Loading...
HomeMy WebLinkAboutBUSINESS PLAN 7/2011} __._ GENE HUGHES, DDS 200 S. MONTCLAIR ST., #D -_ ~~~ _ ~ ~ 0 1 . HUGHES DDS GENE Manager ANNE MAXWELL Location: 200 S MONTCLAIR ST D City BAKERSFIELD CommCode: BFD STA 11 EPA Numb: SiteID: 015-021-002346 BusPhone: (661) 835-7389 Map 123 CommHaz Minimal Grid: 02A FacUnits: 1 AOV: SIC Code:8621 DunnBrad: Emergency Contact / Title Emergency Contact / Title ANNE MAXWELL / OFFICE MGR GENE HUGHES DDS / ORAL SURGEON Business Phone: (661) 835-7389x Business Phone: (661) 835-7389x 2 4 -Hour Phone ( 6 61) 3~ =x~~-Q~p 2 4 -Hour Phone ( ) - x Pager Phone ((~~ )~~ -7~x Pager Phone ( ) - x Hazmat Hazards: React Contact ANNE MAXWELL Phone: (661) 835-7389x MailAddr: 200 S MONTCLAIR ST D State: CA City BAKERSFIELD Zip 93309 Owner GENE HUGHES DDS Phone: (661) 835-7389x Address 200 S MONTCLATR ST D 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 ENT ~~~ ~ p ~Q~7 ;:•r~<;,;~d or my inc;uiry of those individuals respen^ibie for obtaining the information, I certify under penalty of iaw that I have personally cixamined and am fami iiar with the information submitted and believe the information is true, accurate, and complete. Signature Date -1- 07/12/2007 ' , F HUGHES DDS GENE SiteID: 015-021-002346 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... ~SpecHazIEPA Hazards) Frm I DailyMax IUnitIMCPI WASTE FIXER ~R L 5.00 GAL Mini -2- 07/12/2007 -3- o~/la/aoo~ F HUGHES DDS GENE SiteID: 015-021-002346 ~ ~ 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: OUTSIDE STORAGE RM CAS# STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TWaste -T Ambient ~ Ambient ~LASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL 5.00 GAL 5.00 GAL HAZARDOUS COMPONENTS oWt. RS CAS# Silver No 7440224 riHGA1tL 1~55L.7,51~11"~1V 1 a TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 07/12/2007 F HUGHES DDS GENE SiteID: 015-021-002346 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 05/17/2006 ~ 911 FOR EMERGENCY CALLS, OFFICE OF EMERGENCY SERVICE 800-852-7550 AND EMERGENCY TELEPHONE CHEMTREC 800-424-9300. ANNE IS RESPONSIBLE FOR MAKING ALL THESE CALLS. CA DEPT OF TOXIC SUBSTANCE CONTROL 916-324-1826 CAL/EPA HAZARD WASTE HOTLINE 916-323-6042. Employee Notif./Evacuation 05/17/2006 911 FOR EMERGENCY CALLS, OFFICE OF EMERGENCY SERVICES 800-852-7550 EMERGENCY TELEPHONE CHEMTREC 800-424-9300. ANNE IS RESPONSIBLE FOR MAKING ALL THESE CALLS. CA DEPT OF TOXIC SUBSTANCES CONTROL 916-324-1826 CAL/EPA HAZARD WASTE HOTLINE 916-323-6042. Public Notif./Evacuation 02/28/2007 NO PUBLIC EVACUATION NEEDED. FIXER IS A NON-RCRA WASTE A PHOTOCHEMICAL/PHOTOPROCESSING WASTE AND THERE