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Home My WebLink AboutBUSINESS PLAN 4/16/1999 :J\, CORRIDOR L \Y A.Iì\NG ROOM ð OFFICE ~CJ.n- L:J e'AIJAI-r &AI7"PAAI,~ BAtSs . !rUXfUN ~Ad¡'(Jhf}lj / <gï '7 Ti-u~ -/U N A t%f FI1(!¡,/"ly 1)/AØ"tftfV1 , 'S1~e I,D. l4CC l 1 , - MRI SUITE . ¡;; 0 ..,. '.. ò ... V ð 16' ," . :::' OFFICE ~l * ~O ~~~~\'t.~ ía . -$,--\ ~~W\ ~ - \2'-.' f~ DR. PAT~ OFFICE Pc:. 1> ta,~ . lì ". WAITING ROOM II . 17' I" It ," =i i " Q.v -J',.., R.F. X RA.Y NUCLEAR E ~ WAITING ROOM X RAY MAMMO/BIOPSY ULTRA SOUND MAMMO MAMMO I I i If 17 TrumJII AI,. :L1 , 7 v~\ \ ~~"\ ~~---\' ~ <I . ... § ~ :.. ~ ROOM J J '·-10· II '" -:/"'f"'~ 04/19/01 12: 19 'C61n 326 0576 e " BFD HAZ &fAT DIV - IiJ004 - - SITE DIAG~ (), IACIUIY DIAGRAM r , Business Name:=\~~ tJ ~A t) i 0\ oq '-1 r\ "c-b \ ~ \ ç, a.o..l ~ ' t... ,~ . Business Address: 1 ~ \\ ~ ~ t-ù "-' (\ v 1:.. . * t\) ~ ~ 1\ ~",/{h ~ '" ~ (V\ ~ \~t\ftl\ \ ~ "* ~ ~ ~ùti:) !Y\~\\~ j?l1,i¡¿~\~~ 'S~ ~~~«\ . 'I ,--'. , , ! ; r ~ >"'/1 'I f; '''1 I . 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' Permit ID #:: 01S..o00..o01491 TRUXTUN RADIOLOGY LOCATION: 1817 TRUXTUN AVE Issued by: I ¡ 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; , , " ' .. .', This permit Is Issued for the following: It) Hazardous MaterIals Plan o Underground Storage of Hazardous Materials o Risk Management Program o Hazardous Waste On-Site Treabltent Issue Date June 30, 2003 ',. ,.;- :.... .t, '. '~ . I~ BAt-SS 1 ----- . MR' SUITE '0 ;;:¡ .,. I ';1 v I e A '6' ," '- I - OFFICE m I f' ENTRANCE LOBBY 7' :" G . 17' " NUCLEAR E " ; i \~ ~1 X RAY MAMMO MAMMO MAMMO/BlOPSY @ .3> I.. "'f ULTRA SOUND If 17 7iumIII Â/,. ~ .~~~ ò .. . "ø <I .... ¡:.t- o "..., ... .. 0 .. § X RAY ~ e- X RAY . 0 .. WAITING ROOM CON TRO ROOM :]1. CORRIDOR L WAJnNG ROOM A OffiCE ~ ROOM t WAITING ROOM R.F. X RAY ,. ~D .,.,. U ~A/JAJ-r ¡¡AJ1PAAI~£ '2 ... ~' j \ ,'-ID' I~ Bllt.e.s(;~~ ~' I ., T ~5q)n'i~ Q·h.. \ I.. I I ,~ ~ I ;;; 0 oot' . . . 0. I èn W - 9' ~ 3/" 1"-'" 10' II 1/2' ~7'> I -==== I I I ~0...~_~ ./&1.- .... -, = . I~ .. .., l ¡-- .D IY!f\fk . ~ -¡~~... , ~- -. ~.'T"I#.M~ it , ",¡j Iê ~ .-.1';111,.. f/ljrI ~~I , ~ ~v -..~~ iY) MRI SUITE ttu:rHQNC (0J0I"W("' ;==: F - U ~A L::. A ':-1 ~ ~SSI ~ W TRANSCRIBING ... OFFICE - "O.~~ (~~ I 0. CORRIDOR 1 ~ ìVl r r\Jl " I ~ Œ 'QS~OO DARK RO M t v 16' 9- \ 6' 6" orncE .) . '- . A-. -- //.z ~/'/ ENTRANCE lOBBY -i" ~ _ 1I{"'ct " .., c ,. ,. ~. ,- II ",,, t ".,.. .- AAS L)Ioo( "... . c t:au1......tt:' /,.. .'.-,+-" ~..~ NUCLEAR MEß ~ s P ~~A W\ (- J nI. UL RA (IEJ SCJND, ø ~ REST~ REST . . ROOMl ~M fl f\11Ji - - ~. == 0. t:1iP I orn"l =:= - t"'" l ( 1<' "^" nát-. ørf})! -;,. li R..:! Ai rr t> 1=/1": Þ. DR. PATE®t> OFFICE Pc:. 1>þ v ø ;" II lll~~ ~~..... D/RK N SES· .- - þE: OM ; í\TlON -.0 'J ~ ~ ~ ' rl--- lJ\ ~ln c.......... \7' I' 'I a' 9" a' ,. ~ ~I WA TlNG IbRésSIN R~ 1.1 !RooM ) ~./ll= 12' 7' W """""9" o' ¡ \ \J\JnJLJ NUCLEAR E[ ~ X RAY MAMMO MAMMO ~ !Jo \~ J.. @ .3' fo< -IJ""f' 1- ULTRA SOUND ~ '. If 17 Tiw1IIII AlE. WAITING ROOM r 7 ~/a- MAMMO/BIOPSY 1 WAITING ROOM 0. C"1'" i- .;(-'p'vJ-rtr-'Jó I UJ-: .~ (j7 !:::::; - ~ I IUtI ¡ '''''''' 2 X RAY ~ I ¡ Q, ! ~ . rT ~ ..- (~ ~.R'\ ~ ~ Ii. --=-\j-§ ;r OFFICE \ ~ ZšR OfF:C~ ~ r~)RESSING \ u ~ WAITING ROOM :'i . OJ I . A II \7' 6' /'- FAIJN-r 8Nd.ANt.e- 0. "-.... LAJ 0. . \J 'GtST ES OFFICE f11~ä R u ~:=d :I~~~ X RAY X RAY -( ;UOARK \r /1....11 R00.Y-¡¡ CON TROl ROOM l> NURSES ::iI. CORRIDOR R.F. X RAY ( LJ r ~ - ~~~~ I~~:f .,"' ø tlt:-,:'. .