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Home My WebLink AboutBUSINESS PLAN .;~~~ ,y~ ~'~ ,~~ ~ . , -- . ....,....... ,~-' SITE/FACILITY DIAGRAM FORM 5 NORTH SCALE: BUSINESS NAME: L, S (,,<) DS DATE ~! / FACILITY NAME: ,::J (, c:r¡- 3 (.., 0 S- L'¿-n /à")., (CHECK ONE) / FACILITY DIAGRA¡'f SITE DIAGRA){ \.A. f\.-- t 0 ~ ~ A-v-{ - <: ~ ----- \:ì (t-".Jc- '~ , \..~ 6Ì' \ , ~~ ~ ¡ ?~r~'w"-""'" :i- - ~, ,!,O~ \ I~O ; ~;~.~ ~ ,,. , '< I r- . i L--2J . 1-".,·.., ~~., }~~ 1r . . \. ..~ ~ 1. «t~... [@r.i 1 ~ \J \I') ~ ~ '" ~ ,.~ 1 i \ \ .. ' /Î l; i",,~. <:; i ). ~ Me" \., t,.IYi.,t- ",' I ()#~ Cj I I , , (Inspector's Comments): -OFFICIAL USE ONLY- ¿ -SC~ <5RCJð'¿s~~ -<::/..¿;:fJø->", jg;2/S- V/l/IOrJ Æ~ /¿ ~r9-. , - 5A - .. è ~ « 5 FLOOR: OF UNIT #: OF ~ ('\tt 1-;:; , \ I I , I ! ¡ -~....-~- , . .~--.. ~", ~ ~'" S).. '€'f. ~~¡ .5; ..~ ': h~ ¥d~·· J4f/71/ tlAL£K/£ HAM DOblS ¡,M4-r£ler.-1-¿5 LA/1- 1/ C ~ d &-f=~¡ej-t.d!R f70 ßy 9L'S-? ð~~& / - ~qÞl~l DELAYED /?-5~~ ßf.\II«'fíì)¡¡;P~¡¡:N 711P rañ!f¡)!F .¡: '. / t¡'~Jìt'" ~11::;¡J~:¡¡ti!;!f:iffi '\ ,f) ~. €'~ ..:.l '",,"--" þ// ",F ,f /,p /~'_.._- //' ... -, ,,-., /;..ù' i, " "0 - L õ - -¡ , -- ~,~.~ ~_tv. fÄ' .()~ ~c¡w -- '. . ' - . i . -, , - - f\ J\A ",' ./) I . ... 61f- .~ J~ -~C¿~~? To DAM Date Time DPM WHILE YOU WERE OUT M of Phone r -) Area Code Number Extension TELEPHONED PLEASE CALL CALLED TO SEE YOU WILL CAll AGAIN WANTS TO SEE YOU URGENT RETURNED YOUR CALL I I lli ~f- /1/" Message 1 - UAo Á ^ I_I, .l¡"/...)¡,,(1.' "'-~,d "ð S ()./VI..{." (t"'¡ ìl eJ-v¿ 3;;0. -;1. ( I 7 )..., SCðtt Bï-l,I}t?-Ó..-t /j{.!,,,ý' - G Operator .... .. AMPAD ...., EFFICIENCY:!> REORDER if 23·jIOO · _C' City of Bakenfield t" ¿,oF /_ -L (/ _ C ^ I TRANSMln AL SUP' Date..........._....!4?..... .....'/:........L.0..._ 'I . . To_\/«Æ!J!.I_~_.dJd.L'm__ From..........._..·.·=.·.·:.·.·.·~~~....,..__......._ For Your:- o Signature 0 Action 0 Information 0 File Please :- o Return 0 See Me 0 Follow Up 0 Prepare Answer Copy to: .,............................................."...........,..............,......,_............._...,....... Memo: ........................_...........................................................:..............__._.__ .........nn............................_................._.....................u_...._......._....~..................._..__....._..................... ......... ........,....................-................-......................-..............................................-.......... .................................................................................~............._................._..._...._......._.....- ..-...............................-.............................................-............-.......-.........-..............--...--...-......- ........... '............ ............... ..........-..............................................................................................-.......-.....................--.. ...............................................................................................................................................-...........-................-. ..................... ..........., .................................-.......................... ................... ................-..........................-... ........................................................................-..........................................................................................,........ r;:¿¡.qo ,)ópr}Í'JI.J :., /UL'D~- ~.~ ~ ^ < 7P w /JIW.-Ù ~ '¡'Ú.l/Ý-J jrZ¡ 5-31-,;,) ro -;;>.9-C¡O ~, ~J¿,~1~~J CCMYLL W ~ Ct>~. -P~ oK ~ ~QJPh CJ\..(JI,A.1Ú'J~.~ ; ,t.?,'u'.l''ìV\_rt..- 0'" rol', / ; ¡; :.:~:~.' '," ': ---------~ , ..;:;...·L"~_ "-",.' ,4'·~· -..."k·.~·'"··' 'J""~'-''''''.:' ....,~.'~> /YLß-;!: ~ bJ / : ~'¡;'~~~~\::.'~;~,:" ',', .~:"; ~~. PerDl.it to· Operate ¡ ! i Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This permit is issued for the following: zardous Materials Plan ~rground Storage of Hazardous Materials " " agement Program , Waste 3605 PERMIT ID# 015-021-000014 E W FLICKINGER DDS LOCATION Issued by: , UNION ¡II Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (805) 326-3979 FAX (805) 326-0576 ~~~. Ju_ne 30, 2000 Approved by: ' Expiration Date: --~~:.