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Home My WebLink AboutBUSINESS PLAN I '. ~ 12/11/95 -- - A (\~age L¿1J \x\'v l,/L./ \; \ 1 KERN TRANSMISSION 215-000-001512 Overall Site with 1 Fac. Unit General Information Location: 4110 WIBLE RD H Map:123 Haz:3 Type: 3 City . Bakersfield Grid: 13C FlU: 1 AOV: 0.0 . - Contact Name Title r-- Contact Name Title TIM OGDEN I REBUILDER KEN CARROLL / OWNER Business Phone: (805) 836-0157x Business Phone: (805) 836-0157x 24-Hour Phone · (805) 833-2590x 24-Hour Phone · (805) 664-8687x · · Pager Phone · ( ) - x Pager Phone · ( ) - x · · Administrative Data Mail Addrs: 4110 WIBLE RD H D&B Number: City: BAKERSFIELD State: CA Zip: 93313- Comm Code: 215-007 BAKERSFIELD STATION 07 SIC Code: 7537 Owner: KEN CARROLL Phone: (805) 836-0157 Address: 4110 WIBLE RD H State: CA City: BAKERSFIELD Zip: 93313- Summary II I " I e e 12/11/95 KERN TRANSMISSION 215-000-001512 Hazmat Inventory List in MCP Order Page 2 02 - Fixed Containers at Site PIn-Ref Name/Hazards Form Max Qty MCP 02-001 SAFETY-KLEEN 105 SOLVENT Liquid 65 Moderate ~ Fire, Immed Hlth, Delay Hlth GAL 02-002 ATF DEXRON III Liquid 100 Moderate ~ Fire GAL 02-003 WASTE ATF Liquid 175 Unrated ~ Fire, Delay Hlth GAL e e 12/11/95 KERN TRANSMISSION 215-000-001512 02 - Fixed Containers at Site Page 3 Hazmat Inventory Detail in MCP Order 02-001 SAFETY-KLEEN 105 SOLVENT ~ Fire, Immed Hlth, Delay Hlth Liquid 65 Moderate GAL CAS #: 64741-41-09 Trade Secret: No Form: Liquid Type: Unknown Days: 365 Use: CLEANING ---- Daily Max GAL ----r-- Daily Average GAL --r-- Annual Amount GAL -- 65 I 50.00 I 50.00 Storage ~ Press ì Temp Location DRUM/BARREL-METALLIC Ambient Ambient 3 SOLVENT TANKS ON NORTH WALL IN AREA. Components ~ MCP :ruide Moderate 27 Moderate 27 Conc 0.0% 0.0% Mineral Spirits o-Xylene, m-Xylene, ,;p-Xylene 02-002 ATF DEXRON III ~ Fire Liquid 100 Moderate GAL CAS #: Trade Secret: No Form: Liquid Type: Unknown Days: 365 Use: LUBRICANT Daily Max GAL ----r-- Daily Average GAL --r-- Annual Amount GAL -- 100 I' 50.00 I 600.00 Storage ABOVE GROUND TANK r Press T Temp ~ Location Ambient AmbientlWEST WALL SHOP AREA. - Conc l 0.0% Toluene Components r; MCP ~uide Moderate 27 02-003 WASTE ATF ~ Fire, Delay Hlth Liquid 175 Unrated GAL, CAS #: Trade Secret: No Form: Liquid Type: Waste Days: 365 Use: WASTE Daily Max GAL ----r-- Daily Average GAL --r-- Annual Amount GAL -- 175 I 75.00 I 750.00 Storage PLASTIC CONTAINER r pres$cT Temp ~I Location Ambient ÅmbientOUTSIDE SOUTH WALL, BEHIND FENCE - Conc Components MCP -,-Guide e e 12/11/95 KERN TRANSMISSION 215-000-001512 00 - Overall Site Page 4 <D> Notif./Evacuation/Medical <1> Agency Notification CALL 911 <2> Employee