IS NEVER MORE THAN 3 GALLONS IN OUR 5-GAL CONTAINER AT A TIME. THE 5-GAL CONTAINER IS ALSO SITTING IN A LARGER PLASTIC CONTAINER TO PREVENT LEAKS. Emergency Medical Plan 05/17/2006 EMERGENCY FIRST AID - IMMEDIATELY FLUSH SKIN OR EYES WITH WATER FOR 15-20 MINUTES. SEEK MEDICAL ATTENTION FOR EYES. SAN JOAQUIN HOSPITAL, 2615 EYE ST, 395-3000 INGESTION: SEEK IMMEDIATE MEDICAL ADVICE GIVING FULL DETAILS OF AMOUNT SWALLOWED AND TOXICITY. -5- 07/12/2007 F HUGHES DDS GENE SiteID: 015-021-002346 Fast Format ~ Mitigation/Prevent/Abatemt Overall Site ~ Release Prevention 05/17/2006 S 9'PORFTTIf1SIHE-6HP-HH'P9~B£ 4'£PR~iPL ~92P4-~~ro,-~~ n " bu.~~Xec ~.D~ Its ~'e~ ~n c ur u).d art r' ~n o. 1 ~ra~ c~ 5~~~Q~r~ ~~~5 ~~~ ~r~Sid~r~~a ~l~hc~ jam. Release Containment 05/17/2006 Clean Up 05/17/2006 FLUSH WITH WATER, FOR SMALL SPILLS. FOR LARGER SPILLS, WE HAVE A DRY ABSORBENT (CHEMSORB) WE USE, THEN SWEEP IT UP AND PUT IN A SPILL KIT BAG. THEN CONTACT STERICYCLE AND THEY WILL PICK IT UP AND DISPOSE OF IT. V1.11G1 i\G w7VUl VG l~l.. l.1VQl.1 V11 -6- 07/12/2007 F HUGHES DDS GENE SiteID: 015-021-002346 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ JjJC C:1d1 I1dGdIU~ Utility Shut-Offs 02/28/2007 GAS - LEFT SIDE OF BLDG ELECTRIC - BACK OF OFFICE IN FIRST DOOR WATER - RIGHT SIDE OF BLDG KEY TO DOOR IS KEPT INSIDE OUR OFFICE Fire Protec./Avail. Water 02/28/2007 FIRE HYDRANT - ACROSS ST TO THE LEFT OF BLDG, DIRECTLY ACROSS FROM STE A. Building Occupancy Level 05/17/2006 3 EMPLOYEES -7- 07/12/2007 ~J3 ~. ~`- F HUGHES DDS GENE SiteID: 015-021-002346 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 05/17/2006 ~ MSDS IN BINDER IN OUR FILE CABINET. BRIEF SUMMARY OF TRAINING PROGRAM: WE RECEIVE THE OSHA REVIEW ON A MONTHLY BASIS AND DO THE EMPLOYEE TRAINING ON HAZARDOUS WASTE MAN. ETS A DIVISION OF STERICYCLE INC, 2775 E 26TH ST, VERNON CA 90023. rage ~ nC.LU ic~i ruLU.ce use nciu tvt rULlA1C u.7'C -g- 07/12/2007 ~, ~(vR~ ~° , w Prevention Services UNIFIES PROGRAM INSPECTION CHECKLIST! H P R s F. D 900TruxtunAve., suite 210 -- FARE Bakersfield, CA 93301 SECTION 1: 'Business Plan and Inventory Program ~~ ARrM t Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME INSPECTION DATE INSPECTION TIME ADDRESS ~'+ - L ZpO S . M O ice- G L P I 12 S ~" ~ HOpN~E N~O. U~ - `~j ~ . NO OF EMP OYEES FACILITY CONTACT BUSINESS ID NUMBER 15-021-bIS ~ 02\ --6Q 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 ^ BUSIneSS PLAN CONTACT INFORMATION ACCURATE ^ VISIBLE ADDRESS ^ CORRECT OCCUPANCY ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES ^ VERIFICATION OF LOCATION ^ PROPER SEGREGATION OF MATERIAL ~ .To. / ^ VERIFICATION OF MSDS AVAILABILITY - /~ , ^ VERIFICATION OF HAZ MAT TRAINING , no~ Y ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED ^ ~~ HOUSEKEEPING ~j~~~JL. C!I' trj0 ~•,-.