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HomeMy WebLinkAboutBUSINESS PLAN 2/8/2007r-.~.. SOUTHWEST HEALTH CENTER ,`' ~ 8501 CAMINO MEDIA SUITE 200 ~- __ _ __._- - - - ---___ /, I ~~ i-. SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 Manager TROY D SORENSEN DC Location: 8501 CAMINO MEDIA 200 City BAKERSFIELD BusPhone: (661) 665-1800 Map 123 CommHaz Minimal Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title TROY D SORENSEN DC / OWNER / Business Phone: (661) 665-1800x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone (661) 477-4900x Pager Phone ( ) - x Hazmat Hazards: React Contact TROY D SORENSEN DC Phone: (661) 665-1800x MailAddr: 8501 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Owner TROY D SORENSEN DC Phone: (661) 665-1800x Address 8501 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo• Emergency Directives: PROG H - HAZ WASTE GEN I?ased on my ir~quir,i of those individuals re:~GOnihie for obtaining, the information, I certify under penalty of law that I have personally examined and am farnifiar with the information submitted and believe the information is true, accurate; and complete. ~~~,Id;~c, ~ ~b`~ i ature D t ~~~ e ~ p ~ ~ ~~~~ t r U a e -1- 02/06/2007 '_ F SOUTHWEST HEALTHCARE CENTER ~ Hazmat Inventory ~ MCP+DailyMax Order = SiteID: 015-021-002988 ~ By Facility Unit ~ Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP WASTE FIXER R L 5.00 GAL Minl -2- ~,. 02/06/2007 -3- 02/06/2007 F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ ~ 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: DARKROOM CAS# = STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TWaste ~mbient ~ Ambient ~STIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL 5.00 GAL 5.00 GAL i7T •77~n7'~nrtn rr~wer~~*Tri*Tmn ~ __ __- _.__ iZ1"1G~riRLVUJ l..Vllt'V1V L'1V1J oWt. RS CAS# Silver No 7440224 l1tiL~tiLCL Li~ J a7.G.7 J1~1L' 1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 02/06/2007 F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification L~UL~J1UyCC 1VV1,11. / P~VdUUdl.lUil • i ~.. r 1.W 111.: 1V 1.J 1..11. ~ P.~VQ1~UQl.1 Vll l~ulciycial.Y a-acui~.ai r~.all -5- 02/06/2007 F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention ltclcaac \.V111. Ci 111LLLC11V V1G0.11 Vt,J V 1.11C 1. iCC w7-V UILC HC.: l.1Vdl.l Vll -6- 02/06/2007 ~ F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ ' Fast Format ~ ~ Site Emergency Factors Overall Site ~ special riazaras Utility Shut-Offs Fire Protec./Avail. Water ~uiiuiiiy v~..~..uNaii~y Lcvci -7- 02/06/2007 F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training rc~ye L nelu Lur ruLUre use nc.~u ivi ru~.uic ~5c -8- 02/06/2007 i-~-- - ~ Prevention Services _ UNIF°yE PROGRAM= INSPECTION -CHECKLIST P A r a s F ,;' ~ 900Truxtun Ave., Suite 210 " - ,~~ F~~E Bakersfield, CA 93301 SECTION 1: Business.Plan and Inventory Program ° i°Rr"' -Tel.; (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME ~ - Sou--t~,~~~ M~~~~C~ e ~ ~.~e ~ INSPECTIO DATE l.3 INSPECTION TIME ADDRESS ,[ 1 _ _ TJ S~~ I" ~~ N~ 1 /1 f1 m e~`~ ` PHONE NO. ` b'E~S" 1$~a NO OF EMQPLOYEES ` (J FACILITY CONTACT - ~ - - BUSINESS ID NUMBER 15-021-OI S^ oLi-dU ~ Section 1: Business Plan and Inventory Program I_ __ - - _ _- -_ ^ ROUTINE >~ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V ( C=Compliance OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND " ^" BUSIr1eSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ~.