Notif./Evacuation VERBAL NOTIFICATION OF EMPLOYEES. EMPLOYEES EXIT THRU NEAREST EXIT AND ASSEMBLE ON WEST SIDE OF BUILDING IN PARKING LOT. <3> Public Notif./Evacuation DOES NOT APPLY. .";.... <4> Emergency Medical Plan CALL 911. TAKE ANYONE NEEDING MEDICAL CARE TO BAKERSFIELD MEMORIAL HOSPITAL. e .:.... e 12/11/95 KERN TRANSMISSION 215-000-001512 00 - Overall Site Page 5 <E> Mitigation/Prevent/Abatemt <1> Release Prevention OUR SOLVENT TANKS ARE SERVICED MONTHLY BY SAFETY KLEEN CORPORATION. NEW DRUMS ARE PROVIDED AT THIS TIME AND ALL TANKS ARE INSPECTED FOR SAFETY AND RELIABILITY. <2> Release Containment WE HAVE A CONTAINMENT TANK AROUND OUR WASTE OIL TANK. .:'.. <3> Clean Up WE KEEP ABSORBANT ON HAND AT ALL TIMES TO PICK UP ANY SPILLS. <4> Other Resource Activation I . e e 12/11/95 KERN TRANSMISSION 215-000-001512 00 - Overall Site Page 6 <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs NATURAL GAS/PROPANE: WEST WALL OF BUILDING OUTSIDE (FRONT). ELECTRICAL: (MAIN) WEST WALL OUTSIDE (INSIDE) N.W. CORNER OF SHOP. LOCK BOX: NO. <3> Fire Protec./Avai1. Water WE HAVE A SPRINKLER SYSTEM IN THE BUILDING. FIRE HYDRANT LOCATED ON SOUTH SIDE OF BUILDING AT SPRINKLER. <4> Building Occupancy Level .~ .- ) .1 e e 12/11/95 KERN TRANSMISSION 215-000-001512 00 - Overall Site Page 7 <G> Training <1> Employee Training NUMBER OF EMPLOYEES: 2 MATERIAL SAFETY DATA SHEETS ON FILE: IN RIGHT TO KNOW DEST, BOTTOM RIGHT DRAWER. BRIEF SUMMARY OF TRAINING PROGRAM: WE HAVE PURCHASED A SAFETY COMPLIANCE PROGRAM FROM CAL SAFETY. WE HAVE WEEKLY SAFETY MEETINGS, AND ALL PERSONNEL HAVE BEEN TRAINED IN THE PROPER USE AND HANDLING OF FIRE EXTINGUISHERS AND FIRST AID KIT. EMPLOYEES ALSO KNOW WHICH AGENCIES TO NOTIFY IN CASE OF A SPILL OR EMERGENCY. <2> Page 2 <3> Held for Future Use ," <4> Held for Future Use - " .~. _:~ J; II _ BAKERSFIELD CITY FIRE DEPARTMENT HAZARDOUS MATERIALS DIVISION 1715 CHESTER AVE~ . BAKTSí'Šf;;¡ t301 ~dqcfJ! HAZARDOUS MATERIALS MANAGEMENT PLAN ~~ Cf INSTRUCTIONS: \ d-- ~- \ ~~ V~ " 70 aVOid, fUrT,h, er ac;ion, reTurn ;his form w¡~ dO,YS of receipt. ~ ~ ~ ~ n \\/7 ~ 2. TYP::JPRINT ANSWERS IN :NGUSH. 0 [f; ~ LÇ, U W [f;~ '-'. ,':"nswer tne auesTions below fer ¡he business as a wnole. . .:.. 3e orief ane ccnc:se as ::::ossibie. AUG 2 9 1994 SECTION 1: BUSINESS 1DENTIFICATION DATA By:. ~ 3USiN~SS NAME: j(é-ìL N T l2..A-N~ rV\\ S.S\ON LCC,':',TiON: Ì1l \ 0 - \-\ 'W \ßLE:.. 12b MAIL!NG ADDRESS: SAME Ac:; 1SPt~SF'G-~ éA.. q~3\3 CiTY: c::¡ 1\ _I =, I ì ...... I r\ '-. .¡ I ¡ , , A ED 'y E... ZIP: PHONE: ~3b -ðlSì SIC C8DE: 'ìC;37 CUN & SRACSiR=:::: NUM3=~: ?RIMARY i~C~V1TY: --ÄUT6 I(2..PrNS-VVllSSlùN ~ÞPPrl f?.. OWNER: K; ,"-1 LPrI¿fl..O \ \ ¡V1.A,!LiNG ACQR:::SS: -=?I\M2.