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HAZARDOUS MA TEJtLS INSPECTION
Business Name:
Location:
Business Identification No. 215-000 - tJefJ tp'; ~ 7
.ersfield Fire Dept.
Haz ous Materials Division
v'
(Top of Business Plan)
Station No.
?
Shift C- Inspector
Departure Time:
Arrival Time:
0-> 0erification of Inventory Matenals
, /G\.~ Verification of Quantities
, \t :-;\0
~ ~omme~.
Verification of Location
Proper Segregation of Material
Verification of MSDS Availability
Number of Employees:
Verification of Haz Mat Training
Comments:
Verification of Abatement Supplies & Procedures
Comments:
Inspection Time:
Adequate Inadequate
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Emergency Procedures Posted
Containers Properly Labeled
Comments:
D
D
D
D
D
D
Verification of Facility Diagram
Special Hazards Associated with this Facility:
Violations: ft/l tJ {/ /( tl TC? 7 9' (JJ f( /I û-t/ h Jé j' L /f---/
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SIGNATURE
Business OIYner/Manager PRINT NAME
Wh~e-Haz Mat Div
Yellow-Station Copy
All Items O.K LI
Correction Needed LI
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Pink-Business Copy
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H'AZAROOUS MAT&LS INSPECTION
Business Name:
Locatio .
Business Identification o.
Station No. ?
.kersfield Fire Dept.
H_rdous Materials Division
tI
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- cJd' Çll ~ 7 (Top of Business Plan)
Shift C Inspector
Departure Time:
Arrival Time:
~ ~ommenœ:
Verification of Inventory Materials
, Verification of Quantities
Verification of Location
Proper Segregation of Material
Verification of MSDS Availability
Number of Employees:
Verification of Haz Mat Training
Comments:
Verification of Abatement Supplies & Procedures
Comments:
Inspection Time:
Adequate Inadequate
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Emergency Procedures Posted
Containers Properly Labeled
Comments:
o
o
o
o
o
o
Verification of Facility Diagram
, Special Hazards Associated with this Facility:
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Vlm.tiORS. ' TCl f;;~jU-!:1J};~J~&j ..
No ,,~¡J'h. ~, ALl 1,." <f'ß 40'" ,f id", ~,~--e~¿ Þ-ne ,'5
WA-I(eJ Or'! ~-Pr"¡ 5/ck~, :r. c /..eeW ÐR--j ,'/llt (ooctee:;Þ/ s 16~ I f5+.5
B~j ~~/M~~ger p~d:;?~ I SIGNA TURE Corre~~I~~e~:e~è~ g
White-Haz Mat Div
Yellow-Station Copy
Pink-Business Copy
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Bakersfield Fire Dept.
Hazardous Materials Division
2130 "G" Street
Bakersfield, CA. 93301
110:;0 \
HAZARDOUS MATERIALS MANAGEMENT PLAN
lØ1T
/~~~~ll~~~
lf~ OCT 28 1992 . ~
By=:
INSTRUCTIONS:
rØ ~ -0-
l.
2.
3.
4.
To avoid further action, return this form within 30 days of receipt.
TYPE/PRINT ANSWERS IN ENGLISH.
Answer the questions below for the business as a whole.
Be brief and concise as possible.
r9?J-1 ~~
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SECTION 1: BUSINESS IDENTIFICATION DATA
BUSINESS NAME: lV\ ~ \ \ £~'s. \4.'V~o~~--\-\" E:
L 0 CA TIO N: ~ 3:> ::l '-\ W' \ \;\e... ~QQ....à.
MAILING ADDRESS: L\~l\ W\~~ ~~~
CITY: ~~e..'("~e...\~ STATE:~~ ZIP: q~~\~ PHONE: (~05)3q'l-~a\5
DUN & BRADSTREET NUMBER: S'l , - 9lo - lo ~~l() SIC CODE: ~ S -::, ~
PRIMARY ACTIVITY: o....\.)-\-c~~·\ve.... \' ~\ r- ~ ~o.:,~\~'N)..~c....L.
OWNER: ç C"~ ~. i ~E:O~~\~\a.... \. M; \\E\L
MAILING ADDRESS: I...\~ dL1 w\ h\e... ~ooA I ßcx...'(.~~-'.s.4\~d) (.~ q~"3>\ ~
SECTION 2: EMERGENCY NOTIFICATION:
CONTACT
TITLE
BUS. PHONE
24 HR. PHONE
1. f"\~ ~.I~~\\e..< OUJ\'\4..,(, ('ir()5)~'\7-%O\~ (~o.s)~:3Þ~.~\'\J
2. NE Cß~~\EL+CL N\, \\e:( Dw\\~ (~o5').:~H~~"ö\S <",~QS)~"3.Co·~\4ry
, 1.
FD..
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. Bakersfield Fire Dept. .
