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HomeMy WebLinkAboutBUSINESS PLAN-- CJ- --- ---,~------_-____ ----- - -- ~_ -. --. - - Tom-=6ri -s - _-_ ~.~ ~- 99 -- - - 5129 Buenu Vista Rd - --. _ . ti .;~ . it ~~~, TOM BRIGGS (MARILYN) Manager MARILYN BRIGGS Location: 5129 BUENA VISTA RD City BAKERSFIELD CommCode: BFD STA 15 EPA Numb: SiteID: 015-021-002235 BusPhone: (661) 664-1143 Map 122 CommHaz Moderate Grid: 24A FaCUnits: 1 AOV: SIC Code:4221 DunnBrad: Emergency Contact / Title Emergency Contact / Title MARILYN BRIGGS / OWNER / Business Phone: (661) 664- 1143x. Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Contact MARILYN BRIGGS Phone: (661) 664-1143x MailAddr: 5153 BUENA VISTA RD State: CA City BAKERSFIELD Zip 93311 Owner MARILYN BRIGGS Phone: (661) 664-1143x Address 5153 BUENA VISTA RD State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG T - ABOVEGROUND STORAGE TANK ~~~ ~~~ s;t,:,cd ~n my inquiry Of r`~:s~'r.;~"'t'';? iar oi:iat«~ainn the (hose indi+~iduais u~~~J~.r i~en m l for « a ation, I ce f~, of ra.v,~ that I rtify *xamin°d and am f have amiliar su~,mifte with the i~, orsrroiatioln d ~r;rJ he!ieve the inf acGUrat armatian ~ • t e, and con~olefe. is .rue, ~ ~ Date --'~-7 -1- 07/16/2007 ~-~ , F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... ISpecHazIEPA Hazards) Frm I DailyMax IUnitIMCP, GASOLINE G 250.00 GAL Mods -2- 07/16/2007 .-~,,~ -3- o~/i6/2oo~ ~,~ F TOM BRIGGS (MARILYN) ~ Inventory Item 0001 COMMON NAME / CHEMICAL NAME GASOLINE Location within this Facility Unit EQUIP YARD SiteID: 015-021-002235 ~ Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8006619 STATE TYPE PRESSURE TEMPERATURE Gas TMixtur~mbient ~ Ambient CONTAINER TYPE ABOVE GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 500.00 GAL 250.00 GAL 250.00 GAL rlr~~.ytcl~~ua wlnrvlv~ly 15 °sWt. RS CAS# 100.00 Gasoline No 8006619 t1HGH1CL 1~55~~~1~1~1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod -4- 07/16/2007 F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 Fast Format ~ Notif./Evacuation/Medical Overall Site ~ Agency Notification Employee Notif./Evacuation Public Notif./Evacuation iuiciycii~.Y a•acui~.ai riaii 9 9 -5- 07/16/2007 i~~ F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ iCC1CGt.5"C YLCVC11L1V11 Release Containment t.1C0.11 V~J V 1.1101 xCSVUrce L-~C,L1VaL1OI1 -6- 07/16/2007 ~.: ,~ .~ F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ _, .~Nc~..l.ai nac~atua ~ _ .~a___~ ..rr v~,iii~.y w~alu~.-vl.l_~ rliC rLC~~~c:./s-~vdl.i.. wcLLer DUllu11'ly vl.:l.:u~Jalll:y LCVC1 -7- 07/16/2007 .~X~. k F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training rayc ~ lulu 1V1 rul.uLC V5c nclu tCJI rUI.UlC U.5'~ -8- 07/16/2007 ( {" ' l TOM BRIGGS (MARILYN) J SiteID: 015-021-002235 Manager MARILYN BRIGGS BusPhone: (661) 664-1143 Location: 5129 BUENA VISTA RD Map 122 CommHaz Moderate City BAKERSFIELD Grid: 24A FacUnits: 1 AOV: CommCode: BFD STA 15 EPA Numb: SIC Code:4221 DunnBrad: Emergency Contact / Title Emergency Contact / Title MARILYN BRIGGS / OWNER / Business Phone: (661) 664-1143x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Contact MARILYN BRIGGS Phone: (661) 664-1143x MailAddr: 5153 BUENA VISTA RD State: CA City BAKERSFIELD Zip 93311 Owner MARILYN BRIGGS Phone: (661) 664-1143x Address 5153 BUENA VISTA RD State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG T - ABOVEGROUND STORAGE TANK ~O ~N~e~ ~- ~ ~ ~ ~,Q~7 Based on my inquiry of these ind'eviriuais responsible for obtaining the information, S certify under penalty of law that I have personally examined and am familiar with the inforrriatian submitted and believe the information is true, accurate, and complete. ` J ,B~` 99'~ ~D~ a 7 ' ignature Date -1- 04/18/2007 ~ 9~ F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP GASOLINE G 250.00 GAL Mod -2- 04/18/2007 -3- 04/18/2007 F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME GASOLINE Days On Site 365 Location within this Facility Unit Map: Grid: EQUIP YARD CAS# 8006619 STATE T TYPE ~- PRESSURE TEMPERATURE ~ CONTAINER TYPE ~GaS I Mixture I Ambient ~ Ambi Pnt- - I ARnvF r_Rnrrnm mnrru AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 500.00 GAL 250.00 GAL 250.00 GAL HAZARDOUS COMPONENTS ~Wt• RS CAS# 100.00 Gasoline No 8006619 rlt][~riRL YiJ JP~J Jl•1L'1V1~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Mod -4- 04/18/2007 F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification _, ~ ~~ LiuNivycc i~v~.ii . / uva~.ua~.ivit ruutlc, iVVl.1t / P~VdC:UdL1Uil ~uiciy~llc:y ri~uic,ai rlan -5- 04/18/2007 F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ tC~leci.5'C Yi~VCi1l.1V11 Release Containment ~.icall vN Vl.ilCt AGs7Vl.l1 l..G I']1. 1.1 VCLLlVll -6- 04/18/2007 F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ Special nazarus V1..1111.y ~711UL-V11.5 Fire Protec./Avail. Water DU11U111t~. VC: C.:Upollcy LCVC1 -7- 04/18/2007 F TOM BRIGGS (MARILYN) SiteID: 015-021-002235 ~ Fast Format ~ ~ Training Overall Site ~ employee lrainiug rctyC G Held for Future Use _, t_ aaciu ivi rut,utc vac -8- 04/18/2007 Prevention Services UNIFIED PROGRAM INSPECTION CHECKLIST'' A__ E R s F ,_ D 900Truxtun Ave., suite 210 Fine Bakersfield, CA 93301 SECTION 1: Business- Plan and Inventory Programm ~ "Rr"' r Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME INSPECTI N DATE INSPECTION TIME ADDRESS ~ iZ~ ~ s ~ PHO NO. 6Y- ,~ 3 NO OF EMPLOYEES / . t - a ~~, ~. r FACILITY CONTACT i r ~ ~ BUSINESS ID NUMBER 15-021- O b ~~ 3 ~ j v v~ -, Section 1. Business Plan-and Inventory Program ~~1~ ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C - V ~ C=Compliance OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND ^ BUSIIIeSS 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 ^ VERIFICATION OF HAZ MAT TRAINING t ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~ ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE 8 ON HAND nor-ou i~ ANY HAZARDO ASTE ON SITE? ^ YES O / EXPLAIN: ~ / ~ `' ~ J QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 - ~_ ~~-~l~ 1 ~ •8 si'nes/ S ~ ~ ~ ~ible P~/P ~ ~O~nn.S Inspector (Please Print) Fire Prevention / 1~` In /Shift of Site/Station # ~ Y ( ) White -Prevention Services Yellow -Station Copy Pink -Business Copy ~ FD 2155 (Rev. 09/05 :~t + TOM BRIGGS (MARILYN) ________________________________ SiteID: 015-021-002235 + Manager MARILYN BRIGGS Location: 5129 BUENA VISTA RD City BAKERSFIELD CommCode: BFD STA 15 EPA Numb: BusPhone: (661) 664-1143 Map 123 CommHaz Moderate Grid: 18C FacUnits: 1 AOV: SIC Code:4221 DunnBrad: Emergency Contact / Title Emergency Contact / Title MARILYN BRIGGS / OWNER / Business Phone: (661) 664-1143x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Contact MARILYN BRIGGS Phone: (661) 664-1143x MailAddr: 5153 BUENA VISTA RD State: CA City BAKERSFIELD Zip 93311 Owner MARILYN BRIGGS Phone: (661) 664-1143x Address 5153 BUENA VISTA RD State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: ~ PROG A - HAZMAT / PROG T - ABOVEGROUND STORAGE TANK ~ ~~ l E~''p J U L 14 2006 0~ ~D ~~ h~~ Based on my inquiry of those individuals ~~ V responsible for obtaining the information, I certify under penalty of lain that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. ate ignat a ~`~ Date -1- 06/13/2006 UNIFIE® PROGRAM INSPECTION CHECKLIST SECTION 1 Business Plan and Inventory Program u Bakersfield Fire Dept. Enironmental Services 1715 Chester Ave Bakersfield, CA 93~~Q? 3 FACILITY NAME /~ INSPECTION DATE INSPECTION TIME --- --- ~ ~ --~.1 fir'-, ~' -~---- -------- - ------ -- - - -_... --...