The URL can be used to link to this page

Home My WebLink AboutHAZ-BUSINESS PLAN 11/15/2005,_J p ~ -Y.,~s- .. ,,,,,..~.,..,...~:: fL ~' ~~ , KLEENERZ ~i, I~ ~ 2219 BRUNDAGE LANE ~ (NMMP) •~, "HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFIED PROGRAM CONSOLIDATED FORMr °APPLJCATION . BUSNESS OWNER/OPERATOR IDE7Yi1FICA710N FORM (HAZARDOUS MATERIALS FACILITY INFORMATION) ~- P/RL D ARTY r BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 "' I. FACILITY IDENTIFICATION ~ " FACILITY ID NO. , Year Beginning ,oo Year Ending ,o, BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) s B SINESS PHONE 7Od a ,oz ¢etnerz 8- SITE ADDRESS ,a, CITY T P ~ ,oa CA Ip 33 a ,os DUNN & BRADSTREET ~~ SIC CODE / r ~ / (4 Digit #) J ,o~ COUNTY /~Qr ~~ OPERATOR NAME ~C.1E~a~,~ ,os OPERATOR PHONE - as-33 „o - II. OWNER INFORMATION- OWNER NAME ~ac--~~~ >>> OWNER PHONE ~ - ~a - i~d 3 „z OWNER MAILING ADDRESS ~ ~ S~v ei,~~~ «ti ~ fw 14 s „a CITY .~ ~ „a STATE „s C Ip X330 „s ~ ~~ ' ~ ~ III. ENVIRONMENTAL CONTACT ~ - ' CONTACT NAME ~vo,J ~6 ~ ~ ksQ~/' ,n CONTACT PHONE Cn~ ~ ~- 3a~ -~ 33 7 „s CONTACT MAILING ADDRESS ~°~ al ~~ •~ „s c. ~ r CITY 6 i~ ~ ,2o STATE ,z, C ZIP ~t 330 ~~ ." ~ ~.~ ~.s a A - '-,PRIMARY' ~: = IV; EMERGENCY CONTACTS - -SECONDARY-.~• NAMES ~ I~'J~ /' ~ 123 NAME ~~ N~ JYI'Pf~ 126 TITLE 01~.N C~ ~ 124 TITLE d ~C -~ ~'~ G 129 BUSINESS PHONE (~ _ 3 a a - I So -3 125 BUSINESS PHONE = ~~ - 130 24-HOUR PHONE ~C~ (- ~o f - g~-~G 126, - 24-HOUR PHONE 131 PAGER NO. ~ } :' ~ ~` `` ~ 127 PAGER NO. 132' ?=` 133 V. CERTIFICATION Certification: Based on my inquiry of those individu als responsible for obtaining ihe.in#ormation;•.I certify "uriifer penalty of law that I have personally examined and am familiar with the information submitted in this inventory and bel.;eves.the information is true, accurate, and complete. NAME OF CUMEN T SIGNER (Full punted name) 136 DAT ~ 134 NAME OF DOCUMENT PREPARER 135 (( `` SIGNATURE OF OWNER/OPERATOR/OR DESIGNATED REPRESENTATIVE t37 TITL OF O NER/OPERATOR/DESIGNATED 138 . REPRESENTATIVE (SIGNER) I 'j FD2089 (Rev. 02/05) s..~ ~,: ..1t. ~~•~>' :x ` 3,; (Hazardous Materials Facility Information - HNIIVIP) Business Owner/Operator Identification • Please submit the Business Activities page, the Hazardous Materials Faci/ity Information (HMMP) Business Owner/Operator Identification Form - FD2089, and Hazardous Materials Inventory Chemical Description Form - FD2086 for all hazardous materials 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 fo/%ws the data a%ment numbers that are on the Business Owner Operator Form page. These data a%ment number. are used for e/ectronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary. P/ease number all pages of your submittal. This he/ps our CUPA orAA identify whether the submittal is comp/ete and if any pages are separated. 1 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,Iegal name of the business. 