HomeMy WebLinkAbout2650 MT. VERNON AVENUE_HMBP 2.24.11l
UNIFIED PROGRAM. CONSOLIDATED.FORM
.FACILITY INFORMATION
BUSINESS ACTIVITIES.
Page 1 of
I. -FACILITY IDENTIFICATION ;
FACILITY ID #
F
EPA ID # (Hazardous Waste Only) z
(Agency Use Only) .
3
BUSINESS NAME (Same as Facility Mime of DBA- Doing. Business As):
BUS INE ITE ADDRESS 103
BUSINESS SITE CITY Boa
CA
ZIP CODEq ios
II. ACTIVITIES. DECLARATION
NOTE: If you check YES to any part of this list,
please submit the. Business. Owner /Operator Identification- page (OES Form 2730).
Does your facility:..
If YES, please com lete these pages of the UPCF....
A. HAZARDOUS MATERIALS
Have on site (for any purpose) hazardous materials at or above 55
BUSINESS OWNER/OPERATOR
gallons for liquids, 500 pounds for solids, or 200 cubic feet for
IDENTIFICATION
compressed gases (include liquids in ASTs and USTs); or.the
VES ❑ NO 4
applicable Federal threshold, quantity for an extremely hazardous
HAZARDOUS MATERIALS INVENTORY
substance specified in 40 CFR Part 355, Appendix A or B; or
- CHEMICAL DESCRIPTION
handle radiological materials in quantities for.which an. emergency
.10
Ian is required pursuant to CFR Parts 30, 40 or 70?
B. REGULATED SUBSTANCES
Have Regulated Substances stored onsite in quantities greater than
❑ YES O 4a
Coordinate with your local Agency
the threshold quantities established by the California Accidental
responsible for CaIARP.
Release Prevention Program CalARP ?
❑YESO 5
UST FACILITY
UST TANK (one per tank)
C. UNDERGROUND STORAGE TANKS (USTs)
Own or operate underground storage tanks?
F-1 YES �O 8
NO FORM REQUIRED TO CUPAs
D. ABOVE GROUND PETROLEUM STORAGE
Store greater than 1;320 gallons of petroleum products (new or
used ) in above round tanks or containers.
May require SPCC plan.
E. HAZARDOUS WASTE
r
[:1 YES, L� NO 9
EPA ID NUMBER - provide at the top of
Generate hazardous waste?
this page
❑ .YES U,-N60 10
RECYCLABLE MATERIALS REPORT (one
Recycle more than 100 kg /month of excluded or exempted
recyclable materials (per HSC 25143.2)?
perrecycler)
Treat hazardous waste on site?
❑ YES ENO 11
ONSITE HAZARDOUS WASTE
TREATMENT - FACILITY
ONSITE HAZARDOUS WASTE
TREATMENT -UNIT (one page per unit)
Treatment subject to financial assurance requirements (for
❑ YES DNO 12
CERTIFICATION OF FINANCIAL
Permit by Rule and Conditional Authorization)?
ASSURANCE .
Consolidate hazardous waste generated at a remote site?
❑ YES 0,K0 13.
REMOTE WASTE/ CONSOLIDATION
SITE ANNUAL NOTIFICATION
Need to report the closure /removal of a tank that was
❑ YES VW, 14
HAZARDOUS WASTE TANK CLOSURE
classified' as hazardous waste and cleaned onsite?
CERTIFICATION
Generate in any single calendar month 1,000 kilograms (kg) (2,200
pounds) or more of federal RCRA hazardous waste, or generate in
Obtain federal EPA ID Number, file
any single calendar month, or accumulate at any time, 1 kg (22
❑ YES ENO 14a
Biennial Report (EPA Form 8700- 13A/B),
pounds) of RCRA acute hazardous waste; or generate or
and satisfy requirements for RCRA Large
accumulate at any time more than 100 kg (220 pounds) of spill
Quantity Generator.
cleanup materials contaminated with RCRA acute hazardous
Waste?,
❑YES 14b
See CUPA for required forms.
Household Hazardous Waste (HHW) Collection site?
F. LOCAL REQUIREMENTS: Note: If you have answered "NO" to question "A" listed above, complete and,submifthe Statement
15
of Exemption page.
