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HomeMy WebLinkAboutBUSINESS PLAN 7/9/2007~cADEPT DENTAL GROUP 8605 CAMINO MEDIA 100 \, ADEPT DENTAL GROUP SiteID: 015-021-003000 Manager CAROL REED Location: 8605 CAMINO MEDIA 100 City BAKERSFIELD BusPhone: (661) 664-1814 Map 123 CommHaz High Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title THOMAS GORDON DDS / OWNER CAROL REED / OFFICE MANAGER Business Phone: (661) 664-1814x Business Phone: (661) 664-1814x 24-Hour Phone (661) 665-8026x 24-Hour Phone (661) 765-6191x Pager Phone ( ) - x Pager Phone (661) 809-0409x Hazmat Hazards: Fire Press React ImmHlth DelHlth Contact CAROL REED Phone: (661) 664-1814x MailAddr: 8605 CAMINO MEDIA 100 State: CA City BAKERSFIELD Zip 93311 Owner THOMAS A GORDON DDS Phone: (661) 664-1814x Address 8605 CAMINO MEDIA 100 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 ENT'D J !J L 12 2~QQ7 inquiry of those individuals I certify tion mY , ~ the informa Based on alawgthat f have personally respon`+bie for o tion of under penalty familiar with the informa e , examined and am . itted and bell2te the information is ru subm accurate, and comp ~ ~ , ~~ Date Signature -1- 06/29/2007 T. ~ F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP NITROUS OXIDE F P IH G 818.00 FT3 Hi OXYGEN F IH DH G 502.00 FT3 Low WASTE FIXER R L 5.00 GAL Min -2- 06/29/2007 -3- 06/29/2007 F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: MEDICAL GAS CLOSET CAS# 10024-97-2 ~GasATE T TYPE PRESSURE ~ TEMPERATURE ~~ CONTAINER TYPE ~ I Pure Above Ambient I Ambient I PORT. PRESS. CYLINDER I AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 409.00 FT3 818.00 FT3 818.00 FT3 HAZARDOUS COMPONENTS ~Wt. RS CAS# 100.00 Nitrous Oxide No 10024972 I1riGtiiCL tiw7 JL'+.7 J1~1L' 1V 1 .7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Hi ~ Inventory Item 0002 COMMON NAME / CHEMICAL NAME OXYGEN Location within this Facility Unit MEDICAL GAS CLOSET STATE TYPE PRESSURE _ Gas Pure -Above Ambient Facility Unit: Fixed Containers at Site ~ Days On Site 365 Map: Grid: CAS# 7782-44-7 TEMPERATURE CONTAINER TYPE Ambient PORT. PRESS. CYLINDER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 251.00 FT3 502.00 FT3 I 502.00 FT3 HAZARDOUS COMPONENTS %Wt. 100.00 Oxvaen, Combressed ZARD RSI CAS# No 7782447 AS SESSMENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low -4- 06/29/2007 F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ ~ 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 Waste Ambient Ambient PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL 5.00 GAL 5.00 GAL HAZARDOUS COMPONENTS °sWt. RS CAS# Silver No 7440224 L1HUri[CL tiJ JP.~iJ iJl•1L'1V1J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -5- 06/29/2007 F ADEPT DENTAL GROUP SitelD: 015-021-003000 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 10/12/2006 ~ EMERGENCY SPILL PROTOCOL: POUR CAT LITTER OVER SPILL. AFTER ABSORPTION, USE SMALL SHOVEL TO SCOOP LITTER INTO BUCKET WEARING PPE (LOCATED IN SPILL KIT). CALL FOR SPILL PICK-UP TO REMOVE FROM BUILDING. Employee Notif./Evacuation FIRE ALARM. STAFF ESCORTS PATIENTS SOUTH OF BUILDING. STAFF LOCATION MEETING PLACE. 10/12/2006 HEAD COUNT TAKEN AT ,_ , ~„ rUiJl1V 1VV 1.11. ~ P~V0.l.U0.1..1 V11 Emergency Medical Plan 10/12/2006 911 CALL IS MADE. ADMINISTER OXYGEN TO PATIENTS OR STAFF MEMBERS. PORTABLE OXYGEN UNITS ON SITE. LOCAL HOSPITAL: MERCY SOUTHWEST. -6- 06/29/2007 F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 02/21/2006 ~ SAFETY CHECKS DAILY BY STAFF FOR FIXER AND DEVELOPER OVERFLOW. Release Containment 02/21/2006 NITROUS AND OXYGEN TANKS IN CLOSET AT SOUTH SIDE OF BUILDING INSIDE. SPENT PHOTOGRAPHIC FIXER CONTAINER TYPE PLASTIC SETS INSIDE PLASTIC CONTAINER FOR OVERFLOW CATCH. Clean Up 10/12/2006 SPILL KIT ON SITE FOR WASTE FIXER. CAT LITTER USED FOR