HomeMy WebLinkAboutBUSINESS PLAN
Per
it to
Operate·
Hazardous Materials/Hazardous Waste Unified Permit
CONDITIONS OF ,PERMIT ON REVERSE SIDE
This permit is issued for the following:
zardous Materials Plan
. round Storage of Hazardous Materials '
agement Program
. Waste
5201
WHITE
PERMIT ID# 015-021.001540
MEMORIAL CENTER HOSPIT
LOCATION
, Issued by:
Bakersfield Fire Department
OFFICE OF ENVIRONMENTAL SER VICES
1715 Chester Ave., 3rd Floor
Bakersfield, CA 93301
Voice (805) 326-3979 .
FAX (805) 326-0576
Approved by:
Expiration Date:
June 30, 2000 .
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MEMORIAL CENTER FOR BEHAVIORIAL
SiteID: 015-021-000046
Manager :
Location: 5201 WHITE LN
City BAKERSFIELD
BusPhone:
Map : 123
Grid: 15D
(661) ,398-1800 '
CommHaz : Low
FacUnits: 1 AOV:
CommCode: BAKERSFIELD STATION 13
EPA Numb:
SIC Code:8063
DunnBrad:
Emergency Contact / Title
~EN LA BK~CUUE~;r¡i / SAFETY COORD
Business Phoné\10dr6~1) 327-4647x1812
24-Hour Phone : (661) - x
Pager Phone : (661) 632-3287xCELL
Emergency Contact . L Title
GERALD ~ ß'f'ARR--MtJofl#. DIRECTOR
Business Phone: (661) 398-1800x204
24-Hour Phone : (661) 832-2087x
Pager Phone : (661) 335-3556x
Hazmat Hazards:
Fire
DelHlth
Period :
Preparer:
Certif1d:
parcelNo:
to
Phone: (661) 398-1800x
State: CA
Zip : 93309
.
Phone: (661) 398-1800x
State: CA
Zip : 93301
TotalASTs: = Gal
Total USTs :. = Gal
RSs: No
Contact :
MailAddr: 5201 WHITE LN
City : BAKERSFIELD
Owner
Address
City
GREATER BAKERSFIELD MEMORIAL HOSP
: '420 34TH ST
: BAKERSFIELD
Emergency Directives:
JERRY MOORE, PAGER 336-1104.
;f.(fJ¿¡yt~-~Þle2Do hereby certify that I have
I, . )
(TyÞØ or print name .
reviewed the attached hazardous matenals manage-
t Plan for ;v1eMor1aIC(;'¡f If1Kd that it along with
men" {Name of BUSiness)
any correètions constitute a complete and correct man-
agement plan for my facitity.
~tI~
Sl~
1-7-0~1
Date I
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08/27/2004
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F MEMORIAL CENTER FOR BEHAVIORIAL SiteID: 015-021-000046 9
STORAGE CONTAINER DATA (UST FORM A)
Last Action Type:
FACILITY/SITE INFORMATION
Business Name: MEMORIAL CENTER FOR BEHAVIORIAL
Cross Street :
Business Type: Org Type:
Total Tanks : 1 IndnRes/Trust: No PA Contact:
PROPERTY OWNER INFORMATION
Name : GERALD A STARR Phone: (661) 398-1800x204
Address:
City : State: . Zip:
Type : CORPORATION
TANK OWNER INFORMATION
Name : GERALD A STARR Phone: (661) 398-1800x204
Address:
City : State: Zip:
Type : CORPORATION
BOE UST Fee# : 033861
Financ'l Resp:
Legal Notif : Business Mailing Address
Date :'06/08/1993 Phone: ( ) - x
Name:BILL PLILER Ttl:PLANT MANAGER
State UST # : 1998 Upg Cert#: 00703
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08/27/2004
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F MEMORIAL CENTER FOR BEHAVIORIAL
f= Hazmat Inventory
f== MCP+DailyMax Order
SiteID: 015-021-000046
By Facility Unit
Fixed Containers on Site
9
ì
ì
DailyMax Unit MCP
1000.00 GAL Mod
Hazmat Common Name...
specHaz EPA HazardS Frm,
DIESEL FUEL #2
F
DH
L
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08/27/2004
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f= Inventory Item 0001
F== COMMON NAME / CHEMICAL NAME
DIESEL FUEL #2
SiteID: 015-021-000046 9
Facility Unit: Fixed Containers on Site 9
Days On Site
365
Location within this Facility Unit
20FT S OF EMERGENCY GENERATOR, E SIDE
Map:
Grid:
CAS#
68476-34-6 .
STATE - TYPE
Liquid Pure
PRESSURE
Ambient
TEMPERATURE
Ambient
CONTAINER TYPE
UNDER GROUND TANK
Largest Container
1000.00 GAL
AMOUNTS AT THIS LOCATION
Daily Maximum
1000.00 GAL
Daily Average
550.00 GAL
U OMP EN
%Wt. RS CAS#
100.00 Diesel Fuel No. 2 No 68476302
HAZARDO S C
ON TS
TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP
No No No No/ Curies F DH / / / Mod
HAZARD ASSESSMENTS
Ag.Defined1:
Ag.Defined5:
Ag.Defined8:
MISC. LOCAL AGENCY DATA
Ag.Defined2: Ag.Defined3: Ag.Defined4:
Ag.Defined6: Ag.Defined7:
Ag.Defined9: Ag.DefinelO:
- Ag.Define11
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F MEMORIAL CENTER FOR BEHAVIORIAL SiteID: 015-021-000046 ì
f= Inventory Item 0001 Facility Unit: Fixed Containers on Site ì
STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2
Last Action Type:
Location In Site: 20FT S OF EMERGENCY GENERATOR, E SIDE
TANK DESCRIPTION
Tank ID#: 1 Mfr: Joor
Installed: 6/1987 Capacity: 1000 Gals
Additional Info:
Compart Tank: N
No. Of Comparts:
Tank Use: MOTOR VEHICLE FUEL
MatI Name:DIESEL FUEL #2
TANK CONTENTS
Petrol Type: DIESEL
Cas #: 68476-34-6
TANK CONSTRUCTION
Type : DOUBLE WALL
Material(p): STEEL CLAD W/FIBERGLASS R. P.
Material(s): STEEL CLAD W/FIBERGLASS R. P.
Lining : GLASS LINING
Corr Prot: FIBERGLASS REINFORCED
Spill Cnt : 1987
Drop Tube : 1987
Striker Plate: 1987
Sgl Wall:
PLASTIC
Alarm· :
Ball Float :
Fill Tube S/O: 1987
TANK LEAK DETECTION
Dbl Wall: INTERSTITIAL MONITORING
Installed:
Installed:
Exempt: No
Last Used:
TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE
Qty Remaining: Was Filled: No
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08/27/2004
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F MEMORIAL CENTER FOR BEHAVIORIAL SiteID: 015-021-000046 9
f= Inventory Item 0001 Facility Unit: Fixed Containers on Site 9
STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2
- PIPING CONSTRUCTION
UnderGround Piping
SUCTION
DOUBLE WALL
AboveGround Piping
Type :
Const:
Mfgr :
Mtl :
& :
Corr :
Prot :
FIBERGLASS
FIBERGLASS
.
