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BUSINESS PLA 7/15/2007
i SURGICARE SURGERY CENTER ~ ~ 4850 COMMERCE DRIVE #200 Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This _r~ermit is issued for the following: [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials [] Risk Management Program PERMIT ID # 015-021-002247 [] Hazardous Waste On-Site Treatment SURGICARE SURGERY :?~.~.~:~: LOCATION: 4850 COMMERCE ,~? '~'~':' '* ' Is SU ed by: Bake rsfield Fi re Depa ~ment ~~~ ~ OFFICE OF EN~R ONMENTAL SER ~CES' 1715 Chester Ave., 3rd Floor App~v~by: Issue ~te Bakersfield, CA 93301 Voice (661) 326-3979 F~ (661) 326-0576 Exp~tionDate: June 30~ 2003 UNIFIED PROGRAM INSPECTION.CHECKLIST SECTION 1: Business Plan and Inventory Program • Section 1: Business Plan and Inventory Program Id ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ~ ~q ^ RE-INSPECTION ~~ an r:esrt n F/RE ARTM Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661)_ 326-3979 Fax: (661) 872-2171 ~~ ITY NAME - _ - INSPECTION DATE INSPECTION TIME i ,,~y/C~cs,~~v -G~/~~/,cue-ss ~:nz ~-~6'~f ~-s-~' ADDRESS PHONE NO. NO OF EMPLOYEES ~ rY-r 2c~ ~ Z~ ~~ 3~w ld FACILITY CONTACT BUSINESS ID NUMBER ~Sln-4•~/ GJ ~ 15-021- ~zz ~7 C V (C=compliance OPERATION V=Violation COMMENTS I~^ APPROPRIATE PERMIT ON HAND ~ L°I ^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ENT O ~ ~ ~ ~ ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ~/ Lo J ^ VERIFICATION OF MSDS AVAILABILITY ~ / I,d' ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE _ ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? ^ YES ~NO EXPLAIN: QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (667) 326-3979 Inspector (Please Print) Fire Prevention / 1" In /Shift of Site/Station # Business Site /Responsible Party (Please Print) White -Prevention Services Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 Manager FAYE BERAERON Location: 4850 COMMERCE DR 200 City BAKERSFIELD BusPhone: (661) 327-3800 Map 102 CommHaz High Grid: 34B FacUnits: 1 AOV: CommCode: BFD STA 11 EPA Numb: SIC Code:8011 DunnBrad: Emergency Contact / Title Emergency Contact / Title MILAN SHAH MD j PHYSICIAN PAVAN SHAH / ACCOUNTING Business Phone: (661) 327-3800x Business Phone: (661) 327-3800x 24-Hour Phone (714) 381-0044x 24-Hour Phone (661) 900-8087x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact '~itr'KS~19~ S~~?'+r~o Phone: (661) 324-6720x MailAddr: PO BOX 11630 - - - State: CA City BAKERSFIELD Zip 93389-1630 Owner DARSHAN R SHAH MD Phone: (661) 327-3800x Address PO BOX 11630 State:. CA City BAKERSFIELD Zip 93389-1630 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A- HAZMAT ~`~'"p J U L 1~ ZOQ7 ~3aaed on my inquiry of those individuals _ respon,itle for obtaining the information, (certify uncior penalty of law that I have personally examiner' ~d am familiar with the information submi sd ,end believe the information is true, acc~ ~ ~e, nd complete, ~i- at ~ e Da e -~~( ~~ -1- 06./29/2007 F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP NITROUS OXIDE F P IH G 485.00 FT3 Hi OXYGEN F IH DH G 250.00 FT3 Low -2- 06/29/2007 -3- 06/29/200'7 F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: DR/MEDICAL GASES CLOSET CAS# 10024-97-2 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Gas TPure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 485.00 FT3 485.00 FT3 485.00 FT3 HAZARDOUS COMPONENTS °sWt . RS CAS# 100.00 Nitrous Oxide No 10024972 nr~c~e-u~L r~a ar,a~ri~lvl~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Hi ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid:. - SURGERY CTR/MEDICAL GASES CLOSET CAS# 7782-44-7 ~GasATE TPureE ~-AboveSAmbEent AmbientT~E PORTCOPRESSERCYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 250.00 FT3 250.00 FT3 250.00 FT3 raa~c~ri[u~vv.7 L.vi~irvl~~tvt.7 - - °~wt . ~ Rs -. cAS# 100.00 Oxygen, Compressed No 7782447 ru-~c,ru~L r~~ a~aarlrivl~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low -4- 06/29/2007 F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 10/10/2006 ~ ADMINISTRATOR, DIRECTOR OF NURSES, PHYSICIAN TO CONTACT EMERGENCY PERSONNEL. 911 AND OFFICE OF EMERGENCY SERVICES 800-852-7550. Employee Notif./Evacuation 02/22/2007 EMERGENCY CONTACT LIST IS UPDATED QUARTERLY AND POSTED IN STAFF LOUNGE, COPIES ~ KEPT I1~T-STAFF- RESOUR.CE~'~BINDERS -AND- IN`-CLINICAL AREAS . "EVACUATION ROUTES/EXITS POSTED IN CENTER WITH ILLUMINATED EXIT SIGNS POSTED ABOVE DOORS. Public Notif./Evacuation 10/10/2006 ADMINISTRATOR RESPONSIBLE FOR NOTIFYING AUTHORITIES, CALLING CLEAN-UP COMPANIES. CHAIN-OF-COMMAND: ADMINISTRATOR, BUSINESS OFFICE MANAGER, DIRECTOR OF NURSES. Emergency Medical Plan ~ 03/31/2006 THE SURGERY CENTER HAS EMERGENCY MEDICAL AND EVACUATION POLICIES AND PROCEDURES IN PLACE. SHOULD AN EMERGENCY HAPPEN, 911 WILL BE CALLED AND PATIENT/STAFF WILL BE TRANSFERRED TO THE NEAREST HOSPITAL. -5- 06/29/2007 F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site ~ Release Prevention 03/31/2006 STAFF ORIENTATION'AND TRAINING, POLICIES AND PROCEDURES IN PLACE BEFORE A HAZARD OCCURS. SPECIFIC POLICIES AND PROCEDURES FOR HANDLING, STORING, USING ANY HAZMAT. Release Containment 03/31/2006 CHAIN-OF-COMMAND. NOTIFY ADMINISTRATOR, WHO WILL THEN CALL PROPER AUTHORITIES-`AND- INFORM -STAFF :-~ -""-' ° ~ ~`-- - - -N"` - ~ - - -- Clean Up 03/31/2006 NOTIFY ADMINISTRATOR, STATE EMERGENCY. REFER TO MSDS. 'ENSURE SAFETY OF PATIENTS, STAFF, VISITORS BY MOVING A SAFE DISTANCE AWAY. ACTION PLAN TO BE IMPLEMENTED FOR SPECIFIC SPILL. CONTAIN SPILL USING ABSORBENT SHEETS AND PILL PILLOWS. COVER DRAINS. STOP LEAK. VENTILATE. CLEAN UP SPILL WITH SOLIDIFICATION TABLETS. CHECK MSDS TO DISPOSE PROPERLY. DOCUMENT SPILL CAUSE OF SPILL. DETERMINE REMEDIAL ACTION. Other Resource Activation -6- 06/29/2007 F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ .7~J~C:1d1 ticl'GdLU:i Utility Shut-Offs 01/26/2007 I NATURAL GAS/PROPANE: BACK OF BLDG . -WATER : ~ - E~ "SIDE-OF`BLDG- - - -~' - LOCKBOX: YES Fire Protec./Avail. Water 01/26/2007 PRIVATE FIRE PROTECTION: SIMPLEX GRINNELL - 24/7 MONITORING FOR FIRE ALARMS. SPRINKLER SYSTEM MAINTAINED BY SIMPLEX GRINNELL. FIRE HYDRANT: 4900 COMMERCE DR. DR WILLIAMS OFFICE FRONT OF BLDG. Building Occupancy Level 10 EMPLOYEES AND PHYSICIANS 02/22/2007 -7- 06/29/2007 __ F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 01/26/2007 ~ MSDS ON FILE IN NURSES STATION. BRIEF SUNIMARY OF TRAINING PROGRAM: TRAINING TO BE GIVEN BY AIRGAS PURITAN. INSTRUCTIONS ON GASES, ON AND OFF, EMERGENCY SHUT-OFF, ALARMS, TROUBLESHOOTING DANGERS AND HAZARDS. rayc ~ nciu iv.[. ru~.uic v~C azclu tvt rul.uLC VSC -8- 06/29/2007 ~~ BAKERSFIELD WELLNESS SURGERY CTR 'Manager ~~~ ~c CZC~c (Lo r- Location: 4850 COMMERCE DR 200 City BAKERSFIELD SiteID: 015-021-002247 BusPhone: (661) 327-3800 'Map 102 CommHaz High Grid: 34B FacUnits: 1 AOV: CommCode: BFD STA 11 EPA Numb: SIC Code:8011 DunnBrad: Emergency Contact / Title Emergency Contact / Title MILAN SHAH MD / PHYSICIAN PAVAN SHAH / ACCOUNTING Business Phone: (661) 327-3800x Business Phone: (661) 327-3800x 24-Hour Phone (714) 381-0044x 24-Hour Phone (661) 900-8087x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHltfi Contact " ~~`~ $c~~.~C-C~t~ Phone: (661) 324-6720x MailAddr: PO BOX 11630 State: CA City BAKERSFIELD Zip 93389-1630 ........... Owner DARSHAN R SHAH MD Phone: (661) 327-3800x Address PO BOX 11630 State: CA City BAKERSFIELD Zip 93389-1630 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT Based on my inquiry of those individuals the informatio ~ y e responsible for obtaining rsonatl that I have p under penalty of law nd am familiar with the information examined a d and believe the information is true, submitte accurate, and complete. EtY~ F E B 2 2 2007 _ ~ \~~~ --"°°° Date Si ture -1- 01/26/2007 F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP NITROUS OXIDE F P IH G 485.00 FT3 OXYGEN F IH DH G 250.00 FT3 ~~w -2- 0l/26/~bo7 -3- O1/26/Zb07 P BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ ' COMMON NAME / CHEMICAL NAME NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: DR/MEDICAL GASES CLOSET CAS# 10024-97-2 ~GasATE TYPE T PRESSURE TEMPERATURE CONTAINER TYPE TPure I Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 485.00 FT3 485.00 FT3 ~ 485.00 FT3 HAZARDOUS COMPONENTS %Wt. RS CAS# 100.00 Nitrous Oxide No 10024972 t1E'~GKKL 1~5JJ;551~1J;1V 1 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Hi ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME °" OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: -- SURGERY CTR/MEDICAL GASES CLOSET CAS# 7782-44-7 STATE T TYPE PRESSURE TEMPERATURE CONTAINER TYPE ~GaS I Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 250.00 FT3 250.00 FT3 250.00 FT3 riEiG1-1CCLVU.'~ 1..V1~lYV1VJ;1V 1.7 %Wt. RS CAS# 100.00 Oxygen, Compressed No 7782447 ri1~GEitCL HJJJ;~~1~11;1V1a TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Lr7vu -4- 01/26/2007 F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ Fast Form~:t ~ ~ Notif./Evacuation/Medical Overall Sits ~ ~ Agency Notification 10/10/2005 ~ ADMINISTRATOR, DIRECTOR OF NURSES, PHYSICIAN TO CONTACT EMERGENCY PERSONNEL: 911 AND OFFICE OF EMERGENCY SERVICES 800-852-7550. Employee Notif./Evacuation Public Notif./Evacuation 10/10/20(75 ADMINISTRATOR RESPONSIBLE FOR NOTIFYING AUTHORITIES, CALLING CLEAN-UP COMPANIES. CHAIN-OF-COMMAND: ADMINISTRATOR, BUSINESS OFFICE MANAGER, DIRECTOR OF NURSES. Emergency Medical Plan 03/31/2005 THE SURGERY CENTER HAS EMERGENCY MEDICAL AND EVACUATION POLICIES AND PROCEDURES IN PLACE. SHOULD AN EMERGENCY HAPPEN; 911 WILL BE CALLED AND PATIENT/STAFF WILL BE TRANSFERRED TO THE NEAREST HOSPITAL. -5- 01/26/2007 F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Sits ~ ~ Release Prevention 03/31/20F7i~ ~ STAFF ORIENTATION AND TRAINING, POLICIES AND PROCEDURES IN PLACE BEFORE A HAZARD OCCURS. SPECIFIC POLICIES AND PROCEDURES FOR HANDLING, STORING, USING ANY HAZMAT. Release Containment 03/31/20k~5 CHAIN-OF-COMMAND. NOTIFY ADMINISTRATOR, WHO WILL THEN CALL PROPER AUTHORITIES AND INFORM STAFF. Clean Up 03/31/20l7~5 NOTIFY ADMINISTRATOR, STATE EMERGENCY. REFER TO MSDS. ENSURE SAFETY OF PATIENTS, STAFF, VISITORS BY MOVING A SAFE DISTANCE AWAY. ACTION PLAN TO }3E IMPLEMENTED FOR SPECIFIC SPILL. CONTAIN SPILL USING ABSORBENT SHEETS AND PILL PILLOWS. COVER DRAINS. STOP LEAK. VENTILATE. CLEAN UP SPILL WITH SOLIDIFICATION TABLETS. CHECK MSDS TO DISPOSE PROPERLY. DOCUMENT SPILL CAUSE OF SPILL. DETERMINE REMEDIAL ACTION. V1.11C 1. iCC .S'V UI_UC HC: l.1Vdl.1 U11 -6- Ol/26/~~07 F BAKERSFIELD WELLNESS SURGERY CTR ~ SiteID: 015-021-002247 ~ Fast Format ~ ~ Site Emergency Factors Overall Sits ~ ~ Special Hazards """ N~~ . Utility Shut-Offs NATURAL GAS/PROPANE: BACK OF BLDG WATER: E SIDE OF BLDG LOCKBOX: YES 01/26/2007 Fire Protec./Avail. Water 01/26/2007 PRIVATE FIRE PROTECTION: SIMPLEX GRINNELL - 24/7 MONITORING FOR FIRE ALARMS. SPRINKLER SYSTEM MAINTAINED BY SIMPLEX GRINNELL. FIRE HYDRANT: 4900 COMMERCE DR. DR WILLIAMS OFFICE FRONT OF BLDG. Building Occupancy Level 10 EMPLOYEES ~~~ ~~~~ \C~~ 11/30/2006 -7- Ol/26/~007 ,~ S F BAKERSFIELD WELLNESS SURGERY CTR SiteID: 015-021-002247 ~ Fast Formal ~ ~ Training Overall Sites ~ '~ Employee Training 01/26/2007 ~ MSDS ON FILE IN NURSES STATION. BRIEF SUMMARY OF TRAINING PROGRAM: TRAINING TO BE GIVEN BY AIRGAS PURITAN: INSTRUCTIONS ON GASES, ON AND OFF, EMERGENCY SHUT-OFF, ALARMS, TROUBLESHOOTING DANGERS AND HAZARDS. rciyc ~ nciu tvi ru~u.cc USC ............ u ure se -8- 0l/26/200~ . ~ ~`~ ~HnnnnP~ BAKERSFIELD FIRE DEPT. HAZARDOUS MATERIALS MANAGEMENT PLAN Prevention Services (UNIFIED PROGRAM CONSOLIDATED FORM) 9OO TrUxtUri AVe., Suite 210 _ . - __ ; ~ :. --- :~ _..__: _ ! B B R S P i n Bakersfield, CA 93301 F AI T Tel.: (661) 326-3979 APPLICA710N A T ONVNER/OPEfiATOR DENTFIIJgiTION FORM ` ' ~ Fax: (661) 852-2171 (HAZARDOUS MATERIALS FACILITY INFORMATION) ~ ' Page 1 of 2 ~ , . , I. FACILITY IDENTIFICATION FACICrfY ID NO. 1 Year Begin~r~ ^~ 100 (r Year Ending 101 BU INESS N (S a as FACT ITY NAME or DB -Doing BWSiness As 3 ~1.Kersi-e~c~, Werlness ~ e~ BUSINESS PHONE 102 (o i • aa~ • 3800 SITE ADDRESS 10g ~ 850 COm nner~e~ ~- ~°•e~ . ~ 200 c -~i ~~ ,p< cA .P 33 DUN~N 8 F~RADSTF~EET~ ~ Q ~ ~ ~ _ ~ ~ ~ ~ ~~ ~ t~ I ~{ ~~ (IC CODE _ ~ 4 Digit #) 107 COUNTY t Kern OP TOR 7AM_E p - n In 10s VtLC~ 1~ . Sl'LGLKi. ~- ' V • OPE~TOR PHONE 110 ~O 1 / ~~Z~ ~ ~~~ IL OWNER INFORMATION OWNER NAME ttt M -a. R I h ~ ~ )OWNER PHONE t lO ~ ~a 3 S ao OWNER MAILING ADDRESS t13 P- n - ~~x I ((0 3 r7 CITY 1ta ~ake~~~f~ ~c~ STATE 115 Cn . Ip 11a a33g IIL ENVIRONMENTACCONTACT' CONTACT NAME m ~ar1 ~acc,m~n~". CONTACT PHONE na 1~to l ~ 3~.~ -1~7a-D CONTACT (LING ADDRESS 11a CITY ~~, r-~~ t2o STATE ~ 121 ZIP ~~ t~ .PRIMARY Iv. EMERGENCY CONTACTS `-SECONDARY- " NAME 123 Mi I ~~ M ~-p. ~ N E 128 ~~~a-~ . TITLE 124 Ph s TITLE 129 -li - ci~a,r,.., n n USI PHONE 125 to lP 3a - 38 as USIN S PHONE 130 c~~ 3~7 - soa HO P NE 126 ~ i ~+ 3S 1-- ©t~ ~-~ 24-H UR PHONE 131 ~rDi q oo-gag 7 PAGER NO. 127 PAGER N0. 132 133 V. CERTIFICATION Cert~cation: Based on my inquiry of those ind:i~riduals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted in this inventory and believe the information is true, accurate, and complete. SIGDMTU OF SI ER ~~ 136 - `~ DATE 134 z~~~~ NAME OF DOCUMEN PREPARER 135 ~ ~ K ~ t~..r r~ um o NAME OF N IbOP R (SDIGNATURE & PRINT) 137 TITLE OF OWNER/OPERATOR 136 /~ ~~ n .~ In ~, ~~p ~ 'f ~ ,. FD 2142 (Rev. 09/05) (Hazardous Materials Facility Informatioot~ - HMMP) Business Owner/Operator Identification Please submit the Business Activities page, the Hazardous Materials Faci/itylnformation (HMMP) BuSan~;ss Owner/Operator Identification Form; and Hazardo~ Materials Inventory Chemical Description Form for all hazardous materials inventory submissions. For the inventory to be considered, please complete this page, it must tie signed by the appropriate individual. NOTE.• The numbering ofthe instructions fo/%ws the data e%ment numbers that are on the Business ~OHVner Operator Form page. These data a%ment numbe are used fore%tronic submission and are the same as the numbering used in 27CCR, Appendix C, the Business Section ofthe UniTied Program Data Dictionary. P/ease numbers//pages ofyoursubmilta/. This he/ps our CUPA orAA identity whether the submitta/is complete and ifany pages are separated. 