ABSORPTION. CLEAN-UP PLACED IN BUCKET FOR HAZMAT PICK-UP. V1.11C 1_ 1CC~VULUC t]C l.1Vdl~1 Vi1 -7- 06/29/2007 F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~ Special Hazards 02/21/2006 ~ NITROUS AND OXYGEN TANKS LOCATED SOUTH OF BUILDING IN CLOSET. NO LOCK ON CLOSET BY BACK DOOR ENTRANCE. TANKS ARE STRAPPED TO WALL. Utility Shut-Offs 10/12/2006 NATURAL GAS/PROPANE: E SIDE OF BLDG ELECTRICAL: S SIDE OF BLDG BY BACK DOOR EXIT-IN CLOSET OUTSIDE WATER: S SIDE OF BLDG LEFT FROM BACK DOOR OUTSIDE LOCK BOX: YES, N SIDE FRONT DOOR, LEFT SIDE OF WALL Fire Protec./Avail. Water 10/12/2006 3 FIRE EXTINGUISHERS INSIDE, ALARM SYSTEM, OVERHEAD SPRINKLER SYSTEM. 2 FIRE HYDRANTS N SIDE BLDG 120 FT FROM ENT ON CAMINO MEDIA & MILL ROCK WY. FIRE DEPT WATER SOURCE AT S END OF BLDG ON LIBERTY PARK RD 20 FT FROM BACK DOOR. Building Occupancy Level 02/21/2006 20 FULL-TIME AND PART-TIME EMPLOYEES -8- 06/29/2007 . :. F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 10/12/2006 ~ MSDS FOR STAFF USE ON SITE. BRIEF SUMMARY OF TRAINING PROGRAM: FIRE DRILLS, SPILL CLEAN-UP, SAFETY TRAINING. rayc c nciu tvi ruI.UIC UDC nc.tu i~L r u~ure use -9- 06/29/2007 1; ~. „7 ADEPT DENTAL GROUF Manager CAROL REED Location: 8605 CAMINO MEDIA 100 City BAKERSFIELD SiteID: 015-021-003000 BusPhone: (661) 664-1814 Map 123 CommHaz High Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title THOMAS GORDON DDS / OWNER CAROL REED / OFFICE MANAGER Business Phone: (661) 664-1814x Business Phone: (661) 664-1814x 24-Hour Phone (661) 665-8026x 24-Hour Phone (661) 765-6191x Pager Phone ( ) - x Pager Phone (661) 809-0409x Hazmat Hazards: Fire Press React ImmHlth DelHlth Contact CAROL REED Phone: (661) 664-1814x MailAddr: 8605 CAMINO MEDIA 100 State: CA City BAKERSFIELD Zip 93311 Owner THOMAS A GORDON DDS Phone: (661) 664-1814x Address 8605 CAMINO MEDIA 100 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 EN~'~ ~ ~' ~ ~ 3 ~u~; €~a~e~l Sn rtty inquiry of those individuals Ant~ible for obtaining the information, I certify re~p under pprtalRy of law that I have personally amined and am familiar with the information ex submitted and believe the information is true, mplete urate, and co acc ~ l C~ / ~ Li' ~!~ ~~S~~~i-~'-~ Signature Date -1- 01/24/2007 ~ } F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP NITROUS OXIDE F P IH G 818.00 FT3 Hi OXYGEN F IH DH G 502.00 FT3 Low WASTE FIXER R L 5.00 GAL Min -2- 01/24/2007 -3- 01/24/2007 ,, F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ ~ Inventory Item 0003 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME NITROUS OXIDE Days On Site 365 Location within this Facility Unit Map: Grid: MEDICAL GAS CLOSET CAS# 10024-97-2 STATE T TYPE T PRESSURE ~ TEMPERATURE ~~ CONTAINER TYPE ~ ~GaS I Pure I Above Ambient I Ambient I PORT. PRESS. CYLINDER I AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 409.00 FT3 818.00 FT3 818.00 FT3 I11iGKKLVUJ 1,V1~lYV1V.CilV1.7 °sWt. ~ RS CAS# 100.00 Nitrous Oxide No 10024972 11Pi4L~i1LL tiJ J L' J~71°1L~1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F P IH / / / Hi ~ Inventory Item 0002 Facility Unit: Fixed Containers at Site ~ COMMON NAME / CHEMICAL NAME OXYGEN ~ Days On Site 365 Location within this Facility Unit Map: Grid: MEDICAL GAS CLOSET CAS# 7782-44-7 STATE T TYPE PRESSURE ~~ TEMPERATURE ~~ CONTAINER TYPE ~ Gas I Pure Above Ambient I Ambient I PnRT _ PRF.