,
PIPING LEAK DETECTION
UnderGround Piping AboveGround Piping
AUTOMATIC LEAK DETECTORS
i
I
Installed:
i
DISPENSER CONTAINMENT
Type: NONE
OWNER/OPERATOR SIGNATURE
I
Date: 06/09/1993
Name:BILL PLIER
prbt Number: 0046
!
TANK/LINE TEST :
I
CP¡CERT. :
MANWAY INSP. : 07/01/1999
UST MONIT. CERT:04/19/2004
I
Ttl:PLANT MGR.
Approved: Yes Expiration Date: 06/30/2003
AGENCY DEFINED
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08/27/2004
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F MEMORIAL CENTER FOR BEHAVIORIAL
I
p= Notif./Evacuation/Medical
r=: A. gency Notification
CALL 911.
SiteID: 015-021-000046 9
Fast Format 9
Overall Site 9
12/21/1999 ]
12/21/1999
Employee Notif./Evacuation
EVACUATION PROCEDURE IN PLACE, CALL 911.
Public Notif./Evacuation
OS/27/1993
MEMORIAL CENTERS PUBLIC ADDRESS SYSTEM WOULD BE UTILIZED TO WARN PUBLIC IN
THE EVENT OF AN EVACUATION.
Emergency Medical Plan
02/12/2001
RN" ON DUTY 24 HOURS A DAY (ON SITE). MERCY HOSPITAL, 2215 TRUXTUN AVE,
327-3371 OR MEMORIAL HOSPITAL, 420 34TH ST, 327-1792. EMERGENCY SITUATIONS
BEYOND RN SCOPE WOULD BE HANDLED BY CALLING 911 AND TRANSPORTING PERSONS TO
NEAREST 24 HOUR EMERGENCY RM WITH SPACE AVAILABLE.
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MEMORIAL CENTER FOR BEHAVIORIAL
S't ID 015 021 000046
]. e : - - :
Manager : BusPhone: (661) 398-1800
Location: 5201 WHITE LN Map : 123 CommHaz : Low
City : BAKERSFIELD Grid: 15D FacUnits: 1 AOV:
CommCode: BAKERSFIELD STATION 13 SIC Code:8063
EPA Numb: - DunnBrad:
K. e:{'\ l ñ u. ,^'" [f"" T!.. ~ ~~ 1 ..1 .A. :-5'"V," r r
.
Emergency Contact / Title Emergency Contact / Title
KITTY RINCER / SAFETY COORD ~IRDREJ 'fERl.:ggKI / DIRECTOR
Business Phone: (661) 6J2 :;:;J2* 3Z.1~q-¡ Business Phone: (661) 398-1800x204
24-Hour Phone : (661) ,~~ áGeOx ~- fBI2. 24-Hour Phone : (661) 832-2087x
Phone : (661) 632-3287x Pager Phone' . ' (661) 335-3556x
c....?,\ \
Hazmat Hazards: Fire DelHlth
.
Contàct : Phone: (661) 398-1800x
MailAddr: 5201 WHITE LN Statè: CA
City : BAKERSFIELD Zip : 93309
Owner GREATER BAKERSFIELD MEMORIAL HOSP Phone: (661) 398-1800x
Address : 4~0 34TH 'ST State: CA
City : BAKERSFIELD Zip : 93301 '".,~.~
Period to TotalASTs: = Gal
Preparer: TotàlUSTs: = Gal
Certif'd: RSs: No
ParcelNo:
Emergency Directives:
JERRY MOORE, PAGER 336-1104.
I, ~Je~~:>I'~=l'" . Do hereby œrti~ ~~. ~ heMS
revjewe~ me attached hazardous maierials manage-
ment plan for ~\MðY-\ol (}Y\.\er and that it along with
(Name ofßuslness)
any corrections constitute a complete and correct man-
agement plan for my facility.
.~.~- ". :.,AZ .-'At'·, _.~~' ".:< .,
.Q". ".""'<"'~.'. .,if!P"jiü. '. ' " . +'" .
. " ~ .... 'i' '3
~ -~ ~
".)~q'/'1!t'@' ~,~
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04/21/2003
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F MEMORIAL CENTER FOR BEHAVIORIAL SiteID: 015-021-000046 ì
S ORAGE CONTAINER DATA (UST FORM A)
T
Last Action Type:
FACILITY/SITE INFORMATION
Business Name: MEMORIAL CENTER FOR BEHAVIORIAL
Cross Street :
Business Type: Org Type:
Total Tanks : 1 IndnRes/Trust: No PA Contact:
PROPERTY OWNER INFORMATION
Name : .~~ :P~RLESKI Phone: (661) 398-1800x204
Address: . S\R'Q..Q..
City : State: Zip:
Type : CORPORATION
TANK OWNER INFORMATION
Name : DEIRDRE £~RLE3KI Phone: (661) 398-1800x204
Address: ~ta.ld .. IH2..(L..
City : State: Zip:
Type : CORPORATION
BOE UST Fee# : 033861
Financ' I Resp:
Legal Notif : Business Mailing Address
Date:06/08/1993 Phone: ( ) - x
Name :~LL ~L~3ën~ h\O()'fe. Ttl:PLANT MANAGER
State UST # : 1998 Upg Cert#: 00703
One Unified List ì
All ~aterials at Site ì
f= Hazmat Inventory
p== Alphabetical Order
Hazmat Common Name. . .
SpecHaz EPA Hazards
DailyMax
MCP
DIESEL FUEL #2
F
DH L
1000.00 GAL Mod
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04/21/2003
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f= Inventory Item
=== COMMON NAME /
DIESEL FUEL #2
FOR BEHAVIORIAL
0001
CHEMICAL NAME
SiteID: 015-021-000046 9
Facility Unit: Fixed Containers on Site 9
Days On Site
365
Location within this Facility Unit
20FT S OF EMERGENCY GENERATOR, E SIDE
Map:
Grid:
CAS#
68476-34-6
STATE - TYPE
Liquid Pure
PRESSURE
Ambient
TEMPERATURE
Ambient
CONTAINER TYPE
UNDER GROUND TANK
Largest Container
1000.00 GAL
AMOUNTS AT THIS LOCATION
Daily Maximum
1000.00 GAL
Daily Average
550.00 GAL
%Wt. RS CAS#
100.00 Diesel Fuel No. 2 No 68476302
HAZARDOUS COMPONENTS
TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP
No No No No/ Curies F DH / / / Mod
HAZARD ASSESSMENTS
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04/21/2003
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F MEMORIAL CENTER FOR BEHAVIORIAL
I
f= Notif./Evacuation/Medical
~ Agency Notification
L:ALL 911.
SiteID: 015-021-000046 ì
Fast Format ì
Overall Site ì
12/21/1999 ]
12/21/1999
I
Public Notif./Evacuation
OS/27/1993
Employee Notif./Evacuation
EVACUATION PROCEDURE IN PLACE, CALL 911.
