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GOOD SAMARITAN HOSPITAL-SOUTHWEST Manager SCOTT SEXTON Location: 5201 WHITE LN City BAKERSFIELD SiteID: 015-021-000046 BusPhone: (661) 398-1800 Map 123 CommHaz Moderate Grid: 15D FacUnits: 1 AOV: ~~~' CommCode: BFD STA 13 SIC Code:8063 EPA Numb : ~ ~\~~~ ~,~G -~ ~~(~+DunnBrad : , ~- ~~ ., .. ~ ~ flc~1 n Eme Conta / Ti 1 P Conta ~ / i.~1e-_ / Id~-'B / ADMIN Hess Phone: (661) 39 - 800x ~~~~ urines one: (661) 98-1800x204 2 4 -Hour Phone ( 6 61 2 4 -Hour Phone ( 6 61 ~-4~8~ -~ Pager Phone ( ) Pager Phone ( ) - Hazmat Hazards: Fire DelHlth Contact IkE Phone: (661) 398-1800 ~ ~~ MailAddr: O1 WHITE LN State: CA City BAKERSFIELD Zip 93309 Owner GOOD SAMARITAN HOSPITAL-SOUTHWEST Phone: (661) 398-1800x Address 5201 WHITE LN State: CA City BAKERSFIELD Zip 93309 Period to TotalASTs: = Gal Preparers TotalUSTs: = Gal Certif'd: RSs: No ParcelNo: Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD PROG U - UST ~'N~® ~ r tP Z ~ 9 U U ~~®/ Waitng for permit fees for minitor cert. i3ased on my inquiry of th~~c~ indi~'i~Q~tais respcnsib(e for abta.ining tho init~~rn~iti~r~, f certify under penalty of law that I P~~vi~ ~cr,onaliy examined and am familiar with tht~ inforer~ation submitted and be6ieve the informa tion is true, accurate, and complete. at.. R. Signature Date q~~~ -1- 07/11/2007 ~ GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: GOOD SAMARITAN HOSPITAL-SOUTHWEST Cross Street (a,rd5sa,r/~ Business Type : p~y~~;K~~P~ t.. I~osp•~ ~•~ Org Type Total Tank 1 IndnRes/Trust: No PA Contact: Dsg O Oper :~°•~ve,~ ~b~r~ Z{crn ~'4av~~i?Nne.J~`~, ~v~te~ ICC Nbr: PROPERTY OWNER INFORMATION Name -~i- (,~I1~r~ °~~vf'Sf,~sti'~ Phone: (661} 398-1800x204 Address : ~o~L Ns,~ L~~ C~,2~ Two ° Type CORPORATION ~1' ~ 30~ ~ ~~~2. State : Zip _~ TANK OWNER INFORMATION Name DAA4~.. ~~,~ ~, ~~r ~~ ~Q,f1~~Phosnb~~(16~5~398-1808 Address : • ~"`"~~"'~1'' City ~;, ~ ,~~ State: ~ Zip:Gl-~3Oc~ Type CORPORATION BOE UST Fee# 033861 Financ'1 Resp: Legal Notif Tank Owner Mailing Address --(~~~.. ~~q~"~~~ p~~ Date : Phone : ~' 1-1.8-P9.9~-1-x Name: ~ ~~ Tt1:rPLANT MANAGER State J 1998 Upg Cert#: 00703 -2- 07/11/2007 r GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers on Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP DIESEL FUEL #2 F DH L 1000.00 GAL Mod -3- 07/11/2007 -4- 07/11/2007 ~ GOOD SAMARITAN HOSPITAL-SOUTHWEST = ~ Inventory Item 0001 COMMON NAME / CHEMICAL NAME DIESEL FUEL #2 Location within this Facility Unit 20FT S EMER GEN E SIDE STATE TYPE PRESSURE Liquid Mixture Ambient SiteID: 015-021-000046 ~ Facility Unit: Fixed Containers on Site ~ Days On Site 365 Map: Grid: CAS# 68476-34-6 TEMPERATURE CONTAINER TYPE Ambient ~ER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum Daily Average 1000.00 GAL 1000.00 GAL 550.00 GAL - - rir~~ratcLVU~ ~vinrvlv~ly r~ %Wt. RS CAS# 100.00 Diesel Fuel No. 2 No 68476302 ri1~GF~1.