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Home My WebLink AboutBUSINESS PLAN860`~C~KATZ INO MEDIA #200 ~ --- -- F? . KATZ DMD MARK D MEDIA 200 BusPhone: Map 123 Grid: 05E SiteID: 015-021-002989 Manager MARK D KATZ Location: 8605 CAMINO City BAKERSFIELD CommCode: BFD STA 09 EPA Numb: SIC Code: DunnBrad: (661) 665-0077 CommHaz Minimal FacUnits: 1 AOV: Emergency Contact / Title Emergency Contact / Title MARK D KATZ DMD / OWNER / Business Phone: (661) 665-0077x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact MARK D KATZ Phone: (661) 665-0077x MailAddr: 8605 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Owner MARK D KATZ DMD Phone: (661) 665-0077x Address 8605 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 ~N~~ J~~ ~ ~ I~~Q~ '3~.c~~c on my inquiry of those individuals re_~ae~~islbio far obtaining the i nformation, I certify an~ior penalty of law that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. ~] Si nature Date -1- 07/12/2007 F KATZ DMD MARK D ~ Hazmat Inventory = ~ MCP+DailyMax Order = SiteID: 015-021-002989 ~ By Facility Unit ~ Fixed Containers at Site ~ Hazmat Common Name... ISpecHazIEPA Hazards) Frm I DailyMax IUnitIMCPI WASTE FIXER R L 5.00 GAL Minl -2- 07/12/2007 -3- o~/ia/aoo~ F KATZ DMD MARK D SiteID: 015-021-002989 ~ ~ 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 -~ Ambient ~ Ambient ~ PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL 5.00 GAL I 5.00 GAL I1HGEitCLVU.7 l.VP7YV1V1.S1V 1.7 °sWt. RS CAS# Silver No 7440224 IlEiGHICL HA ~L~.7J1~1J~J1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 07/12/2007 F KATZ DMD MARK D SiteID: 015-021-002989 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 06/06/2006 ~ 911 AND THE OFFICE OF EMERGENCY SERVICES AT 800-852-7550. Employee Notif./Evacuation 06/06/2006 911 AND THE OFFICE OF EMERGENCY SERVICES AT 800-852-7550. Public Notif./Evacuation 02/27/2007 911 AND ES 800-852-7550. Emergency Medical Plan 02/14/2006 911 OR TRANSPORT TO MERCY SOUTHWEST HOSPITAL, 400 OLD RIVER RD -5- 07/12/2007 F KATZ DMD MARK D SiteID: 015-021-002989 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 02/14/2006 ~ HAZARDOUS MATERIAL IS IN CONTAINER, PLACED INSIDE ANOTHER CONTAINER TO PREVENT A LEAK OR SPILL. Release Containment 02/14/2006 HAZARDOUS MATERIAL IS IN A CONTAINER, PLACED INSIDE ANOTHER CONTAINER TO PREVENT A LEAK OR SPILL. Clean Up 06/06/2006 WE HAVE A SPILL-PROOF SYSTEM PICKED UP BY X-RAY SOLUTION SERVICES INC, 4700 EASTON DR 45, BAKERSFIELD, CA 93309, 637-0404. PICKED UP AS NEEDED, APPROXIMATELY EVERY 60-90 DAYS. V1~11C i. 1CC.y~v Ul C,e ACL1VaLlon -6- 07/12/2007 F KATZ DMD MARK D SiteID: 015-021-002989 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ especial nazaras Utility Shut-Offs 06/06/2006 NATURAL GAS/PROPANE: E SIDE OF BLDG ELECTRICAL: S SIDE OF BLDG WATER: S SIDE OF BLDG LOCK BOX: NO Fire Protec./Avail. Water SPRINKLERS, FIRE ALARM AND FIRE EXTINGUISHER. FIRE HYDRANT NW OF OFFICE ON CAMINO MEDIA. 