1 FACILITY LD. NUMBER -This number is assigned by the CUPA or AA. This is the unique n~wmber which identifies your facility. 3 BUSINESS NAME -;Enter the full legal name of the business. _ , -___ 100 BEGINNING DATE - Enter'the beginning year and date of the report. (YYYYMMDD) - • 101 ENDING DATE -Enter the ending year and date of the report. (YYYYMMDD) ~ ' 102 BUSINESS PHONE -Enter the phone number, area code first, and any extension ' 103 BUSINESS SITE ADDRESS -Enter the street address where the facility is logted. No post ~cpffice box numbers are allowed. This information must provide a means to geographically locate the facility. ' 104 CITY- Enter the city or unincorporated area in which business site is located. 105 ZIP CODE -Enter the zip code of business site. The extra 4 digit zip may also be added. ' 106 DUNN & BRADSTREET -Enter the Dunn & Bradstreet number for the facility. The Dunn & IBradstreet number may be obtained by calling (610) 882- 7748 or by intemet. ' ' 107 SIC CODE -Enter the primary Standard Industrial Classfication Code numtaer for primary hoariness activity. . NOTE.• lfcode is more than 4 digits, report on/y the first four. • 108' COUNTY -Enter the county in which the business site is located. 109 BUSINESS OPERATOR NAME -Enter the name of the business operator. 110 BUSINESS OPERATOR PHONE -Enter business operator phone number, ff different from Ibusiness phone, area code first, and any extension. 111 OWNER NAME -Enter name of business owner, if different from business operator. ' 112 OWNER PHONE -Enter the business owner's phone number if different from business phone., area code first, and any extension. 113 OWNER MAILING ADDRESS -Enter the owner's mailing address 'rf different from business site address. , , 114 OWNER CITY -Enter the name of the city for the owner's mailing address. 115 OWNER STATE -Enter the 2 character state abbreviation for the owner's mailing address. 116 OWNER ZIP CODE -Enter the zip code for the owner's address. The extra 4 digit zip may also be added. ' 117 ENVIRONMENTAL CONTACT NAME -Enter the name of the person, if different from the Business Owner or Operator, who receives all environmental correspondence and will respond to enforcement activity. 118 CONTACT PHONE -Enter the phone number, if different from the Owner or Operator, at whidh the environmental contact can be contacted, area code first; and any extension. 119 CONTACT MAILING ADDRESS -Enter the mailing address where all environmental contact correspondence should be sent, if different from the site address. ' 120 CITY-Enter the name of the city for the environmental contact's mailing address. 121 STATE -Enter the 2 character state abbreviation for the environmental contact's mailing address. • 122 ZtP CODE -Enter the zip code of the environmental contact's mailing address. The extra 4digit zip may also be added. 123 PRIMARY EMERGENCY CONTACT NAME -Enter the name of a representative that can tae contacted in case of an emergency involving hazardou materials at the business site. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regardint incident mitigation. - - 124 TITLE -Enter the title of the primary emergency contact. 125 BUSINESS PHONE -Enter the business number for the primary emergency contact, area omde'first,!and any extensions. ~ t 126 24HOUR PHONE - Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day. If it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individu, stated above. , , ~ < 127 PAGER NUMBER -Enter the pager number for the primary emergency contact, if available, 128 SECONDARY EMERGENCY CONTACT NAME -Enter the name of a secondary representative that can be contacted in the event that the primary emergency contact is not available. The contact shall have FULL facility access, sfte familiarity, and authority to make decisions for the business regarding incident mitigation. - 129 TITLE -Enter the title of the secondary emergency contact. , 130 BUSINESS PHONE -Enter the business telephone number for the secondary emergency contact, area code first, and any extension. 131 24-HOUR PHONE - Enter a 24-hour phone number for the secondary emergency contact. Tine 24-hour phone number must be one which is answered 24 hours a day. If it is not the contad's home phone number, then the service answering the phone must be able to immediately contact the individual stated above. 132 PAGER NUMBER -Enter the pager number for the secondary emergency contact, if available. 133 ADDITIONAL LOCALLY COLLECTED INFORMATION -This space may tae used for CUPA's nor AA's to collect any additional information necessan to meet the requirements of their individual programs. Contact your local agency for guidanoe. 134 DATE -Enter the date that the document was signed. (YYYYMMDD) •135 NAME OF THE DOCUMENT PREPARER (FULL PRINTED NAME) -Enter the full printed name of the persornwho prepared the inventory submittal information. 136 NAME OF DOCUMENT SIGNER (FULL PRINTED NAME) -Enter the full printed name of the person signing the page. The signer certifies to a familiarity-with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information, all the information submitted is true, accurate and complete. 137 SIGNATURE OF OWNER/OPERATOR/OR DESIGNATED REPRESENTATIVE -The Business Owner/Operator, or officially designated representative of the Owner/Operator, shall sign in the space provided. This signature certifies that the signer is familiar with the signer's belief that the submitted information is true, accurate and complete. 138 TITLE OF OWNER/OPERATOR/OR DESIGNATED REPRESENTATIVE (SIGNER) -Enter the title of the person signing the page. Page 2 of 2 FD 2142 (Rev. 09/05) -, ft FI. ' HAZARDOUS MATE IALS MANAGEMENT PLAN ~ ~~ BAKERSFIELD FIRE DEPT. ~__ =-:. i~ _ APPLICATION ~ ~ FOR SECTION DISCOVERY AND ~ NOTIFICATION (FORMS) ~ ': INSTRUCTIONS 1. 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. Be as brief and concise as possible. -- -~ St(r'CIV,N 1: hAC{LIJ Y fUtN t trll:Al fVN - - - _ - - -- BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) Pxtker~-~~(d~ irv~l ~~ess ~S~c.-r ~ C~-~-~ ADDRESS (For local use only) X850 ~m m_ -e--e ~ J7ri v~e} ~~i- e ~0 0 FACILITY ID N0. ~ SECTION 11.1: DISCOVERY AND NOTIFICATIONS _ A. LEAK DETECTION AND MONITORING OCEDURES: P~ss~ ~ ~ til.a,f -`ern I ~o tom(, o ~~?~~~ -~- B. EMPLOYEE AND AGENC N TIFICATION: ~YY) J~ C:~.~ P-Er51~7~. n 2~' ~ ~ q -1-1 a~ o-F~ cam, c7~ P~ ~~-~n C~ c~¢rv-~-CLS J ~ ssw ~5~ - 55~ lntC.~~EN,,VIRONMENTAL RESPLONS~E MANAGEMENT: I- /~ t'CG~~'n ~S~q;T tr1' 1"'~2SPOYkS~ U~ v T"~' I~ ~ ~ i ny Q,1,(`~ o~~t ~S ~ Ca I L,U~q C. I ~U..~ - t~ C~rn('~~eS , Cha,(.~ of ~~mmct,ncQ. /~c~-min~islvz(~aY'~ P;~us-I~J>°ss D-(-j~C..e, D. EMERGE Y MEDICAL PLAN: "~ Y, S (,~~ C ~-~1-~ f,~ hQ S ~C~i ~'' .L,~~'~ ~1 C (.p ' I ' eCI~ n (J -VIA t L ~ a cuct.~ fi o~ ~ o I i ~ ~ e s ~ ~ e~c,~s iy,., Lae e . J ~h 1~Q~ c~,n ~w~n ~~-u,~ c~~ `~'"~-P~-e. ru~~,~,ot hog -Iz~..e. SECTIr~N 11.2: RELEASE RESPONSE PLAN -- - --- - A. HAZARD ASSESMENT AND PREVENTION MEASURES:: S-~ p~~-~- -~ ~(,~ ~ 1~~~,(,yl'~ ~ ~„C~/J cy V Qrucc~cL~,~,~ ~•, PIu~=Q- ~~~~a hazr.;-~ .~c~~~.rs. ~S~ec~~~~ o.~c.Gce~ ~ G~c~CS ~ hCU~G~ L~ ~-I~r-Vlc. l.(S C,nc aYl L hC1zCUl U~~ Cl.u1JLCG ~ . B. RELEASE CONTAINMENT AND/OR MITIGATION: ~R CL~~ ~ n ~~ n ~ ~ ry ~~~~' 1 ~~ ~ -~~-'~ Cali I ` L,- CK l~l ~~~'' ~ ~ d~ C. CLEAN-UP AND RECOVERY PROCEDURES: ~ ~ -i-( ' ~~~^-~-~~v~/'~ 5'~~ ~~ ~.~~~,.,, r ~ ~ DS - nsu.r-e scc...~ u~- P~~`~~ as-t~-=~~ ~ v ~ ,=1-~rs by ~,,~ ~ `~`IJ a d, ~~~fzz~.C~ . G[,u~ cu ~c~ l C(.~-~. +~ bx- - _ p ~m.e~,.-E ~~ -o-~- ~ ~-e c~i.~~ s ~e. ._ ~ Un ~ _s P ~ abs a~r -~ ~- s ~ ~~..~u?s . ~~ ct.~-cur-s ~ lQ.~ k.. ~/~~ . a , (~'n „ _ ('~_ ~ ~ n~ ~/ ~ wl.L7~ ~'-'`~r~C/~~-b-.~ ~~~l~Q~~~ ~j., /~ n. n _ 6~ G ~S~s -~F ~ 69 (Rev. 09105) L~~!, ~~ ~p~C r"~~1~.~ ~~ ~ t~~QJ ~ ~rlj~)/CJC~. 1, ~ \-lr/CiVCi ~~ Prevention Services H S a s F I D P/Re 900 Truxtun Ave., Ste. 210 wRTl1I T Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 Page 2 of 2 SECTION II 2 RELEASE ,RESPO PLAN-DON'T. .: - ;:1 SAT YO U R FACILIT Y) UTILITY SHUT-OFFS (LOCATION OF SHUT-0FF Y ' n n~ , .~, ~ ~ p NATURAL GAS/PROPANE: ~ ~.ll/`-C/ F~~ ~-~..~./ L ELECTRICAL: WATER: ~ICJ~ti SPECIAL: PRNATE FIRE PROTECTIONNVATERAVAlLABILITY: A PRNATE FIRE PROTECTION: -7 , ~A .~N 1 d o~ n/~ h 1 ~/ ~h.~C~G ~ 5/. ~Q ~j q~ pp A~ yy I ~ / , y~ ~~ ~ y~ B. WATER AVAILABILITY (FIRE HYDRANT): I~~~.resf ~~r~ h dre~.v~t is /acaf~~ c~~ ~t9©+~ Cvrn.n~er~e~ ,~`~ vim, .,,. -- ~. .~~ .z ,. ,_ -- SECTION-III: TRAINING ,. n _: _ _-_ __ NUMBER OF EMPLOYEES: ' MATERIAL SAFETY DATA SHEETS ON FILE: c ~ ~ ac~~ ~~ t;r~ ~ s B EF SUMMARY OF TRAININ ROGRAM: ' ~-rQ~Cr~,r_;v1 ~ b2 91 v~e.~- ~~l ~`- r~t~c~ S 1' (~x1,.~a.t.-~ .. .fin s-~tC,~ OYl s p n aQS' ~S •. i7~" ge,~ andt ~ hc~za,,-~s , . CERTIFiCA~TION Based on my inquiry of those individuals responsible for obtaining the information, 1 certify ender penalty of law that 1 have personally examined and a familiar with the information submitted and believe the information is tnr+e, accurate, and complete. SIGNATG O R / PERATOR OR DESIGNATED REPRESENTATIVE DATE 477 ti~'~-~~O~o~ NAME OF SIGNER (print) 478 TITLE OF SIGNER 479 FD 2169 (Rev. osios) ~;-, r~ (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN ~' `~ UNIFIED PROGRAM CONSOLIDATED FORMS ~ H B R S P t D -,j F/R6 CHEMICAL DESCRIPTION FORM `_,~~ ~` HAZARDOUS MATERIALS INVENTORY NEW ^ ADD ^ DELETE ^ REVISE 200 BAKERSFIELD FIRE DEPT. ~' Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-21'71 (One form per material, per building, or area.) Paae1 of 2 _ _____ FACILITY INFQRMATfON BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) Bak ~ ~ CHEMICAL LOCATION 201 CHEMICAL LOCATION 20 D ~O n I ~~ l.~ ~( CONFIDENTIAL (EPCRA) ^ Yes ^ N FACILITY No. ~ 1 MAP No. (optional) 203 GRID NO. (optional) - - 20 _ - _ IL`CHEMICAL INFORMATIiI~N _ _ __ __ _ _ _ CHEMICAL NAME 205 20 /~ i TRADE SECRET ^ Yes ^ No COMMON NAME 207 . ~ EHS' ^ Yes ^ No ~' ~ 20 CAS No. 209 'If EHS is "Yes;' all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 21 TYPE 211 212 CURIES 21 p PURE ^ m MIXTURE ^ w WASTE RADIOACTIVE: b Yes ~No PHYSICAL STATE ^ s SOLID ^ I LIQUID ~g GAS 214 LARGEST CONTAINER ~-g~ rccb~ ~t- ~ Ind P.-~ -~' 21 FED HAZARD CATEGORIES ~~~,,, ~~~/// yq 1 FIRE ^ 2 REACTIVE ~3'PRESSURE RELEASE ~4,ACUTE H EALTH ^ 5 CHRONIC HEALTH 21 (Check all that apply) r ANNUAL WASTE 217 MAXIMUM 21g AVERAGE 219 STATE WASTE 22 AMOUNT DAILY AMOUNT DAILY AMOUNIr CODE 221 222 ^ UNITS ^ ga GAL ~ ~~ CU FT ^ Ib LBS ^ to TONS DAYS ON SITE 2 / If EHS, amount must be in lbs. J [ O 22 STORAGE CONTAINER (Check all that apply) ~ a ABOVEGROUND TANK ^ f CAN ^ k BOX ^ p TANK WAGON ^ b UNDERGROUND TANK ^ g CARBOY I CYLINDER ^ q RAIL CAR ~(~ c TANK INSIDE BUILDING ^ h SILO ^ d STEEL DRUM ^ i FIBER DRUM ^ n PLASTIC BOTTLE ^ e PLASTIC/NONMETALLIC DRUM ^ j BAG ^ o TOTE BIN 22 STORAGE PRESSURE ^ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 22 STORAGE TEMPERATURE ^ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT ^ c CRYOGENIC %WT 'HAZARDOUS'CO MPONENT E HS # C . i AS 1 226 227 ^ Yes ^INo 228 22 2 230 ~ 231 ^ Yes ^INo 232 23 3 234 235 ^ Yes 17 No 236 237 4 238 239 ^ Yes ^ No 240 241 5 242 243 ^ Yes I~ No 244 24 IIL SiGNATt1RE , ---- PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE .. fl A n ~ FD 2144 (Rev. 09105) CALIFORNIA WASTE CODES Code Description Inorganics III Acid solution 2 < pH < 7 with metals (antimony, arsenic, barium, beryllium, cadmium, chromium, cobalt, copper, lead, mercury, molybdenum, nickel, sellenium, silver, thallium, vanadium and zinc) 112 Acid solution without metals 113 Unspecified acid solution 121 Alkaline solution pH >12.5 with metals (see 111) 122 Alkaline solution without metals 123 Unspecified alkaline solution 131 Aqueous solution (2 < pH < 12.5) contain- ing reactive anoins. (azide, bromate, nitrite, Perchlorate and sulfide aniions) 132 Aqueous solution with metals (seep 111) 133 Aqueous solution with total organic residues 100% or more 134 Aqueous solution with total organic residues less than 10% 135 Unspecified aqueous solution 141 Off-spec, aged, or surplus inorganics 151 Asbestos containing waste 161 FCC Waste 162 Other spent catalyst 171 Metal sludge (see 111) 172 Metal dust and machining waste Qsee 111) 181 Other inorganic solid waste Organics 211 Halogenated solvents (methylene chloride, chloroform, TCE, TCA) 212 Oxygenated solvents (acetone, butanol, MEK) 213 Hydrocarbon solvents (stoddard solvent, xylene) 214 Unspecified solvent mixture 221 Waste oil and mixed oil 222 Oil/water separation sludge 223 Unspecified oil -containing waste 231 Pesticide rinse water 232 Pesticide and other waste associated with 241 Tank bottom waste 251 Still bottoms with halogenated organics 252 Other still bottom waste 261 PCB's and material containing PCB's 271 Organic monomer waste (includes Code Description Organics (con't) 272 Polymeric resin waste 281 Adhesives 291 Latex waste . 311 Pharmaceutical waste 321 Sewage sludge 322 Biological waste other than sewage sludge 331 Off-spec, aged or surplus organics 341 Organic liquids (non-solvents) with halogens . 343 Unspecified organic liquid mixture 351 Organic solids with halogens Sludges 411 Alum and gypsum sludge 421 Lime sludge 431 Phosphate sludge 441 Sulfur sludge 451 Degreasing sludge 461 Paint sludge ~ •~ -- 471 Paper sludge/pulp 481 Tetraethyl lead sludge 491 Unspecified sludge waste Miscellaneous 511 Empty pesticide containers 30 gal or more 512 Other empty container 30 gal or more 513 Empty containers less than 30~ga1 521 Drilling mud , 531 Chemical toilet waste 541 Photo chemical/photo processing waste 551 Laboratory waste chemicals 561 Detergent and soap 571 Fly ash, bottom ash, and retort ash 581 Gas scrubber waste 591 Bag house waste 611 Contaminated soil from site clean-ups 612 Household wastes Page 3 of 3 FD 2144a (Rev. 09/05) .• , (HMMP) ~~ HAZARDOUS MATERIALS MANAGEMENT PLAN UNIFIED PROGRAM CONSOLIDATED FORMS CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIALS INVENTORY ~~ NEW !"I ADD ^ DELETE ,^ REVISE 200 BAKERSFIELD FIRE . I~@VCIIt10II .~lV1C@S 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 (One form per materrai, per cui;drng. or area.) D.