- f\ Ç. V\-ß ô\{ L SECTION 2: EMERGENCY NOTIF1CATION: CONTACT \ nTLE \ " 1 .--r, ~ 0 bbErJ '. , ,\ ~EOv ,L()'- e 2. J<W ·C~oU DV\lÐ<- BUS. PHONE 24 HR. PHONE ~3{ - 0 \S'7 13b--b\<57 ~:5>3~ 2~7 ö 66t¡-7Þ37 DaKerSne.Lü ~ lI'e .uept. .ardous Materials Division e HAZARDOUS M~TERIALS MANAGEMENT' PLAN ~: ,-.....~;. . -' SECTION 3: TRAINING: NUMBER OF EMPLOYEES: 7- MATERIAL SAFETY DATA SHEEïS ON FILE: IN ï2¡lo~ ID'<-NÖvJ ·Þ£s.i¿. ~M e-lb<.t-1 1)e.A-tJ'EL 8RIE~ SUMMARY OF TRAINING PROGRAM: WE- b--t-A-VE- 'PV{2L~~ A 4A-F-'f-:.-¡~ CO'M-?L-lA.vU- Pr20~~~ r(2QM.. e.~ L. ~FE-c "1 .,W E- H-A-\JE- \¡\t ÞË ¿L'1 7A-'P ¡::""'-'-1 VV\.r;..þ1l rJle5) ~ þ p.. LL "PE-a. S ~N f:- L ~ V F-- f.S ~ ""'fYl-A-t rJ E.Q 'I-,.J ~ P f2 Ö P E-I2.. \)~E:- A-.....ù H-A-ì'l 1> LA N &- tJ+ F- \ f2. €- 2: ¥- T\ tV ~ U \ $. I+£. \K- c:;. p..N~ Y((2..7\ A--tÇ> l¿l'\. £VV\p\O\(£.bS ~'->O KNoW" W\-h6~ A~c...1t1i"S -(2) NCS'1ì l='t ~ GA.sL t.;:Ç- (\ qp(L.-L-- C>tL ~-Ge C:> fZr.s0-¡ . SECTION 4: EXEMPTION REQUEST: I C~RT¡FY UNDER PENALTY OF PERJURY THATÎvlY BUSINESS IS EXEMPT FROM THE REPORTrNG REQUIREMENTS OF CHAPTER ó.95 OF THE "CALIFORNIA HEll.LTH & SAFE:Y C:::OE" FOR THE FOLLOWING RE.~SONS: WE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MA Të:RIALS, BUT THE QUANTiTIES AT NO TiMEEXCEE:J THE MINIMUM i<E?ORTiNG QUANTfTfES. """'-WE:"] (spc::rrc::v "'r-.\ ~CN) UIII t'\. ~.......,il· :"(~.~j" SECTION 5: CERTIFICATION: I, K1.2N C f'ee- () L-L- CERTIFY THAT THE ABOVE INFOR- MAïION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY F¡RM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER ó.95 SEC. 25500 ET AL.) AND THÁT INACCURATE INFORMATION CONSTITUTES PERJURY. 4M SiGNA TURE !J W N£12- TITLE 7- 27--9'1 DATE ') . .......... . J:)aKerSnelO. r1I'e lJeDt. . e Hazaràous Materials Di~sio_ . /~ .. ;,. 11 HAZARDOUS. MATERIALS MANAGEME.\{T PLAN Facility Unit Name: ~'E.e.N le-f+,../S ~ts. ,,:>, ð-vi SECTION ó: NOTfFICÄTION AND E'I ACUATlON PROCEDURES: ,-<, . ,-\G::NCY NCT[FiCATlCN ,= ~CC~JURES: ~ALL q\\ -. =:'/1 P LCY== NCT!F:C.-\ TiC Ì'1 ,..\N 0 ::'./ A,C:';AJ¡C N: "£~AL- H DIl ;= \L~ ~. O¡::: "E-M'? l,--ð"f é..~ .s E ~ {.,. .. tt t2 \J 1\sS ~13L-e... ON ~ eST IpA/lJL¡ ,.. ~ L-crr-. ~ r- L a't téf:::-<; . N E..-A-.e.-~ S ~ k. (. -¡- "'S(1)£., Df- 13u \0 b, N b ArvD :r:.J..J ""' ;:~5UC ::VAC:JATiCN: Dt e: "7 ~ OJ i\:PPL; '1 ,J. =:'IERG::NC,( NIE:J!C.~L ?~P,N: C A-L L q, \ . I A- ~ ~ 'I ON, E N£-F-Dt N b VV\.f:..D ¿It L- CALL Ïõ {?,A"'¡ t:.t-s¡:. &L!) ~ ð'û, A C ~srrl Î t'f G. ~ .=:1~ _ BakersñeldFire Dept. e , Hazaràous Materials Division .,__.r~· :~: HAZARDOUS MATERIALS MANAGEMENT PLAN SECTICN 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: A. ~EL=.