~ J \ '·-10· II CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ADDRESS F ACILITY CONTACT INSPECTION TIME INSPECTION DATE PHONE NO. BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES Section 1: Business Plan and Inventory Program D Routine D Combined D Joint Agency D Multi-Agency D Complaint D Re-inspection OPERATION C V COMMENTS Appropriate pennit on hand Business plan contact infonnation accurate Visible address Correct occupancy Verification of inventory materials Verification of quantities Verification of location Proper segregation of material Verification of MSDS availability Verification ofHaz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardous waste on site?: Explain: DYes DNo Questions regarding this inspection? Please call us at (805) 326-3979 Business Site Responsible Party White - Env. Svcs. Yellow· Station Copy Pink - Business Copy Inspector: """,,- --- - \ . cusnle & NO. ft5 -':¿1~1 - MISCELLANEOUS RECEIVABLES ADJUSTMENT DATE3- Ib-:ß NEW ACCOUNT! ADDReSS CHANGE CLOSE ACCT I : FINANCE CHARGE I ~ I 'OTHERADJ !,~ CUSTOMER NAME ~ ùAo C\. Qad; 0 'ð~ '-\ (Y\~ct ca.-^. Gr MAILING ADDRESS \'bl~ \rù'{-\-~<\ À-v~ CITY bCL-h(:)~ ~ \6- STATE (V~.. ZIP CODE ~ ~ SITE ADDRESS i PARCEL NUMBER , (IF APPUCASLE) ADJUSTMENT i " R~;S:'o~: ~Ó ~<>rc-ha~~ sloJcÁ\re.... APPROVED BY -Vø~_~.y _. I: Per Ït Operil.te to Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This permit is issued for the following: :':~@~ardous Materials Plan , Of"~ ~;[sround Storage of Hazardous Materials "'q~gement Program """ Waste 1817 PERMIT ID# 015-021.001491 TRUXTUN RADIOLOGY LOCATION Issued by: TRUXTUN Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (805) 326-3979 FAX (805) 326-0576 Approved by: Expiration Date: June 30, 2000 ....... e e CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 r 0"t:cf6ÍÌ\ :J~7 I I FACILITY NAME·-rf<U)(W,.,) <;{A()fot.o(;.c( ADDRESS 1 g 17 TQ-J~TU¡J FACILITY CONTACT Lf:7J'Nc( INSPECTION TIME 14 30 INSPECTION DATE '119(, '~ PHONE NO. 3ÂS-- 6<tÞO BUSINESS ID NO. 15-210- NEvJ NUMBER OF EMPLOYEES ·;5.... '-{a Section 1: Business Plan and Inventory Program o Routine ~ Combined o Joint Agency o Multi-Agency o Complaint ORe-inspection OPERA TION C V COMMENTS Appropriate permit on hand ~ ~p ~ tJ.I1A-~~ A-n:<- Business plan contact information accurate ,/ Visible address V Correct occupancy ¡./ Veritìcation of inventory materials ;/ Veritication of quantities Ý Op'>TA,Né'> õrJ II\JSP<::L7fo-J Veritìcation of location I Proper segregation of material I Verification of MSDS availability V Verification ofHaz Mat training ./ Veritication of abatement supplies and procedures I Emergency procedures adequate V Containers properly laheled V Housekeeping 1I Fire Protection t/ Site Diagram Adequate & On Hand vi' vPr>A'1""éD C=Compliance V=Violation Any hazardous waste on site?: .. Yes 0 No Explain: vVÞc~-rE PHd'ic> e..ÆE-µ\- While - Env, Svcs, Pink - Business Copy /év 5 ¡I/"t AI'f Business Site Responsible Party Wf¡V8 Questions regarding this inspection? Please call us at (805) 326-3979 Y clio\\' . Station Copy Inspector: ..... ~.¡ -, Truxtun Radiology Medical Group November 17, 1998 Mr. Ralph Huey Bakersfield Fire Department 2101 H Street Bakersfield, CA 93301 Dear Mr. Huey: e RECEIVED NOV 1 8 1998 ~ tfy;~ \ L\ct l lL Girish Patel, M.D. Manjul Shah, M.D. Martha Wiedman, M.D. James Nichols, M.D Tony M. Deeths, M.D We are enclosing a signed Hazardous Materials Business Plan. There are no changes that need to be made at this time. If you have any questions, please feel fÌ'ee to contact me at 325-6800 ext. 149. Sincerely, ,~;;:Je- ~ <r-:2) Scott Ziemann Business Manager Truxtun Radiology Medical Group SZ Enclosure {> 1817 TrUxtun Avenue Bakersfield, CA 93301 (805) 325,6800 FAX (805) 325A734 (800) 464,9999 3940 San Dimas Street Bakersfield, CA 93301 (805) 325,6200 FAX (805) 325,4941 (800) 464,9999 .. - . e e j TRUxTÙN RADIOLOGY ~-'" ~ .; SiteID: 215-000-001491 Manager Location: 1817 TRUXTUN AVE City BAKERSFIELD NQV 1 8 1998 usPhone: ap : 102 Grid: 25B (805) 325-6800 CommHaz : UnRated FacUnits: 1 AOV: .