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HomeMy WebLinkAbout6901 WHITE LANEHA~ARDOUS MATERIAL MANAGEMENT PLAN Il APPLICATION BUSINESS OWNER/OPERATOR IDENTIFICATION FORM (HAZARDOUS MATERIAL FACILITY INFORMATION) ~ 8 H R F I D P/Re ~ ARTAI T ~ BAKERSFIELD FIRE DEPARTMENT Prevention Services 1501 Truxtun Avenue, lst Floor Bakersfield, CA 93301 Phone: 661-326-3979 • Fax: 661-852-2171 Page 1 of 2 I. FACILITY IDENTIFICATION FAC[LITY ID # 1 YEAR BEGINNING 100 YEAR ENDING 101 BUSINESS NAME (Same as FACILITY NAME or DBA) 3 BUSINESS PHONE 102 ~ Q ~~ ~ c~ W Z SITE ADDRESS 103 1 0 1 ~ CITY ~~~E~~IE~/ 104 Z~PCOOE q 3 105 c~ 3 DUNN & BRADSTREEf # 106 SIC CODE 107 COUNTY ~ct~y lpg OPERATOR NAME 109 OPERATOR PHONE 110 II. OWNER INFORMATION OWNER NAME 111 OWNER PHONE 112 Q ~ i - 'L OWNER MAILING ADDRESS ~l I 113 ~~TY 114 STATE 115 ~ ZIp CODE ~~/ 116 III. ENVIRONMENTAL CONTACT CONTACT NAME 117 CONTACT PHONE 118 CONTACT MAILING ADDRESS 119 CITY 120 STATE 121 ZIP CODE 122 _. ..__ . ._...,_ _ ._...._._ .__....'_. ._.. . . . _-._._.. _ __-____..,-.__~... _. .. .~._. IV. EMERGENCY CONTACTS _._.._ ' .._ ._ _-..__.._-~..._.' .. .._ ._ _______.. PRIMARY SECONDARY . NAME J a ~ ~ 123 NAME I 128 TITLE 124 TITLE ~ lZ9 V• BUSINESS PHONE ~ ~ ~ ' ~ ~7 _ L G/ lZS BUSINESS PHONE ~ _~ ~ 130 24-HOUR PHONE 126 24-HOUR PHONE 131 CELL PHONE 127 CELL PHONE 132 133 V. CERTIfICATION Certification: 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 sub mitted in this inventory and believe the information is true, accurate, and complete. SIGNATURE OF DOCUMENT PREPARER 136 DA T~ ~' ~ 134 v o NAME Of DOCUMENT PREPARER (PR T)~~ ~ 1' - ' 135 O ~ ivr, ME OF OWNER/ PE TOR (S[ N F P INT) 137 TITLE OF DOCUMENT PREPARER 138 ~ r~•~ i~ a i-1 A i~ 'I • cc% U /~/ Fozlaz (aev o6/07) HAZARDOUS MATERIAL FACILITY INFORMATION BUSINESS OWNER/OPERATOR IDENTIFICATION Please submit the Business Activities page, the Hazardous Material Facility Information (HMMP) Business Owner/ Operator ldentification Form, and Hazardous Material Inventory Chemical Description Form for all hazardous material 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. 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. 101 ENDING DATE - Enter the ending year and date of the report. 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 NUMBER - Enter the Dunn & Bradstreet number for the facility. The Dunn & Bradstreet number may be obtained by calling 610-882-7748 or by Internet. 107 SIC CODE - Enter the primary Standard Industrial Classification Code number for primary business activity. NOTE: If code is more than 4 digits, report only 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, area code first, and any extension. 111 OWNER NAME - Enter name of business owner. 112 OWNER PHONE - Enter the business owner phone number, area code first, and any extension. 113 OWNER MAILING ADDRESS - Enter the owner mailing address. 114 OWNER CITY - Enter the city for owner mailing address. 115 OWNER STATE - Enter the 2 character state abbreviation for the owner mailing address. 116 OWNER ZIP CODE - Enter the zip code for the owner address; extra 4-digit zip may also be added. 117 ENVIRONMENTAL CONTACT NAME - Enter the name of the person who receives all environmental correspondence 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. 119 CONTACT MAILING ADDRESS - Enter the mailing address where all environmental contact correspondence should be sent. 120 CITY - Enter the name of the city for the environmental contact mailing address. 121 STATE - Enter the 2 character state abbreviation for the environmental contact mailing address. 122 ZIP CODE - Enter the zip code of the environmental contact mailing address; 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 hazardous material, at the business site. The contact shall have FULL facility access, site familiarity, and authority to make decisions for the business regarding 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 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 that can be 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 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 home phone number, then the service answering 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 PREPARER (FULL SIGNATURE) - Enter the full signature of the person preparing 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 signer belief that the submitted information is true, accurate, and complete. 