~-~-~'-""~~ :"~ , I I ! IIÞ STATEMENT OF ACCOUNT 4It CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA 93301-5201 TO: EW FLICKINGER 3605 UNION AV BAKERSFIELD. DATE: 9/01/98 CUSTOMER NO: 2805 CHARGE DATE TOTAL AMOUNT ------ -------- -------------- 8/01/98 7/13/98 REFND 8/19/98 .00 178. 50';'- 178.50 ~,::~< .~~)f if i~l FOR GUÊSTliÔ OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- -------------- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- -------------- -------------- DUE DATE: 10/01/98 PAYMENT DUE: TOTAL DUE: 178. 50-- $178. 50-- 5·"';, ~ -- e CITY OF BAKERSFIELD CLAIM VOUCHER I Vendor No. I certify that this claim is correct and valid, and is a proper charge against the City Agency and account indicated. I CLAIMANT'S NAME AND ADDRESS: E W Flickenger DDS 3605 Union Ave Bakersfield, CA 93305 (AUTHORIZED SIGNATURE OF CITY AGENCY) Date: 08-12-98 Initials of Preparer: CITY DEPARTMENT: FINANCE PLEASEPROVIDE SHORT EXPLANATION OF PAYME (Including Contract Number if Applicable) This business double paid their Hazardous Materials bill. For that reason they now have a credit of $178.50 which we will be refunding. Fund Dept. Base Ell Objt Project # Invoice # Amount Date of Invoice 011 0000 123 7900 $178.50 - VOUCHER TOTAL $178.50 SECTION 72, PENAL CODE FINANCE DEPT. USE ONLY Section 72, Presenting False Claims. Every person who with intent to defraud, presents for allowance or for payment to any state board or officer. or any county, town. city district, ward or village board or officer. authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, Examined & Approved for Payment Amount or writing. is guilty of a felony, ¡ ; ¡ I \ II ¡ , I i :;Y.' ':' ~ ¿Jf, l J ;':.'j'~ ~ BAKERSFIELD FIRE DEPARTMENT . e -- MEMORANDUM DATE: August 5, 1998 TO: Susan Chichester FROM: Esther Duran SUBJECT: Claim Voucher Please issue a Claim Voucher to refund over payment of$178.50 paid by E.W. Flickenger, DDS. They made a payment on 7/01/98 of $178.50 and again on 7/13/98. The second payment created the credit of$178.50. Please send a refund' of $178.50 to: E W Flickenger DDS 3605 Union Ave Bakersfield, CA 93305 Thank you, led 'Y~ de ??onwuuu(? ,%;p ~0P6 ~U/l- A W~ n .;:1/:.:- ;~ /Î,._t e STATEMENT OF ACCOUNT e CITY OF BAKERSFIELD 1501 TRUXTUN AVE BAKERSFIELD, CA 93301-5201 (805~ 326-3979 DATE: 8/01/98 TO: EW FLIC~INGER DDS 3605 UN I ON N./E BAKERSFIELD, CA 93305 CUSTONER NO: 2805 CUSTOMER TYPE: ESJ 2805 ---------------------------------------------------------------------------- CHARGE DATE DESCRIPTION REF-NUMBER DVE DATE TOTAL AMOUNT ------ -------- ------------------------- ---------- -------- -------------- 6/30/98 BEGINNING BALANCE 7/0i/98 PAYMENT 7/ i3/98 Pt-1rYMENT 178,50 i 78, 50-- 178. 50-- FOR QUESTIONS OR CHANGES TO YOUR ACCOUNT PLEASE CALL THE NUMBER AT THE TOP OF THIS STATEMENT. -------------- -------------- -------------- -------------- CURRENT OVER 30 OVER 60 OVER 90 -------------- -------------- ----,---------- -------------- DUE DATE: 8/31/98 P A Yl"1ENT DUE: TOT AL DUE: 178, 50-- $178. 50-- . ".,",'¡,. . ·L':;,t:": - - , , - 6ETACH AND"SEND 'THIS (COpy WITH REMITTANCE' <') :" ;:'j"o'/;;'>~;""f . :,¡ /':; " .~¡,' ", DÜE'·~DATE: ,,,',,.,>' REMIT AND MAKE CHECK PAYABLE TO: CITY OF BAKERSFIELD PO BOX 2057 BAKERSFIELD CA 93303-2057 CUSTOMER NO: 2805 CUSTOMER TYPE: ES/ TOTAL DUE: 2805 , $178.50- ,/ \" .: -.c- ,4 e 0 ~(Ç;~~W~D' e DDS ------- -/ ------------ ~ --------- ------- þ------------ --------- I DEC :J1997 BusPhone: '-Sy-- '1 Map : 103 L- - Grid: 20A SiteID: 215-000-000014 + .' ~+ E W FLICKINGER Manager : L~cation: 3605 UNION AV City BAKERSFIELD (805) 322 -2117 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 04 SIC Code:8021 EPA Numb: DunnBrad: +==============================================================================+ +=======================================+======================================+ Emergency Contact / Title Emergency Contact / Title E W FLICKINGER / MARJORIE FLICKINGER / Business Phone: (805) 322-2117x Business Phone: (805) 322-4552x 24-Hour Phone : (805) 872-6886x 24-Hour Phone : (805) 322-4552x Pager Phone : () x Pager Phone : () x +---------------------------------------+--------------------------------------+ I Hazmat Hazards: Fire Press ImmHlth I +------------------------------------------------------------------------------+ . Emergency 'Dirèctives:· ~... --. -. ,--" ,.;..