HomeMy WebLinkAboutBUSINESS PLAN
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GRISSOM'S FORKLIFT SERVICE
2014 South Union Avenue
Bakersfield. California 93307
(805) 834-3455
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B A K E R S F I E L 0
September 13, 1994,
Grissom's Forklift Service
2014 South Union Avenue
Bakersfield, California 93307
Dear Owner:
Our office has notified you on several occasions
regarding your past due hazardous materials account. To
date we have not received payment.
The City of Bakersfield is hereby demanding payment in
full on hazardous materials account HM384001 in the
amount of $439.86. If payment is not received within ten
(10) working days of your receipt of this demand you will
force us to take legal action.
City of Bakersfield · Treasury Division. P.O. Box 2057
Bakersfield · California · 93303
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CITY of BAKERSFIELD . n /1t)(;~; !4i~,~~.¡\Ù~~~~\
"WE C-1RE" Ü¿ßÌ1i' ,"'1 ¿ =~i, {I :::,:::S
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Carrie J. Grissom
(tYDe or print
nameì
RECEIVED
OCT 2 3 1989
Ans'd,...
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Do here b:--
C Q ~... i .Ç ~~
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tha t I ha "\-e
revieh-ed
the
attached Hazardous Materials business plan
for
Gri ssom I s Fork1 i ft Serv.
e -ct~
/(0' ið ';)\
'~,
(name of business)
and that it along with the attached additions
or corrections constitute a complete and correct
Business Plan for my facility.
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slgnature
July 1, 1989
date
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SRXSSOMS FORXLIFl
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O~-OOl Pennzoil Motor Oil 30wt
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01-004 Grease Bulk 705 Pennzoil
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OS/2&/89
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GRISSOMS FORKL¡F~ S¿RVICE
:':të\f18 ()':J~;
Overa:: S~~e hAZMAY XN~~NTORY - 0EfR:~S
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GR1SSOMS ~ORKLIFT S~R~ICE
f·.)a~:~~ ous
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GRISSO~S FORXLIFY
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No~~f./Evacuatio~/~E~~c¿l
Si '~e
~-------------
(~) A~ency Notifica~io~
In case of emergèncy call 911.
release call 326-3979.
In the event of a release or threatened
<2> Employee Notif./Evacuatio~
3~ SEC 2) EMPLOYEE L~RVE BLDG 1HRU =X1T DOORS 10 LRRSE ~LLEV OR S1"REEI.
:t r: CG!'!S I DEfiED t::iV¡::::iiGE '\!CY B~·\!-<E.I·-ŒF:i. EL0 F I ìŒ DEPT IS Cr"jLLED.
<Z} ~!~~~ic Nc~j.f~/Evac~~tion
Notify all employees and all surrounding businesses.
05/;:::~S/â9
e GL).' "'C~q~"s '': O¡.~I"I ·"1":1 81:,:';I\I'{". "". ," 1":-
r\.!.~o.....;¡'1 ~ 1'\1'\'-00',1 __., .!.~t::. t-ë\Q2 "';:'/û
~~o~~?o/Evacuaticn/M2¿ica: for~ OV2ra~1 Si'~e
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---
<4} Emer~ency ~edica~ Plan
2A see 5) LEE J. R~C~~RDS, M.D.
3803 Ui\: ï Q¡\! (~\íE
327-(~5i3
0:5/26/8'0
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GR1SS0MS FORK~~F7 S~RVlC¿
(E) Miti£ation/Prev2nt/~bat2m~ for~ Dvera~l Si~e
~=la!; e 009
~----...~
---.----"-----.
(1) Release Prevention
3A SEC 1) A~L O¡~ IS CONTAiN~D IN METRL DRUMS IN SAFE A~EA TO PREVENT
RCC!DENfRL SPILL~GE. IN CRSE OF SPILLAGE~ PHOPEH ~~OU~T OF FLOO~
SWEE~ & S~ND AVRI~A~LE FOR CL~RN UP.
(2) Rsleess CO¡~'~ainm8nt
Concrete floors w'ith proper floor sweep.
