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PEDERSEN DDS RAYMOND SiteID: 015-021-002298 Manager RAYMOND PEDERSEN Location: 1729 26TH ST City BAKERSFIELD BusPhone: (661) 324-9532 Map 102 CommHaz Minimal Grid: 25B FacUnits: 1 AOV: CommCode: BFD STA 04 EPA Numb: SIC Code:8021 DunnBrad: Emergency Contact / Title Emergency Contact / Title '~" RAYMOND PEDERSON / OWNER / `~ Business Phone: (661) 324-9523x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact RAYMOND PEDERSEN Phone: (661) 324-9523x MailAddr: 1729 26TH ST - State: CA City BAKERSFIELD Zip 93301 Owner RAYMOND PEDERSEN DDS Phone: (661) 324-9523x Address 1729 26TH ST State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif ' d: RSs : No ParcelNo: Emergency Directives: ENT~D J U L 1 9 X007 PROG H - HAZ WASTE GEN Based on my inq~siry of those individua{s responsible ~ ;r ok~t,rling the information, I certify under penalty cif ia~v that i have personally - - . examined and am familiar ~n~ith the information sui,mitted and t~elieve the information is true, accurate, and complete. ~ _ _ ~~ `~/ ~~ ~ Signet r r Date -1- 07/13/2007 ,~ F PEDERSEN DDS RAYMOND SiteID: 015-021-002298 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... ISpecHazIEPA Hazards) Frm I DailyMax IUnitIMCPI WASTE FIXER R L 5.00 GAL Minl -2- 07/13/2007 ;, -3- 07/13/2007 ~; F PEDERSEN DDS RAYMOND SiteID: 015-021-002298 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME WASTE FIXER Days On Site 365 Location within this Facility Unit Map: Grid: CAS# Liquid TWaste ~mbient~E ~ AmbientT~E ~PLASTOICTCONTAINERE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL 5.00 GAL 5.00 GAL nra~tucL~u~ ~~i~ir~lv~lvla %Wt. RS CAS# Silver No 7440224 riE~GHttL L~~Ji;a~1~1L"1V1J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 07/13/2007 F PEDERSEN DDS RAYMOND SiteID: 015-021-002298 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ 1"~y Clll:y 1VV 1~1L11:Q L1V11 Employee Notif./Evacuation ,~ tU3/11V 1VV l.1L ~ ~V0.l.. LLGLV 1.V11 Emergency Medical Plan -5- 07/13/2007 I, T ~ F PEDERSEN DDS RAYMOND SiteID: 015-021-002298 ~ ~~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ xelease rrevenzi~n Release Containment ~.icall VN V~.11C1 LCCe7VLL1l.:C til:LlVGl 1.1 Vll -6- 07/13/2007 ~ ,: _y i F PEDERSEN DDS RAYMOND SiteID: 015-021-002298 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ J fJCC: ld1 Ild'GdL UPS" Utility Shut-Offs Fire Protec./Avail. Water i7LLlllA Illy Vl.. l.. Ut.J0.111ry LC V C1 -7- 07/13/2007 J F PEDERSEN DDS RAYMOND SiteID: 015-021-002298 ~ Fast Format ~ ~ Training ~ .Overall Site ~ ~ Employee Training Page z Held for Future Use Held for Future Use -8- 07/13/2007 + PEDERSEN DDS RAYMOND ________________________________ SiteID: 015-021-002298 + Manager Location: 1729 26TH. ST City BAKERSFIELD BusPhone: (661) 324-9532 Map 102 CommHaz Minimal Grid: 25B FacUnits: 1 AOV: CommCode: BFD ~STA 04 _ ' _ _ .. SIC. Code.: 8.021 - EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title RAYMOND PEDERSEN / DDS / .Business Phone: (661) 324-9523x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React ___. _Contac _-:_-RAYMOND :PEDER_ SEN. _-. - _. _ ~_._ _ _.__-_. -. Phone:- -(661) 324--9523x °--- -- - MailAddr: 1729 26TH ST State: CA City BAKERSFIELD Zip 93301 Owner RAYMOND PEDERSEN Phone: (661) 324-9523x Address :-1729 26TH ST State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: = Gal Preparers _ TotalUSTs: = Gal Certif'd: RSs: No _ ParcelNo: Emergency Directives: PROG H - HAZ WASTE.GEN ENrp ~Ay 2 5 2446 Based on my inquiry of those individuals responsible for obtaining the information, t certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurat and complete. ' s-~~ o~ Sign Date -1- 05/22/2006 ;~: llNIFIED~PROGRAM INSPECTION CHECKLIST ..: ~~i~ \~,~,.p:.~V;';,q~.'1S Y:M1S,~r e... .7 .. ~. t .... .tf .. • r.,... n.. ... ... .. - ..'