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Home My WebLink AboutBUSINESS PLAN 5/18/2007 ,u. (,~ 4 <{CO/1 UNIFIED PROGRAM INSPECTION CHECKLIST Prevention Services . D 900 Truxtun Ave.. Suite 210 . Bakersfield. CA 93301 Tel.: (661) 326-3979. Fax: (661) 872~2171' SECTION 1: Business ~Ian and Inventory Program ~~ '~'gd[;~'~':: < ,,^"y .c'> ,," <", ':~';" ____~ ".' ',~ "-,.t- INSPECTION TIME FACILITY NAME r-\\ ~'- 0 ~I- "1 "\ 5 0 W~\-\-<:.. v:>~\ ""o...~ c~ .", >. (; -- ADDRESS L..... E FACILITY CONTACT ""'-, () (\., ROUTINE " "t\';,S~ctfon'~;;,;;~~usJ!J,~~~,. JiibCOMBINED 0 JOINT AGENCY o COMPLAINT c V (c complianCej V=Violation OPERATION COMMENTS o 0 ApPROPRIATE PERMIT ON HAND ~ G.. ~ ~ - '5>-'" ~o;...( ~ E...vv .~"'-.s\-",:)~ o 0 Business PLAN CONTACT INFORMATION ACCURATE o VISIBLE ADDRESS o CORRECT OCCUPANCY o VERIFICATION OF INVENTORY MATERIALS o VERIFICATION OF QUANTITIES o VERIFICATION OF LOCATION o PROPER SEGREGATION OF MATERIAL o VERIFICATION OF MSDS AVAILABILITY o VERIFICATION OF HAZ MAT TRAINING " ~t~ J\JN o VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES o EMERGENCY PROCEDURES ADEQUATE o CONTAINERS PROPERLY LABELED -0 0 HOUSEKEEPING -....0 0 FIRE PROTECTION --......!;;jJ 0 SITE DIAGRAM ADEQUATE & ON HAND ANY HAZARDOUS WASTE ON SITE? A:) YES EXPLAIN: va ~-t G! .(\ X Eo a2.- o NO QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979 ufi.,t- ~-( Inspector (Please Print) Fire Prevention /1" In / Shift of Site/Station # White - Prevention Services ., Yellow - Station Copy Pink - Business Copy FD 2155 (Rev. 09/05 ~~ 'f"!"l ~ -":" CITY OF BAKERSFIELD FIRE DEPARTMENT OFFICE OF ENVIRONMENTAL SERVICES UNIFIED PROGRAM INSPECTION CHECKLIST 1715 Chester Ave., 3rd Floor, Bakersfield, CA 93301 FACILITYNAME~\fl\...~ C)~e.~ '\ Wv\\ i\Q':>~ (e""h- INSPECTION DATE 5/ If/~) Section 4: Hazardous Waste Generator Program EP AID # <;')t ~ ,"- p t o Routine e Combined o Joint Agency o Multi-Agency o Complaint ORe-inspection OPERATION C V COMMENTS Hazardous waste detennination has been made - f-> , l::/< 8 "'" PI EP A ID Number 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 - .,J Containers are compatible with the hazardous waste - J , Containers are kept closed when not in use --- J Weekly inspection of storage area - ~ Ignitable/reactive waste located at least 50 feet from property line v7~ Secondary containment provided - ~ Conducts daily inspection of tanks - ~ Used oil not contaminated with other hazardous waste N7)l. Proper management of lead acid batteries including labels tJ 7 ,A. Proper management of used oil filters r\Jfh Transports hazardous waste with completed manifest r ) Sends manifest copies to OTSC ,~- ~::J .50\ V1-\ - Retains manifests for 3 years /CT Retains hazardous waste analysis for 3 years \ Retains copies of used oil receipts for 3 years JfV/A Detennines if waste is restricted from land disposal - l.J C-Comphance C ~~'-J V=Vlolatlon Pink - Business Copy Inspector: Office of Environmental Services (661) 326-3979 White - Env. Svcs. BAKERSFIELD FIRE DEPT. Prevention Services 1600 Truxtun Ave Suite 401 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 SELF-CERTIFICATION CHECK-bISi ~rn~?'Zj:t1u:J:~l't:4!t:~7'".;,!!_~.,re:>~~:~l!.'DP:;";-'WS.:.':~'l>X~'i~.';:;-o..,,:(~g~,-n:'!.~~f~:~~BtrtZ;,c;':''"i~'''_'JF;~~~':-:_~';~;'I!':~,:;;i::;f;.'