HomeMy WebLinkAbout1124 DOBRUSKY LANE (2)UNIFIED PROGRAM INSPECTION CFIECKLIST~;
: -_^__ - -- - -- -- _ _
__~ _. _ `. _ _.----- _:_- ,-___ ~:__-_ ____- . __._,__ ,
SECTION 1: Business Plan and Inventory Program. ~
A A K P. R S F 1 E I. D
P/RE
D ARTM ~N~
Prevention Services
900 ~-uxtun Ave., Suite 210
Bakersfield, CA 93301
Tel.: (661) 326-3979
Fax: (661) 872-2171
FACILIN NAME
~
1 l~G INSPECTION DATE
~ ` ~ ~ - d 9 INSPECTION TIME
~
3
- .r ~ ~
~ ~
.
ADDRESS
~'h
I1 Z HONE NO.
~`2Q~00
~ O OF EMPLOYEES
~
~ Yc.L ~
FACILITY CONTACT BUSINESS ID NUMBER
15-021- C7 U Z~7' ~/5
Section 1: Business Plan and Inventory Program
^ ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION
C V ( c=comP~iance~ OPERATION
V=Violation COMMENTS
^ APPROPRIATE PERMIT ON HAND
^ BUSIfI@SS PLAN CONTACT INFORMATION ACCURATE
L~ ^ 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
~J ^ EMERGENCY PROCEDURES ADEQUATE
^ CONTAINERS PROPERLY LABELED
^ HOUSEKEEPING
^ FIRE PROTECTION
^ SITE DIAGRAM ADEQUATE R ON HAND
ANY HAZARDOUS WASTE ON SITE?
EXPLAIN:
^ YES C~YNO
QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979
/ - ~ ~..~- ~ ca ~.."~S c~ ~` ~/~
Inspector (Please Print) Fire Prevention / 1" In / Shift of Site/Station # Business Site / Responsible Party (Please Print)
While - Prevention Services Yellow - Station Copy Pink - Business Copy FD 2155 (Rev. 09/OS
+ CALI~ORNIA WATER SRV 153-O1
Manager : TIM TRELOAR
Location: 1124 DOBRUSKY LN
City : BAKERSFIELD
_________________________ SiteID: 015-021-002949 +
BusPhone: (661) 396-2400
Map : 124 CommHaz : High
Grid: 06A FacUnits: 1 AOV:
CommCode: BFD STA 06 SIC Code:4941
I
EPA Numb: I
DunnBrad:006913578
+______________________________________________________________________________+
+_______________________________________+______________________________________+
Emergency Contact / Title Emergency Contact / Title
TIM TRELOAR / DISTRICT MGR RUDY VALLES / ASST DIST MGR
Business Phone: (661) 837-7200x Business Phone: (661) 837-7271x
24-Hour Phone : ( ) - x 24-Hour Phone : ( ) - x
Pager Phone : ( ) - x Pager Phone : ( ) - x
+---------------------------------------+--------------------------------------+
~ Hazmat Hazards: React ImmHlth ~
+------------------------------------------------------------------------------+
Contact : BILL ROSICA Phone: (661) 837-7278x
MailAddr: 3725 S H ST State: CA
City : BAKERSFIELD Zip : 93304
+------------------------------------------------------------------------------+
Owner CALIFORNIA WATER SERVICE CO Phone: (661) 837-7200x
Address : 3725 S H ST State: CA
City : BAKERSFIELD Zip : 93304
+------------------------------------------------------------------------------+
Period . to TotalASTs: = Gal
Preparer: TotalUSTs: = Gal
Certif'd: RSs: No
ParcelNo:
+------------------------------------------------------------------------------+
~ Emergency Directives: ~
PROG A - HAZMAT
PROG T- ABOVEGROUND STORAGE TANK
-*______________________________________________________________________________+
-1- 08/25/2008
+ CALIFORNIA WATER SRV 153-O1 _________________________ SiteID: 015-021-002949 +
+= Hazmat Inventory ________________________________________= By Facility Unit +
+_= MCP+DailyMax Order ______________________________ Fixed Containers at Site +
+--------------------------------+-------+-----------+-----+----------+----+---+
~ Hazmat Common Name... ~SpecHaz~EPA Hazards~ Frm I DailyMax ~UnitIMCP~
+--------------------------------+-------+-----------+-----+----------+----+---+
~ SODIUM HYPOCHLORITE R IH L 200.00 GAL Hi I
+______________________________________________________________________________+
-2- 08/25/2008
+ CALIFORNIA WATER SRV 153-01 _________________________ SiteID: 015-021-002949 +
+= Inventory Item 0001 _______________ Facility Unit: Fixed Containers at Site +
+_= COMMON NAME / CHEMICAL NAME ______________________________+________________+
SODIUM HYPOCHLORITE I Days On Site I
365
Location within this Facility Unit Map: Grid: +----------------+
I CAS# I
7681-52-9
+_____________________________________________________________+________________+
+= STATE _+= TYPE ___+_= PRESSURE ___+ TEMPERATURE __+___= CONTAINER TYPE _____+
~ Liquid ~ Mixture ~ Ambient ~ Ambient ~ ABOVE GROUND TANK ~
+_________+__________+_______________+_______________+---_----------------_____+
+__________________________+ AMOUNTS AT THIS LOCATION =________________________+
I Largest Container I Daily Maximum I Daily Average I
200.00 GAL 200.00 GAL 200.00 GAL
+__________________________+_________________________+_________________________+
+_______+______________ HAZARDOUS COMPONENTS =_____________+___+______________-+
I 12t50ISodium Hypochlorite INoSI CAS#7681529I
+_______+__________________________________________________+___+_______________+
+_______+___+______+__________= HAZARD ASSESSMENTS =__+_________+_______-+_____+
TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP
No INo I No I No/ Curies I R IH I~~~ I I Hl I
+_______+___+______+____________________+_____________+_________+________+_____+
+__________________________ MISC. LOCAL AGENCY DATA =__________________________+
I Ag.Definedl: Ag.Defined2: Ag.Defined3: Ag.Defined4: ~
Ag.Defined5: Ag.Defined6: Ag.Defined7:
Ag.Defined8: Ag.Defined9: Ag.Definel0:
+- Ag.Definell ----------------------------------------------------------------+
