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HomeMy WebLinkAboutBUSINSS PLAN 5/28/2007UNDERGROUND STORAGE TANK ~ KCL COLD STORAGE - - - - - - 210 SLTNIlVER STREET _ - - (Removed: 6-21-96; Closed 12-18-96) 140016C ~ ~~3~0( -~ ,~ . `' ~ ~; f n f~~! r ~, °,U" - 4 - I ,y, - Prevention Services UNIFIED-PROGRAM- INSPECTION CHECKLIST:. R T R s r , ._ n 900 Zruxtun Ave., suite 210 " _ Fief : Bakersfield, CA 9330.1 ~ . SECTION .1: Business Plan and Inventory Program °- aerM Tel.:. (661) 326-3979 - _ ~ Fax: (661) 872-2171 FACILITY NAME INSPECTION DATE. INSPECTION TIME N y ~QV1,G~ ~Q!>p GnS ~' ~ n-}-d ~~ cyt. ~ 2 ~" ADDRESS - - ~ PHONE NO. .- NO OF.E OYEES 21 O S~ m n Q ~ S~ a~ E ~~lo- 1 FACILITY CONTACT - . BUSINESS ID NUMB R 15-021-644 - _ - __ - ' ~ - -- - ,~ I ^ Section 1,: Business Plan and fnventoiy Program ROUTINE ~ COMBINED ^ "JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT 1 ^ RE-INSPECTION C V ( C=Compliance OPERATION V=Violation COMM ENTS - ^ APPROPRIATE PERMIT ON HAND ^ BUSIf1eSS 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 - Q ~QQ ^ - VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES N~~ ^ EMERGENCY PROCEDURES ADEQUATE ^ ~ CONTAINERS PROPERLY LABELEL3• ^ HOUSEKEEPING C d~ ~` ~~~ d ^ e apt.. paC. cx ^ FIRE PROTECTION ~ ~~~ nn .(~ ^ SITE DIAGRAM ADEQUATE & ON HAND - ANY HAZARDOUS WASTE ON SITE? ~ YES ^ NO ` EXPLAIN: ~»° 1 ~u !b 1 1 ~` ~ m 1 S ~ ~ Y\rcl ~'E` y ®~~ QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (667) 326-3979 Inspector '(Please Print) Fire Prevention / 1~` In /Shift of Site/Station # Business it White -Prevention Services Yellow -Station Copy Pink -Business Copy FD 2155 (Rev. 09/05 ~~ ~045~" -"~`' CITY OF BAKERSFIELD FIRE DEPARTMENT ~c c ~E' CA FACILITY NAME N Y L r(`R-w~~ Tyr LE 2 ~ ~ ~a Qc.P4~ INSPECTION DATE GfJ a '~ Section 4: Hazardous Waste Generator Program ^ Routine ~ Combined ^ Joint Agency EPA ID # ^ Multi-Agency ^ Complaint ^ Re-inspection OPERATION C V COMMENTS Hazardous waste determination has been made EPA ID Number N a ~~ E~~ Authorized for waste treatment and/or storage Reporteii release, fire, or explosion within 15 days of occurcence Established or maintains a contingency plan and training Hazardous waste accumulation time frames to ~ ~Q -~- ~w-}- ~. Containers in good condition and not leaking Containers are compatible with the hazardous waste Containers aze kept closed when not in use Cl~~-~ p'~` ~~ q,r I ~, ~, Weekly inspection of storage azea Ignitable/reactive waste located at least 50 feet from property line iJ Secondary containment provided N a~ Se.-c,c~ ~n~ ~. ! ' o~ ~ Conducts daily inspection of tanks Used oil. nat contaminated with other hazazdous waste Proper management of lead acid batteries including labels 1~ Proper management of used oil filters Transports hazazdous waste with completed manifest Sends manifest copies to DTSC ~E ~ ~ ~ ~ Retains manifests for 3 years '~ Retains hazardous waste analysis for 3 years Retains copies of used oil receipts for 3 yeazs Determines if waste is restricted from land disposal =~ompuance v=vrotanon Inspector: ~ 7 ° `~Z"~'' Office ofEnvironmenta) Services (661) 326-3979 White -Env. Svcs. OFFICE OF ENVIRONMENTAL SERVICES y UNIFIED PROGRAM INSPECTION CHECKLIST rp "~4ti ~ 1715 Chester Ave., 3~d Floor, Bakersfield, CA 93301 `/ .. onsible Party Pink -Business Copy w.b G~~, ~3 (-01'7 BUSINESS ACTIVITIES KERN COUN'T'Y F.NM1'iRONMENTA[.HEAUH SERVICES DEPARTMENT X700 M ST'REE'T', SUf7'E 300 Unified Program Consolidated Form (t1PCF) BAXE':RSFIELD, C.A 93301 FACILITY INFORMATION (667`A6Z-8700 Fax (661 862-8707 !