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Home My WebLink AboutBUSINESS PLAN J ;,:'~. ·.JÞ!.fl ~. -~ SITE/FACILITY DIAGRAM FORM 5 NORTH SCALE: BUSINESS NAME: -- Dent:{. ~ I ~ \ FLOOR: \ OF t ~ 0...... tl ~ DATE :c.f /'3'~' FACILITY ~AME: UN IT #: OF I \ (CHECK ---- ONE) SITE D IAGRA~! FACILITY DIAGRÆ~ ~ ¡~. '.~; L\~l, . .:¡-.. ,':,' <'! /,., ~C' :...... -: ,'..< ::.~ . "~.: : ,.' ~_; t"~i;j.~-*£:~:i?¡..~n N t. ^ V ' Glt5{ flu. . ,~ I:: .. " ,', ,', ~ . , ~.: . -': P~~l. Sø~ WllfEI¿ " t~ ~¥,., ,'.- .. , " , ~ ". . . .. . ,-,.-\." -. ." . '. .-,' ,', .c I, Ke.9,,}iñ\2- V~ ""\ '. ''':,'.: '<, ~;.'.i\ ~ "'r"~ '- ----"~---"'''''------- I ¡ ! I 1 ~" I I \ j~ ,¡ gÎ :::::t ¡ ¡ " " I ~ ~'<:? .... '-:''''~' .' :;, --, (Inspector's Comments): -OFFICIAL USE ONLY- - 5A - ¡; ;;- e - QUICK SHOP SiteID: 015-021-001386 Manager : Location: 349 UNION AVE City BAKERSFIELD BusPhone: Map : 103 Grid: 32C (661) 322-2102 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 06 EPA Numb: SIC Code:5541 DunnBrad: Emergency Contact / Title BALDWINDOR SHERGILL / OWNER Business Phone: (661) 872-8742x 24-Hour Phone : (661) 322-2102x Pager Phone : ( ) - x Emergency Contact BALBIR SHERGILL Business Phone: 24-Hour Phone : Pager Phone : / / (661) (661) ( ) Title 872-8742x 366-7116x - x Hazmat Hazards: Fire DelHlth Period : Pre parer: Certif'd: ParcelNo: to Phone: (661) 322-2102x State: CA Zip : 93307 Phone: (661) 322-2102x State: CA Zip : 93306 TotalASTs: = Gal TotalUSTs: = Gal RSs: No Contact : MailAddr: 349 UNION AVE City : BAKERSFIELD Owner Address City JOHN SOHAL/ß~ìn.. S~~ttGrilA" : 2612 VYN DR : BAKERSFIELD Emergency Directives: " "11'1(£; ðÄN~ Do hereby certify that I have (Typa or print name) reviewed the attached hazardous ma~eriafs manage- ment plan for Q"1;K SH,()« Blnd ~hat it along with (Nanø of BusÌMss) any corrections constitute a comp~ete and correct man- agement plan for my facUlty. _ c:2£-- Signature ~ 1).1-(°1 Date -1- 09/22/2004 ii' e - ~- F QUICK SHOP SiteID: 015-021-001386 9 STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: QUICK SHOP Cross Street : Business Type: Org Type: Total Tanks : 3 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : BALBIR SHERGILL Phone: (661) 872-8742x Address: City : State: Zip: Type : INDIVIDUAL TANK OWNER INFORMATION Name : BALBIR SHERGILL Phone: (661) 872-8742x Address: City : State: Zip: Type : INDIVIDUAL BOE UST Fee# : UNKNOWN Financ'l Resp: INSURANCE Legal Notif : Property Owner Mailing Address Date:04/26/2000 Phone: ( ) - x Name:BALWINDOR SHERGILL Ttl:MANAGER State UST # : 1998 Upg Cert#: 00845 / -2- 09/22/2004 ... . ~ e e (¡.. SiteID: 015-021-001386 ï By Facility Unit 9 Fixed Containers on Site 9 specHazEPA Hazards Frm I DailyMax unitlMCP F DH L 10000.00 GAL Mod F DH L 10000.00 GAL Mod F DH L 10000.00 GAL Mod F QUICK SHOP f= Hazmat Inventory p== MCP+DailyMax Order Hazmat Common Name... REGULAR UNLEADED UNLEADED GASOLINE SUPER GASOLINE -3- 09/22/2004 -" e e ..... SiteID: 015-021-001386 9 Facility Unit: Fixed Containers on Site 9 F QUI CK SHOP p= Inventory Item 0001 ¡== COMMON NAME / CHEMICAL NAME REGULAR UNLEADED Days On Site 365 Location within this Facility Unit NE CORNER OF LOT Map: Grid: CAS# 8006-61-9 STATE - TYPE Liquid Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 10000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 10000.00 GAL Daily Average 4500.00 GAL %wt. I 100.00 Gasol1.ne HAZARDOUS COMPONENTS ~ CAS # I 8006619 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod HAZARD ASSESSMENTS Ag.Defined1: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag.Defined9: Ag.Define10: Ag.Defined8: - Ag.Define11 -4- 09/22/2004 ~ e e -- F QUICK SHOP SiteID: 015-021-001386 9 f= Inventory Item 0001 Facility Unit: Fixed Containers on Site 9 STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: NE CORNER OF LOT TANK DESCRIPTION Tank ID#: 1 Mfr: MODERN WELD Installed: 05/1988 Capacity: 10000 Gals Additional Info: Compart Tank: N No. Of Comparts: Tank Use: MOTOR VEHICLE FUEL