02/01/2007 Building Occupancy Level 02/14/2006 i Z EMPLOYEES -7- 07/12/2007 F KATZ DMD MARK D SiteID: 015-021-002989 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 10/12/2006 ~ BRIEF SUMMARY OF TRAINING PROGRAM: WE HAVE A SPILL-PROOF SYSTEM WITH REGULAR PICK-UPS. WE TAKE AN ANNUAL OSHA CLASS. WE ALSO HAVE REGULAR STAFF MEETINGS TO REVIEW PROCEDURES. IN CASE OF AN EMERGENCY WE CALL 911. WE WOULD ALSO CALL THE OFFICE OF EMERGENCY SERVICES AT 800-852-7550. rayc ~ Held for Future Use . 1 J L . aici~.a ivi i u~..utc vac -8- 07/12/2007 ~. i KATZ DMD MARK D Manager MARK D KATZ DMD Location: 8605 CAMINO MEDIA 200 City BAKERSFIELD CommCode: BFD STA 09 EPA Numb: BusPhone: Map 123 Grid: 05D SIC Code: DunnBrad: SiteID: 015-021-002989 (661) 665-0077 CommHaz Minimal FacUnits: 1 AOV: Emergency Contact / Title Emergency Contact / Title MARK D KATZ DMD / OWNER / Business Phone: (661) 665-0077x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact MARK D KATZ DMD Phone: (661) 665-0077x MailAddr: 8605 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Owner MARK D KATZ DMD Phone: (661) 665-0077x Address 8605 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 Based on my inruiry of thaase indivldual~ responsible for obtaining the information. i certify under penalty of lasv that I have personally examined and am familiar wifh the information information is true. th ENT'D F EB 2 6 2007 e submitted and believe accurate, and complete. a to ~ Date ig -1- 02/01/2007 ~. F KATZ DMD MARK D SiteID: 015-021-002989 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP WASTE FIXER R L 5.00 GAL Min -2- 02/01/2007 -3- 02/01/2007 F KATZ DMD MARK D SiteID: 015-021-002989 ~ ~ 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 %Wt. RS CAS# Silver No 7440224 rlti4tuCL ti. 7 JP~~7 J1"lP~1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 02/01/2007 F KATZ DMD MARK D SiteID: 015-021-002989 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall-Site ~ ~ Agency Notification 06/06/2006 ~ 911 AND THE OFFICE OF EMERGENCY SERVICES AT 800-852-7550. 911 OR TRANSPORT TO MERCY SOUTHWEST HOSPITAL, 400 OLD RIVER RD -5- 02/01/2007 ~ Emergency Medical Plan 02/14/2006 ~ F KATZ DMD MARK D SiteID: 015-021-002989 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 02/14/2006 ~ HAZARDOUS MATERIAL IS IN CONTAINER, PLACED INSIDE ANOTHER CONTAINER TO PREVENT A LEAK OR SPILL. Release Containment 02/14/2006 HAZARDOUS MATERIAL IS IN A CONTAINER, PLACED INSIDE ANOTHER CONTAINER TO PREVENT A LEAK OR SPILL. Clean Up 06/06/2006 WE HAVE A SPILL-PROOF SYSTEM PICKED UP BY X-RAY SOLUTION SERVICES INC, 4700 EASTON DR 45, BAKERSFIELD, CA 93309, 637-0404. PICKED UP AS NEEDED, APPROXIMATELY EVERY 60-90 DAYS. Other Resource Activation -6- 02/01/2007 F KATZ DMD MARK D SiteID: 015-021-002989 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ w7~1C 1:10.1 nc~G Cti uS Utility Shut-Offs 06/06/2006 NATURAL GAS/PROPANE: E SIDE OF BLDG ELECTRICAL: S SIDE OF BLDG WATER: S SIDE OF BLDG LOCK BOX: NO Fire Protec./Avail. Water 02/01/2007 SPRINKLERS, FIRE ALARM AND FIRE EXTINGUISHER. FIRE HYDRANT NW OF OFFICE ON CAMINO MEDIA. Building Occupancy Level 02/14/2006 7 EMPLOYEES -7- 02/01/2007 F KATZ DMD MARK D SiteID: 015-021-002989 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 10/12/2006 ~ BRIEF SUMMARY OF TRAINING PROGRAM: WE HAVE A SPILL-PROOF SYSTEM WITH REGULAR PICK-UPS. WE TAKE AN ANNUAL OSHA CLASS. WE ALSO HAVE REGULAR STAFF MEETINGS TO REVIEW PROCEDURES. IN CASE OF AN EMERGENCY WE CALL 911. WE WOULD ALSO CALL THE OFFICE OF EMERGENCY SERVICES AT 800-852-7550. rayc Held for Future Use ncs.u ivi r u~u.LC vac -8- 02/01/2007 UNIFIED PROGRA~II INSPECTION CHECKLIST .;~k.