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Prevention Services
UNIFIED PROGRAM INSPECTION CHECKLIST R F R 5 f , , p 90o Truxtun Ave., suite 210
~~a~ __._,ws~~ w.-_», .,,a.~~~,a~- .~.T~;;~~ __ _g~ .~-.~~~~~ _ _~_~~.~..na -e_ ~-- FIRE Bakersfield, CA 93301
SECTION 1: Business Plan and Inventory Program ~ aRTM Tel.: (661) 326-3979
i ~ Fax: (661) 872-2171
FACILITY NAME INSPE ION DAT INSPECTION TIME
ADDRESS
~h PHONE NO. NO OF EMPLOYEES
0 8 1 s-~~ ~ --~ S3 ~ ~ ~~~
FACILITY CONTACT
' BUSINESS ID NUMBER
15-021-
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^ ROUTINE ^"'-COMBIN Section 1: Business Plan and Inventory Program
ED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION
C V ~ C=Compliance OPERATION
V=Violation COMMENTS
^ ~ APPROPRIATE PERMIT ON HAND
,L 6
e G
^ ~ BUSIneSS PLAN CONTACT INFORMATION ACCURATE ~ ~~Sre~ ) ~,
^ VISIBLE ADDRESS
^ CORRECT OCCUPANCY
^ VERIFICATION OF INVENTORY MATERIALS
~ ^ VERIFICATION OF QUANTITIES
++
?Isla ^ VERIFICATION OF LOCATION
t
~I ^ PROPER SEGREGATION OF MATERIAL - -- '
^ ® VERIFICATION OF MSDS AVAILABILITY
^ .~I VERIFICATION OF HAZ MAT TRAINING
^ ~ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES
^ EMERGENCY PROCEDURES ADEQUATE
^ CONTAINERS PROPERLY LABELED
^ HOUSEKEEPING
^ ~ FIRE PROTECTION lit ~ ~~ N ~ ~ ~- ~ rC ~~~t v~ u ( ~
t)
^ ^ SITE DIAGRAM ADEQUATE & ON HAND
'~'C c, r
~~
~/ ti~
ANY HAZARDOUS WASTE ON SITE?
EXPLAIN:
QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979
-~~Q-,~ ~ ,-`J
Inspector (Please Print) Fire Prevention / 1" In /Shift of Site/Station #
White -Prevention Services Yellow -Station Copy Pink -Business Copy
^ YES ~NO
~~~
at ~v~
FD 2155 (Rev. 09/05
~~`~-,.~
v ------
SELF-CERTIFICATION CHECKLIST
C.v ^'R~~:: '-~:I_.s.1a" J?~SI+,Y:.31:s'::._1~.. '...,..:i .-..'ae..la.:'-_ -~e2..~i:.'a't{..'-._..sll....:.., C .w .. ::'/S e:...t~
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Fire Prevention
BAKERSFIELD FIRE DEPT.
Y`"-'~
- Prevention Services
~`~~
BA'~
b`ERSFI.:K D 1600 Truxtun Ave Ste 401
.
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fiIR~ ~ ~~ Bakersfield, CA 93301
,
D,EP~l~TM$T Tel.: (661) 326-3979
`'' ,T""- .F~
•- \, ~>~ Fax: (661) 852-2171
FACILITY NAME: __--___._---~~ -__--_ -_-_ -- ---_ ELF-CERTf I 10 DATE: _---_-~---_-
r /"
SITEADDRES -,[~,~ ~tP~D1--~^--
`• I ~~crZL•`Jl . P O E UMB ~~ -~
..~
MAILING ADDQESS r, ZIP CODE FAX NUMBER:
DONOfiDISCARD'=FAILURE TO RETURN WILL RESULT IN FIRE DEPARTMENT INSPECTION
INSTRUCTIONS: Please verify and check each item as appropriate. Include comments on each line o r at the bottom as necessary.
en completed, make a second copy for your records and mail the oribinal to the address above. Failure to return will result in inspection.
