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'aTE/FACILITY DIW;F,!'G,~AM
FORM 5 P' c5Z 7¿
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BUS rNESS NAME:CS . ~ ~ ~~õirY"""
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DATE OF REINSPECTlON (1) (2) , (3) a:
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DATE
ADDRESS "
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BLOCK NO.
ZIP CODE
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BUSINESS LlC'ENSE NO.
PERMIT REQUIRED
PERMIT NO.
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YES 0
NO~
, BUILDING CLASS/TYPE OF OCCUPANCY
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BUSINESS NAME
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BUSINESS MGR./RESPON~IBLE
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HOME PHONE
?J3/ $70~
NO. OF FLOORS
SQUARE FOOTAGE
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'VIOLATION NOTICE ISSUED?
OCCUPANT LOAD
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. BAKERSFIELD CITY FIRE DEPAR£-
2130 "G" STREET
BAKERSFIELD, CA 93301
(805) 326-3979
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\ ¡~¡Ij: \ \ \...... ;F~IAL USE ONLY
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HAZARDOUS MATERIALS
BUSINESS PLAN AS A WHOLE
FORM 2A
INSTRUCTIONS:
1. To avoid further action, return this form by
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business as a whole.
4. Be as brief and concise as possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
A. BUSINESS NAME: '5. ~,~'IA~¥ -=-r.,J'~~ \.... V¥\,~
B. LOCATION / STREET ADDRESS: ~:2..."3 \' y ~ ~
CITY: '6'IA\<e-v-s-.Ç'~ZIP: '\"3'3 C> \ BUS.PHONE: ~~ 3' .¿r-Z,¿,+\
SECTION 2: EMERGENCY NOTIFICATIONS
In case of an emergency involving the release or threatened release of a
hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify
your local fire department and the State Office of Emergency Services as required by
law.
EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:
NAME AND TITLE ,\ \ \ DURING BUS. HRS. Af¡ER BUS. HRS.
A._'f'v...-Ar'.J. \r\.,. ..~~~ .J Ph# 3;(. 7'2 ~ ~, Ph# ts ~ \ 3 7 ~ ':)
B. ~_ \ C:.-"J _ ../ Ph' '3 ~.., ~ '2.,-\'( Ph.<¡ 1..(, <;>(;) c;;. 7
\ ...
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE:
B. ELECTRICAL: t.:T'-J~ d \ ~
C. WATER:
D. SPECIAL:
E. LOCK BOX: YES / ~ IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS? YES / NO
FLOOR PLANS? YES / NO
MSDSS? YES / NO
KEYS? YES / NO
- 2A -
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SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
~!~
SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR VOUR BUSINESS AS A WHOLE
'fY\D.-r ~ ~CIoIr cr'
~~
- --.- - -
SECTION 6: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES E~PLOYEES WITH INITIAL AND
REFRESHER TRAINING IN THE FOLLOWING AREAS. \ ~ ~\\~
CIRCLE YES OR NO INITIAL REFRESHER
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
MATERIALS: . . . '. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES:..........................
C. PROPER USE OF SAFETY EQUIPMENT:. . . ... ... ...... .. .
D. EMERGENCY EVACUATION PROCEDURES:.................
E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS:.... ...
YES NO YES NO
YES NO YES NO
YES NO YES NO
YES NO YES NO
YES NO YES NO
SECTION 7: HAZARDOUS MATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS OF A
SOLID, 55 GALLONS OF A LIQUID, ~ 2~C~BIC FEET OF A COMPRESSED GAS, ...... YES NO
I, C:S. :J, ~~¥~... ,\~ Ce2fY 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.
