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HomeMy WebLinkAboutSLO Motorsports HMBP 2HAZARDOTJS MATERIALS BUSINESS PLAN FORM S — SAN LLi JBISFO COUNTY CERTIFIED :)GRAM AGENCY ` BUSINESS OWNER/OPERATOR IDENTIFICATION FA u —] j'� }� o I. EDENTINICATION BiJ$ (5 FACIt.ITY A - usi y 3 1 WSJJE � loz • BU Ess ADn s 103 CM lo< ZIP co 105 CA 108 CotwTy"� ).�.h %14n BUSINESS O R E log s o TOR lie II. BUSINESS OWNER OWNER NAME 111 OW r Ilz OWNER IyIQ,�Ll1�IG D 113 ,,.oCITY L,l�'1 114 1 STATE 115 1 ZIP 116 VA WLt/L11'w0 i III. ENVIRONMENTAL CONTACT CONTACT NAME 117 1 CO C�T i01-� 118 CONTACT MAWWG 5 119 CITY (1 L 120 ST 121 U ZIP 122 M I _P RY_ IV. EMERGENCY CONTAC _S pNDpRY- NAME . y 123 NAME y 128 129 TITLE 124 TITLF E' e-V / 123 BU5 s OI'tl�* r -a 130 BUSINESS Pli cro _ 24-HOUR PHONE 1�6 24-HOUR OKE— r PAGER if l CELL PHONE # 127 PAGER 11 / CELL PHONE # 1 132 133 ADDITIONAL LOCALLY COLLECTED INFORMATION: 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 ith th ido don submitted and believe the information is true, accurate, and complete. 31GNA OF O ❑ TOR OR DI SIGNAT1iD REFRESENTA I7VE TE NA�4�' O� DOC PREP 135 � Vl y F SI NER tpr �) . 136 TnIE OF SIGNER t37 7q3a160 8110 76 a Folr yes 2,00-5 u3 e— rII O:1DOCUMENT1Jeffp1FORMS1Business Plan FormslFRM-S.DOC 08/08/02 Business Owner/Operator Identification Please submit the Business Activities page, the Business Owner/Operator Identification page (OES Form 2730), and Hazardous Materials - Chemical Description pages (OES Form 2731) for all hazardous materials inventory submissions. For the inventory to be considered complete this page must be signed by the appropriate individual. qs (Note: the numbering of the instructions follows the data element numbers that are on the UPCF (Unified Program Consolidated Form) pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps the Department of Toxic Substances Control (DTSC) identify whether the submittal is complete and if any pages are separated. 3. BUSINESS NAME - Enter the full legal name of the business. 1. BUSINESS PHONE - Enter the phone number, area code first, and any extension. 2. 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. 3. CITY - Enter the city or unincorporated area in which business site is located. 4. ZIP CODE - Enter the zip code of business site. The extra 4-digit zip may also be added. 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, if different from business phone, area code first, and any extension. 111. OWNER NAME - Enter name of business owner, if different from business operator. 112. OWNER PHONE - Enter the business owner's phone number if different from business phone, area code first, and any extension. 113. OWNER MAILING ADDRESS - Enter the owner's mailing address if different from business site address. 114. OWNER CITY - Enter the name of the city for the owner's mailing address. 115. OWNER STATE - Enter the 2-character state abbreviation for the owner's mailing address. 116. OWNER ZIP CODE - Enter the zip code for the owner's address. The extra 4-digit zip may also be added. 117. ENVIRONMENTAL CONTACT NAME - Enter the name of the person, if different from the Business Owner or Operator, who receives all environmental correspondence and will respond to enforcement activity. 118. CONTACT PHONE - Enter the phone number, if different from Owner or Operator, 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, if different from the site address. 120. CITY - Enter the name of the city for the environmental contact's mailing address. 121. STATE - Enter the 2-character state abbreviation for the environmental contact's mailing address. 122. ZIP CODE - Enter the zip code for the environmental contact's mailing address. The 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 materials 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's home phone number,'then the service answering the phone must be able to immediately contact the individual stated above. 127. PAGER NUMBER - Enter the pager number for the primary emergency contact, if available. 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 tide 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's home phone number, then the service answering the phone must be able to immediately contact the individual stated. 132. PAGER NUMBER - Enter the pager number for the secondary emergency contact, if available. 133. ADDITIONAL LOCALLY COLLECTED INFORMATION - This space may be used for DTSC to collect any additional information necessary to meet the requirements of their individual programs. Contact DTSC, or your local agency for guidance. 134. DATE - Enter the date that the document was signed. (YYYYMMDD) 135. NAME OF DOCUMENT PRLPARER - Enter the full name of the person who prepared the Inventory submittal informadon. 136. NAME OF SIGNER - Enter the full printed name of the person signing the page. The signer certifies to a familiarity with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information, all the information submitted is true, accurate and complete. SIGNATURE OF OWNER/ OPERATOR OR DESIGNATED REPRESENTATIVE - The Business Owner/Operator, or officially designated representative of the Owner/Operator, shall sign in the space provided. This signature certifies that the signer is familiar with the information submitted and that based on the signer's inquiry of those individuals responsible for obtaining the information it is the signer's belief that the submitted information is true, accurate and complete. 137. TITLE OF SIGNER - Enter the title of the person signing the page. 0:\DOCUMENT1Jeffp\FORMS\Business Plan FormslFRM- S.DOC 8-Aug-02 g, of I) FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNEF ED PROGxAM AGENCY (CUPA) CHEMICAL INVENTORY one page ver material per building or area) DD ❑DELETE REVISE 200 I. FACILITY INFORMATION BUSINESS N (Same as F CILN r D A — Doing Bus' As) I FY s CHEMICAL LO O '-ci CHEMICAL LOCATION CO ENTIAL 202 EPCRAi 3 YES O t f MAp# 203 GRID# 204 FACILITY ID # �f N I I I I I 1 (Agency use only) f II. CHEMICAL INFORMATION xas TRADE SECRET ❑ Yes KYO CHEM NAME 206 If Subject to EPCRA, refer to instructions COMM ear EHS* ❑ Yes No 208 CAS# M r } *If EHS is "Yes", all amounts below must be in lbs. oL FIRE CODE HAZARD CLASSES (Complete if required by CUPA) zta 211 212 HAZARDOUS MATERIAL TYPE i a. PURE ❑ b. MIXTURE ❑ c. WASTE 'RADIOACTIVE ❑Yes N CURIES 213 (Check one item only) Ala PHYSICAL STATE ❑ a. SOLID ❑ b. LIQUID 1kc. GAS LARGEST CONTAINER (Check one item only) 216 FED HAZARD CATEGORIES °leaFIRE ❑ b. REACTIVE ❑ c. PR1SSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH °l� (Check all that apply) AVERAGE DAILY AM LGNT 23T MAXIMUM DMYM.OU218 ANT_,WUNT 2t9 STATEWASTECODEl2 �'' UNITS* ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS 22l DAYS ON SITE:zZ2 (Check one item only) *If EM, must be in pounds.STORAGE ❑ a. ABOVE GROUND TANK e. P C/NONMEFALIJC DRUMM m. GLASS BOTTLE 225 ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER CONTAINER ❑ b. UNDERGROUND TANK ❑ f. N ❑ c. TANK INSIDE BUILDING ❑ g C-ARBOY �7 k• BOX E) o• TOTE BIN ❑ 9• RAIL CAR [Id. STEEL DRUM ❑ . SILO 1. CYLINDER © p. TANK WAGON 224 STORAGE PRESSURE ❑ a. AMBIENT b. ABOVE AMBIENT ❑ c. BELOW AMBIENT STORAGE TEMPERATURE (Ea. AMBIENT / ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS C NENT (For mixture or waste only) EHS CAS # 226 227 228 �� ❑ Yes iNaLre) 224 1 bo ygp 231 2S2 ❑ Yes ❑ No 233 2 3 � 23s r 236 ❑ Yes ❑ No z37 z38 239 li 240 ❑ Yes ❑ No 241 q 242 y gas ❑ zaa Yes ❑ NoL gas 5 Il more bsxardow eompooeuts are present at greater than IS by weight itDon mrancraiea , or O.i'k by weight it aminogeoic, aeieeh additional -beets of papcapturing the infamuioa. 