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(0Z0•Z9•96 :0w8 `t.•909 :0 .d:D) S63baad 3181SIA StIOUZE (6.6ZLZ :b00) J,mvnNNd a31b'adn 03b31N3 N011b'WbOdNI S�130 - 600060E (080.99'96 :OWB) aNdH NO llWb3d 31`dibdObddV 1N3WWOa u011elOIA aoulW II`1 !uolIeloln =A S2] 3 0 N O I IVN 3 d O 9ouelldwo0 =3 n a NO1103dSNl 3b ❑ 1NIb'1dWOO ❑ AON3Jd I11fIW ❑ AON30V iNIOf ❑ a3N18WOO ❑ 3NIlflOb*:I 'fl 5 uG..uG ssau�s,n_ _ , � \MI ..r: •. . ": ,:�., d E .��.. F., .....: �' .. . ...:....:.. ,. � .:. :.e ..c.,;.:ti .}.:. .i.._,i:,K iro dt E•... R .t......... _ ... . „ .... ..',. '� .S ., .:.:...:.................. :..,.w.. , -:. -.. .: F?•f ". .� 'LZ..,,Lv f. :.[: f .f, ff : (( _., :.. .., : € ..E < : ^-: f ': ✓ # "' ....... t '1. E `t sb A:fl E C. 1E ...if f €irl.f:e ✓.,. ._v._ ... ... L �...:I �• ., F: -_,n ILIZ-Z98 (199) :xt3 u01138asul 6L6£ -9Z£ (199) : taz ueld ssauisns sieua;ew snopaezeH � � N OI1`a3 S i0££6 VD `PIOUSJ331ea '3 ; s 1334S.H IOIZ ` ,,; 1,,,,,,,H,. N01133dSNi WVtI901Id ail =IINn saatn taS U0TjU0naJa 4 'j daa amia a iziasuaxva Y,.a ,ur r- mss,.• _ _ . _ . _ _ _ r;, __ . >.. .. a,.. c ...r.„. . r «... _ _.. ,...._.,....1r .> .... ,. F'e' alIll /MeN joadsul of juesuo b39nnN al SS3NISf18 10ViNO0 A11110' =I S33AO1dW3 d0 ON 'ON 3NOHd SS3baat/ � �y y,1M }yq'gy5 t CC 3AU N01103dSNl -31t/C] N01103dSNl �Y 31NVN A11113V=1 ILIZ-Z98 (199) :xt3 u01138asul 6L6£ -9Z£ (199) : taz ueld ssauisns sieua;ew snopaezeH � � N OI1`a3 S i0££6 VD `PIOUSJ331ea '3 ; s 1334S.H IOIZ ` ,,; 1,,,,,,,H,. N01133dSNi WVtI901Id ail =IINn saatn taS U0TjU0naJa 4 'j daa amia a iziasuaxva Y,.a ,ur r- mss,.• _ _ . _ . _ _ _ r;, __ . >.. .. a,.. c ...r.„. . r «... _ _.. ,...._.,....1r .> .... ,. F'e' BAKERSFIELD FIRE DEPT. aRTX Prevention Services UNIFIED PROGRAM INSPECTION CHECKLIST 2101 H -Street Bakersfield, CA 93301 Haz -Mat Business Plan and Inventory Program Tel.: (661) 326 -3979 Fax: (661) 852 -2171 FACILITY NAME INSPECTION DATE INSPECTION TIME zj ADDRESS PHONE NO. NO OF EMPLOYEES FACILITY CONTACT BUSINESS ID NUMBER ' qq Consent to Inspect Name /Title • Correct the violation(s) noted above by • Within 5 days of correcting all of the violations, sign and return a copy of this page to: Bakersfield Fire Dept., Prevention Services, 2101 H Street, California 93301 White — Business Copy Yellow — Business Copy to be Sent in after return to Compliance . Signature (that all violations have been corrected as noted) Date Pink Prevention Services Copy FD2155 (Rev 1/14) ROUTINE ❑ COMBINED ❑ JOINT AGENCY ❑ MULTI - AGENCY ❑ COMPLAINT ❑ RE- INSPECTION C V ( C= Compliance) OPERATION COMMENTS V= Violation d ❑ VISIBLE ADDRESS (CFC: 505.1, BMC: 15.52.020) 13/ ❑ APPROPRIATE PERMIT ON HAND (BMC: 15.65.080) ❑ CERS UPDATED FOR THE CURRENT CALENDAR YEAR (H &S 25404(e) ❑ ❑ BUSINESS PLAN CONTACT !INFORMATION ACCURATE (CCR: 2729.1) ❑ VERIFICATION OF INVENTORY MATERIALS (CCR: 2729.3) `M ' ❑ VERIFICATION OF QUANTITIES (CCR: 2729.4) ❑ VERIFICATION OF LOCATION (CCR: 2729.2) ❑ PROPER SEGREGATION OF MATERIAL (CFC: 5004.1) ❑ ❑ SAFETY DATA SHEET AVAILABILITY (CCR: 2729.2(3)(b)) ❑ ❑ VERIFICATION OF HAZ MAT TRAINING (CCR: 2732) I ❑ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES (CCR:2731(c)) LJ ❑ EMERGENCY PROCEDURES ADEQUATE (CCR: 2731) Q ❑ CONTAINERS PROPERLY LABELED (CCR: 66262.34 (f); CFC: 5003.5) © ❑ HOUSEKEEPING (CFC: 304.1) ❑ FIRE PROTECTION (CFC: 903 & 906) CO ❑ SITE DIAGRAM ADEQUATE & ON HAND (CCR: 2729.2 (3)) ANY HAZARDOUS WASTE ON SITE? ❑ YES ❑ NO E x p l a i n: i nature of Recei t: 7, ; a POST INSPECTION INSTRUCTIONS FOR RETURN -TO- COMPLIANCE: • Correct the violation(s) noted above by • Within 5 days of correcting all of the violations, sign and return a copy of this page to: Bakersfield Fire Dept., Prevention Services, 2101 H Street, California 93301 White — Business Copy Yellow — Business Copy to be Sent in after return to Compliance . Signature (that all violations have been corrected as noted) Date Pink Prevention Services Copy FD2155 (Rev 1/14) GAMBRO HEALTH CARE 3761 MALL VIEW ROAD • • Prevention Services UNIFIED PROGRAM INSPECTION CHECKLIST'- B F R s F . D 9ooTruxtun Ave., Suite 210 - _ FIRE Bakersfield, CA 93301 SECTION 1: Business Plan and Inventory Program ' ARrM Tel.: (x61) 32x-3979 - ~ Fax: (661) 872-2171 FACILITY NAME ` ~ INSPECTION DATE INSPECTION TIME ~ rt~ 9 -~ - 06 l /~ ADDRESS 3 ! ~ ~ /"T ll U PHONE NO. NO OF EMPLOYEES a ~e%t/ 87a- S 6 FACILITY CONTACT ~ ~ BUSINESS ID NUMB15-~21 ~ QQ' O ~ E. ~.1/ (/Lc~.yl0 - 3~ ~q T Section 1: Business Plan and Inventory Program. L/h ~ l Lam- ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V ~ C=Compliance OPERATION V=Violation COMMENTS ~ ^ APPROPRIATE PERMIT ON HAND ~' ^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE ~ ^ VISIBLE ADDRESS i~ ^ CORRECT OCCUPANCY .®- ^ VERIFICATION OF INVENTORY MATERIALS .~- ^ VERIFICATION OF QUANTITIES -~ ^ VERIFICATION OF LOCATION - ,®- ^ PROPER SEGREGATION OF MATERIAL ~ ^ VERIFICATION OF MSDS AVAILABILITY .