~ Page 1 of I. FACILITY IDENTIFICATION FACILITY ID # I EPA ID # (Hazardous Waste Only) '- ~ I~ i t t 3U.~1NfSS NAME (Same as Facility Name of DBA-Doing Business As) ( ~~ 1 ~ { iV ~ ~ ~ ~ ~ ~~ ~~ I ~' IL ACTIVITIES DECLARATION NOTE: If you check YES to any part of this list, please submit the Business Owner/Operator Identification page (KC Form 2730). Does your facility... If Yes, please complete these pages of the UPCF'.... A. (-IAIARDOUS MA"fER1.ALS Have on site (for any purpose) hazardous materials at or above 55 HAZARDOUS MATERIALS INVENTORY - I gallons for liyuids. 500 pounds for solids, or 200 cubic feet for CI-IEMICALDESCRIPTION (KC Form z7-tn Compressed gases (include liyuids in ASTs and USTs); or the ^ yES ~NO 4 CONSOLIDATED CONTINGENCY PLAN I applicable Federal threshold quantify for an extremely hazardous (KC Form z7ssl substance specified in 40 CFR Part 355, Appendix A or B; or handle radiological materials in quantities for wfiich an emergency plan is 1 SI"TE MAP tt.c Form z7sa) t required pursuant to ] 0 CFR Parts 30, 40 or 70? I B. UNDERGROUND STORAGE TANKS (USTs) UST FACILITY (KCFom, n) I. Owu or operate undergrowtd storage tanks? ^ YES ^ NO 5 US"f TANK (one pageperr~kl the Forn, R> 2.. httend to upgrade existing or install new USTs? ^ YES ^ N p ~~~~ ST FACILITI' T~IN~ST~LAT~~ER'I'IFICATEOF COMPLIANCE (one page per tank) (KC Forn CI 3. Need is repOYt closing a UST? ^ YES ^ NO 7 UST TANK (closure portion bne pnge per,ank) C_Ar30VE GROUND PE"('ROLEUM STORAGE ~'.4NKS (ASTs) i Own er operate ASTs above a total capacity for the facility of greater than 1,320 gallons? [[YES ^ NO 8 NO FORM REQUIRED TO KCEI ISD D. I-(A7_ARDOUS PlASTE A 1. Generate hazardous waste? ^ YES ^ NO 9 EPA ID NUMBER -provide at the top of this page WASTE GENERATOR FORM (ta' Form?735) 2. Recycle more than 100 kglmonth of excluded or exempted ree clable materials (per HSC 25143.2 ? y ~ ^ YES ^ NO 1 ~ RECYCLABLE MATERIALS REPORT (one per recyder) (KC Porm 2732) 3. Treat hazardous waste on site? ^ YES ^ NO 11 ONSITE HAZARDOUS WASTE 1REA~hMENT-FACILITY tKC Forn: 177211 ONSITE HAZARDOUS WASTE TREATMENT-UNIT (one page perw,iq(KCForm 1772u) 4. 'I•reatment subject to financial assurance requirements (for ^ YES ^ NO 12 CERTIFICATION OF FINANCIAL Permit by Rule and Conditional Authorization)? ~ ASSURANCE (KC Forn, Izszl 5. Consolidate hazardous waste generated at a remote site? ^ YES ^ NO 13 REMOTE WASTE /CONSOLIDATION SITE ANNUAh NOTIFICATION (KCForm ~ ie6) 1 b. Need to repot ~ the closure/~ emoval of a tank that was classified as ^ YES ^ NO 14 HAZARDOUS WASTE TANK CLOSURE hazardous waste and cleaned onsite? CERTIFICATION txc Forn, (zaa) E. LOCAL REOU[REMEN'fS ~ is Have Regulated Substances (RS) stored or. site at greater than the threshold REGULATF.,D SUBS"1'ANCES quantities established by the Ca;ifornia Accidental Release Program ^ YES ^ NO 15 REGISTRATION (KC Form 2736) (Cal ARP):' A RS is any substance listed in Section 2770.5 of CCR Title 19, Division 2, Chapter 4.5 s RISK MANAGEMENT PLAN (when