1
Revised (6106)
BUSINESS OWNER/OPERATOR IDENTIFICA'T'ION
KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT Unified Program Consolidated Form (UPCF)
.2700 M STREET, SUITE 300 FACILITY INFORMATION
BAKERSFIELD, CA 93301
661 862 -8700 Fax 661) 862 -8701
.... .. .. : Page of
I. IDENTIFICATION
FACILITY ID#
1
BE G. ATE 100
ENDIN DA / lol
21
/��
V V
BUSINESS E (Same as FA 1•YNAjMEor••` Doin mess As) 3
BU$INES PH •�-�/ loz
BUSINESS SITE _ DRE
103
(USINESSTAX
l o2a
b .
BUSINESS SI TY l04
CA
�los
COUNTY 8
KERN'
DUN & BRADSTREET 106
PRIMARY SIC 107
P AI S 107a
BUSINESS MAIL RE S 108a
BUSINESS MAILING C ^
"
1 .IOBb
I
S� 108c
ZIpS^ � 108d
IHO (
BUSINESS OP AM
� 109
BUS Ip( S
P
OR 110
II. BUSINESS OWNER
OWNER NAME .. 111
QFIER
112
OWNER , I kDDRESS
OWNER M
?
Z 116
III. ENVIRONMENTAL CONTACT
CONTACT NAME \ 117
CONTACT RHONE 118
CONTAC
119
IG I 1 I1� I �
CONTACT EMAIL 119a
CONTACT MAILING CITY 120.
STATE 121
ZIP CODE tzz
- PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY-
NAME 123
NAME 128
TITL 124
� �
TI 129 -
BUSINESS P NE 125
BUS SS P ONE
130
24 -HOUR PHO 126
- --CO
24 -HOUR P ONE
. 131
- - 6
PAGER # 127
PAGER # l3z
ADDITIONAL LOCALLY COLLECTED ORMATION: 133
APN:.
Certificatio 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 'th the information submitted and believe the information is true, accurate, and complete.
SIGNA F OWNER/OPERATOR QR,D�ESIIGNATED REPRESENTATIVE.
D
TE 13a .
AME OF DOCUMENT P 135
W SI NE c) 136
IP y\' A
E 07. S G 137
\ v 0 ..
(05/2008 revised) KC Form 2730
HAZARDOUS MATERIALS INVENTORY - CHEMICAL DESCRIPTION
KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT Unified Program Consolidated Form (UPCF)
2700 M STREET, SUITE 300 HAZARDOUS MATERIALS
BAKERSFIELD, CA 93301
661 862 -8700' " Fax 661 862 -8701 ' (one page per material per building or area) '
ADD ' . ❑ DELETE - ❑ REVISE 200
Page of .
I. FACILITY.' INFORMATION
BU SS NAME ( ame as FACILITY N o DBA— Doing B iness s). 3
CHEjgCAL LOCA
201
CHEMICAL LOCATION CONFIDENTIAL EPCRA_ 202
❑ YES NO
FACILITY ID #
a« g
��
I
MAP4 (optional) 203
GRIDit ,(optional) 204
II. CHEMICAL INFORMATION
CHEMICAL NAME
2os
TRADE SECRET ❑ Yes No 206
�Ulow t
If Subject to EPCRA,.refer to instructions
COMMON NAME 207
208
Co
EHS* .. ❑ Yes ' [ To
*If EHS is "Yes ", all amounts below must be in lb s...
CAS#i I /\ t (� // �^ /� . 209
FIRE CODE HAZARD CLASSES (Not currently required.by KCEHSD) 210
HAZARDOUS MATERIAL 211
V.PURE
zlz
RADIOACTIVE ❑ Yes o
zl3
CURIES
TYPE (Check one item only) ❑"b. MIXTURE ❑ c. WASTE
PHYSICAL STATE � 214
r - 215
LARGEST CONTAINER
(Check one item only) ❑ ID E a. SOLD) b. LIQUID ❑ .e. GAS _
FED HAZARD CATEGORIES / 216
(Check all that apply) ❑ a. FIRE ❑ b. REACTIVE �. RESSURE RELEASE d. ACUTE HEALTH P'ee CHRONIC HEALTH
AVERAGE DAILY AMOUNT 217
MAXIMUM DAILY AMOUNT. 218
ANNUAL WASTE AMOUNT 219
STATE WAS CODE 220
i- D
1 3�
I'1
UNITS* ❑ a. GALLONS ❑ b. CUBIC FEET POUNDS, El d. TONS 221
DAYS ON SITE: 222
(Check one item only) * If EHS, amount must be in pounds.