<;'1r:;::;:': ~;;';,.'1i.J\!-;s;:r-!i:';(:v' Fire Prevention ~ ELF-CERTIFICATION DATE: t;"-t-.c;' INSTRUCTIONS: Please verify and check each item as appropriate. Include comments on each line or at the bottom as necessary. en completed, make a second copy for your records and mail the original to the address above. Failure to return will result in inspection. Y N OPERATION COMMENTS o V Spent fluorescent tubes saved in a suitable container and recycling* (If y~y on an outside agency for the recycling, please indicate the name, address, and phone number of the agency that removes your tubes.) Name: Phone No.: ddress: .1\ 0 0 Waste batteries saved in suitable container for recycling* U\ , 0 0 Discarded electronic devices saved for recycling* !A '.'+ \: - 11' 0 Discarded items containing Mercury saved for recycling* \ .~'S .-( t=', \~ ~~ 0 0 Discarded non-empty aerosol spray cans saved for recycling* ~o lzI()o Y'D ........;0 '-~o 1'J 0 o '7'6 g.)0 ~D Current annually serviced "ABC Type" fire extinguisher every 75 feet of travel Extension cords not used in place of what should be permanent wiring All exits indicated by exit signs, not more than 100 feet apart, if occupant load IS 100 or more Minimum of 30 inches of clearance in front of electrical panels Cover platfil~ installed on all electrical outlets, switches, and junction boxes (no exposed wlnng) Flammable and combustible material stored properly and not adjacent to a source of ignition (check hot water heater and furnace area) Do you use or store any hazardous materials on site? Does your building have a monitored fire alarm system? Does your building have a fire suppression (sprinkler) system? *Recycle at the Kern County Special Waste Facility, 4951 Standard Street. Bakersfield. CA 93308. Phone: (661) 862-8922 COMMENTS: LEASE CALL us AT (661) 326-3979 1 ~fD1CD@~ ~ ifC ...0 ~ Rev. 09/06) ~-~ APPLICATION BUSINESS OWNER/OPERATOR IDENTIFICATION FORM (HAZARDOUS MATERIAL FACIUTY INFORMATION BAKERSFIELD FIRE DEPT. Prevention Services 1600 Truxtun Avenue, Suite 401 Bakersfield, fA.~J~.L ?:;~c'ift~~i~~r,lq7: d~ Page 1 of 2 {I..J ~ 5 . ~ , ,~ii'~ ;; (HMMP) r;'<ifAtAltboUS MATERIAL MANAGEMENT PLAN PROGRAM CONSOUDATED 3 102 103 CA 105 EM'T'O JUN 0 1 106 107 108 110 113 116 119 122 129 130 131 132 138 \)\ FD2142 (Rev. 03/07) \ 'a-9:>I\\P FACILITY 1.0. NUMBER,- :J:his number is assigned by the CUPA or AA. This is the unique-humber,.which 'identifies'your facility. BUSINESS NAME - Enter the full legal name of the business. BEGINNIN<i"DATE - Enter the beginning year and date of the report. ENDING DATE - Enter the ending year and date of the report, BUSINESS PHONE - Enter the phone number, area code first, and any extension. , 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 Dun!) & Bradstreet number may be obtained by calling 610-882-7748 or by Internet. . ,.. ~. . '" ,<.. ,':. ~~, .,..