~~ _ C''YT,TNI~F.R I AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 251.00 FT3 502.00 FT3 I 502.00 FT3 nr~urucLVUa ~.V1•lr VlV AlvtJ %Wt• RS CAS# 100.00 Oxygen, Compressed No 7782447 iZriL~tl[CL tiJ JIJJ Jl•1L'1V1J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F IH DH / / / Low -4- 01/24/2007 ~ ~ F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ ~ 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# Liquid TWaste ~ Ambient~E ~ AmbientT~E I PLASTOICTCONTAINERE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL 5.00 GAL 5.00 GAL rlti4tiRL V V w7 1. V1•!t' V1V L' 1V 1 J %Wt. RS CAS# Silver No 7440224 1"1tiL~tiIVJ 1'i JJL' Jw71"1L'1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP .No No No No/ Curies R / / / Min -5- 01/24/2007 F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 10/12/2006 ~ EMERGENCY SPILL PROTOCOL: POUR CAT LITTER OVER SPILL. AFTER ABSORPTION, USE SMALL SHOVEL TO SCOOP LITTER INTO BUCKET WEARING PPE (LOCATED IN SPILL KIT). CALL FOR SPILL PICK-UP TO REMOVE FROM BUILDING. Employee Notif./Evacuation 10/12/2006 FIRE ALARM. STAFF ESCORTS PATIENTS SOUTH OF BUILDING. HEAD COUNT TAKEN AT STAFF LOCATION MEETING PLACE. r 1.1J/ 1 1 1.. 1V V 1. 1 1 .~ J.:1 V Q 1.. LLCi V 1 V l l Emergency Medical Plan 10/12/2006 911 CALL IS MADE. ADMINISTER OXYGEN TO PATIENTS OR STAFF MEMBERS. PORTABLE OXYGEN UNITS ON SITE. LOCAL HOSPITAL: MERCY SOUTHWEST. -6- 01/24/2007 'i F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 02/21/2006 ~ SAFETY CHECKS DAILY BY STAFF FOR FIXER AND DEVELOPER OVERFLOW. Release Containment 02/21/2006 NITROUS AND OXYGEN TANKS IN CLOSET AT SOUTH SIDE OF BUILDING INSIDE. SPENT PHOTOGRAPHIC FIXER CONTAINER TYPE PLASTIC SETS INSIDE PLASTIC CONTAINER FOR OVERFLOW CATCH. Clean Up 10/12/2006 SPILL KIT ON SITE FOR WASTE FIXER. CAT LITTER USED FOR ABSORPTION. CLEAN-UP PLACED IN BUCKET FOR HAZMAT PICK-UP. V1.11C1 AC.7 Vl.Li I:C til,: l.1VdV1V11 -7- 01/24/2007 - :. F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~ Special Hazards 02/21/2006 ~ NITROUS AND OXYGEN TANKS LOCATED SOUTH OF BUILDING IN CLOSET. NO LOCK ON CLOSET BY BACK DOOR ENTRANCE. TANKS ARE STRAPPED TO WALL. Utility Shut-Offs 10/12/2006 NATURAL GAS/PROPANE: E SIDE OF BLDG ELECTRICAL: S SIDE OF BLDG BY BACK DOOR EXIT-IN CLOSET OUTSIDE WATER: S SIDE OF BLDG LEFT FROM BACK DOOR OUTSIDE LOCK BOX: YES, N SIDE FRONT DOOR, LEFT SIDE OF WALL Fire Protec./Avail. Water 10/12/2006 3 FIRE EXTINGUISHERS INSIDE, ALARM SYSTEM, OVERHEAD SPRINKLER SYSTEM. 2 FIRE HYDRANTS N SIDE BLDG 120 FT FROM~ENT ON CAMINO MEDIA & MILL ROCK WY. FIRE DEPT WATER SOURCE AT S END OF BLDG ON LIBERTY PARK RD 20 FT FROM BACK DOOR. Building Occupancy Level 02/21/2006 20 FULL-TIME AND PART-TIME EMPLOYEES -8- 01/24/2007 F ADEPT DENTAL GROUP SiteID: 015-021-003000 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 10/12/2006 ~ MSDS FOR STAFF USE ON SITE. BRIEF SUMMARY OF TRAINING PROGRAM: FIRE DRILLS, SPILL CLEAN-UP, SAFETY TRAINING. rayc ~ nclu tvL r UI.uLC UDC 11c1u tV1 tul.UlC V.7C -9- 01/24/2007 Dc Cordon's ~' ~~dept D_ ent~1 Group ~~ ___ ___ __~-~_~ A MULTI-SPECIALTY PkACTICE Thomas A. Gordon, D.D.S. General Dentistry 8605 Camino Media, Suite 100 • Bakersfield, CA • 93311 PH: 661.664.1814 • FAX: 661.664.0129 UNIFIED PROGRAM INSPECTION CHECKLIST vF.: v.;=-.:s"'..£.~"...ca;.4ix~ .... _:;,...':c...7'n ...,..f..:..r .<:.~.-.:?~v. cY#.'v. .:-:..° ,.u.-..: „t._,. ,.'w +. ..., ...,-..a... -...... SECTION 1: Business Plan and Inventory Program BAKERBFIELD FIRE DEPT Prevention Services w~~I 900 Truxtun Ave., Suite 210 AR1rIM T Bakersfield, CA 93301 ~~ Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY AME NSPECTION DATE INSPECTION TIME 8Pf ~i ~,a o ~r o /,7~,~, as • ADDRESS 86oS Cq.k.~~ /YI ~ r d o HON N l06 - t 8/ O OF EMPLOYEES FACILITY CONTACT USINESS ID NUMBER 15-o2t- do g o ~ o Tab Itrlr{,q ~ r2 o sf Section 1: Business Plan and Inventory Program ?