[L AJ~L';771~11"~1V 1"7 TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod -5- 07/11/2007 GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 12/21/1999 ~ CALL 911. Employee Notif./Evacuation 12/21/1999 EVACUATION PROCEDURE IN PLACE, CALL 911. --- Public Notif./Evacuation 02/21/2007 GOOD SAMARITAN HOSPITAL-SOUTHWESTS PUBLIC ADDRESS SYSTEM WOULD BE UTILIZED TO WARN PUBLIC IN THE EVENT OF AN EVACUATION. a 02/21/20 RN ON DUTY 24-HOURS A DAY (ON SITE). GOOD SAMARITAN HOSPITALS, ~1~~#'~ T'n. EMERGENCY SITUATIONS BEYOND RN SCOPE WOULD BE HANDLED BY CALLING 911 AND TRANSPORTING TO NEAREST 24-HOUR EMERGENCY RM WITH SPACE AVAILABLE. -6- 07/11/2007 C~ f GOOD SAMARITAN HOSPITAL-SOUTHWEST SitelD: 015-021-000046 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 04/17/2006 ~ DIESEL #2 PROPERLY STORED IN AN UNDERGROUND STORAGE TANK. Release Containment 04/17/2006 UST AND PIPING ARE DOUBLE-WALLED WITH LEAK DETECTION MONITOR PROBES AND ALARMS. LIQUID LEVEL INDICATOR PROVIDES CONSTANT DIGITAL READOUT IN INCHES OF FUEL IN TANK. ALARMS MONITORED AT NURSES STATION 24-HOURS A DAY_~ - - ~~5, 1..1C0.11 V~/ i 1_ V 1.11C1 nC.7V U.1 VC [-~1. 1.1V0.1.1 V11 -7- 07/11/2007 ^~, e- ~ GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ .~Nc~,iai nac~aiu~ Utility Shut-Offs 12/29/2006 A) GAS - OUTSIDE MEDICAL RECORDS STORAGE RM SE CRNR LOADING DOCK B) ELECTRICAL - BET MAINT & MECH RMS & LOADING DOCK E C) WATER - MAIN BACKFLOW PREVENTER SW END FAC GRISSOM ST & IN EQUIP RM NEXT TO FIRE SPRINKLER NEXT TO MAIN ELECT RM D) SPECIAL - UST (#2 DIESEL) 1,000-GAL MAX E) LOCK BOX - YES (KEYS) MAINT SHOP E SIDE NEXT TO LOADING DOCK & ADULT NURSING HAS MASTER KEY AT NURSES STATION Fire Protec./Avail. Water 02/01/2007 PRIVATE FIRE PROTECTION - SPRINKLERS AND ~ PORTABLE FIRE EXTINGUISHERS. NEAREST FIRE HYDRANT - W END S WING AT GRISSON ST (SW CRNR OF SITE). Building Occupancy Level 03/29/2006 130 EMPLOYEES -$- 07/11/2007 . .., ~. ~~GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 12/29/2006 ~ MSDS SHEETS ON FILE. BRIEF SUNlN1ARY OF TRAINING PROGRAM: EMPLOYEES RECEIVE TRAINING IN HAZARDOUS MATERIALS WHEN HIRED AND WHEN A NEW SUBSTANCE IS INTRODUCED. NEW MATERIALS INTRODUCED MUST FIRST HAVE APPROVAL OF SAFETY COMMITTEE FOLLOWED BY TRAINING IN MSDS BEFORE SUBSTANCE IS USED. rayc c I1C1U 1VL lUI.ULC U5C r1c 1lA tvt lUl. Ui.C U.7"C -9- 07/11/2007 UNDERGROUND STORAGE TANKS BAKERSFIELD FIRE DEPT. ~~R~ Preveatioa Services At 1A/ T 900 Truxtun Ave., Ste. 210 APPLICATION ,~ Bakersfield, CA 93301 TO PERFORM ELD /LINE TESTING Tel.: (661) 326-3979 / S6989 SECONDARY CONTAINMENT TESTING Fax: (661) 852-2171 (TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION page 1 of 1 ~ ~ ~ ~~ PERMIT NO. J .LS ENHANCED LEAK DETECTION .CS LINE TESTING .e5 SB-988 SECONDARY CONTAINMENT TESTING FS TANK TIGHTNESS TEST .~5 TO PERFORM FUEL MONITORING CERTIFICATION SITE INFORMATION O _ J ~G r, IL1TY ~ y~Cf ,J~ll 'k~~5 I ~ 1 I NAME & PHONE NU BER OF COy~ CT P R Ye C ~ 6 ~ ~ -'~~~a J e/r~ !~'~ ADDRES~. n fl ~ VU /%~`~Pi L~I,~J' ~ - /~ ~~R~I ~~l ~: ! / ~ ~~~ _ - =OWNERS E _ ~_ -~. _ ~O ~' - - i ~~~~ ~. /(~u u' ~ OPERATORS AME ~ ~ lll?