Y N OPERATION COMMENTS
^ ^ Spent fluorescent tubes saved in a suitable container and recycling* Name:
(If yo u rely on an outside agency for the recycling, please indicate the name, address, and phone number of the
Phone No
:
agency that removes your tubes.) .
_
ddress:
^ Waste batteries saved in suitable container for recycling*
~ ^ Discarded electronic devices saved for recycling*
`L~i ^ Discarded items containing Mercury saved for recycling*
'®'~ ^ Discarded non-empty aerosol spray cans saved for recycling*
^ ~ Current annually serviced "ABC Type" fire extinguisher every 75 feet of travel
^ ~~ Extension cords not used in place of what should be permanent wiring
^ A1{ exits indicated by exit signs, not more than 100 feet apart, if occupant load
is 100 or more
^ Minimum of 30 inches of clearance in front of electrical panels
^ Cover plates installed on all electrical outlets, switches, and junction boxes (no
exposed wiring)
^ ~ Flammable and combustible material stored properly and not adjacent to a ((~j ~,n~`~~, ~~, ~~~
"~ [~ r"tlJ
source of ignition (check hot water heater and furnace area)
^ ~ Do you use or store any hazardous materials on site?
^ '~ Does your building have a monitored fire alarm system?
^ '~ Does your building have a fire suppression (sprinkler) system?
*Recycle at the Kern County Special Waste Facility, 4951 Standard Street, Bakersfield, CA 93308. Phone: (661) 862-8922
COMMENTS:
~~,1~
REGARDIN IS CHECKLIST? PLEASE CALL US AT (661) 326-3979
,~"^ `~
Business Site /Responsible Party (Please Print)
~0~~~~
~~ 2155b (Rev. 09J06)
~,plr~-"?I~OU)S MATERIAL MANAGEMENT PLAN
fin- ~,
APPLICATION
BUSINESS OWNER/OPERATOR IDENTIFICATION FORM
"(HAZARDOUS MATERIAL FACILITY INFORMATION)
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1600 Truxtun Avenue, Suite 401
s a s F 1 n Bakersfield, CA 93301
P/RB Phone: 661-326' 3979 . Fa~ 661-852-2171
ARfJM l f ~-. Q~
Page 1 of 2 ~`~ p ~^~
~S ~ ~
I. ;FACILITY IDENTIFICATION
FACILITY ID # 1 YEAR BEGINNING 100 YEAR ENDING 101
BUSINESS NAME (Same a/^s~ FACILITY NAME or DBA) 3
_ ~ ~Y YT ~ BUSINESS PHONE
- 102
SITE ADDRES (~
1 V
103
CITY ~r'C It-.EI~7~~~L.Y 104
c~ ZIP CODE
3v t 305
DUNN & BRADSTREET # 106 SIC CODE 107
couNTY
~'Q-~2v~ ~N~
C loe
OPERATOR NAME-
o
~ t-. 109 OPERATOR PHONE
~~r - 3y~rL~la
110
II. OWNER INFORMATION
OWNER NAME
111
OWNER PHONE /2 Cy~ ~ ^ ~ ~
/~i JVC G,iL ',L
,~{y~ 112
1'~, `
O NER MAILING ADDREQSS~
O ~
~~ 113
CI ~ Ilq STATE 115 ZIP CODE
~ b 116
III. ENVIRONMENTAL CONTACT
CONTACT NAME ~ ~ 117
~, CONTACT PHONE 118
CONTACT MAILING ADDRESS ~ ~ 119
CITY
_.___-,. ._. __._ _ _--- _ -- _
.PRIMARY 120 STATE 121 ZIP CODE
.. _.. ___. _.r ._ -_ _ _. .. _ .. .. _ _ .-... ,_ .. .._~_.
