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HomeMy WebLinkAboutHAZ-BUSINESS PLAN 7/30/2007o ~~~ F ~S ~~ ~~ ~ ,~,.. ~~ .LS ?1F~0 008 ~ FDI2~IFZ ~ 'd2KD ~I 21LS i ',I ~v~ 1 /~, _ _ / F~ZA~!OUS MATERIAL MANAGEMENT PLAN BAKERSFIELD FIRE DEPARTMENT I °a~~ -°' I vi P ti S ° C' ~ reven on er ces 1600 Truxtun Avenue, Suite 401 APPLICATION s e n H I p Bakersfield, CA 93301 BUSINESS OWNER/OPERATOR IDENTIFICATION FORM FIR6 Phone: 661-326-3979 . Fax: 661-852-2171 (HAZARDOUS MATERIAL FACILITY INFORMATION) AATIU T Pa e 1 f 2 g o ~~' ,/~ (~ A• 11 /1 I. FACILITY IDENTIFICATION FACILITY ID # 1 YEAR BEGINNING 100 YEAR ENDING 101 BU ^SS NAME me as FACILITY NAME or DBA) 3 BUSINESS PHONE 102 ~ ~e I _.~3 i ~ ~~~~ SITE ADDRESS 103 ~~ ~~~ /~ V ~ c T CITY ~~1`/~f~~~El.._D 104 /~~ G/"C ZIP ODE 105 ~~ DUNN & BRADSTREET # 106 0 SIC CODE 107 COUNTY ~~ ~~ - 108 OPERATOR NAME 1pg OPERATOR PHONE 110 II. OWNER INFORMATION ~VN~ NAME ~ (,-,, ~~ .., 111 pyyry~ HONE ~ ~~ ~ 112 ~^[ ~ILING ADD~ 113 ~ V~ K ~ CI I,Yj~~W~-C,`, ~~` { 114 1 ^Ut STATF~, _ 115 L/"~` ~ ZIP C,¢pE 116 G/``f III. ENVIRONMENTAL CONTAC T NTACT NAME ~~ 117 CONTACT PHONE /~ 118 l~ l- 3~ NTACT MAILI~RESS ~ q 119 CIf ~C~~`~ A ~~~~~ 120 STATE ~ • _ 121 ZJ•,p ~ ~ ~ ~ 122 „(~7~/n '~ IV. EMERGENCY CONTACTS l/`°I'A'//N~l (fir PRIMARY SECONDARY NAME Q 123 NAME 128 TITLE 124 TITLE 129 BUSINESS PHONE 125 8 - S3 BUSINESS PHONE 130 24-HOUR PHONE 126 24-HOUR PHONE 131 CE~L~L /P'H~ONE /^ ~q ~ ~ p 127 ~--~lA lJL S IJL ~ ll"~~ CELL PHONE 132 133 ' 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 information 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 NAME OF OWNER/OPERATOR (SIGN & PRINT) 137 TITLE OF DOCUMENT PREPARER / 138 ( FD21.42 (Rev 06/07) li ~~/~1 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. i 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. 308 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, 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; arid. 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 2iP CODE -Enter the zip code of the environmental contact mailing address; extra 4-digit zip may also be adiied. 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 dny 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 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 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 H s R P I nBakersfield, CA 93301 P/R/ Phone: 661-326-3979 • Fax: 661-852-2171 ARIA/ 1f Page 1 of 2 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. i3e as brief and concise as possible. SECTION ~.I: FACILITY IDENTIFICATION BUSSWESS NAME (FACILITY NAME or DBA) 'r ADDRESS (for local use only) V~ V FACILITY ID # 1 SECTION IL1: DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: B. EMPLOYEE AND AGENCY NOTIFICATION: C. ENVIRONMENTAL RESPONSE MANAGEMENT: D. EMERGENCY MEDICAL PLAN: SECTION.II.2: RELEASE RESPONSE PLAN A. HAZARD ASSESMENT AND PREVENTION MEASURES: B. RELEASE CONTAINMENT AND/OR MITIGATION: C. CLEAN-UP AND RECOVERY PROCEDURES: FD2169 (Rev 06/07) _ ~age2gf2 1{-^ •( SECTION IL2~: RELEASE RESPONSE PLAN (CONY) UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) NATURAL GAS PROPANE: ELECTRICAL: WATER: SPECIAL: PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A. PRIVATE