HomeMy WebLinkAboutBUSINESS PLAN 5/28/2006i
~~ ~I MORENTIN'S AUTO REPAIR
~ 4300 WIBLE ROAD,SUITE A
~,
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+ MORENTINS AUTO REPAIR _______________________________ SiteID: 015-021-002466 +
Manager BusPhone: (661) 835-7589
Location: 4300 WIBLE RD A Map 123 CommHaz Minimal
City BAKERSFIELD Grid: 14D FacUnits: 1 AOV:
CommCode: BFD STA 07 SIC Code:
EPA Numb: DunnBrad:
Emergency Contact / Title Emergency Contact / Title
CARLOS MORENTIN / OWNER JIM CREECH / PROPERTY MGR
Business Phone: (661) 835-7589x Business Phone: (661) 619-0290x
24-Hour Phone (661) 342-8223x 24-Hour Phone ( ) - x
Pager Phone ( ) - x Pager Phone ( ) - x
Hazmat Hazards: Fire DelHlth
Contact CARLOS MORENTIN Phone: (661) 835-7589x
MailAddr: 4300 WIBLE RD A State: CA
City BAKERSFIELD Zip 93313
Owner CARLOS MORENTIN Phone: (661) 835-7589x
Address 4300 WIBLE RD A State: CA
City BAKERSFIELD Zip 93313
Period to TotalASTs: = Gal
Preparers TotalUSTs: = Gal
Certif'd: - RSs: No
ParcelNo:
Emergency Directives: ~
PROG H - HAZ WASTE GEN
s 2006
Based e~ ~}i inquiry of those individuals
responsible fer ebtelt~iry~ tlid ;nfdrmatlon, I certify
under p ity of law #ryat i have personally
examin nd Qm #j~r~jllar with the information
submi ed nd believe the informal' n is true,
accur te, a d complet®.
~. /~
n r net
+====7________________°________________________________________________________+
-1- 05/19/2006
· CITY OF BAKERSFIE-Yiil
o?F'ICE OF ENVIRONMENTALW:RVICES
1715 Chester Ave., CA 93301 (661) 326-3979
ART. T#C¡{}~
./"-"'~'-d~- BUSINESS OWNER I OPERATOR IDENTIFICATION
If/11ð/1 FACILITY INFORMATION
S..!oó I
/.)3 -¡C/O
Page _ Of
.." '\~;i~o.;"X~.FACILlTv II)EN.TïFICATlO~ '~.
FAClLI1Y ID # 1 Year Beginning IO~ I' 6..;,
BUSINESS NAME (Same as FACILl1Y NAME or DBA· Doing Business As) ,..
l_ (YlOv'>Q...V\. UtA ( S Ä...VLÒ ne...¡Oc\1 ý'
I
I SITEADDRESSY30Ö W \hft¿ IZ-d ~U~
r CITY ß)4 (7- -Vs Fí¡J J c 14
I .
I DUN&
BRADSTREET
')0 I Year Ending
I
~ BU~~ï~~ 3S ~ 7 S ð-1102
-h
101
103
104 i
CA I ZIP 93313
106 I SIC CODE
(4 Digit #),
105
107
I OWNER NAME
j OWNER MAILING
i ADDRESS
I CITY
¡
i
108
O~1 vt
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C,c,v./CI S Ø10MIh7íh
ccJ ÚJttle Ad #-
-~
OPERATOR PHONE 6l[ 2:.-
113
: CONTACT NAME
,
! CONTACT MAILING
, ADDRESS
I CITY
119
122 '
127 24-HOUR PHONE
;,',¡' '.';-F,·' : :';:':, ':'- ~,-,\. '::~,"'~,
CONDARY~t;
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TITLE
BUSINESS PHONE
I 24-HOUR PHONE
I PAGER #
130
131
132
128 I PAGER #
133
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I Certificatio . Bas d on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined
~and am miliar ith the information submitted in this inventory and believe the information is true, accurate, and complete.
