION PROCEDURES: ............., ..,. S NO E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ...,... YE NO REFRESHER @NO NO NO NO NO SECTION 7: HAZARDOUS MATERIAL CIRCLE YES * NO - NONE DOES YOUR BGSINESS HANDLE HAZARDOUS MATERIAL IX QUANTITIES,LESS'THAN.500 POGNDS OF A SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YES NO I. Lo/s. iuCL-tl·(j~r:;. if,;.), , certify that the above information is accurate. I understand that this information will be used to fulfill my firm's obligations under the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter 6.95 Sec. 25500 Et AI.) and that inaccurate information constitutes perjury. . SIGNATURE 1ijJ;t~ TITLE 1 ~ ¡idfn.¿11.«dr~ DATE -..3 - c:t s- -t J? - 2B - ;Oi..~'~ , e e BAKERSFIED CtTY FIR:: DF.P.\RT:EX7 2130 "G" STREET BAKERSFIELD. CA 93301 OFFICIAl CSE OXLY ID# ------ BUS INESS XA:'<Œ: BUSINESS PLAN SINGLE FACILITY UNIT FORM 3A INSTRUCTIONS 1. To avoid further action. this form must be returned by: 2. TYPE/PRINT YOGR ANSWERS IN ENGLISH, 3. Answer the questions below for THE FACILITI U~IT LISTED BELOW 4. Be as BRIEF and CONCISE as possible. - - .--" - -: FACILITY UNIT# FACILITY UNIT NA.'Œ: ,Gol'den State EÿeCenter " . - ~ . ~ , . " SECTION 1: MITIGATION. PREVENTION, ABATEME:\¡ï PROCEDURES _, __, 1. All Oxygen tanks. are 'hÈÜd by ~sup:port-~ranspòrt çarriedÜ3 or anchored to the wall with chain. Series II ethylene oxide cylinders (5"x1t") are Kept in ce~tral supply room dravyer in. origÜial shippingboxdw~ th separate section'f1?r ea~h cylinder., They are handledon~y when used an.d empty c6ntainers,are discarded into trash after use as per mfg. . instructions (no gas or'pressure remãins). 2. Containment or cleanup: release of oxygen - no cleanup necessary. Greatest danger is tank falling with valve breaking injuring personnel via rapid movement of tank from ,pressure Wi thin. ' Release of EO - Open all doors ånd let 'air pass for 4 hours - keep air fans on (as per manuel instructions from company.) SECTION 2: ~OTIFICATTON A~~ EVACGATICN PROCEDL~ES AT ~,IS L~TT O\LY No evaèuation necessary for oxygen release. Evacuation neê,essary for EO relecisefor:.4 hou;r:'s. - ~ , ,"'^ e e ,..~. , . , >. ,~ ,- .-¡ SECTIO~ 3: HAZARDonS ~ATERIALS FOR THIS ú)¡IT OXLY A. Does this Facility Unit contain Hazélråous :-1aterials?..,.. 6v ~O If YES, see B. If NO. continue with SECTIO~ 4. B. Are any of the hazardous materials a bona fide Trade Secret YES ~ If No, complete a separate hazardous materials inventory form marked: ~O~-TRADE SECRETS OXLY (white form :4A-1) If Yes, complete a hazardous materials inventory form marked: TRADE SECRETS O~LY (yellow form :4A-2) in addition to the non-trade secret form. List only the trade secrets on form 4A-2. SECTION 4: PRIVATE FIRE PROTECTTO~ :Building sprinkler6~:; Extinguishers: I each substerile area, waiting room, emergency exit. Alarm pulls: I each substeril e hall exit, changing room, wài ting room exi Evacuation maps: waiti~g room, substerile hall. .. S~8N <Y:;ïtó-ê.¿T'IO~eg¡tJÄTt~·SÙPPLY FOR USE BY E)ŒRGENCY RESPONDERS 1. Back of building 2. Across street·, fron fro'nt east 3. Across street from front west 4. ~Standpipe connection f6r,sprinklers front east corner SECTIO~ '6: LOCATIOX OF UTILITY SHUT-OFFS AT:THIS mnT .OXLY. A. XAT. GAS /PRO?\XE: East side Qf building, _fr~nt corner B. SLECTRICAL: Same I, 0, C. WATER: Front sidewalk, east' of m±ddle .