IV. 'EMERGENCY CONTACTS
SECONDARY ~ 122
__._.. .. ..__
NAME \\
`fir'
~, 123 NAME 126
TITLE 124 TITLE 129
BUSINESS PHONE
~~ 125
~~ BUSINESS PHONE 130
24~h16HR-Wt6NE
~~ 126 24-HOUR PHONE 131
CELL PHONE , _ ~~~ ~ r ` ~ ~ 127
S CELL PHONE i /~ ~~
L!('6}` 132
- ~ 133
V. CERTIFICATION
Certification: Based on my inquiry of those individuals 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.
SIGNATURE OF DOCUMENT PREPARER 136 DATE 134 NAME OF DOCUMENT PREPARER (PRINT) 135
NAME OF OWNER/OPERATOR (SIGN & PRINT) 137 TITLE Of DOCUMENT PREPARER 138
~ ~ c ~ ?, ~~a- =1 ~ ~l ~ c~~ ~
FD2142 (Rev 06/07)
1 C~
~.
HAZARDOUS MATERIAL FACILITY INFORMATION ~, -~
,~ BUSINESS OWNER/OPERATOR IDENTIFICATION
Please submit the Business Activities page, the Hazardous Material Facility Information (HMMP) Business Owner/
Operator Identification Form, and Hazardous Material Inventory Chemical Description Form for all hazardous material
inventory submissions. For the inventory to be considered, please complete this page; it must be signed by the
appropriate individual:
NOTE: The numbering of the instructions follows the data element numbers that are on the Business Owner/Operator
Form page. These data element numbers are used for electronic submission and are the same as the numbering used
in 27 CCR, Appendix C, Business Section of the Unified Program Data Dictionary. Please number all pages of your
submittal. This helps our CUPA or AA identify whether the submittal is complete and if any pages are separated.
i FACILITY I.D. NUMBER -This number is assigned by the CUPA or AA. This is the unique number 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.
101 ENDING DATE -Enter the ending year and date of the report.
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 located. No post office 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 8c BRADSTREET NUMBER -Enter the Dunn & Bradstreet number for the facility. The Dunn & Bradstreet number may be
obtained by calling 610-882-7748 or by Internet.
107 SIC CODE -Enter the primary Standard Industrial Classification Code number for primary business activity. NOTE: If code is more
than 4 digits, report only 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, area code first, and any extension.
iii OWNER NAME -Enter name of business owner.
112 OWNER PHONE -Enter the business owner phone number, area code first, and any extension. '
113 OWNER MAILING ADDRESS -Enter the owner mailing address.
114 OWNER CITY -Enter the city for owner mailing address.
115 OWNER STATE -Enter the 2 character state abbreviation for the owner mailing address. ~ ~ -
116 OWNER ZIP CODE -Enter the zip code for the owner address; extra 4-digit zip may also be added.
117 ENVIRONMENTAL CONTACT NAME -Enter the name of the person who receives all environmenta_I:correspondence and will respond
to enforcement activity.
118 CONTACT PHONE -Enter the phone number at which 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.
120 CITY -Enter the name of the city for the environmental contact mailing address.
121 STATE -Enter the 2 character state abbreviation for the environmental contact mailing address.
122 ZIP CODE -Enter the zip code of the environmental contact mailing address; extra 4-digit zip may also be added.
123 PRIMARY EMERGENCY CONTACT NAME - Enter the name of a representative that can be contacted in case of an emergency,
involving hazardous material, at the business site. The contact shall have FULL facility access, site familiarity, and authority to make
decisions for the business regarding 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 code first, and any extensions.
126 24-HOUR 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 home phone number, then the service answering the phone must be able to
immediately contact the individual.
127 CELL NUMBER -Enter the cell number for the primary emergency contact.
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,"site 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. The 24-hour phone number must be one
which is answered 24-hours a day. If it is not the contact home phone number, then the 'service-answe'r`ing the phohe~must_be able to
immediately contact the individual. _
132 CELL NUMBER -Enter the cell number for the secondary emergency contact.
133 ADDITIONAL LOCALLY-COLLECTED INFORMATION -This space may be used for CUPA or AA•to collect any additional information
necessary to meet the requirements of their individual programs. Contact your local agency for guidance.