MEMORIAL CENTERS PUBLIC ADDRESS SYSTEM WOULD BE UTILIZED TO WARN PUBLIC IN
THE EVENT OF AN EVACUATION.
..
Emergency Medical Plan
02/12/2001
RN ON DUTY 24 HOURS A DAY (ON SITE). MERCY HOSPITAL, 2215 TRUXTUN AVE,
327-3371 OR MEMORIAL HOSPITAL, 420 34TH ST, 327-1792. EMERGENCY SITUATIONS
BEYOND RN SCOPE WOULD BE HANDLED BY CALLING 911 AND TRANSPORTING PERSONS TO
NEAREST 24 HOUR EMERGENCY RM WITH SPACE AVAILABLE.
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I
f= Mitigation/Prevent/Abatemt
Release Prevention
SiteID: 015-021-000046 ì '
Fast Format ì
Overall Site ì
OS/27/1993
Release Containment
OS/27/1993
MATERIAL (DIESEL #2) PROPERLY STORED IN AN UNDERGROUND STORAGE TANK.
UST (STORAGE TANK) AND PIPING ARE DOUBLE WALLED WITH LEAK DETECTION MONITOR
PROBES AND ALARMS. LIQUID LEVEL INDICATOR PROVIDES CONSTANT DIGITAL READ
OUT IN INCHES OF FUEL IN TANK. ALARMS MONITORED AT NURSES STATION 24 HOURS
Clean Up
Other Resource Activation
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F.MEMORIAL CENTER FOR BEHAVIORIAL
I
f= Site Emergency Factors
l Special Hazards
Utility Shut-Offs
SiteID: 015-021-000046 ì
Fast Format ì
Overall Site =¡
I
12/21/1999
A) GAS - OUTSIDE MEDICAL RECORDS STORAGE RM BE CORNER OF LOADING DOCK
B) ELECTRICAL - BETWEEN MAINTENANCE & MECHANICAL RMS & LOADING DOCK E
C) WATER - MAIN BACK FLOW PREVENTER AT SW END FACILITY AT GRISSOM ST AND IN
EQUIPMENT RM NEXT TO FIRE SPRINKLER NEXT TO MAIN ELECTRICAL RM
D) SPECIAL - UST (#2 DIESEL) 11000 GAL MAX
CEh LOCK BOX - YES (KEYS) MAINTENANCE SHOP E SIDE NEXT TO LOADiNG DOCK AND
)rifULT NURSING HAS MASTER KEY AT NURSES STATION
Fire Protec./Avail. Water
OS/27/1993
PRIVATE FIRE PROTECTION - FULLY SPRINKLERED FACILITY INCLUDING FIRE EXTERIOR
FIRE HYDRANTS, 24 PORTABLE FIRE EXTINGUISHERS LOCATED THROUGHOUT FACILITY.
NEAREST FIRE HYDRANT - WEND OF·S WING AT GRISSON ST (SW CORNER OF SITE).
Building Occupancy Level
'=:. Lock..~)<" ~\\-~ \)~~\ /!'~s 6'h',"\ ~ \.\ -\:~ _ _\ödc \?O,?- ~' ~()t¡k.- ßr", \
h~<::' Keï +0 ~LI\\1'j ·,'tì5·,d~. L:1)(J~- tx¥ts, lóU\.\e.ò \Y\ -\1-oV'.\
c-\- ~~ ~'dj on. Re.ÞAe-k.5IJe o~ -k~e £<ï-<;' í \?d'e.t.
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04/21/2003
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F MEMORIAL CENTER FOR BEHAVIORIAL
I
F Training
Employee Training
SiteID: 015-021-000046 9
Fast Format 9
Overall Site 9
02/12/2001
WE HAVE 130 EMPLOYEES AT THIS FACILITY.
WE DO HAVE MSDS SHEETS ON FILE;
BRIEF SUMMARY OF TRAINING PROGRAM:
MATERIALS WHEN HIRED AND WHEN A NEW
INTRODUCED MUST FIRST HAVE APPROVAL
IN MSDS BEFORE SUBSTANCE IS USED.
EMPLOYEES RECEIVE TRAINING IN HAZARDOUS
SUBSTANCE IS INTRODUCED. NEW· MATERIALS
OF SAFETY COMMITTEE FOLLOWED BY TRAINING
Page 2
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Held for Future Use
Held for Future Use
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/)
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R,CEIVED BusPhone: (661) 398-1800
~.ÉB 0.9 .2001 Ma~ : 123 CommHaz: Low
~~.~ Grld: 15D FacUnits: 1 AOV:
STATION {¡NV!Rn\\' ~q~VICE§)IC Code: 8063
DunnBrad:
SiteID: 015-021-000046
Manager :
Location: 5201 WHITE LN
City BA~ERSFIELD
CommCode: BAKERSFIELD
EPA Numb:
Emergency Contact / ! Title bì"
.DEIRDRE TERLESKI / ~Ql~ -,~£f' ~
Business phone: (661) 398-1800x :)..C"¡
24-Hour Phone (661) 832-2087x
Pager Phone : (~I) 335- 35%c
Hazmat
Fire
DelHlth
Phone: (661) 398-1800x
State: CA
Zip 93309
Phone: (661 ) 398-1800x
State: CA
Zip . 93301
.. TotalASTs: Gal
TotalUSTs: Gal
RSs: No
Contact .:
MailAddr: 5201 WHITE LN
City BAKERSFIELD
Owner
Address
City
GREATER BAKERSFIELD MEMORIAL HOSP
420 34TH ST
BAKERSFIELD
Period
Preparer:
Certif'd:
to
Emergency Directives:
Terri 'f'f\ørre..
1>a.~ (~r.1)3~b-lIo'f
I, -.lli,'rltæ. Tf2,("lt.'&Ii Do hereby certify that I have
(Type or pnnl name)_
reviewed the attached hazardous materials manage-
ment plan for \(e~ Co...Je.r.-and that it along with
( ame 0 BUsinass)
any corrections constitute a complete and .correct man-
agement plan for my facility.
~ ~lf4/.
Signature
') 1- 30-01
Dale
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12/12/2000
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F MEMORIAL CENTER FOR BEHAVIORIAL
SiteID: 015-021-000046 ì
)
STORAGE CONTAINER DATA UST FORM A
Last Action Type:
FACILITY/SITE INFORMATION
Business Name: MEMORIAL CENTER FOR BEHAVIORIAL
Cross Street :
Business Type: Org Type:
Total Tanks : 1 IndnRes/Trust: No PA Contact:
PROPERTY OWNER INFORMATION
Name : DEIRDRE TERLESKI Phone: (661) 398-1800x
Address:
City : State: Zip:
Type : CORPORATION
TANK OWNER INFORMATION
Name : DEIRDRE TERLESKI Phone: (661) 398-1800x
Address:
City " Zip:
: , State:
Type : CORPORATION
BOE UST Fee# : 033861
Financ'l Resp:
Legal Notif : Business Mailing Address
Date:06/08/1993 Phone: (W )~,t -Ige>{) x 1/3
Name:~I~~ PbIßHR J""e.rry ~ Ttl:PLANT MANAGER FQc;l,'t, S~t':>(Y""
State UST # : 1998 Upg Cert#: 00703
One Unified List ì
All Materials at Site ì
p= Hazmat Inventory
f== As Designated Order
Hazmat Common Name...
