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Home My WebLink AboutBUSINESS PLAN 10/2/2003 · rUperil.te , it Per Waste Unified Permit Materials/Hazardous Hazardous CONDITIONS OF PERMIT ON REVERSE SIDE " JAN ~ 2001 Issue Date PERMIT ID # 015-021-002193 COMPLETE AUTOMO Approved by: Expiration Date: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 7001 LOCATION -' Issued by: ~ '-" ,.. ~ tt - N Sm:DIAG~. Pi"U1'fJf~ :=:=.: ~\\~,_~\\s _ _ _~G\ ~I ~~ " j ~ L~ ~ i s ~ ~~ 'Vf .. ~ i i W~ìL-LN \ uJ( ~\ UNIFIED PROGRAM INSPECTION CHECKLIST SECTION 1 Business Plan and Inventory Program Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 '-- FACILITY NAME C ~ ADDRESS 700\ FACILITYCONTACT INSPECTION DATE INSPECTION TIME . f 5 ~ I~_~__ No. of Employees ._~---------- A..u.. T<.) ~~VL__..Le-\?~c_ .'--________________________ White Lr-J :1:1:-_-1lS_'---______ QC129 1.~~~______ 132 y <ïs;t~o Business 10 Number 15-021- 0 Sectiof11: Business Plan and I.nventory Program ~utine LJ Combined LJ Joint Agency LJ Multi-Agency LJ Complaint LJ Re-inspection C V ( C=Compliance ) V=Violation OPERATION COMMENTS ~ LJ ApPROPRIATE PERMIT ON HAND ~----,---------------~---------------~-------- ---,----.-.-----'. ----~--------_._._"' -.--...-----.-.-,.----.-------..----------.---.---------...- "IrJ LJ BUSINESS PLAN CONTACT INFORMATION ACCURATE __.______.___ ___.__..__________._..___ ._.__ .._____________.____.__.______.____.__ ..___________._____. _ _._.-..__.+_____0'.____·___··__·· ..___..__ .._.__ .___._.__.__._ œI LJ VISIBLE ADDRESS --_._._-------_.__._.--~-_._--_.._--_. -.--. - _.._._-~-_._------- - ~----_._-----_._-_.__._--_.__._--._-_.._.~---- -... - -..-----...--- - - - -+----.--.-.- ra LJ rI LJ CORRECT OCCUPANCY ------.---.----.--.--.. ---~_.------ _._.._--_._...__._-_._--_..~.._.__._-_._------_..._._--.-.----..------..--.---.-..... -- VERIFICATION OF INVENTORY MATERIALS _.______________.___..______.____._n.____._ ___._._____._.._.______.__..__,,________..~_____.________.-...----------------...--- .--.. .-...-..-------- . ~ LJ VERIFICATION OF QUANTITIES -_.~-----_._--~-----_._---_._----_.__._------'----_._-..........-- --------_._.._._._.__._-----------_.__._----------_.~.--.----.-.---.-..---..---.--.---- ¡m LJ VERIFICATION OF LOCATION --------~--------_._--------_._-----_._--- -------.-------.-----.------.--------.--.--.--..-----.---.-------.--..- ~ LJ PROPER SEGREGATION OF MATERIAL ..---...-.----.---------..-.-.----. ..-.-----.--------------.--.-...-....-----.-------.---. .----.-----.---.--.--. --.......--- ~ LJ VERIFICATION OF MSDS AVAILABILlTYE ----------.