<3> C:f.C22~"¡ ~J;:J
-------
In case of spillage proper amount of floor sweep and sand available for
clean up. Put in metal containers for disposal.
If further assistance is needed call M.P. Vacuum Service.
~)ô/25/Ð9
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G~ISSOMS FORKL!~T S~HV!CE
<E> !'t¡i·:;i~i':;\·;;:OT¡/P1·~eVE):'ïì:;/nba·i;2j':¡t: 'j='::)"'J O\fe1'~¿\l1 G:i.·i;e
------
<4> Other Resource ~=~ivat~o~
Ca 11 Fi re Depa rtment of( EPA.
~:la8e 0 ~ 0
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Gg~SSOMS ~O~~~¡FT S~RVICE
P£\i;;2 O~, i
<F} S i 'ì:; e Emet' g SriCY ¡::- ac'(; Ct'S := OJ"' n OVa¡·'a}.~. S ,. .;; 2
-----
C.} SiJeC i ¿::;. :';¿;"¡;;.:a:"c:is
Pressurized acetylene tank,
(2) Utility Shut-Offs
-----------
ê~~~ S::::C 3)
~) GRS - NO GAS ~T ALL B) EL~CTRICAL - BATHRUOM B~HIND WAL~ DOO~ ABOVE
TOILET
SOU'¡¡-: ~~P.LL C) Wr-)TE¡'~ -- WHí\! i_INE: ;-œ:) o¡.: BLDG iNSIDE r-ti-::OVE B:-r¡";-:::~UUr'¡ S:JlhH
í,'J~LL.
~) SPECIRL - NONE E) LOCK BOX - NO
(3) Fire Prctac./Rvei~" Water
-..--
Nearest fire hydrant S. Union and Watts.
OS/25/3'3
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------.--.----
~AZARDOUS MATERIALS INVENTORY
Farll and AI~ticulture 0 Standard Business
NON-TRADE SECRETS Page
B£~¢NE2S NAHE0'i€t.%OM$ - VPri dOWNER NAH~R'I-?SSOyVJ NAME OF THIS FACILITYÒ' -
L TI N' ADDRESS' ~ """'! STANDARD IND. CLASS C 0>: --
~H N~ Itfp:, _' ~RÒ~~ ~t!J:' , _ '9~ ,~%DUN AND BRA~JR~E¿j~~B~Rd-;PO-
REFER' CODES of
1 2 3 1 8 9 10" ,12 I J U
Trans TYDe Max . Dys Cont Cont Cont Use locat Ion Vhere 'by NUles of l!ìxture{colIPonents
Code Code Alt on SIte Type Press Temp Code Stored In FacIlIty Wt See Instruc Ions
'3~5' C> 0 S· ~wJ. eI .sAt,
Component.1 Nalle & C.A.S. Number
CITY of BAKERSFIELD
..
-L- Qf.2.
o Fire Hazard
o Reactivity
o De I ayed 0 Suddfn Re I ease
Health 0 Pressure
O ,Component'2 Name I C.A.S, Number
ImmedIate
Health
Component.3 Name I C.A.S, Number
o Fire Hazard
o De layed 0 SUddfn Re I ease
Health 0 Pressure
o Reactivity
z. ' MOlHL·
Component.1 Nalle & C.A.S, Number
(
O d' Component.2 Name I C.A.S, Number
Imme late
Health
Component.3 Name' C.A.S. Number
LL. 2tJ.3J
PhYSical end Health Ha~ard
(Check all that apply!
o Fire Hazard 0 Reactivity
o Delayed 0 SUddfn Release
Health 0 Pressure
42 , 50. LùAl.L--:C;l)~(dÁ... Œ.c.£'t
Component. 1 Nalle I C.A.S. Number
O ,Component'2 Name I C.A.S. Number n-'-
ImmedIate
Health
Component.3 Name I C.A.S. Number
I
.-
Q
lL
Physical eod Health Ha~ard
(Check all that apply!
