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i 'HARRY MALHOTRA, DDS - .2031 17th STREET, STE. #1 UNIFIED PROGRAM INSPECTION 'CHECKLIST SECTION 1: Business Plan and Inventory Program • C Prevention Services B F a s F t . 0 900 Truxtun Ave,, Suite 210 ,FARE Bakersfield, CA 93301 _ aerM Tel.: (661) 326-3979 Fax: (661) 872-21`71 FACILITY NAME - /~o~ INSPECTION DATE 9-z~-o~ INSPECTION TIME y~s- ADDRESS Zoe / ~~ HONE NO. 3Z~/- 7GG8 NO.OF EMPLOYEES . =- FACILITY CONTACT t 7©,3-- z 5'i Q /"e BUSINESS ID NUMBER 1s-o21-~~~~( __- - _ ~j,,~j - M Section. 1: Business Plan and Inventory Program ~0'cJ~ ~I _- _ _ _ _ _ _ . - ___ _ _J ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY - ^ COMPLAINT ^ RE-INSPECTION - C V ~ C=Compliance OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND ^ BUSI1TeSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ ~ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ~~~r~ ~f n ~ ; t y 1~,1 ^ VERIFICATION OF LOCATION J~ ^ PROPER SEGREGATION OF MATERIAL L ~ ^ VERIFICATION OF MSDS AVAILABILITY ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~P ^ EMERGENCY PROCEDURES ADEQUATE ~"{ ^ CONTAINERS PROPERLY LABELED ` ll `~~ L1 Q ^ HOUSEKEEPING ~ + ^ FIRE PROTECTION ~ ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITES OYES ^ NO ^_ /~ EXPLAIN: ~s f// S ~/ --- - - - __ QU/ES/TIONS REGAR~DING/THIS INS/PECTION? PLEASE CALL US AT (661) 326-3979 7`i~i,~ ril/o-od idc~v-df ~ - C Inspector (Please Print) Fire Prevention / 1s` In /Shift of Site/Station # White -Prevention Services Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 'Z. .` ~ ~ ~/ - ~ ~ ~ v ~ ~ '^/v\Y' MALHOTRA DDS HARRY 015-021-003044 Sit ID e : ,~ Manager HARRY MALHOTRA DDS BusPhone: (661) 324-7668 Location : 2031 17TH ST 1 Map 102 CommHaz Low City BAKERSFIELD Grid: 25D FacUnits: 1 AOV: CommCode: BFD STA O1 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title DR HARRY MALHOTRA / OWNER DR ROBERT MOWER / OWNER Business Phone: (661) 324-7668x Business Phone: (661) 324-1007x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: ~ Fire React ImmHlth DelHlth Contact HARRY MALHOTRA DDS Phone: (661) 324-7668x MailAddr: 2031 17TH ST 1 State: CA City BAKERSFIELD Zip 93301 Owner HARRY MALHOTRA DDS Phone: (661) 324-7668x Address 2031 17TH ST 1 State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: ~ = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: ~ PROG A - HAZMAT (-~ ~V PROG H - HAZ WASTE GEN ~, Lased on my inquiry of those indivira~:~.;_, I certify sible for obtaining the information tA,~~ C-V ~ /~ , respon that f have personally f l n 9 2 aw under penalty o 007 examined and am familiar with the information submitted and believe the information is true, accurate, and complete. Signa ure Date -1- 02/02/2007 r _~. F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP OXYGEN WASTE FIXER F IH DH G R L 498.00 5.00 FT3 GAL . Low Min -2- 02/02/2007 -3- oa/oa/aoo~ r F MALHOTRA DDS HARRY ~ Inventory Item 0001 COMMON NAME / CHEMICAL NAME OXYGEN Location within this Facility Unit OP RMS STATE TYPE PRESSURE _ Gas TPure -Above Ambient SiteID: 015-021-003044 ~ Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 7782-44-7 TEMPERATURE CONTAINER TYPE Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Co249100rFT3 Daily 498100m FT3 I Daily 498r00e FT3 r1t~GxtcLVU~ ~ul~irc~lv~;iv 15 %Wt. RS CAS# 100.00 Oxygen, Compressed