-==10,"="'SIC-CODE--Enter.the"'primary'Standard'In'duSt:rial'Classification-Code-n'unloerforprii'i1aFYousin'ess'aetiVity: . NOTE: ' If code is more than 4 digits, report only the'first four., ' , COUNTY - Enter the county in which the business site is located. BUSINESS OPERATOR NAME - Enter the name of the business operator..." , .. ,', . . { " ,,'" BUSINESS OPERATOR PHONE - Enter business operator phone number, area code first, and any extension. OWNER'NAME - Enter name of business owner. OWNER PHONE ~ Enter the business owner phone number, area code first, and any extension. OWNER MAILING ADDRESS - Enter the owner mailing address. OWNER CITY - Enter the city for owner mailing address. .' -';- OWNER STATE - Enter the 2 character state abbreviation for the owner mailing addreSs. . OWNER ZIP CODE - Enter the zip code for the owner address; extra 4-digit zip may also be added. ENVIRONMENTAL CONTACT NAME - Enter the name of the person who receiv~s all environmental;correspondeQce and will. respond to enforcement activity. 118 CONTACT PHONE - Enter the phone number at which the environmental contact can be contacted, ,area code first,.and any extension. , . CONTACT MAILING ADDRESS - Enter the mailing address where all environmental contact correspondence should be sent. CITY - Enter the name of the city for the environmental contact mailing address. STATE - Enter the 2 character state abbreviation for the environmental contact mailing address. ZIP CODE - Enter the zip code of the environmental contact mailing address; extra 4-digit zip may also be added. 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 FULLfaci]ity access, site familiarity, ard authority to IT)ake decisions for the business regarding incident mitigation. -, . ,- I ' TITLE - Enter the title of the primary emergency contact. BUSINESS PHONE - Enter the business number for the primary emergency contact, area code first, and any extensions. _ I 24-HOUR PHONE - Enter a 24-hour phone number for the primary emergency contact. The 24-ho'ur 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 thaticanbe 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 n,umber 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 horrie phone number, then the service answerin'g 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 SIGNER (FULL SIGNATURE) - Enter the full signature of the, person signing 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 'si'gm:ir belief that the sub'mitted information is true, accurate, and complete. . - '" - ' .' . 138 TITLE OF DOCUMENT SIGNER - Enter the title of the person signing the page. ' , HAZARDOUS MATERIAL FACILITY INFORMATION (HMMP) BUSINESS OWNER/OPERATOR IDENTIFICATION ) " '\.. f,,',;,: . ..w- ,-l Please submit the Business Activities page, the Hazardous Material Facility Information (HMMP) Business Ownerl Operator Identification Form, and Hazardous Material Inventory Chemical Description Form for all hazardous materi~1 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. ), \ \ <:0 ;:... - . ~. 1 3 100 101 102 103 i ~ ... .t 108 109 110 111 112 113 114 115 116 117 1-' ,. _ \ f"/ ( _ r' 119 120 121 122 123 124 125 126 .", '\ Page 2 of 2 FD2142 (Rev. 03/07) / ~ ff #'j .,,~ ~~~BP...~~~,~AT~~I~r~~~~~~~~~!.~~~~ t,~~ 'APPI.ICATION t~ FOR SECTION DISCOVERY & NOTIFICATION ilo~',;'~,,', (FORMS) ;~l -,' INSTRUCTIONS 1. To avoid further action, return this form within 30 days of receipt. _ 2. Type/print answers in ENGUSH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. BAKERSFIELD FIRE DEPT. Prevention Services 1600 Truxtun Avenue, Suite 401 D Bakersfield, CA 93301 . OFFICE: '661-326-3979 FAX: 661-852-2171 Page 1 of 2 Cj330 t_:~1~~;-r'4;:;?J~\%:~: ,t~7J&;1j.