~ ~~ ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INS ECTION • C V ~ C=Compliance OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND ^ BUSIYtASS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ENT ®r', T f ll// ~^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL J - /~ [~ ^ 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 ~~ q d ANY HAZARDOUS WASTE ON SITE? OYES ^ NO r 1 . _ Jt/ ~ O e EXPLAIN: •OUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (861) 326-3979 A//e,~ er ~ - L~ Inspector (Please Print) Fire Prevention / 1" In /Shift of Site/Station # White -Prevention Services Yellow -Station Copy Pink -Business Copy FD2049 (Rev. 02/05) ;, ,; + ADEPT DENTAL GROUP =____~____________________________ SiteID: 015-021-003000 + Manager CAROL REED BusPhone: (661) 664-1814 Location: 8605 CAMINO,MEDIA 100 Map 123 CommHaz High City BAKERSFIELD Grid: 05D FaCUnits: 1 AOV: CommCode: BFD STA 09 SIC Code: EPA Numb: DunnBrad: Emergency Contact / 'Title Emergency Contact / Title THOMAS GORDON DDS / OWNER CAROL REED / OFFICE MANAGER Business Phone: (661) 66.4-1814x Business Phone: (661) 664-1814x 24-Hour Phone (661) 665-8026x 24-Hour Phone (661) 765-6191x Pager Phone ( ) - x Pager Phone (661) 809-0409x Hazmat Hazards: Fire Press Reac t ImmHlth DelHlth Contact CAROL REED Phone: (661) 664-1814x MailAddr: 8605 CAMINO MEDIA 100 State: CA City BAKERSFIELD Zip 93311 Owner THOMAS A GORDON DDS Phone: (661) 664-1814x Address 8605 CAMINO MEDIA 100 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 Fused on my inquiry of those individuals responsible fray obtaining the information, I certify under penalty of law that 1 have personally examined and am fc~millar with the information submitted and bc~ilevg the information is true, accurate, and complete. n Date ~Ig~~~~~'~~~~`~ ~6 -1- 03/10/2006 ~^~' ~ a tJNI~IED PROt3R/!M INSPECTION CHECKLIST ~. SECTION 1 Business .Plan and Inventory Program 1~ FACILITY NAME „A~G~r ADDRESS ~ ~/~ ,~ !n FACILITYCONTACT C9't~ = 573f~ U~ {~-v'~~- Bakersfield Fire Dept. Environmental Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 933 1 Tel: (661)_326-397 EC ? ? ?(~Q§ ---- .. _ . --~~` C~ ------- _ _ PHON No. No. of Employees -- - ~~~. l$lq- Business I 15-02 ~ ~ j `~ ~ -- Section 1: Business Plan and Inventory Program 'N~- ~ 300 ^ Routine O Combined ^ Joint Agency ^hulti-Agency ^ Complaint ^ Re-inspection C V nce~ OPERATION atil ~ V=V COMMENTS 1 ~,3 - 0 5 ~ io on ^ ^ APPROPRIATE PERMIT ON HAND ~.J ~JL~ (~' NG"~~L`7 ~~,/Z 1~/[-c.J (~/~,~-(~jyJ ^ ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE ^ ^ VISIBLE ADDRESS ^ ^ CORRECT OCCUPANCY ^ ^ VERIFICATION OF INVENTORY MATERIALS i ~p~~ ~tX.~Z ~Z _ ___ _ __. ^ -- ^ ---..-- VERIFICATION OF QUANTITIES -- ------- -- __ _._ _._ _. _ _ ___ __ _ . . ~ ~` ~94, '~ ~ Z _ _ _ _ _ _ _ ?Sl. ~ _ _ . lY ^ ^ .VERIFICATION OF LOCATION t ~1'S t 6~C- f.~tJC R~~1 )'t'l6l~f 5 CC~S'E"I" ^ ^ PROPER SEGREGATION OF MATERIAL ^ ^ VERIFICATION OF MSDS AVAILABILITYE ~ /~ ~ ^ ^ -- - - - . VERIFICATION OF HAT MAT TRAINING - r -- -... _ . ..__.._...._ _ ._ _ _ _ ~~/.. .~. V ~ C~" _----...._. _...------.... ^ ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ ^ EMERGENCY PROCEDURES ADEQUATE ~ _. ^ ^ CONTAINERS PROPERLY LABELED ^ ^ HOUSEKEEPING ^ ^. FIRE PROTECTION ^ ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARD/OUS'nW.cASTE ON SI/TES: *~ YES ^ NO EXPLAIN: ~'^' i G- 1~ ~ x'E2. QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661 } 326-3979 Ins ctor Please Print Fire P vention 1st-In/Shift of Site White -Environmental Services Yellow - Stelion Copy QLO t p~ Business Site esponsible Party ( le se Pri Pink -Business Copy ~04y'`' ~'"~`~ CITY OF BAKERSFIELD FIRE DEPARTMENT ~~ d ~~,,,~ FACILITY NAME ~ni:~~ pG~~L C~~u,P INSPECTION DATE ~ <~ / ~ Section 4: Hazardous Waste Generator Program EPA ID # ^~'~ ^ Routine [~ Combined ^ Joint Agency ^Multf-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made ~~ 1 ~~,,~~ ~ ~~ 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 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 ~=~ompuance v=vroranon Inspector: C~7 hK~ Office of Environmental Services (661) 326-3979 White -Env. Svcs. b OFFICE OF ENVIRONMENTAL SERVICES ~" UNIFIED PROGRAM INSPECTION CHECKLIST .