FIRE PROTECTION: v foG 7"7h-Urt~.. B. WATER AVAILABILITY (FIRE HYDRANT): SECTION III: TRAINING NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: ^ YES ^ NO IF YES, LOCATION: BRIEF SUMMARY OF TRAINING PROGRAM: 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 OWNER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 477 NAME OF SIGNER (PRINT) a7a TITLE OF SIGNER 479 FD2169 (Rev 06/07) T" ,. y HAZARDOUS MATERIAL MANAGEMENT PLAN CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIAL INVENTORY NEW ^ ADD ^ DELETE ^ REVISE z'oo BAKERSFIELD FIRE DEPARTMENT Prevention Services ~ - - ' B B R S P I n 1600 Truxtun Avenue, Suite 401 FIg~ Bakersfield, CA 93301 AAr,i1 t Phone: 661-326-3979 • Fax: 661-852-2171 Page 1 of 2 (One form oer material oer building or area ) - I. FACILITY INFORMATION AME FACILITY NAME or DBA) B SINESS N ( 3 A , ' ~~ ~ICAL LOCA ~~ ~Qlc. ~ ~` I l~ ~~ ~ ~ ~ + ~~ / ~ n z01 ~' lY~ CHEMICAL LOCATION CONFIDENTIAL (EPCRA) ^ zo2 Yes ^ No FACILITY ID # 1 MAP # (optional) 203 GRID # (optional) 204 ,.~ II. CHEMICAL.INFORMATION CHEMICAL NAME 205 206 - ' TRADE SECRET ^ Yes ^ No © ~ If subject to EPCRA, refer to instructions OMMON NAME 207 - ~ ~N EHS* ^ Yes ^ No CAS # ~ iCD rS .n{.~~ .- ~ 209 lJ~-1 tr f , ~ ~ ~ ~ pounds. is yes, all amounts below must be In l o r-fl~, s t cJ . ~ i f i rt. ~S FIRE CODE HAZARD CLASSES (complete if requested by local fire chief) 210 TYPE 211 RADIOACTIVE: ^ Yes ~~JNo 212 CURIES 213 ^ PURE ^ MIXTURE WASTE J~ PHYSICAL STATE ^ SOLID LIQUID ^ GAS 214 LARGEST CONTAINER /, lOt~f"~ ," p 1 :~,^ ~~lJ ~-~J\,~,JY 1 215 216 FED HAZARD CATEGORIES ^ FIRE ^ REACTIVE ^ PRESSURE RELEASE ^ ACUTE HEALTH ^ CHRONIC HEALTH (Check all that apply) ANNUAL WASTE 217 AMOUNT ~~ ~v ~ MAXIMUM .r 218 DAILY AMOUNT ~ ~ ~ ~~ . AVERAGE DAILY AMOUNT ~~ ~ J r 219 STATE WASTE CODE ~~' 220 ii ,, 221 DAYS ON SITE 222 ^ UNITS"' l~[ GAL ^ CU FT ^ LBS ^ TONS ~If EHS, amou t us[ be in lbs . STORAGE CONTAINER: \\\ ~~` 223 $ ABOVEGROUND TANK ^ CAN ^ 80X ^ TANK WAGON '~'` UNDERGROUND TANK 7~ Q ~ ^ CARBOY ^ CYLINDER ^ RAIL CAR Y ^ TANK INSIDE BUILDING 1 QY1~C... ^ SILO ^ GLASS BOTTLE ^ OTHER STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ^ TOTE BIN PLASTIC/NONMETALLIC DRUM ^ BAG , ` STORAGE PRESSURE: ~~~ /// y[ AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT • \ 224 STORAGE TEMPERATURE: AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC 225 %WT HAZARDOUS COMPONENT EHS CAS # 1 226 227 ^ Yes ^ No 228 229 Z 230 231 ^ Y25 ^ NO 232 - 233 3 234 235 ^ Yes ^ No 236 237 4 23S 239 ^ Yes ^ No 240 241 5 2a2 ~ za3 ^ Yes ^ No zaa zas -III. SIGNATURE PRINT NAME & TITLE OF ~ AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE ~ DATE 246 ~i'1V1 (~' Cc~-° awt~e,r ~a ~ ~~ 3 ~ -~ ~ ~ // ~ FD2144 (Rev 06/07) ~. w CALIFORNIA WASTE CODES C e Description Inorganics '111 Acid solution 2 < pH < 7 with metals (antimony, arsenic, barium, beryllium, cadmium, chromium, cobalt, copper, lead, mercury, molybdenum, nickel, selenium, silver, thallium, vanadium, and zinc) 112 Acid solution without metals 113 Unspecified acid solution 121 Alkaline solution pH >12.5 with metals (see 111) 122 Alkaline solution without metals 123 Unspecified alkaline solution 131 Aqueous solution (2 < pH < 12.5) containing