100 BEGINNING DATE - Enter the~6eginning 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'eztension 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 & BRADSTREET -Enter the Dunn & Bradstreet number for the facility. The Dunri & 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.• /fcode is more than 4 digits, report on/y the first foul 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, if different from business 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 if 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 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, 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 ZIP CODE -Enter the zip code of the environmental contact's mailing address. The 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 materials 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. tf it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individua 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, 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'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 be used for CUPA's or AA's 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. (YYYYMMDD) 135 NAME OF THE DOCUMENT PREPARER (FULL PRINTED NAME) -Enter the full printed name of the person who 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 FD2089 (Rev. 02/05) w APPLI FOR SEC NOTIFICA (HMMP) CATION TION DISCOVERY AND IS MATERIALS MANAGEMENT PLAN BAKERSFIELD FIRE DEPT. TION (FORMS) INSTRUCTIONS Page 1 of 2 _ z, 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. d Ra ac hriaf and rnnrica ac nnccihla 1 `. ~. _ = ~ • ~~ • - SECTION I: FACILITI('IDENTIFICATION ~- F BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) ,~ ,o Q ~.. ADDRESS (For local use only) ~~1 R aru nda e ~,~ ~u~~rS~'i~/d t33~y FACILITY ID NO. ~ SECTION 11:1: DISCOVERY AND NOTIFICATIONS s ~~-~ _ -- A. LEAK DETECTION AND MONITORING PROCEDURES: ~ - ~ - -. q• VrsvaL. c.H~oc/Z I,S da.ne b~~ at THa/n+d em~?~Cor o,~'...eaal~ rnornl~g b.v-~at~ STar~ yr o-f I'riac1+/~n ~cr y ` . B. EMPLOYEE AND AGENCY NOTIFICATION: Bm 6 IIo+.~,gy~~ (p ~j~l ~d/~ ~'S~I G / s LO b P h0'r~'fipc( IINM~dlo7~Y I-~Th~f-o rs a haza/,do~5 skit o>^.u.,mor9oncy. ~o~-atl no~n,orn=vtytna•~ Sto~/ls calf (olo~- 3a1o-39~9~ -~6h45prli`l~a?!S ~t Th~~p~t Zo• ~~-fPj 5~~~7 01 il.oapu/hor,~rn~~rrf call mf~ficPef~~orgPatySarvrl~S X00-85~-?55 C. ENVIRONMENTAL RESPONSE MANAGEMENT: A~'}a%r~d .e 'rKl?lof.o~v wit / Tu~r o~•l rria'L~IiN o-~ ~ ta~'//-, ~ l St-t ~.+~ d wlo w',ollt n sft-~ y p~s~ a u:~.et ~Tt,'vs;.:.~ T1-utr vd.o ~x/v~Co-~ i.~ ~ t,.?%tl L, o -bld~na?.o 7ev ~~Ob>7 vp ~hocaSS D. EMERGENCY MEDICAL PLAN: ~ '' • ~ :. ~ ° - ~ -. . ~Tk~1n~-l Prnf°~'°`I"~ ~'lJ/ Ca/~ ~j/~ i/-~ Surd ,r-~vr~d `Z~ r~ar~si.. .0 rnnr5a~cy hpo»^ . . ~.~ SECTION 11.2: -RELEASE RESPONSE PLAN, , ' ~ J A. HAZARD ASSESMENT AND PREVENTION MEASURES: T'~.~ lt..oan/r-~j rnac~/r .v Ig y-oYe~~ ,.ent~.oso~ nod /u-S ~, L~~a/r. n~o~ 7efn/1 /rl `fl~v~ove"xya-~- a Spilt. ,4T1~alnrd ~rn~,Cor•.o does q resoat c~~a~lz d.