134 DATE -Enter the date that the document was signed.
135 NAME OF DOCUMENT PREPARER (FULL PRINTED NAME) -Enter the full printed name of the person who prepared the inventory
submittal information.
136 SIGNATURE OF DOCUMENT PREPARER (FULL SIGNATURE) -Enter the full signature of the person preparing the page. The signer
certifies to a familiarity with the information submitted and that based on the signer inquiry of those individuals responsible for
obtaining the information, all the information submitted is true, accurate, and complete.
137 SIGNATURE OF OWNER/OPERATOR/DESIGNATED REPRESENTATIVE -The Business Owner/Operator, or officially-designated
representative of the Owner/Operator, shall sign and print in the space provided. This signature certifies that the signer is familiar
with the signer belief that the submitted information is true, accurate, and complete.
138 TITLE OF DOCUMENT PREPARER -Enter the title of the person preparing the page.
Page 2 of 2 FD2142 (Rev 06/07)
59
Page 2 of 2
SECTION IL2: 'RELEASE RESPONSE PLAN (CONY)
UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY)
NATUR L GAS ROPANE: 1
~ V N~ ~~ ~ `~
ELECTRICAL:
C /
WATER: -V ~ (.l L
SPECIAL:
PRIVATE FIRE PROTECTION/WATER AVAILABILITY: '
A. PRIVATE FIRE PROTECTION:
~I ~ ~ ~;T.
B. WATER AVAILABILITY (FIRE HYDRANT): '
~~
SECTION -III: TRAINING ~,~
NUMBER OF EMPLOYEES: I
~W ~~~
MATERIAL SAFETY DATA SHEETS ON FILE: ^ YES ^ NO IF YES, LOCATION:
BRIEF SUMMARY OF TRAINING PROGRAM:
CERTIFICATION'"'
~,
Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally
examined and am familiar with the information submitted and believe the information is true, accurate, and complete.
SIGNATURE OF OW NER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE a77
NAME OF SIGNER (PRINT) a7a TITLE OF SIGNER a79
FD2169 (Rev 06/07)
HAZARDOUS MATERIAL MANAGEMENT PLAN
APPLICATION
FOR SECTION DISCOVERY & NOTIFICATION
(FORMS)
BAKERSFIELD FIRi= DEPARTMENT
Prevention Services
1600 Truxtun Avenue, Suite 401
H R S P I aBakersfield, CA 93301
P!R` Phone:661-326-3979 . Fax:661-852-2171
ARTAI T
Page 1 of 2
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.
d
SECTION~:I: FACILITY IDENTIFI TION
BUSINESS NAME (FACILITY NAME or DBA)
a'
ADDRESS (for local use only)
FACILITY ID # 1
SECTION II.1.:,~ DISCOVE AND NOTIFICATIONS
A. LEAK DETECTION AND MONITORING PROCEDURES:
8. EMPLOYEE AND AGENCY NOTIFICATION:
C. ENVIRONMENTAL RESPONSE MANAGEMENT:
D. EMERGENCY MEDICAL PLAN:
SECTION IL2: RELEASE RESPONSE PLAN
A. HAZARD ASSESMENT AND PREVE ION MEASURES:
B. RELEASE CONTAINMENT A D/OR MITIGATION: - '
C. CLEAN-UP AND R OVERY PROCEDURES:
FD2169 (Rev 06/07)
,R
HAZARDOUS MATERIAL MANAGEMENT PLAN
CHEMICAL DESCRIPTION FORM
HAZARDOUS MATERIAL INVENTORY
^ NEW ^ ADD ^ DELETE ^ REVISE zoo
BAKERSFIELD FIRE DEPARTMENT
,Prevention Services
H H R S P I D" 1600 Truxtun Avenue, Suite 401
pIR~ Bakersfield, CA 93301
ARM T Phone:-661-326-3979 • Fax: 661-852-21
Page 1 of 2
(One form oer material oer buildin° or area )
71
I FACILITY~INFORMATION
BUSINES~ NAME (FACILITY NAME or DBA) 3
CHEMICAL LOCATION ~b~ ~ 201 CHEMICAL LOCATION 202
~
l7~bl CONFIDENTIAL (EPCRA) ^ Yes ^ No
W' KKaP.~ ~
r i.w t
FACILITY ID # 1 MAP # (optional) 203 GRID # (optional) 204
s
II. CHEMICAL-INFORMATION , _
CHEMICAL NAME 205 206
~ TRADE SECRET ^ Yes ^ No
If subject to EPCRA, refer [o instructions
COMMON NAME 207
EHS* ^ Yes
^ No
~
(~ \ \
L/\ 208
CAS # 209 'If EHS is yes, all amounts below must be in
pounds.
