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Home My WebLink AboutBUSINESS PLAN 10/3/2007I, ,JERRY W. GASSAWAY DS INC I ~ P 4000 STOCKDA:~:~E EIWY SUITE A CEP 8 209 1~ ,i .,, GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 Manager JERRY W GASSAWAY Location: 4000 STOCKDALE HWY A City BAKERSFIELD BusPhone: (661) 324-8055 Map 102 CommHaz Minimal Grid: 35C FacUnits: 1 AOV: CommCode: BFD STA 03 EPA Numb: SIC Code:8021 DunnBrad: Emergency Contact / Title Emergency Contact / Title JERRY W GASSAWAY / OWNER / Business Phone: (661) 324-8055x Business Phone: ( ) - x 24-Hour Phone (661) 324-8055x 24-Hour Phone ( ) - x Pager Phone ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact JERRY W GASSAWAY Phone: (661) 324-8055x MailAddr: 4000 STOCKDALE HWY A State: CA City BAKERSFIELD Zip 93309 Owner JERRY W GASSAWAY DDS Phone: (661) 324-8055x Address 4000 STOCKDALE HWY A 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 ~N~U ~~,'~ ~ ~QO~ pie^~~ on my inquiry of those indivic?z~~i: rc~;~!-.~an_,i:;icy tar o~.~2~,ini^g the inform:!tion, I °^~ii:y un~~ar ~aenalty C:f laiv that I h2ve persanaf!y rxeminet! anc'1 am familiar with the !nforma?ion submitted ~,~d believe the information is true, acourate, a' ~d e~ ~r. plete. _ _ ~~~~7 ~° ~~ar,,u~ Date -1- 10/01/2007 ~~: ;, F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ ~ 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 ,}..h}'0~.1~PrIY Min (.DD~~i-/"erL .1-~-- ~S o~ `a'U % W`~- ~2Je ~~'l~rJc~„Q -~-~ Q~, ~_ -2- 10/01/2007 -3- 10/01/2007 F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ ~ 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# Liquid TWaste -~mbRent~E ~ AmbientT~E ~ PLASTIOCTCONTAINERE AMOUNTS AT THIS LOCATION J Largest Container Daily Maximum 5. 0 0 GAL ~~ j k2~- .,L.-8~6- GAL Daily Average l l i~`P~ -~'0-GAL r~~r~tcLVUS wrir~ivr~iv 1 %Wt. RS CAS# Silver No 7440224 ri1~GHKU AJ51';JSi~1iS1V1,7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 10/01/2007 F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 Fast Format ~ Nbtif./Evacuation/Medical Overall Site ~ Agency Notification 02/28/2007 N/A 9 9 Employee Notif./Evacuation 02/28/2007 N/A Public Notif./Evacuation N/A 02/28/2007 Emergency Medical Plan 02/28/2007 EMPLOYEES HAVE DESIGNATED IN THEIR EMPLOYEE FILE WHO THEY WOULD LIKE TO SEE IN CASE OF A WORK-RELATED INJURY OR INCIDENT. THEY HAVE ALL DESIGNATED THEIR PERSONAL PHYSICIAN. -5- 10/01/2007 F GASSAWAY DDS INC JERRY W SitelD: 015-021-002305 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 02/28/2007 ~ N/A Release Containment 02/28/2007 N/A Clean Up 02/28/2007 WASTE FIXER HELD IN DOUBLE-WALLED CONTAINER SETTING IN LARGE