required) ~iJSiNESS OWNER/OPERATOR IDENTIFICATION 1:ERN COLiNTY' ENVIRONMENTAL HEALTH SERVICES DEPARTMENT 2700 M STREET, SUITE 300 Unified Program Consolidated Form (UPCF) BAICERSF1fsLD,C.A 93301 FACILITY INFORMATION GG1)8G2-8700 Fax (661)862-8701 • NEW BUSINESS ^ OUT' OF BUSINESS ^ REVISEIUPDATE (EFFECTIVE 1 / ) Page __oC_ ~ L IDENTIFICATION FACII_,ITY ID# I ~ ~ BEGINNING DATE ioo, ENDING DATE I ' 101 ~ _ ! ~ BUSINESSNAME(SamcasF.4Cti.tTYNAMEor~BA-~omgBusinessns) 3 BUSINESS PHONE - toe BUSINESS SITE ADDRESS = - 10; S ~1C7 Sc~;'~ Rccr toa CI"fY ZIP CODE ios ~~ r~.; DUN & BRADSTRF.ET 106 SIC CODE (4 digit #) X07 COUNTY ~ Os i Kern County _ j BUSINESS OPERATOR NAME 109 BUSINESS OPERATOR PHONE ~ ~0 ~- ~ ~ II. BUSINESS OWNER OWNER NAME ~ ~ ~ OWNER PHONE ~ ~'- ~~~i~ L;~ ~ ~ ~ ~ ~ ~ - r~ i OV~'NIR MAILING ADDRf?S ~ ~~ ~~; CI"fY ~ is STATE ~ is "LIP CODE ~ ~~ ~ j~jG i t ca cR _ I11. ENVIRONMENTAL CONTACT CONTACT*JAME ~~~ CONTACT PHONE its CONTACT MAILtN'G ADDRESS i i° CIr j-Y- 120 i ~--- STATE t'-i IfPCODE ~-z ~ -1TRIMARI'- IV. EMERGENCY CONTACTS ,-SECONDARY- NAME 123 - NAME ~'s ~ ' ,~~~ ~ "TITLE ~ i2a TITLE ~?° ~_~ ~. BUSINESS PHONE 125 BUSINESS PHONE ~ iso 24-HOUR PHONF. 126 24-HOUR PHONE ~n ~3~ ~ PAGER # 1z~ 1 PAGER # ~ i3z ~AUDITIONAL LOCALLY CO1..LEC"fID INFORMATION: /~ ia3 A PN: - - - - , - ,1-~ U Environmental Contact E-Mail Address: Certifiication: Based on my induiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personally examined and am familiar with the infonralior. s omitted and believe the information is true, accurate, and complete. ' SIGNA'fUR ~. , , ~',T U ~DE51GN TED REPRESENTATIVE DATE isa NAME OF DOCUMENT PREPARER is .t~. ~ ~ d riot) lib NAM ' ~' TITLE OF SIGNER ~ X37 nn pp ~ '1t~[ Y~[t~Y Cl(.~l .1c1~ I~Z M t}A ~ CONSOLIDATED CONTINGENCY PLAN KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT ~ Unified Program Form 2700 M STREET, suITE 300 ~ COVER PAGE BAKERSFIELD, CA 93301 _ Page of I. FACILITY IDENTIFICATION ~ EPA ID # (Hazardous Waste Only) 2 FACILITY ID # BUSINESS NAME (Same as Facility Name of DBA-Doing Business As) s - -. 7 . t-~ The Conso4idated Contingency Plan provides businesses a format to comply with the emergency planning requirements of the following two written hazardous materials emergency response plans required in California: a Hazardous Materials Business Plan (HSC Chapter 6.95 Section 25504 (b) and 19 CCR Sections 2729-2732), a Hazardous Waste Generator Contingency Plan (22 CCR Section 66264.52), and, This format is designed to reduce duplication in the preparation and use of emergency response plans at the same facility, and to improve the coordination between facility response personnel and local, state and federal emergency responders during an emergency. A copy of the plan shall be submitted to this Department and at least one copy of the plan shall be maintained at the facility for use in the event of an emergency and for inspection by the focal agency. Describe below where a copy of your Contingency Plan, including the hazardous material inventories, Training Records, and Site Map(s), are located at your business: ~K I~PPb e ~F F ~c~ - . 801 ~uc'K ~u~c--~ ail ~ ~T~ 1 I h __P~A1~EfZ~~IGGD ca 9~30~ ~66~) 631- o~?