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HomeMy WebLinkAboutBUSINESS PLAN 7/1/1987 'I' ~:'! ROGERS~A1iTO REPAIR L, \ 1~ 4 " , ' .---=--~ ... - iJ I' ~ ci. I I' I I 1,1 , I I! I "I ". " : ) " II II 1\, I I i " ,I i ( n I, ;il 't ~$;~ i\ n 1'1 ~ J S2 i '~J ~ I W ~~ , I I 11 .:' i , '. J 1UJ-16 5'--tt \: I f~' -~ ~; ~ I) , n~i:~ ~'~~~~:~,o;:_.., , .;' -.'- . ~ / "- / ,--, '. " , 31ð! ,. ik, ,~¡tftl:t /Ló' - TE/FACILITY DI RAM FORM 551ft 1., \ .. / NORTH l' SCALE: BUSINESS NA~E: FLOOR: I OF f UNIT ~: ,OF 1 ¡,!/: æ DATE:7/ I 137FAGILITY NAi'1E: :5a.-M e (CHECK ONE) SITE DIAGRA~ )(' FACILITY DIAGR.~'1 ~ \1"- ~ ~ 1-=. V} \i1 " .<e;;:. \) , ~, ~.~ ) - .~ ,..~ ." , ¿,1\ '3 ,0 -\'j>- ~J *1\0 \19 ~ l' ~ tD .,' .:- "fV1à ~ðV1,tV3 C"Y7 5frtlc4., IN\ ~ "f ...~ ' ,~. . :.. ~+- ~ , 3 ~~ ~ " ',. .. -).,;:7- ï r J . ~ r/.1Tll , rta. ,,,, 7?>a.,,~Â( '"I j I r r I-H--H-il t +-1+- (Inspector's Comments): I ~OFFICIAL USE ONLY- - 5A - '" ,-' , . SITE D1AGRAH (Re.d iteas) 1. Address: Ident the principle bUildings by the Street numbers. 9. Lock I) Box 10. M5DS Storage Box 2, Strèet(sl. Alleys, Driveways. and Parking Areas adjacent to the property. Include the street naaeo. 11, Railroad Tracks__ 12, Fence or Barrier -11. !fIre 3. Storm Drains. Culverts. Yard Drains b. Masonry c. Wood 4, Draina¡e Canals, ~itches. Creeks, d. Gates 5. 8ullrlings a. Frase construction b. Masonry construction )C c. Metal construction 13, Power lines 14. Guard S~ation b. Fire Sprinkler Connections d. Access Door Storaie Tanks: Identify the capacity in gal. a. Above iround 6. Utility Controls a. Gas b. Underground 16. Dikin¡ ~r Bera b. Electricity 17. Evacuation Route c. Water 18. Evacuation Area: Identity the location where eaployees will a.. 7. Fire Suppression Systeas: a. Fire Hydrants ,'^' c. Pire Standpipe Connections ......-.~.... d. Water Control Valves Cor protection syste.s 21. OutaideHazardous Mater fal Use/Handline , e. Fire PUllp 22. Type oC Haza~dous Material/Waate . -- Stored ,~ . or Used (See Below) 8. Fire Departaent Access TYPE OP HAZARDOUS MATERIAL P · FlUllable £ · EJtploaive L · Liquid C · Corrosive 0 · Oxidizer G · Gas It · Water Reactive T · Toxic S · 5011 d R . Radioloiical P . Pobon H . Cryo¡enic D . Waste B . Et.1olorical Exa.ple: Fla..able Liquid. FL FACILITY DIAGRAM (Required iteas in addItion to the above) 1. Risers tor Sprinklers 2. Paru t Ion. 3. Steirways: Indicate the levels served Croe hi¡hest ta loweèt. 4. Escalator: Indicate the levels served Cro. highest to lowest. 5. Elevator 8. Attic Access 7. Skyl1¡hts 8. Pire Escapes Air ConditionIng Units 11. Inside Hazardouo Waste Star8K" Inside Hazardous Materials Use/HandJin¡ 14. Sewer Drain InJets , .c;$:;~~: , , ' £='''"A-_''o '~ ,,) ~--- 1', -:. .... /' '\ ':0> (fj I . . . ., -~ ~ .. "'~ ''"'' !: ¿, " ~¢ " -, t?~ fe C ~~ì", '. /-'¡lAlr::. Fe~ ce G~:f-e . . ... ·l"),~: .~ , Wð,;s+1 / ". r¡:: L D \ -~ *'~ . (' ,(\ . '\, "' '\' ~ ~~ ' 'M~rðr , ' . fl " ðl' ~ 5'fZJ~tØ ~ ~ ,~ ~ , I :\ ~ ~ ~, ~ ~ '~ ~ 2.C''1 ~ ..... -'\ ,( ~ f '0;:",'' ^' ' p' , C/ ßow*, ~~ OFF/cé fI. /)þ d\ f:..~ ~, 0\ I"" ) tVl).ølt/ ~' ,,01# . ,°/11, ,q [)()(')r 0001' ~. ~ ,~ '- (S ''-: \"" ~~ -, ~ . -4 ~.~ t , ' NORTH SCALf:: n.UE : ttITE/FACILITV DI4tGRAM FORM 5 ... BCSI\'ESS NA~E: , ~7!1ACI L IT\" :\AME; (CHECK ONE) SITE DIAGRA~ o*l " ~ ~ o ~Ol{ " " ~VR: ¡OF I C;"IT 1t, OJ;' ". ) . FACILITY DIAGRA~ ~ w Ct.-- / ( ~ ~ ~ ,\.) " ~ (Inspector's Comments): -OFFICIAL USE ONLY- - 5A - , SiTE DiAGRAM (Required items) 1. Addt'ess: Iden- the principle bUi~gs by the Street numbers. 