HomeMy WebLinkAbout1700 MT. VERNON AVENUEB. Emer ency MedkA Facility, Page of
List the closest emergency medical facility that will be used by your business in the event of an accident of injury caused by
a release or threatened'release of a hazardous material
HOSPITAL /CLINIC: .
HO N r�
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Y
ADDRESS: I ^/
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CITY:. • .
ZIP CODE:.
C. Private Emergeftg Response
DOES YOUR BUSINESS HAVE A PRIVATE ON -SITE EMERGENCY RESPONSE.TEAM? ❑ Yes o
If yes, provide an attachment.that describes what policies and procedures your business will follow to notify your on -site
emergency response team in the event of a release or threatened release of hazardous materials.
CLEANUP/DISPOSAL CONTRACTOR
List the contractor that will provide* cleanup services in the event of a release. .
NAME OF CONTRACTOR: � n
PH _ Nlr� Q� Cf
ADDRESS: ,
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CITY: a�
ZIP CODE:
I). Arrangements with Emdgency Responders
If you have made special (i.e. contractual) arrangements with any police department, fire department, hospital, contractor, or
State or local emergency response team to coordinate emergency services, describe those arrangements in the space below:
E. Evacuation Plan
1. The following alarm signal(s) will be.used,to begin evacuation of the facility (check all which apply):
e Verbal Telephone (including cellular) ❑ Alarm System ❑ Public Address System ❑ Intercom
❑ Pagers ❑. Portable Radio ❑ Other (spec):
2. vacuation map is prominently displayed throughout.the facility.
3. ,Name of individuals) responsible for coordinating evacuation including spreading the alarm and confirming the business has
been evacuated: 1
F. Earthquake Vulnerability+
Identify.areas of the facility where releases could occur or would require immediate inspection or isolation because of the
vulnerability to earthquake related ground motion.
Hazardous Waste/ Hazardous Materials Storage Areas ❑ Production Floor ❑ Process Lines
❑ Bench/ Lab ❑ Waste Treatment ❑ Other:
Identify mechanical . systems where releases could occur or would require immediate inspection or isolation_ because of the
vulnerability to earthquake related ground motion.. .
❑ Utilities ❑ Spriiikler Systems ❑ Cabinets ❑ Shelves
❑ Racks ❑ Pressure Vessels ®�Gas:Cylinders ❑ Tanks
T-1 Process Piping ❑ Shutoff Valves ❑ Other:
G. Emer&ng Procedures Page of
Bri efly-describe your, business standard operating procedures in the event of a release or threatened release of - azardou:,
materials /wastes:
1. PREVENTION (prevent the spill/release) -. Consider the types. of spills /releases associated with the hazardous -
material's /wastes pcesent'at your facility: What actions does your business take to prevent these spills /releases fi-om occurring? You .
may include a discussion of safety and storaee procedures:
2. MITIGATION (stop the release /spi11) - Describe what actions are taken to reduce the harm or the damage to person(s),
property, or the environment, and prevent what has occurred from getting worse or spreading: What is your immediate response to a
leak, spill, fire, ex losion; or airborne release at your business?
4ay an mo �U�1�� ti� ex 1 I
3. ABATEMENT (clean up the spill /release) - Describe what you would do to clean up the spill/release. How do you handle
the complete rocess of cleaning u and disposing of released materials at your facility?
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IW . Emergency Equipment. Page. of
22 CCR, Section 66265.52(e) [as referenced by Section 66262.34(x)(3)] requires thaf emergency
equipment at the facility be listed. Completion of the following Emergency Equipment Inventory Table
meets this 're uirement.
EMERGENCY. EQUIPMENT INVENTORY TABLE
1
Equipment
Category
2.
. Equipment.
T e.
3.
Location
4.
Description*
Personal
❑ Cartridge Respirators '
Protective,
❑ Chemical Monitoring Equipment (describe)
Equipment,
❑ Chemical Protective Aprons/Coats
Safety :
❑ Chemical Protective Boots
Equipment,
❑ Chemical Protective Glo %s
and
❑ Chemical Protective Suits (describe)
First Aid
❑ Face Shields
Equipment
,E' First Aid.Kits /Stations (describe)
❑ Hard Hats
❑ : Plumbed Eye Wash Stations '
-ET—Portable Eye Wash Kits (i.e. bottle type)
Q,,
❑ Respirator Cartridges (describe)
Safety Glasses/Splash Goggles
be
Q
❑ Safety Showers
❑ Self- Contained Breathing Apparatuses (SCBA)
❑ Other (describe)
Fire
❑ Automatic Fire sprinkler Systems
Extinguishing
❑ Fire Alarm Boxes /Stations
Systems
:'Fire Extinguisher Systems (describe)
C hACIP
�(
❑ Other (describe) .
Spill
❑ Absorbents (describe)
Control
❑ Berms/Dikes describe
Equipment
❑ Decontamination Fquipment (describe)
and
❑ Emergency Tanks (describe
Decontamination
Exhaust Hoods
Equipment
❑' Gas Cylinders Leak Repair Kits (describe)
❑ Neutralizers (describe)
❑ Overpack Drums
❑ Sumps (describe)
❑ Other (describe)
Communications
❑ Chemical Alarms (describe)
and
❑ Intercoms / PAS stems
Alarm
❑ Portable Radios
Systems
,Er Telephones
❑ Underground Tank Leak Detection Monitors
❑ Other (describe)' '
Additional
Equipment
(Use Additional
Pages if
Needed.)
' Describe the equipment and its capabilities. If applicable, specify any testing %maintenance procedures /intervals. Attach additional pages, numbered
appropriately, if needed.
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