CONTAINER IN CASE OF SPILL. COMMERCIAL COMPANY USED FOR CLEAN-UP IN CASE OF SPILL. v~.iici. iccavui.uc tllrl.lVQl~1V11 -6- 10/01/2007 F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ ., ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~~/c~ia.L nac~aiu~ Utility Shut-Offs 02/28/2007 GAS - NE CRNR OF BLDG 1 ELECTRICAL - CIRCUIT BREAKERS IN DARKROOM WATER - BACK DOOR ENTR TO OFFICE Fire Protec./Avail. Water 02/28/2007 ABC PORTABLE FIRE EXTINGUISHER INSIDE OFFICE (5 LB) FIRE HYDRANT - CRNR MCDONALD WY & STOCKDALE HWY Building Occupancy Level 02/28/2007 10 EMPLOYEES -7- 10/01/2007 F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ Fast Format ~ ~ 'braining Overall Site ~ ~ Employee Training 02/28/2007 ~ BRIEF SUMMARY OF TRAINING PROGRAM: ANNUAL OFFICE MEETING AT WHICH TIME SAFETY AND EVACUATION PROCEDURES ARE ADDRESSED. rays ~ nciu ivt ru~.uLC Vac L1CLU LVL r UI.uLC V.`iC -8- 10/01/2007 -"% ~ ~~ UNIFIED PROGRAM INSPECTION CHECKLIST ~ _ ~_ ~-Y--- -~..e- _-- .._ __-_ - _. _~,__-_-- --- __ _ _. ~ SECTION 1: Business Plan and Inventory Program Prevention Services 900 Truxtun Ave., Suite 210.. B E_R S F I __D F/RE Bakersfield, CA 93301 ARTM r Tel.: (661) 326-3979 Fax: (661) 872-2171 FACILITY NAME ~ I~E~TI'O~~AT~E / INSPECTION TIME Fb S fl w A ~ ~~ ADDRESS ~/ 0c7o S'1"oc~pAc_,E ~w~ ~ PHONE NO. ~~ -~~SS NO OF EMPLOYEES 1 ~ FACILITY CONTACT BUSINESS ID NUMBER 15-021-D15-OL( -Oo .:Section 1: Business. Plan artd Inventory Program ^ ROUTINE COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION C V (C=Compliance OPERATION V=Violation COMMENTS ^ APPROPRIATE PERMIT ON HAND ^ BUSIfIt?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 `~ ^ VERIFICATION OF HAZ MAT TRAINING ^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES ^ EMERGENCY PROCEDURES ADEQUATE ^ CONTAINERS PROPERLY LABELED \Ql ^ HOUSEKEEPING ^ FIRE PROTECTION ^ SITE DIAGRAM ADEQUATE & ON HAND rcer-tiuis 3oS ANY HAZARDOUS WASTE ON SITE? YES ^ NO EXPLAIN: ~ ° i~ a ~; ~ ~ Q ~ QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL. US AT (661) 326-3979 Inspector (Please Print) Fire Prevention / 1~` In /Shift of Site/Station # Business Site / R sponsible arty (Please Print) White -Prevention Services Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 ~~. ?`~ ~T~`" CITY OF BAKERSFIELD FIRE DEPARTMENT ~ OFFICE OF ENVIRONMENTAL SERVICES b •y i7NIFIED PROGRAM INSPECTION CHECKLIST k~"~gti,~~~ 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITY NAME G, r~s5~ tr~A~ 17D s INSPECTION DATE _~ I Z~.