Loading...
HomeMy WebLinkAboutBUSINESS PLANI I ~ II CALIF COLLEGE OF VOC CAREER _ _ _ 2822 F STREET, SUITE L -IiA2ARDOUS MATERIAL MANAGEMENT PLAN ~t~ APPLICATION BUSINESS OWNER/OPERATOR IDENTIFICATION FORM (HAZARDOUS MATERIAL FACILITY INFORMATION) BAKERSFIELD FIRE DEPARTMENT Prevention Services 1600 Truxtun Avenue, Suite 401 a a x F I n Bakersfield, CA 93301 FIRE Phone: 661-326-3979 . Fax: 6C~ 852-2171 wRTll/ T ,,// ~ 5 ' ~+ Page 1 of 2 1/~ ~~ U tV/ ~ ~ y~ I. FACILITY IDENTIFICATION LF~C~ILI~ ID # 1 YEAR BEGINNING 100 YEAR ENDING 101 ~x~~vl P7" 1 9 99 PR.F.SENT . . BUSINESS NAME (Same as FACILITY NAME or DBA) ~ 3 BUSINESS PHONE 102 SITE ADDRESS 103 2822 F. S T . Suite L ~~ j ~c^ CITY ~~~EfW~~EL<~ 104 ZIP CODE 93301 105 C~ DUNN & BRADSTREET # 106 SIC COCE~ _~ - 107 f S ~ fi I 1 55827459 - c~IOO! '6 al ~ COUNTY - 108 KERN ,;:, OPERATOR NAME - 109 OPERATOR PHONE llo ~'iar h Ruiz II. OWNER INFORMATION OWNER NAME 111 OWNER PHONE 112 OWNER MAILING ADDRESS 8 2007 v 113 CITY 114 STATE 115 ZIP CODE 116 Bakersfield III. ENVIRONMENTAL CONTACT CONTACT NAME 117 CONTACT PHONE 118 S CONTACT MAILING ADDRESS _ ~~ 119 CITY 120 STATE 121 ZIP CODE 122 _Bannockburn. -LL 60015 - IV. EMERGENCY CONTACTS PRIMARY SECONDARY NAME 123 NAME 128 - Program Director TITLE `" 124 ~ TITLE ~~ 129 Registered Dental Assistant BUSINESS PHONE 125 gU5INE5S PHONE 130 661- 323- 6791 661- 323- 7 1 24-HOUR PHONE 126 24-HOUR PHONE 131 CELL PHONE 127 CELL PHONE 132 661 - 332=4784 661-33 - " 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 the inform ation submitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF DOCUMENT PREPARER ,. 136 DATE 134 NAME OF DOCUMENT PREPARER (PRINT) 135 B. Suzi Fern N E OF OWNER/OPE S GN & PRI 137 TITLE OF DOCUMENT PREPARER 138 udesindo Fernandez Cam us Director / - U FD2142 (Rev 06/07) 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. 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. 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. ~ ~1"~ 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. iii 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 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. 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 the event that ---~ `V` the=primary-emergency contact-is not ava'ila6le: The contact shall-have FULL facility access; site-familiarlty;`end 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 and 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) ;, ;. HAZARDOUS MATERIAL MANAGEMENT PLAN APPLICATION FOR SECTION DISCOVERY & NOTIFICATION (FORMS) BAKERSFIELD FIRE DEPARTMENT Prevention Services ,~ 1600 Truxtun Avenue, Suite 401 _ a B x P I nBakersfield, CA 93301 POR/ Phone: 661-326-3979 • Fax: 661-852-2171 ~er~rir >r ' Ob 3 Page 1 of 2 0 v~ INSTRUCTIONS ' 1. To avoid further action, return this•form within 30 days of receipt. ~ ~~~,~' 2. Type/print answers in ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. ` SECTION-I: FACILITY IDENTIFICATION BUSINESS NAME (FACILITY NAME or DBA) c~~t ,~ l v o ~ ~. ~ ADDRESS (fo local use only) - FACILITY ID # I SECTION IL1: DISCOV,I14ND NOTIFICATI O N S y~ ~/~/~ ~// ~ p A. LEAK DETECTION~IA~N~D; M~ON,yITO~RING PROCEDURES: .~ //~ B, '~ t "~~,G~" ~ ~~' ~"~Y `"'"- . (~(~~ ~~~W~,-w.l L~ 'L(a~~YD ~C//~ ~ ~/~L~,-~-, , I//IvC.F l,'(~~G~C/~- ~G~Z~'~~'~~~6~ V (~ ~ ~ (~-W~ ~f r, ~ n~ ~,~ /.- ~W7iL Y // - B. EMPLOYEE AND AGENCY NOTIFICA ON: ~~~ ~~/ ' "` ~~ " ~ ~, ~~~~ ~ ~~ j~r~ ,L //''C. ENVIRON~M~EN~~TAL~RE~SPO~NS/E MANAGEMENT: ~,,~/~~`T ~'~,NWI w /F~~~~ - I ~,X~C/ v[~I,.s(.f~~y/ \N- - ~ ~Y~.~~~~ (~I X~~L~ .. Cd~/ `-cZ%t, ' l.G~ ~ D. EMERGENCY MEDIC P// ~ ~ i, ~AN~~ L//'' ///~~ // . / / I ~y ~~r~+0-~ ~fiCGt C. ,, U ~f/G~IG%CG~~/Z~~.. ~rf% ~! ~ ~" C~~ ~ ~~Z ~ . SECTION II.2: RELEASE RESPO N E PLA N S ,t ~ ~ ~ ~ / ,f~ / A/ A. HA~ESMENTANLD PREVENTION MEA$A1RES: ~ ~(.Q.LZ/~~L,l~c-u-Y ~~V i`^~''i ~C~" L/l'" , /J 4((J ~~' ljj/N /~~,,VV AA__~~((// ~°r7JT/__"i^I ~ ~~ ~ Q ~/ ~C-J` ~ T ~ ~ (~ l ' g 7J ~ / B. RELEASE CONTAINMENT AND/OR MITIGATION: (~ V C. CLEAN-UP A D RECO ERY PROCEDURES: Ar ~ / ~ ~ ~txi i //H d /~J In i t (1~ i.~C,. ~'>i,l ~W' ~~ S ~ -/`.~C~~..-~~~~'~Ci~c+yti~(~ ~Q~~~~ G ~ `~ ~~L~'''~ l iK ~ ~ ~ ~ ~ / CiLCGI i J a ~~/~~lC%/~~ ~~~ 6/,! fc o V ~ ~~.~•V'r/~~7rU ~-' ~ vfiJti `f'~'--~~LUL'u-7~1~O~~-ev 06 ~j,/~/w/ lam. N/_I 'Av'/'c/ ~ ~~~~~ ,y~~L `~L~6 ~I/-~ /r~"~" ~2.1(,L ~,' ~~~ ~Zy l~L~ ~y2d f/ , C~~~~%,Lf~~!UV" .~ ~" ~ ~ f/ ~ i ~ t Page 2 of 2 P LA N ( C ON~) - ' • SECTION II.2: RE L EASE R ESPO NSE y '~j~ ~ y ~~/ ,L f// ~,~ // ~ ,~ ~ UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) - ' /~q p ~1G~%C.:C/W ~/ "l/~ `""" - - ~ GII~ \1 C~ ~` / .. f/ ~ ~NATURALGAS PROPANE: ~ ELECTRICAL:: G WATER: a SPECIAL: ' (/ ' ~ v ~ PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A. PRIVATE FIRE PR~~T/ECTION: f/y+f~ /~~QQ ~ > .,~p ~ ~'' ~ '~" i.`~~~(jG' ~~C/f`~~~ ~~-~jC/ (~ C `rte 1~ %~ " ~`~ [ L ,V ~/ t/V 4L ,~ B. TER~AV(~AI/L,{A~B~ILITY (FIRE HYDRANT): `~ ~/~~~C-~' ,// _ rz- ~; SECTIpN III: TRAINrING NUMBER OF EMPLOYEES: " • MATERIAL SAFETY DATA SHEETS ON FILE: (''YES ^ NO IF YES, LOCATION: -- 'BRIEF SUMMARY OF TRAINING PROG ~yk/%'`~~`-/' '~G~~~ ~ ~L~~ °/l~L ~ / i~ ~ s, ~ G/9~ ~ ~~ ~2~5y~1 ~ ~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 the information submitted and believe the information is true, accurate, and complete. SIGNATURE OF OW R/OPERATOR OR DE NATED REPRESENTATIVE DATE - 477 NA E OF GN R RINT) F 478 r U ~ . L~.Zi ~ ~~~~~ ~~GP ~ ~- L OF SIGNER 479 ~ GC j/I'l. Gf S r.JI' e'~~V o2'~ FD2169 (Rev 06/07) a. `t~A2ARDOUS MATERIAL MANAGEMENT PLAN = ,'i ~~. 