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HomeMy WebLinkAboutBUSINESS PLAN,~ ~~ ~~- ~- ommy_s o i e u ~e 508 Butte St - -- - w- f' t . ~. TOMMYS MOBILE LUBE SiteID: 015-021-003484 Manager TOMMY NIETO JR Location: 508 BUTTE ST City BAKERSFIELD BusPhone: (661) 328-1769 Map 103 CommHaz Low Grid: 29C FacUnits: 1 AOV: CommCode: BFD STA 02 EPA Numb: SIC Code:7538 DunnBrad:563-06-0449 Emergency Contact / Title Emergency Contact / Title ANGELIC COLEMAN / SECTY/RECEPTION MONA NIETO / SECTY/RECEPTION Business Phone: (661) 328-1769x Business Phone: (661) 827-0394x 24-Hour Phone (661) 204-4555x 24-Hour Phone (661) 204-4316x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire DelHlth Contact TOMMY NIETO JR Phone: (661) 204-4315x MailAddr: 4805 POPPYSEED ST State: CA City BAKERSFIELD Zip 93313 Owner TOMMY NIETO JR Phone: (661) 204-4315x Address 4805 POPPYSEED ST State: CA City BAKERSFIELD Zip 93313 Period to TotalASTs: - Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG H - HAZ WASTE GEN ENT'D JUG 2 5 2007 -~?^.:"~ on m}~ inq;;iry rf those individuals rt •~4=~"~R ,'ih!;~ f:~r o?~§ainin~ the information, I c%rtify ' uszt3er or ;nalty of ia~~l that i have personally examined and am familiar with the information s;ar~m~tied and haliEVe the in#ormation is true , accurate, and complete. ~--, 1Signatur ~~ ~ Z3 ~d~ rJate -1- 07/16/2007 "+' 1 F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP WASTE OIL F DH L 500.00 GAL Low MOTOR OIL F DH L 290.00 GAL Min MOTOR OIL F DH L 110.00 GAL Min MOTOR OIL F DH L 100.00 GAL Min -2- 07/16/2007 ~, Z ~• -3- 07/16/2007 F TOMMYS MOBILE LUBE ~ Inventory Item 0004 COMMON NAME / CHEMICAL NAME WASTE OIL Location within this Facility Unit SE CRNR OF YARD STATE TYPE PRESSURE Liquid TWaste ~ Ambient SiteID: 015-021-003484 ~ Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# TEMPERATURE CONTAINER TYPE Ambient ABOVE GROUND TANK AMOUNTS AT THIS LOCATION - Largest Container Daily Maximum I Daily Average 500.00 GAL 500.00 GAL 500.00 GAL t11~GEiL[LVU~ 1:V1~lYV1VI;1V15 %Wt. RS CAS# 100.00 Waste Oil, Petroleum Based No 0 ril-~GtitCL 1~.7~L' ~.71~1L"1V 15 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Low ~ Inventory .Item 0002 COMMON NAME / CHEMICAL NAME MOTOR OIL Location within this Facility Unit E WALL OF GARAGE STATE - TYPE PRESSURE Liquid Mixture ~mbient Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8020835 TEMPERATURE ~~ CONTAINER TYPE Ambient I PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 0.25 GAL 290.00 GAL 290.00 GAL ru~urucLVVO ~.vrlrvlv~ly 1.S %Wt. RS CAS# 100.00 Motor Oil, Petroleum Based No 8020835 i1tiG+tiRL a`ii J ~J r+.7.71.1P~1V 1 w7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Min -4- 07/16/2007 P TOMMYS MOBILE LUBE SitelD: 015-021-003484 ~ ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME MOTOR OIL Days On Site 365 Location within this Facility Unit Map: Grid: E WALL OF GARAGE CAS# 8020835 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE = Liquid TMixtur~mbient ~ Ambient DRUM/BARREL-METALLIC AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 55.00 GAL 110.00 GAL 110.00 GAL t1AGAKLVU~ 1:V1~lYV1V1";1V15 %Wt. RS CAS# 100.00 Motor Oil, Petroleum Based No 8020835 riHGE1tCL 1~~J~1"~JJ1~1~1V 1 7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Min ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME MOTOR OIL Days On Site 365 Location within this Facility Unit Map: Grid: TANK IN VEHICLE CAS# 8020835 STATE TYPE PRESSURE Liquid Mixture Ambient ~ TEMPERATURE CONTAINER TYPE Ambient OTHER - SPECIFY AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 100.00 GAL 100.00 GAL 100.00 GAL nr~~r-~tcLV ua ~vrirvlv~ly 1 a %Wt. RS CAS# 100.00 Motor Oil, Petroleum Based No 8020835 t1HGKKL L-~J~L" .7.71~1~1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Min -5- 07/16/2007 F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 11/03/2006 ~ CALL 911 AND OES 800-852-7550 AND OWNER, TOMMY NIETO 204-4315. ,_ Gut~.IlvyCC iVV 1.11 / L~VdC:Udl.l Vil Public Notif./Evacuation 11/03/2006 OWNER OR SECRETARY WILL HANDLE CLEAN-UP, OR CALL APPROPRIATE COMPANY AS NEEDED. Emergency Medical Plan 11/03/2006 CALL 911 AND/OR TRANSPORT TO NEAREST MEDICAL FACILITY. SAN JOAQUIN HOSPITAL HANDLES HAZARDOUS MATERIALS ACCIDENTS. -6- 07/16/2007 ~. ,'C; F TOMMYS MOBILE LUBE SitelD: 015-021-003484 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 11/03/2006 ~ OIL STORAGE ABOVEGROUND TANK WITH SECONDARY CONTAINMENT, OUTSIDE AWAY FROM POTENTIAL PROBLEMS. Release Containment 11/03/2006 WASTE OIL TANK SITS INSIDE CONTAINMENT BOX TO CONTAIN ANY POTENTIAL SPILL. Clean Up 11/03/2006 SAWDUST OR ABSORPTION MATERIAL WILL BE KEPT TO ABSORB POTENTIAL SPILLS. V~.11C.1 iCC .7VU1 l:C t'11.L1VC1L1V11 -7- 07/16/2007 ~. ~, y: F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ .7YCC:1c11 ridGdLU.S' Utility Shut-Offs NATURAL GAS/PROPANE: W END OF BLDG ELECTRICAL: W END OF BLDG WATER: S SIDE OF BLDG FRONT BET UNITS 500 AND 504 LOCK BOX: NO 11/03/2006 Fire Protec./Avail. Water PRIVATE FIRE PROTECTION: FIRE EXTINGUISHERS IN SHOP FIRE HYDRANT: CRNR TULARE ST & BUTTE ST APPROX 150FT FROM OFFICE 11/03/2006 Building Occupancy Level 3 EMPLOYEES 11/03/2006 -8- 07/16/2007 ., ~, ,,_ F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 11/03/2006 ~ BRIEF SUMMARY OF TRAINING PROGRAM: VERBAL COMMUNICATION OF POSSIBLE HAZARDS AND COURSES OF ACTION IN THE EVENT OF AN ACCIDENT. rayv ~ Held for Future Use Held for Future Use -9- 07/16/2007 ~. ~.J TOMMYS MOBILE LUBE SiteID: 015-021-003484 Manager TOMMY NIETO JR Location: 508 BUTTE ST City BAKERSFIELD BusPhone: (661) 328-1769 Map 103 CommHaz Low Grid: 29C FacUnits: 1 AOV: CommCode: BFD STA 02 EPA Numb: SIC Code:7538 DunnBrad:563-06-0449 Emergency Contact / Title Emergency Contact / Title ANGELIC COLEMAN / SECTY/RECEPTION MONA NIETO / SECTY/RECEPTION Business Phone: (661) 328-1769x Business Phone: (661) 827-0394x 24-Hour Phone (661) 204-4555x 24-Hour Phone (661) 204-4316x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: Fire DelHlth Contact TOMMY NIETO JR Phone: (661) 204-4315x MailAddr: 4805 POPPYSEED ST State: CA City BAKERSFIELD Zip 93.313 Owner TOMMY NIETO JR Phone: (661) 204-4315x Address.: 4805 POPPYSEED ST State: CA City BAKERSFIELD Zip 93313 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: Nq ParcelNo: Emergency Directives: PROG A - HAZMAT PROG H - HAZ WASTE GEN ~N~`B ~ ~ ~ ~ ~ ~QQ7 E3ased on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is 4rue, accurate, and complete. --,- ~ 2 Z,lo, Signature Date -1- 02/16/2007 p 3, F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP WASTE OIL F DH L 500.00 GAL Low MOTOR OIL F DH L 290.00 GAL Min MOTOR OIL F DH L 110.00 GAL Min MOTOR OIL F DH L 100.00 GAL Min -2- 02/16/2007 -3- 02/16/2007 ~, 5 P TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ ~ Inventory Item 0004 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME WASTE OIL Days On Site 365 Location within this Facility Unit Map: Grid: SE CRNR OF YARD CAS# STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TWaste ~ Ambient ~ Ambient ABOVE GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 500.00 GAL 500.00 GAL 500.00 GAL -- t1AL,L-1tCLVUb 1.V1~lYV1VL'1V7J %Wt. RS CAS# 100.00 Waste Oil, Petroleum Based No 0 Y1HGE~iCL E~. JJL' J51~1t'ilV l J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Low ~ Inventory Item 0002 COMMON NAME / CHEMICAL NAME MOTOR OIL Location within this Facility Unit E WALL OF GARAGE STATE TYPE PRESSURE Liquid TMixture ~mbient Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8020835 TEMPERATURE CONTAINER TYPE Ambient _~STIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 0.25 GAL 290.00 GAL 290.00 GAL t1E~G1-itC1J V U .7 1. V1~lY V1V J~,1V -1 .7 %Wt. RS CAS# 100.00 Motor Oil, Petroleum Based No 8020835 ti!