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Home My WebLink AboutBUSINESS PLAN_ HMMP) ~FbAeZI~ t ~ U~ MATERIALS MANAGEMENT PLAN (UNIFIED PROGRAM CONSOLIDATED FORM) APPLICAl10N . BOSNESSOVIMBZ/OPBiATORDENTFKrA~TiION FORM {HAZARDOUS MATERIALS FACILITY INFORMATION) tee H B R S F I D F/R6 A~ T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave., Suite 210 Bakersfield, CA 93301 Tel.: 661-326-3979 Fax: 661-852-2171 Page 1 of 2 y~ L FACILITY>IDENTiF{CATION ' FACILITY ID NO. 7 Year Beginning 700 Year Ending tot BUSINESS NAME (Same as FACILITY NAME or A- Doing @usines A~ 3 USINESS PHONE 702 S , t Irn( n SITE DR SS w - 703 CITY ~ -Z =~ ton CA Ip ~ ~~ to5 DUNN & BRADSTREET 706 SIC CODE 707 (4 Digit #) COUNTY 2 ~1 toe OPERATOR NAME __ 708 ~I _-~ ~ •.-S OPERATOR P1-IONE - ~ i ^ ~ CC~J y tto II. OWNER INFORMATION OWNER NAME 777 WNER PHONE 772 U z -l~ 9,~ OWNER MAILING ADDRESS 773 ~ CITY 0 tta STATE n5 IP 778 S CA III. ENVIRONMENTAL CONTACT CONTACT NAME 777 CONTACT PHONE n8 CONTACT MAILING ADDRESS 179 lJ GG CITY 720 STATE 727 ZIP 722 1~ . ( ,~ -.PRIMARY Iv. I=_nnERGeNCY coiVf,acTS -SECONDARY- NAME ,~ 123 NAME ~ ~ 128 TITLE ' 124 TITLE e 129 ~ Y BUSINESS PHON 9. 125 i BUSIN SS PHO E 6 6 ~ ~- 130 24-HOUR PHONE 126 24-HOUR P NE 131 6~ ~- c~o13 ~G~ 7 -~ a ~ PAGER N0. 127 PA R NO. 132 133 ,..._ '. V: CERTIFICATION Cert~cation: 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. SIGN U E OF SIGNER ~ 136 DATE 134 NAME OF DOCUMENT PREPARER 135 NAME OF OWNER/OPERATOR ( DIGNATU & PRINT) 137 TITLE OF OWNER/OPERATOR 138 ' ~ r _ n eu ~ 550 FD 2142 (Rev. 09/05) (Hazardous Materials Facility Information. - HMMP) Business Owner/Operator Identification Please submit the Business Activities page, the Hazardous Materials Faci/itylnformation (HMMP) Business Owner/Operator Identification Form, and Flazardo~ Materials Inventory Chemical Description Form for all hazardous materials inventory submissions. For the inventory to lie considered; please complete this page, it must be signed by the appropriate individual. NOTE.- The numbering ofthe instructions to/%ws the data a%ment numbers that are on the Business Owner Operator Form page. These data a%ment numbe, are used for e%tronic submission andare the same as the numbering usedin 27 CCR, Appendix C, bye Business Section ofthe Unified Program Data Dictionary. P/ease numbers//pages ofyoursubmilta/. This he/ps our CUPA orAA identify whether the submitta/is comp/ete and ifanypages are separated 1 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. (YYYYMMDD) - ~ -'-- ' '_ - 101 ENDING DATE -Enter the ending year and date of the report. (YYYYMMDD) - _ 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 -Enter the Dunn & Bradstreet number for the facility. The Dunn & Bradstreet number maybe obtained by calling (610) 882- 7748 or by intemet. - 107 SIC CODE -Enter the primary Standard Industrial Classification Code number for primary business activity. -. _ NOTE.' /fcode is more than.4 digits, report on/y the first four ' . - ' ' - _ 108 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, if different from business phone, area code first, and any extension. 111 OWNER NAME -Enter name of business owner, if different from business operator: - - - ~ ' ~ - • • - 112 OWNER PHONE -Enter the business owner's phone number if different from business phone, area code first, and any extension. 113 OWNER MAILING ADDRESS -Enter the owner's mailing address 'rf different from business site address. 114 OWNER CITY -Enter the name of the city for the owner's mailing address. - - ~ ' 115 OWNER STATE -Enter the 2 character state abbreviation for the owner's mailing address. 116 OWNER ZIP CODE -Enter the zip code for the owner's address. The extra 4 digit zip may also be added. ' 117 ENVIRONMENTAL CONTACT NAME -Enter the name of the person, 'rf different from the Business Owner or Operator; who receives all environmental correspondence and will respond to enforcement activity. 118 CONTACT PHONE -Enter the phone number, 'rf different from the Owner or Operator, at which the environmental contact can be contacted, area code first, and any. extension. . __ -. 119 CONTACT MAILING ADDRESS -Enter the mailing address where all environmental contacx correspondence should be sent, if different from the site address. 120 CITY -Enter the name of the city for the environmental contact's mailing address. 