138 TITLE OF DOCUMENT PREPARER - Enter the title of the person preparing the page. Page 2 of 2 FD2142 (Rev 06/07) HAZARDOUS MATERIAL MANAGEMENT PLAN INSTRUCTIONS ~ FOR SECTION DISCOVERY & NOTIFICATION (FORMS) SECTION I. - BUSINESS IDENTIFICATION DATA: BAKERSFIELD FIRE DEPARTMENT Prevention Services 1501 Truxtun Avenue, lst Floor Bakersfield, CA 93301 Phone:661-326-3979 • Fax: 661-852-2171 Page 1 of 2 The Business Owner/Operator ldentification Form FD2089, Chemical Description Form FD2086, and other forms (underground storage tank information, hazardous waste treatment, etc.) may be submitted as the first section of the Hazardous Material Management Plan in order to avoid duplication of information for initial submissions. SECTION II.1 - DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: Describe the procedures and equipment used to detect any release or threatened release of a hazardous material from any storage container, tank, or vessel at your business. Please provide a written explanation that also includes the make and model number of any automated or electronic leak detection equipment in use at your facility. B. EMPLOYEE AND AGENCY NOTIFICATION: What agencies and/or corporate officials are notified in case of a hazardous material spill or emergency - what procedures are used to notify these parties? At a minimum, you must call 911 and the Office of Emergency Services at 800-852-7550 to report any spills that are a threat to life, safety, or the environment, or for other non-emergency spill reporting, please call our office at 326-3979. C. ENVIRONMENTAL RESPONSE MANAGEMENT: Please describe who will be responsible for what activities (notifying authorities, clean-up companies, etc.), and what the chain-of-command is at your facility for making sure these activities are carried out. D. EMERGENCY MEDICAL PLAN: Summarize your plan for handling medical emergencies occurring at your business. List the local medical facility capable of handling an accident involving hazardous material used at your business. SECTION II.2 - RELEASE RESPONSE PLAN A. HAZARD ASSESSMENT AND PREVENTION MEASURES: Explain the procedures that you have developed and implemented to help prevent an incident from occurring. These steps could include, but are not limited to, storage methods, container types, segregation, safety equipment, and/or procedures used. B. RELEASE CONTAINMENT AND/OR MITIGATION: Explain the procedures that you have developed and implemented to assist in keeping a hazardous material incident at your business as small or confined as possible. C. CLEAN-UP AND RECOVERY PROCEDURES: Explain what clean up procedures will be implemented in case of a release at your business. This should address small spills as well as a major release of material once the material is contained. Hazardous Waste: Please provide the name of the hazardous waste company that regularly removes the waste from your business, and how often that waste is removed. Please keep all disposal receipts for the last three years available on site for inspection. B S B B 9 P I B D R/R~ ~ AR1M T FD2169a (Rev 06/07) HAZARDOUS MATERIAL MANAGEMENT PLAN SECTION II.2 - RELEASE RESPONSE PLAN (CONT) UTILITY SHUT-OFFS List locations of shut-offs using compass points and known or obvious landmarks. If you have a lock box containing keys and maps of the facility for the Fire Department to use, please list its location also. PRIVATE FIRE PROTECTION/WATER AVAILABILITY A. Private Fire Protection: Describe on-site fire protection for your business or facility unit, including sprinklers, fire extinguishers, alarm systems, and private response teams. B. Water Availability (Fire Hydrant): Give the location of the closest water supply or fire hydrant to be used by the Fire Department in case of an emergency. SECTION III - TRAINING List the number of employees that are working in the area of the hazardous material, use, or storage. Include all employees who have any occasion to be in those areas. Give the location where Material Safety Data Sheets (MSDS) are kept on file. The MSDS must be readily available on site in a place where employees can access them. Give a brief summary of your Hazardous Material Training Program. Employees are required by State law to have a program which provides employees with initial and refresher training in the following areas: 1. Methods for safe handling of the hazardous material used by your business. 