-~ +-S~ ~l •~ /Y~.ti'~1.~-,,,,)s ^ FIRE PROTECTION ^_' ^ SITE DIAGRAM ADEQUATE & ON HAND ~~C ~ ~~~~ ~ ANY HAZARDOUS WASTE ON SITE? YES ^ NO EXPLAIN: ~.A~ °' S'~Q ~1 k4 ~~~ T ~GA -W n~ QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 Inspector (Please Print) Fire Preventio / t~` In /Shift of Site/Station # White -Prevention Services Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 ~,~ r .. ~~tOw~' 'r~`~ CITY OF BAKERSFIELD FIRE DEPARTMENT ~e d `~ c~d~ FACILITY NAME prF +~ G. I^i-E 5 ~ D S INSPECTION DATE .3~Z ~! ~ ~ Section 4: Hazardous Waste Generator Program EPA ID # ~~ ~ ~"~ ~ ^ Routine C~ Combined ^ Joint Agency ^Muiti-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number j(~ y~,~-~' 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 /~1~c71 l~ Ay V~s•~'~ AI,~ Containers in good condition and not leaking ~ ~~ -" ~t ~. ~,•~ ~ Containers are compatible with the hazardous waste ~ ~'°~-S 1 Containers aze 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 t-.1 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 .S-~''er ~' G ~ G ~ Retains manifests for 3 years Retains hazazdous waste analysis for 3 years Retains copies of used oil receipts for 3 years ~ ~ Determines if waste is restricted from land disposal ~,=~.ompuance v=vto~ac~on Inspector: ~ ~G~/~'~ ~ ~~ Office of Environmental Services (661) 326-3979 White -Env. Svcs. b OFFICE OF ENVIRONMENTAL SERVICES •'''' UNIFIED PROGRAM INSPECTION CHECKLIST '~° ti 0 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 usiness It ponst le Party Pink -Business Copy 1 >~ <~ ~F HUGHES DDS GENE Manager ~n2 ~,~IM.~t l Location: 2 0 S MONTCLAIR ST D City BAKERSFIELD CommCode: BFD STA 11 EPA Numb: SiteID: 015-021-002346 BusPhone: (661) 835-7389 Map 123 CommHaz Minimal Grid: 02A FacUnits: 1 AOV: SIC Code:8621 DunnBrad: Emergency Contact / Title 0~-~1f,2. Emergency Contact / Title ANNE KLEINHAMPLE / crror_ n~ns~lYlQf1 , ' GENE HUGHES DDS / ORAL SURGEON Business Phone: (661) 835-7389x Business Phone: (661) 835-7389x 24-Hour Phone (661) 391-9168x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact ~~~,>° NOD-~WQ.