~i~y B. RELEASE CONTAINMENT AND/OR MITIGATION: 't-~ Gl`.t4n /-^q I'Yta t~tii>< •~ !,s r~i1~sL ~ ~I n GAS ~ ~ dry t~ a 2/Yt~4/N I'N wnZ' Tear/~. ~Mp~~p' 4h~'I'1"ar~ v~ 20 Tu~-r D{~ ~'yfaC~rpJ"~• I~- -~,C~•6 rs ea'fS!10 (7c GeH~nlrl~~-ti.7'7'nt/~ ~.o ~-t(r~- c l.-dT~ t u~l ~e-w N ~,. a 6se r ~1 7~ SB ~ „.~~ C. CLEAN-UP AND RECOVERY PROCEDURES: S e G ~ Pr-y r s. So o l~.o a yr w / ~ ~ B Tter ~/(.a~~ an .~ ~1~,r.P-r se 1, v®r~7 I S iCQLBt~~h~0,~ /y~ ~riQG`t~1~,G sa•-~~r7~ l~.o~oy~ P/c~l,~~ u~ a/I ~id~t~euS ~~57-P Prevention Services ~~R~ 900'IYuxtun Ave., Ste. 210 ARTM f Bakersfield, CA 93301 .~- ~ Tel.: ' (661) 326-3979 . _ .Fax: ,(661) 852-2171 rozoas (Rai. oz)os) Page 2 of 2 ,~ Gn . ~~-~;~ -~ ~, ~~ SECT t~rll 2 EL SAS ~ ~._ - ~ ---,~ - ~,~ ~ ;~~ 10 .. ~R EY~~,E_RESPONSEPLAN}-CO~I'T ;~, , ,, .~ ~. .• ~+~~,a'':." s'' -~ ~ v>,,.......~,....e~.~. ' .~..._ ..,~., ate- ..a ~:~_.r.~ 5~ ,.~,-a.,G;?a.,.•ru.~c ~ s ~t~ a ~t.;:~,Yv~ r- - - - UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) G o h r~ -- D-E g~/ L d ~ n 4 NATURAL GAS/PROPANE: S E C A _ ELECTRICAL: ~7 ` ~ (~..~~4 }~ ~ ~ ~ (, /L ~ / 1~ Q/ WATER: O T 19 D J W G ,a O , SPEC4AL: PRIVATE FIRE PROTECTIONNVATER AVAILABILITY: A. PRIVATE FIRE PROTECTION: B. WATER AVAILABILITY (FIRE HYDRANT): ' NE Co~D'a o--F ~I~vn~eyr aril ~lvq~~S .• .N,w. ~~o-t-r;,,-o~~-~`~t~y„,vs°•a•,~ ~.~W~a~ s&~ ~~~°~ss • ' ,, .~:r, SECTION~III TRAINING ~ ~ ~ S`~,3 `° - - ~ ~ ~- _ _ . .. F4 NUMBER OF EMPLOYEES: . . _ _ i ~ • • MATERIAL SAFETY DATA SHEETS ON FILE: 13 e r 6 rya 4 ~ p t 0 ~ 4 r`r ' n Z' a _ . , ,i t r ~ . i ~ / j f Y r . BRIEF SUMMARY OF TRAINYNG PROGRAM: ' `, ^ ' ' . ~ . ~~; y..iv a r-e T~a:r ~o-J •~ n ~ .•P~~,~ US ~ g • ~»~/ra~S ~,, ~ o y o anc (~~teC.v.~/i/ ~ G~av~ c.~ Ski/lS -- A+u /1tSbS S/~;/~s aH/ al~oi~s~oLv . .. .._ r r a ~ _ ~ ~ r C~ERTIFI*CATION µ~, ~~ t ~.. ~ ~-~ .~> ~~ ' "? 7 v ~ 7 t , ~ +L. ~ _ tn -fi ~ ~. , ~~ ~. 1 t •~r.,.rc a~;~; .r . -ro , ~ F ,,:~... .~,;'i~ v Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that !have personally examined and'am familial with the information submitted and believe the information is true, accurate, and complete. .; SIGNATURE OF OWNER / PERATOR OR DESIGNATED REPRESENTATIVE • DATE - 477 NAME OF GNER (print) 478 TITLE O SIG ER 479 FD2085 (Rev. o2ros~ (HMMP) ~~ w HAZARDOUS MATERIALS MANAGEMENT PLAN UNIFIED PROGRAM CONSOLIDATED FORMS ~ P I D --- P/RL CHEMICAL DESCRIPTION.FORM ~~ r HAZARDOUS MATERIALS INVENTORY L~NEW ^ ADD ^ DELETE ^ REVISE 200 tiAKLf'K;,r1LL1J r'lKLf' LLf'Yl'. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 ~~~ Tel.: (661) 326-3979 Fax: (661) 852-2171 (One /orm per material, per building, or area.) Pwnw1 of 7 I. FACILITY INFORMATION ' _,;;;<t: , .;~.~, : . :..; ; : I;,;,; , , ;, ,,, , BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 .O+Q » ~P J-- Z- CHEMICAL LOCATION 201 CHEMICAL LOCATION 202 s0`'~ wu`~ p-{r~~cr~jL~/I'~'1 Q`'~IG~ ~ ~ QL/ CONFIDENTIAL(EPCRA) ^YesCdlNo ~~ C ,r , ~p~lr ~ /' FACILITY ID No. 1 MAP No. (optional) 203 GRID NO. (optional) 20 IL'CHEMICAL INFORMATION CHEMICAL NAME 205 20 T~~ Q Ll~ h ~?