+______________________________________________________________________________+
-3- 08/25/2008
+ CALIFORNIA WATER SRV 153-01 _________________________ SiteID: 015-021-002949 +
+_________________________________________________________________ Fast Format +
+= Notif./Evacuation/Medical ____________________________________ Overall Site +
+_= Agency Notification _______________________________________________________+
+______________________________________________________________________________+
+__= Employee Notif./Evacuation _______________________________________________+
+______________________________________________________________________________+
+___= Public Notif./Evacuation ________________________________________________+
+______________________________________________________________________________+
+____= Emergency Medical Plan _____________________________________ 10/18/2006 +
MEDICAL ASSISTANCE WOULD BE PROVIDED BY MERCY HOSPITAL, TRUXTUN AVE.
+______________________________________________________________________________+
-4- 08/25/2008
+ CALIFORNIA WATER SRV 153-O1 _________________________ SiteID: 015-021-002949 +
+_________________________________________________________________ Fast Format +
+= Mitigation/Prevent/Abatemt ___________________________________ Overall Site +
+_= Release Prevention ____________________________________________ 10/18/2006 +
DAILY SITE VISIT BY CWS PERSONNEL TRAINED IN HAZMAT REPORTING.
+______________________________________________________________________________+
+__= Release Containment _________________________________________= 10/18/2006 +
LIQUID CHLORINE - SECONDARY CONTAINMENT
+______________________________________________________________________________+
±___= Clean Up ____________________________________________________ 10/18/2006 +
RELEASE ABATEMENT WOULD BE PERFORMED BY AN INDEPENDENT REMEDIATION
CONSULTANT, AS NEEDED, AND TO THE SATISFACTION OF THE RESPONSIBLE REGULATORY
+------------------------------------------------------------------------------+
------------------------------------------
+____= Other Resource Activation ______________________________________________+
+______________________________________________________________________________+
-5- 08/25/2008
+ CALIFORNIA WATER SRV 153-01 _________________________ SiteID: 015-021-002949 +
+_________________________________________________________________ Fast Format +
+= Site Emergency Factors _______________________________________ Overall Site +
+_= Special Hazards ___________________________________________________________+
+______________________________________________________________________________+
+__= Utility Shut-Offs ____________________________________________ 07/20/2007 +
ELECTRICAL: MAIN BREAKERS IN ELECT PANELS
WATER: WATER WELL
+______________________________________________________________________________+
+___= Fire Protec./Avail. Water __________________________________= 10/18/2006 +
WATER AVAILABILITY - WELL DISCHARGE
+______________________________________________________________________________+
+____= Building Occupancy Level ___________________________________ 03/08/2006 +
UNMANNED SITE
+______________________________________________________________________________+
-6- 08/25/2008
+ CALIFORNIA WATER SRV 153-01 _________________________ SiteID: 015-021-002949 +
+_________________________________________________________________ Fast Format +
+= Training _____________________________________________________ Overall Site +
+_= Employee Training _____________________________________________ 10/18/2006 +
MATERIAL SAFETY DATA SHEETS ON FILE IN BUILDING AND OR PANEL/CWS FIELD
OFFICE.
BRIEF SUMMARY OF TRAINING PROGRAM: SITE VISITS ARE MADE DAILY BY PUMP
OPER.ATORS TRAINED IN HAZMAT REPORTING PROCEDURES. MONTHLY COMPANY SAFETY
t______________________________________________________________________________+
+__= Page 2 ______________________________________ +
+______________________________________________________________________________+
+___= Held for Future Use _____________________________________________________+
+______________________________________________________________________________+
+____= Held for Future Use ____________________________________________________+
+______________________________________________________________________________+
-~- oa/2s/2oos
+ CALIFORNIA WATER SRV 153-01 _________________________ SiteID: 015-021-002949 +
+_________________________________________________________________ Fast Format +
+= Response/Risk Management ____________________________________= Overall Site +
+_= Operations ________________________________________________________________+
+______________________________________________________________________________+
+__= Planning _________________________________________________________________+
+______________________________________________________________________________+
+___= Logistics ---------------------------------------------------------------+
---------------------------------------------------------------
+______________________________________________________________________________+
+____= Finance/Administration _________________________________________________+
+______________________________________________________________________________+
-8- 08/25/2008