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Home My WebLink AboutBUSINESS PLAN , 'W _.._-v:-".,......::.,'....~.... ~ ~ () "2 .ô·,,.' .- '.. ....'.¡.:',>.. '.' sm: DIAGRAMJ><[ FACUJ'IY DIÅG~~":" . Bulin.. Name: STDc..ý~£ ~ CovØ2-~~ . '.- BUlineø Address: /210 fA/¡ 8[£ 7ØÀD . .' .1 ' ::;': " '. J ,,,., ¡ l' !...:' ." .." ','. " ". . 1> ',; ~...,...~.,:.; þ~.. :¿,)/- .,îi:·, ,Q·~~\.-.f.NCJ, ' , .-::'¡f;'. JI"~~ ·~tffSliU4(S. . _, . ..'. 5nJ¡U't) ',: V ~1l. ¿¡ :Ntl ¡./ 11\11 frI-' ~,.~~, w'&\~:~MlSD .' ~ AD~vi (I~b~,JJ" ~~ ':: ~·:;~~~r-. . " ;,~.~\.'j;"\"" . - +::', ,~¡ , , - . ;,~:._~~ f: ":' :\ { t 1'\~\.... Q~ ~<?7\ , '. ,J.; l i ; '. , .- .~: . '; : .' "; I ':, , I , I . , , : I , I EMT>rý Lor . ,/' : " " .' ,.' "' -~~. ì~ -1:-- I: ,'. I; I, ·l; t: f ¡:;~Jlr()(t.4Nr &J1RAt.lC.£.!t;$..I' ïl'> --rAR6e:r " '. , , ,. .~\ "':, :': 1 , @ , _ --," ~.J ..'-\ \ "': ~ R.oofZ....¿;,v02tN'q (~J.J~e)) \' ''''.." , i -- -- - -·-----------'T r~ ',,' ,',' / r ~ . . CsH~II\) I ~ I . ~ '2 I "'-...J ~R~T . . \. ~ No ~A.t#£l.£lll.S IAI 8u-/~//l/6 ~ , . . ~ , (1)AR~I''-lb ) G'N77<A/</Œ .70 7'/1'<.6£/ ", GI ~ E ~. ..!/' /l----- I I: I , I \ i l ¡ , I 'I . . i i _ ,3 AREH~ ~ ~ ~ , ~ ~ ." UJ5 /Ãco5 'i' , " C-N/R.ÂNC£ 7i; --r;i..,l<6~' It~ 'Jþ Nor 7ô, '~ ;&:; , ¡;" f....r 1/1/#'4·; 1V6AIll~,')'" ,. , FIRE CHIEF RON FRAZE ADMINISTRATIVE SERVICES 2101 ·H" Street Bakersfield. CA 93301 VOICE (661) 326-3941 FAX (661) 395-1349 SUPPRESSION SERVICES 2101 ·H· Street Bakersfield. CA 93301 . VOICE (661) 326-3941 FAX (661) 395-1349 PREVENTION SERVICES 1715 Chester Ave, Bakersfield, CA 93301 VOICE (661) 326-3951 FAX (661) 326-0576 ENVIRONMENTAL SERVICES 1715 Chester Ave, Bakersfield, CA 93301 VOICE (661) 326-3979 FAX (661) 326-0576 TRAINING DIVISION 5642 Victor Ave, Bakersfield. CA 93308 VOICE (661) 399-4697 FAX (661) 399·5763 e e May 3,2001 Mr, Don and Ms, Pamela Mahan Stockdale Floor Covering 1210 Wible Road Bakersfield, Ca 93304 Dear Mr.& Mrs. Mahan: Enclosed, please find the Site and Facility Diagram Instructions packet. When your Hazardous Materials Management Plan and Inventory were submitted it was lacking the diagram portion. Please draw and submit the diagram( s) of your facility by June 8, 2001, The diagram should include the following: 1) 2) 3) 4) 5) 6) 7) 8) name of your business; business address; indicate which direction is North; the cross streets neighboring business addresses (within 300 feet) entrances and exits location of utility shut-off's; location of the nearest fire hydrant; portions of the building protected by automatic sprinkler system; and most importantly the location of the hazardous material(s). 9) If you have any questions, please feel free to call me at (661) 326-3658. Thank you for your assistance. Sincerely, RALPH E. ~Y, DIRECTOR OFFICE OF ENVIRONMENTAL SERVICES c:-( Esther Duran, Accounting Clerk II Office of Environmental Services ED\db Enclosures ~~ CY' . J/' (/' . (}£,ÞY {i77l /./ </' .,., .]e/~r..'ut0· bu: (x,//l//lN/tE/'0' .f()/~ t./r:L)o/~e .J/ur/b './ (:J r:Jàlú,/,'¥' I: Ii 'i Per... it to Operate Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (805) 326-3979 FAX (805) 326-0576 This permit is issued for the following: zardous Materials Plan round Storage of Hazardous Materials agement Program Waste STOCKDALE FLOOR,RI LOCATION 1210 WIBLE Issued by: Approved by: Expiration Date: June 30, 2000 -:~--- ~"'_. · .' -- µ~~ ~' CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 ,-1';.. FACILITY NAME SíCk:)LI)AU(P¿.NIV CCl¡)~Í2-'I.I'INSPECTION DATE A~~, /?J i91ff ADDRESS ¡LIIl ~L-L¡ ~ --j PHONE NO. "111 ,rr FACILITY CONTACT k. I1ArJ BUSINESS ID NO. 15-210- /" z..1 INSPECTION TIME / ¿) Ill) A NUMBER OF EMPLOYEES ¿ , Section 1: Business Plan and Inventory Program ")$l Routine o Combined o Joint Agency o Multi-Agency o Complaint ORe-inspection OPERA TION C V COMMENTS Proper segregation of material ,Nt:I Visible address Correct occupancy Veritication of quantities Veri tication of location Verification ofMSDS availability Verification ofHaz Mat training Emergency procedures adequate Containers properly labeled C=Compliance V=Violation ;}.lb7P DYes ÑNO Housekeeping Fire Protection Site Diagram Adequate & On Hand Any hazardous waste on site?: Explain: Questions regarding this inspection? Please call us at (805) 326-3979 While - En\'. S\'cs. Yellow - Station Copy Pink - Busincss Copy Inspector: (1,! 'â _ . £, ~ ~ -:;'........ r t < ". ~- e - I' 1 o~- Bakersfield Fire Dept. Hazardous Materials Division 2130 "G" Street Bakersfield, CA. ,93301 RECEIVED FE B 2 0 ~~2 Aos'd...... ...... . , HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: 1. To avoid further action, return this form within 30 çjays 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: ,..5'·me.