SpecHaz EPA Hazards
DailyMax
MCP
DIESEL FUEL #2
F
PH
L
1000.00 GAL Mød
I
-2-
12/12/2000
co
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f MEMORIAL CENTER FOR BEHAVIORIAL
p=Inventory Item 0001
=== COMMON NAME / CHEMICAL NAME
DIESEL FUEL #2
SiteID: 015-021-000046 ì
Facility Unit: Fixed Containers on Site ì
Days On Site.
365
Location within this Facility Unit
20FT S OF EMERGENCY GENERATOR, E SIDE
Map:
Grid:
CAS #
68476-34-6
STATE - TYPE
Liquid Pure
PRESSURE
Ambient
TEMPERATURE
Ambient
CONTAINER TYPE
UNDER GROUND TANK
Largest Container
1000.00 GAL
AMOUNTS AT THIS LOCATION
Daily Maximum
1000.00 GAL
Daily Average
550.00 GAL
HAZARDOUS COMPONENTS
%Wt. RS CAS #
100.00 Diesel Fuel No. 2 No 68476302
HAZARD ASSE MENT
TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP
No No No No/ Curies F DH / / / Mod
SS
S
-3-
12/12/2000
;
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~
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F MEMORIAL CENTER FOR BEHAVI OR IAL
I.
p= Notif./Evacuation/Medical
r=: Agen.cY Notification
CALL 911.
SiteID:
015-021-000046 "I
Fast Format "I
Overall Site "I
12/21/19991
12/21/19991
OS/27/1993
r: Employee Not if . /Evacuation
~ACUATION PROCEDURE IN PLACE,
CALL 911.
Public Notif./Evacuation
MEMORIAL CENTERS PUBLIC ADDRESS SYSTEM WOULD BE UTILIZED TO WARN PUBLIC IN '
THE EVENT OF AN EVACUATION.
Emergency Medical Plan
12/21/1999
RN ON DUTY 24 HOURS A DAY (ON SITE). MERCY HOSPITAL - 2215 TRUXTUN AVE -
327-3371 OR MEMORIAL HOSPITAL - 420 34TH ST - 327-1792. EMERGENCY
SITUATIONS BEYOND RN SCOPE WOULD BE HANDLED BY CALLING 911 AND TRANSPORTING
PERSONS TO NEAREST 24 HOUR EMERGENCY RM WITH SPACE AVAILABLE.
-4-
12/12/2000
.,
.... -:..
-
e
'7-
"
F MEMORIAL CENTER FOR BEHAVIORIAL
I
p= Mitigation/Prevent/Abatemt
Release Prevention
SiteID: 015-021-000046 ì
Fast Format ì
Overall Site ì
OS/27/1993
MATERIAL (DIESEL #2) PROPERLY STORED IN AN UNDERGROUND STORAGE TANK.
Release Containment
OS/27/1993
UST (STORAGE TANK) AND PIPING ARE DOUBLE WALLED WITH LEAK DETECTION MONITOR.
PROBES AND ALARMS. LIQUID LEVEL INDICATOR PROVIDES CONSTANT DIGITAL READ
OUT IN INCHES OF FUEL IN TANK. ALARMS MONITORED AT ,NURSES STATION 24 HOURS
Clean Up
Other Resource Activation
-5-
12/12/2000
j
~ 0
-
e
F MEMORIAL CENTER FOR BEHAVIORIAL
I
f= Site Emergency Factors
~ Special Hazards
Utility Shut-Offs
SiteID: 015-021-000046 ì
Fast Format ì
Overall Site ì
I
12/21/1999
A) GAS - OUTSIDE MEDICAL RECORDS STORAGE RM SE CORNER OF LOADING DOCK
B) ELECTRICAL - BETWEEN MAINTENANCE & MECHANICAL RMS & LOADING DOCK E
C) WATER - MAIN BACK FLOW PREVENTER AT SW END FACILITY AT GRISSOM ST AND IN
EQUIPMENT RM NEXT TO FIRE SPRINKLER NEXT TO MAIN ELECTRICAL RM
D) SPECIAL - UST (#2 DIESEL) 1,000 GAL MAX
E) LOCK BOX - YES (KEYS) MAINTENANCE SHOP E SIDE NEXT TO LOADING DOCK AND
ADULT NURSING HAS MASTER KEY AT NURSES STATION
Fire Protec./Avail. Water
OS/27/1993
PRIVATE FIRE PROTECTION - FULLY SPRINKLERED FACILITY INCLUDING FIRE EXTERIOR
FIRE HYDRANTS, 24 PORTABLE FIRE EXTINGUISHERS LOCATED THROUGHOUT FACILITY.
NEAREST FIRE HYDRANT - W END OF S WING AT GRISSON ST (SW CORNER OF SITE) .
Building Occupancy Level
-6-
12/12/2000
~'
~~ ~
;>; -,,~ ~.
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e
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F MEMORIAL CENTER FOR BEHAVIORIAL
I
F Training
Employee Training
SiteID: 015-021-000046 1
Fast Format 1
Overall Site ì
OS/27/1993
WE HAVE 130 EMPLOYEES AT THIS FACILITY. .
WE DO HAVE MSDS SHEETS ON FILE.
BRIEF SUMMARY OF TRAINING PROGRAM: EMPLOYEES RECEIVE TRAINING IN HAZARDOUS
MATERIALS WHEN HIRED AND WHEN A NEW SUBSTANCE IS INTRODUCED. NEW MATERIALS
INTRODUCED MUST FIRST HAVE APPROVAL OF ~IEBI~ SAFETY COMMITTEE FOLLOWED BY
TRAINING IN MSDS BEFORE SUBSTANCE IS USED.
Page 2
[
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Held for Future Use
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I
Held for Future Use
",
-7-
12/12/2000
... -~..- ';4'~
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-
MEMORIAL CENTER FOR BEHAVIORIAL
S' ID
5
o
J.te : 21 -000-0 0046
~ ""
Manager : BusPhone: (805) 398-1800
Location: 5201 WHITE LN Map : 123 CommHaz : Low
City : BAKERSFIELD Grid: 15D FacUnits: 1 AOV:
CommCode: BAKERSFIELD STATION 13 SIC Code:8063
EPA Numb: DunnBrad:
~. "'II. .......L.-
Emerg¿ncy Contact / Title Emergency Contact / Title
Mi'iiiI'"T"1'J ~~-Q~ / C.E.O. DEIRDRE TERLESKI / ASSISTANT C.E.O
Business Phone: ' (805) 398-1800x :;1\3 Business Phone: (805) 398-1800x
24-Hour Phone : (805) 834-6887x 24-Hour Phone : (805) 832-2087x
Pager Phone : ( ) - x Pager Phone : ( ) - x
Hazmat Hazards: Fire DelHlth
Contact : Phone: ( ) - x
MailAddr: 5201 WHITE LN State: CA
City : BAKERSFIELD Zip : 93309
Owner GREATER BAKERSFIELD MEMORIAL HOSP Phone: (805) 398-1800x
Address : 420 34TH ST State: CA
City : BAKERSFIELD Zip : 93301
Period : to Tota1ASTs: = Gal
Preparer: TotalUSTs: = Gal
Certif'd: RSs: No
Emergency Directives:
One Unified List ì
All Materials at Site ì
p= Hazmat Inventory
p== MCP+DailyMax Order
Hazmat Common Name...