~' , D. SPECIAL: 1:. LOCK BOX :@' ~O ::- YES, LOc.UIOX: East side of building toward front YES / @''';ò, YES / :ø i IF YES, SITE PLAXS? FLOOR PLAXS? ~[SDSs? :\:EYS? . YES / ß!à ~i~e/~tion has key - 33 - -- -- -- IIAKEItHa: 1 ~I.U G II\' i' I Uh, Ubl'AU I Ha.U' ~ FORM 4A-1 NON-TRADE SECRETS HAZARDOUS MATERI ALS' INVENTORY II . Pí1(:C (If __-I ...-. . ; . , . .. FACII.ITY UNIT t:______ UNIT NM'E: surp;ice!tt.er II\'; I rlESS NMIE: Golden State Eye Center \llIlnESS: 1001 'rower Way I I Y, 7. I\': Gakersfield, CA 93309 IIIIII F ': - 5¿,/-44:J:J OWNER NAHE: Ronåld. L. Morton, MD AUURESS: 7700 SRddlehR~k FACILITY CITY,ZIP: Bakersfjeld, r.A 93309 PIIONE .: 8"34-7555 " 507 C () N T II SRI, 0 CAT I ON I N T III S eu!!]., CU!![. _--EAC I L I TY UN I T ..~------ I ? :1 ,II ",^X ^NNII^J. , 1111. ~~'11J N 1 MIl) U N T UN I T };/ ,_ ~~." --- -:-;ññ- ~~;- 04 -1C/~' I~ ~; pQ~ ~~ ~. It3 04 27 I p --~ -. 6£. -ft3 -;-;:---;; J ---- 36 Centra..L SUPPLY .l. ~:8ßªìJ.~~:tfigf88m 3-recovery area _ 6:5 7 , ,~~67 -- ~--- lE-êff ~~tr - 7 é<3f3 710 36 '. -0Jn " ;}Þ~/ ---~~r1./v5' I~' /Y ., f / Air);; .Æ ~¿ '!H"/.' _ ~'D 7~ / .- ~f8f ~D'/vf:~ Q¿' \\)('/\- .. - -- -.----- ~ .--.-- .- ------- ---- o % nY WT. 1r\r\ 100 100 10 F Fie I A I. II SEe fiR S r: 11 ) r ONI.Y _u 10 \I^7.^III) ell E H Uì ^ L 0 .!L£Q!H!º.!Ll!A ME CO) E '~~4 , ,\ (;'/~ 1ï'+hylE'p.e- Oxid~o-J~O<Lb. - ,-" NFLG 9 I ' Oxygen _(M)cylinder Oxygen:- E cylinder ¿¿¡1 J;t j I d35, ~~ ~ --- - _.:.,\ Ii ¡:,: -------ïJ;-'viJatklns _ T I TI.E: Admlnlstrator 91 ONATURE I ~I Fin; Ëïiï:Ÿ-cõÎn ACT: ~. Morton, MD T I Ti,E I ,Director ~~-;ø C PJlONE' nus IIOURS: AFTER nus IIRS: PIIONE . nus IIOURS: AFTER BUS. IIRS: : Ii' 'I Ii r IIC Y cON T ^CT: Carol Kirkendall TITLE: Office Manap;er Illrîl'^L. III/SINESS ^CTIVITy:_AmbU..Latory ;:;urgery Center - II ,,--, - NFLG NFLG ),() 1 ~~V-'!I!: _e-- -'- - --- ----- -'- -- ------ ---. --' --- ---- ----.-.. ------ ---- .-~_.. . OA T E : 3.2f.--j, ~ 327-4499 834-7555 327-4499 834-1791 -, -..---- I ; , I ' .. '( ( c. e e FUNCTIONAL SAFETY PROGRAM FIRE PROTECTION PLAN Policy: To provide optimum response during a fire situation and delineate the emergency measures to be taken in the event of a fire condition. ' Equipment: 1. 2 fire alarm pulls: a. 1 in the substerile area exit outside the OR. b. 1 by the exit located next to men's changing area. c. 1 by the exit in the waiting room. 2. Phone to dial Fire Department a. 1 in the nursing station b. 1 in O.R. 3. A.B.C. fire extinguishers a. 1 in substerile area b. 1 in waiting room c. 1 by emergency exit 4. Evacuation maps a. 1 in Patient waiting area b. 1 in the substerile area Procedure: Any staff membe+ who notices a fire shall: 1. Call aloud "Code Red" to cormnunicate a fire or related condi tion. ' 2. Activate the nearest fire alarm pull box. 3. Dial the Fire Department and state: a. Type of fire b. Location of fire c. Possible injuries 4. Patient/family evacuation should begin irmnediately utilizing the closest and safest accessible route. The staff will usher patients out in a calm and orderly manner. 