-.-.-_ --- _ _ _ _ ~'~~-a a-/~ S -- ,~ .--!Yi ~ r~.--- - ADDRESS PH E No. No. of Em to ees FACILITYCONTACT Business ID Number 15-OZ1- ~© 3 /~ Y`_ il~f Section 1: Business Plan and Inventory Program outine ^ Combined ^ Joint Agency ^Mnlti-Agency ^ Complaint ^ Re-inspection COMMENTS i• 'PJ ^ 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 HAT MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES EMERGENCY PROCEDURES ADEQUATE CONTAINERS PROPERLY LABELED HOUSEKEEPING ^ FIRE PROTECTION ~ -v'~---- ----- ----- - _ --- --- ----- ._~.__..... - --- -- - ~ - ^ ^ SITE DIAGRAM ADEQUATE Si ON HAND ANY HAZARDOUS WASTE ON SITE: ^ YES NO EXPLAIN: • QUESTIONS REGARDING THIS INSPECTIONS PLEASE CALL US AT ~66~ ~ 326-3979 J 0 11 ~ W~'~`/ 1 ~ ~ C.~ Inspector (Please Print) Fire Prev ntion t st-In/Shift of Site White -Environmental Services Yellow - Station Copy _ ~ ~J~ us' ess Site Res onsible Party (Pleas P nt rn g N Pink -Business Copy CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME"'~'~/vk t~5 INSPECTION DATE ~-~//'~/~! ADDRESS ,~"'[.2q -- ,5~,~:5 l~c,.-..,a t6srac PHONE NO. ~(o4 ,- FACILITY CONTS~CT_"~rv'x t~re~C,6'fl . BUSINESS ID NO. 15-210- INSPECTION TIME NUMBER OF EMPLOYEES~)~''t''' /z3/g e.. Section 1: Business Plan and Inventory Program ~/2 Z/ /~ Routine [] Combined [] Joint ~Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V COMMENTS Appropriate permit on hand Business plan contact information accurate Visible address Correct occupancy Verification of inventory materials ~,,txSt~-~'~"~ A~ ~ Verification of quantities ~ ~tx~t.o~ Verification of location <~ ~.~c, aO O~ x/trY'cC> A-T ~-/~ ~ Proper segregation of material Verification of MSDS availability Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand C=Compliance V=Violation Any hazardous waste on site?: [] Yes ~No Explain: ~ Site/~ s~pO Questions regarding this inspection? Please call us at (661) 326-3979 Business nsible Party White- Env. Svcs. Yellow- Station Copy Pink- Business Copy Inspector: ~,J 'af~-~-5 / / ~~_~.,,~ :~ CITY OF BAKERS FI EL ~'~~__ OFFICE OF ENVIRONMENTAL SERVICES ~nnrt~r. ,,,_* 1715 Chester Ave., CA 93301 (661) 326-3979 H~RDOHS MAIERIALS INVENIORY CHEMICAL DESCRIPTION (one [orm ~er material ~er Outldmg or a~a) EW ~ ADD ~ OELETE ~ REVISE -- 200 Page I. FAClLI~ INFORMATION CHeMiCAL LOCAnON ~ ~ ( O ~ ~ ~ O ~ P~ ~ ~ 201;~ CONF~DENmLCHEM~CAL LOCAnON(~pc~) ~ Y~ ~ No 202 II. CHEMICAL INFORMATION CHEMICAL NAME ~ ~ ~ ~ ~ ~ ~ If Su~m to EPCm. refer to inslmctions ............................ 207 COM~N NAME fillS' ~ Y~ ~ No ~8 CAS # 209 'If EHS is'Yes.' all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by lOCal fire chief) 210 -~.?~5[~ ................ PURE [] m MIXTURE [] w WASTE 211 RADIOACTIVE [] Yes [] NO 212 CURIES 213 PHYSICAL STATE [] s SOLID /,~LIQUID [] g GAS 214 LARGEST CONTAINER ~ 215 FED HAZARD CATEGORIES ~ [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH 216 Ir'-"~ck all that apply) IRE [] 2 REACTIVE [] 3 PRESSURE RELEASE ALWASTE '217 ; MAXIMUM 218 AVERAGE 219 STATE WASTE CODE 220 i DAILY AMOUNT DAILY AMOUNT '"~. ~ ' ,A,,,oUNT I DAYS ON SITE 222 UNITS* [] ga GAL [] d CU FT [] ~b LBS [] tn TONS 221 · If EHS, amount must be in lbs. STORAGE CONTAINER ,~ [] m GLASS BOTTLE [] q RAIL CAR 223 (Check all that apply) ABOVEGROUND TANK [] e PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] b UNDERGROUND TANK E] t CAN [] j BAG [] n PLASTIC BOTTLE [] r OTHER [] c TANK INSIDE BUILDING [] g CARBOY [] k BOX [] o TOTE BIN [] d STEEL DRUM [] h SILO [] I CYLINDER [] p TANK WAGON STORAGE PRESSURE ~a AMBIENT [] aa ABOVE AMBIENT [] ba BELOWAMBIENT 224 ; STORAGE TEMPERATURE ~ AMBIENT [] aa ABOVE AMBIENT [] ba BELOW AMBIENT [] c CRYOGENIC 225 i %VVT HAZARDOUS COMPONENT EHS CAS # [ ....... ? .................. I I ! 