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Home My WebLink AboutBUSINESS PLANCRIMSON REGIONAL MGMT. 3012 DISTRICT BLVD. e ' (HMMP) HAt'•:i~RDO~JS MATERIALS MANAGEMENT PLAN ~' (UNIFIED PROGRAM CONSOLIDATED FORM) ~ !, _. _ -• - APPLICATION ausNESS o~uvr~ i o~ATOR oovrFlCA-~nor~ wRM (HAZARDOUS MATERIALS FACILITY INFORMATION) ' B 13 $ F D FAIEB Ali<r/I- r BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: 661326-3979 Fax: 661-852-2171 Page 1 of 2 ~`,r/y~j L FACILITY IDENTIFICATION ~ FACILITY ID NU. i ! 1 Year Beginning 10o Year Endmg t01 BUSINESS NAME (Same as FACILITY NAME or DBA- Doing usiness ) ~ 3 BU N S O E o ~ _ S E A RE S - 103 CITY - 104 IP _ 105 CA DUNN & BRADSTRE T t08 SIC DE to7 '-- -- (4 Digit #) COUNTY ~ ~ 108 OPERATOR NAME toe OP T Rf HONE p II; Q1fatNER=IQ{~MATION' -- - - -- OWNER NAME - -- 111 OWNER PHONE 112 11~ ~ - OWNER MAILING ADDRESS __ , / tt3 -z- O CITY 11a STATE 11s IP tts III. ENVIRONMENTAL CQNTACT - - - -- _ CONTACT NAME ~ 117 -- CONTACT PHONE l ~ r, CONTACT MAILING ADDRE I 1te ~ 14/ !!/ CITY t20 ST TE 121 Zlp t72 -PRIMARY IV. EMERGENCY CON TACTS -SEC ` DARY- NAME 123 r> NAME 128 TITLE 124 r TITLE 129 BUSINESS PHONE 12S BUSINESS PHONE 130 24-HOUR PHONE 126 24-HOUR PHONE 131 ~~ y ~ .~~ PAGER N0. 127 °- PAGER NO. V 132 133 - _ - -- - V. CERTIFICATIpN Certfication: Based on my inquiry of those indlv~luals responsible for obtaining the' information; I certify under penalty of law that I have personally examined and am famili ith the information e;ubmitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF SIGNER' ~ 136 DATE 134 NAME OF DOCUMENT PREPARER 135 ..~ -- NAME OF OWNERf/O~P ~ R ( I NATO & PRI`NTJ) 137 TITLE OF OWNERIOPERATOR y~ 138 ~ (~ / / C` ~l 5~~'' FD 2142 (Rev. 09105) °~;~ (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 ofthe instructions fol%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 ofthe Unified Prngram Data Dictionary. Please numberaf%pages ofyoursubmittal. Thrs he/ps our CUPA orAA identity whether the submrttat is comp/ete and ifany pages are separated 1 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. (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 geographiglly locate the faality. 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 intemet. 107 SIC CODE -Enter the primary Standard Industrial Classification Code number for primary business activity. NOTE.• /fcode 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, ff 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, 'rf 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, ff 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 ZIPCODE -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 qn 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 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 24HOUR 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 contacts 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 necessar to meet the requirements of their individual programs. Contact your local agency for guidarvice. 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/OPERATORlOR 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 the of the person signing the page. Page 2 of 2 FD 2142 (Rev. 09/05) yJ~~N ~~