~SE PREVENTION STE?S: S'E--¡kV L c-G-..C. tI'V\{>,,~v '( ""be- v 1- S fITI2-£. P I2-i:JJ t ß £.0 ~_ ~>J'~Lcr~ ~ t)..Jr¿ ~U'./~ ~<.> ¥+Q~ ~ "{ Sp,-ýG--.4 -¿(,£-G-I ¿ét2...P. NE:..v-J' (\-:1'~-7 Í\~~ ~'P ~\.A.... ~¡¿S 7A---r~1 ~'? !2.e-l,-t p...ß (L, ( 0 . 3. ~El=ASE'C8NTAINMENT ,A.ND/CR MINIMIZATION: 1.JJt.. I.+-A-\I E:.- ~ ~~( N I\A- f2Nr ~ W l\ S--¡-1:;.- Ól L ~ l¿ . yV2 ð1J ,..J t:> ()/Q. /""0 :=~=~~,N-UP P~CC=JUR=3: '-.tJ E..- \1 v-. 'G:. c;. l~-P Aß Sðfl.SA f\f7"' -rD ,?\¿t2 up ~'1 O;..J l~ ~ ~ t>\("t.-S-. ~ Al-L- SECTION 8: UTILITY SHUT-CFFS (LOCATiON OF SHUT-OFr=S AT YOUR FAC¡llTY): "~ATURAl GAS/PROPþ,Ì'lE: V\.I~S"" "'-JA-\ I ~ ßVlI-þ(,.."Jb 0Vï~ (D ~ C~) =:_='=~R C,;L:(yv\~h4 ') 'NÞ-~ í LuA!.-L ffiJTStQft.,,, ~StoE;) N· W. lótl"J'Ul. oÝ SH-ðP '\/\ - -..., ,-=> :f--i. W ~"Í b-Ç-- IfY'.. ~n rJ ~~ ^ i Gfi- . ,Vr-,I:::-:. - - ~- -'~ s:= =,= :AL: LC:·C:< SOX: '/C:~O ' L_~' :r= YES. ~Gc.; ¡¡ON: SECTION 9: PRIVATE FIRE PROTECTION/WATER A V AILABlllTY: ,~. PRIVATE riRE PROTECTrON: \Ne.. l+Avt-. ~ 't c; ~ ~ m-A--L ß J) l..--vt ,.J l,- f\. 7 ~e\'c-.J \¿vft.R-. ~. WATE~ AVAILABIUTY (FiRE HYDRANT): ðN <;auí1-\ ~(bE- if BUlL- Ol A.J6- $Ÿ7if~ A7 $? €t rJ I~LJi:,.c· ~ ~_. . ,~' " BAK~SFIELD '61TY FIRE cfpARTMENT HAZARDOUS MATERIALS DIVISION 1715 CHESTER AVE. BAKERSFIELD, CA. 93301 (805) 326-3979 HAZARDOUS MATERIALS INVENTORY :1 , i i i FACILITY DESCRIPTION I ' I CHECK :F 3USiNESS IS A FARM [ ] I I V' .-- 1 BUSiNESS NAME J'\ b.-e N t R-A-NSM. \ S S\ ð"l \ FAC:UïY NAME Wi BLE- Go MM~ C I (.\-L c:.f:..r..,TËi<;.. I SITE f~CORESS ~ \ \ 0 - H Wl ßL E... 12-Þ , I CiTY ßA\¿£.Il.SF-c£L-Þ STATE ~A, NA TUFE CF =USiNESS Ti<...A-N. ~VV\.l <'::::. S \ OtV <Ç l-+t)~ z!pß"33\) I SIC CeDE jC:;3 f DUN & BRADSTREET NUMBER · Q\NNE:=';CPE?A TCR -K t=-N ~ fi...£l.. 0 ~ \ MAIL;NG ACCRESS ~,\ () -H vJ, ß L-£' R-D , : CiTi ßA-KEÛ4F ,£L)::) STATE CA \ PHONE '&,bbt -<::61o~7 ZIP ~,J3 \ » :\ ;1 NAME J(e:-N t___ A--l2-(2D \ , BUS¡NESS r:~ONE <6~--O\S-' EMERGENCY CONTACTS TITLE () W'NE-£- 2d-HOUR PHONE 610 Lf"'~ <i'6<37 NAM E 31 ""- 0 fa 1> r&-N i BUSiNESS PHONE ~~b- 0\ Ç'l ! II TI TLE £ ('1\9 £., 0 't ~ L 2.4-HOUR PHONE <t 33 - 2.S'\O F'.EGION V lE?C $T Þ.NCAF\C ¡:. BAKERSFIEL.D CITY FIRE D, EPARTMENT HAZARD~S MATERIALS INVENTOR'll' ':.1:--"",-, Page_of>" slness Name J(£12-1-.t leA7J.5.M.lsStl\;J Address l..\\\O-\'-+ CHEMICAL DESCRIPTION W \ ~ L£.... R.1> 2) Common Name: 5AF ~ï'1 - \l.L.E-£.,v Chemical Name: A !-;[. 'PH- A TX:: L \ oc; SoL.V ~N,) l..-\:'DIZO LAeßð,J Check if chemical is a NON TFlADE SECRET}4. TFlADE SECRET ( I 3) DOT # (optional) VtoJi'1.6ls>, Þt.....m AHM [ J CAS# bLtlLi\-i;¡ -q .) INVENTORY STATUS: New ~ Addition ( 1 Revision [ 1 Deletion ( ) ~) PHYSICAL & HEALTI-i HAZARD CATEGORIES PHYSICAL "ire' ~ _ Reactive [! Sudden Release of Pressure [ 1 HEAL TI-i I Immediate Health (Acute) ~ Delayed Health (Chronic) ftJ I 5) WASTE CL;..SSIFICATìCN ...2....