4 CHEMICAL DESCRIPTION FORM ~_,~ HAZARDOUS MATERIAL INVENTORY '~ ~ NEW ^ ADD ^ DEL-ETE ^ REVISE zoo BAKERSFIELD FIRE DEPARTMENT Prevenfion Services B a x s n T A 1600 Truxtun Avenue, Suite 401 pl~~ Bakersfield, CA 93301 ARfiY T Pfiorie' 661-326-3979 • Fax: 661-852-2171 Page 1 of 2 (One form oer material. oer buildin°. or areal ,~ 'I~ FACILITY IN~ORMATTON _; ~" - ... - -- SINESS AME (FACILITY NAME or DBA) 3 CHEMICAL OCATION ,/~ F 201 ~ y.~ /I_ j/., ~~{~! n i~ ~~ ~~ ~ ~®~ " ` CHEMICAL LOCATION 202 CONFIDENTIAL (EPCRA) ^ Yes No ~ , ' fJ1 C I~-~~ ~ ) G t FACILITY ID # 1 # (optional) 203 M AP GRID # (optional) 204 - II CHEMIGAL~INFORMATION ~ ~~- x ~~ ~: .. , ~ C EMICAL NAME 1/- ~1 ~. '~.~ ~ ~ r I 205 /11J _ , ~/' \ ( ~f 206 TRADE SECRET ^ Yes ^ No If sub)ect to EPCRA, refer to Instructlons MON NAME ~ ~ 207 .~- ~ ~ t G ~~ ] ~ _ r COJII Y l-~/ I W~ ( EHS* ^ Yes ^ No 208 ~ , ~J CAS # - 209 •If £HS is yes, aB amounts below must be In pounds. FIRE CODE HAZARD CLASSES (complete if requested by local Flre chief) 210 ,~ 1 ~ ~ ~ ~~ _ _ _ _ __ _ ~ TYPE 211 ^ PURE ~ MIXTURE ^ WASTE 212 ~ RADIOACTIVE: ^ Yes ^ No CURIES 213 LARGEST CONTAINERc 215 PHYSICAL STATE ^ SOLID ~ LIQUID ^ GAS 214 216 FED HAZARD CATEGORIES ^ FIRE ^ REACTIVE ^ PRESSURE RELEASE ^ ACUTE HEALTH ^ CHRONIC HEALTH (Check all that apply) ANNUAL WASTE `217 MAXIMUM ~ -(~ JQ ~~Q~5218 DATLY AMOUNT ;J DAILRY AMOUNT 219 CODEE WASTE 220 AMOUNT 221 DAYS ON SITE 222 C) UNITS' ^ GAL ^ CU FT ^ LBS ^ TONS f 'If ENS, amount must be in lbs. m ` STORAGE CONTAINER: 223 ^ ABOVEGROUND TANK ^ CAN ^ BOX ^ TANK WAGON U UNDERGROUND TANK ^ CARBOY ^ CYLINDER ^ RAIL CAR ^ TANK INSIDE BUILDING ^ SILO (7 GLASS BOTTLE 6r' ~ OTHER ^ STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ^ TOTE BIN ^ PLASTIC/NONMETALLIC DRUM ^ BAG ~I~. q J 2za STORAGE PRESSURE: ^ AMBIENT ^ ABOVE AMBIENT ^ ~ BELOW AMBIENT Y -e- 2zs STORAGE TEMPERATURE: C AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC %WT HAZ-AR OUS 60MPONENT EHS GAS # 1 ~ ~ 226 (J'C~0. ,`~yy, i -~ a27 ^ Yes f7'No 228 ,~ ~ ~"'~.~~ J 229 Z 3 ^ ~ 230 t ~ ` ` .~ 231 f_7 YBS ^ NO 232 ~- ~- _ ~3 ~~ ' 233 3 ~ 234 ~ '~ -~ ~ ~ 235 ^ YES ^ NO 236 ~ ~ f j ~ ~3 ~ ~"' 237 4 2 1 ~ J 238 ((~„~ ~~ {~. ,. 239 Li Yes ^ NO 240 ~' ~ r~ r' 241 5 1 - Z 242 ~ ~ n~~ 243 ^ Yes ^ No 244 la.~ ~,3 ! ^~ 245 n 0.t. ~- ~'~3~ ~ ti 5 III. SIGNATURE ,: PR 7 NAME & TI'fl.E OF AUTIiOitIZE[) COMPANY (tEPRESENTATIVE SIGNATURE DATE 246 f ~ ~ y/ ~~ ~ o ~(Z~ D~ ~i ' r' / ) FDZ144 (Rev 06/07) ~ ~ ~. ~. t~ALL.IED n1A[i-IDSTIC IAtiisats 1~saiint~s, ~, Material Safety Bata Sheet #D-272SOD-WS, 27251-VVS SECTION I - G~neral Igfor anon Produ t Name: )~:a~EMQq.Develop'er`Replenlstier Catalos No. 27260D-WS, 27281-WS (Working Strength) S Chemi~al Family: Photographic Developer Properll,O.T. Shipping Name: .r Not Regulated Manuf~j~~r; 6 AI'<vL1EQ~Diagnostls~:Imag~g:Re9onrces,,.)<nc, s~4~~~itts~na~=~ar>rw~-y SECTION II - P~oduct and Hazardous lueredients Information ~~~%,~ //~~'''' a. li~~' Formula: Aqueous Mixture A.O.T. Hazard Classftlcation: Not .Applicable Manufacturer's Phone Number: (~~o) 4att-oiso CHEb1TREC Phone Nnmber: (800j42A-9300 Item CAS# Potassium Hydroxide 1310-58-3 PERCENT p , ~ ~----- EL TwA SSA R ~p Sodium Sulfite '7757-83-7 ~ 2 mg!m3 3-8 1000#/ N/A Potassium Sulfite 10117-38-1 N/A I_2 N/A N/A Sodium Carbonate 497_19_g N/'~ 1-3 N/A N/A Hydroquinone 123-31-9 N/'`~ I -2 N/A N/A Water 7732-18-5 2 mg/m3 85-90 N/A I #/S 00# N 111 - P~ sisal D t N/A NIA a a Soiling oint: >212o p, Vapor ressurc (mmTC I 0 g)~ 7 Specffie Gravity: 1,070 Vapor IDensi ty (nttnNg); O.G Solubili~ in Water: Complete Percent Yolatfle by Weight: 60% Appear nee aad Odor: Pale yellow odorless Evaporation Rate: N/A , pT~: 10.6 ylY- F' a and Ex losion Hazard Dat a Flash P int: None Extingu skiing Media: Use method appropriate for surrou Special Fire FightlYig proce:lur'es; U nding fire. se protectiVC clothing to prevent contact with skin and eyes. Unttsua~ Fire skid ;Exploslolts Hazards: When heated to dccom osidon i possibly CO, p , t can emit toxic fumes o f $p2, COZ and - nn:u[n riaxard llata TLV (ACG1Id): Itjydroquinone (2mg/m3), potassium Hydroxide (2mg/m3). Tnhalatien: Low haaard for ordinary industrial handling. EYcs~ Vapor may cause inritation. Contact may cause burns. Skin: R~ pcated and prolonged contact may cause irritation. Ingestioq:: Do Not take internally. May be harmful if swallowed. Evidence of Carci?noeen• Hydroquinonc Teratog nuity: N/A Reproductive Toxicity: N/A Mutagenlciry: N/A Page ~ of 2 5440 Oakbrook Parkway • Norcross, GA 30093-2251 PHONE; (770) 448-0250 • FAX: (77p) 448.0257 SbibZ'd Q3I~~d WdZS:ZT Z0~ TI AON ~aL~~E~ oUt6Nas7~ nAa&Miti 1tESauxcES, tNC. lV~ateriai Safety Data Sbieet #D-272$OD-W5, z?2S1-WS Synergistic Products: N/A sJmereenev 1?first Aid Procedures: Skin: gash skin with soap and water. if irritation occurs, seek medical attention. Eyes: Flush with large amount ofwater for 1S minutes. Ingests n: Induce vomiting only as directed by medical personnci. Seek medical attention immediately giving full detarls f amount ingested avid toxicity. Inhala on: Move to fresh air. SECTION YJ -'R~Cacti~itY Data StAbilit~: Staiilc. lncomp~atibility: Strong bases, strong acids- ~Iazardbus Deeomposltlon Prodnets: When heated to decomposition, it can emit toxic fumes of Sb2 , COZ and possibly CO. Flazar ns Palymerizatlon: Wil{not occur. Conditi ns to Avoid: None known. SECTION VII - Shill or Leak Procedures Steps to be Taken in Case Material is Released or Spilled: Wear protective clothing as speaificd in Section V111- Ncutralizewith sodium bicarbonate. If federal, state and !peal Laws permit, flush to sewer with large amounts of water. . . Waste Disposals Neutralizt with sodium bicarbonote. If.federal, state, and/or local laws pctnut, flush to sewer with large amounts of water. Otherwise, dispose of contaminated product and materials used in cleaning up the spill in a manner Bpproved for this material. Consult proper federal, state and/or local regulatory agencies to ascertain proper disposal procedures. SECTioN VIII-Special Protection lnformatlon: 12espirat*ory Proteetioa (Specify Type): Should not be necessary under normal conditions. If exposed to vapors that exceed TLV or PEI., wear approved vapor respirator. Protectife Eouioment: Gloves: 'Impervious gloves. Eyes: Vlycaz protective goggles, Other: AS necessary to prevent skin contact- Eyewash facilities in vicinity of use. SECTION IX -Sudcial Frecautions Precautions to be Taken in Handling and Storage: po not store or consume food, drink or tobacco in surrounding area. Do not store near strong acids orbases. Wash thoroughly after handling. The information cotsrained in this material safety data sheet is furnished without warranty of any kind. The user should consider this data a supplement to other informadon gathered and must make independent determination of suitability and completeness of information from! this and other sources to assure proper use and disposal ofthe materials and the health and safety of employees and cuspomers. This statement is incorporated as part of this Material Safety Dana 5hect: Revised: March 22, 1994 gage 2 of 2 5440 Oakbrook Parkway • Norcross, GA 30093-2251 PHONE: (770) 448-0250 • FAX: (770) 448-0257 SbiS2 ' d Q3I1~d WdzS : zj z0 ~ S Z P,ON i HAZARDOUS MATERIAL MANAGEMENT PLAN '~~ CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIAL INVENTORY ~. ~S MEW O ADD .? DEL-ETE n REVISE 200 _, _~ BAKERSFIELD FIRE DEPARTMENT ~`ys- -~~~; Prevention Services f ~- --~`; ,`~ B ~~~, n a s F_ ~~H~t a 1600 Tfvxtun Avenue, Suite 401 ~.; . ~.;~, >rIRaT t~~' BakeTSfieid, CA 93301 ,E~,~ARf/IIF~T Pfione: 661-326-3979. Fax: 661-852-2171 Page 1 of 2 ~ _~, ~ ~ ` (One form_aer_material. oer_bvltt)ino. or area.) I. FACILITY INFORMATION SINESS AME {FACILIT'Y NAME or DBA) 3 CHEMICAL OCATION 201 ...~ C ~ ~ ~ ~ ~ ~I / /~ ~ ~~ CHEMICAL LOCATION 2a2 CONFIDENTIAL. (EPCRA) ^ Yes ^ No ~ ~'{ ~ ' ~~ ~ f , ~ G ,'. FACILITY Ip # ~ 1 MAP ~ (oDtionap~_`^ _ _-_-- 203 GRID # (optianat)!_- 204 `~ ~ II. CHEMICAL. INFORMATION CHEMICAL NAME 205 206 TRADE SECRET Ll Yes ^ No If subject to EPCRA, nder [o tnstructlons COMMON NAME 207 _ ~ ~ ~~~,..~ ~~ f a ` EHS' G' Yes i) No 208 ~ 209 CAS # ~~~ ~tf ENS is yes, at! amounts bebw must be in _ ----_ . _ _. - -____..._.-_ _ .. --" pamds. ~- ~ ~ _ _-__.....___._W~_.~..__._.____-_ ~. .. .. _ . . .~- - { 210 co rnpleee if requested by lot ai Rre chief) FIRE CODE HAZARD GASSES ff `` // tt ,^, , r ~ ~'~ ~~ ' YJ - Cir 24.1 4 l PE 211 ~O ~~ /lt~ ~ PURE ~; MIXTURE U WASTE `~Y 212 RADIOACTIVE: ^ Yes ^ No . CURIES 213 i/ UID =: Ga PHYSICAL STATE ~ SOLID t~ Li 2 4 LARGEST CONTAINER ~ 215 Q S 1 ~~ ~~ 226 FED HAZARD CATEGORIES FIRE ~~ REACT[VE fJ PRESSURE RELEASE _ ACUTE HEALTH .~ CHRONIC HEALTH (Check ail that aDPh) -. ---~-- _~__-- -^ ---------~~ ANNUAL WASTE 217T ue MAXIMUM AVERAGE `--219 STATE WASTE '220 AMOUNT ~ ~~~ ~1 c~ ~ DAILY AMOUNT DAILY AMOUNT Lis CODE 222 GAYS ON SITE 222 UNITS' Lu GAL _; CU FT ^ LBS ^ TONS n HIS, amount mcat be in tbs. STORAGE CONTAUVER: 223 ABOYEGROtlND TANK ~ CAN ^, BOX ~ TANK WAGON UNDERGROUND TANK ! CARBOY ^ CYLINDER ^ RAIL CAR .: TANK [NSIDE BUILDING ~ SILO ^ GLASS BOTTLE ~r -OTHER ^ STEEL DRUM J FIBER DRUM ^ PLASTIC BOTTLE ^ TOTE BIN .. ! PLASTIUNONMETALL)C DRUM n BAG 224 STORAGE PRESSURE: ^ AMBIENT ^ ABOVE AMBIENT BELOW AMBIENT 225 STORAGE TEMPERATURE: ^ AMBIENT C: ABOVE AMBIENT BELOW AMBIENT v CRYOGENIC _ _ %WT HAZARDOUS COMPONENT ^ ~ ~ ENS --..--- -------`- CASv# ---_.~._ 1 226 '` :l': i%~' ~-" r» ~{~'1~., i1~ p`~ ~ ~ !~ ves r No 228 ~ - ~' - zz9 2 230 231 (] Yes fl Nd 232 ~ 233 3 23a r ~ 235 ^ Yes ^ No 236 237 4 338 ,. 239 (_i Yes !' NO 240 241 5 2a2 2a3 ~ Yes ii No 244 245 III. SIGNATURE PR NAME rk TITLE OF A IZED COMPANY REDRESENTATI _ ~ SIGNATURE ^^ ~ DATE 2a6 i ~ ' - ~, - !