9, LOCk.) Box ;; ~ ~ 10. MSDS Storage Box 2, Street(s), Alleys. Driveways. and Parking Areas adjacent to the property, Include the street names, 11. Railroad Tracks 12. Fence or Barrier a. Wire b. Masonry 3, Storm Drains, Culverts, Yard Dt'ains c. Wood' 4, Drainage Canals. Ditches, Creeks, d, Gates 13. Power lines 5, ,Au i I rl i ngs a. Frame construction 14. Guard Station b. Masonry construction c, Metal construction d, Access Door 6, Utility Controis a. Gas b. Electricity c, Water 7. Fire Suppression Systems: a, Fire Hydrants 15, Storage Tanks: Ident lfy the capaci ty in gal. a. Above ground b. Underground 16. Diking or Berm 17. Evacuation Route 18. Evacuation Area: 'I den ti fy the location where , employees will meet, b. Fire Sprinkler Connections 19, Outside Hazardous Waste Storage c. Fire Standpipe Connections 20. Outside Hazardous Material Storage d. Water Control Valves for protection systèms 21. Outside Hazardous Material Use/Handling ,e, Fire Pump 22, Type of Hazardous Material/Waste Stored or Used (See Below) 8. Fire Department Access TYPE OF HAZARDOUS MATERIAL F Flammable E Explosive L Liquid R Radiological C = Corrosive 0 Oxidizer G Gas P Poisqn W Water Reactive T Toxi c S Solid H Cryogenic D Waste B = Etiological Example: Flammable Liquid = FL FACILITY DIAGRAM (Required items in addition to the above) 1. Risers for Sprinklers 8. Fire Escapes 2. Part i tions . 9, Air Conditioning Units 3. Stairways: Indicate the 10. Windows levels served from highest to lowest. 11. Inside Hazardous Waste Storage 4. Escalator: Indicate the levels served from 12, Inside Hazardous highest to lowest. Materials Storage 5. Elevator 13, Inside Hazardous Materials Use/Handling 6. Attic Access 14, Sewer Drain InJets ~ . K £'3 er I ~ J4-u- +0 ~-e, pð..-~ - ,?--Z?-<õ'~ . ' D ï ctß r t:L,~ ~ï+e i ..... ' *,.~, ~ -...." ... -....,. -----. -..'-- .. ."------ "-------~-....-~-._._-- - ~ ----_. -- - - -- - ---- --"--- '.-----.--..-- ----. --- --- . ---- - --.------. - ---------...-------.- -- ------- -- -.-.--- ---~. --~--- ~------+_.. --~ -- '""'"---- -----..----'--- ------ -------------- ~. -. ~. ' , ". ---- --------~_...:.--- -----~ -. ------ ------- --, ------ .....--_:..- --- ---..-- --,-----~, ~ ~' .- (9?~---'--- -\~~- ___zQ____,____~- ~ ~ I /í..... ~ ~-'- '--'~ _______._____·__h --- -------- /~ .j~ --,~- -------- c::::::><s:-- --- -------~ --. ~~,.J .. \1 -- ~ .------ ~ ~ ---------.. -......-- ---- , I 1-- ------ ---- ------------- ----..------ ~ ---- --------...<.- -- --- ---- --.------ -ê;;~" .~ ___ ___ _4 ------- - ------'-~--E~-'-- -- ----- ---.....--. - --- --- _.-- -.--- -.,----- --- - - - - --_. ---- .. ------ - ,-- I i -------- ----" ""--___~_._~ _......o-~_ ----~-- --- - ------ --- ----------- .. - - _.. 00--.- - --- - -- -------- --- -- ~-~.~_. -~------ - - --- --,- ------- -..._- ~~.----- ---.- -~- _._---~._~ ----- ' I ----~-- -- ---- --- --- -- ~-- ~------- ------- -------- ---. -- -~ -- - ------ -~-----~ --..--- -----.----0._-- _ _ __ ~/. ---\ ",,--,,------- -,--- _ --- ,-- --, ,-------- -- -- - --- --, - ~-'-- ~~=~ -=---1 . i~'="""----..... ~--. -----------~ --------- ----,-~ ----- --'-------- - ,__~_._____..u -- -,-- r - -,---- ----,,- ',;1----- -,--~ - --- ~------ -- ---- ----- - - ---~~- ---- ----------_._---~--_..----~---- - .....-----~~-~_.- ~_... ------........--- -~--- . ------ - ._~- ---~ --~.~-- ~- ---------------------~----_._---"------ - - - ----- ---- --.--...---- "------ -"' --- - .--- _.~ ~ , I~_.... .. Q~ -~..--- 'D~TE ,if'" , ~ -J~ -~e 'BUS!' ,ADDRESS.,' , ZIP CODE FEE BLOCK NO. 'P.ERMIT REQUIRED PERMIT NO. Q a: o u &1.1 II: Z o ¡::' U &1.1 'A,; en 2 - , ,¿¿ 310 ,"', tþ ~ s+, -,+,./ 09 - /10 Ih-¿jltl1~f: 1- ,3) 9 , IS 7g(P-'5 70-1-0' ,BUILDING CLASS/TYPE OF ,OCCUPANCY " ,. YES 0 NO'm I BUSINESS NAME , /-J -, 0t1-nð1J'L ,¡C:"9I'f#,~ç /f(/fv' ;ey.P?/~ BUSINESS MGR./RESPONSIBLE ....OJ~+~r" . ' I ¡.;. , Ai. &1.1 o iii II: - '~, o ... '&1.1 - U;. en (2) (3) OTHER ..' :",,-,,,'11: , ," . S~ATION/SHIFT/STATIÖNPHONE #";::~~;:';<-'T~r ' ' "= ",," ,,,',,,, :,'/!~,.",,:.;',}?Ú J?Ú(.,: ,©®~IP~Œ~ŒOO .,~ " . ~àlÜj~t\Bt~~ji:~~;t~~~M~:~t~::';!if:Þt~~~:ài)i\":..i..;fw~~~tl~~~}i~~~~Jty,,;0j.