---/ BY: CommCode: BAKERSFIELD STATION 01 EPA Numb: CAL000097824 SIC Code:8011 DunnBrad: Emergency Contact / Title Emergency Contact / Title LENNY KUSHMAN / SAFETY OFFICER SONNY DOSHI / CONTROLER Business Phone: (805) 325-6800x Business Phone: (805) 325-6800x 24-Hour Phone : (805) 589-5408x 24-Hour Phone : (805) 329-6912x Pager Phone : (805) 638-4597x Pager Phone : (805) 665-8418x Hazmat Hazards: React ImmHlth Contact : Phone: (805) 325-6800x MailAddr: 1817 TRUXTUN AVE State: CA City : BAKERSFIELD Zip : 93301 Owner GIRISH PATEL MD Phone: (805) 325-6800x Address : 1817 TRUXTUN AVE State: CA City : BAKERSFIELD Zip : 93301 Per±od : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Çertif'd: RSs: No Emergency Directives: THIS IS A WASTE TREATMENT SITE WHICH REQUIRES A JOINT INSPECTION. PLEASE CALL ENV SVCS TO SCHEDULE THIS INSPECTION WITH HOWARD WINES. ALSO CALL AHEAD TO THE FACILITY TO MAKE ARRANGEMENTS FOR INSPECTION. One Unified List ì All Materials at Site ì p= Hazmat Inventory p== As Designated Order Hazmat Common Name... SpecHaz EPA Hazards DailyMax MCP 32 GAL Min 80 GAL Min 110 GAL Mod WASTE FIXER R L WASTE DEVELOPER R L PHOTOGRAPHIC FIXERS R IH L I, ~.z)ek-,o...__ Do hereby certify that I have (Type Of pltllt name) reviewed the attached hazardous materials manage- ,~ ~-+v.... 12~ cl í~ I05Y ment plan for M~ <:1- c;:; y~ and that it along with (Name of Buaiheaa) any corrections constitute a complete and correct man- agement plan for rAy facility. tt.:, , ~\~' . . ~;d~~ Signan:ro g'V'~ lc.J f.S'..s MAd At;~ .:~~ JJ) ,¿,c:,~ Date . 10/01/1998 -- I I j e e . F TRUXTUN RADIOLOGY f= Inventory Item 0001 i== COMMON NAME / CHEMICAL NAME WASTE FIXER WASTE PHOTOGRAPHIC FIXER Location within this Facility Unit AT EACH OF FOUR PROCESSORS IN BLDG SiteID: 215-000-001491 ì Facility Unit: Fixed Containers at Site ì Days On Site 365 Map: Grid: CAS # STATE - TYPE Liquid Waste PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container 5.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 32.00 GAL Daily Average 32.00 GAL %Wt. I Silver HAZARDOUS COMPONENTS ~ CAS # I 7440224 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min HAZARD ASSESSMENTS f= Inventory Item 0002 = COMMON NAME / CHEMICAL NAME WASTE DEVELOPER PHOTOGRAPHIC DEVELOPER WASTE Location within this Facility Unit AT EACH OF FOUR PROCESSORS IN BLDG Facility Unit: Fixed Containers at Site ì Days On Site 365 Map: Grid: CAS # STATE - TYPE Liquid Waste PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE DRUM/BARREL-NONMETAL Largest Container 30.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 80.00 GAL Daily Average 40.00 GAL HAZARD US E %Wt. RS CAS # Silver No 7440224 Potassium No 7440097 o COMPON NTS HAZARD S E T TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min A S SSMEN S -2- 10/01/1998 e e 'Õ SiteID: 215-000-001491 ì Facility Unit: Fixed Containers at Site ì F TRUXTUN RADIOLOGY f= Inventory Item 0003 = COMMON NAME / CHEMICAL NAME PHOTOGRAPHIC FIXERS Days On Site 365 Location within this Facility Unit AT EACH OF FOUR PROCESSORS IN BLDG Map: Grid: CAS # 64-19-7 STATE - TYPE Liquid Mixture PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container 30.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 110.00 GAL Daily Average 55.00 GAL %Wt. RS CAS # 46.00 Ammonium Thiosulfate No 7783188 2.00 1,2-Butylene Oxide No 106887 5.00 Acetic Acid Solution No 64196 HAZARDOUS COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R IH / / / Mod HAZARD ASSESSMENTS -3- 10/01/1998 ~ e e ~ SiteID: 215-000-001491 9 Fast Format 9 Overall Site 9 I F TRUXTUN RADIOLOGY I p= Notif./Evacuation/Medical r== Agency Notification Employee Notif./Evacuation 02/02/1998 SUPERVISORS WILL DIRECT ACTIVITIES OF THE STAFF MEMBER IN THEIR AREAS 1) ASSIGN PERSONNEL TO TAKE FIRE EXTINGUISHERS AND REPORT TO THE SCENE OF THE FIRE. 2) CALM AND REASSURE ANY PATIENTS WHO MAY BE IN YOUR AREA. 3) TURN OFF ALL EQUIPMENT AT THE MAIN SWITCHES. 4) TURN OFF ALL WATER IN THE DARKROOM. TURN OFF FANS, BLOWERS AND DRYERS. 5) ASSIGN PERSONNEL TO CLOSE ALL DOORS, FILE CABINETS, ETC. REMEMBER THAT THE PATIENTS AND THEIR FAMILIES WILL REACT TO YOU. STAY CALM, IF YOU ARE IN DOUBT OF WHAT YOU SHOULD BE DOING OR WHERE YOU SHOULD BE, CHECK WITH YOUR SUPERVIROS. Public Notif./Evacuation 02/02/1998 1) PATIENTS AND PERSONNEL IN THE WEST WIND OF THE FACILITY, THIS INCLUDES X-RAY, CT, PATIENT WAITING RM, THE BREAKROOM, DOCTOR'S READING ROOM AND DARKROOM ARE TO USE THE EXIT AT THE S END OF BLDG, OR THE EXIT IN THE PATIENT WAITING AREA. 2) PATIENTS AND PERSONNEL IN THE MRI SUITE AND DR SHAH'S OFFICE SHOULD USE THE EXIT BY THE TIME CLOCK. 