MatI Name:REGULAR UNLEADED TANK CONTENTS Petrol Type: REGULAR UNLEADED Cas #: 8006-61-9 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Corr Prot: FIBERGLASS REINFORCED Spill Cnt : 1999 Drop Tube : 1999 Striker Plate: 1999 Sgl Wall: PLASTIC Alarm : Ball Float : Fill Tube S/O: 1999 LEAK DETECTION Dbl Wall: INTERSTITIAL MONITORING Installed: Installed: Exempt: No TANK Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -5- 09/22/2004 ; e e . F QUICK SHOP SiteID: 015-021-001386 9 f= Inventory Item 0001 Facility Unit: Fixed Containers on Site, STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION Piping Type: Const: Mfgr : Mtl : & : Corr : Prot : UnderGround PRESSURE DOUBLE WALL TOTAL CONTAINMENT "FLEX" AboveGround Piping "FLEX" PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS Installed: 04/29/1999 Date: 05/03/2000 Name:BLADWINDOR SHERGILL Prmt Number: 1386 DISPENSER CONTAINMENT Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Ttl:OWNER Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. : 07/01/1999 UST MONIT. CERT:11/17/2003 -6- 09/22/2004 .P e e SiteID: 015-021-001386 ì Facility Unit: Fixed Containers on Site ì F QUICK SHOP f= Inventory Item 0002 F= COMMON NAME / CHEMI CAL NAME UNLEADED GASOLINE Days On Site 365 Location within this Facility Unit NE CORNER OF LOT Map: Grid: CAS # 8006-61-9 STATE - TYPE Liquid Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 10000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 10000.00 GAL Daily Average 4500.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS ~ CAS # I 8006619 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DR / / / Mod HAZARD ASSESSMENTS Ag.Defined1: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag.Defined8: Ag.Defined9: Ag.Define10: - Ag.Define11 -7- 09/22/2004 ~ .¡¡ e e F QUICK SHOP SiteID: 015-021-001386 9 f= Inventory Item 0002 Facility Unit: Fixed Containers on Site 9 STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: NE CORNER OF LOT TANK DESCRIPTION Tank ID#: 2 Mfr: MODERN WELD Installed: 05/1988 Capacity: 10000 Gals Additional Info: Compart Tank: N No. Of Comparts: Tank Use: MOTOR VEHICLE FUEL MatI Name:UNLEADED GASOLINE TANK CONTENTS Petrol Type: UNLEADED PLUS/MIDGRADE Cas #: 8006-61-9 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Corr Prot: FIBERGLASS REINFORCED Spill Cnt : 1999 Drop Tube : 1999 Striker Plate: 1999 Sgl Wall: PLASTIC Alarm : Ball Float : Fill Tube S/O: 1999 TANK LEAK DETECTION Dbl Wall: INTERSTITIAL MONITORING Installed: Installed: Exempt: No Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -8- 09/22/2004 J' e e F QUICK SHOP SiteID: 015-021-001386 ì f= Inventory Item 0002 Facility Unit: Fixed Containers on Site ì STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION Piping Type: Const: Mfgr : Mtl : & : Corr : Prot : UnderGround PRESSURE DOUBLE WALL ENVIROFLEX "FLEX" AboveGround Piping "FLEX" PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS Installed: 04/29/1999 Date: 05/03/2000 Name:BLADWINDOR SHERGILL Prmt Number: 1386 DISPENSER CONTAINMENT Type: DISP. PAN SENSOR w/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Ttl:OWNER Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED TANK/LINE TEST : CP CERT. : MANWAY INSP. :07/01/1999 UST MONIT. CERT:11/17/2003 -9- 09/22/2004 ./ e e SiteID: 015-021-001386 , Facility Unit: Fixed Containers on Site ì F QUICK SHOP p= Inventory Item 0003 F= COMMON NAME / CHEMI CAL NAME SUPER GASOLINE Days On Site 365 Location within this Facility Unit NE CORNER OF LOT Map: Grid: CAS# 8006-61-9 STATE - TYPE Liquid Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 10000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 10000.00 GAL Daily Average 4500.00 GAL %wt. I 100.00 Gasollne HAZARDOUS COMPONENTS ~ CAS # I 8006619 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod HAZARD ASSESSMENTS Ag.Defined1: MISC. LOCAL AGENCY DATA Ag.Defined2: Ag.Defined3: Ag.Defined4: Ag.Defined5: Ag.Defined6: Ag.Defined7: Ag.Defined8: Ag.Defined9: Ag.Define10: - Ag.Define11 -10- 09/22/2004 · J: e e F QUICK SHOP SiteID: 015-021-001386 9 f= Inventory Item 0003 Facility Unit: Fixed Containers on Site 9 STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 1 of 2 Last Action Type: Location In Site: NE CORNER OF LOT TANK DESCRIPTION Tank ID#: 3 Mfr: MODERN WELD Installed: 05/1988 Capacity: 10000 Gals Additional Info: Compart Tank: N No. Of Comparts: Tank Use: MOTOR VEHICLE FUEL Matl Name:SUPER GASOLINE TANK CONTENTS Petrol Type: PREMIUM UNLEADED Cas #: 8006-61-9 TANK CONSTRUCTION Type : DOUBLE WALL Material(p): STEEL CLAD W/FIBERGLASS R. P. Material(s): STEEL CLAD W/FIBERGLASS R. P. Lining : UNLINED Corr Prot: FIBERGLASS REINFORCED Spill Cnt : 1999 Drop Tube : 1999 Striker Plate: 1999 Sgl Wall: PLASTIC Alarm : Ball Float : Fill Tube S/O: 1999 TANK LEAK DETECTION Dbl Wall: INTERSTITIAL MONITORING Installed: Installed: Exempt: No Last Used: TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE Qty Remaining: Was Filled: No -11- 09/22/2004 i· J J e e F QUICK SHOP SiteID: 015-021-001386 9 f= Inventory Item 0003 Facility Unit: Fixed Containers on Site 9 STORAGE CONTAINER DATA (UST FORM B and AGENCY-DEFINED) Page 2 of 2 PIPING CONSTRUCTION UnderGround Piping PRESSURE DOUBLE WALL AboveGround Piping Type : Const: Mfgr : Mtl : & : Corr : Prot : FIBERGLASS PIPING LEAK DETECTION UnderGround Piping AboveGround Piping AUTOMATIC LEAK DETECTORS Installed: 04/29/1999 DISPENSER CONTAINMENT Type: DISP. PAN SENSOR W/ POS. SHUTOFF OWNER/OPERATOR SIGNATURE Ttl:OWNER Approved: Yes Expiration Date: 06/30/2006 AGENCY DEFINED Date: 05/03/2000 Name:BALDWINDOR SHERGILL Prmt Number: 1386 TANK/LINE TEST : CP CERT. : MANWAY INSP. : 07/01/1999 UST MONIT. CERT:11/17/2003 -12- 09/22/2004 ;- ~ , GAop Jg¡~JY WICK #141 e -- SiteID: 015-021-001386 Manager : Location: 349 UNION AVE City BAKERSFIELD BusPhone: Map : 103 Grid: 32C (805) 322-2102 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 06 EPA Numb: SIC Code:5541 DunnBrad: Emergency Contact / Title Emergency Contact / Title BALDWINDOR SHERGILL / BALBIR SHERGILL / Business Phone: (805) 872-8742x Business Phone: (805) 872-8742x 24-Hour Phone : (805) 322-2102x 24-Hour Phone : (805) 366-7116x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire DelHlth Contact : Phone: ( ) - x MailAddr: 349 UNION AVE State: CA City : BAKERSFIELD Zip : 93307 Owner JOHN SOHAL Phone: ( ) - x Address : 2612 VYN DR State: CA City : BAKERSFIELD Zip : 93306 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: I, MbOWI.l'iOOQoo hereby carmy that ~ ha\l~ (Ty~ or print nama) reviewed the attached hazardous matsrials manage- ment plan for ,cfL S and ~hat i~ along with (Name of Busina any corrections consîituts a complete and correct man- agement plan for my facility. rQ~ I~ te -1- 11/16/2000 '¡; e e F JOHNNY QUICK #141 SiteID: 015-021-001386 ì STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: JOHNNY QUICK #141 Cross Street : Business Type: Org Type: Total Tanks : 3 IndnRes/Trust: No PA Contact: PROPERTY OWNER INFORMATION Name : BALBIR SHERGILL Phone: (805) 872-8742x Address: City : State: Zip: Type : INDIVIDUAL TANK OWNER INFORMATION Name : BALBIR SHERGILL Phone: (805) 872-8742x Address: City : State: Zip: Type : INDIVIDUAL BOE UST Fee# : UNKNOWN Financ'l Resp: INSURANCE Legal Notif : Property Owner Mailing Address Date:04/26/2000 Phone: ( ) - x Name:BALWINDOR SHERGILL Ttl:MANAGER State UST # : 1998 Upg Cert#: 00845 One Unified List ì All Materials at Site ì SpecHaz EPA Hazards DailyMax MCP F DH L 10000.00 GAL Mod F DH L 10000.00 GAL Mod F DH L 10000.00 GAL Mod F Hazmat Inventory f== As Designated Order Hazmat Common Name... LEADED GASOLINE UNLEADED GASOLINE SUPER GASOLINE -2- 11/16/2000 ~ e e SiteID: 015-021-001386 ì Facility Unit: Fixed Containers on Site ì F JOHNNY QUICK #141 f= Inventory Item OOO~ = COMMON NAME / CHEMICAL NAME LEADED GASOLINE Days On Site 365 Location within this Facility Unit NE CORNER OF LOT Map: Grid: CAS # 8006619 [ ~TA~EI TYPE ~ P~ESSURE ----r TEM~ERATURE ~ CONTAINER TYPE =L~qu~d __pure ~mb~ent ---1 Amb~ent ~ UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 10000.00 GAL 10000.00 GAL 4500.