~~-- - ,..,' +==============================================================================+ += Hazmat Inventory ========================================= One Unified List + +== MCP+DailyMax Order ================================= All Materials at Site + +--------------------------------+-------+-----------+-----+----------+----+---+ I Hazmat Common Name... SpecHazEPA Hazards I Frm I DailyMax IUnitMCpl +--------------------------------+-------+-----------+-----+----------+----+---+ OXYGEN F P IH G 1080 FT3 k I, ~J~o~~ Do hereby certify that I have reviewed the attached 1'8zardous materials manage- ment plan fo~~41ßE~~~!,~nd that it al0l1.~ with any corrections constitute a complete and correct man- agement plan for my facility. d" if' ~ D-~y-q~ Onto r NO~ ~L. œ ~~ ~t +==============================================================================+ -1- 11/07/1997 .. . r, e e ~+ E W FLICKINGER DDS ================================== SiteID: 215-000-000014 + +================================================================= Fast Format + += Notif./Evacuation/Medical ==================================== Overall Site + +=~Agency Notification =========================================== 12/12/1991 + CALL 911 +==============================================================================+ +--- Employee Notl'f /Evacuatl'on ----------------------------------- 12/12/1991 + --- . -----------------------------------, VERBAL AND CALL ~ 11 . +==============================================================================+ +---- Publl'C Notl'f /Evacuatl'on ------------------------------------ 12/12/1991 + ---- . ------------------------------------ VERBAL +==============================================================================+ +' - -'.=':' - - Emerge'n'cy~Me-d'l' 'c' 'a~l' = 'PI' an' --= ""-~ ---'-- ~ - - - ---~'- -:-...r_ -'- - - - - ---'-=''-- - -- - -'--'--" 12'/'12 / 1-9,91:'''- +-- ----- ------------------------------------- MEMORIAL HOSPITAL - 420 34TH ST - 327-1792. +===========================================;==================================+ , - -- ,>." .-- - ,-- _. -.- -2- 11/07/1997 e e ~+ E W FLICKINGER DDS ================================== SiteID: 215-000-000014 + +========================,========================================= Fast Format + += Mitigation/Prevent/Abatemt =================================== Overall Site + +== Release Prevention ============================================ 09/06/1990 + BOTTLES CHAINED AND STORED WITH PROPER FIXTURES AND VALVES. +==============================================================================+ +=== Release Containment ======================================================+ I I +==============================================================================+ +==== Clean Up ================================================================+ ,I I +==============================================================================+ +===== Other Resource Activation ==============================================+ I "=--' c"~~"~_-~O'~~_ -.--- -- -,---, -,- '-~- c~-~,,___ '---~~ ~c - -------~--- ~- I--~~ '"""">-- +==============================================================================+ - . .-. .::;~- ,..c:- '.-~- -3- 11/07/1997 -;; "- e e . ~+ E W FLICKINGER DDS ================================== SiteID: 215-000-000014 + +================================================================= Fast Format + += Site Emergency Factors ======================================= Overall Site + +== Special Hazards =~=========================================================+ I I +==============================================================================+ +--- Ut;l;ty Shut-Offs -------------------------------------------- 12/12/1991 + --- ~ ~ -------------------------------------------- A) GAS - NORTH SIDE OF BUILDING NEAR FRONT B) ELECTRICAL - INSIDE OFFICE AT BACK OF HALL IN CLOSET C) WATER - FRONT OF BUILDING UNDER MY SIGN D) SPECIAL - METAL HOUSING FOR GASES ON NORTH SIDE OF BUILDING E) LOCK BOX - NO +==============================================================================+ . , / . 1 W t 12/12/1991 +==== F~re Protec. Ava~. a er =================================== + 'PRIVATE' -FTRE~PROTECTTON~"=~?'??'?'?'???- ,-- =-" -~=--~--=~----..,..-- -.---'":.~-------_._.~- FIRE HYDRANT - ????????? +==============================================================================+ +===== Building Occupancy Level ===============================================+ I I +==============================================================================+ - .