. x;c. . .... ... .SECTION 1: Business Plan and Inventory Program '~ Tel.: (661) 326-3979 Fast: (661) 872-2171 FACILITY NAME ~~ MO ~v ~E -U Q~ S ~ '~ ~.~~ NSPE TION DATE 107 NSPECTION TIME ADDRESS r ~ ~ q ~ ~ ).1~ 5~ 1 1 ~ H~iNO~ c ~ 7 [' / G O OF EMP OYEES FACILITY CONTACT ~ USINESS ID NUMBER 15-021- ~ 9, Section 1: Business Plan and Inventory Program ^ ROUTINE /~ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V ~ C=Compliance OPERATION V=Valation COMMENTS ^ APPROPRIATE PERMIT ON HAND ^ BUSItlBSS 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 AVAILABILITY IAA R 8 ~oo/ ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ~~ ^ HOUSEKEEPING ^ FIRE PROTECTION ^ $ITE DIAGRAM ADEQUATE 8 ON HAND ANY HAZARDOUS WASTE ON SITE? ^617(E$ ^ NQ EXPLAIN: ~"~ °` S~C ~ QUESTIONS REGARDING THIS INSPECTIONS PLEASE CALL US AT (887) 328-3979 Inspector (Please Print) Fire Prevention / 1 In / Shift of Site/Station # urine te/Schoot Site esponsible Party (Please Print) BASERSFIELD FIRE DEPT a Prevention Services ,R~~~ 9001Yuxtun Ave., Suite 210 ARfN s Bakersfield, CA 93301 White -Prevention Services Yellow -Station Copy Pink - Business Copy FD2049 (Rw. 02105) :~ ~~ FACILITY NAME Section 4: Hazard ^ Routine `!~] Combined ^ Joint Agency ^hulti-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number ~X ~ „~ p T Authorized for waste treatment and/or storage Reported release, fire, or explosion within 15 days of occurrence Established or maintains a contingency plan and training Hazardous waste accumulation time frames Containers in good condition and not leaking Containers are compatible with the hazardous waste Containers aze kept closed when not in use Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line X11 Secondary containment provided Conducts daily inspection of tanks Used oil not contaminated with other hazardous waste ~ Proper management of lead acid batteries including labels N Proper management of used oil filters ~ ~ Transports hazardous waste with completed manifest Sends manifest copies to DTSC Retains manifests for 3 years ~'" J . r•- l.J a rr a ,.-. Retains hazardous waste analysis for 3 years x- ~ s©1w-~~~. s Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal =c;ompttance vv=vtotatton Inspector: `' ~ " ~~ ` ~ ~~ `') Office of Environmental Services (661) 326-3979 White -Env. Svcs. ~ OFFICE OF ENVIRONMENTAL SERVICES b ~" UNIFIED PROGRAM INSPECTION CHECKLIST w~~~~~ 1715 Chester Ave., 3'd Floor, Bakersfield, CA 93301 ~.y V..,,~~,~ i~ 6 D L 2s E ~. INSPECTION DATE ~ ~ _~_ `~~~- CITY ®F BAKERSFIELD FIRE DEPARTMENT ous Waste Generator Program EPA ID # ~X~h' ~ r Pink -Business Copy Busi ss Site Responsible Party _ ___ _ _ _ COB 4/12/2007 3:09:36 PM PACE 4/011 Fax Server ~g358 PEDERSEN DDS RAYMOND SiteID: 015-021-042298 Manager BusPhone: (661} 324-9532 Location: 2729 26TH ST Map 102 ComtnHaz Minimal City BAKERSFIELD Grid: 25B FacUnits: 1 AOV: CotmnCode: BFD STA 04 STC Code:8021 EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title RAYMOND PEDERSON / DDS / Business Phone: (661) 324-9523x Business Phone: ( ) - x 24-Haut Phone { ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( } - x Aazmat Hazards: React Contact RAYMOND PEDERSEN Phone: (661) 324-9523x MailAddr: 1729 26TH ST State: CA City BARERSFIELD Zip 93301 Otaner RAYMOND PEDERSEN Phone: (661) 324-9523x Address 1729 26TH ST State: CA City BAKERSFIELD Zip 93301 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParceJ.lao Emergency Directives: FROG H - HAZ WASTE GEN ~ ~~fl ~ ~~ •r ~n ~ ~ ;UtrY f ,.t::.r:~ o lhr. in tc,r r;h!sirti;t ;!.A ; se divid~asS U'1(~rsl j:F'•f!<Rff :[ `~ rli0ff11:iti01 . ~ ! Y cacti, exnm~r,ua ,,1C am f a t`+at i havg . 9ubnliifgd ~n 3'hiliar with Pe~s4n„!ly the inl d b . or alievE mation accurate, the information is true and Cofn~,fefE . S 4 ignature -.-- - j L-~ 7 Dot- a ""-=f- -1- 04f12/2407