SpecHaz EPA Hazards
DailyMax
MCP
DIESEL FUEL #2
F
DH
L
1000.00 GAL Mod
I S~\) t'I\.oor~ Do hereby certify that I have
, (Typé or print name)
reviewed the attached hazardous materials manage-
ment plan for~'r\~ ~"~~and that it along with
(Name of Busin88ll)
any corrections constitute a complete çmd corrsct man-
agement plan for my facility.
~
I
-1-
12/20/1999
..
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F MEMORIAL CENTER
p= Inventory Item
= COMMON NAME /
DIESEL FUEL #2
FOR BEHAVIORIAL
0001
CHEMICAL NAME
SiteID: 215-000-000046 ì
Facility Unit: Fixed Containers on Site ì
Days On Site
365
Location within this Facility Unit
20FT S OF EMERGENCY GENERATOR, E SIDE
Map:
Grid:
CAS #
68476-34-6
r ~TA~E T TYPE
Llquld Pure
Largest Container
GAL
~ P~ESSURE ---¡ TEM~ERATURE -,
~mblent ---1 Amblent ~
AMOUNTS AT THIS LOCATION
Daily Maximum
1000.00 GAL
CONTAINER. TYPE
UNDER GROUND TANK
Daily Average
550.00 GAL
HAZARDO
%Wt. RS CAS #
100.00 Diesel Fuel No. 2 No 68476302
US COMPONENTS
HAZARD ASSESSMENT
TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP
No No No No/ Curies F DH / / / Mod
S
-2-
12/20/1999
.~
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e
F MEMORIAL CENTER FOR BEHAVIORIAL
I
p= Notif./Evacuation/Medical
r=: Agency Notification
~ALL 9-1-1. . .
r=:: Employee Notif./Evacuation
~ACUATION PROCEDURE IN PLACE,
Public Notif./Evacuation
SiteID:
215-000-000046 ì
Fast Format ì
Overall Site ì
OS/27/1993 ]
1
OS/27/1993
CALL 9-1-1.
OS/27/1993
MEMORIAL CENTERS PUBLIC ADDRESS SYSTEM WOULD BE UTILIZED TO WARN PUBLIC IN
THE EVENT OF AN EVACUATION.
Emergency Medical Plan
OS/27/1993
RN ON DUTY 24 HOURS A DAY (ON SITE) .
MERCY HOSPITAL - 2215 TRUXTUN AVE - 327-3371
MEMORIAL HOSPITAL - 420 34TH ST - 327-1792
EMERGENCY SITUATIONS BEYOND RN SCOPE WOULD BE HANDLED BY CALLING 9-1-1 AND
TRANSPORTING PERSONS TO NEAREST 24 HOUR EMERGENCY ROOM WITH SPACE AVAILABLE.
"
-3-
12/20/1999
"
e
e
F MEMORIAL CENTER FOR BEHAVIORIAL
I
p= Mitigation/Prevent/Abatemt
Release Prevention
SiteID: 215-000-000046 ~
Fast Format ì
Overall Site ì
OS/27/1993
MATERIAL (DIESEL #2) PROPERLY STORED IN AN UNDERGROUND STORAGE TANK.
Release Containment
OS/27/1993
UST (STORAGE TANK) AND PIPING ARE DOUBLE WALLED WITH LEAK DETECTION MONITOR
PROBES AND ALARMS. LIQUID LEVEL INDICATOR PROVIDES CONSTANT DIGITAL READ
OUT IN INCHES OF FUEL IN TANK. ALARMS MONITORED AT NURSES STATION 24 HOURS
Clean Up
Other Resource Activation
-4-
12/20/1999
~
~
e
e
f MEMORIAL CENTER FOR BEHAVIORIAL
I
p= Site Emergency Factors
r== Special Hazards
Utility Shut-Offs
SiteID: 215-000-000046 ì
Fast Format ì
Overall Site 9
I
OS/27/1993
A) GAS - OUTSIDE MEDICAL RECORDS STORAGE ROOM SE CORNER OF LOADING DOCK B)
ELECTRICAL - BETWEEN MAINTENANCE & MECHANICAL ROOMS & LOADING DOCK E C)
WATER - MAIN BACK FLOW PREVENTER AT SW END FACILITY AT GRIS~OM ST AND IN
EQUIPMENT ROOM NEXT TO FIRE SPRINKLER NEXT TO MAIN ELECTRICAL ROOM
D) SPECIAL - UNDERGROUND STORAGE TANK #2 DIESEL 1,000 GAL MAX
E) LOCK BOX - YES (KEYS) MAINTENANCE SHOP E SIDE NEXT TO LOADING DOCK AND
ADULT NURSING HAS MASTER KEY AT NURSES STATION
Fire Protec./Avail. Water
OS/27/1993
PRIVATE FIRE PROTECTION - FULLY SPRINKLERED FACILITY INCLUDING FIRE EXTERIOR
FIRE HYDRANTS, 24 PORTABLE FIRE EXTINGUISHERS LOCATED THROUGHOUT FACILITY.
NEAREST FIRE HYDRANT - W END OF S WING AT GRISSON ST (SW CORNER OF SITE) .
Building Occupancy Level
-5-
12/20/1999
;- '" .. ~
e
e
F MEMORIAL CENTER FOR BEHAVIORIAL
I
F Training
Employee Training
SiteID: 215-000-000046 ì
Fast Format ì
Overall Site ì
OS/27/1993
WE HAVE 130 EMPLOYEES AT THIS FACILITY.
WE DO HAVE MSDS SHEETS ON FILE.
BRIEF SUMMARY OF TRAINING PROGRAM: EMPLOYEES RECEIVE TRAINING IN HAZARDOUS
MATERIALS WHEN HIRED AND WHEN A NEW SUBSTANCE IS INTRODUCED. NEW MATERIALS
INTRODUCED MUST FIRST HAVE APPROVAL OF MEDICAL SAFETY COMMITTEE FOLLOWED BY
TRAINING IN MSDS BEFORE SUBSTANCE IS USED.
Page 2
[
I
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Held for Future Use
Held for Future Use
-6-
12/20/1999
.'
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,..