~g:d£~~-%~,;~&~~t~Ji¿~·Ùi~~';;'~~~;'~¿ìj~~ßJW~~ttll:ii.;,iJ;¿;,J;,,{:";, ~ -> ¿.,.-.,- -'L HOME PHONE' -,...., ?~'" "7" "?, II _', ç;, ' ø 0/ NO. OF FLOORS , g} (I ~ J J ê) / SQUARE FOOTAGE 'ONL 3,1~/LjY , NOTICE ISSUED? OCCUPANT LOAD,' " '. ".' . ~ DATEOF'REINSPECTION· ,(1) INSPECTOR .. , ',,: .~<~·~:·~i~~~~iJ¡;'~,~tii0D~ '. -. . .~ ~-,.- ~.-- ~..". ""!'"'-. ~ - 1(P -,() tJ fYlOÅ~ , ' ( ß~~ Pywc ¡ -7 a;CLr~ J'ý~ / r1J d~ Æ ~rrz C(j "'-1 I e' _. . . _ ".... ....~ - -- -- "- " ..--- - - -- - -.. '", ~- '- --- ----- ------ ------------ ------------- ----------- ------ ------------ ------------- ----------- r¡IES j ILUNG HISTORY FOR AN ACCOU~T RuTL10ï 4(91 ==============================~======~~~~~~=~~~~======= t>AGE 1 ----- -------- -- -------- , ACCOUNT NU~!:ìEK : 407301 SERVICE" NAME: ROGERS A lJ TO REPAIR CYCLE STATUS: Cl SERVICE AD{)RES~: 3901 wlalE RD - STE 6 S T A TU S : Fe CITy' 5T ,.\T E ZI P: BAKERSFIELD, CA 93301 wATER SEWER j' 3ILl BALANCE CHARGE/ CHARGE! --------------------- PERIOD POSTINGS ------------__________ BILL \ CATE FORwARJ (GNS CONS DATE .ð....,OLJNT TYPE DESCRIPTION IDENTIFIER AMOUNT -------- ----- -------- --------- -------- ---------------. --------------------------------- ------ CURRENT 471.02 471.02 .. 01101/91 471.02 471.Cl J8/02/90 450.00 05/01/90 D.02 B92 FINANCE CHARGE t\¡M*lš1é4*2*8 ~ 471.02 as/Ol/90 15.00 B91 PE NAl TY NM*8164*2*83 02/ 15/90 300.00 02/15/90 150.00 FFF NM*8088*2*250 450.00 tJ2/10/ö9 31 LL History recorc for 01 II cate 02/10/d9 not founa. BILLHIST5>407301*7712) . " oj ~ i. " . . .. July 17, 1990 TO: Bill Descary, City Treasurer FROM:, Ralph E. Huey, Hazardous Materials Coordinator SUBJECT: Rogers Auto Repair Account # HM 407301, is apparently· no longer in business, the owners wi£e says they £iled bankruptcy on May 24, 1990. The owners name is Roger Herrick, with a last known address and phone number ~£ 809 Piute St., Bakers£ield, Ca. 93309, (805) 834-3301. According to my computer run dated 6/12/90 they have an outstanding balance o£ $471.02. .. July 17, 1990 TO: Bill Descary, City Treasurer FROM: Ralph E. Huey, Hazardous Materials Coordinator SUBJECT: Rogers Auto Repair Account # HM 407301, is apparently no longer in business, the owners wi£e says they £iled bankruptcy on May 24, 1990. The owners name is Roger Herrick, with a last known address and phone number o£ 809 Piute St., Bakers£ield, Ca" 93309, (805) 834-3301. According to my computer run dated 6/12/90 they have an outstanding balance o£ $471.02. Nina, could you please put this business on a list to not send out a sta1;ement? Thanks Ç"C6l--I\,¿'I\¡¡¡e'UO / r Af\O.e..J . I Adequate Inadequate " ?, __~í' £x£/YvP r . Bakersfield Fire D.. Hazardous Materials Inspection cøJ2f2 - Date Completed 7 - /1- R 1 Q-c, FA 16'v JL () f1l9Ýft~ to Business Name: ~ðGe(lS I ~í~ !; 9(9 / P, V)G .s: v (1 Location: '3 0 I Plan 10 # 215-000 !:..¡i (Top right comer Business Plan) Station No. I c Inspector Shift I D D D D Verification of Inventory Materials Verification of Quantities erification of Location Proper Segregation of Material Comments: WI ~l;z RcfJ, D D D D o o erification ofMSDS Availability \)~ Q~.. Verification of Haz Mat Training ~ Comments: Number of Employees D D Verification of Abatement Supplies & Procedures D Comments: D Emergency Procedures Posted D D Containers Properly Labeled Comments: D D Verification of Facility Diagram D Special Hazards Associated with this Facility: D Violations: FD 1652 ,(Rev. 3-89) .L-"_.......·__. . White-Haz Mat Div. Yellow-Station Copy Pink-Business Office · ... {~ BUSINESS NAME ROGERS ~ REPAIR LOCATION 3101- J 10.TI-I ST ? ?c>/ Lv;bL~ 10 NUMEA215-000-'Ø00548 Hr~AZARD RATING Z 1, OVERVIÊW LAST C!iAN6E 10/ 1 3/88 BYE.STER JURIS CODE ~15-001 JURIS BAKERSFIELD STATION 01 MAP PAGE 10Z GRID ~SC FACILITY UNITS l' HAZARD RATING Z RESPðNSE SUMMARY 2A SE;:C 4) NO PRIVATE RESPONSE TEAM. EMERGENCY CONTACTS ZA SEC Z} ROGE;RHERRICK - 322-7311 OR $34-3301 ¿!1'~ RD'5 ~,y UTILITY SHUTOFFS ZA SEC 3) A) GAS - N END OF BLDG B )E:LECTRI CAL - N END OF BLOG C} WATER .