7.. ADDITIONAL LOCALLY COLLECTED INFORMATION O:\DOCUMENT\Jeffp\FORMS\Business Plan Forms\FRM-I.DOC 8-Aug-02 Form I - San Luis Obis, :ounty Certified Unified Program / ncy - Chemical Inventory You must complete a separate Hazardous Malerials 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 aver 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 materials at your facility, reported separately for each building or outside adjacent area, with separate pages for unique occurrences of physical state, storage temperature and storage pressure. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, the 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. 3. BUSINESS NAME - Enter the full legal name of the business. 200. ADDIDELETEJ 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 annuals . 201. CHEMICAL LOCATION - Enter the building or outsided 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 Section 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 time 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 Chenustry (IUf AC) 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 trade Secret information is bound by HSC Section 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 Trade Secrecy form (40 CFR 350,27) to US EPA. 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. 210. FIRE CODE HAZARD CLASSES - Fire Code Hazard Classes describe to first responders the type and level of hazardous materials which a business handles. This information shall only be provided If the local fire chief deems 4 necessary and requests the CUPA or AA to collect it. A list of the hazard classes and instructions on haw 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 appi[cable 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. tiAOIOACTIVE - Check Yes if the hazardous male rial is radioactive 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 CATFGORIFS - Chork all rntannriac that riacrnha fhe nKv i l n,.4 hayrrr, k_.M, a :..�...•r ...rh �h., >ti..Y.,..e....� ..•...�...:..r PHYSICAL HAZARDS HEALTH HAZARDS Acute Health (immediate); Highly Toxic, Toxic, Irritants, Sensitizers, Corrosives, other hazardous chemicals with an adverse effect with short term exposure Fire: Flammable Li uids and Sot ids, Combustible Li uids, horics, Oxidizers Reactive: Unstable Reactive, O niC Peroxides, Water Reactive, Radioactive Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long tern a sure � , . • r. � �r,r Q UML 1 n+wuurr i - L.aKk wjaie ure average eamry amount or the hazardous material or mrxture containing a nazar}ous matedal, in each building Or adfacenU 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 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 adjacentfoutside area at anyone 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, 4r revisions projected for the current year. This amount should be consistent with time 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 Ilsted on the back of the Uniform Hazardous Waste Manifest. 221. UNITS -Check the unit of measure 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 Exrremmely 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 SfTE - List the total number of days during the year that the material is on site. 223. STORAGE CONTAINER -Check all boxes that describe the typra of -Mrimgn 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 COMPONENTS 1-5 (% BY WEIGHT) -Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available, report the highest percentage in that range. (Report for components 2 through 5 in 230, 234, 238, and 242.) 227. HAZARDOUS COMPONENTS 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. (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 No if it is not (Reportfor 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 crAA to collect any additional information necessary to meet the requirements of their individual programs. Contact the CUPA orAA for guidance. O:\DOCUMENT\Jeffp\FORMS\Business Plan Instructions\Frm-i-in.doc 8-Aug-02 7; o F I 1 FORM I - SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHENUCAL INVENTORY (one page per material per building or area ❑ADD ❑DELETE SE 200 I. FACILITY INFORMATION BUSINESS N S e as FA Tl'Y NAME a A - Dping Business As) 3 ij� CHEMICAL J.00ATI¢N �01 CHEMICAL LOCATION CONFIDENTIAL 202 r �d�� Up � ktrf b� . O OYES O lig FACILITY ID # � 1 MAP# zo3 GRID# � (Aged use only) II. CHEMICAL INFORMATION I AL N 205 TRADE SECRET ❑ Yes No 206 rc Dffi �v �� If Subject to EPCRA, refer to instructions CO O - 207 \N I VIA f� �k 208 EHS" ❑Yes �No CAS# 209 [ sH E1HS is "Yes", all amounts below must be in lbs. FIRE COD HAZARD CLASSES (Compi m if required by cum) 210 HAZARDOUS MATERIAL TYPE +�_ 211 ❑ a. PURE �b. MIXTURE J�'� WASTE 212 RADIOACTIVE ❑Yes �o 213 CURIES (Check one item only) PHYSICAL STATE 214 ❑ a. SOLID 19 b. LIQUID ❑ c. GAS 215 LARGEST CONTAINER Q® (Check one item only) 216 FED HAZARD CATEGORIES �j FIRE ❑ b. REACTIVE [3 c. PRESSURE RELEASE [3 d. ACUTE HEALTH ❑ e. CHRONIC HEALTH (Check all that apply) �f "� A v7 GE DAILY OUN �� 217 U DAILY OUNT(o 21 Kv N L UN 211 STATE WASTE CODE � UNITS' ❑ a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS 221 DAYS ON SITE: (Check one item only) OV EHS, amount must be in pounds. STORAGE a. ABOVE GROUND TANK El e. PLASTICINONMETALLIC DRUM i. FIBER DRUM ❑ m. GLASS BOTTLE CONTAINER b. UNDERGROUND TANK ❑ E CAN ❑ j: BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER (3c. TANK INSIDE BUILDING g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ q. RAIL CAR 0 d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON 224 STORAGE PRESSURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 225 STORAGE TEMPERATURE a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # zze r � � ❑Yes �No 229 230 231 ❑ Yes ❑ No 233 3 234 235 ❑ Yes ❑ No 236 237 238 4 239 240 ❑ Yes ❑ No 241 5 242 243 ❑ Yes ❑ No 2" gas U more baurdom compoDmu ate pteseat st peaterShan L% by we3ibi1tuo�, w O,111. by w*X itcudwcmk, attach ddWo*O sb$W of pupa capturhlg the required id mration. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If I e 0:1D0CUMENTWeffp\F0RMS1Business Plan FonnslFRM-I.DOC 8-Aug-02 Form I - San Luis Obi:' County Certified Unified Program' ancy - Chemical Inventor] You must complete a separate Hazardous Materials inventory - Chemical Description page for each hazardous material (hazardous substances and hazardous waste) that you handle at your facility in aggregate quantites 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 materials at your facility reported separately far each building or outside adjacent area, with separate pages for unique ocCurrenoes of physical state, storage temperature and storage pressure, (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR. Appendix C, the 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. 3. BUSINESS NAME - Enter the full legal name of the business. 200. ADDfDELETE1 REVISE - Indicate 0 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 Section 25506. 202. CHEMICAL LOCATION CONFIDENTIAL - EPCRA - All businesses which are subject to the Emergency Planning and Community Right to KnowAct (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 Servile a (CAS) number of the hazardous material. This should be the Intemational 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 bade secret, or No if it is not State requirement Nyes, and business is not subject to EPCRA, disclosure of the designated trade secret information is bound by HSC Section 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 Trade Secrecy form (40 CFR 350.27) to USEPA. 