/ U - 7~ FD2144 t(Rev ~6/OZ) '~ v E DEhtTAL AMALtiAM ALLOY . MAT_ ~RIgL SAFETY DATA SHEET ManufaCturad by: Getdamlth G Rovsre 2~2-South Dvan Strvst Engfaweod, }t„ 076;!i (201).894-53CQ inyradlflnts: Sitvnr Capper 71n Zinc (it not marked "Non-,~lne"} Physical Ghsracterlattcs: Appearance: Snvsr ca(arrd powder Spoaltlc Gravity: 9gt;itc+-. Mvft€nL Pairt: 15iJd°C - Sitvor powder alloy can be a cc;;ribus- tibta solid. - Taxtc fumes msy ba t?rusiucsd in 8 titfl. • Uav dry cnemtcats ap;^_roprlatts for,extingulshtng matat`fRas.' ' - Da not use water: Ho»ith Hazard data: Routes of entry, (nhal»tlan OSHAtiitjal ilrnlt for 8-hour sxpossxs is t).t7tmg/rti3 Skirl !t akin pontacia st(v»r dust or smatf par- tiele5~or.Fars sm»tt Cvts, teitootng rn~y occur,. Wash. thoraughiy to prevent statriin~. EYs Flush immodiststy With a large quannt). of water. Soak msdica€ aEteniian. HaHa±idt€n~g b~. Storaz3s: • Friar to working w?th ahoy y«, should by trained on its props; handitng find storago. - Thls sliver snot' must bo stored to avoid contact with acsi~yESns,~ arnmonla, hydragan~paroxitla, or athylonaimanv since a violent roactlon win occur. Gvnerni Prvcoutlons: Avoid bra»ttrit7g dust, avoid sk3,a Con- tact. MERCURY (IF ALLOY IS CAPSULATLa) FviA7-ct~lia,L SAFETY DATA SHEET Distr€butad bv; Gotdsmtih {~ Rvvsra 242 South Dsar, Stravl Eny~iawood, tiJ ~763t (201) 884-56r39 CAS F1um~Qr_ Da: Numt.r:r: 7439.97-8 - l}N?809 t3SNA Pei; _r^,~iCIN 7t.V' 0.t mg }{g/m-t ~ G.Cti my tigtrt3 Physical Charactvrist~cs: - Appearance: Silver coiCred linuid Specli'tC Gravity: t0 fmree k!aitin0 Pn;n!' Lt;tnt,i ri rntini titm€.r:r. ntt:rn < i30it: nL }~Clilit: tl(.?°(~ Firms Fiotnrti' ` Pa"ssanous ties produced ir. tire, ' Ua6 dry Cnam€CRI, ~~~_, water apt Ay, or lasm DXti ng Uta Ele=.'. ' Mercury moat be stared to evnt~ contact with Ct?lorina dlaxtdc, nitric ac€d, n€U`etea, a:hg~€ene axtde, C131ar- trs and n:athytaz(GO. Violent rsae- ttana Wt€I aCCUf.. Health iinzard Detn:. .. Acute Haatth Etfect:; The tanawtn;y acute (short-t9im) health streets may occur Immedtntety or shortly char ex- posure to hierctiry. 'Exposure to high revers of t,lercvey vapor (7.2 mg/m3) can ttritata the EungE, coustng cough. chart tightnea:, ahart- ness otbreath end raver, Thta uaaiatiy bagir Fs ono to tour hours attar exposure and can .Qo nn tti fluid In the tun;,a (pulmonary edema} and death, Chronic Neaf3h E#faats: Tha #o#owing chronic (tonp•term} health etfecta cnn occur at aoirte lima attar axposuro io Marrury and and can tent for mantht or years. ' Rspseled tow gxpoavra cr a vary ttlgh single exposure can cause Marcury,pgtaoriCnp. Symptoms In- clude trainbr#`{ahaktng), trouble remembering and concantrattnQ, gum problvma, increapad aativatlon, lass ui apposite and wsipht, ~BRd' bhanfla's ln`mood and,pera,oriatity. ` Rapeat~ed vzipar exposures (usually ntiare~than Nva yeat8) c,a,n pause clouding al the eye lens. ' Mo{curt' rrsey cause a itrln energy, it aiioigy~de.veihps, v©ry tcw ~futnie oxpoautes can cause t4chlrig`snd a skin rash::. '. Exposures can cause:ktdriey dflmagv. • }daraury may towsr sax drtva, tlaz~ard .~zununr±rY; "Msrcury car. attoci you wttan orvattivd lrt anq~by passing ihrotrgh ya~r sxin, ' High tixpr~swa can cause Chart pairs, shorintiss of breetki,'and a buP€d-up at tlutdlnthti tAngS (pt3tmorary adsme). Tti3s can cauia dttath. " Rsjieatad exposures asri cuusv Mer- curypotsoning vrtlh kEdnay dlseaso. irarnars, hum probletns,.iroubls ramomboring and conpentratlnp rind ehangos to mood. ' [.ang-lafm expa3Ufa Can CnUSa cicuding os iha ayss. ' Msrcury is a CiJRROS€VE CHEi.'- iCAI. Precautions tar Sata Htindtinp: " Arior to vrorking with Msrcury, you should bs trained to Its proper t:an_ dtlnQ and storage. ' Avoitl contact with skin. ' SplEl should ba cleansd up imms- d;atflly. Kits stiact(ic for cleanup of Msrcury are avallabto. ' It is necessary to dispose of Mercury as haz»rdous wasto. VrARNth;G: Ttiis product contains a Chamic»; known to the Stara al CalitCrnia in rnusa hlrt€i dnlnCls or nilivr rrprad:r^- tivo hsrut- t'st93 ~. ._ s ~ -....._.... v i I ,~'~r~-•~it MEDICAL WASTE TRACKING FORM NUMBER ~~ ~~ Stericycle ® i IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-234-0051 ~, >tinut~ ~: 501 - o t~~vr~~o~~~~ 1 1: Generator's Name, 'Address and Telephone Number ~ ~~ ~ ~ .ATT'rd: Tammy Sera=Y~ev ~~ ~~~~~~~~~ ~ ~ fi ~ ~~~~~~ ~1 ~~ ~ ~~ ~ ~ ~~~ C~LIFC~RNIA Ct?LLEO'E OF ~~~?~" CAR ' ~82t F 3TREFT STE $ 1?~REfiSFIELD, O'.A 43301. (661y 383-E731 cli8i:?00'T CUSTOMER NUMBER ~° tt t ~ ~, ~ L'r .~. (~ ©~ GENERATOR'S REGISTRATION # 2A. DESCRIPTION OF WASTE ZB• CONTAINER TYPE 2C. NO. OF 2D. VOLUME CONTAINERS REGULATED MEDICAL WASTE, n.o.s., 6.2, TB57 - 30 Ual Tuh (Big:,} {12 etc f1;} Cu Ft UN 3291, PG II . REGULATED MEDICAL WASTE, n.o.s., 6.2, r~B~ l5 _ 4 +~ Cal Tu}? (Bio} {,5 . {J ~u ft} C Ft UN 3291, PG II u . ~ REGULATED MEDICAL WASTE, n.o.s., 6.2, TB21 - 20 r3sl Tub (Bin) {~ - + Cu ft) ~ } ~• ~~ C Ft 0 UN 3291, PG II u . REGULATED MEDICAL WASTE, n.o.s., 6.2, rrB2~j _ 10 Cal Tub j)ispr gal {l. ~3 au ft) Ft C UN 3291, PG II u . W Z REGULATED MEDICAL WASTE, n.o.s., 6.2, UN 3291, PG II TBlS - ~0 Ccal Tuk+ (g'ath} (;Z .'} ~u f'G) Cu Ft. W REGULATED MEDICAL WASTE, n.o.s., 6.2, UN 3291, PG II TYIS - Gtt f+al Tut {r_'1'y~p} (~ .'~ cu $t) Cu Ft. REGULATED MEDICAL WASTE, n.o.s., 6.2, UN 3291, PG II Cu Ft. REGULATED MEDICAL WASTE, n.o.s., 6.2, UN 3291, PG II Cu Ft. PhalTnac~utical V`das?e Cu Ft. 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ~ ~ ~ ~ Cu Ft. described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations." e ~ a "~i-f ..{~ ~~l ~;"1 ~ /'!.".` `Y`!".~ >`%z %t ~lei iz~ ~ ~ -- `z'k ' X ~ . t, ;; .- - r7 PrintedlTyped Nam ~ Signature . Date ~ 4. TRANSPORTER 1 ADDRESS: ~ .Phone.#: { 8 0 (Y) ~~,~~ - 9 c 7 8 w Bt~ri::~ele - `v'ernon ~ Applicable Permit Numbers; ~ ~??:~ Eases '36tH B'tr~~b Q O ~ This is a Thresucxh $I^ii~r4leFit ~ N ~.~erron,C.~. 