© ^ VERIFICATION OF LOCATION ENT,D ^ PROPER SEGREGATION OF MATERIAL .,. ^ VERIFICATION OF MSDS AVAILABILITY -fji ^ VERIFICATION OF HAZ MAT TRAINING ~~ ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ~J ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED "-~ ^ HOUSEKEEPING ~m ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? YES ^ NO EXPLAIN: ~ a' S~ ~ ~~~d ° ~" %~~S QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 Inspector (Please Print) Fire Prevention / 1s` In /Shift of Site/Station # usiness Site /Responsible Party (Please Print) White -Prevention Services Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 Z• ~`- -Td+`~ CITY OF BAICERSFIELD FIRE DEPARTMENT ~~a OFFICE OF ENVIRONMENTAL SERVICES ~P UNIFIED PROGRAM INSPECTION CHECKLIST ,k~,`~gti~t 1715 Chester Ave., 3~d Floor, Bakersfield, CA 93301 -.......- ME.L~1 C A1, C6nsTG6L, / 3 °~ FACILITY NAME Sa~.'~ H vacs-o INSPECTION DATE Section 4: Hazardous Waste Generator Program EPA ID # ~ x ~ °`^ P r ^ Routine ~ Combined ^ Joint Agency ^Muiti-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number ~ ~ ~ .~,. p -j' Authorized for waste treatment and/or storage Reported release, fire, or explosion within I S 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 N Secondary containment provided Conducts daily inspection of tanks Used oil not contaminated with other hazardous waste ~ /~ Proper management of lead acid batteries including labels ~~ ~ Proper management of used oil filters b~ `~ Transports hazazdous waste with completed manifest Sends manifest copies to DTSC r,~; Retains manifests for 3 years Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years ~ / ;Et. Determines if waste is restricted from land disposal C:=t:ompnance v=v~olahon Inspector: C.~~~x---- Office of Environmental Services (661) 326-3979 White -Env. Svcs. Pink -Business Copy Business Site Responsible Patty UNIFIED PROGRA~II INSPECT~I,ON CHECKLIST; ZK ,. ,,-_.~~"!.?;'Rga:v%~"d'w..f_....u~..~t w#7`;°s'i'1C?P r e. _1... afl c _.. :'1. 3+3.n4 ... ~ - .s+u.a_...> -. ~..... £ .~.+i~i-, SECTION 1: Business Plan and Inventory Program • BAKERSFIELD FIRE DEPT a p Prevention Services ~Itt 900 Truxtun Ave., Suite 210 ARTM T Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME NSPECTION DA E INSPECTION TIME .So v ~,/ t6 T c i/G'a Ec~T~C. /O // D / ass >,•v 5 ADDRESS , ww~, ~ p ^ ' ~ ~ Cw,'I ~ONErN, O./ tlDO • G J a I O OF EMPLOYEES FACILITY CONTACT ESS ID NUMBER U S IN 15-021- Oo2Q~tc4 Section 1: Business Plan and Inventory Program ~ ~~~ ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION • C V (C=Compliance OPERATION V=Violation COMMENTS ____ Q ^ APPROPRIATE PERMIT ON HAND ^ BUSlrlt?SS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS l.E~ ^ CORRECT OCCUPANCY ENT O C T ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION lid ^ PROPER SEGREGATION OF MATERIAL ~ Ild ^ VERIFICATION OF MSDS AVAILABILITY -- ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES L9' ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? hdYt$ ^ NO EXPLAIN: 56~~~L~ >c~~~L _ .QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 Inspector (Please Print) Fire Prevention / t°` In / Shift of Site/Station # usiness Site/School Site Responsible Party (Please Print) White -Prevention Services Yellow -Station Copy Pink -Business Copy