--- -..--.-----....----- . ----.-.--- ---------.------- -.-- -_.~--_..._._--_._----_._~------_._.._._------_._--_.-----.-_. -~-- rø LJ VERIFICATION OF HAT MAT TRAINING .----.--------------.-----.....---.- .------..--..---.--------------.--------.----------.--..--.-...-.--.----------------..+--.- IS3 LJ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ----------.--.---.-.-.--.-----------...----- ------------_.__.._--_.-_._._-_._-~_._---_.._----_.__..-.--...-------.--- ~ LJ EMERGENCY PROCEDURES ADEQUATE -~-_._-_._._----------_.--_._._--_._--_._-----_._._-- _.._-----------------_._--_.._._._--_.__._-_._----~_..---.--.--------- -~-~--------_._._-_._._-_.__._-._-- ~ LJ CONTAINERS PROPERLY LABELED __.___....---________._.__~__~____.__.__________".. __..____.____ _.___.______________~___.__.__.._._._._______._.____._.____·.__·n_~___·___·_____·__·___ 11!1 LJ HOUSEKEEPING f -_._--_.__.._~----_._--~-_..__._------_._._-_..- -------_._-------------~-_._--------_._---_._-_.__._-"-- ~ LJ FIRE PROTECTION ___~_.___________.._________.~________.__.____.____ __________._.____~___.______.____.____________.._______ .__..__n______._ " LJ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE?: f!!.. YES LJ No ~ EXPLAIN: W+S.TCc.....- OIL White - Environmental Services QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326- b.~~LC---_-_-.--_--~~-S-~--. Inspector Badge No, Yellow - Station Copy ~ COMPLETE AUTOMOTIVE RÈ~AIR SiteID: 015-021-002193 Manager : Location: 7001 WHITE LN 115 City BAKERSFIELD A 1.~ t»~ \. '" BusPhone: Map : 123 Grid: 16D (661) 834-4899 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 09 EPA Numb: SIC Code:7538 DunnBrad: Emergency Contact KIRK LOWE Business Phone: 24-Hour Phone : Pager Phone : / Title / OWNER (661) 832-8280x (661) 834-4899x ( ) - x ,} Emergency Contact / Title JO(\( A.VOliliA LOWE / OWNER Business Phone: (661) 837-6060x 24-Hour Phone : (661) 834-4899x <:JJ \ Pa!e.L Phone : (~\»\ );xß -\~ x Hazmat Hazards: Fire DelHlth Contact : KIRK LOWE MailAddr: 8828 CLYDESDALE City : BAKERSFIELD Period : Preparer: Certif'd: ParcelNo: to Phone: (661) 834-4899x State: CA Zip : 93307 Phone: (661) 834-4899x State: CA Zip : 93307 TotalASTs: = Gal TotalUSTs: = Gal RSs: No Owner Address City KIRK LOWE : 8828 CLYDESDALE : BAKERSFIELD Emergency Directives: I, 'io~'f\cì ~~-e Do hereby certify that I have l'fjjië or print ....) reviewed the attached hazardous materials manage-- ment plan fO~~) and that it along with any corrections constitute a complete and correct man- agement plan for my facility. ~~ ~I/(o~ Da1t -1- 08/04/2003 F