90D23 a ~ TRANSPORTER}CERTIFICATION: Receipt of medical waste as described above. '~ fir-, ,3 ~ ~~ ., ~--~-"- ~ 1~~- t=~- ~ ~ /~ M~ P i UT N , r n ype ame Signature Date 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: / N W w a ~. Applicable Permit Numbers: K ~ J W Zw= INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. ~? ~ PrinUType Name Signature Date ~., W 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: la Q ~ Applicable Permit Numbers: ~OJ W d zw= INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. z _ . F. PrinUType Name Signature Date r 7. DISCREPANCY INDICATION Transferred ~ntainers. t;u ~ to ~ ~ ~ ~ 8A. Designated Facility: ~ 8B. Alternate Facility: ~ 8C. Alternate Facility: ~ 8D. Alternate Facility: ~ 8E. Alternate Facility: J d € Autoclavable Treatment Autoclavable Treatment Autoclavable Treatment Incineration Treatment U y = a Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. i ~ 3 t 277 E. 26th Street 1345 Doolittle Drive, Suite C 4135 W. Swift Avenue 90 North 1100 West I- E ~ CA 93722 North Salt Lake, UT 84054 Vernon, CA 90023 San Leandro, CA 94577 Fresno Z e W m" , (323) 362-3000 (510) 562-1781 (559) 275-0994 (801) 936-1555 Class V Incineration ~ a MWTF Permit # P-115 MWTF Permit # TS-31 MWTS/OST Permit # TS/OST-22 Permit #91-02 H ~ ~ MWTS Permit # P-6 MWTS Permit # TS/OST-25 Treatment by incineration Q ~~ W o ~ TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have ~ ~- ~ a received the above indicated wastes in accordance with the requirement outlined in that authorization. ~ ~~ Print/Type Name Signature Date LEAVE AT~GENERATORu.r~ = - ~--~.- ,;.- -_ - -- - - -- „~.,. ~_ _ .c- _. i.- :. ~ . _ :..~,u.._crrsccs.,u:i~-r_A..,._oinr HAZARDOUS MATERIAL MANAGEMENT PLAN 8 fl fl S A I D BUSINESS ACTIVITIES PAGE ~At~ r (HAZARDOUS MATERIAL FACILITY INFORMATION) .~ BAKERSFIELD FIRE DEPARTMENT Prevention Services - 1600 Truxtun Avenue, Suite 401 Bakersfield, CA 93301 Phone: 661-326-3979 • Fax: 661-852-2171 Page 1 of 1 - I. FACILITY IDENTIFICATION - - " FACILITY.ID # (for office use only) 3 EPA ID # USINESS NAME (FACILITY NAME or DBA) ~q~ 103 II, ACTIVITIES DECLARATION DOES Your Facility... If Yes, Please Complete... 1z9 A. HAZARDOUS MATERIAL ^ Yes No • CHEMICAL DESCRIPTION FORM 130 1. Have on site (for any purpose) hazardous material • HAZARDOUS MATERIAL MANAGEMENT PLAN at or above 55 gallons for liquids, 500 pounds for Minimum required planning elements: solids, or 200 cu. ft. for compressed gases (include • Emergency Response Plan liquids in AST and UST)? . Maps • Training • Prevention . Certification B. 11IEGULATED SUBSTANCES (RS) ^ Yes No • CHEMICAL DESCRIPTION FORM 131 1. Have on site RS at greater than the threshold • RISK MANAGEMENT PLAN (RMP Submit to USEPA) planning quantities established by the California • CONSOLIDATED COMPLIANCE PLAN Accidental Release Prevention program (CaIARP)? • Incorporating CaIARP Program Elements C. UNDERGROUND STORAGE TANKS (USTI ^ Yes No • UST FACILITY FORM 13z 1. Own or operate Underground Storage Tanks? • UST TANK FORM (one per tank) // ^ Yes L9~No • UST FACILITY FORM 133 2. Intend to upgrade existing or install new UST? . UST TANK FORM (one per tank) • UST INSTALLATION FORM (one per tank) D. TANK CLOSURE/REMOVAL ^ Yes No • UST TANK FORM (Closure section -one per tank) 1. Need to report closing an UST that held hazardous material or waste? 2. Need to report the closure/removal of a tank that ^ Yes ~No . UST TANK CLOSURE FORM was classified as hazardous waste and cleaned onsite? E. ABOVEGROUND PETROLEUM STORAGE TANKS ^ Yes o • HAZARDOUS MATERIAL MANAGEMENT PLAN (AST1 • Incorporating Federal Spill Prevention Control and Countermeasure 1. Own or operate AST above these thresholds; any (SPCC) Elements pursuant to 40 CFR Part 112. tank capacity is greater than 660 gallons or the total capacity for the facility is greater than 1,320 gallons? F. HAZARDOUS WASTE as ~ EPA ID NUMBER -provide on this page 1. Generate hazardous waste? ' ? O . To obtain EPA ID Number, please phone (916) 324-1781 2. Recycle more than 100 kg/mo of recyclable ^ Yes ENO . RECYCLING FORM material at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable ^ Yes ENO • RECYCLING FORM material at an off-site location different from the point of generation? 4. Treat Hazardous Waste on site? ^ Yes IYNO . TP FACILITY FORM • TP UNIT FORM (one per unit) 5. Subject to Financial Assurance requirements? ^ Yes C~ No • CERTIFICATION OF FINANCIAL ASSURANCE 6. Consolidate Hazardous Waste generated at a ^ Yes H No . REMOTE WASTE/CONSOLIDATION SITE NOTIFICATION remote site? FORM NOTE: If you checked YES to any part of Sections IIA - IIF above, then in addition to the forms requested above, please submit BUSINESS OWNER/OPERATOR IDENTIFICATION FORM. FD 2143 (Rev 06/07) Haardous Material Inventory -Chemical Description You must complete a separate Hazardous Material Inventory -Chemical Description page for each hazardous material (hazardous substances and hazardous waste) that you handle at your facility in aggregate quantities equal to or greater than 500 pounds, 55 gallons, 200 cubic feet of gas (calculated at standard temperature and pressure) or the Federal threshold planning quantity for Extremely Hazardous Substances, whichever is less. Also complete a page for each radioactive material handled over quantities for which an emergency plan is required to be adopted pursuant to 10 CFR Parts 30, 40, or 70. The completed inventory should reflect all reportable quantities of hazardous material at your facility, reported separately for each building or outside adjacent area, with separate pages for unique occurrences of physical state, storage temperature and storage pressure. (NOTE: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, and Business Section of the Unified Program Data Dictionary. Please number all pages of your submittal. This helps your CUPA or AA identify whether the submittal is complete and if any pages are separated. 