FD2049 (Rev. 02!05) :} ;~ + SOUTHWEST HEALTHCARE CENTER _________________________ SiteID: 015-021-002988 + Manager TROY D SORENSEN DC Location: 8501 CAMINO MED~CA 200 City BAKERSFIELD BusPhone: (661) 665-1800 Map 123 CommHaz Minimal Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code: DunnBrad: Emergency Contact / ",~"itle Emergency Contact / Title DR TROY D SORENSEN / OWNER / Business Phone: (661) 665-1800x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ~;~: ~) ~ 1'' - N `1 ~ Ox Pager Phone ( ) - x 4 Hazmat Hazards: React , Contact TROY D SORENSEN DC Phone: (661) 665-1800x MailAddr: 8501 CAMINO MED~CA 200 State: CA City BAKERSFIELD Zip 93311 Owner TROY D SORENSEN DC Phone: (661) 665-1800x Address 8501 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif' d: RSs : No ParcelNo: Emergency Directives: ~ PROG A - HAZMAT PROG H - HAZ WASTE GEN Based on -~,y in~lrairy pf those individuals responsibly fqr gbteinin~ the information, I certify under penalty of Igvy that I have personally examined and ar~r farnlllar with the information submitted and believe the Information is true, accurate, and complete. ,~ ignature Date ~~T'~ M~~ ~ ~ ~o~ -1- 03/10/2006 r~ ~ ~F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 Manager TROY D SORENSEN DC Location: 8501 CAMINO MEDIA 200 City BAKERSFIELD BusPhone: (661) 665-1800 Map 123 CommHaz Minimal Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIG Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title TROY D SORENSEN DC / OWNER / Business Phone: (661) 665-1800x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone (661) 477-4900x Pager Phone ( ) - x Hazmat Hazards: React Contact TROY D SORENSEN DC Phone: (661) 665-1800x MailAddr: 8501 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Owner TROY D SORENSEN DC Phone: (661) 665-1800x Address 8501 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG H - HAZ WASTE GEN ~u~ 2 ~ 2007 Based on my inquiry of those individuals respcnsible for obtaining the information, I C~;rtify under penalty of iav~ that ! have personally examined and am famiiiar Frith the.. information submitted and l,eiieve the information is true , accurate, and compiete. Signature Date -1- 07/16/2007 ~ ~ i F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm ~ DailyMax ~UnitIMCP~ WASTE FIXER R L -5.00 GAL Minl -2- 07/16/2007 f y -3- 07/16/2007 f ~ F SOUTHWEST HEALTHCARE CENTER ~ Inventory Item 0001 COMMON NAME / CHEMICAL NAME WASTE FIXER Location within this Facility Unit DARKROOM SitelD: 015-021-002988 ~ Facility Unit: Fixed Containers at Site ~ Days On Site 365 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 HAZARDOUS COMPONENTS %Wt. RS CAS# Silver No 7440224 riAGEiKL A~~1";~~1~1L'~1V'17 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 07/16/2007 F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 04/13/2007 ~ 911 Employee Notif./Evacuation 04/13/2007 VERBAL NOTIFICATION. EXIT THROUGH FRONT OR ANY OF FOUR EMERGENCY EXITS. Public Notif./Evacuation 04/13/2007 VERBAL NOTIFICATION. EXIT THROUGH FRONT OR ANY OF FOUR EMERGENCY EXITS. Emergency Medical Plan 04/13/2007 TRANSPORT TO HOSPITAL BY AMBULANCE IF NEEDED. -5- 07/16/2007 r a ' F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 04/13/2007 ~ CLOSED CONTAINERS WHEN NOT IN USE. Release Containment SECONDARY CONTAINMENT 04/13/2007 Clean Up 04/13/2007 SMALL SPILL - PAPER TOWELS AND