I SIGN URE OWNER/OPERATOR DATE. 134 NAME OF DOCUMENT PREPARER ¿,ill
l' r- C#t ~- -0.; <.£s c ~
I NA ES OWNER/OPERATOR (print) 136 TITLE OF NER/OPERATOR 137
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Morentin '5 Auto Repair
~
22 YEARS Exp. WITH
~-::--
FOREIGN Be DOMESTIC CARS Be TRUCKS
SE HABLA ESPAÑOL
OPEN 8-5
(M-F) (SAT: 9-3)
661-835-7589
CARLOS MORENTlN OWNER
4300 WIBLE RD.
SUITE A
BAKERSFIELD, CA 933,13
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I
I CITY OF BAKERSFIEW
OF CE OF ENVIRONMENTAL ~VICES
1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979
HAZARDOUS MATERIALS MANAGEMENT PLAN
Section 11.1 - DISCOVERY AND NOTIFICATIONS
I. FACILITY IDENTIFICATION
BUSINESS NAME (Same as FACILITY NAME or DBA . Doing Business As)
ðV'et/l TI A./l
ADDRESS (For local US8 only)
'3C3ó
FACILITY ID tI
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DISCOVERY
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C. SPECIFIC RESPONSIBILITIES OF EMPLOYEES: W c... G\ ~ Ò ~ S; I í I ) G-d ~ I
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D. CLOSEST LOCAL MEDICAL FACILITY:
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HADOUS MATERIALS MANAGE.T PLAN
Section 11.2 - RELEASE RESPONSE PLAN
I PRELI",INARY ASSESSMENT'
I
I A. HAZARD ASSESSMENT AND PREVENTION MEASURES:
1/ Co,t/ n~ J"ICY"7~T ¡é"c;y c..d V,rLr¿., ~
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B. RELEASE CONTAINMENT AND MITIGATION:
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HAZARDOUS MATERIALS MANAGEMENT PLAN
Section 111.1 - FACILITY AND LOCALITY INFORMATION
I UTILITY SHUT .oFFS
I LOCATION OF SHUT-OFFS AT YOUR FACILITY: \ t
NATURAL GAS/PROPANE: S0u1~ s¿C>e. of" 8u ~\d(~~
ELECTRICAL:-1.I",,\ \ \J0""'j '11\) ~p
WATER:
-CA 4JL/
SPECIAL:
LOCK BOX: YES /@ IF YES, LOCATION:
PRIVÀ TE FiRE' PRÓTECTION I WATER AVÄiLABIL¡fy, ..
A.
PRIVATE FIRE PROTECTION: Ftv.e.-. ~ T\ U ''''4~
WATER AVAILABILITY (FIRE HYDRANT): S O-J T4 [; ( J '( a,Ç' 0 u; I J ~.
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NUMBER OF EMPLOYEES:
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MATERIALS DATA SHEETS ON FILE:
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BRIEF SUMMARY OF TRAINING PROGRAM:
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Based on my Inquiry th Indlvtduals responsible for obtaining the InformaUon. I certify under penalty of law that I have )efSOI1naty examined and am familiar with the InformaUon submitted and believe the
lnformaUon Is true. ccu e. and complete.
CERTIFICATION
NAME OF IGNER (print)
!-uì
SIGNATURE 0 OWNE I OPERATOR OR DESIGNATED REPRESENTATIV
C-. M~ 7
C
DATE
G3
477.
478, TITLE OF SIGNER
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e CITY OF BAKERS FIE.
OFFICE OF ENVIRONMENTAL ~RVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
DNEW
DADD
D DELETE
200
D REVISE
(one form per material per building or area)
Page of
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I. FAcii:tr'(; iN,FÒRMA TlON
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BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As)
(JQ() It-e vfrl)J I.ç A~f[o
2011 CHEMICAL LOCATION
CONFIDENTIAL (EPCRA)
203 GRID # (optional)
.....
~~r('
, CHEMICAL LOCATION
1 MAP # (opoonal)
, C~EM'ltÄt¡j~~()RMA TlOttiiy:;¿~' ", ~
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205 TRADE SECRET
CHEMICAL NAME
DYes 0 No 202
204
"1
,
o Yes 0 No 206
COMMON NAME
EHS'
If Subject to EPCRA, refer to instructions
o Yes 0 No 208
207
oö(ôV\.
l' -e.- Ot
209 °If EHS is'Yes, . aD amounts below Jiws¡ bCin 'ùi~ :,.