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS ~ CAS # I 8006619 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod HAZARD ASSESSMENTS f= Inventory Item 0002 = COMMON NAME / CHEMICAL NAME UNLEADED GASOLINE Facility Unit: Fixed Containers on Site ì Days On Site 365 Location within this Facility Unit NE CORNER OF LOT Map: Grid: CAS # 8006-61-9 STATE - TYPE Liquid Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container 10000.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 10000.00 GAL Daily Average 4500.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS ~ No CAS # I 8006619 HAZARD ASSESSMENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod -3- 11/16/2000 e e F JOHNNY QUICK #141 F Inventory Item 0003 = COMMON NAME / CHEMICAL NAME SUPER GASOLINE SiteID: 015-021-001386 ì Facility Unit: Fixed Containers on Site ì Days On Site 365 Location within this Facility Unit NE CORNER OF LOT Map: Grid: CAS # 8006-61-9 [ ~TA~E I TYPE ~ P~ESSURE ~ TEM~ERATURE ] CONTAINER TYPE =Llquld __pure ~mblent ---1 Amblent __ UNDER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 10000.00 GAL 10000.00 GAL 4500.00 GAL %Wt. I 100.00 Gasoline HAZARDOUS COMPONENTS ~ CAS#a006619 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod HAZARD ASSESSMENTS -4- 11/16/2000 e e Employee Notif./Evacuation SiteID: 015-021-001386 ì Fast Format ì Overall Site ì 03/19/19981 03/19/1998 F JOHNNY QUICK #141 I p= Notif./Evacuation/Medical r=: Agency Notification LL 911. CONTACT ALL PERSONS AT SITE TO EVACUATE TO A SAFE AREA. Public Notif./Evacuation 03/19/1998 CONTACT ALL PERSONS AT SITE TO EVACUATE TO A SAFE AREA. Emergency Medical Plan 03/19/1998 KERN MEDICAL CENTER - 1830 FLOWER ST - 326-2000. -5- 11/16/2000 e e F JOHNNY QUICK #141 I p= Mitigation/Prevent/Abatemt ~ Release Prevention r=== Release Containment Clean Up SiteID: 015-021-001386 9 Fast Format 9 Overall Site 9 I I 03/19/1998 EMPLOYEES WOULD USE A FLOOR DRY MATERIALS ON SMALL SPILLS, DISPOSE OF PROPERLY. FOR LARGE SPILLS EMPLOYEES WOULD SHUT OFF GAS AND CALL 911 AND KEEP ALL PEOPLE AWAY. Other Resource Activation -6- 11/16/2000 e e SiteID: 015-021-001386 ì Fast Format =¡ Overall Site ì I F JOHNNY QUICK #141 I p= Site Emergency Factors r== Special Hazards Utility Shut-Offs 03/19/1998 A) GAS - OUTSIDE EMERGENCY SHUT OFF B) ELECTRICAL - INSIDE IN BACK RM C) WATER - OUTSIDE IN FRONT D) SPECIAL - GASOLINE SHUT OFF AT SE END OF BLDG E) LOCK BOX - NO Fire Protec./Avail. Water 03/19/1998 PRIVATE FIR PROTECTION - 3 FIRE EXTINGUISHERS. NEAREST FIRE HYDRANT - 4TH AND UNION AVE. Building Occupancy Level -7- 11/16/2000 · ..., ... e e F JOHNNY QUICK #141 I F Training Employee Training SiteID: 015-021-001386 ì Fast Format ì Overall Site ì 03/19/1998 WE HAVE 3 EMPLOYEES AT THIS FACILITY. WE HAVE MATERIALS SAFETY DATA SHEETS ON FILE. GIVE A BRIEF SUMMARY OF TRAINING PROGRAM: MSDS ARE REVIEWED WITH EMPLOYEES AND EMPLOYEES ARE INSTRUCTED ON HANDLING CHEMICAL EMERGENCIES. Page 2 [ I I Held for Future Use Held for Future Use -8- 11/16/2000 ....... .. .. _ RECEIVED e JOHNNY QUICK #141 SiteID: 215-000-001386 Manager : Location: 349 UNION AVE City BAKERSFIELD BY: BusPhone: Map : 103 Grid: 32C (805) 322-2102 CommHaz : Low FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 06 EPA Numb: SIC Code:5541 DunnBrad: Emergency Contact / Title Emergency Contact / Title BALDWINDOR SHERGILL / BALBIR SHERGILL / Business Phone: (805) 872-8742x Business Phone: (805) 872-8742x 24-Hour Phone : (805) 322-2102x 24-Hour Phone : (805) 366-7116x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire DelHlth Emergency Directives: p= Hazmat Inventory One Unified List ì f== MCP+DailyMax Order All Materials at Site ì Hazmat Common Name.. . specHazEPA Hazards Frm DailyMax UnitMCP LEADED GASOLINE F DH L 10000 GAL Mod UNLEADED GASOLINE F DH L 10000 GAL Mod SUPER GASOLINE F DH L 10000 GAL Mod ~~ l3ìLL ~ .sHe¡¿t,I·~ fr¡~wsby eelii1y ~ha1 ~ halV~ ('ú , Ip;1 Bíb\Œ ~ !