1 FACILITY ID 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. 200 ADD/DELETE/REVISE -Indicate if the material is being added to the inventory, deleted from the inventory, or if the information previously submitted is being revised. NOTE: You may choose to leave this blank if you resubmit your entire inventory annually. 201 CHEMICAL LOCATION -Enter the building or outside/adjacent area where the hazardous material is handled. A chemical that is stored at the same pressure and temperature, in multiple locations within a building, can be reported on a single page. NOTE: This information is not subject to,public disclosure pursuant to HSC §25506. 202 CHEMICAL LOCATION CONFIDENTIAL - EPCRA -All businesses which are subject to the Emergency Planning and Community Right to Know Act (EPCRA) must check yes to keep chemical location information confidential. If the business does not wish to keep chemical location information confidential check no. 203 MAP NUMBER - If a map is included, enter the number of the map on which the location of the hazardous material is shown. 204 GRID NUMBER - If grid coordinates are used, enter the grid coordinates of the map that correspond to the location of the hazardous material. If applicable, multiple grid coordinates can be listed. 205 CHEMICAL NAME -Enter the proper chemical name associated with the Chemical Abstract Service (CAS) number of the hazardous material. This should be the International Union of Pure and Applied Chemistry (IUPAC) name found on the Material Safety Data Sheet (MSDS). NOTE: If the chemical is a mixture, do not complete this field; complete the "COMMON NAME" field instead. 206 TRADE SECRET -Check yes if the information in this section is declared a trade secret or no if it is not. State requirement: If yes, and business is not subject to EPCRA, disclosure of the designated trade secret information is bound by HSC §25511. Federal requirement: If yes, and business is subject to EPCRA, disclosure of the designated Trade Secret information is bound by 40 CFR and the business must submit a Substantiation to Accompany Claims of Trade Secrecy form (40 CFR 350.27) to USEPA. 207 COMMON NAME -Enter the common name or trade name of the hazardous material or mixture containing a hazardous material. 208 EHS -Check yes if the hazardous material is an Extremely Hazardous Substance (EHS), as defined in 40 CFR, Part 355, Appendix A. If the material is a mixture containing an EHS, leave this section blank and complete the section on hazardous components below. 209 CAS # -Enter the Chemical Abstract Service (CAS) number for the hazardous material. For mixtures, enter the CAS number of the mixture if it has been assigned a number distinct from its components. If the mixture has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the appropriate section below. 210 FIRE CODE HAZARD CLASSES -Describes to first responders the type and level of hazardous materlal which a business handles. This information shall only be provided if the local fire chief deems it necessary and requests the CUPA or AA to collect it. A list of the hazard classes and instructions on how to determine which class a material falls under are included in the, appendices of Article 80 of the Uniform Fire Code. If a material has more than one applicable hazard class, include all. Contact CUPA or AA for guidance. 211 HAZARDOUS MATERIAL TYPE -Check the one box that best describes the type of hazardous material: pure, mixture, or waste. If waste material, check only that box. If mixture or waste, complete hazardous components section. 212 RADIOACTIVE -Check yes if the hazardous material is radioactive or no if it is not. 213 CURIES - If the hazardous material is radioactive, use this area to report the activity in curies. You may use up to nine digits with a floating decimal point to report activity in curies. 214 PHYSICAL STATE -Check the one box that best describes the state in which the hazardous material is handled: solid, liquid, or gas. 215 LARGEST CONTAINER -Enter the total capacity of the largest container in which the material is stored. 216 FEDERAL HAZARD CATEGORIES -Check all categories that describe the physical and health hazards associated with the hazardous material. 217 AVERAGE DAILY AMOUNT -Calculate the average daily amount of the hazardous material or mixture containing a hazardous material, in each building or adjacent/outside area. Calculations shall be based on the previous year inventory of material reported on this page. Total all daily amounts and divide by the number of days the chemical will be on site. If this is a material that has not previously been present at this location, the amount shall be the average daily amount you project to be on hand during the course of the year. This amount should be consistent with the units reported in Box 221 and should not exceed that of maximum daily amount. 