No 7782447 t1HGKKIJ 1~5,Jr;,5,51~1iS1V 15 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME WASTE FIXER Days On Site 365 Location within this Facility Unit Map: Grid: DARKROOM CAS# Liquid TWaste i~mbRient~E ~ AmbientT~E ~ PLASTOICTCONTAINERE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL 5.00 GAL 5.00 GAL tltiGnttLU U .7 l..ul~lrvly t',lv l b %Wt. RS CAS# Silver No 7440224 t1F~GKtCL L~J ~~551~1~1V 1 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 02/02/2007 F MALHOTRA DDS HARRY SitelD: 015-021-003044 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ .1yC11C:y 1VV1.1L1C:dL1Uil '~~ S-~~ Employee_Notif./Evacuation Public-Noti€./Evacuation Po~~ rJIIIC I,.yC11C:y 1.1CU11:d1 r1d11 ~~~~ -5- 02/02/2007 a F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~`Release_Prevention~ i /cn_I~ p~ V v I~~v - ~Re""lease Containment ~, - S..1Cd11. UfJ; ~~ v - Other Resource Activation -6- 02/02/2007 F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ .~Nc~.iai nac~aiu~ Utility Shut-Offs riic r1Vl.Cl:. /tiVd11. WdI.CL V~ , rsuilaing occupancy Level, -~- 02/02/200 -~ F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ Fast Format ~ ~ Training _ Overall Site ~ _, - employee lraining ' ~ ~ rcty C L Held for Future Use nc.LU iui r u~uiC uac -8- 02/02/2007 a + MALHOTRA DDS HARRY __________________________________ SiteID: 015-021-003044 + Manager HARRY MALHOTRA DDS Location: 2031 17TH ST 1 City BAKERSFIELD BusPhone: (661) 324-7668 Map 102 CommHaz Low Grid: 25D FacUnits: 1 AOV: CommCode: BFD STA Ol EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title DR HARRY MALHOTRA ~/ OWNER DR ROBERT MOWER / OWNER Business Phone: (661) 32'4:-7668x Business Phone: (661) 324-1007x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire React ImmHlth DelHlth Contact HARRY MALHOTRA DDS Phone: (661) 324-7668x MailAddr: 2031 17TH ST 1 State: CA City BAKERSFIELD Zip 93301 Owner HARRY MALHOTRA DDS Phone: (661) 324-7668x Address 2031 17TH ST 1 State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: ~~`~ PROG A - HAZMAT ~ ~~r PROG H- HAZ WASTE GEN I ENTb J U L 2 5 2006 Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examiried and am familiar with the information submitted and believe the information is true, accura , and com I e. i n ture Date Py ~M~d~ -1- 02/28/2006 ~~ HARRY MALHOTRA, DDS v 2031 17TH STREET ~- ~' ~~ n_J/ , O ~: MALHOTRA DDS HARRY SiteID: 015-021-003044 Manager HARRY MALHOTRA DDS Location: 2031 17TH ST 1 City BAKERSFIELD CommCode: BFD STA Ol EPA Numb: BusPhone: (661) 324-7668 Map 102 CommHaz Low Grid: 25D FacUnits: 1 AOV: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title DR HARRY MALHOTRA / OWNER DR ROBERT MOWER / OWNER Business Phone: (661) 324-7668x Business Phone: (661) 324-1007x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire React ImmHlth DelHlth Contact HARRY MALHOTRA DDS Phone: (661) 324-7668x MailAddr: 2031 17TH ST 1 State: CA City BAKERSFIELD Zip 93301 Owner HARRY MALHOTRA DDS Phone: (661) 324-7668x Address 2031 17TH ST 1 State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG H - HAZ WASTE GEN based on my inguiry of those individuals ~-/~ respctnsibfe for obtaining the information, I certi#y I~ n ll t I h ~ ~~ y ave perso a under penalty of law tea examined and am familiar with the information ~~~ submitted and belie~~e the information is true, accurate, and complete. ' ~ ~ ~ I~ ~ignatui . Date -1- 07/12/2007 f" ~ F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP OXYGEN WASTE FIXER F IH DH G R L 498.00 5.00 FT3 GAL Low Min -2- 07/12/2007 -3- 07/12/2007 F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ ~ 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: OP RMS CAS# 7782-44-7 ~GasATE T TYPE T PRESSURE TEMPERATURE CONTAINER TYPE I Pure I Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 249.00 FT3 498.00 FT3 498.00 FT3 r1H~Hx1_,OUS COMPONENTS °sWt. RS CAS# 100.00 Oxygen, Compressed No 7782447 t1HGEiKL H~.7L' .7.71~1L" 1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL~NAME WASTE FIXER Days On Site 365 Location within this Facility Unit Map: Grid: DARKROOM CAS# STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid Waste Ambient Ambient PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL 5.00 GAL 5.00 GAL t31iGHKLVUw7 LV1~lYV1V1'~1V17 %Wt. RS CAS# Silver No 7440224 ritiGl~itCL H.~.7L"a.71~1L"1V-1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 07/12/2007 F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 05/09/2007 ~ POSTED Employee Notif./Evacuation 05/09/2007 POSTED AND TRAINING BOOKS Public Notif./Evacuation 05/09/2007 POSTED Emergency Medical Plan 05/09/2007 POSTED -5- 07/12/2007 F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 05/09/2007 ~ IN SECOND BARREL Release Containment TN SECOND BARREL 05/09/2007 Clean Up 05/09/2007 QUICK SORB V L11Ci 1CC~TVULUC liC: l,lVdl.l Vil -6- 07/12/2007 F MALHOTRA DDS HARRY SiteID: 015-021-003044 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ a~~~:1a1 na~al.u~ V 1.1111.y ~711U1..-V115 Fire Protec./Avail. Water 05/09/2007 YES Building Occupancy Level 05/09/2007 1 LEVEL -7- 07/12/2007 F MALHOTRA DDS HARRY SitelD: 015-021-003044 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 05/09/2007 ~ BRIEF SUMMARY OF TRAINING PROGRAM: MONTHLY rayC ~ i7C1U LVL L'UI. LLLC l.JSC RG ll.l LVL t'Ul.U1C Vw7C -8- 07/12/2007 ~_~ a M HAS AN APPOINTMENT ON MON. ~ TUES. ~ WED. ~ THUR. ~ FRI. ~ SAT. r . A.M. DATE AT P.M. ROBERT MOWER, D.D.S.- ORAL AND MAXILLOFACIAL SURGERY 2031 17th St. Ste. #1 (661) 334-1007 BAKERSFIELD, CA 93301 IF UNABLE TO KEEP APPOINTMENT, KINDLY GIVE 24 HRS. NOTICE. IF HAVINGGENERAIANESTHESIA, PLEASE HAVE NOTHING TO EAT OR DRINK FOR AT LEAST 8 HOURS BEFORE M - HAS AN APPOINTMENT ON ^ MON. ^ TUES. ^ WED. ^ THUR. ^ FRI. ^SAT. A.M. DATE AT P M DR. HARRY MALHOTRA / ENDODONTIST 2031 17th Street, Ste. #1 Bakersfield, CA 93301 (661) 324-ROOT (7668) KINDLY GIVE 24 HRS. NOTICE OF CANCELLATION OR THERE WILL BE A $25 CHARGE UNIFIED PROGRAM INSPECTION CHECKLIST Bakersfield Fire Dep`~ C ~ s Environmental Services c SOS 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel: (661)_326-3979 SECTION 1 Business .Plan and Inventory Program FACILITY NAME ADDRESS __ ~.t7 31 FACILITYCONTACT - -- ~~ No. I No. ID Number /,--- - -' - --- - 15-0 1- ~/ Section 1: Business Plan and Inventory Program `' ` O Routine .Combined O Joint Agency OMulti-Agency O Complaint O Re-inspection ANY HAZARDOUS WASTE ON SITE?: YES ^ NO EXPLAIN: 1/J ~ t ~ ~f X{~'"'//// ~~~` QUESTIONS REGARDING THIS INSPECTIONS PLEASE CALL US AT ~66'I ~ 32t)-3979 ~~~--s .~~-~ Inspector (Please Print) Fire Prevention 1st-In/Shift of Site White -Environmental Services Yelbw -Station Copy t us ess Site Res I le Party (Pleas rintj ~ Pink • Business Copy