2. The Cal-OSHA Hazard Communication Standard. 3. Correct use of emergency response equipment and supplies available at your business. 4. The prevention, minimizing, and clean-up procedures you have developed for your business. 5. The emergency evacuation plans you have developed as well as your notification procedure and medical plan. 6. Procedure to coordinate with and assist the local emergency personnel that may respond to your business. 7. Who and how to call for immediate assistance in the event of an accident involving hazardous material. CERTIFICATION Please fill in your name, title, signature, and date on the signature line. IMPORTAl~fT You must return this plan, inventory forms, and map within 30 days of receipt. If you have any questions please call us at 326-3464. Thank you for helping to keep our All America City cleaner and safer. CITY OF BAKERSFIELD BAKERSFIELD FIRE DEPARTMENT OFFICE OF PREVENTION SERVICES 1501 Truxtun Avenue, Bakersfield, CA 93301 PagO 2 of 2 FD2169a (Rev 06/07) HAZARDOUS MATERIAL MANAGEMENT PLAN APPLICATION FOR SECTION DISCOVERY & NOTIFICATION (FORMS) BAKERSFIELD FIRE DEPARTMENT ~ Prevention Services 1501 Truxtun Avenue, is~ Floor s s r i aBakersfield, CA 93301 P/R! Phone: 661-326-3979 • Fax: 661-852-2171 ~ AIPTAI - f ~ Page 1 of 2 INSTRUCTIONS 1. To avoid further action, return this form within 30 days of receipt. 2. Type/print answers in ENGLISH. 3. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. SECTION I: PACILITY IDENTIFICATION BUSINESS NAME (F~CI~ NAME or DBA) W ~ ADDRESS (for local use only) ~ 0l -~ ~ ~~ ~ ~~~ FACILITY ID # 1 SECTION II.1: DISCOVERY AND NOTIFICATIONS A. LEAK DETECTION AND MONITORING PROCEDURES: hc~l~ Q~ec~ Rwov~~r ~etltc~ B. EMPLOYEE AND AGENCY NOTIFICATION: t~~~c., InQa~a.. lkU~taqc.~uw~ t5 ~U~o~cr~Y Oc~t~(ct'~, ~.Jr~r~i.~~ ~~e~~ctk~ ~or A ~'ct~ ~t C. ENVIRONMENTAL RESPONSE MANAGEMENT: D. EMERGENCY MEDICAL PLAN: N c~~r~.~~ ~~sP ~~a. ~ SECTION II.2: RELEASE RESPONSE PLAN A. HAZARD ASSESMENT AND PREVENTION MEASURES: I (~ ea~C. ~e~ccl~ioc~ J ~yc3 ~~/ A~ttf,~.~ -~-~~~ ~L i S Q~ ~~~ L ~1Jc~~~ C~ J B. RELEASE CONTAINMENT AND/OR MITIGATION: ~cco~~~~~.y ~oc~{~<<~~~ar~ ~~ -~t~lL cu ~ ~ fMO~n~~~or dccl~c~ C. CLEAN-UP AND RECOVERY PROCEDURES: L.L~y (~-~c~ ~scc~ a5 ~n ~asor~a~~ l~u~cr~a< < ~~~ ~, ~ _. .. FD2169 (Rev 06/07) Page2of2 _ _ _ _ SECTION II.2: RE'LEASE RESPONSE ~PLAN (CONT) UTILITY SHUT-OFFS (LOCATION OF SHUT-OFFS AT YOUR FACILITY) ~ NATURAL GAS PROPANE: ~ L ELECTRICAL: ~' L` WATER: SPECIAL: e-~ PRIVATE FIRE PROTECTION/WATER AVAILABILITY: A. PRIVATE FIRE PROTECTION: B. WATER AVAILABILIfY (FIRE HYDRANT): ~,-~y l~ e.-(Z~ ~ SECTION III: TRAI'NING ~ , NUMBER OF EMPLOYEES: MATERIAL SAFETY DATA SHEETS ON FILE: ES ^ NO IF YES, LOCATION: BRIEF SUMMARY OF TRAINING PROGRAM: Norv ~. -1~~ -~H~~}' "CERTI FIGATI ON ° 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 and believe the information is true, accurate, and complete. SIG URE OF OWNE PERATOR OR D SIG ED REPRESENTATIVE /U~" _`^~ 1j N' DATE a77 ~ ~ ~ U NAME F SI~ E<JR (;R~T) ~ *~~ ~~ a7s J ;~, ,~; , - TITLE OF SIGN~~~ / ~ 479 M 7 c~/ FD2169 (Rev 06/07) HAZARDOUS MATERIAL MANAGEMENT PLAN I INSTRUCTIONS CHEMICAL DESCRIPTION FORM HAZARDOUS MATERIAL INVENTORY FORM BAKERSFIELD FIRE DEPARTMENT Prevention Services 1501 Truxtun Avenue, lst Floor a s a s p~ n Bakersfield, CA 93301 P/RB ' A~ r Phone:661-326-3979 • Fax:661-852-2171 Page 1 of 3 Make as many copies of the chemical description form as necessary to report your entire inventory of hazardous material. Report every hazardous material handled in quantities equal to or exceeding 55 gallons of a liquid, 500 pounds of a solid, or 200 cubic feet of a gas. Report ~ amount of any hazardous waste being generated or handled on site. FACILITY INFORMATION: Check the appropriate box for a new inventory or for additions, revisions, or deletions to an existing inventory. Enter the business name at the top of the form. Enter the page number in the right hand comer. Describe the exact location of the hazardous waste or material being reported. NOTE: Chemical location information is considered confidential unless you check no. If a site map is being submitted, you may refer to the map number and grid coordinates for the approximate location of the material, as shown on the map. i FACILITY I.D. NUMBER - This number is assigned by the CUPA or AA. This is the unique number which identifies your facility. 