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HomeMy WebLinkAboutBUSINESS PLANW !~~ F z a 'I :~w .~ Hsi WH ;~ 'UN~~ 'F ~ N ', ~ O ~~ N, _- `~, ~~ ~\ :~ e>t LANG MD JOHN W SiteID: 015-021-002241 Manager DEBBIE HANSON Location: 2020 21ST ST City BAKERSFIELD BusPhone: (661) 325-1212 Map 102 CommHaz High Grid: 25B FacUnits: 1 AOV: CommCode: BFD STA O1 EPA Numb: SIC Code:8011 DunnBrad: Emergency Contact / Title Emergency Contact / Title JOHN W LANG / MD FAGS DEBBIE HANSON / O FFICE MANAGER Business Phone: (661) 325-1212x Business Phone: (661) 325-1212x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone (661) 203-3993x Pager Phone (661) 205-3662x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact DEBBIE HANSON Phone: (661) 325-1212x MailAddr: 2020 21ST ST State: CA City BAKERSFIELD Zip 93301 Owner JOHN W LANG MD Phone: (661) 325-1212x Address 2020 21ST ST State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT Eased on my inquiry of those individuals ~~~Y~ responsihie for o"twining the information, I certify ll ~~~ ~~~ y er;aity of law that I have persona d er p un examined and am familiar with the information sui~mitted and (1~lipve the information is true, accur«te, and complete. ignature Date -1- 07/12/2007 r, F LANG MD JOHN W SiteID: 015-021-002241 ~ ~ 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 249.00 FT3 Hi OXYGEN F IH DH G 249.00 FT3 Low CARBON DIOXIDE F P IH G 331.00 FT3 Min -2- 07/12/2007 -3- 07/12/2007 z F LANG MD JOHN W SiteID: 015-021-002241 ~ ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 10024-97-2 ~GasATE TYPE T PRESSURE TEMPERATURE CONTAINER TYPE TPure I Above Ambient Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Co249100rFT3 Daily 249100m FT3 I Daily 249r00e FT3 riAGHK1JVUS 1:V1~lYV1V~IVT~ %Wt. RS CAS# 100.00 Nitrous Oxide No 10024972 riHGHKL A5515551~11'~1V 15 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Hi ~ Inventory Item 0001 COMMON NAME / CHEMICAL NAME OXYGEN Location within this Facility Unit STATE TYPE PRESSURE _ Gas TPure ~-Above Ambient 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 Container Daily Maximum Daily Average 249.00 FT3 249.00 FT3 249.00 FT3 riLiGH1CLVUJ 1.V1~lYV1V~1V1J %Wt. RS CAS# 100.00 Oxygen, Compressed No 7782447 I1HGHtCL H. 7.7~.7.71~1~1V-1.5 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low -4- 07/12/2007 F LANG MD JOHN W SiteID: 015-021-002241 ~ ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME CARBON DIOXIDE Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 124-38-9 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Gas TPure ~-Above Ambient Cryogenic INSUL.TANK / CRYOGENIC AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 331.00 FT3 331.00 FT3 331.00 FT3 t1A[,titc.uvua 1:V1~lYV1V~1V 1 J $Wt. RS CAS# 100.00 Carbon Dioxide No 124389 tl!-~GHKL F1JJ~JJ1~1~1V 1 a TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / j j Min -5- 07/12/2007 F LANG MD JOHN W SiteID: 015-021-002241 Fast Format ~ Notif./Evacuation/Medical Overall Site ~ Agency Notification 02/27/2007 FIRE ALARM THROUGH SONITROL. WHEN THE ALARM SYSTEM IS ACTIVATED, IT AUTOMATICALLY SIGNALS THE FIRE DEPT WHO SENDS A FIRE TRUCK TO THE SURGERY CENTER. 