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Home My WebLink AboutHAZ-BUSINESS PLAN 4/1/2006tii. '.~~ .. _ _ "~~:~~~ SOUTH H DENTAL :,;~_~-; =~` 2707 S. "H" STREET -. ~; (HMMP) BAKERSFIELD FIR E DEPT. ., ,~ _.-., HAZARDOUS MATERIALS MANAGEMENT PLAN ~e Prevention Services (UNIFIED PROGRAM CONSOLIDATED~FORM) _-_ ._ ___ _,~ ____ _ ,_r.__ 9OO Truxtlin AVe., Suite 210 -._. ' -- - -- ~P~C/01~~N 8 ER3Fi D wRTSA/ r Bakersfield, CA 93301 Tel.: 661-326-3979 ~~ ~j BUSINESS O~IVNER/ OPB2ATOR DENTFICATION FORM Fax: 661-852-2171 5 ~ / (HAZARDOUS MATERIALS FACILITY INFORMATION) ~' - Page 1 of 2 ~~~~d I. FOCII ITY II~FNTtFIC4Tl(~N FACILITY ID NO. t Year Beginning too a~~6 q ) Year Ending tot BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 Sd~c Oei'1ta BUSINESS PHONE toe ~6~!- X33 $~zz SITE ADDRESS °~ ~-7 0 / cSoGl.'t~/l(, S-Ei^2efi ~IC41~•fl.e tos CITY toa ~a~~ ~e~d CA Ip 105 ~ ~ o DUNN & BRADSTREET toy SIC CODE 107 (4 Digit #) COUNTY ~~~~~ t08 OPERATOR NAME ~[ ~~~ a Yl Z tos OPERATOR PHONE ~ /` / ~2 ~~ tto - - 11. ,OWNER 1 NFORMATION OWNER NAME ~ ~ ttt .1,ac~an an OWNER PHONE ~~~' ~~ ~~ ~ /' f tt2 b a OWNER MAILING ADDRESS 1t3 ~ ~v S~ooko(u~I~ ~,1^G,~ CITY t1a STATE t15 IP tte IIL ENVIRONMENTAL CONTACT _____ _ CONTACT NAME tt7 CONTACT PHONE tt8 CONTACT MAILING ADDRESS tt9 CITY tan STATE t2t ZIP tae -PRIMARY iv. EMERGENCY coN TacTS -SECONDARY= NAME 123 u;-~;~ ~ an _ _ NAME 128 ,. TITLE 124 l~rs TITLE 129 BUSINESS PHONE 125 G6~- 7r~~. X66' BUSINESS PHONE 130 . 24-HOUR PHONE ~~ r ~ ~ ~ ~ ~ ~ ~ ~ 126 / 24-HOUR PHONE 131 PAGER NO. 127 PAGER NO. 132 133 _ --- V. CERTIF{CATION ) Cert~cation: 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 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 OWNER/OPERATOR (SDIGNATURE & PRINT) 137 J; ac~ia~~ Zan TITLE OF OWNER/OPERATOR ~ 138 ~71~5 FD 2142 (Rev. 09/05) (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 fo/%ws the data a%ment numt~rs that are on the Business Owner Operator Form page. These data a%ment numbe are used for e%ctronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section ofthe UniTied Program Data Dictionary. P/ease number a//pages ofyoursubmitta/. This he/ps our CUPA orAA identify whether the submitta/is comp/ete and Many pages are separated. 1 FACILITY I.D. NUMBER -This number is assigned by the CUPA iir ~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 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 -Enter the Dunn & Bradstreet number for the facilty. The Dunn & Bradstreet number may be obtained by calling (610) 882- 7748 or by intemet. 107 -. SIC CODE: Enter the primary Standard Industrial Class cation Code number for primary, business activity.. , NOTE.• lfcode is more than 4 digits, report only the fist 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, if different from business phone, area~code first, and any extension. 111 OWNER NAME -Enter name of business owner, 'rf different from business operator. ~ ' 112 -OWNER PHONE -Enter the business owner's phone number 'rf 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, if 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, 'rf different from the Owner or Operator, at which the environmental contact can Lie 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 ZIP CODE -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 pn 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 contact's 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 ft 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 Lie used for CUPA's or AA's to collect any additional information necessan to meet the requirements of their individual programs. Contact your local agency for guidance. 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 OwnedOperator, shall sign in the space provided. This signature cert'rfies 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 title of the person signing the page. Page 2 of 2 ~ FD 2142 (Rev. 09/05) ~. ~ , , ~~ ~~ SOUTH H DENTAL SitelD: 015-021-003470 Manager 1'IQY10~ ~~~ BusPhone: (661) 833-8822 Location: 2707 S H ST B Map 123 CommHaz Minimal , City BAKERSFIELD Grid: OlD FacUnits: 1 AOV: CommCode: BFD STA 06 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title HUIMIN ZHANG / WIFE / Business Phone: (661) 717-2166x Business Phone: ( ) - x 24-Hour Phone (661) 397-8438x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact JIACHANG ZHANG Phone: (661) 717-2266x MailAddr:~ 2707 S H ST B State: CA City BAKERSFIELD Zip 93304 Owner JIACHANG ZHANG Phone: (661) 717-2266x Address 140 STOCKDALE CIR