reactive Anions. (azide, bromate, chlorate, cyanide, fluoride, hypochlorite, nitrite, Perchlorate and sulfide anions) 132 Aqueous solution with metals (see 111) 133 Aqueous solution with total organic residues 100% or more 134 Aqueous solution with total organic residues < 10% 135 Unspecified aqueous solution 141 Off-spec, aged, or surplus. inorganics 151 Asbestos containing waste 161 FCC Waste 162 Other spent catalyst 171 Metal sludge (see 111) 172 Metal dust and machining waste (see iii) 181 .Other. inorganic solid waste Organics 211 Halogenated solvents (methylene chloride, chloroform, TCE, TCA) 212 Oxygenated solvents (acetone, butanol, MEK) 213 Hydrocarbon solvents (Stoddard solvent, xylene) 214 Unspecified solvent mixture 221 Waste oil and mixed oil 222 Oil/water separation sludge 223 Unspecified oil -containing waste 231 Pesticide rinse water 232 Pesticide and other waste associated with pesticide production 241 Tank bottom waste 251 Still bottoms with halogenated organics 252 Other still bottom waste Code Description Organics (cont) 26i PCB and material containing PCB 271 Organic monomer waste (includes unreacted resins) 272 Polymeric resin waste 281 Adhesives i 291 Latex waste 311 Pharmaceutical waste 321 Sewage sludge 322 Biological waste other than sewage sludge 331 Off-spec, aged or surplus organics 341 Organic liquids (non-solvents) with halogens 343 Unspecified organic liquid mixture 351 Organic solids with halogens Sludge . 411 Alum and gypsum sludge 421 Lime sludge 431 Phosphate sludge 441 Sulfur sludge • , 451 Degreasing sludge 461 Paint sludge 471 Paper sludge/pulp 481 Tetraethyl lead sludge 491 Unspecified sludge waste Miscellaneous 511 Empty pesticide containers 30 gal or more 512 Other empty container 30 gal or more 513 Empty containers less than 30'gal 521 Drilling mud 531 Chemical toilet waste 541 Photo chemical/photo processing waste 551 Laboratory waste chemicals 561 Detergent and soap 571 Fly ash, bottom ash, and retort ash 581 Gas scrubber waste 591 Bag house waste 611 Contaminated soil from site clean-ups 612 Household wastes Page 3 of 3 FD2144a (Rev 06/07) ~, ~ BAKERSFIELD FIRE DEPARTMENT HAZARDOUS MATERIAL MANAGEMENT PLAN Prevention Services a a R S F 1 n 1600 Truxtun Avenue, Suite 401 PIRA Bakersfield, CA 93301 BUSINESS ACTIVITIES PAGE ~~rei T Phone: 661-326-3979 • Fax: 661-852-2171 (HAZARDOUS MATERIAL FACILITY INFORMATION) Page 1 of 1 I. FACILITY IDENTIFICATION FACILITY ID # (for office use only) 3 EPA ID # BUSINESS NAME (FACILITY NAME or DBA) 103 V` II. ACTIVITIES DECLARATION DOES Your Facility... If Yes, Please Complete... 1ze 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 olanning elements: solids, or 200 cu. ft. for compressed gases (include • Emergency Response Plan liquids in AST and UST)? • Maps • Training • Prevention • Certification B. REGULATED 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 (UST1 ^ Yes ^ No • UST FACILITY FORM 13z 1. Own or operate Underground Storage Tanks? • UST TANK FORM (one per tank) ^ Yes ^ 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 ^ No • HAZARDOUS MATERIAL MANAGEMENT PLAN AST • Incorporating Federal Spill Prevention Control and Countermeasure 1. Own or operate AS7 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 EPA ID NUMBER -provide on this page 1. Generate hazardous waste? ^ Yes ^ No , To obtain EPA ID Number, please phone (916) 324-1781 2. Recycle more than 100 kg/mo of recyclable ^ Yes ^ No . RECYCLING FORM material at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable ^ ves ^ No . RECYCLING FORM material at an off-site location different from the point of generation? 