3) PATIENTS AND PERSONNEL IN THE FRONT OFFICE, WAITING AREA, AND CHILDREN'S PLAYROOM CAN EXIT OUT OF THE CLOSEST EXIT FROM THE LOBBY. 4) PATIENTS AND PERSONNEL IN THE WOMEN'S CENTER, US, NUCLEAR MEDICINE AND DR PATEL'S OFFICE SHOULD USE THE EXIT AT THE E END OF BLDG IN NUCLEAR MEDICINE. 5) PERSONNEL WHO ARE ON THE SECOND FLOOR SHOULD USE EITHER SET OF STAIRS AND EXIT FROM EITHER THE DOOR BY THE TIME CLOCK OF THE FRONT DOOR. IT IS THE RESPONSIBILITY OF ALL PERSONNEL TO ASSURE THAT ALL PATIENTS ARE ESCORTED OUT OF THE BLDG TO A SAFE AREA. ALL PERSONNEL AND PATIENTS ARE TO MEET IN THE PARKING LOT ADJACENT TO DR PRAGATI PATEL'S OFFICE ON THE E SIDE, ACROSS THE ALLEY. EACH SUPERVISOR IS RESPONSIBLE FOR MAKING A FINAL CHECK INTHEIR AREA TO ASSURE THAT NO ONE IS LEFT BEHIND. Emergency Medical Plan -4- 10/01/1998 ~ e e ro . SiteID: 215-000-001491 ì Fast Format ì Overall Site 1 02/02/1998 F TRUXTUN RADIOLOGY I f= Mitigation/Prevent/Abatemt Release Prevention ALL HAZARDOUS CHEMICALS ARE STORED IN CONTAINERS ADJACENT TO EACH OF THE X-RAY PROCESSORS. ALL OF THE X-RAY PROCESSORS HAVE BEEN INSTALLED IN ACCORDANCE WITH LOCAL CODES. THEY ARE VENTED DIRECTLY OUR OF THE BLDG. THE CHEMICAL BY PRODUCTS OF PROCESSING FILM IS FILTERED THROUGH AN APPROVED WASTE TREATMENT SYSTEM. THESE TANKS ARE CHANGED ON A QUARTERLY BASIS BY JIM WARREN X-RAY SOLUTION SERVICE. IN ACCORDANCE WITH STATE, COUNTY AND CITY REGULATIONS, THE WASTE WATER LEAVING THE TREATMENT SYSTEM IN MONITORED QUARTERLY. SAMPLES ARE TAKEN AND SENT TO THE LAB FOR ANALYSIS. THESE REPORTS ARE VERIFIED AND SENT TO THE COUNTY. THE CLOSED TREATMENT TANKS ARE STORED IN THE FACILITY FOR NO LONGER THAN 30-60 DAYS AFTER CLOSE. THEY ARE DISPOSED OF BY JIM WARREN X-RAY SOLUTION SERVICE. A COPY OF THE MANIFEST IS KEPT ON FILE BOTH HERE AND WITH JIM WARREN X-RAY SOLUTION SERVICE. Release Containment 02/02/1998 EACH EMPLOYEE WILL ATTEND AN IN SERVICE ON HAZARDOUS MATERIALS ANNUALLY. THE FIRST STEP IS CONTAINMENT. AS SOON AS A SPILL OF ANY KIND HAS OCCURED, INSURE THAT THERE IS AS MINIMAL SPREAD AS POSSIBLE. THIS CAN BE DONE BY POURING CAT LITTER COMPLETELY AROUND THE SPILL. THE CAT LITTER CAN BE FOUND IN EACH DARKROOM AND BY EACH LASER CAMERA. POUR AS MUCH LITTER AS NEEDED, IN THIS CASE MORE IS BETTER. REMOVE ALL PATIENT FROM THE AREA OF THE SPILL SO THAT THEY ARE NOT EXPOSED TO ANY OF THE FUMES THAT MAY BE PRESENT. TO INSURE THAT YOU ARE NOT EXPOSED TO ANY UNNECESSARY CHEMICALS, PLEASE WEAR GOLVES, GOGGLES, FILTRATION MASK, DISPOSABLE COVERALL, AND DISPOSABLE BOOTIES. NOTIFY THE LEAD TECH FOR THAT AREA, AS WELL AS THE SAFETY OFFICER. Clean Up 02/02/1998 SLOWLY SWEEP THE CAT LITTER TOWARDS THE CENTER OF THE SPILL WITH THE BROOM PROVIDED FOR THIS PURPOSE. ALLOW AS MUCH TIME AS NECESSARY FOR THE CAT LITTER TO ABSORB TO THE SPILL. WHEN YOU FEEL THAT THE CAT LITTER HAS ABSORBED ALL OF THE SPILL, SWEEP UP THE LITTER USING THE DUSTPAN ATTACHED TO THE BROOM AND PLACE IT IN THE RED WASTE CAN PROVIDED. WHEN THE SPILL IS COMPLETELY DRY, PLACE ALL OF THE DISPOSABLE YOU ARE WEARING INTHE CAN AS WELL (EXCEPT FOR THE GOGGLES). IF DURING THE COURSE OF CLEANING OF THE SPILL, YOU GET SOME OF THE CHEMICALS ON YOU, IMMEDIATELY REPORT IT TO YOUR LEAD TECHNOLOGIST. FLUSH THE AREA WITH WATER, AND HAVE A DOCTOR LOOK AT THE SITE. IF YOU SPLASH SOME OF THE CHEMICAL INTO YOUR EYES, THERE IS AN EYE WASH STATION IN THE WOMEN'S CENTER DARKROOM. YOU MUST FILL OUT AN INCIDENT REPORT, AND THEN BE SENT TO BE SEEN BY A DOCTOR. SEAL THE CAN AND PLACE IT IN THE NUCLEAR MEDICINE DEPARTMENT FOR PICK UP BY BFI MEDICAL WASTE. AN INCIDENT REPORT MUST BE FILLED OUT, BY THE TECHNOLOGIST THAT CLEANED UP THE SPILL. ONE COpy GOES TO THE SAFETY OFFICER, A COPY TO THE ADMINISTRATOR, Other Resource Activation -5- 10/01/1998 '. e e .' SiteID: 215-000-001491 1 