COMPLETE AUTOMOTIVE RE~AIR SiteID: 015-021-002193 9 Fast Format 9 Overall Site 9 01/03/2001 I f= Notif./Evacuation/Medical Agency Notification Employee Notif./Evacuation 01/03/2001 CHECKED VISUALLY AND BY CRANES WASTE OIL WHEN THEY PUMP THE TANKS, MONTHLY. YO'Of\C- EMPLOYEE WOULD CONTACT OWNERS/EMPLOYEES, KIRK & veNNA IOWE AFTER AUTHORITEIS SUCH AS 911 AND/OR OFFICE OF EMERGENCY SERVICES AT 1-800-852-7550 FOR ALL SPILLS THAT ARE A THREAT TO LIFE, SAFETY ENVIRONMENT. SPILLS NOT CLASSIFIED ABOVE ARE TO BE REPORTED TO PROPER OR LOCAL OFFICE Public Notif./Evacuation 01/03/2001 IT IS A HAZARDOUS SPILL. ~~~~LOWE WILL COMPANIES. KIRK WILL MAKE SURE BLDG IS FOR EMERGENCY RESPONSE TEAM. OWNER KIRK LOWE WILL DECIDE IF NOTIFY AUTHORITIES AND CLEANUP EVACUATED IF NEED AND BE THERE ~Emergency Medical Plan \ ~f\~ OR KIRK WILL CALL 911 WOULD BE KMC HOSPITAL. 01/03/2001 IF EMEREGENCY INDICATES. FACILITY OF CHOICE -6- 08/04/2003 CITY OF BAKERSFIEI"D FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd f'loor, Bakersfield, CA 93301 ~~Ta. FACILITY NAMEAw~ Zei'~(~ ADDRESS ',ore>' w \-l 'TE' L-N"**'" I \C;; FACILITY CONTACT ~Z.~ LOWf: - -=- INSPECTION TIME , 5' rv1ìY\ \'-\.... \ '::> INSPECTION DATE.--J \-\ ~.-b2 PHONE NO. (føtð I) e~ - Y~9 BUSINESS ID NO. 15-210- NUMBER OF EMPLOYEES 2- Section 1: Business Plan and Inventory Program C21 Routine D Combined D Joint Agency D Multi-Agency D Complaint D Re-inspection OPERA TION C V COMMENTS Appropriate pennit on hand Iv Business plan contact infonnation accurate V Visible address V Correct occupancy ........ Verification of inventory materials V ~ . Verification of quantities .1/ Verification of location V Proper segregation of material vI;' Verification of MSDS availability 1/ v 2-1 ilk, +,..., rj~~L ,.., I-'~ h& Verification of Haz Mat training V .- Verification of abatement supplies and procedures V Emergency procedures adequate V Containers properly labeled 1/ Housekeeping V Fire Protection t,.....-' Site Diagram Adequate & On Hand ~ 4 I \ 'Z./-z.¡ t C=Compliance V=Violation Any hazardous waste;Me?: Explain:-ôf.J 4 f}"" ' eeZ €.. æ:(Yes DNo r---- "'-.. -----.......-. -...""..... ...........--.-...<..".,., Questions regarding this inspection? Please call us at (661) 326-3979 White - Env, Svcs, Yellow - Station Copy Pink - Business Copy Inspector: 9e:- r , ., '-~. CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 l :l.?;r(<O r( <1\ HAZ~OUSMATEmALSMANAGEM~LAN , rJ { n ~ \\~\.J \\rý ~ INSTRUCTIONS: l çZ - U f ' ??ftI \ 1. To avoid further . , return this fo within 30 days of receipt. 