S IGNATU~ ~d'¿: ~LE c..........., ""-'
DATE LJ~ ~l
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BAKERSFIELD CITY FIRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFICIAL USE ONLY
BUSINESS
NAME: S.~ ,Q'yooø~ëV"~ ~\r. ~D#
------
BUSINESS PLAN
SINGLE FACILITY UNIT
FORM 3A
INSTRUCTIONS
1. To avoid further action, this form must be returned by:
2. TYPE/PRINT YOUR ANSWERS IN ENGLISH.
3. Answer the questions below for THE FACILITY UNIT LISTED BELOW
4. Be as BRIEF and CONCISE as possible.
FACILITY UNITt
FACILITY UNIT NA~:
SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES
~crr~ L,\:.~~ J ~~~'''''''...J.-..¡
SECTION 2: NOTIFICATION fu~ EVACUATION PROCEDù~ES AT THIS ùÑIT ONLY
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SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY
A. Does th,i s Facil i ty Unit contaJn Hazardous ~[ater ials? , , . .. ~ NO
If YES, see B.
If NO, continue with SECTION 4.
B. Are any of the hazardous matedals a bona fide Trade Secret YES Ð
If No, complete a separate hazardous materials inventory
form marked: NON-TRADE SECRETS ONt~ (white form #4A-1)
If Yes. complete a hazardous materials inventory form marked:
TRADE SECRETS ONLY (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 PROTECTION
~V'~ ~\",\~...h""$~
SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPO~mERS
SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY.
A. XAT. GAS/PROPAN~~
B., ELECTRICAO-...J~ ~,,~.-:.h- ~
C. WATER:\:)...; -\- ~,~ "r~
D. SPECIAL:
~
E. LOCK BOX: YES /®IF YES, LOCATION:
IF YES, SITE PLANS?
FLOOR PLA~S?
YES / NO
YES / NO
MSDSs?
KEYS?
YES ' NO
YES ;' :';0
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BUSINERS
ADDRESS:
CITY, ZIP:
PHONE #:
BAKERSFIELD CITY FIRE DEPARTMENT
FORM 4A-l
NON-TRADE SECRETS
HAZARDOUS MATERIALS INVENTORY
NAME~~~~Y.æ:.,..",\\",-~rW\\ ~ OWNER NAME: )~
ADD RES S: ,L.::) ":2. 3' 'ç r ..J')t'~
CITY, ZIP :'
PHONE #:
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Page
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FACILITV UNIT #:
FACILITY UNIT NAME: t
1
TYPE
, CODE
2
MAX
AMOUNT
3
ANNUM,
AMOUNT UNIT
'-\ Q~.., ~
4
5 6 7
CONT USE LOCATION IN THIS
CODE CODE FACILITY UNIT
á~ ).. '( ~~~~on-.J
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% BY
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9
IOFFICIAL USE CFIRS CODE
ONLY
10 I
HAZARD D.O.T
CODE GUIDE
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CHEMICAL OR COMMON NAME
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NAME: ":::::I. ~, \ò. \(_~V,\\,-~r. TrTLE: ~~
EMÊRGENCY CONTACT: PltAllþ'l fll¡,(\ ')J J~7lY) TITLE:
L. .
EMERGENCY CONTACT: fhfrffÞ] 00fìzx:LYIî-
PRINCIPAL BUSINESS ACTIVr'TY :~~....-Q
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./ p"¿r..,/ /'.Þ-' ~ ~... I... ~
.- --'.or il:._. 'VC4
¿r PHONE # BUgZ1¡OURS:
AFTER BUS HRS:
PHONE # BUS HOURS:
AFTER BUS HRS:
DATE: .L \. '-' ~7
;-1 27'Z2~ .s:t
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SIGNATURE:
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Bakersfield Fire Dept.
Hazardous Materials Division
2130 "G" Street
Bakersfield, CA. 93301
RECe:IVEO
MAR 2 1 1990
Aßs'ø....
..........
HAZARDOUS MATERIALS MANAGEMENT PLAN
INSTRUCTIONS:
1. To avoid further action. return this form within 30 days of receipt.
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business as a whole.
4. Be brief and concise as possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
BUSINESS NAME~ ~uM J J!::itsI:éhJ J k ,< J,¿: I ¡jJ, /).
cØd -: /
LOCATION: Ô· If/v bolO c17)/J .
. { -
MAIMRESS: dO::J:3 --zû {];;¿.