~I ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ®~6 ~ ^ CONTAINERS PROPERLY LABELED ~ ^ HOUSEKEEPING ® ^ FIRE'PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? EXPLAIN: QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661} 326-3979 r~w.w~ ~ G ~ ~l ~ - Inspector (Please P int) Fire Prev tion / 1~' In /Shift of Site/Station # _ Bu ite / Respo sible Party (Please Print) ^ YES ($ NO White -Prevention Services ~ Yellow - Station~Copy Pink -Business Copy FD 2155 (Rev. 09/05 ~~GAMBRO®Healthcare 3761 Mall Uew Road Sukan Veerakul Bakersfield, CA 93306 Center Director USA www. gam brohealthcare. com Tel 661 872 9836 Fax 661 872 9933 Email sukan.veerakulQus.gambro.com INSPECTION RECORD ~~~~ Bakersfield Fire 1715 Chester e. Bakersfield A 93301 '~ ~3oz`~ DATE• 4r~4 ~ FACILITY ADDRESS: 3~~~ ~~ Jt~~ ~ ZIP: FEE: S~~_~ FACILITY NAME: ~~ T7-4C/52.~ I D~ -2ZF, C ? MANAGER NAME: BUSINESS OWNER NAME, ADDRESS, ZIP CODE FACILITY PHO BILL TO: (IF DIFFERENT FROM ABOVE-NAME, ADDRESS, ZIP CODE, PHONE No. OCC TYPE OCC LOAD No. OF FLOORS '~ HI RISE BLDG. YES O NO~ RISER DATE P/ ,~ VIOLATION NOTICE CORRECTION: 1. DATEbFREINSPECTION 2. ~` ~'E-- l T~-~n.~-.~ 0 ~ 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. NOTES ~ ~L~CI•^IS Gib ~-'~ a~ S i~~ jN/~?CR~ C`~Tn.,1/~~ GY~J lhlSP CUSTOMER: '~ INSPECTOR: ~-~ ~ ~~~ ~ No. ~ FIRE PREVENTION SERVICES (661) 326-3979 WHITE ORIGINAL-OWNER YELLOW-INSPECTOR'S COPY PINK-FILE FD1952 ~DO~ a (HMMP) HAZARDOUS MATERIALS MANAGEMENT PLAN _31'i '4..ar`'.:-_'S::i13"s;.'`sus:.4~:..'a-...e.:l..:,t:.aC.-:::~.~.oK r'~- "`'e's~e, 'ti~; ,.:A APPLICATION FORM FOR BUSNESS OMiT1EJRJOPERA'itOR DENTFICATION FORM (HAZARDOUS MATERIALS FACILITY INFORMATION F/IQ< ~wrr r BakersSeld Fire Dept. FIRE PREVENTION 900 Trtixtun Ave., Suite 210 Bakersfield, CA 93301 Tel: (661) 326-3979 Fax: (661) 852-2171 Page 1 of 2 1. FACILITY IDENTIFICATION t FACILITY ID NO. t ear eginrnng t~ N~~, Year Ending tot BUSINESS/NA~ME~(~Same as FACILIT~YpNAME or DBA- Doing Busi (.7~ "vi~E~' LLTlfkl Ci1,1.~,/~Z~ l ~~ V~ ness As) 3 USINESS PHONE tot ITE ADDRESS 3?b ~ r-1~i.~ IIr G-w ~ tos ITY 104 CA Ip tos UN & BRADSTREET toy IC CODE 4 Digit #) toy OUNTY toe PERATOR NAME toy OPERATOR PHONE tto II. OWNER INFORMATION WNERNAME ttt OWNERPHONE 71z WNER MAILING ADDRESS tta ITY na STATE ne IP ns III. ENVIRONMENTAL CONTACT ONTACT NAME tt7 CONTACT PHONE 178 ONTACT MAILING ADDRESS tty ITY -PRIMARY tzo STATE Iv. EMERGENCY CONTACTS t2t ZIP -SECONDARY- t~ AME ~ uKJ~.