HomeMy WebLinkAboutHAZ-BUSINESS PLAN 6/23/1887
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SITE/FACILITY DIAGRAM
FORM 5
S~ALE: BUSINESS NAME:~
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DATE: ~ ,;.ø¿ r¡1FACILITY NAi'fE:..-.-
(CHECK ONE)
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SITE DIAGRA)I
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UNIT #: OF
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(Inspector's Comments):
-OFFICIAL USE ONLY-
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S[TE DIAGRAM (Requ'IIIÞ iteaa)
1. Address: Identify the
principle buildings
by the Street numbers.
e
9. Lock (key) Box
10. M5DS Storage Box
11. Railroad Tracks
12. Fence or Barrier
a, Wire
b. Masonry
c. Wood
d. Gates
2, Street(s). Aiieys.
Driveways, and Parking
Areas adjacent to the
property, 1nclude the
street na.es.
3. Store Drains. Culverts.
Yard Drains
4. Drainage Canals. Ditches,
Creeks.
13. Power lines
5. Buildings
a. Frß.e construction
14. Guard Station
b. Masonry construction
15. Storage Tanks:
Identify the
capact ty In (al ;-"--~
a. Above ¡round
c. Metãrêo,nstr'uct!oñ
d. Access Door
b. Under¡round
6. Utility Controls
a. Ga.
16. DikIne or Bera
b. Electricity
17. Evacuation Route
c. Water
18. Evacuation Area:
Identify the
location where
e.ployees wHI
.eet.
7. Fire Suppression Syste.s:
a. Fire Hydrants
b. Fire Sprinkler
Connection.
19. Outside Hazardous
Waste Storaee
c. Pire Standpipe
Connections
20. Outside Hazardous
MaterIal Storage
d. Water Control Valvea
for protection systews
21. Outside Hazardous
Material
Use/Handline
e. Fire Puap
22. Type of Hazardous
Material/Waste
Stored
or Used (See,
Below)
8. Fire DepartMent Access
TYPE OP HAZARDOUS MATERIAL
F - FllUlllable B - Explodve L - Liquid
C - Corrosive 0 - Oxidizer G - Gas
W - Water Reactive T - Toxic S - SoUd
R - RadIoloiical
P . Poison
H - Cryoeenic
D . Waste B . EtIoloaical
Exaaple: Fla..able Liquid - FL
FACILITY DIAGRAM (Required iteas in addition to the above)
1. Risen for Sprinklera 8. Fire Escape.
Z. Parti tiona 9. Air Conditionina Units
3. Stairwaya: Indicate the 10. Windo..
levels ae~ved fro.
hiahest to lowest. 11. Inside Hazardous Wute
stora.e
4. Escalator: Indicate the
levels served fro. 12. Inaide Hazardoua
hl¡heat to loweat. Mater!al. Storsae
5. Elevator 13. Inside Hazardous
Materials Use/Handline
6. Attic Acceu
14. Sewer Drain Inlets
T. Skyl1¡hts
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2130 "6" STREET
BAKERSFIELD. CA 93301
(805) 326-3979
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RECEIVED
JUN 2 3 1987
Ans·d...........,
OFFICIAL USE ONLY
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~USINESS NA.\fE
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
CITY :15.4 ~1(.5' r: e_ Jd
{)lA... J eJ m () -r" V ê:-
W h / -¡- e.. j.. /? 11/ e_
tJ 33/3 BUS.PHONE:
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A. BUSINESS NAME: 04 If We; ¡f 5-
B. LOCATION / STREET ADDRESS: 7 ()O/
ZIP:
(1® ~~:À -fJ~f,ll
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
Y9~Y local fire department and the State Office of Emergency Services as required by
law.
EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:
NAME AND TITLE
A. 1-1 ¡:¡ 5 ffe- / / -¡¿, /f (l/e..->/
DURING BUS. HRS.
PhI 93~ - f? ~"¥ 7"
AFTER BUS. HRS.
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B.
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SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE
A. NAT. GAS/PROPANE: 8~~~ h e 1»1+1 /Y) ,ttlJ 1 e.. ~,+ h'1; ;¡d ¡ IV ~
B. ELECTRICAL: lt'l II T
C. WATER: I( " " I, I,
D. SPECIAL: , .
E. LOCK BOX: YES /@ IF YES, LOCATION: Y\
IF YES, DOES IT CONTAIN SITE PLANS? YES / NO
FLOOR PLANS? YES / NO
MSDSS? YES / NO
KEYS? YES / NO
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SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE
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SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE
C¡lÞf.- ¡JAß!J jt-4#L#
SECTION 6: EMPLOYEE TRAINING
EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND
REFRESHER TRAINING IN THE FOLLOWING AREAS.