20T 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 Ibis section blank and complete the section on hazardous components below_ 209. CAS 8 - 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 distinctfrom iLscomponents. 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. 210. FIRE CODE HAZARD CLASSES - Fire Code Hazard Classes describe to first responders the type and level of hazardous materials 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 Gass 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. It mixture or waste, complete hazardous components section. 212. RADIOACTIVE - Check Yes if the hazardous material is radioactive or No if it is riot. 213. CURIES - ff the hazardous material is radloactive, 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. PEDERAL HAZARD CATEGORIES -Check all categories that describe the physiical and health hazards associated with the hazardous material. PHYSICAL HAZARDS I HEALTH HAZARDS Fire: Flammable Liq uids and Solids. Combustible Liquids, rics. Oxidizers Acute Health {immediate): Highly Toxic, Toxic, Irritants. Sensitizers, Corrosives, Reactive: Unstable Reactive. Organic Peroxides, Water Reactive, Radioactive other hazardous chemicals with an adverse effect with short term sure Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Health (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long term exposure 217. 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 prc}ect 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 exosed that of maximum dailyamount, 218. MAXIMUM DAILY AMOUNT - Enter the ma)drnum amount of each hazardous material or mixture containing a hazardous material, which is handled in a building or adjaoentloutside area at anyone time over the course or the year. This amount must contain at a minimum last years inventory of the material reported on this page. witty 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 mate rfai 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 -Cheek the unit of measure that is most appropriate for the material being reported on this page: gallons, pounds, cubic feet or tans. NOTE: if lire material [s 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 scored 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 Ore type of storage contalners In which the hazardous material is stored. NOTE: tt appropriate, you may choose more than one. 224. STORAGE PRESSURE - Check the one box that Crest 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 Cl- BY WEIGHT) -Enter the percentage weight of the hazardous component in a mixture. If a range of percentages is available, report the highest percentage in that range. (Reportfor components 2 through 5 in 230. 234, 238, and 242.) 227. HAZARDOUS COMPONENTS 1-5 NAME - When reporting a hazardous material that is a mixture, Ilst 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 than1l% by weight If non -carcinogenic, or 0.1% by weight I carcinogenic, should be reported. H 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 mtxtures, mineral and chemicai composition should be listed. {Reportfort 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 No if it is not (Report for components 2 through 5 in 232, 236. 240, and 244.) 229. HAZARDOUS COMPONENTS 1-5 CAS - List the Chemlcat 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. Coritact the CUPA or AA for guidance. O:\DOCUMENT\.leffp\FORMS\Business Plan Instructions\Frm-i-in.doc 8-Aug-02 4 o� t i FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROURAM AGENCY (CUPA) CHEWCAL INVENTORY (one pge per material per buildine or area) ❑ADD ❑DEL,M REVISE 200 I.7� FACILITY INFORMATION BUSINESS (,camp ac TA[FL'_HXff D — ing B 'mess AS 3 riNrAAMT&.Q CHEMICAL ` 201 CHEMICAL LOCATION CQNFMENTTAL 202 EP f. W @ ST .5 O Kvi? YES NO FACHM ID # 1 MAP# GRID# 204 (Agenry ttse ody) II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE�RET ❑ Yes o 206 If Subject to EPCRA„ refer to instructionsCOMMON NAME 207 2Q S* [3 Yes gNo CAS# 20y *If E][iS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) HAZARDOUS MATERIAL. TYPE y� 21 (Check one item only) /-- PURE ❑ b. MDCTURE ❑ c. WASTE 20 RADIOACTIVE ❑Yes 1 No 213 CURIES PHYSICAL STATE / 214 (Check one item only) ❑ a. SOLID ❑ b. LIQUID X GAS "/ 215 LARGEST CONTAINER FED HAZARD CATEGORIESFIRE❑ b. REACTIVEc. j?IiESSURE RELEASE [3d. ACUTE HEALTH ❑ e. CHRONIC HEALTH 216 / (Check all that apply) AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AM 218 ANNUAL OUNT 219 STATE WASTE CODE 220 (an(( V wjl lu 11901 UNITS* ❑ a. GALLONS CUBIC FEET [Ic. POUNDS ❑ d. TONS �= DAYS ON SITE: 212 (Check one item only) !If ERS, U"wo=u must be In pounds. STORAGE 0 a. ABOVE GROUND TANK e. fLASTiCINONMETAi.LIC DRUM Cl i. FIBER DRUM 0 m. GLASS BOTTLE 223 CONTAINER © b. UNDERGROUND TANK ❑,+ . CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ q. RAIL CAR 0 d. STEEL DRUM �� h. SILO ❑ 1. 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 %WT HAZARDOVS COMPONENT (For mixture or waste only) EHS CAS # 1 226 227 Z28 ❑Yes *0 232 229 1 233 230 231 2 ❑ Yes ❑ No 3 p� 336 ❑ Yes ❑ No 237 238 4 239 , ' [1 240 ❑ Yes ❑ No 241 2 243 Z44 245 5 ❑ Yes ❑ No U more bazardu us cm i»s am present at greale r than IS by weW If non -carcinogenic, or 0.1% by weight if carchwgenic, attach addaiooal sbub of paper captwft the required informadm ADDITIONAL LOCALLY COLLECTED INFORMATION 246 _ If EPCRA. Please Sism Here 0:1DOCUMENT\Jeffp\FORMS\Business Plan FotmsNFRM-I.DOC 8-Aug-02 Form I - San Luis Obi' County Certified Unified Program ancy - Chemical Inventory You must complete a separate Hazardous Materials 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 (cafoulated 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 aver 4uantilies forwhich an emergency plan is required to be adopted pursuant to 10 CFR Parts 00. 40. or 70. The completed inventory should reflect all reportable quantities of hazardous materials at your facility, reported separately for each building or outside adjacent area, with separate pages for unique occurrences of physical state, storage temperature and storage pressure. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used In 27 CCR, Appendix C, the 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. 3. BUSINESS NAME - Enter the full legal name of the business. 200. ADDIDELETEI 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 cr outside) adjacent area where the hazardous matrial 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 Section 25506. 202. CHEMICAL LOCATION CONFIDENTIAL - EPCRA -AII 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 Intemational Union of Pure and Applies! 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 EPORA, disdosure of the designated trade secret information is bound by HSC Section 25511. Federal requirement If yes, and business is subject tD EPCRA, disclosure of the designated Trade Secret information is bound by 40 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 mbdure containing a hazardous material. 208. EHS -Check Yes f the hazardous material Is an Extremely Hazardous Substance (ENS), 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 9 -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. tf the mbdure has no CAS number, leave this column blank and report the CAS numbers of the individual hazardous components in the appropriate section below. 