STORAGE CONTAINER 223
a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ i. F113ER DRUM ❑ m. GLASS BOTTLE ❑ q. RAIL CAR
❑ b. UNDERGROUND TANK ❑ f.. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER
TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN
❑ d. STEEL DRUM ^ ❑ h.. SILO X r. CYLINDER ❑ P. TANK WAGON
224
STORAGE PRESSURE ❑ a.. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT
STORAGE TEMPERATURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225
%WT
HAZARDOUS COMPONENT (For mixture or waste only) -
EHS
CAS 4
226
I
s 227
t ^e
228
❑Yes o
229
1 ��
V
V
230
231
232
233
2
'❑ Yes ❑ No
234
235
236
237
3
❑ Yes ❑ No
238
_ 239
240
241
q
❑ Yes ❑ No .
242
.. 243
244
245
5
❑ Yes El No.
If more hazardous components arc present at greater than 1% by weight if oon-aarcinegenic, or 0.1% by weight if carcinogeni4 attach additional sheets of paper. capturing the required information.
ADDITIONAL LOCALLY COLLECTED INFORMATION 246
If EPCRA Please Sign Here
(5/2008 revised)
KC Form 2731
CONSOLIDATED CONTINGENCY PLAN.
KERN'COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT Unified Program Form
2700 M STREET, SUITE 300 COVER PAGE
BAKERSFIELD, CA 93301
661 862 -8700 Fax 661 862 -8701
Page of
I: FACILITY IDENTIFICATION
FACILITY ID # EPA ID # (Hazardous Waste Only) z
BU SS NAME ame as Facility D ;-7e of D A -Doing Business As)-. ( n. 3
The Consolidated Contingency Plan provides businesses a format to comply with the emergency. planning .
requirements. of the following two,written hazardous materials emergency response plans required in California:
4 Hazardous. Materials Business Plan (HSC Chapter 6.95 Section 25504 (b) and 19 CCR 8ections.2729 --
2732), and
4 Hazardous Waste Generator Contingency Plan (2.2 CCR Section 66264.52)
This format .is designed to reduce duplication in the preparation. and use. of emergency response plans at the
same facility, and to:improve the coordination be facility response personnel and local, state and federal
emergency responders during an emergency.
A copy of the plan shall be submitted to this Department and .at least one copy of-the, plan shall be
maintained at the facility for use in the event of an emergency and for inspection by the local agency.
Describe below where a copy'of your Contingency Plan, including the hazardous material inventories, Training
Records, and Site Map(s),.are located at your business:
PLAN CERTIFICATION
I certify under penalty of law that I have personally. examined and I am familiar with the information provided
by this lan.arid to the best of my knowled e the information is accurate, complete, and true.
Pf ted Name of Owner/ Operator `
u�
r or
Ti Owner/ erato
Signature of 0 er/ perator * _ /
Date .
v
We appreciate the eff of local b esses in completing these plans and are available to assist
in any manner. If you have any questions, please contact this Department at (661) 862 -8700.
ADVISORY
Page, ,� of
The site - specific Contingency Plan is the facility's plan for handling emergencies and. shall be
implemented immediately whenever there is a fire, explosion, or release of hazardous materials or waste.
that could threaten human health and /or the environment. The contingency plan shall be reviewed,. and
immediately amended, if necessary, whenever:
4 The plan fails in an emergency
4 The facility changes in its design, construction, operation, maintenance, or other
circumstances in a way that materially increases the potential for fires, explosions, or releases
of hazardous waste or hazardous waste constituents., or changes the response necessary in an
emergency
4 List of emergency coordinators changes
4 List of emergency equipment changes
Submit a copy of any updates or changes to this Department.
II. EMERGENCY CONTACTS
PRIMARY
.-SECONDARY
NAME 123
�1
NAME . 128
TITLE
124
TITLE
BUSINE S PHONE n _
125
BUSINE PHONE q
j 130
24 -HOUR PHONEac5 (�. (t(QJ w J 05-7 ` —J 126.
