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HomeMy WebLinkAbout3401 CHESTER AVENUE_HMBP 2.28.11BUSINESS ACTIVITIES.. KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT.. Unified Program Consolidated Form (UPCF) 2700 M STREET, SUITE 300 FACILITY INFORMATION BAKERSFIELD, CA 93301 . 61 862 -8700 Fax 661 862 -8701 Page 1 of I.. FACILITY IDENTIFICATION ` FACILITY ID # 1 EPA ID # (Hazardous Waste Only) 2 BUSINESS NAME (Same as Facility Name of DB -Doing Business As) 3 II. ACTIVITIES DECLARATION NOTE: If you check YES to any part. of this list, please submit the Business Owner /Operator Identification page (KC 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 gallons for liquids, 500 pounds for solids, or 200 cubic feet for compressed gases (include liquids in ASTs and USTs); or the YES ❑, NO '4 HAZARDOUS MATERIALS INVENTORY – applicable Federal threshold quantity for an extremely- hazardous CHEMICAL DESCRIPTION (KC Form 2731) substance specified in 40 CFR Part 355, Appendix A or B;'or handle radiological materials in quantities fo`r. which an emergency plan. is required pursuant to 10 CFR Parts 30, 40 or 70? B. UNDERGROUND STORAGE TANKS (USTs) UST FACILITY (KC Fonn A) 1. Own or operate underground storage tanks? ❑YES Ivy 1-0 5 UST TANK (one page per rank) (KC Form B) 2. Intend to upgrade existing or install new USTs? ❑ YES [0 6 UST FACILITY UST TANK (one per tank) UST INSTALLATION - CERTIFICATE OF - COMPLIANCE (one page per tank) (KC Form C) 3. Need to report closing a UST? ❑ YES O 7 UST TANK (closure portion -one page per tank) C. ABOVE GROUND PETROLEUM STORAGE TANKS (ASTs) Own or operate ASTs above a total capacity for the facility of greater than 1,320 gallons? - YES -0 g NO FORM REQUIRED TO KCEHSD D. HAZARDOUS WASTE I . Generate hazardous waste? � ❑ YES Z40 9 EPA ID NUMBER – provide at the top of this page 2. Recycle more than 100 kg/month of excluded or exempted recyclable materials (per HSC 25143.2)? ❑ YES LKO 10 RECYCLABLE MATERIALS REPORT (one per recycler) (KC Form 2732) 3. Treat hazardous waste on site? ❑ YES 040 11 ONSITE HAZARDOUS WASTE TREATMENT – FACILITY.(KC Form 17720 ONSITE HAZARDOUS WASTE TREATMENT –UNIT (one page per wit) (KC Form - 4. Treatment subject to financial assurance requirements (for ❑ YES VNO 12. 1772u) CERTIFICATION OF FINANCIAL Permit by Rule and Conditional Authorization)? ASSURANCE (KC Form 123 2) 5. Consolidate hazardous waste generated at a remote site? ❑ YES [ PTO 13 REMOTE WASTE / CONSOLIDATION SITE ANNUAL NOTIFICATION (KC Form 1196) 6. Need to report the closure /removal of a tank that was classified as YES [�/11 D 14 HAZARDOUS WASTE TANK CLOSURE hazardous waste and cleaned onsite? CERTIFICATION (Kc Form 1249) E. LOCAL REQUIREMENTS 15 A copy of the facility's Contingency/Emergency Response Plan is to be included with the original submission of the Business Plan. KCEHSD is to be informed of any revisions to the plan. Please contact KCEHSD at the above number, for assistance -inc completing the plan. x. (7/02 revised) KC Form 2729 BUSINESS OWNER/OPERATOR IDENTIFICATION KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT Unified Program Consolidated Form (UPCF) .2700 M STREET, SUITE 300 FACILITY INFORMATION BAKERSFIELD, CA • 93301 .(661) 862 -8700 Fay 661) 862 -8701 - .. L. IDENTIFICATION FACILITY ID# 1]-BE tAr loo E jGaATE 101 BUS SS NAME ( neasFAMJTK DBA Do' n Business As ) SINE S P7 W, 102 BUSINESS SITE D SS n 103 av `_' US FAX 102a U 1 BUSINESS SITE 104 CA CODE T05 COUNTY loa KERN DUN & BRADSTREET 106 I)RIMART SIC 107 P IM Y NAICS Ma J BUSINESS MAILItATES c' I loss . NY BUSINESS MAIT..ING C vl 1o8b g rose ZIP cq (� load J l v BUSINESS OP AM� 109 BUSKfS PE OR HO_ 110 �/ _Un II. BUSINESS OWNER OWNER NAME 111 0 R HO I _ ll J(L) 112 . OWNER 113 DRESS , p l OWNER MAILIN Ira � � C n S tts � ZIP ODE 116 0 . III. ENVIRONMENTAL CONTACT CONTACT NAME 117 CO CT HONE 118 CONTAC ING SS 119 CONTACT EMAIL 119a Mwwl CONTACT MAILING CITY( r 120 �JVI I STATE 121 ZIP CODE 122 ~ O - PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- NAME t 123 WA\ � Y� NAME . 