~ '~° ti 1715 Chester Ave., 3'd Floor, Bakersfield, CA 93301 Pink -Business Copy Business Site Respo ible Party CITY OF IOAItERSFIELD .a ,- , ..,._..,-. _ w _ B EF Re ' OFFICE OF ENVIRONMENTAL SERVICES ~ ~ ~~ I wRrui r 1715 Chester Ave., CA 93301 (661) 326-3979 • `~~~_~'~ HAZARDOUS MATERIALS INVENTORY ~ CHEMICAL DESCRIPTION (one (orm per material per building or area) ~tNEW ^ ADD ^ DELETE ^ REVISE 200 Page _ of - r ~ . CIIITY IR~FORMA710N ~ • I. FA ... ~ _ _ BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) _ 3 ' CHEMICAL LOCATION 20 t, CHEtA1CAL LOCATION ^ Yes ^ No Stf~- CONFIDENTIAL (EPCRA) ` ~~ ~ 202 ~ ~- „ --' - _- ~ ----- tI MAP # (optionan-- -- - - ---~- - ~ - 203 I GRID # (optionap---- --- FACILITY ID # - --- I J ~ L~ ~ 1 I i 204 - __ ~ _ -- _ ~ ---- - ----___T,_ _ _ ._-_ _- .. -_ ----__ _ _ __ _ ---- ---_ _ ~ ___ _ --- ~ ~ - ~ ~~ il. CNEMiCAL INFORMATION ~ `'. - -------._...---.._.._.......__.... ---__---------..__.._......----____._....-°---....._. TRADE SECRET ---.. 205 ^ Yes ^ No 206 ( CHEMICAL NAME ' t ~ i (~'~ , ` ~ x L1L If Subject to EPCRA, refer to instructions ~ . ~ - .. ._._ -- . _ ... ...-- ------ - - --207 _ ._.. ----- ----- --- ---- ---- COMMON NAME i EHS" ^ Yes ^ No 208 "' CAS # 209 *If EHS is"Yes,' all amounts below must be io lbs. ~ ,:. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 210 TYPE ----- -------- - - .. ... ---- - - - i, CURIES ^ pPURE ^ m MIXTURE WAS-E ~ R-~p10ACTIVE ^ Yes ^ No 212 ~ 213 PHYSICAL STATE ^ s SOLIOQUID ^ g GAS 214 LARGEST CONTAINER ~ 215 FED HAZARD CATEGORIES ^ 1 FIRE ^ 2 REACTIVE ^ 3 PRESSJRE RELET,SE ^ 4 A:;U': E HEALTH rs,LS CHRONIC HEALTH (Check all that apply) 216 ANNUAL WASTE 217 ;v14XIML'M 218 AVERAGE ~ 219 j STATE WASTE CODE ~ 220 ' AMOUNT DAILY AMOUNT DAILY AMOUNT , UNITS' G~ GAL ^ d CU FT ^ Ib LBS ^ In TONS 221 ~ DAYS ON SITE 222 If EHS, amount must be in lbs. __ ~ ~ ~} STORAGE CONTAINER ^ a ABOVEGROUND TANK ,tie PLASTIC/NONMETALLIC DRUM ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR (Check all that apply) \ i 223 i i ^ b UNDERGROUND TANK ^ f CAN ^ j BAG ^ n PLASTIC BOTTLE ^ r OTHER i ^ c TANK INSIDE BUILDING ^ g CARBOY ^ k BOX ^ o TOTE BIN ^ d STEEL DRUM ^ h SILO ^ I CYLINDER ^ p TANK WAGON STORAGE PRESSURE ~ gMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 224 STORAGE TEMPERATURE /"'AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT ^ c CRYOGENIC 225 %VVi' HAZARDOUS COMPONENT - .,. _... EHS CAS #' ~ 1 i 226 I i - 227 ~ 229 2 230 3 4 5 234 238 242 PRE ^ Yes ^ No 228 I - -----._ 23t -......-..------_--- ------ ^ Yes ^ No 232 -- 233 ', ~ -- I -~ - _- i --- r -- ----- ^ Yes ^ No 236 ----- - 239 ~ ^ Yes ^ No 240 I i 241 j --i 243 ^ Yes ^ No 244 . 245 ,'' I ` ~ III. SIGNATURE °NTATIVE SIGNATURE DATE 2 V UPCF (7/99) S:\CUPAFORMS10ES2731.TV4.wpd ,~.~ CITY OF DAI{ERSFIELD B E R s F' ° OFFICE OF ENVLRONMENTAL SERVICES ~ ~~~' ~ P/RB ' ARTM t 1715 Chester Ave., CA 93301 (661) 326-3979 ~„ • - 1 ot: ~ .,...>y.~~._~'~...„ HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one /orm per material per building or area) 9 '~ ^ ADD ^ DELETE ^ REVISE 200 Pa e _ of _ ;: - ,,. ` 1 FACILITY IRIFORMATION . _ BUSINESS NAME (Same as FACILITY NAME or DBA - Doinq Business As) 3 ~~T QC~/Tv~-~ C ~"~ I CHEMICAL LOCATION r_ _ /~ I~~' ~ w ,~ CU~C~ C~~,R.U~ ~ ~ ~~~ 20~ CONFIDENTIOAL(EP~RA) ^ Yes ^ No 202 j FACILITY ID # r ~ '1 -- -- -- (- ~ I i tl MAP # (ophona 203 i GRID # o tiona 204 II CiiENIiCAL IiYFORMATION 205 TRADE SECRET ^ Yes ^ No 206 CHEMICAL NAME ~ r~ i If Subject to EPCRA, refer to instructions ~ 3 'C - - --- --- --... _....,_ .._---__ -- - ~- --- ------------ - - -- 207 ~. --- COMMON NAME ~ EHS' ^ Yes ^ No I ~ 208 -- --- ----- - - ---- - - __...._ -- - - -- -- - - - _ -- - --V -- - - --i CAS # 209 If EHS is'Yes,' all amounts lxlow must be in ibs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 