210. FIRE CODE HAZARD CLASSES - Fire Code Hazard Classes describe to first responders the type and level of hazardous materials 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. Ira 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 radioactive or No if it is noL 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 - Chuck all rarranrinc that rlpc jiho the "M i�l and hoallh h-aric nc 4�#.A �., k th, ti­r.e PHYSICAL HAZARDS HEALTH HAZARDS Fire: Flammable LIq uids and Solids. Combustible Li uids, Pyrophoncs, Oxidizers Acute Health (Immediate): Highly Toxic, Toxi0. Irritants, Sensitizers, Corrosives, other hazardous chemicals with an adverse effect with short term 220ure Reactive: Unstable Reactive, Organic Peroxides. Water Reactive, Radioactive Pressure Release: Explosives, Compressed Gases, Blasting Agents Chronic Heafth (Delayed): Carcinogens, other hazardous chemicals with an adverse effect with long tens exposure ­Q­ w,ll. r RwiOurt l - v a�cwaie ume average oany amount or me nazardous 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 net 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 dairy 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 adjacenfloutside area at anyone time over the course of the year. This amount must contain at a minimum last years 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 measure 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 matedat 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 thatdessibe 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 COMPONENTS 1-5 (% BY WEIGHT) - Enter the penxrmtage weight of the hazardous component in a mature. If a range of percentages is available, report the highest percentage in that range. (Report for components 2 through Sin 230, 234, 238, and 242.) 227. HAZARDOUS COMPONENTS 1-5 NAME - When reporting a hazardous material that is a mbdure, 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- ardnogenic, or 0.1°Io 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 matures, mineral 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 No if it is not (Report for Components 2 through 5 in 232. 236, 240, and 244.) 229. HAZARDOUS COMPONENTS 1-5 CAS - Ust 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 orAA for guidance. 0;1DOCUMENT1JeffpIFORMS\Business Plan Instructions\Frnn-i-in.doc 8-Aug-02 )0 FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY (one nasYe Der material per ❑:�17i ) BUSINESS NAME (Swine as -�46 CHEMICAL LOCATION FACILITY ID N ❑DELETE I. Y NAME or DBA -- ❑REVISE FACILITY INFORMATION )oing Business As) OR 12 ( 20 CHEMICAL LOCATION CONFIDENTIAL EPCRA YES 200 l r�+) Page _ of_ 3 202 1 MAPN (optional) 203 1 GRIDl1(optionaq 204 II. CHEMICAL INFORMATION CHEMICAL NAME 205 TRADE SECRET ❑ Yes EWD 206 PETROLEUM HYDROCARBON If Subject to EPCRA, refer to instructions COMMON NAME W7 EHS* ❑ Yes No GASOLINE INCLUDES UNLEADED REGULAR ETC. _ CAS# 209•If EHS is "Yes", all amounts below must be in lbs. 8006-6I-9 2tg FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 211 212 213 HAZARDOUS MATERIAL TYPE [-1 a. PURE ® b. MIXTURE ❑ c. WASTE RADIOACTIVE ❑ Yes ® No CURIES (Check one item only) 214 • 215 PHYSICAL STATE ❑ a. SOLID ® b. LIQUID ❑ c. GAS LARGEST CONTAINER �� (Check one item only) 216 FED HAZARD CATEGORIES ® a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ® d. ACUTE HEALTH ® e. CHRONIC HEALTH (Check all that apply) AVERAGE ILY MOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE MOUNT 219 STATE WASTE CODE 220 3j UNITS* ® a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TO S 221 DAYS ON SITE:222 �6 (Check one item only) +If EHS, amount must be iu pounds. STORAGE ❑ ABOVE a. GROUND TANK ❑ e. PLAMCINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. CLASS BOTTLE -223 ❑ OTHER CONTAINER ❑ b. UNDERGROUND TANK ❑ f. CAN [Ir. j. BAG ❑ k. BOX ❑ n. PLASTIC BOTTLE ❑ o. TOTE BIN ©q. RAIL CAR ❑ e. TANK INSIDE BUILDING ❑ g. CARBOY ,Ed- STEEL DRUM ❑ h. SILO ❑ I. CYLINDER ❑ p. TANK WAGON 224 STORAGE PRESSURE ® a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 2Z5 STORAGE TEMPERATURE ® a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 227 TERT BUTYL ETHER ❑ Yes ® No 1634-04-4 229 1 15 226METHYL 231 TOLEUNE El Yes ®No 232 108-88-3 233 2 30 2 15 236 1330-20-7 237 3 21 235 XYLENE El Yes ® No 239 BENZENE ❑ Yes ® No 2 40 71-43-2 241 � 4 5 238 243 1, 2, 4 - TRIMETHYL BENZENE ❑ Yes ® No 241 95-63-6 242 5 5 are present at puler than 1% by weight Ir non<srdnogeuk, or 0.1% b1 weight If mrelnogcuk, attach addilionst sheets of paper capturing the required Information. u more havr,. eompooeuls 24! ADDITIONAL LOCALLY COLLECTED INFORMATION A:\PETGAS.DOC 11-Feb-00 M}q? ^r:�.�: jib , `�.n:;.. • �iEi�c.,0. t: •. S San Luis Obispo aunty Certified Unified Program Age, r FORM M - MAP GRID (see instructions) Map # A B C D E F G H I J K L M N f f [� D Yew Ace`iYlevvc n -r ,ifs A v b A J B l C l D 1. E I F G H i i I J I K+ L I M N Scale: 1 inch = Feet 2 I 3 4 6 6 7 8 9 10 11 12 13 14 Business Name: �,0} 0 �5 ; Y.E-5 Date: Address: Number of Employees in Facility Depicted Above - Day = Night = 0AD0CUMENTUeffpT0RMS16usiness Plan FormsTRM-M.DOC 08/08102 FORM E SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED CtX ti PROGRAM AGENCY (CUPA) EMERGENCY RESPONSE PLAN Or Hazardous Waste Contingency Plan SECTION I -A: BUSINESS IDENTIFICATION DATA BUSWFSSNAME S1TE ADD FACB.rrY UNIT BUSINESS MAILING ADDRESS your business has a (t 1. Hazardous Materials e Underground Storage # 2. Hazardous Waste Generator # J MY CITY o.,.: i�(e vy liffE TELEPH NS NUMBEAL, R QD6. � ZIP CODE any of thefollowing agencies, please indicate the document number. 3. Air Pollution Control District # 4. Responding Fire Dept & Permit # Please provide the following information as it pertains to your business and its location. You are not required to notify these companies in the event of an emergency. This information is provided for your reference and to assist emergency response personnel in responding to a hazardous materials emergency at your facility. List the name and phone number of the utility company. Electric Service � k It - Telephone # - ` y6 1 !2W Gas Service ' Telephone # 1 Sanitation �. ]� �!] �� _ Telephone # , ` r Water District SECTION I-B: OWNER CERTIFICATION OF DATA (Certify either 1 or 2) 1. This is a [NEW Plan [UPDATED Existing Plan. I have personally examined the information it contains and am familiar with the operation of the plan. (If you check either of the above two options, continue to complete the remainder of the Emergency Response / Contingency Plan). 2. ❑ This plan requires no change and is on file with San Luis Obispo County Certified Unified Program Agency and does not need any change. (If you check this section, please proceed directly to Form T, the Training Program.) I certify under pe alty of law that the above information is tru acc �kffi a[bw PRINT AMEOF D oR ❑ TOR SIGMA DATE DOCUMEtM PREPARED BY SIGNATURE DATE 1 O:\DOCUMENTUeffp\FORMS\Business Plan Forms\FRM-E.DOC 08/08/02 SECTIC EMERGENCY RESPONSE PLANS A PROCEDURES Note: Complete all sections of this Emergency Response Procedure below. Use of terms such as 'N/A" (Not Applicable) will not be accepted. A. FIRE, SPILL, OR RELEASE: The fire code requires immediate notification through dialing 911, by whoever first sights the incident. In the event of release or spill of hazardous materials, you must also notify: 1. San Luis Obispo County Certified Unified Program Agency during business hours @ 805-781-5544. After business hours dial 911. 