9 Employee Notif./Evacuation 02/27/2007 THE EMPLOYEE THAT DISCOVERS A FIRE WILL SET OFF THE FIRE ALARM. ALL EMPLOYEES WILL RESPOND BY FOLLOWING PROCEDURES ON POSTED EMERGENCY PLANS AND EVACUATE PATIENTS. Public Notif./Evacuation 02/27/2007 OTHER OCCUPANTS IN AND OPERATING ROOM THE PATIENT IN THE RECOVERY ROOM AREA THE FIRE ALARM AND EVACUATION. THE BLDG SHALL PERSONNEL WILL OPERATING ROOM ALL PATIENTS INSTRUCTED TO BE NOTIFIED AND EVACUATED. THE PHYSICIAN CONCURRENTLY EITHER ASSIST EVACUATION OF OR WILL EVACUATE ANY PATIENTS IN THE IN THE WAITING ROOM ARE TO BE NOTIFIED OF EVACUATE THE AREA BY ROUTE POSTED ON -6- 07/12/2007 F LANG MD JOHN W SiteID: 015-021-002241 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Emergency Medical Plan 02/27/2007 ~ IT IS THE RESPONSIBILITY OF ANY INDIVIDUAL WHO NOTICES A FIRE TO IMMEDIATELY ACTIVATE THE FIRE ALARM SYSTEM BY USING A MANUAL PULL STATION. CHIMES WILL BE HEARD IN THE SUITE AND THE FIRE BELL WILL SOUND IN THE OUTSIDE CORRIDOR. WHEN THE ALARM SYSTEM IS ACTIVATED, IT AUTOMATICALLY SIGNALS THE FIRE DEPT WHO SENDS A FIRE TRUCK TO THE SURGERY CENTER. ANY OPERATIVE PROCEDURE CURRENTLY IN PROCESS WILL BE TERMINATED. THE PHYSICIAN AND CIRCULATING NURSE WILL CONCURRENTLY EITHER ASSIST EVACUATION OF THE PATIENT IN THE OPERATING ROOM OR WILL EVACUATE ANY PATIENT IN THE RECOVERY ROOM AREA. THE SCRUB NURSE AND ANESTHESIOLOGIST WILL EVACUATE THE PATIENT FROM THE OPERATING ROOM ON A GURNEY TO THE HALLWAY. ALL PATIENTS IN THE WAITING ROOM ARE TO BE NOTIFIED OF THE FIRE ALARM AND INSTRUCTED TO EVACUATE THE AREA BY THE ROUTES POSTED FOR EVACUATION. ALL PERSONNEL ARE TO REFER TO THE POSTED DIAGRAM SPECIFYING THE ROUTES TO BE USED FOR EMERGENCY EVACUATION. -7- 07/12/2007 F LANG MD JOHN W SiteID: 015-021-002241 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 02/27/2007 ~ GAS TANKS ARE CHAINED AND SECURED. TURNED OFF AND CAPPED WHEN NOT IN USE. Release Containment 02/27/2007 N/A Clean Up FOLLOW MSDS GUIDELINES. CALL FIRE DEPT. CALL HAZMAT. 02/27/2007 V1.11G1 .RG~7V UIVG t]l.. l..1VQ. 1.1 V11 -8- 07/12/2007 F LANG MD JOHN W SiteID: 015-021-002241 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~YC~:iai na~aiu~ Utility Shut-Offs 02/27/2007 ALLEY BEHIND BLDG Fire Protec./Avail. Water 02/27/2007 ONE 5-LB HALON 1211 EXTINGUISHER IN FRONT OFFICE AREA; ONE 3A40BC EXTINGUISHER IN HALLWAY; AND ONE BC EXTINGUISHER IN REAR CENTRAL PROCESSING DEPT. Building Occupancy Level 02/27/2007 B OCCUPANCY -9- 07/12/2007 ~ ~ ~ F LANG MD JOHN W SiteID: 015-021-002241 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 02/27/2007 ~ BRIEF SUMMARY OF TRAINING PROGRAM: ANNUALLY EMPLOYEES ARE SERVICED ON EXTINGUISHER LOCATION AND USE, ALARM ACTIVATION AND EVACUATION PROCEDURES. rayc c Held for Future Use Held for Future Use -10- 07/12/2007 (` ~~ /, i Z,ANG MU JOHN W SiteID: 015-021-002241 ;, . Manager DEBBIE HANSON BusPhone: (661) 325-1212 Location: 2020 21ST ST Map 102 CommHaz High City BAKERSFIELD ~ Grid: 25B FacUnits: 1 AOV: CommCode: BFD STA O1 EPA Numb: SIC Code:8011 DunnBrad: Emergency Contact / Title Emergency Contact / Title JOHN W LANG / MD FAGS DEBBIE HANSON / OFFICE MANAGER Business Phone: (661) 325-1212x Business Phone: (661) 325-1212x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone (661) 203-3993x Pager Phone (661) 205-3662x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact DEBBIE HANSON Phone: (661) 325-1212x MailAddr: 2020 21ST ST State: CA City BAKERSFIELD Zip 93301 Owner JOHN W LANG MD Phone: (661) 325-1212x Address 2020 21ST ST State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif ~ d: RSs : No ParcelNo: Emergency Directives: PROG A - HAZMAT ~NT`D ~ E ~ 2 ~ ~~07 F3ased on mY in uir responsible for obtarni id g d ~ a n the info mation , j under penalty of law that I r ts ex hate amined and am familiar with the informnally