210 . - --- _. _-- ---- ---- TYPE ~ -------. - - -- - -- ~ CURIES PURE ^ m MIXTURE ^ w WAS-_ ~.. R-J?IOACTIVE ^ Yes ^ No 212 i 213 PHYSICAL STATE ^ s SOLID^ I LIQUID /)(~g GAS 214 LARGEST CONTAINER Z ~ ~ 215 /~^+ FED HAZARD CATEGORIES ^ 1 FIRE I~"2~REQCTtVE ~ PRESS IRE RELE~',SE ^ 4 A.:UTE HEALTH ^ 5 CHRONIC HEALTH (Check all that apply) 216 219 I STATE WASTE CODE WASTE 217 ~ ~ S~~ c18 Sv ~ 220 YAMOUNT DAILY AMOUNT D AMOUNT -- UNITS' ^ DAYS ON SITE ga GAL ~ CU FT ^ Ib LBS ^ to TONS 221 222 ' If EHS, amount must be in lbs. STORAGE CONTAINER ^ a ABOVEGROUND TANK ^ e PLASTIC/NONMETALLIC DRUM ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR 223 (Check all that apply) ^ b UNDERGROUND TANK ^ f 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 ABOVE AMBIENT ^ ba BELOW AMBIENT I 224 I STORAGE TEMPERATURE {~'a AMBIENT ^ as ABOVE AMBIENT ^ b3 BELOW AMBIENT ^ c CRYOGENIC 225 %WT HAZARDOUS COMPONENT ~ ---, 1 i 226 2 i 3 -- ~ 4 I 230 234 238 5 ~ 242 EHS -_~-~_ ~_-_ 227-~I~ -^ Yes ~^ No 228 III. SIGNATURE ESENTATIVE SIGNATURE 231 ^ Yes ^ No 232 235 ~, ^ Yes ^ No 236 i i 239 i ^ Yes ^ No 240 243 i ^ Yes ^ No 244 __ ..J _....__~._.__..._-_._.__.. ~, .CAS# 229 233 i 237 - -~ 241 i . ~ 245 --_4_-/-~~~~-- li' UPCF (7/99) S:\CUPAFORMS\OES2731.TV4.wpd _..._.a...~-_ ,....,,. B E R S F I D F/I~B ~RrM r CITY OF I3AI{ERSFLI/LD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 ~ _ ,4~ HAZARDOUS MATERIALS INVENTORY ~ CHEMICAL DESCRIPTION ^ ADD ^ DELETE ^ REVISE 200 I. FACILITY INFORMATION (one /orm per material perbuilding orareaJ Page _ of _ BUSINESS NAME (Same as FACILITY NAME or OBA -Doing Business As) CHEMICAL LOCATION 201 CHEtdICAL LOCATION rL.1.C~ (r;~(_- ~~ C~US~-~- C'~G~"'yyt_ ©~ '~L(~(j_ CONFIDENTIAL(EPCRA) ~.. ,. FACILITY ID # ~ ~ 1~ MAP # (opbonap 203 GRID # (optanan ~'~I I i ' IL CNEMiCAL LVFORMATION - _i 205 TRADE SECRET CHEMICAL NAME ^ Yes ^ No 206 I t "j`(~) JS ~ty.l .~ ` Ir Subject to EPCRA. refer to instructions , COMMON NAME CAS # FIRE CODE HAZARD CLAS° TYPE PHYSICAL STATE FED HAZARD CATEGORIES (Check all that apply) ANNUAL WASTE AMOUNT - STORAGE CONTAINER (Check al! that apply) STORAGE PRESSURE STORAGE TEMPERATURE 207 EHS' ^ Yes ^ No 208 209 j 'If EHS is'Yes;' all amounts below musi be in lbs. ES (Complete if requested by local fire chieQ i 210 i _ ____ - ^ p PURE m MIXTURE ^ WAS i . ..- -.. .. R-J?IOACTIVc - --------------~- CURIES ^ Yes ^ No 212 , 213 ^ s SOLID ^I LIQUID GAS 21q ~ LARGEST CONTAINER 3D 1 215 j ^ 1 FIRE ^ 2 REACTIVE ~? PRi:SS'JRE RELEd,SE L ~ ~~ .4::UTE HEALTH ^ 5 CHRONIC HEALTH 216 217 ;v14XIMUM ' ~ ~ 218 A.Vt3RAGE ^~/ G 219 ~ STATE WASTE CODE O 220 'I DAILY AMOUNT p DAILY AMOUNT / V ~ ~ UNITS' ^ ga GAL ~ d CU FT ^ Ib LBS ^ to TONS 221 DAYS ON SITE 222 ' If EHS, amount must b in lbs. ~ ~ ^ a ABOVEGROUND TANK ^ e PLASTIC/NONMETALLIC DRU M ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR 223 ^ b UNDERGROUND TANK ^ f CAN ^ j BAG ^ n PLASTIC BOTTLE ^ r OTHER ^ c TANK INSIDE BUILDING ^ g CARBOY k BOX ^ ^ o TOTE BIN ^ d STEEL DRUM ^ h SILO ~~ (( ,.CYLINDER ^ p TANK WAGON a AMBIENT ~aa ABOVE AMBIENT ^ ^ ba BELOW AMBIENT 224 rr .CJ~a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT ^ c CRYOGENIC 225 ~ ' ' j.. - , HAZARDOU$,COMPONENT EHS CAS #_~ %~ 1 --j--- 2 3 -~- 4 51 f zzs - - 230 234 238 _~1--------------_ _ _ - --- - __ 242 ~ ~ ^ Yes ^ No 202 UPCF (7199) S:\CUPAFORMS\OES2731.TV4.wpd `..~-- ~ _ _ ___ __ _ _ _ tea. -;; HAZARDOUS MATERIALS MANAGEMENT PLAN BAKERSFIELD FIRE DEPT. H E R S F I p Prevention Services APPLICATION `p~R>t~ 90o Truxtun Ave., ste. 210 FOR SECTION DISCOVERY AND ARf'llI t• ~.= Bakersfield; CA 93301 NOTIFICATION (FORMS) , r ~ -~ Tel.: (661) 326-3979 . ~ ' - ~ ~ . . " ' Fax: "(6611')' 862=2171 • ~ - ,. ' -~: , ~ .` ,.. Page. 1 of;2 r INSTRUCTIONS - 1. To avoid further action, return this form within 30 days of receipt. 