2. The State Office of Emergency Services - (800) 852-7550 or (916) 262-1621. List the individuals responsible for verifying that these calls have been made and also indicate their position in your company. FOR VERIFYING THE DIALING OF 911: ( �'Vc' %k� f �, --- NAME 1 POSITION li Individual responsible for calling San Luis Obispo County Certified Unified Program Agency and the State Office of Emergency Services: [Normo� the Err)prgincy Coordina(or ofy_9.ur business.) NAME J POSITION 0 B. List the local emergency medical facilities that will be used by your business in the eve yr tyre ten Mr f ( •� �AME ADDRESS oc'ryv, NAME -'iDAESS crrY C. List mergency rdinator(s) at your �Iity. Primary: NAME iI Secondary: NAME TTTI.E an accident or injury caused by a release K6")1- Wqf� V* PHONE Wyl kLD HU PHONE 24HRPHONE PAGER# /may/) Sits PHONE 24 HR PHONE PAGER # D. Does your business have an on -site emergency response team? Yes ONo Describe procedures your business will follow in the event of a release or threatened release of hazardous materials. Nf'm�el OVA I 1,1'i AM OPY 0 1A 10 1(?.,, ft� 0A I 0:00CUMENlUeffpTCRMSSusiness Plan FormsTRM-E.DOC 08/08/02 -10 In 11 , E. If'you have acutely hazardous matt..., Is above threshold planning quantities, list (L. .ame and address) adjacent neighboring businesses and residences, schools, hospitals, etc. Include sensitive facilities (schools, hospitals and rest homes) within 1,000 feet (straight-line distance from your property line). List telephone numbers for all businesses; for apartment buildings, list manager's phone. Do yt ist telephone numbers for private residences. 4—�a�L F. Briefly describe your standard operating procedures in the event of a release or threatened release of hazardous materials. Emergency response procedures must comply with all federal, state and local regulations. Existing emergency response procedures may be referenced and attached to this document. 1. Prevention — Describe the accident potentials associated with the hazardous materials present at your facility. What actions would your business take[ to reduce accident potentials? Include description of safety, storage, and conta ent procedures. -1;nA I l� yWA pfq� -� CA (I � M A,V, A 9�� PKIII. COS i V)r(a Im I it fkIC40 0A 2. Equipment — List the emergency response equipment at your facility (e.g. fire extinguishTig systems, spill control equipment, decontamination equipment). Item Use Location Maintenance Procedure U L J A-Dd 0 3. Evacuation — Describe how you will immediately evacuate your facility. Where are the designated meeting locations? What communications or alarms are used? How will you operate these during power failure? 3 OADOCUMENTUeffpTORMS113usiness Plan FormsTRM-EMOC 08/08/02 4. Shutdown — Describe the procedures to shutdown the facility in case of an emergency. 5a. Response — Describe what is done to lessen or mitigate the harm or damage done to person(s), property, or the environment, and to prevent the event from getting worse or spreading. What is your immediate response to: Fire:Mal _; I t� Explosi n:__Z I ) b. Is this facility located on a 100-year flood plain? es ❑No e. Earthquake - Identify facility areas and list nieclianic20yrother systems that require immediate inspection or isolation because of their vulnerability to earthquake elated d motion. �Y WI P " /I VO 1an 6. Clean -Up — How do you handle the complete process of cleaning up and disposing of hazardous material releases at your facility? G.Ucation — Your business is required to keep a copy of the Business Plan and related Material Safety Data Sheets (MSDS) on -site. )"-? f rV '2 T 1r01/I to -D7( lu o� f 5 o x0 f1,�,�- - o�.� Wnya4vm 4 WDOCUMENTUeffpTORMS1Business Plan FormsTRM-E.DOC 08/08/02 FORM T SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) EMPLOYEE TRAINING PROGRAM o.,r�a i8va' A. Describe the safety training for all employees in the event of a release or threatened release of hazardous materials. This training shall include, but not be limited to the following: new employee training, annual training, and safety meetings which cover familiarization with the facility's hazard communication program and Emergency Response Plan/Contingency Plan. 1. Summarize the training for all employees that work with or come in contact with hazardous materials/hazardous wastes. Describe how these employees are trained to avoid exposure. 2. Summarize training specific to those employees that would respond to a release or threatened release of hazardous materials or hazardous waste. r 5 0AD0CUMENT\Jeffp\F0RMS\Business Plan Forms\FRM-T.DOC 08/08/02 3. Indicate frequency and duration of training for employees that work with or come into contact with hazardous materials/hazardous 4. Describe how employees access training materials. (E.g., bulletin board, employee ewsletter, staff meetings, etc.) �(o1 B. List person(s) in charge f trainin d indicate their qualifications to conduct the tr iningj �] - r Say I (P. hi C. Indicate where training records are kept. (Records must document the type of training, duration, completion dates, names and positions of employees receiving training and a of instructor/trainer.)J - - MA nhal 6 0:ID000MENT\.leffp\FORMS\Business Plan FormsTRM-T.DOC O8/08/02 L "C'( � q FORM S - SAN LUi,, JBISPO COUNTY CERTIFIED UNIFIED GRAM AGENCY , v BUSINESS OWNER/OPERATOR IDENTIFICATION NOV 3 0 Page of I. IDENTIFICATION FACILITY ib#��� !r t BEGINNING DATE 100 ENDING DATE tot BUSINESS NAME (Same as FACIA IT NA or DBA - Doing BusInc A 5 `� Lt 61 5 140J t & 3 �ti BUSINESS PH 102 d jNE BUSINESS SITE ADDRESS 103 CITY - 104 CA ZIP ODE 105 n DLTN & BRADSTREET 1 106 SIC CODE (4 digit # 107 COUNTY - ' toe 1pml Ute n 13USINESSOPERATOR NA E 109 BUSINESSS O TORR PHONE 110 305- SDOL00 H. BUSINESS OWNER OWNER NAME ttt OWNER PHONB 112 OWN M ILING ADDRESS 1 113 �rLnJ lt6 f l� �4o III. ENVIRONMENTAL CONTACT CONAME 117 CONTACT PHQNE 118 e, CON;CT qMILING ADDRESS 119 CITY-{r� - '20 1 STA 121 ZIP ODE 122 -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- NAME ,o l�`� Vt�k__Prb 123 N 128 Ad-&4 TITLE 124 TITLE 129 BUSINESS PHONE 125 641 BUSINESS PHONE 130 aao0 24-HOUD DunNF. 126 24-HOUR PHONE 1 131 17C/v - o� 4 PAGER # 132 PAGER!{ 127 ADDITIONAL LOCALLY COLLECTED INFORMATION: 133 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 f ar with the info trio, submitted and believe the information is true, accurate, and complete. S, , RE OW PERAT OR DESIGNATED REPRESENTATIVE DATE 134 NAME OF DOCUMEqT PREPARER 135 AM E OF SiER (print) 136 TITLE OF SIGNER 137 -L H a naac � A:\Frm-s.DOC 14-Feb-00 I-1s—ol Hazardous aterials Business Plan Reporting Rey, _ lrements San Luis Obispo City Fire Department 2160 Santa Barbara Avenue San Luis Obispo, CA 93401-5240 805 781-7383 Reportable Levels of Hazardous Materials 55 Gallons Liquids are reported in gallons. 200 Cubic Feet Gasses are reported in cubic feet, except for propane, which is reported in gallons. 