Œ.-(3-digit code from DHS Form 8022) USE CODE 6<6 :3) PHYSICAL STATE. Solid [] LQuld ~ Gas ( ] Pure [I Mixture [J Waste [ ] OifOCAU. T}lA.r J.P9t'f Radioactive [ ] ì) AMOUNT AND TIME AT FAC:UTY MiWmum Daily Amount: Average Daily Amount: Annual Amount: Largest SizeCcntaJner: :;. Days On Site ~~ -5f) 3D h(') UNITS OF MEASURE :00 [ ] gaJ f)(I. ~3 [ ] cunes [ ] 8) STORAGE CODES a) ContéUner: b) Pressure: c) Temperature: nb , ï.t Circle 'Nhich Months: ~J, F, M, A. M. J. J. A. S, O. N, D 9) MIXTURE: Ust COMPONENT ~ CAS # <í~ AHM the three most hazardous 1) ~\~~.Q.AL S?<(Lt,c" " ì4\ -~..\\ ,.q .. cnemlcaJ comoonents or 2) (<6-1- ACtoMA·nc:..s;. -"" ~-~ I ,¡ M\¥T\J~E any AHM comoonents . . [ I I 3) ~'l LtNê- J D 'f'I' P- 'T't\- '1 L- ~8-JG..e:.....> E- \~-;'0-'2 b -, \ 2It . i 0) Location '3 SO\ \J~ ì"A-)-.\ \l ~ 6.\.1 I\J~ w~ll ;r:..¡V s b\-z)--p N2-E.ft I I , CHEMICAL DESCRIPTION I 1) INVENTORY STATUS: New l}t.l Addition [ ] Revision [ ] Deletion [ ] r:.::-, ~- 2) Common Name: P t>f-Yí2 t) N :::rn: Check if chemical is a NON TRADE SECRET þi TFlADE SECRET [ ] 3) DOT # (optional) ChemlcaJ Name: ì1Z.~N>M\ SSION Fl..-\J\1:> AHM [ J CAS # ~) PHYSICAL & HEALTI-i PHYSICAL HAZARD C;" TEGORIES Fire 7<1' 'ìeactlve [J Sudden Release of Pressure ( 1 5) WASTE C~SSIFICAT;ON 7_ L L(3-<Ji9,t code from DHS Form 8022\ HEALTH Immediate Health (Acute) [J Delayed Health (Chronic) [ ] USE CODE u I 6) PHYSICAL STATE So lid [J Liauld!'{J Gas [ ] Pure (] Mixture [] Waste [ ] Radioactive ( ] ::-.1£0( ALL ¡"',.¡AiT APØt y 7) AMOUNT ;'NO T¡ME AT ¡=;'CiUTY ~ ' ,'.1axlmum CaJlv ;'mount: ' ;'verage OaJiy Amount: ~ "S'ð ;'nnuaJ Amount: í"2.-CiCJ Largest Size ContéUner: ~ " Days On Site Jte (ev SO ~ð<!) lex:) ~c.ç- UNITS OF MEASURE lbs [ I gaJ !)cI. tt3 [ ] cunes [ I 8) STORAGE CODES a) Co ntaJner: b) Pressure: c) Temperature: 01- \ \.t, - Circle 'Nhich Months~1\ Yeey J, F, M, A, M. J, J, A. S. 0, N, 0 9) MIXTURE: List COMPONENT CAS # % wr AHM I """.. rno" ,~~oo"' "í '" I " E,.., F... (ûTI;:. .D\ - · D'\ __ I cnemlcal comoonents or fp I I T\ nA~ P .1;;11.1 \cJC~ r'.... _I L,-e;~ ~y AHM components 2) ,..Ü,I-\-'r vAIQW1T I ~\b t.TI2-uL-é..v M. f>~ TI L L. A--rL- ~- ""\ ~2 2!!. ~ " [] I 31 \),~}'.~ì) ~\t 'I pr'æ^"rF IoN" ( l ~ \ b4. ìLt UcçO ~ -LffA,\ [ 1 10)ï_0ca1/on WE-err- INA-U -?tt-l)P AaE-A- . / :.00 ni1 WY'rL..L. , r-.- ,,,", ç;:; \ ~;~;:~z:= (~~;::.:~.;::: ~ am ,am"'M .,m m. 'n"~u¡;;;¡¡ ~ aaacnøa OOC;:;q'~; m. 