FIRE CODE HAZARD CLASSES (complete if requested by local fire chief) 210
TYPE 211
RADIOACTIVE: ^ Yes~No 212 CURIES 213
^ PURE ^ MIXTURE ^ WASTE
LARGEST CONTAINER - 215
PHYSICAL STATE ^ ~ SOLID ^ ' LIQUID `9i GAS 214
/~ /~ L/~
d
216
FED HAZARD CATEGORIES ^ FIRE ^ REACTIVE ^ PRESSURE RELEASE ^ ACUTE HEALTH ^ CHRONIC HEALTH
(Check all that apply)
ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 STATE WASTE 220
AMOUNT DAILY AMOUNT DAILY AMOUNT CODE
221 DAYS ON SITE 222
^ UNITS ^ GAL ~ CU FT ^ LBS ^ TONS ,
'If EHS, amount must be in lbs.
STORAGE CONTAINER: - 223
^ ABOVEGROUND TANK ^ CAN ^ BOX ^ TANK WAGON
^ UNDERGROUND TANK ^ CARBOY CYLINDER ^ RAIL CAR
TANK INSIDE BUILDING ^ SILO ^ GLASS BOTTLE ^ OTHER
^ STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ^ TOTE BIN
^ PLASTIC/NONMETALLIC DRUM ^ BAG
224
STORAGE PRESSURE: ^ AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT
225
STORAGETEMPERATURE: ^ AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC
%WT HAZARDOUS COMPONENT EHS CAS #
1 226 z27 ^ Yes ^ No 228 ~ ~ 229
2 ~ 230 231 -^ Yes ^ NO 232 ~ 233
3 234 235 ^ Yes ^ NO 236 237
4 238 239 ^ Yes ^ No 240 2a1
5 242 243 ^ Yes ^ No 244 - ~ ~ 245
';III. SIGNATURE :'
PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE 246
FD2144 (Rev 06/07)
Y ~ CALIFORNIA WASTE CODES ~`
Code Description
Inorganics
111 Acid solution 2 < pH < 7 with metals (antimony,
arsenic, barium, beryllium, cadmium, chromium,
cobalt, copper, lead, mercury, molybdenum, nickel,
selenium, 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) containing reactive
Anions. (azide, bromate, chlorate, cyanide, fluoride,
hypochlorite, nitrite, Perchlorate and sulfide anions)
132 Aqueous solution with metals (see 111)
133 Aqueous solution with total organic residues 100% or
more
134 Aqueous solution with total organic residues < 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 (see 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 pesticide
production
241 Tank bottom waste
251 Still bottoms with halogenated organics
252 Other still bottom waste
Code Description
Organics (cont)
261 PCB and material containing PCB
271 Organic monomer waste (includes unreacted resins)
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
Sludge
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 gal
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 FD2144a (Rev 06/07)
_~
HAZARDOUS MATERIAL MANAGEMENT PLAN
B B R S A 1 D
BUSINESS ACTIVITIES PAGE ~~r~ r
(HAZARDOUS MATERIAL FACILITY INFORMATION) ,~-
BAKERSFIELD FIRE DEPARTMENT
Prevention Services '' ~ '
1600 Truxtun Avenue, Suite 401
Bakersfield, CA 93301 ''
Phone: 661-326-3979 . Fax: 661-852-2171
Page 1 of 1
_ ,t
` ~ I. FACILITY IDENTIFICATION -
~
FACILITY ID # (for office use only)