500 Pounds Solids are reported in pounds. ANY ouantity of hazardous waste. N - P - K Fertilizer Exemption Exempt if less that 10,000 pounds TOTAL. (Not to include Ammonium Nitrates Medical Exemption Oxygen, Nitrogen and Nitrous Oxide are exempt if the total quantity of each gas on -site is 1,000 cubic feet or less and they are used by: Physicians, Veterinarians. Pharmacists, Dentists and Podiatrists. Lubricating Oil Exemption Exempt if the TOTAL volume of all types of lubricating oil handled at a single facility does not exceed 275 gallons. Lubricating oil is defined as any oil intended for use in an internal combustion crankcase, transmission, gearbox, differential, or hydraulic system of an automobile, bus, truck, vessel, plane, heavy equipment, or other machinery powered by an internal combustion or electric powered Agricultural Facility, Above and Underground Fuel Tank Exemption Motor vehicle fuel above and underground tanks at 1,100 gallons or less capacity would be exempt at agricultural facilities from the Business Plan reporting requirements once the inventory and site map has been submitted to the City Fire Department. However, if the TOTAL volume of fuel is greater than 20,000 gallons at a single facility, this exemption would not apply. The One -Time Only Agricultural Exemption Registration fee is $50.00, Liquid Fertilizer Application Exempt under the following conditions: fertilizer is applied no more than 4 times per year, with the application and storage period not to exceed 7 consecutive days for each application, the quantity of fertilizer is less than 1,190 gallons at any one time, and the fertilizer container has a label indicating the fertilizer/fertilizer mixture ingredients. Remote Site Exemption A remote site is defined as an unstaffed facility located in an isolated, sparsely populated area. The facility is secured and not accessible to the public. Exempt if the hazardous material inventory is equal to or less than 500 cubic feet of compressed inert gasses, 500 gallons of combustible liquids used as a fuel source (diesel, fuel oil, kerosene), 200 gallons of electrolytes in closed containers, 500 gallons of lubricating and hydraulic fluids, and 1,200 gallons of flammable gas used as a fuel source (propane). The facility must submit a one-time Hazardous Materials Business Plan to the City Fire Department, complete a Remote Site Exemption form and pay a one-time only Remote Site Exemption fee of $50.00. Warning signs must be posted and maintained for hazardous materials pursuant to the California Fire Code. Please circle the letter that best describes the Hazardous Materials at your business: A - No chemicals are used or stored in my business operations. B - Chemicals are used, handled or stored in my business, but not in disclosable amounts: 500 pounds of a solid, 55 gallons of a liquid or 200 cubic feet of a gas. My business does not use disclosable amounts of Acutely Hazardous Materials. My business does not use, handle or store any amounts of Hazardous Material that would fall into one of the following categories: Class "A" explosive, Class "A" poison, commercial grade pesticide, unsealed radioactive isotope or any legal carcinogen (pure chemical or component of a compound). Chemicals are used or stored in my business and I am submitting my Hazardous Material Business Plan: Chemical Inventory and iness Emergency Plan. Business Owner/Operator Name (Print): Business Owner/Operator Signature: Date Signed: Please return this form to the San Luis Obispo City Fire H/: Business Plan Exemption Form FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY (one pap per material buildin or area) ADD []DELETE ❑REVISE 200 Page Z of I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME or D13A — Doing Business �.ncrva���r�a. a..v�,naavi� •^•• t_nrliVlll./iL LV1A111V1N l.V1Nr1UrIN11AL cvt EPCRA El YES NO 1 MAP# (optional) 20] GRID# (optional) 204 FACILITY ID # II. CHEMICAL INFORMATION CHEMICAL NAME 205 T'RAPE SECRET ❑ Yes allo 206 OXYGEN If Subject to EPCRA, refer to instructions COMMON NAME 207 EHS* ❑Yes No W8 OXYGEN CAS# 209 7782447 *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complete if required by CUPA) ?lt HAZARDOUS MATERIAL TYPE ® (Check one item only) a. PURE 211 ❑ b. MIXTURE ❑ C. WASTE RADIOACTIVE ❑ Yes ® No 212 CURIES 213 PHYSICAL STATE ❑ a. SOLID (Check one item only) ❑ b. LIQUID ® C. GAS 214 LARGEST CONTAINER 215 FED HAZARD CATEGORIES (Check all that apply) ®a. FIRE Elb. REACTIVE ®c. PRESSURE RELEASE ❑ d. ACUTE HEALTH [Ie. CHRONIC HEALTH 216 AVERAGE DAILY AMOUNT 217 MAXIMUM DA.1LY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 sfe-vr lZn�V i3l G �sar UNITS* ❑ a. GALLONS ® b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS 221 DAYS ON SITE: 222 (Check one item only) 'if EHS, amount must be in pounds. STORAGE El a. ABOVE GROUND TANK Ll e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM m. GLASS BOTTLE 223 CONTAINER ❑ b. UNDERGROUND TANK. ❑ f. CAN ❑j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN [] q. RAIL CAR ❑ d. STEEL DRUM ❑ h. SILO ® 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ® b. ABOVE AMBIENT ❑ c. BELOW AMBIENT eta STORAGE TEMPERATURE ® it AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 228 229 1 100 OXYGEN ❑ Yes ® No 7782447 230 J 231 232 233 2 ❑ Yes ❑ No 235 236 237 3 El Yes ❑ No 238 239 240 241 4 J!/ ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No u more hazardous components are present at greater than 1% by weight if non-carclnogemc, or 0.1% by weight If carcinogenk, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA Please-SignHere FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY (one Oage per material CZ building or area) MADD ❑DELETE ❑REVISE Page 3 of I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAME DB — Doing Business ] 3 CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202 EPCRA ❑ YES QKNO FACILITY ID # r? • j.... f 1 MAP# (optional) 203 GRID# (optional) 204 U. CHEMICAL 1NNORMA110N CHEMICAL NAME 205 TRADE SECRET ❑ Yes Lg No 206 ACETYLENE If Subject to EPCRA, refer to instructions COMMON NAME 2m 208 ACETYLENE EHS* ❑ Yes [51 No �If EHS is "Yes", all amounts below must be in lbs. CAS# 209 74862 FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210 HAZARDOUS MATERIAL TYPE 211 (Check one item only) ®a. PURE ❑ b. MIXTURE ❑ c. WASTE 212 RADIOACTIVE ❑Yes No 213 CURIES PHYSICAL STATE 2 N (Check one item only) ❑ a. SOLID ❑ b. LIQUID ® c. GAS 215 LARGEST CONTAINER FED HAZARD CATEGORIES 216 (Check all that apply) ® a. FIRE ❑ b. REACTIVE ® c. PRESSURE RELEASE ® d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 218 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 Cvi'3►L F�C�r-- I 20 1 1 UNITS' ❑ a. GALLONS ® b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS 221 DAYS ON SITE: 222 (Check one item only) ►If EHS, amount must be in pounds. STORAGE ❑ a. ABOVE GROUND TANK © c. PLASTICINONME'I'ALLIC DRUM t. FIBER DRUM ❑ m. GLASS BOTTLE 223 CONTAINER ❑ b. UNDERGROUND TANK ❑ f. CAN [] j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING I] g. CARBOY ❑ k. BOX ❑ o. TOTE BIN © q. RAILCAR ❑ d. STEEL DRUM ❑ h. SILO ❑ 1. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ❑ a. AMBIENT ® b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ® a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 2" %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS N 226 1 100 2.27 ACETYLENE 2M ❑ Yes ® No 229 74862 230 '� 231 232 233 2 ❑ Yes ❑ No 234 3 235 236 ❑ Yes ❑ No 237 23 239 240 241 4 ❑ Yes ❑ No / 242 243 244 245 5 ❑ Yes ❑ No if more hazardous components are present at greater than 1% by weight If non-arcinogeaic, or 0.1% by weight if carcinogenic, attach additional sheets of paper capturing the required information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EP RA Please Si Here C:\example\ACETYLN.DOC 22-Feb-00 FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY (olle Imige per material per building or area) IDD [:]DELETE❑REVISE Page of I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NAM or DBA — Doing Business s) 3 CHEMICAL LOCATION S%iCT�Q/LIO12 201 CHEMICAL LOCATION CONFIDENTIAL 202 -��t 20I w JT Oc .mot IdI� �L� EP YES U5 NO 1 MAPN (optional) (optional) � FACILITY ID J{ 7GRID# I II. CHEMICAL INFORMATION CHEMICAL NAME 2.05 TRADE SECRET ❑ Yes ® No 206 PETROLEUM HYDROCARBON If Subject to EPCRA, refer to instructions COMMON NAME zs EHS* El Yes ®No WASTE OIL/OIL FILTERS CASH 209 *If EHS is "Yes", all amounts below must be in lbs. N/A FIRE CODE HAZARD CLASSES (Complete if required by CUPA) 210 211 HAZARDOUS MATERIAL TYPE ❑ a. PURE b. MIXTURE ®c. WASTE ® 212 RADIOACTIVE ❑Yes No 213 CURIES (Check one item only) PHYSICAL STATE 214 ❑ a. SOLID ® b. LIQUID ❑ c. GAS 215 LARGEST CONTAINER �f \CLJ�1 5 (Check one item only) C— 216 FED HAZARD CATEGORIES ®a. FIRE ❑ b. REACTIVE ❑ c. PRESSURE RELEASE ®d. ACUTE HEALTH ®e. CHRONIC HEALTH (Check all that apply) AVERAGE DAILY AMOUNT 217 MAXIMUM DAILY AMOUNT 21g ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 I Cn 6ALL0 ZC (SA WnOS 6g� C-4aLL�-5 1 221 UNITS* ® a. GALLONS ❑ b. CUBIC FEET ❑ c. POUNDS ❑ d. TONS 221 DAYS ON SITE: 222 (Check one item only) *If EHS, amount must be in pounds. STORAGE ® a. ABOVE GROUND TANK ❑ e. PLASTIC/NONMETALLIC DRUM ❑ I. FIBER DRUM ❑ m. GLASS BOTTLE 223 CONTAINER ❑ b. UNDERGROUND TANK ❑ f. CAN ❑ J. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BUILDING ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ q. RAIL CAR ❑ d STEEL DRUM ❑ It. SILO ❑ I. CYLINDER ❑ p. TANK WAGON STORAGE PRESSURE ID a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT 224 STORAGE TEMPERATURE ® a. AMBIENT ❑ b. ABOVE AMBIENT ❑ c. BELOW AMBIENT ❑ d. CRYOGENIC 225 %WT HAZARDOUS COMPONENT (For mixture or waste only) EHS CAS # 226 227 22" 229 1 100 PETROLEUM HYDROCARBON ❑ Yes ® No 230 231 232 233 2 ❑ Yes ❑ No 234 235 236 237 3 ❑Yes ❑ No 238 234 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 Yes ❑ No ❑ If more hazardous components are present at greater than 1% by weight it non-carcinogenk, or 0.1% by weight If carcinogenic, attach additional sheets of paper capturing the required Information. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If F.PCRA. PI -ise SJLrn Hevr A:\WASTOIL.DOC 11-Feb-00 2 3 4 5 6 7 s 9 10 11 12 13 14 San Luis Obispo C( )ty Certified Unified Program Agenc' FORM M - MAP GRID (see instruction page v) A I B I C I D I E I F I G I H I 1 I J 0g,E,k/zNCrV2� 5-ro2+6:F- 5 C Its IPUAV Map # i I L I M I N v W Awe OI(, —s' r642 �L`cC7f21C�IL � ��� OI l- STCN2) }�r C-'I Ile �k`ri VIGt�[ SH�fes 2 3 4 5 6 7 002 I-°►r4e4V1t:',S s w7n� -$ 9 SI~G ]q7 w—Hfo 10 11 A 12 13 r4{L 1a A B I C I D E �I G H I I J 1 K L M f N Scale: 1 inch = 20 Feet Business Name: L/I ULAS C2aTfE Date: I 1-50,:�:o Address: Number of Employees in Facility Depicted Above - Day = Night = Page of 4 A:\PRM-M.D0C2/.14/2000 10:15 A" FORM I — SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED PROGRAM AGENCY (CUPA) CHEMICAL INVENTORY (one page per malarial per building or area) ADb ❑DELETE ❑REVISE 200 Page ' of I. FACILITY INFORMATION BUSINESS NAME (Same as FACILITY NA14E or DBA — Doing Vusiness As) 3 AA CHEMICAL LOCATION 201 CHEMICAL LOCATION CONFIDENTIAL 202 EPCRA LJ YES El NO 1 MAP# (optional) 203 GRID# (optional) 204 FACILITY ID i0� - - II. CHEMICAL INFORMATION CHEMICAL NAME �8S TRADE SECRET ❑ Yes ❑ No 206 If Subject to EPCRA, refer to instructions COMMON NAME 207 206 EHS* ❑ Yes ❑ No CAS# 20� *If EHS is "Yes", all amounts below must be in lbs. FIRE CODE HAZARD CLASSES (Complcie If tegolred by CUPA) 210 i HAZARDOUS MATERIAL TYPE 211 (Check one item only) ❑ a. PURE ❑ b. MIXTURE ❑ c,,WASTE 212 RADIOACTIVE ❑ Yes ❑ No 213 CURIES PHYSICAL STATE 21d (Check one item only) ❑ a. SOLID ❑ b. LIQUID ❑ c. GAS 215 LARGEST CONTAINER FED HAZARD CATEGORIES 216 (Check all that apply) ❑ a. FIRE ❑ b. REACTly ❑ c. PRESSURE RELEASE ❑ d. ACUTE HEALTH ❑ e. CHRONIC HEALTH AVERAGE DAILY AMOUNT 217 MAXIMUM.f7A1LY AMOUNT 216 ANNUAL WASTE AMOUNT 219 STATE WASTE CODE 220 UNITS* ❑ a. GALLONS ❑ 1P. CUBIC FEET ❑ c. POUNDS ❑ d. TONS 221 DAYS ON SITE: 222 (Check one item only) *If EHS, amount must be in pounds. STORAG: © a. ABOVE GROUND TAN e. PLASTICINONMETALLIC DRUM ❑ i. FIBER DRUM ❑ m. GLASS BOTTLE '_'_3 CONTAINER ❑ b. UNDERGROUND TA1+IK ❑ f. CAN ❑ j. BAG ❑ n. PLASTIC BOTTLE ❑ r. OTHER ❑ c. TANK INSIDE BU1L61NG ❑ g. CARBOY ❑ k. BOX ❑ o. TOTE BIN ❑ q. RAIL CAR ❑ d. STEEL DRUM ❑ It. SILO ❑ 1. 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 II.ZARDOUS COMPONENT (For mixture or waste only) EIS CAS # 226 227 -^ 228 229 1 ❑ Yes ❑ No `. 230 2 1 ' 231 235 232 ❑ Yes ❑ No 236 233 4 _ 237 3 ❑ Yes ❑ No 236 239 240 241 4 ❑ Yes ❑ No 242 243 244 245 5 ❑ Yes ❑ No if more hazardous components are present at greater than 1% by weight 1r non-carcinogenlc, or 0.1% by weight u carrinogenk, attach additional sheets ofpaper ca p urhlg the regWrcd ormatioa. ADDITIONAL LOCALLY COLLECTED INFORMATION 246 If EPCRA Please Sigg Here A:\Chemical Inventory Business Plan.DOC 14-Feb-00 , c co o-13 ag ; K ' r IN F � ry •X.r• ' r:i ' .,L'� ��� . • her �� . . -,,.w. � .i -h:•. �.`• a •n:33'�7��.: nr. ,• r'.: •{ ., A• '(S.nY•'•'s •�•« f ,ir-• i.. •r;yii;; : ;yam. y. F fi r s , f _- • �.. -' - �.:{�°• �, �• 4i i ` Y ,� „kj�x, i '�.: ,�fw•nr`�' •i?w" f �� .. S1, y.n/�,. _'.:.Ic*}'/ " ��;•. �f[,.5a/:y � �`C�`-�i4. .. ti �». r. .. .. if .. mN 'mar• w +y,�„ M56 f- -1 C-.) C 13; FORM E i Page 3_ of 15 SAN LUIS OBISPO COUNTY CERTIFIED UNIFIED BUSINESS NAME SITE ADDRESS PROGRAM AGENCY (CUPA) EMERGENCY RESPONSE PLAN Or Hazardous Waste Contingency Plan (see instruction page vii) Date- 1 k loo 00 SECTION I -A: BUSINESS IDENTIFICATION DATA CITY ZIP CODE 9 34, FACILITY UNIT T TELEPHONE NUMBER BUSINESS MAILING ADDRESS CITY ZIP CODE If your business has a license or pennif from any of the following agencies, please indicate the document number. 1 14 �J -r 3. Air Pollution Control District # 2. Hazardous Waste r 4. Responding Fire Dept '^ �ref Generator # �V & Permit # Please provide the following information as it pertains to your business and its location. You are not required to notify these companies in the event of an emergency. This information is provided for your reference and to assist emergency response personnel in responding to a hazardous materials emergency at your facility. List the name and phone number of the utility company. Electric Service �2Telephone # q�A '�=111(TDC Gas Service Telephone # Sanitation Telephone # .7 r Water District Telephone # 3ns - a f SECTION I-B: OWNER CERTIFICATION OF DATA (Certify either 1 or 2) 1. This is a NEW Plan ❑UPDATED Existing Plan. I have personally examined the information it contains and am familiar with the operation of the plan. (If you check either of the above two options, continue to complete the remained of the Emergency Response / Contingency Plan). 2. ❑ This plan requires no change and is on file with San Luis Obispo County Certified Unified Program Agency and does not need any change. (If you check this section, please proceed directly to Form T, the Training Program.) I certify under penalty of law that the above inforrnati't n is true PRINT NAME OF o OR DOCUM PREPARED BY SIGNATURE 1-30-&o DATE 5 Page q of 6 SECTION 11: EMERGENCY RESPONSE PLANS AND PROCEDURES Note: Complete all sections of this Emergency Response Procedure below. Use of terms such as "N/A" (Not Applicable) will not be accepted. A. FIRE, SPILL OR RELEASE: The fire code requires immediate notification through dialing 911, by whoever first sights the incident. In the event of release or spill of hazardous materials, you must also notify: 1. San Luis Obispo County Certified Unified Program Agency during business hours 0 805-781-5544. After business hours dial 911. 