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HomeMy WebLinkAboutBUSINESS PLAN~~ ~ ~ -HOME'TOWN DENTAL CARE 100 W. COLUMBUS #200 o~~ ~ r-- UNIFIED PROGRAM INSPECTION CHECKLIST, 0 F~- n -- F/RE SECTION 1: Business Plan and Inventory Program ~ aRrM Prevention Services 900 Truxtun Ave., Suite-210 Bakersfield, CA 93301. Tel.: (661) 326-3979 . Fax: (661) 872-2`171 FACILITY NAME ~ - - ~ INSPECTION~TE~~ INSPECTION TIME ADDRESS ~~ ( ,~ ~ ~ ~ ©~ H~~ `OZ~ + NO OF EMP~YEES FACILITY CONTACT ~ ~ - - _ BUSINESS ID NUMBER ~~~ 15-021- Section 1: Business Plan and Inventory Program.: ^ ROUTINE ~ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION - C V ~ C=Compliance OPERATION V=Violation COMMENTS ^ ~ APPROPRIATE PERMIT ON HAND ~.~,-~ ~, s ,mss ~1 _-~ r L ^ ~ BUSIt1eSS PLAN CONTACT INFORMATION ACCURATE i ` ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ~$ ^ VERIFICATION OF QUANTITIES `~ ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ENT°D J U L ^ VERIFICATION OF MSDS AVAILABILITY ^ VERIFICATION OF HAZ MAT TRAINING ~J ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING Q~ ^ FIRE PROTECTION /~ ~/~ -~ ^ SITE DIAGRAM ADEQUATE & ON HAND ~_ ANY HAZARDOUS WASTE ON SITE? ~SYES ^ NO EXPLAIN: ~~~ e /"- ,~a~ QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 c~~~~ ~ Inspector (Please Print) Fire Prevention / 1s' In /Shift of Site/Station # White = Prevention Services Yellow -Station Copy ~ S~~ Busin Site /Responsible Party (Please Print) Pink -Business Copy --~ - - FD 2155 (Rev. 09/05 y,4..~e c4 b ~ ~ .~ :,~ +~: ~E C~~ ~H FACILITY NAME w~. ~, 10 CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Aee., 3'd Floor, Bakersfield, CA 93301 -~.~ n ~' ~ ~°~ C~ Y ~ nvSPECTION DATE ~ (2°-r ~ Section 4: Hazardous Waste Generator Program EPA ID # ~ ~ v~ 6~rt' ^ Routine ~ Combined ^ Joint Agency ^Mulli-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number ~jC~r-ye't' 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 La~ Nr,,J ~,~' , 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 N I~ Proper management of used oil fillets ~ ~q Transports hazardous waste with completed manifest Sends manifest copies to DTSC ~ _ ~~ Retains manifests for 3 years S ~1 ~;'~' 1 v .. J 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=vtotanon Inspector: ~-~~~`~~~ Office of Environmental Services (661) 326-39'79 White -Env. Svcs. ` ~ ~JIJu ''~! B iness Site Responsible Party Pink -Business Copy 1~-~ ;t1A,Z~RDOUS MATERIAL MANAGEMENT PLAN APPLICATION BUSINESS OWNER/OPERATOR IDENTIFICATION FORM (HAZARDOUS MATERIAL FACILITY INFORMATION) BAKERSFIELD FIRE DEPARTMENT Prevention Services 1600 Truxtun Avenue, Suite 401 s a s F I n Bakersfield, CA 93301 P/RB Phone:661-326-3979 • Fax:661-852-2171 ARIA/ T ~~ge~~ l~ 3 0 2007 ENT ~ ~ ~~ L :FACILITY IDENTIFICATION FACILITY ID # 1 YEAR BEGINNING 100 YEAR ENDING 101 BUSINEJ~~SJprNAIM/E (Same as FACILITY NAME or DBA) 3 7 `V1~~~ ~ - ~ BUSINES/S PHONE /~/]L/~/~ 102 ''1' - ['r SITE A/DhDyRESS `,, ~ ,^yxJ~~ 103 V ~ YW ~fJW //~~ ~~// T CITY ~/"C I~.E~~~EL~ 104 ^~ ZIP CODE ~ ^~ ~ 105 (,~Jj DUNN & BRADSTREET # 106 SIC CODE ~ 107 COUNTY 108 OPERATOR NAME 109 OPERATOR PHONE 110 II. OWNER INFORMATION OWNER NAME 111 G ~ rv~ OvyNE P NE ~ _ ~ 112 OWNE AILING ADDRESS • r ~ ~ 113 CITY ~' ~ llq STAT 115 ZIP COgE~ ~ 116 (_~(f III. ENVIRONMENTAL" CONTACT :CONTACT NAME A ~ ~~ ~ 117 (, JI C NTACT PHONE~~~- ~~ ,n 118 !LJ\~_l/•f J'' CONT~CT MAILING AD D 119 RESS (~]y~( 1 (/V CITY 120 STAT 121 ZIP 122 IV. EMERGENCY CONTACTS PRIMARY j~ S EC OLVDARY NAME _ 123 NAME ~ ~ `../l.~ `~~ 128 ,/' ~ /~ TITLE ~ 124 TITLE ~ v 129 C~/ BUSINESS PHO E >~ 125 gUSIN SS HON '~, // „ 130 24-HOUR PHONE 126 24-HOUR PHONE 131 CELL PHON 127 "- i - 7 CELL PHONE 132 u,~~- 3~ 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 th information submitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF DOCUMENT PREPARER Y- „~ 136 ,\./.j/Vf/'I SPAT ~ 134 - / N/1M FfbF DOCUMENT PR ARE~PRINT) 135 ~Y/ N OF OWN OPERATOR~(SIGN & RI T ~ 137 TI TLE OF CUMENT PREPARER 138 v FD2142 (Rev 06/07) ~,b l~ HAZARDOUS MATERIAL FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION Please submit the Business Activities page, the Hazardous Material Facility Information (HMMP) Business Owner/ Operator Identification Form, and Hazardous Material Inventory Chemical Description Form for all hazardous material 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 instructions follows the data element numbers that are on the Business Owner/Operator Form page. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, Business Section of the Unified Program Data Dictionary. Please number all pages of your submittal. This helps our CUPA or AA identify whether the submittal is complete and if any pages are separated. i FACILITY I.D. 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. 100 BEGINNING DATE -Enter the beginning year and date of the report. 101 ENDING DATE -Enter the ending year and date of the report. 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 NUMBER -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: If code is more than 4 digits, report only 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, area code first, and any extension. ili OWNER NAME -Enter name of business owner. 112 OWNER PHONE -Enter the business owner phone number, area code first, and any extension. 113 OWNER MAILING ADDRESS -Enter the owner mailing address. 114 OWNER CITY -Enter the city for owner mailing address. 115 OWNER STATE -Enter the 2 character state abbreviation for the owner mailing address. 116 OWNER ZIP CODE -Enter the zip code for the owner address; extra 4-digit zip may also be added. 117 ENVIRONMENTAL CONTACT NAME -Enter the name of the person who receives all environmental correspondence,and will respond to enforcement activity. 118 CONTACT PHONE -Enter the phone number 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. 120 CITY -Enter the name of the city for the environmental contact mailing address. 121 STATE -Enter the 2 character state abbreviation for the environmental contact mailing address. 122 ZIP CODE -Enter the zip code of the environmental contact mailing address; 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 hazardous material, at the business site. The contact shall have FULL facility access, site familiarity, and authority, to make decisions for the business regarding 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 tie one which is answered 24-hours a day. If it is not the contact home phone number, then the service answering the phone must be able to immediately contact the individual. 127 CELL NUMBER -Enter the cell number for the primary-emergency contact. 128 SECONDARY EMERGENCY CONTACT NAME =Enter the name of a secondary representative that can be contacted in'tYie 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 home phone number, then the service answering the phone must be able to immediately contact the individual.• - -.. - . • • , . 132 CELL NUMBER -Enter the cell number for the secondary emergency contact. 133 ADDITIONAL LOCALLY-COLLECTED INFORMATION -This space may be used for CUPA or AA to collect any additional information necessary to meet the requirements of their individual programs. Contact your local agency for guidance. 134 DATE -Enter the date that the document was signed. 135 NAME OF DOCUMENT PREPARER (FULL PRINTED NAME) -Enter the full printed name of the person who prepared the inventory submittal information. 136 SIGNATURE OF DOCUMENT PREPARER (FULL SIGNATURE) -Enter the full signature of the person preparing the page. The signer certifies to a familiarity with the information submitted and that based on the signer inquiry of those individuals responsible for obtaining the information, all the information submitted is true, accurate, and complete. 137 SIGNATURE OF OWNER/OPERATOR/DESIGNATED REPRESENTATIVE -The Business Owner/Operator, or officially-designated representative .of the Owner/Operator, shall sign sand ..print in the space provided: This signature certifies that the signer is familiar with the signer belief that the submitted information is true, accurate, and complete. 138 TITLE OF DOCUMENT PREPARER -Enter the title of the person preparing the page. Page 2 Of 2 FD2142 (Rev 06/07)