-1GL~.CCL Fi. >~~5A1~1L"1V1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Min -4- 02/16/2007 F TOMMYS MOBILE LUBE ~ Inventory Item 0003 COMMON NAME / CHEMICAL NAME MOTOR OIL Location within this Facility Unit E WALL OF GARAGE STATE TYPE PRESSURE Liquid TMixture ~mbient SiteID: 015-021-003484 ~ Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 8020835 TEMPERATURE CONTAINER TYPE _ Ambient DRUM/BARREL-METALLIC AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 55.00 GAL 110.00 GAL 110.00 GAL - t1AGA.ttL V U 7 l: V 1~1Y V1V L' 1V 15 %Wt. RS CAS# 100.00 Motor Oil, Petroleum Based No 8020835 tiHGH.ttL A~al"~Ja1~1L1V1J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Min ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME MOTOR OIL Days On Site 365 Location within this Facility Unit Map: Grid: TANK IN VEHICLE CAS# 8020835 STATE TYPE PRESSURE MPER E C AINE YPE Liquid. T Mixture I Ambient ~ . TE ATUR Ambient ONT R T OTHER - SPECIFY AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 100.00 GAL 100.00 GAL 100.00 GAL rlti~~c.uvua ~vrirvlv~lvla SWt. RS CAS# 100.00 Motor Oil, Petroleum Based No 8020835 t1HG1~ilCL H. 7~~5~1~1L'1V 15 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Min -5- 02/16/2007 F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 11/03/2006 ~ CALL 911 AND OES 800-852-7550 AND OWNER, TOMMY NIETO 204-4315. r,Ill~J1V~/CC 1VV1.11 / L~VdC:Udl.1V11 = Public Notif./Evacuation 11/03/2006 OWNER OR SECRETARY WILL HANDLE CLEAN-UP, OR CALL APPROPRIATE COMPANY AS NEEDED. Emergency Medical Plan 11/03/2006 CALL 911 AND/OR TRANSPORT TO NEAREST MEDICAL FACILITY. SAN JOAQUIN HOSPITAL HANDLES HAZARDOUS MATERIALS ACCIDENTS. -6- ~ 02/16/2007 F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 11/03/2006 ~ OIL STORAGE ABOVEGROUND TANK WITH SECONDARY CONTAINMENT, OUTSIDE AWAY FROM POTENTIAL PROBLEMS. Release Containment 11/03/2006 WASTE OIL TANK SITS INSIDE CONTAINMENT BOX TO CONTAIN ANY POTENTIAL SPILL. Clean Up 11/03/2006 SAWDUST OR ABSORPTION MATERIAL WILL BE KEPT TO ABSORB POTENTIAL SPILLS. V1.11C 1. iCCAV LLt I:C til: l.lVdl.1 V11 -7- 02/16/2007 F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ aNc~iat na~aiu~ Utility Shut-Offs 11/03/2006 NATURAL GAS/PROPANE: W END OF BLDG ELECTRICAL: W END OF BLDG WATER: S SIDE OF BLDG FRONT BET UNITS 500 AND 504 LOCK BOX: NO Fire Protec./Avail. Water PRIVATE FIRE PROTECTION: FIRE EXTINGUISHERS IN SHOP FIRE HYDRANT: CRNR TULARE ST & BUTTE ST APPROX 150FT FROM OFFICE 11/03/2006 Building Occupancy Level 11/03/2006 3 EMPLOYEES -8- 02/16/2007 ~i • r i~ F TOMMYS MOBILE LUBE SiteID: 015-021-003484 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 11/03/2006 ~ BRIEF SUMMARY OF TRAINING PROGRAM: VERBAL COMMUNICATION OF POSSIBLE HAZARDS AND COURSES OF ACTION IN THE EVENT OF AN ACCIDENT. rctyC 6 Held for Future Use aaciu Lvi i~ u~..uic vac -9- 02/16/2007 (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFIEY~ PROGRAM CONSOLIDATED FORM) APPLICA710N BI.ISNESS ONIINBZ/OP02ATOR DENiFK'.ATION FORM (HAZARDOUS MATERIALS FACILITY INFORMATION) BAKERSFIELD FIRE DEPT. ~w Prevention Services 900 Truxtun Ave., Suite 210 a a a s F i n Bakersfield,. CA 93301 FIRE ARTM f Tel.: 661-326-3979 .~. Fax: 661-852-2171 ,,. Page 1 of 2 ~~I ~i 1~ ~ u. _ -- _. t J. FACILITY IDENTIFICAT{ON FACILITY ID N0. t Year Beginning tao /O 2~' ZAO~ Year Endin tot ~ ~~ BUSINESS NAME (Samq as FACILITY NAME or DBA- Doing Business As 3 BUSIN SS PHONE ~ I~ toz SITE/ADDRESS to3 V ~• CITY toa CA Ip tos ~~ DUNN 8 BRADSTREET r~ tae ~Q ~~ ~~ ~ SIC CODE to7 (4 Digit #) COUNTY toe OPERATOR NAME_ ~ n ~~/~ ~ F ~. tog - -- OPT ~Q,R P~U~ ~~ -- --` no - II. OWNER-INFORMATION OWNER NAME ttt OW ER PHONE ttz ~~~ ~ ~~ OWNER MAILING ADDRESS tt3 ~~ CITY ENT NOV ~~~~~ STATE tt5 ~- IP tt6 9~~~3 III.: ' ENVIRONMENi"AL CONTACT tt7 CONTACT N AM E CON TAC T PHONE tt8 ~~ /n ~/~/~ Ir,\~ ~~ `• a (( + ~O~ CONTACT MAILING ADDRESS tt9 v l . o ~ CITY ( J , ~n tat 1~~y7~C'~~`~-~' ~ ~~~ STATE ~ t2t ~ ZIP ~ i~ (~ to 'PRIN{ARY IV. 