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CUST~e&NO. es - %3'6
MISCELLANEOUS RECEIVABLES ADJUSTMENT
DATE3-7 -Ð
NEW ACCOUNT
ADDRESS CHANGE
CLOSE ACCT i
: FINANCE CHARGE
, OTHER ADJ I
CUSTOMER NAME (Y\VMOrìQ \ 'CQJA~~~ ~O( 6ekL/\/\O\CU\ ~ecJR
MAILING ADDRESS ~O \ WY-4 ~ <- ~
CITY ~t.:e("'~ì -c \J.. STATE (J.Â- ZIP CODe q::,~
SITE ADDRESS
PARCEL NUMBER
QFAPPUCABLE)
ADJUSTMENT
ADJUSTMENT AMOUNT
·S
R~;S: ~~; ~ó ~~rc-ha~~ stojJ'v~
APPAOVEDBY ~~
\',
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Bakersfield Fire Dept.
Hazardous Materials Division
2130 "G" Street
Bakersfield, CA. 93301
"
---^~~
. .'. RECEIVED
APR ,'6 1993
HA.?, MAT DfV.
HAZARDOUS MATERIALS MANAGEMENT PLAN
- '5n 1#J15)-
INSTRUCTIONS: . . 1;;J3 f _ J ¡J~¿
. ~ '~-f
1. . _ To avoid further action, return this form with~~ayS of receipt. (April 26, 1993)
2. '. --TYPE/PRINT ANSWERS INENGlISH,,^ _. ._ '.. . "" '
3. Answer the questions below for the business as awhole:.--'>"'\" . - ->,,'
4. Be brief and concise as possible. ~ ,'>""
r/~/' .
SECTION': BUSINESS IDENTIFICATION DATA -- l<eH1 V/ew '¡'¡OSp:+7~ Wc,
BUSINESS NAM;'BM'fJY/O~/ðl . r!el?~r ¡¿; ??dav/or/:?J ( /ledt~
LGCATION: 5;(01 wh..~ ,Ln. BéJfé",f&¿ ¡t~ 9Y.1oC¡
,
MAILING ADDRESS: 5;Zof Whf-!e 1-/1" g~,wç/'~¿/
CITY: B ðkerS.{!etcf..
STATE: ~ ZIP: fJ53D9 PHONE: (!oS-) 3'l9-/iOO
DUN & BRADSTREET NUMBER:!1r?rf- ;;U/d)(ðhle.. SIC CODE: 23 D6 3
PRIMARY A~~I~~TY: _!l//M1¿~~ ~~~:! rx/fi7 (H.>~flh I)
7:::.: L . ...~.~ '" -- í' .. ~~.: ''''' ,.- ~'" - '/,
OWNER: j,,J {f~.," ~"~,-:~"_ --.l "~"'/~ I /ÞJ; /~I
. ",' -- "-'-':~~<ó: -~Ê'1-;~iÆë:'111~t!-~~~¿Ý;:7ctr;hÚ1'~~Y}3b I
MAILIN~,APDRE$S: :'''--;--: <:,-,,,?,"¡¡'"-'~\''''' tt? 13.:q~"",,,2..,-'_~;, .~_-1:{is'·y;-c1r~~:, -, '::~ '
,',"
....", ,-,'.' .. ('
" .
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SECTION 2: EMERGENCY~NOTlFICATION:
. J.: ;. -:.¡"'·>,:~·ptf...~' .
CONTACT
TITLE
BUS, PHONE '
1, C,E:O. !1>S')3Cf9-I'800
'., . .... CSós2 .
2, 2P (Ç¡' rei r e' --reI-I e£k ,r:,#SJ1¡ e, tJ; t) I '.Jq~.. f ~ Qð
1.
24 HR, PHONE
tð!") (Bg;~ '~~"7
( ?O~J . 8~'~;~?g,H:'l
./ -' -.
~, ..
..... .
- ~/- .
~akersfield Fire Dept. A
Æardous Materials Division ·
--1'
4 ~ " '\
¡-
'¢'...... .:.. ~ , '"
,c~ ~"6
-. --/~""""-'·
HAZARDOUS MATERIALS MANAGEMENT PLAN
1i;;:
'..
~....."
-,
;;:...\ "
~ . I ' r
.... ." I -.~~~
"
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\1 ~; 1 t i \, ".1' ,of ,f' .
SECTION 3: TRAINING:
NuMBER OF EMPLOYEES: I 30
MATERIAL SAFETY DATA SHEETS ON FILE: N-f.. h~ýe .A45'DS (9/7 ñ'l¿
BRIEF SUMMARY OF TRAINING PROGRAM:
èÎ?J pleyee ~ I'e.ceHfe., 'TJ-.J¡-h~M~I'h hð2-2~L~ W>?Jfert;)I{
. W'h~ h/f-e-rfl ~ w¿e-n 'ð /JecA.J ,f"vbcfd-r¡C'e /s 14ff()~et£J,
/l~ ~¿¡./JI£_- /nftol(,(te..c.f~yYJ(.ar-_ f/~sf -~h,ð'lIe. ~PI!t-OY..d L_~.g-
~¿it;. / S:J¡"fy Co7J71h,'f/ee ~;1ov.)~ Ix¡ ¡frav'7l1L7
I.h A/tó IJ 5 6efi,-e. k¿~c-e 1 S uce..dl.
-. ;-:-.=~-:;
SECTION 4: EXEMPTION REQUEST:
I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE
REPORTING REQUIREMENTS OF CHAPTER 6,95 OF THE IICAlIFORNIA HEALTH &
SAFETY COOP FOR THE FOLLOWING REASONS:
WE DO NOT HANDLE HAZARDOUS MATERIALS.
. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO
- -~~~-~I~~¡fEE0,CE'EbTtH~ M~ÎNrMO"¡çrREP'ORTING~Q-Uf\f\JTITlt-S~ '~~'-"~ -- ,'-,
_.<:~'--- .'-$--~",--~,-:-""",:,,,",-,,",-=--~~~-_>:-- ~---,...->~-":=:~=-",~-\.---.--- .". ~ .- ~.- -""--~
OTHER (SPECIFY REASON)
. ,
SECTION 5: CERTIFICATION:
1/ ;ß/I/ P¡''/e-t- CERTIFY THAT THE ABOVE INFOR-
MATION IS ACCURATE, I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO
FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE"
ON HAZARDOUS MATERIALS (DIV. 20 CHApTER 6.95 SEC. 25500 ET AL.) AND THAT
INACCURATE INFORMATION CONSTITUTES PERJURY.
'> .
~~~
SIGNA TURE
ph-a -f- /fhT7 êI~ e¡;-
,TITLE . 0
~µ()/93
,
DATE
2.
FD1590
~Y .. ~ - (..~:~
.;~:
f;/
, " Bakersfield Fire Dept. .
' Hazardous Materials Division '
j§"
./
HAZARDOUS MATERIALS MANAGEMENT PLAN
Facility Unit Name: ft1emot/J / fß/n /ér
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES:
Cðll C¡ft
- -'~--"-'--'
~ ----~-_. -. - -- -
. B. EMPLOYEE NOTIFICATION AND EVACUATION:
EVòÚ(;d'-/o-" fJlv ceeofJu-f-e. /11 pfaeej fYafl( 9/1
f ,.-'
C, PUBLIC EVACUATION: .,'
MM"'0 rid ( f! ~n~r S pu 6//c d £ofk.(s ¿ .r"'....... r'Þ>~14
h-~ (.{i-/ (/ J-¿c/ V7> fA) ~}-rt pu 6 /~ è e:: I '-h Me- even+- of!-
:£n -'€'V~GªAl.£1J71.' _, .' ,_
. .... '.'