'/ cIi2.I
O d' Component.2 Nam8 & C.A,S. Number
IlIIme tate
Health
Component.3 Name & C.A.S. Number
EMERGENCY CONTACTS 1t1 ('2, (S'SP7?tle oc....li)r~ B 3n ~S 1t2Name b ~~(SSCW')
Certifiçatio" fReed and $ign af1f3r c9mp7eting, a 77, sec~ions) , , ,
I ~erttfy under penal\ï 0 la~ that I have persona I~l exalllneQ 0"0'11 familIar WIth the Info(matlon $Ubmltted In thIs ond all
attached documents, ano t at baseO on my tnQuiry 0 hose IndlVldua s responsible for obtaInIng the InformatIon, I belIeve that the
submItted InformatIon IS true, accurate, and complete. .
o fire Hazard
o Oe layed 0 suddfn Re lease
Health 0 Pressure
o Reactivity
I ?(..o~ue
I t e
&2-;l2Jfi!
24 lir "none'
signature
IO!?~<j
lIãte-síqr.ea~'·
.
Na~e ena otlclal tItle Ot o~ner/Oper!tor ON owner/operator's autnorlzea representatIve
CITY of BAKERSFIELD
, . ~AZARDOUS MATERIALS INVENTORY
FarD and Agtlculture [] Standard BusIness ~
__ NON-T~ADE SECRETS
~~8I~IÖ~,NAM~: ~.~.~~~¿¡ 2~~~~s~~ME~V~~ .~~ ~~~~D2~DT~hB.F¿EIŠ§T~¿UE:
BAÒX~ ¡~¡,f~ ::- Þ-----.:!:-:2 ßIÒ~~ ¡1p:~- _.~UN AND BRAQSIR~EI NUMB~R//';~
R~FER Tal u- - CODES Z.:s- .18Q 't:' L - 0
1 2 3 4 5 6 1 8 9 10 11 ,12 13 U
Trans Tyael Max Average Annual Measure . Dys Cont Cont Cont USQ locatIon Vhere 'by Hues of I!ixture/Collponents
Code Code Allt Allt Est Units on SIte lype Press lemp Code Stored In FacIlIty Wt See Instruct Ions
:5 3ct> (;) /tNee- .. N ,àe 'dd. 6ì L,
C.A.S. Number Component.1 Name & C.A.S. Number
Page z__ oj ¿
Physicøl fod Health Hatard
(ChecK a I that apply,
o Fire Hazard o Reactivity o De Jared o SUddfn Release o Component .2 NaDe & C.A.S. Number
I mmed ia te
Hea th o Pressure Health
Component 13 Name & C.A.S. Number
TF·
o Fire Hazard o Reactivity o De lared o SUddfn Release [) . Component'2 Name & C.A.S. Number
ImmedIate
Hea th o Pressure Health
Component .3 Name & C.A.S. Number
o Reactivity o Delared [] SUddfn Release [] Component '2 Name & C.A.S. Number
o Fire Hazard Immediate
Hea th o Pressure Health
Component '3 Name & C.A.S. Number
Component .1
o Fire Ha lard o Reactivity o Delared [] suddfn Release o . Component.2 Name & C.A.S, Number
ImmedIate
Hea th o Pressure Health
Component 13 Nalle & e.A.S. Number
EMERGENCY CONTACTS tI~teIe{<f, <;;,QtSS;OI\1 IM?JÛ~ r tl2N~O 6reiss-0f\1
Certifiçatioo fRekd and $ign afjf3r cÇJmp7eting ç¡77 sections)
I ~ertlfy under penalt~ 0 la~ that I have pe(sona Iy examlneQ ood om familla( with the informatIon $ubmitteð in this ond all
attaçhed dQcUllents, ano t at based on my InquIry 0 those IndIvIduals responsIble for obtaIning the InformatIon. I belIeve that the
submItted Inforlatlon IS true, accurate, and cOlplete. .
ml~i)~L.
ß~~Z7
.
N!~e ena oflc1lal tItle Of owner/operator UK owner/operator's authorlzeo representatIve
signature
/~
<:p~M FV»v~ C N~ ~ r:) tJO
Bakersfield Fire D.t. ÎO __ ( "?;
Hazardous Materials Inspection I
Date Completed <1 - J.. 0 - <?' V¡
SEP t 1 1989
Plan ID # 215-000- occc"Z 6 (Top right comer Business P~.. .... -.. :-1i~. MAT. DIV.