-,l::.l)~ Þ¿ð¿?.-e Gk/¿/-GfC/A../G LOCATION: /2/0 Ø/8CÆ: ßt?A:O MAILING ADDRESS: /2/0 Ø/ßc~ ~ . CITY: ~h"~ STATE: M ZIP: ~ßßof'PHONE: 397-(?S,",.F DUN & BRADSTREET NUMBER: SIC CODE: PRIMARY ACTIVITY: ;CU?Ofië.. M~"vG OWNER: ~~ /?7~ MAILING ADDRESS: /2/0 Ø/8C€' ~_ ð~.4"-e?<? 't933éJ Ý SECTION 2: EMERGENCY NOTIFICATION: , - CONTACT TITLE BUS. PHONE 24 HR. PHONE 1. Lhd ø~ / ~~ ø~ - t1Ø/~ ..::?97~ t'/S~,/' T? /'-6 c/3/ I 2. ~%/ht/úlr. d~/GÆ~A7J - t:fbð'i:~ 39'7-V'..:ß? ?72 - ',/2 Vr? 1. I FDJ -- - ---- ··l '~~.11 .,.: ,..... .;¡ (' _~. j \t . : ~~ ~, '} ~ -. ,.' "HAZARDOUS MATERIALS MANAGEMENT PLAN ~/~;.,;t . \~ t; :., tit Bakersfield Fire Dept. Hazardous Materials Division - -~~ ;hi,., , 1 ; i J' '~.~;¡:' SECTION 3: TRAINING: NUMBER OF EMPLOYEES: (r;:? MATERIAL SAFETY DATA SHEETS ON FILE: Ve=-S BRIEF SUMMARY OF TRAINING PROGRAM: ¿}/~/ß(/ÆF ¿'/~47Z/~ SECTION 4: EXEMPTION REQUEST:, ¡till I CERTIFY UNDER PENALTY OF PERJURYJHAT MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTÈR 6,95 OF THE IICAlIFORNIA HEÀÒH & SAFETY CODEII FOR THE FOLLOWING REASONS: WE DO NOT HANDLE HAZARDOUS MATERIALS, r WE DO HANDLE HAZARDOUS,MATERIALS, BUT THE QUANTITIES AT NO TIMEEXCEEDTHE MINIMUM REPÒRTING QUANìîTIES, " OTHER (SPECIFY REASON) SECTION 5: CERTIFICATION: I, /~~ /??~ CERTIFY THAT THE ABOVE INFOR- MATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER 'THE IICALlFÖRNIA HEALTH AND SAFETY CODEII ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC, 25500 ET AL,) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. #~/L¿f)7fld~ <- SIGNA TURE ~ TITLE ,;/·/.1-7.;1, DATE ~----- --- -- - 2. FD1590 - ~":.:rf :. ~ ../'o! ,fa., 6'" "j " '. , . Bakersfield Fire Dep' Hazardous Materials Division HAZARDOUS MATERIALS MANAGEMENT PLAN Facility Unit Name: i..5/V~~ ~d,.eß.¿)~.HJ& SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES: " ' A, AGEN.CY NOTIFICATION PROCEDURES: B, EMPLOYEE NOTIFICATION AND EVACUATION: #~~v /¡(/~~ ~ /ee-S-ðAJ..r /J ~/u.rv ./1?t/o ,4?cJ~ 7?JøÆeð..s 8 :~ ,- #~-:rr- ~-x "/ C, PUBLIC EVACUATION: t/<::;~~ :/d~ ~ /~...s-cJA.J..s· /"J ~@"/Y ,#ÆJ /#ð~ 7'&@/!;eðS ~sr ê></-;;- D, EMERGENCY MEDICAL PLAN: ,~ 4//;, ~-E3/" G¿7~ /??-éZ>/~ ~~/TV ~~C;" /71::u-?' /.P9'<-- ¿;Z-/J '7ß-c/)C7Z/.J~. ß~P?'-ez.C) " {~ ' .------- 32-7 -.337/ 3. Ft>1$J e Bakersfield Fire Dept. e Hazardous Materials Division HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: ~ 1---" ~~ ] ) /z~ _ .~. J ... RELEASE PREVENTION STEPS: ø~~ ~ ///lJr ¿.,..øé;~ /u.5/£)~ ~;/¿/rY' I A, B. RELEASE CONTAINMENT AND/OR MINIMIZATION: I,P .sr'/U--- p'e~e.sl ,.47tJ 6~ /??e=ØJt:- /!1lfJ ~,P /'TØ£ C/?7b/~ C, ,CLEAN-UP PROCEDURES: &;t/;7??7~ SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY): NATURAL GAS/PROPANE: pt1,¿:r/l,./E3r æ..e..vee ¿;,¿ ~C-//Y ELECTR'ICAL:' /tItJ¡Ç77-I- -e9J"r ðo.e..dee. /j? ~,--/TY WATER: Uø~.$"/ ¿b~ ~¿ ~/.?/7C/ SPECIAL: /1/tluE" LOCK BOX: YES/NO - IF YES, LOCATION: SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A. PRIVATE FIRE PROTECTION: S ec77..Jbc://..s-~.s ¿ ¡;J tØ/h~rfO¡/-S~ .3 ';.J .s:h'ßV.//iûn-vw B. WATER AVAILABILITY (FIRE HYDRANT): -', /!/~~/ ~~ - _,_~/ØÞ~, .5Z/ ~,- ','-.., - , 4, ~ ßC/w/-cr FD1590 Far. and Aqr;cuhur, ...--, '--' HAZARDOUS MATERZALS ZNVENTORY NON-TRADE SECRETS Paqt .L of _L_ '--' . Standard Bus; "tn BUSINESS NAME:c:5"~.#t€ ~aeð'ð'~ LOCATION: 12fO W/8CÆ£ ~ , CITY. ZIP: P~ceG.r.4!:/GÞ!J ·9S.30~ ;;PHONE .: ~-} .ß?f7- O~~15 OWNER NAME: ø~~ /??~ ADDRESS: 270' ð/(;..~ LU:? CITY. ZIP: ~A/a.o 4"3S0'" PHONE It: (8(J~/ /'7/- ~</.s/ R1U'1lR ro INS'l'RUC%'IOIIS 'OR PROPlfR CODIl!I , Irans Cod, 2 TVOt Cod, . AvtI'lC' 5 Annva I , ""ISU... Units 7 IOys . ~ Sit. 1 C~t TV" , Cont Pres, 11 Cont T.., 11 Un Code 12 locn1~ 1Ihtr. Stored In Feci I1ty -- tW~~.5~______ __ to.øcMnt 11 ..... U.S. ..... ,..-, ,..~ r-., ,.-," 1.._" Rncti"ity 1..-.. Delayed 1..-" SucIdtn Rel_ 1.._-' l-.dln. If.a I th of Pressure ..... th to.Qonent 12 .... U.S. ..... eo.pon.nt I] .... U.S. ..... i.___ ---- - ..-., ~-... fi... /g,al'd I, ,I M_ . C.A.S...... Z to.øcMnt 12 ... . C.A.S, IIuMw (¿!o 7 .3) ... . u.s. ..... M_ . u.s. ..... . eo.pon.nt I] ... . u. s. ....... ldl --- to.øcMnt 11 .... . C.A.S. IIuebtr C~t 12 .... . U. 5, IIIitIbtr to.øcMntlJ .... . U. S. bbtr ,.-, ,.-, ,.-, L~.I Delayed 1..-.1 SucIdtn "I... 1..-.1 (-.dl.t. , 1f",lth of P...._ ....Ith ,--, ,.-, ,..-, ,.-., ,.-., '~-.. fll"t Hazard 1.._.1 RNCti"ity 1..-" Dtl.yed 1..-" Sudden R,ltn. 1.._" l-.dt.t.. H..lth of P....su... H..lth 11_1Ll~~~:Ert$/~_T_!:.