- N END OF ~LDG 0> SPECIAL - NONE E) LOCK BOX - NO Z. NOTIFICATION / PUBLIC EVACUATION LAST CHANGE / I BY < NO INFORMATION REÇOROED FOR THIS SECTION> P(.:'JGE 1 031ZV89 13: 38 MATERIAL SAFE;TY DATA SYSTEMS, ìNC. (805) 648.,.6900 BUSINESS NAME ROGERS AVTO.~E~AIR LOCATION 3101-110 18TH BT.. 10 NUMBER Z15-0Ø0-ØØØS48 'HIGH HfiZAHO RATING Z 3. HAZ MAT TRAINING SUMMARY lAST CHANGE / I BY < NO INFORMATION RECORDED FOR THIS, SECTION> 4. LOCAL EMERGENCY MEDICAL ASSISTANCE LAST CHRNGE 10/13/BB BY ESTER ZA SEC 5) MERCY HOSPITAL - 2Z15 TRUXTUN AVE - 3zj-3371. PAGE Z 03/ZZ/89 13;38 MATERIRl SAFETY DATA SYSTEMS, INC. (a0~) 648-6800 . . .ðr Í'.... ,t} 1. ~ Ic; BUSINESS·N~ME ROGERS f'-' REPAIR LOCRTION '3r01-1t~TH ST ÞACILITY.UNIT ~t fl. OVERftLLHAZARDOUS MATER~:ALS INVENTöRY LAST CHANGE 10/13/88 BY ESTER, ID NUMrAZ ¡ 5~ØØØ-000548. HI~AZ~RD RATING 2 ID TYPE NHME' LOCATI ON CONTAINMENT MAX flMT UNI T HAZARD USE PURE MOTOR OIL S WAL,L PLASTIC CÜNiAINER[ 5] ID PERCENT COMPONENTS 2808.00 100.0 Mòt.or Oil 600 GAL UNKNOWN LUBRICANT HAZARD LIST NONE 2 PURE FREON R-IZ S WALL METAL CONTAINERS 10 P~RCEN1 èOMPONENTS 1086.00 100.0 Oichlorc>difluorOMethane 21000 FT3 LOW AEROSOL HAZARoLIST NONE· 3 WASTE WASTE OIL OUTSIDE l.J WALL DRUMS OR BARRELS MET.. 10 PERCENT. CPMPON£NTS 1598.00 lØ0.0 1"¡I3~t& oil ' 200 GHL UNKNOWN WASTE HAZARD LIST l.OW B. FIRE PROTECTION / WATER SUPPLIES L~5T CHANGE 10/13/88 BY ESTER 3A SEC 4) FIRE EXTINGI,JISHf;RS FOR FIRE PROTECTION. ~A SEe 5) FIRE HYDRANT? PAGE :3 03/Z.V89 13: 38 MHTEHIAL SAFETY DA1;A SYSTEMS, I!\IC. (805) 648-6800 BUSINESS NAt1E ROGERS A,UTO REPAIR LOCATION 3101-110 18TH 5T D. EMPLOYEE NOTIFICATION f gVACUATION ID NUM8i:R Z15-000-00ØS48 HIGH HAZARD RATING Z LiiST CHANGE 1ø/13/8e BY ESTER 3A SEe 2) VERBAL NOTIFICATION FOR EYACUATION RNDtALL 911. E. MITIGAnON / PREVENTION / ABATEMENT i: LAST CHANGE 10/13/88 BY ESTER 3A SEe 1) SELF CLOSING OILY RAG Bf1RREL~. FIRE E){TINGUrSHERS. EMPLOYEE AWARENESS. PAGE 4 031ZV 89 13; 3a MATERIAL SAFETY DATA SYSTEMS, INC. {80S) 648-680Ø .~ÎÌò:\ J <ð ."~ ~ . if~) -'~~, _-_ t /~A:r'.' . -,..'-'...';..'" oJ:. i'-.' '0' ,. ""'-s'~ , ;:.' -'III!" "0' \ - -'.J~(', L; =- _ -'-...... v ' , - . -'/,-..,-' t; ,,~~,_., . \. \. r ~-.:., _'., - / .1 \,\'.('..;,'.:..,' /,./ ':1.f{tÜ@>'?!/ .~ I ,. '. . CITY of BAKERSFIELD 6~ Ib "fVE CARE" ®~'~Q\\ (;' ~ 'J? ~-' ~ , 4.Jr;).- ~~o II:J~/r~ . L~D~ or µ~lnL name} ~\IIÜ~ ...\\'\ ..~;;'~;~'::!",,~ ~II_\,.\..) :",'" ,$/'/ ..~. /~~Ä: = l;;' \ '\1- /ill ~ ~ :==. :\;;'~, ''-;' :}§ ~... ,"" I~ 'Ä~;:..~~, \,'. ,)JI~ ¿%íÍÍñ7 ).. \ ~ RECEIVED FE~~' Ô 6 1989' Do hereby certify that I have r e"\- i.e h- e d tl~4ÌI) 11. . .. ........ 'for L~9t?r ~' .4.Jy . (name Df business) AECt:tVID business plan NAY 2 3 1989 {;jJdt/ HAi MAT. DIV. attached Hazardous Materials and that, it along with the attached additions or corrections constitute a complete and correct Business Plan for my facility. (- 3 CJ /?·9 -.. . ~ r date I . BAKERbt-H:LD CITY FIRE DEPARlMENI ., 2130 wG· STREET B'ERSFIELD, CA. 9330~ 16i3-/3A (80S) 326- 3979 1. (L.~/). 7<2 I:" \ ...J")" ~"",", ~ OFFICIAL USE ONLY I D # BUSINESS NAME HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 2A ACclWID MAY Z 3 "ft' HAZ. MAT. DIVI INSTRUCTIONS: 1. To avoid further action, return this from within 30 days of receipt. 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 A. BUSINESS NAME: ;;;'1"'/'"5 /;1", 'fr ¿/d/Y B. LOCATION / STREET ADDRESS: 390/ ¿J/'j, /,,0 )7/ #¿f; CITY :& ~/~+i''¡Þ?I ZIP: 9 3 309 BUS. PHONE: (¡b5Y Zi.s ~ - "5 ~O '5 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 your 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. ~fP/ &--;'-/C'R r&,¿J/7~/'" B. /)-1â/[)~ ~//'/~/-r- ¿::JW/1¡i1/, PH. '93tf.