}~m-4~l;40;:~ri~~:f~-~>j,f~f" 6~J:ifS,,:~;;:~:7i'fi~ti~';"'- '~c12~1~ 'i,;/~"iijr;:,;j;:~'1~~0-ii:tf.,~"J#j~'-;;;;);t1fI~,;rA;~~f>~ =,:~mli~~;t:t:JJ~:g?)Pl$g~~.I;B:l, ,Jll~~,PjJ:~~glml~,"~v r~LEAK DETECTION AND MONITORING PROCEDURES: 't-((s:;.,'i -:'0\ v-..h~<) Se,v'\~es l",c. .i..-\,7e>> i;;"c\"'s-h.,~, * '"I S' k<U"f (. q>~oC\ ~ tt. Co~ 7 - () '-{ 0'-" ~)MPLOYEE AND AGENCY NOTIFICATION: ~""VoJ\.~ ~S ~ bove.. C. ENVIRONMENTAL RESPONSE MANAGEMENT: D. EMERGENCY MEDICAL PLAN: A. HAZARD ASSESMENT AND PREVENTION MEASURES: Se\f &~~,~ B. RELEASE CONTAINMENT AND/OR MmGATION: S.e \ {" C~'^ ~\~ C. CLEAN-UP AND RECOVERY PROCEDURES: - ){-Ro..i':>O\,^-\-~~o'\7 <:>e<<,,;ees rV\c. FD2169 (Rev. 03/07) Page 2 of 2 ~f,. _ .- ~_...~ UllUTY SHUT-OFFS (LOCATION OF SHUT-OFfS AT YOUR FAQUTY) t,~~ \01 ,",^ ELECTRICAL: WATER: SPECIAL: PRIVATE FIRE PROTECTIONjWATER AVAILABIUTY: A. PRIVATE FIRE PROTECTION: S~ (' \~ t'\er S'f>+e-"'"\ J' c: (re e'F-+ l~ F.(~ H,/clr~ T~ --/1:---<';' ~:-_:...":,. - :~~.-..::' '.' '_ ~ - -~ _.~.~.:.~:.... .-.-&" ~- "'":1".-+;" ....:..;-'~.:~. ~ ~~~-...;, --_"".J'.;,,;,"~'.....-.-.~~- ",:~_.c",=-,~':.::;'~_L>-.f:~...;-"t_,.... ~~~.. B. WATER AVAILABIUTY (FIRE HYDRANT): .t..Ov:--+ (.f!> '..I\. \s I^ ffO~\+ 0 ~ ".ffi~ i V\ {: \"0....,..1tt kt~ NUMBER OF EMPLOYEES: )... MATERIAL SAFETY DATA SHEETS ON FILE: -A BRIEF SUMMARY OF )RAINING PROGRAM: ~ '" '^ v...:.--\ ~~~I ~cZel-:~ ". -~~---=--.-.-:. - - - --------- - ~- Based on my inquiry of those individuals responsible for obtaining the information, I certify under penalty of law that I have personall examined and am familiar with the information submitted and believe the information is true, accurate, and complete~ SIGNA1U OF NER/OPERA OR 0 E N RESENTA1lVE DATE ., . .r 5-~1- 07 NAME OF SIGNER (print) fJa.."~ -r 477 ,~ lM 478 TITLE OF SIGNER 479 C)'W'f\~f" . FD2169 (Rev. 03/07) ., ~. ;~.~-- 134 135 141 151 161 162 171 '172 181 CALIFORNIA WASTE CODES 112 113 121 122 123 131 132 133 Other spent catalyst Me~al,sludge (see 1'11) Metal du~t and mac:hiningwaste (see-li!) Other inorganic solid waste Organics 211 Halogenated solvents (methylene chloride, chloroform, TCE, TCA) Oxygenated solvents (acetone, butanol, M!=K) .- Hydrocarbon solvents (Stoddard solvent, xylene) Unspecified solvent mixture Waste oil and mixed oil Oil/water separation sludge Unspecified oil - containing waste Pesticide rinse water Pesticide and other waste associated with pesticide production, Tank bottom waste Still bottoms with halogenated organics Other still bottom waste 212 213 214 221 222 223 231 232 241 251 252 Page 3 of 3 tQdg Description Organics (con't.) 261 271 ,272 281 291 311 321 322 331 341 343 - 351' , ' PCB and material containing PCB - Organic monomer waste (includes unreac;ted resins) , '- - '\ ,'- . - , Polymeric resin .waste, - . Adhesives .... ~ DescriDtion 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)' Acid solution without metals Unspecified acid solution Alkaline solution pH >12.5 with metals (see 111) Alkaline solution without metals Unspecified alkaline solution Aqueous solution (2 < pH < 12.5) containing reactive Anions. (azide, bromate, chlorate, cyanide, fluoride, . 