2. TYPEIP SWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. 5. You may also attach Business Owner / Operator Fonn and Chemical Description Fonn(s) to the front of this plan instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA ftECE\VED nEe , 9 - EK~'~O~, C;f..~ø "~ BUSINESSNAME:~~ \4.~~\t~ ~'\~ LOCATION: ((X)~ ~~ ~ ~~~ )~ C\~ MAILING ADDRESS%~~ ~~~-~~~V<- CITY~~\Ùc.\ STAT~ ZI~HONE:\.\\lt)\ C6~ l\C69q PRIMARY ACTIVITY: ~~~\~(0 (\.<2 ~\X- OWNER:~\~ ~~ MAILING ADDRES~ ~,\~~~~e... PHONE~\~ ~q9 ~$i.-\t$ ~~ C\~~"'\ EMERGENCY NOTIFICATION CONTACT I.\\~X-\-\ ~ --;Ýcr\\\~ ~ - TITLE BUS. PHONE ~ ~ ~,~~~%~o \.9~\ q~\ ~() 1 24 HR. PHONE ~\ <6'3Y L\~ ~\ <t~4<6g -./ HAZARDOUSMATEIDALSMANAGEMENTPLAN SECTION 11.1: DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND M()NITO~G PROCEDURES: I c-~~ck.).. . V · C. ~tl 'r '~c.X bV errN\-~ ~ (Ja\w~-t'^-t ~~p -tc.'-'\lS moY\+0y fJOtr,,~ vVc,~f~ (!)~' ( ....s ""'. ,~.. 4 ,,,,: ....~ 4 1 ~ B. EMPLOYEE AND AGENCY NOTIFICATION: ~~be-~ ... ~~ ~ \a ~~cs_-\ ~~ le«'Ç\Ufe..t:s ~\~'L~~($\~~.~~ ~ ~'<'Ø\\L~ ~ ~ C\\\~~, ~~ ~ ~V\~ ~ \-~c.::::f:)~S~ --"'"")scsa ~ ~"" ~ ' \~,e-~ -\Q \~~ ~ ~ ~~~~. ~~ ~ G- \'&- ~'\~~ ~ ~'(~\'(~. "0\J~S \~ ~~\tsL ~, ~~, ) ~~~~\C\ '~'Ç~ ~~~NT=O~:;\~~~~~ \~ .~ \C;) CL~ ~~\. \IÖ"\~~ ~,,'\ ~~~~ ~~-à\~ ~ C-\~~ CD~~~\~~. ~{\c ~,''\ ~ ~ ~~\~\~ \~ ~~ \~ ~~ ~~~ ~~~ ~ ~'\~~~~ D. EMERGENCY MEDICAL PLAN: '/~~~CX' "'\~'C '+i\\\ ~'" ~\\ \~ ~~, ,'('C\'C~~ . Çc>6\\~ e:,~ ~'\'o,è.sL ~~ ~ ~'Ç\'\L~~~~ 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING NUMBEROFEMPLOYEES:~ - D~ ~\,~~y~ ~~ . . MATERIALSAFE1'YQA. ATASHEETSONFILE~\'NiàS ~\~- ç~\\,<\~ Q ~'\ '\\SD. - -2> BRIEF SUMMARY OF TRAINING PROGRAM: G('Ò. ~\ ~. ~~ <$C<.. ~ ,,~ Ç{'6~S . ~.~~ ~~\~~ \f&\~ ~ \()~"'~ ~~y¿ & ~~S m~~ ~(~~~ CJ.Y:Ò ~~'i:.~- . ~ J ""-"\\ ~ ~ \ ~\.~,~ Q\C>§'\. ~~ ~~ ,~~~ !v~ C; ~ C\<;ro\~ \CCç0,.· ~'ô\~",,-~ ~~ ~ ~~~ - ~O CS>-\\ ~ ,~~~~:~~t~=. ~ ~,~~~ ~ ,,\ CERTIFICATION I, ~\~ \ (~ CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON AID US MATERIALS (DIV. 20 CHAPTER 6.95 SEe. 25500 ET AL.) AND THAT C INFORMATION CONSTITUTES PERJURY. ()\N TITLE - \~" cO DATE 4 "'-~ "..." HAZARDOUSMATEIDALSMANAGEMENTPLAN SECTION 11.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT ANp PREVENTION MEASUR.E.S: , '" _~....., ..c- 'Ñ.Q...... ~,\\. ~ ~~~ Q. ~ \ \~. ,,~'-~'\~ C-~~,\ \D~\\\,~\~,< ~ '\~ ~~ È¿ ~.~ ~~~ B. RELEASE CONTAINMENT AND/OR MITIGATION: -I+ cl'&.ÑW\~·\~'c.. +~ WI'! I teL '~p~c.c..4 b'-{ -tk.. ~v.L<. vJ~~c.....\- f>nJ~ I~ -¡...t~_ ~ ~~~ wc-TtL 0; I, C. CLEAN-UP AND RECOVERY PROCEDURES: .,t C\ fiA lAf> ýV\..