~. Section 4: Hazardous Waste Generator Program EPA ID # ~~~ "'P~ ^ Routine ~ Combined ^ Joint Agency ^Muiti-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number ~~c~~ ~-~' 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 tote 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 P`~ Proper management of used oil filters N~A Transports hazardous waste with completed manifest Sends manifest copies to DTSC ~~ „~ ti,} a t r ~ Retains manifests for 3 years x - Q~~1 ~~ K,~-,. Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 years J~! ~ Determines if waste is restricted from land disposal ~s .. vJ o t r ...--. ~=~ompuance v=vtotanon Inspector: Q/~~'~' 'A +---- Office of Environmental Services (661) 326-3979 White -Env. Svcs. Pink -Business Copy (1~t Business Site Responsible Party ,~ , GASSAWAY DDS INC JERRY W Manager Location: 4000 5TOCKDALE HWY A City BAKERSFIELD CommCode: BFD STA 03 EPA Numb: SitelD: 015-021-002305 BusPhone: (661) 324-8055 Map 102 CommHaz Minimal Grid: 35C FacUnits: 1 AOV: SIC Code:8021 DunnBrad: Emergency Contact / Title Emergency Contact / Title JERRY W GASSAWAY / DDS / Business Phone: (661) 324-8055x Business Phone: ( ) - x 2 4 -Hour Phone ((~~) 3~{ - bo ~x 2 4 -Hour Phone ( ) - x Pager Pho ne ( ) - x Pager Phone ( ) - x Hazmat Hazards: React Contact JERRY W GASSAWAY DDS Phone: (661) 324-8055x MailAddr: 4000 STOCKDALE HWY A State: CA City BAKERSFIELD Zip 93309 Owner JERRY W GASSAWAY DDS Phone: (661) 324-8055x Address : 4000 STOCKDALE HWY A 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 iduals di i ~~~%" v n Eiased on my inquiry of those responsible for obtaining the information, I certify under pena{ty of law that {have personally examined and am familiar with the information submitted and I~ a the information is true, accurate, and o I e. ti- ~~~ ig ate -1- 01/31/2007 F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers at Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP WASTE FIXER R L <1.00 GAL Min -2- 01/31/2007 '~~-ofL~ o N CaMQtn,~~ of W i<< N b'~'" h ~~~ ~/J 6 i v~as~-~ ~ i X~ ors ~ ~. _- -3' ~O1/31/2007 F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ ~ 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# Liquid TWaste ~ AmbRient~E ~ AmbientT~E ~ PLASTICTCONTAINERE AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 5.00 GAL X1.00 GAL ~ 1.00 GAL - HAZARDOUS COMPONENTS °sWt. RS CAS# Silver ~ No 7440224 l1HGtitC.L I~J JL~JJ1~1r,1V 1.7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min -4- 01/31/2007 F GAS'SAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification ,~ ~, `i Employee Notif./Evacuation Nl ~^ r IAJ.J l 1 V 1Y V l.. 1 1 ~ Jj V 0.l. lA0. 1. l V l l r ~ '~" - ~uicl.ycll~.y i•icul~.ai rlcxit ~M ~ lo~~.s ha ~.~ c2c ~ jN a•!-~ %~ ~ it- eM~ 1~~.~ ~t fie- ~ Ino .K,.t wo,~.te~ (-~. -~-~ ~ i~1 c ~. 