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BAKEtlFIELD CITY FIRE DE'ARTMENT
HAZARDOUS MATERIALS DIVISION
1715 'CHESTER,AVL
BAKERSFIELD, CA. 93301 W '1 f?
HAZARDOUS MATERIALS MANAGEMENT PLAN
INSTRUCTIONS:
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i. To avoid further action. reTurn this form within 30 days of receipt.
2. TYPE/PRINT ANSWERS IN ENGLISH.
3. Answer the questions below for the business as a whole.
4. 8e brief and concise as possible.
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SECTION 1: BUSINESS IDENTIFICATION DATA f'/
3USINESS NAME: 5'fE:..¡A~ rY +h-voA. CAe<. ~6PA/(Z
LCCATION:
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ìv1AIL!NG ADDRESS:
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STATE: _ ZIP: q3."3.0'7 PHONE: 551) - 6~L6
DUN & BRADSTRE::T NUMBER:
SIC CODE:
?R!:-lIARY,A.CTIV\TY:
OWNER:
~¿ r.,J <.....>µ 'ITA K<:Sz
;vl~\!~jNG ADDRESS:
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SECTION 2: EMERGENCY NOTIFIC:"'TION:
CONTACT, TiTlE BUS. PHONE
l. C;¿æ~Y WI.{ I rrl.ll-<..::<... ~, ~~1 - b~Zb
2. bcJ.rlLE P6JtJ ~ ~G'<. - I -'oJ - £.A¡....) 11
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.öaKersneld ~'ire Dept.
.rdous Materials Division e
HAZARDOUS MATERIALS MANAGEMENT PLAN
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SECTION 3: TRAINING:
NUMBER OF EMPLOYEES: ..J.
MATERIAL SAFETY DATA SHEETS ON FILE: ?GS
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BRIEF SUMMARY OF TRAINING PROGRAM:
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SECTrON'::~1: EXEMPTION REQUEST:
! C~RTIFY UNDER PENALTY OF PERJURY THArMY BUSINESS IS EXEMPT FROM THE
REPORTING f~EQUIREMENTS OF CHAPTER ó.95 OF THE "CALlFORNIA HEALTH &
SAFETY CODE" FOR THE FOLLOWING REA,SONS:
WE DO NOT HANDLE HAZARDOUS MA ïERIALS.
WE DO HANDLE HAZJ\ROOUS MATERIALS, BUT THE QUANTITIES AT NO
TiÌYIEEXC~ED THE MINIMUM f~E?ORïlNG QUANTITIES.
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SECTION 5: CERTIFICATION:
I, CERTIFY THAT THE ABOVE INFOR-
MATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATfON WILL BE USED TO
FULFILL MY F!RM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFE:ÌÝ CODE"
ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER ó.95 SEC. 25500 ET AL.) AND THAT
INACG~RATE INFORMATION CONSTITUTES PERJURY.
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SI I ATURE TITLE DATE
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HAZARDOUS. MATERIALS MANAGEMENT PLAN
Facility Unit Name:
S(/&v1..L TV FloY\1I)A- CAL. R:CS-OAIIL
SECTION 6: . NOTIFICATION AND EV ACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES:
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a. EMPLOYE~ NOTIFICATION AND EVACUAi!ON:
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C. PUBliC EY ACUA ïION:
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c. ë:v1E~GENC,( MEDICAL PL.':"N:
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Hazardous Materials Division
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HAZARDO'US MATERIALS MANAGEMENT PLAN
SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN:
A. RELEASE PREVENTION STEPS:
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8. RELEASE'CONTAINMENT AND/OR MINIMIZATION:
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ClE,~.N-UP PROCEDURES:
WA'c:..T~ C;>-1L- !?'(jL(5p up ß~ c..f2ANé IS
SECTION 8: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY):
NATURAL GAS/PROPANE:
ELECTR !C,';L:
WAïE~:
5. Ç, Dé- of ')?:Li'>('s'
fV1 A ( AJ ~ l::. z;¡-.Jo cJJ=. ðS L f)G
SPECiAL:
LOC:< SOX: YESíNO
iF YES. LOC,; TION:
SECTIO N 9: PRIV ATE FIRE PROTECTION/WATER A V AlLABlllTY:
A.
PR!V A TE FIRE PROTECTION:
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B. WATER AVAILABILlTY (FIRE HYDRANT):
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BAKERSFIELD CITY FIRE DEP~RTMENT
H.RDOUS MATERIALS INV~ORY .