--- - ~.- -,....,..-.-.......--..=....~...=--..::....,¡.:" --"' ..:::-,..........-------.... -- ---.......... ~-- ---~~ ---'" -~~-~..,,;~.~~-- .,.....~--:-"""'.,....-..:.-....,-;,.~":: . ...-_........,. 0-.__ -4- 11/07/1997 ....- ..., --Ç> '. e e " ~+'E W FLICKINGER DDS ================================== SiteID: 215-000-000014 + +================================================================= Fast Format + += Training ===================================================== Overall Site + +== Employee Training ============================================= 08/18/1993 + WE HAVE 5 EMPLOYEES AT THIS FACILITY DO YOU HAVE MATERIAL SAFETY DATA SHEETS ON FILE? YES BRIEF SUMMARY OF TRAINING: EVERYONE IS REQUIRED AND ATTENDS A STAFF MEETING SPECIFICALLY ON SAFETY TRAINING AT LEAST ONCE A YEAR IN WHICH A THOROUGH MANUAL IS REVIEWED AND PROFESSIONALY ESTABLISHED. MSDS SHEETS ARE IDENTIFIED AND HOW TO USE THEM AND WHERE THEY ARE LOCATED AND THAT THE DESIGNATED PERSON HAS KEPT THEM UP TO DATE AS HOW MATERIALS OR SUPPLIES ARE +==============================================================================+ +=== Page 2 ===================================================================+ ,="'~I~ --. -'-==-"--~'~--,-=-=----,-~--=---,- __c.~___ ~~- I~ +==============================================================================+ +==== Held for Future Use =====================================================+ I I +==============================================================================+ +===;= Held for Future Use ====================================================+ I I +==============================================================================+ I 1'-,,- c__ ~, _ =- -~-.;:...-..:.. =-,,~" -~- ...,.,;.-- ~~-~...:.--=-:=::.:-~--~--- ~~ ::--~~~=-~- -''''-----~---=--=- _.~~--~ -...,.- -- . -5- 11/07/1997 T"'''' ~~:--'~'7''' -\<.--~.-,--.. ·...~T .....~~......--..~..~....- ~~~ 1T~~'~~,""W{',, v- -, ~-w"r"'w~ ~ ¥' .~-""~~Wf,WJ,~~'«~~~~'1"~~..¡~~:-m{f.~...t- - '. \ It, " " ',',:' ",' ¡ . , ',""1" A-'7 A 0:' U~S M A'JERIALS INS~TION . , " " 'II' Bakersfield Fire Dept. H:u'RD ,;,> ~ .... ':~,,?o lC~~ OF1~f5VI~~:::r:"L SERVICES ~, , , ,,:' Bakers'field"CA 93301 '.. . "":~ate ~PI~ted JI;i{i~7 . , F l. ",(/1.)61. R.' J) 0 S Business Nam~: 'E. w¡ Location: :3~o'S" UNrOÅJ AV BusineSSldentitrcation No.' 215-0.0.0.- OOOð 14 (Top of Business Plán) , Station No. ~ Shift R Insped~or ^"(Ci~/.sL6A¡J , ' Arrival Time: q '/0 Departure Time: -1l..1 (" 'Inspection Time: " ~~....~ -.- - - - -. Address Visable Correct Occupancy Verification of Inventory Materials Verification of Quantities Verification of Locàtion Proper Segregation of Material ) M,';; '}, /; Ad~te Ina~uate [;/ D ~ g ,'~ g , Adeqyate Inadequate Emergency'Procedures Posted ~/" ' ." D Containers Properly Lable<t",c"ir 'D Comments: ' ~. - -, " , . ,Comrhents;-'~ ..' ..'....·..'7..C·'-",..'.. ,,,,,-,,",,,,,,,;,-,:'--,- '~'C"""-n¿.." , " VèÌification' of Facility, Diagram , ,~ ' , Housekeeping IIð Fire Protection , ŒJ"" .,......",'",._,. ..""...;':' .',~-:........,' .,-....._'-~'T ;,;.. ..,".,;': - '" -Electrical.--· ,,~..-~' - , Comments:; Verification of MSDS Availablity '~ Number of Employees: Verification of Haz Mat Training Comments: " ~. ' Verification of Abbatement Supplies and Procedures ~~-:=---" Coml1},Ð~s:_~-c, _'.' _ '.' .. Special Hazards Associated with this Facility: D [j [j, '[J -;;':,";' '(;J' D" .. r;t' : USTMonitorirìg:Pro~ram " Comments: [j [j D I d [j '[JA, rp/ Permits sþill Còritrol Hold Open Device Hazardous Waste ÈPANo. ' D [j [j D , ' Proþer Waste DispQsal [j [j .;.,~~~- ~-- _.~~~$econdary-Containment=,-~--g____~.i.;..g~_....:::- __~~ Security [j ',[j IJo :....'\1. . NiT'ADVS 0)( , b~ .','\: JvOW Violations: White-Haz Mat Div. ' '..' I íi) S2? ~ ~ '~" " I' , ".. , '., , . AllltemsO.K Correction Needed [j ~ e:- N U') CD ~ , ',.':·,:::·/:~.::':l;':' :'.:::; .' , , Yellö~S~tiòriCopy< " , , Pink-BusinesS Copy ',',' 0' lL. - - ";¡ '\ . .~- --:> - - // ~\" $ 07/15/93 E W FLICKINGER, DDS 215-000-000014 Overall Site with 1 Fac. Unit Page 1 General Information Location: 3605 UNIONAV Community: BAKERSFIELD STATION 04 ,Map: 103 Hazard: Low Grid: 20A FlU: 1 AOV: 0.0 Contact Name E W FLICKINGER MARJORIE FLICKINGER Title Business Phone (805) 322-2117 x (805) 322-4552 x 24-Hour Phone (805) 872-6886 (805) 322-4552 Administrative Data Mail Addrs: 3605 UNION AV City: BAKERSFIELD Comm Code: 215-004 BAKERSFIELD STATION 04, D&B Number: State: CA Zip: 93305- SIC Code: 8021 Owner: E. W. FLICKINGER, DDS Address: 3605 UNION AVE City: BAKERSFIELD Phone: (805) 322-2117 State: CA Zip: 93305- Summary RECEIVED rAUG 1 3 1993 OV I. J;: 4J, F L l ~JÚJ 9.e4"..:z!