Fast Format 1 Overall Site 1 I F TRUXTUN RADIOLOGY I p= Site Emergency Factors r== Special Hazards Utility Shut-Offs 02/02/1998 A) GAS - B) ELECTRICAL - C) WATER - D) SPECIAL - E) LOCK BOX - Fire Protec./Avail. Water 02/02/1998 PRIVATE FIRE PROTECTION - NEAREST FIRE HYDRANT - Building Occupancy Level -6- 10/01/1998 'J' ., ~ '. e -- e SiteID: 215-000-001491 ì Fast Format =¡ Overall Site ì 02/02/1998 F TRUXTUN RADIOLOGY I F Training Employee Training WE HAVE BETWEEN 35-40 EMPLOYEES AT THIS FACILITY. WE DO HAVE MSDS SHEETS ON FILE. BRIEF SUMMARY OF TRAINING PROGRAM: HAZARD COMMUNICATION AND MSDS. Page 2 [ I I Held for Future Use Held for Future Use -7- 10/01/1998 · r- 'i I; .. , - It - ... CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (805) 326-3979 INSTRUCTIONS: I. 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. SECTION 1: BUSINESS IDENTIFICATION DATA BUSINESS NAME: ---,-n.u~TVtJ P-AD1ùt-O(p.Y LOCATION: 1 ß {ì TI2.c..J'IlTVJ\J AJ MAILING ADDRESS: CITY: STATE: ZIP: 0 ( PHONE: Sz.s--6~ DUN & BRADSTREET NUMBER: SIC CODE: PRIMARY ACTMTY: OWNER: Gr (Q.IS~ PATEL "'1..1>- MAILING ADDRESS: s~~ SECTION 2: EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE 1. L~NftI 5"'$5~- ~4Pß" KcJ$~ IY\A,J ~APc~ CJ'Æ SZ.~-b~ P6- G? ~ 4917 t( 176-. 3 "'Lq - (Óq (L 2. ~t9AJ,vy DO~U-I Ct;1'-J~o~~ (ó(i,s:-- ~41 g- ~tO¿ 14µ-fl.,<;' r AoM,¡V ¿ ~G- "31>Ç" 3$"'17 ~"""11R1/ {?ð?< ~ .::...-=- ¡ 't4Þ6n: ~CJ1..."''''1c'''''r- ~L.I 'Í'r" ~ ~t.. ~ ~c)t..v«' INsPécr,o-j- ~~; eAt..L ~ "'TO ~1.1~ \D ~ ItV<;PB-r<~ e - HAZARDOUSMATEWALSMANAGEMENTPLAN SECTION 3: TRAINING NUMBER OF EMPLOYEES: 3~ --- 4ò MATERIAL SAFETY DATA SHEETS ON FILE: <yE-S BRIEF S~Y OF TRAINING PROGRAM: ~'Z. - CcJ>0 ' ~ M S1)S SECTION 4: EXEMPTION REQUEST I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH & SAFETY CODE" FOR THE FOLLOWING REASONS: WE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION I, LéN,.,;1,I }<ú5-#YVI A-¡J CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT TIllS INFORMATION WILL BE USED TO FULFilL 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 INFORMATION CONSTITUTES PERJURY. ~"£ ~rn1 M¡Pél' ~ TITLE ~f(¡ç/ DATE 2 ,~ - . . HAZARDOUSMATE~S~AGEMŒNTPLAN SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES A. AGENCY NOTIFICATION PROCEDURES: 51;6 Åt ~~-'> p~-.I)uttB B. EMPLOYEE NOTIFICATION AND EVACUATION: C. PUBLIC EVACUATION: D. EMERGENCY MEDICAL PLAN: 3 - e' HAZARDOUSMATE~LSMANAGEMENTPLAN 0- SECTION 7: MITIGATION. PREVENTION AND ABATEMENT PLAN A. RELEASE PREVENTION STEPS: B. RELEASE CONTAINMENT AND/OR MINIMIZATION: C. CLEAN-UP PROCEDURES: SECTION 8: urn..ITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACll.ITY) NATURAL GAS/PROPANE: ELECTRICAL: WATER: SPECIAL: LOCK BOX: YESINO IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/W ATER A V AILABll.ITY .A. PRIVATE FIRE PROTECTION: B. WATER AVAILABILITY (FIRE HYDRANT): 4 YRDOUS MATERIALS INVENT.V Address '. Business Name Page_of_ CHEMICAL DESCRIPTION I) rNVENTOR Y ST A 111S: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] I . ,,~.-:::. P~~..(IC- ç¡ X. =n 2) Common Name: (/V (<-... ç' - 3) DOT /I (optional) Chemical Name: 4) Physical & Health Hazard Categories Fire [ ] Reactive [ AHM [ ] CAS /I PHYSICAL HEALTH ] Sudden Release of Pressure [ ] Inunediate Health (Acute) [ ] Delayed Health (Chronic) ~ (3~git code from DHS Form 8022) USE CODE 46 5) WASTE CLASSIFICATION 6) PHYSICAL STATE Solid [ Liquid &2') Gas [ ] Pure [ 7) AMOUNT AND TIME AT FACILITY.. "2- Maximum Daily AmOWlt ~ Average Daily AmOWlt 3 2- Annual AmOWlt ~40 Largest Size Container ç- /I Days on Site '5 t?