Page_of_
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Business Name <;;P§:.£. AL-rT'
~N'OA
Address
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CHEMICAL DESCRIPTION
1) INVENTORY STATUS: New It! Addition L J Revision I J Deletion I J Check if chemical is a NON TRADE SECRET' IJ' TRADE SEèRET I J
2) Common Name: ¿,JÓSTG 01(...... 3) DOT # (optional)",
Chemical Name: AHM I J CAS #
4) PHYSICAL & HEALTH PHYSICAL ' HEALTH
HAZARD CATEGORIES Fire f.ff Reactive I J Sudden Release of Pressure [ J Immediate Health (Acute) I J Delayed Health (Chronic) fp]'
5) WASTE CLASSIFICATION :27-( (3-digit code from DHS Form 8022) USE CODE 40
6) PHYSICAL STATE Solid I J Uquid ~ Gas I J Pure I J Mixture I J Waste . Radioactive I J
CHEClC.AU. THAT APPLY
7) AMOUNT AND TIME AT FACIU1Y I 05" UNITS OF MEASURE 8) STORAGE CODES \ì>lA<; t,,-
Maximum Daily Amount: Ibs I J gal I"'J 113 [ J a) Container: í)1WJN)
Average Daily Amount: 1 (.>Ù curies I J b) Pressure: 1
Annual Amount: "500 c) Temperature: 4-
Largest Size 'Container: ~S-
# Days On Site '?, '" t;" 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) ~JV\ 01 <... , LJA·c; 1'"6 I J
chemical components or ,
any AHM components 2) I J
, 3) I J
10) Location f0c...J C{2AJR Oç' -:;./(oP
CHEMICAL DESCRIPTION
1) INVENTORY STATUS: New [~ Addition I J Revision I ] Deletion [ ] Check if chemical is a NON TRADE SECRET I J TRADE SECRET I J
2) Common Name: A:fJT ¡ ~eE'"Z.c 3) DOT # (optional)
Chemical Name: AHM I J CAS #
4) PHYSICAL & HEALTH PHYSICAL HEALTH
HAZARD CATEGORIES Fire [ ] Reactive I J Sudden Release of Pressure I ] Immediate Health (Acute) fj¡. Delayed Health (Chronic) I]
5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE ~ C.CVt.AW ,
6) PHYSICAL STATE Solid [ ] Liquid [~ Gas [ ] Pure [fit Mixture [ J Waste ~ Radioactive I J
CHECK Ail THA.T APPlY
7) AMOUNT AND TIME AT FACIU1Y ~ç UNITS OF MEASURE 8) STORAGE CODES f't...)\'<;''T' ( f)(l(,;1A,
Maximum Daily Amount: Ibs [ ] gal (!¡jf 113 [ J a) Container:
Average Daily Amount: SS- curies [ ] b) Pressure: 1
Annual Amount: ~S- c) Temperature:
Largest Size Container: ç~
# Days On Site '3>"~ Circle Which Months: All Year. J. F. M. A. M. J. J. A. S. O. N. D
9) MIXTURE: Ust COMPONENT CAS # ~lJb AHM
the three most hazardous 1 ) e--n-t YL("7\J Ë G-t.KOc..- I J
chemical components or
any AHM components 2) I J
3) [ ]
10) Location µ0 CR&\JR.. 6F ::5J.1oP
c","1y en<l., penelly of low, ..." h"". p.""nelly ",",,",ned end em IemiIIM wi/h ... m/omaliOn '".j~ on 1M """l')-¡ .ocum."" I believe the
submitted information is true, accurate, and complete. 'ß /; / ~ A -
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PRINT Name & Title of Authorized Company Representative SignatuØ " Date
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AE~ Y L£PC STNICNID FCFtM
BAKERSFIfi..D CITY FIRE DEPAR»1ÊNT
HAZARðl5US MATERIALS INVENTO~
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Page_ot_ '"'
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3usiness Name
Address
CHEMICAL DESCRIPTION
1) INVENTORY STATUS: New (1) Addition [ ) Revision [ ) Deletion [ ) Check if chemical is a NON TRADE SECRET' [ ) TRADE SECRET [ )
2) Common Name: Mt à 0«- Dlv 3) DOT # (optional)
- ' ,
Chemical Name: ,/ AHM [ ) CAS #
4) PHYSICAL & HEALTH PHYSICAL HEALTH
HAZARD CATEGORIES Fire [~active [ ) Sudden Release of Pressure [ ] Immediate Health (Acute) ( J. Delayed Health (Chronic) [ )
5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE
6) PHYSICAL STATE Solid [ ) Uquid [~Gas [ ) Pure [ ) Mixture [.~waste " [ ) Radioactive [ f
CHEOC AU. THAT N'Pty
, 7) AMOUNT AND TIME AT FACIUTY _ UNITS OF MEASURE 8) STORAGE CODES
, c;
"""'m,m Dol, Am,."" ~ Ibs [ ) gal H43 [ ) a) Container:.
Average Daily Amount: , curies [ ) b) Pressure: f·
I c) Temperature:
i Annual Amount:
i largest Size Container: .¿:¡- LJ Circle Which Months:~ear. J.
! # Days On Site F. M. A. M. J. J. A. S. O. N. D
¡
"-
9) MIXTURE: Ust COMPONENT 0 CAS # %WT AHM
the three most hazardous 1 ) H.~ éJe , [ )
chemical components or
any AHM components 2) [ ]
3) [ )
I 10) location Ale;; CRrv R- c>l=" S~p
I
! 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 PHYSICAL HEALTH
HAZARD CATEGORIES Fire [ ) Reactive [ ] Sudden Release of Pressure [ ) Immediate Health (Acute) [ ) Delayed H,ealth (Chronic) [ )
5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE
, 6) PHYSICAL STATE Solid [ ) Liquid [ ) Gas [ ) Pure [ ) Mixture [ ) Waste [ ) Radioactive [ )
,
,
CHECK ALl. THAT M¥'t.Y
;
I
7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES
Maximum Daily Amount: Ibs [ ) gal [ ] 11:3 [ ] 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. D
; ,
I 9) MIXTURE: Ust COMPONENT CAS # %WT AHM
I
I the three most hazardous 1 ) [ )
chemical components or
any AHM components 2) [ )
3) [ )
10) location
I certify under penalty of law, that I have personally exammed and am familiar With the mfomation submitted on -tfjls aiier all attacned documents. I Del/eVe me
submitted information is true, accurate; and-complete.
PRINT Name & Title of Authorized Company Representative
Signature
"
Date
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