The URL can be used to link to this page

Home My WebLink AboutBUSINESS PLAN 3/30/2006,. ' - ~ .~-. STOCKDALE CHHtOPRACTIC CLINIC ~ 4550 COFFEE ROAD - -- - - - - _==r t> J + STOCKDALE CHIROPRACTIC CLINIC INC ___________________ SiteID: 015-021-002201 + Manager Location: 4550 COFFEE RD H City BAKERSFIELD BusPhone: (661) 587-0700 Map 102 CommHaz Minimal Grid: 16C FacUnits: 1 AOV: CommCode: KCFD STA 65 SIC Code:8041 I EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title DR ERIC TRYGGESTAD / OWNER DR I OHNSON / EMPLOYEE Business Phone: (661) 587-0700x B siness one: (661) 587-0700x 24-Hour Phone (661)- 7~/7- 4-Ho Phon (661) 588-0343x Pager Phone ( ) - x IZiG~ ager Phone ( ) - x Hazmat Hazards: React Contact Phone: (661) 587-0700x MailAddr: 4550 COFFEE RD H State: CA City BAKERSFIELD Zip 93308 Owner ERIC TRYGGESTAD Phone: (661) 589-1917x Address 4550 COFFEE RD H State: CA City BAKERSFIELD Zip 93308 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: ~ Emergency Directives: ~ PROG A - HAZMAT PROG H - HAZ WASTE GEN Based on --- - - mY inquiry of those undo risible for obtaining the informatfan,lvldugls e~amineq Hefty of law that I have I certify submit and. believe the nfforthe ~forrnatatofn accur e $ matlon is true, fete. Signal ~-----~ (~ ?~ Date ~, ~t.~~. Q~d,-~l~ ~ ~ ~ II ~~f~ ~l~enc- ~~f'S`d7-D7G~ a ~ - I7-o,e~c I~~o~ ~ - G G ~ ~ ~ ~q , -. - ~~-~~ ENT'D APR 1'2 2006 -1- 03/28/2006 E SWIDA-SKILLEN DC CHIRO CORP Manager SHANNON-~~trV~> Location: 4550 COFFEE RD H City BAKERSFIELD CommCode: KCFD STA 65 EPA Numb: 13g~~' BusPhone: Map 102 Grid: 16C SiteID: 015-021-002201 (661) 587-0700 CommHaz Minimal FacUnits: 1 AOV: SIC Code:8041 DunnBrad: Emergency Contact / Title Emergency Contact, / Title E SWIDA-SKILLEN / OWNER SHANNON~{,(~'A(~~~ / MANAGER Business Phone: (661) 587-0700x Business Phone: (661) 587-0700x 24-Hour Phone ( ) - x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact ELIZABETH SWIDA-SKILLEN Phone: (661) 587-0700x MailAddr: 4550 COFFEE RD H State: CA City BAKERSFIELD Zip 93308 Owner ELIZABETH SWIDA-SKILLEN DC -,.. Phone : ((p~Q Q ) ~~- Q'~p~c ~ Address 4550 COFFEE RD H State: CA City BAKERSFIELD Zip 93308 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParceiNo: Emergency Directives: PROG H - HAZ WASTE GEN ~~ ENT'(a APR 2 6 ~0~7 Eased on my ir~quiry of those individuals re,ponsible for obtaining the information, I certify under penalty of lavr that I have personally examined and am familiar with the information submitted and believe the information is true, accurate, a ole ~ l/ Signature Date -1- 04/18/2007 F E SWIDA-SKILLEN DC CHIRO CORP SiteID: 015-021-002201 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... ISpecHazIEPA Hazards) Frm I DailyMax IUnitIMCPI WASTE FIXER R L 5.00 GAL Minl -2- 04/18/2007 -3- 04/18/2007 F E SWIDA-SKILLEN DC CHIRO CORP SiteID: 015-021-002201 ~ ~ 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 ~mbient ~ Ambient ~ PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 25.00 GAL 5.00 GAL 5.00 GAL - ~-- tLKGHKLVU~ 1,V1~lYV1VI;1V1J cwt. Rs cAS# Silver No 7440224 riE~GE~KL 1-~~7 AL" J 51~11;1V 1 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 04/18/2007 F E SWIDA-SKILLEN DC CHIRO CORP SiteID: 015-021-002201 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 04/17/2006 ~ CONSTANT MONITORING OF RECLAIMING TANK; NEVER TO EXCEDE HALF FULL. Employee Notif./Evacuation 03/28/2006 911, OFFICE OF EMERGENCY SERVICES 800-852-7550, LOCAL 326-3979 AND/OR MID-STATE X-RAY SERVICE 559-441-7750. Public Notif./Evacuation 04/17/2006 GEOFF FESSLER, DR ERIC TRYGGESTAD, AND AGENCY NOTIFICATION. Emergency Medical Plan 04/17/2006 FLUSH, MOP UP, TAKE PERSON TO 34TH ST MEDI CENTER. WILL NOT HAPPEN DUE TO CLOSED RECLAIMING SYSTEM. -5- 04/18/2007 F E SWIDA-SKILLEN DC CHIRO CORP SiteID: 015-021-002201 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 03/07/2001 ~ CLOSED RECLAIMING SYSTEM. Release Containment CLOSED RECLAIMING SYSTEM. 03/07/2001 Clean Up 03/07/2001 CLOSED RECLAIMING SYSTEM. V1.11C 1. 1CC.7V U1. l~C til: l.lVdl.l Uil -6- 04/18/2007 F E SWIDA-SKILLEN DC CHIRO CORP SiteID: 015-021-002201 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~Nc~:ia.~ na~aiu~ Utility Shut-Offs 03/07/2001 A) GAS - NONE B) ELECTRICAL - BREAKER BOXES W END OF SUITE C) WATER - OUTSIDE W WALL D) SPECIAL - NONE E) LOCK BOX - NO Fire Protec./Avail. Water 01/11/2007 PRIVATE FIRE PROTECTION - SPRINKLERS, FIRE EXTINGUISHERS, AND ALARM SYSTEM. NEAREST FIRE HYDRANT - N ON HAGEMAN RD. Building Occupancy Level 03/28/2006 3 EMPLOYEES -7- 04/18/2007 F E SWIDA-SKILLEN DC CHIRO CORP SiteID: 015-021-002201 ~ Fast Format ~ ~ Training overall Site ~ ~ Employee Training 01/11/2007 ~ MSDS SHEETS ON FILE IN DARKROOM. BRIEF SUNIMARY OF TRAINING PROGRAM: EMPLOYEES ARE INSTRUCTED TO MONITOR LEVEL OF RECLAIMING SYSTEM TANK. rayc ~ nciu i.vi ru~ui~ ~5C nci.u iii, ru~uic v5C -8- 04/18/2007 :~ UNIFIED PROGRAM INSPECTION CHECKLIST ~` c':E'.'#@$4'.' .W.n'S",siki. w, ...v,...?CS. i.1.dt?ti:Y; t,x~.cx ~.i ...'...~:.: ,.: rN. ~i .: ~:.., . .d..<. :. .. ,...w .'1r ..?~ e.,..:t.,.. i.. 'v~: -` SECTION 1: Business Plan and Inventory Program r~i~ A~ T BAKERSFIELD FIRE DEPT Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAMES NSPECTION DATE INSPECTION TIME ADDRESS HONE NO. O OF EMPLOYEES T ~ ~O~ FACILITY CONTACT USINESS iD NUMBER 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 (~' ~ r ^ BUSlflt?SS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ^ ~ VERIFICATION OF MSDS AVAILABILITY ~' S S ~ S? ^ VERIFICATION OF HAZ MAT TRAINING C~ R%~' ~%IiIG~ ^ VERIFICATION OF ABATEMENT SUPPLIES AND CEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ HOUSEKEEPING 7~ ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDO,,/US WASTE ON SITE? C~tS ^ NO EXPLAIN: ~1~~£ ~~~~~ / _ QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (881) 326-3979 ~a d~ ~ ,a ~¢~~1 inspector (Please Print) Fire Prevention / 1°' In /Shift of Site/Station R us 5' e/School S' nsible Party (Please Prat) White -Prevention Services Yellow -Station Copy Pink - Business Copy FD2049 (Rev. 02/05) Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This ~ermit is issued for the following: [] Hazardous Materials Plan [] Underground Storage of Hazardous Materials [] Risk Management Program [] Hazardous Waste On-Site Treatment PERMIT ID # 015-021-002201 STOCKDALE LOCATION 4550 ~' C6~E:i' · 93308 ~. .. OFFICE OF ENV1R ONMENTAL SER VICES' 1715 Chester Ave., 3rd Floor Approved by: t..Uayeuu~y,r~~.: ~ssu¢ mt~ Bakersfield, CA 93301 ofnceofe~,~m'rs~i¢= ~ Voice (661) 326-3979 FAX (661) 326-0576 ExpimtionDate: J[,l~e ~0.. ~OO~ 1TI~ DIAGRA~ ~ , , FACTUTY DIAGRAM Bus,ess Name: '5-ftc..l/-~[e- C_.~'~.~C~ '~,c.-~,~. ~. Business Address:~55D ~4~ ~" 5~ ~, ~'~ ~, ~ u~ 5P ITE DIAGRAM~~ ~ .~, , FACILITY )IAGRAM [ Business Name: 61,,~kd. I,, 81~,%oca,, L 5 f ~c , STOCKDALE CHIROPRACTIC CLINIC INC SiteID: 015-021-002201 Manager : BusPhone: (661) 587-0700 Location: 4550 COFFEE RD H ~'~ Map : 102 CommHaz : Minimal City : BAKERSFIELD --'~ Grid: 16C FacUnits: 1 AOV: CommCode: COUNTY STATION 65 SIC Code:8041 EPA Numb: DunnBrad: Emergency Contact /. Title Emergency Contact / Title DR ERIC TRYGGESTAD / OWNER ''E-55A-R-~ / Business Phone: (661 587-0700x Business Phone: (661) 587-0700x f~. 24-Hour Phone : (6.61 589-1917x 24-Hour Phone : (661) Pager Phone : ( - x Pa~er Phone : ~ ~/,~ x Hazmat Hazards: React Contact : Phone: (661) 587-0700x MailAddr: 4550 COFFEE RD H State: CA City : BAKERSFIELD Zip : 93308 Owner ERIC TRYGGESTAD Phone: (661) 589-1917x Address : 4550 COFFEE RD H State: CA City : BAKERSFIELD Zip : 93308 Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: j~'~'~, i, ~,~Li{ 7',/.fi,,,/I// Do hereby certify that I have (Type or prihfname) reviewed the attache(~ hazardous materials manage- ment plan for ~½%!~/~,.~r.. ofu//~;wr"~/' '~b'-.~,r~;) t. ~.and that it along with any corrections constitute a complete and correct man- agement plan -1- 12/01/2003 STOCKDALE CHIROPRACTIC CLINIC INC SiteID: 015-021-002201 ~ Hazmat Inventory By Facility Unit -- MCP+DailyMax Order Fixed Containers at Site Hazmat Common Name... ISpecHazlEPA Hazards Frm DailyMax UnitlMCP WASTE FIXER R L 5.00 GAL Min -2- 12/01/2003 -3- 12/01/2003 STOCKDALE CHIROPRACTIC CLINIC INC SiteID: 015-021-002201 ~ Inventory Item 0001 Facility Unit: Fixed Containers at Site WASTE FIXER Days