- 73 ócJ ~ ~ - DURING BUS. HRS. AFTER BUS. HRS. PH. ?-?~- 3?C73 PH. g3V':"33cJ/ PHI ? ~ ~'-?' 30 / SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE A. NATURAL GAS/PROPANE: B. ELECTRICAL: C. WATER: D. SPECIAL: E. LOCK BOX: IF YES, LOCATION: IF YES, DOES IT CONTAIN SITE PLANS? YES / NO MSDSS? YES / NO FLOOR PLANS? YES / NO KEYS? YES / NO ."';" ,~ ~i~.,. _J;' . . ¡. SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE ¡:::-l"ì/e CY + ì~.j ltP; t... P/"7 F>v'5 f 14 /d. 1<"/' f OlAI '7/1 SEC ".ON 5:. LOCAL EMERGENCY MEDICA AS STANCE FOR f",,:,:~'ii i $:..,ìi '", & / ß-ý} é ¡/ /} ,... /" e J4 M Þt/ /Ci/1 c e #~~/-7-e:L/ YOUR BUSINESS AS A WHOLE '3:2-7-9~ ¡;!.s¡ ~t. !f l' Y j,;,þf, ,,, ','1.1 '. ,.l ?""1~/~ :l1G .lAt.;'¡ .Sl\H SECTION 6: EMPLOYEE TRAINING i, EMPLOYERS ARE REQUIRED TO HAVE A TRAINING PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND REFRESHER TRAINING IN THE SAFE HANDLING OF HAZARDOUS MATERIALS. A. NUMBER OF EMPLOYEES AT THIS FACILITY B. 'DO YOU HAVE MSDS (MATERIAL SAFETY MATERIAL YOU HANDLE ? . GIVE A BRIEF SUMMARY OF YOUR ZA DOUS MATERIALS TRAINING PROGRAM: C¿:f,¿I,L,¿pþ1 7cp 6e ?t' 5 ~¿J C'Þ? C:L// /)/J?¿T~//~ /s- C' /p'a v1 0/ F /'ð C ~t1/ /'¡Ç7"5 , ' /'1/\ L4 -56' ð-F :5íþ1/'// j)/~ / / // ~ SHEETS) FOR EACH HAZARDOUS C. SECTION 7: EXEMPTION REQUEST I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE CALIFORNIA HEALTH AND SAFETY CODE FOR THE FOLLOWING REASONS: WE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) -.- ".. :--T-:. SECTION 8: CERTIFICATION I . ~,../' &// / -{'K . ce rt ; fy that the above ,{ nf 0 rma t ion is accura e. I understand that this information will be used to fulfill my firm's obligations under the new California Health and Safety c'ode on Hazardous Materials (Div. 20 Chapter 6.95 Sec. 25500 Et Al.) and that inaccurate information constitutes perjury. ", SIGNATURE~/A--/£e+?/d TITLE ~ú/}M/ DATE -Ç-/7-?ß ;-" ~, BAK.FIELD CITY FIRE DE.TMENT 2130 wG- STREET BAKERSFIELD. CA. 93301 <B05) 326-3979 " BUSINESS NAMe I D # Ii " Ii i; ,I I! !! II OFFICIAL use ONLY HAZARDOUS' MATERIALS BUSINESS PLAN AS A- WHOLE 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. c:; FACILITY UNIT NAME: ~1"'/''2 d¿i:J~ 1/" SECTION 1: ,MITIGATION. PREVENTION. ABATEMENT PROCEDURES Lie CU/l L1 f 6<-1! '51 t' II-=- l' W\ WI pch6-, -Ie!:J LA' ~ e C?<..,í e A/Þ ¡- -/0 é ¡/'{?¿:<.-fe, 5// /I~' ~ I I I SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THE UNIT ONLY ))('C[, I 9 / / v gut' IJ'Ì/¡~ ð(.., V' Jl ~ Pa ¿/t? ~ 1M t1/Le JJ ,'~-I-elJ r f:< . . ~,¡,~ . SECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY A. Does this Facility Unit contain Hazardous Materials?..... /t==;) évNO If Yes, see B. If NO, continue with SECTION 4 B. Are any of the hazardous materials a bona fide Trade Secret? YES~ If NO, complete a separate Hazardous materials inventory form marked: NON-TRADE SECRETS ONLY (white form #4A-1) , 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 ¡¿ Fi'/"e C~+(V)~ u't5he/5 i- 1Ϋ~rY7dl/¿ -r/"//¡~/~/5 SECTION'S: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPONDERS (Fire Hydrant) . , (J NN I Á é- ¡lJd C9 F )3 u ¡'f d( I'V' 3 SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY. A. NATURAL GAS/PROPANE: /\/o,('-fA éý d 07 B. ELECTRICAL: N¿;rf-h CY1A ô-F 6 t{ ¡' /cP ,'v:3 B u rrJl,\ VI] '73 tÅ ; (CÝ Ì'Vl3 C. WATER: .~ ;JtJ/" It eYlð oF D. SPECIAL: E. LOCK BOX: YES & IF YES, LOCATION: IF YES, SITE PLANS? YES / NO FLOOR PLANS? YES / NO MSDSs? KEYS? YES / NO YES / NO - 3B - " ~..;~~.: -"ß CfT)" of BAKERSFIELD \ " ~ì '~-- - F4r.'4nd Aqricu 1 tur! ,~ '--' St4nd4rd Bus;n"s ~ HAZARDOUS MATERIALS INVENTORY NON-TRADE SECRETS ~I 't.- It PeC)! 