2. The State Office of Emergency Services - (800) 852-7550 or (916) 262-1621. List the individuals responsible for verifying that these calls have been made and also indicate their position in your company. FOR VERIFYING THE DIALING OF 911: \J e, Ir SPX, .o-rio(g NAME POSITION Individual responsible for calling San Luis Obispo County Certified Unified Program Agency and the State Office of Emergency Services; (Normally the Emergency Coordinator of your business.) NAME POSITION B. List the local emergency medical facilities that will be used by your business in the event of an accident or injury caused by a release or threatened rele of hhazardous material . , , - - — ► ) r% . , T r rl r I I "�• _ _ f- i' i 1 r _ [=NMMWf:►.■WEB a L+ MW a Van E FM aaa�IfL� NAME ADDRESS ' CITY PHONE NAME ADDRESS / CITY PHONE C. List the Emergency Coordinator(s) at your facility. Primary: _�.Aho - 0110 W [� r-.Ph,A 0A I U A "ArP NAME TITLE BUS INIWPHONE 2lHRPHONE PAGER# Secondary: NAME TITLE USINESS PHONE 24 HR PHONE PAGER N D. Does your business have an on -site emergency response team? ❑Yes 6No If yes, describe 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. � �. � (�'!)�CCT�� �1►2�" i ►2,�1i 1�I �'!� ��C� CIS L� �' - 1 - l - r 4,) 6 Page 1— of M E. If you have acutely hazardous materials above threshold planning quantities, list (by name and address) adjacent neighboring businesses and residences, schools, hospitals, etc. Include sensitive facilities (schools, hospitals and rest homes) within 1,000 feet (straight-line distance from your property line). List telephone numbers for all businesses; for apartment buildings, list manager's phone. Do not list telephone numbers for private residences. F. Briefly describe your standard operating procedures in the event of a release or threatened release of hazardous materials. Emergency response procedures must comply with all Federal, State and local regulations. (Use additional sheets if necessary. Use our format if computerized.) 1. Prevention -- Describe the accident potentials associated with the hazardous materials present at your facility. What actions would your business take to reduce accident potentials? Include description of safety, storage and containment procedures. 5S Cam{ i CsVJ O(L Y)►2L7WA CAW 1zVIQ -_,;:: - C'!tNIVA IV\ L 0CGyuo Ka 12Y Iz<97.i�(P owe/ �� _ f-.(A W-t5=-�57, T(:�- wASTF- arm._ -? CZ !►n!a� 1 L (sEC<fAAVl4gy 2. Equipment -- List the emergency response equipment at your facility (e.g. fire extinguishing systems, spill control equipment, decontamination equipment). Include summary of maintenance procedures. Item Use Location Maintenance Procedure ('it2,,!5 o X r,wc� Filly L 5W-X> 1-STCV244:5f" P4ke s WV104(_ SlFllav ICE iqlY] F2.1 VAtLA02 '<��� �kqr�z- .p12��►- CST 14c/LT�:c2LY l�V ritiTC��I 3. Evacuation --Describe how you will immediately notify and evacuate your facility. What communications or alarms are used? How will you operate these during power failure? 9 ;F TD EXIT, —G i2GVlr� O fj()LC-b ),.� Page 1 4. Shutdown -- Describe the shutdown for each site or facility. aL10 1. err LiA / / ' OEM 5a. Response -- Describe what is done to lessen or mitigate the harm or damage to person(s), property, or the environment, and prevent the event from getting worse or spreading. What is your immediate response to: Fire: COVj-j� F[ i J F R:-A 2W GAS, Explosion:14C1�U4T'c Spill: CC=�ATb4I <f --JW 1-- LAP Severe Ground Motion: r�yWC� )K1T� r4LL- F:r-t/2--qanS 7 .SN(3T C)r4l,— �'%x�'GT121Cr4L Major Power Failure: Flood: poypL Sy p vrr" b. Is this facility located on a 100-year flood plain? ®Yes ONo c. Ground Motion - Identify facility areas and list mechanical or other systems that require immediate inspection or isolation because of their vulnerability to earthquake related ground motion. 6. Clean -Up (Remove the Hazard) -- How do you handle the complete process of cleaning up, and disposing of related materials at your facility? Note: Notify the Certified Unified Program Agency when clean up is complete. 1 I- Lr-3E ✓► tt -1 rr -I- C� � I� AA Vl LlgC �C�12 L1 i2 G. Location -- Your business is required to keep a copy of the Business Plan and related MSDS sheets on -site. Describe where this information is located. FORM T Page 17, of 17 SAN LUIS OBISPO COUNTY CERTHFED UNIFIED PROGRAM AGENCY(CUPA) EMPLOYEE TRAINING PROGRAM Date: A. Describe the safety procedure training for all employees in the event of a release or threatened release of hazardous materials. This training shall include, but not be limited to, the following: new employee training, annual training, periodic refresher courses, and familiarization with Emergency Plans and Procedures of this Business Plan / Contingency Plan. 1. Summarize specific job descriptions for all positions that work with or come in contact with hazardous materials/ hazardous waste and in3icate how these specific positions are trained for their job responsibilities or hazards of exposure (describe training program). Designate whether employee is working with hazardous material (HM), hazardous waste (HV), or both (B). 2. Summarize training specific to emergency response personnel that deal with either hazardous material or hazardous waste release or threatened release. �r ■C� I L ,WALe. Ag Ly, A:\FRM-T.DOC2/14/2000 11:08 A- Page k of 13 3. Indicate frequency and duration of training for each type of employee noted above (a table may be used). 4. Indicate how your business facilitates employee access to training materials. (e.g., bulletin board, employee newsletter, staff meetings, etc.) B. List the personnel in charge of training and indicate qualifications of personnel conducting the training. Wfac go AF C. Indicate where records are kept. Records must document training including training duration and completion dates, names and positions of employees receiving training, and the name(s) of instructors / trainer. 10 A:\FRM-T.DOC2/14/2000 11:08 A: Site Visit Packet Permit No 60-0094 Facility Number: Facility Facility Name: SAN LUIS HONDA Operator: STEVE MYRICK 0 Address Number: 6 Address: HIGUERA ST Suite: City: SAN LUIS OBISPO Zip: 93401 CrossStreet: Parcel No: 004-511-016 Phone No: (805) 541-2200 Facility Type: Operator Name: STEVE MYRICK 0 Address: City: State: Zip: Phone: Miscellaneous SIC Code 5571 Dun Bradstreet Business License 77748 Guarantor Number CAL000071031 Status: Permit Expiration Date: 12/6/99 Property Owner Name: SAN LUIS HONDA YAMAHA Address: 6 HIGUERA ST Care Off Address: BRAD ARNOTT City: SAN LUIS OBISPO State: CA Zip: 93401 Phone: (805)541-2200 Business Owner Name: Address: City: State: Zip: Phone: Environmental Contact Name: Address: City: State: Zip: Phone: Current Balance: $185.00 Emergency Contacts Business 24 Hr Primary Days Last Name First Name Title Phone Phone Pager R ARNOTT BRAD SERVICE MANAGER (805) 541-2200 MYRICK STEVE OWNER (805) 541-2200 ' WRIGHT WALTER SALES MANAGER (805) 541-2200 0 NT cM a U a O Z I- 0 Q�Q O S2 W �2 J C7 J U)coU) a) O 0 w O Z E L a T O O N O O 00 ❑ ❑ ❑ ❑ ❑ 0 0 0 0 T U) w ❑ a 0 •� Q J N O CO O N O Z T Q T x cv _J O W T Ln F OCN V O N c E z E T Z co U) > ~ U 0 E m L Q U U) wLL F El U w w Z) N M U) co N �p O U Z T L C9 E a Q T cu 0 M Z n 0 i x00 0 r- a E z E a z Q > ~ U M E m t Q U `o Hazardous Materials Business Plan - List of Chemicals Permit No: 60-0094 Facility: SAN LUIS HONDA Address: 6 HIGUERA ST, SAN LUIS OBISPO Maximum Physical Largest Chemical Daily Amt Units State Container Grid No ACETYLENE 224 CU FT Gas ETHYLENE GLYCOL 55 GAL Liquid GASOLINE 55 GAL Solid OIL 165 GAL Liquid OXYGEN 283 CU FT Gas WASTE OIL 500 GAL Liquid Tuesday, September 28, 1999 Page I of I