-<- -t if . "ù\ IN f + '" ~ S a.... n...ut.. CoV"l;'C.C+- G-..V\~~ \.~.k!~~ C),', ~._ ~ ~~~ ~DO-~ìZ-~~~- '1- --'1 UTILITY SHUT -OFFS (LOCATION OF SHUT -OFFS AT YOUR FACILITy) NATURAL GAS/PROP ANE: ~;~i::Cðf~E'~~~" r~1 SPECIAL: ,LOCK BOX: YES/NO IF YES, LOCATION: PRIVATE FIRE PROTECTION/W A TER AVAILABILITY A. PRIVATE FIRE PROTECTION: ~'V"C-- ~ .-'- 'fj\..,J~W<.r S B. WATER AVAILABILITY (FIRE HYDRANT): '"¡:.r. ~~ of V<-<-l-I+r 3 CITY OF BAKERSFIELD OF}lCE OF ENVIRONMENTAL SkaVICES 1715 Chester Ave., CA 93301 (661) 326-3979 BUSINESS OWNER I OPERATOR IDENTIFICATION FACILITY INFORMATION Page L Of~ .. t FACILITY IDENTIFICATION ~ <J... '("'\ \ 100: Year~ 3 '. WESS PHONE ! ~~ -34 c¿cl~a 101 102 I l~~~~ l CI~~~\~ i DUN& I BRADSTREET I i COUNTY 103 ~ \\~ 104 I CA : ZIP <i~ ! 106 I SIC CODE ! (4Digit#) -,S ~~ 105 107 108 INFORM~TlO ,. ,·"-d /'<,',:::;:,:J,:,<'''' L ! OWNER NAME ~ \i~ , OWNER MAILING I ADDRESS I CITY 113 ('\ 125 TITLE ~e.x- 130 126 ~\.n \ 131 24-HOUR PHONE 127 24-HOUR PHONE \..Ð.\ 132 PAGER # 128 PAGER # 133 Inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined in at! submitted in this inventory and believe the information is true, accurate, and complete. OPE TOR DATE 134 NAME OF DOCUMENT PREPARER \ \-\~-c::c 136 TITLE OF OWNER/OPERATOR Ö~~ 135 ö~(\o..... l t'\J..)Q - 137 UPCF (7/99) S:\CUPAFORMS\OES2130.TV4.wpd _~E~____~~DD __~~ETE CITY OF BAKERSFIELf OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION o REVISE 200 .----.-----. --.......------.-.- -_.. ~-_._--_.,---------' i-- 201: CHEMICAL LOCATION : CONFIDENTIAL (EPCRA) 203 GRID' (optional) . IL .CHEMICAL INFORMATION .... (one form per malenal per budd;n~r area) Page d- of ::>- o Yes 1:11 No 202 -204- CHEMICAL NAME ~~í ð;\ I COMM:)N NAME0\~ C), \ CAS' 205 TRADE SECRET 0 IIId Yes ~ No 206 If Subject 10 EPCRA, refer to instructions ~ \ If\."'" ~ - \-pc.~Z~ 207 o Yes r, No 208 FIRE CODE HAZARD CLASSES (Complete if requested by local fire cI'1ief) 209 ·U EHS is"Yes." III amouDIS below must be ÍIIIb$. 210 TYPE o p PURE EHS" PHYSICAL STATE o s SOLID o m MIXTURE "'50 (ßcU On.. ç 212 CURIES , 213 211 RADIOACTIVE o Yes ~ No 215 FED HAZARD CATEGORIES (Check all that apply) ANNUAL WASTE AM:)UNT 01 FIRE 216 UNITS" )ð I LIQUID OgGAS LARGEST CONTAINER 219 ST~ l\TE CODE DAYS ON SITE 20 220 214 o 2 REACTIVE o 3 PRESSURE RELEASE o 4 ACUTE HEALTH o 5 CHRONIC HEALTH 221 222 217 ~ /' I' _" _-'" 218 ! AVERAGE ø<. V<-' t.QV" -;) ! DAILY AM:)UNT , o Ib LBS 0 In TONS 223 STORAGE CONTAINER (Check all that apply) o a ABOVEGROUND TANK o b UNDERGROUND TANK OJ TANK INSIDE BUILDING IW d STEEL DRUM MAXIMUM DAILY ,.,UNT ~ GAL