I
24 -HOUR PHONE
131
PAGER # . .127
PAGER # 132
III. EMERGENCY RESPONSE
PLANS AND P OCEDURES
A. Notifications "
Your business is required by State Law to provide an immediate verbal report of any release or threatened. release of a hazardous
material to local fire emergency response personnel, this Department, and the Office'of Emergency Services. If you have a release or
threatened release of hazardous materials, immediately call:
FIRE/PARAMEDICS/POLICE /SHERIFF
PHONE: 911
AFTER the local emergency response -personnel are notified, you shall then notify this Department and the Office of Emergency
Services. r
Kern.County Environmental Health Department: (661) 862 -8700 or after hours, call Dispatch at (661) 861 -2521
State Office of Emergency Service: (800) 852 -7550 or (916) 262 -1621
National Response Center: (800 ) 424 -8802
Inform_ ation to be provided during notification:
d - Your name and.the telephone number from where you are calling.
4 Exact address of the release or threatened release.
4 Date, time, cause, and type of incident (e.g. fire, air release, spill etc.)
4 Material and quantity of the release, to the extent known.
d. Current conditionof.the facility.
d Extent of injuries, if any.
d Possible hazards to public health and/ or the environment outside of the facility.
B., Emergency Medkal Facility Pa a 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:, ���I�
Vv .
PHO N
ADDRESS:
DD
CITY:. , (
ZIP CODE:
C. Private Emerg6ney Emergency Response
DOES YOUR BUSINESS HAVE A PRIVATE ON -SITE EMERGENCY RESPONSE TEAM? [:]Yes. No
If yes, provide an attachment that describes what policies and, procedures your business will follow to notify your on -site
emergency res onse.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: �.
19� as-
PHO• .•
O N
-_
�.
ADDRESS: ryD
CITY:
vl
CODE:
I
D. Arrangements with Emergency Emergeiicy Res orders
If you have made special (i.e. contractual) arrangements with any police department, fire department, hospital, contractor, or
State r local emergency response team to coordinate emergency services, describe those arrangements in the space below:
Y q
E. Evacuation Plan
1. The following alarm signal(s) will be used,to begin evacuation of the facility (check all which apply):
erbal Telephone (including cellular) ❑ Alarm System ❑ Public Address System ❑ Intercom
❑ Pagers ❑. Portable Radio ❑ Other (specify):
2. Ev uation map is prominently displayed throughout the facility.
3. YName of individual(s) responsible for coordinating evacuation including spreading the alarm and confirming the business has
been evacuated: r \ 1 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 ❑ Sprinkler Systems ❑ Cabinets ❑ Shelves .
❑ Racks ❑ Pressure Vessels le---Gas Cylinders ❑ Tanks
T-1 Process Piping, ❑ Shutoff Valves ❑ Other:
G. Emergency Procedures Pa e -.
of
Briefly describe your business standard operating procedures in the event of a release or threatened release of ..azardous
'Materials/wastes:
1.. PREVENTION (prevent the spill/release) - ,Consider the types of spills /releases associated with the hazardous
materials /wastes present at your facility. What actions does your business take to prevent these-spills/releases from occurring? You
may include a discussion of safety and :storage procedures:
S
J
�j
2. MITIGATION (stop the release /spill) - Describe what actions are taken to reduce the harm or the damacre 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, explosion, or airborne release. at yogi business?
Y)(M N I... (OW 6YAW
.,
a-- CA V\ a'ronywl"a
4a V�5t. ally �u��e tie
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3. ABATEMENT, (cleanup the spill /release) - Describe what you would do to clean up the spill/release. How do you handle
the complete process of cleaning up and disposing of.released materials at your facility?
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S 1 Lv
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IV. Emergency Equipment Pag. � of
22 CCR, Section 66265.52(e) [as referenced by Section 66262.34(a)(3)] requires thaf emergency
equipment at the facility be listed. Completion of the following Emergency Equipment Inventory Table
meets this requirement.
EMERGENCY EQUIPMENT INVENTORY TABLE
1.
Equipment
Category.
2.
Equipment.
'Type.