/~L ~ I,o Go-- b b r C Y~ TRADE SECRET ^ Yes ' ' ~ No .2 a Yt Ii Sub ect to EPCR re a to n structions COMMON NAME 207 EHS' ^ Yes J1Q No ~~ ~ ~ C ^a D ~ ~ 208 CAS No. 209 y ? y a - ~ ~~ Q - 'If EHS is "Yes; all amounts below must be in lbs ( . FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 270 TYPE 211 'gy PURE ^ m MIXTURE ^ w WASTE RADIOACTIVE: G Yes ~ No 21 CURIES 213 p LARGEST CONTAINER 215 PHYSICAL STATE ^ s SOLID ~ I LIOUID ^ g GAS 214 I a O q Q L .J 216 FED HAZARD CATEGORIES L~ 1 FIRE ^ 2 REACTIVE C 3 PRESSURE RELEASE ^ 4 ACUTE HEALTH ^ 5 CHRONIC HEALTH (Check all that apply) ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 STATE WASTE 220 AMOUNT Q,~ d~ 77 DAILY AMOUNT ~ ~'O 9a ` 7 DAILY AMOUNT / ,~ 5a CODE 221 222 ^ UNITS ~ ga GAL ^ cf CU FT ^ Ib LBS ^ to TONS DAYS? ~ Sj If EHS, amount must be in lbs. 223 STORAGE CONTAINER (Check all that apply) ^ a ABOVEGROUND TANK rig f CAN ^ k BOX ^ p TAN K WAGON ^ b UNDERGROUND TANK ^ g CARBOY ^ 1 CYLINDER ^ q RAIL CAR / ~c TANK INSIDE BUILDING ^ h SILO ~ m GLASS BOTT E r OT R ~rt, ~ ~ rn GlL ^ d STEEL DRUM ^ i FIBER DRUM ^ n PLASTIC BOTTLE ^ e PLASTICMONMETALLIC DRUM ^ j BAG ^ o TOTE BIN STORAGE PRESSURE ~ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 224 STORAGE TEMPERATURE ~ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT ^ c CRYOGENIC 225 %WT HAZARDOUS COMPONENT EHS CAS # 1 226 227 ^ Yes ^ No 228 229 2 230 - 231 p Yes ^ No 232 233 3 234 235 ^ Yes ^ No 236 23 4 238 239 ^ Yes ^ No 240 241 5 242 243 ^ Yes ^ No 244 245 III. SIGNATURE ~ - PRINT NAME 8 TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE DATE 246 1~ Y l U ~5~ ~ (z o war ro-v~ / ( 0 FD2086 Rev. 02105) n V :~ 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, 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) contain- ing reactive anoins. (azide, bromate, 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 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 (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 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 •sevvage' sludge 331 Off-spec, aged or surplus organics 341 Organic liquids (non-solvents) with halogens 343 ~~ Unspecified organic liquid'mixfure ~ . 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 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 FD2086a (Rev. 02/05) ' (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFlED PROGRAM CONSOIJDATED FARM) UUSINESS ACTIVITIES PAGE (HAZARDOUS MATERIALS FACILITY INFORMATION) F/R< wRTM T BAKERSFIELD FIRE DEPT. Prevention Services 9001Yuxtun Ave., Suite 21Q Bakersfield, CA 93301 Tel.: (661) 326-3979 ~ . Fax: (661) 852-2171 Page 1 of 1. I. FACILITY IDENTIFICATION i FACILITY ID # (For Office use only -please leave blank) 3 EPA 1D # G:~4, ~ 00a a 9~ ~ DBA /FACILITY NAME ~~ II. ACTIVITIES DECLARATION DOES Your Facility ... If Yes, Please Complete ... 