3 BUSINE55 NAME - Enter the full legal name of the business. II. CHEMICAL INFORMATION: Each of the instructions below corresponds to the entry field with the same number on the chemical description form. 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 or a hazardous waste, do not complete this field; complete the "common name" field instead. 206 TRADE SECRET - Check "Y" for yes if the information in this section is declared a trade secret, or "N" for 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 Health and Safety Code, Section 25511. Federal Requirement: If yes, and business is subject to EPCRA, disclosure of the designated Trade Secret information is bound by Title 40 Code of Federal Regulations (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 "Y" for 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 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 section below. 210 FIRE CODE HAZARD CLASES (leave blank) 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 "Y" for yes if the hazardous material is radioactive or "N" for 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 floating decimal point to report activity in curies. 214 PNYSICAL 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 total capacity of the largest container in which the material is stored. 216 FEDERAL HAZARD CATEGORIES - Check all the physical and health hazards associated with the hazardous material: PHYSICAL HAZARDS: i Fire: Flammable liquids and solids, combustible liquids, pyrophorics, oxidizers 2 Reactive: Unstable reactive, organic peroxides, water reactive, radioactive 3 Pressure Release: Explosives, compressed gases, blasting agents HEALTH HAZARDS: 4 Acute Health (Immediate): Highly toxic, toxic, irritants, sensitizers, corrosives, other hazardous chemicals with an adverse effect with short-term exposure. 5 Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long-term exposure. 217 ANNUAL WASTE AMOUNT - If the hazardous material being inventoried is a waste, provide an estimate of the annual amount handled. 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 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's inventory of material reported on this page. Total all daily 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. 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. A list of common State Waste Codes is included on page 3 of these instructions. FD2144a (Rev 06/07) ~ HAZARDOUS MATERIAL MANAGEMENT PLAN INSTRUCTIONS FOR HAZARDOUS MATERIAL INVENTORY CHEMICAL DESCRIPTION FORM Page 2 of 3 221 UNITS - Check the unit of ineasure 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 all boxes that describe the type of storage containers in which the hazardous material is stored. NOTE: If appropriate, you may choose more than one. 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 COMPONENT i-5 (% BY WEiGHT) - If a range of percentages is available, report the highest percentage in that range. 230 HA2ARDOUS COMPONENT i-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in that range. 234 HAZARDOUS COMPONENT i-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in that range. 238 HAZARDOUS COMPONENT i-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in that range. 242 HAZARDOUS COMPONENT 1-5 (% BY WEIGHT) - If a range of percentages is available, report the highest percentage in that range. 227 HAZARDOUG COMPONENT i-5 NAME - When reportin9 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 i% 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. 