~ i PLAN CERTIFICATION ! certify under penalty of law that 1 have personally examined and 1 am familiar with the information provided by this plan I and to the best of my knowledge the information is accurate, complete, and true. Printed Name of Owner/ Operator +~ ~~1u~ '~'~,`' 1 Title of Owner/Operator r . Signature of Owner/ Operator ~~ Date We appreciate the effort of local businesses in completing these plans and are available to assist in any manner. If you have any questions, please contact this Department at (661) 862-8700. B. Emergency IVledical Facility ! List the closest emergency medical facility that will be used by your business in the event of an accident of injury caused b a release or threatened release of a hazardous material HOSPITAL/CLINIC: PHONE NO: ADDRESS: CITY: ZIP CODE: l G4 C. Private Emer enc Response DOES YOUR BUSINESS HAVE A PRIVATE ON-SITE EMERGENCY RESPONSE TEAM? ^ Yes , ~ o If yes, provide an attachment that describes what policies and procedures your business will follow to notify your on-site emer enc res onse team in the event of a release or threatened release of hazardous materials. CLEANUP/DISPOSAL CONTRACTOR List the contractor that will provide cleanup services in the event of a release. NAME OF CONTRACTOR: PHONE NO: 1 ADDRESS: CITY: ZIP CODE: D. Arran ements with Emer enc Res onders If you have made special (i.e. contractual) arrangements with any police department, fire department, hospital, contractor, or State or local emergency response team to coordinate emergency services, describe those arrangements in the space below: I E. Evacuation Plan 1. The following alarm signal(s) will be used to begin evacuation of the facility (check all which apply): [Verbal ^Tetephone-(including cellular) ^ Alarm System ^ Public Address System ^ Intercom ^ Pagers ^, Portable Radio ^ Other (specify): 2. ^ Evacuation map is prominently displayed throughout the facility. 3. ^ Name of individual(s) responsible for coordinating evacuation including spreading the alarm and confirming the ~ business has been evacuated: I F. Earth uake Vulnerabilit Identify areas of the facility where releases could occur or would require immediate inspection or isolation because of the vulnerability to earthquake related ground motion. ^ Hazardous Waste/ Hazardous Materials Storage Areas ^ Production Floor ^ Process Lines ^ Bench/ Lab ^ Waste Treatment ^ Other: Identify mechanical systems where releases could occur or would require immediate inspection or isolation because of the vulnerability to earthquake related ground motion. Ll Utilities L__I Sprinkler Systems U Cabinets ^ Racks ^ Pressure Vessels ^ Gas Cylinders ^ Process Piping ^ Shutoff Valves ^ U Shelves ^ Tanks Other: C. Emergency Procedures _ Briefly describe your business standard operating procedures in the event of a release or threatened release of hazardous materials/wastes: 1. PREVENTION (prevent the spill/release) -Consider the types of spills/releases associated with the hazardous j materials/wastes present at your facility. What actions does your business take to prevent these spills/releases from occurring? You ma include a discussion of safet and storage procedures. lS \ t Y~'2~ w I 2. MITIGATION (stop the release/spill) -Describe what actions are taken to reduce the harm or the damage to person(s), property, or the environment, and prevent what has occurred from getting worse or