1-_ of -t.. NAME OF TinS ~J~JL.!.TY: STANDARD IND. CLASS CODE DUN AND 8RA~S~R:E~~U:8:R_~; 1 2 Ir8n' Tyøe Cod! ,Cod! 3 Ilu Mt . Aver.C), Mt 6 .....Ul'l Units 1 IOys an SIt. 13 'by lit Ie ..... of IUxtUf'l/Caelonlnt. SIt Instructl_ ... . u.s. .... -------------- I, I SK-tt ,--, % ,..-, ,..-., L .J Fir. H.zard 1..-:" RHCtlYlty I.. .J Del.yed I.._.J s..cw.n hl_ I.._.J 1-.lI.t. '. fIN Ith . of Pres",I'I ,....Ith c:o.aøn.nt 12 .... C.A.S. .... ---- eo..-.nt 13 .... C.A.S~ ..... I Phys iel I _ffIN Ith H.lIl'd (Chtc~ tlllt. '1I1IIy) . r~ V ,..-., ,..~~ ,..-, L -V.J FII'I Klzard L_......ctIYity,L~,DeI.yed L_'" Sudden hI.... "" It h of PresIUl'l ec.onent II .... C.A.S. .... --- ............ ,.-., L -... l-.din, IIMhh eo..-.nt 12 .... C.A.S. ..... CaeIonInt 13 .... C.A.S. ..... P,," Ic.1 end 11M Ith Hlr.M! (thlc~ ,II tllet 11I1I1y) u;;;.' Hm~d ~CJ";~ctIYlty ~¡"Jõ;IIyed ~~ØI R!I.... ~e-;-.di.t. H..lth of PI'IS'UI'I HMlth u.s. ..... êã.- '5 r~á.. 1/ c.øon.nt .1... . C.A.S, .... - -l..MJ9-k:...~~æ}J.~Jk~JLJá~~l::L I 1 ~ . ' u.s. .... 7..Y:-=-2-~.::..2::._____ ',,"iel I end HMlth Hlr.1'd ' , (Chlck.lI tlllt ""Iy) ?<~ FIr! Hlllrd ~~~tIVlty ,. V \r;../. ,. .ç Ý I.. A. ,D!IIyed.~.J SuddØl hillS. ~ 1-.l14t. Health' of Prn.ur. H,elth ------- ----- Cœøantnt 12 .... U.S. Ieu.bIr ------------------------- ------ eo..-.nt 13 .... C.A.S. .....r IIIfRGEHCY C( IfACTS ;.rtifjC~!jon (Rttad and sj~n after co.pleting a1.1 s~ctions) I ,C, ., rtif, Y und!r IInIlty of 1.. that I Illy!. ~.rs, onelly ....ined end I. f..iher '!Hh the inforaation SU._Itted i.n this encI~11 .tt , ~tI:~~t bI.ed on ., inquiry of thos, incl, ividuel. rftpon.ibl¡, ,foro~n9 the Inf.&. I beli..:! tllet,tll! subaittld Infor,aation Is trill. .ecur.t., Ind co.ø~. . ' , ~J /-" _ ' 1I:L¥Ç~a~!!2T:Ç;-l-~..,---T~,LLTc-LLiEDR-, --':~7a~4.eC-. -----.-.--- S·--it-- -- __:';?"L.-...,,_ - -,,--4 - /-~----:~----,----- ~t--S' .--z-=~2------------- 4.. 4n ;ð1T,CI. n,. o· ~!r oø.rator own!r OPl!r4,or 5 aUU10ruOOU r!prnØl'4(1Y! '9nl ur! , ' '\HI! lC)nllO ' ~ . ~~~ ,~ ,~ (--...-: Farm and Aqricu 1 ture '--' Standard Business )2Ç HAZARDOUS MATERIALS INVENTORY ':~ 6/ ,.....;ot '"J.r, CIT}T, of BAKERSFIELD BUSINESS NAME: LOCATION: CITY, ZIP: PHONE II: OWNER NAME: ADDRESS: CITY, ZIP: PHONE #: RBFBR TO INSTRUCTIONS PORPROPBR CODBS Page .2..of ~. NAME OF Tf{1Š FA_ÇJL1.Ty:.:s~<2-: STANDARD IND. CLASS CODE' 3 DUN AND BRADSTREET NUMBER ';... _ -- - .:. - ,II ft 1 2 ¡ rans ¡ ype Code Code 3 Max Alllt . Average Allt 5 Annua I Est 6 Measure Units 7 I Oys on Site 9 10 11 tont Cont Use Press T..p Code 12 location Where Stored in facility 13 \ by Wt 14 NaMS of Mixture/COtftoooents See Instructions COIIponent 11 Naill!' C.A.S. Nu.ber ------ ------..;.-------------- ------------------------- --------- :=~ Fire Hazard ~=J Reactivity ~ Delayed ~ Sudden Release ~:J IMediate Hea 1 th of Pressure H..l th CoiIl1OOent 12 NaN' C.A.S. Nu.ber , ' ------ ------------------------------------------------ COIIponent 13 Na..' C.A.S. Nu.ber ---------------------------. ----- -------------------------------------------------- ------- Phys ica 1 and Hea I th Hazard (Check all that apply) C.A.S. Nu.ber ___________ COIIponent 11 Naill!' C.A.S. Nu.ber ----- ------------------------------------------------ ------ r-' r-' r-, r-' r-' L_.I Fire Hazard 1.._.1 Reactivity 1.._.1 Delayed 1.._.1 Sudden Release I._oJ l_ødlatlÍ Hea 1 th of Pressure Høl th COIIponent 12 NaM 'C.A.S. Nu.ber --- ---------------------------- ------- COIIDonent 13 NaM' C.A.S, Nuaber -----------.. ----- -------------------------------------- ------ Physical and Health Hazard (Check all that apply) C.A.S. Nuliber COIIponent 11 NaN' C.A.S. Nuaber ---- ------------------------------------ ------ ,...-, r-' ,..-., ,..-., r-" L_-' Fire Hazard 1.._-' Reactivity 1.._.1 Delayed 1.._-' Sudden Release 1.._.1 l.ediate Hea I th of Pressure Hea I th COIIponen t 12 NaN' C. A. S. Nu.ber ------------------------------------------------ ------- .