231 HAZARDOUG COMPONENT i-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 i% 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. 235 HAZARDOUG COMPONENT 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. 239 HAZARDOUG COMPONENT 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. 243 HAZARDOUG COMPONENT 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 i% 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. 228 HAZARDOUS COMPONENT i-5 EHS - Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "N" for no if it is not. 232 HA2ARDOUS COMPONENT 1-5 EHS - Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "N" for no if it is not. 236 HAZARDOUS COMPONENT i-5 EHS - Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "N" for no if it is not. 240 HAZARDOUS COMPONENT i-5 EHS - Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "N" for no if it is not. 244 HAZARDOUS COMPONENT i-5 EHS - Check "Y" for yes if the component of the mixture is considered an Extremely Hazardous Substance as defined in 40 CFR, Part 355, or "N" for no if it is not. 229 HAZARDOUS COMPONENT i-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. 233 HAZARDOUS COMPONENT 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. 237 HAZARDOUS COMPONENT 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. 241 HAZARDOUS COMPONENT i-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. 245 HAZARDOUS COMPONENT 1-5 CAS - List the Chemical Abstract Service (CAS) numbers as related to the hazardous components in the mixture. III. SIGNATURE 246 SIGNATURE - Print name, title, sign, and date each chemical description form. CALIFORIVIA WASTE CODES Code Descriution Inorganics lil 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) 112 Acid solution without metals 113 Unspecified acid solution 121 Alkaline solution pH >12.5 with metals (see 111) 122 Alkaline solution without metals 123 Unspecified alkaline solution 131 Aqueous solution (2 < pH < 12.5) containing reactive Anions. (azide, bromate, chlorate, cyanide, fluoride, hypochlorite, nitrite, perchlorate and sulfide anions) 132 Aqueous solution with metals (see 111) 133 Aqueous solution with total organic residues 100% or more 134 Aqueous solution with total organic residues < 10% 135 Unspecified aqueous solution 141 Off-spec, aged, or surplus inorganics 151 Asbestos containing waste 161 FCC Waste 162 Other spent catalyst 171 Metal sludge (see iii) 172 Metal dust and machining waste (see 111) 181 Other inorganic solid waste Code Descriotion Organics (cont) 261 PCB and material containing PCB 271 Organic monomer waste (includes unreacted resins) 272 Polymeric resin waste 281 Adhesives 291 Latex waste 311 Pharmaceutical waste 321 Sewage sludge 322 Biological waste other than sewage sludge 331 Off-spec, aged or surplus organics 341 Organic liquids (non-solvents) with halogens 343 Unspecified organic liquid mixture 351 Organic solids with halogens Sludge 411 Alum and gypsum sludge 421 Lime sludge 431 Phosphate sludge 441 Sulfur sludge 451 Degreasing sludge 461 Paint sludge 471 Paper sludge/pulp 481 Tetraethyl lead sludge 491 Unspecified sludge waste Organics 211 Halogenated solvents (methylene chloride, chloroform, TCE, TCA) 212 Oxygenated solvents (acetone, butanol, MEK) 213 Hydrocarbon solvents (Stoddard solvent, xylene) 214 Unspecified solvent mixture 221 Waste oil and mixed oil 222 Oil/water separation sludge 223 Unspecified oil - containing waste 231 Pesticide rinse water 232 Pesticide and other waste associated with pesticide production 241 Tank bottom waste 251 Still bottoms with halogenated organics 252 Other still bottom waste Miscellaneous 511 Empty pesticide containers 30 gal or more 512 Other empty container 30 gal or more 513 Empty containers less than 30 gal 521 Drilling mud 531 Chemical toilet waste 541 Photo chemical/photo processing waste 551 Laboratory waste chemicals 561 Detergent and soap 571 Fly ash, bottom ash, and retort ash 581 Gas scrubber waste 591 Bag house waste 611 Contaminated soil from site clean-ups 612 Household wastes Page 3 of 3 FD2144a (Rev 06/07) , BAKERSFIELD FIRE DEPARTMENT Prevention Services HAZARDOUS MATERIAL MANAGEMENT PLAN B g S R$ A I D 1501 Truxtun Avenue, lst Floor P/R! Bakersfield, CA 93301 CHEMICAL DESCRIPTION FORM w~ ~ Phone: 661-326-3979 • Fax: 