~~.n~$I...;t,~ (I ,Phvsiul IIIcI H..1th'",z.rd C.A.5. ..... (thtck all thlt 'II,) . . ~,,-/ . ~ -.. flrt HI"I'd ,..-., r-, ,.~ ,../ 1..-.. Rtactivit, ..-.. Dtllyed "--' Suddllftlleltn. 1.._" l-.dtlt. Hea Ith of Pressure He,lth ~ fRGENCY COImCTS 11' ~EZA ø~· PM-./2;e ,?7/-(j,?V3/ ' lIi¡.~~·u-..---.-------..---_.____ ntl¡-------·-------- 2Il¡¡:;-Pr;;¡¡----- .........", }~~ ~p .~ ~ ~ ''". '--, NAME OF Tft1Š ~~JL~TY: STANDARD IND. CLASS CODE DUN AND BRADSTREET NUMBER ~~ - - -- 11 'by lit II II.... of IItxtUl't/to.øcMnt. Set I "'t ructi!JII @70y'7' ,;ees,,;¡) G.Y/?? ~.r/¡f ~~~ ~d .I/~Y'~//A."- VØ'V.rd ,i::bc~~~ /?eJ/,J ~: ,,/-;/ 5/¿./ð6v./ L'Ye'.Ä7¿Je P-/~ éA$.' . C,fS/ -ft- ~.c/ e3~ ~.í;,J ó?-J'".' M';19 e hZo~ We ----------- --- --- .~x~ d//~ ~,t'~ '7¿-sL'é?V.:P U¡¡--- ,.------- nnr-------- 2r1IJ'ïI1'IðIII---- ~~tifiCltl~ (R~ad and sign after co.pJetine all ~~ctions~, " ' II ctrtffv undtfo ØtMlty of 1.. that I hlv. Dlrs~.I1V ,.a.ined and .. f..ili,r with tht infOl'..tiøn su"itted In this and ,11 .tUc.... __ts. end thlt based ~ ., inquiry of thos. Individuals ....pansibl. rr o~nl"9 tht i"for..tl~. I be Ii en thlt tilt su"itttd i"fo,..,ti~ 11 tMle. acCUl',t" and C~. - - -- ·a??J/hJ·-~!-l~·(lmJ~~To¡.J-./..-e.~::..~!':--7õ·--·r-~~---·(r~.-..,.---·---.(-£i-. S - ---'ßdÞ:_____________________ ,,";'-s~!.-E- 4" an 0 ICI. t1 t! 0 .,..,tr OOtratOl' UK .,..,tr O:lt!rl,or s au """U.... rtOl'KIIft I IV' I urt unl 19ft,... i I j ,', I o 1/2.3l~9 2, I'" ' ~' STOCKtltE FLOOR COVERING Overall Site with 1 General Information 215-00.01423 Fac. Unit ,_ yUb . Q-JO/q~ © Page 1 . 1 ~1 ~~... Location: 1210 WIBLE RD Community: BAKERSFIELD STATION 09 Map: 123 Grid: 15C Hazard: Low FlU: 1 AOV: 0.0 Contact Name T"tle B s"ness Phone 24 Hour Phone - 1 U 1 - - DON/PÂMELA MAHAN OWNERS (805)- 397-0568 x (805) 871-6431 u ( W £-). &-9 9 Q:~ \ ----:, ~~ - - . . . Administrative Data . .~. ,.. Mail Addrs: 1210 WIBLE RD City: BAKERSFIELD Comm Code: 215-009 BAKERSFIELD STATION 09 Owner: PAMELÁ MEHAN Address: 2708 SILVER DR City: BAKERSFIELD D&B Number: State: CA Zip: 93304-4128 SIC Code: Phone: ( State: CA Zip: 93306- Summary E ¥ I, /);/h~J.A /)JI9NA.J Do h b· " (Type or print name) ere - Y certIfy that I have reviewed thiS attached hazardous materials manage- ment plan tor~()~:{r'eC:~::}a" áild îh¿;¡t it along with any corrections constitute a complete and correct man- agement plan for my facility" RECEIVED ff6 2 0 \992 HAZ. MAT. DN. A~/b 'n~ Signature .:7-/,p.. 7t5l Oat.e , ..'),~~ o 1/2 3 /-9 2 .' STOCKaE FLOOR COVERING 215-00_01423 02 - Fixed Containers on Site Page 2 Hazmat Inventory Detail in Reference Number Order 02-001 RESILIENT FLOORING MULTIPURPOSE ADHESIVE Liquid Fire, Delay Hlth 100 Moderate GAL Daily Max GAL . 100 ADHESIVE CAS #: 108-88-3" Trade Secret: No --, Form:Liquid Type. Amount GAL 150.00 Storage PLASTIC CONTAINER Conc 3.0% Press T Tern Ambient Ambien. Components Location FLOOR r; MCP -:--rList Moderate 02-002 EPOXY RESIN ADHESIVE Immed Hlth, Delay Hlth Liquid 100 Low GAL CAS #: 7631-86-9 Trade Secret: No Form: Liquid Type: Mixture Days: 365 Use: ADHESIVE Daily Max GAL ~ Daily Average GAL ~ Annual Amount GAL -- 100 I' 30.00 I 150.00 Storage PLASTIC CONTAINER r Press T Temp ~ Ambient Ambient WAREHOUSE Location Components Petroleum Unrefined Hydrocarbons Silicon Dioxide ~ MCP ~List Low Minimal Conc 3.0% 6.0% 02-003 PROPANE Fire, Pressure, Immed Hlth Gas 887 High FT3 CAS #: 74-98-6 Trade Secret: No Form: Gas Type: Pure Days: 365 Use: FUEL ---- Daily Max FT3 ~ Daily Average FT3 ~ Annual Amount FT3 -- 887 I 443.00 I 2,366.00 Storage r Press T Temp ~ PORT. PRESS. CYLINDER Ambient AmbientWAREHOUSE Location - Conc l . 100.0% . Propane Components I~ MCP ---rList Extreme I 01/23/.92 .' STOCKaE FLOOR COVERING 215-00_01423 00 - Overall Site Page 3 <D> 'Notif./Evacuation/Medical <1> Agency Notification <2> Employee Notif./Evacuation VERBALLY INFORM ALL PERSON IN FACILITY AND MOVE TOWARD NEAREST EXIT <3> Public Notif./Evacuation VERBALLY INFORM ALL PERSONS IN FACILITY AND MOVE TOWARD NEAREST EXIT <4> Emergency Medical Plan CALL 911; NEAREST LOCAL MEDICAL FACILITY IS MERCY HOSPITAL 2215 TRUXTUN AV BAKERSFIELD, CA, (805) 327-3371 01/23~92 ~ 0 STOCJIIlE FLOOR COVERING 215-00~01423 00 - Overall Site Page 4 <E> Mitigation/Prev~nt/Abatemt <1> Release Prevention MATERIALS ARE NOT OPENED INSIDE FACILITY / <2> Release Containment IF SPILL OCCURS, AN EMPTY METAL CONTAINER AND SCOOP ARE UTILIZED <3> Clean Up <4> Other Resource Activation" 01/23rt92 1:;" :- ~ STOCJltLE FLOOR COVERING 215-00~01423 00 - Overall Site Page 5 <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - EAST END OF COMPLEX B) ELECTRICAL - EAST END OF COMPLEX .1~d C) WATER - EAST END' OF COMPLEX /~ D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water ~ ~O ~ PRIVATE FIRE PROTECTION - ~ EXTINGUISHERS -.