~~ Phone: (661) 835-7389x MailAddr: 200 S MONTCLAIR ST D State: CA City BAKERSFIELD Zip 93309 Owner GENE HUGHES DDS Phone: (661) 835-7389x Address 200 S MONTCLAIR ST D 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 f3ased 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. NT ~ F~ ~ ~ 8 Signature Date ZOO, -1- 02/01/2007 F HUGHES DDS GENE SiteID: 015-021-002346 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... ~SpecHaz~EPA Hazards) Frm I DailyMax IUnitIMCPI WASTE FIXER R L 5.00 GAL Minl -2- 02/01/2007 -3- 02/01/2007 F HUGHES DDS GENE SiteID: 015-021-002346 ~ ~ 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: OUTSIDE STORAGE RM CAS# Liquid TWaste ~ AmbRent~E ~ AmbientT~E ~STOICTCONTAINERE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 5.00 GAL 5.00 GAL 5.00 GAL nxc~s-ucuuu~ ~uinrvlv~lvl~ %Wt. RS CAS# Silver No 7440224 I1HGHtCL 1-~~J .7~.7.71~1L'1V-1~7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 02/01/2007 F F~iUGHES DDS GENE SiteID: 015-021-002346 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 05/17/2006 ~ 911 FOR EMERGENCY CALLS, OFFICE OF EMERGENCY SERVICE 800-852-7550 AND EMERGENCY TELEPHONE CHEMTREC 800-424-9300. ANNE IS RESPONSIBLE FOR MAKING ALL THESE CALLS. CA DEPT OF TOXIC SUBSTANCE CONTROL 916-324-1826 CAL/EPA HAZARD WASTE HOTLINE 916-323-6042. Employee Notif./Evacuation 05/17/2006 911~FOR EMERGENCY CALLS, OFFICE OF EMERGENCY SERVICES 800-852-7550 EMERGENCY TELEPHONE CHEMTREC 800-424-9300. ANNE IS RESPONSIBLE FOR MAKING ALL THESE CALLS. CA DEPT OF TOXIC SUBSTANCES CONTROL 916-324-1826 CAL/EPA HAZARD WASTE HOTLINE 916-323-6042. Public Notif./Evacuation; ~~~~~, -2,vC~CI~C~~o~ ~ee.d ec~ . ~' exec ~`° ~' ~ c~ Q phD~ ©~~m ~ c~ ~ phe~-o(~o~ess~ ~~9 ~~~ ~~ ~o~ ~ ~~~~~ ~n ov~~ 5~11~~ i S 0.(V ~ ~l- (z C.(~~ was- ~.r~ `~S V1 e~v~..t~ ~,n;~t~..~.~.~ o~~ c~~l-g m ~, ~-~--. -~ls~ 5c~. c~ 1110 ~~ ~.r~ ~~s Q~s~ ~.,~kt-~ ~ C n a ~~GS~-ic. 'tea-a~t~zS ~o ~x'e~2r~~ 1~a1~S I arc~e.r Emergency Medical Plan 05/17/2006 EMERGENCY FIRST AID - IMMEDIATELY FLUSH SKIN OR EYES WITH WATER FOR 15-20 MINUTES. SEEK MEDICAL ATTENTION FOR EYES. SAN JOAQUIN HOSPITAL, 2615 EYE ST, 395-3000 INGESTION: SEEK IMMEDIATE MEDICAL ADVICE GIVING FULL DETAILS OF AMOUNT SWALLOWED AND TOXICITY. ~ -5- 02/01/2007 F I,II7GHES DDS GENE SiteID: 015-021-002346 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 05/17/2006 ~ OUR'FIXER/DEV IS STORED INSIDE OUR OUTSIDE STORAGE ROOM IN A 5-GALLON JUG THAT SITS INSIDE ANOTHER PLASTIC JUG. Release Containment 05/17/2006 WE HAVE THE FIXER/DEV OUTSIDE IN THE STORAGE ROOM TO KEEP IT OUT OF THE WAY. WE ONLY BRING IT IN FOR A SHORT TIME TO DRAIN THE OLD FIXER/DEV WHEN WE CLEAN OUR MACHINE. Clean Up 05/17/2006 FLUSH WITH WATER, FOR SMALL SPILLS. FOR LARGER SPILLS, WE HAVE A DRY ABSORBENT (CHEMSORB) WE USE, THEN SWEEP IT UP AND PUT IN A SPILL KIT BAG. THEN CONTACT STERICYCLE AND THEY WILL PICK IT UP AND DISPOSE OF IT. V1.11Ct tcCSVU.LC:C tiC:l.lvclLlon -6- 02/01/2007 F HUGHES DDS GENE SiteID: 015-021-002346 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~Nc~:iai nca~aiu~ Utility Shut-Offs ~~ ~ C~' ~ CCU, S~IU~ ~~~' i ~ ~(~cl,~ 0-~ 6-~ ~ CQ- I ~ ~- ~~rs~- ~~~ 1r~S~c~~- ~ O~ICJ~-- ~5~~ ~ ~ ~ ~~ ~s k Frre Protec./Avail. Water ~'~c ~ ~~~~ ~ C~C~'o~S ~~ sir-e~~- ~ ~-o ~~e. 1-e~ k cod c~ ~ ~~~,d.