~t P ~ ~~~ 05 _ PERMIT TO OPERATE NO. ®~ NUMBER OF TANKS TO BE TESTED IS PIPING GOING TO BE TESTED? .es YES -es NO TANK # VOLUME CONTENTS ' ~0~ v+~ +~/~ TANK TESTING COMPANY NA OFT STING COMPANY ~ NAME & PHONE NUMBER OF CONTACT P RS ~/} MAILING) ~ R / S~• ~ ~ .r-I? u l~~~i ` ~ ~ r / ~ ~ C'r l// / ~ ~~/ V NA E 8 P ONE N MBE OF TESTER OR,s PECI L I SPECTOR ~ c~RTIFICATION C ~ /~~D Z - ~,O _ UCTED ~~ 2! ~-- ICC #: ~ / / / / _ _ ! V ~ ~/' ~ O~"I ME~OI.~~I~ SI PLICANT . A,i DATE ',~ APPROVED BY DATE " - `~ ` FD 2095 (Rev. 09/05) f' ~ t' GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 Manager SCOTT SEXTON Location: 5201 WHITE LN City BAKERSFIELD CommCode: BFD STA 13 EPA Numb: BusPhone: (661) 398-1800 Map 123 CommHaz Moderate Grid: 15D FacUnits: 1 AOV: SIC Code:8063 DunnBrad: Emergency Contact / Title Emergency Contact / Title -SCOTT SEXTON / SAFETY COORD NICK DAMIAN /ADMINISTRATOR Business Phone: (661) 398-1800 _ Busin~~~ Phone: (661) 398-1800x204 24-Hour Phone (661) 444-1158 24-Hour Phone (661) 428-2024 Pager Phone Pager Phone (661) Hazmat Hazards: Fire DelHlth Contact : SUSAN KEENAN Phone: (661) 398-1800x206 MailAddr: 5201 WHITE LN State: CA City BAKERSFIELD Zip 93309 Owner GOOD SAMARITAN HOSPITAL-SOUTHWEST Phone: (661) 398-1800x Address 5201 WHITE LN State: CA City BAKERSFIELD Zip 93309 Period Preparers Certif'd: ParcelNo: to TotalASTs: = Gal TotalUSTs: = Gal RSs: No Emergency Directives: PROG A - HAZMAT PROG C - COMM HOOD PROG U - UST 3^Se~ Otl ,>~,~~ S;1C?CS4i\' 4i fh;~Sr f;idt\'°3:. '!= f@Ft~+C~"'=:;f1fr^.;'iQ; 0`~x';i":^C~ ;1~ lii'i?(??~c'tii'I~t, ~ ......'?i~i/ Ut;CiEi ,,nn~z:.\! C~i i ~'+.1' t}icz'C i ii:^.%"~' lick;'~Il:is`/ E',Xc.?li!!i-~'C:+ 2:!?.+ :-?ft'i i~a'l"liii~;v ~f~';~1 Y}'!^ ir;'ii;"r°~,^_.i47 se_;l:?mii+.ecJ anc h^ii~_;•F,~~ the iris\r,~~~.#iort i:, iru~, acc;~raie, artc? ccm- ci--- 2, L O / pJ icy . ice, ~ ,._.. _ ,__. i~a~~~ ~.._J`__.~' ENTb ~E~ ~ ~ ~~87' -1- 02/01/2007 F GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ STORAGE CONTAINER DATA (UST FORM A) Last Action Type: FACILITY/SITE INFORMATION Business Name: GOOD SAMARITAN HOSPITAL-SOUTHWEST Cross Street Grissom Business Type: gospital Org Type: For Profit Total Tanks 1 IndnRes/Trust: No PA Contact: Dsg Own/Oper ICC Nbr: PROPERTY OWNER INFORMATION Name Good Samaritan Hospital Phone: (661) 398-1800x204 Address: 901 Olive Drive City Bakersfield State: ~ Zip:93309 TYPe ~ California Limited Partnership TANK OWNER INFORMATION Name SAME AS ABOVE Phone: (661) 398-1800x204 Address: City State: Zip: Type BOE UST Fee# 033861 Financ'1 Resp: Good Samaritan Hospital Legal Notif : Nick Damian, Administrator Date:06/08/1993_ Phone: (661)398 -1800x 213 Name:,°Scott Sexton Tt1:PLANT MANAGER State UST # 1998 Upg Cert#: 00703 -2- 02/01/2007 F GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ ~ Hazmat Inventory By Facility Unit ~ ~ MCP+DailyMax Order Fixed Containers on Site ~ Hazmat Common Name... SpecHaz EPA Hazards Frm DailyMax Unit MCP DIESEL FUEL #2 F DH L 1000.00 GAL Mod -3- 02/01/2007 -4- 02/01/2007 i F GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site ~ COMMON NAME / CHEMICAL NAME DIESEL FUEL #2 Days On Site 365 Location within this Facility Unit Map: Grid: 20FT S EMER GEN E SIDE CAS# 68476-34-6 STATE TYPE PRESSURE TEMPERATURE CONTAINER TYPE Liquid TMixture Ambient ~ Ambient -~ER GROUND TANK AMOUNTS AT THIS LOCATION Largest Container Daily Maximum I Daily Average 1000.00 GAL 1000.00 GAL 550.00 GAL r~~EUCli~u~ ~uriruN~iv~l~5 ~Wt. RS CAS# 100.00 Diesel Fuel No. 2 No 68476302 r~~tittli tiaa~~~ln~iv~l~~ TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ Curies F DH / / / Mod -5- 02/01/2007 .} F GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ Fast Format ~ ~ Notif./Evacuation/Medical Overall Site ~ ~ Agency Notification 12/21/1999 ~ CALL 911. Employee Notif./Evacuation 12/21/1999 EVACUATION PROCEDURE IN PLACE, CALL 911. Public Notif./Evacuation 05/27/1993 GOOD SAMARITAN HOSPITAL - SOUTHWEST'S PUBLIC ADDRESS SYSTEM WOULD BE UTILIZED TO WARN PUBLIC IN THE EVENT OF AN EVACUATION. Emergency Medical Plan 04/17/2006 RN_:.C41y. DUTY . 24.-H.OURS..: A DAY (ON SITE) .Good Samaritan Hospital, 9U1 Olive Drive. ~_-, EMERGENCY SITUATIONS BEYOND RN SCOPE WUULU b~ tiANULED 13Y CALL11Vu 911 AND TRANSPORTING TO NEAREST 24-HOUR EMERGENCY RM WITH SPACE AVAILABLE. -6- 02/01/2007 F GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ Fast Format ~ ~ Mitigation/Prevent/Abatemt Overall Site ~ ~ Release Prevention 04/17/2006 ~ DIESEL #2 PROPERLY STORED IN AN UNDERGROUND STORAGE TANK. Release Containment 04/17/2006 UST AND PIPING ARE DOUBLE-WALLED WITH LEAK DETECTION MONITOR PROBES AND ALARMS. LIQUID LEVEL INDICATOR PROVIDES CONSTANT DIGITAL READOUT IN INCHES OF FUEL IN TANK. ALARMS MONITORED AT NURSES STATION 24-HOURS A DAY. t.1 CGL11 V~l V411C1. 1CC.7"VUiC:C HC~l.1Vdl.1V11 -7- 02/01/2007 F GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ Fast Format ~ ~ Site Emergency Factors Overall Site ~ ~~JC l:1Ql na~aius Utility Shut-Offs 12/29/2006 A) GAS - OUTSIDE MEDICAL RECORDS STORAGE RM SE CRNR LOADING DOCK B) ELECTRICAL - BET MAINT & MECH RMS & LOADING DOCK E C) WATER - MAIN BACKFLOW PREVENTER SW END FAC GRISSOM ST & IN EQUIP RM NEXT TO FIRE SPRINKLER NEXT TO MAIN ELECT RM D) SPECIAL - UST (#2 DIESEL) 1,000-GAL MAX E) LOCK BOX - YES (KEYS) MAINT SHOP E SIDE NEXT TO LOADING DOCK & ADULT NURSING HAS MASTER KEY AT NURSES STATION Fire Protec./Avail. Water 02/01/2007 PRIVATE FIRE PROTECTION - SPRINKLERS AND 24 PORTABLE FIRE EXTINGUISHERS. NEAREST FIRE HYDRANT - W END S WING AT GRISSON ST (SW CRNR OF SITE). Building Occupancy Level 03/29/2006 92 EMPLOYEES -8- 02/01/2007 _. ::- F GOOD SAMARITAN HOSPITAL-SOUTHWEST SiteID: 015-021-000046 ~ Fast Format ~ ~ Training Overall Site ~ ~ Employee Training 12/29/2006 ~ MSDS SHEETS ON FILE. BRIEF SUNIlKARY OF TRAINING PROGRAM: EMPLOYEES RECEIVE TRAINING IN HAZARDOUS MATERIALS WHEN HIRED AND WHEN A NEW SUBSTANCE IS INTRODUCED. NEW MATERIALS INTRODUCED MUST FIRST HAVE APPROVAL OF SAFETY COMMITTEE FOLLOWED BY TRAINING IN MSDS BEFORE SUBSTANCE IS USED. rctyC L Held for Future Use nc.LU iui r u~uLC u5c -9- 02/0l/200~