12 A. HAZARDOUS MATERIALS • CHEMICAL DESCRIPTION FORM ~ 13 1. Have on site (for any purpose) hazardous I~Yes ^ No . HAZARDOUS MATERIALS MANAGEMENT PLAN materials at or above 55 gallons for liquids, Minimum required ~lanning elements: 500 pounds for solids, or 200 cu. ft. for ^ Yes ^ No • Emergency Response Plan Maps compressed gases (include liquids in ASTs and . Training USTs)? • Prevention B. i . REGULATED SUBSTANCES (RS) Nave on site RS, at greater than the threshold ^ Yes t~No • CHEMICAL DESCRIPTION FORM 131 planning quantities established by the California • RISK MANAGEMENT PLAN (RMP Submit to USEPA) Accidental Release Prevention program • . CONSOLIDATED COMPLIANCE PLAN Incorporating CaIARP Program Elements (CaIARP)? C. UNDERGROUND STORAGE TANKS (USTs) 13 1. Own or operate Underground Storage Tanks? ^ Yes ~ No • UST FACILITY FORM • UST TANK FORM (One Per Tank) 2. Intend to upgrade existing or install new USTs? ^ Yes dQ No • UST FACILITY FORM 13 • UST TANK FORM jOne Per Tank) • UST INSTALLATION FORM One Per Tank D. TANK CLOSURE /REMOVAL 2. Need to report closing.an UST that held hazardous ^ Yes ~No • UST TANK FORM (Closure section -one per tank) materials or 3. Need to report the closure /removal of a tank that ^ Yes jf~ No • UST TANK CLOSURE FORM was classified as hazardous waste and cleaned on- site? E. ABOVEGROUND PETROLEUM STORAGE TANKS (ASTsI ^ Yes a No • HAZARDOUS MATERIALS MANAGEMENT PLAN 1. Own or operate ASTs above these thresholds; • Incorporating Federal Spill Prevention Control and any tank capacity is greater than 660 gallons or the Countenneasure (SPCC) Elements pursuant to 4o CFR Part 112. total capacity for the facility is greater than 1,320 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 materials at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable ^ Yes No • RECYCLING FORM materials 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 6Z[~lo • REMOTE WASTE /CONSOLIDATION SITE NOTIFICATION FORM remote site? 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 (FD2089) FD2088 (Rev. 02/05) Hazardous Materials Inventory -Chemical Description UNIFIED PROGRAM CONSOLIDATED FORMS You must,complete a separate Hazardous Materials 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 Haiardous 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 Paris 30, 40, or 70. The completed inventory should reflect all reportable quantities of hazardous materials 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, the 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" ff 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 'rf 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 -Fire Code Hazard Classes describe to first responders the type and level of hazardous materials 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 el is not. 213. CURIES - If the hazardous material is radioactive, use this area to report the actively 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 