~n , ~ 0.x-2 \'C1 Su.~- ~ ~- ~e-e~ ~~CL~~ ~ S 2 ~ ? ~ ~ , ~~~c~~~ G~Cro~S ~~~ ~~ 4 ` ~~ o~ ~~ ~~ ~ ~~~ ~~~ o~ ~~~~`~~ ~ ~~~ s ~ Building Occupancy Level 05./17/2006 3 EMPLOYEES -7- 02/01/2007 < ' ;, , F ~II7GHES DDS GENE SiteID: 015-021-002346 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 05/17/2006 ~ MSDS IN BINDER IN OUR FILE CABINET. BRIEF SUMMARY OF TRAINING PROGRAM: WE RECEIVE THE OSHA REVIEW ON A MONTHLY BASIS AND DO THE EMPLOYEE TRAINING ON HAZARDOUS WASTE MAN. ETS A DIVISION OF STERICYCLE INC, 2775 E 26TH ST, VERNON CA 90023. rays ~ •aciu ivi. i•u~..utc ~~c L1G1~A 1V1 L•ul.u1C VAC -8- 02/01/2007 ORAL AND MAX]LLOFACIAL SURGERY 200 S. Montclair St D Bakersfield, CA 93309 (661) 835-7389 · ~ax 835-0317 GENE HUGHES, DDS Manager : Location: 200 S MONTCLAIR ST D City : BAKERSFIELD CommCode: BAKERSFIELD STATION 11 EPA Numb: SiteID: 015-021-00234~ BusPhone: (661) 835-7389 Map : 123 CommHaz : Grid: 02A FacUnits: 1 AOV: SIC Code:8621 DunnBrad: Emergency Contact / Title ANNE KLEINHAMLE / SURGERY ASST Business Phone: (661) 835-7389x 24-Hour Phone : (661) 391-9168xHM Pager Phone : ( ) - x Emergency Contact / Title~bu~eo~ GENE HUGHES / ORAL ,SUR~ Business Phone: (661) 835-7389x 24-Hour Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: React Contact : ANNE KLEINHAMPLE MailAddr: 200 S MONTCLAIR ST D City : BAKERSFIELD Phone: (661) 835-7389x State: CA Zip : 93309 Owner GENE HUGHES, DDS Address : 200 S MONTCLAIR ST D City : BAKERSFIELD Phone: (661) 835-7389x State: CA Zip : 93309 Period : Preparer: Certif'd: ParcelNo: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: -1- 08/13/2003 CITY OF gAKER~FIELD IFttRZ DEPARTMENT OFFICE OF ENVIIRONI~ENTAL UNiFiED P~OG~M ~NSPZCT~ON C~EC~L~ST 171~ Che~e~ Ave.~ FACILITY NAME ADDRESS Zoo FACILITY C©NTACT~,~ 0n e.__ ~ I ?..?itl DAm. D/e__ INSPECTION T~ME ~ Routine [2~'Combined 1~ Joint Agency 1~ Multi-Agency OPERATION 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 availability Verification of Haz Mat training Verification of abatement supplies and procedures Emergency procedures adequate Containers properly labeled Housekeeping Fire Protection Site Diagram Adequate & On Hand INSPECTION DATE PHONE NO. ~35-- 73 BUS~NESS ~D NO. 15-210- NUMBER OF EMPLOYEES [==~] Complaint COMMENTS ec~'r,c //0 Re-inspection Ques~ons reg.'ding this/nspecfion? Please call us at {661 ) 326-3979 White - Env. Svcs. Yellow - Station Copy Pink - Business Copy llnspector: CIlTY OF IBAKEIRSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 11715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME ~c'-~.