CIRCLE YES OR NO INITIAL
A. METHODS FOR SAFE HANDLING OF HAZARDOUS
MATERIALS: . . ., . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . ., YES NO
B. PROCEDURES FOR COORDINATING ACTIVITIES
WITH RESPONSE AGENCIES:.......................... YES NO
C. PROPER USE OF SAFETY EQUIPMENT: . . . . . . . , . . . . . . . . . . ,YES NO
D. EMERGENCY EVACUATION PROCEDURES:.. ............... YES NO
E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS:..... ,. YES NO
11Þ
REFRESHER
YES NO
" SECTION 7: HAZARDOUS MATERIAL
CIRCLE YES OR NO "' "
DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN~~p POU~~F A
SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS~,:... ,"~ NO
I. 4{ r " lCA f\\\J e.-R.. . certify that the above i,nformation 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.
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'SIGNAT~~
DATE 10 -é) I ~ .Y7
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BAKERSFIELD CITY FIRE DEPARTMEXT
2130 "G" STREET
BAKERSFIELD, CA 93301
OFFICIAL CSE ONLY
BUS INESS NA~Œ:
ID# 11 L L.5 ,:0 d 0 "3;), f
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# If IdS FACILITY UNIT NA..'IE: -¡;;-; rJelf's f) LA... 'TOrhð-T; Ve...;
, SECTION 1: MITIGATION, :REVENTION, ABATEME~ PROCEDURES '. -' "'-L
fill Wff S¡6 ð,'1- 15 S To ¡fed I lV, S"Tee-'-:-c þ.':>L.5:..~~~."! r¿
5 Ò f1¿uJ /-' rV fJ...-u. ~5 ~ ~'O LA... JëL'Mf{V'·Ö T-- S'P/;::---:..l·-F~·:-~t:ï!-':fPèd
ð \J f!..; R.. :¡:. rJ The..., ~ ft 5 ~ .0 -F' ð Ne.... Þ ~ / JVÖ" d f7 ~ A (r~d ?-
A ~ P, I J...L 0 e a L{ ~e d) vu e...- ke e P ¡q $,6 Ii þr:) r/¡ R.. ¡ <!.- ~ ,
I-fu..lk Po u)d e ~ (j N P It -e. f'Y7 ,. Ses Tô -S ¿ri9%~-PcJ I L-,
SECTION 2: NOTIFICATION ~\~ EVACUATION PROCEDLKES AT THIS L~IT ONLY
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SECT~OX 3: HAZARDOUS MATBRIALS 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 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
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SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY,Em:RGENCY RESPONDERS
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SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT OXLY,
A. NAT. GAS/PROPAN~~
t3Ree.2e
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B. ELECTRICAL:
(3 R~ e L"ê W 'A-¡
C. WATER:
ß Reet-.~
w ~"i
D. SP¡::CTAI.:
E, LOCK BO~: ~'ES /@J IF YES. LOCATIO~:
IF YES, STTE PLAXS0
::-r.OOR Pr.,\~S')
YES
YES
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NO
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BAKERSFIELD CITY FIRE
FORM 4A-l
NON-TRADE SECRETS
HAZARDOUS MATERIALS INVENTORY
DEPARTMENT
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NAME: 7 U ¡V¡N ~F)'<s HI.¡¡ TO fY\ DT I'll c OWNER NAME:HH5j(~// Ju~rJ~f( FACILITY UNIT #: /P:::'-
'')601 WÝ),' IF- f_rJ, #- ItJr: ADDRESS: ·~¿'()q~eecf,e.f? ftv'e-., FACILITY UNIT NAME:!f. í4 f)'fJP.l/(
P : 12 ¡q. t)' e Ie .5 ...¡::::/ e. !rI '-. <J..33~3 CITY, ZIP: 8J+Ke. if-5.;=';' e... teL ~3~ð ~
~ 3 ~ --- -g 'if J.f J.{ PHONE #: <;( :3/-(;). 4 9 ~ IOFF I C IAL USE CF IRS CODE
ONLY
1 2 3 4 5 6 7 8 9 10
TVPE MAX ANNUAL CONT USE LOCATION IN THIS % BV HAZARD D.O.T
CODE AMOUNT AMOUNT UNIT CODE CODE FACILITV UNIT WT. CHEMICAL OR COMMON NAME CODE GUIDE
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NAME: ¡..¡.¡:¡. c:;/(pj/'T-u Rr:.Jp,R TI·TLE: í'JU) t)e Ie SIGNATURE: DATE :?- ~ -?:;'2
EMERGENCV CONTACT: -41'+ c; f-(@ ,/ f "\ I.A r:< t\) ~R T I !LE : to<.V Nt'--\ PHONE # BUS HOURS: C;!.3 d-.- g&~ 'f~
EMERGENCY CONTACT: HR- 51) ell Th ~ J.'Ie,¡( TITLE: oWlÝe~ AFTER BUS HRS: ><3 J - ~ 't 9 ~
PHONE , BUS HOURS: ~/' ~ e...,
PRINCIPAL BUSINESS ACTIVITY:!+4. II'J/y¡o/,ífe f<. eo -R f+ : f?. AFTER BUS HRS: ,¡j t?.--
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