spreading. What is your immediate response to a leak, spill, fire, ex losion, or airborne release at our business? ~ t ~- 3. ABATEMENT (clean up the spill/release) -Describe what you would do to clean up the spill/release. How do you handle the complete rocess of cleanin u and dis osin of released materials at our facilit ? ~^ rl Ja_ v ©~e N~~u'l ~ ~S a~~~ ~culC1 ~~coov~n ~ ~ i -- IV. Emergency Equipment 22 CCR, Section 66265.52(e) [as referenced by Section 66262.34(a)(3)] requires that emergency equipment at the facility be listed. Completion of the following Emergency Equipment Inventory Table meets this requirement. EMERGENCY EQUIPMENT INVENTOR Y TABLE 1. Equip~nent Cate o 2. Equipment T e 3. Location 4. -- Descri tion* Personal ^ Cartridge Respirators Protective, ~ ^Chemical Monitoring Equipment (describe) Equipment, ^Chemical Protective Aprons/Coats Safety ^Chemical Protective Boots Equipment, ^Chemical Protective Gloves and ^Chemical Protective Suits (describe) First Aid ^Face Shields Equipment ^ First Aid Kits/Stations (describe) ^ Hard Hats ^Plumbed Eye Wash Stations ^ Portable Eye Wash Kits (i. e. bottle type) ^ Respirator Cartridges (describe) ^ Safety Glasses/Splash Goggles ^ Safety Showers ^ Self-Contained Breathing Apparatuses (SCBA) ^ Other (describe) Fire ^ Automatic Fire Sptinkler Systems Extinguishing Fire Alarm Boxes/Stations Systems Fire Extinguisher Systems (describe) ^ Other (describe} Spill ^ Absorbents (describe) Control ^ Berms!Dikes (describe) Equipment and ^ Decontamination Equipment (describe) ^ Emergency Tanks (describe) Decontamination ^ Exhaust Hoods , Equipment ^ Gas Cylinders Leak Repair Kits (describe) ^ Neutralizers (describe) ^ Overpack Drums ^ Sumps (describe) ^ Uther (describe) Communications ^Chemical Alarms (describe) and ^ Intercoms/ PA Systems Alarm ^ Portable Radios Systems ^ Telephones ^ Underground Tank Leak Detection Monitors ^ Other (describe) Additional Equipment _ (Use Additional Pages if Needed.) D<~scribe the equipment and its capabilities. If applicable, specify any testing/maintenance procedures/intervals. Attach additional pages, numbered appropriately, if needed. s~~`C. r S146~ pu .ti ~ ~~ _...+ ~ t ~ tjotv~~u' SS, 00 r-, ~ ~~`, ~o~`~~` ~ '- ~~, 4~ ~~ ~ CONSOLIDATED CONTINGENCY PLAN iiERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT Unified Program Form 2700 M STREET, SUITE 300 SITE MAP BAKERSFiELD, CA 93301 (661) 862-8'i00 Fax 661) 862-8701 Page of I. FACiLiTY IDENTIFICATION FACILITY ID # ~ EPA ID # (Hazardous Waste Only) z 1 1 B USI NESS NAME (Same as Facility Name of DBA-Doing Business As) 3 AA ~~ SITE A DRESS 103 CITY 104 ZIP CODE toa DATE MAP DRAWN MAP # SUB=FACILITY # (if needed) ~: ~p a~ L` ~ O ~r J ~ - ~ i .. rS /~ ~ ~d a ~ ~oQo For Site Map • Loading Areas • Parking Lots • Internal Roads • Storm and Sewer Drains • Adjacent Property Use Locations and Names of Adjacent Streets and Alleys • Entrance and Exit Points and Roads • Evacuation Routes For Storage Map Location of Each Storage Area • Location of Each Hazardous Material Handling Area Location. of Emergency Response Equipment NORTH i> s IIAZARI)OUS 1dIATERIALS INVENTORY - cxEMicaL DESCUirTioN KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT Unified Program Consolidated Form (UPCF) X700 M11 STREET, SUITE 300 HAZARDOUS