0 4- 8 w v~ tL-l a+-.~ i ~~ ,~..~ o~ ; „~ a ~~'" ~ ~ h a v ~ a U -5- 01/31/2007 F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention ~,~ ~ ~~- iCC1CCl w7C t.V111.Q 111111G11L l.1CQll V~J ~~~~ ~~.~En- ~~- i N ~ ~.b~ . wa Ili C.~-~kar,~.e,~ 5e-t~=l~ ~ i n~ ~~ M~~a~ Gau~ a~ u~-~ ~n~ c~za,~ -u-P ~ ~ CkSE ~ 5~1 << . Other Resource Activation -6- O1j31/2007 - ~-~ F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~peclal rlazarus = UL111Ly J11UL-VLLS ~teG~~ ~ ~i 2u,,.;~- bRcalGe~s /o~a~--~ ,~,~ dam k Rom W a--~"~-~- ~In~-I" v~-F ~ o ~ a ~'~. ~ T 6h~ ~- ~2- eNd-~,~« -1~ a~-~ ~5 shk-1- o~~ v~lt/z 1o~2~t~ ~~ N-~• C,vtt~J~-'~ a-F bl~ ~ ,_ r.l.ic rl_v~.c~ .,~ 1-avail . wa~.cl_ Ate -~~~ablc -~~~ ~-~~~~~~- ~aarc~. d~,'c¢, ~ (.~ Ib~o~ DLL1.L 1A111y VIa: U~Jq.lll:y LCVC1 ~~ ~I~p ~uN.el.4 ~'N.s ~I,e,.l~is~'loW~lt¢ vc~,,.~,r/ ~~ l~,i~~ e~- ~~ day -7- 01/31/2007 .., ~ _::~ ~° ~~ F GASSAWAY DDS INC JERRY W SiteID: 015-021-002305 ~ Fast Format ~ ~ Training Overall Site ~ Employee Training A a ~ w~ l a ~~ u, nn~,ktN~ a ~ w (,~ ~IM1- ~-i~ sa~~ ~ ~~a ~ a-~~ ~s ei~- ~ ra~c c azcLU tUL rUI.uLC U5C i1G 1lA 1VL rUl.. I.LLC UDC -8- 01/31/2007 ............... ...:~. "i:t.- /T .--- JERRY W. GASSAWAY, DtIÞ, INC . /~'>"-1:.." . ~ '/'--. ./'" ,./ V SiteID: 015-021-002305 Manager : Location: 4000 STOCKDALE HWY A City BAKERSFIELD '\.~~~ ~ BusPhone: Map : 123 Grid: 02A (661) 324 - 8055 CommHaz : FacUnits: 1 AOV: C:J <J. CommCode: BAKERSFIELD STATION 07 EPA Numb: SIC Code:8021 DunnBrad: Emergency Contact JERRY W GASSAWAY Business Phone: 24-Hour Phone Pager Phone / Title / DDS (661) 324-80ssx () x () x Emergency Contact Title Business Phone: ( 24-Hour Phone : ( Pager Phone : ( / / ) ) ) x x x Hazmat Hazards: React Period Preparer: Certif'd: parcelNo: to Phone: (661) 324-8055x State: CA Zip 93309 Phone: (661) 324-80ssx State: CA Zip 93309 TotalASTs: = Gal TotalUSTs: = Gal RSs: No Contact : JERRY W. GASSAWAY, DDS MailAddr: 4000 STOCKDALE HWY A City BAKERSFIELD Owner Address City JERRY W. GASSAWAY, DDS 4000 STOCKDALE HWY A BAKERSFIELD Emergency Directives: 0\ ~~ 0 I, :::k'f.~ &A~~~w'.'4 ""' cia: ,.,., '" Do hereby certify that I have 0\ .~ 0 0 pe or print name) ;: . oJ :sf ~"'<:S reviewed the attached hazardous materials manage.. .s .. ~ ~ '% oJ::: '" .. 'to ~ . .. ~ IN· 6#1~w~ ''DDS I Ñv ~~~ '" .. ~ ,§ Q,~ ~ '69-;:: ment plan fo and that it along with . := ì Q'? /~~ (Name of BuSiness) I ..,:, ~ ,¡:¡ { any corrections constitute a complete and correct man- .... '" ! ~:t: !:c ~ £: ~~ .. .. æ;-<> S1j ~;:: agement plan for my t 'Iity. 'õ ~ ~~ š ~~ l:)~ .~ ~ <=> ~<=> oJ::: " 'to '" - '" '" t.