í®~¡@W®@ ~Ift® ~Ift®~ Ûì@&élfl\Q)OO~ m®Q®M!$ mæJn~~®o ffi®û'iJU ~~~ ~@fí70~~~t.. ~ UOO~ ß~ ®~@~rø wöüfru ~!FùV OO¡;Y®©\Ò@!Fù~ ©@!Fù~~öítMli® ® ©©mlQ)~~~® ®!iì1ô1 OOli'fí®©Û m®¡ruo ®@®ffi®!iì~ !9J~®ú'ù ~@V ú'VJV <J@ì©ò~Ò~. 3-1'-9{f ~ cc- ':---~':':,-"-' !jM.tufe -1- 03/16/1998 , e e F JOHNNY QUICK #141 p= Inventory Item 0001 ¡:::::= COMMON NAME / CHEMI CAL NAME LEADED GASOLINE SiteID: 215-000-001386 1 Facility Unit: Fixed Containers on Site ì Days On Site 365 Location within this Facility Unit NORTHEAST CORNER OF LOT Map: Grid: CAS # 8006619 [ ~TA~E I TYPE -r: P~ESSURE ~ TEM~ERATURE I =Llquld __pure ~mblent ---1 Amblent ~ AMOUNTS AT THIS LOCATION Largest Container Daily Maximum GAL 10000.00 GAL CONTAINER TYPE UNDER GROUND TANK Daily Average 4500.00 GAL %Wt. RS CAS # 100.00 Gasoline No 8006619 HAZARDOUS COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod HAZARD ASSESSMENTS p= Inventory Item 0002 = COMMON NAME / CHEMI CAL NAME UNLEADED GASOLINE Facility Unit: Fixed Containers on Site 1 Days On Site 365 Location within this Facility Unit NORTHEAST CORNER OF LOT Map: Grid: CAS # 8006-61-9 [ ~TA~E I TYPE -r: P~ESSURE ~ TEM~ERATURE I =Llquld __pure ~mblent ---1 Amblent ~ AMOUNTS AT THIS LOCATION Largest Container Daily Maximum GAL 10000.00 GAL CONTAINER TYPE UNDER GROUND TANK Daily Average 4500.00 GAL %Wt. RS CAS # 100.00 Gasoline No 8006619 HAZARDOUS COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod HAZARD ASSESSMENTS -2- 03/16/1998 e e F JOHNNY QUICK #141 p= Inventory Item 0003 = COMMON NAME / CHEMI CAL NAME SUPER GASOLINE SiteID: 215-000-001386 ì Facility Unit: Fixed Containers on Site ì Days On Site 365 Location within this Facility Unit NORTHEAST CORNER OF LOT Map: Grid: CAS # 8006-61-9 STATE - TYPE Liquid Pure PRESSURE Ambient TEMPERATURE Ambient CONTAINER TYPE UNDER GROUND TANK Largest Container GAL AMOUNTS AT THIS LOCATION Daily Maximum 10000.00 GAL Daily Average 4500.00 GAL %Wt. RS CAS # 100.00 Gasoline No 8006619 HAZARDOUS COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod HAZARD ASSESSMENTS -3- 03/16/1998 e e F JOHNNY QUICK #141 I f= Notif./Evacuation/Medical r=: Agency Notification LCALL 911 Employee Notif./Evacuation SiteID: 215-000-001386 ì Fast Format ì Overall Site ì 01/07/1990 ] 01/07/1990 CONTACT ALL PERSONS AT SITE TO EVACUATE TO A SAFE AREA Public Notif./Evacuation 01/07/1990 CONTACT ALL PERSONS AT SITE TO EVACUATE TO A SAFE AREA Emergency Medical Plan 01/07/1990 KERN MEDICAL CENTER 1830 FLOWER STREET BAKERSFIELD, CA (805) 326-2000 -4- 03/16/1998 e e F JOHNNY QUICK #141 I p= Mitigation/Prevent/Abatemt r== Release Prevention ~ Release Containment Clean Up SiteID: 215-000-001386 ì Fast Format ì Overall Site ì I I 01/07/1990 EMPLOYEES WOULD USE A FLOOR DRY MATERIALS ON SMALL SPILLS, DISPOSE OF PROPERLY. FOR LARGE SPILLS EMPLOYEES WOULD SHUT OFF GAS AND CALL 911 AND KEEP ALL PEOPLE AWAY Other Resource Activation -5- 03/16/1998 e e F JOHNNY QUICK #141 I p= Site Emergency Factors r== Special Hazards Utility Shut-Offs SiteID: 215-000-001386 ì Fast Format ì Overall Site ì I 01/07/1990 A) GAS - OUTSIDE EMERGENCY SHUT OFF B) ELECTRICAL - INSIDE IN BACK ROOM C) WATER - OUTSIDE IN FRONT D) SPECIAL - GASOLINE SHUT OFF AT SOUTHEAST E) LOCK BOX - NO END OF BUILDING Fire Protec./Avail. Water 01/07/1990 PRIVATE FIR PROTECTION - 3 FIRE EXTINGUISHERS FIR HYDRANT - 4TH AND UNION AV Building Occupancy Level -6- 03/16/1998 · . "- e e í JOHNNY QUICK #141 ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë SiteID: 215-000-001386 íëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Fast Format íë Training ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Overall Site íëë Employee Training ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 03/21/1990 ¡ o 0 o WE HAVE 3 EMPLOYEES o o o o o o o o WE HAVE MATERIALS SAFETY DATA SHEETS ON FILE o o MSDS ARE REVIEWED WITH EMPLOYEES AND EMPLOYEES ARE INSTRUCTION ON o HANDLING CHEMICAL EMERGENCIES