~nn1 of 7 1. FACiLiTY`iNFORMATION ~ ; B SINESS NAME (Sam as FACILITY NAME or DBA -Doing Business As) ~. CHEMICAL LOC TION ` 201 CHEMICAL LOCATION t, q /~ 9~ (' I n ~ , ~' ~~+~x-[~.C.CY~ ~ C~ ~ UO~ CONFIDENTWL (EPCRA) ^ Yes FACILITY No. ~ MAP No. (optional) 203 GRID NO. (optionar) . .. 1L CHEMICAL INFORMAT N - CHEMICAL NAME 205 TRADE SECRET ^ Yes ^ No COMMON N 207 EHS• ^ Yes ^ No CAS No. 209 'If EHS is °Yes,° all amounts below mu in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) TYPE 211 RADIOACTNE: ^ Yes 21 ~aNO CURIES ~p P URE ^ m MIXTURE ^ w WASTE LARGEST CONTAINER PHYSICAL STATE ^ s SOLID ^ 1 LIQUID ~g GAS 214 ~~ ~ ~ ~~~~~r l-~I FED HAZARD CATEGORIES ~q t FIRE ^ 2 REACTNE ~3 PRESSURE RELEASE ^ 4,ACUTE HEALTH ^ 5 CHRONIC HEALTH (Check all that apply) , ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 STATE WASTE AMOUNT DAILY AMOUNT DAILY AMOUNT CODE 221 ^ UNRS ^ ga GAL ~(~ CU FT ^ Ib LBS t7 to TONS /' DAYS ON SfTE ff EHS, amount must be in lbs. ` STORAGE CONTAINER (Check at! that apply) ~ a ABOVEGROUND TANK C1 f CAN ^ k BOX ^ p TANK WAGON I] b UNDERGROUND TANK C7 g CARBOY ! CYLINDER ^ q RAIL CAR c TANK INSIDE BUILDING ^ h SILO T ^ d STEEL DRUM f 7 i FIBER DRUM ^ n PLASTIC BOTTLE ^ e PLASTIClNONMETALLIC DRUM ^ J BAG C7 o TOTE BIN STORAGE PRESSURE ^ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT STORAGE TEMPERATURE ^ a AMBIENT U as ABOVE AMBIENT f] ba BELOW AMBIENT ^ c CRYOGENIC 0 /oWT HAZARDOUS COMPONENT -' ~EI•iS.. CAS.# - .: 1 226 227 ^ Yes CJ p1o 228 rt, 2 230 231 ^ Yes ("IINo 232 3 234 235 ^ Yes O No 236 4 238 239 ^ Yes ^ No 240 5 242 243 ^ Yes ^ No 244 I11. SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE ~e rn t `l J r~,r`~ ., F-RB AI~T~ T _..~;. ru c144 t,rcev. vaiu: (HMMP) HAZARDOUS MATERIALS MANAGEMENT' PLAN Y2"-` INSTRUCTIONS SITE & FACILITY DIAGRAM ~`~ B B R S A] D F/RB ~Rrr r <4 d ~~ BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 These instructions explain the use of the site diagram and the facility diagram. Normally, small and medium size businesses will only have to submit a site diagram. If you have subdivided your business into smaller areas because of the complexity or size,, then you will be completing and additional detail map, facility diagram, for each of these areas. Include instructions that show the route to your business if it is in a remote location. All diagrams must be on 8 '/2 x 11" paper and drawn using a straight edge tool. SITE DIAGRAM INSTRUCTIONS The site diagram is used to show your business and to indicate the businesses that immediately surround your property, usually within 300 feel If you will be showing specific area detail on facility diagrams, use the site diagram to show an overall layout of the plant. If you will not be submitting facility diagrams, the site map must include all of the following information: 1. Check the box on the top left corner of the form provided that indicated "Site Diagram". 2. Print the name of your business, as shown in your FIlVIlVIP, on the top of the diagram. 3. Label the location of the hazardous materials and identify them by name and type of hazard (i.e., flammable liquid, corrosive solid). 4. Label the location of utilitly shutoffpoints for gas, electric and water services. 5. Label the location of fire hydrants. 6. Label portions of the bundling protected by automatic sprinkler systems. 7. Label the direction representing north on the diagram. (The diagram form provided includes _, a, north arrow). 8. All labeling and identifiicaution on the diagram must be legible and easily understandable at the scale submitted. Diagrams must be sufficiently legible to produce a legible copy. Try to avoid the use of abbreviations or symbols. If you must use them, provide a legend explaining your system. Maps may be returned for correction if you fail to follow these instructions. z FACILITY DIAGRAM INSTRUCTIONS ,..,; Facility diagrams.are supplemenNs to the site diagram. Use them to show the subdivision details of a large business. 1. Check the box in the upper right hand corner of the form provided that indicated "Facility Diagram". 2. Print the name of your business as shown on your >-IlVIlVIP. Print the name of the area that this map represents. This name should be the same name that you used on this area's inventory report. 3. Indicate which area the diagram~iepresents and the total number of facility diagrams that you are including. If a map represented the first of four areas, it would be labeled # 1 of 4. 4. Follow instructions (3 -8')~* for site diagrams regarding the specific details to be included on each facility diagram. UNDERGROUND STORAGE TANK FACILITIES PLEASE NOTE: * If you operate an Underground Storage Tank (LIST) facility, the facility diagram shall also specify the location(s) of the UST continuous leak monitoring system and/or the location(s) where the UST monitoring will be performed. FD 2170 (Rev. 09/05) ~ ~~ -r (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN C= ~~ SITE & FACILITY DIAGRAM i Page 2 of 2 P _ r 3 ~~ ~ S ~. BAKERSFIELD FIRE DEPT: Prevention Services $ $ a s r ' ~ 900 Truxtun Ave., Suite 210 f/RB Bakersfield, CA 93301 A~ r Tel.: (661) 326-3979 Fax: (661) 852-2171 SITE DIAGRAM FADIILITY DIAGRAM Business Name: ~jQ,~P.i~S-~-~~ CL ~N.~l ~ n25s ~.LU'~~ C~.n.~--~ _ Business Address: ~, g~~ ~ m m 3Ct.Kers~, e~c~~ Cry .. q 3~ ~~ z~ wa ~ ~. o o ~ `Ur s ~p J O o o ( ~/ F D v o Q K Z cC ~ C/1 2 ~ ~ ~' 0 O fd ~ .~ F+ o ~ U X ~,; W W - i W o ~ t~ 4;- a. ~ g it O ~ W ~ ~ w aW( ~ U' ~~ 4Q ~ W W ~_ X ~ - ' Please indicate direction of North FD 2170 (Rev. 09/05) UPdif1E°O PROGRAM INSPECTION CHECKLIST SECTION 1 Business Plan and Inventory Program Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME INSPECTION DATE PHONE No INSPECTION TIME of Employees No ADDRESS ~' ---_~SO ~G/K rK c:r2cG r_.~oo--------------- ----- . (pta~~ -IIR-~,~ . _S_-lD----- - FACILITYCO TgCT i S ~ e ~ '' Business ID Number 15-021-a+o zz ~{ U Section 1: Business Plan and Inventory Program ^ Routine Combined ^ Joint Agency ^Mnlti-Agency ^ Complaint ^ Re-inspection C I~ V ^ IV=V'oationncel OPERATION APPROPRIATE PERMIT ON HAND COMMENTS ~. l~ ^ ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE VISIBLE ADDRESS -- ------------- - ---- ---._.-----------_ __ ------------------- ^ CORRECT OCCUPANCY 3 '[ b' 20d I~ ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITYE l~ ^ VERIFICATION OF HAT MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES (~ ^ ^ EMERGENCY PROCEDURES ADEQUATE CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING - --------•---------------------------- - ^ ^ - ----- -- FIRE PROTECTION SITE DIAGRAM ADEQUATE & ON HAND --------------------- - ------ \~~%/ ~ l/ft//N s t~ ANY HAZARDOUS WASTE ON SITE: ^ YES ~NO S ~ / / ~~ EXPLAIN: QUESTIONS EGAR G T S INSPECTIONS PLEASE CALL US AT ~66'I~ 32B-39T9 ._!' In pector -------------- - -- Badge No White -Environmental Services Yellow - Statbn Copy Busines to Respon ible Pa Pink -Business COPY r .. BAKERSFIELD FIRE DEPT. d~ Prevention Services FIRE PREVENTION INSPECTION a eF~BE t ~ 900 Truxtun Ave., ste. 210 AB1M ~ Bakersfield, CA 93301 Tel.: (661) 326-3979 ^ Fax: (661) 852-2171 DISTRICT BLOCK NO. DATE y,~ f ~ ~ ~ EE [')~ ~J FACILITY ADDRESS CITY, STATTE, ZIP { 1CC~S ) C /^ p FACILITY NAME ` ~~.~ Ian ~.i~~..c,. E:~, Ss,.GGey !_G~.7'~.n MANAGE S NAME rJD~A ~BI v3s~,'.e FA~C~ILITY PHON NO~ BUSINESS OWNER'S NAME AND ADDRESS CITY, STATE, ZIP OWNER'S PHONE NO. BILL TO: (IF DIFFERENT FROM ABOVE) NAME, ADDRESS CITY, STATE, ZIP, BILLING PHONE NO. OCC TYPE OCC LOAD NO. OF FLOORS HIGH RISE BLDG RISER DATE ^ YES ^ NO CORRECT ALL VIOLATIONS VIOLATION REQUIREMENTS CHECKED BELOW No. I DRY 1 Remove and safely dispose of all hazardous refuse and dry vegetation on the above premises (U.F.C.) COMBUSTIBLE WASTE VEGETATION 2 Provide non-combustible containers with tight fitting lids for the storage of combustible waste and rub h en s safe disposal. (U.F.C.) COMBUSTIBLE STORAGE 3 Relocate combustible storage to provide at least 3 feet clearance around motor fuse box/fire door (N.E.C.) (U.F.C.) 4 Relocate fire extinguisher(s) so that they will be in a conspicuous location, hanging on brackets with the top to the extinguisher not more than 5 feet above the floor. (N.F.P.A. No. 10) EXTINGUISHERS 5 Provide and install (amount) ____ approved (type & size) _______________ portable fire extinguisher to be immediately accessible for use in (area) ____________________________ (U.F.C.) 8 Re-charge all fire extinguishers. Fire extinguishers shall be serviced at least once each year, and/or after each use, by a person having a valid license or certificate. (U.F.C.) 7 Provide and maintain "EXIT" sign(s) with letters 5 or more inches in height over each required exit (door/window) to SIGNS fire escape. (U.F.C.) g Provide and maintain appropriate numbers on a contrasting background and visible from the street to indicate the correct address of the building. (B. M.C.) (U.F.C.) g Repair all (cracks/holes/openings) in plaster in (location) __________________~ __________, Plastering FIRE DOORS/ FIRE SEPARATIONS shall return the surface to its original fire resistive condition. (U.B.C.) . 10 Remove/repair (item & location) ________________________ __________________________ elf-closing doors shall be designed to close by gravity, or by the action of a mechanical device, or by an approv smoke and heat sensitive device. Self-closing doors shall have no attachments capable of preventing the operation of the closing device. (U.F.C.) EXITS 11 Remove all obstruction from hallways. Maintain all means of egress free of any storage. (U.F.C.) , 12 Provide a contrasting colored and permanently installed electric light over or near required exit (location) _________,__________________ to clearly indicate it as an exit. (U.F.C.) STORAGE 13 Remove all storage and`or other obstructions from fire escape landings and stairways stair shafts. (Fire escapes/stair shafts are to•be,maintained free from obstructions at all times.) (U.F.C.) 14 Extension cords shall not be used in lieu of permanent approved wiring. Install additional approved electrical outlets ELECTRICALAPPLUINCES where needed. (N.E.C.) (U.F.C.) > 15 Remove multiple attachment cords from specific electrical convenience outlet (one plug per outlet) (N.E.C.) (U.F.C.) OUTDOOR BURNING ~ 16 Violation of Section 1102 dealin with recreational fires or o en burnin U.F.C. FIREWORKS 17 Violations of Section 7802 U.F.C. or 8.49.040 of the Bakersfield Munici al Code B.M.C. re ardin fireworks. OTHER 1g ,rat !~ i~/i~ f CUSTOMER: ~` ~i~~~~'`"-----_ -F-~f)~Yl t Y1 1 ~ I~~TG\ Q ND~ v Si t r Pl e P i t N L ibl ; Titl C.F.C CALIFORNIA FIRE CODE ( gna u e) ( eas r n eg y ame e) U.B.C. UNIFORM BUILDING CODE B.M.C. BAKERSFIELD MUNICIPAL CODE INSPECTOR: ~,~6~-lti.f ~..-S AP N0.1 x.17 N.F.P.A. NATIONAL FIRE PROTECTION (Signature) ASSOCIATION N.E.C. NATIONAL ELECTRIC CODE White -Customer/Original Yellow -Station Copy Pink -Prevention Services FD 2022 (Rev. 09/05) II.··: . ' ~ þ? SURGICARE SURGERY CENTER .,\ // \ SiteID: - /' ..¿?r/ ~~\~~ Busphone: V Map : 103 Grid: 19B 015-021-002247 Manager : KIENDRA BUTTS Location: 4850 COMMERCE DR 200 City BAKERSFIELD (661) 322-1313 CorrunHaz : High FacUrrits: 1 AOV: CorrunCode: BAKERSFIELD STATION 04 EPA Numb: SIC Code:8011 DunnBrad: Emergency Contact / Title Emergency Contact / Title PAULA FISHER / ADMINISTRATOR SYED RIZVI / LIMITED PARTNER Business Phone: (661) 322-1313x Business Phone: (661) 325-1685x 24-Hour Phone : (661) 204-7772xCELL 24-Hour Phone : ( ) - x Pager Phone : ( ) - x Pager Phone : (661) 863-4328x Hazmat Hazards: Fire Press IrrunHlth DelHlth Contact : KIENDRA BUTTS phone: (405 ) 306-2801x MailAddr: 4850 COMMERCE DR 200 State: CA City : BAKERSFIELD Zip : 93309 Owner SYED RIZVI Phone: (661) 325-1685x Address : 4850 COMMERCE DR 200 State: CA City : BAKERSFIELD Zip : 93309 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: One Unified List ~ All Materials at Site ~ p= Hazmat Inventory f== Alphabetical Order Hazmat Corrunon Name... SpecHaz EPA Hazards DailyMax MCP NITROGEN NITROUS OXIDE OXYGEN /., ~~£> ¡( /V) ~ ~7/ ,r(r - //f:~ í/!~ \J.. 19/." '71 . () I ( " to ~ F P F P F IH IH IH DH G G G 25.00 FT3 25.00 FT3 1000.00 FT3 Min Hi Low -1- 08/02/2004 SURGICARE SURGERY CENTER~--~---:'' ~- \: 7 ~- _~ BusPhone: (~61)~ ' 4850 COMMERCE DR 200 ~'L~ Map : 103 Co~ : Hig~ ' Grid: 19B FacUni~~~V: Manager : ~ Bocag~on: : B~KERS~IE~D CommCodo: B~KERSFIEBD ST~TIO~ 0 SIC Code:801~ EPA Nu~: . . DunnBrad: Emergency Contac~ / Emergency Contact / T~tle ~~/~~~~/~M SYED RIZVI / LIMITED PARTNER ~~~e: (661) Business Phone: (661) 325-1685x 24-Hour Phone : (661)/~~ ~ 24-Hour Phone : ( ) - x Pager Phone ~ Pager Phone : (661) 863-4328x Hazmat Hazards: Fire Press Im~lth DelHlth Contac Phon~ ~) -~ MailAdd~-~850_COMMERCE Stat~A -- ~ ~ City : BAKERSFIELD Zip : 93309 Owner SYED RIZVI Phone: (661) 325-1685x Address : 4850 COMMERCE DR 200 State: CA City : BAKERSFIELD Zip : 93309 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: ~ Hazmat Inventory One Unified List -- Alphabetical Order Ail Materials at Site Hazmat Common Name... ISpocHazlEPA HazardsI Frm DailyMax IUnitlMCP NITROGEN F P IH G 25.00 FT3 Min NITROUS OXIDE F P IH G 25.00 FT3 Hi OXYGEN F IH DH G 1000.00 FT3 Low 1 01/22/2003 !~p ?~. ~~ Bakersfield Fire Depto ECT! CH!CK ! T Entronmental Services , p 1715 Chester Ave ~T~ [ Bakersfield, CA 93301 Tel: (661)326-3979 FACILITY NAME INSPECTION DATE INSPECTION TIME PHONE No. No. of Employees FACiLiTYCa~ThcT '~ ~ Business I0 Number Section 1: Business Plan and Inven~ Pr~mm ~ Routine ~Combined ~ Joint Agency ~ Multi-Agency ~ Complaint ~ Re-inspection G V (C=Co~p~i,ncel OPE~TION COMMENTS ~ V=Violation ~ APPROPRIATE PERMIT ON HAND .................................................................................... ~ ~ BUSINESS PLAN CONTACT INFORMATION ACCU~TE ........................................................................................... ~ ~ VtS~aLE AOORESS ~ VERIFICATION OF INVENTORY MATERIALS ........................................................................... ~ VERIFICATION OF QUANTITIES ........................................................................ ~ ~ VERIFICATION OF LOCATION ~ ~ PROPER SEGREGATION OF MATERIAL ~ ~ VERIFICATION OF MSDS AVAILABILI~E ~ VERIFICATION OF HAT MAT T~INING ................................................................ ~ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~ ~ EMERGENCY PROCEDURES ADEQUATE .................................................................. ~ ~ CONTAINERS PROPERLY ~BELED ~ ~ HOUSEKEEPING ~ ~ FiRE PROTECTION ~ ~ SITE DIAGRAM ADEQUATE & ON HAND A.v Ha*~9OUS W*STE ON S~TE?: ~ YES ~No ~XP~IN: QUESTION,~EGAR~G TI~S INSPECTION? PLEASE CALL US AT(661) 326-3979 , <:~ C~,n~/pector Badge No. Re White - Environmental Services Yellow - S{ation Copy Pink - Business Copy SURGICARE SURGERY CENTER SiteID: 015-021-002247 Manager : BusPhone: (661) 325-1685 Location: 4850 COMMERCE DR Map : 103 CommHaz : High City : BAKERSFIELD Grid: 19B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 04 SIC Code:8011 EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title CES CABAL / / Business Phone: (661) 325-1685x Business Phone: ( ) - x 24-Hour Phone : ( ) - x 24-Hour Phone : ( ) - Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact : · ~/~~~/ Phone: (661) MailAddr: 4850 COMMERCE DR S~ ~o State: CA City : BAKERSFIELD ! Zip : 93309 Owner ~/~ ~ ~;° Phone: (661) 325-1685x Address : 4850 COMMERCE DR ~ £D~ State: CA City : BAKERSFIELD / Zip : 93309 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: -- Hazmat Inventory One Unified List --Alphabetical Order Ail Materials at Site Hazmat Common Name... ISpeoHazlEPA HazardsI Frm I DailyMax IUnit]MCP NITROGEN F P IH G 25.00 FT3 Min NITROUS OXIDE F P IH G 25.00 FT3 Hi OXYGEN F IH DH G 1000.00 FT3 Low (Type or prin~ n~me) SURGICARE SURGERY CENTER SiteID: 015-021-002247 9 ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site 9 -- COMMON NAME / CHEMICAL NAME NITROGEN Days On Site 365 Location within this Facility Unit Map: Grid: INSIDE MED GAS STORAGE ROOM CAS# 7727-37-9 STATE ~ TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Gas /Pure Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 25.00 FT3 25.00 FT3 25.00 FT3 HAZARDOUS COMPONENTS 100.00 Nitrogen N 7727379 HAZARD ASSESSMENTS ITSecretl ~SlBioHaz Radioactive/Amount I EPA Hazards NFPA USDOT# I MCP No N No No/ Curies F P IH / / / Min -- Inventory Item 0003 Facility Unit: Fixed Containers at Site 9 -- COMMON NAME / CHEMICAL NAME ! NITROUS OXIDE I Days On Site 365 Location within this Facility Unit Map: Grid: LOCKER ROOM HALLWAY CAS# 10024-97-2 Gas /Pure Above Ambient I Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average 25.00 FT3I 25.00 FT3I 25.00 FT3 HAZARDOUS COMPONENTS io SI 100.00 Nitrous Oxide N 10024972 HAZARD ASSESSMENTS TSecretINO NoRS I BioHazINO Radioactive/AmountNo/ Curies EPAF P HazardsIIH NFPA/// I USDOT# MCPHi -2- 08/19/2002 SURGICARE SURGERY CENTE~r SiteID: 015-021-002247 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site -- COMMON NAME / CHEMICAL NAME OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: LOCKER ROOM HALLWAY CAS# 7782-44-7 Gas /Pure Ii Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum I Daily Average 249.00 FT3I 1000.00 FT3I 1000.00 FT3 ~ HAZARDOUS COMPONENTS 100.00 Oxygen, Compressed N 7782447 HAZARD ASSESSMENTS TSecretI ~SlBioHaz] Radioactive/Amount EPA HazardsI NFPA I USDOT# MCP No N No No/ Curies F IH DH / / / Low -3- 08/19/2002 SURGICARE SURGERY CENTER SiteID: 015-021-002247 Fast Format ~Notif./Evacuation/Medical Overall Site Agency Notification -- Employee Notif./Evacuation Public Notif./Evacuation Emergency Medical Plan -4- 08/19/2002 SURGICARE SURGERY CENTER SiteID: 015-021-002247 Fast Format Mitigation/Prevent/Abatemt Overall Site Release Prevention -- Release Containment Clean Up Other Resource Activation -5- 08/19/2002 F SURGICARE SURGERY CENTER -- SiteID: 015-021-002247 Fast Format ~ Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs -- Fire Protec./Avail. Water Building Occupancy Level -6- 08/19/2002 SURGICARE SURGERY CENTER SiteID: 015-021-002247 Fast Format F Training Overall Site Employee Training Page 2 Held for Future Use ~ Held for Future Use I -?- 08/19/2002 ..... O~E OF ENVIRONMENTAL :ES ~ 1715 Chester Ave., CA 93301 (661) 326-3979 ..... ~~ BUSINESS OWNER / OPE~TOR IDENTIFICATION FAClLI~ INFORMATION Page . : ~ Year Beginning ~oo Year Ending BUSINESS NAME (Same as FACILI~ NAME or DBA- Doing Business ~) 3 BUSINESS PHONE ~o2 SITE ADDRESS lO3 DUN & ~ 106 SiC CODE 107 COUN~ ~ ~ ~ II. OWNER INFORMATION OWNER MAILING III. ENVIRONMENTAL CONTACT CONTACT ~ILING ~ ~9 -PRIMARY- IV, EMERGENCY CONTACTS 4ECONDARY- I TITLE 24-HOURPHONE %%~ ~ N5% -- ~%~k~'27 !24.HOURPHONE ~ V. CERTIFICATION Ce~ification: Based on my inquiw of those individuals responsible for obtaining the info~ation, I ~ai~ under penal~ of law that I have personally examined and am familiar with the information submitted in this inventow and believe the information is tree, accurate, and complete. ~6NATUReOF OWNE~OPE~OR I DATE ,34 iI NAME OF DOCUMENT PREPARER ,35 NAME~OF OWNE~OPE~TOR (print) ~ J TITLE OF OWN OPE~TOR UPCF (7/99) S:\CUPAFORMS\OES2730.TV4.wpd ITE DIAGRAM lrACILITY D RAM [ ! Business Name: '~ ~ ~ ch~~ ~.,a ~--~'~ ~ CITY OF BAKERSFIELD_ OFF~ OF ENVIRONMENTAL SE~ICES 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN Section I1.1 - DISCOVERY AND NOTIFICATIONS I. FACILITY IDENTIFICATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 ADDRESS (For local use only) 476. DISCOVERY A. LEAK DETECTION AND MONITORING PROCEDURES: ENVIRONMENTAL MANAGEMENT C. SPECIFIC RESPONSIBILITIES OF EMPLOYEES: EMERGENCY MEDICAL PLAN D. CLOSEST LOCAL MEDICAL FACILITY: UPCF (7/99) S:~PROCEDURE MANUAL~h~w HMMP form.wpd DOUS MATERIALS MANAGEMI~' PLAN Section 11.2 - RELEASE RESPONSE PI.~ PRELIMINARY ASSESSMENT A. HAZARD ASSESSMENT AND PREVENTION MEASURES: RESPONSE ACTIONS B. RELEASE CONTAINMENT AND MITIGATION: FOLLOW-UP ACTIONS C. CLEAN-UP AND RECOVERY PROCEDURES: ~ ~ ~ ~'\'~-'"'~:k.'~ L~C:::,C-. ~ \"~-- ~ U~F (7~) 8:~R~E~ ~ HMMP f~.~ HAZARDOUS MATERIALS MANAGEMEi~ PLAN Section II1.1 - FACILITY AND LOCALITY INFORMATION UTILITY SHUT-OFFS LOCATION OF SHUT-OFFS AT YOUR FACILITY: ELECTRICAL: LOCKBOX: YES~ IF YES. LOCATION: PRIVATE FIRE PROTECTION I WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: ~ ~ ~\\',~'~,_~'~ ~"'A.~'--'k.,~='e~ --'~-~'~ G,,.~--~t~'"'~ ~-,-~.~,\~-~,.~ \ \~,-~ B. WATER AVAILABILITY (FIRE HYDRANT): ~ ~,~<~ ~,.,.~.~--~ ~ TRAINING A. NUMBER OF EMPLOYEES: B. MATERIALS DATA SHEETS ON FILE: "~------~ C. BRIEF SUMMARYOF TRAINING PROGRAM: CERTIFICATION Based on my inquiry of those individuals restx~sible f~ obtaining the Information, I ceflify undef penalty of law that I have personnaly examined and am familiar with the information submitted and believe the information is true. eccurata, and co~ete. NAME OF SIGNER (prat) 478. TITLE OF SIGNER 479. UPCF (7/99) 8:~PROCEDURE MANUALWew HMMP form.wpd OFFI~' OF ENVIRONMENTAILsI~I~CES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one £on'n per mater~al per building or area) ?j~NEW [] ADO n DELETE [] REVISE 200 Page : .::~ ~.. I. FACIUT~. iNFORMATION' BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 C.EM,CALLOCAT,ON 20,;,OONF,DENT,AL(EPCRA,C.EM,CALLOCAT,ON ' ,Yes=.o FACILITY ID # ~ [~!] I i::~'~?~._, .~.~.,,~.l ~! i1 MAP # (optional) -- 203 r GRID # (optional) 204 ' .': ;:-i: :.i ,¢.:': :? 205 TRADE SECRET CHEMICAL NAME ~ '~,,---'~c-') ,~ ____ [] Yes~No 206 207 208 FIRE ~DE H~RD C~SSES (~plete if ~u~t~ by I~1 fire ~i~ 210 PHYSICAL STATE . 215 ·SOUD ~ UOU~D g GAS 2~ , ~ -_ (chaFED H~RDall that apply)~TE~RIES ~ 1 FIRE ~ 2 REACTI~ ~3 PRESSURE REL~SE ~ 4 ACUIE H~LIH ~ 5 CHRONIC H~LTH 216 ANNUAL WASTE 217 I ~I~M 218 J AVENGE 219 STATE WASTE ~DE 220 A~U~ ~ DAILY A~U~ ) DAILYA~U~ UNITS' ~ ga ~L ~ d CU ~ ~ lb LBS ~ tn TONS 221 DAYS ON SITE 222 STOOGE CO~AINER ~ a ABOVEGROUND TANK ~ e P~SlI~NONMETALLIC DRUM ~ i FIBER DRUM ~ m G~SS BO~LE ~ q ~IL (Check all ~at apply) 2~ ~ b UNDERGROUND TANK ~ f CAN ~ j BAG ~ n P~STIC BO~LE ~ r OTHER ~ c TANK INSIDE BUILDING ~ g ~RBOY ~ k BOX ~ o TOTE BIN ~ d S~EL DRUM ~ h SILO ~1 CYLINDER ~ p lANK WAGON STOOGE PRESSURE a AMBIE~ ~ ~ ABOVEA~IE~ ~ ba BELOW AMBIENT 224 STOOGE TEMPE~TURE ~ a AMBIE~ D aa A~VE A~IE~ Dba 8ELOWAMBIE~ ~ c CRYOGENIC 225 . "~ ..... ~ ','%~ "~ 'P ,~ r2'~~ ~-~:.,> .~ ,~ ~ ~:~;' ;4 ~"?~.,~&~:~ :;~-~'~ ~" ~ ,~:' "~ ';' ~ ~',~ , ~. ~,~~ '~',,, . '" ~ ' .. ~ 229 2 230 231 ~Yes ~No 232 j 233 3 234 235 ~ Y~ ~ NO 236 237 4 ~ 238 239 ~Y~ ~No 240 ~ 241 5 ~ 242 243 , ~ y~ ~ NO 244 ~ 245 PRINT ~ME & TITLE OF AU~ORIZED COMPANY REPRESE~ATIVE SIGNATURE DATE 246 PCF (7~99) S:\CUPAFORMS\OES2731 .TV4.wpd . ~Y OF BAKERSFIELD ~ OFFICE OF'ENVIRONMENTAL SERVICE~ ~ .1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION' (one fo~ per matedal per building or ama) D ADO ~ DELVE ~ REVISE 2~ Page ,: .. '.':'.:,:.;:,,.'.. :~. ~..,. ~ .,. :'~ .' ?~;~,~:?::::~',~{,~ :47., :I::FACl N M~IO~?:: ~..', .' ;S ~ME (Same ~ FACILI~ ~ME ~ D~ - ~ng Busin~ ~) ~ CONFIDE~IAL (EPC~) ID ~ ~ ~ i_ ] . ~ ./ i_ I_ I_ L I ' ~1 ~ ~ (op~na0 *' 203 ~G~op~naO e~o~,,-,'.. ;.,~.,.' .' .... ~ ...... :.,~ : ,.~ . 205 ~ T~DE SECR~ ~ Y~ ~o 206 207 ~ '~;;'- ..';~'.'.'.'. ':;L' :f*':-..' ..~... ........... · 210 ,RD ~TE~RIES .D 1 FIRE ~ 2 ~IVE ~3 P~SSURE ~L~E ~ 4 ACUTE H~L~ ~ 5 CHRONIC H~TH 21 ~at apply) 6 ,ASTE. 217 ~ ~I~MDALLY A~U~ 218 ~ AVENGE ' DALLY ~U~ 219 STATE W~TE CODE U~S' ~ ga ~L ~ d CU ~ ~ lb LBS ~ tn TONS 221 DAYS ON SITE 222 CO~AINER D · ABOVEGROUND T~K ~ · P~S~ON~UC DRUM ~ I FIBER DRUM ~ m G~SS BO~LE ~ q ~IL ~R 2~ hat,ply) ~ b UNDER~OUND T~K ~ f ~N ~ J ~G ~ n P~STIC BO~LE ~ r OTHER D c T~K INSIDE BUI~ING ~ g ~Y ~ k BOX . D o TO~ SIN ~ d S~EL DRUM ~ h SILO ~1 ~UNDER ~ p T~K WAGON P~SSU~ ~'a ~1~ ~ ~ A~VE~IE~ ~ be 8ELOWA~IE~ 224 TE~E~ ~a~lE~ ~ ~ A~VE~I~ ~ ba BELOWA~IE~ ~ c CRYOGENIC 225 ~6 ~7 ~ Y~ ~ No 228 ~0 ~1 ~ Y~. ~ No 232 233 '~ ~5 ~Y~No ~6 237 ~ ~9 ~ Y~ ~ No 240 241 242 243 ~ Y~ ~ No 2~ 245 · .u..~,~.· .~ .~...~. ,~ .~.~, :,~ .. ~;~.~. , ~ :~ ~:.~::.~:L.~.~'.~;t~,:~;.- ~.. .'-~,...h".,~:~ '.' E & TI~E OF AU~OR~ED ~ANY REPRESE~ATIVE ~IG~TURE DATE 246 ' S:\CUPAFORMS\OES2731.TV4.wpd OFFIC F ENVIRONMENTAL SERV S 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one form per material per building or area) '~EW. E]ADD i-~ DELETE i-I REViSE 200 Page _.~ of ~INESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 ;M,C*''OC*T,ON C 'rO e¢ 20.;, CONF,DE.T,^LC"EM'C^L[OCAT'ON E C , kY--ONo 204 205 ~ T~DESECRET' .... y~ No 206 207 ~N~ ~ ~ ~ EHS' ~Y. ~No 208 ~'.:..' 210 ~RDall that apply)~TE~RIES ~ 1 FaRE ~ 2 R~IVE ~3 P~SSURE ~L~SE ~ 4 AC~E H~L~ ~ 5 CHRONIC H~LTH 216 UALWASTE 217 i ~,~M 218 I A~GE 219 STATE WASTE CODE 220 U~ ~ DAILY A~U~ I DAILY A~U~ UN.S* ~ ga ~L ~ d CU ~ ~ lb LBS D tn TONS 221 DAYS ON SITE 222 ~GE CO~AINER ~ a ABOVEGROUND T~K ~ e P~S~ON~T~LIC DRUM ~ i FIBER DRUM aB ~at apply) ~ b UNDERGROUND TANK ~ f ~N ~ j BAG ~ n P~STIC 80~LE ~ r OTHER ~ C T~K INSIDE BUILDING ~ g ~Y ~ k BOX ~ o TOTE BIN ~ d S~EL DRUM ~ h SILO ~1 CYLINDER ~ p TANK WAGON ~GE P~SSU~ ~ a ~IE~ ~ ~ A~VE~IE~ ~ ba BELOWAMBIE~ 224 230 ~1 D Y~ ~ No 232 I 233 '2~ ~5 ~Y~No 236 ~ 237 ~8 ~9 DY~ ~No 240 j 241 I 242 243 ~Y~ ~ No 244 ~ 245 ~ME & TI~E OF AU~ORIZED COMPANY REPRESE~ATIVE SIG~TURE DATE 246 (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd (661) 322-1313 · Fax (661) 323-1786 4850 Commerce Drive, Suite 200 · Bakersfield, California 93309 9/23/02 Betty Wilson Environmental Services 1715 Chester Ave, #300 Bakersfield, CA 93309 Dear Ms Wilson; Thank you for taking the time to meet with me today and assist me with completing the documentation for a Hazardous Waste Permit. Enclosed are the documents 1 believe you need to process our request. I also enclosed some of our facilities policies and procedures related to Hazardous Waste Management. Please let me know if you require anything else. Sincerely, ~on, RN, C NOR Facility Administrator Southwest Healthcare Surgery Centers " Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Communication of Hazardous Materials POLICY #: 13-18 EFFECTIVE DATE: 8~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8/02 POLICY: A variety of materials are used at Surgicare Surgery Center; some of which are potentially hazardous. It is important to this facility to ensure employees are aware of potential hazardous materials in the workplace, and to understand the labeling and communication regarding these materials, in order to safely manage their use. Manufacturers, distributers and importers provide us information on the potential hazards of the materials; this is done via Materials Safety Data Sheets (MSD$). Surgicare Surgery Center has a Hazardous Communication Plan in place to ensure employee safety. The DON is responsible to oversee the implementation of the hazardous materials communication plan, and will review and update the plan as needed. PURPOSE: To ensure employee safety and meet OSHA Hazardous Communication standard 29 CFR 1910.1200: PROCEDURE: · All containers are labled. · MSDS sheets are actively used and all emnployees have access to the MSDS information. · All employees receive effective hazard communicaiton. · A master list of all hazardous materials is maintained at the facility (see list ot follow). · Employees will not use products that are not properly labeled or are unlabeled. · Any unlabeled or badly labeled products are reported to the DON immediately. · Any unlabeled or badly labeled products will be removed from use until properly labeled. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Communication of Workplace Safety POLICY #: 13-27 EFFECTIVE DATE: 8/02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8/02 POLICY: In order to manage a healthy and safe environment, all employees of the center are responsible to communicate in an open and supportive manner. Our communication system encourages staff to inform management about workplace hazards. Employees should not fear reprisal for communication of workplace hazards. PURPOSE: To facilitate a flow of communication between management and employees, that encourages and promotes workplace safety. To facilitate a flow of information Surgicare Surgery Center is committed to the following standards: · Surgicare Surgery Center will provide new worker orientation including a discussion on safety and health P&P for all new hires. _ · Surgicare Surgery Center will perform initial review of our safety and health plan with all employees, and conduct regularly scheduled safety meetings and discussions. · Safety information will be posted in the employee lounge and will include the latest required labor laws posters. · A communication system is in effect that will encourage employees to inform management about workplace hazards anonymously. · Employees will be updated on planned changes in response to their concerns or suggestions. · We will insert "Regulatory Alerts" in the regualtory alerts section of the Stericycle OSHA binder. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Assessment of Potential Workplace Hazards POLICY #: 13-28 EFFECTIVE DATE: 8~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8~02 POLICY: A periodic review of the workplace will be performed to identify and evaluate workplace hazards. PURPOSE: To identify and evaluate workplace hazards. Reviews will be performed according to the following schedule: when the facility initially establishes the safety and health plan. When new substances, processess, procedures or equipment are introduced to the workplace that present a potential hazard. · When previously unidentified hazards are recognized. · When occupational injuryor illness occurs. Whenever workplace conditions warrant a review, Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Regulated Medical Waste Employee Training POLICY #: 13-20 EFFECTIVE DATE: 8/02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8/02 POLICY: The Department of Transport (DOT) considers any employee, who affects hazard materials transportation safety, a Hazmat employee. Hazmat employees will be trained within 90 days of assignment, with formal and written documentation of training on record. These employees: · Handle containers. · Load orunload containers. · Prepare containers for transport. · Complete and sign shipping agreements. · Provide Hazmat instructions. PURPOSE: To ensure compliance with OSHA and DOT regulations. Southwest Healthcare Sur~ Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Hazardous Materials and Waste Management Program POLICY #: 17- 37 EFFECTIVE DATE: 9~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9~02 PURPOSE: To reduce the incidence of chemically or biologically related occupational illness and injury and to increase the availability of hazard information to assist SURGICARE SURGERY CENTER in devising measures to protect i ts s taffm embers and t o give employees t he information needed t o take steps t o protect themselves against potential hazards in the workplace. POLICY: It is the policy of the facility to advise all employees of their rights to examine copies of Material Safety Data Sheets (MSDS) upon request; and all employees will attend an inservice regarding Hazard Communication Program within 30 days of employment and annually thereafter. PROCEDURE: A. General Information In order to comply with OSHA's Hazard Communication Standard, the following Hazard Communication Program has been developed by SURGICARE SURGERY CENTER 1. Container Labeling a. The Purchasing Agent (or designated staff member) will verify that all containers received for use will: 1. Be clearly labeled as to the contents; 2. Bear appropriate hazard warnings; 3. List the name and address of the manufacturer; and 4. Provide specific detail as to the type or severity of hazard. b. No containers will be released for use until the above labeling is verified by purchasing as being on the container. c. No containers purchased for use within the facility will leave the facility premises. d. The Director of Nursing is responsible for ensuring that all secondary containers are labeled with either the manufacturer's label identical to the primary container, or with generic labels that identify the substance and that bear any hazard warning. 2. Material Safety Data Sheets (MSDS) a. The Purchasing Agent (or designated staff member) will be responsible for obtaining Material Safety Data Sheets (MSDS) on all new products brought into the facility. If no MSDS can be provided, the product should not be received. The Director of Nursing/Safety Officer (or designated staff member) will be responsible for maintaining the data sheet system for the facility. If the manufacturer or retailer fails to provide the MSDS for it's product, a prompt request for one will be made by and through the purchasing department. ~_ b. The Director of Nursing will review incoming data sheets for new and significant health/safety information. He/she will see that any new information is communicated to affected employees. c. MSDS will be available to all employees in their work area for review during each work shift. If MSDS are not available, or new chemicals in use do not have MSDS, the Director of Nursing/Safety Officer shall be contacted. 3. Employee Training and Information a. The Director of Nursing/Safety Officer will develop, implement and monitor the Employee Hazard Communication Training Program. All current and new employees will attend an orientation on safety and will be provided with information on: 1. OSHA's Hazard Communication Standard 2. What is and how to read an MSDS sheet; 3. Chemicals and their hazards in the workplace; 4. Proper labeling and handling; 5. Use of personal protective equipment; 6. What the facility has done to lessen or prevent worker's exposure to these chemicals. b. After attending the orientation, each employee will sign a form stating that he/she has received the training. Before any new category_ of chemical hazard is introduced into the facility, each employee will be given information regarding appropriate use of the chemical. The Purchasing Agent (or designated staff member) will be responsible for ensuring that MSDS's on the new chemical are available. B. Location of MSDS's on Hazardous Chemicals 1. A list of chemicals used in the facility is maintained at the Nurses station at ther front of the MSDS binder. Further information on each hazardous chemical noted can be obtained by reviewing MSDS. C. Hazardous Non-Routine Tasks 1. Periodically, employees are required to perform hazardous non-routine tasks. Prior to starting work on such projects, each affected employee will be given information by the Director of Nursing or designee about hazardous chemicals he/she may be exposed to during such activity. 2. The information will include: a. Specific chemical hazards; b. Protective safety measures the employee will take; c. Measures that the facility has taken to lessen the hazards, possibly including the presence of another employee while task is being performed; d. Emergency procedures if applicable. D. Contractors and Vendors 1. Contractors will be provided the following information by the staff member working closest with the contractor: a. Hazardous chemicals that they may be exposed to while on the job; b. Precautions that the employees may take to lessen the possibility of exposure by usage of appropriate protective measures. c. The contractor will be responsible for passing this information to his/her employees. 2. Each contractor will be asked to provide MSDS concerning chemical hazards that the contractor may bring onto the facility property. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Hazardous Materials and Waste Management Plan POLICY #: 17-36 EFFECTIVE DATE: 9~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9102 Objective: This hazardous materials and waste management plan describes how SURGICARE SURGERY CENTER will establish and maintain a program to safely control hazardous materials and waste. Scope: This hazardous materials and waste management plan is facility-wide.in scope. Plan: Facility has adopted processes for the selection, storage, use, and disposal of hazardous wastes from generation through final deposit. Written criteria exists in the form of policies and procedures. This criteria is consistent with applicable law and regulation to identify, evaluate, and inventory hazardous materials and waste used or generated in the facility. These procedures include the management of chemical waste and regulated medical/infectious waste, including sharps. T he c enter provides secure, environmentally controlled hazardous materials and waste storage spaces as well as personal protective equipment (PPE) for those personnel who must work or come into contact with hazardous materials and waste. The reporting and investigation of all hazardous materials or waste spills will be performed through the center's incident reporting system. Each incident will be acted upon by the appropriate persons and the appropriate committee. Center staff will familiarize themselves with the basic components and operation of the Hazard Materials and Waste Management program. This will be accomplished through the center's established orientation program. This program addresses precautions for selecting, storing, using, and disposing of hazardous materials and wastes. The education program also addresses emergency procedures and health hazards r elated t o chemicals i n t he workplace, a s well as reporting incidents t hat involve s pills o r exposure. Incident reporting i s accomplished through the center's incident reporting program. Facility specific training is performed.. Performance standards exist in the form of policies and procedures and standard work practices. These things include staff knowledge and skill necessary for managing hazardous materials and wastes, staff participation in hazard materials and waste activities, monitoring, inspection and corrective action, routine procedures for incident reporting, and the inspection, preventive maintenance, and testing of applicable equipment. There are also mechanisms in place which provide specific precautions, procedures, and protective equipment used during hazardous materials and waste spills or exposures. Hazardous Materials and Waste management program data is collected by the Director of Nursing/Safety Officer and reviewed by the Quality Council on a monthly basis. Data is collected based on staff input and observation of the physical environment, and internal and external monitoring. This review will ensure that certain performance standards are met and maintained. The following table illustrates sources of data to be included in the analysis of the Hazardous Materials and Waste management plan. Material Safe~ Data Sheet Review Internal ~ually (QualiW Co~cil) Staff training records Internal Monthly (Quali~ Co~cil) Bio-H~d waste removal work practices Internal Monthly (Quali~ Co~cil) Review of HAZ-MAT or waste related incidents Internal Monthly (Quali~ Co~cil) Safe~ S~eill~ce Imemal Monthly (Quali~ Co~cil) Preventive Mainten~ce records Internal Mon~ly (Quali~ Council) Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Annual Review of the Hazardous Materials and Waste Managment Program POLICY #: 17- 45 EFFECTIVE DATE: 9/02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9~02 PURPOSE: To maintain the currency and consistency of hazardous materials and waste management policies and procedures and to evaluate the usefulness of the program's performance standards. POLICY: SURGICARE SURGERY CENTER will evaluate annually the objectives, scope, organization, and effectiveness of the hazardous materials and waste management program. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Materials Safety Data Sheets (MSDS) POLICY #: 17- 38 EFFECTIVE DATE: 9102 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9/02 PURPOSE: To ensure that all personnel know the location of the Material Safety Data Sheets within the center. POLICY: It is the policy of SURGICARE SURGERY CENTER to provide Material Safety Data Sheets to employees on request. The Director of Nursing/Safety Officer is responsible for this task. PROCEDURE: 1. A complete, indexed set of master MSDS manual will be located at the Nurses station. 2. MSDS manuals will be reviewed for accuracy at least annually and revised as needed. 3. The Quality Council Committee will review this system at least annually. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Emergency Response to a Chemical Spill POLICY #: 17- 39 EFFECTIVE DATE: 9/02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9~02 PURPOSE: To establish the procedure of responding to a chemical spill within the facility. POLICY: It is the policy of SURGICARE SURGERY CENTER to provide a procedure for an emergency response to a chemical spill. PROCEDURE: A. If a chemical spill occurs in your area, immediately notify the facility Director of Nursing/Safety Officer and the facility First Responder (Administrator or designee). State the emergency, if any personnel have been contaminated or hurt during the accident, and the location and type of spill. If personnel have been in contact with the spilled chemical, refer to the Material Safety Data Sheet for the spilled chemical for appropriate first aid procedure until the first responder arrives. Ensure the safety of patients, visitors, and staff by securing the area. B. If anyone who has been contaminated is instructed by the First Responder (or designee) to seek additional medical treatment (i.e., emergency room), a copy of the MSDS will be sent with the contaminated person. C. The Director of Nursing/Safety Officer will make the call to the local Fire Department if spill is too large to be handled by facility staff. D. An Incident Report will be completed by the First Responder (or designee) and forwarded to the center's Administrator within 24 hours of the incident. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Mercury Spills POLICY #: 17- 40 EFFECTIVE DATE: 9~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9~02 PURPOSE: To provide a standard for the safe handling of mercury at SURGICARE SURGERY CENTER. POLICY: The facility will have a written criteria for the safe handling of mercury within the facility. PROCEDURE: 1. In the event of a mercury spill the Director of Nursing/Safety Officer shall be notified. 2. The Director of Nursing/Safety Officer (or desgnee) will secure the spill area by removing patients, staff and visitors. 