Station No. <¡ Shift C Inspecto .J) ~ I < ~ So 0 "'0
Adequate Inadequate
e
Business Name:
,
G rr 1'5')().......... <;
ç{,>\r' VI C'-e.
~
Location:
JO\t
.
UV\ \ 0",
A.¡(L.
s.
Verification of Inventory Materials
D
D
~
ill
GÀ. vJ> Verification of Quantities
~ Verification of Location
~ft Prope=:on:~~:\ ~~Ò ~_II",
~ 17. Verification of MSDS Availability
/
10 Number of Employees
&f±
RECEIVED
@
~
D
\ - S'o H, Co J- -\-(;\'" k, C Lf- J. S c v. -P-b- )
[jð 0
::L.
Œt
Ve ' lcation of Haz Mat Training
Conunents: Sot£e.í..¡ ~ KJ e~'^
f
h G1 '2. . "'" Q .\- .
C' \ CIS '7
Verification of Abatement Supplies & Procedures
ær
Conunents:
D
D
Emergency Procedures Posted
D
[0
Containers Properly Labeled
Conunents: N n> Fe:;- ~E'J. f rr~ (;:eiu ore>')
Verification of Facility Diagram .
N'ò J'OI?¡Ir""",,,", w;tk ("(j¡,...r,;~p"" p;,...l.-ctvt
Special HazardS Associated with this Facility:
D
Q
D
[5
Violations:
FD 1652 (Rev. 3-89)
White-Haz Mat Div. Yellow-Station Copy Pink-Business Office
..-r- ,.... ~' ,--~~____ C---o ,-~ ---,-- ----- --~
/I-I -&9 -
ß.J2, 1 ~ ~# \t.K-tJì ~.Å:C~_~ .:JttLV(... t1~~AÁu ðtJ
?I cø.1.!I ('rf\.(L I
(t3V13~}3'A
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't". \" {.;0I. I
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BAKERSFIELD CITY FIRE DEPARTMENT
2130 "G" STREET
BAKERSFIELD. CA 93301
(805) 326-3979
~-=-
/;¿ 1-0g~
RECE IVE 0 :lifJ6J ::-
JUN 1 1987
Ans·d............
OFFICIAL USE ONLY
ID#
Ol~ql
008016
IBUSINESS NAME
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: G-R. ~ ~~OVV\ 's. - roRJ:::.l..,' fT Se-~ '
~ --r; 'ß.z.-k ì ,J d R. L (.J r'o Co
B, LOCATION / STREET ADDRESS: ¿to I Lf ~. U;u ì ð;U A-tJ £ . -0'
CITY:ÞA.~.Q.Q~(.{e.ld ZIP: 933'iJL-- BUS.PHONE: (&J5)<3'3l.(-3YSS
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. AFTER BUS. HRS,
A.~~R.ÎE. :So C; R.... ~So lÝ\ Ph# Y>'b<.}~3vS'5 Ph# 03cQ - ~ Õc¡q
B. ~, :Sð c; &?.~ ~ ~ D ~ Ph# ~~'4- ~ 'fS.s Ph# '3'~;l-::2~/ï
SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE: µ 0 '1/.J. 5 ¡q. r ¡if L. L
B. ELECTRICAL::]:N ($//71+ Room W /lI.d w¡:¡.LL DucR A~cJ ¡/E 701:1e. T ~t,.>TA wA-U-
C. WATER:~~\tJ.LIN.[ -~fð¡: ßu,'Ld~<j 'Iw$}C/é 1J.6DUÆ fS1+7'/,d2.CJo1'Y7 Q~<.J7'/" LuA-LL
D. SPECIAL: ~
E. LOCK BOX: YES / NO IF YES, LOCATION:
IF YES, DOES IT CONTAIN SITE PLANS? YES / NO
FLOOR PLANS? YES / NO
MSDSS? YES / NO
KEYS? YES / NO
- 2A -
--
e
, '
. j- ~..~
SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
U . (", I '~" '" I :iT- ...., r
~t ~!ê:¡ £';*,1 t r-k] U ,. y 1'\ -02\J2.