'EMERGENCY CON -- TACTS -SECOI~fDARY- NAME 123 ~--1y1 C. C_c7~ M+~J NAME 128 ~ - ~ ~~ TRLE 124 TITLE 129 BU INES~PHONE ~~~ ~~ 125 BUSINESS PHONE ~~ ~ `~~~ 130 V 24-HOUR PHONE 126 24-HOUR PHONE 131 PAGER NO. 127 PAGER NO. 132 133 V. CERTIFICATION Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the information submitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF SIGNER ~ 136 DATE II 134 NAME OF DOCUMENT PREPARER 135 ~~ ~ ~ `a~ ~OiN44'Yl~l I~ti~l'O NAME OF OWNER/0P TOR (SDIGNATURE & PRI J 137 ~ TITLE OF OWNER/OPERATOR 138 Yin (~ r+ l7 V V ~ V~O 1 ~~ ~ ~~ ~/ ~D FD 2142 (Rev. 09/05) ~~ `~ ~~ ~ b~ .a „ . , ., (Hazardous Materials Facility Information -HMMP) Business Owner/Operator Identification - Please submit the Business Activities page, the Hazardous Materials Faci/itylnformation (HMMP) Business Owner/Operator Identification Form, and Hazardo~ Materials Inventory Chemical Description Form 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 inst/uctions fo/%ws the data a%ment numbers that are on the Business Owner Operator Form page. These data a%ment numbe, are used fore%ctronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary. Please numberallpages ofyour submittal. This helps our CUPA orAA identify whether the submittal is comp/ete and ifany pages are separated. 1 FACILITY I.D. NUMBER-This humber is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3 BUSINESS NAME -Enter the full legal name of the business. 100 BEGINNING DATE -Enter the beginning year and date of the report. (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 extension 103 BUSINESS SITE ADDRESS -Enter the street address where the facility is located. No post office box numbers are allowed. This information must provide a means to geographically locate the facility. 104 CITY -Enter the city or unincorporated area in which business site is located. 105 ZIP CODE -Enter the zip code of business site. The extra 4 digit zip may also be added. 106 DUNN & BRADSTREET -Enter the Dunn & Bradstreet number for the facility. The Dunn & Bradstreet number may be obtained by calling (610) 882- 7748 or by Internet. 107 SIC CODE- Enter the primary Standard Industrial Classification Code number for primary business activity. NOTE.• lfcode is more than 4 digits, report on/y the first four. 108 COUNTY -Enter the county in which the business site is located. 109 BUSINESS OPERATOR NAME -Enter the name of the business operator. 110 BUSINESS OPERATOR PHONE -Enter business operator phone number, 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 hazardou materials at the business site. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regardint incident mitigation. 124 TITLE -Enter the title of the primary emergency contact. 125 BUSINESS PHONE -Enter the business number for the primary emergency contact, area code first; and any extensions. 126 24-HOUR PHONE - Enter a 24-hour phone number for the primary emergency contact. The 24-hour phone number must be one which is answered 24 hours a day. if it is not the contact's home phone number, then the service answering the phone must be able to immediately contact the individu, 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 necessan 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 FD 2142 (Rev. 09105) HAZARDOUS MATERIALS MANAGEMENT PLAN APPLICATION FOR SECTION DISCOVERY AND NOTIFICATION (FORMS) Tel.: 66.1-326-3979 -_ •Fax: 661-.R52-2171 j _ • INSTRUCTIONS ~ " . , ' , . , - ~ Page 1, of 2• . . • . ~! 1. To avoid further action, return this form within 30 days of receipt. 2. TYPE/PRINT ANSWERS IN ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. - ~~ SECTION L FACILITY 1DENTIFICATION BUSINESS~NA~M~E (MSame as FACILITY NAME or DBA -Doing Business As) . ADDRESS (For local use only) ~~' JoS ~s"t"C`~- ~~ FACILITY ID N0. ~ i - --- -~- L- - - SECTION11.1:'.DISCOVERY AND NOTIFICATIONS ~ ;~ Ei~~ D MON ~ RING PROCEDURES: ~~ ~ ~ ~ .. ~ f ~ ~~~?