ç UNITS OF MEASURE Lbs [ ] Gal t5) ft3 [ Cwies [ ] Circle Which Months: 9)~: Li~ the three mo~ hazardous 1 ) chemical components or 2) any ARM components 3) COMPONENT IO)LOCATION AT ~..c ~ ~ PIlOcß;soe-S ,"'; ßëD<e- Mixture [ ] Waste £* Radioactive [ 8) STORAGE CODES (o a) Container: b) PresSW"e: ( c) Temperature 4- All Year, J, F, M, A. M, J, J, A. S, 0, N, D CAS/I %Wf AHM [ ] [ ] [ ] 2) Common Name: 1) INVENTORY STA111S: New ~ Addition [ ] Revision [ ] Deletion [ ] Check ifchemical is a NON Trade Secret [ ] Trade Secret [ ] v~p~ ,'- D6Jr;;u::>Pf?L- 3) DOT # (optional) 4) Physical & Health Hazard Categories AHM[ ] CAS# PHYSICAL HEALTH Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Inunediate Health (Acute) [ ] Delayed Health (Chronic) [ Chemical Name: 5) WASTE CLASSIFICATION (3~git code from DHS Form 8022) 6) PHYSICAL STATE Liquid ~ Gas [ ] Pure [ Solid [ 7) AMOUNT AND TIME AT FACILn:Y_ Maximum Daily AmOWlt <=60 Average Daily AmOWlt ~ Annual AmOWlt 'BÐD Largest Size Container ~D /I Days on Site 'S b ç UNITS OF MEASURE Lbs [ ] Gal fé>J ft3 [ ] Curies [ ] Circle Which Months: 9)~: Li~ the three most hazardous chemical components or any AHM components COMPONENT 1) POT'ð.C:;IIJt'V\ ' 2) 3) USE CODE Mixture~ Waste [ 1 Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c ) Temperature All Year, J, F, M, A. M, J, J, A, S, 0, N, D CAS# %Wf AHM [ ] [ ] [ ] lO)LOCATION AT ~ C>F FVulL ftlockÇSd2.> IN 1$.L1X=r I certifY Wider penalty of law, that I have personally examined and am familiar with the infiz¿onnation ., and 011 attaclæd - I believe the submitted information is true, accurate and complete. _ L...CIl('~ /CUJH'-"'A,., CIV"" r r 511Ft O'ñ:. I ¡{¡fir PRINT Name & Title of Authorized Company R resentative -- Signature Date aw-RDOUS MATERIALS INVENTOI Address - Business Name CHENUCALDESCRDnnON Page_of_ I) lNVENTOR Y STATUS: New ( ] Addition [ ] Revision ( J Deletion ( Check if chemical is a NON Trade Secret ( ] Trade Secret ( ] 2) Common Name: P~cx:;.J?þ...p¡,fIc.... Ft K G<- 3) DOT ## (optional) Chemical Name: AHM [ ] CAS ## 4) Physical & Health PHYSICAL REAL rn Hazard Categories Fire ( J Reactive ( ] Sudden Release of Pressure ( J Immediate Health (Acute) ( 1 Delayed Health (Chronic) ( 5) WASTE CLASSIFICATION 6) PHYSICAL STATE Solid [ (3-<ügít code ftom DHS Form 8022) USE CODE Liquid ~] Gas [ ] Pure [ Mixture [~ Waste [ ] Radioactive [ 7) AMOUNf AND TIME AT FACILITY Maximum Daily Amount 1/0 Average Daily Amount ~ Annual Amount It.!/(;;){:;? Largest Size Container 30 ## Days on Site ~bÇ UNITS OF MEASURE Lbs[ lGal~]ft3[ J Curies [ ] Circle Which Months: 9) MIX11JRE: List the three most hazardous chemical components or any AHM components COMPONENT I) Afs11'1ðN I¡)JV'\ (:1.11 O,$(J LP.t1 'iE" 2) A<:-tETtc... Ac-tl> 3) IO)LOCATION 8) STORAGE CODES ~ a) Container: / ~ b) Pressure: ( c ) Temperature q.. AU Year, J, F, M, A. M, J, J, A. s, 0, N, D CAS## Øc.>77~-I?~ <04- lCf -7 %Wf (ç- !) AHM [ J [ ] [ J A I C~ 0 F fë>c.J~ PfWGEs Sdl-S ¡Ai ß.LC>&- I) INVENTORY STATUS: New [ J Addition [ 1 Revision ( J Deletion ( J Check if chemical is a NON Trade Secret [ ] Trade Secret ( ] 2) Common Name: 3) DOT ## (optional) Chemical Name: ARM [ J CAS ## 4) Physical & Health PHYSICAL REALm Hazard Categories Fire ( J Reactive ( J Sudden Release of Pressure ( ] Immediate Health (Acute) ( J Delayed Health (Chronic) ( 5) WASTE CLASSIFICATION (3-<ügít code ftom DHS Form 8022) 6) PHYSICAL STATE Pure [ Solid [ Liquid [ Gas [ ] 7) AMOUNr AND TIME AT FACILITY Maximum Daily Amount Average Daily AmO\Dlt Annual AmO\Dlt Largest Size Container ## Days on Site UNITS OF MEASURE Lbs[ JGal( Jft3( J Curies [ ] Circle Which Months: 9)MIX11JRE: List the three most hazardous I) chemical components or 2) any ARM components 3) COMPONENT IO)LOCATION USE CODE Mixture [ ] Waste [ J Radioaçtive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, J, F, M, A. M. J, J, A. S, 0, N, D CAS## %Wf AHM [ 1 [ J [ ] r certitÿ under penalty of law, that I have personally examined and am familiar with the information on this and all attached documents. 