~ t 0 00 .... ~ ~ s~ 1J'ktj-10 ~ '" ,.,., ~ë ~ :& ~ Date ..2 := ~ ex: ';::;- ~ 0 Z u. 0 -1- 08/14/2003 '. q; ?..... . f JERRY W. GASSAWAY, D~, f= Hazmat Inventory p== MCP+DailyMax Order INC . SiteID: 015-021-002305 By Facility Unit Fixed Containers at Site WASTE FIXER R L 9 9 9 I DailyMax IUnitlMCP 5.00 GAL Min ~.~~;W t ciAI-. Hazmat Common Name. . . specHazEPA HazardS Frm -2- 08/14/2003 ~ ~' :/;'1' . . F- JÉRRY W. GASSAWAY I ., INC f= Inventory Item 0001 === COMMON NAME / CHEMICAL NAME WASTE FIXER SPENT PHOTOGRAPHIC FIXER Location within this Facility Unit INSIDE DARKROOM SiteID: 015-021-002305 ì Facility Unit: Fixed Containers at Site 9 . Days On Site 365 Map: Grid: CAS# STATE - TYPE Liquid Waste PRESSURE ---- TEMPERATURE Ambient Ambient CONTAINER TYPE PLASTIC CONTAINER Largest Container 5.00 GAL AMOUNTS AT THIS LOCATION Daily Maximum 5.00 l GAL %Wt. I Silver HAZARDOUS COMPONENTS ~ CAS# I 7440224' TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies R / / / Min HAZARD ASSESSMENTS -4 - 08/14/2003 1 ¿ ;ffnó: !. .Çs (){) / CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 393~ 113Ó~A 3 g ð;;¿/ FACILITYNAME.jC.~ W. G,6..s~~ \)ùS INSPECTION DATE 12 (,4(61 f.J! 4. Section 4: Hazardous Waste Generator Program EP AID # o Routine ~ Combined o Joint Agency o Multi-Agency o Complaint ORe-inspection OPERATION C V COMMENTS Hazardous waste detennination has been made EP A ID Number (Phone: 916-324-1781 to obtain EP A 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 containm~ provided (' t>tC~ f}2e.vll)é 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 Detennines if waste is restricted from land disposal C=Compliance V=Violation J1¢&- ¿Y . Inspector: L-J¡ N"f3:5 Office of Environmental Services (661) 326-3979 Business Site Responsible partY-J White - Env. Svcs. Pink - Business Copy iJ1 .... . CITY OF BAKERSFIFA dTFICE OF ENVIRONMENT AL""'ERVICES 1715 Chester Ave., CA 93301 (661) 326-3979 HAZARDOUS MATERIALS INVENTORY CHEMICAL DESCRIPTION . ~EW 0 ADD 0 D_~~E.!~...___,~~,~,~~s.~_. ,,"._,--,-,, · I ·:~<~~ft~~~~~~'r:> BUSINESS NAME (Same as FACILlTYNAMEaDiiÃ:bõiiïgBüsIñëšS'ÄS')-'" ...jé~ 0->, GA?<jAWo.Y vDS 200 - - ~. ... ---.".-.-. -" ... -_..------- I. FACILITY INFORMATION .. .., "--' --.--- . .-----....- ...-.. .-. ._~.. CHEMICAL LOCATION IN <;:"i)r- -:-"'M' v n,...,."" 201' CHEMICAL LOCATION "ç \JI"I.'-"'~' I --., : CONFIDENTIAL (EPCRA) FACILITY ID /iI ~TI-"'" :--í-¡- 11 MAP /I {opÎionsfj-·,··...,--,·,-' ""''''"2(h '--GRID ii (op'iionàï)--"" ¡ .,':;;.Y:;;2.if:;i{t:~~;~;}~~tf,1m:~~t:.'. :õë~ ..L.-LLi.."L,. : '11. CHEMICA~~~;~RMATlON'''-''''''-''''----'''-'' (one fDnn pe' material pe' buitding 0' af8a) Page of ; :::~;' ;?-. ~ . ~ <j?;}:~~{X~,;;;:,. ¡ ':"',""" ", ~.,~......., . 