~.~p,'?'^.r:4Ti'~P,+',C:i ~?J,»:..,r. ~-wA ~:, ..:-,-....',.,., ~ ~ ~:. ~ .on..:. .. a ,.a.~,: '.,s,~ - ~ s ._,.t~: , SECTION 1: Business Plan and Inventory Program M1 • BAKERSFIELD FIRE DEPT Prevention Services ~~t~ 900 Trtixtun Ave., Suite 210 ~RrN ~ Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME NSPECTION D E NSPECTION TIME Z D ~O ii o~ ~ OJT ADDRESS 8 6 0S C~a ~J ~D /1?EDII~ ~,2.ao HON NO. 6 •0077 O OF EMPLOYEES ? FACILITY CONTACT USINESS ID NUMBER ~s-oz~- ovz9~ Section 1: Business Plan and Inventory Program ~~~ V t ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION • C V (C-Compliance` OPERATION V=violation / COMMENTS ,_,/ L7 ^ APPROPRIATE PERMIT ON HAND rr l X . D BUSIn2SS PLAN CONTACT INFORMATION ACCURATE - / IX ^ VISIBLE ADDRESS ®/1 !l..r, GY ^ CORRECT OCCUPANCY ®46' ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ LrY ^ PROPER SEGREGATION OF MATERIAL VERIFICATION OF MSDS AVAILABILITY --- ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES C17~ ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE 8 ON HAND ANY HAZARDOUS WASTE ON SITE? YES ^ NO EXPLAIN: ~,(1 A3T~' t /f~~__ ~ __ .QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (861) 326-3879 ~1 //ei-~ ,~er 9- f1 ~~L~'7 Inspector (Please Print) Fire Prevention / 1" In /Shift of Site/Station # Business Site/School Site ponsible Party (Please Print) White -Prevention Services Yellow - Slation Copy Pink -Business Copy FD2048 (Rev. 02105) ~~ + KATZ DMD MARK D _____________________________________ SiteID: 015-021-002363 + Manager Location: 8605 CAMINO MEDIA 200 City BAKERSFIELD BusPhone: (661) 665-0077 Map 123 CommHaz Minimal Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 SIC Code:8621 EPA Numb: DunnBrad: ---------------- Emergency Contact / Title Emergency Contact / Title KIM JAUCH / MARK D KATZ DMD / Business Phone: (661) 665-0077x Business Phone: (661) 665-0077x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat_ Hazards : _ _ _ __ __ _ . _,_ __~_ __ _ -_ _ _ _ _ _React ____ _ _ Contact KIM JAUCH Phone: (661) 665-0077x MailAddr: 8605 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Owner MARK D KATZ DMD Phone: (661) 665-0077x Address 8605 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif~d: RSs: No ParcelNo: Emergency Directives: ~ ~~ ~,~ ~-b PROG H - HAZ WASTE GEN 1 CAr~ I ~ C'Y ,JUG 2 5 2006 used on my inquiry of those individuals r®spgnslble for obtaining the information, I certify under penalty of law 4hat I have personally examined and am familiar with the information submitted and believe the information is true, accurate, and complete. ~~~ S~ ture ~~ V Date -1- 05/15/2006 + KATZ DMD MARK D =_______==___________________________ SiteID: 015-021-002989 + Manager MARK D KATZ DMD Location: 8605 CAMINO MEDIA 200 City BAKERSFIELD BusPhone: (661) 665-0077 Map 123 CommHaz Minimal Grid: 05D FacUnits: 1 AOV: CommCode: BFD STA 09 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title MARK D KATZ DMD / OWATER / Business Phone: (661) 665-0077x Business Phone: ( ) - x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact MARK D KATZ DMD Phone: (661) 665-0077x MailAddr: 8605 CAMINO MEDIA 200 State: CA City BAKERSFIELD Zip 93311 Owner MARK D KATZ DMD Phone: (661) 665-0077x Address 8605 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 ENT'D ~! ~ N p ~~Q6 Based on my inquiry of those Individuals responsible for obtaining ttre lntormaticn, l certify under penalty of law that I have p~rannally examined and am familiar with the information submitted and believe the information is true, accurate, and compiet®. _ ~ _ Signet Date -1- 03/10/2006 ~! ~(~~`~ ,~ , We sf M -FLOOR PLAN ---, ~t,,r~ ~ l ~1 ~~" c ~~ c~1 G lr ~~ ~,[ ~ 1 ~ t ~~~ ~f e~=tip-.r~C- 5~ 1 t-L-f C-~~~ ,~ ~+- c-~~ 51~~. ~~-~~~~s 1 ~~-e. _. ~~~~ ~ 3~~ (~c~ ~ ~~~ SC~t-[~~- {~ Mark ®. Ka'; D.M.D 8605 Camino M dia, Ste. 200 Bakersfield, A 93311. ~~~ ~~ ,~ ® e ~. _-_ ___ _ __ _ -_~'_"~~ _~ MYL UrO X- CM/ma Oaa1 is~ .orr ~A1' irio uw~ ®_car,l./c ~vw~ oy ..r1. w.+1r Yr• w1. u p- CaNy1~a OLN - czar ,..~ .r ...ir f.... o_ SI1w .1w C~..y- 7(r' F ~~ - ~= ~ ~~~~ ~~e (I F ~-I = ~~ r~~ i3~~ i I ci ~ i ~c~ ~'~'tS SG~~~f- c~h~ ~~~ ~~~-slc~~ ~~ ~: tirol0 YtWYROO.Ort Fib 4p •4s0 wro..a0w ~ OM01L1101 ~ .IOi.~ Q ~~l riVmxi rp~~ ~ MIIW 1~01111~OV1M.r.RW roM>K• Q~7/07FJ / /BOOR RAM IIOfi~ ® I~WL ®.~im~R~mYMrt~-~~~ . ~u awlor m r.a s sns u.a a ~ q~.m mns.awen ..wo 11~.w m was r ~°~~.a ~/~ C ,(,. a wr.u for»wne wu rims ura ~ . l-~1 J 1 • .u rns ww u ~ win ' .. .u ..u sav m.er ro~~um OOOf1 ~OI®LLE . '.® 1rl~iYy.iri~~oMe.o rt'~.a~ero'°io.~ . ® 1Om 00i1M.~Y~IpPD0~0,yl~M~I~YY4 .® b®ir MOl1N~Y 1~OtMR~ . 1/4' IMRDWAR! ~a w rm lui~nawm ® i ~~ 11M.~ ~~ p t 1 S'n as rl~a ila`~'now awns w1.~ w~ wis X~1111 .Oi 1[tM i~ µµ~~ +e~~~ ~'~ .M~~ ' l~f.llYlpO ..1 .-~- N ~ti = }-'I Ct ZC.~ tr'G~C ~-l~ ~~~~-~L = ~IRr»~~b~ ~,~u~~ S~`~~`-' i r`~ I~ I -e r- • ~ %~`~`_ _ Bakersfield Fire D ~ C UNIFIED PR®GRAAA INSPECTI®N CHECKLIST 'Environmental Services?'~?pp~r `° ~ ~ 900 Truxtun Ave., Suite 210 SECTION 1 Business .Plan and Inventory Program Bakersfield, CA 93301 Tel: X661) 326-3979 __ _ __ _ FACILITY NAME INSPECTJION DrTE INSPECTION TIME ADORESS / r ~ fin., s+^ r~, P/H/ONE~N-o. '~7 No. of Employees FACILITYCONT ~ " Business ID Number ~r.<-lam 3 ~Si ~ sn~,- n ~ ~ ~ ~ y~~ 1 s -02 - ->~-; Section 1: Business Plan and Inventory Program ~ ~~j~ ^ Routine Combined ^ Joint Agency ^Mu1ti-Agency ^ Complaint ^ ANY HAZARDOUS WASTE ON SITE?: OYES ^ NO EXPLAIN: ~r~ ~tXC'2 QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT ~G6'I ~ 326-3979 -------~--~ ------ ~---____...._.-_._Z ..-----------.._.