661-852-2171 HAZARDOUS MATERIAL INVENTORY Page 1 of 2 ^ NEW ^ ADD ^ DELETE ^ REVISE zoo (One fQrm~er_materiaL_oer buildina, or area.) I. FACILITY INFORMATION BUSINESS NAM (FACILITY NAME or DBA) 3 t~ ~l ~ ~~~ CL~ CHEMICAL LOCA ION 201 CHEMICAL LOCATION 202 (~ ` I ~ a CONFIDENTIAL (EPCRA) ^ Yes ^ No FACILITY ID # 1 MAP #(optional) 203 GRID #(opUonal) 204 II. CHEMICAL INFORMATION ~ CHEMICALNAME 205 ~_ /206 TRADE SECRET ^ Yes LYNo ~ If subject [o EPCRA, refer to InstrucUOns COMMON NAME Zp7 EHS* ^ Yes CI~~ 208 CAS # 209 "If EHS is yes, ali amounts below mus[ be In pounds. FIRE CODE HAZARD CLASSES (complete if requested by local fire chie~ 210 NPE Z11 ~ RADIOACTIVE: ^ Yes RiRo ZlZ CURIES 213 ^ PURE I MIXTURE ^ WASTE PHYSICAL STATE ^ SOLID l /G UID ^ LARGEST CONTAINER 215 9 Q GAS 214 ~~O I ~ yr ` ~ FED HAZARD CATEGORIES ^ FIRE ^ REACTIVE ^ PRESSURE RELEASE q/'ACUTE HEALTH Cp~CHRONIC HEALTH 216 (Check all tha[ apply) ANNUAL WASTE 217 MAXIMUM zlg AVERAGE 219 STATE WASTE 220 AMOUNT DAILY AMOUNT ~O DAILY AMOUNT CODE ~ 2 z 1 DAYS ON SITE 222 ^ UNITS' Q iGAL ^ CU FT ^ L85 ^ TONS 'If EHS, amounrmust be In Ibs. STORAGE CONTAINER: ZZ3 ^ ABOVEGROUND TANK ^ CAN ^ BOX ^ TANK WAGON ~DERGROUND TANK ^ CARBOY ^ CYLINDER ^ RAIL CAR 0 TANKINSIDE BUILDING ^ SILO ^ GLASS BOTTLE ^ OTHER ^ STEEL DRUM ^ FIBER DRUM ^ PLASTIC BOTTLE ~ TOTE BIN ^ PLASTIC/NONMETALLIC DRUM ^ BAG STORAGEPRESSURE: ^ AMBIENT ^ ABOVEAMBIENT ^ BELOW AMBIENT 22a STORAGE TEMPERATURE: ^ AMBIENT ^ ABOVE AMBIENT ^ BELOW AMBIENT ^ CRYOGENIC 225 %WT HAZARDOUS COMPONENT EHS CAS # 1 ZZ6 ~~ d 227 ^ Y05 ^ NO 228 229 Z 230 z31 ^ YES ^ NO 232 233 3 234 235 ^ Ye5 ^ NO 236 237 4 Z38 239 ^ Y05 ^ NO 240 241 5 242 2a3 ^ Yes ^ No 24a 245 III. SIGNATURE PRINT NAME & TITLE OF AUTHORIZED COMPANY REPRESENTATIVE GNATURE DATE z45 7 ~" ` I ~~N J - ~ ~ N ~ SW/ c. _ ~IL ~ ` ~- ~ ~ J FD27~34 (Re~ 06 07) Hazardous Material Inventory - Chemical Description 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 tempereture and storage pressure. (NOTE: the numbering of the instructions follows the data element numbers that are on the UPCF pa9es. 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 of the 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 trede 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 Trede 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. 230 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 falls 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 AA for 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 redioactive 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 Floating 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 total 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 averege 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 daily 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 ineasure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet, or tons. NOTE: If the material is a federelly 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 renge of percentages is available, report the highest percentage in that renge. (Report for components 2 through 5 in 230, 234, 238, and 242.) 227 HAZARDOUS COMPONENTS i-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 9reater 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, minerel 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 ~o 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 information necessary to meet the requirements of their individual programs. Contact the CUPA or AA for guidance. Page 2 of 2 Fo2iaa (Rev o5/0~) HAZARDOUS MATERIAL MANAGEMENT PLAN H B R 9 A I D BUSINESS ACTIVITIES PAGE n,,i~RrBer r (HAZARDOUS MATERIAL FACILITY INFORMATION) ~ Page 1 of 1 BAKERSFIELD FIRE DEPARTMENT Prevention Services 1501 Truxtun Avenue, 15~ Floor Bakersfield, CA 93301 Phone:661-326-3979 . Fax:661-852-2171 I. FACILITY IDENTIFICATION - FACILITY ID #(for o~ce use only) 3 EPA ID # BUSINESS NAME (FACILITY NAME or DBA) 303 l,t~~~~~~~_ _~U e.. -i!G~tut~af~tL~~k _ _1~.~__ . _ _ _ _ _ __ ___ II. ACTIVITIES DECLARATION DOES Your Facility... If Yes, Please Complete... 