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CAS #
FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief)
210
TYPE
o m MIXTURE ~ WASTE 211 RADIOACTIVE
DYes ~
o P PURE
212 i CURIES
¡
213
PHYSICAL STATE
~UID
S"
bcJ
o 9 GAS
214
LARGEST CONTAINER
o s SOLID
FED HAZARD CATEGORIES
(Check all that apply)
ANNUAL WASTE
AMOUNT
o 5 CHRONIC HEALTH
01 FIRE
o 2 REACTIVE
o 3 PRESSURE RELEASE
o 4 ACUTE HEALTH
217 MAXIMUM
DAILY AMOUNT
UNITS' 0 ga GAL 0 á CU FT
. If EHS. amount must be in Ibs.
218 I AVERAGE
~ DAILY AMOUNT
o Ib LBS 0 tn TONS
215
216
219
STATE WASTE CODE
220
221
DAYS ON SITE
222
STORAGE CONTAINER
(Check all that apply)
223
~OVEGROUNDTANK
o b UNDERGROUND TANK
....B-c"tANK INSIDE BUILDING
~STEEL DRUM
o e PLASTIC/NONMETALLIC 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
STORAGE PRESSURE
o ba BELOW AMBIENT
224
o a AMBIENT
o aa ABOVE AMBIENT
STORAGE TEMPERATURE
o ba BELOW AMBIENT
o c CRYOGENIC
225
o a AMBIENT
o aa ABOVE AMBIENT
226 227 DYes 0 No 228
,
! 2 230 231 DYes 0 No 232
I
3 234 235 DYes 0 No 236
4 238 239 o Yes 0 No 240
5 242 243 o Yes 0 No 244
229
233
237
241
245
c - ØJ~/
246
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UNIFIED PROGRAM IMlPECTION CHECKLIST
SECTION 1 Business Plan and Inventory Program
Bakersfield Fire Dept.
Enironmental Services
1715 Chester Ave
Bakersfield, CA 93301
Tel: (661)326-3979
:::~i;~~~~~~---~~~:~-===--=-==-=j~~~:-~~;:~:~'
Section 1: Business Plan and Inventory Program
LJ Routine
ftEombined
LJ Joint Agency
LJ Multi-Agency
LJ Complaint
LJ Re-inspection
c V
( C=Compliance )
V=Violation
OPERATION
COMMENTS
LJ 0 ApPROPRIATE PERMIT ON HAND
"'m_~___m~,~I!:____"?_'¢"
.."". --- ~ ----., --.._-----.--
----_._._--------_._-------~.__._-_._-~--------_.- - ~.----------'------'---"--'------
o 0 BUSINESS PLAN CONTACT INFORMATION ACCURATE
------_._---'--~~---~----------_._--_._,-- -- _.~---.-_. ,..----...-.-----
. - --......--.--.---- . ..-.-..". -.---.--....
o 0 VISIBLE ADDRESS
._._-----_.~--,---_._---_._-_._-----_.._-._--_._--_..---....---.-------- ---
... .__..._________._. .__._ __ on ____ _ ___ ___ ___.__......u_____ .____.
o LJ CORRECT OCCUPANCY
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--.------..---..-..-.. -.--.-----...--. --------_.---- -.--....--.---.-. .---- ------.. -_._--_._.~ ...-..
LJ LJ VERIFICATION OF INVENTORY MATERIALS
u______,__ ~~ _____º_~~,__,
u____ _________.£C_~___._
I¡JS¡()¡; Nt: (!
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-_._---_.._--_.~------_._---------_._._-----.--_._----- ---.-.---- ----
LJ LJ VERIFICATION OF QUANTITIES
------..-.---- -____·~__________.__u____.._.__.___ _._.._____.____._._
o LJ VERIFICATION OF LOCATION
------..--~--.-----------~----.-~---------__<______________·_________u __________m.__.._________.._.._
o 0 PROPER SEGREGATION OF MATERIAL
____u.___~__________..__________...___.__ .____"_._________________..___..__.__._ __ '__.______'_____'_.'u'" __._h.____ no __ . __.._____.___.u___ ______________ _.._____._.__u_
LJ LJ VERIFICATION OF MSDS AVAILABllITYE
-.--------------------.------------________...__..___ ..__._..______...._u____ .____..___ ___...u__.__ .._."._______.._..__ _. ____.______.___._.__.____ ...._~____._ _._. ._..____~ ___. __ __ _.__. ._._
LJ LJ VERIFICATION OF HAT MAT TRAINING
___u______~______.__.._______________._. _._._ ___. _<__on _ __ _.___ __.____u_____, __. _.___._.__..___.<__ . _ _ u_________..__.. _...__....