ohvsical and health hazards assnciated with the hazardous material PHYSICAL HAZARDS HEALTH HAZARDS Fire: Flammable Li uids and Solids, Combustible Li uids, P ro honcs, Oxidizers Acute Health (Immediate): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, Reactive: Unstable Reactive, Or anic Peroxides, Water Reactive, Radioactive other hazardous chemicals with an adverse effect with short term ex osure Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with Ion term ex osure 217. AVERAGE DAILY AMOUNT -Calculate the average daily amount of the hazardous malaria{ or mixture containing a hazardous material, in each building or adjacenU outside area. Calculations shall be based on the previous year's 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 adjacenUoutside 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). r 222. DAYS ON SITE -List the total number of days during the year that the material is on site. 223. STORAGE CONTAINER -Check all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: If appropriate, you may choose more than one. 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 1-5 (% 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 FD2086 (Rev. 02/05) ~AL17~~V VVV ~~~f1~V~~~Ili.ti/~~~I"~~~llvr.~. r.~• • vr~ / Prevention Services ~~ a r 900 'lYuxtun Ave., Suite ?~~ SITE & FACILITY DIAGRAM ~R ~ r Bakersfield, GA 93301 = Tel.: (661) 326-3979 Page 2 ot2 ~ Fax: (661) 852-2171 SITE DIAGRAM- FACILITY DIAGRAM Business Name: ~,~ ~~ p r ~ ~ S Business Address: a ,~' ~ g~v r ~ 04 ~ ~ r lc.J T .-IG NORTH Piease indicate direction of North ~ ~~ _ ~ 7 i ~~k1~dFOUrbor Fterri bL.Q. Lt~.Looca~har -~ i ~rar~~ wvvv nu-~~ ~~ u~rv o~ev ~.~.v.~...~... . ... ~. / Prevention Services BF/Rt t 9001Yuxtun Ave., Suite 2~ SITE & FACILITY DIAGRAM ~Rrr T Bakersfield, CA 93301 Tel.: (661) 326-3979 Page 2 of 2 ~ Fax: (661) 852-2171. ~~~ SITE DIAGRAM- FACILITY DIAGRAM Business Name: ~,~ ~,,,p Q r ~ ~ S Business Address: ~,~ I ~ Bev r ~ 040 ~ ~ ~1-~yd.ranl' l _ /~ ' / ~ v F tl~ ~' ~~ - ~' Or t .TI t x N ~ ~ •~` -•~ _~ ~' ~ s f~ E,J ~. 4f ~ ~LL~y W T NORTH Please indicate direction of North I"=~oD' G~ nl'r~tv,~ k ~A ~~6 Z 3Sb"7 uti/~d~, ~u~ ~ ~ ,~~ ~~ + KLEENERZ ____________________________________________ SiteID: 015-021-000589 + Manager DON DOERKSEN Location: a~2'3 BRUNDAGE LN City BAKERSFIELD Z z~ q CommCode: BFD STA 06 EPA Numb: BusPhone: (661) 325-3374 Map 102 CommHaz Low Grid: 36D FacUnits: 1 AOV: SIC Code:1541 DunnBrad: Emergency Contact / Title Emergency Contact / Title TIMOTHY DENARI / PRESIDENT DON DOERKSEN / GENERAL MANAGER Business Phone: (661) 664-0950x Business Phone: (661) 325-3374x 24-Hour Phone (661) 203-9900x 24-Hour Phone 1661) 599-5800x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact TIMOTHY DENARI Phone: (661) 664-0950x MailAddr: 5001 CALIFORNIA AVE 140 State: CA City BAKERSFIELD .Zip 93309 Owner TIMOTHY DENARI Phone: (661) 664-0950x Address 5001 CALIFORNIA