~ M. o6-.~,C~'s ~ ~ 05 INSPECTION DATE Z/,z.~/ox-- Section 4: Hazardous Waste Generator Program EPA ID # [] Routine ~Combined [] Joint Agency [] Multi-Agency [] Complaint [] Re-inspection OPERATION C V 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 ~ 4~,0.~,~,~ ~ Inspector: ~ ~ ~ ~5 [,/~ , Office of Environmental Services (661) 326-3979 Business Site Responsible P~trty 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 INSTRUCTIONS: 2. 3. 4. 5. To avoid further action, retum this form within 30 days of receipt. TYPE/PRINT ANSWERS IN ENGLISH. Answer the questions below for the business as a whole. Be as brief and concise as possible. 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 STATE: Cfi ZIP.'~3z~r)~.PHONE: {-l~(,0t- ~ 7~2-? PRIMARY ACTIVITY: OWNER: G'~-~ MAILING ADDRESS: ZOO co, '4o s-cia_ . r PHONE: EMERGENCY NOTIFICATION CONTACT TITLE 5¢r ru BUS. PHONE 24 HR. PHONE HAZA~OUS MATERIALS MANAGEMENT PLAN SECTION II. l' DISCOVERY AND NOTIFICATIONS Ao LEAK DETECTION AND MONITORING PROCEDURES: B. EMPLOYEE AND AGENCY NOTIFICATION:' " C. E~RO~~ ~SPONSE ~AGE~: D. EMERGENCY MEDICAL PLAN: HAZARDOUS MATERIALS MANAGEMENT PLAN SECTION H.2: RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: B. RELEASE CONTAINMENT ,AND/OR MITIGATION: C. CLE~-~ ~ ~CO~RY'PROCED~S: UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) ELECTRICAL: WATER: SPECIAL: LOCK BOX: (~"~0 3 PRIVATE FIRE PROTECTION/WATER AVAILABILITY Bo PRIVATE FIRE PROTECTION,: . . a :.,-, ~1~, SJK~c I ll~7_.O~qrl v-I VO0~ __ WATER AV~IL~Y (F~ ~YD~NT): , HA~OUfi ~TE~Lfi ~AGE~NT PL~ SECTION I]1; TRAINING CERTIFICATION INFORMA:FION IS ACCURATE. I U'}qDERSTAND 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 CONSTrrLrrES PERJURY. DATE CITY OF BAKERSFIELD OF~E OF ENVIRONMENTAL S~VICES 1715 Chester Ave., CA 93301 (661) 326-3979 BUSINESS OWNER / OPERATOR IDENTIFICATION FACILITY INFORMATION Page Of I. FACILITY IDENTIFICATION ~ I! i.. I' i: t ~ I ' ~ t, 1 Year Beginning 1OO YearEnding 101 FACILITY ID # I SITE ADDRESS 3 BUSINESS PHONE ~o2 103 DUN & lo6 SIC CODE lO7 COUNTY 108 II. OWNER INFORMATION 11o OWNER MAILING ADDRESS 2-O( %' dW, r C:TY ~.~..~~kd 114 i STATE 116 III. ENVIRONMENTAL CONTACT __CONTACT NAME ~.~ ~f~ ~._~ ~. ~,i .