^1 l!G-~KUsr. 123 AME 128 ITLE ~c-~ ~ r=v_ n~~~ ~~~ 124 ITLE 129 BUSINESS PHONE ~ 2' - ~ FS h 125 - BUSINESS PHONE t30 4-HOUR PHONE 126 4-HOUR PHONE 131 AGER No 127 PAGER No V. CERTIFICATION 132 ertification: Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally xamined and am familiar with the information submitted in this inventory and believe the information is true, accurate, and complete. IGNATURE OF OWNER/OPERATOR 133 ATE 134 NAME OF DOCUMENT PREPARER 135 NAMES OF OWNER/OPERATOR (print) 136 ITLE OF OWNER/OPERATOR 137 FD2089 •(Ht1AMP) ~~ HAZARDOUS MATERIALS MANAGEMENT PLAN CHEMICAL DESCRIPTION FORM ~' HAZARDOUS MATERIALS INVENTORY NEW ^ ADD ^ DELETE ^ REVISE 200 P/R~ A t tsaxersneia mire liept. Environmental Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel: (661) 326-3979 (One form per material, per building, or area.) Paoe1 of 2 I. FACILITY INFORMATION ~~ BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 CHEMICAL LOCATION 201 CHEMICAL LOCATION 20 / ~5 ` ~ / ~~~~ ~~ L CONFIDENTIAL (EPCRA) ^ Yes ^ N FACILITY ID No. 1 MAP No. (optional) 203 GRID NO. (optional) 20 II. CHEMICAL INFORMATION CHEMICAL NAME 205 20 ~~ ~ ~ ~ ~~Sr ~ ~ TRADE SECRET ^ Yes ' ^ No ~ ~~ ~ t 5 ect to EPCRA refer to i If Sub nstructions COMMON NAME 207 i EHS' ^ Yes ^ No 20 CAS No. 209 •If EHS is "Yes,' all amounts b elow must be in lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 21 TYPE 211 21 CURIES 21 ^ p PURE MIXTURE ^ w WASTE RADfOACT{VE: ^ Yes ^ No PHYSICAL STATE ^ SOLID QUID ^ AS 214 LARGEST CONTAINER 21 s g G 3Uv 21 FED HAZARD CATEGORIES ^ 1 FIRE ^ 2 REACTIVE ^ 3 PRES SURE RELEASE ~,g ACUTE HEALTH ^ 5 CHRONIC HEALTH (Check all that apply) ANNUAL WASTE 217 MAXIMUM 218 AVERAGE 219 STATE WASTE 22 AMOUNT DAILY AMOUNT O ~~ O DAILY AMOUNT ~ CODE ^ UNITS ~ja'f1AL ^ cf CU FT ^ Ib LBS ^ to TONS 221222 DAYS ON SITE ~If EHS, amount must be in lbs. 22 STORAGE CONTAINER ^ k BOX ^ p TANK WAGON (checrr an rnat apply/ ~-er~ABOVEGROUND TANK ^ f CAN ^ b UNDERGROUND TANK ^ g CARBOY ' ' I CYLINDER ^ q RAIL CAR ^ c TANK INSIDE BUILDING ^ h SILO ^ m GLASS BOTTLE ^ r OTHER ' ^ d STEEL DRUM ^ i FIBER DRUM ^ n PLASTIC BOTTLE ^ e PLASTIC/NONMETALLIC DRUM ^ j BAG ^ o TOTE BIN 22 STORAGE PRESSURE ~a AMBIENT ^ as ABOVE AMBIENT ^ ba BELOW AMBIENT ~ 22 STORAGE TEMPERATURE ~i a AMBIENT ^ as ABOVE AMBIENT ~~- ^ ba BELOW AMBIENT ^ c CRYOGENIC °f°WT HAZARDOUS COMPONENT EHS CAS # 1 226 227 ^ Yes ^ No 228 22 2 230 X231 ^ Yes ^ No 232 23 4 238 239 ^ Yes ^ No 240 241 5 242 243 ^ Yes ^ No 244 24 III. SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIG NATURE DATE 24 ~+ ~r4roS' FD2086