128 TITL) 1 \/ V\ . — 1 l l! 124 TITLE, �29 BUSINESS P NE 125 BUS SS P ONE 130 24 -HOUR PHO 126 = --O 24-HOUR P ONE 131 = _ 6 PAGER 4 127. PAGER # 132 ADDITIONAL LOCALLY COLLEC D FORMATION: 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, atid.complete. SIGN A F OWNER/OPERA. TOtt OR DESIGNATED REPRESENTATIVE DA 1 1134 AME OF OCUMENT PRF�ARER 135 N OF SIG (print) 136 W k�y s � E OF SIGNER 137 0( Q U r (05/2008 revised) 1 KC Form 2730 HAZARDOUS MATERIALS INVENTORY - _CHENHCAL DESCRIPTION KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT Unified Program Consolidated Form (UPCF) 2700 M STREET, SUITE 360 HAZARDOUS MATERIALS Br'kERSFIELD, CA 93301 ." 661 862-870k. Fax 661)862-8701. (one page per material per building or area) Rf ADD' . ❑ DELETE ❑ REVISE 200 Pa a of I. FACILITY INFORMATION.. BUSINESS N Same as F CILITY N �DBA Business As) T71 C) 3 CHEMICAL LOCA71710 201 �� CHEMICAL L CATION CONFIDENTIAL EPCRA [:1 YES-. LT NO 202 ray. -e . 1 MAP# (optional) 203 GRID# 204 FACILITY ID # , F1 I _(optional). II. CHEMICAL INFORMATION CHEMI N 205 TRADE SECRET ❑ Yes EL-No zo6 I If Subject to EPCPA,.refer to instructions COMMON E 207 EHS* ❑ Yes [D WO *If EHS is "Yes ", all amounts below must be in lbs. . 208 • CAS# r /� 209 FIRE CODE HAZARD CLASSES (Not currently required by KCEHSD) 210 HAZARDOUS MATERIAL 211 —/ 212 RADIOACTIVE ❑ Yes � No CURIES 213 TYPE (Check one item only) a. ,PURE ❑ b.. MDCTIJRE ❑ c: WASTE PHYSICAL STATE 214 LARGEST CONTAINER s (Check one item only) ❑ a. SOLID QA�. LIQUID ❑ c. GAS FED HAZARD CATEGORIES 216 ^/ �, (Check all that apply) [:1 a. FIRE El b. REACTIVE RESSURE RELEASE V u" ACUTE HEALTH �' e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 211 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT " 219 STATE WA TE CODE 220 UNITS* El a. GALLONS [_1 c. b. CUBIC FEET POUNDS. El d. TONS 221 DAYS ON SIT zzz (Check one item only) * If EHS, amount must be in pounds. lJd STORAGE CONTAINER 223 Na. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETAL'LIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE ❑ q. .RAIL CAR ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ j. BAG. ❑ n. PLASTIC BOTTLE ❑ r. OTHER 0-t� TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ d. STEEL DRUM '^ ❑ h. SILO INDER ❑ p. CYL TANK WAGON STORAGE PRESSUR ❑ a. AMBIENT ❑ b. ABOVE AMBIENT [:1 c. BELOW AMBIENT E zza STORAGE TEMPERATURE ❑ a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC .. 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS , CAS # 226 CcLfbon t , 227 I 228 ❑ Yes ❑ No 04 Z9 I 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑ Yes ❑ No 238 - 239 240 241 4 ❑ Yes ❑ No 242 243 - 244 245 5 ❑ Yes ❑. No.. Irmore hazardous components arc present at greater than 1% by weight if non - carcinogenic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information ADDITIONAL LOCALLY COLLECTED INFORMATION " 246 IfEPCRA 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) 2 BUSINESS NAME Same as Facility Name of BA -Doing Business As)- s 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 Sections 2729 - 2732), and 4 Hazardous Waste Generator, Contingency Plan (22 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 between 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 1 certify under penalty of law that I have personally examined and I am familiar with the information provided by this plan and to the best of my knowledge the information is. accurate, complete, and true. t�a/ e o Own r/ erat c V" J Title of'Owne /pper t ' O Signature of Own / perator , ^ Da We appreciate the e ort.of local b smesses 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, r ufl_ 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 ; j 1 1123 NAME 128. TITLE 1 TITLE 'm ! X � s 129 BUSINESS PHONE n I 125 BUSINESS PHONE _ 130 24 -HOUR PHONE _ ��_ V ��� 126. 24 -HOUR PHONE /\ , \ 13 1 PAGER # iy, 132 PAGER # 127 III. EMERGENCY RESPONSE PLANS AND PROCEDURES 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/PARAMEDI C S/P OLI CE /SHERIFF PHONE: 911 AFTER the local emergency response personnel are notified, you shall then notify this Department and the .Office of Emergency Services. x 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. d Date, time, cause, and type of incident (e.g. fire, air release, spill etc.) d Material and quantity of the release, to the extent known. 4 Current condition of.the facility. d Extent of irijuries, if any. 4 Possible hazards to public health and/ or the environment outside of the facility.