2. TYPE/PRINT ANSWERS IN ENGLISH. .. 4 ;. 3. .Answer.the questions below for the_ business,as a whole.. ° ' ' " 4 ~~ Be`as brief and concise a's~possible. SECTION I: FACILITY IDENTIFICATION ~ BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) ~c~e -1- pehr~-~L G c~. `+~~: j~06Mas Gordo--i ,_ .,• ADDRESS (For loc I use only) ' ' ~b05 ~~rnl~o l~'ledia, ~vo .. FACILITY ID NO. I ~ 1 - -`-- -- ------ SECTION 11.1:` DISCOVERY AND NOTIFICATIONS ~~ - , r-. ' 'A. LEAK OETECTION'AND MONITORING PROCEDURES: ~ `' - ' e -. ~ SPen~-; F~ Xer ~~~ e~,lce~cd' ~elu: ~ l~ by' :~~ . •. .. ' . ; r - ,r -. B. EMPLOY~AEyE AND AGENCY NOTIFICATION: , .. C. ENVIRONMENTAL RESPONSE MANAGEMF~Nf: ~ .. . , ENT'D ~ ~ ~ ~~-1,2006 ... , eresa ~1' ~'ti,ns -., ~~ n ( b+ to D. EMERGENCY MEDICAL PLAN: _ r -. M Grey Svtc ~v~.s-~-, . ii SECTION 11.2: RELEASE RESPONSE PLAN i A. HAZAR ASSESMENT AND PREVENTION MEASURES: ~a'~e' rne~f i h5S loves rnas~ `e. e weir ~a~'e-~Y ~t~ prnen.~- (•~'~'~ ~ 9 ~ B. RELEASE CONTAINMENT AND/OR MfTIGATION: ~e/I'~" `~~Cr ScJ4l(On ~n~'Qrner STS (f1 ~(L15'~IC puQr' t'~0~"~ll..b, Gh~ck>~ cQ flail , C. CLEAN-UP AND RECOVERY PR CEDURES' •. ~.{,li,~ ~.,, p .c,'t,~...cc~ •,~~ X/l u,~ s ~P.~,z~wr~o S.,ebv.,~:~x ' a, aZ W m~ ~ _ ~ ~ ~~.~.t,wu.. YNkclt,%~!. u1 ~.~i. , ~ / FD 2169 (Rev. 09105) i..~> I-- - - Pale 2 of 2' -CG('TIl1hl 11 7•, D~GI ~ACC'1?~CD(_lA1CG:b1 AA1-(`t1A1'T - - --~ :. , UTILIZY SHUT-0FFS (LOCATION OF SHUT-0FFS AT YOUR FACILRY) ~,,/ NATURALGAS/PROPANE: ~lI ~ v~% ae ~ ~U /CA/~ ELECTRICALi..J~kTf~glCfri V~ bkil~~n bQ.Ck C~Odr C l .Lh rr(Q9t,~ , WATER: ~ Ll~7!7 / '~ 1. // ~~~/ ~rD/'1") (/ ~ ~e SPECIAL: o ~ 5 • re n-~ ~vo ~ ~-P-~•~ 9 ~c~e O~ ~a ~~• PRNATE FIRE PROTECTIONNVATERRVAILABILITY: A PRNATE FIRE PROTECTION: d t~.~ ~~ ~~ r~nkleY ~ ~~e~i-~ B. WATER AVAILABILITY (FIRE HYDRANT): oZ ~1re. ~~fa4rar~{- S Nor~4 h s~c1e bu~ld~'h !~D ~ee~-tomn~ ~-~rarc~ tl 12e~ t,Jay. ' ~ Y-~~ nCr ~ on CaM pro mutia. d+~.d `C.VI,e. ~~ wa.~-er Source ~ Sow4~1~ er.,c~;a~.bt,;J,c1.,• "Yj ~D/Y ~i~ p-~-~ ~aa,~G ~~ - ---- -- ~ p~'ee~ ~t~r~ I5a.~,E._ ~o r.,` SECTION III: TRAINING NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: - ~,ne ~ ~-~ 01N ' /Vl~ 1),~ I N G~ t~"a.~ 1C' ~- y/ R d o wl ~'~ BRIEF SUMMARY OF TRAINING PROGRAM: ~~ ~ ~ /~ ~ r ^~- CERTIFiCAT(QN Based on my inquiry of those individuals responsible for obtaining the information, 1 certify under penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. SIGNATU O~/O`WNE~R /~O,P¢E,~RA~TO,{R~OR DESIGNATED REPRESENTATIVE DATE / / . , 477 NAME O I~GTNER (print) 478 U 1 A'!v (~-- ~!I ~t2'~ O h) ` TRLE OF $IGNER- - . ~ 479 ,/~~(n~> rte` G~~~~', . a ~ ~ ~ 1'U 11(iy (Rev. 09/05) 4 - , ~. + ADEPT DENTAL GROUP __________________________________ SiteID: 015-021-003000 + +_________________________________________________________________ Fast Format + += Notif./Evacuation/Medica.l ____________________________________ Overall Site + +_= Agency Notification _______________________________________________________+ - ~~~ c~~ ~~ 0-<-~c.~.- C-o~-~. ~.• La c>.,¢.~., ~'~¢'L ' C~- f '`~.'` ie,Q`"1~b2 l~~ ~r,~,ac.e.. ~~~.a-Q ~c.G(,, U"" ~ ~ ~- ~~Z,¢.c~' ,-tic-~ . "t'D ~' +__= Employee Notif./Evacua.tion _______________________________________________+ +___= Public Notif./Evacuation ________________________________________________+ +____= Emergency Medical P7L.an _________________________________________________+ ~ } ~ ~ ~ ~ ~~ ,~ p~ rn x~~ ~o ~'~~~'`' ~~"~' ~ ,~ . ~~ -6- 12/22/2005 + ADEPT DENTAL GROUP __________________________________ SiteID: 015-021-003000 + +_________________________________________________________________ Fast Format + += Mitigation/Prevent/Abaterrut ___________________________________ Overall Site + +_= Release Prevention ________________________________________________________+ ~.,~ ~~ j b j X66 D`'~.dX~' dw~f~p.