1 believe the submitted information is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date HAZARDOUS MATERIALS INVENTORY e Address e I) INVENTORY STATUS: New { 1 Addition [ 1 Revision [ 1 Deletion [ ] Check if chemical is a NON Trade Secret[ 1 Trade Secret ( ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) Physical & Health PHYSICAL HEAL 111 Hazard Categories Fire [ 1 Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ . Business Name , '. CHEMICAL DESCRIPTION 5 ) WASTE CLASSIFICATION (3-digít code ftom DHS Form 8022) 6) PHYSICAL STATE Solid [ Liquid [ Gas [ ] Pure [ 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container # Days on Site UNITS OF MEASURE Lbs[ ]Gal( ]ft3( ] Curies [ ] Circle Which Months: 9)~: Li~ the three mo~ hazardous I) chemical components or 2) any AHM components 3) COMPONENT 10)LOCATION Page_of_ USE CODE Mixture [ ] Waste ( ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, I, F, M, A. M, I, I, A., S, 0, N, D CAS# %Wf AHM ( ] ( ] ( ] 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion ( ] Check if chemical is a NON Trade Secret [ ] Trade Secret ( ] 2) Common Name: 3) DOT # (optional) Chemical Name: ARM [ ] CAS # 4) Physical & Health PHYSICAL HEAL 111 Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) ( 5) WASTE CLASSIFICATION (3-digít code ftom DHS Form 8022) 6) PHYSICAL STATE Gas [ ] Pure [ Solid [ Liquid [ 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container # Days on Site UNITS OF MEASURE Lbs[ ] Gal [ ]ft3[] Curies [ ] Circle Which Months: 9) MIXTURE: Li~ the three most hazardous I) chemical components or 2) any AHM components 3) COMPONENT 10)LOCATION USE CODE Mixture [ ] Waste [ ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, I, F, M, A., M, I, I, A., S, 0, N, D CAS# %Wf AHM [ ] [ ] [ ] I certi1ÿ under penalty of law, that I have personally examined and am familiar with the infonnation on this and all attached documents. I believe the submitted infonnation is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date ~RDOUS MATERIALS INVENT. Business Name Address CHEMICAL DESCRIPTION Page_of_ I ) rNVENTOR Y STATUS: New [ ) Addition [ ) Revision [ ) Deletion [ ) Check if chenùcal is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) OOT II (optional) Chemical Name: ARM [ ] CAS II 4) Physical & Health PHYSICAL HEALTH Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5 ) WASTE CLASSIFICATION (3-digit code from DHS Fonn 8022) 6) PHYSICAL STATE 'Pure[ Solid [ Liquid [ Gas [ ] 7) AMOUNT AND TIME AT FACILITY Maximwn Daily Amount Average Daily Amount Annual Amount Largest Size Container II Days on Site UNITS OF MEASURE Lbs [ ] Gal [ ] ft3 [ Cwies [ ] Circle Which Months: 9)~: Lim the three mom hazardous 1) chemical components or 2) any AHM components 3) COMPONENT lO)LOCATION USE CODE Mixture [ J Waste { ] Radioactive ( J 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, J, F, M. A. M. J, J, A. S, 0, N, D CASII %Wf AHM [ ] ( ] [ ] 2) Common Name: 1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check ifchemical is a NON Trade Secret [ ] Trade Secret [ ] 3) OOT II (optional) AHM { ] CAS II PHYSICAL HEALTH Fire [ ] Reactive { ] Sudden Release of Pressure { ] Immediate Health (Acute) [ ] Delayed Health (Chronic) ( Chemical Name: 4) Physical & Health Hazard Categories 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) 6) PHYSICAL STATE Pure [ Solid [ Liquid [ Gas [ ] 7) AMOUNT AND TIME AT FACILITY Maximwn Daily Amount Average Daily Amount Annual Amount Largest Size Container II Days on Site UNITS OF MEASURE Lbs [ ] Gal [ ] ft3 [ Curies [ ] Circle Which Months: 9)~: Lim the three most hazardous 1) chemical components or 2) any AHM components 3) COMPONENT IO)LOCA TION USE CODE Mixture { J Waste { ] Radioactive ( 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, J, F, M. A. M. J, J, A. S, 0, N, D CASII %Wf AHM ( ] ( J ( ] { certify under penalty of law, that I have personally examined and am familiar with the infonnation on this and all attached documents. I believe the submitted infonnation is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date - Busmess Name HAZARDOUS MATERIALS INVENTORY e e Address Page_of_ I ) [NVENTOR Y ST A 111S: New [ ) Addition ( J Revision [ J Deletion [ J Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) DOT 1# (optional) Chemical Name: ARM [ J CAS 1# 4) Physical &. Health