121 STATE -Enter the 2 character state abbreviation for the environmental contact's mailing address. 122 ZIP CODE -Enter the zip code of the environmental contact's mailing address. The extra 4 digit zip may also be added. 123 PRIMARY EMERGENCY CONTACT NAME -Enter the name of a representative that can be contacted in case of an emergency involving hazardou materials at the business site. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regardinc 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.any 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's home phone number, then the service answering the phone must be able to immediately contact the individu, stated above. -- ... 127 PAGER NUMBER -Enter the pager number for the primary emergency contact, 'rf available. 128 SECONDARY EMERGENCY CONTACT NAME -Enter the name of a secondary representative that qn be contacted in the event that the primary emergency centact is not available. The contact shall have FULL faality 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's home phone number, then the service answering the phone must be able to immediately contact the individual stated above. 132 PAGER NUMBER -Enter the pager number for the secondary emergency contact, if available. 133 ADDITIONAL LOCALLY COLLECTED INFORMATION -This space may be used for CUPA's or AA's to collect any additional information necessan to meet the requirements of their individual programs. Contact your local agency for guidance. 134 DATE -Enter the date that the document was signed. (YYYYMMDD) 135 NAME OF THE DOCUMENT PREPARER (FULL PRINTED NAME) -Enter the full printed name of the person who prepared the inventory submittal information. 136 NAME OF DOCUMENT SIGNER (FULL PRINTED NAME) -Enter the full printed name of the: person signing the page. The signer certifies to a familiarity with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information, all the information submitted is true, aaxirate and complete. 137 SIGNATURE OF OWNER/OPERATOR/OR DESIGNATED REPRESENTATIVE -The Business Owner/Operator, or officially designated representative of the Owner/Operator, shall sign in the space provided. This signature certifies that the signer is familiar with the signer's belief that the submitted information is true, accurate and complete. 138 TITLE OF OWNER/OPERATOR/OR DESIGNATED REPRESENTATIVE (SIGNER) -Enter the title of the person signing the page. Page 2 of 2 FD 2142 (Rev. 09/05) HMMP) HA7,A_ RDO€JS MATERIALS MANAGEMENT PLAN r ~ ~ BAKERSFIELD FIRE DF.,PT:: Prevention Services ~ ° -~-_==~ ~ ~ ~~-~ ~ - _ a e x s A I n g00 TrilXtun Ave., Suite 210 SITE & FACILITY DIAGRAM ~Rreer T Bakersfield, CA 93301 Tel.: 661-326-3979 Page 2 oft Fax: 661-852-2171 SITE DIAGRAM FACILITY DIAGRAM i j Business -Name: - - ~ ~ Business Address: ~~ _ _ \~IC o - ~~. ~lil~ S E~(~ _ ~! ~le~}roc: ~c~~ 'c3~`X jinn ~ o f-~ ~~ VJ t~'LC-f2 ~~ e~ t~yc~run~ ~~ NORTH Please indicate direction of North FD 2170 (Rev. 09/05) (HMMP) F °- HAZARDOUS MATERIALS MANAGEMENT PLAN '~;~:~4~~~~ - e°`_"_.."°"'.~^ _. r- -s~~~---:.,.- 8 H R S F I D '~" ~ ~ r, - FIRE INSTRUCTIONS ~ ~ ~ ~Rrer r SITE 8~ FACILITY DIAGRAM. ~~ BAKERSFIELD FIRE ~E~'. Prevention Services 900 Truxtun Ave., Ste. 210 Bakersfield, CA 93301 Tel.: 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 and 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 '/2 x 11" 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 will not be submitting fa_ cility 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"Iiusiriess as~shown in your HNIlVIP, on.the top"of the diagram. 3. Label the location of the hazardous materials and identify them by name and type of hazard (i.e., flammable liquid, corrosive solid). F 4. Label the location of utility shutoff points-for-gas,-eleetr-ie-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 identifcation 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. r .. ......... .... r ..... ~......- 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 F~VIl~7P. 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'fANK FACILITIES PLEASE NOTE: * If you operate an Underground Storage Tank (UST) facility, the facility diagram shall also specify the location(s) of the UST continuous leak monitoring system and/or the location(s) where the UST monitoring will be performed. FD 2170 (Rev. 0905)