State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: . ~ PROG H - HAZ WASTE GEN ~~ l~~ ~.N~'~ ~~~ ~ Q ~,(~Q7 E3a;=ed on my inquiry of those individua9s resprnsible for obtaining the informati I on, c~;rtify exa ne ld a m d an am familia with the mfo mation submitted and believe th i e nformation is true, accurate, and complete. Si `- ~ ~ - i, gn ture Date -1- 04/12/2007 F SOUTH H DENTAL ~ Hazmat Inventory = ~ MCP+DailyMax Order = SiteID: 015-021-003470 ~ By Facility Unit ~ Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP WASTE FIXER R L 2.00 GAL Min -2- 04f12f2007 -3- 04/12/2007 L ~ F SOUTH H DENTAL SiteID: 015-021-003470 ~ ~ 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: CAS# Liquid TWaste ^~Ambient~E ~ AmbientT~E -~STOICTCONTAINERE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 0.50 GAL 2.00 GAL 2.00 GAL rita~t~tcLUU~ ~uinrvly r:i~ 1-5 °sWt. RS CAS# Silver No 7440224 riHGHKL A.7 aL" J Jl~1L'ilV l J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 04/12/2007 L F SOUTH H DENTAL SiteID: 015-021-003470 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification _, t ,r L~LLItJLVyGC 1VV 1.11. / 7:+V 0.1.U0.1.1 V11 • / .... t lii.J 1 1 V 1V V V 1 1 ~ Li V 0.l. 1..10. 1. 1 V 11 IJ LLLCLI~. C11C:y 1"1C U1Vd1 Y1d11 -5- 04/12/2007 F SOUTH H DENTAL SiteID: 015-021-003470 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ tCC1Cd~5'C YLCVC11l.1Vil Release Containment a..l caii v~ v~.itci nc.7vui~.c til.l..1VCLl.1V11 -6- 04/12/2007 F SOUTH H DENTAL SiteID: 015-021-003470 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ w7 ~JC l:1 Cl1 L1G1 G CiL lAa Utility Shut-Offs ,„ i~i.LC r.LV~.c~...~tivaii. vva~.cL Building Occupancy Level 3p ~p1e -7- 04/12/2007 ~• . F SOUTH H DENTAL SiteID: 015-021-003470 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training rayc ~ nciu ivi r u~.u~. c voc nclu ivi ru~uic v~C -8- 04/12/2007 ~ !' SOUTH H DENTAL SiteID: 015-021-003470 Manager MARIA CONTRERAS Location: 2707 S H ST B City BAKERSFIELD BusPhone: (661) 833-8822 Map 123 CommHaz Minimal Grid: O1D FacUnits: 1 AOV: CommCode: BFD STA 06 EPA Numb: SIC Code: DunnBrad: Emergency Contact / Title Emergency Contact / Title HUIMIN ZHANG / OWNERS WIFE / Business Phone: (661) 717-2166x Business Phone: ( ) - x 24-Hour Phone (661) 397-8438x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact JIACHANG ZHANG Phone: (661) 717-2266x MailAddr: 2707 S H ST B State: CA City BAKERSFIELD Zip 93304 Owner JIACHANG ZHANG Phone: (661) 717-2266x Address 140 STOCKDALE CIR State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG H - HAZ WASTE GEN ENrp ~~~ n , E3ased on n?y ina,uiry of those indi,~lduals ] 9 2QO, res~o+~~:i~--ie `or olat~ining tt+e information, I certify under pQnaity of la."~ tha.t I have personally examined and am familiar ~t'iti't the information submitted and belie~~e the information is true, accurate, an ~ compiete. ~.r~G ~~S `~ ~~ ~~~ i nature Date -1- 07/16/2007 ~~ 5 `. F SOUTH H DENTAL ~ Hazmat Inventory = ~ MCP+DailyMax Order = SiteID: 015-021-003470 ~ By Facility Unit ~ Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP WASTE FIXER R L 2.00 GAL Min -2- 07/16/2007 ,.? g S" -3- 07/16/2007 5 F SOUTH H DENTAL SiteID: 015-021-003470 ~ ~ 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: CAS# STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid Waste ~mbient ~ Ambient PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 0.50 GAL 2.00 GAL 2.00 GAL ru-ic~tucLV~~ ~.vi~trvlvaly t a oWt. RS CAS# Silver No 7440224 IltiL~ti1CL rio oLiJ J1.1L~1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 07/16/2007 J 3 'r F SOUTH H DENTAL SiteID: 015-021-003470 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ raycii~..Y 1VV1.111VQ1.11l11 ~o CtiQn~ employee Notii.~r:vacuation ~ ~ C1no.nc~~eS _,_ , ,~ ru~ilc: ivozi= . ~ evacuation emergency ineaical rlan ~u ~ar1~eS -5- 07/16/2007 1 Y Y' F SOUTH H DENTAL SiteID: 015-021-003470 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention ~~ C~na~9es xelease ~onLainmenL ~~ ~a"~~5 dean up ~, o ~~s v~.iici Aci7VU1l:C tiC:l,lVdl.lCJi1 ~n ~~~ -6- 07/16/2007 1' ~ °~, F SOUTH H DENTAL SiteID: 015-021-003470 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ special xazaras v ~ ~~V~ ~~ Utility Shut-Offs ~ IMG~~eS rare rroLec.~r~vail. water 0 V~ ~,Qn S Building .Occupancy Level 30 1~o C~nan~e5 04/20/2007 -7- 07/16/2007 ,. =~ F SOUTH H DENTAL SiteID: 015-021-003470 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training q~'~ CMGu~~S - rayC ~ nCiu 1.vi ruI.UIC U5C 17c 11A tvt L'UI. uLC VAC -8- 07/16/2007