229 1 226 [ 227 ; []yes []No 228 1 2 230 II 231 ,, [] Yes [] NO 232i 233 3i 234 ! 235 i r-I, Yes[] NO 236 ! 237 ---; ........................... 1 ............................................................... : ....................................... ~ .................... ~ ........................................ ;- ................ -;:;- .............................................................. : ......... III. SIGNATURE "~-;O-T- D~:M8 & ¥~¥ k~' b ~-~-U-T~5 ~5 k gffiS-~Lii5~ ~i k-/~ E-~ ~T~ FQ ~- .................. §li3-g~;rua E .................................................................................. DATE--'-'~-~- ' UPCF (7/99) S:\CUPAFORMS\OES2731 .TV4.wpd Hazardous Materials Inventory - Chemical Description You must comple(e .t ,~eparate Hazardous Matenals Inventory - Chemical Description page for each hazardous malarial (hazardous substances and hazardous waste) that you handle at your fac~l~ty ~n aggregate quanh/ies equal to or 9rearer than 500 pounds. 55 gallons, 200 cubic feet of gas (calculated at standard temperature and pressure) or Ihe ,'ederal threshold planning quantity for Extremely Hazardous Substances, whichever is less. Also complete a page for each radioactive material handled over quam~t~es for ',vh~ch an emergency plan ~s required to be adopted pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory should rellect all reportable quantities o! hazardous materials at your facility, reported separately for each building or outside adjacent area, w~th 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 numbem 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 Oictionary.) 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. ADDIDELETEI REVISE - Indicate if the material is being added lo 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 §255O6, 202. CHEMICAL LOCATION CONFIDENTIAL - EPCRA - All businesses which are subject to the Emergency Planning and Community Right to Know Act (EPCRA) must check "Yes' lo 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 malarial. This should be the International Union of Pure and Applied Chemistry (IUPAC) name found on the Material Sat'ely 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, discJosure of the designated trade secret information is bound by HSC §2551 Federal requirement: If yes, and business is ~ubject 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 malarial 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 matadat. 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 - 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 §re 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 Ihe 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 cudes. 214. PHYSICAL STATE - Check the one box that best describes the state in which the hazardous matedal is handled: solid, liquid or gas. 215. LARGEST CONTAINER - Enter the total capacity of the largest container in which the matedal is stored, 216. FEDERAL HAZARD CATEGORIES - Check all categories that describe the physical and health hazards associated with the hazardous material. J . PHYSICAL HAZARDS HEALTH HAZARDS Fire: Flammab e Liqu ds and So ids, Combustible Liquids Pyrophodcs Oxidizers Acute Health (Immediate): Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, Reactive: Unstable Reactive, Organic Peroxides, Water Rea~ve, Radioactive I other hazardous chemicals with an adverse effect with short