218 MAXIMUM DAILY AMOUNT -Enter the maximum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or adjacent/outside area at any one time over the course of the year. This amount must contain at a minimum last year's inventory of the material reported on this page, with the reflection of additions, deletions, or revisions projected for the current year. This amount should be consistent with the units reported in Box 221. 219 ANNUAL WASTE AMOUNT - If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled. 220 STATE WASTE CODE - If the hazardous material is a waste, enter the appropriate California 3-digit hazardous waste code as listed on the back of the Uniform Hazardous Waste Manifest. 221 UNITS -Check the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet, or tons. NOTE: If the material is a federally defined Extremely Hazardous Substance (EHS), all amounts must be reported in pounds. If material is a mixture containing an EHS, report the units that the material is stored in (gallons, pounds, cubic feet, or tons). 222 DAYS ON SITE -List the total number of days during the year that the material is on site. 223 STORAGE CONTAINER -Check the one box that best describes the type of storage container in which the hazardous material is stored. 224 STORAGE PRESSURE -Check the one box that best describes the pressure at which the hazardous material is stored. 225 STORAGE TEMPERATURE -Check the one box that best describes the temperature at which the hazardous material is stored. 226 HAZARDOUS COMPONENTS 1-5 (% BY WEIGHT) -Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available, report the highest percentage in that range. (Report for components 2 through 5 in 230, 234, 238, and 242:) 227 HAZARDOUS COMPONENTS 1-5 NAME -When reporting a hazardous material that is a mixture, list up to five chemical names of hazardous components in that mixture by percent weight (refer to MSDS or, in the case of trade secrets, refer to manufacturer). All hazardous components in the mixture present at greater than 1% by weight if non-carcinogenic, or 0.1% by weight if carcinogenic, should be reported. If more than five hazardous components are present above these percentages, you may attach an additional sheet of paper to capture the required information. When reporting waste mixtures, mineral and chemical composition should be listed. (Report for components 2 through 5 in 231, 235, 239, and 243.) 228 HAZARDOUS COMPONENTS 1-5 EHS -Check yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or no if it is not. (Report for components 2 through 5 in 232, 236, 240, and 244.) 229 HAZARDOUS COMPONENTS 1-5 CAS -List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. (Repeat for 2-5.) 246 LOCALLY COLLECTED INFORMATION -This space may be used by the CUPA or AA to collect any additional information necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance. Page 2 Of 2 FD2144 (Rev 06/07) HAZARDOUS MATERIAL MANAGEMENT PLAN SITE & FACILITY DIAGRAM BAKERSFIELD FIRE DEPARTMENT Prevention Services 8 a R S F I D 1600 Truxtun Avenue, Suite 401 F/R6 Bakersfield, CA 93301 ARTM T Phone: 661-326-3979 • Fax: 661-852-2171 Page 2 of 2 i SITE DIAGRAM FACILITY DIAGRAM Business Name: Business Address;,,,.1 ~~eZ ~ I ~~ I ~1~,t ~~ ~ ,. ~~ ~^ VV `~` NORTH Please indicate direction of North 1. HAZARDOUS M_ATERIAL_MANAGE_MENT PLAN $ $ R s p , D ~--- F~R~ INSTRUCTIONS r SITE & FACILITY DIAGRAM BAKERSFIELD FIRE DEPARTMENT Prevention Services 1600 Truxtun Avenue, Suite 401 Bakersfield, CA 93301 Phone: 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 an 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'/sx11-inch paper and drawn using a straight edge tool. ,SITE DIAGRAM INSTRUCTIONS The site diagram is used to show your business and to indicate the businesses that immediately surround your ~' 'property, 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 followirg information: ` ~ ~"" ~ "~~~`~° "u ~ `~' ~ .._' '~' '-=~ ~`~ ..~ 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 HMMP, on the top of tl~,~,dia,gram~,,,,_,_,,,. _,.:~,! . 3. Label'tha• location of the'T~azardous material and identify them by name .and type of hazard (flammable liquid;.cosrosive solid).. ~ 4. Label'.the location of utility shut-off points for gas, electric, and water ser~,ices, _ :` ~_ ~~ 5. Label:,the location of fire hydrants. ,, ~-` 6. Label'~portions of the building protected by automatic sprinkler systems. ~~ __ ~..i€ 7. Labelle direction r,~presenting north on the diagram. (The diagram form provided includes a north a rr~yy; ) 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 af~breviations 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. - i~- ,.- FACILITY DIAGRAM INSTRUCTIONS ~''""='~"='~-'~'~`~- -° ==~~-°"~ Facility diagrams are supplements to the site diagram. Use them to ~~pw:o~the subdivisiari-~det: of a large business. i. Check the box in the upper right hand corner of the form provided that indicated "Facility Diagram." 2. Prillt~~th~e=name=ofwyo~r business as shown on your HMMP. 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:faciiity..diagram shall,also specify the location gfrthe UST continuousae~monitoring system and/or the location where the UST monitoring will be performed. -~~ ~ .,~,~ FD2170 (Rev 06/07) (n ~~ ~, UNIFIED PROGRAM INSPECTION CHECKLIST SECTION 1: Business Plan and Inventory Program n r a se•_t n F/RE D ARTM Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: .