~__l______l___________J______________l________..;.__L____'____L___L-L--L~---L------------------- ----- ------------- --- -, - - - - --------------------------- ------ ...--..----- COIIponent 13 NaN' C. A. S. Nu.ber Physica I and Hea lth Hazard (Check all that apply) C .A.S. HUllber _______________ COIIponent 11 NaM & C.A.S. Hu.ber ---- ------------------------------------------------ ------ r-, L - -'Fire Hazard r-' r-, ,..-., I.. _ -' Reactivity I.. _.I Delayed I.. - oJ Sudden Release , Hea 1 th of Pressure \ r-' I._oJ IlIIIIediate Hea I th COIIpÖnent 12 Na..' C.A.S, HÙllber -------------------------------------------------------- ---- - -- COIIponent 13 HaN' C.A,S. NUllber .....................................-...............---. -.-..- ..~ ' ,Ü:RGEHCY CONTACTS 11 ' nã¡¡,ë - ~--- - ~---:--------------,~~------------ TiHë------------------------ 2 (-RF-Pñõñë- ------ 12 lIiië-------------------------------- Tit n------------------------- '21-R~-P!\añl!'----'--- ~ " Certification (Read and sJgn after completing all sections) ¡ certify under penalty of law that I have personally examined and all ta.iliar with the information su~ this and all~tt c docu.~~ based on .y inquiry of those individuals responsible . ' fO~. ',,". d. "t'~ b'HÞ'¿"':J¿""'H'" '~f,...tlœ" t~, "~"".~' ,~',"'. ~ ~ ~. no - Ç/a:..c¿e..c.r1- - - -D7-ZL-¿OR------7--=a~ / -!¡/Ja neCr.-- S·---j.:-'- - ~&::::.-..-: ___d.~::_~____________. r--s·::::a·6--=----- ---------------- ~ ;an ?fFìë1a'-n, eo owner oper;ator owner operator 5 ~fea'¡.epresen',a'lv.e 19nhlJre ..--7-------,..' , a,~ .1gne ".,!.," "- ~\/ ~- ':"'~ \.. <:,. - "'\ i:-;;¡.\ t'i\ ~ ~~ ~~~~ L_' ,/ ~~ ~ 4ItAKERSFIELD CITY FIRE DEPARTMEtIÞ 2130 "G" STREET BAKERSFIELD, CA 93301 (805) 326-3979 RECEIVED JUl ~v 9 1987 \ ()\í í\\" Ans'd. \.Y, ........... ~rJSP I , ..L OFFICIAL USE ONLY --' ID# / (~7~/n BUSINESS NAME HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM ··2A ' , , , . INSTRUCTIONS: 000548 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 , A. BUSINESS NAME, Æo/",,/'~'f 1Î~.p, ~;a.iL 0 0, B. LOCATION / STREET ADDRESS: ,-'~ /¿; / //a'ii1.otý¡{:# //¿; 9'-#/¿;9 CITY: Bt:t-Ktl/''S' -He // ZIP: q "3 3ð!J / BUS. PHONE: (8ð ~1 ,/~i;1;Z - 73 / / :t SECTION 2: EMERGENCY NOTIFICATIONS In case of an emergency involving the release or threatened release of a hazardous materi"al, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify your local fire department and the State Office of Emergency Services as required by law. EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY:, NAME ..AND TITLE DURING BUS. HRS. AFTER BUS. HRS. A. ,1rb91?' J/!?/'/',I-ck-C)¡,¡IJ1!?/' Ph# 3~~-7~// Ph# 8.~i.f- 33~/ B. Ph# Ph# , SECTION 3: LOCATION OF UTILITY SHUT-OFFSFOR BUSINESS AS A WHOLE t ~~~~~1~:~~if!/;r L J:t¡:it:t D. SPECIAL: . ' E. LOCK BOX: YES ~ IF YES, LOCATION: IF YES, DOES IT CONTAIN SITE PLANS? YES / NO MSDSS? YES / NO ' FLOOR PLANS? YES / NO KEYS? YES / NO - - 2A ~ . . -"'~1" ,.,' ,}¡ ~¿.;j .:! r;,. .-';. ...~ ('f i .'-;;;;' . .ì ~. ,j :'. " \ e1~: .. i' SECTION 4: PRIVATE RESPONSE TEAM FOR BUSINESS AS A WHOLE ,l1!ðAJé SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE /YJerc:J Hers p;" feL-l :~:ì ~t~ ':¡'J- ¡, , 4:" ,t ,~':' (' ."., , ,!..;' ';)I ,ff;} 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 REFRESHER A. ~~~~~¡L~~~.~~~~.~~~~~~~~.~~.~~~~~~~~~........,..~ NO '~NO B. PROCEDURES FOR COORDINATING ACTIVITIES ~ WITH RESPONSE AGENCIES:..........,........"..... YES;Nõ) ,i~ C. PROPER USE OF SAFETY EQUIPMENT: . . . . . . . , . , . . . . . . .. Is ~ E NO D. EMERGENCY EVACUATION PROCEDURES:.. ..........,.,'. S NO, . NO E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS:..... .. Y S @ S ~ SECTION 7: HAZARDOUS MATERIAL CIRCLE YES OR NO DOES YOUR BUSINESS ~ANDLE HAZARDOUS MATERIAL IN QUANTITlES LESS THAN 500 POUNDS OF~.,' SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF 'A COMPRESSED-·GAS:...... , YES e5Þ I, ~~~ ¿'tPdA ~rrì~~ certify that the above information is accurate. I un rstand 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. SIGNATUREJ7~ J?