term exposure Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long term exposure 217. AVERAGE DALLY AMOUNT - Calculate the average daily amount of the hazr~rdous material or mixture cDr;la n nga hazardous i~ia;.er;a~, in each building or adjacent/ outside area. Calculations shall be based on the previous year's inventory of matedal 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 DALLY 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 matedal 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 [he 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 matedal 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. STO .RAGE CONTAINER - Check all boxes that describe the type of storage containers in which the hazardous maladal 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 matedal 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 mixlura presenl at greater than 1% by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than live 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. (Repo~'t 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" il[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 informalion necessary lo meet the requirements of their individual programs. Contact the CUPA or AA for guidance. UPCF (1/99) 7 OES Form 2731 ITE DIAGRAM [ ~'~"~] FACILITY DIAGRAM [~] Business Name: Business Address: t( ' t{ 4 ' 5"t 5-3 l- S:\PROCEDURE MANU A L\diag rammst, wlxl CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS: 1. To avoid further action, retum 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. 5. You may also attach Business Owner / Operator Form and Chemical Description Form(s) to the front of this plan instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA BUSINESS NAME: '"'7-0 tv1 '~t (~4S (7' LOCATION: ~{2q ~U~ ~t%~ ~ ~L~G~D~SS: ~/~ ~oC~ ~s~ ~ CITY: ~KC~S~t~ STATE: ~ ZIP:~SN3 PHONE: P~Y ACTWITY: ~tM~ OWNER: '~3~ ~t~6% PHONE: MAILING ADDRESS: ,_~j ~'-~ ~oE'---~,t', ~6~F~ ~o EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE 2. HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II. 1: DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: B. EMPLOYEE AND AGENCY NOTIFICATION: C. ENVIRONMENTAL RESPONSE MANAGEMENT: D. EMERGENCY MEDICAL PLAN: HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: B. RELEASE CONTAINMENT AND/OR MITIGATION: C. CLE~N-UP AND RECOVERY PROCEDURES: ? (- UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: ELECTRICAL: WATER:' SPECIAL: LOCK BOX: YES/NO IF YES, LOCATION: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: d B. WATER AVAILABILITY (FIRE HYDRANT): --/+ a ~ ~7. _,ca-wo. ~quf..aO ~, C3. 3 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING NUMBER OF EMPLOYEES: /~///~ MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: CERTIFICATION I, CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY.. SIGNATURE TITLE DATE HAZ MAT MNOMNT PLAN & INSTRUC · 4  CITY OF BAKERSFIELD · ~-~;,~'~?', OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 FACILITY INFORMATION Page BUSINESS ~ME (~ ~ FAClLI~ ~E ~ DBA- ~i~ B~l~ ~) ~ -BUSINESS PHONE SITE ADDRESS CIW ~ ~ CA ZIP DUN & ~ SIC CODE B~DSTREET (4 Digit ~) COU~ OPE~TOR ~ME ~ ~ OPE~TOR PHONE I O~ER ~ILING Cl~ CONTACT ~ME ~7 CO.ACT PHONE CONTACT ~ILING ADDRESS ~ME ~ ~E TITLE ~ TITLE BUSINESS PHONE ~a BUSINESS P~ONE 24-HOUR PHONE ~ 24-HOUR PHONE PAGER PAGER Ce~a~on: Bas~ on my Inqul~ of ~oi~ I~lviduall ~nllble for obalnlng ~e Inlo~a~on, I ce~ under penal~ of law ~al I ~ve pt~nally and am famtllar ~ ~e Info~a~on submlff~ In ~ls Invento~ a~ believe ~e Info~a~on Is ~e, a~umte, and ~mplete. SIGNORE OF O~E~TOR DATE 1~ ~ OF ~CUME~ P~P~ER ~MES OF O~E~PE~TOR (pdnl) 1 ~ TITLE OF O~E~PE~TOR