Hazardous Materials Division
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 3: TRAINING:
NUMBER OF EMPLOYEES: ø
MATERIAL SAFETY DATA SHEETS ON FILE: r,t""\ +~Q... ~'c~~~c~ ~e..+1'\ t'\~
BRIEF SUMMARY OF TRAINING PROGRAM:N 0 E"""-Ç> LO YE €~
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 "CALlFORNIA HEALTH &
. SAFETY CODE" FOR THE FOLLOWING REASONS:
WE DO NOT HANDLE HAZARDOUS MATERIALS.
WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT NO
TIMEEXCEED THE MINIMUM REPORTING QUANTITIES. '
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION:
I, r-ç- ~ð... Þ\. 1Y\~\\~.,. CERTIFY THAT THE ABOVE INFOR-
MATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO
FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALlFORNIA HEALTH AND SAFETY CODE"
ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT
INACCURATE INFORMATION CONSTITUTES PERJURY. I'
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SIGNA TURE
D\.,µ\\(~..:\
TITLE
\O/;)'ð}~
DATE
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2.
FD1590
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Bakersfield Fire Dept.
Hazardous Materials Division
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HAZARDOUS MATERIALS MANAGEMENT PLAN
Facility Unit Name: ~ \ \ \ E: R1 s ~\.)-\C~D-\·, ~ 6'
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES:
A. AGENCY NOTIFICATION PROCEDURES:
c...~LL ~ 11.
B, EMPLOYEE NOTIFICATION AND EVACUATION:
NC €t"C'..ç>\C"J-e...e-s. \ b\.J-\- '\" ~\..EL.- €-\l<L~-\ c*- O-~
e...~e-("~ ~c_y -\-~L.. ~ ~\:)~ \ s s'""~ \ e...~~0~ \....
+-~o.-+- ~ ve..'(' bel o...~~cù~c_e.)(,~-~~ o~ ~,,~cJc.~ o~
\ s ~\ \ -\-~~ \ ~ ' ~e...~Ç.&a...'y.
C. PUBLIC EVACUATION:
I" ~ e... e...:\I e.. ~ 0 ~ CM'\. ~"""'- ~r 5 e. ~ c:....:J ~ ~e- '5 \~ ?
\ S 5 ~ \ e..~ c\.)~ ""' -\- ~<^-\- Co..... v E~.X- bCA.\ Q..'f-\. t'\c \)"c-Q...~e.:r,-\
o ~ e.. \J CÃ...t...u ~\ c" \ ~ 0...\\ -\- ~ '^- 1- i '::> " e..-c....'2_5~ S 0.. 1" Y .
D. EMERGENCY MEDICAL PLAN:
NE()...\ e..s.-\- ~CS?\-\-o-\
3.
FO\€OO
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Bakersfield Fire Depa.
Hazardous Materials Divi~
HAZARDOUS MATERIALS MANAGEMENT PLAN
SECTION 7: MITIGATION, PREVENTION AND ABATEMENT PLAN:
A.
RELEASE PREVENTION STEPS: I ~o....'Ve... ~ W~~ fiL. ~,\ ~~ uro--s..
( T ~~ ~ c..~~~ ~\ ~ i \ \ a ~o...\ ~:) u..J "", <Ù-.,. CII.. '("'" e.. e...~\ e...à. ~ "'~ 'f'.
~\",) \ \ a ('" \ ~ C\ a ol~'y"; I I..N ~ \ '--\... e.. \J ~..:(" ~ c~e....s. ..ç , co .s.. -\ ., .l. --' ~ f:.(..
\. ^ '
},.~~. f'L. r-.."
RELEASE CONTAINMENT AND/OR MINIMIZATION: r~ 0.... ~~ C"\() C' \~()...¥..
0, So ~.. \ \ ~ ~ ð c:..c..\..\ \'5> c.> O~ e..- 0-.."0 So ör b e.,,- ~ \:. \)'~ e...J... -\-0
c..\.A..o-.", \ +- \J ~. :t: -Ç- +'" ~ ~ r' \ \ \ ~ e.. \ So \ o...'\~ ~ I a...s. ~ '" CL u> \. Ç) ~
a\,u ""- (l..'o.sc,be.;f'~ w~~\cl. ~ u~e.ð.. -\-0 c:...c.~~~e... ~~ s.~. \ \
C>..T'\d "- Q.... wo..~-\-e.. 0'. \ Se.:(,,~~e...: WO~ \~ ~ ~\\u:l \l' -t-ò
c...\~o..~ ;-t u~.
CLEAN-UP PROCEDURES: .