LJ LJ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES
---.--------- --.-~--~- -_~_____·____·_·__·_·_·__·_·_"__h.__._ .____,,_. _<,_._____.__._ ___..______."._.__ ____._.._..._ ___..__..___.. ____ ______.___ .__ _._ .____________.__
LJ LJ EMERGENCY PROCEDURES ADEQUATE
---_____m'________'___m' ,... '_,.._____..__,,___,__......__.._______,___ ______..,..,_'u,~--..--..--..-..-- _,_ ".. ____,_, ,,_, ,___ ....__,_ __ ...,_ _ u.,..,,_
o 0 CONTAINERS PROPERLY LABELED I
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LJ LJ SITE DIAGRAM ADEQUATE & ON HAND
,
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ANY HAZARDOUS WASTE ON SITE?:
~S
LJ No
EXPLAIN:
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,--~~-----------
Business Site Responsible Party
à;
QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979
---.-.----.---.--------.- -.-----..-----.---.-.
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Inspector
Badge No_,
White - Environmental Services
Yellow -Station Copy
Pink - Business Copy
.' t' .;':.'.. ""'f."P~'.
,:,:..., ',:;..;:~.: :': I. FACILITY INFORMATION
BUSINESS NAAE (s.m. _ FACILITY ÑÃMËÕtOBA - oöj;,gšUãJñ-š'Ãsï-'" ,'.. -- ..... .,
Mt9R.:re..NT/to,J '.$, ____~ "..1?c;P~I_~...,....,
CHEMICAL LOCATION Ë..,- n 201 CHEMICAL LOCATION - 0 0
INS (Ú~. Nc::;-- Crê.N,ç., tJF- S-HdP . CONFIOENTIAl(EPCRA) - Yes No 202
FACIUTY 10" ~rr'- - ;--- ---:----¡r'-MAPiiaøfjonsl) ..--..., ..._- ,---- ... - -2õ:j" '-àRìöii{opÏionaÏ)--" 204
. ',...',','_:,,'.'~,..,...i..,¿:',;,.,,":!,';¡p,,·,~,._:·.'.'f',"..:',,....'"",:i ¡ LL~ : II. CHEM C~_'-";F-ORM"A"TlON -''''-~---,,'-' <,',,:,.. .. , '" . '...~..'..I
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205 , TRAOE SECRET 0 Yes 0 No 2Q6
If SuÞjeclIO EPCRA. lei. 10 InsIructions
CITY OF BAKERSFIEI£
O.CE OF ENVIRONMENTAL.RVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
~EW
I
DADO
D OELETE
D REVISE
200
'-.. .....----. ~_._,.__._- -.. ..... ....-..
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CHEMICAL NAAE
W4-~ ~
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COMMON NAAE
! EHS·
Dyes D No 208 .
- .------------.- . ..... -...._- . -- - -.. . --- .
(one fomt per __rial per building or area)
Page 01
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CAS'
209
.If.~i~;:,'·,~.{i.IÞ'!
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FIRE CODE HAZARD a.ASSES (CompIeJe if NC IIIIItedby lOCal h- cNeI)
------... -..--. .-......- .--.- ---.-.-
210
~ WAS';': -'~-:-:..:..~OOACT~--- 0 y"¡- ~
--_.~_._-_.._-_..._-- ...
¡
213
TYPE
OpPURE
o m MlXT\JRE
212 ¡ CURIES
214 : LARGEST CONTAINER
ss-
PHYSICAL STATe
ø, lIQUIO
D . SOUD
.D g GAS
--..-.--
-...--------- ~ ----.---..--
: FEO HAZARD CATEGORIES
: (Chedc an IIIaI apply)
¡ ANNUAL WASTE
, AMOUNT
ø.,. ACUTE HEALTH
o 1 FIRE
02REACTJVe
D 3 PRESSiJRE RELEASE
o 5 CHRONIC HEALTH
220 .
-.--,-
--..-... .....--.-...----.-.-----------.--
211 I MAXJa.tJM ,.....~ 218 i AVERAGE
, DAII. Y AMOUNT ~ ~ ~ CAlLY AMOUNT
--L ___.__ _.....___~._. ___._._____..__. __ ____ .....