CITY (<JJ(¿.JJ STATE: MZIP:~3!)/pHON ' \?bs- 3;;n. ddi-/7
DUN & BRADSTREET NUMBER:
SIC CODE:
PRIMARY ACTIVITY:
OWNER:
MAILING ADDRESS:
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT
TITLE
BUS. PHONE
24 HR. PHONE
1.
2.
~
1 .
F01590
· Bakersfield Fire Dept.
Hazardous Materials Division .
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 3: TRAINING:
NUMBER OF EMPLOYESS:
MATERIAL SAFETY DATA SHEETS ON FILE:
BRIEF SUMMARY OF TRAINING PROGRAM:
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 &
XD:;::T::::~~~~N:A::::::S~ MATERIALS.
WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO
TIMEEXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION:
I, (()p,,eq /1/ If)¡ bb)r¿.fO(} CERTIFY THAT THE ABOVE INFOR-
MATION IS ACCURATE. I UNDERSTAND THAT THIS 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.
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HOPPER MEDICAL
2601 UNION AVE.. BAKERSFIELD. CALIF,. (805) 861-71J1
~~"~' if. tJ. p¿..,.1S/!I, ~'&.!I.1.135...y5/.9
BATC..
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HOPPER
MEDICAL
Sf\-yV'v\:'L E:--...AS.2v!IétE
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A5 Oxygen D (122) Each IC9 5% C0212% 02 8ALN2 (H) , - Each 't:!;;it¡.ì~'?,"ß '(11; Q:,wq!1
A6 0 S -'~"" <oj .... ·.I"......u D 5% C02 %028 LN2 (C) ': ~:¡':=" ';'Eà' .I; ""'~~.~'~t', ~ ....--=7tr..~.s1r-
xýgen,~'»'V" "3;Ú1\·(,150) "~\' ,:.Each,~ 'Ø{)( Jljí!' '; ~dtol ffi'( '. 1..): ~_ ~,_ .).2,.. '. ~ ..>¥",:; .IT:·~à €'1~ ~~c.' rÆ~~ ~~~¥$~;"
A7 OXygÉ!n:-;'r~·:-'::·:~~I:ì~K,'(244) -" ,.~Ëach,'", ,"~':;~';I";' ~¿~;:;~-'~, D2' 5%C0220%028ALN2 (H(~l'~:::, ~~:;S¡¿tt;:: '0'1'
I 'R rl ,.. .... - .. . . . . ~ ",-"", '" . .,. ii!'¡",;
·,~d1.Y~'-., ,ru.(t'.T".. ....:,"..·,..d.V.....¡.·· , 4<¡,J<" "~
A8 Oxygen__ "';;;¡::~~"1 r/: .)} ~",~ch ";"'"?!')~;"\i!';::'i8 t D3 5%,CO~,20%Œ;~~L,~~,JW ,rb~',~~Eh;,J
A9 Oxy/en T (330) Each , .;¡o.:;Y:;lol ,~9:J~. ·~~!t ~:'~~~:r,:
~~i:-t,1 ._..,.:I"J~~-"-~ ~v ·.....:.v..<-~ f.ö"'.,~~~,:_·:
81 Oxygen--OT?"cVGL (4500) "'''1'', ..Each . n~':' t COMP; AlA, ,,':8W (,'<?32), 'J~3 'i'!Each¡ "'f.j1!ìifj;::i<.._ ::0:
-~".,.....;, '" . '--" --"f ~_ '}..J.~ ..I~ ..d' . .:. ..L-oI:' ',í\/¡I,.rH,): ",'.';'.,' ¡..,.j1:;Jr""·"·~·" ~:.at
82 Alliators '8r OXY':uji ,<27~r: ';l:: ~ :<r,'c.h~? .;~~ '4~~C -: '~:;-!QA ~, D5 COMP.: ~IA;- Q():: 1¥::~2~,» rl',~Î:. ::'1~~R('lfJi!~
B3.- ·..-::.:>:1".,11',....:.é,,.,í. ,·d,_~,..I ,riA..,;"':". ¿ç.;;:OV1:: ' . ·.."'·,..·<1.ì02"';''''·..IRJi!.',W'OJ'-·,H:¡IJ)~',e¡{!flJ,
Oxygen. 8µ/k"'r,~~ "III P:;¡J ' ::' '~r . ::"¡" , , "~ (11" .\ ~-r.¡' ,... D6 pOMP. Þ,.IR .',. ~..,I..($09). ~.';:""; , ~9tr .;., t,,,,,~f'-¡¡:'
~ ( , . . ;ot·o" .7.J . ',lI .;.I¡_, . \., '.. -;, 'it . .'," ............-0 "'!:..;.\ -.-,.{ "I t·.. '....,m··.p:-L-. ,-: ..!_~-\'f';.. ..;~ . .~I..rA-ç.