:¡: ~ -\-\-..(L e..\I~~~ o~ 0... \o..--c~-e.. ~'~; \\ 04 ~Cr..'-o..~ c\o\J~
~~ -\- €-\\ Q,.. \ 0..... ~ '1-0.., ~ \.I S \.N ~ s~ ~~ \.9...<) S \J c..-\....
a,..$ t.-'O-~e;s. WC).~*~ o~ \J ~ (\\J \~ ~e.. Q_o..\\e..ð..·, ~ ~í
~-\,~c,..~-'-'~. ~ .-\- \.." ~<J~). ...t. -A> -:¡:.ç.. a..... ~\ "-or \~"-Qr
s?\ \)o...~e. oc....c..\J(S 5~~e.. ()...'o.s.~'\bQ...~ \ s \js.~ -\-0 C-\-e.....Q..~ .+ù~.
SECTION 8: UTILITY SHUT -OFFS (LOCATION OF SHUT -OFFS AT YOUR FACILITY):
B.
C.
NATURAL GAS/PROPANE: D\.)"T ~\t:>6
~t::::~\
~Cl..;S\ 1-\ C~~ CU::>~€.R..
ELECTRICAL: :t't'\ ~\ c\ e... ~l
\ C\.)T \
WATER: \qé~(" fi.,-,- ~;d\~
c\)"\s.'~€ SDI....>\\-\~¡. ~~L..'-
~~I'".u \ \ r~~ (1--"-'11- 9 \.à C(t... we ~-\-
W~\\
SPECIAL: N()~E.
LOCK BOX: YES@ IF YES, LOCATION:
SECTION 9: PRIVATE FIRE PROTECTION/WATER AVAILABILITY:
A, PRIVATE FIRE PROTECTION: -í€L.- Tee... ~
, _ ;:¿ -+: r ~ ex1- i f"I 5 \J i 's. ( S,
, - s.f='("":~\C..~(.5
B. WATER AVAILABILITY (FIRE HYDRANT):
'S~~~~ v-J~~ c..-Ù\ Ï\e.--r
4.
CITY OF BAKERSFIELD
HAZARDOUS MATERIALS INVENTORY
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o Farm and Agriculture iZI Standard Business
pageLofL
NON - TRADE SECRET
BUSINESS NAME:
LOCATION: '-\
CITY, ZIP:
PHONE *:
NAME OF THIS FACILITY:
STANDARD IND. CLASS CODE:
DUN AND BRADSTREET NUMBER/FEDERAL ID *
~ - ~- - p- - -
'=:>'1) - q \0 - <0 ~\o\o
14
Names of Mixture/Components
See Instructions
.\
I
Physical and Health Hazard C.A.S. Number ~ ~\
(Check all that apply)
I]ë(' Fire Hazard 0 Sudden Release 0 Reactivity D ImmediateQ(! Delayed
of Pressure Health Health
Component 1# 1 Name & C.A.S. Number
Component 1# 2 Name & C.A.S. NUmber
Component 1# 3 Name & C.A.S. Number
I,.
\00 M04ro<'
I'
Physical and Health Hazard
(Check all that apply)
,t;XJ Fire Hazard 0 Sudden Release 0 Reactivity 0 Immediate f$l Delayed
of Pressure Health Health
C.A.S. Number
0 \00
Component 1# 1 Name & C.A.S. Number
Component 1# 2 Name & C.A.S. Number
Component 1# 3 Name & C.A.S. Number
~~c
Physical and Health Hazard
(Check all that apply)
W Fire Hazard 0 Sudden Release 0
of Pressure
C.A.S. Number
Component 1# 1 Name & C.A.S. Number
Reactivity 0 IlIUIIediate \XI Deiayed
Health Health
Component 1# 2 Name & C.A.S. Number
Component 1# 3 Name & C.A.S. Number
:-i
I·~
N
Physical and Health Hazard C.A.S. Number
(Check all that apply)
o Fire Hazard 0 Sudden Release 0 Reactivity a IlIUIIediate 0 Delayed
of Pressure Health Health
Component 1# 1 Name & C.A.S. Number
component 1# 2 Name & C.A.S. Number
component 1# 3 Name & C.A.S. Number
EMERGENCY CONTACTS
*1 çt"e.ß. þ¡. N'\,\"'--r
Name
O\Ñf'\4.t'
Title
€ ()~"-O~-('þ. Mi n £f'.
Name
OWt\U'"
Title
.;,.¡
24 Hr Phone
Certification (READ AND SIGN AFTER COMPLETING ALL SECTIONS)
I certify under peanlty of law that I haver personally examined and am familiar with the information submitted in this and all attached documents and that based on my inquiry of those
individuals responsible for obtaining the information. I believe that the submitted information is true, accurate, and complete.
LV'
r,e-à. 1\. J'I\~ \ \ ~() C)~~~{"
NAME AND OFFICIAL TITLE OF OWNER/OPERATOR OR OWNER/OPERATOR' S AUTHORIZED REPRESENTATIVE
ft;P~;;&.
SI ATURE
'o/d~lq";;)..
DATE SIGNED