UNITS" JSfaa GAL D d CU FT 0 IÞ l8S 0 In TONS
. If EHS. amount must be in Ills.
~r
áCì
STORAGE CONTAINER
(Check all/hal apply)
D. ABOVEGROUND TANK
Db UNDERGROUND TANK
DC TANK INSiDe BUILDING
.,.Hd STEEL ORUM
o e PlAST1CJNONMETAlUC DRUM
01 CAN
o g CARBOY
o h SILO
o ¡FISER ORUM '
Cj8AG
Ok BOX
OICYUNDER
o m GlASS BOTTlE
o n PlASTIC BO'ITLE
00 TOTE BIN
o P TANK WAGON
-.-...... ._. .-.......- ....-------.-----
i STORAGE PRESSURE
,
~, N.ØlENT
o .. ABOVE AMBIENT
o be BELOW AMBIENT
-----..---.--------....-..-...-.-.- .. "._-- ---.-. .--.-..---.-
STORAGE TEMPERATURE
)!(.AMBIENT
o ba BElOW M'BIENT
o .. ABOVE M'BIENT
215 :
216 .
219 ¡ STATE WASTE CODe
I
i CAYS ON SITE
221 I
222.
o q RAIL CAR
Or OTHER
I
m!
224 !
o c CRYOGENIC
2251
I
/ '~,:~~~~~?~y~;~:~:~~~'-Çß~~~,~;r;~~;;;;:'
-..,-"-------.---" -.. '__..H______~.. ~_~~_9_~_~ ,L
231 I 0 Yes 0 No 232 !
--.-------.-------.-.-... ...-.----_._ ...--~.. ... .__._¡-__.._....4...__..... _;_
235 ; 0 Yes 0 No 236 I
__'__H_""_ -..-.. ,..-----__, _.. ..__---1--__
m:~Y.D~~
-------..--------.. - -- -._-- "- -.- .
243 0 Yes 0 No 244
---....--- --
":'.~{::~:-f.·;'<~¥~;~!:m~:;~I~~!µ~ ': ;:',:~.." {.,.'
., , " " . SiGÑÃrORE' ,--,------
2 230
I
3 ! 234
i
i 4 238
5 242
---.-.....--.
-.-.---.-- --.-. - - -------- _.~._-. --
..-..... .--.. --.- -... --..-.-....-....--.----... ..~.
UPCF (7/99)
229 :
233
237 ¡
I
241 I
I
S:\CUPAFORMS\OES2731.TV4.wpd
'. f"·' ;':.'.. "1" ~".
:.:""; ',:i.~~,:,:':: I. FACILITY INFORMATION
BUSINESS NAME (s.m. . FACILITY ÑÃMËÕr-OBA . DCiñgãí.siniiïš Às")-'-- , '.. - - . ---' -,
MöQErJ<rfN$ -~ «Ç~~,I~,_,....,.. ,.
CHEMICAL LOCATION,e- ~ _ r-- JI .. . ~ 201 CHEMICAL LOCATION - 0 0
, N os. H')~ f'Jf;. c... ~....... ~ .s'l''fUr . CONFIDENTIAL (EPCRA) - Yes No 202
FACILITY 10 /I ~rr:-' :--~ ·-~--ln.wri(O IIOnII) --'-, ...,-- .., - -2iïj"'-äRìöÏi{oPÏionaÏ)--- 204
. " ..:,',:"..,','~,..,...;,;.'.~.."":'.',:",,,p:,,_~'."'.','~.',.,...',".} 'LL~ : II.CHEM'CAI..'--'~;F-ORM"A'·T/ON --"--~---.,'-' .',. ,,,,,'; '""1i"¡" ,
-.., .. . ".., ':~£« :~;-~, ~'~':'~-E ¡
205 , TRADE SECRET 0 Yes 0 No 206
If SuIIjed to EPCRA, relet to insIructions
CITY OF BAKERSFIE(.Q
dalCE OF ENVIRONMENTAL_RVICES
1715 Chester Ave., CA 93301 (661) 326-3979
HAZARDOUS MATERIALS INVENTORY
CHEMICAL DESCRIPTION
~EW
DADO
D REVISE
200
D OELETE
---. ...~~---_. -----.- ... .'... ..~.__.
.- -.--.------.--
. .--. -_.....