~ IN WAREHOUSE AND..eNB IN SHOWROOM; ...QVERIIEAÐ OPRINKLßR ~·~-~'f!M~ .þ FIRE HYDRANT -~ FEET FROM FRONT OF FACILITY <4> Building Occupancy Level 1ft) o !/2~/~,92 STOCKtltE FLOOR COVERING 215-00~01423 00 - Overall Site Page 6 <G> Training <1> Page 1 C, WE HAVE Y EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE DISTRIBUTE LITERATURE <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use ~ ------..,------ ~ -.,----- ';..,,' - ~/I ',~'" '1-· fA. , ~ e Bakersfield Fire Dept. . HAZARDOUS MATERIALS DIVISION Date Completed au ¡J-etu MJ .,.,,,,..;', -..,~;..~<~... '....- "j StoJ-Jcdt f!uón to 2 6/ t0utt ¿,µ Business Name: Location: / 1~-3 ~ O¡J , Business Identification No. 215-000 (}()Ò 1(/"&3 (Top of Business Plan) Station No. i Shift ---I!::.- Inspector ;4øs ù J RECEIVED DEC 5 1991 ·.Aas'd Verification of Inventory Materials Verification of Quantities Verification of Location Proper Segregation of Material Comments: Adequate D D D D --.".....- Inadequate D D D D Verification of MSDS Availablity o Number of Employees Verification ofHaz Mat Training Comments: o D D D Verification of Abatement Supplies & Procedures Comments: D Emergency Procedures Posted Containers Properly Labeled Comments: D D D D D Verification of Facility Diagram Special Hazards Associatedwith this Facility: D <-(0 ~~ ~ Violations: All Items O.K. 0 Correction Needed 0 Business Owner/Manager FD 1652 (Rev. 1-90) White~Haz Mat Div, Yellow-Station Copy Pink·Business Copy. ......--,-'. .,-~ e e .,..,,~ , ~,~ , /0;" ~ (}'1. , ' ' ';.1-\'.~ .. , , , ""..ö~1;",;·;:,;~~,.\G , " ~ ~ ":L,,J:-,: ~ ,,',"" '1</f"-""",,, '" S~,,\~~ ~ '\.""'$ -:><j\(~~ 1U~ f\;.~ ¡j.nl.\"'\'\ t.o> , f\tS.1~°:ii\..~ ~~ q~ ' \ ~lo ~ ~f..\..~~~\OE.~ , \Î~ý-~\ "(G "" ~:ß.11,l , ' i " CITY:-OF BAKERSFIELD I.: ' .' ,.'<P.O. BOX 2057 . . \ '~AKERSfl',~D ;'CA~lfORN~~ 9330~.~057 . \?~/L:'i'~, >., ';~~:.,,:;;, ,:' .': ~,. " :" , "" I':', :,",',', ADDRÈS5 CORRECTION REQUESTEb ' ,;I ,'í:',",' "..,~~:NpTFORWARD.' ".' , 1 "'~::'~/~'i::~':' '.' ~":"': ",:,', ,,',. II, .,,'.'.i..,,:··,.:',·,' " '..~ . '..... ' , ..., I " ,',' , ", I, . ~:' ,",": : ~"',>, ' . 1 '....,',' I ,;\\ : :,":i, ': ¡ " ~þ ",~; " \ '/~' r< . '.~.' ", '(:," I,;'.:,.,,; . :" ,'; ..' 1 .' .' j " .' \ '. ,:,\ , ,', , ' 1 I. ". " , . - ~ '., . ". .. " _ L' . _ ~-. . ,'" ,"', .. " . \ '. . ~..... . ,. 4{~" ..~. 1" :~~J, ·,',i\, ". ..'~~:;. .~" ,';:, t·; . ./ ,-.....''""; '. ' . -." ," ,: :¡,. .}, ,. . .' HM418401 --.... . :" , " . , ,~ ' . I' :' ,1 ! :,- : ;'\:,:';: ' , ' .. " ; , I ,'. . '..:~! " . " .,,-";,.' . ~ .. ~.O, ~o~ ~6'·····~· ..... çC>¿b . ~.=ð)./' ~: ~ .c: '.~ .' ',..··~....~.r ,~ /â~ C-'O ~' . ..YJ.. .¡.i; . ' MAIL TO -"" _.-.. -~ ~~.. ""- -"" C<"" -- - " ¡ ., ~ . '.,1. '~ f. ' ! ~', .j ." .:- .i. . STOCKDALE flOOR COVERINGS 6261 WHITE IN BAKERSFIELO, CA93309 ,. .,~ . :~ ~~ . 'f" I " ' ... _._,:,; ~' , ".-, r , . /' BAKER6t- H:LD lil fY t" IHe Ut:t-'AH MeNI tt 2130 'G' STREET __ BAKERSFIELD, CA. 93301 (805) 326-3979 OFFICIAL lJ ^ ... 4 "" '3- U ~,~ (',.' ".' ',' v' "'.. . -' ,;' - BUSINESS NAME .~.q&~ HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 2A ® RECEtVED "-"-<~-~- -- -- + , JU~i;'b:\~;,§á( HAZ.' MAT. 'D'V. INSTRUCTIONS: 1. To avoid further action, return this from 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 A. BUSINESS NAME: STCX/(l/AL£ Ft..roR CðVER//l/é:¡ , B. LOCA TION / STREET ADDRESS: {P2&>1 (¡fINITE LANE -# /05 CITY:. :8A./!£R5F/EtD ZIP: 9'3309 BUS. PHONE: (¿:v5) ,"397-05IP8 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. f)ON MAliAN / PA~ELA M4HAN - OWAlER... PHI .3'17-05(,8 PHI f371-~'I3/ / B..:5c.o7T (A/I-I£4LV - 1<1ANA.f:¡£1< PHI 317-ô5(P~ PHI 581- O~&>3 SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE A. NA TURAL GAS/PROPANE: EAsT EN.£) OF COMPLE}¿ B. ELECTRICAL: .E"45¡ EAJO of COH1PLEY. C. WATER: ~A:5í !3Nf) OF rOMPLE'X D. SPECIAL: E. LOCK BOX: YES /~ IF YES, LOCATION: IF YES, DOES IT CONTAIN SITE PLANS? YES / NO MSDSS? YES / NO FLOOR PLANS? YES / NO KEYS? YES / NO e e '.1, ~ .<> "'~1~ I "Ò' , .; I f It '.' ~."' , j. '-, SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE 6CVERAL.. E-XJTS ¡ARE CAPAßt.E OF EXTINt¡OISHINq 5t'1A'-L F/RE. SECTf6~V1~93floCAL EMERGENCY MEDICAL ASSISTANCE CA'L~ :c:j.'-ï~(j NEAREST LOCAL ME.f)ICAL FAOLITV . ~ it ~ n~'1 íRt!K.TVN A VF-' ,VHJ '-~'AM .SAH FOR YOUR BUSINESS AS A WHOLE 15 rl1EI<C V HCJ5PllAt.