G1 CRYOMED FltC "'i!i1iC(LB)' C) ,3m C! ¡;¡0!!SIØ '.:i115';'.f.""" '.~ '¡';1i:¡¡¡¡l~¿,~ E6·· COMPo AIR ·4i1"';·þ¡;l'E·' '(-'2·1"','J· J~~~" \h::,;r,. "''''..-1 C¡~;~~~ J,'
;...·i_~~: (f¡ ,,. I -~:~- 'r .!~CII ~. :J'¥..t.¿f~ ',_
... __. ' ~ A' : "[..,::' ::";. - .. ~~ ~.. 7;!.¡f;:f.~~;.·:~'} . .~.;~#;ít~'.: \ ~~
'.' .. ',- ;,C;, ,.::.:. iy¡"¡ ~. ,j "''-iv'.'; ~ ,: ï ·...-:;3' ~âi' D7 Nitrogen " ,>0 ~ T (300) "Q¡¡1·õ~Each.< ~::ï1Ma8~ ,i(1,,·.-i;é~·
'_,,, '.. ..-,. :,{"~,';;~,:r.',;i; 'D8 Nitrogèn.' '>"''-':~'''''LD-10 '""',;>; :'~Each"~~:¿ ,'''}'.~q...", -"¿"'''i!..:..~,.
: ,.. -" '=:r;J,~"-". . .;) tt?C'c","~' ~a'-.;~...' -';{ ;g-:~/ft:JE,H¡:H.Lr ;r'~'l9ff.9'êf~"/fh~o~rr"Virl'1..""""
.~:-(~f .,' " . :~ZW;. D9 Nitroge'n .. " ):.:.~~~~~J*3)~: ":,~(;;' ~,,~é~:~j t.~~~~~;:~> t?}l~.~ '
-,'09111!'11 ·..)c; ~)[1! '30 !t~2¡. Ft Nitrogen ~ ,S~,~ .",'!t:,(250) ';'jO¡V' ,(Each "h91·,,¡rr :::n .,9''',..-,' .; ,:~~"
,··.V" , ,~ ~,};¡Q"o!Q', '.', "9?6¡~S;)L.:,_ ~~",d·,J3CßT"',40¡''Îù!j',:o.'!MÎ,¡ (; ".·..A~!~·~
.',--:;,-.-'''' ~r"'r"S!,~¡'"I£' ')4hÚ!-': ---.- 'to' ,~..-1 -I'"o:"~;.~,-.~ _~4"'PT'~ ':::"/~"¡'~~'!:' t:,·~·~:..;~·.¡...;....· ....~H.._;... ~ ::':;I'Q"'*i't~~~f.~~~'
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TEM
A1 Oxygen
A2 Oxygen
" ;' D (95ga)
E (165 ga)
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A3 Oxygen ".. '"
XL (70)
Q(80)
A4 Oxygen
_..' '.J
B4 Nitrous ·..,~,~,,,O (250 ga)
85 Nitrous::l~I¿_::':.''È (420 ga)
86 Nitrous
F (1200 ga)
, .;·,:;,~::'¡;G\3655 ga)
"<;':';;"'''-i (4200 ga)
87 Nitrous
88 Nitrous
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INVOICE NO.