-- ".-- _. --..
M ....___._.___
CHEMICAL NAME
V ~C'?
ð((_
-. ----------_.. ...- ....
..... - .. .. ..
------- - ....-æ~--
~ COMMONNAME
! EHS"
-----..--------.- ...........-... --.. -.. . -._-- .
CAS /I 209
FIRE CODE HAZARD Q.ASS£S (CcmplereifrecPlltedbylclCll tire ~------- - ----'--:'- ,--,- ---,_._-
TYPE
J -.,--,.."'----- .------,-
o m WCTURE ~ w WAS;: .. ~: : R..OIOACTIVE 0 Yes ~
--_.~_._-_...__....._-- ---
(OM (0"" per m.ten.¡"., bui1á/ng or area)
Page at
..
. ''''
. ."' -. . "':.'"
~. , -"'<' . .........:... .
'. ~H~.-.:...· ::··:~f~>~'<-
3
DYes oNo 208 '
210
o P PURE
PHYSICAL STATE
]i{uaUID
,0 g GAS
214 ; LARGEST CONTAINER
o s SOUO
..:s.-.s.-
--.-.--
-...----------. ----.------
¡ FED HAZARD CATEGORIES
: (Check all ilia! apply)
, ANNUAl WASTE
j AMOUNT
~FIRE
02 REACTIVE
D 3 PRESSuRE RELEASE
o 4 ACUTE HEAL T}
o 5 CHRONIC HEAL T}
-.--.,- -,.-- - ...-....--.----...-.-------------
~ 217 ¡MAXIMUM .--'r!'""'"'" 218 : AVERAGE ""> p\
.J -d> , DAILY AMOUNT ...:::> ..} ; CAlLY AMOUNT oJ I.,d
--L __._______L-._..___._.._____..__.__ ______.0
UNITS* fii("ga GAL D d CU FT 0 Ib LBS 0 In TONS
" " EHS. amount must be In Ibs.
¡ STORAGE CONTAINER
. (Check aU ilia! appIyJ
D a ABOVEGROUNOTANK
Db UNDERGROUNOTANK
o c TANK INSIDE BUILDING
~ S'ÆEl DRUM
o e PlAS11CINONMETALUC DRUM
Of CAN
09 CARBOY
0" SILO
o I FIBER DRUM
OJ BAG
Ok BOX
o I CYLINDER
o m GLASS BOTTLE
o n PLASTIC BOTTLE
00 TOTE BIN
Op TANKWAGON
--_...... -_. ..-......- ....-.--.-..----
STORAGE PRESSURE
A. AMBIENT
o aa ABOVE AMBIENT
o be BELOW AMBIENT
--------.---------.... -....-.- . ,.--- ...... ...-.------
212 ¡CURIES
213
~5 :
219 ¡ STATE WASTE CODe
I '2.. ~I
i DAYS ON SITE
221 I
216
220;
222 :
o q RAIL CAR
o r OTHER
2231
;
224 I
'-::~~~~~~~Wš~,
/ ~i;;,'~~W~J·;:j;:·~;~:~~ÔÛ~'"@~~~"N.T;~·:<i<'\<~: ': .','
STORAGE TEMPERATURE
Þla AMBIENT
o aa ABOVE AMBIENT
o ba BELOW AMBIENT
228
."_.._____._____. _ _"" ,___,___..__:.. ~_~~_o~~~ ,L
231 I 0 Yes 0 No 232 !
--....-.----.----------.-..- ...------.. ......'.. -. ---.-¡--.-...--..---.... -;--
235 ; 0 Yes 0 No 238 I
---- --- ,-, --~~y: 0 No ¿j
._ , ,--___-..----=-= ;4~l:G:~_No 244/
'}f:(·}\~:;~··,~'::'·;:#::¡;~::M~:;'~~~!Y~ ,/ ";,:~,,' t.
" . " " ' SIGNATURE' --,",---
2 230,
I I
3 ! 234
¡
i 4 238
5 242
--_._.~...__.
.------- -..--..-..- -------- _...__..-
.... ._... ..... -... --.-.-..-.....--..---..- -..
UPCF (7/99)
!
229 :
233
237 ¡
,
i
I
241 I
I
I
245 !
I
,
·'~if.~~'~"t
S:\CUPAFORMS\OES2731.TV4.wpd