'R/NT Name 6- Title or .4l.JÚ7onzea Comoany Ae,oresenraave Signature Date "Iœo... l.IPClT.tfiCWIIIO~fI , , - - I ,,;f~ BAKE~ELD CITY FIRE DEP~TMENT ç;~ , . . . H DOUS MATERIALS INVE ORY Page_ of_ ~usiness Name Address i CHEMICAL DESCRIPTION I 1) INVENTORY STATUS: New~ Addition ( ] Revision ( ] Deletion ( ] Checlc if chemical is a NON TRACE SECRET [ ] TRACE SECRET [ ] 2) Common Name: vJA~~ A<-r~ 3) DOT # (optional) Chemical Name: AHM ( ] CAS # - I 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fi re If'! Reactive ( ] Sudden Release of Pressure { I Immediate Health (Acute) [ ] Delayed Health (Chronic).ß <¿, -z. I I 5) WASTE CLASSIFICATION (3·digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE, Solid [ ] Liquid ~ Gas [ ] Pure [ ] Mixture [ ] Waste ~ Radioactive [ ] CHEO< ALl.. mAT APPlY 7) AMOUNT AND TIME AT FACIUTY /75: UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: Ibs [ ] gal ~ ft3 [ ] a) Container: 10 Average Daily Amount: 7b cunes [ ] b) Pressure: ( Annual Amount: 7Çi c) Temperature: 4- Largest Size 'Container: '7f ~J,F,M, # Days On Site ¿3(..., Circle Which Months: A. M. J. J, A, S. 0, N, 0 9) MIXTURE: Ust COMPONENT CAS # %WT AHM the three most hazardous 1) (/J.ÂS'Té ÄT'F [ ] chemical components or any AHM components 2) [ ] 3) [ ] 10) Location ðolS\Oé S (".I'-S~L ß~'-v1J ~-.JC£. I CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New ( ] Addition [ 1 Revision [ ] Deletion [ ] Check if chemical is a NON TRADE SECRET [ ] Tl'IADE SECRET [ ] , 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # , 4) PHYSICAL & HEALTH PHYSICAL HEALTH ¡ HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure ( ] Immediate Hearth (Acute) [ ] Delayed Health (Chronic) [ I ¡ i 5) WASTE CLASSIFICATION (3-digit code from oHS Form 8022) USE CODE ,I 6) PHYSICAL STATE Solid [ I Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste [ ] Radioactive [ ] I I I ':>ifCX ALl.. mAr AÞPt 'f ,:! I' I , 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES I ,'..lax/mum Dally Amount: Ibs [ ] gal [ ] ft3 [ ] a) Container: ! Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: , # Days On Site Circle Which Months: All Year. J, F. M, A. M. J. J. A. S, O. N. 0 I 9) MIXTURE: Ust COMPONENT CAS # %WT AHM the three most hazardous 1) [ ] chemical components or any AHM components 2) [ ] 3) [ ] ,II 10) Location \ an am ramlllar w/m me mromat1on su Ittad on thIS ana ail atRIc"'.....I "ocuments. ¡ "elleve /TIe ¡certifY unaer penalty or law. that I nave personallY exammea ;ubmitted informaDon is true, accurate, and complete. I; f£...; ~II /)wrve£-. r~: r::e & Title of Authorizea Company Representative a r, Signature ill€œQI¥ UJIICSf.tfilClNllOFCIW CA"cn~"'1 CLLJ --- - - ---- - ----- - \"11· Y 1'"'. Ht: Ut:~AHIMt:NI HAZAR[tþUS