On Site 365 Location within this Facility Unit Map: Grid: IN DARK ROOM CAS# F STATE -- TYPE PRESSURE i TEMPERATURE CONTAINER TYPE Liquid Waste Ambient Ambient PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container I Daily Maximum Daily Average 25.00 GAL 5.00 GAL 5.00 GAL HAZARDOUS COMPONENTS Si lver NoRs 7440224 TSecret S BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No N No No/ Curies R / / / Min 4 12/01/2003 F STOCKDALE CHIROPRACTIC CLINIC INC SiteID: 015-021-002201 Fast Format ~ Notif./Evacuation/Medical Overall Site --Agency Notification 03/07/2001 CONSTAlgT MONITORING OF RECLAIMING TANK. NEVER TO EXCEDE 1/2 FULL. -- Employee Notif./Evacuation 03/07/2001 911, OFFICE OF EMERGENCY SERVICES (800) 852-7550, LOCAL 326-3979 AND/OR MID STATE XRAY SERVICE (559) 441-7750. Public Notif./Evacuation 03/07/2001 GEOFF FESSLER, DR ERIC TRYGGESTAD AND THEN AGENCY NOTIFICATION. Emergency Medical Plan 03/07/2001 FLUSH, MOP UP, TAKE PERSON TO 34TH ST MEDI CENTER. WILL NOT HAPPEN DUE TO 'CLOSED' RECLAIMING SYSTEM. -5- 12/01/2003 STOCKDALE CHIROPRACTIC CLINIC INC SiteID: 015-021-002201 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site -- Release Prevention 03/07/2001 CLOSED RECLAIMING SYSTEM. -- Release Containment 03/07/2001 CLOSED RECLAIMING SYSTEM. -- Clean Up 03/07/2001 CLOSED RECLAIMING SYSTEM. Other Resource Activation 6 12/01/2003 F STOCKDALE CHIROPRACTIC CLINIC INC SiteID: 015-021-002201 Fast Format F Site Emergency Factors Overall Site Special Hazards --Utility Shut-Offs 03/07/2001 A) GAS - NONE B) ELECTRICAL - BREAKER BOXES W END OF SUITE C) WATER - OUTSIDE W WALL D) SPECIAL - NONE E) LOCK BOX - NO -- Fire Protec./Avail. Water 03/07/2001 PRIVATE FIRE PROTECTION - SPRINKLERS, FIRE EXTINGUISHERS AND ALARM SYSTEM. NEAREST FIRE HYDRANT - DIRECTLY N ON HAGEMAN RD. Building Occupancy Level -7- 12/01/2003 STOCKDALE CHIROPRACTIC CLINIC INC SiteID: 015-021-002201 Fast Format = Training Overall Site ~-- Employee Training 03/07/2001 WE HAVE 3 EMPLOYEES AT THIS FACILITY. WE DO HAVE MSDS SHEETS ON FILE IN THE DARK ROOM. BRIEF SUMMARY OF TRAINING PROGRAM: EMPLOYEES ARE INSTRUCTED TO MONITOR LEVEL OF RECLAIMING SYSTEM TANK. lPage 2 --Held for Future Use Held for Future Use 8 12/01/2003 Bakersfield Fire Dept.~ . J UNIFIED PROGRAM INSPECTION CHECKLIST ! Enironmental Services ~-'" .......... '"" ............ '] 171.5 Chester Ave '~',~ SECTION 1 Business Plan and Inventory Program Bakersfield. CA 93301 .J'K2 Tel: (661)326-3979 t FACII. ITY NAME IINSPECTION DATE INSPECTION TIME ADO,ESS :~ ~ONE No. l No. o, Emp,o,ee, { 15-021- ~_7..o! Section 1: Buaineaa Plan an6 inventory Program [] Routine /5~Oombin~:~ [] 3oint ^gency [] Mulli-^gency [] Complaint [] C V [ C=Compliance ~, V=Violation ) OPERATION COMMENTS [] [] APPROPRIATE PERMIT ON