ðb hereby certify th t r h (Typo or pnn! Mme) , a ave reviewed the attached hazardous materials manage- ment plan fO~~+)'(C'£~)lbPa)'d that it along with (N.une of B' sm sa) any corrections constitute a complete and correct man- agement plan for my facility. t; ~¿ " ,!(...'" ~.VI?,S Sign&¡ 1f/~/éf 3 ( 'Date ~--~-~--- e--- e (, 07/15/93 E W FLICKINGER DDS 215-000-000014 Page· 2 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site f PIn-Ref Name/Hazards Form Max Qty MCP' ,- 02-001 NITROUS OXIDE Gas 768 High ~ Fire, Pressure, Immed HIth FT3 02-002 OXYGEN Gas 1080 Low ~ Fire,' Pressure, Immed HIth FT3 ,. " e e 07/15/93 E W FLICKINGER DDS 215-000-000014 02 - Fixed Containers on Site Page 3 Hazmat Inventory Detail in MCP Order 02-001 NITROUS OXIDE ~ Fire, Pressure, Immed Hlth Gas 768 High FT3 CAS #: Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3 ~ Daily Average FT3 ~ Annual Amount FT3 768 I 384.00 2,048.00 Storage r' Press T Temp ~ Location FIXED PRESS. CYLINDER Above AmbientMETAL HOUSING - Conc _I 100.0% Nitrous Oxide Components r; MCP ~uide High , I 14 02-002 OXYGEN . Fire, Pressure, Immed Hlth Gas 1080 Low FT3 CAS #: 7782-44-7 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3 ~ Daily Average FT3 ~ Annual Amount FT3 1,080 I 540.00 I 3,420.00 Storage FIXED PRESS. CYLINDER PORT. PRESS. CYLINDER Press ì Temp Location Above Ambient METAL HOUSING Above Ambient INSIDE MAIN HALLWAY BY OPERATORS - Conc -I 100.0% Oxygen, Compressed Components I~ MCP ~uide Low 'I 14 .. t'. '" r e < 07/15/93 E W e FLICKINGER DDS 215-000-000014 00 - Overall Site I <D> ~otif./Evacuation/Medical Page 4 <1> Agency Notification CALL 911 <2> Employee Notif./Evacuation VERBAL AND CALL 911. , , <3> Public Notif./Evacuation VERBAL <4> Emergency Medical Plan MEMORIAL HOSPITAL - 420 34TH ST - 327-1792. .' e e 07/15/93 E W FLICKINGER ,DDS 215-000-000014 00 - Overall Site Page ' 5 <E> Mitigation/Prevent/Abatemt <1> Release Prevention BOTTLES CHAINED AND STORED WITH PROPER FIXTURES AND VALVES. <2> Release Containment <3> Clean Up I <4> Other Resource Activation ¡ I ~ ~\~ .~ e . ~ 07/15/93 E W FLICKINGER DDS 215-000-000014 00 - Overall Site Page 6 <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - NORTH SIDE OF BUILDING NEAR FRONT B) ELECTRICAL - INSIDE OFFICE AT BACK OF HALL IN CLOSET C) WATER - FRONT OF BUILDING UNDER MY SIGN D) 'SPECIAL - METAL HOUSING FOR ,GASES ON NORTH SIDE OF BUILDING E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - ???????? FIRE HYDRANT - ????????? <4> Building Occupancy Level I , "'~~--'_._-._~_._- ~-"- !......... e e i;. - . \. ... 07/15/93 E,W FLICKINGER DDS 215-000-000014 00 - Overall Site Page 7 <G> Training <1> Page 1 WE HAVE 5 EMPLOYEES AT THIS FACILITY DO YOU HAVE MATERIAL SAFETY DATA SHEETS ON FILE? '1<6 ~ , BRIEF SUMMARY PF TRAINING: £"'JI."'¿ Io=;~ ~.~~"rF<·¡'~'-" ~~~~evt~~~~, ~A-(Lç-, ~" ~ --<'~ ~ ~~ ~, 7Í-J-J-4, c:4æ~~........ L-. ~ ~ "'P b-'~' ~ ~~ -"", ~ c--uz... ~. <2> Page 2 as needed <3> Held for Future Use I <4> Held for Future Use OS/22/90 "ÞR.. FLI tVK IN&-&~ ~ SCQTT BROOI(CÐV DBS' 215-000-000014 Overall Site wi~h 1 Fab. Unit Page 1 General Information ê Cont acot Name ] ,L C, ~S~T ~~~~~~"v . Df~:t4I!5Ë: BARNCT+: Title -T , _1~ Business PhoY"le 322-2117 x ) ~~.:::2-2117 x 24 ---, LClw --1 VUl:~ HCIUr~ Phl:IY"leJ' ) 871-1089 ) 861-9.:::27 Location: 3605 UNION AV Ident Number: 215-000-000014 Nap: 103 Gr~id: 20A Hazar~d : Ar~ea of ,Administrative Data Mail Addrs: 3605 UNIONAV City: BAKERSFIELD Comm Code: 215-004 BAKERSFIELD STATION 04 D&B Number~: State: CA Zip: SIC Code: 93305- l I I I I Owner: t. SCOTT ~RQ9K£B¥1 ºÐ~ Address: Ql00 ~A1ST~ CT City: B~~FICLD PhoY"le: ( State: CA Zip: 93305- r Summar~y I .. ..--.. I I I I I .....I I, f· 0, FLc1)Ú;J1/. Do hereby certIfy that I have (TyPÐ or print name) rl)S reviewed the attached hp.z~~.rd(.;uú materials manage- ment pian f';I__... ';:;..'.',__' ,_:__~~_..__£~:l(¡ that it a!I:>ng with any C"-"- ,·,H~.., ~ ~¡' ,', ..'"." ,"" --' '-:'I"""ðÝ" --n"'! '-''''-''~'ct man ' ....'~ .;:;: ,..,\"1. I',;" ¡,j,..,' """, ,'.' ,~.: i.., "',,;,. ,¡;";~;;¡";¡ ~ '.' vv. ! t~ - . ' agemmlt p!