3 o Yes 0 No 202 204 ._~---,--_._---_... ': :f~::~>:: ' .>".: ,< e·:,·r:fy~r;11t' 205 ; TRADE SECRET 0 Yes 0 No 206 I If Subject to EPCRA. refet to instrudions , CHEMICAL NAME i I i I ~ 'If.. _,_£~ ~~____"_.. . .-".."- .. -.. .-. ---.-~.__._- .,., '2õ'f +--- ¡ EHS' o Yes 0 No 20B COMMON NAME -.--..--. ..-.----.---.-.-----..- .__...-.- ---.-. 209 .'f~¥~~;E~~~i\li CAS/iI FIRE CODE HAZARD ClASSES (Complete if requested by local fire Chief) ----... -.---....--. -----. --..-- ------._----- 212 CURIES 213 rl'-_··_-·d'~,-.--- .-.-----...-. ~ WAS,: :;:.:' R.:.DIOACTIVC: 0 Yes 0 No -- _.~- ---.--.---...-----.--. i 214 ' LARGEST CONTAINER TYPE o P PURE o m MIXTURE ~QUID o 9 GAS ..___....__.__l...-___ .__..___..____..._._____. 210 s- PHYSICAL STATE o s SOLID --.-.-------- FED HAZARD CATEGORIES (Check an that apply) ANNUAL WASTE AMOUNT 03 PRESSJRE RELEASE ~4 ACUTE HEALTH o 5 CHRONIC HEALTH 220 o 2 REACTIVE 01 FIRE .- .------- ----.--------.. ---- .-..'---' ....---.. .--.-- -----_. -.------_.. .5 218 ¡ AVERAGE "._L~A.I::~MOU~....___".., .,. ----..-.. 221 DAYS ON SITE 222 rT') 211 ,\1AXIMUM .:::> ........ ; DAILY AMOUNT .___.-1-_. UNITS' OgaGAL OctCUFT . If EHS, amount must be in Ibs. o In TONS o Ib LBS 215 216 219 STATE WASTE CODE STORAGE CONTAINER (Check an that apply) .~ PlASTlCINONMETALLlC DRUM Of CAN o 9 CARBOY o h SILO o m GLASS BOTTLE o n PLASTIC BOTTLE o 0 TOTE BIN o P TANK WAGON o i FIBER DRUM OJ BAG o k BOX o I CYLINDER o a ABOVEGROUND TANK o b UNDERGROUND TANK o c TANK INSIDE BUILDING o d STEEL DRUM o q RAIL CAR o r OTHER 223 --.--......--. .--.. ..-..---.....--------.-. 224 .-----. STORAGE PRESSURE _&a AM8I~~_____~aa ABO~.:~~~~~NT_..___ "d._~_~a~.~~,WAMBI~~ STORAGE TEMPERATURE o aa ABOVE AMBIENT o ba 8ELOW AMBIENT 22S ~"·'}?~i\1~tI\~·}·Wi~it~gðD,~;~p~Ë9.~~:Ñr);:::~:~~u·:··t~~i~:.! ~ ,·:..>?:r¡:;\··· ,. , , ", :t:f~:;:: o c CRYOGENIC Qa AMBIENT 226 2 230 3 234 4 238 5 242 I __,__,d._'__.___.__,,_____ ...... _,. .... ,_,__.'_ ,_~~:_L~,~~,9_~,~~~, 231 , 0 Yes 0 No 232 I --.---..-¡---.--- -'---'--'-"'-1 235 ' 0 Yes 0 No 236 i ___.'_.d........__.__,___,_ ",,,,,._. --.....,--..-"'...---¡-.---- ,-i 239 ¡ 0 Yes 0 No 240 _______,_____..h,..._______.. -,. uu--~4~-r~ ~~-~ NO-~44 ~ _-'_."""--_ I .,...,.~.~.~ . -?i~~;l:,,":,'~~/~·',:~fR~~''f';t,jJlì¡.~,~I~Ñ~!~~E,.:~'L:::, ..; '. ," ,: '. '. ; MPANY REPRESENTATIVE SIGNATURE -.----.-- ------- __~_m__._~ ._.._______ __________ ....---..-- . -.. .-----_... __....... ___ _ ·____..u ... ..._..._ ______ ._...._.._. ___ _ _ .._ ......_____... ._.__ .._..~ __..._ ____. _._ . .__..____..___..._ 229 233 237 241 245 IZ/141ð7 UPCF (7/99) S:\CUPAFORMS\OES2731.TV4.wpd