4. Treat Hazardous Waste on site? ^ Yes ^ No . TP FACILITY FORM • TP UNIT FORM (one per unit) 5. Subject to Financial Assurance requirements? ^ yes ^ No . CERTIFICATION OF FINANCIAL ASSURANCE 6. Consolidate Hazardous Waste generated at a ^ Yes ^ 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. FD2143 (Rev 06/07) S' ~ Y Hazardous 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 material 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 i-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 i-S 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 ~ - B fl R S F I D P/RB ARr~I T BAKERSFIELD FIRE DEPARTMENT Prevention Services 1600 Truxtun Avenue, Suite 401 Bakersfield, CA 93301 Phone:661-326-3979 • Fax:661-852-2171 Page 2 of 2 P~ HAZARDOUS M__ATE_RIAL_MANAGEMENT PLAN -- f - µ;% INSTRUCTIONS SITE & FACILITY DIAGRAM ~` 4,c j ~--- BAKERSFIELD FIRE DEPARTMENT a fl R S F I n prevention Services FlA!Q 1600 Truxtun Avenue, Suite 401 ABTA/ T 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'/zx11-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 wiH not be' submitting facility diagrams, the site map must include all of the following information: 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 the diagram. 3. Label the location of the hazardous material and identify them by name and type of hazard (flammable liquid, corrosive solid). 4. Label the location of utility shut-off points for gas, electric, and water services. 5. Label the location of fire hydrants. 6. Label portions of the building protected by automatic sprinkler systems. 7. Label the direction representing north on the diagram. (The diagram form provided includes a north arrow.) 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 abbreviations 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. FACILITY DIAGRAM INSTRUCTIONS Facility diagrams are supplements to the site diagram. Use them to show the subdivision details of a large business. 1. Check the box in the upper right hand corner of the form provided that indicated "Facility Diagram." 2. Print the name of your 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 facility diagram shall also specify the location of the UST continuous leak monitoring system and(or the location where the UST monitoring will be performed. FD2170 (Rev 06/07) UNIFIED PROGRAM INSPECTION CHECKLIST~~ Prevention Services H ~ _a_S_F ,_ _ 0 900 Truxtun Ave., Suite 210 _ _ _ ~._. ~.. Y_ ~_ _ _~ a~ , F/R6 Bakersfield, CA 93301 =~,--_ _ _ ~RrM r Tel.: (661) 326-3979 SECTION 1: Business Plan and Inventory Program ,I ~ Fax: (661) 872-2171 ~. FACILITY NAME R LN,~~ INSPECTION DATE r~- - INSPECTION TIME ~~z ADDRESS ~d L PHONE NO. NO OF EMPLOYEES FACILITY CONTACT YY II IJ v N~ ~^~~~ 3~{O ~r~6~ (a,~ BUSINESS ID NUMBER 15-021- ~b V~~~ _ ~ - Section 1: Bcsiness Plan and Inventory Progr~nt ~~ ITYROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V ~ C=Compliance OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND COY ^ BUSIfl6SS PLAN CONTACT INFORMATION ACCURATE ^~ ^ VISIBLE ADDRESS ® `~oo~ C L~' ^ CORRECT OCCUPANCY C~/ ^ VERIFICATION OF INVENTORY MATERIALS ^ VERIFICATION OF QUANTITIES CLI. ^ VERIFICATION OF LOCATION CCsy ^ PROPER SEGREGATION OF MATERIAL C~ ^ VERIFICATION OF MSDS AVAILABILITY D ~^ VERIFICATION OF HAZ MAT TRAINING D/ ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE Q~ ^ CONTAINERS PROPERLY LABELED ~ ^ HOUSEKEEPING ~ ,/ LJ ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND QUESTIONS REG`A~RDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 In pector (Please Print) Fire Prevention / 15~ In /Shift of Site/Station # White -Prevention Services - Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 ANY HAZARDOUS WASTE ON SITE? C~S'ES ^ NO i' _j` + SIR LUBE ____-________________________________________ SiteID: 015-021-000501 + Manager BusPhone: (661) 323-8348 Location: 800 OAK ST Map 102 CommHaz Low City BAKERSFIELD Grid: 36A FacUnits: 1 AOV: CommCode: BFD STA 03 SIC Code:5541 EPA Numb: DunnBrad:77-0375328 Emergency Contact / Title Emergency Contact / Title JON HULSEY / OWNER RUBEN GARCIA / MANAGER Business Phone: (661) 32'3'-8348x Business Phone: (661) 323-83.48x 24-Hour Phone (661) 6E3-7779x 24-Hour Phone (661) 323-6801x Pager Phone (661) 549-7655x Pager Phone ( ) - x Hazmat Hazards: Fire DelHlth Contact Phone: (661) 323-8348x MailAddr: 800 OAK ST State: CA City BAKERSFIELD Zip 93304 Owner JOHN & CARI HULSEY Phone: (661) 663-7779x Address 10506 DORCHESTER ST State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: ~ Emergency Directives: ~ PROG A - HAZMAT PROG H - HAZ WASTE GEN ~~~ PROG T - ABOVEGROUND STORAGE TANK ~~~ ~~~~ ®®6, Based on my inquiry of those individuals nn responsible for obtaining the information, I certify DO UU under penalty of law that I have personally examined and am familiar with the information ~ bmitted and believe the information is true, a irate, and complete. - ~O. .. ~ -,~ ~ ~ ~- S S' nature Date -1- 03/02/2006 UNIFIED PROC~RAIVI INSPECTION CHECKLIST ~~ -~ SECTION 1 business Plan and Inventory Program • FACILITY NAME i ' -------------- ------...-------------- ADDRESS FACILITYCONTAC~~ ~ ~~ outine D Combined Bakersfield Fire Dept. Environmental Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Te~IQ: (661) 326-3979 __ _ __ _ ~~~ ~!/ ~~ I ~S F~T~`t~IME .. .. Business ID umber 15-021- (~~~ Ij 1: Business Plan and Inventory Program D Joint Agency aMulti-Agency ~ Complaint O Re-inspection C] ANY HAZARDOUS WASTE ON SITE?: ^ YES ^ NO EXPLAIN: • QUESTIONS REGARDING THIS INSPECTIONS PLEASE CALL US AT ~66'I ~ 3Z6-3979 Inspector (Please nt) Fire Prevention 1st-In/Shift of Site White -Environmental Services Yellow -Station Copy s ess Site Responsible Party ase Print) ~ B Pink - Busine Copy a~o~ SIR LUBE Manager Location: City r T7R~ ~~y 800 OAK ST BAKERSFIELD CommCode: BFD STA 03 EPA Numb: SiteID: 015-021-000501 BusPhone: (661) 323-8348 Map 102 CommHaz Low Grid: 36A FacUnits: 1 AOV: SIC Code:5541 DunnBrad:77-0375328 Emergency Contact / Title Emergency Contact / Title JON HULSEY / OWNER A~dGl~~{U~ MANAGER Business Phone: (661) 323-8348x Business Phone: (66 ) 323-8348x 2 4 -Hour Phone ( 6 61) 3 4 0- 8 6 6 5 x 2 4 -Hour Phone ( 6 61) 3~3-~~A3~~ ~ -~D Pager Phone (661) 549-7655x Phone (~ j ) 3~(d-~~'s;' ~ Hazmat Hazards: Fire DelHlth Contact ~l3-~(G~ ~ Ct-u.C.