~ .~drITLE (1)LA //?Æ'/ '.' DATE 7-1-:?',7 I, - 2B - Õ' -' -I'·.,-~~ ~, '[i'~ ~ o -11 7. '" .~ :.,~, ,,~ :;: ".,..,.. '. ,'.;'13ÂKERSFIELD CITY FIRE:'DEPARTMEiá ",;"; \ ,2130 "G" STREET BAKERSF~ELD, CA 93301 I~ - .. - OFFICIAL USE ~NLY ID# ------ BUS.INESS·NA~Œ : BUSINESS PLAN SINGLE FACILITY UNIT FORM 3A . INSTRUCTIONS 1. To avoJd further action, _this form must be returned by: 2. TYRE/~RINT YOUR ANSWERS IN ENGLISH, 3. Answer the questions below for THE YACI~!TY UNIT LISTED BELOW 4, Be as BRIEF and CONC1SE as possible. FACILITY UNIT# I FACILITY UNIT NA.\fE: :)' Að ¡J" / SECTION J: MITIGATION, PREVENTIO~, ABATEMENT P~~CEDURES 5'¡g/..f CÞs/1P & i/pt /f~ ~11't!!-// Fire ¿?'x7-ìr1:J U)'-5 ¡\ßÎ~ Em/þ!é!¿' ./!W¿lr)1~-5$ SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THIS v~IT ONLY Ver bo./ &-11 !lIð f r Fí Ct2- fÎcJ /1 Cfl/ £r EVc:lc-ua. + i'¿:J¡/1 ROGER'S AUTO REPAIR 3101 16th ST. UNIT 110 BAKERSFIELD,CA 93301 (805) 322~7311 . ,BAR REG. #AK-121064 3A .--------- . . ~ ',. ~'r._ " ~. .~~. ~ >, '!>;. r ;-:f' ¡. ..-;.-~ B I, SECTION 3: HAZARDOUS MATERIALS FOR THIS ù~IT ONLY A, Does this Facility ünit contain ,Hazardous MaterIals? . . . ,. @ NO If YES, see B. If NO, continue with SECTION 4. B. Are ,any of the hazardous materials a bona fide Trade Secret YES e If-No, complete a separate hazardous materials inventory form-marked~ NON-TRADE SECRETS ONL~ (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 secrét form. List only the trade secrets on form4A-2. SECTION 4: PRIVATE FIRE PROTECTION HÌ"e E'X+ÌY1.ßu is t\f?.í5 I, SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY. EMERGENCY RESPONDERS , , . ., SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY. A. NAT. GAS!PROPAN~~ B. ELECTRICAL: C. WATER: D. SPECIAL: .' ~.:j E, LOCK BOX, YES 16 IF YEsYLoÚTION,,"; , , ' " . ,1 ~. . .,. ," ( - IF YES, SITE PtANS?- FLOOR PLANS? YES- / NO-----MSDS's? YES ! NO KEYS? YES'! NO- YES ! NO ~- -..-,~. .._~---.- - 38 - ~/---- 1. D, # r' ,~';. ..- Page -.L olL BAKERSFIELD CITY FIRE DEPARTMENT FORM 4A-1 NON-TRADE SECRETS ' HAZARDOUS MATERIALS INVENTORY ~ BUSINESS NAME:~(2q~I~,~~ )(e~;/- OWNER NAME: ~C}¡t?/ l/er/:./c/..¿ , FACIL.ITY UNIT #: ) ADDRESS: 3 Jð 1_ '/:..;.¡__~2/o ___ ADDRESS::?":? //'" I-- L~ 1/~,.",,__#;z- FACILITY UNIT NAME: 5~(':? n CITY. ZIP; ~,.JG ,- '9;¡ CITY. ZIP :)?A ~ r-;it? /d' q :?'=I,,;() 9 / PHONE #: <;2'::>- '? 3/1 ~ PHONE #: .5J~f- "3"3t'?) IOFFICIAL USE CFIRS CODE ONLY 1 2 3 4 5 6 7 8 9 10 TYPE MAX ANNUAL CONT USE LOCATION IN THIS % BY HAZARD D.O.T CODE AMOUNT AMOUNT UNIT CODE CODE FACILITY UNIT. WT. CHEMICAL OR COMMON NAME CODE GUIDE J"~1~ðð 3JS-ðO GAL It") 2.In <"n..f-}¡ £JA JI /~() M/J-b,r /0;- / ~7\~ CfYljA) ~)~ bL¿?t1¿? ~:¡~¿?a þ~~ 13 :3 S(9uf~ Wa,I/ lot) ¡:::-AJeðAl f<-J;;L InxL EXP1- :2C;¿ P í ¿) ·~o &/J.J- /3 ~. /",:>~ f.-J EM &:IJ£!'dfC /¿;¿J '/?'"r ~;~r~ 'f) j D r~M'r &'J L -, I I. E..~J...Cþ ¡/ ~ G<ð G1tL I ~ J" /f)ðO 71e l6Jð C~.I' InllJ'.o+OÎ ~PJ1":Lt/o CleOIAPI' - P S- ::2¿? 'bill- J,~ ~ mi/hi'/e 100 '5P~a.t,{ p~~~-¡-=-' _~ P ~5 1~5"O !(;/lL Ole) g /'¡O¡I!-fe/l?u &+~ Ph ¡OO 54++u I!kJi?/J ,<); /I/~/J I' F!LLG .1~1?tF~òo :2J(}CO ff/lLfJln L/()I/)IJ~~¡Ar:tA.{f)1i¡J IC)Ô I~)a'-~-I¡q é0 / /c:Hc/ 98~ ,7 í) ~. - FCA ~' -P ,9 ~ ~A-L J ~ '71 1,5;tt.+~&"í"--/ aí/lR/ l¿'Jð ~ r 1/\ + T~ ~V\ .A B,r -. "7 NAME';: '27. ~- ~-/A~ TITLE: Oth/j'1 €'..-" SIGNATURE: EItfEF\GErrt;y CONTACT: ~ð'e'/' A/&/'./' ,,;-¿...k TITI.E: ~/../,.!fl¡é7/ , EMERGENCY CONTACT: TITLE: , PR~I NC I PAL BUS I NE S S ACT IV I TY: -L'?v -,I-.e?.h1¿J ~,."Þ'¡C? A? ~d. ¡r- ~ ~__ i~ .l'/A....-4 7A/ V PHONE # BUS HOURS: AFTER BUS HRS: PHONE' BUS HOURS: AFTER BUS. H.RS: DATE: 7- :?-:?7 ~ß--;:::/ - , - 4A-1 - "