'hypochlorite,.nitrite, perchlorate and-sulfide.:a,nions) . Aqueous solution with metals (see 111) Aqueous solution with total organic residues 100% or more Aqueous solution with total organic residues < 10% Unspecified aqueous solution Off-spec, aged, or surplus inorganics Asbestos containing waste FCC Waste . Latex waste Pharmaceutical waste . Sewage sludge Biological waste other than sewage sludge Off-spec, aged or surplus organics Organic liquids (non-solvents) with halogens Unspecified organic-,liquid mixture." " OrganiC'solids with halogens" - Sludge 411 421 431 441. 451 461 471 481 491 Alum and gypsum Sludge Lime sludge Phosphate sludge Sulfur sludge Degreasirig sludge Pail)t sludge 'Paper' sl~dge/pulp Tetraethyl lead sludge Unspecified sludge waste - .... . Miscellaneous 511 512 513 521 531 541 551 561 571 581 591 611 612 Empty pesticide containers 30 gal or more Other empty container 30 gal or more Empty containers less than 30 gal .. Drilling mud . . ~ . i." Chemical toilet waste Photo chemical/photo processing waste Laboratory waste chemicals Detergent and soap Fly ash, bottom ash, and retort ash Gas scrubber waste Bag house waste Contaminated soil from site clean-ups Household wastes FD2144a (Rev. 03-07) (HMMP) HAZARDOUS MATERIAL MANAGEMENT PLAN UNIFIED PROGRAM CONSOLIDATED FORMS CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIAL INVENTORY BAKERSFIELD FIRE DEPT. Prevention Services.'. I. 1600 Truxtun Avenue, Suite 401 Bakersfield, CA 93301 OFFICE: 661-326-3979 FAX: 661-852-2171 Page 1 of 2 --. ~ '\. o NEW o DELETE o REVISE 200 o ADD FAOUTY 10 NO. CHEMICAL NAME ,W"<A.s.k COMMON NAME .~~. -v~,:..- ';-.r-_'" ",. CAS NO. FIRE CODE HAZARD CLASSES (complete if requested by local fire chief) TYPE o PURE o MIXTURE o WASTE PHYSICAL STATE ~UQUID o GAS o SOLID FED HAZARD CATEGORIES (Check all that apply) o FIRE o REACTIVE ANNUAL WASTE AMOUNT MAXIMUM DAILY AMOUNT 217 o UNITS' ~ GAL S' "If EHS, amOlfrit must be In Ibs. o CU FT n LBS STORAGE CONTAINER o ABOVEGROUND TANK '0 UNDERGROUND TANK o TANK INSIDE BUILDING o STEEL DRUM o PLASTIC/NONMETALLIC DRUM -":-"--_.'"'i~:_'" STORAGE PRESSURE '1 o ABOVE AMBIENT o AMBIENT STORAGE TEMPERATURE 0 AMBIENT o ABOVE AMBIENT HAZARDOUS COMPONENT 229 OfoWT 226 2 3 230 234 4 238 5 242 jj"""lf .:~ T 201 CHEMICAL LOCATION 202 CONFIDENTIAL (EPCRA) 0 Yes 0 No 203 GRID NO. (optional) 204 ~~. -. '4 - .~:. 209 *If EHS is yes, all amounts below must be In pounds. 210 211 212 213 CURIES RADIOACTIVE: DYes 0 No LARGEST CONTAINER 215 214 216 o PRESSURE RELEASE 0, ACUTE HEALTH o 'CHRONIC HEALTH 218 AVERAGE , DAILY AMOUNT 220 219 STATE WASTE CODE 221 DAYS ON SITE 222 o TONS 223 0 CAN 0 BOX 0 TANK WAGON 0 CARBOY 0 CYLINDER 0 RAIL CAR 0 SILO 0 GLASS BOTTLE 0 OTHER 0 FIBER DRUM )<::"PLASTIC BOTTLE 0 TOTE BIN 0 BAG ..,. - .-.,.' ""'.' - _._~~~~"'-?-'-. .:.)~ '''' ~~. " -..........;. :.:"...:_- 224 o BELOW AMBIENT 225 o BELOW AMBIENT o CRYOGENIC EHS CAS # 227 0 Yes 0 NO 228 231 0 Yes 0 No 232 235 0 Yes 0 No 236 233 237 239 0 Yes 0 NO 240 241 243 ~- 'S r:- 6J FD2144 (Rev. 03/07) / ,1:.1 - ';.