Z, 0 d CUFT " If EHS. amount must be in Ibs, o e PLASTICINONMETALLIC DRUM Of CAN o 9 CARBOY o h SILO o i FIBER DRUM OJ BAG Ok BOX o I CYLINDER o m GLASS BOTTLE o n PLASTIC BOTTLE o 0 TOTE BIN o p TANK WAGON o q RAIL CAR o r OTHER 226 o Yes 0 No 228 2 230 231 o Yes 0 No 232 233 3 234 235 o Yes 0 No 236 237 4 238 239 : o Yes 0 No 240 241 5 242 243 o Yes 0 No 244 245 STORAGE PRESSURE o aa ABOVE AMBIENT o ba BELOW AMBIENT -PRlÑT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE _!š~~~ LCi.\£ \ ~\'ç'{"' UPCF (7/99) 224 DATE 246 \\-\q"Cù S:\CUPAFORMS\OES2731.TV4.wpd CITY OF BAKERSFIELV OFFICE OF ENVIRONMENTAL SEJ.{VICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION _~~~___ 0 ADD 200 --------.----.-----..--.-----..-..- ... --.-.-.--.-.. -------- 3-d o DELETE o REVISE I. FACIUTY INFORMATION --.~~A~ NAME or DBA - Deing Business As) --- ~~~\~~ ~~,~ CHEMICAL LOCATION (one form per malenal per bulldì~r 3rea) Page 3.. 01 .J- __._.._ n __.__ FACILITY 10 # i I I 203 201' CHEMICAL LOCATION CONFIDENTIAL (EPCRA) GRID # (optional) DYes 1;11 No 202 204 II. CHEMICAL INFORMATION -'. .". 205 I TRADE SECRET 0 1IId Yes jIW No 206 If Subject to EPCRA. refer to instructions CHEMICAL NAME \ - 207 DYes ~No 208 ..... COMMON NAME ~(\~\ EHS' 209 ·If EHS is'Ves,' IIlIlllOllDls below must be m Ibs. CAS # FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) TYPE .a--;;;- ~RE ~:ID 214 LARGEST CONTAINER FED HAZARD ,CATEGORIES (Check alllhal apply) ANNUAL WASTE AMOUNT o 4 ACUTE HEALTH 05 CHRONIC HEALTH 219 210 , 213 215 216 CODE 220 222 o w WASTE 211 RADIOACTIVE 0 Yes 1!i1 No 212 CURIES ,\ GU~~ o P PURE PHYSICAL STATE o s SOLID o 1 FIRE 0 2 REACTIVE o 3 PRESSURE RELEASE 217 MAXIMUM DAILY AMOUNT 218 i AVERAGE , /"... L "'""'. ' DAILY AMOUNT \.9C-.... - " UNITS' ga GAL t\.....D cf CU FT 'If EHS. am~e in Ibs, o Ib LBS 0 tn TONS 223 STORAGE CONTAINER (Check alllhal apply) o i FIBER DRUM OJ BAG Ok BOX o I CYLINDER o m GLASS BOTTLE o n PLASTIC BOTTLE o 0 TOTE BIN o p TANK WAGON o a ABOVEGROUND TANK o b UNDERGROUND TANK g;. TANK INSIDE BUILDING Wd STEEL DRUM De PLASTICINONMETALLIC DRUM Of CAN o g CARBOY o h SILO 221 o Q RAIL CAR o r OTHER o aa ABOVE AMBIENT o ba BELOW AMBIENT 224 STORAGE PRESSURE ~MBIENT ~MBIENT o aa ABOVE AMBIENT o ba BELOW AMBIENT o c CRYOGENIC 225 STORAGE TEMPERATURE 226 2 230 3 234 4 238 242 227 o Yes 0 No 228 231 o Yes 0 No 232 235 o Yes 0 No 236 239 o Yes 0 No 240 243 o Yes 0 No 244 229 233 237 241 245 -PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE !\S~-~ LC:\.\.£ \ ~\'ç?:Ç' DATE 246 __ \~- ~CÙ UPCF (7/99) S:\CUPAFORMS\OES2731.TV4.wpd