~C~ j p ~OI~~~ ~,o~T,~l P~t~'1~'T B. EMPLOYEE AND AGENCY NOTIFICATION: C~Jl~f'~~-j p~c~! I~-P•..' `"C't)ItY~1M~ Iii i~,~ ~"~ •~ CI~LI. ~ ~ ~ {'~ri.$C~ TE+~- ~L~ o~ ~~P~Cs~I~~`q S~ItC,~, t Cr"Co - t -4 l 00 ~ .~ 1=~00 ., ~SZ.- ~jS~b C. ENVIRONMENTAL RESPONSE MANAGEMENT: - C`~i~- tV~~'t, ~ dR~ 5~-~TP~~! S Yet LL {>~~~L~-' __C~C. D. EMERGENCY MEDICAL PLAN:' C~'lLl~. ~ ~ l uviJQ ~Q Tn ,~ ~?~ 't~ ~~(~j~Lr~T' ~ ~Ie,/~t~fC` ~~,ly 1. t~ , l `<TV V ~~ a7 ~1~~p ~°rQy4 iJ 1-~OSP1TiPrt.. ~I~NDL~S y~PcZ~Oc~s VwrPf~°~~Z.NA~ l~l SECTION 11:2: RELEASE RESPONSE PLAN A HAZARD ASSESMENT AND PREVENTION MEASURES: ~q 1 L ~©n /L(~'~ ~f7 `y (`~L~ ~~ U`~ ~°_C~,~ ~C,caN~'a2~ ~-C~1Jr\1T~1IVtM.~C~f`~~v v~~ 1,~1J~/~z I~vJ~~l "~c~!4 PoTI~~'Tfi~1Z~ B. RELEASE CONTAINMENT AND/OR MITIGATION: ~ ~~~ O t ~ ~,~ 1~ S (T~ 6 N [' )J~U l..fJly r~~ 1 V '43C`!~ ~Cc~ ~ar~C~l N I~,N, Po~N~v~ ~P1~CS, ! J C. CLEAN-UP AND RECOVERY PROCEDURES: ~11~-~J' ~T ~Z„ ~C~ ~ f,~'rtr,lpC j ~j ~,,, y v~ ~~ ~L ~ ~ ~-~~o~D Pc~t~tb4L Sal ~~.+5~~.~+~ ~ . . ~ ,~ FU 1169 (Rev. 09105) BAKERSFIELD FIRE DEPT. H H R 9 F I n Prevention Services P/RD 900 Truxtun Ave., Ste. 210 ARTM ! ~ Bakersfield; CA 93301 ~, Page 2 of 2 r _ - _ '~-` SECTION 11.2. 'RELEASE RESPONSE PLAN-CONT. ~, UTILITY SHUT-OFFS (LOCATION OF SHUT-0FFS AT YOUR FACILITY) ~ {~ NATURAL GASIPROPANE: , ' ~ ~ /t.{1 ELECTRICAL: ^ ~ U CS ~ ' i Q ~ WATER: ~ St lJr' ~l~ `JU'~~~j"~' ~JN ~O SPECIAL: PRVATE FIRE PROTECTIONNVATERRVAILABILITY: A. PRIVATE FIRE PROTECTION: ~~~ ~~~~~~1~• /~ 'ter ~~OQ B. WATER AVAILABILITY (FIRE HYDRANT): ~ICZc,2 1-Ey~tZ~(~(' ~' CoP.~I~t~R Og -C'Ul.~ ~ ~ ~~z~ ~'"~v Y-~~pP~o r - ~ f ~~ ~=f~~om O~1 cam, SECTION 111: TRAINING NUMBER OF EMPLOYEES: r MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: - -• ~I-~,~cL.. ~ovw~uVv-~~t ~9r~1 p~- ~ ~~~~L2 ~{pr2t~2-~ ~ . - &~fl L' ... ;. GERTIFlCATION Based on my inquiry of those individuals responsible for obtaining the information, 1 certify under penalty of law that 1 have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. SIGNATURE OF OWNER /OPERATOR OR DESIGNATED REPRESENTATIVE DATE 477 T ~ -" to~3~~0~ NAME OF SIGNER 'nt) 478 TITLE OF SIGNER 479 IIw~~ ~ V ~ 169 (Rev. 09/05) 13AKr:K~1''ll'rLJ~ r 1K1J L1:Y'1'. (HMMP) Prevention Services HAZA~DOUS.;MATERIALS MANAGEMENT PLAN ti -f UNIFIED PROGRAM CONSOLIDATED FORMS e S R S P i D 900 TI'UXtun Ave., Ste. 210 FUi<B Bakersfield, CA 93301 CHEMICAL DESCRIPTION FORM "Rr"' r -Tel.: 661-326-3979 HAZARDOUS MATERIALS INVENTORY ~ Fax: 661-852-2171 ~W ^ ADD ^ DELETE ^ REVISE 200 (One form per material, per building, or area.) ____ PanP1 of 2 ___ L FACILITYINFORMATI~N ___ BUSINES~S~NpAME (Same as FACILITY NAME or DBA -Doing Business As) OIN~YV~y,! YVti®~( CHEMICAL LOCATION ",,~ 201 CHEMICAL LOCATION 20 ~ D~~` ^~ ~ p_~/1~~yn~ O~ (~1 ~ ~rj"'~` CONFIDENTIAL (EPCRA) Yes ^ N FACILITY ID No. r',J{„) `J'am P•~` " ^' (~/ ~ C (, 1 MAP No. (optional) 203 GRID NO. (aptionaq 20 ` II ('HF.MIC'AI INF[IRM~TiI[aN CHEMICAL NAME 205 20 y` j . /1 rf'~ yam ~ " TRADE SECRET ^ Yes o ~ ' c~l ~; (J {"~ ~ o COMMON NAME ~~ ©` ~ 207 EHS• D Yes No ~ 20 CAS No. 209 •If EHS is "Yes," all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 21 TYPE 211 ~p PURE ^ m MIXTURE ~w WASTE RADIOACTIVE: ^ Yes 21 ~ No CURIES 21 LARGEST CONTAINER 21 PHYSICAL STATE ^ 5 SOLID LIQUID ^ g GAS 214 S OO G,r+rl_. FED HAZARD CATEGORIES ^ 1 FIRE ~ REACTIVE ^ 3 PRESSURE RELEASE ^ 4 ACUTE HEALTH ^ 5 CHRONIC HEALTH 21 (Check all that apply) ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 STATE WASTE 22 AMOUNT ~ CV ~~ ~~ DAILY AMOUNT C+O~ ~A~ DAILY AMOUNT CODE 221 222 ^ UNITS ~a GAL ~ ^ ~ CU FT ^ Ib LBS ^ to TONS DAYS ON SIT ~ If EHS, amount must be in lbs. ~ 22 STORAGE CONTAINER (C~eck all.that apply) ~ a ABOVEGROUND