5. Contain or fight fire: a. Close all doors and windows " ( ( l e e FUNCTIONAL SAFETY PROGRAM PROCEDURE (Con't) b. All 0 valves turned off All efectrical equipment turned off if time, but leave lights on. Use fire extinguisher 1. Remove plastic tamper-check strap 2. Pull metal safety ring pin 3. Aim nozzle at base of fire 4. Squeeze handle to activate; release to stop c. d. 6. Staff assignments: a. Evacuate patients/family b. Close doors/windows c. Turn off 0 valves d. Fire extinðuishers manned e. Telephone attended f. All electrical equipment turned off (leave lights on) g. Important files taken All personnel shall be familiar with the fire protection plan and be able to take their assignments quickly during a fire drill. A fire drill for all personnel shall be performed quarterly and so logged with the unit report completed. 7. 8. Personnel shall also be ,instructed in the use of the A.B.C. fire extinguishers during the inservice education meetings at least once a year with attendance andparticipátion documented in the inservice education manual. 9. Inspection and charging of all fire extinguishers by qualified personnel will be performed by an independent contractor according to state and city codes. All reports will be filed in the Preventive Maintenance Manual. . ... .. ----"... e e . FUNCTIONAL SAFETY PLAN ( FIRE PROTECTION PLAN Fire Drill Assignments Doors closed Operating Room Nurse Recovery Area Nurse Admissions Area Admissions Staff Oxygen valves attended Operating Room Tech. Recovery Area Nurse Fire equipment attended Operating Room Tech. Recovery Area Surgeon Patients instructed Operating Room Surgeon ~ecovery Area Nurse Telephones attended Nursing Station Recovery Staff Electrical equipment Operating Room Tech. Recovery Area Nurse C' Files attended Nurses station Recovery Staff e L , e - f. ..~ ~",;~:~~::':;:;\<!:-_ - .;~),"" ... ---- ~ ~ --~..~ ~,.,'~~-,~:~ ~~ <~~_\:'~'" ,: :f'-:=~___ _ __ ...:_r ......' FIRE DRILL ( \ UNIT REPORT DATE NUMBER OF PERSONNEL ON HAND TIME ALARM SOUNDED BY WHOM TIME ALL DUTIES COMPLETED TIME "ALL CLEAR" SOUNDED EMERGENCY DUTIES DOORS CLOSED YES NO YES NO YES NO ( / YES NO ( YES ( NO ( YES ( NO ( OXYGEN VALVES ATTENDED PERSONNEL PROPERLY STATIONED PATIENTS/VISITORS INSTRUCTED FIRE EQUIPMENT ATTENDED (' ELECTRIC AND AIR CONDITIONING ATTENDED WERE EMPLOYEES: CONFUSED ( ) CALM ( ) ORGANIZED () EFFICIENT ( ) PROMPT ( ) HOW COULD DRILL BE IMPROVED? SIGNATURE DATE SIGNED SIGNATURES OF EMPLOYEES ON DUTY SIGNIFYING PARTICIPATION IN DRILL. 1. I ! ~> 2. 3. 4. l ¡ '1 , " .' r ~ I. I ( l r.:: e e FUNCTIONAL SAFETY PROGRAM DISASTER PREPAREDNESS POLICY: To insure effective performance during an emergency situation that will provide for the optimum safety of patients, visitors and personnel. PROCEDURE: A disruption of services may result from: a. severe weather conditions b. flooding c. earthquakes d. explosions e. fire (see fire protection plan) f. power outages (see emergency power plan) 1. A disruption of services is any occurrence that impedes, alters, or halts the ability of the Golden State Center from providing normal services. 2. The prime responsibility of all personnel is to remain calm and prevent undue alarm to patients, visitors and staff. 3. Immediate notification of the nature of the problem, location, and the actual or potential hazard should be directed to the surgeon or senior person present. 4. The person in charge shall be responsible for setting into motion that activity which will most effectively cope with the existing situation. 5. There will be annual disaster drills held by the surgicenter and as part of a community disaster drill. All drill critiques will be on file.