(661) 872-2171 FACILITY NAME - INSP CTION ATE INSPECTION TIME ;.t;"c,.~~-~cic~ti~c~ C tte 4 C~,roO~e. `~ 17 i. ADDRESS ~ ~, NE NO. PHO NO OF EMPLOYEES /' (~ 7 ry FACILITY CONTACT BUSINESS ID NUMBER ~~~~ ~~ ~ Z 15-021- ~s... ~ .. Section,l: 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 lV ~ .J .~ s, .,, .s ,~ ^ ~ BUSIf1eSS PLAN CONTACT INFORMATION ACCURATE / ^ VISIBLE ADDRESS ..~ ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ~oo~ ^ VERIFICATION OF MSDS AVAILABILITY ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ ~ CONTAINERS PROPERLY LABELED N~ (1 `~ os~~ ~~„' 1 ~~ p.~ u ,} .,, ys ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS `W A.SnTE ON SITE? ~ YES /^ NO Lv ,~ EXPLAIN: "V ~ `~~t;- a °~ ~ `~,S a`~°L l QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661} 326-3979 Inspector (Please Print) Fire Prevention / 1s' In /Shift of Site/Station # B siness Site /Responsible Party lease Print) White -Prevention Services _ Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 ,~ r.... ~`- ~~~` CITY OF BAKERSFIELD FIRE DEPARTMENT ~~c OFFICE OF ENVIRONMENTAL SERVICES • ~P UNIFIED PROGRAM INSPECTION CHECKLIST w '' 4ti,~ 1715 Chester Ave., 3'd Floor, Bakersfield, CA 93301 ''oWIIID*' FACILITY NAME ~.\~ or ••.~ Co\~e V~ A~,INSPECTIONDATE ~~ ~ ~ ~ to c . ~ , Section 4: Hazardous Waste Generator Program EPA ID # ~~~ >`' l~ ^ Routine I$ Combined ^ Joint Agency ^Multf-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number ~ ~ ~ ~ .~ Authorized for waste treatment and/or storage Q ~ ~. p~,,,l ~~ Reported release, fire, or explosion within 15 days of occurrence Established or maintains a contingency plan and training Hazardous waste accumulation time frames ~ ~~,~ ~ ~ ~~~~ „~, q 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 ~ ~~,ec~ ~cGp:.,a~,. C~-` ln.lnr~w. 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 h/ Transports hazardous waste with completed manifest Sends manifest copies to DTSC ~•° ~ ~~ sfiy ;-•{ Retains manifests for 3 years N ~ ~~,,~-; ac-~ ~ Retains hazardous waste analysis for 3 years ~ -~~~ ~t~ C_ y~,~ ~ ~' ~'~ Retains copies of used oil receipts for 3 years N J~„ '~`~`~~" 0 Determines if waste is restricted from land disposal ~,=~,ompnance v= v ~ota[ion Inspector: ~ ~~'~-k---~-- ~ Office of Environmental Services (661) 326-3979 White -Env. Svcs. Business Site Resp sible Party Pink -Business Copy ~~~ "~ Jo. -6- I - ~rt-~~-c,+~ t-r~tL w ~ ~r c- r-t ~-t~ , c. - o c ems. (- ~ ~t ..._ . ~ .. ~,~. ~'"` - .., SELF-CERTIFICATION CHECKLIST ~'i $ ,,--~-~=..•.._ - : i FIR! ~: Fire Prevention '€ DE~ARTM1 '~ !, 4~ ~- BAKERSFIELD FIRE DEPT. Prevention Services 1600 Truxtun Ave Suite 401 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 F/~ILITY NAME: ~ 'J ~1 / ~ n 1. _Ct~~ ~r _'n c`~. `p___ ~Q,C~ o~~l pClt ~~61^Sc C~C~.~~-~~' S _____ ELF-CERTIFICATION DATE: o I ~ ~~- ADDRESS: (Complete Address with Cit .State ..nd Zip Code) Z Z.-z..~ '~-~ L Kars ~ ~ 33 of HONE MBER: 32-3 cod- ~ ~ F ITY CONTACT: AX NUMBER: • 5wz~ ~.-e-r~~.,,..dt,e~ 32.3 c~~-9Z DO NOT DISCARD - FAILURE TO RETURN .WILL RESULT IN FIRE DEPARTMENT.INSPECTION INSTRUCTIONS: Please verify and check each item as appropriate. Include comments on each line or at the bottom as necessary. hen completed, make a second et;~py for your records and mail the original to We address above. Failure to return will result in inspection. Y N OPERATION _ ^ COMMENTS _ ' Spent fluorescent tubes saved in a suitable container and recycling* I~l ^ Name: (If you rely on an outside agency for the recycling, please~indicate the name, address, and phone number of the agency that removes your tubes.) Phone No.: ddress: f~l ^ W st e batteries saved in suitable container for recycling* a ~ l / ---------~ W-~- - -------- ---- --- - --- ------ -- --- - -- ~ ^ Discarded electronic devices saved for recycling* N1~ pa ^ Discarded items containing Mercury saved for recycling* ® ^ Di$c ded non-empty aerosol spray cans saved for recycling* ~ C '~! ^ urrent annually serviced "ABC Type" fire extinguisher every 75 feet of travel ~ ^ Extension cords not used in place of what should be permanent wiring 6C ^ All exits indicated by exit signs, not more than 100 feet apart, if occupant load is 100 or more its' ^ Minimum of 30 inches of clearance in front of electrical panels ~" ^ Cover plates installed on all electrical outlets, switches, and junction boxes (no exposed wiring) ~' ^ Flammable and combustible material stored properly and not adjacent to a source of ignition (check hot water heater and furnace area) fib ^ Do yo4 use or store any hazardous materials on site? - -`~{-_ - U~a._~.,i,I.elr_,dur ~GIG~ S~s#~eTr±'_---- - ~~ -----i~e._f3iov1Jn5_f+e_~_ ^ Does your building have a monitored fire alarm system? [~ ^ Does your building have a fire suppression (sprinkler) system? -rsecycte at the Kern county spectat waste racutty, asst stanaara street, t-saKerstteta, cA 833Ut3. YtIOnQ: (661) ti6'L-89ZZ COMMENTS: ,f. C~ ~ QUESTIONS REGARDING THIS CHECKLIST? PLEASE CALL US AT (661) 326-3979 ignature . Business Site / Res onsible Party (Pleas rtnt) I1~~, L ~ '~,~~-~ XY il~ C~ta.r,d P S~ 6 ~ i ~t,a.ndc.~d~. llJl ~ ~ -~.~ " ,C ^~'~9 ~LrF 1~SSb (Rev. 09/06) "~. ~ I ~ i -----~I - ~~~ V