TANK ^ f CAN k BOX ^ p TANK WAGON ^ b UNDERGROUND TANK ^ g CARBOY ^ I CYLINDER ^ q RAIL CAR ^ cTANK INSIDE BUILDING ^ h SILO *~ d STEEL DRUM ^ i FIBER DRUM ^ n PLASTIC BOTTLE ^ e PLASTIC/NONMETALLIC DRUM ^ j BAG ^ o TOTE BIN ~n STORAGE PRESSURE p~ I a AMBIENT ^ as ABOVE AMBIENT ^ V ba BELOW AMBIENT 22 STORAGE TEMPERATURE ~ a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AM BIENT ^ c CRYOGENIC 22 %WT - HAZARDOUS COMPONENT T I EHS CAS #` '~ 1 226 227 ^ Yes ^ Na 228 22 2 230 231 ^ Yes ^ No 232 23 3 234 235 ^ Yes ^ No 236 237 4 238 239 ^ Yes ^ No 240 241 5 242 243 ^ Yes ^ No 244 24 111. SIGNATURE PRINT NAME 8 TITLE O F A UT HORIZED COMPANY REPRESENTAT IVE SIGNATURE DATE 2 1 ' 2 T p ~~ N~C~ t~~ ~ \~ / ~ ~ ~ ti~0 X U FD 2144 (Rev. 09/05) %r Code Description CALIFORNIA WASTE CODES Inorganics ill Acid solution 2 < pH < 7 with metals (antimony, arsenic, barium, beryllium, cadmium, chromium, cobalt, copper, lead, mercury, molybdenum, nickel, selenium, x, 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 anions. (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 O'ttier 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 ® 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 sewage sludge 331 Off-spec, aged or surplus organics 341 Organic liquids (non-solvents) with halogens 343 Unspecified organic liquid mixture 351 Organic solids with halogens 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 49.1 Unspecified sludge waste s_' 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 FD 2144a (Rev. 09/05) (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN (UNIFIED PROGRAM CONSOLJDATED FORM) BUSINESS ACTIVITIES PAGE (HAZARDOUS MATERIALS FACILITY INFORMATION) H B R S F I D P/RE ARfAI T BAKERSFIELD FIRE DEPT. Prevention Services ~ ~ ,r. 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: 661-326-3979 Fax: 661-852-2171 Page 1 of 1 L FACILITY IDENTiFICATiON i - FACILITY ID # (For Office use only -please leave blank) 3 EPA ID # DBA / F ACILITY NA E to M T 1 1 ~~~ ~l~ s ~Q~ L~ ~~ II. ACTIVITIES DECLARATION I __.-_ DOES Your Facility ... If Yes, Please Complete ... t2 A. HAZARDOUS MATERIALS CHEMICAL DESCRIPTION FORM 13 1. Have on site (for any purpose) hazardous ~`Y1 es ^ No "• HAZARDOUS MATERIALS MANAGEMENT PLAN materials at or above 55 gallons for liquids, Min • imum required planning elements: Emergency Response Plan 500 pounds for solids, or 200 cu. ft. for ^ Yes ^ No Maps compressed gases (include liquids in ASTs and Training USTs)? Prevention B. REGULATED SUBSTANCES (RSl 131 1. Have on site RS at greater than the threshold ^ Yes ~nlo T" - • CHEMICAL DESCRIPTION FORM planning quantities established by the California • RISK MANAGEMENT PLAN (RMP Submit to USEPA) Accidental Release Prevention program • CONSOLIDATED COMPLIANCE PLAN (CaIARP)? . Incorporating CaIARP Program Elements C. UNDERGROUND STORAGE TANKS (USTs1 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 o • UST FACILITY FORM 133 • UST TANK FORM (One Per Tank) • UST INSTALLATI N FORM On r ank D. TANK CLOSURE /REMOVAL 2. Need to report Closing an UST that h~ hazardous ^ Yes C~Jo • UST TANK FORM (Closure section -one per tank) materials or 3. Need to report the closure /removal of a tank that ^ Yes [710 • UST TANK CLOSURE FORM was classified as hazardous waste and cleaned on- t site? E. ABOVEGROUND PETROLEUM STORAGE TANKS (ASTsI ^ Yes 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 Countermeasure (SPCC) Elements pursuant to 40 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? es ^ No • To obtain EPA ID Number, please phone (916) 324-1781 2. Recycle more than 100 kg/mo of recyclable ^ Yes o RECYCLING FORM materials at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable ^ Yes 'L~flo • .RECYCLING FORM materials at an off-site Location different from the point of generation? 