~n fur my f:::LcmtV. " . ¡,,,,,.. ~ '}--2.l ,q~ð 05/é::C:/':JO L ~LUI I ~nUUKb~Y UUb ~~~-VVV-VVVV1~ Hazmat Inventory List in Reference Number Order ¡-'d~t:' to;;. 02 - Fixed Containers on Site Pln~Ref Name/Hazards Quarlt it Y MCP 260 High FT3 260 Lc,w FT3 100 Lc,w FT3 F clrm 02-001 NITROUS OXIDE ? 02-002 OXYGEN ? 02-003 OXYGEN ? ï55/22ïgÖ -y'~ L SCOTT BROOKSBY' DDS 215-000-0(H)0 1 't 02 - Fixed C6~tainers on Site ¡I-"age .j'. ,I Hazmat Inventory Detail in Reference Nij~ber Order 92-001 NITROUS OXIDE ? 260 High FT3, CAS #: Trade Secret: No Form: Unknown Type: Pure Days: ' Use: MEDICAL AID OR PROCESS - Daily l~lax FT3 ' Daily Avet~age FT3-~1 260 -¡ 0 - 99 Ayw"lua 1 Amcluyy!; FT3 1 , 040 St ot~age FIXED PRESS. CYLINDER Pt~ess T Temp I I I IMETAL HOUSING LClcat iOY"1 - CCIY"IC I 100.0~ Nitrous Oxide CC1mpOY"leY"lt s r- 1"1, CP --r- i st High I 02-002 OXYGEN ? 260 LClw 'FT3 CAS #: Trade Secret: No Form: Unknown Type: Pure Days: Use: MEDìcAL AID QR PROC~SS ---:-- Dai ly Max FT3 --¡ Dai ly Avet~age FT3 --r- AY"IY"IUc:\l 260, I ' 0 - 99 I Amc'lmt FT3 520 Stclt~age r Pt~ess T Temp ---r: Locat i':IY"1 FIXED PRESS. CYLINDER ,- IMETAL HOUSING --- - CCIY"IC -1 ' 100.0~ Oxygen, Compressed - COmpc.Y"leY"lt s ~ i~lCP ---rL i st Low I 02-003 OXYGEN ? 100 LClw FT3 CAS #: Tt~ade Sect~et:, N.:I Form: Unknc.wn Type: Pure Days: Use: MEDICAL AID OR PROCESS - Dai lyMax FT3 -¡- Dai ly Avet~age FT3 -,- AY"IY"lual Amc,u'(lt FT3 100 I 0 - 99 I 100 Stc.rage r Press T Temp Lc.catic.n PORT. PRESS~ CYLINDER -1 INSIDE E OPERATORY - 'CCIY"IC' l 100.0~ Oxygen, Compressed CClm pCIY"leY"lt s ~c.:CP list 051 22/'::K) L~LU I I, J:lHUU!"',bJ:l Y UUb 1:::1 ;:)-U\~II_-I_I\_I\~H~.l'+ 00 ~'Overall Site , J-'c:\Y'=" .... <D> Notif./Evacuation/Medical <1> Agency Notification (!ill q (J <2> Employee Notif./Evacuation 3A SEC 2) VERBAL AND CALL 911. <3> Public Notif./Evacuation <4> Emergency Medical Plan 2A SEC 5) MEMORIAL HOSPITAL - 420 34TH ST - 327-1792. 05/22/90 L SCOTT BROOKSBY DDS 215-0UO-UUUU1~ 00 - Overall Site <E} Mitigation/Prevent/Aba~emt ~age ~ <1} Release Prevention ~A SEC 1) BOTTLES CHAINED AND STORED WITH PROPER FIXTURES AND VALVES. <2} Release Containment <3} Clean Up <4} Other Resource Activation OS/22/30 L bLUI I ,~KUUKb~YUUb" ~l~-VVV-VVVV£~, 00 ~ Overall 'Site ~dY~ o , ' CF} Site Eroergency Factors <1} Special Hazards C2} Utility Shut-Offs 2A SEC 3) A) GAS - N SIDE OF BLDG'NEAR FRONT B) ELECTRICAL - INSIDE OFFICE AT BACK OF HALL IN CLOSET C) WATER -FRONT OF BLDG UNDER MY SIGN D) SPECIAL - METAL HOUSING FOR GASËS ON ~ SIDt OF BLDG E) LOCK BOX - NO <3} Fire P~otec./Avail. Water 3A SEC 4) NO PRIVATE FIRE PROTECTION. 3A SEC 5) FIRE HYDRANT? C4} Held for Future use OS/22/90' L SCOTT BHOOKSBY DDS--215-0PO-000014 00 - Overall Site page ( <G> T 1'~ ëd n i n g <1> Page 1 WE HA~E 5 EMPLOYEES AT THIS FACILITY .DO YOU HAVE MATERIAL SAFETY DATA SHEETS. ON FILE? BRIEF SUMMARY ÒF TRAINING: <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use ~ -- BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 , (805) 326-3979 RECEIVED AUG 2 0 1990 HA~{, ~,t~T: DIV. OFFICIAL CSE ONLY ID# BUSINESS XAME HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 2A & e~c) r~ INSTRUCTIONS: 1, To avoid further action, return this form by 2,' TYPE/PRINT ANSWERS IN ENGLISH, 3, Answer the questions below for the business 4. Be as brief and c~ncise as possible. \ \- d-b- <6~ as a whole, SECTION 1: BUSINESS IDENTIFICATION DATA - A. BUSINESS NAME: E.W. FI¡{~kr()9 ~rl/Ð Ð~ 31005 UnIDt1 (Ãuen{ße ZIP: 93305' BUS. PHONE: (80s) 3a~-õH\7 B, LOCATION / STREET ADDRESS: CITY: ß(J kefüf'ieJd SECTION 2: EMERGENCY NOTIFICATIONS In case of an ~mergency 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: XAME AND TITLE Þ'1~' E. W - F JjcK ¡ nJe f{_JJ~~, f J1AftT OTtL F/...cJc./jJe; ~ '" , / " DURING BUS. HRS. AFTER B[5, HRS, Ph# &05 ~4d \ \1 Ph# ~O6- t7a-lDR 8'<0 Ph# &,0)- )J..à Ý ("52 Ph# ~ SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE A, NAT, GAS/PROPANE: B. ELECTRICAL: C, WATER: D. SPECIAL: E. LOCK BOX: o -ttrc.e IF YES, DOES IT CONTAIN SITE PLANS? YES / NO FLOOR PLANS? YES / NO MSDSS? YES 'NO KEYS? YES NO -- -" '~! 1..:, " \ , 'I I ~.,' ·1~.:C:~ . J' ,(U. ~,SECT.ION 4-: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE I SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE SECTION 6: EMPLOYEE TRAINING EMPLOYERS ARE REQUIRED TO HAVE, A PROGRAM WHI·CH PROVIDES -~EMPLOYEES WITH INITIAL AND REFRESHER TRAIXING IN THE FOLLOWING ARtAS~ ,CIRCLE YES OR NO INITIAL REFRESHER ~A , METHODS' FOR .SAFE HANDLING OF HAZARDOBS :-t<\TERIALS: , , , . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO YES NO 8, PROCEDURES FOR COORDINATING ACTIVITIES WITH RESPONSE AGENCIES: . . . '. . . . . . . . . . . . ',' . . . . . . . . . YES ~O YES NO C, PROPER USE OF SAFETY EQUIPMENT:................. . YES NO YES NO D. EMERGENCY EVACUATION PROCEDURES:.... ............. YES NO YES NO E, DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: . . . . . . . YES NO YES NO SECTION 7: HAZARDOUS MATERIAL CIRCLE YES OR NO QR NONE DOES YO~R BC§INESS HANpLE HAZARDO~S MATERIAL IN QUANTITIES LESS THAN 500 pOCNDS OF A :'SOLro', 55 GALLONS OF A LIQUro.OR,200 CUBIC FEET OF ACÒMPRESSED GAS:,..",.' YES NO "~ , ' I, . certify that the above informatioiJ~ ~acurate. 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 ~ ' TITLE ºÁT~ '. ...-- ' - 28 - . I II ,D. # BAKERSFIELD CITY FIRE DEPARTMENT FORM 4A-l Page of ~ í NON-TRADE - þ., SECRETS ¡ -- HAZARDOUS MATERIALS INVENTORY · ~~~~~;~~ ~~ME';££~a~~~\):> OWNER NAME: FACILITY UNIT # : ADDRESS: FACILITY UNIT NAME: CITY, ZIP. ~ ~ c. ~o5 CITY,ZIP: PHONE #: 8'0 'S 3~ð.- a \\', PHONE # : ,- IOFFICIAL USE CFIRS CODE ONLY I 1 2 3 4 5 6 7 8 9 10 TYPE MAX ANNUAL CONT USE LOCATION IN THIS % BY HAZARD O.O.T CODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT WT. CHEMICAL OR COMMON NAME CODE GUIDE ['~ f I (J¡1¡t=.3 8 .f.¡ 3 03 c9.? mefa.//... l1(VJfl)~ outaidc. 10C#0 N if ro~~ OxtcJe.. PL/.. G ~ $eû+f. Alo¡,f/)..,3¡dt!- ò+' ìiHid,na '-- /tJn;+'Þ .3 ' rå ~~3 ~ () 'X \1 a e,r, ":;)¡øI) c".ç¡. O~ a/'J .s A me. loocfo Ft..63 p /dn¡f:J \ ' .c~~' 04 ~') \f\sirle ma\oOo.\\wo.'t' \00% IV FL/3S , ' 100 c.u.# 'i>-\' oWo.\on'~s' ' ~ X\i a px,\ I' IJ , ~ I , I It \ , I - , ,INAME: ' E, uJ~ Flìdc..rn (3(" DOS TITLE: OWher SIGNATURE: DATE: ,~MERGENCY CONTACT: ~ é. W , FJìck:..fnqer 0 os :Ë:~fE RG E NC Y CONTACT: ¡PR I Ñc I PAL nus I NESS ACT tV I TY: I , I ! TITLE: owner TITLE: PHONE # BUS HOUR, S: ~s 3dó)..a~~ AFTER BUS HRS:, ~ ~ìa- \ø (0 PHONE t BUS HOURS,: AFT.ER BUS HRS: - 4A,:-1- - " , /:)1 ! I 'Y'''l - , '1; / I !. I' I, """ . . BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301,' 'OFFICIAL CSE ONLY ID# BUSINESS N,\ME: ------ BUSINESS PLAN SINGLE FACILITY UNIT FORM 3A INSTRUCTIONS 1, To avoid further action. this form must be returned by; l \ -~6-cg'ß' ,2. TYPE/PRIXT YOUR ANSWERS IN ENGLISH. , 3, Answer the questions below for THE FACILITY UNIT LISTED BELOW 4, Be as BRIEF and CONCISE as possible. FACILITY UNIT' FACILITY UNIT NAME: SECTION 1: MITIGATION, PREVENTION, ABATEMENT PROCEDURES SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THIS UNIT ONLY - 3A - II . ~ ~^ ~'t""". f'í l; l' ....'~ ''':, , t SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY A, Does this Facility Unit contain Hazardous ~aterials?". YES NO If YES, see 8, If ~O, continue with SECTION 4, B, Are any of the hazardous materials a bona fide Trade Secret YES NO If No, complete a separate hazardous materials inventory furm marked: NON-TRADE SECRETS ONLY (white form #4A-l) 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 SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPONDERS SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY. A, NAT. GAS/PROPANE: B, ELECTRICAL: C, WATER: D, SPECIAL: E, LOCK BOX: YES / NO IF YES, LOCATION: IF YES, SITE PLANS? FLOOR PLANS? YES / NO YES / NO MSDSs? , KEYS? YES / NO YES / NO - 3B - ,~~'fi,~~- ;:;; ;Y e tit BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 (805) 326-3979 I~ 3 - ;;-o,t éO :2rJ5PC( OFFICIAL USE ONLY !BUSINESS NAME ID# ~ ~lqD 000014 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: t. S-tø7r ~ !20DJ:::5 ~L/ D])5 , , I '_ B. LOCATION / STREET ADDRESS: ~ ¿, D :S~ UI'J I O/U ./9 t/ /.:=- . r--J I/~\) D1 CITY: D t7-~1, ZIP: -/ 3305- BUS.PHONE: (~ 3-¿-¿-2//'7- ;'}o -SECTION 2: EMERGENCY NOTIFICATIONS In case of an emergency involving the release or threatened release of a hazbrdous material, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify your local fire department and the State Offi~e of Emergency Services as required by law. ' EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY: NAME AND TITLE /) A. it 5"//>~àJ;sBLI 2)/)5 B.-:P£/L-¡ S'F_ i)L}J2Æ£'o-- DURING BUS. HRS. Ph# 1fDS'" ,3'22- 211'7 Ph# '''ÓDÝ 322' 2t /1- AFTER BUS. HRS. Ph# ;~OÇ-322..