tJ..Jv:I..'\.(/.Vè,
~LClo R ~L>'Q...ep F-o R. '-~ù I'd
SECTION 5: LOCAL EMERGENCY MEDICAL ASSIST~~CE FOR YOUR BUSINESS AS A WHOLE
;;}€-e. -So R'~c- fA ~ ed ~ tn· Ò I
~"8()~ ~ A-tJ~
ß~K~¡e.)r-.,·.t..lJJ CA ,
~.s .... S ~ì-'1S J 3
SECTION 6: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHItH PROVIDES E~PLOYEES WITH INITIAL AND
REFRESHER TRAINING IN THE FOLLOWING AREAS,
CIRCLE YES OR NO
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
MATERIALS: . . . . . . , . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . .
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES:..................,.......
C. PROPER USE OF SAFETY EQUIPMENT:.................,
D, EMERGENCY EVACUATION PROCEDURES:.. ,...,..........
E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS:..... ..
INITIAL REFRESHER
YES GJ YES NO
YES YES NO
YES YES NO
YES YES NO
YES YES NO
SECTION 7: HAZARDOUS MATERIAL
CIRCLE YES OR NO
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUN~~
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS:,., , ,. ~~
I,{!/J-U/E ::::S-~R~ ~~o»'\.. , 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.
SIGNATUR~ {...J~ TITLE ~_
DATE 5 -;2~~ ð'l
- 2B -
... ., ~<i
. .. ¡."~
L .
.
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e
BAKERSFIELD CITY FIRE DEP.~TME~~
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFICIAL GSE ONLY
ID# _ _ _' _ _ _
BUSINESS NAME:
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 UNIT#
tf
FACILITY UNIT NA~:
SECTION 1: MITIGATION, PREVENTION, ABATEME~Jr PROCEDURES
aff ~ M ~ ~ YI1Ø"Al Ò)LIA'VI. ~ ~ S~i=£ A(2~ 1õ
f J'Q. u -e-4 0....<:...=. ~ ol...O""",:t A <.. S p ; L l .,... '1 t . ~
1 0 f- fJ- ðö R. ~<.ÀJ 4.. ~ P
.I:.# c. þ\"'&£ òF- <¡;;p,'l<"A'7EJ p.AopJl..fZ.. ~ùUtV
C" () . b L ,r , ~ c... I-e. fA. µ Ù \0 .
o--o--v-,)' Â U c.., L ¡\ .e U""""'(<.. I
SECTION 2: NOTIFICATION k~ EVACUATION PROCEDURES AT THIS ù~IT 01~Y
~.~ ~ 6~~ 7h~l.<. €-1?¡'r DðtJ/¿-S 7õ
::t yq. f2.C¡ e .4 t..... (. e 1 0 tê. â. l' R -12. e. T --
d ( , '1\1·~,"'R." C,·t...Lcf. ~ R.t. ~ "A-rtrmer'7 is CI1CC-e..cl'
J'F-' Qc,rJ'St .Q~~C> .s2...1"vI...e.«.c¡elVc1 Ð....~'""'" .:.1- Uf¿r
- .'3A -
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SECTION 3: HAZARDOUS ~ATERIALS FOR THIS U~IT ONLY
A. Does this Facility Unit cont:nin Hazardous ~!aterials?..,., ~ ~O
If YES. see B.
If NO, continue with SECTION 4.
B. Are any of the hazardous materials a bona fide Trade Secret YES ~
If No. complete a separate hazardous materials inventory
form marked: NON-TRADE SECRETS ONLY (white form #4A-1)
If Yes, complete a hazardous materials inventory form mark~d:
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 PROTECTIO~
11\...{) (}....ß-
SECTION 5: LOCATION OF WATER Su?PLY FOR USE BY E~RGENCY RESPO~~ERS
~,~
SECTION 6: LOCATION OF üTILITYST~JT-CFFS AT THIS ù;xIT O~LY.