3 EPA ID_#
BUSINESS NAME (FACILITY NAME or DBA) ~""" ~ 103
_ II.: ACT~IVITIES.DECLARATI~ON
DOES Your Facility... If Yes, Please Complete... 129
A. HAZARDOUS MATERIAL ^ Yes ^ No • CHEMICAL DESCRIPTION FORM 130
1. , Have on site (for any purpose) hazardous material • HAZARDOUS MATERIAL MANAGEMENT PLAN
at or above 55 gallons for liquids, 500 pounds for -Minimum required planning elements:
solids, or 200 cu. ft. for compressed gases (include • Emergency Response Plan
liquids in AST and UST)? . Maps
• Training
• Prevention
• Certification
B. REGULATED SUBSTANCES (RS) ^ Yes No • CHEMICAL DESCRIPTION FORM 131
1. Have on site RS at greater than the threshold • RISK MANAGEMENT PLAN (RMP Submit to USEPA)
planning quantities established by the California • CONSOLIDATED COMPLIANCE PLAN
Accidental Release Prevention program (CaIARP)? • Incorporating CaIARP Program Elements
C. UNDERGROUND STORAGE TANKS (UST) ^ Yes ~No • UST FACILITY FORM 13z
1. ~ Own or operate Underground Storage Tanks? • UST TANK FORM (one per tank) '
^ Yes No • UST FACILITY FORM 133
2. Intend to upgrade existing or install new UST? • UST TANK FORM (one per tank) -
• UST INSTALLATION FORM (one per tank)
of
D. TANK CLOSURE/REMOVAL ^ Yes No • UST TANK FORM (Closure section -one per tank) ; , ,,
1. Need to report closing an UST that held hazardous
material or waste?
2. Need to report the closure/removal of a tank that ^ Yes ^ No .UST TANK CLOSURE FORM
was classified as hazardous waste and cleaned
onsite?'
E. ABOVEGROUND PETROLEUM STORAGE TANKS ^ Yes No • HAZARDOUS MATERIAL MANAGEMENT PLAN
(AST) • Incorporating Federal Spill Prevention Control and Countermeasure
1. Own or operate AST above these thresholds; any (SPCC) Elements pursuant to 40 CFR Part 112.
tank capacity is greater than 660 gallons or the
total capacity for the facility is greater than 1,320
gallons?
F. HAZARDOUS WASTE EPA ID NUMBER -provide on this page
1. Generate hazardous waste? ^ Yes No . To obtain EPA ID Number, please phone (916) 324-1781
2. Recycle more than 100 kg/mo of recyclable ^ Yes No . RECYCLING FORM
material at the same location it was generated?
3. Recycle more than 100 kg/mo of recyclable ^ Yes No . RECYCLING FORM
material at an off-site location different from the
point of generation?
4. Treat Hazardous Waste on site? ^ Yes ^ No . TP FACILITY FORM '
• TP UNIT FORM (one per unit)
5. Subject to Financial Assurance requirements? ^ Yes ^ No . CERTIFICATION OF FINANCIAL ASSURANCE
6. Consolidate Hazardous Waste generated at a ^ Yes No . REMOTE WASTE/CONSOLIDATION SITE NOTIFICATION
remote site? FORM
NOTE: If you checked YES to any part of Sections IIA - IIF above, then in addition to the forms requested above, please submit
BUSINESS OWNER/OPERATOR IDENTIFICATION FORM.