129 A. HAZARDOUS MATERIAL es ^ No • CHEMICAL DESCRIPTION FORM iso 1. Have on site (for any purpose) hazardous material • HAZARDOUS MATERIAL MANAGEMENT PLAN at or above 55 gallons for liquids, 500 pounds for Minimum reouired olanning elements: solids, or 200 cu. R. for compressed gases (include . Emergency Response Plan liquids in AST and UST)? • Maps • Training • Prevention . Certification B. REGULATED SUBSTANCES fRS) ^ No • CHEMICAL DESCRIPTION FORM 131 1. Have on site RS at greater than the threshold . RISK MANAGEMENT PLAN (RMP Submit to USEPA) planning quantities established by the California . CONSOLIDATED COMPLIANCE PLAN Accidental Release Prevention program (CaIARP)? • Incorporating CaIARP Program Elements C. UNDERGROUND STORAGE TANKS (USTI es ^ No . UST FACILITY FORM i3z 1. Own or operete Underground Storage Tanks? • UST TANK FORM (one per tank) 0 Yes o • UST FACILITY FORM 133 2. Intend to upgrade existing or install new UST? • UST TANK FORM (one per tank) • UST INSTALLATION FORM (one per tank) D. TANK CLOSURE/REMOVAL ^ ves ^ No • UST TANK FORM (Closure section - one per tank) 1. Need to report closing an UST that held hazardous material or waste? 2. Need to report the closure/removal of a tank that ~ Yes ^ No . UST TANK CLOSURE FORM was classified as hazardous waste and cleaned onsite? E. ABOVEGROUND PETROLEUM STORAGE TANKS ^ Yes ^ No . HAZARDOUS MATERIAL MANAGEMENT PLAN 195I1 • Incorporating Federel Spill Prevention Control and Countermeasure 1. Own or operate AST above these thresholds; any (SPCC) Elements pursuant to 40 CFR Part 112. tank capacity is greater than 660 gallons or the total capacity for the facility is greater than 1,320 gallons? F. HAZARDOUS WASTE EPA ID NUMBER - provide on this page 1. Generate hazardous waste? ^ ves ^ No . To obtain EPA ID Number, please phone (916) 324-1781 2. Recycle more than S00 kg/mo of recyclable ^ ves ^ ruo . RECYCLING FORM material at the same location it was generated? 3. Recycle more than 100 kg/mo of recyclable ^ Yes ^ No . RECYCLING FORM material at an off-site location different from the point of generation? 4. Treat Hazardous Waste on slte? ^ Yes ^ No . TP FACILITY FORM • TP UNIT FORM (one per unit) 5. Subject to Financial Assurance requirements? ^ res ^ ruo . CERTIFICATION OF FINANCIAL ASSURANCE 6. Consolidate Hazardous Waste generated at a ^ ves ^ ruo . REMOTE WASTE/CONSOLIDATION SITE NOTIFICATION remote site? 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 06/07) H_AZARDOUS MATE_RIAL MAN_AGEME_NT PLAN' INSTRUCTIONS SITE & FACILITY DIAGRAM B 8 R S F I D FIR~ ~ ARTIII T ~ BAKERSFIELD FIRE DEPARTMENT Prevention Services 1501 Truxtun Avenue, ist Floor Bakersfield, CA 93301 Phone: 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 an 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'/zxll-inch 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 facility 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 business, as shown in your HMMP, on the top of the diagram. 3. Label the location of the hazardous material and identify them by name and type of hazard (flammable liquid, corrosive solid). 4. Label the location of utility shut-off points for gas, electric, 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 identification 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. 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 HMMP. 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 TANK FACILITIES PLEASE NOTE: If you operate an Underground Storage Tank (UST) facility, the facility diagram shall also specify the location of the UST continuous leak monitoring system and/or the location where the UST monitoring will be performed. FD2170 (Rev 06/07) HAZARDOUS MATERIAL MANAGEMENT PLAN ~ SITE & FACILITY DIAGRAM B 6 R 5 F I I~ D F/RB ~ ARTA1 T ~ BAKERSFIELD FIRE DEPARTMENT Prevention Services 1501 Truxtun Avenue, ist Floor Bakersfield, CA 93301 Phone: 661-326-3979 . Fax: 661-852-2171 Page2of2 axar-. rARm ~NSUnnNCIE rn NAHFIt,, J,7~SWANT & SI-1ARNJIT J.386 TORRANCE AV~ SUNNYVAT.E CA 94089-2608 Type: BUSINESS - MISC Coverage inforrnation 1~-BUTLDTNG 550000 C-.LOSS INC ACT LOSS L-BUSN ~7:A~ ~.000000 GEN AGGREGT 2000QOQ PCO AGGREG'C 2000Q00 M-M~T~/PFRS~i 5000 JU.LY Q7, 7008 Fi.re Policy Status ~1 Ph. (408) 431--2602 GENL Policy: 97-D3W?988-5 C Y,r, ~,ssd: 2007 ~ref: Location: 6901 WHZ~'F~ T.