submitted and b elieve the inform ation .curate, and complete. ation is true, ~ ' ~/~ ~ Signature ' - - ~ a ~ -Q? Date -1- 02/02/2007 F SANG M3:~ JOHN W SiteID: 015-021-002241 ~ '~ 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 249.00 FT3 Hi OXYGEN F IH DH G 249.00 FT3 Low CARBON DIOXIDE F P IH G 331.00 FT3 Min -2- 02/02/2007 -3- 02/02/2007 F-LANG MD JOHN W SiteID: 015-021-002241 ~ ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 10024-97-2 ~GasATE TPureE ~-AboveSAmbEient AmbPeRATURE - PORTCOPRESSERCYLINDER AMOUNTS AT THIS LOCATION - Largest Container Daily Maximum I Daily Average 249.00 FT3 249.00 FT3 249.00 FT3 IIHGKKLV U.7 1.V1~lYV1V L' 1V 1 ~ %Wt. ~ RS CAS# 100.00 Nitrous Oxide No 10024972 riHGK1CL 1-~~.71;5~1~1~1V 1.7 TSecret RS BioHaz ,Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Hi ~ 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: CAS# ' 7782-44-7 ~GasATE TPureE ~-AboveSAmbEent AmbientT~E PORTCOPRESSERCYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 249.00 FT3 249.00 FT3 249.00 FT3 rarauruu~v~o \.V1•lr V1V LSIV 1.7 - oWt. RS CAS# 100.00 Oxygen, Compressed No 7782447 r11"~L~tiLCL 1'i~ 7 iJ L' JJ1`1l~lV 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low -4- 02/02/2007 F`LANG MD JOHN W SiteID: 015-021-002241 ~ `~~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME CARBON DIOXIDE Days On Site 365 Location within this Facility Unit Map: Grid: CAS# 124-38-9 ~GaSATE TYPE PRESSURE TEMPERATURE ~~ CONTAINER TYPE TPure Above Ambient Crvoaenic I INSUL.TANK / CRYOGENI~ AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 331.00 FT3 ~ 331.00 FT3 331.00 FT3 t1HGE~tCLVU.> 1:V1~lYV1VL"1V1.7 %Wt. RS CAS# 100.00 Carbon Dioxide No 124389 ri.'iGHl[1J L-~~JJ1;771~11"~1V-17 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Min -5- 02/02/2007 ;F~,,LANG MD JOHN W SiteID: 015-021-002241 Fast Format ~ Noti-f./Evacuation/Medical Overall Site ;Agency Notification Fire Alarm through Sonitrol. __ When the al-arm system is activated, it aut atica].ly signalSthe fire department who sends a fire truck to the surgery centre. ,~ --- P~lll~Jl Vy CC 1VV l..1l ~ P~VQI: {ACL L.l Vll The employee that discovers a fire will set off the fire alarm. All employees will respond by following procedures on posted emergency plans and evacuate patients. Public Notif./Evacuation' Other occupants in the building shall be notified and evacuated. The physician and operating roomp~i~a~-1- will concur- rently either assist evacuation of the patient in the operating room or wi]_]- evacuate any patients in the recovery room area. A].1 patients in the waiting room are to be notified of the fire alarm and instructed to evacuate the area by route posted on evacuation. Emer-gency Medical Plan- 1) It is the re~a~sibil_ity of any irr~ividus]- ~ rY~.iaes a fire to INMEIfIA'IFI~Y activates the fire alarn syst_an .~ usirx~ a m~rnka]_ pull statirn. 2) 07i~ will be herd in the suite ar~d the fire bell will sand in the cuts_ic~ e~ricbr. 3) [~ the alarm systan is activated, it autmatically signals the fire d~arh~t ~ s~ a fire track to the surgery o~t~. 4) Any e~erati~ ~oo~~e atJ y in process will be t~riirut:ed. 5) 'Ihe physician ar~d circxalat~ng rnarse will aaxt]y either assiste evaaaat~.rn of the patio in the c>~rat:ar~g roan or wi]1 evaaatsd arty pat.i~t in the reov~ry roan arm. 6)'Ihe scrub rnarse aryl ar>~sthesiologist will evarzaated tl-~ patient from the ~r-atarx~ roan cn a gurney to the halltiay. 