4. Treat Hazardous Waste on site? ^ Yes o • TP FACILITY FORM • TP UNIT FORM (One per unit) 5: Subject to Financial Assurance requirements? ^ Yes o • CERTIFICATION OF FINANCIAL ASSURANCE 6. Consolidate Hazardous Waste generated at a ^ Yes o REMOTE WASTE /CONSOLIDATION SITE NOTIFICATION FORM remote site? NOTE: !f 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 FD 2143 (Rev. 09105) _~. ~ 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 fatality in aggregate quantities equal to or greater than 500 pounds, 55 gallons, 200 cubic feet of gas (calculated at standard temperature and pressure) or the federal. threshold planning quantity for_Extremely Hazardous Substances, whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory should reflect all reportable quantifies 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 chemipl 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 checc "Yes' to keep chemical location information confidential. 1f the business does not wish to keep chemical location information confidential check "No". 203. MAP NUMBER - ff a map is incuded, enter the number of the map on which the location ofthe-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. 208. TRADE SECRET - Checc "Yes" ff the information in this section is deGared 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" Porn (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 - Chetac "Yes" if the hazardous material is an Extremely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section blank and complete the section on hazardous components below. 209. CAS # -Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the appropriate section below. 210. FIRE CODE HAZARD CLASSES -Fire Code Hazard Classes describe to first responders the type and level of hazardous materials which a business handles. This informafiol shall only be provided if the local fire chief deems R necessary and requests the CUPA or AA to collect it A list of the hazard classes and instructions on how to determine which Gass 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 Gass, 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, chetac only that box. If mixture or waste, complete hazardous components section. 212. RADIOACTNE -Check "Yes" if the hazardous material is radioactive or "No" ff it is not. 213. CURIES - ff the hazardous material is radioactive, use this area to report the activity in curies. You may use up to nine digits with a floating decimal point to report activity in curies. 214. PHYSICAL STATE - CheGc 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 capaaty of the largest container in which the material is stored. 9~Ii. FE~FRAI HA7ARf] CATFQ(1RIFS - Check all ratennriec that dacrrihe The nhvsiral and health ha~aMc assnriated with the ha7arrinus matedat PHYSICAL HAZARDS HEALTH HAZARDS Fire: Flammable Li uids and Solids Combustible Li uids ro horics 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 sure Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other hazardous chemigis with an adverse effect with Ion tens ex sure 217. AVERAGE DAILY AMOUNT -Calculate the average daily amount of the hazardous material 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. ff 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 wfth 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 - ff 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 Cal'Ifomia 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 pourids. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons). 222. DAYS ON SITE -List the total number of days during the year that the material is on site. 223. STORAGE CONTAINER - Checc 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 miMure present at greater than 1% by weight if non- prcinogenic, or 0.1% by weight if prtanogenic, 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, Pan. 355, or "No" ff 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 FD 2144 (Rev. 09/05) HMMP) HAZARDOUS,MATERIALS MANAGEMENT PLAN -.