o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëë Page 2 ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëëë Held for Future Use ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ 0 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj íëëëëë Held for Future Use ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj i' " e -- I General Information ./ \0"& /j ,,~ ?z~-~ Page 1 ~ 09/10/93 JOHNNY QUICK #141 215-000-001386 Overall Site with 1 Fac. Unit Location: 349 UNION AV Map: 103 Hazard: Low Community: BAKERSFIELD STATION 06 Grid: 32C FlU: 1 AOV: 0.0 - Contact Name Title Business Phone - 24-Hour Phone BALDWINDOR SHERGILL (805) 872-8742 x (805) 322-2102 BALBIR SHERGILL (805) 872-8742 x (805) 366-7116 Administrative Data Mail Addrs: 349 UNION AV D&B Number: City: BAKERSFIELD State: CA Zip: 93307- Comm Code: 215-006 BAKERSFIELD STATION 06 SIC Code: 5541 Owner: JOHN SOHAL Phone: ( ) - Address: 2612 VYN DR State: CA City: BAKERSFIELD Zip: 93306- Summary , v'C:U , OCT 0 8 1993 HAZ. MAT. 0 IV. o+-- I, '3ìLL~ J }fER 6 Zb 0 h cry orprinlnamè) ~ 0 ereby certify that I have reviewed the attached;hazardous materials mar.aae- ment plan for Jö µ ~' + .- (I1arne ~B I~and thal It along with any corrections constitute a complete and correct man. agement plan for my facility. ~~~ /p'.:L~9 :5 Date -- ------ - . e e 09/10/93 JOHNNY QUICK #141 215-000-001386 Page 2 Hazmat Inventory List in MCP Order 02 - Fixed Containers on Site PIn-Ref Name/Hazards Form Max Qty MCP 02-001 LEADED GASOLINE Liquid 10000 Moderate ~ Fire, Delay Hlth GAL 02-003 SUPER GASOLINE Liquid 10000 Moderate ~ Fire, Delay Hlth GAL 02-002 UNLEADED GASOLINE Liquid 10000 Moderate ~ Fire, Delay Hlth GAL e e 09/10/93 JOHNNY QUICK #141 215-000-001386 02 - Fixed Containers on Site Page 3 Hazmat Inventory Detail in MCP Order 02-001 LEADED GASOLINE ~ Fire, Delay Hlth Liquid 10000 Moderate GAL CAS #: 8006619 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL ~, . Da..ilY Average GAL --r-- Annual Amount GAL -- 10 , 000 I,~ 4 , 500 . 00 I 36 0 , 000 . 00 Storage UNDER GROUND TANK r Press T Temp ~I Location Ambient AmbientNORTHEAST CORNER OF LOT - Conc l 100.0% Gasoline Components r; MCP --¡Guide Moderate 27 02-003 SUPER GASOLINE ~ Fire, Delay Hlth Liquid 10000 Moderate GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL ~ Daily Average GAL --r-- Annual Amount GAL-- 10,000 I . 4,500.00 I 360,000.00 Storage UNDER GROUND TAN~ r Press T Temp ~ Location Ambient AmbientNORTHEAST CORNER OF LOT - Conc l 100.0% Gasoline Components r; MCP --¡Guide Moderate 27 02-002 UNLEADED GASOLINE ~ Fire, Delay H1th Liquid 10000 Moderate GAL CAS #: 8006-61-9 Trade Secret: No Form: Liquid Type: Pure Days: 365 Use: FUEL Daily Max GAL ~ Daily Average GAL --r-- Annual Amount GAL -- 10,000 I 4,500.00 I 360,000.00 Storage UNDER GROUND TANK r Press T Temp ~ Location Ambient AmbientNORTHEAST CORNER OF LOT - Conc l 100.0% Gasoline Components r;MCP --¡Guide Moderate I 27 e e 09/10/93 JOHNNY QUICK #141 215-000-001386 00 - Overall Site Page 4 <D> Notif./Evacuation/Medical <1> Agency Notification CALL 911 <2> Employee Notif./Evacuation CONTACT ALL PERSONS AT SITE TO EVACUATE TO A SAFE AREA <3> Public Notif./Evacuation CONTACT ALL PERSONS AT SITE TO EVACUATE TO A SAFE AREA <4> Emergency Medical Plan KERN MEDICAL CENTER 1830 FLOWER STREET BAKERSFIELD, CA (805) 326-2000 e e 09/10/93 JOHNNY QUICK #141 215-000-001386 00 - Overall Site Page 5 <E> Mitigation/Prevent/Abatemt <1> Release Prevention <2> Release Containment <3> Clean Up EMPLOYEES WOULD USE A FLOOR DRY MATERIALS ON SMALL SPILLS, DISPOSE OF PROPERLY. FOR LARGE SPILLS EMPLOYEES WOULD SHUT OFF GAS AND CALL 911 AND KEEP ALL PEOPLE AWAY <4> Other Resource Activation ~ ,. e e 09/10/93 JOHNNY QUICK #141 215-000-001386 00 - Overall Site Page 6 <F> Site Emergency Factors <1> Special Hazards <2> Utility Shut-Offs A) GAS - OUTSIDE EMERGENCY SHUT OFF B) ELECTRICAL - INSIDE IN BACK ROOM C) WATER - OUTSIDE IN FRONT D) SPECIAL - GASOLINE SHUT OFF AT SOUTHEAST END OF BUILDING E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIR PROTEéTION - 3 FIRE EXTINGUISHERS FIR HYDRANT- 4TH AND UNION AV <4> Building Occupancy Level ., ~ '. .. .... e e 09/10/93 JOHNNY QUICK #141 , 215-000-001386 00 - Overall Site Page 7 <G> Training <1> Page 1 WE HAVE 3 EMPLOYEES WE HAVE MATERIALS SAFETY DATA SHEETS ON FILE MSDS ARE REVIEWED WÌTH EMPLOYEES AND EMPLOYEES ARE INSTRUCTION ON HANDLING CHEMICAL EMERGENCIES <2> Page 2 as needed <3> Held for Future Use <4> Held for Future Use ât-~ 2]fJJ . ." - .. ~.......... .