- ;/ SECTION 6: EMPLOYEE TRAINING EMPLOYERS ARE REQUIRED TO HAVE A TRAINING PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND REFRESHER TRAINING IN THE SAFE HANDLING OF HAZARDOUS MATERIALS. A. NUMBER OF EMPLOYEES AT THIS FACILITY .~ B. DO YOU HAVE MSDS (MATERIAL SAFETY DATA SHEETS) FOR EACH HAZARDOUS MATERIAL YOU HANDLE ? y£~ . C. GIVE A BRIEF SUMMARY OF YOUR HAZARDOUS MATERIALS TRAINING PROGRAM: f)/5T"R18tJTE LITE;RA.TV!?ë SECTION 7: EXEMPTION REQUEST ¡V/~ I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE CALIFORNIA HEALTH AND SAFETY CODE FOR THE FOLLOWING REASONS: WE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MATERIALS, BUT .THE QUANTtTIES AT. NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 8: CERTIFICATION I, ~J.k ~1!1~ ' . , . , certify "that 't;;he above informati~n is accurate. I understand that this information,wil.,l be used ~o fulfill my firm's obligations under the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter 6.95 Sec. 25500 Et Al.) and that inaccurate information constitutes perjury. SIGNATURE P~/þ'd./ ~a,...-I TITLE ~ DA T E ~--/.,Þ; I~·· ,- . ¡' ~.. ~. to. BA.SFIELD . CITY FIRE OEttRTMENT 2130 wG- STREET BAKERSFiELD. CA. 93301 (805) 326-3979 "-. I D # II It II It ~ !i 11 OFFICIAL USE ONLY BUSIN:SS NAMë HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE 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 # A</A- FACILITY UNIT NAME: AÇ/~ SECTION 1: MITIGATION. PREVENTION. ABATEMENT PROCEDURES I1AT£RIAI..5 ARE: Nor OPéN£D INS/DE AC./L/T}/· IF S?/t..L tJCL.tlR5 A.N E/I1?TY' , . I I /J1C111L. CONTAIfl./E/2.. -AND &ooP A,R£ tJT/L/ZE:Ð IAI CDII/T/f/NfflENT: SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THE UNIT ONLY V£!?ßA.Lé.}l //JFORJ"VI ALL ;:¡¿RSON5 /N PtCJLIT/ AA/D ¡vroVE ~W7fRO NE4R~T EXII: e e r . 'i I . ~' ~ECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY A. Does this Faci 1 ity Unit contain Hazardous Materials?..... (§) NO 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 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 rWO IEXTlN€t(,JISH~ - ONE IN W,4REHOV5¡¡; AND ONE /N 5HOWROðM Þ OIl£RHEAD SPR/^,I(LER ~Y5TE71/f. SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPONDERS (Fire Hydrant) lOt) Fp£T FRoI11 FRoNT ()¡:: RtC.IL/~Y. .' , SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY:" A. NATURAL GAS/PROPANE: ~r END Ofé C6~PL€X. B. ELECTRICAL: 13/fST E.ND ðF comPLex. C. WATER: G'-AST JE'ND OF COW/P/'£x', D. SPECIAL: N/A.. E. LOCK BOX: YES /~ IF YES, LOCATION: IF YES, SITE PLANS? YES / NO FLOOR PLANS? YES / NO MSDSs? KEYS? YES / NO YES / NO - 3B - ..' .,' , "-"~ ~ .ß.. . \./J ,A-'........... --- ...-- -I Far. and Aqr;cultur@ '--' Standard BU5;n@ss ~ HAZARDOUS MATER:I: ALS :I: NVENT·ORY NON-TRADE SECRETS Page _f..- of _£ BUSINESS NAME: .c;-roCKJ)ALE Fl..O>R.. CoV.ERlI'I& LOCATION: ~2fp1 W/.JIT£ LANE #/05 CITY, ZIP: B.4~ERSt::"~~2 ' CA 13~9 PHONE .:~O~) ~17-0 ' OWNER NAME: R1m£t...A fI/l'-¡H#?/II ADDRESS: 2.7ðß SILlIER OR. CITY, ZIP: RAKER5F/~¡ t"'A Q3s0(P PHONE .:~) &7/-~~ ørø TO INS'rRUCTIONS 'OR PROPIlR CODD NAME OF Tft1Š FACILITY: STANDARD IND. -CLÄSSCODE 57/' DUN AND 8R~DSTREET NUM8ERAf~ ~ 77- cJ J C¿ - .5 _£:2. _ 1 2 frans Ty" (od@ Cod@ 3 lie. AIIt . Averag, AIIt 5 Annu.1 Est 6 lIe.sure Units 7 . 1 IIys Cont, on Sit' TYIM! , 10 Cant Cont Prnl T_ 11 U.. Code 12 Location hre Stored In Faci lity 13 'by lit Ie II.MS of IIbture/eo.oon.ntl Set Instruct ions Physic. I .nd HM Ith Haz.rd tr.IlKk .11 that .pply) ___ r-., . Fir. H.urd L.. -.. R.activity C~t 1\ ..... C.A.S. IMber (d@(L~t!1PJdZ.eç.ß.é!!i£. ________________ CA,5.: I()B-~-3 ____ ~~ o.laytd ~:J Sudden RelHS' ~:J l-.dlat' II.. I th of Prasur. 11M I th Cœaontnt 12 ..... U.S. IMber ~t 13 ..... U.S. IMber W4'?Mð~ Physic.l and HM\th Haz.rd (tl-«k .11 that .pply) r-, ~-, ..¿ ,._, ,.~ .. -.. FIre Haz.rd L.. -.. Aøctivlty L -.. Del.yed L.. -.. Sudden ReI.... L..._" l-.diatt HH I th of Prnsure 11M 1th Cœøontnt 1\ "_, C.A,S. IIuàr to.øonent 12 "_, C.A.S. ....... 5/L./coN DIC>XIC>E' FILLER. Coaoontnt 13 ..... U.S. IMber Sl>XV RESIN I qt/!I1 RóSIN CAs: IV/A R>XV-RßltJ -AJ)H£3¡I/E: fJ4RT 8~ dC'Œ Pa..YA.n-JINé CAS: /II/K ¿¡t.ptJID1ò~'/NI1I~E. /?ES!¡\/ CAS: 1f-E?;fa- I~C()N /)(ðXll>£ rtt.£.£R CAS: 7¡'51-e~-<¡ 'C61 AI ESTl:::7< RE3I N U.S. IMber ~t 11 ..... U.S. IMber ~-., ,.-., ,.-, .. -.. Fire Haz.rd L.. -.. ReactIvity L.. -.. I~i.t. HHlth Cœøontnt 12 "_, C.A.S. IIuebIr -L---____l_____________l__________J_____-'-__ Cœøontnt 13 1__--1-_ Physical and HMlth Hazard (CI-«k .11 that .pply) Co.øonent II N_' C.A.S. IIuebtr ,..-, ,.-, r-., ,.-., ,._., .. -.. Fire H.zard L.. -.. RNctivÜy L.. -.. o.laytd L.. -... Sudden Release L.. -.. 