ABSORBANT LARGE SPILL - CALL MXR Other Resource Activation -6- 07/16/2007 ~" .i r F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ DYCC1d1 ridGCLIUS Utility Shut-Offs 04/13/2007 GAS: W SIDE OF BLDG ELECTRICAL: S SIDE OF BLDG WATER: S SIDE OF BLDG Fire Protec./Avail. Water 04/13/2007 FIRE EXTINGUISHERS AND SPRINKLER SYSTEM FIRE HYDRANT: FRONT OF BLDG Building Occupancy Level 04/13/2007 20 EMPLOYEES -7- 07/16/2007 J1 ~, jq F SOUTHWEST HEALTHCARE CENTER SiteID: 015-021-002988 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 04/13/2007 ~ BRIEF SUMMARY OF TRAINING PROGRAM: OSHA AND IN-HOUSE. rays ~ RGlu iv1 rut.ulc vac Held for Future Use -8- 07/16/2007 i Health Care for the Entire Family ;, -- l.- ~'~ ~ .Troy _D Sorensen, D.G - ~ Keeping you adjusted for Peak Performance 8501 Camino Media, Suite 200 Bakersfield,.CA 93311 _ _ _ Tel 661:665.1800 • Fax 661:665.8858 =_-_= Adjusting Times Monday 7 - 11 AM 2-6PM Tuesday 2 - 6PM ` Wednesday 7 - 11 AM 2-6PM Thursday 2 - 6PM Friday 7 - 11 AM 2-6PM Saturday 8 - 9 AM A challenge with your appointment? Call, we appreciate you! Keep Spreading the Word! ' SP = ~"" Bakersfield Fire Dept. fi. ~ N UNI~IE® PR®GRAIVI INSPECTI®N CHECKLIST 'Environmental Services ~r~ ~~"'""" 900 Truxtun Ave., Suite 210 SECTION 1 Business ,Plan and Inventory Program Bakersfield, CA 93301 ~ Tel: (661. 326 3979 FACILITY NAME INSPECTION D TE INSPECTION TIME ADDRESS ~~,-~.n PHONE No. No. of Employees FACILITVCONTACT Business ID Number 15-02 - NC~c,) Section 1: Business Plan and Inventory Program ~'2~ ~~ ^ Routine ^ Combined ^ Joint Agency ^Mnlti-Agency ^ Complaint ^ Re-I n ~ V \V=VioatonnCe~ OPERATION COMMENTS ^ ^ APPROPRIATE PERMIT ON HAND i~J ~~Zl"1~T S~ o C ^ ^ VERIFICATION OF QUANTITIES . _ Aw~.~C ~r~~~ e'- ~` J ^ ^ .VERIFICATION OF LOCATION ~NS~~~ ~~~ n~ tom" _ 1 ^ ^ PROPER SEGREGATION OF MATERIAL ^ -- -- ^ --. VERIFICATION OF MSDS AVAILABILITYE _- -- - - .... .- -- ---- --- -- ------ - --- -- I J~ _ -....._.... ..._...__ ..._ _.. .- ~~d' ' ^ ^ VERIFICATION OF HAT MAT TRAINING r ! ~" ^ _ ^ ___---------------_.~.-- ------------- ------- .... .. ... .... VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES __.._.... -_.- ._..G'IC.-.. ....-jj-~~ .._.._._.. _._._._-._.. -----......__. __. ~ V~ ~J ^. ^ EMERGENCY PROCEDURES ADEQUATE ~ ^ ^ ' CONTAINERS PROPERLY LABELED ~u./~~ ~~ ^ ^ HOUSEKEEPING ^ ^• FIRE PROTECTION ^ ^ SITE DIAGRAM ADEQUATE 8t ON HAND ?0p5 D ANY HAZARDOi1S WASTE ON SITE?: YES ^ NO EXPLAIN; ~~ ~! x-C'~ QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT ~GC)'I ~ 326-3979 ~ ~ ~~ --- --- ----- -------- - ------------- ------- ------~c'- -~3------ ---- .. - -._ Inspector (Please Print) Fire Prevention 1st-In/Shift of Site While • Environmental Services Yellow -Station Copy 1 ss Slte esponsible Party (Pleas nnt) Pink • Business Copy ~04~`~ -'"~`~ CITY OF BAKERSFIELD FIRE DEPARTMENT e ~' CA FACILITY NAME ~~`'~^~~r ~`~-`~ ~~2 INSPECTION DATE 4" l 'q'~°~ Section 4: Hazardous Waste Generator Program EPA ID # '~" / ~ ^ Routine ~~Combined ^ Joint Agency ^hulti-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number _ 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 are kept closed when not in use Weekly inspection of storage area Ignitable/reactive waste located at least 50 feet from property line Secondary containment provided ~~~ Pow Conducts daily inspection of tanks Used oil. not