- 1¡. .; ~:;- .' ,0 "~, ~~ i ", ~...:.\ ~~ ~:t c:,j f;;: ". l~: I ,,' :/~ 'Ii'." ....::" ,. .' ~ .. BAK~SFIELD CITY FIRE DEJ6TMENT 2130 we- STREET BAKERSFIELD, CA. 93301 (805) 326-3979 P'(} (k(k-2. ~G- ¿ r' OFFICIAL USE ONLY ~ (" 3'"" ~ c... ~ ~ (/;;t4 98erOo f 3<[; (0 I D # BUSINESS NAME HAZARDOUS MATERIALS ' BUSINESS PLAN AS A WHOLE FORM 2A RECEIVED 'APR 1 7 1989 HAZ. MAT. OlV. INSTRUCTIQNS: ,t. To avoid further action, return this fro~ within 30 daY5 of receipt. Z. TYPE/PRINT ANSWERS IN EN6LISH. 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: ~ioh.ï~ ~"\.a'1II .,v¡, B. LOCATION J STREET ADDRESS: ~4. q Lh~J'bJ. ft-J-e... CITY: ß~ BUS. PHONE: (~() '6:l.;2...~, tJ.;l. ZIP: ~:5~o7 SECTION 2: EMERGENCY NOTIFICATIONS In ca5e of an e~ergency involving the release or threatened release of a hazardous ~aierial, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify your local fire deøart~ent and the State Office of E~ergency Services as required by law. EMPtOYEES TO NOTIFY IN CASE OF EMER6ENCY: NAME AND TITLE 1\. ß.n!eu-'7JJ,)e'^ ~WJ¡p'¿) PH# B. &-/)ð/R ~£4'lL PH# DURING BUS. HRS. AFTER BUS. HRS. 3.:2;2. .,;J..) Ð 2- PH# '8 ?,;). . f/ "12... . 8 7;2 , ?7 Y.2. . <.366, 71) l PHI SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WHOLE A. NATURAL GAS/PROPANE: ¡jf}S . exJ- 51 J'iF' ~)~~ ~~.} ¿þfL . B. ELECTRICAL: T~ <5,.Jr .'Lu 'ßAP.'Y R~oJ.o\ . "'-=:::::J C. WATER: ~ v-It"' ÎN ~-l' D. SPECIAL: & Gß~o JJi.JE. <:))0';' -O~.F (0. ç~w~~ /JEjq~j. ~LW o"c .Euk!. E. LOCK BOX: YES NO IF YES, LOCATION: IF YES, DOES IT CONTAIN SITE PLANS? YES I NO MSOSS7 YES ¡NO FLOOR PLANS? YES! NO KEYS? YES ¡ NO It e ... - . -... . ;3ECTION 3: PRI'JATE RESPOf\lSE-.l!;:".1t1 FOR 8_UStNESS AS A I,.JH~~V /)')11" E/)1"p,h/ EE.5 )I...Jo(..J/c! U$E 7/00/2- L)..e/. // ,..9 5/H.J9LL .:S)D/L-L. Æ/2- 1:1 . Sp.l '/ Is E~"..o.J, /.éÆS )U~ GJ/d CA¿¿ 7.1/ ",9,ud ,A-~Æ'p .;l)¿¿ ?.é/2.~~~. ; ~.lA.JA/ ..-cfi'oÞ? /J/ZE~. I., '9~ ¡,I 1It,~ ~> (,./ '1 . SECTION 5: LOCAL EMERGENCY MEDICAL ASSISTANCE FOR YOUR BUSINESS AS A WHOLE ):. /(£{ ^ !vfeott'~ C£M!c"e. .''-,'''' ',' - , '.. ~ - '<. '. !: ~', . .' ,..;. . :'.'~ ':... .. ,',' .... '. ." SECTION S: EMPLOYEE TRAINING .. . EMPLOYERS ARE REQUIRED TO HAVE A TRAINING PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND REFRESHER TRAINING IN THE SAFE HANDLING OF HAZARDOUS f1ATER I AL S . A. NUMBER OF EMPLOYEES AT THIS FACILITY ¡;~IIc.., C -5 ) 8. DO YOU HAVE MSDS (MATERIAL SAFETY DATA SHEETS) FO, EACH HAZARDOUS MATERIAL YOU HANDLE ? / C. GIVE A BRIEF SUMMARY OF YOUR HAZARDOUS MATERI~ S TRAINING PROGRAM: ~ ¡/...U bj þ;z-ð'bY.à ,u'lv>'df 6J"cf.:L ,.... .., H2Þ:?··~,:~·~>¥t{;~~).. fI.¥· ~.~ h_ßAJ)n:,,_ ~~~M.. ..',. ,~ SECTION 7: EXEMPTION REQUEST r~~ ..' ,va 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: ~;JE DO NOT HANDLE HAZARDOUS MATERIALS. WE DO HANDLE HAZARDOUS MATERIA.LS, BUT THE QUANTITIES AT NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES. OTHER (SPECIFY REASON) SECTION 8: CERTIFICATION I, ¿~4o::J~ Çu~ ' certi fy the.t the ·above inforMe.tion is accurate. I understand that this inforMation will be used to fulfill MV firM'~ obligations under the new California Health and Safety code on Hazardous Materials (Div. 2Ø Chapter 6.95 Se.c. 2550Ø Et AI.) and that inaccurate infor .,tion constitutes perjury. SIGNATUFì:E, T1Tl.E ~ DATE .~-/7'-ry , ~"\ "" - \- .. )"Ç;(... BA!RSFIELD CITY FIRE D~ARTMENT 2130 wG- STREET BAKERSFIELD, CA. 93301 (805) 326-3979 .' Co_. BUSINESS NÁME I D # :1 ~ il I; ,I H !! 