1~I.te Health of Pressure Health --------- ----- C~t 12 "_, C.A.S, llùebtr --------------------------------------------------------- ------ t 13 11_' C.A,S. Nullbtr liE RGENCY CONTACTS I' Af1.I!1É-'::9-J!1.~I:tðt!.._______________ ~o/¡~Ëf5..----------------- <<:{{:It:!-L---- 12 ,,~~.llj¿Ú.Ik.d.q------------- 41ï.tMLo<t.ezÉß__________ ~ar-;~~~---- , Certification (Read and sign after co_pieting all sections' ~ c...e-u-uvvV\~ .¿;. ~ , I certify under øenalty of 1.. that I have person.lly ....ined .nd .. f..fli.r .lth the inforllltion subllitted In this and all .ttac" doc_n, and that based on "f inquiry of those Individu.ls responsible for ~'nlng the ,nfor..t;on. I believe that tilt! subllfttt!d InfOl"llltion IS true. .ccur.te, .nd c08plet . ~, 11_.. --/r1a-I!}::~ti.l -. /!?,..1l!..¡ý.lvTc~---t2.lJ!o1!-§..~-7-----~--·----~Iiõ-·-~,,---------~-~--- S· ~- - - ~L~________________________ D-~--S~=!,;:L:.2.-------------------- ... an ornc.. t1(j:-~i OW\@r ooerdtor . owner O;¡erdlor 5 aUl rll~ reor.5I!nlallv. 1 na\Ur@ ale 19n~ , .,:. ,- '.' ...........ß..... A. VJ .....,............. --- ".-- --'-.--,-. Fare and Aqr;culture ~ ,......, Standard Bus ine55 '---' HAZARDOUS MATERZALS ZNVENTORY NON-TRADE SECRETS Zf'/ Plqe ____ 0 ::1._ BUSINESS NAME: LOCATION: CITY, ZIP: PHONE II: OWNER NAME: ADDRESS: CITY, ZIP: PHONE II: Uß'D 2"0 INSrRUCTIOIfS 'OR PROPD CODIlS 1 2 Irans TVt! (ode Code 3 lie( AIIt 4 Averag. AIIt 5 AnnUlI Est & IlelSure Units 7 . I Ovs Cont on Sit. TVIII , 10 Cant Cont PrlS' T.., 11 III. Code 12 locltion ....... Stored In Flc; I1ty OrJ5£ ------ -- EL...aJR 1:1:.!QL. - ",c/LL~R .AI/.q (74LC/¿)111 SIJ¿,FAT£ Q45 : NIt< Phys;ca I and Haith Hazard fCheck .11 that .ppIV) -~ Firl Hmrd ~:~ RHCtiYity ~~IIv-d [:J Sudden RII.... ~:~ I-.liatl .. HHlth of Pressurl IIMlth Cœøonent 11 11.-. C.A.5. ...... ta.Qonent 12 ..... C. A. 5. ...... Cœponent I] ..... U.S. ...... PhysicII end HaIth Hazlrd (Check .11 that Ipp Iy) r-<' ~ .¿,; Fire Hazard OtJSE Cœøonent II 11_' C.A,S. IIwber ,.-, ,._/ ,.-, ,.~ L_.... IIHctlvfty LZJ Dellyed L_.... Sudden 1111_ L_.... (-.lIlt. Haith of Pl'ISsvre 11M Ith to.øanIIIt 12 11_' C.A.S. IIuIIbIr to.øanIIIt I] ..... C.,. S. ...... #.. U.S. IIuMIr REHotlSF- Cœponent 11 Phyt;cII IIId HaIth HlZlrd (Check III that applv) r"'/ r-., ~y.; Fire Hazard L_.... Reac:tiY;ty r~ ,.-., ,."..- L_.... Delayed L_.... Sudd", ReINS!! L_.... 1-.llatl HHlth of Pressure Haith Cœøonent 12 11_' U.S. Cœøonent 13 11_' C.A.S. -~___L____________1--____________ Physic.1 and Haith HIZ.rd (Check all that a"lv) -------l-----l-L____J_-----L-.l_--L ClIQOIIent 11 ,,_. C.A.S. IIuebIr ,..-, ~-., r-, r-.., ~_.J Fire Hlzard L_.... RHCtiYity L_.J Delav-d L_.... Sudd", RelelSe Heal th of Prt!Ssurl Co.øonent 12 ,,_. C.A.S, IIIiaIbIr NAME OF Tft1Š ~~JLLTY: STANDARD IND. CLASS CODE DUN AND BRADSTREET NUMBER 13 'by lit 14 ,,_ of IIhlture¡to.øanIIIt. SII In.tructiOlll #/4 ¡ ST~Ro-I CAS:N/I( ----------~----------- -- Certification (Rf!lJd and sjgn after co.pletjng all sectjonsJ I certify under IIIIMltv of le. that r have IIt!rson.l1y ".a.int!d Ind a. fl.ili.r .lth the infor..tion subllitted In this Ind III IttlCr.d doculllllts. end that based on ., inquiry of those IndiYiclulls responsible for "bta ininq the inforeat ion. I be hevl! that tilt! subllitted inforut ion, is tl"llt!. accurate, and co-p letl!. __ __ ~ SEAI11 5Q\:L£R - COAT/JY(:z !:5 7õ1l'-&J.E C4S: /08-&8-3 <5 7'0 XYt..£NE C>1S: /3.30- 2.0-7 j1't)¿YM'=~ R~ wITH ¡lfL..IPf{,¿¡TIC /SOCY~NAT£.. C4S: ~l?'f111 ,~ ADHeslyE TETRAHYt)RbF()~N 015: 109-99-9 ---- /0 C rCL.£)fI~NONE ~: 108-9~- I Di - ;?-þTH V(.#é-XYL PHT~T/£- {'..q.s: 1/ -SI-7 RESI C:>1S: N /A . --------------------------------------------------------- ------ --- ----- "E~GENCY CONTACTS II 12 Aãië-~----------------------------------- n£T¡----------------------- 2I-R;:-PI\iiñ¡------ lIiii-------------------------- ntn----------------------- 7tì\pr-pl\ðll,------ A:;Ïo¡;-ãña-õJmiãl-ti{l¡;-õJ-õWñ¡;¡:7õõë;:ã[õ;:-onWñ¡;¡:7õ¡¡ë;:¡{õ¡:~š-¡ü{liõ;:mn¡¡õrëšiñ{¡m¡ Siijñ¡{ü;:¡;--------------------------------------------------- O¡{¡;-Siijñ¡a--------------------------- .' '-"~~ ~ VJ .-............-.-...------ Far. and Aqdcu 1 turl! '---' ,......, Standard Bus inl!SS '---' HAZARDOUS MATERXALS XNVENTORY NON-TRADE SECRETS 3 d PaCJe ____ of _1__ W1RßHOr.J>£ _________ 10 7õ1/~€!:L€.__.£:45: I08-€!~- 3___ __ ~" - r:-rUYL A' /"/"11 }",..I i)EN4TZ/I?;':::O :::::=...::... '~J J7 --VfTV'-1 ,,~' (P ~_/ _ 5 ILICLJN-LJ/a<IDE C.4S: 7~3/-t!3&>-9 __ ¿¡,S ~ ACRYLIC RESIN, RxVJtU/VLj . CHLORIO£/ ,Q:)'¿YVt'NVLJ Ac¿-1'47'E, ,Ð/Ff'~/C .E57E¡;? C:-dS.:: N./f\ BUSINESS NAME: LOCATION: CITY, ZIP: PHONE II: OWNER NAME: ADDRESS: CITY, ZIP: PHONE II: RlUD 1'0 INS'l7lUCI'IONS 'OR PROPIlR CODD 1 2 I rans Ty" Cod, Cod, 3 ÞIa~ Alat . AVl!raqe A8t 5 Annual Est & leISure UnHs 7 . . Oys Cont on Site Ty.. t 10 11 Cont Cont Us. Presl T.... Code 12 Loc.tlon Nhere Stored In F.cillty PhysiC.1 .nd HH Ith Har.rd (f.Ilt!Ck .11 thlt 'IIly) ~ ,..