MATERIALS BAKERSFIF..LD, CA 93301 (661 862-8700 Fax 661 862-8701 (one pate per material per bucking or area) ^ADD ^DELETE ^REVISE 200 Page, of I. FACILITY INFORMATION -RI-I- NES/S NAME (Same as FACILITY NAME or DBA -Doing Business As) I ~/ r V ~' ~ 1 CHEMICAL LOCATION 20 CHEMICAL LOCATION CONFIDENTIAL EPCRA zoz I j ^ YES ^ NO ~ ~ I MAP# (optional) 203 GRID# (optionaq 2oa ~ FACtI.,ITY ID # 1~- II. CHEMICAL INFORMATION Cf-1F,.MICAL NAME ''-0S TRADE SECRET ^ Ycs No 'zov if Subject to EPCRA, refer to instructions COMMON NAME zo7 zos [+~N * ^ Yes o EHS CASi~ 209 *If EHS if"Yes", all amounts below must be in pounds FIRE CODE HAZARD CLASSES (NotcurremlyrequiredbyxCEHSO) ~ 710 HAZARDOUS MATGKI;\L 21I TYPE. (Check one item only) ^ a. PURE ^ b. ~41XTURE ~c. WASTE ,,/ RADIOACTIVE ^ Yes yJ No ?IZ 213 CURIES PHYSICALSTrV'I,E 21S (Check one item only) ^ a. SOLID ~b. LIQUID ^ c. GAS 214 LARGEST CONTAINER ~ FED FIAZARD CATEGORIES zlv (Check all that apply) ^ a. FIRE ^ b. REACTIVE ^ c. PRESSURE RELEASE ^ d. ACUTE HEALTH ^ e. CFIRONIC HEALTH A\%ERAGE DAILY AMOUN"f 317 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 v c G ' r CJ n lV ~'~ ~ < ''2 DAYS ON SITE..: '-''2 UNITS; a. GALLONS ^ b. CL!BIC FEET ^ c. POUNDS ^ d. TONS (Check one item onl ) * If EHS, amount must be in ounds. STORAGE J/ CONTAINER ~J a. ABOVE GROUND TANK ^ e. PLASTIC/NONMETALLIC DRUM ^ i. FIBER DRUM ^ m. GLASS BOTTLE ^ q. RAIL CAR ^ b. UNDERGROUND TANK ^ f. CAN ^ j. BAG ^ n. PLASTIC BOTTLE ^ r. OTHER ` ^ c. TANK INSIDE BU1I.DING ^ g. CARBOY ^ k. BOX ^ o. TOTE BIN I ^ d. STEEL DRUM ^ h. S1L0 ^ 1. CYLINDER ^ p. TANK WAGON '_23 STORAGE PRESSURE ^ a. AMBIENT ^ b. ABOVE AMBIENT ^ a BELOW AMBIENT 224 STORAGE TEMPERA"PURE a. AMBIENT ^ b. ABOVE AMBIENT ^ c. BELOW AMBIENT ^ d. CRYOGENIC ?25 %WT ~ HA7ARDOUS COMPONENT (For mixture or waste only) EHS CAS # 1 zzv '227 ^ Yes ^ No 2z8 229 Z 2so 231 ^ Yes ^ No z33 33; 1 3 ?i4 zss ^ Yes ^ No zsv zs~ 4 'zsa 239 ^ Yes ^ No 2ao 241 S 342 1 1 243 ^ YCS ^ NO 244 245 If mm•t hazardous components are presto[ at greater than I % hV weight if non-carcinogeniq or 0.1 % by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION z4v I ~ If EPCRA, Please Sign Here a;e -, ;i ~-IAZARDOUS WASTE GENERATOR KERN COIiNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT Unified Program Form 2700 M STREF,'I', Sl11TE 300 BAIhF.RSFiELD, CA 93301 661)862-8700 Fax 661 862-8701 Page of I. FACILITY INFORMATION FACILITY ID # ~ ~ EPA ID # (Hazardous Waste Only) ~ ~ ~' BUSINESS NAME (Same as Facility Name of DBA-Doing Business As) s # OF EMPLOYEES n f II. TYPE OF GENERATOR PLEASE CHECK THE BOX THAT APPLIES B RCRA GENERATOR (FEDERAL WASTE) NON-RCRA GENERATOR (CALIFORNIA WAS"I'EONLY) LARGE QUANTITY GENERATOR (>1000 KG HAZARDOUS WASTE PER MONTH SMALL: QUANTITY GENFiRATOR (>100 KG BUT <1000 KG HAZARDOUS WASTE PER MONTH) ~ ~ i CONDITIONALLY EXEMPT SMALL QUANTI`T'Y GENERATOR (<100 KG HAZARDOUS WASTE PF.R MONTH) ~ ~ III. WASTE STREAM IDENTIFICATION PLEASE COMPLETE THE TABLE BELOW. (SEE INSTRUCTIONS ON THE BACK FOR CODES AND EXPLANATIONS) PROCESS C WASTE DESCRIPTION D WASTE ID E AMOUNT F PER YEAR UNITS G STORAGE H METHOD DISPOSAL [ METHOD / cert~ that the information provided herein is true and accurate to the best of my knowledge. OWNEK/OPERATOR NAME ~ Y OWNER/OPERATOR TITLE K OWNERIOPER ~J DATE L '-