~N BAK~RS~'~~LD CA 93309 Ter,m; CoNT Renew date: S~p--24-08 Premium: 7~3.00 Wr.xt~en dat:~: SEP-24-07 E~s~Cim~te Num: W3B9-H6AA-7 Axn4unt pai.d: Date paid: J3~. J. J. to : Prev prem: 733.,oa NOv~29-07 INSD 0 Prev xi.sk: 0 Deduc~tibles a.pp].ied:1000 A.LU PER OTHER DED MAY APPLY Mcssages: ~ Year buiit: 7.995 7one: 40 Sub zone: 01 Cor~str: NON-COMB Hom~ alErti: BA ~ T ~ ~l; ..~/1 ~S~ C'r~.~.o ~ ~~dP.r~., oo ~ • / ~ ~ ~ au~e ~~pM GURMEET GIU.~ A~ent Llcanse #0508119 i 51 6emal Rd Suite 1 U ~N~u~~xc San Jose CA 95119 ~~: ~408~ ~243737 F~x; (4Q8} 365-1183 , stATe nnaM iNSUanncn ~n JvLY o~, 2oae Fi,~e Policy SLa•rus MORTGAG~;~; IN~EP~ND~'NCE BANK ITS SUCCESSORS A~ID I•1SSIGNS BEN~I':[(;~I~RY 4533 N~7~CARTHUR BLVD STE B NEwPOI~T f3FA,CH CA 92660-2067 I,Q7.1N N0: 600062~55 M~Ve~;.n; a EnL-ry: NOV-7_b-0'l .FMP seg: 03 ~ROPERTY I~OC~TIONS GOC CMPX ADDRFSS LIAT3~~,,ITY STCLS $LD AMT CONTENTS PREMIUM EXPQSURE I~IMIT PREMIUM 70:L 6901 D~~{ZTE LN }3AKE~RSFIELD C,F1 93309 705 550000 567 ~g$ 2789 100Q000 .166 ~ ~ ~ ~YAYE •ArtM INSUAAMGR 0~ N.~1I-~.A,~~, JASWAN7' & SHA,RNJIT 1386 TORRAi~CE AvF~ SUNNYVAL.E CA 94089-2608 Type: BUSIN~SS -- MT~SC Cov~ra.ga i.nformation A-BUILDING 550b00 C-LOSS :CNC AC.T. LOSS L-BUSN Y~TAB 1000000 GEN AGG~EGT ~000000 PCO 1~GGREGT 20000d0 M-MED/PERSN 5000 JU.LY 07, 2008 Fixe Policy Sta~us H Ph. (408) 431--2602 G~NT~ Palicy: 97-~A3-2988-5 G Yr i.~sd: 7b07 Xref : T~OCA~~oT~: 69{11 WIIITE Tr1~ Bl•1i{FftSFT~LD CA 93309 Tex'zn: CONT R~new date: SEP-24-08 Pr.emium: 733.00 Wri~C~en, date: S~~'-24-07 Es~.ima~te Num: W3B9-H6An--7 Amou~nt pai.d: Date paid: B~.].1 to: Prev p,r,em: 733.00 NOV--29-07 INSn 0 Prev r.~sk: 0 Ded~~ctibles applicd:1000 ALJ~ PER O~H~R DED MAY APPLX Messac~es : Year built: 1995 2one: 40 Sub za~.e : O1 Constx: NON-COMS Hame a.lert : F3A ~ % j /1~. .~~ S~ _P~4 ~'. uYll~~tGcJ DO ~/ ` I ~ ~. GURME~S G1L1-., A9~~ s~-,~ ~~~~~ #0508118 151 Bemat Rd Su4te 10 ~MSU~AN~ SvnSoseCAg5~19 ptt;ce: (aos) 22a-a73~ ~ax: (aos) ~-1 ~ es 6TATF FAG M IN4UAAMCq qn Fir~ Polic~ Status MORTGAGFE INDEPEI~DENCE Bl~NK rTS SUCC~SSORS AND I~SSZGNS BENE FI C I,i1RY 4533 MACARTI-iUR 137rVD STE B N~WPORT 13EACH CA 97_660-2067 z,OAN NC): 804062455 Move-i.za: 0 ~n~~ry: NOV-26-Q7 FMP s~g: 03 LOC CMPX STCI,S 001 705 798 L'ROPERTY LOCATIONS JULY o~, aoa$ 11DD~FSS LIABTLITY ]3LD 11MT CON`~~N'CS ~R~M7UM EXPOSURE LIMIT 6907. TniH~TE LN BAKERSFZELD CA 93309 5'i0000 567 2789 ~R~M:1:UM 1000000 166 ~ ~ ~ ~crnr~R 6ARM 1Mt~irtAMr,E (~ G. G~~~ Stat~ FaFr~n ~nsu,r~~ee Age~c,y Prnvid~i~a~ ln~n~n~e a~r~d ~~nancial S~rviices ).51 Bernal Road, SuTte I o San J~se, C~ 95l l.9 Tel: 408~22r~-3737 Fa~;408-365-1183 T~y:_ ~~. ~ur.`_~_~^,v~c~aA.uro~ y _ r xti; ~v a,~aQ ,~, ~- __..._. . ~ ~....~~~'I From: ~,~,-r ~ ~, `.~'cital at~~nber of pages includir~g cover sheet: ~ .. _ gJrgent `~Tor Revi.ew ~~Pleasc Re,piy ..` C:om~ents: --~•--~..~~5~.~_ ~ ~~tnn ~.0 , C12 sTAio Rehm IMSypANCE OM1 N~HAZ,, JA.SWANT &. SI-lAR1VJIT 13 8 6 TO~RANCE 1~,VE SUNNYV,ALE CA 94089-2608 Type: BUSINESS - MZSC Coveragc ~,;nfoxmatioz~ A-BUILDTNG 550000 C-LOSS TNC l1CT ;LOSS L-BUSN LT,AB 1000000 G~N AGGREGT 2000Q00 ~'CO AGGREGT 2000000 M--M~D/PE~tSN 5000 ri,r.e Yolicy Status JULY 07, 2008 I1 Ph. (948) ~13~-2602 GENL ~olicy: 97-D3-~2~gg-5 G X.r issd: 2007 X,~ef . Location: 690J. WH~TE .LN BAK~RSk'ICL~D CA 93309 Tex.'m: CONT Ren,ew datP: SEp-29-pg Prem~um: '733.00 writLen date: SFP-24--0'7 Estimate Nuxn; W3n9-H6AA-7 Amount paid: 733.00 b~.te paid: NOV--29-Q7 Bi13. ~:o: INSD Prev prem: p 1?.r~v r_isi~: p Deductibles a~aplied. Y000 AL~ PER OTHFR DFD MAX APT?,LY ~fessageg : Year built: 1995 Zon,e: 40 Sub zone: 01 Consfir: NON-COMB Home alert: BA J~j ~ ~ nl: .~i~ ,Syp C'4i.o ~ ~./~ dP.r~~.~ oo ~- ~ ~ ~. 9TA1! ~ARM ~V~M~~ Gf~-~. ~SA~ ~~se #D508i 19 15~ gemal Fld $uitA 1 ~ fNfuaAN~ SanJoseCA95119 Of(ice: (408) 22M~737 Fex: (408) 365-1 i 83 srnrF Fn¢µ Ip1suRAMCE ~.i JtJ.LY 07, 2006 Fi.r~ Policy S~Latus MORTG7~.GEE ~NDEPENDENCE BANK ITS SUCCJ~SSORS ~ND ASSIGNS BFNE FT C T.I~RY 4 5 3 3 MACAI2THUR B1:~VD STE B NEWP,ORT I3EI~CI3 CA 92660-2067 LOAN N0: 800062455 Move--in : O Entry: NOv-26-0~7 FMP seg: 03 PROP~R~'Y LQC~T~ONS ~OC CMPX ~DbRESS LIA$ILTTY STCLS BLD 1,-1MT CONTENTS PI~~M7UM EXP.OSURE LIMtT PREt+~IUM ?07. 6901 WH?TE LN BAK~RSFTFLD C.~ 93309 705 5500p0 56"1 79~ ~~89 1000000 166 ~ ~~ ~.