B~~7H ê~ITT~.BY 1 X 70515 S
~A1 SHIf
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SALES'e_ t
CYl. PRICE
CU. FT. PER
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Each
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EXTEN. CYL. LINE
SION REf: NO,
ITEM
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.~. C6
~:;¡;i\ C7
,::..C8
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C0202
C0202
5/95 D (99 ga)
5/95 E (174 ga)
5/95 H (1408 ga)
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E1 ,88/12.STEAILANT ..·.':(25) ·',":c.;:~ ;:'_~c~
,"'(1' 691<;1 E2 88/12 STEAILANT I (135):,}A ::H_~ctt);
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E3 C02 ""'. ":~\!)'JÌ'F(20) ,dt-,:?Each' .~;tf>919'· ;WOfõ~Ÿ6~"~
E4 C02 _ '··""1:¡\! ,,,- rG (50) ~:!' ,Eactt." ·"'~P!T . "'"';';'1
... ,:::,1':,."" .,j ..'"'' ;~I '-,;rt,.,jl ~ß~I:!~~$'¡\'~'~~-)~:'::
,~ .':..,: -1:";- -l _..:;,'~ "}:;£<:\~'......{ ~,~"q ~-.:.;
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C2 Helium. E (131 ga) Each..
C3 HèÚûin'·'J :;". ..,1.'" é'iff(242)'- ..':" 'Eaèh"~
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C4 C02, vns or.9:J.&Ð:(250 ga) ,:JI ':Ii ·,Each:;; 1:"ì~,~O~;: JI~,~.,.b~::,;,~~I· "11 ,,,,If~? -".,"f'....., "r, ¡1'.'~'C\~(")¡;f! "'~'¡¡~f 2 ,'e'vue "" ':.~:-~¿~:&W:
C5 C02':: :_,~,,;,~~ ....·E (420 ga)' -"" 'Ëach "".",1... ,......-.,.. _93 GŸU~der Cap :~:1:~';,:~~, ~·.~;:~~~ëh~J. ~;¡':tº~(:~:, '~~;,~~!i~: ~~
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FIRST'è::OL'M'; SUB~TOTAL 'V,!J3'n.:: ;",'j"o!n~,'n<;\"ìnG '71/1'1" >1m ,:;h,;":;;fV}; ¿nOli t2ND COL'M. SUB-TOTA.L fJ3V¡Al¡ì 11~A:OOIT4::>I~tOOM ¡; r' l~::'..
IMPORTANT: PLEASE AEAD CAAEFULL Y THE TERMS AND CÒNDITIONS OF SALE WHIC~ÂPPEAA COMBINED '''.,' . " " ',:;,;,.,,,?
..'..,,-- o"ON THE AEVEASE SIDE OF THIS DOCUMENT. ALL SALES MADE ARE SUBJECT TO SUB-TOTAL ~'L1A¡ft=T.J.Mf.! "'<'~>:~:-:
~. SUC.., TERMS AND CONDITIONS, UNLESS THIS SALE IS COVERED BY A SEPARATE _. "';.,1":".,.,.;. "'" ,-, ".'..i.....;;-.; .,~ ..;a~1G: '
_j:;.;,i!lMiJ¡;~~~" . .~:,,'·~/inJ iJ, '::L.':" ':"".e,,,,
CAUTIONS USE NO OIL OR LUBRICANT OF ANY KIND ON CYLINDERS.
;" : VALVES, GAUGES, REGULATORS OR ANY OTHER FITTINGS. AS
ï SUCH USE IS DANGEROUS AND MAY CAUSE EXPLOSION.
"THIS IS TO CERTIFY THAT THE ABOVE NAMED MATERIAIoS'ARE PROPERLY CLASSIFIED, DESCRIBED,
PACKAGED. MARKED AND LABELED AND ARE IN PROPER CONDITION FOR TRANSPORTATION
ACCORDING TO THE APPLICABLE REGULATIONS OF THE DEPARTMENT OF TRANSPORTATION',
Z81M5
MEDICAL GASES ~
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