3. A mercury spill kit will be used to contain the spill. The procedure to be used to accomplish this is contained within the spill kit. 4. Goggles and gloves will be worn while handling the spill. 5. A Center Incident Report will be completed on the incident and forwarded to the Administrator within 24 hours. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Labeling of Bio-Hazard Materials and Waste POLICY #: 17-41 EFFECTIVE DATE: 9102 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9/02 POLICY: SURGICARE SURGERY CENTER will protect staff, patients and visitors from all hazardous or potentially hazardous bio- hazard materials and/or wastes. PURPOSE: To protect staff, patients and visitors from all hazardous or potentially hazardous bio-hazard materials and/or wastes, the center will identify the following items, by use of the universal "bio-hazard" symbol, as appropriate: 1. Containers of bio-hazard materials and/or waste. 2. Refrigerators/freezers containing bio-hazard materials and/or waste. - 3. Sharps disposal containers 4. Other containers used to store, transport, or ship bio-hazard materials and/or waste. - Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Radiation Protection Guidelines POLICY #: 17- 42 EFFECTIVE DATE: 9/02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9102 PURPOSE To provide protection guidelines for personnel who may come in contact with radioactive materials in the center. POLICY A. The following guidelines are basic protection rules intended for personnel who may only occasionally come in contact with radiation areas. - 1. Employees will not handle any container that is marked "Radioactive Material" unless they have received written procedures or instructions on how and when to do so. 2. Containers marked "Radioactive Material," which appear damaged and/or wet, should not be handled until surveyed and inspected by trained personnel. B. Personnel who come into frequent contact with radioactive areas or devices should consult the Director of Nursing for procedures regarding radiation safety. Southwest Healthcare Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Disposal of Infected Waste POLICY #: 17- 44 EFFECTIVE DATE: 9~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9~02 POLICY Infectious wastes shall be handled, transported, and disposed of in such a manner that minimizes the risk of transmission of disease to center personnel, patients, visitors, and others from the time of generation of the wastes to final disposal. DEFINITIONS Facility waste designated as infectious includes: 1. Sharps used in patient care. 2. Unabsorbed blood or blood products, or body fluids such as suction fluids, excretions, and secretions. This includes items that are saturated with these fluids. 3. Tissue or body parts removed from a patient, and the following body fluids. 4. Any discarded live and attenuated vaccines. PURPOSE To outline the proper procedure for disposal of infectious wastes to minimize the transmission of disease. PROCEDURE: 1. All disposable sharps that can cause injury (scalpel blades, lancets, needles) are to be placed in puncture resistant, appropriately labeled, containers without being bent, broken, or recapped (per policy). 2. Infectious wastes shall be placed in red biohazard impervious bags at the point of generation. 3. Filled sharps containers are to be placed in the Infectious Waste container. 4. When Infectious Waste containers are filled, they are sealed and properly stored in the designated collection area. 5. The Infectious Waste containers will be removed weekly by Stericycle for incineration and - disposal. 6. Patient excretions and secretions (urine, sputum, etc.) may be carefully poured down the bathroom commode or a hopper leading to the sewage system, using universal precautions and safeguards to prevent splashing. 7. All medical waste shipping documents will be kept on site for three years. 8. Emergency Plan: If for any reason Stericycle cannot pick up medical waste within seven days, and no other alternate carrier can be obtained, the County of Kern Environmental Health Services Department will be notified, at the Resource Management Agency at (661) 862-8700. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment Of Care TITLE: Personal Protective Equipment (PPE) POLICY #: 17-43 EFFECTIVE DATE: 9~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9102 POLICY: All healthcare workers should routinely use appropriate barrier precautions to prevent exposures when contact with blood and body fluids of any patient is anticipated. Adequate infection control devices and supplies will be readily available in all patient care areas. PURPOSE: To minimize the risk of exposure to blood and body fluids. PROCEDURE: A. GLOVES 1. Gloves will be worn when it can be reasonably anticipated that contact may occur with blood and other potentially infectious materials, mucous membranes and non-intact skin. Gloves will be worn when handling or touching contaminated items or surfaces. 2. Disposable gloves will be replaced as soon as possible when contaminated, torn, or punctured, or when their ability to function as a barrier is compromised. 3. Gloves will be changed after contact with each patient. Change gloves when performing procedures from one body site to another on the same patient. Remove gloves and wash hands before leaving the room. In general, double gloving is not necessary; however, double gloving has been shown to reduce the chance of blood exposure. Disposable (single use) gloves will not be washed or decontaminated for reuse. _ 4. Utility gloves must be discarded if they are cracked, peeling, torn, punctured, or exhibit signs of deterioration or when their ability to function as a barrier is compromised. 5. Gloves will be readily accessible to all healthcare workers (appropriate in type and size to the procedures, activity, and type of exposure). 6. In the event of a suspected latex glove allergy, the employee will report the allergy to the Director of Nursing. B. MASKS AND EYE PROTECTION 1. Masks, eye protection and face shields will be worn whenever splashes, spray, spatter or droplets of blood or other potentially infectious materials may be generated and eyes, nose and mouth contamination can be reasonably anticipated. 2. These items should be changed after contact with each patient. C. GOWNS 1. Gowns and other protective body clothing will be wom in occupational exposure situations. The type and characteristics of the protection of body clothing depend upon the task and degree of exposure ._ anticipated. Based upon this determination, appropriate protective clothing will be selected. 2. Disposable gowns and/or waterproof gowns are made available for use. If a garment is penetrated by blood or any other potentially infectious material, the garment shall b e removed immediately or as soon as feasible. The center will provide laundering for personal clothing contaminated by blood or other infectious materials. INFECTION CONTROL DEVICES 1. Engineering and work practice controls shall be used to eliminate or minimize exposure, and shall be examined and modified on a regular basis to ensure their effectiveness, per SURGICAR~ SURGERY CENTER Infection Control Bloodbome Pathogen Policy #14-13 and the Risk Management Exposure Control Plan #13-1. 2. Needleless Systems shall be used (as defined in policy) for: A. Withdrawal of body fluids; B. Accessing a vein or artery; C. Administration of medications or fluids; and D. Any other procedure involving the potential for an exposure incident for which a needleless system is available as an alternative to the use of needle devices. 3. If needleless systems are not used, needles with engineered sharps injury protection Shall be used for: A. Withdrawal of body fluids; B. Accessing a vein or artery; C. Administration of medications or fluids; and D. Any other procedure involving the potential for an exposure incident for which a needle device with sharps injury protection is available. 4. If sharps other than needle devices are used, these items shall include engineered sharps injury protection. Exceptions to this include: A. The engineering control is not required if it is not available in the marketplace. B. Patient Safety: If a healthcare professional directly involved in a patient's care determines, in the reasonable exercise of clinical judgment, that use of the engineering control w ill jeopardize t he _ patient's safety or the success of a medical, dental or nursing procedure involving the patient. E. Additional engineering controls and infection control devices will be evaluated by the Quality Council Committee as appropriate. Specific training on these items will be the responsibility of the Director of Nursing/Safety officer. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Emergency Preparedness Management Plan POLICY #: 13-34 EFFECTIVE DATE: 8~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8/02 Objective: This Emergency Preparedness Management Plan describes how SURGICARE SURGERY CENTER will establish and maintain a program to ensure effective response to disasters or emergencies affecting the environment of care. Scope: This Emergency Preparedness Management Plan is facility-wide in scope. Plan: _ Specific procedures are implemented in response to a wide variety of possible disasters, both internal and external. These procedures are: External Disaster/Evacuation Plan Cardiac and/or Respiratory Arrest Bomb Threat Disruptive Behavior Emergency Fire Through discussion with the local Emergency Management Department officials, it has been determined, based on the size and scope of service of this facility, that the center will not be integrated into the city-wide disaster response program. Therefore, the center's role in the event of a community-wide disaster, whether drill or a actual, would be minimal at best. Local officials believe that the number of large acute care center facilities in the area would accommodate, without the need of any aid provided by this facility, a large scale, community-wide disaster. Based on this determination, this center will exercise its external disaster plan according to an annual published schedule (twice per year) based on the assumption that assistance will be provided by, not given to, city emergency response personnel. In the case of an actual disaster adversely affecting the operations of the center, each emergency response procedure, as appropriate, has a method of notifying external authorities of emergencies. This is typically done by notifying the local 911 service, as with the notification of '- · extemal authorities, each emergency response procedure, as appropriate, has a method of notifying center personnel. There are a variety of methods available (i.e. verbally, cellular telephone, 'runners', etc.). As appropriate, the center administrator, Director of Nursing, or person of highest authority can make the determination to establish a centralized command post in response to a disaster which adversely affects the operations or services provided by the center. This command post, the location of which will be announced to all staff members, will serve as the clearinghouse for information and assignments regarding the disaster. Supply, space, security, and patient management will be directed by the command post. coordinator, usually the center administrator or Director of Nursing, as appropriate, based on the size, 'type, and complexity of the disaster. To accommodate these things, the center's disaster/evacuation plan describes procedures for evacuating the facility when the environment cannot support adequate patient care and treatment, as well as alternate roles and responsibilities of key personnel. The center has also initiated transfer agreements to establish an alternative care site in the event that the environment cannot support adequate patient care and treatment.. An alternative source of essential utilities in the event of failure during a disaster or emergency is outlined in detail in the center's utilities management plan. An orientation program has been established to familiarize all staff with the basic components of the emergency preparedness plan. This is completed upon initial employment through general orientation and as needed thereafter based on a review of data collected during staff testing, drills, and r~dom interviews. The orientation program addresses specific roles and responsibilities during emergencies, staff roles and skills required to perform duties during emergencies, and utilities, and vendors. Emergency preparedness program performance standards exist in the form of policies and procedures and standard and emergency contingency plans. These plans cover such things as emergency preparedness knowledge and skills for staff, levels of staff participation, monitoring and inspection activities, emergency and incident reporting procedures that specify when and to whom reports are communicated, the inspection, preventive maintenance, and testing of applicable equipment, appropriate use of space, replenishment of supplies, and management of staff. Emergency Preparedness Data is collected by the Director of Nursing based on staff testing, drill performance and review, and observation of the essential emergency preparedness processes. This review will ensure that certain performance standards are met and maintained. The Director of Nursing shall report data to the Quality Council Committee monthly. The following table illustrates sources of data to be included in the analysis of the utility systems management plan. Critiques Internal Quarterly (QC) Scheduled drills Internal Quarterly (QC) Stall'training Internal Quarterly (QC) Stafftesfing and interviews Internal Quarterly (QC) Annual Evaluation of the Emergency Preparedness Program Internal Annually (QC) The objectives, scope, performance, and effectiveness of the center's Emergency Preparedness Management Plan is evaluated annually by the center's Quality Council Committee (QC) and changes made to improve the plan are based on committee recommendations. * Reference EOC P&P #17-1 - Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Emergency Preparedness Plan Overview POLICY #: 13-35 EFFECTIVE DATE: 8~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8~02 