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 ,/as
and
❑ Chemical Piotective Suits (describe)
First Aid
❑ Face Shields
Equipment
First Aid.Kits/Stations.(describe)
}
❑ Hard Hats
❑ Plumbed Eye Wash Stations
Portable Eve Wash Kits (i.e., bottle type)
❑ .Res irator Cartridges (describe)
Safety Glasses /Splash Goggles
Y t, �
S
❑ Safety Showers
❑ Self- Contained Breathing Apparatuses (SCBA)
❑ Other (describe)`
Fire
❑ Automatic Fire Sprinkler Systems
Extinguishing
❑ Fire Alarm Boxes /Stations
Systems
Fire Extinguisher Systems (describe) 4
2 !
-:YKFIM AN
❑ Other. (describe)
Spill
❑ Absorbents (describe) .
Control
❑ Berms/Dikes (describe
Equipment
❑ Decontamination Equipment (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/ PA Systems
Alarm
❑ Portable Radios
Systems
Tele phones
e
❑ •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 procedureshntervals. Attach additional pages, numbered
appropriately, if needed.
CONSOLIDATED CONTINGENCY PLAN
KERN. COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT
Unified Program Form
2700 M STREET, SUITE 300
SITE MAP.
BAKERSFIELD, CA 93301
661 862 -8700 Fix 661 862 -8701.
Page of
L. FACILITY IDENTIFICATION
FACILITY ID #
f
N th 41
t}
EPA ID # (Hazardous Waste Only) 2
BUS1VESS NAME (Same as Facility Name of D -Doing Business As)
3
SITE ADD SS 103
C=
aoa.
ZIP CODE ios
�n
ATE MAP DRAWN
MAP #
SUB- FACILITY # (if needed)
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na ,mil. CV
fi e d
J
f
N th 41
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For.Site Map
• Loading Areas
• Parking Lots
• Internal Roads
• Storm and Sewer Drains
Adjacent Property. Use
• Locations and Names of
Adjacent St eets.and
Alleys
• Entrance and Exit Points
and Roads
• Evacuation Routes -
For Storage Map
• Location of Each Storage
Area
• Location of-Each
Hazardous Material
Handling Area
• Location of Emergency
Response Equipment
r
ust Aide Xdt
2 c n — poilabl eye wash kit— har0S� K C Y'e-C C. Y s:
Lue
3 Safety glasses/splash goggles I uc; Vv
L4 ?Gloves or fire praof blanket
5 Fite eXtinguishess;
LP Exhaust hoods - Ki -n
—7 Telephones_
'j �Uhere is your evacuation plan posted (office area ?) -
C) Office area
C� Cook station
.Bathrooms
(2 Coe tanks. 1� Yl�eYY*N
Entrance i erpncyh
nsut
t L4B off poiunt (power shut off)? - <!) le
Thank you!
Let me know if you have any questions
- FACILITY # (if needed)
For Site Ma
CONSOLIDATED CONTINGENCY PLAN
KERN - COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT . Unified Program Form
2700 M STREET, SUITE 300
BAKERSFIELD, CA 93301 SITE MAP.
k 661 862 -8700 Fax(661 862 -8701
Page of
L. FACILITY IDENTIFICATI ®N
FACILITY ID # 1 EPA ID # (Hazardous Waste Only) 2
BU ESS NAME (Same as Facility Name of D -Doing Business As) r �, 3
l (/
SITE ADDRESS 103 CITY aoa. ZIP CODE 105
ATE MAP DRAWN MAP # . SUB
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• Locations and Names of
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• Entrance and Exit Points
and Roads
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• Location of Each Storage
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• Loading Areas
• Parking Lots .
• Internal Roads
• Storm and Sewer Drains
a Adjacent Property. Use
• Locations and Names of
Adjacent Streets and
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• Entrance and Exit Points
and Roads
• Evacuation Routes
For Storage Map
• Location of Each Storage
Area
• Location of Each
.Hazardous Material
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• Location of Emergency
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• Parking Lots .
• Internal Roads
• Storm and Sewer Drains
a Adjacent Property. Use
• Locations and Names of
Adjacent Streets and
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• Entrance and Exit Points
and Roads
• Evacuation Routes
For Storage Map
• Location of Each Storage
Area
• Location of Each
.Hazardous Material
Handling Area
• Location of Emergency
Response Equipment
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