PHYSICAL HEAL 111 Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure ( ] Immediate Health (Acute) ( ] Delayed Health (Chronic) [ .. CHEMICAL DESCRIPTION 5) WASTE CLASSIFICATION (3-digit code &om DHS Form 8022) 6) PHYSICAL STATE Solid [ Liquid [ Gas [ ] Pure [ 7) AMOUNT AND TIME AT FACILITY Maximwn Daily Amount Average Daily Amount Annual Amount Largest Size Container 1# Days on Site UNITS OF MEASURE Lbs( ]Gal( ]ft3( ] Curies ( ] Circle Which Months: 9) MIXTURE: List the three most hazardous I) chemical components or 2) any ARM components 3) COMPONENT USE CODE Mixture [ ] Waste ( ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature All Year, I, F, M. A. M. I, I, A. S, 0, N, D CASI# %wr AHM [ ] [ ] [ ] IO)LOCATION 2) Common Name: I) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Seaet [ ] Trade Seaet [ ] Chemical Name: 3) DOT 1# (optional) AHM [ ] CAS 1# 4) Physical &. Health PHYSICAL HEAL 111 Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code 1iom DHS Form 8022) 6) PHYSICAL STATE Gas [ ] Pure [ Solid [ Liquid [ 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container 1# Days on Site UNITS OF MEASURE Lbs[ ]Gal[ ]ft3[ ] Curies [ ] Circle Which Months: 9) MIXTURE: List the three most hazardous I) chemical components or 2) any ARM components 3) COMPONENT USE CODE Mixture [ ] Waste ( ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature AU Year, I, F, M. A. M. I, I, A. S, 0, N, D CASI# %wr AHM ( ] [ J ( ] IO)LOCATION ( certi1ÿ under penalty of law, that I have personally examined and am familiar with the infonnation on this and all attached documents. I believe the submitted information is true, accurate and complete. \ Siguatw'e Date PRINT Name &. Title of Authorized Company Representative ------ HAZARDOUS MATERIALS INVENTORY - Address e Page_of_ ~ Business Name ~ CHEMICAL DESCRIPTION I) rNVENTORY STATUS: New ( J Addition [ ) Rcvision [ J Delction [ ] Chcc:k ifchemical is a NON Trade Secret [ J Trade Secret C 2) Common Name: J) DOT II (optional) Chemical Namc: AHM ( J CAS 1# .¡) Physical & Health PHYSICAL HEAL rn Hazard Categories Fire ( J Reactive ( ] Sudden Release of Pressure ( ] Immediate Health (Acute) ( J Delayed Health (Chronic) ( J 5) WASTE CLASSIFICATION (3-digit code &om DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ Liquid [ Ga[ ] Pure [ Mixture [ ] Waste [ ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature AU Year, J, F, M. A, M. I, I. A, S, 0, N, D 7) AMOUNT AND TIME AT FACn.rrv Maximum Daily Amount Average Daily Amount Annual Amount Largest Size Container II Days on Site UNITS OF MEASURE Lbs( JGa1( Jft3( ] Curies ( ] Circle Which Months: 9)~: Liß the three most hazardous I) chemical components or 2) any AHM components 3) COMPONENT CASII %wr AHM ( ] [ ] ( ] IO)LOCATION 1) INVENTORY STA1US: New ( ] Addition [ ] Revision ( J Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret [ ] 2) Common Name: 3) OOT f# (optional) Chemical Name: AHM [ ] CAS II 4) Physical & Health PHYSICAL HEAL m Hazard Categories Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) [ 5) WASTE CLASSIFICATION (3-digit code &om DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ Liquid [ Gas [ ] Pure [ Mixture [ ] Waste [ ] Radioactive [ 8) STORAGE CODES a) Container: b) Pressure: c) Temperature 7) AMOUNT AND TIME AT FACILITY Maximum Daily Amount Average Daily Amount Annual AmoUDt Largest Size Container /I Days on Site UNITS OF MEASURE Lbs[ JGa1[ ]ft3[ ] Curies [ ] Circle Which Months: AU Year, J, F, M. A, M. I. I, A, S, 0, N, D 9)~: Liß the three mOß hazardous I) chemical components or 2) any AHM components 3) COMPONENT CAS# %wr AHM [ ] [ ] [ J IO)LOCATION I certifÿ WIder penalty of law, that I have personally examined and am familiar with the infonnation on this and all attached documents. 1 believe the submined infonnation is true, accurate and complete. PRINT Name & Title of Authorized Company Representative Signature Date : N SITE DIAGRAM r Business Name: Business Address: e e FACILITY DIAGRAM r 1 ~ 1