POLICY: Surgicare Surgery Center has an emergency preparedness program designed to manage the consequenses of a natural disaster or other emergencies that disrupt the center's ability to provide care and treatment. PURPOSE: To provide a set of preplanned responses to manage disruptions of normal operations and services. PROCEDURE: The emergency preparedness program consists of written plans for the following: · Fire- Code Red. · Cardiac and/or Respiratory Arrest-Code Blue. · Malignant Hyperthermia- Code MH · Emergency/Disruptive BehaviorAssistance-Code Orange. · Inclement weather (tornados/severe thunderstorm)-Code Green. · Disaster/Evacuation Plan- Code Yellow. · Bomb Threat- Code Brown. The above polices will address the responsibilites of the medical/clincial staff, nursing, and support staff. To activate any element of the plan, staff must communicate verbally within the facility. The phone system/fire alarm system is used to notify the fire department of a code red. Reference EOC P&P #17-2 Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Annual Review of the Emergency Preparedness Plan POLICY ti: 13- 36 EFFECTIVE DATE: 8~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8~02 PURPOSE: To maintain the currency and consistency of emergency preparedness program's policies and procedures and to evaluate the usefulness of the program's performance standards. POLICY: SURGICARE SURGERY CENTER will evaluate annually the objectives, scope, organization, and effectiveness of the emergency preparedness management program. Reference EOC P&P # 17-3 - Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment of Care TITLE: Response to Community persons with Emergencies POLICY #: 17-13 EFFECTIVE DATE: 9[02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9[02 POLICY: Surgicare Surgery Center staff will call 911 for the appropriate response team, in the event that a person from the community presents themselves to the center for the care of a emergency medical conditon or crisis. Basic Life Support (CPR) will be initiated by center staff. PURPOSE: To provide a preplanned response to manage the arrival of a community person at the center with a medical emergency or crisis. SoUthwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Environment of Care TITLE: Emergency Preparedness Plan Evacuation Procedure POLICY #: 17-4 EFFECTIVE DATE: 8102 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8102 POLICY: Surgicare Surgery Center has an evacuation plan in place in the event of an emergency. Employees will be aware of appropriate evacuation procedures for the facility, know the emergency contacts and emergency equipment. Emergency numbers are located in the Staff Resource Binders in each department. Emergency disaster drills are conducted quarterly, and conducted by the DON. The facilities evacuation area is the back parking lot. PURPOSE: To ensure the safe evacuation of employees, patients and visitors in the event of an emergency. PROCEDURE: · Disaster is identified and reported to the Director of Nursing (DON), Administrator or Business Office Manager (BOM). · The Administrator (or designee) will be responsible to coordinate the emergency evacuation plan. · The Administator (or designee) will assist the local emergency personnel that respond to the facility. · The disaster is reported to the emergency services via phone as deemed necessary by the Administrator or designee; the emergency services will be called at #911, and the Office of Emergency Services at #1-800-852-7550, to report any spills that are a threat to life, safety, or the environment. For other non-emergency spill reporting, the administrator (or designee) will call the Bakersfield Fire Dept at # 661-326-3979. · The Administrator will document the time and date when each agency was notified and the name of whom she/he spoke with. · The Administrator will delegate duties to employees at necessary and follow up with each employee to ensure duties have been performed. The Administrator will notify the Medical Director and the President of the Management company of the emergency. · The disaster is evaluated by the appropriate manager and the need for evacuation of the facility determined. · All ambulatory patients are evacuted on foot. · All non-ambulatory patients are evacuated via wheelchair or guerney. · Any patients requiring assistance with respirations are assisted via manual ambubag until tranported to the nearest receiving hospital. · Patient safety is maintained as the highest importance during any disaster. · Visitors are escorted to the evacuation area by employees. · The main evacuation area is the back parking lot. · Evacuation exits are either the back door/patient exit door, the front entrance doorway or the supply delivery doorway. Once all patients and visitors and employees are evacuated, a head count is made to ensure everyone is accounted for. Accounting for visitors is based on the limited interaction with visitors and employees. Reference RM P&P #13-33 Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Emergency Preparedness Plan Evacuation Procedure POLICY #: 13-33 EFFECTIVE DATE: 8102 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8102 POLICY: Surgicare Surgery Center has an evacuation plan in place in the event of an emergency. Employees will be aware of appropriate evacuation procedures for the facility, know the emergency contacts and emergency equipment. Emergency numbers are located in the Staff Resource Binders in each department. Emergency disaster drills are conducted quarterly, and conducted by the DON. The facilities evacuation area is the back parking lot. PURPOSE: To ensure the safe evacuation of employees, patients and visitors in the event of an emergency. PROCEDURE: · Disaster is identified and reported to the Director of Nursing (DON), Administrator or Business Office Manager (BOM). · The Administrator (or designee) will be responsible to coordinate the emergency evacuation plan. · The Administator (or designee) will assist the local emergency personnel that respond to the facility. · The disaster is reported to the emergency services via phone as deemed necessary by the Administrator or designee; the emergency services will be called at #911, and the Office of Emergency Services at #1-800-852-7550, to report any spills that are a threat to life, safety, or the environment. For other non-emergency spill reporting, the administrator (or designee) will call the Bakersfield Fire Dept at # 661-326-3979. · The Administrator will document the time and date when each agency was notified and the name of whom she/he spoke with. · The Administrator will delegate duties to employees at necessary and follow up with each employee to ensure duties have been performed. · The Administrator will notify the Medical Director and the President of the Management company of the emergency. · The disaster is evaluated by the appropriate manager and the need for evacuation of the facility determined. · All ambulatory patients are evacuted on foot. · All non-ambulatory patients are evacuated via wheelchair or guerney. · Any patients requiring assistance with respirations are assisted via manual ambubag until tranported to the nearest receiving hospital. · Patient safety is maintained as the highest importance during any disaster. · Visitors are escorted to the evacuation area by employees. · The main evacuation area is the back parking lot. · Evacuation exits are either the back doodpatient exit door, the front entrance doorway or the supply delivery doorway. · Once all patients and visitors and employees are evacuated, a head count is made to ensure everyone is accounted for. Accounting for visitors is based on the limited interaction with visitors and employees. Reference EOC P&P #17-4 Southwest Healthcare 'gery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Code Red- Fire Plan POLICY #: 13-37 EFFECTIVE DATE: 9~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 9/02 PURPOSE: To promote the safety of all patients, staff and visitors during any episodes of fire or smoke detection, false or real. POLICY: SURGICARE SURGERY CENTER will support an ongoing fire safety program to include general fire safety, orderly and safe evacuation procedures, the purpose and usc of fire fighting/suppression equipment, the use of and response to the fire/smoke alarm system, and the recognition and prevention of fire hazards. A. The Administration of SSC recognizes the importance of training employees in fire protection and fire safety. This training is an essential part of being prepared for emergencies. PROCEDURE: I. In Case of Fire and/or Fire Alarm A. The necessary steps to be taken during a fire are located in each department. The degree of imminent danger, where survival time is critical, and thc number of employees on hand to help are contingencies which may change the priorities. Thc first steps of the procedure must always be initiated. These will be described in more detail but are as follows: 1. Rescue 2. Alert 3. Confine 4. Extinguish B. Rescue t from areas of danger. 1. Because of the facility's sophisticated fire/smoke detection system, an alarm might be sounded before the actual fire is located. 2. Move all patients in the area of danger to those smoke containment compartments within the building where there is no danger of smoke inhalation or fire. This procedure is known as "horizontal evacuation." 3. Only on the order of the Administrator, designee, or the Fire Department officer in charge, will patients be evacuated to outside the facility. C. Alert by announcing verbally (loud and audibly) "Code Red" and location of the fire (three times) in a very calm manner. 1. If the fire alarm system is not already in alarm condition, activate the nearest manual pull station to energize the fire alarm system. 2. At t his time t he receptionist o r designee w ill notify t he fire department b y dialing 911. The facility twenty-four hour alarm monitoring company will also notify the Fire Department. 3. The receptionist will notify all other building occupants of the fire (eg adjacent offices). D. Confine the fire by closing all doors. 1. All doors to hallways must be closed after it is determined the rooms do not - contain activated medical gases. 2. The facility is divided into smoke containment compartments. This creates safe zones throughout the building except for the area in which the fire i s located or smoke is a problem. 3. In safe areas, patients maybe left in their locations, but all doors must be closed. 4. Anesthesia or the Director of Nursing or designee shall be responsible for closing the main oxygen cut-off valve serving the area in which the fire is located. The Director of Nursing or designee will ensure that tank oxygen is available for oxygen dependent patients located in the affected area. E. Extinguish the fire with a portable fire extinguisher until the fire department arrives only if: 1. Conditions do not pose a personal threat to your safety. 2. The fire is controllable. F. "All Clear" announcement. 1. After determining that the fire area is safe and can be reoccupied, the Administrator or designee will broadcast verbally the "Code Red-All Clear" announcement. II. Staff Responsibilities A. Upon discovering smoke or an actual fire, a staff member will b e responsible for taking immediate action in accordance with the established fire response procedures. B. Specific ~ will be assigned to certain staff as determined by the Administra~i~Y(or Director of Nursing ). - C. After normal business hours, or if out of the facility, the Administrator will be notified of the "Code Red" and location. D. The Fire Management Team will normally be made up of the following: During regular working hours: 1. Administrator 2. Director of Nursing 3. Business Office Manager E. The Administrator's designee will: 1. Report to the fire area. 2. Confirm that fire department has been notified. 3. Judge the severity of the emergency. 4. Determine the degree of evacuation necessary (if necessary). 5. Establish communication l~om the fire area. 6. Call for help from other departments or areas if needed and give instructions. F. Available staff will respond to the alarm area and report to the F ire Management - Team to assist as instructed. G. Physicians will: 1. Listen for further instruction and be prepared to initiate first aid and treatment of the burned or injured being evacuated from the fire area. H. Nurses and other staff will: 1. In the Fire area: a. Initiate fire safety procedures. b. Assure safety of patient's charts. 2. Other locations: a. Remain ready to receive patients being evacuated from the fire area. b. Calmly assure the patients that all is under control. c. Listen for further instruction. I. Ancillary Personnel: Clear all cleaning equipment from the hallways, close closets, and listen for further instructions. . m. Fire Prevention - A. Inspections: Periodic safety inspections are made of the fire protection system equipment. These inspections are performed by experienced and qualified contract agencies, or with the Fire Department. B. Storage: Removing trash reduces a source for fuel and propagation of fire. Housekeeping efforts will assure orderly and proper storage of materials which must be kept on the premises. 1. Accumulated trash will be removed daily. 2. Combustible storage items will be kept away from heat producing appliances such as boilers, water heaters, furnaces, stoves, dryers, etc. 3. The top of any stored material or item will have at least an 18 inch clearance of the ceiling or any other overhead obstruction. 4. Containers of supply deliveries or other stored items will not be allowed to block access to fire alarm boxes or fire extinguishing equipment. 5. Flammable liquids and solvents will not be stored in the facility unless they are kept in U1/FM approved fire proof cabinets. C. Smoking: The CENTER prohibits smoking. However, because many people continue to smoke, the following rules pertaining to smoking will be enforced: 1. Under no circumstances will smoking be permitted in the facility. 2. Any ashtrays or waste containers used by the center must be made of - noncombustible material. 