~'ey ~- Phone : ( 661) 323 - 8348x MailAddr: 800 OAK ST / State: CA City BAKERSFIELD Zip 93304 Owner JON & CARI HULSEY Phone : ( 661) 3~-~8frfr5x5~~1'-y Address 10506 DORCHESTER ST State: CA City BAKERSFIELD Zip 93311 Period to TotalASTs: = Gal Preparers TotalUSTs; = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT I n vl~o PROG H - HAZ WASTE GEN PROG T - ABOVEGROUND STORAGE TANK ~N~°~ M~~ ~ ~ ~~ ~1 Qased on my inquiry of #hose inrlivlduals respons'sh!E :or oh°.~ininr~ thy; infcr~ i~4,tit~n, I c;Urtify under penalty of iavJ that I have personally examined and am familiar with the information submitted and believe the information is true, a~ .urate, and complete. t ~~0 7 ~i nature Date ~~ -1- 02/06/2007 ~ SIR LUBE SiteID: 015-021-000501 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers on Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP WASTE OIL F DH L 2000.00 GAL Low WASTE ANTIFREEZE F DH L 110.00 GAL Low ANTIFREEZE L 110.00 GAL Low TRANSMISSION FLUID F DH L 100.00 GAL Low OIL F DH L 900.00 GAL Min WASTE OIL FILTERS F DH S 110.00 GAL UnR -2- 02/06/2007 -3- 02/06/2007 :~ S IR LUBE ~ Inventory Item 0004 COMMON NAME / CHEMICAL NAME WASTE OIL Location within this Facility Unit N CTR PARKING LOT Liquid TWaste ~AmbRent~E AMOUNTS AT THIS LOCATION Largest Container Daily Maximum 2000.00 GAL 2000.00 GAL HAZARDOUS COMPONENTS %Wt. RS CAS# tiHGE~ttL 1-~.7.7L" 5.~1~1L' 1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Low ~ Inventory Item 0006 Facility Unit: Fixed Containers on Site ~ COMMON NAME / CHEMICAL NAME , WASTE ANTIFREEZE Days On Site 365 Location within this Facility Unit Map: Grid: N SIDE OF BLDG CAS# 107-21-1 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid Waste Ambient Ambient PLASTIC CONTAINER AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 55.00 GAL 110.00 GAL 55.00 GAL nxc~sitcLVU~ ~.vl~ir~lvr,ly 15 %Wt. RS CAS# 30.00 Ethylene Glycol No 107211 ru~~~-uc~ t~a~~~ari~ivl~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Low SiteID: 015-021-000501 ~ Facility Unit: Fixed Containers on Site ~ Days On Site 365 ~ Map: Grid: CAS# ' 221 TEMPERATURE CONTAINER TYPE Ambient ABOVE GROUND TANK Daily Average 1000.00 GAL -4- 02/06/2007 .~ SIR LUBE SiteID: 015-021-000501 ~ ~ Inventory Item 0007 Facility Unit: Fixed Containers on Site ~ COMMON NAME / CHEMICAL NAME ANTIFREEZE Days On Site 365 Location within this Facility Unit Map: Grid: W PART OF BLDG NEAR BULK OIL CAS# STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE _ Liquid TMixture~Ambient ~ Ambient DRUM/BARREL-METALLIC AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 55.00 GAL 110.00 GAL 55.00 GAL r1t~~t~tcLVUJ ~VrirVivl;lylJ %Wt. RS CAS# 100.00 Ethylene Glycol No 107211 L11~'~~J~Y ~JJIJ L~I.~lY1~11V 1. 1.