contaminated with other hazardous waste Proper management of lead acid batteries including labels Proper management of used oil filters Transports hazardous waste with completed manifest Sends manifest copies to DTSC Retains manifests for 3 years Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years Determines if waste is restricted from land disposal c;=~ompuance ! _v,=vtotat~on Inspector: W t ~'`~ Office of Environmental Services (661) 326-3979 White -Env. Svcs. b OFFICE OF ENVIR®NMENTAL SERVICES .y UNIFIED PROGRAM INSPECTION CHECKLIST ` `~"gti ~ 1715 Chester Ave., 3~d Floor, Bakersfield, CA 93301 Pink -Business Copy Business Site Responsible Party ~'"~"~ - CITY OF BAKERSFIELD ~,o ~. B Ep~~e' ,° ~ OFFICE OF ENVIRONMENTAL SERVICES ~~ ARTM t 1715 Chester Ave., CA 93301 (661) 326-3979 14~ '_'.~~_~~..~, HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRfPTfON (one lomr per material per building or area) NEW ~ ADD ^ DELETE ^ REVISE 200 Page _ of _ I. FACILITY hFORMATION ~ ~ ~~~ BUSINESS NAME (Same as FACILITY~NAPotE or DBA~- Doing Business~AS) ~ 3 CHEMICAL LOCATION ~ t n___- 20t CHEfdICAL LOCATION ^ Yes .^ No 202 ' rl`'S t~ L ~/~II,IL 1 ~ CONFIDENTIAL (EPCR.4) -- FACILITYID# - j--~._~ _I_._;... _ I .-..._.._~...MAP-~(IiptionaQ_.__. _. 203 GRID#(optionaQ -------------- 20a ,yy . , ,T. I I - .r II. CHEMICAL INFORMATION CHEMICAL NAME ~ ~q ,~ ~...~ 205 TRADE SECRET ^ Yes ^ No 206 C~ y^C) t L /~ J ,~~ I! Subject to EPCRA. refer to instructions i -------- -------....- -.._ \ ... 207. .... _ ------------------ ------ ---- COMMON NAME EHS' ^ y~ ^ No 208 CAS # 209 `It EHS is'Yes,' all amounts below must be in lbs. i FIRE CODE HAZARD CLASSES (Complete it requested by local fire chielj 210 i TYPE ^ p PURE ^ MIXTURE ~w WAS-O_ .. R-JJIOAC7IVE ^ Yes ^ No 212 CURIES 2t3 PHYSICAL STATE ^ s SOLID LIQUID ^ g GAS 214 LARGEST CONTAINER ~ 215 FED HAZARD CATEGORIES ^ 1 FIRE ^ 2 REACTIVE ^ 3 PRESS JRE REL&:SE ^ 4 .4 JU-E HEALTH ~ CHRONIC HEALTH 216 (Check all that apply) ANNUAL WASTE 217 :v14XIMUtit 218 q.VE:RAGE 219 STATE WASTE CODE 220 AMOUNT DAILY AMOUNT 5 GAILY AMOUNT 5 UNITS' ~.pa GAL ^ cf CU FT ^ Ib LBS ^ to TONS 221 DAYS ON SITE 222 ' If EHS, amount must be in lbs. STORAGE CONTAINER ^ a ABOVEGROUND TANK e PLASTIGNONMETALLIC DRUM ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR 223 (Check atl that apply) ^ b UNDERGROUND TANK ^ 1 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 CJ p TANK WAGON I ----- ------.... . _ ._ ... __ . ..- -- - _. --_- .... -- -. ... ---------- _ STORAGE PRESSURE ~~ AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 224 STORAGE TEMPERATURE ~aAM81ENT ^ as ABOVE AMBIENT ^ b3 BELOW AMBIENT ^ c CRYOGENIC ! %WT ~ ~ HAZARDOUS COMPONENT EHS i 1 , 226 ~ 227 ^ Yes ^ No 228 ' 2 230 i 23t ! ^ Yes ^ No 232 3 i 234 i 235 ^ Yes ^ No 236 4 238 239 ^ Yes ^ No 240 ~_5 _i_ I _ _- . ._..----------...242--r---.__... _ _ 243 ~ ... .... _ . ... _...... _ - - _ - __.._..-_..... __ __ ............ __ ..._........._. ^ Yes ^ No 244- ~--- -------- III. SIGNATURE 229 233 237 241 245 --- -I I ------- - ._._........._.- ------- .............. ........ ..- _ _ _.. .. _ _ ... _ ......-- --...... ---- ----- - - - PRINT NAME 8 TITLE OF AUTHORIZED COMPANY REPRESENTATIVE ~ ~ ~ ~~~ ~ ~ ~~ ~SIGNATIJRE ~ / t ~ DATE 246 Cr„l~y ,/) _ _- __ . ----.___ _ - --- --_ __~ ~4~GS=-- -- UPCF (7/9~) S:\CUPAFORMS10ES2731.TV4.wpd CAS # 225