3. Visitors are permitted to smoke outside the facility only. D. Electrical Equipment: All electrical equipment will be kept in a good state of repair and safely used by staff at all times. The following rules will be followed: 1. Electrical circuits will not be overloaded (this will be detected by excessive heating of distribution panels and tripping of breaker switches). 2. All electrical equipment brought into the center will be inspected by the Biomed company as needed. This applies to equipment owned or rented. 3. Paper and other combustible materials will not be allowed contact with light bulbs or other heat producing items. 4. All electrical equipment will be kept clean and free of defects by responsible department. 5. Over-current protection devices and branch power panels will be labeled to identify the equipment or circuit each controls. 6. Adapters to negate the purpose of grounding will not be permitted in the center. 7. Extension Cords: a. Will not be supplied by outside parties such as equipment vendors or patients families. b. Shall be 16 gauge or heavier and meet the requirements of technical standards. c. Shall not exceed more than one extension cord per duplex receptacle or two cords per 4-way receptacle. d. Must b e in continuous lengths from appliance to receptacle without splices or tapping into another cord. e. Will not run under carpets, through, or walls, or be attached to building surfaces in any fashion. f. Will be considered a temporary item and permitted only while in immediate use with portable appliances or fixtures - 1985 Fire Prevention Code 703.1 and 703.2. g. Overload protected power strips will be allowed with the approval of Administrator. OR's must use circuit protectors with fuse or circu7t breaker. E. Oxygen: Oxygen does not bum, but it enriches the atmosphere causing ordinary combustible materials to bum rapidly and flammable liquids to bum explosively. The following rules concerning oxygen will be followed: 1. Oxygen cylinders are under high pressure; handle t hem with c are. Protect them from mechanical shock. 2. Where oxygen is stored, or in use, "no smoking" signs will be posted. 3. Cylinders, whether empty or full, must be properly secured and capped when not in use. While in use, they must be secured in place. 4. Combustible materials, oily cloths, and other flammable materials (petroleum jellies, alcohol, etc.) will not be stored in the same room with oxygen. 5. Oxygen rooms storing more than two cylinders must be vented. 6. Cylinders with excessive corrosion, dents, or other surface defects will be regarded as hazardous and be bled down to atmospheric pressure and disposed of by the responsible supplier. 7. Cylinders must have stamp o flnterstate Commerce Commission test. The ' stamp date must be within 5 years of current date, otherwise, cylinders will not be accepted from the supplier. IV. Fire Drills A. Notification will be made to the fire alarm monitoring agency prior to the fire drill. B. The procedure for a fire drill will be identical to those actions taken in the event of a real fire. C. There will be one fire alarm drill during each quarter conducted by the Director of Nursing. D. The emphasis on these drills is to familiarize the staff in executing fire protection procedures. E. All staff members will participate in each drill as if it were a real fire. F. Judgement will be exercised to protect the well being of our patients during fire drills. V. General Fire Information A. Exits will be accessible at all times. They will be clearly marked and fi-ee of obstructions. B. Main corridors will be at least 8 feet wide at all times and should be clear of obstructions (equipment, supplies, containers, furniture, etc.) C. All exit sigt~l~rhall be illuminated at all times. D. Porches and other areas where exits discharge will be kept clean and clear of obstructions (trashcans, furniture, etc.) E. Exit doors will become unlocked on the inside during a fire and will never be chained or tied in the closed position. F. Locations of exits in two directions for each area of the building, smoke containment compartments, location of fire extinguishers, and manual fire alarm pull boxes will be diagramed on a small scale building plan and posted at strategic locations throughout the building. G. Exit Signs, corridor lighting, and medication areas are provided with emergency power in case of power failure. H.. Smoke partition doors/windows close automatically when the fire alarm is activated; therefore, they shall never be tied back or obstructed in any way. J. All employees should familiarize themselves with the location of the fire alarm master control panel in their facility. K. All personnel not involved in the evacuation of patients or in confining the fire are to remain in their department and listen for further instructions. -' VI. Reporting and Education A. In the event of an actual fire, the Director of Nursing will file a report with administration. B. False alarms and scheduled fire drills will be documented, critiqued, and reviewed by the Quality Council. These reports will be the responsibility of the Director of Nursing. Southwest Healthcare Surgery Centers Clinical Policies and Procedures Manual SECTION: Risk Management TITLE: Emergency Preparedness Plan Master List POLICY #: 13-32 EFFECTIVE DATE: 8~02 REVISION DATE: REVIEWED BY: F.Bergeron, RN on 8/02 POLICY: Surgicare Surgery Center recognizes that the best way to prepare for an emergency is to prepare for it before is happens. The best line of defense is to be prepared. Employees will be aware of appropriate evacuation procedures for the facility, know the emergency contacts and emergency equipment. Emergency numbers are located in the Staff Resource Binders in each department. PURPOSE: To ensure adequate communication of emergency phone numbers in the event of an emergency. (see emergency phone number list to follow) .... EMERGENCY PHONE NUMBERS SERVICE PHONE # [-IALL AMBULANCE EMERGENCY 911 NON-EMERGENCY 327-9000 FIRE EMERGENCY ' 911 NON-EMERGENCY 324-4542 POLICE EMERGENCY 9 ! I NON-EMERGENCY 327-7111 PG&E (GAS & ELECTRIC) 800-743-5000 CITY OF BAKERSFIELD 'WATER DEPARTMENT 396-2400 PUBLIC WORKS SEWER DEPARTMENT 326-311 l TELEPHONE COMPANY BUSINESS 800-228-7 102 P,.EPA IRS 611 KERN COUNTY 911 -- EMERGENCY MEDICAL SERVICES 861-3200 (DISASTER PLAN) COUNTY ENVIRONMENTAL HEALTH SERVICES 862-8700 (HAZARDOUS WASTE) ~ COUNTY CORONER 861-2606 AMERICAN RED CROSS 324-6427 POISON CONTROL CENTER 800-876-4766 MHAUS (MALIGNANT HYPERTHERMIA ASSOCIATION 800_644.9737 OF 19'NITED STATES) SURGICARE SURGERY CENTER 4850 COMMERCE DRIVE, BAKERFIELD, CA, 93309 #661-322-1313 BIOTERRORISM ATTACK CONTACT LIST; 2002 Faye Bergeron H:397- C:333-7341 #132 Facility Administrator 3816 Mark Turner H:210-764- C:210-241- N/A Chief Operating Officer 2313 8940 Dr Syed Rizvi H:872- O:325-1685 #111 Medical Director 5015 H: C: N/A Director of Nursing Kem County Health Dept 868.-0554 N/A N/A State Health Dept, Local 336-0543 N/A N/A Office State Health Dept, 916-445- N/A N/A Sacramento 4171 Bakersfield Police Dept 327-7111 N/A N/A FBI Field Office, Los 310-477- N/A N/A Angeles 6565 CDC Hospital Infection 404-639- N/A N/A Program 3311 Bioterrorism Emergency, 770-488- N/A N/A CDC Emergency Response 7100 Office CDC Bioterrorism Hotline 888-246- N/A N/A 2676 md.bioterror.info.contaetlist.2002 I ~7~5 C~e~er Ave.~ 3~ ~:~r~ ~kers~e~d~ CA FACILITY NAME ~ ~g' - ~C.,~o c~,~ ~SPECT~ON DATE ADDRESS ~ ~~ ~ PHONE NO. FACILITY CONTACT ~¢~ ~~ BUSINESS ~SPECTiON TIME NUMBER OF EMPLOYEES OPERATION COM M ENTS Appropriate permit on hand 3,f(.C~,J Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials Verification of quantities C.) 30'x,,.4~c> Verification of location £o~ Proper segregation of material Verification of MSDS availability Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation Explain: Questions reg~u'ding %~s ~nsl~eetion? Pllease eall~ us m (6611) 326-3979 /Business Si~e Responsible Parly / White - Env. Svcs. Yellow - Station Copy Pink - Business Copy Ilnspector: OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one form per material per building or area) [] NEW [] ADD [] DELETE [] REVISE 200 Page __ of __ I. FACILITY INFORMATION BUSINESS I~ME (Same as FACILITY NAME or DS,~:"b~i-~' ~i~s~'As-)' ................................... 3 CHEMICAL LOCATION ~J~ I ~ C ~'~--'~ ~ ~ ~ "'"" CONFIDENTIAL (EPCRA) [--I Yes [] No 202 ............................ L FACILITY ID # : -'~---~ '-'?-i '-; .... 1~- MAP#(optionaO 203 II, CHEMICAL INFORMATION 205 ; TRADE SECRET I--iyas []No 20~ CHEMICAL NAME ~'~'~ '"~"~ {~-----'~ ................. --il If Subject to EPCRA, refer to instructions 207 , COMMON NAME EHS* [] Yes [] No 208 CAS # 209 i *If EHS ts"Yes,' a/l amours be/ow m~t be f~ lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 210 TYPE [] p PURE [] m MIXTURE [] w WASTE 2'; : RADIOACTIVE [] Yes [] No 212 CURIES 213 PHYSICAL STATE [] s SOLID E~]I LIQUID [] g GAS 214 ' LARGEST CONTAINER ~ ~' I,. 2~5 FED HAZARD CATE~RIES [] 1 FIRE [] 2 REACTIVE [] 3 PRESSURE RELEASE [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH 216 (Che~k all that apply) ANNUAL WASTE 217 MAXIMUM 218 -AVERAGE 219 t STATE WASTE CODE 220 AMOUNT ' DAILY AMOUNT ~ DAILY AMOUNT UNITS* [] ga GAL [] cf CU FT [] lb LBS ~ tn TONS 221 DAYS ON StTE 222 · If EHS, amount must be in lbs. STORAGE CONTAINER [] a ABOVEGROUND TANK [] e PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS Bo'UrLE [] q RAIL CAR 223 (Check all that apply) [] b UNDERGROUND TANK [] f CAN ~ j BAG [] n PLASTIC BOTTLE [] r OTHER [] c TANK INSIDE BUILDING [] g CARBOY [] k BOX [] o TOTE BIN [] d STEEL DRUM [] h SILO ~,L~YLINDER [] p TANK WAGON STORAGE PRESSURE [] a AMBIENT '~Laa ABOVE AMBIENT [] ba BELOWAMBIENT 224 STORAGE TEMPERATURE ? ~ AMBIENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT [] c CRYOGENIC 225 %WT ' ': ' HAZARDOUS COMPONENT EHS , ', CAS # 1 226 227 [] Yes [] No 228 229 2 ........................................ 230 231 [] Yes [] No 232 233 238 239 [] Yes [] No 240 241 242 243 [] Yes [] NO 244 245 .. IlL SIGNATURE PRINT NAME & TITLE OF A0-THORIZED COMPAI~Y REPRESENTATIVE SIGNATURE DATE 246 UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 "~'¥""~~"~'~'"'" HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one form per material per building or area) [] NEW [] ADD [] DELETE [] REVISE 200 Page __ of __ ' ~ I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) ....................... 3 CHEMICAL LOCATION -....... 201 CHEMICAL LOCATION [] Yes [] No 202 CONFIDENTIAL (EPCRA) ' II, CHEMICAL INFORMATION 205 i TRADE SECRET [] Yes [] No 206 CHEMICAL NAME ~,~ ~__.~ ~_~. ,! If Subject to EPCRA. refor ,o instructions ................... -~o~ COMMON NAME i EHS* [] Yes [] No 208 CAS # 209 FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 210 TYPE [] p PURE [] m MIXTURE [] w WASTE 2~; : RADIOACTIVE [] Yes [] No 212 I CURIES 213 PHYSICAL STATE [] s SOLID []1 LIQUID [] g GAS 214 : LARGEST CONTAINER 215 FED HAZARD CATEGORIES [] 1 FIRE [] 2 REACTIVE [] 3 PRESSURE RELEASE [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH 216 (Check all that apply) ANNUAL WASTE 217 ,MAXIMUM ,~ ~ 218 , AVERAGE 219 STATE WASTE CODE 220 AMOUNT ! DAILY AMOUNT ~ DAILY AMOUNT UNITS' [] ga GAL ~ CU FT [] Db LBS [] tn TONS 221 DAYS ON SITE 222 * If EHS, amount must be in lbs, STORAGE CONTAINER [] a ABOVEGROUND TANK [] e PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTTLE [] q RAIL CAR 223 (Check all that apply) [] b UNDERGROUND TANK [] f CAN ~ j BAG [] n PLASTIC BOTTLE [] r OTHER [] c TANK INSIDE BUILDING [] g CARBOY [] k BOX [] o TOTE BIN [] d STEEL DRUM [] h SILO ~LJ~YLINDER [] p TANK WAGON STORAGE PRESSURE [] a AMBIENT ~'aa ABOVE AMBIENT [] ba BELOW AMBIENT 224 STORAGE TEMPERATURE '~a AMBIENT [] aaABOVE AMBIENT [] ba BELOWAMBIENT [] c CRYOGENIC 225 5 t ................................ 242 I 243 4E]Yes E]No 244/ 245 ' ~ , . ' III, SIGNATURE ~::' tPRINT I~AME & TITLE oF AUTHORIZED coMPANY REP[R~-S--~-N~A~-~ ....... ~(~-A~J~- ............................... DATE 246 UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd f CITY OF [~AKERI OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 "~'""~'~~'"~"' HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one form per matedal per building or area) [] NEW [] ADD [] DELETE [] REVISE 200 Page __ of __ · L FACILITY INFORMATION BUSINESS NAME (Saree as FACILITY NAME or DBA - Doing ~[~.~)- .......................... 3 CHEMICAL LOCATION 201 CHEMICAL LOCATION [] Yes [] No 202 CONFIDENTIAL (EPCRA) ............ 203 -~lD # ~op~ional) 204 II. CHEMICAL INFORMATION 205 TRADE SECRET [] Yes [] No 206 CHEMICAL NAME If Subject to EPCRA, refer to instructions 207 COMMON NAME EHS° [] Yes [] NO 208 CAS# 209 *If El-IS ts°Y~$, ' all ammmts belowmu~t be ta lira FIRE CODE HAZARD CLASSES (Complete if requested by loc. a{ fire chie0 210 TYPE [] p PURE [] m MIXTURE [] w WASTE 2': RADIOACTIVE [] Yes [] No 212 ; CURIES 213 PHYSICAL STATE [] s SOLID []1 LIQUID [] g GAS 214 LARGEST CONTAINER ~.. <~y}. 215 FED HAZARD CATEGORIES [] 1 FIRE [] 2 REACTIVE [] 3 PRESSURE RELEASE [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH 216 (Chec~ all that apply) ANNUAL WASTE 217 MAXIMUM 218 ; AVERAGE 219 STATE WASTE CODE 220 AMOUNT : DALLY AMOUNT ~ DAILY AMOUNT UNITS* [] ga GAL [] cf CU FT [] lb LBS [] tn TONS 221 DAYS ON SiTE 222 * If EHS, amount must be in tbs, STORAGE CONTAINER [] a ABOVEGROUND TANK [] e PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BO'I-TLE [] q RAIL CAR 223 (Check all that apply) [] b UNDERGROUND TANK [] f CAN [] j BAG [] n PLASTIC BO'I-rLE [] r OTHER [] c TANK INSIDE BUILDING [] g CARBOY [] k BOX [] o TOTE BIN [] d STEEL DRUM [] h SILO [] I CYLINDER [] p TANK WACq~N STORAGE PRESSURE [] a AMBIENT [] aa ABOVE AMBIENT [] ba BELOWAMBIENT 224 STORAGE TEMPERATURE [] a AMBIENT [] aa ABOVE AMBIENT [] b3 BELOW AMBIENT [] c CRYOGENIC 225 %WT HAZARDOUS COMPONENT EHS CAS # I 226 227 Yes [] No 228 229 2 230 231 ] [--{yes [] No 233 3 234 235 ; []yes[]No 236 237 4 238 239 [] Yes [] No 240 241 5 242 243 [] Yes [] No 244 245 IlL SIGNATURE PRINT NAME & TI**H.E OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE 24~ UPCF (7/99) S:\CUPAFORMS\OES2731.TV4.wpd