MATERIALS INVENTOe ~~:-- P~~e~òJL Jsiness Name Address CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New ( I Addition ( J Revision ( ) Deletion [ ] Check if chemical is a NON TRADE SECRET, ( ) TRACE SECRET [ ) 2), Common Name: 3) DOT # (optiOnal) Chemical Name: AHM ( I CAS # ~) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] ReactIVe ( I Sudden Release of Pressure [ ] Immediate Health (Acute) ( J Delayed Health (Chronic) [ ) 5) WASTE CLASSIFICATION (3-digit code from DHS Form 60221 USE CODE S) PHYSICAL STATE Solid [ ] liquid [ ] Gas [ ] Pure [ ] Mixture [ ) Waste [ ] Radioactive ( ) CHECK.ALL mAT APPlY ì) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: 100 [ ] gal [ ] ft3 [ ] a) Container: Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: Largest Size Container: ;# Days On Site Circle Which Months: All Year. J, F, M. A. M, J. J. A. S. O. N. 0 9) MIXTURE: List COMPONENT CAS # %WT AHM the three most hazardous 1) [ ] chemical comoonenlS or any AHM comoonenlS 2) [ ) 31 [ ] ! 1 0) ~ocatlon 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) ChemicaJ Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ I Reactive [ I Sudden Release of Pressure [ I Immediate Health (Acute) [ ] Delayed Health (Chronic) [ ) 5) WASTE CLASSIFICATION (3-digit code from DHS Form 60221 USE CODE 5) PHYSICAL STATE Solid [ I Liquid [ ] Gas [ ] Pure [ ] Mixture [ ] Waste ( ] Radioactive [ ] I GHECKALl. T'rfATA,PØl'r ! 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES ,'.1axlmum Daily Amount: lbs ( ] gaJ [ ] ft3 ( ] a) Container: Average Daily Amount: cunes [ ] b) Pressure: Annual Amount: c) Temperature: , Largest Size Container: ;; Days On Site Circle Which Months: All Year, J. F. M. A. M. J. J. A. S. O. N. D !9) MIXTURE: Ust COMPONENT CAS # %WT AHM the three most hazardous 1) [ I chemical comoonenlS or any AHM components 2) [ ) 3) [ ] , 10) Location \ ert1ty unaer cenalry OT law, Ulat { have personally exammea ana am Tamil/at w/UI t/'!e mromaaon suomlCtea on t/'!/s ana ail artacnea aocuments. I oel/eve me I :Jmittea information is true, accurate. and complete. 'INT Name & Title of Authorizea Company Representative Signature Date Af:atoIV \..EJIICST~~u I ....3C1'~ ... tllVl.Vl 1""' r Lð...L ~ - 1 Y .u-u:- ~" -.;",t¡.; .. SITE DIAGRAM I....?" I Business Name: ~J~.'[Z.-~ FACILITY D(AGRAM ~ I1Z..PrlJ ~VV\l$'$(~ Business Address: Y \ \ 0 - 1-\ V~ l f3LE. eD. M~. LA ~ q ~ 3\). For OHice Use Only I I \ :::::c::;i:~~tion: Area Meo it of NORTH 0 \N \~ J:..TE- L.. N. ""(tl'" ~~L.. (), ~') ~ ¡ýÝ'7 ~~~ )\~}f Q ~\L '" \ (L (»" \>-1. -P1i~~IN 0 A- Î2-0-A A~ ->¡Ú --.r.! ,J-< '-70 0- .() '/ 3 ::r:. ..-..~ ) WF-...-r-E.~ ~I.JI\"'1)I,)l,. Mo.->rcorro.l.c.. \