A. :\.i·\T. GAS/PROPA~È': M Î~ a:::t ~
B. ELECTRICAL:"1n~ ~~ ~ ~D
~ - ~~, wa.n-.) ~ ~~ ~ ~cJß. l:JO~/,d~ (~ J
I .
C. WATER:~WoV.-~~Ia~ ~ M~ ~~
D. SPECIAL:
E, LOCK BOX: YES ~F YES, LOCATION:
IF YES. SITE PLA~S?
FLOOR PLANS?
YES / NO
YES / NO
~SDSs?
KEYS')
YES I ~:o
YES ¡ XO
- 38
ý
1. D, #
BAKERSFIELD CITY FIRE DEPARTMENT
FORM 4A-l
NON-TRADE SECRETS
HAZARDOUS MATERIALS INVENTORY
BUSINESS NAME:Ct("~~Dht'~ .c-oiek.Lìf-r ~, OWNER NAME:~p...R.«.ìE:. G..R.¡<b~orY\ FACILITY UNIT #:L'
ADDRESS:~'-t ~. (Jv~o,.v A-\JI(. ADDRESS:Jl~oS" PA.c.h.e.,ø Rei. FACILITY UNIT NAME:
CITY, ZIP: ~k~Rb ~ \1~ 01 3~o ~ CITY, ZIP: ßAk-4.~¡:,,.e.Ldu't'2>1> 9._'1.______ ____________
PHONE #: ""0 ':;- 'j¡>'3. '-t.- ~ '-\.$ ~ PHONE #: 'i0<'¡;- 8~~ -:;J '3 "'9
Page -L of -L
[OFF ~~i~L--USE-CF IRS CODE_
7
--------- ------ - --- - -- -------
1 2 3 4 5 6 7 8 9 10
TYPE MAX ANNUAL 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
0p 55 04> ~lo . ~80~
300 q/tL ¡JI fA s í 00?/V ¡¿r<... P.ÞvI_ '0 ro~ o:j ~D lPJT ÇL l.. q
55 !>o--o oCc dlG, e - , c:9~\3 FLL GI
94( ¡1.¡'€.4s.r ~o Iê. I\J e...¡e. '~'Ljl ~. .!::J-I~ fl..T'F
f 5'5 '6èrC> e-.~ 4 w q{¡, \ 1:?Y fé(c;
e>¡A-l... 0," ;¿<., ~ ·£¡qsT ~,e¡v~ -:..0 ~d. ~(J¡'cf
O~ ~
·m 5 bO qA-( 08 €A-"vT W'A-LL '5A.F-TY I<é. ~-oA) PA-iT's WAShefR.- ¡::"LCQ
tv) 5 ~O QA-L ()fo og f.r. ~T uJ ~ Ll. d~ t "'-'CI .£.oLu e..V1.(- ?c.. L q
~p " I E>~OY
I~o ~<tO /65 o~ á(p l2A-cJ w~LL GR-eJ~.'6€ 'ßcJ¿Iç: '70 ~ R2.,vrv'\(i" L r¿~L
",(.
cy;~ r .A ,c/ lr:.C/iCr) . A-6rl J If. 169 r
~~I :....~~ I~ qA- (, {)G ~~ ~ð1J(~ w ¡p.. \...L WA $Tfé (),' L 44 ÇL.L Q
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<L fAt[ I :;Jy(/O c()~)'CW ð1 42- ~ c)I.ft ~ \v~LL u.., R-L& I N'l --rð (( c t. I=>\'\ ~ .;ü s. , ~~ ~
('1" ^<¿$et! 'flCerVé;,;J. -4 ()Ý.ýe:¡bH' ~ ~ '-
3,30 33CO Jr3 0'1 12. 5ou.-t'h /UII o...c Q-tvlo)\j,p {à-\(.l ~L l(l
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NAME: tA-egíE.. G.-R Î SC;o IY\. TITLE: () U<-' ~ U¿ SIGNATURE{",.."A , .Arl .....: n-- DATE:.,Ç:- ~~- f'7
EM~RGENCV CONTACT: C'~~/t <;'1ê.. 'ì S. So 0 "»-I.. TITLE: o I,J.J .IV e..--te PHONE # BUS HOURS:~~Y-3-tSS
. Co,
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EME RG E NC V CONT AC T : -::Je (;",1<.( S~D?'n.