7) All p~tiezts in the vait.lrx~ roan are to be mt-;- fie3 of the fire alaam aryl instnict~1 to evaax~ts the axsa bi' the routes ~stsd far e~raoat;irn. 8) AU- ~ are try refer to the pesta3 diagran specifyirx~ the routes to be u~3 fc~r an~acy evaaaatiaz. 9 -6- 02/02/2007 ~F•LANG,.NID JOHN W SiteID: 015-021-002241 ~ _ Fast Format ~ ~~Mitigation/Prevent/Abatemt Overall Site ~ Release Prevention Gas tanks are chained and secured. Turned off and capped when not in use. tCC1Cd5C LUS1l.d1SllllCill. .. l Nat applicable I.l GCL11 lJ~l t Follow MSDS guidelines. Call Fire Department Call Hazmat. V ~.11C1 iCC.7VU1lrC til:Ll VQl.1 V11 -7- ~ 02/02/2007 F,LANG,NID JOHN W SiteID: 015-021-002241 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ JjJCU1d1 IIdGdiU~ - _ _ ~.__ . r_ i~~ ~ v~ -~ `,., -- Utility Shut-Offs A]_1_ey behind building Fire Protec.-/Avail. Water= Extinguishers 1) 51b Halon 1211 in front office area. 1) 3A 40BC in hallway 1) BC in rear central processing dept. =Building Occupancy Level' B OCCUPANCY -8- 02/02/2007 r ;~ tl_ ~ !, i' ~~LANG,NID JOHN W SiteID: 015-021-002241 ~ Fast Format ~ ~ Training Overall Site ~ Employee Training ,` :_, ~ ~ ' Anually F~nployees are serviced on extinguisher location and use alarm activation and evacuation procedures. r<xyc ~ nciu ivi ru~.uic vac nciu l.ui r u~uiC u~c -9- 02/02/2007 4009 FIRE PLAN )Policy: The office's responsibility to the patient, visitor, employee and staff is to provide a plan in the event of a fire emergency. It is also to provide rules and regulations that will nat only prevent fires but will provide a knowledge for action in the event of a fire emergency. The primary emphasis in the event of a fire is the protection of all patients and employees and the secondary emphasis is the containment of the fire. By law, fire exits must remain unlocked during business hours. The employees who are the first to arrive in the morning and the last to leave in the evening will attend to unlocking and locking the office's exterior doors. In case of a fire during office hours, the Pararnedic/Fire Department is immediately notified by dialing 911. After notification of the Fire Department, an attempt is made to contain a small localized fire by use of the fire extinguishers. These extinguishers are located in the following areas: the storage room, the recovery room, operating room, and the workroom. All personnel are familiar with these extinguishers as to their proper use and placement throughout the ~Office. These extinguishers are serviced and replaced annually by ~~Q~- `~~uLfiQ ~ If containment is not. possible, prompt evacuation of the office personnel will commence. ff the fire occurs during patient office hours, office personnel are responsible for all patients occupying the suite and operating rooms. Patients in the reception room and examination rooms will be notified of the fire and instructed where to exit the building. Patients are cautioned not to use elevators. Patients occupying the operating roams and/or recovery room and who have received medication, are placed on the portable transportation gurney, covered with a warm blanket, securely strapped, and swiftly carried via the appropriate exit. Additional patients in the operating room suite area are handled in similar fashion, keeping in mind the patient's comfort and safety at all times. Exits from all areas in the ofT'lce suite is through unlocked doors except for two locked doors Located in the main hallway. Exit from these doors is accomplished by a key located to the side of each door knob. After the initial opening, preferably by office personnel, the doors are propped open by door stops to facilitate the flow of patients and personnel. 