~ _ k:- SITE & FACILITY DIAGRAM Page 2 of 2 ~r BAKERSFIELD FIRE DEPT. ; Prevention Services 8__ B R S A I n 900 TT'UXtun Ave., Suite 210 P~1!! Bakersfield, CA 93301 w~ T Tel.: 661-326-3979 Fax: 661-852-2171 C ~~ SITE DIAGRAM __~ FACILITY DIAGRAM Business Name: ~OVv~V~/~~l~S ~(~/l,p~~ (~~ L.v -1--------------------------------------~ --------------------------- Business Address: = boo c-~~- ~~ o~~ v~ oc~o~ ~-~~~~ s. Owl L~ _, yip--a ~~ ~~ ~~ ~~ c~(c._ r. ~~~ ~ ~I ~~~~ ~d~ ~~ (G~' ~- sS ~- ._- p~~S ~~~ ~ ~'~~~ofL ~~ NORTH Please indicate direction of North FD 2170 (Rev. 09/05) :, ~ (HMMP) HAZARD©US MATERIALS MANAGEMENT PLAN INSTRUCTIONS SITE & FACILITY DIAGRAM 8 H R$ F 1 D P/RL r BAKERSFIELD FIRE :~EP'f. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: 661-326-3979 Fax: 661-852-2171 Pale 1 of 2 . . These instructions explain the use of the site diagram and the facility diagram. Normally small and medium size businesses will only have to submit a site diagram. If you have subdivided your business into smaller areas because of the complexity. or size, then you will-be.completing and additional detail map, facility diagram, for each of these areas. Include instructions that show. the route to your business if it is in a remote location. All diagrams must be on 8 '/2 x 11" paper and drawn using a straight edge tool. SITE DIAGRAM INSTRUCTIONS The site diagram is used to show your business and to indicate the businesses that immediately surround your property, usually within 300 feet. If you will be showing,specific area detail on facility diagrams, use the site diagram to show an overall layout of the plant. If you will not be submitting facility diagrams, the site map must include all of the following information: 1. Check the box on the~top left corner of the form provided that indicated "Site Diagram". 2. Print the name of your business, as. shown in your,HNIMP, on the top of the diagram. 3. Label the location of the hazardous materials and- identify them-by name and type of hazard (i.e., flammable liquid;>corrosive solid). . 4. Label the location of utility shutoff points for gas, electric and water services. 5. Label the location of fire hydrants. ' 6. Label portions of the building protected by automatic sprinkler systems. 7. Label the direction representing north on the diagram. (The diagram form provided includes ' a`northarrow). ~ - - - . 8. All labeling and identification on the diagram must be legible and easily understandable at the scale submitted. Diagrams must be sufficiently legible to produce a legible copy. Try to avoid the use of abbreviations or symbols. If you must use them, provide a legend explaining your system. Maps may be returned for correction if you fail to follow these instructions. FACILITY DIAGRAM INSTRUCTIONS Facility diagrams are supplements to the site diagram. Use them to show the subdivision details of a large business. 1. Check the box in the upper right hand corner of the form provided that indicated "Facility Diagram" - ~-~ 2. Print the name of your business as shown on your I-IlVINIP. Print the name of the area that this map represents. This name should be the same name that you used on this area's inventory report. 3. Indicate which area.the diagram represents and the total number of facility diagrams that you are including. If a map represented the first of four area`s, it would be labeled # 1 of 4. 4. Follow instructions (3 -8)* for site diagrams regarding the~specific details to be included on each facility diagram. UNDERGROUND STORAGE TANK FACILITIES PLEASE NOTE: * If you operate an Underground Storage Tank (UST) facility, the facility diagram shall also specify the location(s) of the UST continuous leak monitoring system and/or the location(s) where the UST monitoring. will be performed. FD 2170 (Rev. 09/05)