~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies / / / Low ~ Inventory Item 0003 COMMON NAME / CHEMICAL NAME TRANSMISSION FLUID Location within this Facility Unit W WALL INSIDE BLDG Facility Unit: Fixed Containers on Site ~ Days On Site 365 Map: Grid: CAS# 0 Liquid TMixture ~mbient~E ~ AmbientT~E ~ PLASTICTCONTAINERE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 100.00 GAL 100.00 GAL 100.00 GAL L1HGH[CLVU.7 1.,V1~lYV1VI;1V lJ %Wt. RS CAS# 100.00 Transmission Fluid (Petroleum-Based) No 0 I1tiGt1KL H J.7r..7.7P7r.1V 1 .7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Low -5- 02/06/2007 _F SIR LUBE SiteID: 015-021-000501 ~ ~ Inventory Item 0002 Facility Unit: Fixed Containers on Site ~ COMMON NAME / CHEMICAL NAME OIL Days On Site 365 Location within this Facility Unit Map: Grid: W WALL INSIDE BLDG CAS# 8020835 Liquid TMixtur~ Ambient~E ~ AmbientT~E ~ OVE GROIINDRTANKE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum ( Daily Average 900.00 GAL 900.00 GAL I 450.00 GAL t1AGKKL V U w7 lL V1~lY V1V L' 1V 1.7 %Wt. RS CAS# 100.00 Motor Oil, Petroleum Based No 8020835 riHGt~1CL Ei7 ~l;~:i1~l~1V 1 J TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Min ~ Inventory Item 0005 Facility Unit: Fixed Containers on Site ~ COMMON NAME / CHEMICAL NAME WASTE OIL FILTERS Days On Site 365 Location within this Facility Unit Map: Grid: N CTR PARKING LOT CAS# 221 ~SolidE TWaste -~ Ambi.ent~E ~ A~PeRATURE DRUM/BNARRELEMETALLI~ AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 55.00 GAL 110.00 GAL 110.00 GAL HAZARDOUS COMPONENTS - ~ , °sWt . RSI CAS# HAZARD AS S~~~1~11=,1V1~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / UnR -6- 02/06/2007 f SIR LUBE SiteID: 015-021-000501 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 05/20/1999 ~ CALL 911. = Employee Notif./Evacuation 07/11/2006 WE HAVE 911 POSTED IN EACH SHOP IN CASE OF EMERGENCY. EMPLOYEES HAVE BEEN TOLD WHERE TO MEET AFTER AN EMERGENCY. Public Notif./Evacuation 05/20/1999 THERE ARE SIGNS POSTED WARNING OF HAZARDOUS WASTE AND AN AREA POSTED WHERE THE WASTE IS LOCATED. Emergency Medical Plan 07/11/2006 WE HAVE INSTALLED FIRST AID KITS. WE HAVE 911 POSTED. SAN JOAQUIN HOSPITAL, 2615 EYE ST, 395-3000. -7- 02/06/2007 ~ SIR LUBE SiteID: 015-021-000501 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 07/11/2006 ~ THE SYSTEM WE USE IS A DIRECT DRAIN FROM THE LUBE PIT INTO A BULK OIL TANK. IT IS NOT HANDLED BY ANY EMPLOYEE. IF WE HAVE A SMALL SPILL, WE USE OIL SORBS TO CONTAIN AND ABSORB THE OIL. Release Containment ..lcall V~ V1.11C1 iCC .7V UI.VC tiU l.1 VC1L1Vll -8- 02/06/2007 F SIR LUBE SiteID: 015-021-000501 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ..~i+c~.iai raac~aiuo Utility Shut-Offs 07/11/2006 A) GAS - NE CRNR OUTSIDE OFFICE BLDG B) ELECTRICAL - BACK OF CENTRAL HALLWAY BET OFFICE & WAITING ROOM C) WATER - N SIDE OF LOT NEXT TO BLOCK FENCE D) SPECIAL - NONE E) LOCK BOX - NONE Fire Protec./Avail. Water 12/07/2006 PRIVATE FIRE PROTECTION - FIRE EXTINGUISHERS FIRE HYDRANT - SE CRNR OAK ST & CHESTER LN. Building Occupancy Level 12/07/2006 5 EMPLOYEES -9- 02/06/2007 -~ SIR LUBE SiteID: 015-021-000501 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 07/11/2006 ~ BRIEF SUMMARY OF TRAINING PROGRAM: WE HAVE A MONTHLY MEETING ON WASTE HANDLING AND EVERY SIX MONTHS WE RECEIVE, FROM PENNZOIL, AN UPDATE ON INFORMATION PERTRAINING TO OIL AND GREASES THAT WE USE. rayc ~. L1C 111 1V1 L'LLl. l1LC V5C 1ZC 111 1VL L'UI.ULC U5C -10- 02/06/2007