FD2143 (Rev 06/07)
~~ Hazardous Material Inventory -Chemical Description `c ~~'
You must complete a separate Hazardous: Material Inventory -Chemical Description page for each hazardous material (hazardous substances and
~ hazardous waste) that you handle at your facility in aggregate quantities equal to or greater than 500 pounds, 55 gallons, 200 cubic feet of gas (calculated
at standard temperature and pressure) or the Federal threshold planning quantity for Extremely Hazardous Substances, whichever is less. Also complete
a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40, or
70. The completed inventory should reflect all reportable quantities of hazardous material at your facility, reported separately for each building or
outside adjacent area, with separate pages for unique occurrences of physical state, storage temperature and storage pressure. (NOTE: the numbering of
the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are
the same as the numbering used in 27 CCR, Appendix C, and Business Section of the Unified Program Data Dictionary. Please number all pages of your
submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated.
1 FACILITY ID NUMBER -This number is assigned by the CUPA or AA. This is the unique number which identifies your facility.
3 BUSINESS NAME -Enter the full legal name of the business.
200 ADD/DELETE/REVISE -Indicate if the material is being added to the inventory, deleted from the inventory, or if the information previously
submitted is being revised. NOTE: You may choose to leave this blank if you resubmit your entire inventory annually.
201 CHEMICAL LOCATION -Enter the building or outside/adjacent area where the hazardous material is handled. A chemical that is stored at the same
pressure and temperature, in multiple locations within a building, can be reported on a single page. NOTE: This information is not subject to public
disclosure pursuant to HSC §25506.
202 CHEMICAL LOCATION CONFIDENTIAL - EPCRA -All businesses which are subject to the Emergency Planning and Community Right to Know Act
(EPCRA) must check yes to keep chemical location information confidential. If the business does not wish to keep chemical location information
confidential check no.
203 MAP NUMBER - If a map is included, enter the number of the map on which the location of the hazardous material is shown.
204 GRID NUMBER - If grid coordinates are used, enter the grid coordinates of the map that correspond to the location of the hazardous material. If
applicable, multiple grid coordinates can be listed.
205 CHEMICAL NAME -Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This
should be the International Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: If the
chemical is a mixture, do not complete this field; complete the "COMMON NAME" field instead.
206 TRADE SECRET -Check yes if the information in this section is declared a trade secret or no if it is not. State requirement: If yes, and business is
not subject to EPCRA, disclosure of the designated trade secret information is bound by HSC §25511. Federal requirement: If yes, and business is
subject to EPCRA, disclosure of the designated Trade Secret information is bound by 40 CFR and the business must submit a Substantiation to
Accompany Claims of Trade Secrecy form (40 CFR 350.27) to USEPA.
207 COMMON NAME -Enter the common name or trade name of the hazardous material or mixture containing a hazardous material.
208 EHS -Check yes if the hazardous material is an Extremely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. If the material
is a mixture containing an EHS, leave this section blank and complete the section on hazardous components below.
209 CAS # -Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has
been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of
the individual hazardous components in the appropriate section below.
210 FIRE CODE HAZARD CLASSES -Describes to first responders the type and level of hazardous material which a business handles. This information
shall only be provided if the local fire chief deems it necessary and requests the CUPA or AA to collect it. A list of the hazard classes and instructions
on how to determine which class a material falls under are included in the appendices of Article 80 of the Uniform Fire Code. If a material has more
than one applicable hazard class, include all. Contact CUPA or AA for guidance.
211 HAZARDOUS MATERIAL TYPE -Check the one box that best describes the type of hazardous material: pure, mixture, or waste. If waste material,
check only that box. If mixture or waste, complete hazardous components section.
212 RADIOACTIVE -Check yes if the hazardous material is radioactive or no if it is not.
213 CURIES - If the hazardous material is radioactive, use this area to report the activity in curies. You may use up to nine digits with a floating decimal
point to report activity in curies. --
214 PHYSICAL STATE -Check the one box that best describes the state in which the hazardous material is handled: solid, liquid, or gas.
215 LARGEST CONTAINER -Enter the total capacity of the largest container in which the material is stored.
216 FEDERAL HAZARD CATEGORIES -Check all categories that describe the physical and health hazards associated with the hazardous material.