HAND [] [] BUSINESS PLAN CONTACT INFORMATION ACCURATE [] [] VISIBLE ADDRESS [] [] CORRECT OCCUPANCY [] [] VERIFICATION OF INVENTORY MATERIALS [] [:~ VERIFICATION OF QUANTITIES [] ~] VERIFICATION OF LOCATION [] [] PROPER SEGREGATION OF MATERIAL [] [] VERIFICATION OF MSDS AVAILABILITYE [] [] VERIFICATION OF HAT MAT TRAINING [] [] VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES [] [] EMERGENCY PROCEDURES ADEQUATE ~ CONTA,NERS PROPERLY ~BELED , 1 ~_t__c.,~_. ~__ ~._._.~.7~_~....~.~ [] [] HOUSEKEEPING [] [] FIRE PROTECTION [] [] SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE?: I~YES [] No EXPLAIN: g.,'~'~."T'L~_ ~'~ QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 32~ ...... ~-' --/---/~-'~lnspector .......................... ~-- '~-Badge No., ................ ~:~---~ '~-s~o-~'~i~'a~y ............. White - Environmental Services Yellow - Station Copy Pink - Business Copy CITY OF BAKERSFIELD FIRE DEPARTMENT 1/ OFFICE OF ENVIRONMENTAL SERVICES V~,~, C? UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ~ T-~_.gr.'.'.'.'.'.'.'.'.'~ ff_A4t~~tc... ~SPECTION DATE ~t~3 Section 4: Hazardous Waste Generator Program EPA ID g ~ Routine ~ Combined ~ Joint Agency ~ Multi-Agency ~ Complaint ~ Re-inspection OPERATION COMMENTS Hazardous waste determination has been made EPA ID Number (Phone: 916-324-1781 to obtain EPA ID #) 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 C=Compliance V=Violation Inspector: Office of Environmental Services (661) 326-3979 ible Party White - Env. Svcs. Pink - Business Copy CITY OF BAKERSFIELD OFFICE OF ENVIRONMENTAL SERVICES 1715 Chester Ave., Bakersfield, CA (661) 326-3979 HAZARDOUS MATERIALS MANAGEMENT PLAN c~t ~. : R~further a ¢Sre~cce TYPE/PRINT ANSWERS IN ENGLISH. bin 30 day ipt. //~.. a 1'¢~] ~u/J! / 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. 5. You may also attach Business Owner / Operator Form and Chemical Description Form(s) to the front of this plan instead of completing SECTION I. below for initial submission. SECTION I: BUSINESS IDENTIFICATION DATA LOCATION: - ' ill ' . ~ / EMERGENCY NOTIFICATION CONTACT TITLE BUS. PHONE 24 HR. PHONE /11 . -' _ HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II. 1: DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: C. ENVIRONMENTAL RESPONSE MANAGEMENT: D. EMERGENCY MEDICAL.PLAN: 2 HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION II.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: B. RELEASE CONTAINMENT AND/OR MITIGATION: C. CLEAN-UP AND RECOVERY PROCEDURES: .'~ ~/~,ot e.<~l~,...;7 <1~>,.- UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS/PROPANE: ~iO/O ELECTRICAL; WATER: O~.Jr~.,-dt l~e~ '~a[/ t ' '' SPECIAL: LOCK BOX: YES/NO IF YES, LOCATION: PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. PRIVATE FIRE PROTECTION: - ~"[t,'^k/tr'~, /CT[ct B. WATER AVAILABILITY (FIRE HYDRANT>:- HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION III: TRAINING NUMBER OF EMPLOYEES: ~ MATERIAL SAFETY DATA SHEETS ON FILE: BRIEF SUMMARY OF TRAINING PROGRAM: CERTIFICATION I, CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE. I UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIV. 20 CHAPTER 6.95 SEC. 25500 ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY. SIGNATURE TITLE DATE 4 Ol E OF ENVIRONMENTAL ;ERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 BUSINESS OWNER / OPERATOR IDENTIFICATION FACILITY INFORMATION Page Of BUSINESS ~E ~Sa~e a~ FAC~ NAME or DBA-~ng Business ~) 3 BUSINESS PHONE DUN & ~oa SIC CODE B~DSTREET (4 Digit g) COUN~ OWNER NAME ~ ~ ~ O~ER PHONE ~ ~ ~ ~ ADDRESS ~ ~ .... CONTACT ~ILING . ~ r n t ~ .x, , TITLE BUSINESS PHONE ~/'T~7-O 200 ,26 BUSINESS PHONE ~/- F~2-6 ) ~ PAGER ~ t~ PAGER ~ Ce~ifionlion: Based on my inqui~ of ~ose individuals responsible for ob~ining Ihs info~alion, I ~i~ under pen~l~ of law ~at I have personally examined and am ~milinr ~ Ihs in~nlion submiBed in lhis invenloD and believe the info~alion is l~e, ao~u~le, and ~mplele. NA~ES OF ~NE~OPEBTO~ (pri~l) ~j TITLE OF OWNE~OPE~TOR UPCF (7}99) S:\CUPAFORMS\OES2730.TV4.wpd B I FImE I OFFICE OF ENVIRONMENTAL SERVICES t ,a ttrM r 1715 Chester Ave., CA 93301 (661)326-3979 H RDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one fo~ per matedal per building or ama) 200 Page L of ~ NEW ~ ADD ~ DELETE ~ REVISE BUSIN~S~ NAME (Oa~e as F~CJLI~ ~ME ~ ~BA - Doing Busin~ ~) 3 FACILIWlD~ ~ .[~ : '~/~ ~ I ~P"(op~.~ 20~(op~onaO 2~ ,~.~.' :~ 4~ ..~-".~. : :< ~ ~ ;~.:.~.~: :~: ::: ::::~ '~A~~ '~,~:~:~ ~ ~,'~.'~'~:' ,:~' ~4:~:~ ~: ~:~: ~:.~ .;'F%~:; .:~:~ :~3g~:~ ~ ~: : ,, ' :~ .:: ~4 :~ ~:~: ;~: <. ' {.: ,~b*. -~ - ::*. : · . 205 T~DE SECRET ~ Y~ ~No 206 CHeMiCAL NAM~ ~ ~ F~ ~ If Subj., to EPC~. refer to inst..ions ~M~N ~ME ~. 207 EHS* ~ Y~ ~ No FIRE ~DE H~RD C~SS~plete if ~u~t~ by I~1 fire ~i~ 210 ~PE ~ ~RE- ~ m MITRE ~w WASTE 211 ~DIOACTIVE ~ Y~ ~No 212 CURIES 213 (Ch~ all that apply) UNITS* ~ ga ~L ~ d CU ~ ~ ~b LBS ~ tn TONS 221~ DAYS ON SITE · ,f EHS. am~nt must be in ,bs. i~,'ly STOOGE CO~AINER ~a ABOVEGROUND TANK ~ e P~STI~NONMETALLIC DRUM~ ~ i FIBER DRUM ~ m G~SS BO~LE ~ q ~IL.CA~~ (Check all ~at apply) ~ b UNDERGROUND TANK ~ f ~N // ~ j BAG ~ n P~STIC BO~LE ~ ~ ~OTHER ~ c TANK INSIDE BUILDING ~ g CAR~Y ~ k BOX ~ o TOTE BIN ~ ~ d STEEL DRUM Dh S~ D, CYLINDER Dp TAN~N STOOGE PRESSURE ~ a AMBIE~_ ~~ a ABOVE AMBIE~ ~ ba ~4 ~ 227 [] Yes [] No 228 3 234 / 235 ~ Y~'~ NO 236 ~7 / /- 239 4 238.-~ ~ ~ Y~ ~ No 240 241 5 242 ~ * .- -.~'~'" 243 ~Y~ ~No 2~ 245 PRINT NAME & TITLE OF AU~ORIZED COMPANY REPRE. SENFATIVE DATE UPCF (~/99) S:~CUPAFORMS~OES2T3~.~4.