11/01/97 XIT POST-OP EXIT ~~~~ DR. LANG'S OFFICE C.P.D, AREA ~~~ 3 2 O.R. #2 FRONT OFFICE EXIT WAITING ROOM RECOVERY AREA O.R. #1 ~a ~~ ~ Prevention Services UNIFIED PROGRAM INSPECTION CHECKLIST ~ B E R s F , 0 900Truxtun Ave., Suite 210 ~..._._____ ~ ~__v___.____ ~_.___._ ~. ~-.__ _ ___ Fine Bakersfield, CA 93301 SECTION 1: Business Plan and Inventory Program ~~ "'~:"' r Tel.: (661) 326-3979 (; ~ Fax: (661) 872-2171 FACILITY NAME - INSPECTION DATE INSPECTION TIME - F n Lan i~,~ 5/~~0~ v4~3o ADDRESS t s'T ~ PHONE NO. 3 (2-(2- NO OF EMPLOYEES ~ FACILITY CONTACT -~ ©~ r Lan USINESS ID NUMBER 15-021- 00 ~ad l J Section 1:Business Plan aid lnventaryProgram ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V ~ C=Compliance OPERATION V=Violation - COMMENTS ^ APPROPRIATE PERMIT ON HAND C ~ , _ ,/ ^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE 13 1 _ / (1d~ ^ VISIBLE ADDRESS C~ ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ~/ L7 ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION It ~ ^ PROPER SEGREGATION OF MATERIAL - / l~Y ^ VERIFICATION OF MSDS AVAILABILITY ra- ^ VERIFICATION OF HAZ MAT TRAINING EN ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES CrY ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? EXPLAIN: ^ YES C]' NO nnr-nuns QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 X11 ~ ~~ I~.d--d ~ ~ Inspector (Please Print) Fire Prevention / 1~` In /Shift of Site/Station # White -Prevention Services Yellow -Station Copy Pink -Business Copy o ~ /~~'/ ~ ~~~~~ responsible Party (Please Print) FD 2155 (Rev. 09/05 t~ :~...._,..:4e + LANG MD JOHN W ______________________________________ SiteID: 015-021-002241 + Manager DEBBIE HANSON BusPhone: (661) 325-1212 Location: 2020 21ST ST Map 102 CommHaz High City BAKERSFIELD Grid: 25B FacUnits: 1 AOV: CommCode: BFD STA O1 SIC Code:8011 EPA Numb: DunnBrad: ______________________________________________________________________________t Emergency Contact / Title Emergency Contact / Title JOHN W LANG / MD .,FAGS DEBBIE HANSON / OFFICE MANAGER Business Phone: (661) 325-1212x Business Phone: .(661) 325-1212x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone (661) 203-3993x Pager Phone (661) 205-3662x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact DEBBIE HANSON Phone: (661) 325-1212x MailAddr: 2020 21ST ST State: CA City BAKERSFIELD Zip 93301 Owner JOHN W LANG MD Phone: (661) 325-1212x Address 2020 21ST ST State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: = Gal Preparers ~ TotalUSTs: = Gal Certif'd: ,3 ~3 O ~ RSs: No ParcelNo: Emergency Direc ive ~ ~ PROG A - HAZMAT ~~~~ ~ ~ ~+~06 -1- 03/08/2006 UNIFIED PROGRAM INSPECTION CHECKLIST SECTION 1 Business ,Plan and Inventory Program Bakersfield Fire Dept. Environmental Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 933 Tel: (661) 326-3979 ____1 S 1005 FACILITY NAME W`SPECTION DATE INSPECTION TIME ADDRESS ~ PHONE No. No. of Employees FACILITYCONTACT BusinesslDNumber -~ ~----- -----~- _._.. Gi h ~~+ ~~ ~ ~ IS-021- ~u.~y/ Section 1: Business Plan and Inventory Program ~1 Routine O Combined ^ Joint Agency ^MultI-Agency ^ Complaint ^ Re-inspection Ir1 ~J C V n~ l OPERATION t V v a i COMMENTS o n = w t \ ^ APPROPRIATE PERMIT ON HAND ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ~- ^ CORRECT OCCUPANCY ^ ~ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES .~ ^ .VERIFICATION OF LOCATION ~. ^ PROPER SEGREGATION OF MATERIAL ^ VERIFICATION OF MSDS AVAILABILITYE ---- --- ^ ---- . .--- ---~------- -._..__ .. .__ ......... _.. _ - ---.._ ._.. ........_ VERIFICATION OF FIAT MAT TRAINING f _..__...._ . .._... --__ ... _. _ ._ _....... _ .._....... --- - -- __._._._ .--- - --.. _._..... _ ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ,~ ^ EMERGENCY PROCEDURES ADEQUATE i ~I ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ;i~ ^. FIRE PROTECTION ~ ^ SITE DIAGRAM ADEQUATE S ON HAND ANY HAZARDOUS WASTE ON SITE: ^ YES C~NO EXPLAIN: QUESTIONS REGARDING THIS INSPECTIOIJ~ PLEASE CALL US AT ~66') ~ 326-3979 _._..---~A~ ~ _~~-__" ~ ~-- ---------~-~--- _~ ~ --------- _____... __ _._ Inspector (Please Print) Fire Prevention 1st-In/Shin of Site WhNe - Envgonmenlal Services Velknv -Station Copy B iness Site Responsible Party (Please Print) g Pink -Business Copy + WESTCHESTER SURGERY CENTE?' __________________________ SiteID: 015-021-002241 + as- lat Manager BusPhone: (661) Location: 2020 21ST ST Map 102 CommHaz High City BAKERSFIELD Grid: 25B FacUnits: 1 AOV: CommCode: BFD STA O1 SIC Code:8011 EPA Numb: DunnBrad: EmergTeTn~cy~7~~Contact / '~'itryle Emergency Contact / Title JOHN YV LANG / MD FAGS 3oZ5~\~ MTDT/1TT R('1T /1V / .~ Q..~.~-. a~0.5~ Business Phone: (661) '^'~' =~~~__ \d- Business Phone: (661) ~~` ~ 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x (,' ~` Phone ( (P(v I ) a,O3 - 3R9 3x ~, ,~-Phone ((Q(~ N ) ~S-3(v(c~x Hazmat Hazards: Fire Press ImmHlth DelHlth Contact DEBBIE HANSON MailAddr: 2020 21ST ST City BAKERSFIELD Phone : ( 6 61) ' `.~-9~0~ State : CA 3 as- 1 a--\a--. Zip 93301 Owner '~vh r~ ~ . l-A- n~ ~ M • ~. Phone : ( 6 61) 3z~9§3~8x- Address 2020 21ST ST State: CA ^va5-l~\a-- City BAKERSFIELD Zip 93301 Period to Preparers Certif'd: ParcelNo: TotalASTs: _ TotalUSTs: _ RSs: No Gal Gal Emergency Directives: PROG A - HAZMAT Based on my inquiry of those individuc~.'s 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. ture Dat ~N~'D MAC 0 6 2006 -1- 02/27/2006 ~~~ ~'r~ CITY OF BAKERSFIEl.D FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES ~~ UNIFIED PROGRAM INSPECTION CHECKLIST _W>~Ql~.~ 1715 Chester Ave., 3~" Floor, Bakersfield, CA 93301 FACILITY NAME .~t/GS~i6<6s~cv fr~'gw ADDRESS ~ ?-~ ?-~ ~~~ FACILITY CONTACT Lri., G ~'~ ~ ~ ~ INSPECTION TIME /~ ~.~•~~ INSPECTION DATE //-/~ DJ _ PHONE NO. ~~S- qs 7X BUSINESS ID NO. 15-210- ~?-~// NUMBER Of EMPLOYEES i Section 1: Business Plan and Inventory Program Routine ^ Combined ^ Joint Agency ^hulti-Agency (~ Complaint ^ Re-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact information accurate J FC . Visible address ~ ' Correct occupancy J Verification of inventory materials ~ /~~ O O R Verification of quantities J r Verification of location [' n Ds l a~ ~ Q'E,iQ /3 ~i"Q ~ Proper segregation of material J /~'% ~ , • ~ S X39 ~'`} / ~ Verification of MSDS availability `~'~ "`'`'~v ~~-~-e~ Verification of Haz Mat training may, ~ r Verification of abatement supplies and procedures ~~ °® ~ Emergency procedures adequate Containers properly labeled '~,~' Housekeeping ~j Fire Protection J y~ ~~ ~< < ~~, fc ~ , ~ 7e~ t ~~ ~ ,,µ -•~ /. Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardou wast~n bite?: ~ Yes ^ No Explain: ~~ ~' ~ o t ~ Questions regarding this inspection? Please call us at (661) 326-3979 White -Env. Svcs. Yellow -Station Copy Pink -Business Copy ,~ ,~ / ;;' r" ~~j Business Site Responsibl Party Inspector: ~ I ~--'