~:;; ,- _ _;'- 1.... Hazardous Material Inventory - Chemical Description UNIFIED PROGRAM CONSOUDATED FORMS 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 ace 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 ofthe 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 failS 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 AAfor 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 f1oatin'g 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 totai 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 dally 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 1-5 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 1-5 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 inform.ation necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance. Page 2 of 2 . FD2144 (Rev. 03/07) (HMMP) HAZARDOUS MATERIAL MANAGEMENT PLAN (UNIFIED PROGRAM CONSOUDATED FORM) j~~~ ..~.~.~~!- '1(1~-'" BUSINESS ACTIVITIES PAGE (HAZARDOUS MATERIAL FACILIlY INFORMATION) ;_ r,'. BAKERSFIELD FIRE DEPT. Prevention Services "'-"_-..; '" (. 1600 Truxtun Avenue, Suite 401 Bakersfield, CA 93301 OFFICE: 661-326-3979 FAX: 661-852-2171 Page 1 of 1 DOES Your Facility___ A. HAZARDOUS MATERIAL 1. ~,Have'on site-(for any purpose). hazardous material at or above ,55 gallons for liquidsI' 500 pounds for' solids, or 200 cu. ft. for compressed gases (include liquids in AST and UST)? B. REGULATED SUBSTANCES CRSl 1. Have on site RS at greater than the threshold planning quantities established by the California Accidental Release Prevention program (CaIARP)? C. UNDERGROUND STORAGE TANKS lUSn 1. Own or operate Underground Storage Tanks? 2. Intend to upgrade existing or install new UST?-: . D. TANK CLOSURE/REMOVAL 1. Need to report closing an UST that held hazardous material or waste? 2. Need to report the closure/removal of a tank that was classified as hazardous waste and cleaned onsite? E. ABOVEGROUND PETROLEUM STORAGE TANKS LASD 1. Own or operate AST above these thresholds; any tank capacity is gr~?ter tt)an 660 gallons or the , . " -total capacity for the facility-is greaterihan 1,320 gallons? F. HAZARDOUS WASTE 1. Generate hazardous waste? 2. Recycle more than 100 kg/mo of recyclable material at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable material at an off-site location different from the point of generation? 4. Treat Hazardous Waste on site? 5. Subject to Financial Assurance requirements? 6. Consolidate Hazardous Waste generated at a remote site? DYes' No DYes 0 No DYes 0 No DYes 0 No DYes 0 No DYes 0 No DYes 0 No es 0 No If Yes, Please Complete___ 129 . CHEMICAL DESCRIPTION FORM . HAZARDOUS MATERIAL MANAGEMENT PLAN Minimum required olimnina elements: . Emergency Response Plan · Maps . Training · Prevention . Certification . CHEMICAL DESCRIPTION FORM . RISK MANAGEMENT PLAN (RMP Submit to USEPA) . CONSOUDATED COMPUANCE PLAN . Incorporating CalARP Program Elements 130 131 . UST FACILITY FORM . UST TANK FORM (one pei- tank) . UST FACIUlY FORM .UST TANK,FORM(one!per tank) · UST INSTALLATION FORM (one per tank) 132 133 . UST TANK FORM (Closure section - one per tank) . UST TANK CLOSURE FORM . HAZARDOUS MATERIAL MANAGEMENT PLAN · Incorporating Federal Spill Prevention Control and Countermeasure (SPCC) Elements pursuant to 40 CFR Part 112. _ ,..J ~f_'l.;_ :~, DYes 0 No . RECYCLING FORM EPA ID NUMBER - provide on this page · To obtain EPA ID Number, please phone (916) 324-1781 DYes 0 No . RECYCLING FORM DYes 0 No . TP FACILITY FORM · TP UNIT FORM (one per unit) DYes 0 No . CERTIFICATION OF FINANCIAL ASSURANCE DYes 0 No . REMOTE WASTE/CONSOLIDATION SITE NOTIFICATION 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. 03/07)