-., "'ø: ,..-., ,..-., Fire H.urd '- -. RHctivity '- . Del.yed '- -. Sudden RelM" '- -. I-.elf.te HI!' I th of Pressure 11M I th COIIIOntIIt'l ..... C.A.5. IMber to.Qanent 12 ..... C .A.S. IIueber Cœøonent 13 .... U.S. ...... 11_ . C.A,5. IIuår I. I r-, ~-, ~_., ,._, ,.._, ,,-. FI... H.urd '--. IIHctfvfty '--. Del.yed '--. Sudden Rel_ '--. 1-.elI.te HHlth of P....su... IIMlth . t.A.S. IIuØer c-t n ..... U.S. ...... Phvtfc.1 end HHlt" HII'1'd (Check .11 thlt .Iy) U.S. 1IueIIIr_ c-t 11 .... U.S. ...... ~-, ,.-, ,.-, ,.-, ,..-, "_..J Ffrl! Har.nI '--. Rtlctfvity L._' Del.yed L._' Sudden Rl!lHSe '--. I-.elfate Htllth of Pressure HHlttl to.øonent 12 11_' C.A.S. IIuØer to.øonent 13 ..... C. A. 5. IIwber -~Li gA..b_L~_~1~__L~_~L.::.__J2ALI.3~5 Læ.L.LJ.1..1_~ c5IIoWRt)()111 Phvtic.l IIId HHIt" H.urd C.A.S. IIIIIIber Cœponent 11 11_' C.A.S. IIUIIber (Cllt!Ck .11 thlt 'IIly) ---------------- ,..-, ,.-, r-., ,..-, ,..~ " _..J Firl! Hazard '- - j RtlctivHy L. _..J De I eyed L. - j Sudden RelNse '- -. (-.elfate Hl!alth of Prl!Ssure Health Cœøonent 12 11_' C.A.5, IIùIIber Cœøonent 13 .... C. A. S. IIUllber NAME OF T!1Š ~~JL~TY: STANDARD IND. CLASS CODE DUN AND BRADSTREET NUMBER 13 'by lit II II.... of IIbtu.../eo.oon.ntl See Inltruct ionl (/V7ïE&:...~_..LJ!2t1..~/ if£' -------.-- c --- --- CL.£ANER. / ~ , )j)¡l/1'Yl mES7i45/LICATE CAS: ú>8~6- -. ~~--- ----- 2- Bv7'o~VETl-/ANOL C,.l\S: ///-76- 2 --------------------------------------- ------ /v1b<10E7HA,NOLOMINE C,<fs.· 1<//- ~3- ~ERGENCY CONTACTS II 12 Aã..-~--------------------------------- Tìn¡----------------------- '.-R¡:-Pr.öñ¡------- lIiii------------------------- ntl¡------------------ 7r'1I1'-PIlðllI------ C.rtification (Read Bnd sign after co.pJeting all sections) I cl!rt1fy under ""'!ty of Ie. thlt I hive Dl!rson.l1y e~e.int!d end .. fe.ili.r with the inforMtion subeitttd In thfs IIId .11 .tt.chlld doc~t.. IIId thlt blsed on ., inquiry of thole fndfvidu.l. rl!SOIIlibl. for 'Obtaininq the inforMtion. I believl! thlt the subloitttd intor..tion is true. accuretl!, and cœplete, A.;'¡ - ãña- õ JHëiã'-f it l¡-õJ- ö;ñ¡¡:Toõ¡¡:¡fõ¡:-OJl-ö;ñ¡¡: 7õÖ¡¡: ãtõ¡:Tš-ã¡;tfiõr;iëà-mmëñt ãtiÿ¡ , 5i ijñãt¡;¡:¡---------------------------------------------------- Oãt¡-5iijñ¡a------------------------------ i .~ '\ i '-"~ ~ ~ '-"J ~............ ..-- ..-- ---- Far. ,nd Agriculture '--' .---. St,ndard Business ~ HAZARDOUS MATERIALS INVENTORY NON-TRADE SECRETS LJfLl Paqe :I__ 0 _7__ ~ BUSINESS NAME: LOCATION: CITY, ZIP: PHONE .: OWNER NAME: ADDRESS: CITY, ZIP: PHONE .: IlJUI'D ro INSTRUCTIONS 'OR PROPIR CODIlS 11 Use 12 locltlon !INrI Physical and HII1th Hazard (Check .11 that ,pp Iy) :a r-., ...,Fir. Hazard L._..I Reactivity Phys ieal and HII1th Haurd (Check .11 that aDD Iy) / M/A . U.S. ..... ---- CœIIantnt 11 11_ . C...S. IIuàr /0 CœIIantntl2 ... . C...S. ....... S eo.oonent IJ ..... U. S. ..... /35 'W4REl/óU5£ to.paMnt II .... . c...s. .... 27 to.paMnt12 11_ . c...s. ..... 72 to.paMnt'] ..... c...s. bbIr I C...S. IIuMItr r-., r-, ,._, ~_., ,._, 1..-..1 fll"l Hazard L._..I IINctlvity L._..I DeI.Y-' L._..I Sudd.n ReI.... L._..I ¡-.lllte H81th of PI"ISIUI"I Hea Ith PI'tn iCll IIId HII1th Hazlrd (ChKk a" that .pply) ,./ ,.-., I.. - J Fir. Hazard L. _..I R.activity r-., ,.-, ,.~ L._..I Del.yed L._..I Sudden R.INS' L._..I 1-.dlat. HHI th of PressuI"I Heal th __~B;7.~~~'!~-"_?~_éI31~_~·72~.J}.ÞI,~s LØ"_l I lL9i,' I W.~RE.fIot/S£. Pl'tnic.1 IIId Hlllth Haz.rd .rJC:..S. IIu8ber "7.1./-48-(, Cœøonlllt II "_. c...s. IIUIIbIr (Check all that 'IIly) _-'.1__-'.1_________ ~ ~e Hazard r: ~ RHctivity r:~ Delayed r~ Sudden Rel..s. r~-.dI.t. HHlth of Pressure Health Co.porIIIIt 12 11_' C...S, llùllbtr Cœøonent'] 11_' C..,S. Nu8blr - NAME OF Tft1S ~£JL~TY: STANDARD IND. CLASS CODE DUN AND BRADSTREET NUMBER I. II.... of IIixtul"l/CoeøonInt. Set Instruct ionl £..Œ.A - 5TR~f;rItL..£L~ER. (é.ON 'r) W4ïE:1?) 6URP-"tCTANT) tJDoRANT -----------------~~--- --- .J( ONCE:::: IAI ÞONE" 2- :S()7DXYETfI~N()L C,tts-' /1/-7&-2. 'ÁM{V/O/JIIJf'//1 HVDRoXlDE CAS:N!K. pot.YIKRVLK R8SIN I WUTINé¡ Aq~{l/7; -AN]) TE I'--IENT ADHE;5/t/E ___ ____ VM~ P ,AMPrHA CAS~~ (3032.-'3'2-'/ CoiS : P£rRðLE,UÞ'v\ t:~DE AsÞt#I-T lJif-2¡j" lÞl. YOŒ.1=IN FI8~R. Q\s: ,A.//;1 , V 'ÆN£ ---. ----- ---------------------------------- ------ "E RGENCY CONTACTS " 12 lIi¡¡-~-------------------------------- T1£l¡----------------------- 21-R¡:~POOñë------ lIi.