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 I' FACILITY UNIT # FACILITY UNIT NAME: SECTION 1: MITIGATION. PREVENTION. ABATEMENT PROCEDURES E/?/pÆs/éé'.S Would use /1" 7/coþ. Oft/ /~~A¿' O~ Sh?/I¿'? 15;:>(2-£5, D/$~¿ o,F j)µ>IéP-Ú ,) /0/2- <9. 5..P,) 15 Ep? /~çE:.s Wð~/¿ \:: /:.vh t"o.N~~rN¿:/l-. / . SAu'; of,c Gr-JS AI-Vd CALL- 9// /1~d /..eEj:J ,9¿L- )J£A.ft:1~S ,4Þ'JA/ SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THE UNIT ONLY GJJV./PC/^ /l¿¿ 'p£ftSO~ @ 5/ /£ /0 ¿1/",9CVð~& ;1;, $#/¿ /I/2éA /9~d D?// ?//. -- '" e e i ..... I ßECTION 3: HAZARDOUS MATERIALS FOR THIS UNIT ONLY A. Does this Facility Unit 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~ 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 3 h fiE . b';'. ~ SECTION '5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPONDERS (Fire Hydrant) 'Jdl /}~Lhl ¿)IÚ/~d "livE· SECTION 6: LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT ONLY, A. NATURAL GAS/PROPANE: /V0)2..1), .5, 'dl:. c> ¡:: )3¿Jk!. B. ELECTRICAL: jlJo/2.f;' 51 d¿ OF .8/.JJd. C. WATER: ¿IIS}- 'S,,¿é OF B~Jd D. SPECIAL: /' . _I D.. Jj <.:?H.so/þ.J6 Shvl of;:: @ ¿.,<IS; S/df o¿: /Ç/UP:;;:. E. LOCK BOX: YES ~ IF YES, LOCATION: IF YES, SITE PLANS? YES / NO FLOOR PLANS? YES / NO MSDSs? KEYS? YES / NO YES / NO - 3B - Standard Bus iness CIT}T of BAKERSFIELD ~HAZARDOUS MATERIALS NON-TRADE ~~~;;S~;:E' ~~~~~~ PHO.E., ~ - RD'D TO I 'S'l'RUCTIOIfS rOR PROPIlR COD8S 0: ... FarM and Aqriculture l-J INVENTORY SECRETS { t - ~~~~;~~~'žt~~~~ CITY, ZIP: . ~~~;Z PHONE ,: - - NAME OF Tft1S ~~JL~TY: STANDARD IND. CLASS CODE DUN AND BRADSTREET NUMBER AI~ --~ 1 2 3 . 5 6 7 . 9 10 11 12 13 Irans TV!!! IlaK IV@rage Annua I llenure 'Oys Cont Cant Cant Use location II""', 'by (ode Code AIIt AIIt Est Units on Site T YIII Prll' T eaI Cod, Stored In Facl Hty lit I ~ OJ:_.!:Et..__ _ IIøt . U.S. IIøbIr Ie Ha_ of Nh!tu.../eo.øan.nt. See Instruct ions ---------------------.----------------- ------ ~--. r--. ,..-.., ,..~ L._.J Reactivity L._.J Delayed L._.J Sudden RelHse ~.J l-.diate Hea I th of Pressure 11M I th CoiIQOIIent.2 1Ia.. C,I.S. bber ---- ------ ------ eo.panent 13 ..... C. A. 5. IIuIIber eo.pan.nt 1\ 11_' C.A,$. IIuIIbIr .- ------ ----- r-, ,.-., r--, ,.~ L. _.J React Ivity L. _.J Delayed L. _.J Sudden ReI.... '4J ¡-.cIilt, . HH Ith of Pl'tSsu... H..lth COIIØOIIent'2 11_' C.A.5. bber -- ---- (~..('a~..6 ________ ______ ---- ---- ,..Tl, r-., ,.-., ,.-., r"Vt LA.J fire !llurd L. _.J React;v;ty L. _.J Delayed L. _.J Sudden ReltaS! ~.J IM1!CIiate Hea Ith of Pressure Hea Ith COIIØOIIent'2 Ha.' C.A.5. IIu.ber ---------------------- ---- Cœøonent 13 H_' U.S. Nueblr ---l___L_________L____________l___________J____--'_____l___.1___-1-__1.___-1___ ------ --- ------------- Phys ica I IIId HN I tll Hazard (Check a11 that apply) C., . ~, Hullber ______________________ COIIponent II N_' C, A. 5. HUIIbtr .. -------------- ------ r-, ~-, r-" r-.., r-, L _.J Fir! !lnard L. _.J R!ðctiv;W L. _.J Delayed L. - -' Sudden Relean L. _.J IMediate Health of Pressure Health COIIIDntIIt 12 H_' C.A.S. Nlillber .---------------------------------------------- ------- CoiIpanent 13 H_' C.I.S. Nu.ber "ERGENCY CONTACTS .1 fI¡¡¡-ß..-4./.Big..--.sIldA.l.f..L-__ Tim-----tb.1-~--------- ~?~:~~---- .211____éhvI~~__~ aM -------- nm----~-ti----------- '21-'tl~1-~1-§- Certification (RelJd and sign after co.pierinl! ail sections) £ . I certify under penelty of law that 1 havl!! øersooallv I!!~alllined and.. fa.ihar with the infor\llltion subllitted in thi and 11..e doculllllts. Ind that based on "y inquiry of those individu.ls responsible for obtaining the infor..tion. I believe that the sub.itted inforllation is true, accurate, and cOllplete. R- --- --¡¡--n----l---rl---T-------r.:--------M------7--------~----.r=---=~----. -----r-r--- 5'·"'"''-''''' ._--~_._.._._......_. .,.-s---~::.!..:..:...í}---------------~---- ~W\@ an OTT'c,a en I!! OT OWOl!r¡ODerator u" ownl!!r operator s au"",rile<> reDresemaove 'qna\ure ..."II! '9ri~--