~, ¢~,h~,, '¥~0 [~_' "? ' CONTACT PHONE CONTACT MAILING CITY 12o , STATE 121 ; -PRIMARY- IV. EMERGENCY CONTACTS 119 -SECONDARY- 122 123 125 126 130 131 127 24-HOUR PHONE 132 128 PAGER # 133 V. CERTIFICATION Certification: Based on my inquiry of those individuals responsible for obtaining the information, I certi~ 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. 135 SlGNATUT/~/F O~~TtR ! NAM E-~O.~,V~ R/(~P ~,~/~)R~(~H nj )~''-'¢ 136 DATE 134 NAME OF DOCUMENT PREPARER TITLE OF OWNEPJOPERATOR 137 UPCF (7/99) S:\CU PAFORMS\OES2730.TV4.wpd CITY OF BAKERSFIEL~II OI~II~CE OF ENVIRONMENTAL ~RVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION (one fo[m per material per building or area) I-'l NEW [] ADD [] DELETE [] REVISE 200 Page __ of __ I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 FACILITY ID #: i f!. ': i ii' ':: -] I i, ,i [ I MAP # (optional) IL CHFMICAL INFORMAIION 201[ CHEMICAL LOCATION ~'~ Yes~No 202 CONFIDENTIAL (EPCRA) 203 GRID # (optional) 204 CHEMICALNAME COMMON NAME CAS# 205 : 207 209 TRADE SECRET [] Yes [] No 206 If Subject to EPCRA, refer to instructions EHS* [] Yes ~Z~No 208 *If EHS is'Yes,' all amom~ts below must be i~ lbs. FIRE CODE HAZARD CLASSES (Complete if requested by local fire chief) 210 TYPE [] p PURE .[~m MIXTURE [] w WASTE 211,I RADIOACTIVE []Yes "~o 212 CURIES 213 PHYSICAL STATE []S SOLID ~[J LIQUID ~"-] , GAS 214 j LARGEST CONTAINER O~'~[.t[O~"~ 215 FED HAZARD CATEGORIES [] 1 FIRE [] 2 REACTIVE [] 3 PRESSURE RELEASE [] 4 ACUTE HEALTH [] 5 CHRONIC HEALTH 216 (Check all that apply) AMOUNT , DAILY AMOUNT , DAILY AMOUNT UNITS' -~ ga GAL [~'cf CU FT lb LBS tn TONS * If EHS, amount must be in lbs. 219 STATE W~_~ iODE 220 ' DAYS ON.SITE-. . 222 STORAGE CONTAINER [] a ABOVEGROUND TANK [] e PLASTIC/NONMETALLIC DRUM [] i FIBER DRUM [] m GLASS BOTTLE [] q RAIL CAR 223 (Check a/I that apply) []b UNDERGROUND TANK '~f CAN ..~'~).~1'3~,. [--]j BAG []n PLASTIC BOTTLE []r OTHER [] c TANK INSIDE BUILDING [] g CARBOY [] k BOX ~'o TOTE BIN [] d STEEL DRUM [] h SILO [] I CYLINDER [] p TANK WAGON STORAGE PRESSURE ~ a AMBIENT [] aa ABOVE AMBIENT [] ba BELOWAMBIENT 224 STORAGE TEMPERATURE [] ba BELOWAMBIENT [] c CRYOGENIC 225 %wrr ~'~a AMBIENT [] aa ABOVE AMBIENT HAZARDOUS coMPONENT EMS CAS # 229 241 23~ 23s [] Yes [] No 2~0 242 243 [] Yes [] No 244 245 III. SIGNATURE j UPCF (7~99) S:\CUPAFORMS\OES2731 .TV4.wpd OFFICE LOCATION i~b,l tar i~or-f¢-c6¢n STOCKDALE HWY. BRUNDAGE LN. SMALL STORAGE ROOM ~ -. · "' ,. WINDOW ' ' STERILIZATION ',BREAK CONSULTATION SURGERY 'ROOM ROOM ROOM - ROOM - ~ ~-- CUPBOARD ..,%~'~ .~ -- . ' ~ . ~ . ~,,.~. ~ EMpLOYEEI I .. .' .'. ', ,.' .. : : : ' ,DOToOR · · " · ' "" FRONT WIND0~I/' ~. WINDOW "· ' ' ' I DESK ._.TO ' '" . WAITING I .r~z:~,*~r~,'~ - '"* " WAITING ' ROOM [ ' .- . DESK DESK .......... ' ' . CUPBOARD