-----------_-----..._ ___ Ins ctor Please Print Fire Prevention 1st-In/Shift of Site Business esponsible P (PI se 'nt) White -Environmental Services Yellow -Station Copy Pink - t3usiness Copy r04~` ~~_- CITY OF BAKERSFIELD FIRE DEPARTMENT w ~e c ~. FACILITY NAME I'hnti~ (~ ~~Z U~ 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 ~t~C.. it-~~ l9tC- 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 V-VV/~l~,ll~[lllV{i •-YlV1aUVll Inspector: "l.J r ~~ , - Office of Environmental Services (661) 326-3979 Bu ess Site Re onsible Party White -Env. Svcs. Pink -Business Copy OFFICE OF ENVIRONMENTAL SERVICES y UNIFIED PROGRAM INSPECTION CHECKLIST k~~gti ~ 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 -~ ,-~~~ CITY OF ~AItERSFIELD o s B E R s P ~` ° OFFICE OF ENVIRONMENTAL SERVICES ~ ~ ~6 P/RB • .11 RTM T 1715 Chester Ave., CA 93301 (661) 326-3979 A~~~'~j,' _ ~Tuar n.a'° ~~''~~~~~' HAZARDOUS MATERIALS INVENTORY ~ CHEMICAL DESCRIPTION (one /orm permaterial perbuilding orarea) ^ ADD ^ DELETE ^ REVISE 200 Page - of : ~~ ~ .. ~;. I FACILITYIR~FORMATION ~~~ ' _ ~ BUSINESS NAME (Same as FACILITY NAME or OBA -Doing Business As) 3 ~ CHEMICAL LOCATION , f,.S t n ~/S2.lL L ~ YJt CHEt~11CAL LOCATION CONFIDENTIAL (EPCRA) ^ Yes ^ No 202 i - - ~ FACILITY ID # ~ _ r r - ~ ~ I ~ ---------- -- - - - -- - - ~ I 1~ MAP # (opfionaq ~ -_ - - ._ 203 ~ ~_ _ ~ .- - GRID # (optrona~ 204 I i - - ~ II CNEMiCAL LVFORMATION ` , ~ - ~ 205 TRADE SECRET ^ Yes ^ No 206 ~ CHEMICAL NAME _ If Subject to EPCRA, refer to insWCtions -----------... .- - - COMMON NAME 207 EHS' ^ Yes ^ No 208 CAS # j 209 ', "If EHS is"Yes, • all amounts below must be in lbs. i i .- .. ----- -- - - -- - - FIRE CODE HAZARD CLASSES (Complete if requested by local f re chief) - - ---------- 210 -- TYPE I - -- --p-------------------------- - -- ... . ^ PURE ^ m MIXTURE w WAS-E R-.QIOACTIVc - --------...-----~ CURIES ^ Yes ^ No 212 213 i PHYSICAL STATE --------------. -.~._. ^ s SOLID LIOUID ^ g GAS 214 LARGEST CONTAINER ~ 215 FED HAZARD CATEGORIES ^ 1 FIRE ^ 2 REACTIVE ^ 3 PRESSURE REL& ;SE ! ~ 4 .4::UTE H EALTH ~ CHRONIC HEALTH 216 (Check alt that apply) ~- ~ ANNUAL WASTE AMOUNT 217 w14XIML'tit 218 DAILY AMOUNT ~ AVERAGE DAILY AMOUNT -- --- 219 i STATE WASTE CODE 220 UNITS' J~ GAL ^ cf CU FT ^ Ib LBS L7 to TONS 221 i DAYS ON SITE 222 ~ ' If EHS, amount must be in lbs. I R STORAGE CONTA NE l ll h ^ a ABOVEGROUND TANK ~e PLASTIC/NONMETALLIC DRUM ^ i FIBER DRUM ^ m GLASS BOTTLE ^ q RAIL CAR 223 ; y) at app (Check a t ^ b UNDERGROUND TANK ^ f CAN G j BAG ^ n PLASTIC BOTTLE ^ r OTHER j ^ c TANK INSIDE BUILDING ^ g CARBOY ^ k BOX ^ o TOTE BIN ^ d STEEL DRUM ^ h SILO ^ I CYLINDER ^ o TANK WAGON STORAGE PRESSURE ~~ AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT 224 STORAGE TEMPERATURE ~ AMBIENT ^ as ABOVE AMBIENT ^ b3 BELOW AMBIENT ^ c CRYOGENIC 225 ~~ , ` ~' ~/aV1/T HAZARDOUS COMPONENT EHS CAS # '-~ I 1 i 226 ~ 227 ~ ^ Yes ^ Na 228 I 229 I---- 2 230 i --- -- -- 231 ^ Yes ^ No 232 i 233 1 3 ~ 234 i - -- - _.-....._ - - - -- - - 235 ^ Yes ^ No 236 ~----- ---- i 237--- ~ 4 238 239 ^ Yes ^ No 240 i 241 5 242 3 ' ^ Yes ^ No 244 i 245 jj~, III. SIGNATURE • .,. ~ PRINT NAME 8 TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE ~ - DATE 246 , ~~,~ UPCF (7199) S:\CUPAFORMS\OES2731.TV4.wpd