------------------------ T1t1i------------------ 7r1I'-P1IðIII------- Certification (Read and sign after co.pJeting all sections} I cørtity undl!r "'"_!ty of la. that I hav. I!rsona lly ....ined and a. fa.i t;ar .ith the infor..tion su.ittad in this and a 11 Inlchad doc_tl. and that based-on W1'I inquiry of those Indtvidua Is responsible for I1bt.inin9 the infor..t ion. I III! ¡¡I!VI! that the su.itted info,...t ion is tru.. accurate, and co.ø !I!t.. . A:;;@-;¡ñ1rõmmnm¡¡-õY-õWñi¡;Toõë¡:m¡:-OR-õWñi¡;7õõë¡;ãtõ¡;'š-åütñõmia-;:¡õFëšiñtãHÿ¡ . Sigñãtü¡:¡------------------------------------------------- Dãti-Siijñ¡a------------------------ __.__~ <t ": .~~'~, ." tr~"'" .,,~ -. ' ::;..,..0 ..:. . ( .' t' A~o' .... ',- ,. " .,.......- ':_,.0 !",::'. -.~ . 1:1' . f;O! . - \'. 'j>. . O:t;" <' v..· .' "'\·.0 ~'," .. ;..".,-- ,!-O. '. :1'. - . .;~; . , ¡. ....~....-- ~ ~~~ . .. '.' i:· . " ¿::':-/' ~~~. . ¿.:, ". .,.,., (: ~,. 0 _ ........ . ,.....- ¡ç,; .', f .. ~~ ~ 1:( ',~ f ".' ~' .' , <~' --' ,,'. ,- ~ ~ r: _ ..-. -.... d . I''"! '" ~.~ MeN...'· :;,.;¡,.ià.... '. ~' I ;~; ,....... .- --, .E¥ ~:,:.:...¡,::.. ~iE1 .\. ø.~- --, -.- ._~ _ _ '1 . ,WOM&..... ~...' _. _ . ,'j:, 1"'''' -- ~ , .. ,2., \ . ;: '. . ~::.,' "'~'::',.".:,," ......,.. --...Aí¡ ,..... 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(~:"~7. f "'.' ~-' ~ \j 1 - SITE/FACILI.TV DI'GRAM FORM 5 ..., .., NORTH SCALE:\":'=ù' BCSr:-':ESS ~A~E: ~iOC.Ic:::ÞA\-E F=~,,~EQ~OR: ~ OF f..ø7.Jot '\luna~. ~i!~",=,iZlœ'-íJ L.c-,-,~, DAE:5 31/gc¡fACILITY XA~E: (j;\;IT #: OF (CHECK ONE) SITE OIAGRA~! /' FACILITY OIAGRÆ~ I . '-VLlIì\E t-"-'. Ie &;.aA9s, þ.>2eA-------~-~ I I I J ----- S 7A~~I~C~ ~ . ---.....,. ~-+( I l I w V\ -j uJ ¡, - t .:s I I ' ~ ',vA. 5 Q. \Ò ~ . LÙ III )~ \) 18 bAS J.J , ~ a ~ "11 ~ ~ () ~ ~ .:5 () I 11-1 ~ I~ 0 EI-EL-T ~fi ::i \- ::¡I ~ : -:ì ~ \j [ñ \J \fJ ~ 'V), ~~ -=t - ··'-ç;-WE._.~-r_D~~.~_1;!. Ai4.EA À.LlE.Y ,'tJ <J1 ~ ~ ¿ C> I\-:) C. ¡z.¡;;..-r¡¡¡æ. ""'P5 1-0 u:. ¿ol'.:) ~ -r , lZ~ïl~a:. ~1'-ï::>1b.,¡6- S?i2.IN~L...fži'Z~ í t·HZ ižE t..::s) EX \ ÇT c;. (Inspector's Comments): -OFFICIAL USE ONtY- - 5A - SITE DIAGRAM (Required items) 1, Addl'ess: Ident_the principle buildings by the Street numbers, - 9, Lock (key) Box '~" ~~ - ~y:¡- '~ J.. L' I 10, MSDS Storage Box 2, Street(s), Alleys, Driveways. and Parking Areas adjacent to the property, Include the street names, 11, Railroad Tracks 12, Fence or Barrier a, Wire b, Masonry 3, Storm Drains. Culverts, Yard Drains c, Wood 4, Drainage Canals, Ditches. Creeks. d, Gates 13, Power! ines 5, Au I I r1 I ngs a, Frame construction 14, Guard Station b, Masonry construction 15, Storage Tanks: Ident ify the capacity in gal. a, Above ground c, Metal construction d, Access Door b, Underground 6. Utility Controls a, Gas 16, Diking or Berm b, Electricity 17, Evacuation Route c, Water 18, Evacuation Area: I den t ify the location where employees wi 11 meet, 7, Fire Suppression Systems: a, Fire Hydrants b, Fire Sprinkler Connections 19, Outside Hazardous Waste Storage c, Fire Standpipe Connections 20, Outside Hazardous Material Storage d, Water Control Valves for protection systems 21. Outside Hazardous Material Use/Handling e, Fire Pump 22, Type of Hazardous Material/Waste Stored or Used (See Below) 8, Fire Department Access TYPE OF HAZARDOUS MATERIAL F Flammable E Explosive L Liquid R Radiological C = Corrosive 0 Oxidizer G Gas P Poison W Water Reactive T Toxic S Solid H Cryogenic D Waste B Etiological Example: Flammable Liquid = FL FACILITY DIAGRAM (Required items in addition to the above) 1. Risers for Sprinklers 8, Fire Escapes 2, Parti t ions 9, Air Conditioning Units 3. Stairways: Indicate the 10. Windows levels served from highest to lowest. 11. Inside Hazardous Waste Storage 4, Escalator: Indicate the levels served from 12. Inside Hazardous highest to lowest. Materials Storage 5. Elevator 13. Inside Hazardous Materials Use/Handling 6, Attic Access 14, Sewer Drain InJets ~v--j..-Tf, ~, 'J ~ ~"ì \ l\ ~ ~l r 'Q'~ ~\ . . I I I I, { I~ Š !. ~ ~ 1.:"1 'l, Ie '-./., l( Hl\fMP P~ MAP SITE DIAGRAM J- -=>< r FACILITY DIAGRAM F==,-~~ Business Name: ..5'7Z?C?£:"~~ ~.ø~V"~..dG7 Business Address: / Z/Ò . Ø/8~ ,e¿}, 9530c./ For Office Use Only First In Station: Area Map # of NORTH 0 Inspection Station: ~ ADJIf#IVd' SfTr,f/A f#ol' '''1 P"'f'Id'* V 4IAtI '''''I) ti~f1i' -I. ~ " f .-> ..' I ( ,rzø þ"".:) ~ ç ..! (i ... , . . . Ÿ' /~--:._. !trµ;lJlú ¡VolE : ð/WtMtt: 8/,ðU:. 4tWtST . ,PtJ sp,.e,AI..tc.øc.s -rJf/f1 (eo) Ðc./ rs' - --- (>~ _.-------_._--~-_.~- 6~ e'A/~u:- ..eð.