-2¡/~/89¡:'/o 2'9 Ph# ~fol- cyZZ~ SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE A. B. C. D. E. ItH/l /7z()vVf IF YES. DOES IT CONTAIN SITE PLANS? YES / NO 'MSDSS? YES / NO FLOOR PLANS? YES / NO KEYS? YES / NO - 2A- {"'"'õo' f 1- '. . e ~.', .~ . SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE tv\~\..oy-M Ho~ ?,'?~ E. R. ~ i),,'\.-~ ~) t1.r'Q~~V i'c.,f.o tlJLp O~Z_ 1- /Ji.¿J. SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE 5'4'n1F. SECTION 6: EMPLOYEE TRAINING EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND REFRESHER TRAINING IN THE FOLLOWING A~EAS, CIRCLE YES OR NO INITIAL A. METHODS FOR SAFE HANDLING OF HAZARDOUS MATERIALS:. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ~ NO B. "PROCEDURES FOR COORDINATING ACTIVITIES- WITH RESPONSE AGENCIES:......................... .]fES NO C. PROPER USE OF SAFETY EQUIPMENT:. . . . . . . . . . . . . . . . . , E NO D. EMERGENCY EVACUATION PROCEDURES: . . . . , . . . . , . . . . . .. (Yþ. NO E. DO YOU MAINTAIN EMPLOYEE TRAINING, RECORDS: ,.... .. YES ~ REFRESHE.R 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 I /' ¡,ALLONS 0 , LIQUID. OR 200 CUBIC FEET OF A COMPRESSED GAS: . . . .. . @ NO I, ~ ~ D I certify that the above information is accurate. I understand that this inform ion 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. '~) TITLE D L-v /L(J""J DATE 5 -/ ,;'-7 ?- - 2B - / .,~ '"1'::5;" r- :? .e"~¡'l·"'" '" ~ ,/ I /7,~ .. - è , e e BAKERSFIELD CITY FIRE DEPARTMENT ,2130 "G" STREET BAKERSFIELD, CA 93301 OFFICIAL USE ONLY ID# BUSINESSNA'ME) .-' ~ , ------ "BUSINESS PLAN SINGLE FACILITY UNIT FORM 3A INSTRUCTIONS 1. To avoid, further action, this form must be ~eturnedby: -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 13NIT# FACILITY u~IT Nfu~: SECTION ,1: MITIGATION, PREVENTION, ABATEME~l PROCEDURES ß~ ~-I5~ ({?~Ul ~¡I/~ v- çJ cJ¿~ SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THIS UNIT ONLY ~ ,~ CJ.J2f¿ q J J " - 3A - . . SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY A, Does this Facility Unit contain Hazardous Materials? , . , " YES NO , \ If YES, see B. If NO, continue with SECTION 4. B. Are any of the hazardous materials a bona fide Trade Secret YES NO If No, complete a separate hazardous, materials inventory form'marked: NON-TRADE SECRETS ONL~ (white form #4A-l) If Yes, complete a hazardous materials inventory form marked: TRADE SECRETS ONLY (yellow form #4A-2) in addition to the non-trade sèè'rêtform:-' LÍst'on"lythe trade seêrets on form "4A-2·. SECTION 4: PRIVATE FIRE PROTECTION SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPONDERS SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY, A. NAT, GAS/PROPANE: B. ELECTRICAL: C, WATER: ,., D. SPECIAL: E, LOCK BOX: YES! NO IF YES, LOCATION: IF YES, SITE PLANS? FLOOR PLANS? YES / NO YES / NO MSDSs? KEYS? YES / NO YES .I NO I I ' ' - 38 - \- , I'~, ' "'\~ ~...'~. ;....~ ' "-.~, ~~;~,~z- ~"" /' I . D. .J NO'N-TRADE SECRETS t'U,,\'l'l' ~ t"'\ ,i -' HAZARDOUS MATERIALS INVEBTORV "'BU,SINEBS NAME: L. ~~'~~l' ~'~;DD.~' 8'1, OllNER NAME' ~M £ FACILITY UNIT t, _ AQDR,E~~S,;~('DS-::-=-U~, '.=--~:.'-,.' ,~ ADDRESS, ~$"bU/<;7~ ~ FACILITY UNIT NAME' CJTy,ZIP,_ ~~______~-' =CITY,ZlP, ~7> ,eç:;oò, ,'PHONEI, 'S0'C; ;"~'7 -'71\1 PRONE " ~;;:?' '11 '¡-{-I0"3 '1 ' 10FFICIAL USE CFIRS CODE , I ONLY ~.. . 1 2 3, 4 5 6 7 8 9 10 TYPE. MAX ANNUAT. CONT USE LOCATION IN THIS %. BY HAZARD D.O.T CODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT WT. CHEMICAL OR COMMON NAME, - CODE GUIDE ~? 1/"""''''-'' ~ 4 &rlIQ). ft"7 ",,;6rAL ""~~~j ~b. ' 1007. ¡O,IY-CIAS ~4-S -ÇLLQ.. , '2"D ~t. O!;J z;+ ' - ,.,. ,. "";.... 'Q 1--. IJÐMçr - 2ðo1fI'¡ '.Ç.} j T ~lIP¿)% D3 Z1 '.1ÅM F 07 ;;:¿Ó~cr FL~5 : ,~3)? hllll 1 ~\,; 3 I 6(:)1.,. ,.Ç.f '} - 1-11,,>40 J, ~I\.t ... 'tt,-r", Ú.... F¿'.5 'fCD .\- 0'7 J-vO~, .;) ?-.SC1 I ' 1 ( V I , - i I, , //þ~ , 1 V-;'J) " N AM E' L, S¡/> TO Mf2DO.~........ '-,.-.,.,. T IT L E , = ()W ",,£ t'é S I G N AT U R E;;:::::7"" ~ ,r /7 ' ...--r-4<' - -'~."> DA T E' Oif'':¡ 3 -'¡ r "'';¡¿ ¡; EMERGENCY CONTACT, /... -¿.~ p,_ ' . .,.,,,< TITLE' nw". _ f" pnONE t BUS liOURS: <;?o, ·'n], ?IJ '. .:. ,,,,' AFTER BUS HRS, "'.......DI -",,,'-IO~' , r . .ÈME.I'G EN C Y CONTACT: -:¡)1M ~ ,,~ T·I TL E : ,¡¿U> tph" ki<T" PHONE t BUS HOURS: <¡n <' ,ZZ -21; 1- , . P8l1kl!~L 8US INESS ACTIVITY ':::PI;' NT. ,r ,,-- AFTER BUS HRS: J'ð!> 1f'1-9z"''1- I '. ' - ".' ." ' .' _', I' - 4A,..1 ,-' . - - I I I I I I