~ y~,~. +__= Release Containment _____________________________________+ ~l 7 ~'O'u S G7~tn. ~ l~1 X ~ ~G'~'~~- y y -Po,__ou~,~~,,_v_cafeG~ __________________ +___= Clean Up ________________________________________________________________+ OY"'_ _ ~ J~_,y-yam ~~ ~,~f.~lri-~~8-'~ hr~~~~ ~~~' ~~. +____= Other Resource Activation ______________________________________________+ -7- 12/22/2005 _ f}Z ~~' ~~ + ADEPT DENTAL GROUP __________________________________ SiteID: 015-021-003000 + _________________________________________________________________ Fast Format + += Site Emergency Factors~_______________________________________ Overall Site + +_= Special Hazards ___________________________________________________________+ h _ -~-i~~a nee . -~-- ~~ ~r~~~~ --fa wall, +__= Utility Shut-Offs ________________________________________________________+ ~~~ ~e~?~~~~ ... So~s~a1~- ~c,.~Io4i~ btu ~X(~- rn ~ vse~ +___= Fire Protec./Avail. i~8'a.ter _______________________________________________+ ~P~- ,~ ~ ~~ ~~~ '~ D'h ~ t her~-Y ~a.rL k `rL o a_oQ +____= Building Occupancy Level _______________________________________________+ ---- -------------------------------------------------------------------- -8- 12/22/2005 + ADEPT DENTAL GROUP _________________________________= SiteID: 015-021-003000 + +_________________________________________________________________ Fast Format + += Training ____________________________________________________= Overall Site + +_= Employee Training _________________________________________________________+ L~_ /.~~ l~..G~- -~L A ~' ~ ~!~- +__= Page 2 ___________________________________________________________________+ +___= Held for Future Use _____________________________________________________+ r +____= Held for Future Use ____________________________________________________+ -9- 12/22/2005 (~ .. _ _ _ - ,;. _ =- -- (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN INSTRUCTIONS SITE & FACILITY DIAGRAM ~ 8 B R S F I D PIRG _~ r BAKERSFIELD FIRE DEPT. Preveation Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 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 astraight edge tool,.: : ~ ~~ ~ a ,_ SITE DIAGRAM INSTRUCTIONS . The site diagram is used to show. your business and to indicate the businesses that immediately surround your properly, 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 I-IMNIP, 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 north arrow). 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 FIlVIlVIP. 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 areas, 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. 0905) ',~ (HMMP) ~~ HAZARDOUS MATERIALS MANAGEMENT PLAN - - --~ -_ _. ___._._.... wr SITE & FACILITY DIAGRAM Page 2 of 2 4 ,~ 8 HitSPI D °f-tQ F~~B A`_ i A~ T BAKERSFIELD FIRE Dig Preveation Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 L____~ SITE DIAGRAM FACILITY DIAGRAM Business Name: Business Address: NORTH Please indicate direction of North FD 2170 (Rev. Os/o5) ~•-~1°c.r~cnc Lock. lox a•~YYiaR C~aS~shu'l"o~F - ® hnai n wa+cr Shkf oC~- ,~,; ~1,fro~s ~oxy9en cylinders ~ Wafter source /worker t-4yd~ttnts P.~11 f rct h ce. e. i •t'S ~' l .X 1~ber~y ~A~k E. (ee~y~ cca L Shu.{ c~~ p~~`~' ~ ~~ r e ~.•~-~-~crto~ 4i S~o-'S 'Fire 4e~. water Sa.rce N ~ S peh~ Fr X ~' /~e/oiler ~-~~~wf 3 J u O L4J --J a ~ II I I lL (I~.~a~~~`~1 L,~/ --J I I I I tl I I I I 11 --J I I I I LL 1 n I I LL rTti 1 ----------------------- II _ ~ i ~ I r t. W '~ I I I I I ---I -~ i I I I J L J L i I F==~ F==~ I t l I F==~ ~ I \ F==~ I I I I t I 1 --+--I----F---1-~ --_---11 I I I Y ' --, I '.--,-,c•,---. --- --..{J _ ~~ f~ \\_ ~~ - \ 1 r-~r ~ --- r-n- L-JL-J //_ \\ //l_`\ S l f ~ _ J ~ I ' U~~J I s-_ii*~~«~ E~~~--- ~ Ade }per,.+a~ GcoK~, gLo~ cA~--no iMed,a s~,i~o too a M i n o i~1ed; c,. ~~