217 AVERAGE DAILY AMOUNT -Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each
building or adjacent/outside area. Calculations shall be based on the previous year inventory of material reported on this page. Total all daily
amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this location, the
amount shall be the average daily amount you project to be on hand during the course of the year. This amount should be consistent with the units
reported in Box 221 and should not exceed that of maximum daily amount.
218 MAXIMUM DAILY AMOUNT -Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled
in a building or adjacent/outside area at any one time over the course of the year. This amount must contain at a minimum last year's inventory of
the material reported on this page, with the reflection of additions, deletions, or revisions projected for the current year. This amount should be
consistent with the units reported in Box 221.
219 ANNUAL WASTE AMOUNT - If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled.
220 STATE WASTE CODE - If the hazardous material is a waste, enter the appropriate California 3-digit hazardous waste code as listed on the back of
the Uniform Hazardous Waste Manifest.
221 UNITS -Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet, or tons.
NOTE: If the material is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture
containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons).
222 DAYS ON SITE -List the total number of days during the year that the material is on site.
223 STORAGE CONTAINER -Check the one box that best describes the type of storage container in which the hazardous material is stored.
224 STORAGE PRESSURE -Check the one box that best describes the pressure at which the hazardous material is stored.
225 STORAGE TEMPERATURE -Check the one box that best describes the temperature at which the hazardous material is stored.
226 HAZARDOUS COMPONENTS i-5 (% BY WEIGHT) -Enter the percentage weight of the hazardous component in a mixture. If a range of
percentages is available, report the highest percentage in that range. (Report for components 2 through 5 in 230, 234, 238, and 242.)
227 HAZARDOUS COMPONENTS 1-5 NAME -When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous
components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to manufacturer). All hazardous components in
the mixture present at greater than 1% by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than five
hazardous components are present above these percentages, you may attach an additional sheet of paper to capture the required information. When
reporting waste mixtures, mineral and chemical composition should be listed. (Report for components 2 through 5 in 231, 235, 239, and 243.)
228 HAZARDOUS COMPONENTS 1-5 EHS -Check yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in
40 CFR, Part 355, or no if it is not. (Report for components 2 through 5 in 232, 236, 240, and 244.)
229 HAZARDOUS COMPONENTS 1-5 CAS -List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture.
(Repeat for 2-5.)
246 LOCALLY COLLECTED INFORMATION -This space may be used by the CUPA or AA to collect any additional information necessary to meet the
requirements of their individual programs. Contact the CUPA or AA for guidance.
Page 2 of 2 FD2iaa (Rev o6/0~)
~ ._
HAZARDOUS MATERIAL MANAGEMENT PLAN
SITE & FACILITY DIAGRAM
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BAKERSFIELD FIRE DEPARTMENT
Prevention Services
B fl R 5 F I n 1600 Truxtun Avenue, Suite 401
F/R6 Bakersfield, CA 93301
ARTN ! Phone: 661-326-3979 . Fax: 661-852-2171
Page 2 of 2
SITE DIAGRAM
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Business Name: ---~ ~ ~
Business Address: /~~~ /~~~~
FACILITY DIAGRAM
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NORTH
Please indicate direction of North
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HAZARDOUS MATERIAL_MANAGEME_NT PLAN s a R s r i n
P1RE
INSTRUCTIONS r
SITE & FACILITY DIAGRAM
4~- .+ ~.
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1600 Truxtun Avenue, Suite 401
Bakersfield, CA 93301
Phone: 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 an 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~/zxii-inch 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 feet. 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 HMMP, on the top of the diagram.
3. Label the location of the hazardous material and identify them by name and type of hazard (flammable
liquid, corrosive solid).
4. Label the location of utility shut-off points for gas, electric, and water services.
5. Label the location of fire hydrants.
6. Label portions of the building 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 identification 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.
FACILITY DIAGRAM INSTRUCTIONS
Facility diagrams are supplements 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 HMMP. 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 represents 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 (UST) facility, the facility diagram shall also specify the location of the UST continuous leak monitoring
system and/or the location where the UST monitoring will be performed.
FD2170 (Rev 06/07)