AVE 140 State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT ENT'D D E C Q 8 2006 t====----------~_------------------------------------------------------________+ -------- ------------------------------------------------------ -1- 03/09/2006 F UNIFIED PI SEC~'ION 1 • -GRAM INSPECTION CHECKLIST usiness .Plan and Inventory Program Bakersfield Fire Dept. Environmental Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel: (661)_326=3979 _ FACILITY NAME ~~ 1 ~e.X•~-.~ _ WSPECTION DATE INSPECTION TIME C~ 1 _~__~__~_ _ _ t'~o. _ - _ - ADDRESS `ZZ ~ ~ ,r c~ r ~~ -~ ~ _ PHONE No No. of Employees :325 33 7 FACILITYCONTACT ~.~. ,moo w' ~~r Business 10 Number 15-021- vaO S~' Section 1: Business Plan and Inventory Program ~ ~ d O Routine O Combined O Joint Agency l7 Multi-Agency O Complaint O Re-inspection • ANY HAZARDOUS WASTE ON SITE?: LEI YES ^ NO EXPLAIN: ~ C. ~ ~ ~i+-fl '~+-• ~~'.°1 l/~~-G iti ~~,,~. • QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT 661 326-3979 __ _ ~ ~_~ ~ 3a Ins. ~6-~- ------ ---_~_------ -------~;~ (--____.. __ --- Inspector (Please Print) Fire Prevention 1st-InlShift of Site White -Environmental Services Yelbw - Stettin Copy business Site Responsible PaAy ( ease nnt) a B Pink • Business Copy _ ~ (, 5 3~ ~ ~,. B~ASERBFIELD FIRE DEPT UNIFIED PR®GRAM INSPECTION CfiECKLIST~; a Prevention Services Rlss 9001Yuxtun Ave., Suite 210 .~,, ~.~~~ ~,~~.~,.~ ~...., . ~ ~ <,; .,r ~.~ -:..... _ ,. <, .: .:... ,. .:.,.<.~ ,::, ,.: ~Rral Bakersfield, CA 93301 SECTI®N 1 : $USIt1@SS Plan and InVE'1'1tOtj/ Program ~ Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME t ,.= i ,r'~ q NSPECTION DATE ryJ NSP{ECTIJON TIME ADDRESS ^~ ! 4,,.~ HONE NO. ry t O OF EMPLOyYEES FACILITY CONTACT --~• ~~ ~ a ~ ~. l USINESS ID NUMBER ,s-oz,-boo ~g a , ~ ,~, .~,, ; • = ~' Section 1: Business Ptan and Inventory Program ~ ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY. ^ COMPLAINT ^ RE-INSPECTION C V (C.Compiiance` OPERATION J COMMENTS V=Violation ~ ^ .` APPROPRIATE PERMIT ON HAND , '~ ~3 _ ^ BUSIIIBSS PLAN CONTACT INFORMATION ACCURATE i~ ^ VISIBLE ADDRESS . "C7 ^ CORRECT OCCUPANCY Of ^ VERIFICATION OF INVENTORY MATERIALS ^~ ^ VERIFICATION OF QUANTITIES r' ~ r O ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL __ ~~rD ~ AY ,,r~. l. (~J ^ VERIFICATION OF MSDS AVAILABILITY lL'J ^ VERIFICATION OF HAZ MAT TRAINING r 1"J ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~~ ^ f EMERGENCY PROCEDURES ADEOUATE ^ ® CONTAINERS PROPERLY LABELED ^ ^ HOUSEKEEPING ^ FIRE PROTECTION f ~® ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITES tL~'1 YES ^ NO EXPLAIN: - _ __ QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (861),328-3879 ~' ; Vin, . ~ ~F ~ r_,~..., ~ - f ,,,+,-~^' Inspector (Please Print) Fire Prevention / 1" In / Shift of Site/Station q Btu' ~ f.Site/Sdtool Site Responsible Party (P~ase Prim I ~ • 4 ._..- White -.Prevention Services Yellow -Station Copy Pink -'business Copy FD2t>4e tRw. 02!05)