. PR~tNC·IPAI. BUSINESS ACTIVITY: f.:e1J<.,l<.ll f T
TITLE: OuJl-J~
72.a. P A. " R....
- 4A-l -
AFTER BUS HRS: « 3 L. -::2. ~"'9
PHONE , BUS HOURS: 'ð''5 2. - ':). '3 '7 '1
AFTER BUS HRS: % ~ ':2 - ;2.. '39'1
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SITE/FACILITY DIAGRAM
FORM 5
NORTH SCALE: ~ BUSINESS NAME: FLOOR: OF
R,~SOî'Vl t:-ceJGl/FT ~~.
DATE:s ~Õ / 'b1 FACILITY NAi'fE ;c;.RfS~Õ»1 ~ Fè(¿k!. t f- r UNIT :;:'-1 OF t(
(CHECK ONE) SITE DIAGRA\[ V; FACILITY DIAGR.~'f
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(Inspector's Comments): -OFFICIAL USE ONLY-
W/J.5¿;J/?1 ~.æ~¿//=/ sàzo/~¿;--
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SITE DIAGRAM (ReqU~ite.S)
1. Address: Identity the
principle bUildin¡s
by the Street nu.bers.
b. Masonry construction
e
9. Lock (key) Box
10, M5DS Stora¡e Box
11. R4i lroad Tracks
12. Fence or BarrIer
a. Wire
b. Masonry
c. Wood
d. Gates
13. Power lines
14. Guard Station
15. Storage Tanks:
Identify the
capacity in gill.
a. Above ¡round
b. Under¡round
16. Dikin¡ or Bel'.
17. Evacuation Route
-..,
~ ,
.
.e".....;;_~
,
"
2. Street(s), Alleys,
Driveways. and Parking
Areas adjacent to the
property. Include the
street na.es.
3. Store Drains. Culverts.
Yard Dralna
4. Drainage Canals. DItches.
Creeks,
5. Buildings
a. Frase con9truction
c. Metal construction
d, Access Door
6. Utility Controls
a. Gas
b. Eiectricity
c. Water
18. Evacuation Area:
Identity the
location where
e.ployee. "ill
...t.
7. Fire Suppression Syste.s:
a. Fire Hydrant.
b. Fire SprInkler
COMecUons
19. Outside Hazardous
Wa.te Storace
c. Fire Standpipe
ConnecUon.
20, Out.ide Hazardous
Natarial Storage
d. Water Control Valves
tor protection syste..
21. Outside Hazardous
Material
Un/Handling
e. Fin Puap
22. Type ot Hazardous
NaterIal/Wute
Stored
or U.ed (See
Below)
8. Fire Depart.ent Access
TYPE OF HAZARDOUS MATERIAL
F · Flauable B · BJtplol1ve L · LIquId
C · Corroa1Ye 0 · Oxidizer G · Ga.
W · Water Reactive T · Todc S · Solid
R . RadiologIcsl
P . POlaon
H . Cryo¡enic
o . Waste 8 . EUolo¡lcal
Exa.ple: Plaaaable Liquid· PL
FACILITY DIAGRAM (Required ite.. In addition to the above)
1- Rilen tor Sprinklen 8. Fire hcapes
2. Partition. 9. AlrCondl'tionin. Unit·,
3. StaIrwaya: Indicate the 10. Windon .'"<
levels se~ved Cro. I
hi¡hest to lowe.t. 11, In.ide Hazardous Waste
Store,e '.,'\. -'.
4. Escalator: Indicate the
l~vel. served tro. 12, InDide Hazardous ..
hI~hest to loweat. Natarials Store,.
.'" .....
5. Elevator 13. InsIde Hazardous
Nateriale Use/"andlln~
ð. Attic Acc:eu
14. Sewer Drain Inlets
7. Skyll¡hts