D. EMERGENCY MEDICAL PLAN:,q ,,", " , ,
leN On DufP~./l)jf:· hð-UfS ;]r~c1?/(., Id~·'~/-f~J..-'"
I (. l' \J J. ~
M. ¿f-V'-¡ ¡-1bS f/~~ I -:2 ~ Ij- Tf(.(xI-WY7 ¿ve~ .5 ~ 7....-"33 7(
tM.l/WJof-/:J1 !fo.5(J,'hI-4- ~(/ .34-r!, s:f-, - 3.::'<?-179;l-
e me¡'--fj~S tlu 'df,t:iJ-r7 5 hMjo-not' !ê AI S Co ¡-e w /) ui~ be-, -
h7rvrlJ {6.,. c. rllllý- 'It( G?>-<I H3nS'¡Jor.J,'':1_ ? C',l-J 077 5, ,~!:ó
f7e'Qre sr ~4 /ww..' e.mu;""'r J-Oð7>'o ",;r:t;. {pce z¡fa, ".If". -
3.
R:>1$(
\
.
Bakersfield Fire Dept. _
Hazardous Materials Division ~~
"'"
, t~"~~' :. ' ,,~
. ~~
HAZARDOUS MATERIALS MANAGEMENT PLAN .
SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN:
A,
RELEASE PREVENTION STEPS: . I t:A ~
I, /J1'df.f?l-fò/ (t;;>íese( .#,;t) p¡..ofel-1 tfo1-~ In (JI'/ u!YI 'er¡ÑQ .
3f-01--? e. ta-71/(" '. ',.
s. -/,R~:r:- i:;:f:'w~£z ~;t£¡:l~!~;;::~$~¡~<I~-~ fIt
, ..2, '¿/iu/cf {-¿vel IÁd/t<J-hrr pJ-ollk/e5 (!..4/>?Jrf-:3~f- d7/f;i/
f'oI/:l!Jcf ow+- ¡ ", I~ck 5 op ~ e ( if,,¡ 7-';;p1,/( .
:3. 41:J¡.--ms mOI7Ih,re..f/ 2+ itI~¡.¡e> srð~t(1y\ ..:¿ .¡.-hf..f. (J cf~ /
C, CLEAN-UP PROCEDURES: { ,
SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY):
NATURAL G8S/PROP.ANE: 0 +$; J.e... M.-iI2,~? ee..co, d2~ ,1-4
, - SewHÎ e-ð-;)"I- Co;-I'/er ~:,j /ó (J~t~~ c!O"er.
ELECTRICAL: ~e' L. /1:tl/lU c:fr/l1ec~ .c.. 120
Å ({)'?) é3¥'/ fll ~ (J "PC/,'
", '--WÞ.Jtl~1Ø-3/~ -oW~ V. / e --3 -, 7u)~ n G,./I;S<> sf:
--' - @ EpifJm~-roo7ri- -Ire-)#- '70 P¡'f(!.;S¡JJ-//} e,. wet' ,a/fe- /oC'Q _/Je:Jtf' To ;tr¿í71."
0&. /J ~ b (/ t:le£l!.i./-c.-àf. /ê~
SPECIAL: 1..//1 ~J.ðvn&Y S:h12-Ç{J \¡ð//ìC .~ #.,2 Ð)f'~ / II O~ G 3//' Ø??K'..
ß (/. ® / ' ~ ,r/)
,~_=-_~?~~ BOX: (~5~If,NO IF YES, LOCATION: ô ~- /;M l~ ðñ~ <'4?g'}~~J:;"~;;V);
~'~---,-,J;.{ßY£_~^'-(} &i/l E;;;f~ f/c/e cPt- C/t /l~Y-¡:-"?-"::>
\.i'J. - III '2r//~'7 cIó C-K- . ,Sftf¡&:.
@ Adulf /Vll¡(f/~ hð~/JJð~ K~ ðT /II{Þ...ür .pt
SECTION 9: PRIVATE FIRE PROTECTION/'ÍÍATER A V AILABILlTY:
A. PRIVATE FIRE PROTEC~ON: Jtj,::,.d4., SI';,'Alâ,¡; ACll,'(.- /1I~{U¿'-1~
,Þ¡, /v-t . 'exferl.'-or- jr/I--e. hyt/r~'7fr ( (~) ~4- fo¡.hble ¡:::.:"l Pd-i~t{.s/IIÞz-
/~redl ;'¿~If ~T :p;;¡c./ /"ry ,
B. WA TER A V AILABILlTY (FIRE HY,DRANT): ~ werT eJ fYf J~ )
w J~dðf 6-).. I' SS ()'h--\ d+ee';f-. (s ¡ uJ , Co¡...n lÞ1- ðF S ì +e
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BAKERSFIELD CITY 'FIRE DEPARTMENT
HAZARDOUS MATERIALS DIVISION
2130 "G" STREET
BAKERSFIELD, CA. 93301
(805) 326-3979
HAZARDOUS MATERIALS INVENTORY
FACILITY DESCRIPTION
CHECK IF BUSINESS IS A FARM []
BUSINESS NAME't:Bft- fv1{> VhOh'd ( CeVli-;,r¡¡;'-'BetJ;:Ot'/~ r . J-!~;ì4
FACILITY NAME $'~rn-·-e
SITE ADDRESS S- ~O / W-#¡'h,L/1 -
CITY g :;,/út..fßefcP STATE C4- ZIP 9.3:5 0 '1
NATURE OF BUSINESS I/W~ I /-(e )/¡¿ /-fr:,ð'/l/f;;¡ (
SIC CODE
$>0 b 5
DUN ,& BRADSTREET NUMBER /1or ~1I2/!at k.. .
·9PERATOR nt~0)~~?-'>l
MAILING ADDRESS ~)2º_~ -?3? ~. SL"_ ,.>,
CITY 82/(19I-f'{}e{j) STATE (',;f
,! .
PHONE ($>05-) :3 C~3:..(j.'?f~,
ZIP 9':5 30'/';;'
EMERGENCY CONTACTS
NAME A:ar!-/J¡ Brd!j-. TITLE C. r 0.
BUSINESS PHONE(J05).3 9 9 - f 80 Õ 24-HOUR PHONE (fOS) '834 - {; 887
NAME ~ Ei 'f- cI r ~ . ']¡¡.. /eS k/
BUSINESS PHONE (;ðos) :3 c¡ ¡>...( POO
TITLE A~S7: {!, ESO.
24-HOUR PHONE (105 )[-;8~32-..!Zii8-=7·
\ '.
5eplember 30, 1992
REGIONV LEPC STANDAROFORM
\!
Business Name
BAKERSF"'D CITY FIRE DEPA"ENT
HAZARDOUS MATERIALS INVENTORY
/!4-tø7Q-t'I'd/ (!~n~ Address Sólol vvh/-h 1./1. C)' 3309
-t: ~,~ .~~.
Pagel.oti
CHEMICAL DESCRIPTION
2) Common Name:
'b~ e Se ( ~e-\ -#.;{..
Check if chemical is a NON TRADE SECRET ~DE SECRET [ ]'.
3) DOT # (optional)
1) INVENTORY STATUS: New ~Addition [ ] Revision [ ] Deletion [
Chemical Name:
AHM [ ]
CAS # 0B47b "34-6
4) PHYSICAL & HEALTH
HAZARD CATEGORIES
PHYSICAL
Fire ~ Reactive [] Sudden Release of Pressure [ ]
HEALTH
Immediate Health (Acute) [] Delayed Health (Chronic)
5) WASTE CLASSIFICATION
(3-digit code from DHS Form 8022)
USE CODE
/'1
6) PHYSICAL STATE
Solid [] Uquid [~ Gas' [ ] ,
Pure [t('Mixture [] Waste []
CHECKALL THAT APPLY
Radioactive [ ]
7)AMOUNTAND JlME.AT fACILITY _
Maximum Daily Amount: /'000
Average Daily Amount: 5~
Annual Amount: / dO 0
Largest Size Container: / tJoo
# Days On Site 3 hS'
~_UNITS~OF MEA§JdRE -
Ibs [ ] gal [I,.( ft3 [ ]
curies [ ]
~_8) STORAGE cqDES.
. a) Container: .
b) Pressure:
c) Temperature:
O~l
/
4-
CirCle Which Months:
M, A, M. J, J, A. S, 0, N, D
9) MIXTURE: List
the three most hazardous
chemical components or
any AHM components
1 )
..ß ?OMPONENT
~ /PJeA ~f.( -#- 6L
CAS #
6B4.7b-34-t:>
%WT
/00
AHM
[ ]
[ ]
2)
1 0) Location
r;;( 0 -Pt.
·ou.~
I}'
3)
CHEMICAL DESCRIPTION
1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ]
Check if chemical is a NON TRADE SECRET [] TRADE SECRET [ ]
2) Common Name:
3) DOT # (optional)
Chemical Name:
AHM [ ]
CAS #
4) PHYSICAL & HEALTH
HAZARD CATEGORIES
Fire [
PHYSICAL
Reactive [] Sudden Release of Pressure [ ]
HEALTH
Immediate Health (Acute) [ ]. Delayed Health (Chronic) [ ]
5) WASTE CLASSIFIc:;~TIO~
,(3~diQit_code_from DHS Form 8022)
USE CODE
- 6) PHYSICAL STATE - Solid [1 .-liquid H &Gas~[ ]
·Pure [ ¡-Mixture [.] Waste []
Radioactive [ ]
CHfCKA.L1 THAT APPLY
7) AMOUNT AND TIME AT FACILITY
Maximum Daily Amount:
Average Daily Amount':
Annual Amount:
Largest Size Container:
# Days On Site
UNITS OF MEASURE
Ibs[]gal[] ft3[]
curies [ ]
8) STORAGE CODES
a) Container:
b) Pressure:
c) Temperature:
CirCle Which Months: All Year, J. F, M, A. M. J, J, A. S, 0, N, D
9) MIXTURE: List
the three most hazardous
chemical components or
any AHM components
COMPONENT
CAS #
%WT
AHM
[ ]
[ ]
[ ]
1 )
2)
3)
10) Location
~///
PRINT Name & Title of Authorized Compa
.:.....
~~~~
Signature
4µo/9c3
Date
Scurnòw3Q 1æ:i!
RECãCJ\lY LEPCSTNttDAAOFCFIW
'--
~Q
~...........~
.........;:)~..'.
",-~
CMEMORIALR
ENTE
for Behavioml Health
.,--- ~~~._~
~_. ',' .... '.~ ~
o
Bill Pliler
Plant Manager
JÞlò/ wht'-k4?-
~hl1n C:":Jn ')iR.a..:. Sln:cl
Bakersfield, California 93301'
Telephone (80SJ.-aZl-mlt
~X (ie'S) 32.3-o/.z¡)" :"'I.
Z93-lft)C./ <
^ MAIL TO:
~":_1á '-~II Y Ur bA~t:ti;:,rlcLU
,,~ -~P:>Ô,;BQX'2057
BAKERSFIELD, CA 93303
. ,..', ':LlCENSE.
APPLICATION FOR BUSINESS lICENSEITAX CERTIFICATE
PURSUANT TO ORDINANCES OF THE CITY OF BAKERSFIELD
MEMORIAL CENTER FOR BEHAVIORAL~ HEALTH
r
""'TV "I:' D ^ Vr:D~I:"I:" n
~.. . (tÞJÎ=ORNìÄ '-'--
PREMISES MUST CONFORM TO ZONING,
AI III nlN~ J:'IRt= ðNn "..n=A·' TJ..I (':nnF'~
APPLICANT SHOULD ALLOW TWO WEEKS
FOR NECESSARY INSPECTIONS.
q
NAME OF FIRM
CHANGE OF D. NEW 0'
OWNERSHIP BUSINESS
CHANGE OF []
ADDRESS
DAtE 3/2/93
--
"
MAfLlN0 ADDRESS
5201 WHITE LANE, 93309
LOCATION OF BUSINESS
SAME
TELEPHONE . 327 7621
KIND OF BUSINESS OR PROFESSION
(Separate License Required For Each Location)
HOSPITAL
NAMES AND ADDRESSES OF ALL OWNERS (Or Principle Officers, If a Corporation)
NAME HOME ADDRESS
. TELEPHONE J
'>
"
" "
.
.>
8 INSPECTION RECORD
- OFFICIAL USE ONLY
H.O.P.
Zoning
AUTHORIZATION
DATE:
REQUIREMENTS OR CONDITIONS
PLANNING DEPT,
'-
BUILDING DEPT,
FIRE DEPT,
cl APPLICATION CONTINUED:
TYPE OF ORGANIZATION: ,
PARTNERSHIPD . CORPORATION 0 FEDERAL EMPLOYER IDENTIFICATION NUMBER
INDIVIDUAL 0 NAME SSN
DATE COMMENCED BUSINESS IN BAKERSFIELD 3/2/93
CALIFORNIA STATE CONTRACTOR'S LICENSE NUMBER, IF ANY
NATURE OF BUSINESS FORMERLY AT THIS LOCATION
\
\
FORMER OWNER ' CHARTER HOSPITAL
SALES TAX PERMIT NO, Sales or Use Tax may apply to your business; contact nearest STATE BOARD OF EQUALIZATION OFFICE.
ESTIMATED ANNUAL GROSS RECEIPTS IN BAKERSFIELD
I SWEAR UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
TITLE DATE
. Signature Owner. Partner, Agent or Officer (if Corporation),
-,
License Code Sec\. Stm\. Frq, Prm. lass Tax Rate
17834
-
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